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ON A CASE IN WHICH THE OPERATION OF CASTRATION WAS RESORTED TO FOR THE CURE OF EPILEPSY.
only be made out by careful study. The pulpy degene7-atioii of of much carelessness upon your own part. But, before conthe synovial membrane, as described by Sir B. Brodie, is one of cluding, let me try to impress upon you one point of great them; and although the surgeon may in some cases form a importance, and one which you should always attempt to reatolerably correct opinion as to its existence, these cases are ob- lize and to follow, as it will prove of immense value to you in scure in their origin and in their progress. When this disease the diagnosis of disease, as well as in its treatment-and it is is present, you will find its progress has been very gradual, and it has not been attended with much pain or tenderness; the bones will appear natural, and not enlarged ; there will not be any fluctuation or other symptom of fluid within the joint,I in its early stage the cellular tissue and integument will appear healthy and uninvolved, although at a later period it may become implicated; yet the joint, as a whole, is evidently enlarged. To the hand it gives a soft and yielding feel, especially in parts between the bones, and therefore directly over the joint and synovial membrane. This pressure will also produce an impression of elasticity, and will be somewhat peculiar to I the disease. Upon the whole, these symptoms are tolerably characteristic, and, if present, should lead you to expect the presence of that disease called the pulpy degeneration of the synovial membrane. It is not, however, a common affection. There is another disease of the synovial membrane, which I believe is more generally mistaken for the preceding, and pathologically depends upon a ch1’onic inflammation. The synovial membrane inflames and pours out a little serum, but This fibrinous effusion organizes more organizable materials. and forms a membrane upon the inner surface of the synovial membrane; a second and third layer may follow at short intervals, and the synovial membrane itself becomes considerably thicker, the same material becoming infiltrated, as it were, between its fibres. As a result, the membrane, with its new product, becomes considerably thickened, sometimes to the extent of an inch or more, and in rare cases almost filling up the joint. The progress of this disease is not unlike that which we see in chronic inflammation of the bursa patellas, when the bursa thickens by frequent deposits of fibrinous material, and I
this: In all cases of disease which you are called upon to treat, and more especially in the diseases of joints, regard the part at first purely pathologically; attempt to realize the xnnrof its different structures; recall the process by bid which structure has deviated from its healthy state; and to bring before your mental eye the present condition of the diseased structure. So that recognising the process by which the tissue has erred from its state’ of health, and, as it were, handling the part, and carefully examining its present condition, you can apply your remedy with greater certainty,4 and will do so with greater success. This plan of regarding disease increases much your interest in every case, makes the practice of the surgical profession a science, and removes it from the mere character of an art; for, instead of (like the empiric) treating symptoms alone, you direct your treatment to the causes which produce them, and. as a consequence, will become a more successful practitioner.
conditions
attempt each
ON
A CASE IN WHICH THE OPERATION OF
CASTRATION WAS RESORTED TO FOR THE CURE OF EPILEPSY. BY
JOHN
W.
OGLE, M.D., F.R.C.P.,
ASSISTANT-PHYSICIAN TO ST.
GEORGE’S
HOSPITAL.
MANY will have read with much interest the history of the in which Mr. Holthouse lately removed both testicles for the cure of epilepsy, as described in THE LANCET of the 22nd ult. The details of the case are so important, and the treattory, it is distinct. You will find that there have existed at ment adopted so novel, that, being in possession of some pardifferent intervals several attacks of inflammation, accompanied with effusion and its symptoms; and the progress, instead ticulars connected with it beyond what are given in that hisof being gradual and uniform, will be broken by the inflamma- tory, I venture to make them known. The patient who has undergone this operation came under tory attacks and their attendant symptoms. We will now pass on to a later period of the diseases of a my notice in June, 157. He had been for many years under joint; and disregarding for the present the seat of the original medical treatment in America, his native country; after which disorder, we shall find a joint presenting all the symptoms of what was called a " white swelling." This term is certainly time he had been in England for a short period.He then visited Paris, where he was under medical care; and it was a general one, and far too general for scientific men to employ to one another. It is useful to employ when we must give a after his sojourn in Paris that I saw him, and learnt the circumname to a disease which we are treating, for the public and his case, which, in most reuninitiated will have a distinct name applied to their disease; stances-revolting enough-of with those summed up so well by closely spects, corresponded and it must, therefore, be classed with such words as a tumour, Mr. P. Adair, in THE LANCET. a dropsy, an inflammation, and such-like general terms. On one or two points, however, the particulars which 1 It is the last stage, or nearly so, of a chronic disease of a and which I took at the time in writing, are more exteiicommenced in the whether that disease have, bones, synovial joint, membrane, or cartilages. All of them are involved to a greater sive than those given in THE IjANCET. In the first place, or less extent, this extent depending upon the original seat of although degrading and debilitating habits had been contracted the disorder. The external tissues have not escaped the general by the unfortunate patient at the commencement of his attacks influence; and the skin is found firm, stretched, and immov- (when but ten years old), yet, as he informed me, his disease able. The cellular tissue is infiltrated with inflammatory pro- was at the time attributed to disturbance consequent on his Before this ducts, and the joint will generally present a hard, uniform, eating green fruit in too large an abundance. " and tense swelling; the bones will be recognised, but not dis- period also, he had been the subject of prolapsus ani;" and; of my observation, he had frequently tinctly, their outlines being lost in the general infiltration. indeed, up to the time There will not, as a rule, be any distension of the synovial had this prolapsus, and also occasional bleedings by the rectum. membrane; but this will be thickened both in itself and by All this points to the supposition that intestinal irritation may deposit upon its inner surface. If there is any mobility of the at any rate have co-operated, with other causes, in giving joint, the peculiar crepitation of exposed bone will be detected; origin to, and keeping up, a predisposition to epileptic seizures. As respects the character of the seizures themselves, the and this will also be present if the patella can be at all moved. This symptom sufficiently indicates the degeneration