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lotions, and to a simple dressing, changed twice a day. When the bone itself is necrosed, the dressing should be carefully attended to, and the case narrowly watched so as to remove the exfoliated portions when they become detached, then a stimulating ointment, or an ointment powdered over with bark, may be used as a dressing.

[An able paper on this subject has been recently published by Professor Levy, of Copenhagen (Beobachtungen über des Kephalämatom, &c., in the Journal für Kinderkrankheiten, p. 161), based on the personal observation of fourteen cases, aided by reference to the experience of other observers. The following are the most important conclusions arrived at by the author: 1stly, that too much stress is not to be laid on the assertion of different writers, that the affection is chiefly met with in primiparæ, since, out of fourteen cases, four were not such; 2ndly, that there is even less reason for believing its frequency of occurrence in boys to much exceed that in girls, as the ratio was only 8:6; 3rdly, that the views of Valleix, as to its usual origin or ordinary mode of formation, are probably incorrect, the disease being rather due to a strong resisting force applied to a particular portion of the head by some part of the bones of the pelvis, varying according to the point of greatest frictional pressure during labour. The assumed cause of Valleix, viz., circular pressure by the neck of the uterus, only produces sub-pericranial ecchymosis, between which and cephalæmatoma the difference, although in one repect scarcely more than in degree, is symptomatically very great. The former is only known to exist by post mortem investigation, and is of importance practically to the medical jurist only; 4thly, in respect to diagnosis, there are two points demanding attentive consideration. The first is, that the base of the tumour never approaches nearer to the edges of the bone than from one to one line and a half, and never intrudes upon a suture or a fontanelle. The second, that the base of the well defined swelling is encircled by a hard ring. By attention to the former, and also to the facts that the tumour is non-pulsating, does not move during deep respiration, crying, or coughing, cannot be lessened by pressure, and that the want of bone is an illusory sensation, cephalaematoma is to be distinguished from hernia cerebri. The presence of the "ring" is constant in mature cephalæmatoma. Sometimes it is formed by the first day after birth, in other cases it is not complete in its whole circumference until several days after. It begins to be formed so soon as the periosteum ceases to be separated from the bone, in consequence of the increase of the circumferential swelling of the tumour being arrested. 5thly, Valleix is probably correct in the main as regards the nature of this "bony pad or cushion." It is due to ossification taking place in plasma-exudation, poured out by the periosteum in a state of irritation from the constant distention and pressure it suffers when it is separated from the bone by the extravasated fluid of the tumour. 6thly, as regards treatment it may be stated, that the latter may heal spontaneously, or inflammation or suppuration may ensue, or even caries of the underlying bone. Guided by the first fact, cold evaporating lotions may be applied to hasten the resorption of the extravasated blood. If in six or seven days no very marked diminution of it ensues, the hair is to be shaved from the whole surface of the swelling, and widely around its base; a puncture a quarter of an inch long is to be made by a lancet at a depending point of it, equable pressure to be applied by the fingers to expel as much of the contents as possible, and afterwards general pressure by a compress, the strapping and bandages to be maintained undisturbed for about six days. During this time attention must be directed to the patient and the tumour, so that the effects of the pressure, or the supervention of inflammation, &c., may be known.-P.H.B.]

2. ON SUPRACRANIAL CEPHALEMATOMA.

This species of cephalæmatoma comes under the history of bloody tumours of the cranium. The blood is situated beneath the aponeurosis and above the pericranium, as Bandelocque, MM. Velpeau and P. Dubois have established. It is composed of coagulated blood infiltrated into the cellular tissue, where it remains several days, and whence it usually disappears by absorption, as in the ecchymosis of adults. Thus situated, it has at least the advantage of never causing the disease as

or the destruction of the bone. It sometimes also constitutes a true effusion, en masse, above the pericranium.

According to P. Dubois, this bloody swelling is constantly the result of a difficult labour, especially when it is prolonged some time after the escape of the liquor amnii; it is also seated on the parts which first present themselves to the outlets of the pelvis; it does not fluctuate, it preserves the impression of the finger, the skin which covers it is of a violet tint; lastly, there is not around its base the osseous swelling which is observed in the cephalæmatoma, properly so called. Sometimes there is in the same subject a combination of this true cephalæmatoma and supercranial cephalæmatoma which adds much to the difficulty of the diagnosis.

When the effusion of blood is not very extensive, absorption causes it to disappear rapidly; if, on the contrary, it is very considerable, the sac may burst, inflame, and cause the death of the child.

