THE AMERICAN MEDICAL INTELLIGENCER. Vol. II. December 15, 1838. No. 18. ART I-TUMOUR AT THE BASE OF THE CRANIUM, PRODUCING AMAUROSIS, EXOPHTHALMOS, AND DEATH. BY S. LITTELL, JR., M. D., One of the Surgeons to the Wills Hospital for the Diseases of the Eye. (Read before the College of Physicians of Philadelphia, December 4, 1838.) J— B—, aged thirty years, by profession a porter, of medium stature and robust frame, applied for admission into the Wills Hospital, in July of the present year. He was afflicted with amaurosis, not wholly complete, for he could still distinguish light from darkness, but there was a certain obtuseness of expression, which seemed to indicate its origin in some serious organic disease; and had it not been for the importunity with which it was urged, his application would probably have been rejected in consequence. He had recently been an inmate of the Pennsylvania Hospital, whence he had been discharged, as he stated, at his own request, that he might seek entrance into an institution founded with more express reference to the diseases of the eye and I felt reluctant to send him away, so long as any uncertainty remained of the curableness of his complaint. All doubt upon this subject was removed when time was allowed for a more thorough investigation of the case. He complained of severe pain in the two temples and over the head, aggravated towards evening to such a degree as to deprive him of rest during the greater part of the night; a copious secretion from the nasal cavities of an offensive mucus, passing through the posterior nares, was discharged by the mouth; and symptoms of gastric derangement were also present, the constitution manifestly sympathising with the local affection. Vision first began to be impaired in January, and several physicians had been consulted previous to his admission, the following March, into the Pennsylvania Hospital. He had been once salivated while there, and was now again under the alterative use of mercury. There was no assignable cause for the production of the malady; for though he had been addicted to onanism a year or more before his sight began to fail, this seemed inadequate to explain phenomena which evidently originated in organic mischief. Opium and the abstraction of blood by cupping procured sleep and afforded temporary relief; but had no effect in retarding the progress of the symptoms. The pain was felt over the whole head, but especially in the temporal and occipital regions; he breathed with difficulty through the nostrils; the amaurosis soon became complete, and the eyes unusually prominent. The discharge also grew more profuse, was sometimes mixed with blood, and on two occasions hemorrhage occurred,-in one instance to an alarming extent. All hope of improvement from a longer sojourn in the hospital having been abandoned, he was discharged after a few weeks, and I continued my attendance at his home. The subsequent history of this melancholy case may be related in a very few words. The projection of the eyes steadily increased, the palpebra were gradually everted, and the globes, nearly protruded from their sockets, and surrounded by the red, swollen and infiltrated conjunctiva, exhibited a sad and revolting appearance. The VOL. II.-18 appetite of the patient, far from being diminished, was morbidly increased; the discharge continued, more puriform in character; a fungous excrescence could be felt in each nostril; but the pain, though still a constant subject of complaint, was happily masked by the attending stupor, from which however he could be readily aroused. For the last six or eight weeks of his existence, he was more or less delirious; his appetite decreased, failed altogether, and he became greatly emaciated as the fatal termination grew nigh. Though generally lying in bed, he was still able to sit up, or even to walk about the house; and what is remarkable, evinced a strong desire or craving for ardent spirits, which he had not been accustomed to use when in health: a symptom occasionally noticed as one of the earliest manifestations of insanity. The unfortunate man, reduced to the lowest degree of human wretchedness, a spectacle harrowing to the feelings of his attendants, and the object of compassion to every beholder, at length became comatose; and, after continuing in that state a few days, expired. The autopsy, made by candle-light, and under circumstances which precluded a very minute investigation, revealed the following particulars :— The first thing which arrested the attention, on looking at the corpse, was the unusual distance between the inner canthi of the eyes; which, being measured by my friend, Dr. J. Parrish, who kindly assisted in the examination, was found to be two inches and five tenths. On laying aside the calvarium, the vessels of the pia mater were observed to be uncommonly injected; and the cerebrum softened in its anterior lobes, particularly towards their lower portion, but in other respects not deviating from its normal structure. The brain being removed, a firm, irregular tumour was seen projecting from the base of the cranium into the sulcus between the anterior and middle lobes. It appeared to arise from the body of the sphenoid bone, and extended an inch or more in a direction upwards and backwards, pressing upon the optic nerves at their junction, and reaching as far on the right side as the surface of the pars petrosa, to which it was inseparably adherent. In order to obtain a more satisfactory view of its extent and connections, the frontal bone was taken away by sawing across its angular and nasal