and ab- patient stated that at the outset (i. e., about the year 1825), sorption of the articular cartilages. Upon the whole, it would i they were of about half an hour’s duration, and were attended appear we if all distinction between the tissues had disappeared, by much struggling and foaming at the mouth, and biting of and that a different structure had been deposited. The joint the tongue, and that they gradually increased in number and strength up to the year 1834, when, owing to the use of nitrate may, and will, in some cases, present many fistulous either communicating with the joint or with one of its diseased of silver, which he took daily for several months, and eventutissues, these nstulse being merely the remains of old abscesses ally at the rate of half a grain three times a day, they began in the part, and leading either into the joint or into the dis- to diminish. The attacks, which almost invariably occurred in the day time, generally were followed by much headache or eased articular extremities of the bones. I have now cursorily run over the chief points which mark in THE LANCET, this patient came to England * According to the the principal diseases of the joints, and have pointed out to on this occasion to history have tracheotomy performed, following the advice oi’ seen him in America. This I can hardly underDr. Marshall who had be considered as Hall, you the symptoms which may diagnostic of as it appears that when Dr. M. Hall saw him in America, at which time their different diseases. If you impress these upon your memory, stand, his larynx, his attacks were quite mild Dr. Horace Greene was I can hardly say you will never fall into an error of diagnosis, comparatively, and quitecauterizing free from anything like laryngismus-the only syn’prender would but I believe that it will be rare, and that it must be the result tom which tracheotomy advisable.
whfn at la.st it
mav
befnmc almost soUd-
Upon examining a joint affected with this disease, the manipular indications are not unlike those which are presented by the disease previously described; but by attending to the his-
case
openings,
156
heavy sleep on the night after, and always took place without of the frame from which some so-called aura is felt or supposed to thus seekingto arrest the affection by extirpatinga premonitory symptoms of any kind. Excepting a voracious take origin, he had never part where nervous disturbance or irritation arises, and from aupetite, from which some years ago he suffered, and any symptoms of intestinal worms. He was never benefited by which it is conducted by the nerves to the spinal centres, emetics or purgatives, and the only medicine from which he thence, as it were, reflected or distributed centrifugally, causing the nitrate of silver I spasm; or with the intention of destroying a part, the absence appeared to have derived any goodforwas several months to the of which physiologically produces the abatement or annihilataken internally, and applied daily emotions as, being unduly exercised, so greatly upper part of the larynx and pharynx by Dr. Greene, in Ame- tion of such
It seems that his general habit has been to have a re- affect the entire nervous system as to predispose to unwonted laxed state of the bowels, and occasionally diarrhoea. He excito-motor action of the muscles or bloodvessels of the body. also, at the time of my seeing him, complained of faezccrzt It is possible that it was with some such view as the last mentioned that the operation was first enjoined in epilepsy; for it cramps in the legs at 1â[Jld, and stiffaess of the leg,3 wnl hand8. When he first visited me, in 1857, his attacks, although de- appears, according to this patient, that it was originally menscribed as being more severe than they were when Dr. Greene tioned, although vaguely perhaps, as a possible method of cure in such cases, (inasmuch as epileptics were generally lascivious,) was applying the nitrate of silver to his throat (at which time Dr. Marshall Hall saw him), were, nevertheless, described as in some medical lectures at Edinburgh, which many years ago being comparatively mild. It is true they were of almost a student from Georgia was attending. This student, returning daily occurrence, but yet they were described as being not of a to America, had an epileptic patient, aged seventeen, whose severe form, nor attended by screaming, but consisted of attacks testicles, owing to injury from a fall, he was obliged to remove, of giddiness, passing on to insensibility, which, however, were and who thus got cured of his epilepsy. The case is mentioned, transient, only lasting for a few moments, during which he according to my patient, in Dr. Reece’s Medical Journal for might, or might not, drop down-the petit mal, in fact. These 1854 or 1855, a work to which I have no access. Subsequently attacks I never had the opportunity of witnessing. a neighbouring surgeon ill Tennessee tried the operation in five Not the least remarkable fact connected with the case was or six epileptic negroes with success, and the reputation of the extreme staining of the integument of the entire body pro- these cases led to some one prescribing the operation to the duced by the persistent use of the nitrate of silver. This was patient. When he wished to obtain my consent, I refused it, of a dark slate colour, those parts which were freely exposed but prescribed for him afresh the nitrate of silver, as he certo the light being by far the most affected. This change of tainly had received some benefit from it, and I thought that he colour was, however, by no means confined to the surface of could not well become more affected in the skin by it than he the body, for even the mucous membrane of the eyelids, lips, was.* It appeared also not to have injured his digestion, or inside of the cheeks and pharynx, and also the gums (except the interfered with his general health materially. I thought I half neccrest to the teeth*), were of a bluish-black colour. The could not endorse the recommendation of castration, as I could cicatrices of the various injuries, all of which he had suffered find no trace of any aura commencing in the testis and as I since the use of the nitrate of silver (for after its disuse the was of opinion that, even if the testes were removed, with the attacks came on more violently than before), were but slightly physiological view of destroying sexual desire, and so destroycoloured, as compared with the neighbouringz parts of the ing an immediate source of excessive reflex action, yet the .lein habit of epileptic attacks would probably remain. In fact, I After trying so many things in America without any perma- was very strongly opposed to the operation, under every view 1 nent or long-continued benefit, he was advised-whether em- of the case. Such are the additional remarks which my acquaintance with pirically or on rational grounds, I know not-as a last resource, to permit thetesticles to be removed; but this piece of friendly this case eighteen months ago have enabled me to make; and advice had been overruled from another quarter. The idea. that I feel quite sure that I am only echoing the wishes of many this operation was the only thing likely to do him good seemed others when I state that I hope we shall hear of its future proto have taken root in his mind, and to have developed; and when gress; and how far my fears that this most grave operation I first saw him, I must confess