Modern surgery, general and operative . e head, and arterial sedatives). A simple fracturewith moderate depression and without cerebral symptomsis treated expectantly, and so also is a simple fracturein which symptoms existed but are abating. Simple frac-ture with marked depression requires immediate trephin-ing, even when brain symptoms are absent. Wemake an exception in young children, and wait awhile before trephining, in the expectation that theexpansile brain will lift the depressed but elastic boneup to the level. Trephining in cases in which no symptoms exist, althoughthere is marked de
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Modern surgery, general and operative . e head, and arterial sedatives). A simple fracturewith moderate depression and without cerebral symptomsis treated expectantly, and so also is a simple fracturein which symptoms existed but are abating. Simple frac-ture with marked depression requires immediate trephin-ing, even when brain symptoms are absent. Wemake an exception in young children, and wait awhile before trephining, in the expectation that theexpansile brain will lift the depressed but elastic boneup to the level. Trephining in cases in which no symptoms exist, althoughthere is marked depression, often prevents disastrous consequences arisingin the future, and is known as preventive trephining (Agnew, Keen, Horsley, Macewen, von Bergmann, and others). In all com^pound fractures shave andasepticize the entire scalp, enlarge the incision, and explore the bone. If afissure exists, it must be asepticized, and if a hair or other foreign body isfound in it, in order to effect removal and secure asepsis the outer table of the. Fig. 517.—Fracture ofskull with depressed frag-ments. Compression ofbrain by bone (Scudder). Fractures of the Base 791 skull at this spot must be cut away by a chisel, the fissure being thus convertedinto a broad groove. In a compoimd fracture with much depression trephine, elevate, and irrigate. In any fracture trephine if distinct symptoms exist.In punctured wounds of the brain {punctured fractures) always trephine, openthe dura, and disinfect. In a comminuted fracture the usual custom is toremove loose fragments. Schaak has recently advocated their reimplantation(Archiv. fiir klin. Chir., April 6, 1912). My usual custom has been to re-move them. In any case of fracture of the vault in which trephining has beenperformed it is wise to open the dura and examine the brain. In an open frac-ture and after every operation of trephining in which the dura was openedadminister urotropin in order to make the cerebrospinal fluid bactericidal. Fractures