(2) If the patient complains that he has constant pain in his head on the same side as that on which the injury was originally inflicted, that the pain is steadily increasing in severity, and that in addition he feels a sensation of pulsation in his head; and if, furthermore, you inspect closely the site of the original wound, and pass your finger cautiously over the spot, but fail to discover any appreciable external swelling, you may feel almost certain that a splinter or a spicule of bone projects from the inner table of the skull cap into the substance of the brain. Then, when the surgeon believes that the condition as just described truly represents the existing intracranial lesions, he should not hesitate to make an opening in the calvarium over the affected spot and remove the offending splinter.
(3) If the patient, after the external wound has healed, complains of a throbbing and roaring in his head, not merely in the region of the actual injury but involving the entire head, and if the symptoms tend rather to increase than to diminish, and eventually become so severe that the patient is almost beside himself with the pain, then is the surgeon justified in believing that a clot of blood is imprisoned somewhere beneath the cranium and is gradually being converted into an abscess or a condition of ulceration. And if at the same time some swelling appears in the vicinity of the eyes, or if a bloody and purulent discharge begins to flow from the nose or the ears, he may not merely entertain a belief that his diagnosis is correct, but may assert with positiveness that the lesions just named really exist. And then the proper treatment for him to adopt is [in essentials] the following: The head having first been shaved over the site of the original wound, make a crucial incision through the scalp and pericranium, turn the flaps back, apply a strong, sharp-edged chisel to the surface of the bone, and remove enough of the cranium to afford a satisfactory view of the underlying parts. [Among the effects first observed] probably pus will well up into the opening, and the patient will then experience relief; and if a spicule of bone comes into view, remove it forthwith. The plan of treatment here suggested is the only one which can be trusted to effect a cure in a case like that which is now being considered. . . . If a boring instrument is employed for making an opening in the bone, be careful not to allow any of the chips made by the borer to enter or remain in the cranial cavity. Some surgeons teach that, if pus be not found at the first opening, a second one should be made at the distance of a finger's breadth from the first, and that the inter-
