trephining
as a means of relieving TENSION.
It used to be
a
much-debated
point
iii
physi-
ology whether the capacity of the adult cranial cavity and the bulk of its contents could underTheoretically, and as a matter go any change. of measurement, the gross contents of this rigid bony globe must 110 doubt always remain the same ; but the distribution of the contents may
undergo relative iucrease and diminution, and the density of the material may vary considerably without any variation in bulk. The lymph cavities of the brain
elongated capacity.
cumstances, and to
dinary
or
are
and the
numerous
and
some
sinuses are also chambers of considerable aggregate These no doubt under ordinary cir-
large,
of them
venous
some
pathological
extent under extraor-
conditions
also, provide
for increase and decrease of size of the more solid contents of the cavity. But there is a limit to this kind of adaptation and in
cases
tion and
gressed,
a
O
of
new
congestion, effusion, extravasagrowth, this limit once trans-
state of tension is
established within
#
the skull
causing compression, and this state becomes known by disturbance, impairment or abolition of the function of the encephalon. The evils caused by impaction or overstuffing of cavities in other parts of the body, are well known. According to the degree and duration of the condition or annulled, and
nutrition
is either
deranged
the improvement obtained by of incision or the relief of tension by means evacuation is also a very familiar fact in the within recent practice of surgery. It is only and power of years that the full significance
TREPHINING.
Op%. 1890,]
tension as a pathogenic agent and the importance of relieving tension as a therapeutic expedient hfive been clearly and fully recognized* The relief of tension has in fact coine to be considered
one
as
of the
leading principles
of
branch of of all which
and it constitutes
303
these the
parietal or occipital region of one or sides, \y-\iere the skull is .thinnest andleaqt bqtli
liable to difference of thickness and where no siuuses exist should be selected, and the portion removed Bhould be Considerable, ap-
repeated
plications of the trephine or bone forceps or chisel being made. Th? operation should be conHilton so well expounded, namely, rest. ducted under the strictest possible autiseptic preLittle attention has, however, as yet been paid cautions, and the propriety of dividing the dura to tension as a factor of brain disease and as a jusand implautiug fragments of bone iii the apertification of surgical interference. The exis- ture will depend on the nature of the case. tence of compression is well understood, and the Instances have come under our observation relief of compression whether caused by dimin- 111 jvhich relief from symptoms of compresished capacity of the skull or impaction of its sion, convulsious or epilepsy could only in the absence of any observed local lesion be attricontents are commonly enough spoken and buted to removal of tension ; and we shall be written of, but operation is generally resorted
surgical therapy, that most important principle
a
a view to finding and if possible removing material?fluid or solid, abscess, clot or tumour?causing compression. The idea of removing a portion of the rigid skull-globe for the purpose of relieving tension, enlarging the capacity of the cavity and rescuing the encephalon from injurious pressure has not been clearly realized. In practice, it is found that
to witli
the
wonderful amelioration of symptoms often ve" suits from a
raising depressed
bit of skull with the
bone
removing
or
trephine
even
when
no
morbid material can be found or taken out. In such cases the improvement may be temporary or permanent, but it seems reasonable to attribute it to simple relief of tension. In many of these cases the bulging of material which takes place on the
trephine-
removing
button, attests imprisons its
the pressure under which the skull contents, and this pressure must operate more or less in every direction. The use of antiseptics has robbed the of
trephining
of its
dangers,
operation
and when
carefully properly performed it may be looked upon as a measure involving little or no risk to life. The danger as in many other instances, e.g. tracheotomy and herniotomy, depends not on the and
operation operation
itself, but
on
required. Considerations such
any
case
the conditions for which
is
as
these indicate that in when evidence of intracranial tension
and pressure exits, whether caused by effusion
or
tumour,
an
congestion,
in the skull the contents of
opening
should be made in order to give If indications of localizathe cavity more room. tion exist, such opening should be made where these indications
point;
but iu the absence of
to receive cases which contribute to the support of this view.
glad
as a means of relieving TENSION.
