It appears, therefore, that fracture of the base, even excluding rare complications, presents many dangers; the mortality is great, and depends of course on the severity of the injury and the presence or absence of complications. Fractures through the middle fossa of the skull are by far the most frequent, but fractures through the posterior fossa have the greatest mortality.

The treatment of uncomplicated fractures of the skull is in the main expectant: rest, good nursing, if necessary esophageal feeding, and the local application of cold. Great care must be exercised to guard the patient against any additional injury.

It is an open question whether the external auditory meatus should be cleansed with a disinfecting solution when there is hemorrhage from the ear. Personally I consider it impossible to achieve complete disinfection in this way, and only allow the outer portion of the meatus to be carefully wiped out. On the other hand, the ear itself and the surrounding skin are thoroughly disinfected and dressed with sterile cotton. The objection to using a syringe is that there is danger of carrying infection to the deeper portion of the wound and thus bringing on meningitis.

As the pressure of the hemorrhage on the surface of the brain rather than the contusion of the brain-substance is regarded as the cause of death, it follows logically that trephining is greatly to be recommended. Some very satisfactory results have been obtained by this operation in recent times.

Fractures of the skull heal by bony union with an astonishingly small amount of callus-formation, which is owing to the slight degree of dislocation, to the fact that the fragments are completely put at rest, and to the fact that the capacity of the dura mater for producing bone is less than that of the periosteum of the long bones. In rare cases loss of substance remains after fracture of the roof of the skull, especially in small children; it is sometimes accompanied by meningocele.

III. INJURIES OF THE FACIAL BONES

The bones of the face are accessible to examination either from without or by way of the nasal and aural cavities, so that fracture of these bones rarely presents diagnostic difficulties. Fractures of the nasal bones are always

to be regarded as compound, since there is necessarily

an open communication between the seat of fracture and the nasal or oral cavity. It is remarkable that notwithstanding this condition recovery usually takes place without any special complications or dangers due to infection. Injuries of the nasal bones are always due to direct violence by a blow or a fall. Fracture of the nasal bones and parts of the bony septum behind them usually produces distinct, and sometimes excessive, deformity

(traumatic saddle-nose); the displacement may be reduced in recent cases by means of a forceps introduced through the nasal cavity. The obvious symptoms are suggillation, and hemorrhage from the nose; a slight degree of cutaneous emphysema may be produced by entrance of air-bubbles

through the opening in the mucous membrane into the cellular tissue about the seat of fracture. [This is rare.-ED.] Fractures of the malar and superior maxillary bones result from direct injuries, mostly the kick of a horse; they are, therefore, very frequently compound. The diagnosis presents no difficulties. The treatment demands reduction and fixation of the displaced fragments. This should be done by proper operation. This part of the treatment should be properly intrusted to a dentist, who may be able to save some of the teeth that have become loosened. I have sometimes obtained a good result by simply securing a fragment with a nail. The mouth must be kept clean with a 3% boric acid solution, and the patient put on liquid diet.

Fracture of the lower jaw is a more frequent accident. The condition is easily recognized, either from without or through the mouth, so very little needs to be said about the diagnosis. In fractures of the body or arch of the lower jaw a typical dislocation is observed, the posterior fragment being drawn upward by the masseter, while the anterior fragment is displaced downward by the action of the digastric and other muscles attached to the chin.

Fig. 26. Specimen of fracture of the lower jaw with lateral displacement.

In the great majority of cases there is also a certain lateral dislocation by virtue of which the two fragments override each other so that the arch of the bone becomes shorter and narrower. Double fracture of the lower jaw is occasionally met with, and comminuted fractures are not so very rare.