Part 86

[26] [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.]

[27] [Dr. Maunoir, of Geneva,[28] relates a curious instance, strongly corroborative of the occasional hereditary tendency of this affection. While investigating this subject, he became acquainted with the history of a woman whose grandfather, uncle, two aunts, and two cousins, all on the paternal side, had had cataract, and who had all been operated upon. She herself, at the age of twenty, was attacked with it. Finally, out of four children which she had, one was born with cataract; and, what is remarkable, neither her father, mother, nor sisters, had ever had any affection of the kind. The same writer states that Roux once operated for this disease upon three brothers, whose father and grandfather had suffered similarly. A brother, much younger than themselves, had the affection in its incipient stage. Instances more frequently occur in which several members of a family are affected with cataract, without any traceable hereditary predisposition on the part of either parent. Professor Drake met with a case not long ago, where five out of nine children were blind from this cause; and last autumn I operated on two boys and a girl from Mississippi, who had lost their sight in a similar manner.—ED.]

[28] Essay on Cataract, translated by Dr. Bowditch, of Boston.

[29] [The two subjoined tables, the one constructed by Mons. Maunoir, and the other by Professor Fabini, demonstrate the immense influence which age exerts upon the production of cataract:—

TABLE I.

From 20 to 29 years 5 patients 30 39 3 40 49 11 50 59 25 60 69 41 70 82 27 ——— 112

TABLE II.

From 1 to 10 years 14 patients. 11 20 16 21 30 18 31 40 18 41 50 51 51 60 102 61 70 172 Above 70 109 ——— 500

It has been said that men are more liable to cataract than women; the difference, however, if any, is probably very slight. Thus, in the first table, 61 were males and 60 females; in the second, 268 were males and 232 females.—ED.]

[30] [This expression admits of some modification. In young persons with good constitutions, whose previous health has been good, and who have not been subject to ophthalmia, I should not hesitate to operate on both eyes at the same time. In six or eight cases, in which I have lately followed this practice, no unpleasant effects whatever occurred: in all the inflammation was exceedingly moderate.—ED.]

[31] [In congenital cataract there can be no valid reason for postponing the removal of the opaque lens even to as late a period as that mentioned in the text. The operation is perfectly simple, unattended with risk, and may be performed within six or eight weeks after birth.—ED.]

[32] [This must, I suppose, be a typographical error. The author can certainly not mean that the instrument should be introduced at the centre of the cornea, as would inevitably happen if we were to carry out his directions. The proper point is the lower and outer part of the cornea, about a line anterior to its junction with the sclerotic coat.—ED.]

[33] See Elements of Pathological Anatomy, vol. i., p. 489, for description of this fascia.

[34] Boston Medical and Surgical Journal, Dec. 29th, 1841.

[35] [This opinion is certainly erroneous. That the obstruction occasionally exists in the situation adverted to, cannot be doubted, but that it does so constantly, or even generally, is not true. When the lining membrane of the antrum is inflamed, it does not follow that it must be so throughout its entire extent; most commonly, indeed, there is reason to believe that the morbid action is circumscribed, and hence when matter forms it may readily, in many cases, find its way into the nose. It is only where the whole of the mucous lining is involved, or that portion of it which covers the inner wall of the antrum, that the edges of the communicating aperture will be likely to be so much thickened as to produce complete obstruction. It is difficult to conceive how Mr. Liston could have committed such an error.—ED.]

[36] [These abscesses are sometimes acute, the suppuration occurring as a consequence of active inflammation. They are seated in the submucous cellular substance, and often acquire a large size; at first there is merely soreness in the throat and pain in swallowing, but when matter begins to be poured out difficulty of breathing is superadded, from the pressure which it exerts upon the epiglottis and mouth of the larynx, and if it be not speedily evacuated the patient may die from suffocation. As soon as fluctuation is recognised, or even before, if there be much swelling and difficulty of respiration, relief should be afforded by a free incision, made with a sharp-pointed bistoury with the back towards the tongue, which is to be depressed with the forefinger of the left hand.—ED.]

[37] [There is no subject of greater importance to the country practitioner than the extraction of the teeth; an operation which, from his insulated situation, he is constantly obliged to perform. Like the operation of venesection, it may be executed well or indifferently, and precisely as he does the one or the other will be the measure of his standing with his patients. The following observations in relation to this subject are condensed mainly from the excellent work of Mr. Bell, “The Anatomy, Physiology, and Diseases of the Teeth,” which should be in the hands of every physician in the country.

Mr. Bell thinks that the separation of the gum from the teeth, as a preliminary measure, is unnecessary; a view in which I must entirely disagree with him. That it materially facilitates the removal of the organ from its socket, ample experience has long since convinced me. The operation may be performed with a gum-lancet, or, what I have always preferred, a sharp penknife, which should be passed completely round the neck of the tooth, down to the alveolar margin of the jawbone. In the removal of the first teeth in children the previous separation of the gum is unnecessary.

The incisors of the upper jaw will require the use only of a small pair of straight forceps, the application of which is extremely simple. As the roots of these teeth are conical, and generally perfectly round, they will require merely a slight rotation, when they may be drawn downwards in the direction of the socket. The forceps should be placed as high on the root as the alveolar process will admit, and pressed so firmly as to prevent the blades from slipping, while at the same time care is taken not to crush the tooth.

The extraction of the lower incisors is effected in a very different manner. The roots of these teeth being very much flattened laterally, it is obvious that they cannot be dislodged upon the principle of simple rotation in the socket. When the tooth is even, or nearly so, with the others on each side of it, the best instrument will be the hawk’s-bill forceps, of very small size, and with narrow blades. The instrument being fixed as low on the neck of the tooth as possible, a gentle but firm movement is to be made forwards, so as just to separate the organ from the back part of the alveolar cavity, and then, continuously with this motion, the tooth is at once to be raised out of the socket.