It used to be
a
much-debated
point
iii
physi-
ology whether the capacity of the adult cranial cavity and the bulk of its contents could underTheoretically, and as a matter go any change. of measurement, the gross contents of this rigid bony globe must 110 doubt always remain the same ; but the distribution of the contents may
undergo relative iucrease and diminution, and the density of the material may vary considerably without any variation in bulk. The lymph cavities of the brain
elongated capacity.
cumstances, and to
dinary
or
are
and the
numerous
and
some
sinuses are also chambers of considerable aggregate These no doubt under ordinary cir-
large,
of them
venous
some
pathological
extent under extraor-
conditions
also, provide
for increase and decrease of size of the more solid contents of the cavity. But there is a limit to this kind of adaptation and in
cases
tion and
gressed,
a
O
of
new
congestion, effusion, extravasagrowth, this limit once trans-
state of tension is
established within
#
the skull
causing compression, and this state becomes known by disturbance, impairment or abolition of the function of the encephalon. The evils caused by impaction or overstuffing of cavities in other parts of the body, are well known. According to the degree and duration of the condition or annulled, and
nutrition
is either
deranged
the improvement obtained by of incision or the relief of tension by means evacuation is also a very familiar fact in the within recent practice of surgery. It is only and power of years that the full significance
TREPHINING.
Op%. 1890,]
tension as a pathogenic agent and the importance of relieving tension as a therapeutic expedient hfive been clearly and fully recognized* The relief of tension has in fact coine to be considered
one
as
of the
leading principles
of
branch of of all which
and it constitutes
303
these the
parietal or occipital region of one or sides, \y-\iere the skull is .thinnest andleaqt bqtli
liable to difference of thickness and where no siuuses exist should be selected, and the portion removed Bhould be Considerable, ap-
repeated
plications of the trephine or bone forceps or chisel being made. Th? operation should be conHilton so well expounded, namely, rest. ducted under the strictest possible autiseptic preLittle attention has, however, as yet been paid cautions, and the propriety of dividing the dura to tension as a factor of brain disease and as a jusand implautiug fragments of bone iii the apertification of surgical interference. The exis- ture will depend on the nature of the case. tence of compression is well understood, and the Instances have come under our observation relief of compression whether caused by dimin- 111 jvhich relief from symptoms of compresished capacity of the skull or impaction of its sion, convulsious or epilepsy could only in the absence of any observed local lesion be attricontents are commonly enough spoken and buted to removal of tension ; and we shall be written of, but operation is generally resorted
surgical therapy, that most important principle
a
a view to finding and if possible removing material?fluid or solid, abscess, clot or tumour?causing compression. The idea of removing a portion of the rigid skull-globe for the purpose of relieving tension, enlarging the capacity of the cavity and rescuing the encephalon from injurious pressure has not been clearly realized. In practice, it is found that
to witli
the
wonderful amelioration of symptoms often ve" suits from a
raising depressed
bit of skull with the
bone
removing
or
trephine
even
when
no
morbid material can be found or taken out. In such cases the improvement may be temporary or permanent, but it seems reasonable to attribute it to simple relief of tension. In many of these cases the bulging of material which takes place on the
trephine-
removing
button, attests imprisons its
the pressure under which the skull contents, and this pressure must operate more or less in every direction. The use of antiseptics has robbed the of
trephining
of its
dangers,
operation
and when
carefully properly performed it may be looked upon as a measure involving little or no risk to life. The danger as in many other instances, e.g. tracheotomy and herniotomy, depends not on the and
operation operation
itself, but
on
required. Considerations such
any
case
the conditions for which
is
as
these indicate that in when evidence of intracranial tension
and pressure exits, whether caused by effusion
or
tumour,
an
congestion,
in the skull the contents of
opening
should be made in order to give If indications of localizathe cavity more room. tion exist, such opening should be made where these indications
point;
but iu the absence of
to receive cases which contribute to the support of this view.
glad
