whole time, greatly facilitating the operation, and, in my opinion, materially improving the chances for recovery. A crucial incision was made, extending beyond the limits of the injury, and the flaps dissected from the bone. Finding the fractured pieces so interlaced that no one could be elevated without depressing the others, I applied the trephine on their outer margin, when they were readily removed with the elevator and duck-bill forceps. It was then seen that the sharp edge of one fragment had divided the dura mater for about half an inch, exposing the cerebral substance beneath, though neither that nor the dura mater showed any evidences of inflammation. But little blood was lost, though there was oozing of the sub-arachnoid fluid, which persisted for several days. The rim of bone having been smoothed, the edges of the flaps were brought in apposition with stitches, and dressed with adhesive plaster. The mother fancied that the child manifested signs of immediate improvement, and declared that she had not seen her so like herself since the accident. The weather then, and for the ensuing three weeks, was very warm, and the rooms of my patient were ill-ventilated, in a rear building, between a privy and a stable. There was some fever for the next three days, and the child was only allowed barley-water, and took one or two teaspoonfuls of castor-oil.

Aug. 18th. Dressings removed. Doing well.

Aug. 20th. The brain is protruding through the opening in the dura mater, and has reached the level of the scalp.

Firm pressure was now applied with graduated compresses of lint, and maintained by a bandage; while the child's bowels were kept regular, and the diet of an unstimulating character. The pressure was borne remarkably well, never producing any unpleasant symptoms.

Sept. 4th. The hernia has attained the size of a mushroom, having become flattened and pedunculated. Removed the mass with a single incision. Neither pain nor great loss of blood. Pressure accurately reapplied as before.

Oct. 9th. During this lapse of time persistent pressure has been continued. The symptoms of irritation have subsided during the last two weeks, while the patient's health has improved under the use of quinine and a nutritious diet. The nitrate of silver has been occasionally used to the margins of the wound to hasten cicatrization, which is nearly completed. Purulent discharge has been very free. Pressure discontinued.

In another week perfect cicatrization had taken place, and the child's health was entirely restored. It had gained flesh, was lively, brighteyed, and rosy.

The prognosis in injuries of the head at all periods of life is so uncertain, that a collection of some cases of these accidents to children under eight years of age, may not be devoid of interest; though I have been surprised to find so few reported in Braithwaite, Ranking, the London Lancet, the Gazette Médicale, the N. Y. Journal of Medicine, and the Am. Journal of Med. Sciences, complete files of which have been examined for the purpose.

It is probable that the frequency of fracture in the bones of the fœtal head during labor, is not appreciated; since, in many of the cases unaccompanied with effusion, there is sound reason to believe that "nature charges herself with the burden of the cure." I remember a case in the Dublin Lying-in Hospital, where a woman in lingering labor from rigidity of the perineum, gave birth to a still-born child without assistance. A fellow-pupil, preparing the head for his own museum, surprised us all with the sight of fissures of the parietal bone, involving its entire thickness, and radiating from the center of ossification. There was no effusion, nor could the fracture be considered as the cause of death.

Billard speaks of a marked indentation of the anterior and superior part of the right parietal bone, which he attributed to mechanical compression applied during the period of ossification.-Mal. des Enf., p. 620.

The explanation of Billard is, however, open to criticism, since the uniform facility with which the living intra-uterine foetus moves itself from sources of irritation, is now well recognized, and shown, by the masterly argument of Dr. Simpson, to be effected through the agency of the excito-motory system of nerves; an application of the views of Marshall Hall, wholly due to the distinguished Edinburgh Professor. Now, there may be sources of irritation—as the encircling of a limb by the funis— from which there can be no escape; but, it is not so easy to conceive of a mechanical cause capable of thus gradually producing the effect in question.

While Resident Physician of the Lying-in Asylum of this city, there was a woman under my care, laboring with her second child. Part of the waters were evacuated, and the os fully dilatable; but the large and well-ossified head hung over the pelvic brim, and refused to enter. It was movable, and presented well; and as the foetal heart was vigorous, and the mother's condition good, sleeping between the pains, it was decided to wait.

No urgent symptoms appearing, the labor terminated without assistance, twenty-four hours afterwards. The child was lusty, and the mother did unexceptionably well. On the following morning, my attention was

called to the child's scalp, which was livid from congestion over a portion of the right parietal bone. It sloughed a thin plate of bone, the size of a sixpence, was exfoliated. Water-dressing alone was employed, and the wound rapidly healed.

The child had no symptom of constitutional irritation, nursing all the while.

Billard doubts the existence of symptomatic fever before the period of dentition.

The Gaz. Méd. for 1848, p. 407, contains the following case of intrauterine fracture of the cranium, reported to the Academy of Medicine in Paris, by M. Blot, Interne of the Maternity :

The mother fell from the second-story window, fracturing her right thigh. When examined, the head had passed the os internum, and crepitated under the finger. Foetal heart inaudible. The woman was delivered with great ease by the forceps. The child was dead; its scalp uninjured, the cervical aponeurosis intact; but the pericranium separated from the upper parts of both parietal bones by effused blood. Beneath, each parietal bone was fractured from the boss to the sagittal suture. No other injury.

