be carried out under the indication of the rays with ease and security, even the length of the incision. necessary for the removal of bone-splinters being shown by the skiagraph.

It is surprising that surgeons who find it most natural to relieve by immediate operation bone-pressure caused by a depressed fracture of the skull should hesitate to perform the similar operations upon the spinal column. Nothing, indeed, is more natural than reduction or removal of a fragment pressing upon the spinal cord. Blood-clots can then be evacuated from the cord; and its membranes, and even wounds of the nerve-tissue, may be united. It is hardly necessary to add that such procedures must be carried out under the most stringent aseptic precautions. (Compare p. 52.)

The best method of exposing the spinal canal (trephining of the spinal canal, or laminectomy) is by the formation of a lateral flap. This is done by making an incision about seven inches long over the arches down to the periosteum and by reflecting the soft tissues to the bases of the spinous processes, which are then divided with cutting bone-forceps. The processes may be lifted up in the flap, like a bone-flap in the skull. (Fig. 160.) The dissection is continued to the other side until the exposure of the fractured area is complete. Now the depressed bone may be lifted or removed, a hematoma may be evacuated, and lacerated nerves may be united. If the bone-flap is reinserted now, union by first intention can be expected, the remaining bone-gap being filled up with thick fibrous tissue.

But if suppuration is present, the principles of open wound treatment should be kept up.*

In case of excessive callus, pressing upon the cord, or of faulty union, laminectomy is also indicated, even at a late period. Sometimes in such cases occlusion of the spinal canal, caused by adhesions of the membranes, is observed. It goes without saying that they must be thoroughly freed.

In view of the soft, spongy consistence of the vertebral bodies, it is evident that long-continued immobilization at least three months-is necessary for thorough consolidation. If the patient is allowed to get up too early, compression will be increased by the weight of the body, and kyphosis will be a natural consequence.

In severe cases the treatment may be continued for a whole year. Massage treatment should be commenced after three months; later on, faradization is in order.

Fractures of the arch are rare, and occur more frequently in the lower than in the upper portion of the vertebral column. They are caused by indirect. violence (fall or blow on the long spinous process) the effect of which is transferred to the arch.

Among the signs the predominant one is the downward displacement of the spinous process of the vertebra involved. Otherwise the signs as well as the treatment of this type require much the same consideration as those of the fracture of the vertebral body. Fracture of the spinous and transverse processes is extremely rare.

*Compare author's essay on Surgical Bulletin," Feb. 1, 1894.

Laminectomy,' American Medico

Fractures of the spinous processes are caused by direct violence (blow or fall), and prevail at the lower dorsal and the lumbar portions of the vertebral column.

The signs are well marked, the predominant one being abnormal mobility of the fragment.

Fractures of the transverse processes are still rarer, and their recognition is extremely difficult on account of the thick muscular layer protecting them.

The treatment of this fracture type is very simple. Patients should assume the dorsal decubitus for two weeks, and are then provided with a plaster-of-Paris corset for another few weeks.

A good skiagraph will show a fissure as well as an infraction at any part of the spinal column. In reproducing it in print, however, much of the delicacy of the representation becomes lost, and for that reason the author has preferred not to offer any of his skiagraphic illustrations of this fracture type.

FRACTURES OF THE SKULL.

Fractures of the skull are comparatively rare (1.3) per cent. of all fractures). They deserve special consideration for the reason that their course can seldom be foretold with certainty, extensive penetrating injuries sometimes healing with little reaction and no ill consequence, while comparatively small lesions of apparent insignificance are liable to be followed by fatal meningitis. They concern the vertex or the base of the skull or the bones of the face.

Fractures of the skull are uncommon in children on account of the thin and elastic structure of the bones,

which makes them yield to direct violence. This explains why fissures and fractures of the tabula vitrea are so extremely uncommon in childhood. The bones being united by soft sutures and the dura mater being firmly adherent to the infantile cranium, it follows that an injury of the skull will be, with few exceptions, combined with a laceration of the intracranial tissues; at least, of the dura mater. Sometimes the arteria meningea media is found ruptured. Such cases require very careful observation and judgment, since the early symptoms of meningitis or encephalitis may be veiled.

In

The treatment consists mainly in rigid asepsis. In hernia cerebri caused by compound fracture of the skull transplantation of bone-tissue is indicated. fracture of the skull in older children, in whom the bones are consolidated, the conditions are the same as in adults.

FRACTURES OF THE VERTEX

represent the great majority of fractures of the skull, and are nearly always caused by direct violence (fall or blow on the head, weapon, gunshot). Indirect violence, the force inflicted radiating, causes it but rarely. (An illustration of the insignificance of indirect violence is afforded by the case of President Lincoln, in which the bullet, after having pierced the left side of the occiput, went to the cranial base below the right anterior lobe. The autopsy revealed a fracture in the roof of the right orbit, which had not been touched by the bullet.)

There may be a simple fissure in the skull, as well as comminuted and compound fractures.

A remarkable feature of fractures of the vertex is the much greater extent of the fracture in the internal

Fig. 156.-Protrusion at the inner table, caused by a blow from a hammer. table than in the external. This is caused by the force bending the portion involved inward. Thus the outer

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