processes, thereby exposing the cavity of the orbit, and the upper half of the tumour. The ramifications of the morbid production, which was at least equal in size to a small orange, were now observed extending into and occupying the neighbouring cavities, the orbits, sphenoidal and ethmoidal sinuses-and reaching below as far as the inferior turbinated bone. The delicate lamina composing the ethmoid, still further attenuated by absorption, were situated in the centre of the tumour and entirely involved by it; the cribriform plate was absorbed in its posterior margin to a considerable extent, as were likewise the orbitar processes of the os frontis; the whole presenting a sharp, jagged, and irregular outline. The frontal sinuses, which were greatly enlarged and prolonged into the orbitar processes, were filled with a dark-coloured viscous secretion; on the left side, the thin shell of bone separating the sinus from the cavity of the orbit, had also been removed, leaving between them a communication several lines in diameter. The consistence of the tumour varied in different parts; above, and where it was connected with the petrous portion of the temporal bone, it was firm, semi-cartilaginous, and of a whitish colour; its section exhibiting a strong resemblance to that of a scirrhous mamma; beneath the cribriform plate it was softer, and in several places presented a medullary or encephaloid appearance; while the inferior division, which has been described as projecting into the nostril, was of intermediate density, and not unlike a polypous excrescence. The structure of the morbid growth left no doubt of its malignant character upon the mind either of Dr. Parrish or myself, but the precise spot in which it originated, is shrouded in greater obscurity; perhaps, however, it would be more consonant with all the facts of the case, to refer it to the sphenoidal or posterior ethmoidal cells. S. LITTEL, JR. Philadelphia, Dec. 6, 1838. ART. II.-LETTER FROM PROFESSOR CALDWELL. [We see no objection whatever to the insertion of the following correspondence. There is doubtless misconception somewhere, which can be removed only by explanation. It need scarcely be said, from the whole tenor of this journal, that it is not the creature of any school or of any party. A main object with it is to uphold the dignity and respectability of that profession for the promotion of whose best interests it was undertaken. In furtherance of this view, it has been the editor's determination to refuse insertion to every observation that tends to reflect unworthily upon any institution or individual, unless the public conduct of such institution or individual should, in justice, demand animadversion. To this course he will rigidly adhere, as the only one that can prevent unnecessary and derogatory controversy.-Ed.] Louisville, Nov. 13th, 1838. Dear Sir, I perceive, by the "American Medical Library and Intelligencer," ," of November 1st, that the editor of that work speaks of having received a pamphlet of fifteen pages, entitled "Refutation of Charges made by Dr. Caldwell, through the Louisville Journal, against Professor James C. Cross, of Transylvania University." In justice to you, sir, I take this opportunity of saying, that you have never mentioned Professor Cross in the columns of the Louisville Journal, and never written one word for that paper alluding to him either directly or indirectly. Yours truly, Senior editor of the Louisville Journal. DR. CHAS. CALDWELL. Louisville, November 15th, 1838. To the Editor of the American Medical Library and Intelligencer. Sir,-To the above note from the senior editor of the Louisville Journal, I shall only add, that I not only did not write the articles in that journal, containing the charges of which Dr. Cross complains in his pamphlet; I did not in any way, direct or indirect, contribute to their production;-I neither furnished matter, gave counsel, nor expressed a wish in relation to them. The first intimation I had of their existence, or of a design in any one to write them, reached me through the journal, by their appearance in its columns. Nor am I now convinced that I ever even read them, or heard them read. Most assuredly I have not the faintest recollection of the nature or bearing of any one of them. So slight is the interest I take in Dr. Cross, his character, or concerns. The doctor's refutation" of the charges, I have never seen. Nor, unless for reasons and from motives to which I am now a stranger, shall I ever consume time in reading a production so utterly groundless in imputation as I know it to be, and so violent and offensive in manner and spirit as I am told it is. In truth, sir, I wish to make it by this letter distinctly and generally understood, that, for several years past, my resolution and practice have. been, to hold with Dr. Cross no shadow of intercourse, direct or indirect. With my reasons for this I shall not at present trouble you or your readers; they are satisfactory to myself; and that is all that the occasion requires. I need hardly add, that if Dr. Cross possess the slightest sentiment of justice, gentlemanliness, or self-respect, he will make atonement for the outrage committed by his pamphlet. If he refuse this, the public will understand from his delinquency, somewhat better than they do at present, what kind of estimate they should set on his character. As you have announced in your journal the existence and title of a pamphlet designed to injure me, I trust you will perceive no just ground of refusal to the admission of this note of vindication, and of that from the editor of the Louisville Journal, into the pages of the same work. And am respectfully your obedient servant, CH. CALDWELL. ART. III.