Reports of Societies.

THE LOUISVILLE CLINICAL SOCIETY.*

Stated Meeting, October 22, 1901, the President, Ewing Marshall, M. D., in the Chair.

Multiple Sebaceous Tumors of the Scalp. Dr. Ewing Marshall: This gentleman, Mr. S., age forty-three years, was operated upon by me a week ago last Friday; I removed six sebaceous tumors from his scalp. I brought with me two of the tumors, not because of their rarity but because of their size; you will notice they are fully as large as hen eggs. I have never seen any as large as this before in the scalp.

There were six of these growths, and he thinks they date back at least twenty years, and they made a very ugly appearance before he was operated upon. With the larger tumors considerable portions of the scalp were taken away, and while the remaining scars are not perfectly smooth at present, I believe they will become so later.

The points of interest in the case are, first, the duration of these growths; second, the number, and third, the large size of several of them.

Chloroform was given as the anesthetic, and just as I was removing the sixth growth the patient's face became purple, his respiration was bad, and I was considerably worried about his condition. Believing that it would be a great calamity to lose a patient under such a simple operation, I hurried too much over removal of the sixth tumor, causing me to overlook a twin tumor, and that is the principal reason I asked the patient to come before you. I took one growth out at the right side of the back of the neck, just above the hair line, and when I came to dress his head afterward I found that a twin tumor had been left behind.

In thinking over the matter, the subject of the anesthetic came up. I have seen it suggested somewhere to have a veil or cover between the patient's head and the operator; of course this would not be feasible where you are operating upon the head, as in this case, but in any other part of the body it would relieve you of any anxiety about the patient, or the person giving the anesthetic being annoyed by the operator. Dr. Griffiths assisted me in the operation upon this patient.

Cyst of the Epiglottis.

Dr. M. F. Coomes: The following case is reported simply on account of its rarity. Ten weeks ago I was asked to

* Stenographically reported for this journal by C. C. Mapes, Louisville, Ky.

see a colored woman who had a cyst occupying the front of the epiglottis ; the growth covered the entire front of the epiglottis, with the exception perhaps of a line in width on one side. The tumor was fully the size of a large plum, and was perfectly cystic. It looked exactly like a “fish bladder." This growth caused no inconvenience by its presence, and the patient did not appear to know any thing about it.

Cysts of the larynx do occur occasionally, but I have searched the literature and can find no mention of the report of a case of cyst in this exact location. The woman promised to come back and allow me to remove the growth, but she failed to do so.

The

Discussion. Dr. S. G. Dabney: I had a case in many respects very similar to the one reported by Dr. Coomes, about two years ago. patient was a lady, aged fifty-five years. She was in bad health in other respects; in fact, a chronic invalid. I was asked to see this patient by a general practitioner, for some trouble about her throat. She, however, had much more decided subjective symptoms than the case reported, probably because of the location of the growth. It grew apparently from about the junction of the epiglottis, with the fold that runs around toward the arytenoid. When I saw her the pyriform sinus was occupied by a perfectly clear, transparent mass of considerable size. It adapted itself to the shape of the cavity in which it was contained, so that it would be easily compressed, and under certain conditions it would lap over on the windpipe and slightly obstruct respiration, and this was what she complained of. She had no pain; enlargement of the growth had been gradual, and it had existed for several years. I was anxious to remove the growth en masse and examine it, but as soon as my instrument (snare) tightened around it, the tumor collapsed. It had perfectly fluid contents.

I did not examine the literature of the subject at the time, but this is the only cyst in that location that I have seen.

Depressed Fracture of the Skull. Dr. Irvin Abell : A negro was brought into the city hospital last Saturday night with a depressed fracture of the left temporal fossa; this depression was one inch long and three quarters of an inch wide. Upon removing the depressed bone it was found there was a slight laceration of the dura, and a little blood issuing from it. Opening the dura at that point, it was discovered that laceration of a small vein in the fissure of Sylvius was causing the hemorrhage. The only symptom the man presented because of the fracture was that of loss of speech. It is now over forty-two hours since the operation, and

his general condition is perfect, but he is only able to utter a few monosyllables. His mental condition is clear, and he can write answers to any questions asked him. The only other symptom is a slight paralysis of the muscles of the tongue of the left side.

The slight hemorrhage and consequent pressure should not cause such symptoms as these. I take it his symptoms are due to injury of the center at that point.

I would like to ask the opinion of the members as to the probable ultimate outcome of the case; in the event he recovers, what will be his condition of speech?

Discussion. Dr. C. Weidner: The case is interesting, from the fact that it beautifully illustrates the accepted view of the physiology of the parts concerned in this injury.

As to the probable outcome, I do not know that I can give an opinion; I suppose the doctor will have to wait. There is possibly a certain amount of congestion, or a condition of edema has taken place, and there may be improvement in a short time. Frequently the acute symptoms are much worse than later on, for the reason that we have an acute hyperemia, and possibly an edema, which may wear off after a certain amount of time has elapsed.

