face covered now therefore with torn capillaries) is in contact with extravasated blood operating almost like a foreign body, which will in the meanwhile change from its bland quality, it cannot appear surprising "That the bone itself at length suffers, perishes at its surface, if only in the form of thin plates, and that then nature, as in analogous cases, undertakes a trial at reparation. In this way is the bony peripheral ring to be explained. It is a line of demarcation on the cranial bone, similar to what is observed in largely exposed surfaces of the cranium followed by exfoliation." (p. 20.) "In such cases, the pericranium also becomes thickened and hardened by pathological exudations at the periphery of the tumour, and increases the sensation of a circumferential boundary on external examination." (p. 21.) Dr. Weber next alludes to "contusion of the cranial integuments," arising from a large head being forced through a narrow pelvis having a greatly projecting promontory, or from unfavourable position of the forceps. We shall not dwell upon this subject, but pass on to " alterations of the bones of the cranium." Our attention is first directed by the author to flattening of the parietal bone "without fracture or flaw of it," produced in most cases by pressure of the promontory in prolonged labours and forceps cases. Examples of the above have frequently come before his notice, and he discusses at some length the general and important influences which pressure on, and alteration of, the symmetry of the skull, have upon the brain and intellectual element. Without denying that the development of the brain has a great influence upon the development and form of the skull, Dr. Weber believes it" to be undeniable that deviations of the form of the latter produced adventitiously are often prejudicial to the development of individual portions of the cerebrum, and that the act of parturition is by no means rarely such an adventitious cause." (p. 23.) "Deviations of the form of the cranium will be found, on careful examination, to be far more frequent than is supposed; and if flattening even of the frontal bone is noticed only after a lengthened period, or not at all, by the parents, far less likely is it that flattening of the parietal with its hairy covering will force itself upon their attention. Through the kindness of Professor Jessen, of Hornheim, I have had frequent opportunity of examining the bodies of persons who had been insane, and have arrived at the conclusion, that this condition of the skull -namely, inequality of form of both sides at the frontal and parietal bones, is of very frequent occurrence amongst insane people. The flattening is, as a rule, accompanied by thickening of the dura mater and firm adhesion of it to the inner surface of the skull parallel with the flattening on the same side a circumstance from which I conclude, that the state of the bones and of the dura mater is primitive and causative, that of the psychical element being on the other hand consecutive in its character." (p. 24) Overlapping of the parietal bones" and "projection of the occipital bone," are often accompanied by a caput succedaneum. The head has then a very remarkable and elongated appearance, which has caused the term "sausage-form" to be applied to it in Germany. A few days after birth, the cranium acquires a more natural condition, progressively improving as absorption of the serous effusion and expansion of the brain ensue. In some cases, however, the parietal bones do not regain a proper and equal position, and the consequence is, that the occipital suffers permanent projec tion outwards and backwards, giving to the head a peculiar character for life. "In all crania in which the occipital bone greatly projects, the lambdoid suture contains more or fewer of the so-called Wormian bones. Their presence proves, that during that period of life in which the bones of the cranium are specially developed-as soon after birth-a considerable space has existed between the occipital and parietal bones. Where the Wor mian bones occur along with a greatly projecting occiput, it is not improbable that such a projection of the occipital bone has its origin in the persistency of a deformity taking place during birth." (p. 28.) Dr. Weber, in concluding his remarks upon "Obliquity of the Skull," thus sums up: "The conclusion is substantiated, that obliquity of the skull has for its cause, in almost all cases, hindrance to the mechanism of labour from an abnormal state of the pelvis. The more frequent deformities having this origin are the following: "A frontal bone appears flattened, because it is pushed backwards and beneath the other half. "A whole half of the cranium appears flattened, because it is pushed somewhat back, and as if its frontal and parietal bones were driven beneath the bones of the other half." (p. 30.) Dr. Bednar touches but slightly on the above points, in the body of his work, but gives a valuable appendix of ten tables of measurements, &c. The first seven tables include the following measurements of 119 boys and 112 girls from 3 days to 8 years and 4 months old--namely, of the greatest periphery of the head, from ear to ear; from the occipital protuberance to the root of the nose; of the transverse and long diameters of the head; of the length of the body, and of the circumference of the thorax. The eighth table contains like measurements of 8 children presenting abnormal conditions of the cranial bones, of the brain, or of its membranes. The ninth, of 6 children having congenital hydrocephalus; and the tenth, of 8 children having chronic hydrocephalus, not congenital, but acquired. The author has been led to these inquiries, from his belief that an account of the circumference and diameter of the head, in