Note 26 — PART SECOND. OF PARTICULAR SURGICAL SUBJECTS.

[As there are no facts in surgery so valuable as those of a statistical kind, I shall offer no apology for transferring to these pages an abstract of a very able article on hernia cerebri, published by Dr. Gurdon Buck in the fourth number of the New-York Journal of Medicine and Surgery. The paper in question is founded on an analysis of thirty-three cases, all collected, save one which occurred in his own practice, from the writings and reports of different American and European surgeons.

Of these cases only two occurred in the female. The age of the youngest was two years and a half; of the oldest, forty; seventeen were twelve years or under; nine from thirteen to twenty years; and seven, twenty-one or upwards. The seat of the wound giving rise to the disease, occupied, in fourteen cases, some part of the frontal region; in seventeen the parietal; and in two the occipital. In fourteen cases the brain was lacerated, and a portion of its substance discharged; in five it was wounded without loss; in one its surface was simply denuded; in ten there was no exposure; and in three its condition is not noticed. The dura mater was torn in twenty-one cases, and in another perforated; the cranium in all, except one, was broken into several fragments; and in twenty-four the scalp was more or less lacerated; in another it was pierced; in three there was no solution of continuity; and in five no mention is made of its condition.

The period of the appearance of the morbid growth from the occurrence of the injury varied in different individuals. In eleven cases it manifested itself prior to the sixth day; in fifteen between the seventh and twelfth; and in five between the twelfth and twenty-fifth. In one instance it did not begin until the eighth week: in another the time is not specified. The earliest period of its appearance was the third day, and that in two cases only; in more than three-fourths it commenced on or before the twelfth day. The average period was the ninth day from the accident.

In regard to the volume of the tumour, it varied from half an inch in diameter to a mass measuring six, by three and a half inches upon the surface, and two and a half in thickness. In twenty-two cases in which the dimensions are stated, the tumour in five was of the size of a hen’s egg; in eight it exceeded that magnitude; and in nine it fell short of it. The morbid growth was dissected only in eleven of the cases; in nine of these it consisted of cerebral substance, in which the cortical and medullary tissues were distinctly recognised, and in the other two it was composed of coagulated blood of a fibrous texture. In seven cases the tumour assumed a sloughing character; in five it yielded a fetid, sanious discharge; in one it bled freely on the slightest touch; in three it was enveloped by the pia mater; and in three others the surface was coated with a layer of clotted blood. In the centre of the largest tumour a cavity existed, filled with an ounce of limpid serum, and lined by a transparent, glistening membrane.

The general symptoms, indicative of disturbance of the vascular system, and of the cerebral functions, may be next considered. In twenty-three cases there was more or less excitement of the heart and arteries; in four none was apparent; and in the other six the symptoms are not stated. “In fourteen cases some one or more of the following symptoms of disturbance of the brain and nervous system were present: coma, delirium, pain in the head, general irritability, and insensibility. In six paralysis of the side of the body opposite to the injury was superadded to the preceding symptoms; and in two convulsions. Three cases were remarkable as presenting some striking exceptions to the general characteristics, and are, therefore, deserving of more particular notice; one of them, from the circumstance that there was no apparent shock to the nervous system, not even as the immediate effect of the injury, though its severity was so great that several fragments of bone and pieces of coal penetrated the brain, causing a discharge of three or four teaspoonsful of its substance. In another the patient remained in a state of complete insensibility and general paralysis for twenty-three days; the hernia appearing on the seventh day, and no inflammatory symptoms supervening. The third case exhibited a character of most frightful violence. Besides paralysis of one side, there were spasmodic actions of the muscles of the face and of all the limbs; nausea, retching, quivering of the eyelids, fixed eyeballs, strabismus, grinding of the teeth, alternate contraction and dilatation of the pupils, intolerance of light and sound, and other signs of the most alarming nervous commotion, often threatening to terminate life.”

Of the thirty-three cases in question, seventeen recovered, at a period varying from three weeks to four months; and sixteen terminated fatally, on an average, about the twenty-fourth day. More young persons recovered than old. Of the sixteen fatal cases, eleven were examined, and exhibited the following lesions: in eight the portion of the brain subjacent to the hernia was softened, pulpy, more or less disorganised, and sometimes intermixed with clots, while in the account of the other three no notice is taken of its condition. In eight other cases there were signs of acute inflammation of the arachnoïd membrane as indicated by thickening, opacity, adhesions to the dura mater, and deposits of lymph or pus. The portion of the dura mater around the opening through which the fungous mass protruded was thickened, black, and sloughy, in three of the eleven cases in question. In four the ventricles were filled with bloody serum; in one there was a large abscess in the brain full of pus, and lined with a false membrane. In one case a clot of blood was found between the dura mater and the cranium; in four the fracture extended through the base of the skull; and in one of these the edges of the osseous aperture, through which the hernia protruded, were rounded off by absorption.

In respect to the general treatment, it was uniformly antiphlogistic, consisting of the abstraction of blood by venesection and leeching, and the use of purgatives, proportioned to the urgency of the inflammatory symptoms. The local means employed were, excision of the hernial tumour, the application of the ligature, pressure, and caustics, either singly or together. In one of the cases that resulted favourably a spontaneous cure took place after copious hemorrhage from the morbid mass, excited by an accidental attack of vomiting. In another, after the ineffectual use of the nitrate of silver and other escharotics, the ligature was applied and gradually tightened from day to day; in five pressure alone was sufficient; in two the pressure was conjoined with lime-water; and in one with the nitrate of silver. In seven other favourable cases excision was resorted to, either once, or repeatedly, accompanied with pressure; in some dilute nitric acid—twenty drops to the ounce of water—lime-water, or nitrate of silver, were employed in addition. In the sixteen cases that terminated fatally the local treatment was, pressure alone in two; in five excision with pressure; in two the ligature; in one both ligature and excision; and in another escharotics. In five no mention was made of the local means.—ED.]