The superior cuspid and bicuspid teeth may generally be removed by means of the same straight forceps as the incisors. The extraction of the former will be considerably facilitated, by giving a slight degree of rotation previous to its actual dislodgement from the socket. The bicuspids, on the contrary, having flatter sides, and less solid roots, will not allow of any degree of rotation; and must therefore be dislodged by first of all moving them a little outwards towards the cheek, so as to destroy the attachment to the inner alveolar plate, and then, by a perpendicular pull, they may be lifted directly from the socket.

The cuspids of the lower jaw are to be removed by the same means as the incisors. For the extraction of the bicuspids the key is the best instrument. The claw, placed in the usual position, should be rather small, and the fulcrum well covered with lint.

The removal of the first and second molars of the upper jaw will generally be best effected with a pair of large forceps, slightly bent at the blades. In applying this instrument to the teeth in question, the edges must be thrust as far under the border of the gum as possible, and a firm, steady hold taken of the tooth. It is then to be dislodged by first a steady, gradual bearing outwards until it is slightly moved, when, with a contrary motion into its former position, followed by a firm pull downwards, the tooth is removed with considerable facility. The corresponding teeth of the lower jaw may be extracted by the same means, or with a pair of hawk’s-bill forceps, the longer blade of which is to be placed on the inner gum. The operator standing on that side of the patient from which the organ is to be removed, and having taken a firm hold, first moves the tooth a little outwards towards himself, and then, with a steady and continuous movement, draws it almost straight from the socket; a motion which the inclination of the handle will greatly facilitate. The wisdom-teeth are best extracted with the forceps; their roots are small, and but little force is required for their removal.

When the crowns of any of the teeth are so entirely destroyed that the forceps and the key are alike insufficient to remove the roots which remain, the elevator, as it is called, will be found a very simple and efficient means to effect it. The edge of the instrument is to be inserted between the root and the alveolus, so far as to secure a sure hold, and the root is then to be lifted, as it were, from the socket, by resting the instrument upon the alveolar process, or even upon the side of a neighbouring tooth. There is not the least danger of injuring the latter if care be taken not to depend too exclusively, nor to bear with too much force upon it.—ED.]

[38] [I have been in the habit, for many years, of keeping the edges of incised wounds of the face, forehead, and eyelids, in contact with gold pins finer than the most delicate sewing-needle. They should be from an inch to an inch and a half in length, and be provided with heads of sealing-wax, by which they can be more easily carried across the skin than in any other way. From the materials of which they are composed they are entirely exempt from oxidation, which is not the case with the common needle; and I am convinced, from ample experience, that wounds thus healed are seldom attended with permanent deformity, from the formation of unsightly scars.—ED.]

[39] [In this country goitre is most common in the mountainous districts of Pennsylvania, Virginia, New-York, Connecticut, New-Hampshire, and Vermont. It is very rare in the natives of the western and southern states.—ED.]

[40] [I have in two instances succeeded completely, and in another partially, in curing goitre of long standing, by the internal and external use of iodine; and am disposed to place more reliance upon this remedy in the treatment of this affection than upon any other with which I am acquainted. To be beneficial, it should be administered in large doses, and be continued for at least three or four months. The local remedy which has best succeeded in my hands consists of equal parts of iodine and of camphorated mercurial ointment, rubbed thoroughly upon the surface of the tumour twice a day.—ED.]

[41] [To obtain a full stream of blood, the lancet should be carried _obliquely_ upwards and outwards, by which means the fibres of the platysma-myoid will be cut across, instead of being divided vertically, and the edges of the incision will retract so as to form a much larger orifice. The pressure below the opening should not be removed until the wound has been closed, to avoid the introduction of air into the vein, an accident which may occur when this precaution is neglected.—ED.]

[42] [I am induced to subjoin the following example of axillary aneurism for which the subclavian artery was tied, in the belief that, from the unique manner of its termination, it will be interesting and instructive to the reader. The particulars of it, together with an analysis of twenty-six other cases reported by different surgeons, will be found in the _Western Journal of Medicine and Surgery_ for June, 1841.

Daniel Monday, a married negro, thirty-six years of age, of a stout muscular frame, and a brickmaker by occupation, consulted me, in February, 1841, for a circumscribed, pulsating tumour, produced by the recoil of the butt-end of a yager, and situated beneath the right pectoral muscle, extending from the clavicle down towards the cartilage of the fourth rib. It was of an irregular, conical shape, and about the volume of a large fist, measuring fully four inches at its base in one direction, by three and a half in the other. In its feel it was tense, as well as inelastic; the blood rushed into it with a whizzing noise, and the pulsation was so distinct that it could be seen at the distance of some feet from the patient. The clavicle was thrown above its natural level; the whole limb, from the top of the shoulder to the ends of the fingers, was benumbed, painful, and almost deprived of power; the pectoral muscle was much stretched; and the patient constantly inclined his head towards the affected side, keeping the elbow nearly at a right angle, and supporting it carefully with the opposite hand, to prevent tension of the tumour. The swelling of the limb, however, was slight; the temperature was also good, and the pulse at the wrist was nearly as distinct as in the natural state. For the last four weeks the pain was almost incessant; it was particularly severe at the chest and shoulder, and had become so agonizing of late as to deprive him of sleep, and even prevent him from lying down. The appetite was also much impaired, and the countenance expressive of the deepest distress. The tumour had grown with great rapidity during the last two months; and, as there was danger of its bursting, an operation was at once decided upon.