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ON TRACHEOTOMY IN EPILEPSIA LARYNGEA.
308 situated over the uterine vein oil the left side." The arteries epilepsia laryngea. In several cases not only have the comrunning in the plexuses under the peritonaeum Sir Charles Bell plexion and the general appearance and the general health said demonstrated that they were not bands of elastic tissue, been greatly improved by tracheotomy, but the impaired mind, itself has become restored. This was remarkably the case ill or modifications of cellular substance or fibrous matter." Mr. Markarsie’s, Dr. Neill’s, and Dr. Bucknill’s patients. (To be continued.) The sources of danger to life in epilepsy are-apoplectic asphyxia and, as in tetanus, exhaustion of the nervous powers -that is, coma, and laryngeal or bronchial asphyxia from ON paralysis of the pneumogastric nerves, and exhaustion and TRACHEOTOMY IN EPILEPSIA LARYNGEA. sinking from the violence and repetition of the attacks. All these are questions, not for hasty and superficial criticism, BY MARSHALL HALL, M.D., F.R.S., &c. but for patient and careful investigation. And now to the proper subject of this communication. I Now resume the question of the institution of tracheotomy There are Two cases of epilepsy in which,the propriety and in epilepsy. In doing this, I present to the readers of THE LANCET the results of several years of careful investigation. efficacy of tracheotomy admit of no doubt. The .first of these is the epilepsia laryngeal, of inorganic I can conscientiously affirm that my hopes of relief in this direst of human maladies, from tracheotomy, are more sanguine origin, in its early stage, threatening mind or life, not yet than ever. I do not, and never did, expect to cure epilepsy, involving organic change; that is, spccsnaoc7ic laryngismus and and especially epilepsy in its inveterate stages, or with organic its effects. The same remark applies to other convulsive diseases, puerlesions, by tracheotomy. I did not expect much from the use of this measure amongst the " incurables" of the lunatic asylum peral convulsion inclusive. The second is, the epilepsia laryngea, proceeding to coma or the workhouse. I did not expect any good results, except by accident, in the cases in which the patient was subjected to and pa1’alytic laryngismus or stertor, augmenting the coma tracheotomy without a just and previous d iag nO.5 is for it is and endangering life. The same remark applies to the coma left by other convulstill necessary to repeat, that it is for laryngismns, spasmodic sive diseases, and to all kinds of 5iniple apoplexy; that isor paralytic, and its effects, and not for epilepsy, any more than for apoplexy, that I have proposed tracheotomy as a apoplexy without lesion or rupture of vessels, deep intoxication, narcotic poisoning, &c. remedy. In a word, I proposed tracheotomy for epilepsy in its direct It may now be well to take a brief retrospect, and consider form, short of inveteracy and organic lesion,-in effect, whilst what has been done. Of Mr. Cane’s case, the first and the most brilliant of all, hope still remained. I proposed it for that form-that of the epilepsia ’yf/M,—assuredly expectingit to recZnee it to some life was immediately saved, and the patient was preserved’ other milder abol’th’e form; and my hopes have ?lot been dis- afterwards-notwithstanding some indiscretions, such as occaappointed. In one case,-a case in a lunatic asylum, too,-the sionally closing the trachea-from his attacks, which had prefits were reduced, by ’Ita moderate and impartial estimate, viously occurred on an average five times in a fortnight. The case of Mr. Anderson was one of the greatest possiblefifty per cent. in frequency, and seventy-five per cent. in severity;" and were "entirely Cha71[led, there being not the inveteracy, and tracheotomy was performed altogether without diagnosis, for epilepsy not for laryngismus. Yet was its slightest lividity of the face, or frothing of the mouth," &c. &c. In the next place, I proposed tracheotomy for the paralytic violence mitigated. In Dr. Niell’s case there was great improvement. On onelaryngismus which follows the severest attacks of epilepsy inwith an attack, of which he was stantly endangering life; and by it life has been preserved occasion "he was threatened already in many cases, beginning with that of Mr. Cane, and, conscious;" "removed a temporary plug," and "the sympfor the present, ending with that of Dr. Williams, of Wrexham. toms disappeared!" " He made arrangements to renew his I say this, notwithstanding the fact that the latter patient business; walked about the streets in the confidence and condied afterwards; for he was rescued from a first danger to sciousness of a strength of mind and purpose which he had succumb to a second and totally different one. not experienced for a long period." On another occasion a seizure occurred; the tracheal tube, To render the proof of the efficacy of tracheotomy still more complete, it has been observed that the fits havebeen slighter or it is supposed, dropped out, and the patient " died almost more severe, according as the tracheal tube was freely patent, instantaneously !" In Dr. Herrick’s case, the convulsions, after recurring or obstructed by mucus-an event, from its tenacity, very apt to occur. In one case the tracheal tube fell severe, and the patient expired.
