All compound fractures.
In all these instances, from the presence of depressed fragments of bone, from associated injury to the intracranial contents, or from other causes, no mere expectant policy should be pursued. The surgeon has to look into the future, to bear in mind the possibility of meningeal infection, and the more remote results of head-injuries in general (see [Chapter VI]). In other words, early and active surgical interference is imperatively demanded, for not only is it necessary to strain every endeavour to save the patient’s life, but the surgeon should also adopt those procedures which guard most effectually against the more remote possibilities of the case.
With regard to simple fractures, if it can be determined that the fracture, whether fissured, stellate, or comminuted, is simple and uncomplicated by any serious intracranial lesion, no active surgical treatment is required. The determination of such conditions is, however, quite another matter, always difficult and sometimes, from the presence of overlying hæmatomata, quite impossible.
In the general estimation of these cases it should be borne in mind that simple uncomplicated vault fractures are decidedly rare. For instance, Dwight, in 145 cases of fractured skull that came to autopsy, only found six that evidenced a fissured fracture localized to the vault. It may, of course, be urged that these statistics are fallacious, insomuch as simple uncomplicated vault fractures would probably not come to the post-mortem table. Clinical evidence, however, coincides with Dwight’s statistics, and clinical evidence shows, furthermore, that a blow sufficing to fracture the vault of the skull almost invariably results in further injury.
In these doubtful cases the surgeon is greatly aided in his decision by a general review of the patient’s condition, more especially by those symptoms which are regarded as exemplifying the clinical conditions of concussion, irritation, and compression.
When the fracture is associated with mild concussion
it may be inferred that the brain is practically uninjured, and that operative treatment is not required.
When the fracture is associated with severe concussion
it may be inferred that the brain is damaged, to a degree proportionate to the depth and duration of the stage of unconsciousness. The question of operation depends to a very large extent on the general condition of the patient, and more especially on the temperature and temperature changes (see [p. 114]). With a persistent subnormal temperature it may be inferred that the brain-injury is of a very severe nature, and that operative measures are, for the time being, contra-indicated. In the event of the temperature rising it may be accepted that the patient is passing from the state of shock to that of reaction, operative measures again hinging on the further progress of the case. If the temperature rises progressively, the patient passing from the stage of reaction to that of compression, operative measures are indicated. Under other circumstances an expectant attitude can be adopted.