can then be controlled by light sponge pressure, and the vessels picked up and tied. This is a much better plan than attempting to secure the vessels as the operation proceeds. It is nearly always possible to bring the edges of the skin together afterwards by the use of tension stitches, but when this cannot be done, the margins of the wound should be approximated as far as possible, the part left open being allowed to granulate or being covered with skin-grafts. For the largest nævi, electrolysis (see Vol. I. p. 256) is the best treatment, combined, if desired, with excision after the size of the nævus has been reduced.

CIRSOID AND OTHER ANEURYSMS.

The scalp is a favourite seat of cirsoid aneurysm, which usually affects the auriculo-temporal region. In this form the arteries become elongated and tortuous as well as dilated. The capillaries are also dilated, and the accompanying veins may likewise be involved; the result is the formation of a tumour composed of tortuous vessels. The cause of this condition is practically unknown. Sometimes there is a history of injury; in other cases the condition apparently arises in a previously existing nævus.

TREATMENT.-The treatment of cirsoid aneurysm is a matter of difficulty, and a great variety of methods have been employed. The best of all is extirpation, whenever the situation or the size of the tumour permits of its employment. In carrying out extirpation of the tumour, the main trunks of the arteries feeding it should be first exposed and ligatured. In the ordinary situation, the trunk of the temporal artery must be exposed as it passes over the zygoma, and after it has been tied, the skin may be dissected off the tumour, any redundant portion over the most prominent part being removed; outlying large vessels are clamped, and the mass of dilated vessels is taken away.

The only limit to excision is the extent of the tumour. When this is very large and much skin has to be taken away, the space may, however, be filled up by skin-grafts. In cases which are not suitable for excision, various other methods of treatment have been recommended, such as ligature of the main trunk of the external or the common carotid arteries, the application of caustics, the use of electrolysis, or the injection of coagulating materials; but these methods are unreliable and ineffectual.

True aneurysms are rare and can generally be dealt with by the direct operation (see Vol. II. p. 181). False aneurysms, the result of injury, may, however, be met with, and in former times were not very uncommon. They were usually found on the anterior branch of the temporal artery and arose in connection with phlebotomy. Aneurysmal varix may also arise from simultaneous puncture of the vein and the artery. The treatment of these conditions is excision of the sac (see Vol. II. p. 169).

CHAPTER XXX.

FRACTURES OF THE SKULL.

FRACTURES of the skull vary in character and gravity according to various circumstances. Thus, the situation of the fracture is of importance, the chief point being whether it involves the vault or the base. The fracture may be slight (simple fissure) or very extensive (comminuted fracture); it may be complete, or only one table may be injured; the broken pieces may be depressed, or not. The character of the instrument which inflicts the injury is also of great importance.

The effects of injuries which are sufficiently severe to produce a fracture of the skull are not limited to the bone itself. Various complications may ensue; among the most important are concussion, laceration, and compression of the brain; septic complications, such as erysipelas and cellulitis of the scalp, osteo-myelitis of the skull, lepto-meningitis, or cerebral abscess; hernia cerebri; paralyses of motion, sensation or special sense, subsequent mental derangements, persistent headaches, or traumatic epilepsy. These complications will be considered in detail later on. In the present chapter we shall simply deal with fractures per se, classifying them, according to their situation, into those of the vault and those of the base. Gunshot injuries of the head, although strictly included under these headings, will, for convenience, be considered in a separate section.

FRACTURES OF THE VAULT OF THE SKULL.

These fractures are generally due to direct violence, though sometimes they are merely upward extensions of a widespread fracture of the base; the whole thickness of the skull may be involved or one table only may be broken.

FRACTURE OF THE EXTERNAL TABLE ALONE.

In some cases, especially when the injury has been inflicted with a sharp instrument and the blow has fallen obliquely upon the skull, the outer table alone may be injured. This form of injury may also occur in

situations where there is a considerable interval between the outer and inner tables, notably over the frontal sinus, or the mastoid process. In the case of the frontal sinus, the anterior wall may be broken or depressed without fracture of the deeper part of the frontal bone.

The importance of these fractures mainly depends on whether they are compound or not. When compound, they are naturally prone to become the seat of various septic complications; fractures of the outer table alone are almost always compound.

Treatment. When there is no external wound-This is the type of injury usually found in the anterior wall of the frontal sinus. Although this fracture is, strictly speaking, compound, that is to say, communicates with one of the accessory sinuses, and consequently with the nasal cavity, septic infection is not a common complication, and all that is necessary is to keep the patient at rest for a few days and apply an evaporating lotion to the seat of the injury.

When there is an external wound.-Here the treatment must be that required for a scalp wound and for a compound fracture. The scalp and the wound in the soft parts must be thoroughly disinfected in the manner already described (see p. 328), after which the surface of the skull is carefully examined, any loose or projecting portions of bone removed and any obviously soiled area gouged or chiselled away. The bone and soft parts are then rubbed over with undiluted carbolic acid and a drainage tube of sufficient size is inserted before putting in the sutures. The dressing should be similar to that employed for scalp wounds, and the drainage tube may be left out if no septic complications occur within three days.

FRACTURE OF THE INTERNAL TABLE ALONE.

