from escaping from the fourth ventricle into the subarachnoid cavity, by a firm, reddish membrane, which formed a cul-de-sac below the inferior angle of the ventricle.

The spinal cord may either present congenital deficiencies, or malformations, or more or less traces of disease. The substance of the cord has been found entirely wanting, the membranes alone remaining; forming sometimes a closed sac, filled with a fluid. It may be diminished in size, divided into two parts, or expanded into a membrane. It is often, according to Ollivier, preternaturally long. The spinal nerves have been seen floating in the fluid of the tumor. They have been found, also, distributed on the inside of the tumor, forming, occasionally, a kind of nervous network. More commonly, however, the substance of the cord is softened, like the walls of the cerebral ventricles in hydrocephalus. Very generally, traces of meningitis of the spine exist, often extending even to the brain. Fischer (London and Edinburgh Philosoph. Mag., vol. x.), in two cases, observed a union of two or more sacral ganglions, their respective nerves passing through the sheath in one bundle, the termination of the spinal cord being united with the walls of the sac.

Hewett (London Med. Gaz., 1844) refers to cases on record, in which neither the cord nor the nerves had any connection with the sac; these parts following their usual course down the spinal canal. In far the greater number of cases that have been published, some kind of connection between the nerves and the sac was observed. Of twenty preparations of spina bifida, occupying the lumbo-sacral region, examined by Mr. Hewett in various collections, he found but one in which such connection did not exist. If the tumor 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. when the tumor occupies partly the lumbar and partly the sacral regions, both the cord itself and its nerves will be found intimately connected with the sac. Cruveilhier believes, from the dissections made by him, that this connection is constant.

But

When the cord and its nerves pass through the cavity of the sac, it is probable, Mr. Hewett thinks, that the fluid was originally effused into the subarachnoidal tissue, after extensive adhesions had united the cord and its nerves to the two layers of arachnoid membrane covering its posterior surface; whereas, when the liquid is effused into the cavity of the arachnoid, before adhesions take place between the two layers of the membrane, he believes that no nerves will be connected with the sac.

In regard to the pathology of hydro-rachis, numerous discordant opinions have been entertained. The disease is evidently a true congenital dropsy, either of the spine, or of the spine and brain; the deficiency in the vertebræ, as well as the external tumor, being the result of the accumulation and pressure of the fluid within the cavities of the cranium and spine.

When the tumor in the spine is not formed, the child usually perishes soon after birth, with symptoms of hydrocephalus; or tumors,

in some instances, form upon the head, in all respects similar to those of spina bifida, the fluid protruding the dura mater and a layer of the arachnoid membrane, through an opening in one of the bones of the cranium. Dropsy of the spine, with the formation of an external tumor, has succeeded to hydrocephalus, produced by contusion of the head; or has resulted from disease of the spinal cord.

In regard to treatment. It would appear, from a careful examination of all the facts upon record, and from the result of few cases which have fallen upon our own notice, that, when the tumor is small, and more especially when it is covered with the common integuments in a sound state, and the infant, as is generally the case, suffers little or no inconvenience, the most prudent course is to let it alone, merely guarding the tumor from accidental pressure, and from every source of irritation. So long as the tumor remains closed, there is, comparatively, little danger, but soon after it becomes opened, meningeal inflammation, with all its train of fearful consequences, soon sets in, and quickly destroys the child. The opening of the tumor is always, therefore, to be considered a most unfortunate circumstance. Hence, if the infant be born with an ulcerated tumor, but incompletely perforated, it ought not to be opened and its contents discharged. It is true that the operation first practised by Ruysch, and revived by Abernethy, of puncturing the tumor with a fine needle, and afterwards employing gentle pressure, has been performed, and it is said, in several cases with success. The operation has, however, been unsuc cessful in the hands of Otto, Berndt, Hayer, Sherwood, Trompei, Churchill, and others. When decided upon, the puncture should be made with a needle or slender trochar, and, according to Mr. Hewett, never along the median line of the tumor, especially in the sacral region, for it is generally at this part that the cord and its nerves are connected with the sac. The puncture he directs to be made on one side of the sac, and at its lowest part. Very recently, two cases are related by Dubourg, in which a perfect cure was effected by cutting off the tumor, and then bringing the edges of the divided skin together, and retaining them so until union took place, by means of the twisted suture, great care being taken to prevent the entrance of air into the spinal canal, and, as much as possible, the escape of the spinal fluid.