relation to the circumference of the chest and length of the body, would be of more avail in those diseases of the brain and its membranes, which are consequent upon the increase of growth and changes of form of the skull, than an account of the weight of the cerebral mass, as the former may be of use in relation to diagnosis during the life of the child. Dr. Bednar considers his tables of measurements as yet too incomplete to admit of safe generalization from them; but trusts to perfect them for this purpose by a future time. We can confirm from experience the following remarks by Dr. Weber on the "Strength of the Skull." "Though it may be the rule, that the development and strength of the cranial bones progress pari passu with the development of the rest of the body, so that large children have also large heads and strong cranial bones, yet such is by no means always the case. very forcibly struck me, that little delicate children, with small heads, have thick strong bones It has sometimes over a large extent of the cranium, and conversely, that in large, powerfully developed ones, with large heads, the bones of the skull are thin and easily cut through by the scissors. I have observed this so often as to forbid its being considered as exceptional. I am unable to offer a satisfactory explanation of it. Probably the osseous system of the mother, as also the qualitative conditions of her blood, have here some influence. But it will be asked-why, then, do weak, delicate mothers bear, not rarely, large, well-nourished children ?” (p. 31.) The frontal and parietal bones are the only ones which Dr. Weber has seen fissured and fractured by the act of parturition. According to the greater or less extent of the fracture, and particularly the distance of separation between the edges of the injured bone, so is the amount of injury to the vessels of the locality of the fracture. Rupture of small ones always occurs, as is proved by the most delicate fissure being indicated by a red streak. The periosteum is generally elevated by extravasated blood, and there are marks of sugillation from effusion into the cellular tissue of the scalp. In these cases, internal cephalhæmatoma may occur. alluded to must be distinguished from those which follow rupture of the longitudinal But the extravasations here sinus and of the larger cerebral veins. It is true that both forms may be present, but, according to Dr. Weber, the latter are not the consequences of the fracture, but rather of the same cause which gave rise to the fracture-namely, "a too violent forcing of the bones over each other. Bednar, besides referring to the fissures and fractures, dwelt on at some length by the former writer, remarks, that "In the cranial bones of new-born children, chinks are sometimes observed running from the surface for several lines deep into the bone, generally in a somewhat oblique direction. Their origin we cannot explain, as, from the yielding character of the bone, we are unable to produce them in the corpse by stroke or pressure." (p. 173.) The same writer also states, that the cranial bones of children affected with congenital syphilis are more porous and brittle than in the healthy child. Once only has Dr. Weber met with "a large, so-called false fontanelle;" it was situated in the centre of the sagittal suture, both parietal bones forming portions of its boundaries. Alluding to "membranous gaps," not interstitial, Bednár observes, "These are most frequently met with in the parietal bones, rarely in the occipital; they are found in greater or less number, and when of rather large size may be distinguished through the scalp by the application of the finger. They indicate incomplete ossification of the skull, especially of the parietal bones, whose membranous basis becomes converted into bone, without the previous formation of cartilaginous matter. Well-developed children, and weak and premature ones, are born in the above condition. It has no further signification, being removed as progressive ossification of the skull ensues." (p. 169.) Increase of size of the true fontanelles, and the occurrence of large interstitial spaces between the bones, are noticed by Dr. Bednàr; as also premature closure of the sutures. In consequence of excessive ossification, a wall of bony matter is sometimes formed, which projects for one or two lines above the course of the suture, and may easily be felt through the coverings of the cranium. Such premature ossification, besides influencing materially the form and development of the skull, forms a hindrance to the development of the brain. To proceed to Dr. Weber: "One of the most frequent appearances connected with the cranial bones of new-born children, especially as regards the parietal, the upper portion of the frontal, and the occipital bones, is, that these bones are deeper coloured from capillary injection than in the normal state, indeed, not unfrequently having a dark red-blue colour. This may be present to a high degree without there being actual rupture of capillary vessels.” (p. 32.) "I do not ascribe, in every case, this congested condition of the cranial bones to the pressure which the head experiences on its larger periphery; for many, and especially juridical, dissections (in a word, those where, the pelvic relations being normal, death had ensued after respiration was established), have taught me that a congestive condition of the cranial bones may be seen in children suffocated sometimes under the bed-clothes. Nevertheless, I must expressly state, that in the latter instances I have never witnessed the intenser grades of such condition, even when other evidences of suffocation were plainly existing. These are only to be seen when the head has been subjected to strong pressure." (p. 33.) We proceed to