be irrigated with an antiseptic solution and dressed with gauze wet with a 1-3000 bichloride solution and the ordinary dressing applied over it as a temporary dressing.

Now, after extensive crushes we have to fight against shock. The body must not only be treated, but also the mind, and we can do much by reassuring them. The pain can be relieved by the sulphate of morphia, which in small doses is a stimulant, but in large doses depresses. The dose should be from one-eighth to one-quarter of a grain, hypodermatically, and it may be repeated at intervals of an hour, if necessary. I have seen two cases that I am satisfied were killed by too large doses of morphine, and in one of the cases the physician acknowledged having given a grain hypodermatically, as he said "the patient was restless and very hard to control." the restlessness never kills.

The head should be lowered and hot-water bags or bottles (the latter can almost always be had) should be put around the body, which should be well covered. There is little use in putting medicine in the stomach, as it will probably be vomited. Warm salt solution thrown into the bowel does equally as well, if not better, than that given by infusion. An enema consisting of a pint of the normal salt solution to which has been added an ounce or two of whisky and several ounces of black coffee will be found. to be very effectual. Larger amounts of the solution are not so apt to be retained. The patient should be kept quiet and should not be moved any considerable distance, if shock is marked. The amputation may be postponed for several days, if necessary.

This is one of the conditions; the other is that of the patient who has been injured close to a hospital where everything is in readiness for an immediate operation; both thighs possibly have been crushed, but in a short time he is on the operating table. The morphia (one-eighth of a grain) and the enema have been given. The anes

thetic has been commenced and in less than an hour the patient is in bed with the foot elevated, the hot-water bags are about him and reaction soon begins to take place. The last two cases I have seen of double crushes of the thighs have recovered, and in both cases two of us operated at the same time. Drainage should always be used and an iodoform gauze dressing will prevent the early decomposition of the secretions. It should be changed, however, in twenty-four hours.

Three grains of the mild chloride of mercury should be given as soon as reaction has been established, and this should be followed in eight hours by half an ounce of epsom salts, which should be repeated every four hours till the bowels have acted well. Should the third dose prove ineffectual, an enema consisting of half an ounce of fel bovis and half a pint of glycerine with a quart of warm water should be given.

The diet is an important factor. If he is in a hospital, he will be put on a liquid diet, but he does not always get it, as milk is on this list. Unmodified sweet milk drunk by the glass curds in the stomach in a large curd which is hard to digest and predisposes to flatulence. It is almost universally given and I mention it only to condemn it. If it is drunk through a nipple or small pipette very slowly, as suggested by Dr. Harris, it may be very good. Many of its modifications are very valuable, and especially is this so of malted milk and many of the creamed broths. Mixed vegetable soups containing meat fats are also bad. Various meat broths, albumens and other prepared foods may be had which will give variety and will answer every purpose.

His whisky should be kept up indefinitely if he has been a drinking man, and if he is a cigarette smoker, pity him and let him have them in moderation. Also if he has any drug habit, reduce it gradually. The small things in our work often decide the result.

FRACTURES OF THE SKULL.

BY W. A. NORTON, M.D., SAVANNAH.

Having treated several cases of severe cranial injuries during the last five years, I have had occasion to determine some of the most salient features which the subject presents. In corporation work fractures of the skull are not at all infrequent, and are fully as interesting and important as any branch of surgery.

The skull is prone to complete depressed fractures and the underlying viscera to extensive injury. The gravity of the case does not depend so much on the extensiveness of the fracture as upon the intra-cranial injuries. In extensive fractures of the skull, extreme displacement often occurs, and considerable force is required to disengage and restore the separated portions to their normal positions. In reducing fractures of the skull a great deal more gradual pressure can be applied without doing further damage than the skull could sustain under a sudden stroke.

Fractures of the skull may be classified as follows:

(a) Complete, in which the line of the fracture involves both the outer and inner tables.

(b) Incomplete, in which only one table is fractured. (a) may be further classified into

(1)

Complete depressed fractures.

(2) Compound comminuted fractures.

Punctured fractures and gunshot fractures may be

either complete or incomplete. They are usually complete, and are complicated by wounds of the viscera. Time will not permit lengthly description of them. Symptoms.-Escape of brain tissue or cerebro-spinal fluid always points to fracture of the skull. If cerebrospinal fluid escapes through the external auditory meatus fracture of the base has occurred. Focal symptoms, such as loss of vision or strabismus, point to fracture of the base; exophthalmus and ecchymosis of the lid to fracture of the orbital plate of the frontal bone. Facial paralysis would point to fracture of the petrous portions of the temporal bone. An ecchymosis, developing several days after the reception of an injury may indicate a fracture of any portion of the outer table.

Let me quote Duret's explanation of concussions, for a case recently occurred in my practice which brought it forcibly to my mind. "A blow delivered on the cranium causes a depressed cone, the apex downward and at the center of greatest violence. This produces a bursting effect on the cranial walls. The explosive force will be greatest towards the sides or in the lateral areas as regards the point where the force was applied. When the force is applied over a larger area the riving (splitting with a wedge) effect is great, and the cranial wall may give way at some distant point where it may be weakest. This distant fracture occurs before the local one, and may be the only one to occur. This would seem to be the most natural explanation of the fractures produced by contrecoup, which always occur at the point opposite to where the force was applied."

Case 1-On March 7, 1907, H. S. White, age forty, was struck from behind by an engine and sustained a complete depressed fracture of the skull. He was removed to the hospital and immediately prepared for op

eration. Examination showed that the skull had been driven in from two inches above to half an inch below the occipital protuberance. The depressed fragments were removed and wound cleansed with normal saline. The adjoining depressions were then elevated, and one angle extending toward the right lateral sinus, which was deeply depressed, upon being elevated was followed by a great gush of blood. Hot gauze was packed into the opening and allowed to remain. The patient was put to bed and died on the third day without regaining consciousness. An ecchymosis of the right eyelid was noticeable on the second day. Postmortem revealed in addition to the fracture already mentioned, a contre-coup fracture on the inner surface of the right orbital plate of frontal bone, extending from the inner to the outer margin of the supra-orbital arch. This fracture could not have cccurred by the man falling forward on his face, for there was no external bruise to indicate it.

Case 2 represents an example of suspended thought, the injury interrupting the thought current before it reached the speech center. As a preface to this case, let me quote the following from the American Journal of Nervous and Mental Diseases: "A youth was rendered insensible by the kick of a horse, and as soon as the depressed bone was removed, he cried, 'Whoa, Dolly,' (the horse's name) and then stared about him in great amazement. Three hours had elapsed since the accident. He was not conscious that the mare had kicked. The last thing which he remembered was that she wheeled round her heels and laid back her ears."

My case was J. H., colored, injured June, 1905, by a blow from an iron pipe, which he was endeavoring to loosen from a machine which was in motion. The pipe he was holding was thrown outward, striking him over