INTERMEDIATE AND IRREGULAR FRACTURES.—Most fractures of the skull are, in a sense, intermediate between the two great divisions of circumscribed and fissured fractures, for with every sharp blow there is seen to be some compression of the whole globe, and even the blunt est force, if applied with sufficient mo mentum, will cause a local crushing. But an understanding of the two great classes will elucidate all such cases. Ex ceptionally the brain is compressed by the blood effused beneath a circum scribed fracture, and its evacuation is followed by immediate relief of symp toms; but, we repeat, such cases are ex ceptional.
-Those which cause a local fracture are very liable to produce a local brain-lesion and to lead to infec tion; hence they present special thera peutic indications.
around the foramen magnum are caused by a sudden blow upon the buttocks which forces the spine up into the skull, carrying a ring of the basilar portion of the occipital bone along with it.
—A piece of depressed hone may lacerate both dura and pia and even the brain. In so doing it may tear the great sinuses or the middle menin geal artery. If the fracture involves the inner ear, the hearing may be perma nently lost. Various nerves and vessels and the cord itself may be torn at their points of exit from the skull. Any amount of brain-laceration may accom pany the fracture.
Process of Repair.—Most of the mem brane-formation is done by the diploe, the osteopoietic faculties of the peri cranium and dura being very slight. Consequently there is very rarely any superabundant callus, and consequently, too, if a piece of skull is removed it will be replaced only by fibrous tissue, and not by bone.
PROGNOSIS.—The gravity of the prog nosis depends on two things, either of which may exist without any fracture at all, namely: the damage to the brain and its adnexa, and infection. The im portance of depressions of small areas of the vault has been unduly magnified. Stimson strongly advises against med dling with simple depressed fractures unless focal symptoms present them selves. It is certainly absurd to suppose that the depression of a square inch of bone to the depth of half an inch or so could cause the severe and lasting shock that is so often attributed to such an in jury, nor should the elevation of such a splinter be expected to relieve these grave disorders.
TREATMENT.—Simple Fractures.—At tend to the general condition of the patient and leave the fracture alone un less focal symptoms present themselves as the result of a depression or a hmmor rhage from the middle meningeal artery. In such cases operate to elevate the de pression or to stop the luemorrhagc. Many surgeons hold that all depressed fractures should be elevated at once. As the choice lies between the problem atical danger from the existing depres sion and the real danger from possible infection, the question cannot be said to be definitely settled.
Compound Fractures.—Operate im mediately for the purpose of cleansing the wound. Fill the wound itself with gauze wet in bichloride 1 to 10,000, then shave and cleanse the whole scalp, or at least half of it. Next enlarge the skin
wound if necessary in order to catch all bleeding-points and to expose the lacera tion of the soft parts. If there is any depressed bone it can usually be elevated by prying up the most elevated corner and extracting this piece by gentle ma nipulation with the forceps, after which the rest will follow easily. Occasionally the chisel or trephine may be necessary; but in all compound fractures the bone must be elevated for the purpose of as suring the asepsis of the subjacent tis sues. Having elevated and removed the splinters the whole wound is copiously irrigated with "normal" salt solution. If any intracranial hemorrhage persists, the wound must be left packed with sterile or iocloform gauze for forty eight hours, after which it may be closed. If there is no bleeding the Jura is sutured; if torn, and the pericranium, aponeurosis, and skin sutured in layers, the first three with catgut, the last with silk. An aluminium, silver, or celluloid plate or a sheet of gold-foil or rubber tissue may be interposed in the gap left by the removal of fragments of bone in ' order to strengthen the scar.
If a fissure of the skull appears in the wound, it should be thoroughly cleansed as far as infection may have traveled. the wound being slightly enlarged and the edge of the fissure chiseled away for this purpose, if necessary. There is no object in endeavoring to find the limits of the fissure, which may extend half way around the skull or even farther. If from the force of the blow a depres sion of the inner table seems possible, that is no indication for increasing the patient's risks of brain-infection by tre phining. Such depressions are extremely ' rare, and unless they give rise to focal symptoms they are innocuous.
Punctured wounds should always be opened up, the punctured part of the skull being entirely removed by the tre phine and the whole wound then irri gated and drained. Bullets located near the surface may be removed at once; if deeper and not to be touched by gentle probing, they had best be left alone, as their presence does not materially influ ence the prognosis. If they give rise to symptoms later, they may be located by the X-rays and their removal attempted with a greater prospect of success. In fection from the air-passages in fractures of the base cannot very well be guarded against. It is futile to render the middle ear aseptic when germs may con stantly reach it through the Eustachian tube.
Fracture of the Vertebrae.
The importance of fractures of the vertebrae, like those of the skull, is de pendent almost entirely on the amount of damage done to the inclosed nervous tissues; on this the symptoms, progno sis, and treatment depend.
SYmPToms.—The symptoms are mainly those of an injury to the spinal cord. If the displacement is such as to com press or tear the cord, paraplegia results, with loss of control over the vesical and anal sphincters, and in the male priapism usually occurs. Locally there is tender ness and pain, increased by motion, ecchymosis, and deformity, and crepitus in some cases.