-PHILADELPHIA HOSPITAL (BLOCKLEY). DR. DUNGLISON, ATTENDING PHYSICIAN. Summary of Cases treated in Women's Lunatic Asylum from Sept. 3d, 1838, to Oct. 6th, 1838, (six weeks). Reported by DR. A. M. VEDDER, of New York, Senior Resident Physician. Mania.-A brief account of this interesting case will be given hereafter. Insanity, recent.-Bridget H., æt. 20, entered the hospital with mania à potu; after the cure of which she remained insane. She has been a drunkard or two or three years, drinking at times for a week from half a pint to a pint of gin daily. After recovery from mania à potu, she was stupid and obstinate, refusing to speak. She would remain whole days without seeming to notice any thing. Sleep was imperfect. She remained in this state for about a fortnight. Discharged Sept. 12th. Insanity is not an uncommon sequela of this disease; it would be interesting to know what proportion of cases terminate in this way, but unfornately we possess no data. 1 There are recorded, from January 1st, 1836, to Oct. 16th, 1838, 204 cases occurring among females, of which number 16 terminated fatally, besides some cases which occur in the medical wards, which are not included. That is, 1 case in every 13 was fatal; which is much more favourable than among males. In the men's department there are recorded 401 cases from January 1st, 1836, to January 1st, 1838; of this number, 56 were fatal: that is, 1 was fatal in every 7. Showing that the disease was more fatal among males than females, in the proportion of two to one, nearly. A. M. V. CASE 2.-Frances F., a native of Germany, aged 29, large and muscular, entered September 21st. The day previous she was thought to be insane; which was evident on her admission, from her attempting to leap from the window, breaking furniture, &c. Was formerly a catholic, but for a short time lately has attended the meetings of another denomination, where she became greatly excited from the tone and character of the preaching. This was thought to be the cause of her insanity. During the first night (21st), she was singing psalms and praying alternately at the top of her voice. At times she would leap up and down, vociferating at the same time. Menstrual function regular. Arterial system natural and equalised. She continued in this state for about two weeks, sleeping during this period only three or four hours at night. The tincture of opium was given in repeated and large doses whenever she became excited. Oct 3d she expressed a desire for some employment, which was hailed as a favourable symptom; since then she has continued to improve, and is now entirely well. This case is not entered cured in the summary. CASE 3.-Jane T., æt. 60, has always been considered non compos mentis, since she has been in the house (about two years). She was very loquacious, officious, and exhibited a loose connection of ideas. Sept. 10th she went to the city on a visit, and was taken up by the city watch while wandering about the streets. For seven successive days and nights she slept none,-v -was constantly singing and talking. She has two scars on her head; in one of them the bone is evidently depressed. Her condition on the 18th Sept. was as follows:-Expression rather wild; pupils contracted; conjunctiva slightly injected; no vomiting; head cool; pulse rather frequent; insomnia continues. Two grains of opium were given every hour until sleep was produced. No hallucination of the senses. Thinks she is omnipotent, possesses unbounded wealth, and can create or destroy at pleasure. She beat the wall with her hands for several days, invoking devils, which she called her work. Her bowels were costive, and could be moved only by drastic cathartics; this might be owing to the opium which was given to keep her quiet. Oct. 12th-Still entertains the same extravagant ideas; her physical condition is so much improved that she is permitted to walk about. Her mind on the whole is much improved. CASE 4.-M. H., æt. 32, remained in the hospital only one day. Was seen to leap into the Schuylkill in a fit of insanity by a boatman, who rescued her. Was pregnant, and advanced to the full period. The insanity would seem to have been caused by an incautious expression used by a physician, viz. "that something was wrong;" after which she became very much depressed: this was two weeks previous to the attempt at suicide. Notwithstanding every remonstrance, she was removed by her friends from the hospital; two weeks after this time, she was delivered of twins, one of them living. She was again sent to the hospital, labouring under confirmed insanity. Monomania, religious.—Both these cases are of many years' duration. Melancholia (suicidal propensity).—One of these cases will be reported separately hereafter. The case of meningitis will also be reported separately. Epilepsy.-Both of these cases will be given hereafter, inasmuch as they are adapted to illustrate the power of narcotics in suspending the paroxysms. Mania à Potu.-These cases will be given hereafter. Several of them are interesting; one illustrating the Stahlian method of cure by expectation, and another the use of animal magnetism as a therapeutic agent. Typhoid Fever.-This patient was a coloured girl; the case, as frequently happens, was very protracted. The taches roses, or "rose-coloured spots," of course could not be demonstrated; but all the other signs of what has been termed dothinenteritis were well marked,—the expression of countenance, diarrhea, meteorism, &c. &c. |