that he not a little surprised me would not be followed by arrest of the fits, were rational and by the urgency with which he made the strange demand that justifiable. In conclusion, I would observe, that this case of epilepsy, either tracheotomy or castration-he had not much choiceshould be performed upon him. The details of habitual and whilst under Trousseau’s care in Paris, was commented upon unrestrained indulgence of dissolute propensities afforded by his in the Gazette des Hûpitaux, Jan. 17th, 1857, but mainly with autobiography, the freedom with which they were conversed reference to the peculiar state of the skin. In that paper it is about, and his excessive craving for notoriety, had already made asserted that Trousseau had great expectations of curing the me suspicious either that, owing to the continuous concenpatient with belladonna in three months’time; but this favourtration of his mind (not in any way practically engaged) able view of the case could hardly have been entertained at the in one direction, and that a sensual one, upon himself, his Bicetre, where a seton was applied. In the medical paper just actions, and morbid feelings, it had undergone some alienation; alluded to, however, owing to the attacks of epilepsy being acor that there was some previously deranged condition of the companied by certain rotatory movements, it is surmised that mental faculties, connected or not with organic cerebral altera- some disease of the cerebellar lobes existed.II may here repeat, tion, to which his peculiar views about himself, which had the without at all wishing to be understood that I am asserting that semblance of delusions, were to be referred. But this suspicion organic cerebral or spinal lesion exists, that he was in the habit of became strengthened when I found him so vehemently insist- suffering from cramps and stiffness of the extremities. In that upon this mutilation of his person, and doubly strength- journal, also, speculations are entered upon as to the best ened when, on cross-examination, I found that whilst in Paris, method of preventing or destroying the change of colour in after his first visit to England, he had not only been under the the skin and mucous membranes so frequently care of Nelaton and Trousseau, as described in THE LANCET, by the long-continued use of nitrate of silver, especially as but that Trousseau had sent him, after a time, from the Hotel regards the use of iodide of potassium externally and internally, Dieu to the Bicêtre, where he remained from March 9th to as proposed by Patterson,!! and looked favourably on by May 27th, partly under Dr. Moreau’s care, and had a seton * It is worth recording that, according to this patient, the staining of his placed in his neck.t At the end of this time, he obtained a skin was so extreme, and rendered him so swarthy, that people in New York ticket of leave, and again came to England, as I have stated. actually would refuse to meet him, owing to their prejudióes being roused by I was very anxious to ascertain, if possible, whether the opera- their associating the coloured skin with the anti-slavery question. He was tioa for removal of the testes, as a cure for epilepsy, had ori- styled the " blue man," and was so referred to by several newspapers in Engginally been suggested empirically, or with the legitimate view land. t Had any true aura been noticed in the testicles, perhaps the effect of comof removing a presumed or known cause of his symptoms. As pression or temporary ligature of the upper part of the scrotum, and so of the far as I see any reasonableness in such a proposition, it must nerves in the spermatic cord, might have been beneficial. t I do not, of course, suppose that the operation of castration was recomeither be put forward with the intention of removing a portion rica.
I
ing
’ This colouring’ by the nitrate of silver of that portion of the gums which ,s tho mot remote from the teeth is in marked contrast with that caused by poison of lead. t There are cases on record of epileptics and lunatics attempting, and occa,;olla]]} succeeding, to perform the operation of castration upon themselves. I T’’as rather afraid that this patient might be doing the same. Such a case is l’eCérdi’d in the American Medical J01".nal for 1852, page 362, and others I Lave heard of from my friend, Dr. AVaterfield, late Commissioner in Lunacy. I I believe that epileptics are not allowed to go in the streets of Paris without an official certificate of their being fit to do so. i
the
produced
mended with a view to the production of any counter-irritation, or so-called revulsion, or in the hopes that it might act merely through the emotions. § Experiments, as of Flourens, Magendie, and quite lately of Brown-Sequard, show, of course, that spasmodic attacks, attended with rotatory motions, are more commonly traceable to parts nearer the centre of the brain at the base.
I! Dr. C. Patterson’s observations are to be seen in the D2sbLzn Medical Pres8 for 1842, and in them he states that the discoloration may be removed by the internal and external use of preparation of iodine. He also combats the theory of Dr. A. T. Thompson, that as the colour depends on the formation of a chloride of silver, it may be prevented bv the use of nitric acid alone with the nitrate of silver; and states that the colouring of the skin is not from the chloride itself, the niet-,illi(, base obtan’’Ml hv O?0()mnrniti()n ^f th
but from
157
Mialhe.**
This subject is also alluded to at page 116 of the valescent. The second case is one of some interest, from the in a quotation from the statements of Eichmann, fact of the patient, a female, aged fifty-four years, having been who says that he has succeeded in eliminating the staining of a considerable sufferer for four years from extensive disease of the skin -with nitrate of silver by frequent baths of potash and the right tibia, the result of chronic inflammation. She has soap. Such a case as the present would form a good oppor- been an inmate of the hospital for sixteen months, and has unnity for trying decisively the use of various means calculated to dergone operations for the relief of the tibial disease, but without any permanent benefit. She went out for a month to ob. disengage such a colouring of the tissues. tain change of air, and re-entered the institution. Her health Upper Brook-street, Feb. 1859. was very bad, and as the disease of the leg was so exhausting, without a possibility of cure by any direct treatment to the part itself, amputation was proposed, to which the patient consented. This proceeding was performed by Mr. Lawrence on the 29th January, who made rectangular flaps in the manner we have described on a previous occasion. OF THE PRACTICE OF When we saw the patient on the 2nd February, the stump had nearly healed, a little discharge oozing from its left side; AND union by adhesion seemed to have taken place remarkably quick, more so, indeed, than was wished, as there is a possiIN THE matter being thus retained within the interior of the stump. Her general health seems to have improved also, and HOSPITALS OF LONDON. that the removal of the limb will be followed by it is
same
journal,
A Mirror
MEDICINE
SURGERY
bility of
expected
a
Nulla est alia pro eerto noscendi via, nisi quam plurimas et morborum ett dissectionum historias, tam aliorum proprias, collectas habere et inter se com-." parare.—MORGAGNI. De Sed. et Caus. Morb., lib. 14. Proœmium.
