Extracted from The American Journal of the Medical Sciences, March, 1895. 
A CASE OF TRAUMATIC MENINGOCELE; OPERATION, 
FOLLOWED BY PERFECT RECOVERY. 
Howard Lilienthal, M.D., 
ASSISTANT ATTENDING SURGEON TO MT. SINAI HOSPITAL, NEW' YORK ; CLINICAL LECTURER ON 
SURGERY, NEW YORK POLYCLINIC, ETC. 
On the 12th of August, 1893, Jacob F., four years old, was brought 
to my department of Mt. Sinai Dispensary to be treated for a swelling 
over the back of his head. Three weeks before he had fallen from a 
first-story window and had sustained a scalp wound. The boy was very 
dirty, and his hair was matted over a swelling as big as a duck’s egg, 
which was plainly fluctuating. It wras a busy day in the dispensary, so 
I gave the case to my assistant, Dr. D. D. Goldstein, for incision, think- 
ing it to be an abscess under the scalp. Dr. Goldstein, having carefully 
shaved and scrubbed the part, noticed that something more than ordi- 
nary fluctuation was present, and called my attention once more to the 
patient. On questioning the boy’s parents we then learned that he 
had been for a few raomenls after the accident unconscious, but that 
he quickly recovered himself and ran about as usual. He vomited 
once on that day, but had no convulsion or other suspicious symptom. 
For nearly three weeks the boy had been well except that an enlarge- 
ment at the back of his head had been slowly forming. For two days 
before he was brought to me there had been persistent vomiting, but no 
other symptom. No chill nor fever had been noted. 
Examining the patient very carefully, the swelling was found to be 
of a thick sausage-shape, running from the most prominent part of the 
occiput to the left and downward. It was fluctuating, softly pulsating, 
and could be partly reduced. It became tense when the child cried. 
When partly reduced, one could feel a crevice in the bone extending 
vaguely in the direction of the swelling. A fine sterile hypodermatic 
needle was thrust into the tumor, and clear, non-albuminous fluid with- 
drawn, about thirty minims in all. The diagnosis of traumatic menin- 
gocele was now considered practically certain, and the patient was 
transferred to my service in the hospital. For the following two days 
the boy’s condition remained unchanged except that the vomiting tem- 
porarily ceased. The patient was irritable and appi-ehensive, crying 
whenever one but looked at him. On the 14th the tumor had become 
very tense, and the boy vomited his dinner, so three drachms of fluid 
were removed by aspiration. 
On August 17th I operated. An incision was made around the 
tumor in the shape of a horseshoe, with the curve above and the pedicle 
below. I tried to separate the sac from the scalp, intending then to cut 
off the redundant portion, suture the stump and return it to the cranial 
cavity. The sac was so very thin and so adherent, however, that it 
burst at the first attempt. There was no shock, and the child bore the 
chloroform well, so the operation was continued. The fissure in the 2 
LILIENTHAL: TRAUMATIC MENINGOCELE. 
left parietal bone through which the meningocele protruded was now dis- 
closed. It was about a quarter of an inch in width, and began quite 
abruptly about an inch to the left of the junction of the sagittal and 
latnbdoid sutures, whence it extended downward and to the left parallel 
with the margin of the occipital bone and toward the mastoid process of 
the temporal for two and a quarter inches. Here the edges of the 
crevice came together, and the break extended farther as a closed crack, 
the end of which I did not deem it necessary to see. Looking into the 
fissure one could see apparently normal pia covering the brain. With 
a small sharp spoon I removed that part of the meningocele sac which 
covered the edges of the fracture, and at the same time thoroughly 
scraped the bone from inner to outer table, so as to excite new bone- 
formation. To protect the subdural space from infection a strip of iodo- 
formized gauze was tightly packed into the crevice and was brought out 
at the left lower angle of the wound. The inner aspect of the scalp 
flap was now well scraped to free it from the adherent sac, and wras 
sutured back into its old place with catgut. After the operation, which 
lasted about half an hour, the patient’s pulse was 114, respiration 28; 
temperature 99.6° There was some general collapse, which rendered 
necessary a stimulating enema of hot water and an ounce of whiskey. 
Next day the boy’s condition was good. Highest recorded temperature 
99.2°. On the 20th patient vomited bis supper. His wound was dressed 
the first time five days after the operation, and the deep packing of iodo- 
formized gauze was removed through the angle of the wound. There 
was some stitch-hole suppuration, but not enough to interfere with the 
healing of the flap into its old position. 
Subsequently the case progressed in an uneventful manner, and the 
boy was discharged on September Bd. apparently well. 
On November 2, 1894, I again saw the little fellow, and there was a 
sound scar with not a trace of fissure or protrusion. 
I have reported this case on account of its extreme rarity and to in- 
dicate a method of dealing with such conditions. 
The reason for the existence of the meningocele I am unable to give. 
Fracture of the skull is a common enough accident, while traumatic 
meningocele is uncommon.