As a summary, therefore, it may be laid down that it is necessary to remove all loose fragments of bone, the deficiency in the vault being rectified, if necessary, at a later date by one of the methods enumerated in Chapter VI.
The scalp-flap is accurately sewn up with interrupted salmon-gut sutures, a gauze or cigarette drain being inserted at the most convenient and dependent point, to be removed at the end of forty-eight hours or more according to the progress of the case.
=Punctured fractures.= Here there is a special liability to dural laceration and in-driving of comminuted fragments of bone. A full exposure of the parts is therefore absolutely essential. The trephine can be applied in the immediate vicinity of the puncture, or, as is often advisable, in such a manner that the punctured area is included in the trephine circle: this latter method may necessitate that the trephining should be carried out without the aid of the guiding fixation-pin, for which process some experience is needed.
After removal of the bone, the craniectomy forceps may be required, to allow of adequate dural inspection. The dura mater is opened up with blunt-pointed scissors, and the brain examined for in-driven fragments of bone. These, when found, are removed. Deeply situated fragments of bone and foreign bodies may be previously diagnosed by means of an X-ray picture.
If possible, both membrane and scalp should be sutured without drainage, but in the event of possible sepsis, a small cigarette drainage-tube should be inserted so as to lie beneath the dura mater on the one hand and emerge through the scalp wound at the other.
=Fractures limited to the external table.= For this class of fracture the reader is referred to the section dealing with bullet-wounds of the skull (see p. 296).
=Fractures limited to the internal table.= As previously indicated, the diagnosis of this condition is only practicable when the depression of the osseous fragments, or the hæmorrhage resulting from an injured meningeal vessel, so irritate the dura mater and brain that localizing symptoms ensue. For instance, epileptic fits of a Jacksonian type may develop shortly after the accident, this condition demanding a full exposure of the affected region. The operations required in the treatment of traumatic epilepsy and intracranial hæmorrhages are discussed in subsequent chapters.