not even the dura was injured. Many died of shock a few hours after the operation.3 The final report as to their mental and general condition was as follows: No history obtained, 1; uncertain, 1; no improvement, 7; slight improvement, 7; "some," 1; much improvement, 2. Permit a few more words as to the results of the operation.

Dr. Vander Veer, of Albany, N. Y., reported the case of a girl two years of age. Forceps operation of four hours' duration resulted in extensive lesion of the scalp. Never developed mentally; had as many as twenty-five convulsions daily, with and without vomiting, after the age of three months. Operation October 14, 1893, on the left side of cranium, four and one-half inches long, extending to nearly the lambdoid suture, and one inch wide. Left hospital October 30th. Seventeen short days after that, November 15th, the family physician reports that since November 8th the child did not sleep well, and had returns of the nervous spells or partial convulsions; but before that, ten days after leaving the hospital, the child seemed brighter and took more notice of things. around her.

The following case was also reported by Dr. Vander Veer:

Arthur McKee F -, born May 22, 1891. Previous to his birth a miscarriage at six weeks and a still-birth. Mother had albuminuria every time (syphilis?). Teething at nine months. Then the fontanelle was noticed to have closed. Examined July 1, 1892. No vision, eyes roll, head not sustained, body well developed. Convulsions frequent. Operation October 6, 1892, on left side from frontal to occipital bones, four inches long, one wide. November 2d appeared "more natural." Second operation May 19, 1893, on the right side. Examination

According to Ackerman the causes of death after the performance of the operation, and depending thereon, were acute sepsis, loss of cerebro-spinal liquor, shock, collapse, fever, acute anæmia, and the anaesthetic employed during the operation. Altogether the deaths amounted to from fifteen to twenty per cent. of all the operations collected and discussed.

of the left side of the skull at this time did not give evidence of any great development of the brain, as there was rather a tendency for the dura to sink in than to rise above the surrounding portions of bone. November, 1893, more quiet, does not see, recognizes sound, moves arms and legs, and stands when supported.

Dr. John E. Wyeth reports a case which appears to be one of premature ossification with cerebral complications, though there be no exact measurements. The fontanelles are said to have closed when the child was four weeks old. The operation was performed when the child was eleven months old. January 7, 1891, two long trenches were dug from above the eyes to occipital borres, and joined posteriorly, the bone torn off from the dura and elevated so as to produce a fracture anteriorly. On September, 1893, a 'triumphant letter" was received from the mother. On January 31, 1894, however, she writes that the child was now four years of age, but two or more behind in mind. It may be remembered that this is three years after the operation.

Léon Gallez says, in his "La Tréparation du Crâne," p. 417, 1893, of craniotomy that elle procure le plus souvent une amélioration évidente. That is an over-estimation. Personal knowledge of the facts he does not claim. Firstly, the mortality of the operations is very great. Secondly, a large number of cases are admitted not to have been benefited at all. Thirdly, when amelioration has been reported, what does it mostly amount to? It would be absurd, theoretically speaking, to deny the power of observation or the veracity of those who report; but who are they in most instances? In the majority of cases they are loving, hoping mothers. Who has not seen to what extent the idiotic child in a family-frequently the first born-is petted, made most of, admired, and how every ray of mental light is reflected from a magnifying mirror of adoring and anxious scrutiny. Besides, many of the reports are made soon after the operation, and therefore become rather valueless. Moreover, after the performance of that serious operation, made for a special purpose, attention and training are doubled; and progress

attained through assiduous training was never questioned even before the times of Edward Seguin. Finally, a difference of from one-half to two years amounts to a great deal in a child of one or two years of age, in the possibility of mental improvement.

A temporary relief, either entire or partial, of epilepsy, does not mean much, for any operation on any part of the body is apt to modify its course.

Altogether, the mortality and the insufficient results in those who survive have exerted a discouraging influence on my surgical friends. What here follows are the opinions of some of them as they were expressed but a short time ago.

In a letter dated June, 1892, when he had operated on twelve cases, Dr. Keen makes the following statement: "I would at present operate on cases under eight years of age, but not over, and in cases with sufficient physical vigor to make recovery probable. I would only operate on one side at a time, but make the incision as long as possible, from the forehead to the occipital bone, and possibly, or even probably, T-shaped by a vertical incision toward the ear. My results have been those of improvement in almost all the cases that survived; an improvement makes the operation worth doing. But do not promise too much intellectually or even physically." In a letter I received from the doctor lately (1894) he says: "The mortality is very high, and in my experience the gain is moderate, but possibly worth the risk."

Dr. Wyeth formulated his experience for me on February 22, 1894, as follows: "My operations were eight.5 There were three deaths, one dying of hemorrhage on the table, two of shock, of whom one after twelve hours, and one with temperatures of 104° and 105° F., on the fourth day. There are two varieties of microcephalus, one due to premature ossification and consequent compression; and one due intrinsically to deficient brain development. These can be made out by incision through scalp, when 4 Journal of the Arkansas Medical Society, October, 1893. 5 The histories Dr. Wyeth was so good as to place at my disposal, refer to eight cases, with nine operations.

the white cartilage lines can be seen in the intercranial sutures. Operation is useless in these cases, unless cyst or tumor be present. In the other cases, temporary improvement at least can be expected." In a letter published in the Journal of the Arkansas Medical Society, October, 1893, he says: "The operation is so dangerous that I shall hereafter undertake it only in cases of very marked microcephalus with undoubted symptoms of compression."

66

In reference to these operations Dr. B. Sachs says he has not advised them since 1891. He regards the danger "extremely great in all young children, the shock and uncontrollable hemorrhage from the scalp and bone being greater than most children are able to stand." And Dr. Arpad Gerster, who performed the operations for Dr. Sachs, expresses himself as follows: The operation of linear craniotomy is a very serious one in small children, on account of the unavoidable hemorrhage accompanying it. Yet, in view of the otherwise hopeless outlook, I am still willing to undertake it in well-nourished individuals, at the direct request of their parents. As our diagnosis is very unsatisfactory as to the condition of the brain in microcephalus, the operation is often the only test of the presence or absence of cerebral structures which, if present, might develop, if the confinement due to premature ossification of sutures be believed by craniotomy. On the whole, my standpoint as regards the future of the operation, is not a very cheerful one." Finally, Dr. McBurney is only willing to perform the operation on the responsibility of a medical man in whose judgment and knowledge he has absolute confidence.

Lastly, and unfortunately, what is the result of the operation in reference to the intended enlargement of the cranial cavity? In a letter dated March 11. 1894, Dr. Vander Veer says: "Both Dr. Hun and myself have the impression that the skull has not expanded, but that there is some reason for believing that the resulting cicatrix in the scalp and membranes has caused a diminution rather than an enlargement of the brain." Bourneville finds a narrowing of its interior by thick fibrous bands encroaching upon it in a case the drawing of which he publishes,