Dr. J. W. Irwin : The case is interesting because it shows the physiology of what has been long recognized. The injury seemed to have occurred above the center of speech; I believe the center of speech is three fourths of an inch lower down, situated, of course, in part of the anterior portion of the brain. It is possible that there is in this case nothing but what might be called a relative lesion. Any shock in that neighborhood might have paralyzed that part of the brain. Shock or a blow at or near the center of speech might cause a certain amount of loss of speech. If that is the case, he will entirely regain his speech, and I believe this will occur.

Dr. M. F. Coomes: An interesting condition is the paralysis of the tongue. I have seen but two cases of motor paralysis of the tongue. The paralysis in this case proves conclusively that the man received other injuries aside from fracture of the skull. If you will recall your anatomy you will find that the tongue is supplied by a special nerve of motion, and that nerve does not perform any function save to furnish the tongue with motion.

During the past summer a little girl was brought to my office by her

mother, who said that the girl could not speak very plainly, and that in sticking out her tongue it would go to one side. After looking over the case carefully I insisted that the child had been injured. The mother said this was not true, but the next day she came back to tell me that a few days before the little girl had turned her head around to one side suddenly, and it had remained in that position for a long time, and that a doctor had to be called to get it back, etc.

The second case was in the person of an elderly man. He had motor paralysis of the tongue, but was otherwise perfectly well. The only cause for the trouble that could be discovered was that the man had been to a dentist; he said the dentist took an impression of his mouth and nearly broke his neck. I am sure that the dentist was the causative factor in this case; that he stretched the motor nerve while the patient was in his chair, and that the injury was produced in this way.

In the case reported by Dr. Abell the patient must have had his neck twisted at the time of the injury to the skull. I believe the man will regain his speech. (This man made complete recovery, regaining his speech.)

Dr. Ewing Marshall: I have seen a number of head injuries where speech has been lost, and must disagree with Doctors Irwin and Coomes about its being so certain that perfect recovery will take place. On the other hand, I have seen cases where after removal of spiculæ of bone from the brain in this region, when the patients recovered from the effects of the anesthetic, the power of speech would be restored.

The first experience of this kind I had was a case in which I was associated with Dr. Roberts. A man had fallen from a railroad bridge and struck some rocks. I saw him at the end of thirty-six hours after the accident, and Dr. Roberts was called in consultation. He cut down over the injury and removed a spicula of bone-a long thin sliver of bone almost like a knife-blade-which had been jammed down into the brain, and supposed that was all of it. When the man came from under the influence of the anesthetic he could speak, the first word he had spoken since receipt of the injury. That patient did well for a year or more, when secondary troubles developed and he died from abscess of the brain.

In injuries to the brain, where there is any destruction of brain tissue, we can not always give a favorable prognosis.

Dr. Irvin Abell: The paralysis of the tongue, in this case, being on the same side as the injury, is a little peculiar. It seemed to me that the injury was very near the speech center, over the inferior frontal convolution.

The essay of the evening, on "Emotional Insanity," etc., was read by Ewing Marshall, M. D. [See page 441.]

Discussion. Dr. Carl Weidner: I agree with the essayist in every respect as to the management of these cases. He is right in saying they ought to be taken charge of in the proper way in an institution, either temporarily or permanently. The expression homicidal or suicidal tendency usually makes a most marked impression upon an average jury, while the physician will see many other aspects of the case to make him believe the patient ought to be confined to an institution.

As to the sexual forms of insanity: I have seen quite a number of these cases, and some of them undoubtedly make beautiful recoveries. I recall two such instances, one in a young man, the other in a young girl. The young man represented a typical case of this form of insanity; one of the prominent symptoms being Onanism. He masturbated for a number of years. He was sent to an asylum, and was discharged after a year's time as cured. He was mentally perfectly bright, had a good education, and showed by an ordinary examination no defective condition of the mind.

I knew a young lady, a sister of this young man, who I think had some sexual derangement. She was well developed physically, had had some uterine trouble, was ready to try all kinds of patent medicines, etc. She developed a peculiar form of melancholia, and at the same time she was ready to attack her parents or any of her friends. She soon developed all the symptoms such as we see in mania. Sitting in her room one day she smeared the contents of the chamber and an inkstand over herself. I advised her parents that she be sent to an institution where she could be properly cared for. Not more than five days later she got married, and from all reports I have been able to obtain since, she has been cured. There was a neurasthenic history in these cases, particularly on the mother's side.

I believe all cases of this kind ought to be sent promptly to an institution, particularly, as Dr. Marshall has stated, when they present these two factors, when they are ready to attack someone else, or commit suicide. Still we frequently have trouble in bringing these cases before a jury to prove that they are insane, the term insanity has such a wide range. The causation of these troubles we know very little about. I am astonished to hear that alcoholism seems accountable for such a large percentage of cases; on the other hand, that such a small percentage