NOTES OF A CASE OF FUNGUS OF THE DURA MATER; WITH REMARKS.

457 If he has had the privilege of their own hearths, or perhaps I should say stoves, he will have become convinced that the influences of politics, societetics, and climate, have resulted in the production of a most kindly, friendly, and orderly variety of the Anglo-Saxon race, full of domestic affections and social sympathies, peculiarly liable to be led by moral and reasonable guidance. And these are the men for whom the American physicians declare that bonds of hemp and iron are absolutely indispensable in the treatment of their mental maladies, while for the rough Englishman, the dour

for their patients, and all possible publicity in the management of their institutions, I feel as sure as that they and their countrymen are destined in the ages to be our own great rivals in the race of social and scientific progress in this and in all other matters. In a few years they will look back upon their utterances in defence of mechanical restraint with the same wonderment with which they may now regard all that has been said in defence of domestic slavery, but with no wounding recollections of war and conflict, and then they will forgive me or my memory for that I have written the above words which may perchance have hastened this happy change. (To be continued.)

imperfect civilisation. knowing many Americans at

most

Scot, and the hartnackig German, they have been proved

to

be both superfluous and mischievous !

I should hesitate to declare that all races were equally fit for the non-restraint system, and perhaps a house full of maniacal Malays or Kaffirs would be troublesome to manage NOTES OF A by moral and reasonable methods. The essence of the nonrestraint system is to lead the lunatic by such remains of CASE OF FUNGUS OF THE DURA MATER; mental power and coherence as the physician can lay hold WITH REMARKS. upon, and where there has been least mind there will be the slightest means of moral guidance; but to make the BY JAMES F. WEST, F.R.C.S., men of the United States an exception because they, more SENIOR SURGEON TO THE QUEEN’S HOSPITAL, BIRMINGHAM. than others, have learned how to rule themselves, is a blundering censure upon their culture and their virtues. EMMA F-,aged forty, was admitted into the Queen’s Moreover,if American patients are independent, ingenious, under Mr. West. The patient on Nov. Hospital and not and bold, therefore easily guided and controlled, had been married 18th, 1875, are not the physicians Americans also, and being possessed twenty years, and had nine children, and of the qualities of their race, do they not stand in the same one miscarriage; four of her children are dead; three died relation to their patients as the physicians of other countries in infancy, from three to four months old. She has been to their insane countrymen ?P Do they not possess the same accustomed to carry bricks on her head, having worked in a advantages of courage, culture, and experience, and above brickyard. There was no history of any particular blow on all, that of a sound mind in a sound body, which qualifies them to undertake the care and treatment of their com- the head, but she has been knocked about a good deal with patriots who are bowed down by mental infirmity and fists by her drunken husband. She states that she suffered frequent physical disease ? Verily we believe that this from what was called rheumatic fever by a medical man last spread-eagle apology for the bonds of freemen is the most January, but no pain or swelling of any joint occurred, feeble, futile, and fallacious which could possibly be although at that time there was very severe pain in the imagined. Another, however, which is worse, I shall leave head, and she noticed three painful lumps rise on her head: unanswered, because it does not seem worthy of an answer. one in each temporal region, and one in the right parietal It is this, that because in the treatment of insanity certain medicines are useful, and are, so to say, a restraint upon region. Those in the temporal region soon disappeared, abnormal changes in the organism, therefore the restraint but that in the parietal became more swollen, painful, and of locked chairs and strait-waistcoats is justified. When tender, and was opened by her medical attendant, when a such an argument is used, as it was by Dr. Hughes, of St. large quantity of matter escaped, and the wound has conLouis, the quiver of the logician must be about empty. tinued to discharge pus ever since. I for make an the uncommust Finally, apology myself Six weeks ago pieces of dead bone began to come away, promising manner in which I have criticised the utterances and opinions of my professional brethren in this matter. I and on Monday, Nov. 22nd, Mr. West removed a shell of necrosed bone nearly an inch square involving the entire .am seriously afraid that it will cost me some good will in quarters where I most earnestly desire to retain it, and if thickness of the skull, which he found standing out from a this were not a question of the highest principle with me, ragged, elevated ulcer on the scalp, two smaller pieces were removed from the edges of the wound, leaving a pulsaton which I should not hesitate to sacrifice, if need be, the most cherished friendships, I would most willingly have ing mass protruding from the interior of the cranium, about been silent, or have spoken with bated breath. But that the size of a walnut, more or less globular in shape, and the American nation, whom I have learnt to know only to presenting all the characters of a hernia cerebri, except respect and to love, should remain under the incubus of this that the pulsation was not synchronous with the respiraprofessional prejudice; that the American superintendents, tion. There were exuberant granulations around the edge among whom I count some of my dearest friends, should lag of the wound, and marked tenderness and swelling of the lamentably behind the science of their age; that the greatest surrounding scalp. The patient is fairly well nourished; face somewhat reform in the treatment of mental disease, inaugurated by and among Anglo-Saxons, should be bounded by national florid, with enlarged capillaries. She states that she lost barriers, and denied to the largest community of thei flesh from the commencement of her illness up to four Anglo-Saxon race, this I could not sit down with a quiet months ago, when she was so feeble as to be unable to walk conscience silently to think upon. Far be it from me to across the room; since then, however, she has gained flesh dogmatise my psychiatric colleagues in the United States; and strength, and now feels quite well, with the exception but I may be permitted earnestly to entreat them to take a of occasional headache, not severe, and worse in the mornwide and general view of their position in their own social ing ; eyesight failing slightly during the last five or six surroundings, and in the wide world of science. My fervent weeks; no difference in size of pupils; no numbness or hope for them is that by doing so they will decide to cast twitching in the limbs; no change in intelligence or loss of behind them a narrow prejudice, and thus be able to re- memory. No history of syphilis can be elicited. On Monday, Nov. 29th, Mr. West had the patient put instate themselves in the front ranks of practical philanthropy, and in the confidence of their compatriots. They under the influence of ether, and made three exploratory are men, as I most willingly testify, animated by the highest radiating incisions through scalp, so as to expose the bone motives of humanity, but ignorant and mistaken in their in the neighbourhood of the tumour. He removed several application of means to the furtherance of that great end I pieces of necrosed bone, and discovered a hole in the crato which we all press forward-namely, to the care and nium about one inch square, through which a fungating of the insane with the least amount of suffering. That they tumour passed, which seemed to spring from the dura will do this without much delay I very confidently predict; mater. that they will sink five fathoms deep their bonds of hemp The patient went on well after the operation, and on and to a mind diseased" only medicine Dec. 6th Mr. West ordered a well-padded mould of gutta. bring and iron ; in the shape of medical and mental influence; that they percha to be applied over the tumour, so as to exercise will jealously guard the enjoyment of all innocent freedom moderate pressure upon it. This was well borne, and about