out, the fit
was
every hour
or
two from three o’clock to nine o’clock P.M.,
"kept recurring every twenty or thirty minutes; the face The effect of tracheotomy in spasmodic laryngismus is only and lips were swollen and livid; the breathing much obdiscovered in the induced absence of fits, or in the mitigated structed by mucus, slow and stertorous; the veins of the’ It was concluded that form of the fits which do occur. In paralytic laryngismus it is face and neck much distended." different; the lividity of the countenance, the distention of the " the patient could not survive an hour unless relieved. "’ veins, the dyspnoea subside à 1’ue d’aeil; the effect is imme- Tracheotomy was performed, and followed by "amost diate, and beyond a doubt. The danger is averted; life marked improvement," "the breathing being more natural, the countenance less livid." On the two following days therepreserved. In this case all depends on the early institution of the opera- were only four convulsions, and these less protracted and tion. The laryngismus arises from paralysis of the laryngeal severe than any previous to the operation. nerves. But other branches of the pneumogastric are paralyzed, Unfortunately, this patient was only relieved. He died onand if this condition has long subsisted, the bronchial tubes the third day of bronchial asphyxia. Both Dr. Neill and Dr. Herrick weresatisfied with thebecome clogged with mucus, and the patient dies of bronchial, after having escaped from laryngeal, asphyxia. This was the power of the remedy. The former had to regret its ineffievent in Dr. Herrick’s case. It occurs too, undetected, in many ciency, the tracheal tube having been expelled; the latter, its too tardy performance. cases in which the laryngismus has subsided, and for whom a Henceforth let us carefully select our cases. Let a just vain hope is therefore entertained. I visited such a patient many years ago with my friend, Dr. Webster: the fit had passed diagnosis be instituted; let there be a fair degree of 7zope: let away, but a diffused bronchial rattle remained, and the patient the disease be laryngeal, of sufficient gravity to justify the died of bronchial asphyxia. remedy, but not inveterate, not yet involving organic changes. I have much to say hereafter on the subject of irritution, I conclude by repeating that there are Two cases of epilepsy and of pal’Cllysis of the pneumogastric nerve in all its branches, in its direst forms, in which the PROPRIETY and EFme_icv of events still unrecognised by the profession. But I now resume tracheotomy admit of no doubt: these are-,fli-6t, epilep8Ía the topic of this paper. laryngeal, with spasmodic laryngismus, threatening the extinction Amongst the questions in regard to epilepsy, twomost im- o/’MiND; second, epilepsia laryngea, with paralytic laryngismus, ones have never yet been considered: the first, what the precise forms of the epilepsia trachelea, and what are the abortiL’e forms of epilepsy when the effects of laryngismus have been superseded by tracheotomy in the epilepsia laryngea? -the second, what are the causes and modes of death in
portant are
epilepsy ?
I should conclude that there is usually little danger for mind, limb, or life, in the epilepsia trachelea, judging from the effects of tracheotomy in mitigating this danger in the cure of
the extinction of LIFE. I now propose to add notes of the recent events which have illustrated the use of tracheotomy in epilepsy. These are given in the words of the observers themselves, who havee pursued the inquiry. The first document is a note from Mr. Mackarsie :The following simple detail will not fail to interest your readers. It affords a proof of the value of tracheotomy in epilepsia laryngea, by contrasting the condition of the
threatening
309 In any such case the diagnosis must be established by obpatient before, during, and after the existence of the tracheal opening. Had this orifice been maintained freely patent, it is serving the state of the larynx, of the neck, of the face, and of obvious that the loss of intellect first, and the loss of life next, the cerebrum. In the absence of laryngismus, the deep purple would humanly speaking have been averted ! lividity and tumefaction, and the subsequent deep coma, &c., The present note completes the account of one of the most are equally absent, and tracheotomy of course hors de propos. Much observation is still required to complete our knowledge interesting of the cases in which tracheotomy has hitherto been performed in epilepsy; and, as the able and judicious of the forms of epilepsy. The third document I beg to adduce, is an extract from an writer justly observes,-" there is much that is important to
be learnt from it." There is indeed much to be learnt from the following striking paragraphs :" Clay-cross, September 20th, 1854. "MY DEAR SIR,-For many months I have been anxious to communicate to you the results in my case of epilepsy treated by tracheotomy. "When I last wrote to you, my patient had a recurrence of fits, but in a much mitigated form; his mind had improved, .and his complexion from being of a dusky hue had assumed a natural colour, only remaining perhaps a little paler than natural. " At this period the tracheal opening was allowed to close through neglect, and the fits resumed the severe form they had had before. I wished to re-open the orifice into-the trachea, but was not permitted to do so. I watched my patient with intense interest, and observed him revert to his former condition ; the fits became more severe, and the coma more prolonged, the dusky hue of his complexion returned, and his mindagain gave way, until at length I found it necessary to remove him to an asylum. "In this asylum my patient remained a few months, and died from the frequent recurrence of the fits. - eventually " Ithink there is much of importance to be learnt from this interesting case. " I shall always consider it a great honour to correspond with you. "I ’I remain, dear Sir, yours very faithfully, remain, "W. J. MACKARSIE. "To Dr. Marshall Hall."
able note from Dr. Edwards.