It is only very rarely indeed that the internal table is broken without. the external one being simultaneouly fractured, but a few cases of the kind have been put on record.

In children there may be a sort of green-stick fracture of the skull in which the internal table gives way as the result of a blow, and the external table is simply bent inwards, thus giving rise to a saucer-like depression of the bone. Under such circumstances there are not necessarily any symptoms, unless an intra-cranial hæmorrhage accompanies the injury to the skull.

TREATMENT.-Unless the fractured portion of the internal table gives rise to symptoms of cerebral irritation or unless there are signs of compression produced by some co-existing hæmorrhage, the condition may not be recognised. Should these symptoms arise, appropriate treatment (vide infra) must be carried out. Usually no symptoms arise if the child is simply put to bed and an ice-bag applied. The bone is elastic and the depression is spontaneously obliterated in a short time; operation is seldom called for.

FRACTURE OF BOTH TABLES OF THE SKULL.

Fractures of the skull vary in character according to the nature of the instrument which causes the injury and the direction in which the force is applied. They are usually divided into three main groups, namely, fissured fractures, depressed or comminuted fractures, and punctured fractures.

Fissured Fractures. These can only be recognised when the surface of the bone is exposed. When there is no wound, the existence. of a fissure may be suspected when complications, such as intra-cranial hæmorrhage, or traumatic cephal-hydrocele, are present. As a rule there is no noticeable difference in level between the two portions of the bone, but the internal table is more widely fractured than the external, and portions of the former may project downwards on to the dura mater.

Depressed Fractures.-Depressed fractures may be simple or compound; as a rule, they are compound. The bone is broken up into several fragments according to the degree of violence producing the fracture; some of these fragments may be loose, so that there is a true comminuted fracture; others again may be only partly detached; even these may be bent downwards and exert pressure on the brain. In addition, it is usual to find fissures of the skull radiating from the area of comminution.

The internal table is always more extensively broken up and more detached than the external, so that the amount of injury evident externally does not fully indicate the amount of damage in the deeper parts. These fractures are always associated with more or less hæmorrhage, and the amount of blood effused beneath the skull is the chief cause of the symptoms of compression which may follow. It is seldom that the bone is sufficiently depressed to cause general compression symptoms of itself, although when the depression is over a motor area it may give rise to paralysis or to symptoms of irritation of that area. When the general symptoms characteristic of compression are associated with a depressed fracture, it will generally be found that there is a collection of blood between the bone and the dura mater, in addition to the depression of the latter. The hæmorrhage in these cases may be severe and usually occurs from branches of the middle meningeal artery. It may also result from injury to one of the sinuses of the brain, or from laceration of the brain at the site of the injury, or at the opposite pole of the skull. This condition of intra-cranial hæmorrhage is considered on p. 370.

Punctured Fractures.-Punctured wounds of the skull are caused by some pointed instrument, such as a bayonet or a sword. The fractures are always compound and the inner table of the skull is often more extensively fractured than the external. In a punctured

fracture for instance, one caused by a bayonet-a small and smooth hole in the external table is all that is noticeable from the outside, but the internal table is usually considerably detached and the fragments project against the dura mater, and may even perforate it, in which case their sharp edges may project into the brain itself. It is important to remember that, however insignificant the external wound may appear, there is certain to be considerable and serious damage to the internal table, which must be remedied. In these cases also, the instrument itself is very likely to puncture the dura mater and lead to hæmorrhage from the vessels in it, or even from those on the surface of the brain. In sword or axe-wounds the essential conditions are the same, except that, instead of a hole in the external table, there is a long cut-the so-called 'gutter fracture.' The internal table in these cases is also extensively broken up and depressed. As these fractures are always compound, they are liable to be followed by suppuration.

TREATMENT.-I. Of a simple Fissure. Very little in the way of active treatment is required in these cases; unless accompanied by some intra-cranial lesion the injury is only recognised when the fracture is compound, and the treatment is then similar to that of a scalp wound (see p. 328). The disinfection of the wound should be thorough, and, provided it is effectual, the patient will be apparently well after a few days' rest in bed. Every fracture of the skull, however, is of necessity accompanied by some amount of injury to the brain, and although the patient may exhibit no definite symptoms pointing to an intra-cranial lesion, he will none the less be unable to carry out work requiring mental effort and concentration for a considerable time. It is therefore advisable after all cases of serious head injury to prescribe a long period of rest and abstinence from mental work and excitement.

In some cases these fissures are followed by intra-cranial hæmorrhage or intra-cranial suppuration, and in these appropriate treatment must be adopted; otherwise nothing need be done in the way of operation in the first instance. When the fissures are extensive and numerous, and when there is some irregularity about the edges, however, it may be well to make a small trephine opening so as to ascertain the condition of the internal table. The procedure is the same as that described below for other forms of fracture.

2. Of Depressed Fracture.-It may be laid down as an axiom that the depressed fragments should be elevated or removed, any detached portions of bone taken away, and all hæmorrhage arrested, without waiting for cerebral symptoms to supervene. Hence, operation is advisable in all cases of depressed fracture, except the saucer-like depressions in young infants (see p. 340), whether the fracture be simple. or compound, and the sooner the operation is performed after the patient has recovered from the shock the better.

Simple depressed fracture. The first procedure is to shave the scalp