I

i cure


458 the 27th December the tumour had disappeared, and logous, according to Virchow’s recent definitions in his had cicatrised over. About this time, however, she began lectures on tumours. They originate in the layers of osteal to have occasional numbness in the extremities and loss of cells, and are composed of those cells altered in appearance speech, and on the evening of Dec. 27th she had a fit, in and degenerate in function. When, together with the which she lost consciousness; had right-sided convulsions, altered histological characters, the clinical history of the the right arm being twitched and the hand turned inwards; tumours is considered, they ought to be ranked among there was also rigidity of the right leg, twitchings of the cancerous diseases." The appearance presented by the facial muscles, and some dilatation of the right pupil. In cranial bones in my case certainly tends to confirm Mr. Tait’s the next few days the fits became more frequent, at first opinion as to the disease originating in the osteal cells, for left-sided, and afterwards general, and she died comatose the outer layer of the skull was superficially eroded over No rise of temperature took place till the space of a square inch in front of the spot where the on Jan. 2nd, 1876. the last two days, when it rose to 102°. actual perforation had taken place, while the corresponding A post-mortem examination was made on Jan. 4th. Scalp portion of the tabula vitrea and the subjacent dura mater stripped off and brain removed by Hutchinson’s method. appeared uuaffected by the cancerous disease; at that No meningitis; no effusion along the course of the vessels, point, at any rate, there could have been no pressure from but great congestion of the meninges and of the brain-sub- within, and yet the bone was softening down in such a way stance. Three or four flat hard nodules in the dura mater that probably before long a second opening into the covering the right hemisphere, about half an inch thick, cranium would have been formed. flattening the convolutions beneath, and causing absorption My case is unique in affording proof of the coexistence of the bones of the skull on which they pressed. No pro- of malignant disease in another organ. In the case which trusion from the aperture in the cranium; the brain-sub- Mr. Tait records this evidence is wanting, as he had no stance came up to the surface of the scalp, and was only opportunity of examining any of the thoracic or abdominal covered over with a thin cicatrix. On the internal surface viscera. Althoughthepatientis said to have died of tubercular of the right parietal bone, around the opening, the brain disease of the lungs, Mr. Tait seems to suggest that possibly and thickened dura mater were incorporated together, and there may have been cancer in some other organ. I believe The aperture in that in my case the disease began in the periosteal layer of were adherent to the margin of the bone. the right parietal bone was ragged and irregular in shape, the dura mater, and that although the perforation of the two inches in length by one in width. On the outer surface skull which already existed was due to the more active of the frontal bone, about an inch in front of the parietal growth of that portion of the disease which had its seat in opening, there was erosion over a space as large as a shilling, the dura mater, there was also a concomitant affection and a sequestrum of the tabula crassa was beginning to of the pericranial covering of the skull, and that another separate. Deep and disseminated in the substance of the aperture in the cranium would soon have resulted from the liver, five or six round masses, as large as a walnut, were extension of the disease from without inwards. The following points appear noteworthy in the clinical found, which, with those in the dura mater, presented all the microscopic characters of scirrhus. The lungs, heart, history of the case :-The patient had been in the habit of kidneys, and uterus were healthy, and there were no en- carrying heavy weights, and had frequently had blows on the head. It is difficult to say whether these injuries had larged abdominal glands.* Remarks.