"Grosvenor-street, Cheltenham, Sept. 26th, 1854. " MY DEAR SIR,—* ** The effect of the operation (see THE LANCET of -’vIay28th, 1853,) was immediate, self- evident, axiomatic, to all present. Dr. Allardyce expressed his opinion then, and repeated it this morning, that not only were the effects such, butthat without it the case must havebeen *
*
**
*
utterly hopeless.’ "I may sum up here, that Mo fit of any severe c7ta2-acte2- tookplace in my patient from the moment the tracheal opening was made, so long as the tube, of whatever kind or form, was kept perfectly clear, and so long as it was kept in the trachea ; and that whenever a seizure of a severe character occurred, the tube was found invariably more or less obstructed. "Slight abortivefits occurred ; but these were so dwindled into insignificance, that the patient, having occasionally but a
he was quite well. ’’ The tube was now removed by the patient. The patient continued well until December, when he became comatose, sank, and died, the history of the attack being wanting. "Believe me, dear Sir, very faithfully yours, "CHARLES EDWARDS."
momentary feeling,said
I have taken the liberty of abbreviating the last paragraph of Dr. Edwards’ admirable note. Dr. Edwards has done great good to the cause by a most important discovery, for which I feel deeply indebted to him. This is to he found in detail in THE LANCET, vol. i. 1853, p. 548. The second document I adduce is an extract from an able It is, that the tracheal tube, and even the exterior tube when an interior one is withdrawn, is extremely apt to be clogged and -note from Dr. Bucknill, full of the deepest interest :obstructed by viscid mucus. A fit may then occur, and be as "Devon County Lunatic Asylum, Exminster, Sept. 34th, 1854. severe as if the operation had never been performed. " MY DEAR SIR,-"Both cases on which I operated for The case requires no commentary. Tracheotomy has saved tracheotomy have died: one of phthisis, the other of epilepsy. - mind and life! What can be added to such a statement ? The mode of death in the latter was very instructive. It 1 will now beg your readers’ attention to a few short parawas the second case mentioned in my paper in THE LANCET graphs, embracing the principles which should guide us in the for August 13th, 1853, p. 138:use of this heroic remedy in epilepsy; they are five in number:" ** * * * The wonderful change in the character of the First.-The treatment by tracheotomy should, as in all other fits I have described continued for a period of about nine cases of the use of remedies, be founded on an accumonths. About that time her sister paid her a visit, and rate DIAGNOSIS; theimportant case should be unequivocally laryngeal. they had a quarrel about their mother’s will. The day Secondly.-The case should admit of REMEDY; it should not afterwards she was distinctly hysterical, and in the middle have been organic in its origin, or have sustained organic change - of the following night she had severe epileptic convulsions. in its progress. These continued at intervals of ten minutes for about sixteen Thirdly. -Not only should there be no organic disease, but the hours, when she died from exhaustion, (failure of the heart’s case should not be inveterate, even if it be stiji one of function, action, I suppose,) distinctly not from coma. During the For this reason I do not think the cases already conwhole of this period, the tracheal opening was quite free, and to an asylum or the workhouse can offer much promise the large canula was carefully kept clear. During each fit, signed of permanent benefit from tracheotomy, or from any mode of the external muscles of respiration could be felt in a state of treatment. The cases must be of such date as to present Aopc. tonic spasm; and it is probable that the diaphragm was must be so severe and threatening in regard to mind or also fixed. For a short period in each fit the respiration was Theyas to life, present sufficient cause or reason for the operation. - completely arrested. I kept the patient sitting in an easy It will be readily understood that I do not expect the lunatic to prevent the accumulation of mucus in the air-tubes. .chair, asylum or the workhouse often to furnish cases for tracheo" I quote from memory, but have the case ready for publi- tomy. The cases in these institutions are generally already cation. inveterate or organic. ’ *remain, my dear Sir, yours very truly, Fourthly.-The tracheal apeiture should be ample, and be "J. C. BUCKNILL. Dr. Marshall Hall." sustained unequivocally FREE. I have for some time been investigating the causes of death Fifthly.-Our expectations should be reasonable; we should in convulsive and apoplectic diseases. The case of which a expect to remedy largngismus and its EFFECTS, whatever these .note has been given was evidently one of exhaustion of the vis may be, and nothing more. If these five principles guide us, there will be an end of all nervosa. In this manner tetanus seems to destroy life. Each - successive fit adds to the exhaustion induced by the previous discreditable controversy; the remedy will have a fair and unones, until the patient expires. prejudiced trial; weshall rejoice if it provesuccessful, and If two frogs be affected with strychnism, and one be excited, mourn if it proveafailure. and the other left in secured tranquillity, the former dies, and For myself I have only to say, that I have not, in any case the latter survives. in which tracheotomy hasbeen performed, had the opportunity The different forms assumed by epilepsy require to be in- of forming the diagnosis for myself, having never had occasion vestigated-the tracheal, the laryngeal, the abortive in cases to witness a paroxysm in any of them. I believe iio proper in which tracheotomy is instituted, the syncopal, and not diagnosis has been established in some of them-in Mr. Anderleast, this of nervous exhaustion. son’s, for example. And what shall I say of Dr. Andrea Verga’s It is difficult to imagine how the respiration can be arrested case ? Is it not lamentable to see such things brought forward without closure of the glottis. There are three modes, how- on so grave an occasion ? I fear that that -will long be said of tracheotomy in epilepsy ever, in which this may occur : one is, at a full expiration; the second, at a full inspiration; the third, the muscles of inspira- which is constantly said of other operations as that for tion and the muscles of expiration being simultaneously and hernia-that when instituted, it is instituted too tardily,. too late. Another observation may be made: I know positively equally contracted. -
