been cut off, its exterior was found to consist merely of a layer of coagulated blood, the rest of the mass was brain, possessing a natural appearance, the distinction between the cortical and medullary matter being readily seen, with the convolutions and pia mater dipping down between them. During the remainder of the day on which the operation had been performed, the boy was upon the whole more tranquil. For the next two days he remained much in the same state, but on the third, he became worse; was completely insensible; had strabismus and a remarkable quickness of pulse. On the following morning he died.

Examination.

On removing the dressings from the scalp, the brain was seen to have protruded in a slight degree through the opening in the skull. A cake of blood was found, of about the size and thickness of a dollar, between the bone and the dura mater, near to the seat of the injury. All that part of the dura mater adjacent to the ulcerated aperture through which the brain had protruded was black, sloughy, and much thickened. The exposed surface of the brain from which the portion had been cut off, exhibited a softened and broken down texture; a state of disorganization which extended deep into its substance. About an ounce of foetid and darkcoloured fluid was found between the dura mater and arachnoid membrane. Several small effusions

of blood were met with both between the membranes, and in the substance of the brain. The arachnoid membrane was thickened and opaque over each hemisphere. The vessels on the surface and in the substance of the brain were remarkably free from blood. The lateral ventricles were large and filled with transparent fluid, and there was some found between the membranes at the basis, so that altogether, the quantity of fluid when collected from these two sources was very considerable. The fracture had extended directly through the basis to the foramen magnum. The thoracic and abdominal viscera were all healthy.

It is only necessary here to remark that the unfavourable termination of this case is sufficiently accounted for by the generally diseased condition both of the membranes, and substance of the brain. Whether these effects commenced immediately after the accident, or were the consequence of the injury offered to the brain by the removal of the protruded portion, and by the subsequent compression, will perhaps be regarded as doubtful. We may however observe that no increase of irritation succeeded immediately to the removal of the protrų, sion, and that up to the period when the protrusion appeared, the case was going on in every respect favourably. It is therefore probable, that this was the time when the diseased changes in the brain and membranes had their commencement.

VOL. VIII.

11

CASE II.

The second case occurred also in a boy aged about years, who was brought to the hospital on Friday, September 3rd, 1813, having fallen from a two pair of stairs window. On examination of his head, a fracture was discovered in the upper and middle part of the frontal bone, a portion of which about two inches in length, and one in breadth, was completely insulated and broken into several fragments, which were driven inwards beneath the adjacent bone. In order to elevate the depressed bone, it was necessary to apply the trephine and to make use of Mr. Hey's saw. The fragments being raised, were wholly removed; and it is right to remark, that here, as in the former case, the dura mater was uninjured. The edges of the scalp were approximated as closely as possible by adhesive plaster, and a bandage was bound lightly over the wound. It may also be mentioned, that the jaw was broken near the symphysis, and both bones of the fore-arm were fractured near the wrist. Under this complication of injury, we had but little hopes of the boy's recovery. Without entering into any tedious account of the symptoms that successively appeared, it will be sufficient to state, that on the first and second day, there was little more than ge、 neral restlessness, and on the third, pain in the head and delirium. Under these circumstances he was bled largely, and copious evacuations were pro

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cured from the bowels. From the use of these measures, on the fourth and fifth days, the unfavourable symptoms gradually retired, and on the sixth day every thing seemed to be going on well: the wound was healthy, and his general health rapidly recovering. On the seventh day there was no alteration in the symptoms, but on dressing the wound, there was seen projecting through the aperture in the skull, a soft substance about the size of a hazel nut, and in its appearance resembling coagulated blood. When pressure was made upon the protrusion no pain was produced, nor was the sensibility of the boy affected. The nature of the protruding tumor was doubtful. In its external appearance it resembled coagulated blood, but from the recollection of the former case, we were inclined to view it as a protrusion of the brain, with blood effused and coagulated upon its surface. By examining the base of the tumor, we could ascertain that it had passed through an opening in the dura mater, and we also noticed around its circumference the appearance of a membrane with its edges ragged and torn, which we were inclined to believe was the remains of the ulcerated pia mater and arachnoid membrane. I this day simply applied a dossil of lint upon the swelling, and made a moderately firm pressure upon it. On the next day no unfavourable symptom had arisen, and the general health of the boy was rapidly recovering. On dressing the wound it was seen that the pressure which had been made upon the protrusion

having prevented its increase in height, it had extended laterally, so that altogether it was about twice as large as on the previous day. With the impression that the tumor was formed by protruded brain, I pared off its upper part, and on examination of the portion removed, its exterior was found to be merely coagulated blood; but beneath this, it consisted decidedly both of cortical and medullary substance. The wound was dressed as before, care being taken to make firm pressure by plaster and bandage During the next two days the same plan was continued; the boy's health still remained undisturbed, but the protrusion was evidently increasing. Since it now appeared that pressure alone was inadequate to restrain the protrusion, I this day removed the whole mass down to the level of the skull. The portion cut off consisted wholly of medullary substance. Just at the time when the scalpel was passing through the tumor, the boy complained of pain, which however immediately ceased. The cut surface of the brain bled freely from numerous vessels of large size. By graduated compresses and bandage, very firm pressure was again made upon the wound. During the next three days the boy did not complain, the pressure being still applied as firmly as possible. Although the tumor still rose in a trifling degree, it had by no means increased in the same ratio as before the removal of the former protrusion, and the use of firmer pressure. On dressing the wound the next day, we observed that the disposition to protrusion