The application of gradual and gentle pressure, as recommended by Abercrombie and Sir Astley Cooper, is probably the treatment that will be found the best adapted to the generality of cases; it is said to have produced a radical cure in some instances. It has been very correctly remarked, that when the tumor is very large, puncture should not be attempted, while in cases where the fluid effused in the spine communicates with the ventricles of the brain, pressure must always be of very doubtful propriety.

Beynard and Latil have practised the linear ligature by means of two quills or pierced wooden rods, retained on the two sides of the tumor by a proper contrivance, and containing in their interior a thread; by the gradual tightening of which, lateral constriction is applied; the tumor at the end of a few days is destroyed, and a permanent cure effected. Dubois combines the ligature with puncture,

while Chassaignac proposes puncture followed by injection of iodine. The success of this plan has been but small; several of the patients in whom it was practised were destroyed by it. (Bouchut, Diseases of Children.)

A case or two, it is true, is recorded by Brainard (Chicago Med. Jour., Aug. 1860), and by Dr. Lézene (Mon. des Sciences Med., Oct. 1861), in which a complete cure is said to have been effected by injecting into the spinal tumor a solution of iodine, and making continuous pressure on it externally. The testimony of those who have had the largest amount of experience in the treatment of the malady is, nevertheless, most pointedly opposed to any operation. Velpeau recommends simply compression, with the application of astringent lotions in cases where the parietes of the tumor are intact.

In all cases much benefit will be derived from placing the patient under a hygienic course of treatment adapted to improve the health and nutrition of the body generally. Hence, the importance of changing the milk of the mother, if the quality of this be doubted, for that of a healthy nurse; of removing the infant from the confined and impure air of the city, to a dry, healthy situation in the country; of clothing it warmly, and carrying it abroad, every fine day, in the open air; of sponging its body daily with warm water, and using frictions over its entire surface, and of keeping its bowels regular by gentle aperients.

It has been proposed to apply repeated small blisters above the tumor, in the course of the spine, each being kept on so long as to cause a rubefacient effect only, with a view, in this manner, to promote the absorption of the fluid. The preparations of iodine may also be administered with the same intent.

When the disease is associated with hydrocephalus, or with meningeal inflammation, either of the brain or cord, the treatment adapted to the later affection will, of course, become necessary.

9. Inflammation and Ulceration of the Navel. Within the first nine or ten days after birth, inflammation of the navel, followed by ulceration, is very liable to occur. Upon the sepa ration of the cord, instead of a quick and perfect cicatrization succeeding, the navel in some cases remains raw, and soon becomes irritated and inflamed, presenting a deep red, ulcerated surface, with an inflamed condition to a greater or less extent, of the surrounding parts. A thin, purulent, and often offensive discharge takes place from the surface of the ulcer; the infant suffers considerable pain, as is evinced by its general fretfulness, and its cries when the ulcer is examined or accidentally touched. Not unfrequently the ulceration at the navel presents an elevated surface, with somewhat prominent edges, and the discharge is then generally the most profuse. Sometimes a kind of fungous excrescence, of a dark-red color, protrudes from the centre of the navel, without any appearance of ulceration, and with but little discharge, and scarcely any inflammation of the surrounding skin. We have often, indeed, seen the skin, up to the very edge of the umbilical depression, remain perfectly natural.

INFLAMMATION AND ULCERATION OF THE NAVEL. 727

The fungoid tumor, which generally bleeds upon the slightest irritation, may either present a narrow base with a round, expanded head, like a cherry, or a broad base from which it tapers gradually towards the summit, being more or less conical in form.

Ulceration of the navel is very generally the result of neglect or mismanagement on the part of those who wash and tend the infant. In a few instances, it is true, it may result from a slow and imperfect separation of the cord, in consequence of which it remains long attached by a thin, firm filament, keeping up a constant irritation, by which the healing of the navel is prevented, and ulceration induced. More commonly, however, it is produced by rude management in washing and dressing the child, previous to the coming off of the cord or by rude dragging, or other injudicious attempts to facilitate its separation, or by the ridiculous practice of dressing the navel subsequently, with a burnt rag, grease, and even still more improper things. It may also arise from inattention to cleanliness; especially in leaving a quantity of the vernix caseosa upon the skin surrounding the umbilicus, long enough for it to acquire an irritating character. From a peculiar irritability of the skin, some infants are more liable to ulceration, or rather tardy and imperfect healing of the navel than others.