310 that the
operation has not generally been efficient, for want of ampler orifice, freely sustained. Now, let us imagine a youth attacked by epilepsy-by epilepsia laryngea; let us observe that, after a certain number of these attacks, the mind begins to fail; that there is incoherence of ideas, loss of memory, &c.; that this state of things is augmenting ; that the patient is in danger of becoming a maniac or an idiot; that all other remedies have failed; that tracheotomy affords a nopE. Who will hesitate to perform so simple an operation ? Or, let us imagine that, after a severe epileptic attack, the patient remains in a state of coma, his life being obviously endangered, as in the cases of Mr. Cane, Dr. Herrick, Dr. Williams ; &c., who will hesitate to avert this danger by performing tracheotomy? In all these three cases the danger was so
tice in London fully bears out this experience, and it is only in old rebellious cases of gleet, in spermatorrhœa, and in chronic affections of the bladder, that I now employ nitrate of silver injections; but in these cases the judicious employment of caustic is of the greatest value, and will at once effect a cure when all other means fail; still, even in these cases, the remedy must be employed with care, otherwise ill consequences will arise. In the subacute stages of gonnorrhoea, when there is noscalding, but a good deal of discharge, I have found the solution of lead answer best in London, together with copaiba capsules, not taken in large numbers, but at repeated intervals, so as to charge the urine constantly with the essential oil; but I still (as in the last edition of my book) continue to insist that gonorrhoea, will rarely be rapidly cured, unless the surgeon takes the precaution to show a patient how to use his syringe, and AVERTED! I will only add, that as I understand the question better, my see that the instrument be properly made. Having insisted hopes of success become more, not less, sanguine. Only let the elsewhere in great length on these points, I do not think it remedy be instituted in cases perfectly appropriate, after a just necessary here to revert to them; but to these petty matters I attribute much of my success, and not to any specific treatand adequate diagnosis, and in a manner perfectly efficient. ment. It is, however, worthy of note, that the time of year 1854. September, and the damp weather have a great influence in retarding a
an
cure.
A SKETCH OF THE
PRESENT CONDITION AND TREATMENT OF
DISEASES OF THE URINARY AND GENERATIVE ORGANS IN PARIS, COMPARED WITH THOSE IN LONDON. BY WILLIAM
ACTON, ESQ., M.R.C.S.,
GLEET.
I am sure, be glad to hear a few the treatment which has proved most successful in this obstinate affection. It is not my intention to enter into the various pathological changes chronic discharges from the urethra depend upon, or the indications which should be followed out; suffice it for the few lines I can devote to the subject, to state, that in the more obstinate instances the surgeon meets with, Ricord strongly now recommends the employment of bougies of metal, which possess the curve seen in the adjoining woodcut.
infany of particulars
my
readers, will,
on
FORMERLY EXTERNE TO THE VENEREAL HOSPITALS OF PARIS.
(Concluded from p. 8.) GONORRHœA.
IT is to be regretted, but still the conscientious surgeon is obliged to admit the fact, that notwithstanding all the improvements that have taken place in the treatment of diseases of the urinary and generative system during the last few years, little progress has been made in the cure of gonorrhœa. It is true that we have in this the nineteenth century a better These instruments were brought under the notice of the knowledge than we before possessed of the pathology of the disease, and we have expunged many a vulgar error which was profession by M. Benique, and are of various sizes, eachentertained about the complaint; but as to the discovery of a number being a little larger than the other; and although certain rapid cure, we are as far distant from it as ever, and employed by their inventor for the treatment of stricture, are perhaps it is only with a reputation such as Ricord’s that a now found very useful in old-standing gleets, where we may teacher dare make the acknowledgment that, after performing suppose the canal has undergone some thickening. The employvarious experiments during a long course of years, no certain ment of these graduated bougies is then one of the remedies’ plan of cure has been discovered. This, however, is not so I should recommend, gradually increasing the size; and Ricord’s surprising to the old practitioner as it is to the tyro, who does experience seems to bear out the strong recommendation which not consider the situation the discharge comes from, the fre- I gave in the last edition of my work " On Diseases of the quency with which the disease occurs, the liability of relapse, Urinary Organs," p. 119, to employ dilatation, accompanied. together with the little attention a patient will pay to the com- with injections, in the treatment of gleet. Since the publication of my last edition I have experimented plaint ; bu‘, above all, that the urine, loaded with all sorts of stimulating substances, must necessarily pass over the inflamed largely with counter-irritation, and I think my success surfaces many times in the twenty-four hours; and it would deserves a few moment’s