cure.
permanent There is much but
to be said in favour of Nlr. Teale’s method of
an extended experience is still necessary be. amputating ; fore coming to any positive opinion as to the advantages it may possess over the ordinary Hap operations.
ST. BARTHOLOMEW’S HOSPITAL. CHRONIC
PEMPHIGUS,
RECURRING AFTER A CURE EFFECTED
ST. THOMAS’S HOSPITAL.
SEVERAL TIMES BY ARSENIC.
(Under the THERE is
a
of Dr.
BURROWS.) in Faith ward, Mary Ann P-,aged girl care
SEQUEL
TO THE CASE OF AXILLARY ANEURISM IN WHICH
LIGATURE
OF THE
SUBCLAVIAN ARTERY WAS PER-
FORMED.
who is on the eve of discharge from the hospital, (Under the care of Mr. LE GROS CLARK.) after recovery from an attack of chronic pemphigus of the face, IN our "Mirror" of the 15th of January, we gave the par. arms, legs, and body. She has been the subject’of the disease for five years, and has been successfully treated for it in other ticulars of an instance of recent axillary aneurism in a healthy aged forty, with the progress of his case to the sixth day hospitals, as well as in St. Bartholomew’s, by the administra- man, tion of some one of the preparations of arsenic. Soon after she after deligation of the subclavian artery in the third part of its by Mr. Le Gros dark; We now append the terminaquits the hospital, however, the bullse (so characteristic of the course tion of this interesting and at one time most promising case; affection) reappear, with much pain, uneasiness, and itching. is and it with regret we have to mention that it ended fatally, is health stated to be all Her general at times pretty good, and the only irregularity about her is that she has never menstruated. entirely through imprudence on the part of the patient himself, The bullse have appeared all over the face, and, although now who, in a paroxysm of anger, shook his maimed limb at a inmate of the same ward; this detached the ligatemporarily cured, have left an uniform deep crimson colour, neighbouring ture, and was followed by repeated attacks of haemorrhage, which simulates that seen in extensive congenital discolora- with dissolution four daysafter its first occurrence. The posttions of the face. The chronic form of pemphigus, described kindly furnished us by Mr. Sidney Jones, made a most careful dissection, follow the notes of the by Willan and Bateman under the name of pompholix, is re- who presented in the case of this girl; for, so far as we can learn, case. to the thirteenth day, this patient was without a single the bullar eruption has not been attended by any fever or in- untoward symptom. He slept tranquilly, his appetite was flammation, as is noticed in the acute form. The chronic form good, and his allowance of food liberal. The standard of his is stated to be more common in adult and old men than in pulse was unvarying, not exceeding 80, soft, and regular. He Cazenave speaks of a man, thirty years of age, in one was free from pain; the healthy suppuration from the wound women. of M. Biett’s wards, who had been subject to bullse in various was daily diminishing, and the wound itself had almost closed, only a granulating surface, and the orifice from which parts of his body from infancy, and who remained uncured. We leaving The sac was soft, and had shrunk so as to the have ourselves seen, in the Hospital of St. Louis, in Paris, two be but little perceptible beneath the pectoral muscle, and it instances in old women, who were the subjects of the disease was entirely free from all tenderness. On the night of that. day, or rather the early morning followfor many years. Should the uterine functions in Dr. Burrows hemorrhage first occurred, and the immediate cause of patient at any time assume their natural condition, they may ing, unlooked-for disaster was not ascertained until two days this most materially influence the permanent cure of the malady. had elapsed. Some of the patients then stated that Dhad quarrelled with a neighbouring inmate of the ward, and, E:1IIPLOYMENT OF RECTANGULAR FLAPS IN AMPUTATIONS. to his naturally violent temper, had risen in bed and ’ yielding (Under the care of Mr. LAWRENCE.) shaken the fist of the maimed limb in this paroxysm of anger. Mr. Teale’s method of amputation by means of rectangular in spite of the strict injunctions he had received not to attempt flaps has been tried in two instances by Mr. Lawrence, with, to raise himself in bed, nor to move the arm in the slightest we may say, good results. In the first case, the patient, a degree. On lying down, he exclaimed that he was bleeding. man, did not go on well; the stump had to be laid open, but Immediately, a severe and prolonged shivering fit ensued, sucultimately it healed, and the patient is at the present time con- ceeded by vomiting. There was but little blood lost, for pressure soon arrested the haemorrhage; and some brandy was chloride. Dr. Patterson also comes to the conclusion, that, to prevent the deposit given by the sister, which stopped the rigor. This occurred of the silver which colours the skin, we must give some salt of silver in the place of the nitrate, which is not capable of being acted on by chlorine or the between four and six o’clock. When seen by Mr. Le Gros sun’s rays, such as the ioduret of silver, which remedy, accordingly, he recomClark at nine, the pulse had risen to 130; the skin was hot. mends in doses of a quarter of a grain, in epilepsy, hooping-cough, and such with occasional perspiration. The ligature was found lying diseases of the mucous membrane as are ordinarily treated with the nitrate of loose in the wound, and he admitted having felt a painful jerk silver. I may state here, that some oculists have attempted the removal of the dis- at this spot just before the bleeding took place. coloration of the conjunctivae, caused by the use of nitrate of silver applied to Prior to the above explanation of the patient’sviolence, it the eye, by means of a lotion formed with solutions of cyanuret of potassium. was conjectured that suppuration of the sac might be com* See the Supplement au Dictionnaire Universale de Matiere Medicate of mencing, and yet there had not been a single premomtors 60.
