envelope of the cord, death generally follows in a short time— usually from peritoneal irritation, followed by convulsions, etc.

When the tumor is large and irreducible, the patient generally has the symptoms usual in intestinal obstruction in other situations, viz., nausea, colicky pains and constipation. If the obstruction be not removed, or if the tumor become strangulated, without speedy relief the prognosis is of course unfavorable.

TREATMENT. This will vary materially according to the size and kind of tumor, and should be adapted to the peculiar requirements of each individual case. For the congenital or acquired tumors of children, where the rupture is small and reducible, and contains only a loop of the large or small intestine, an operation may be necessary. This consists in bringing the edges of the ring together, after the hernia has been reduced, and retaining them in position by means of needles passed through the sides of the abdominal opening and fixed with thread, as in the operation for harelip.

If the nature of the case is such that it is not considered safe or necessary to operate, reduction may be accomplished and afterwards maintained by means of a truss or pad. A flat or slightly convex pad may be kept in close apposition with the tumor by means of adhesive strips passing over it and attached to the sides of the abdomen. This appliance not only prevents the tumor from enlarging with every effort of the child, but it assists in obtaining a cure by favoring the closure of the ring. A very simple truss may be made by fixing a flat pad of celluloid, vulcanized rubber, or wood in the center of a band three or four inches wide and long enough to encircle the body. This band may be made of cloth, rubber webbing or rubber adhesive plaster, as may be thought best. The pad is placed over the enlargement and retained in position by the belt or band to which it is attached. Spring trusses of various patterns are also made by instrument makers for the treatment of this disease.

When the tumor is large and irreducible it may become necessary to sustain it by means of an abdominal supporter, made of some elastic material or inflated rubber.

If symptoms of obstruction are present the treatment should be, rest in the supine position, local applications of ice, opium internally, and an enema to empty the lower bowel and a purge to clear

the upper. If the tumor is found to be strangulated taxis should be tried as in other varieties of hernia.

When all other means have failed to relieve the strangulation, herniotomy may be necessary. When performing the operation the surgeon should endeavor, if possible, to avoid opening the peritoneal sac, as death almost invariably results when this is done. The stricture, when found, should be divided and the bowel returned with as little manipulation as possible. If the hernia is irreducible the surgeon should, if possible, divide the stricture and leave the bowels in their adopted locality.

INJURY OF THE HEAD WITH FRACTURE

OF THE SKULL.

WM. LOMAX, M. D., MARION, IND.

Miss O. W.- a healthy, athletic young lady, while riding in an open buggy with her sister on the twenty-second of September last, met with an accident resulting in severe injury of the head. One of the wheels striking a stump threw her sister, who was driving at the time, out of the buggy, and, letting go of the reins, left the subject of this narrative alone in the buggy with no means of controlling the frightened horse. Alarmed at her perilous condition, she leaped from the vehicle when it was moving at rather a rapid rate, and was thrown forcibly upon the ground. The head struck upon a stone or other solid substance, inflicting a severe contusion of the soft tissues just above the right brow, with fracture and slight depression of a fragment of bone beneath. She was stunned and insensible, and for a time thought to be lifeless. Respiration, which at first was measurably suspended, after a short time returned, and, with the assistance of a gentleman meeting her just as the accident occurred, she was enabled to get to a house near by. I saw her in a short time, probably two hours, and was told that as consciousness returned she was able to speak somewhat intelligibly of the accident, and manifested an anxious concern for her sister who had been thrown from the buggy; but she soon lapsed into an incoherent and partially unconscious state, with a strong tendency to coma; the pupils dilated, the right more than the left; pulse feeble, slow and intermitting; temperature of body

reduced, and the extremities very cold, accompanied by nausea and vomiting.

Warm applications were sedulously made to the extremities and cold applied to the wound upon the head, and whisky and opium in small quantities were given by the stomach. In the course of three or four hours the warmth of the body returned, and consciousness was partially restored, with more or less confusion of ideas; the pulse improved in force and rythm, but continued slow, varying in frequency from 50 to 56 per minute.

After this she was placed upon a litter and carefully carried to my house, a distance of two miles, without the least injury. As consciousness returned there was exalted sensibility to light and sound, with pain and excessive heat of the head when not energetically subdued by free applications of ice and ice-water, while the tendency to coldness of the feet required the constant employment of bottles filled with hot water placed around them to maintain a normal temperature. The nurses observed that it required much less effort to keep the head cool when the inferior extremities were kept warm. For some five or six days there was a marked disposition to stupor, and more or less fever for a week, but never excessive. Under the vigorous use of acetate of ammonia and spirits nitre, with veratum viride internally, and cold applications to the head, it never became strongly developed. The pulse rarely ever became hurried. A few times it ran up to 80 or 85, never higher. It was usually sluggish, below 60, and feeble, never acquring a force that would justify venesection. A full cathartic was given on the morning after the injury, consisting of calomel, jalap, rhubarb and bicarb. soda, and by the assistance of an enema it operated freely, and was followed by improvement of the brain symptoms. After this a laxative condition was steadily maintained. The cold applications to the head and warm to the feet, with sedative medication internally, were persevered in for six days before the disposition to excessive reaction had notably subsided. After this they were employed more sparingly until the eleventh or twelfth day, when they were left off. She was now able to sit up and walk about the house, but feeble and subject to vertigo, and had a very unpleasant feeling, as if a strong band were drawn tightly around the forehead. At this time she was taken home by her friends, and steadily improved until all

the inconveniences of the injury had passed away and the health was perfectly restored. There still remains a slight depression of the fractured bone, but she enjoys good health and suffers very little inconvenience from the accident.

The value of all observations in practical medicine is derived from the illustration of some principle which they may tend to fix in the mind of the physician as a reliable rule to guide him in the adaptation of his remedies to the various phases of suffering he may be called to treat; or of some physiological fact of scientific moment in elucidating the abstruse endowments and functions of the living animal economy. And they may also be suggestive of profitable investigations, directing professional thought into channels and upon subjects that may yield rich compensatory contributions of great benefit to the age and the race. There can scarcely be any case, however simple, in all the broad and varied field of professional duty that will not involve elements of vital interest that are only imperfectly understood, leaving much that is submerged in the obscurity of the dark unknown and unexplored. Hence every glimpse of concealed truth, physiological, pathological and therapeutic, that may be caught by the vigilant eye of scientific observation should be faithfully registered and carefully studied, until the mantle of darkness may be lifted from the arena of many dormant agencies and, as yet, sleeping activities which may be of inestimable benefit to the future of the healing art. In this spirit we propose to review the case before us, and endeavor to educe from its analysis such conclusions as may be logically drawn from its teachings, and which, it is hoped, may not be without some practical value.

In the first place, the case presents a condition which, in surgical expression, is termed concussion of the brain; and it may be remarked that in the sense in which the term is here employed, a liberty of speech has been taken by the profession in no wise restricted to its true etymological signification. In professional acceptation the term is made to overreach the mere vibrations among the aggregate molecules of the brain itself, and to embrace all those disturbances of normal friction and those pathological phenomena which result from the mechanical violence. The suspended consciousness, confusion of intellect, depressed circulation, pallor of