consideration. In addition to the almost appear as if gonorrhœa would ever continue to be the means above stated, I am in the habit of recommending my opprobrium medicorum and the pest of the patient, notwith- patients to paint the under surface of the urethra with tincture standing all the science bestowed upon it. In saying this, how- of iodine every night, as well as applying the liquid to the periever, I would not be understood to mean that gonoi-rhcea should næum, so as to produce a slight peeling off of the skin. The last an indefinite length of time; far from it, for in 19-20ths of remedy is then to be left off, and repeated when the skin has the cases the affection is to be cured readily and easily in persons regained its cuticle. In the more chronic cases I employ a who will take ordinary precautions; but every now and then solution of cantharides dissolved in chloroform,* with which I cases occur which linger on many weeks, and yield at last to paint the skin well in the situation mentioned above. The’ change of air or abstinence from all treatment, the disease chloroform evaporates, leaving the cantharidine in situ. But as I intend shortly publishing a paper on this subject, I shall apparently wearing itself out. During the last few years, M. Ricord has been gradually re- not further allude to it here. linquishing the employment of caustic injections in the treatSWELLED TESTICLE. ment of this complaint. He still thinks that in many cases this is the treatment attended with the most certain success; but of the testis, by means of strapping, has now Compression every now and then instances occur in which the pain is very been nearly given up by M. Ricord, in his hospital; it is, he severe, the inflammation runs high, and then, instead of a cure still admits, an excellent remedy when well applied, but a being obtained, the disease relapses into a chronic state, which patient should be seen, in the early stages, twice a day, and resists all our means of cure; in addition to this, the patient the strapping re-applied if necessary. Without watching, this requires a great deal of watching, more than a surgeon in full treatment is sometimes accompanied with disagreeable con. practice is able to devote to each individual; so that, as I sequences, which aggravate the complaint, at least the French mentioned above, Ricord now employs caustic injections very professor thinks so; but in London, in private practice, I have rarely, and prefers prescribing capsules, and the following ! every reason to be satisfied with the treatment, which shortens injection :-Sulphate of zinc, acetate of lead, of each fifteen duration of the disease very much, and dispenses with the grains; tincture of catechu, one drachm ; Sydenham’s laudanum, * This one drachm; rose water, six ounces and a half. My own pracmay be procured at Messrs. Bells’, Oxford-street.
! the
out, the fit
was
every hour
or
two from three o’clock to nine o’clock P.M.,
"kept recurring every twenty or thirty minutes; the face The effect of tracheotomy in spasmodic laryngismus is only and lips were swollen and livid; the breathing much obdiscovered in the induced absence of fits, or in the mitigated structed by mucus, slow and stertorous; the veins of the’ It was concluded that form of the fits which do occur. In paralytic laryngismus it is face and neck much distended." different; the lividity of the countenance, the distention of the " the patient could not survive an hour unless relieved. "’ veins, the dyspnoea subside à 1’ue d’aeil; the effect is imme- Tracheotomy was performed, and followed by "amost diate, and beyond a doubt. The danger is averted; life marked improvement," "the breathing being more natural, the countenance less livid." On the two following days therepreserved. In this case all depends on the early institution of the opera- were only four convulsions, and these less protracted and tion. The laryngismus arises from paralysis of the laryngeal severe than any previous to the operation. nerves. But other branches of the pneumogastric are paralyzed, Unfortunately, this patient was only relieved. He died onand if this condition has long subsisted, the bronchial tubes the third day of bronchial asphyxia. Both Dr. Neill and Dr. Herrick weresatisfied with thebecome clogged with mucus, and the patient dies of bronchial, after having escaped from laryngeal, asphyxia. This was the power of the remedy. The former had to regret its ineffievent in Dr. Herrick’s case. It occurs too, undetected, in many ciency, the tracheal tube having been expelled; the latter, its too tardy performance. cases in which the laryngismus has subsided, and for whom a Henceforth let us carefully select our cases. Let a just vain hope is therefore entertained. I visited such a patient many years ago with my friend, Dr. Webster: the fit had passed diagnosis be instituted; let there be a fair degree of 7zope: let away, but a diffused bronchial rattle remained, and the patient the disease be laryngeal, of sufficient gravity to justify the died of bronchial asphyxia. remedy, but not inveterate, not yet involving organic changes. I have much to say hereafter on the subject of irritution, I conclude by repeating that there are Two cases of epilepsy and of pal’Cllysis of the pneumogastric nerve in all its branches, in its direst forms, in which the PROPRIETY and EFme_icv of events still unrecognised by the profession. But I now resume tracheotomy admit of no doubt: these are-,fli-6t, epilep8Ía the topic of this paper. laryngeal, with spasmodic laryngismus, threatening the extinction Amongst the questions in regard to epilepsy, twomost im- o/’MiND; second, epilepsia laryngea, with paralytic laryngismus, ones have never yet been considered: the first, what the precise forms of the epilepsia trachelea, and what are the abortiL’e forms of epilepsy when the effects of laryngismus have been superseded by tracheotomy in the epilepsia laryngea? -the second, what are the causes and modes of death in
portant are
epilepsy ?