eighteen,
mortem appearances, Up ligature hung.
I
1846, p.
_
158
this: In all cases of disease which you are called upon to treat, and more especially in the diseases of joints, regard the part at first purely pathologically; attempt to realize the xnnrof its different structures; recall the process by bid which structure has deviated from its healthy state; and to bring before your mental eye the present condition of the diseased structure. So that recognising the process by which the tissue has erred from its state’ of health, and, as it were, handling the part, and carefully examining its present condition, you can apply your remedy with greater certainty,4 and will do so with greater success. This plan of regarding disease increases much your interest in every case, makes the practice of the surgical profession a science, and removes it from the mere character of an art; for, instead of (like the empiric) treating symptoms alone, you direct your treatment to the causes which produce them, and. as a consequence, will become a more successful practitioner.
conditions
attempt each
ON
A CASE IN WHICH THE OPERATION OF
CASTRATION WAS RESORTED TO FOR THE CURE OF EPILEPSY. BY
JOHN
W.
OGLE, M.D., F.R.C.P.,
ASSISTANT-PHYSICIAN TO ST.
GEORGE’S
HOSPITAL.
MANY will have read with much interest the history of the in which Mr. Holthouse lately removed both testicles for the cure of epilepsy, as described in THE LANCET of the 22nd ult. The details of the case are so important, and the treattory, it is distinct. You will find that there have existed at ment adopted so novel, that, being in possession of some pardifferent intervals several attacks of inflammation, accompanied with effusion and its symptoms; and the progress, instead ticulars connected with it beyond what are given in that hisof being gradual and uniform, will be broken by the inflamma- tory, I venture to make them known. The patient who has undergone this operation came under tory attacks and their attendant symptoms. We will now pass on to a later period of the diseases of a my notice in June, 157. He had been for many years under joint; and disregarding for the present the seat of the original medical treatment in America, his native country; after which disorder, we shall find a joint presenting all the symptoms of what was called a " white swelling." This term is certainly time he had been in England for a short period.He then visited Paris, where he was under medical care; and it was a general one, and far too general for scientific men to employ to one another. It is useful to employ when we must give a after his sojourn in Paris that I saw him, and learnt the circumname to a disease which we are treating, for the public and his case, which, in most reuninitiated will have a distinct name applied to their disease; stances-revolting enough-of with those summed up so well by closely spects, corresponded and it must, therefore, be classed with such words as a tumour, Mr. P. Adair, in THE LANCET. a dropsy, an inflammation, and such-like general terms. On one or two points, however, the particulars which 1 It is the last stage, or nearly so, of a chronic disease of a and which I took at the time in writing, are more exteiicommenced in the whether that disease have, bones, synovial joint, membrane, or cartilages. All of them are involved to a greater sive than those given in THE IjANCET. In the first place, or less extent, this extent depending upon the original seat of although degrading and debilitating habits had been contracted the disorder. The external tissues have not escaped the general by the unfortunate patient at the commencement of his attacks influence; and the skin is found firm, stretched, and immov- (when but ten years old), yet, as he informed me, his disease able. The cellular tissue is infiltrated with inflammatory pro- was at the time attributed to disturbance consequent on his Before this ducts, and the joint will generally present a hard, uniform, eating green fruit in too large an abundance. " and tense swelling; the bones will be recognised, but not dis- period also, he had been the subject of prolapsus ani;" and; of my observation, he had frequently tinctly, their outlines being lost in the general infiltration. indeed, up to the time There will not, as a rule, be any distension of the synovial had this prolapsus, and also occasional bleedings by the rectum. membrane; but this will be thickened both in itself and by All this points to the supposition that intestinal irritation may deposit upon its inner surface. If there is any mobility of the at any rate have co-operated, with other causes, in giving joint, the peculiar crepitation of exposed bone will be detected; origin to, and keeping up, a predisposition to epileptic seizures. As respects the character of the seizures themselves, the and this will also be present if the patella can be at all moved. This symptom sufficiently indicates the degeneration and ab- patient stated that at the outset (i. e., about the year 1825), sorption of the articular cartilages. Upon the whole, it would i they were of about half an hour’s duration, and were attended appear we if all distinction between the tissues had disappeared, by much struggling and foaming at the mouth, and biting of and that a different structure had been deposited. The joint the tongue, and that they gradually increased in number and strength up to the year 1834, when, owing to the use of nitrate may, and will, in some cases, present many fistulous either communicating with the joint or with one of its diseased of silver, which he took daily for several months, and eventutissues, these nstulse being merely the remains of old abscesses ally at the rate of half a grain three times a day, they began in the part, and leading either into the joint or into the dis- to diminish. The attacks, which almost invariably occurred in the day time, generally were followed by much headache or eased articular extremities of the bones. I have now cursorily run over the chief points which mark in THE LANCET, this patient came to England * According to the the principal diseases of the joints, and have pointed out to on this occasion to history have tracheotomy performed, following the advice oi’ seen him in America. This I can hardly underDr. Marshall who had be considered as Hall, you the symptoms which may diagnostic of as it appears that when Dr. M. Hall saw him in America, at which time their different diseases. If you impress these upon your memory, stand, his larynx, his attacks were quite mild Dr. Horace Greene was I can hardly say you will never fall into an error of diagnosis, comparatively, and quitecauterizing free from anything like laryngismus-the only syn’prender would but I believe that it will be rare, and that it must be the result tom which tracheotomy advisable.
