munity will be made easier, more satisfactory, and will be more gracefully performed, the more time and attention we give to purely medical work. If too much of our time is taken up in the court of medical ethics in arguments of ethical questions, the incidental will destroy the principal and there will be left us no affection or welcome in the hearts of the community. Having no use for us it will cast us aside, and though we may be, in form, exclusive, exacting and exact, the answer will come back that until we know to a finish how to act, not to attempt to act for it Evidently what the community want is truth supported by directness. They want intelligence and professional attainments unembarrassed by creed or arbitrary rule, and if they receive that they will mete out to us as much favor as they accord to other helps and other professions. Society unassisted by advice, without much advance in its feelings of gratitude, but from pure motives of selfishness, will, when we have plainly drawn the line of distinction between the medical pretender and ourselves, judge which will meet its demands. If we are true to the principles of science, are accurate in our observations and cor rect in judgment, need we fear which will be chosen?

ARTICLE III.

FRACTURES OF THE SKULL-REPORTS AND OBSERVATIONS OF THREE CASES.

BY S. MARKS, M. D., OF MILWAUKEE,

Chairman of Committee on Surgery.

Fractures and depressions of the skull are prominent among the ugly things with which the surgeon has to deal, owing to their extreme liability to be attended with serious cerebral complications, arising from hemorrhage or from injury to the brain substance or to the membranes. Where these complications are found-where there is persistent compression, due either to hemorrhage or the pressure of depressed bone - rational treatment involves the elevation or removal of the bone. Even where there are no marked cerebral symptoms, the danger of future complications is so considerable that an operation is indicated when the fracture and depression are of such a character as to lead to the belief that a fractured inner table may injure the membranes. In the case of adults, particularly, recovery from a depressed fracture without operation has been frequently followed by epilepsy. Yet there are some recoveries among children, and even among adults, also, without operation, and after very discouraging indications of brain disturbance, in which there are no subsequent cerebral complications The expectant treatment

to which army surgeons have been prone, even in the case of adults -the waiting for pronounced symptoms of brain disturbance before operating for the removal of imbedded pieces of bone-has in some cases, contrary to reasonable fears, led to favorable conditions which have rendered an operation of doubtful wisdom. The surgeon is occasionally amazed not only by the amount of injury the membranes and brain substance and the branches of the middle meningeal artery may undergo without leaving any permanent effects, but also by the depth to which a fractured bone may penetrate and

remain, without any remote consequences. So, while the rule of early operation for the removal of depressed fractured bones is sound, it is not to be anticipated that in cases where there has been failure to operate for any reason, particularly in the case of children, serious consequences will invariably follow. The least hopeful case is that in which there is laceration as well as depression; yet among the cases to which I am to call attention is one in which a boy of six years, suffering from a compound comminuted fracture of the skull, with the probable imbedding of detached pieces of bone deep in the substance of the brain, and with some hemorrhage and the exudation of brain substance, recovered without any operation for the removal of the bone a case in which a probe was passed to the depth of two and a half inches. This and one other case, somewhat similar, go to show that while as a general rule immediate operation is to be insisted upon, yet the expectant treatment may be followed by the happiest results The nature of the fractures, and the persistence of the concussion in these cases in the first hours indicated operation; but operation being delayed, though not by intention, the reaction was so decided and there was so complete an absence of cerebral disturbance that the dangers of the expectant treatment were at the minimum.

There is little difference of opinion among surgeons regarding the treatment of compound fractures of the skull with depression of bone ; nearly all urge elevation of the depressed bone, even though symptoms of compression are absent; it is thought that with our present means of guarding against excessive inflammation, the removal of the depressed fragments of bone, even though requiring the use of Hey's saw or the trephine, does not add materially to the dangers of the case. But with regard to the treatment of simple fractures of the skull, without symptoms of compression, there is still a difference of opinion among eminent surgeons. One class of surgeons recommend that "in all cases of recent fractures, whether simple or compound, even though entirely without symptoms of compression, if there is reason to believe the internal table is depressed" there should be surgical interference unless the condition of the patient is hopeless, owing to the concussion. Surgeons of this class contend that trephining is not attended with any great danger in the hands of the skilful operator. Dr. Roberts insists that "the removal of a portion of the cranium by the trephine is, if properly done, attended

with but little more risk to life than amputation of a finger through the metacarpal bone."