the meninges. Blood may be effused on the surface of the brain between the dura mater and the arachnoid, from rupture of the superior longitudinal or transverse sinuses, and, it is probable, from that of the veins leading to these sinuses. In a case in which the longitudinal sinus was ruptured, the author found the brain external to the arachnoid, "inundated" with half-coagulated, half-fluid blood. It had even passed to the base, forcing its way beneath the tentorium, and encircled the cerebellum. Sanguinolent effusion may likewise take place from the bleeding of capillary vessels; but observation seems to show that this is the least frequent of all sources of extravasation on the brain. "Occasionally new-born children live for some time with more or less complete paralysis of one half of the face, or they may entirely recover from it. The cause of it is an extravasation of blood, which, as dissections teach me, is situated between the arachnoid and the dura mater.” (p. 35.) 66 Many of the hæmorrhages on the surface of the brain of new-born children which do not terminate in death, are, I am persuaded, frequent causes of their continued delicacy of health. The death of neonati in convulsions is also in many cases due to such extravasations." 66 'We are sometimes surprised that in infants who are born with strong pulsating cord and heart, respiration cannot be established in spite of every exertion, the pulsation becoming weaker and weaker until they die. Whoever examines their bodies after death will find in the majority of cases such post-mortem appearances as I have already described, and as I shall further allude to when speaking of the vascular system of the spinal marrow." (p. 36.) Children are now and then born with facial hemiplegia, which, as Dr. West has remarked, is quite independent of any injury to the brain, but "As the result of injury to the nerve from application of the midwifery forceps, or, as has in one or two cases been observed, from injury received during the passage of the head through the pelvis, without any instruments having been employed.. In the only case of the kind which has come under my own observation, the distortion of the face, though very great at birth -one eye being wide open, and the corresponding side of the face powerless, so that the child was unable to suck-had already greatly diminished within forty-eight hours, and had quite disappeared within a week." (p. 152.) Dr. Weber has frequently met with blood effused between the fibrous layers of the dura mater. Its usual position is between the lamellæ of the tentorium, near to the place of junction of the longitudinal and transverse sinuses, and, less frequently and in less quantity, between the fibrous layers of the larger falx near the longitudinal sinus. Considering the dark venous character of the blood, &c., it is probable that it is poured out by the neighbouring sinuses. Dr. Weber gives another theory of its origin, which he thinks admits of something being said in its favour, though yet in great want of accurate observation for its basis. This theory, so far as we understand it, is, that the so-called extravasation is really no extravasation at all, but the natural sanguinolent contents of small supernumerary sinuses. The author makes some interesting remarks upon increased size or width, particularly of the larger sinus. Such increase he regards as not being without influence on the continuance of the life of the child, and as demanding, as much as possible, avoidance of all artificial pressure on the head. The normal character of the "contents of the sinus" should be borne in mind when making examinations for judicial purposes. The arachnoid and pia mater are, when healthy, perfectly transparent in the neonatus; on the other hand, in advanced age, and in the proximity of the Pacchionian bodies, they frequently appear somewhat opaque, and this without any disease having previously existed. Therefore "Every departure from the normal transparency and colour in new-born children is to be regarded as the consequence of a pathological process. I need scarcely here allude to the yellowish colour which is always present in the meninges, and in the serous humidity sometimes found beneath the arachnoid in the so frequently occurring jaundice of children. "Another and more important colouration, especially of the highly-vascular pia mater, is that which is produced by a congestive state of the latter, and which is so frequently seen. I have long since passed that period, when one discovers congestion of the cerebral vessels every time one opens a skull. A true congestive condition of a high degree is here alluded to, and it is this which not uncommonly gives to the whole cerebral surface of neonati a deep red colour (as if from saturation), by means of the extremely fine injected capillaries. That it is connected with a pathological process, the exudation which is present sufficiently proves." (p. 42.) This capillary injection is sometimes so intense as to produce a dark red colour, and yet no rupture of vessels can be found. The exudation accompanying it is seen under two chief forms, between which exist many transitional varieties. In the first, it is found in considerable quantity (ad 3i.) beneath the arachnoid, is quite clear, transparent, and watery, or analogous to what is met with in certain kinds of caput succedaneum. The second is observed when the pia mater is paler in hue, and, so far as its colour is concerned, has very great resemblance to pus. On closer inspection it looks like a half-coagulated croupose deposit, which may be taken up in large pieces. by the forceps. According to Dr. Bednar, effusion of blood into the sac of the arachnoid, both on the hemispheres and at the base of the brain, is now and then found