-Fungus of the dura mater is not very uncom- anything to do with the causation of the disease; probably mon, but its insidious approach, and the difficulties attend- they had, but certainly, as far as we could ascertain, ing its pathology and diagnosis, induce me to place this syphilis had not. Another feature of interest was the absence of any cerebral symptoms until within a few weeks case on record. differ her death, and their on-coming soon after the outward as the of to exact in which Pathologists category such tumours should be placed, as to whether they should growth of the tumour had been checked by the application be considered as simply fibro-plastic or as cancerous of very moderate pressure to its surface. Relief of pain growths. I incline to the opinion that this was a cancerous followed the removal of the necrosed fragments of the skull growth, from the general and microscopic appearances it on each occasion. For the establishment of a correct diagnosis, the explopresented; and I prefer to call it scirrhus from its hardness, the abundance of fibrous material in its structure, its not ratory operation undertaken on Nov. 29th was most satisbeing very vascular, and from analogous tumours existing factory ; until then I could not be positive as to the nature of the disease of the skull, and until the post-mortem exsimultaneously in the substance of the liver. Considerable variety of opinion also prevails among those amination itself, I was unaware of there being any implicawho have written on this subject as to the starting-point tion of the liver. To the tumours being small, separate, of the disease: some authors-as Louis and Chelius- and not extending to the surface of the organ, it is perhaps assigning the dura mater as the part from which the due that no symptoms of hepatic derangement, no pain or disease springs; others, as Siebold, thinking that cancer icteroid tinge of the surface, were ever present, and yet may arise in the diploe; while Mr. Oliver Pemberton, in cancerous masses must have been forming in the substance his " Clinical Illustrations of Cancer," narrates the case of of the liver for a considerable time. a woman, aged twenty-seven, in whom the cancer originated Birmingham. in the compact tissue of the cranial bones. Rindfleisch, one of the most eminent of modern German pathologists, gives the following sketch of the growth and OBSTRUCTIVE SUPPRESSION OF URINE progress of this disease:—" The fungus of the dura mater AS A CONSEQUENCE OF RENAL springs from the outer surface of the membrane, forces its CALCULUS. way along the vessels into the compact tissue of the bone, destroys the tabula vitrea, extends somewhat less actively BY JAMES MIDDLETON, M.D. in the diploe, but ultimately perforates the outermost as a of the cranial bones, protruding fungoid compact layer THE most common cause of obstructive suppression of tumour and pushing the scalp before it. Not unfrequently, too, it extends inwards through the dura mater, the opposed urine is the impaction of a calculus in the ureter of a persurfaces of the arachnoid are glued together, and then a son having only one kidney capable of secreting urine; the fungus of the pia mater becomes associated with that of other having previously become disabled by disease or accithe dura mater."t The following case, which came under observation A very good account of these tumours is given by Mr. dent. Lawson Tait in a paper entitled, 11 On the Variety of Peri- last spring, seems to possess considerable interest, as preosteal Disease of the Skull generally known as Fungus of senting a typical example of this affection. the Dura Mater," published in the British and Foreigu G. W-, a commission agent, aged forty-nine, married. Medico-Chirurgical Review for January, 1870. It contains a Though not intemperate, he had always lived freely till good résumé of the cases recorded by various authors, and within the last eighteen months, since which he has been concludes : °° These tumours may be regarded as homo- more regular in his habits. He had always enjoyed excellent health, and from childhood had" never required a * For the notes of this case I am indebted to Dr. M’Queen, senior doctor" till about three years ago, when he suffered from a house-surgeon of the Queen’s Hospital. &dag er; Rindfleisch, Pathol. Histology, vol. ii., p. 359, large carbuncle on the left hip, which was freely incised