Spina bifida has been found engaging the whole length of the spinal column, which is, however, very rare, and sometimes it has passed, not through a divided or imperfect vertebra, but through a space accidentally ex isting between the last lumbar vertebra and the first piece of the sacrum.t This affection of the foetus, though some times found unaccompanied by any other, is in many instances complicated with morbid lesions of an important kind, such as hydrocephalus, malformation of the lower extremities, which are apt to be curved inwards, or otherwise distorted, deficiency in the coverings of the abdomen, and umbilical hernia, hare-lip, &e. : in one instance in the writer's museum, in which there was adhesion between the fmtus and the amnion, spina bifida is accompanied by malformation of the lower limbs, and an enor mous umbilical hernia, in which are contained almost all the abdominal viscera.i (See .fig. 153.) The spinal marrow is sometimes healthy, but more frequently it is morbidly affected and sometimes deficient ; it is sometimes displaced from the spinal canal and lodged in the cavity of the tumour, especially when the latter occurs over the lumbar vertebra; sometimes the cauda equina has been contained in the tumour, and its component nerves found separated and floating in the fluid, or spread over the walls of the tumour.
Children thus affected seldom survive, what ever treatment may be adopted ; some rare exceptions have, however, been met with, in which life has been continued even up to adult age; as in the case related by Mr. Jukes,* in which the woman had arrived at the age of twenty at the time of writing the ac count ; the tumour, which had been at birth about the size of a pigeon's egg, had acquired dimensions much greater than those of the head ; after birth, the limbs, which had been well formed, became in a few years curved inwards, and the woman was gradually reduced to a most miserable condition. A similar case of survival to the age of twenty is mentioned by Warner4 A case has been recently recorded in which an enormous tumour of this kind delayed the delivery of the body of the child for two hours after the birth of the head, which it equalled in size, extending from the third cervical verte bra to the eighth rib, and containing a quart of fluid, which communicated with the ventricles of the brain.: Cranial tumours.—It has been already sug gested that there were other tumours observable on the head of the child at birth of a totally different character from the encephalocele, but which might be mistaken for it ; an error into which it is said that the celebrated Ledran fell : these tumours are generally the result of pres sure during labour, producing ecchymosis and sometimes bloody effusion between the scalp and the cranial bones; they differ in all respects from the enceplialocele ; they are darker co loured, without any pulsation, situated over the solid part of the bones, especially over the parietal of one or other side; they cannot be diminished at the instant by pressure, nor does pressure cause the internal distress which results from it when applied to the hernia eerebri; and lastly, no opening can be ascertained in the bone; but with regard to this last point of diagnosis, I wish to direct attention to a cir cumstance calculated to embarrass the examiner and lead him into error; in examining tumours of this kind, it is not unusual to find around their base a defined and slightly elevated cir cular margin, which at first one would be al most certain was the circumference of an aper ture in the bone, but on further examination it will be found, that if the point of the finger be pressed within this circular margin, it will there meet with as decided and firm a resistance as it did outside of the base of the tumour. I
have known this peculiarity lead to the pro nouncing of a very erroneous opinion as to the nature and prognosis of such a tumour.
These tumours have been found to contain bloody serum, or pure blood, either fluid or coagulated, and sometimes both; the effusion takes place either between the bone and the pericranium, or external to the latter and under the integuments : the former variety has been called ceplialtematome by Nwgele,* who, as well as Schmitt, has given an account of it.
!laving stated that these bloody tumours are generally the result of pressure during labour, I should add that I have reason to believe that they are formed occasionally quite indepen dently of any such cause. I very lately at tended a patient who gave birth to a child which had hardly arrived at seven months, with an easy and expeditious labour, yet the infant had a very large tumour covering the greater part of the right parietal bone, having all the characters of the ceplialwmatome, and was not removed till the termination of a month.
Injuries of the cranial bones.—The same causes which give rise to the formation of the bloody tumours just described, not unfrequently produce fractures or depres sions of the flat bones of the cranium, espe cially of the parietals ; more particularly in cases of contracted pelvis, where the promon tory of the sacrum projects considerably in wards ; though I have known such accidents happen without the concurrence of any such state of the pelvis, but from the interposition of an arm between the head and the bony wall of the pelvis : in one case where the labour required version of the child, the arm got be tween the side of the head and the pubes and produced so much difficulty in the delivery, that the left parietal bone was completely depressed. Siebold has reported a case in his journal, in which the labour was painful and tedious, and the child was born dead : a large bloody tumour was found over the right parietal hone; and on exposing the bonc, it was tra versed by three distinct fissures passing in different directions : no instruments had been used.* But I have reason to know that these injuries of the cranial bones may occur, not only independently of contracted pelvis, but even of slow or difficult labour. I some time since attended a lady in her second labour, and after about three hours from its commencement, she gave birth to a healthy boy, but with a depression in the left temporal •bone which would readily have contained an almond in its shell ; by degrees the depression disappeared, and at the end of a few months no trace of it remained ; the lady's first labour was easy, as were also those that succeeded the birth of this child, and no such injury was observable in any other of the children. More recently I was informed by Mr. Mulock, of a case in which, on the subsidence of a cranial tumour, a spicula of bone was felt distinctly projecting under the integuments ; the labour had been slow but natural. When these injuries of the fetal head were first observed, they were attri buted to violence by Haller, Rosa, and others, the error of which opinion was first perceived by Renderer and Baudelocque, and it is need less to say how important is the distinction, especially in a medico-legal point of view.