Another class of surgeons go to the other extreme and contend that in a case of simple fracture of the skull, without symptoms of compression, non-interference should be the rule; that experience has justified this, in many cases where marked depression has been followed by no ill effects when the surgeon has not interfered. They insist that antiseptic surgery does not render trephining free from danger, indorsing Dr. Campbell, who says: "I have ever regarded trephining as one of the most serious of capital operations." Dr. Kinloch thinks an exploratory incision always adds to the risks, and declares that the operation, if justifiable in simple fracture, is justifiable only on the presumption of secondary complications, "which presumption," he says, "is not clearly demonstrated by statistics." It appears to me that we have extreme views in these two classes of surgeons, and that we cannot follow the teachings of either in all cases. To advise trephining in every case, in children as well as adults, if there is reason to believe there is depression of the internal table, is to give unwarranted license to ambitious surgeons (of whom we have many) to take a button from the cranium of every person who may suffer from ever so slight a depressed fracture. I am confident the experience of surgeons will sustain the belief that trephining is more dangerous than amputation of the finger through the metacarpal bone. On the other hand, to advocate non-interference in all cases of simple depressed fracture is extremely hazardous. Almost every surgeon of experience has seen cases where the location and degree of compression in simple depressed fracture were such as to make it almost a certainty that grave cerebral disturbances must follow.

The three cases which I have to report, in all of which operation was strongly indicated but in all of which it was delayed and in two of which it was not performed at all, show that the dangers of delay are not always as serious as we might expect.

CASE I. The first case I find in my records, dated June 10, 1860 -that of a boy between 9 and 10 years of age, supposed to have been kicked by a horse, as he was found unconscious in a pasture near his home. In less than an hour after he was found I was called, and discovered he was suffering from an ovoid fracture of the skull, about five-eighths of an inch in length, on the

The frag

left side of the frontal bone, a trifle below the eminence. ments of bone were apparently depressed fully their thickness. The soft parts over the fracture were bruised and somewhat lacerated, but were not entirely cut through at any point. The inferior maxillary bone was fractured near the angle of the left side; there was aiso a fracture of the same bone a trifle to the left of the symphysis. Both the upper and the lower lips were cut through in several places. Pulse and respiration were abnormally slow. He remained entirely unconscious during the examination-how long he had been in that condition no one knew.

Being satisfied that the fragments of bone were pressing upon the brain, I advised that they be elevated, but the mother absolutely refused to allow any operation for that purpose. I was simply requested to dress the wounds as best I could After I had removed the blood and dirt from the head and face, and while introducing sutures through the lips, the boy suddenly aroused and began screaming, striking and kicking with great violence. Extreme delirium continued ten or fifteen minutes, after which he became quiet and rational, and complained of pain in his jaw and face, but not of pain in the head. The wounds of the lips were closed with sutures and the fracture of the jaw was treated with a compress extending from between the angles of the jaw to near the chin, and a Gibson bandage. Simple cold water dressing was applied over the fracture of the skull. The pulse and respiration of the patient became more frequent; during the next twenty-four hours he was restless, showed some fever, and the pain in his face and jaw was so severe that it was necessary to use opiates. I found it exceedingly difficult to keep the fragments of the jaw in apposition. Whatever dressing was applied, he would contrive some plan to disarrange it, and for that reason union was somewhat delayed. The wounds in the lips healed by first intention and the lacerated soft parts over the fracture of the skull healed kindly by granulation. Union in the jaw was firm at the end of eight weeks, and the boy appeared to be in his usual health. During the time this paitent was under treatment he did not complain of pain in his head or show the least cerebral disturbance. The case was under observation for six years, and through others I learned that up to his nineteenth year, nearly ten years after the injury, he had not suffered in the least from the fracture of his skull. The depression at the point of fracture was well marked at that age.