I should conclude that there is usually little danger for mind, limb, or life, in the epilepsia trachelea, judging from the effects of tracheotomy in mitigating this danger in the cure of
the extinction of LIFE. I now propose to add notes of the recent events which have illustrated the use of tracheotomy in epilepsy. These are given in the words of the observers themselves, who havee pursued the inquiry. The first document is a note from Mr. Mackarsie :The following simple detail will not fail to interest your readers. It affords a proof of the value of tracheotomy in epilepsia laryngea, by contrasting the condition of the
threatening
309 In any such case the diagnosis must be established by obpatient before, during, and after the existence of the tracheal opening. Had this orifice been maintained freely patent, it is serving the state of the larynx, of the neck, of the face, and of obvious that the loss of intellect first, and the loss of life next, the cerebrum. In the absence of laryngismus, the deep purple would humanly speaking have been averted ! lividity and tumefaction, and the subsequent deep coma, &c., The present note completes the account of one of the most are equally absent, and tracheotomy of course hors de propos. Much observation is still required to complete our knowledge interesting of the cases in which tracheotomy has hitherto been performed in epilepsy; and, as the able and judicious of the forms of epilepsy. The third document I beg to adduce, is an extract from an writer justly observes,-" there is much that is important to
be learnt from it." There is indeed much to be learnt from the following striking paragraphs :" Clay-cross, September 20th, 1854. "MY DEAR SIR,-For many months I have been anxious to communicate to you the results in my case of epilepsy treated by tracheotomy. "When I last wrote to you, my patient had a recurrence of fits, but in a much mitigated form; his mind had improved, .and his complexion from being of a dusky hue had assumed a natural colour, only remaining perhaps a little paler than natural. " At this period the tracheal opening was allowed to close through neglect, and the fits resumed the severe form they had had before. I wished to re-open the orifice into-the trachea, but was not permitted to do so. I watched my patient with intense interest, and observed him revert to his former condition ; the fits became more severe, and the coma more prolonged, the dusky hue of his complexion returned, and his mindagain gave way, until at length I found it necessary to remove him to an asylum. "In this asylum my patient remained a few months, and died from the frequent recurrence of the fits. - eventually " Ithink there is much of importance to be learnt from this interesting case. " I shall always consider it a great honour to correspond with you. "I ’I remain, dear Sir, yours very faithfully, remain, "W. J. MACKARSIE. "To Dr. Marshall Hall."
able note from Dr. Edwards.
"Grosvenor-street, Cheltenham, Sept. 26th, 1854. " MY DEAR SIR,—* ** The effect of the operation (see THE LANCET of -’vIay28th, 1853,) was immediate, self- evident, axiomatic, to all present. Dr. Allardyce expressed his opinion then, and repeated it this morning, that not only were the effects such, butthat without it the case must havebeen *
*
**
*
utterly hopeless.’ "I may sum up here, that Mo fit of any severe c7ta2-acte2- tookplace in my patient from the moment the tracheal opening was made, so long as the tube, of whatever kind or form, was kept perfectly clear, and so long as it was kept in the trachea ; and that whenever a seizure of a severe character occurred, the tube was found invariably more or less obstructed. "Slight abortivefits occurred ; but these were so dwindled into insignificance, that the patient, having occasionally but a
he was quite well. ’’ The tube was now removed by the patient. The patient continued well until December, when he became comatose, sank, and died, the history of the attack being wanting. "Believe me, dear Sir, very faithfully yours, "CHARLES EDWARDS."