The ability of the foetal cranium to sustain an amount of pressure capable of greatly diminishing the biparietal diameter, and the compatibility of life with the existence of fracture of those bones unattended with effusion, as testified to by Velpeau, Chaussier, Dugés, Jacquemier, and others, have induced Prof. Simpson to urge the resort to turning as an alternative for craniotomy, or the long forceps, in deformities of the pelvic brim; and experience has amply justified the operation in this dangerous class of cases.

Neither is the remarkable resiliency of the cranial bones after parturition unexampled at later periods of life, as the following case, communicated to me by Dr. Van Buren, fully proves :—

A boy, under seven years of age, was struck senseless to the ground by a piece of wood carelessly thrown from the fourth story of an unfinished house. When seen, within an hour after the accident, there was depression of one parietal bone, capable of containing a hen's egg; declared, however, by the friends, to be less deep and extensive than when the boy was brought home. The symptoms were those of concussion and compression. While the head was being shaved, the depression obviously diminished, with corresponding relief to the symptoms of com

pression; and the operation was deferred. Within three hours, the indentation had so far disappeared, and the cerebral functions were so far restored, that all idea of trephining was abandoned. The child slowly and perfectly recovered. Nothing was felt, at the seat of injury, which rendered the existence of fracture certain.

Cases are not wanting to prove the power of the brain to accommodate itself to pressure of indented bone, as well in infancy as in adult life-Nélaton, Dupuytren, Hennen, Malgaigne, and others, furnish well-attested examples of the latter class of accidents; but we are not justified in pronouncing a patient free from all danger, either when the depression has relieved itself, or when the brain appears to have entirely recovered from the shock, and accommodated itself to the pressure. It is scarcely probable that much indentation can take place without fissure; and we may be mistaken in declaring that there is no compression by bone because the outer table retains its normal relations; since that may coexist with depression of the inner table, as is shown in the case of Sarah Murray, to be reported presently; while the American Journal of Med. Sciences, vol. ii., p. 492, contains the following case by Dr. Dudley, proving the length of time which may elapse in these cases before the development of unpleasant symptoms:

A boy, aged five years, had a portion of the right parietal bone fractured and depressed by a kick from a horse. No subsequent trouble until ten years later, when he had epilepsy, and was successfully trephined. A process of bone, half an inch in length, was found to project from the inner table.

Examples of children born alive after evacuations of portions of the brain by the perforator, are so numerous, as emphatically to demand from the operator the attempt to destroy the medulla oblongata; but perhaps the following result may be considered as one of the most unexpectedly fortunate on record :

A woman, aged 34, had been delivered, in her first labor, of a stillborn child with forceps. In her second labor, a similar attempt was unsuccessful, when the practitioner in attendance perforated the cranium, and made futile efforts at extraction. Dr. Lagae, being then summoned, performed the Cæsarean section, and extracted a living child with a large wound in its cranium, to the right of the sagittal suture and a few lines in front of the posterior fontanelle. The brain was visible, and a small portion had escaped. Mother and child recovered. The child's

intellect was perfectly sound at the age of nine years.-Am. Journ. of Med. Sciences, Jan. 1850, p. 229.

Out of twenty-one cases of severe injuries of the head, between the ages of one and eight, which I have collected, eleven have died, at intervals of time varying from two days to three months.

The case of the boy who lived three months, is to be found in the London "Lancet " for 1852, vol. 2, p. 54; and is extremely interesting, from the fact of the patient's having survived, the fracture of his skull, from a blow with a pickax; the operation of trephining; the occurrence and removal of hernia cerebri,-and then, thirty-three days after leaving the hospital, he died from a fall on a fender, which had reproduced all his former symptoms in an aggravated form, including the reprotrusion of a mass of the brain.

The cerebral substance is stated to have been injured, or lost, at the time of the accident, or during treatment, in fifteen cases; nine of which terminated fatally; while injury of the dura mater is mentioned in the two other fatal cases. Hernia cerebri made its appearance in six cases;

two of which recovered.

In the London "Lancet," 1848, vol. 1, p. 305, will be found the case of a boy admitted into the London Hospital, under Mr. Luke, with a compound fracture of the left side of the frontal bone, caused by a quoit. The depressed portions were removed, and the space immediately filled by the rising of the dura mater, which was superficially lacerated. On the ninth day, a tumor was observed protruding under the dressings, which soon increased to the size of a walnut. He died on the twentythird day, when the tumor was found to possess "an irregular, fungoid appearance," and to contain no true cerebral substance. At its base was

a small abscess.

In five cases, hernia cerebri followed the operation of trephining; in one, the removal of depressed portions of the bone with the forceps alone.

The period of time, when first noticed, varied from two to ten days. In three cases it was excised; in one, removed several times with the knife, and ligature; in another, treatment not stated; in Dr. Cheesman's case, not removed. In no one case does the removal appear to have been followed by pain or much hæmorrhage. Flow of the sub-arachnoid fluid, so evident in my own, does not appear to have been noticed in the others, though it is mentioned in some cases of encephalocele occurring congenitally, or shortly after birth. The well-known case of Mr.