whfn at la.st it
mav
befnmc almost soUd-
Upon examining a joint affected with this disease, the manipular indications are not unlike those which are presented by the disease previously described; but by attending to the his-
case
openings,
156
heavy sleep on the night after, and always took place without of the frame from which some so-called aura is felt or supposed to thus seekingto arrest the affection by extirpatinga premonitory symptoms of any kind. Excepting a voracious take origin, he had never part where nervous disturbance or irritation arises, and from aupetite, from which some years ago he suffered, and any symptoms of intestinal worms. He was never benefited by which it is conducted by the nerves to the spinal centres, emetics or purgatives, and the only medicine from which he thence, as it were, reflected or distributed centrifugally, causing the nitrate of silver I spasm; or with the intention of destroying a part, the absence appeared to have derived any goodforwas several months to the of which physiologically produces the abatement or annihilataken internally, and applied daily emotions as, being unduly exercised, so greatly upper part of the larynx and pharynx by Dr. Greene, in Ame- tion of such
It seems that his general habit has been to have a re- affect the entire nervous system as to predispose to unwonted laxed state of the bowels, and occasionally diarrhoea. He excito-motor action of the muscles or bloodvessels of the body. also, at the time of my seeing him, complained of faezccrzt It is possible that it was with some such view as the last mentioned that the operation was first enjoined in epilepsy; for it cramps in the legs at 1â[Jld, and stiffaess of the leg,3 wnl hand8. When he first visited me, in 1857, his attacks, although de- appears, according to this patient, that it was originally menscribed as being more severe than they were when Dr. Greene tioned, although vaguely perhaps, as a possible method of cure in such cases, (inasmuch as epileptics were generally lascivious,) was applying the nitrate of silver to his throat (at which time Dr. Marshall Hall saw him), were, nevertheless, described as in some medical lectures at Edinburgh, which many years ago being comparatively mild. It is true they were of almost a student from Georgia was attending. This student, returning daily occurrence, but yet they were described as being not of a to America, had an epileptic patient, aged seventeen, whose severe form, nor attended by screaming, but consisted of attacks testicles, owing to injury from a fall, he was obliged to remove, of giddiness, passing on to insensibility, which, however, were and who thus got cured of his epilepsy. The case is mentioned, transient, only lasting for a few moments, during which he according to my patient, in Dr. Reece’s Medical Journal for might, or might not, drop down-the petit mal, in fact. These 1854 or 1855, a work to which I have no access. Subsequently attacks I never had the opportunity of witnessing. a neighbouring surgeon ill Tennessee tried the operation in five Not the least remarkable fact connected with the case was or six epileptic negroes with success, and the reputation of the extreme staining of the integument of the entire body pro- these cases led to some one prescribing the operation to the duced by the persistent use of the nitrate of silver. This was patient. When he wished to obtain my consent, I refused it, of a dark slate colour, those parts which were freely exposed but prescribed for him afresh the nitrate of silver, as he certo the light being by far the most affected. This change of tainly had received some benefit from it, and I thought that he colour was, however, by no means confined to the surface of could not well become more affected in the skin by it than he the body, for even the mucous membrane of the eyelids, lips, was.* It appeared also not to have injured his digestion, or inside of the cheeks and pharynx, and also the gums (except the interfered with his general health materially. I thought I half neccrest to the teeth*), were of a bluish-black colour. The could not endorse the recommendation of castration, as I could cicatrices of the various injuries, all of which he had suffered find no trace of any aura commencing in the testis and as I since the use of the nitrate of silver (for after its disuse the was of opinion that, even if the testes were removed, with the attacks came on more violently than before), were but slightly physiological view of destroying sexual desire, and so destroycoloured, as compared with the neighbouringz parts of the ing an immediate source of excessive reflex action, yet the .lein habit of epileptic attacks would probably remain. In fact, I After trying so many things in America without any perma- was very strongly opposed to the operation, under every view 1 nent or long-continued benefit, he was advised-whether em- of the case. Such are the additional remarks which my acquaintance with pirically or on rational grounds, I know not-as a last resource, to permit thetesticles to be removed; but this piece of friendly this case eighteen months ago have enabled me to make; and advice had been overruled from another quarter. The idea. that I feel quite sure that I am only echoing the wishes of many this operation was the only thing likely to do him good seemed others when I state that I hope we shall hear of its future proto have taken root in his mind, and to have developed; and when gress; and how far my fears that this most grave operation I first saw him, I must confess that he not a little surprised me would not be followed by arrest of the fits, were rational and by the urgency with which he made the strange demand that justifiable. In conclusion, I would observe, that this case of epilepsy, either tracheotomy or castration-he had not much choiceshould be performed upon him. The details of habitual and whilst under Trousseau’s care in Paris, was commented upon unrestrained indulgence of dissolute propensities afforded by his in the Gazette des Hûpitaux, Jan. 17th, 1857, but mainly with autobiography, the freedom with which they were conversed reference to the peculiar state of the skin. In that paper it is about, and his excessive craving for notoriety, had already made asserted that Trousseau had great expectations of curing the me suspicious either that, owing to the continuous concenpatient with belladonna in three months’time; but this favourtration of his mind (not in any way practically engaged) able view of the case could hardly have been entertained at the in one direction, and that a sensual one, upon himself, his