momentary feeling,said
I have taken the liberty of abbreviating the last paragraph of Dr. Edwards’ admirable note. Dr. Edwards has done great good to the cause by a most important discovery, for which I feel deeply indebted to him. This is to he found in detail in THE LANCET, vol. i. 1853, p. 548. The second document I adduce is an extract from an able It is, that the tracheal tube, and even the exterior tube when an interior one is withdrawn, is extremely apt to be clogged and -note from Dr. Bucknill, full of the deepest interest :obstructed by viscid mucus. A fit may then occur, and be as "Devon County Lunatic Asylum, Exminster, Sept. 34th, 1854. severe as if the operation had never been performed. " MY DEAR SIR,-"Both cases on which I operated for The case requires no commentary. Tracheotomy has saved tracheotomy have died: one of phthisis, the other of epilepsy. - mind and life! What can be added to such a statement ? The mode of death in the latter was very instructive. It 1 will now beg your readers’ attention to a few short parawas the second case mentioned in my paper in THE LANCET graphs, embracing the principles which should guide us in the for August 13th, 1853, p. 138:use of this heroic remedy in epilepsy; they are five in number:" ** * * * The wonderful change in the character of the First.-The treatment by tracheotomy should, as in all other fits I have described continued for a period of about nine cases of the use of remedies, be founded on an accumonths. About that time her sister paid her a visit, and rate DIAGNOSIS; theimportant case should be unequivocally laryngeal. they had a quarrel about their mother’s will. The day Secondly.-The case should admit of REMEDY; it should not afterwards she was distinctly hysterical, and in the middle have been organic in its origin, or have sustained organic change - of the following night she had severe epileptic convulsions. in its progress. These continued at intervals of ten minutes for about sixteen Thirdly. -Not only should there be no organic disease, but the hours, when she died from exhaustion, (failure of the heart’s case should not be inveterate, even if it be stiji one of function, action, I suppose,) distinctly not from coma. During the For this reason I do not think the cases already conwhole of this period, the tracheal opening was quite free, and to an asylum or the workhouse can offer much promise the large canula was carefully kept clear. During each fit, signed of permanent benefit from tracheotomy, or from any mode of the external muscles of respiration could be felt in a state of treatment. The cases must be of such date as to present Aopc. tonic spasm; and it is probable that the diaphragm was must be so severe and threatening in regard to mind or also fixed. For a short period in each fit the respiration was Theyas to life, present sufficient cause or reason for the operation. - completely arrested. I kept the patient sitting in an easy It will be readily understood that I do not expect the lunatic to prevent the accumulation of mucus in the air-tubes. .chair, asylum or the workhouse often to furnish cases for tracheo" I quote from memory, but have the case ready for publi- tomy. The cases in these institutions are generally already cation. inveterate or organic. ’ *remain, my dear Sir, yours very truly, Fourthly.-The tracheal apeiture should be ample, and be "J. C. BUCKNILL. Dr. Marshall Hall." sustained unequivocally FREE. I have for some time been investigating the causes of death Fifthly.-Our expectations should be reasonable; we should in convulsive and apoplectic diseases. The case of which a expect to remedy largngismus and its EFFECTS, whatever these .note has been given was evidently one of exhaustion of the vis may be, and nothing more. If these five principles guide us, there will be an end of all nervosa. In this manner tetanus seems to destroy life. Each - successive fit adds to the exhaustion induced by the previous discreditable controversy; the remedy will have a fair and unones, until the patient expires. prejudiced trial; weshall rejoice if it provesuccessful, and If two frogs be affected with strychnism, and one be excited, mourn if it proveafailure. and the other left in secured tranquillity, the former dies, and For myself I have only to say, that I have not, in any case the latter survives. in which tracheotomy hasbeen performed, had the opportunity The different forms assumed by epilepsy require to be in- of forming the diagnosis for myself, having never had occasion vestigated-the tracheal, the laryngeal, the abortive in cases to witness a paroxysm in any of them. I believe iio proper in which tracheotomy is instituted, the syncopal, and not diagnosis has been established in some of them-in Mr. Anderleast, this of nervous exhaustion. son’s, for example. And what shall I say of Dr. Andrea Verga’s It is difficult to imagine how the respiration can be arrested case ? Is it not lamentable to see such things brought forward without closure of the glottis. There are three modes, how- on so grave an occasion ? I fear that that -will long be said of tracheotomy in epilepsy ever, in which this may occur : one is, at a full expiration; the second, at a full inspiration; the third, the muscles of inspira- which is constantly said of other operations as that for tion and the muscles of expiration being simultaneously and hernia-that when instituted, it is instituted too tardily,. too late. Another observation may be made: I know positively equally contracted. -
310 that the
operation has not generally been efficient, for want of ampler orifice, freely sustained. Now, let us imagine a youth attacked by epilepsy-by epilepsia laryngea; let us observe that, after a certain number of these attacks, the mind begins to fail; that there is incoherence of ideas, loss of memory, &c.; that this state of things is augmenting ; that the patient is in danger of becoming a maniac or an idiot; that all other remedies have failed; that tracheotomy affords a nopE. Who will hesitate to perform so simple an operation ? Or, let us imagine that, after a severe epileptic attack, the patient remains in a state of coma, his life being obviously endangered, as in the cases of Mr. Cane, Dr. Herrick, Dr. Williams ; &c., who will hesitate to avert this danger by performing tracheotomy? In all these three cases the danger was so
tice in London fully bears out this experience, and it is only in old rebellious cases of gleet, in spermatorrhœa, and in chronic affections of the bladder, that I now employ nitrate of silver injections; but in these cases the judicious employment of caustic is of the greatest value, and will at once effect a cure when all other means fail; still, even in these cases, the remedy must be employed with care, otherwise ill consequences will arise. In the subacute stages of gonnorrhoea, when there is noscalding, but a good deal of discharge, I have found the solution of lead answer best in London, together with copaiba capsules, not taken in large numbers, but at repeated intervals, so as to charge the urine constantly with the essential oil; but I still (as in the last edition of my book) continue to insist that gonorrhoea, will rarely be rapidly cured, unless the surgeon takes the precaution to show a patient how to use his syringe, and AVERTED! I will only add, that as I understand the question better, my see that the instrument be properly made. Having insisted hopes of success become more, not less, sanguine. Only let the elsewhere in great length on these points, I do not think it remedy be instituted in cases perfectly appropriate, after a just necessary here to revert to them; but to these petty matters I attribute much of my success, and not to any specific treatand adequate diagnosis, and in a manner perfectly efficient. ment. It is, however, worthy of note, that the time of year 1854. September, and the damp weather have a great influence in retarding a
an
cure.