in new-born children. As there is often no other affection of the nervous centres to be seen, such extravasation must be regarded as resulting from the rupture of delicate vessels during parturition. (p. 28.) We proceed with Dr. Weber to the "colour and consistency" of the cerebral substance. (p. 43.) "General humidity of the brain of new-born children is one of the most frequent appearances met with, and is almost always found where the whole vascular apparatus without and within the cranial cavity indicates, partly from extravasation which has ensued, partly from great injection of the capillaries, a highly congestive condition. . Individual cases frequently occur, where, notwithstanding the existence of the latter, the brain is relatively dry, or, at most, only normally humid." (p. 45) Dr. Weber thinks it not unlikely that in the latter instances, the sudden and severe determination of blood to the brain rapidly produced such a state of apoplexy, as to cause the death of the child before there was time for serous effusion to ensue. Amongst the causes of "oedema of the brain," Dr. Bednar refers to protracted facepresentations, which are often accompanied by hæmorrhage into the substance of the brain. The colour of the brain varies very much according to the amount of blood in the capillaries; transitions from the lightest pale red to a bright red tint may be seen. Occasionally, where the capillary injection is but slight, the humidity above spoken of is greatest. True capillary apoplexy, so far as post-mortem evidences can show, is, according to Dr. Weber, rare in the new-born child; whilst Dr. Bednar remarks "Cerebral hemorrhage consists in the extravasation of blood into the substance of the brain. It is found in new-born children most frequently in the form of capillary apoplexy, by which the substance of the medullary or cineritious matter is coloured red from punctiform and streak-like extravasations, the intermediate cerebral substance being of a normal colour, or reddened and of soft consistency." (p. 36.) The author appears to have in view children who survive the birth for some days or even longer, as he afterwards refers to gangrene of the navel as a complication of the cerebral hemorrhage when the sanguinolent clot is of rather a large size. (p. 37.) Anæmia of the brain in children a few days old is mentioned by Dr. Bednar, hæmorrhage from the umbilical arteries being one of its causes. (p. 41.) To return to Dr. Weber: "In relation to the abnormal consistency of the brain of the child, I have yet to make mention of a condition I have but once observed. This was decided sclerosis of the greater part of one hemisphere." "The right hemisphere was felt to be of a cartilaginous hardness; the left, of normal consistency. On section, the former cut like soft cartilage, the left not so. For comparison, both hemispheres were elevated to the same level. The left showed normal grey and white substance; the right, cartilaginous, hard, grey matter, bordering upon a light brown hue. At a greater depth the medullary substance was less hard, whilst the outer grey portion was so indurated as to give the former the character of being surrounded by a cartilaginous edge. On still further section, sometimes the grey, sometimes the white matter appeared hardest. Where the brain was of normal consistency, as in the left hemisphere, the capillaries were fully injected, while the whole of the sclerotic portion was in a state of complete anæmia. Further, the corpus striatum and the posterior portion of the thalamus on the right side were indurated, while the same parts on the left were healthy. The ventricles contained some amount of fluid tinged with blood." (p. 47.) The child had strong convulsions the first week after birth, but lived until it was six months old. Alterations of the colour of the ventricular plexus, of the septum lucidum, of the contents of the ventricles, and the occurrence of hydatids in the brain, are next touched upon by Dr. Weber. Upon these points we shall not dwell, but pass on to chronic hydrocephalus. On reference to the works of Rilliet, Fabre, West, &c., and to our article in the 6th volume of this Review (p. 140), the reader will find fitting introduction or commentary to the somewhat curt observations of our author on this malady. But from these we shall take the following extract, as it touches upon the litigated question, as to what is in most cases the origin of congenital internal hydrocephalus. "There prevails up to the present moment, as Hyrtl, in his Manual of Anatomy,' avows, much obscurity concerning the anatomical relations of the meningeal membranes in the interior of the brain. I am of opinion, that where we are deprived of the possibility of investigation in the healthy brain, pathological conditions are often of especial service in clearing up the difficulty. If the dissections which I have had opportunity of making, in connexion with chronic hydrocephalus, had not been prosecuted at a time when I was less mindful of the prevailing doubts of the anatomical relations of the arachnoid in the ventricles, they would have offered me the means at least of more facile inquiry. This much I can affirm with precision, that concerning the entire investment of the cerebral ventricles by the pia mater, there cannot any longer be the slightest doubt, when the pathological relations of this membrane to the walls of the ventricles have been observed. The pia mater (and the arachnoid also must be here included) in chronic hydrocephalus is morbidly changed to such a degree, that it clothes the cerebral ventricles as a thick, firm, opaque, scarcely tearable membrane. It is, undoubtedly, this serous membrane which is the originally diseased structure, producing the extensive effusion of serum, and |