Bicetre, where a seton was applied. In the medical paper just actions, and morbid feelings, it had undergone some alienation; alluded to, however, owing to the attacks of epilepsy being acor that there was some previously deranged condition of the companied by certain rotatory movements, it is surmised that mental faculties, connected or not with organic cerebral altera- some disease of the cerebellar lobes existed.II may here repeat, tion, to which his peculiar views about himself, which had the without at all wishing to be understood that I am asserting that semblance of delusions, were to be referred. But this suspicion organic cerebral or spinal lesion exists, that he was in the habit of became strengthened when I found him so vehemently insist- suffering from cramps and stiffness of the extremities. In that upon this mutilation of his person, and doubly strength- journal, also, speculations are entered upon as to the best ened when, on cross-examination, I found that whilst in Paris, method of preventing or destroying the change of colour in after his first visit to England, he had not only been under the the skin and mucous membranes so frequently care of Nelaton and Trousseau, as described in THE LANCET, by the long-continued use of nitrate of silver, especially as but that Trousseau had sent him, after a time, from the Hotel regards the use of iodide of potassium externally and internally, Dieu to the Bicêtre, where he remained from March 9th to as proposed by Patterson,!! and looked favourably on by May 27th, partly under Dr. Moreau’s care, and had a seton * It is worth recording that, according to this patient, the staining of his placed in his neck.t At the end of this time, he obtained a skin was so extreme, and rendered him so swarthy, that people in New York ticket of leave, and again came to England, as I have stated. actually would refuse to meet him, owing to their prejudióes being roused by I was very anxious to ascertain, if possible, whether the opera- their associating the coloured skin with the anti-slavery question. He was tioa for removal of the testes, as a cure for epilepsy, had ori- styled the " blue man," and was so referred to by several newspapers in Engginally been suggested empirically, or with the legitimate view land. t Had any true aura been noticed in the testicles, perhaps the effect of comof removing a presumed or known cause of his symptoms. As pression or temporary ligature of the upper part of the scrotum, and so of the far as I see any reasonableness in such a proposition, it must nerves in the spermatic cord, might have been beneficial. t I do not, of course, suppose that the operation of castration was recomeither be put forward with the intention of removing a portion rica.
I
ing
’ This colouring’ by the nitrate of silver of that portion of the gums which ,s tho mot remote from the teeth is in marked contrast with that caused by poison of lead. t There are cases on record of epileptics and lunatics attempting, and occa,;olla]]} succeeding, to perform the operation of castration upon themselves. I T’’as rather afraid that this patient might be doing the same. Such a case is l’eCérdi’d in the American Medical J01".nal for 1852, page 362, and others I Lave heard of from my friend, Dr. AVaterfield, late Commissioner in Lunacy. I I believe that epileptics are not allowed to go in the streets of Paris without an official certificate of their being fit to do so. i
the
produced
mended with a view to the production of any counter-irritation, or so-called revulsion, or in the hopes that it might act merely through the emotions. § Experiments, as of Flourens, Magendie, and quite lately of Brown-Sequard, show, of course, that spasmodic attacks, attended with rotatory motions, are more commonly traceable to parts nearer the centre of the brain at the base.
I! Dr. C. Patterson’s observations are to be seen in the D2sbLzn Medical Pres8 for 1842, and in them he states that the discoloration may be removed by the internal and external use of preparation of iodine. He also combats the theory of Dr. A. T. Thompson, that as the colour depends on the formation of a chloride of silver, it may be prevented bv the use of nitric acid alone with the nitrate of silver; and states that the colouring of the skin is not from the chloride itself, the niet-,illi(, base obtan’’Ml hv O?0()mnrniti()n ^f th
but from
157
Mialhe.**
This subject is also alluded to at page 116 of the valescent. The second case is one of some interest, from the in a quotation from the statements of Eichmann, fact of the patient, a female, aged fifty-four years, having been who says that he has succeeded in eliminating the staining of a considerable sufferer for four years from extensive disease of the skin -with nitrate of silver by frequent baths of potash and the right tibia, the result of chronic inflammation. She has soap. Such a case as the present would form a good oppor- been an inmate of the hospital for sixteen months, and has unnity for trying decisively the use of various means calculated to dergone operations for the relief of the tibial disease, but without any permanent benefit. She went out for a month to ob. disengage such a colouring of the tissues. tain change of air, and re-entered the institution. Her health Upper Brook-street, Feb. 1859. was very bad, and as the disease of the leg was so exhausting, without a possibility of cure by any direct treatment to the part itself, amputation was proposed, to which the patient consented. This proceeding was performed by Mr. Lawrence on the 29th January, who made rectangular flaps in the manner we have described on a previous occasion. OF THE PRACTICE OF When we saw the patient on the 2nd February, the stump had nearly healed, a little discharge oozing from its left side; AND union by adhesion seemed to have taken place remarkably quick, more so, indeed, than was wished, as there is a possiIN THE matter being thus retained within the interior of the stump. Her general health seems to have improved also, and HOSPITALS OF LONDON. that the removal of the limb will be followed by it is
same
journal,
A Mirror
MEDICINE
SURGERY
bility of
expected
a
Nulla est alia pro eerto noscendi via, nisi quam plurimas et morborum ett dissectionum historias, tam aliorum proprias, collectas habere et inter se com-." parare.—MORGAGNI. De Sed. et Caus. Morb., lib. 14. Proœmium.
cure.
permanent There is much but
to be said in favour of Nlr. Teale’s method of
an extended experience is still necessary be. amputating ; fore coming to any positive opinion as to the advantages it may possess over the ordinary Hap operations.