A SKETCH OF THE
PRESENT CONDITION AND TREATMENT OF
DISEASES OF THE URINARY AND GENERATIVE ORGANS IN PARIS, COMPARED WITH THOSE IN LONDON. BY WILLIAM
ACTON, ESQ., M.R.C.S.,
GLEET.
I am sure, be glad to hear a few the treatment which has proved most successful in this obstinate affection. It is not my intention to enter into the various pathological changes chronic discharges from the urethra depend upon, or the indications which should be followed out; suffice it for the few lines I can devote to the subject, to state, that in the more obstinate instances the surgeon meets with, Ricord strongly now recommends the employment of bougies of metal, which possess the curve seen in the adjoining woodcut.
infany of particulars
my
readers, will,
on
FORMERLY EXTERNE TO THE VENEREAL HOSPITALS OF PARIS.
(Concluded from p. 8.) GONORRHœA.
IT is to be regretted, but still the conscientious surgeon is obliged to admit the fact, that notwithstanding all the improvements that have taken place in the treatment of diseases of the urinary and generative system during the last few years, little progress has been made in the cure of gonorrhœa. It is true that we have in this the nineteenth century a better These instruments were brought under the notice of the knowledge than we before possessed of the pathology of the disease, and we have expunged many a vulgar error which was profession by M. Benique, and are of various sizes, eachentertained about the complaint; but as to the discovery of a number being a little larger than the other; and although certain rapid cure, we are as far distant from it as ever, and employed by their inventor for the treatment of stricture, are perhaps it is only with a reputation such as Ricord’s that a now found very useful in old-standing gleets, where we may teacher dare make the acknowledgment that, after performing suppose the canal has undergone some thickening. The employvarious experiments during a long course of years, no certain ment of these graduated bougies is then one of the remedies’ plan of cure has been discovered. This, however, is not so I should recommend, gradually increasing the size; and Ricord’s surprising to the old practitioner as it is to the tyro, who does experience seems to bear out the strong recommendation which not consider the situation the discharge comes from, the fre- I gave in the last edition of my work " On Diseases of the quency with which the disease occurs, the liability of relapse, Urinary Organs," p. 119, to employ dilatation, accompanied. together with the little attention a patient will pay to the com- with injections, in the treatment of gleet. Since the publication of my last edition I have experimented plaint ; bu‘, above all, that the urine, loaded with all sorts of stimulating substances, must necessarily pass over the inflamed largely with counter-irritation, and I think my success surfaces many times in the twenty-four hours; and it would deserves a few moment’s consideration. In addition to the almost appear as if gonorrhœa would ever continue to be the means above stated, I am in the habit of recommending my opprobrium medicorum and the pest of the patient, notwith- patients to paint the under surface of the urethra with tincture standing all the science bestowed upon it. In saying this, how- of iodine every night, as well as applying the liquid to the periever, I would not be understood to mean that gonoi-rhcea should næum, so as to produce a slight peeling off of the skin. The last an indefinite length of time; far from it, for in 19-20ths of remedy is then to be left off, and repeated when the skin has the cases the affection is to be cured readily and easily in persons regained its cuticle. In the more chronic cases I employ a who will take ordinary precautions; but every now and then solution of cantharides dissolved in chloroform,* with which I cases occur which linger on many weeks, and yield at last to paint the skin well in the situation mentioned above. The’ change of air or abstinence from all treatment, the disease chloroform evaporates, leaving the cantharidine in situ. But as I intend shortly publishing a paper on this subject, I shall apparently wearing itself out. During the last few years, M. Ricord has been gradually re- not further allude to it here. linquishing the employment of caustic injections in the treatSWELLED TESTICLE. ment of this complaint. He still thinks that in many cases this is the treatment attended with the most certain success; but of the testis, by means of strapping, has now Compression every now and then instances occur in which the pain is very been nearly given up by M. Ricord, in his hospital; it is, he severe, the inflammation runs high, and then, instead of a cure still admits, an excellent remedy when well applied, but a being obtained, the disease relapses into a chronic state, which patient should be seen, in the early stages, twice a day, and resists all our means of cure; in addition to this, the patient the strapping re-applied if necessary. Without watching, this requires a great deal of watching, more than a surgeon in full treatment is sometimes accompanied with disagreeable con. practice is able to devote to each individual; so that, as I sequences, which aggravate the complaint, at least the French mentioned above, Ricord now employs caustic injections very professor thinks so; but in London, in private practice, I have rarely, and prefers prescribing capsules, and the following ! every reason to be satisfied with the treatment, which shortens injection :-Sulphate of zinc, acetate of lead, of each fifteen duration of the disease very much, and dispenses with the grains; tincture of catechu, one drachm ; Sydenham’s laudanum, * This one drachm; rose water, six ounces and a half. My own pracmay be procured at Messrs. Bells’, Oxford-street.
! the