In addition, he points to the very important fact that the localized hæmorrhages are commonly situated in relation to the mid-cerebral cortex, close to the sinus, and on one or both sides of the falx cerebri. In addition, therefore, to the symptoms of general cerebral compression, certain definite localizing symptoms are to be observed, these being in direct proportion to the size of the clot. In an analysis of 74 autopsies on infants still-born or dying within the first few days, Archibald[11] found ‘intrameningeal’ hæmorrhage in 32, in 19 of which it was of considerable extent: and in 5 others there was extra-dural hæmorrhage. In only two or three was effused blood found within the cerebral cortex. The importance of these facts from a surgical point of view cannot be over-estimated. [Illustration: FIG. 25. DIAGRAM TO ILLUSTRATE THE EFFECTS AND POSITION OF A BIRTH-HÆMORRHAGE. _sc._, Scalp; _b._, Bone; _d.m._, Dura mater; _br._, Brain; _s.l.s._, Superior longitudinal sinus; _c.v._¹, The protected part of a superficial cerebral vein; _c.v._², The unprotected part of a superficial cerebral vein; _c._, The subdural clot, exercising pressure on (1) the cortical leg arm, (2) the arm area, and (3) the face area.] =Symptoms.= Besides the history of protracted labour and the ‘blue’ asphyxiated appearance of the baby, other evidence is to hand with respect to both general and local increase of brain-pressure. The _general_ increase is evidenced first and foremost by the bulging and non-pulsatile anterior fontanelle. The fontanelle may be regarded as an index of intracranial pressure. The margins of the fontanelle are outlined with some difficulty, and, owing to the free communication between the intra- and extra-cranial venous systems, the scalp-veins are unduly prominent. The general condition of the child varies according to rise of intracranial pressure. In the more serious cases it may be impossible to arouse the patient: in the slighter hæmorrhages the child may appear but little the worse, with the exception, perhaps, of being rather more irritable than usual. The effect of the pressure on the medullary centres is shown by respiratory difficulties--irregularities of rhythm, &c.--some retardation in pulse-rate, and increase in blood-pressure. The reflexes are increased and the child is readily thrown into general convulsions. The effect of the _localized_ pressure on the upper Rolandic centres seldom becomes evident till after the lapse of a few days--and often after a longer period--when muscular weakness, twitchings, rigidity, or paralysis--more especially of the contralateral lower extremity--becomes apparent. The mother often draws attention to the fact that the child does not move one of its legs properly. When the extravasation is extensive, spreading downwards over other motor areas, the upper extremities and even the face may be involved.