ST. BARTHOLOMEW’S HOSPITAL. CHRONIC
PEMPHIGUS,
RECURRING AFTER A CURE EFFECTED
ST. THOMAS’S HOSPITAL.
SEVERAL TIMES BY ARSENIC.
(Under the THERE is
a
of Dr.
BURROWS.) in Faith ward, Mary Ann P-,aged girl care
SEQUEL
TO THE CASE OF AXILLARY ANEURISM IN WHICH
LIGATURE
OF THE
SUBCLAVIAN ARTERY WAS PER-
FORMED.
who is on the eve of discharge from the hospital, (Under the care of Mr. LE GROS CLARK.) after recovery from an attack of chronic pemphigus of the face, IN our "Mirror" of the 15th of January, we gave the par. arms, legs, and body. She has been the subject’of the disease for five years, and has been successfully treated for it in other ticulars of an instance of recent axillary aneurism in a healthy aged forty, with the progress of his case to the sixth day hospitals, as well as in St. Bartholomew’s, by the administra- man, tion of some one of the preparations of arsenic. Soon after she after deligation of the subclavian artery in the third part of its by Mr. Le Gros dark; We now append the terminaquits the hospital, however, the bullse (so characteristic of the course tion of this interesting and at one time most promising case; affection) reappear, with much pain, uneasiness, and itching. is and it with regret we have to mention that it ended fatally, is health stated to be all Her general at times pretty good, and the only irregularity about her is that she has never menstruated. entirely through imprudence on the part of the patient himself, The bullse have appeared all over the face, and, although now who, in a paroxysm of anger, shook his maimed limb at a inmate of the same ward; this detached the ligatemporarily cured, have left an uniform deep crimson colour, neighbouring ture, and was followed by repeated attacks of haemorrhage, which simulates that seen in extensive congenital discolora- with dissolution four daysafter its first occurrence. The posttions of the face. The chronic form of pemphigus, described kindly furnished us by Mr. Sidney Jones, made a most careful dissection, follow the notes of the by Willan and Bateman under the name of pompholix, is re- who presented in the case of this girl; for, so far as we can learn, case. to the thirteenth day, this patient was without a single the bullar eruption has not been attended by any fever or in- untoward symptom. He slept tranquilly, his appetite was flammation, as is noticed in the acute form. The chronic form good, and his allowance of food liberal. The standard of his is stated to be more common in adult and old men than in pulse was unvarying, not exceeding 80, soft, and regular. He Cazenave speaks of a man, thirty years of age, in one was free from pain; the healthy suppuration from the wound women. of M. Biett’s wards, who had been subject to bullse in various was daily diminishing, and the wound itself had almost closed, only a granulating surface, and the orifice from which parts of his body from infancy, and who remained uncured. We leaving The sac was soft, and had shrunk so as to the have ourselves seen, in the Hospital of St. Louis, in Paris, two be but little perceptible beneath the pectoral muscle, and it instances in old women, who were the subjects of the disease was entirely free from all tenderness. On the night of that. day, or rather the early morning followfor many years. Should the uterine functions in Dr. Burrows hemorrhage first occurred, and the immediate cause of patient at any time assume their natural condition, they may ing, unlooked-for disaster was not ascertained until two days this most materially influence the permanent cure of the malady. had elapsed. Some of the patients then stated that Dhad quarrelled with a neighbouring inmate of the ward, and, E:1IIPLOYMENT OF RECTANGULAR FLAPS IN AMPUTATIONS. to his naturally violent temper, had risen in bed and ’ yielding (Under the care of Mr. LAWRENCE.) shaken the fist of the maimed limb in this paroxysm of anger. Mr. Teale’s method of amputation by means of rectangular in spite of the strict injunctions he had received not to attempt flaps has been tried in two instances by Mr. Lawrence, with, to raise himself in bed, nor to move the arm in the slightest we may say, good results. In the first case, the patient, a degree. On lying down, he exclaimed that he was bleeding. man, did not go on well; the stump had to be laid open, but Immediately, a severe and prolonged shivering fit ensued, sucultimately it healed, and the patient is at the present time con- ceeded by vomiting. There was but little blood lost, for pressure soon arrested the haemorrhage; and some brandy was chloride. Dr. Patterson also comes to the conclusion, that, to prevent the deposit given by the sister, which stopped the rigor. This occurred of the silver which colours the skin, we must give some salt of silver in the place of the nitrate, which is not capable of being acted on by chlorine or the between four and six o’clock. When seen by Mr. Le Gros sun’s rays, such as the ioduret of silver, which remedy, accordingly, he recomClark at nine, the pulse had risen to 130; the skin was hot. mends in doses of a quarter of a grain, in epilepsy, hooping-cough, and such with occasional perspiration. The ligature was found lying diseases of the mucous membrane as are ordinarily treated with the nitrate of loose in the wound, and he admitted having felt a painful jerk silver. I may state here, that some oculists have attempted the removal of the dis- at this spot just before the bleeding took place. coloration of the conjunctivae, caused by the use of nitrate of silver applied to Prior to the above explanation of the patient’sviolence, it the eye, by means of a lotion formed with solutions of cyanuret of potassium. was conjectured that suppuration of the sac might be com* See the Supplement au Dictionnaire Universale de Matiere Medicate of mencing, and yet there had not been a single premomtors 60.
eighteen,
mortem appearances, Up ligature hung.
I
1846, p.
_
158