The resolution of this species of cephalæmatoma should be assisted

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by cold and discutient applications, and in case suppuration takes bsorpti place, it should be opened early with a bistoury.

3. ON INTRACRANIAL CEPHALEMATOMA.

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This exceptional form of cephalæmatoma has been referred to by Hore, Baron, MM. Moreau, Padieu, Ducrest. The blood is collected between the bones of the cranium and the dura mater, under the form of a black, semi-coagulated mass, compressing one of the cerebral hemispheres, the cerebellum, or the upper part of a

the medulla.

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Convulsive and paralytic symptoms thence result, due to the compression of the encephalon; we may suspect the existence of this lesion, if it coincides with an epicranial cephalæmatoma, but it is userimpossible to diagnose it when it exists alone, for its symptoms are those of meningeal apoplexy and of some other cerebral diseases. The uncertainty of diagnosis is not so much to be regretted, for in

both cases the hæmorrhage is cured much more readily by the tute Se simple efforts of nature than by therapeutical means.

[Instances of this species of cephalæmatoma are sufficiently rare. Dr. Bednár

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states that only once has he seen the veins between the parietal bones and the dura mater gorged with blood and effusion between the latter on the left side; and Dr. Weber, in describing a case of the more common variety, says, "that in this instance also a cephalæmatoma internum was found, easily explainable by the inordinate distention and consequent rupture of the capillaries which connect the dura mater with the inner surface of the skull. I must here observe that I have had but rarely opportunity of seeing this, but where it occurred similar rupture of capillary vessels and effusion existed at other spots, namely above the orbit, between the dura mater and the skull. Although such may be of the same nature as the former, yet the yet the term of cephalæmatoma internum is scarcely applicable to it.”—P.H.B.]

4

CHAPTER V.

AMYELIA.

Absence of the spinal cord is described under the term of amyelia. It is a very uncommon vice of conformation, of which Morgagni and Ollivier have related some examples, and which always coincides with absence of the brain. It appears to be the result of a disease of the foetus, which in consequence leads to a more or less decided arrest of development. Children who present this deformity die immediately after birth.

In other children the spinal cord exists, but is incomplete or in some manner mutilated. It is divided into two distinct cords, and the medulla oblongata exists in a rudimentary state; these may live a little longer, but they soon die. The same is the case with those who present this longitudinal division of the cord combined with spina bifida, of which Billard has related an instance. Death follows soon after their birth.

[There is only one case on record of aneuria, or complete absence of brain, spinal cord, and nerves, in a monstrous fœtus. This is alluded to by Fabre as being recorded by Clarke in the Philosophical Transactions for 1793; but whether the case was really as represented may admit of doubt.

From the time of Morgagni, numerous instances have been given of amyelencephalia, or absence of the brain and spinal cord. Whether these are cases in which the development of the cerebral nervous matter has ever taken place, or whether it has, and this matter has afterwards become destroyed by increasing secretion of the cerebro-rachidian fluid, is at present undecided, but the latter is most probably the case. The acute remark of Fabre, that as yet no author has described the nonexistence of the spinal nervous centre in the embryo, but that all known examples refer to the foetus when seven, eight, or nine months old, seems to support the view, that the causes determining the absence or destruction of this organ are only developed at a period more or less distant from its first formation, and that, therefore, its absence is never primitive.

Complete absence of the brain, and of particular parts of it, and limited vices of conformation, are not unfrequently met with. M. Lawrence relates a case of a child, born without a brain, which lived four days.-(Med. Chir. Transact., vol. v.)

It is doubtful whether there is a sufficiently trustworthy example recorded of amyelia, or absence of the cord, the brain being present. Morgagni, copying Raygei, has given two such cases; but the opinion of one of the highest authorities in this matter, Ollivier, is, that the description of them is not complete or precise enough to warrant their acceptation.

Illustrations of atelomyelia or imperfect conformation of the spinal centre are by no means wanting; generally speaking, absence of any portion of the encephalon is accompanied with that of the walls of the cranium, and when both are extreme, they constitute a case of acephalia, or headless condition.

In amyelencephalia, separation of the parts of the vertebræ, either through the whole length of the spine, or in parts of it, always occurs-but not constantly with protrusion of a membranous sac, as in spina bifida. It has been affirmed that when the brain and spinal cord are both absent, neither cranial cavity nor spinal canal can exist: this assertion is opposed by Fabre, and is entirely unsupported.-P.H.B.]