In all cases, the utmost attention should be paid to cleanliness. The navel and surrounding skin should be carefully washed, at least twice a day, with lukewarm water, and then wiped perfectly dry with a soft linen cloth. If the remains of the cord still continue attached by a thin filament, their removal by the knife or scissors, will often, as stated by Dewees, be sufficient to allay the irritation, and thus allow the navel to cicatrize.

When the ulceration is superficial, without much inflammation, washing it with a little rose-water, twice a day, and dressing it as often with the ceratum zinci oxydi impur., spread upon a soft rag, will often cause it promptly to heal; or, if this should not succeed in causing cicatrization, the ulcer may be washed daily with a solution of sulphate of copper (ten grains to an ounce of water), and then dressed with the same salve. In slight cases, by sprinkling the ulcerated surface with finely-powdered oak bark or galls, we have repeatedly found cicatrization to take place very promptly, without any other dressing.

If the ulceration should still show no disposition to heal, it may be washed by a weak solution of the nitrate of silver, and then dressed with an ointment formed of one scruple of the acetate of lead, intimately combined with an ounce of lard. In aggravated cases of ulceration of the navel, prompt and very decided benefit is said by Dr. Eberle to be derived from applying to the ulcerated surface, three or four times daily, by means of a soft hair pencil or feather, a liniment made by slowly simmering the coarsely-powdered root of the wild indigo (baptisia tinctoria), in cream, and then squeezing the decoction through a thick piece of muslin or flannel.

In all cases in which the ulceration is attended with considerable inflammation extending to the surrounding parts, stimulating applica

tions of every kind should be withheld until the inflammation is reduced by soft, emollient poultices, and frequent washing of the inflamed skin with a solution of the acetate of lead. In some instances, we have seen the inflammation, in cases of ulceration of the navel, so extensive as to demand the application of a few leeches.

It is not unfrequent for the bowels of infants affected with ulcerated navel to be considerably disturbed, the passages being frequent, thin, and attended with griping. Whenever this is the case, the administration of very minute doses of calomel and ipecacuanha, combined with a few grains of magnesia, with the daily use of the warm bath, will be demanded.

When a fungoid tumor forms or protrudes from the navel after the separation of the cord, if it have a narrow base, we may readily remove it by a ligature applied around its pedicle, sufficiently tight to arrest the circulation without cutting into its substance. The tumor usually separates in the course of a few days, when the ulcerated surface may be washed with a solution of sulphate of zinc (fifteen grains to an ounce of water), or dressed with the ointment of acetate of lead.

It is seldom, however, that the separation of the tumor by means of the ligature is attended with any permanent benefit; very generally, the fungous growth will recur to as great an extent as at first. It is better, therefore, to treat it at once by astringent applications, as the decoction of galls or oak bark, or solutions of the sulphate of copper or zinc, in the proportion of one drachm to the ounce of water; or, we may sprinkle the surface of the tumor with finely-powdered oak bark or galls, and wash carefully, night and morning, with lukewarm water. It is said that the root of the sanguinaria Canadensis, in fine powder, is an admirable application for the removal of these fungoid growths.

When the tumor is soft and spongy, and not invested by a membrane, applying to its surface daily, by means of a camel's hair pencil, a pretty strong solution of the nitrate of silver will generally destroy it in a few days, and allow the navel to cicatrize.

10. Intumescence and Inflammation of the Breasts.

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Infants of both sexes are very liable to a tumid, hard, and painful condition of the breasts, which is occasionally present at birth, but more generally presents itself a day or two subsequently, and is, in some cases, attended with a degree of redness and inflammation of the external skin.

Even when the swelling and hardness are very considerable, they will both, after continuing, perhaps, for a week or two, without any sensible abatement, very generally subside spontaneously. Unfortu nately, a vulgar notion is prevalent among mothers and nurses, that the swelling of the breasts, in the female infant at least, is the result of the presence of milk, which it is necessary, by all means, to draw or squeeze out; which opinion is confirmed, as they suppose, by the escape, sometimes, of a white-colored fluid at the nipple. Very rude measures are sometimes resorted to, in order to expel the offending