CHAPTER VI.

ON HYDRORACHIS OR SPINA BIFIDA.

Hydrorachis, or spina bifida, is a vice of conformation characterized by the existence, at the posterior part of the spine, of a cleft in the bones, whence the coverings of the cord, sometimes a part of the cord itself, and always a greater or less quantity of serum, protrude. Thence one or two tumours containing liquid, situated along the vertebral column, result. Usually there is only one of them, and it is situated in the lumbar region. Bidloo, Valsalva, Hoin, have seen examples which occupied the whole length of the vertebral column; and Dubourg has seen one which descended in the form of a calabash as low as the heels.

Hydrorachis is a congenital disease, the causes of which are entirely unknown. Camper has observed it in twins. It has been referred to external violence received during pregnancy, to a vicious position of the embryo, to the accumulation of the cranial serosity, which prevents the reunion of the vertebræ, &c. It is very frequent, and, according ne to Chaussier, it has been met with twenty-two times in 22,293 children

born or left at the Maternité, that is to say, in the proportion of one // case of spina bifida in one thousand births.

Hydrorachis is observed under the form of a tumour of variable size, wide or narrowed at the base, and pedicellate or bilobate. It is rounded, soft, opaque, sometimes transparent, and without any change in the colour of the skin. It is fluctuating, and compression reduces its size very much, by causing the return of the serum it contains. If there are several tumours, fluctuation is readily transmitted from one to the other, and what one loses in size is compensated for by the

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increase of the adjoining tumour. Pressure by the hand causes crying, sometimes convulsions, and discovers the cleft spine, the lamina of which are turned outwards. It also detects more or less decided movements of expansion, which correspond to expiration, and a movement of depression, which coincides with inspiration.

[The different degrees of spina bifida have been grouped into three classes by Fleischmann and others.

1. When the entire vertebra is divided; this is exceedingly rare. Ollivier recites three cases, related by Tulpius, Malacarne, and Zuringer, in which it existed. 2. Absence of a greater or less portion of the lateral arches of the canal; this is the most common variety.

3. When the arches are well developed, but without union posteriorly; here, however, the separation can be but a few lines, resembling a groove rather than an aperture. Ruysch, Aerell, and Isenflamm have each described a case of this kind, the former in the lumbar region, the second in the sacrum, and the latter in the first cervical vertebra.

The absence of the spinous process does not necessarily imply a communication with the interior of the cord. Béclard has found them absent several times as s simple malformation, the bodies preserving their integrity.

Fisher (London and Edinburgh Philosophical Magazine and Journal of Science, vol. x, p. 316) found, in two cases, a union of two or more sacral ganglions, the passage of their respective nerves through the sheath in one bundle, and the union of the end of the spinal marrow with the walls of the sac.

Hewett observes (Cases of Spina Bifida, with Remarks, London Medical Gazette, vol. xxxiv, 1844), in regard to spina bifida: "The connection which generally exists between the cord or the nerves and the walls of the sac is a point of the utmost importance. Some cases are related, by various authors, in which neither the cord nor the nerves had any connection with the sac; these parts followed their usual course down the spinal canal, but in by far the greater number of cases that have been placed upon record the nerves presented some kind of connection with the sac. Of twenty preparations of spina bifida occupying the lumbo-sacral region, which I have examined in various collections, I have found but one in which the nerves were not connected with the sac. If the tumour corresponds to the two or three upper lumbar vertebræ only, the cord itself rarely deviates from its course, and the posterior spinal nerves are generally the only branches which have any connection with the sac. But if the tumour occupies partly the lumbar and partly the sacral region, then generally the cord itself and its nerves will be found intimately connected with the sac. M. Cruveilhier believes, from his dissections, that this

connection is constant."

This is well illustrated by the case of a patient, five months old, who died under Mr. Tatum's care. The cavity of the tumour was intersected by the cord and by the nerves emanating from it. The cord and its nerves, passing out of the spinal canal at the upper part of the opening, run across the cavity of the tumour to its posterior wall, where they are firmly fixed, the nerves being here flattened and spread out upon a fine membrane. From the sac, the anterior branches of the first four sacral nerves return in distinct bundles, forming large loops, to the anterior sacral foramina, through which they pass as usual to form the sacral plexuses. The fluid had evidently been effused between the visceral arachnoid and pia mater; and the walls of the sac were formed by the visceral and parietal arachnoid and by the skin, all of which were much thickened and firmly united to each other.

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