APPENDIX TO THE REPORT OF A CASE OF APNŒAL EPILEPSY, FOR THE RELIEF OF WHICH TRACHEOTOMY WAS RESORTED TO.

from the tendency of the extravasated blood to decompose. There is also the sudden extensive haemorrhage, sometimes subdued for a time, but always ending fatally. This follows the extensive ulceration of smaller deposits of tubercular matter, usually confined to one lung only. or nearly so, where the deposit has taken place in the immediate neighbourhood of large vessels. Many of these cases are very chronic, having shown a small amount of constitutional disturbance. and are accom panied with a slow pulse. As a general rule in the commence. ment of tubercular disease, haemorrhage takes place from the exudation of blood through the membranes of the lungs ; ir the latter attacks it takes place from the lesion of bloodvessels,

APPENDIX TO THE REPORT

and his pulse, observed at this moment, was 72, soft. I omitted the ferro-citrate of quinine, and put him on the use of two grains of sulphate of ziuc three times a day. 14th.-Last night he jumped suddenly out of bed, and, run. ning backwards, fell and struck his head violently. He has had three distinct epileptic convulsive attacks since, and during the interval has not quite recovered his consciousness. All this time the canula has been carefully kept free from mucus. Now, as he lies in bed, his face is flushed; tongue moist, with a clammy white fur; pulse 96, somewhat hard; respirations 24, full-drawn, easy ; pupils natural. He complains a little of headache ; has taken no food all to day, but has had no retch. ing ; the bowels have not acted for twenty-four hours. He was ordered a turpentine enema at once, and to leave off the zinc pills. 15th.-The

enema

acted

immediately,

and he seemed better

for awhile, and continued so till evening. Since then he has had a fit every two hours. The fits are more severe, not preCASE OF APNŒAL EPILEPSY, FOR THE ceded by a shriek, but followed by crying and indefinite RELIEF OF WHICH TRACHEOTOMY WAS complaints of pain. Altogether he has had eight or nine fits since the noon of yesterday. Now he is restless, crying, appaRESORTED TO. rently suffering pain, but cannot express himself, and takes little notice of external objects. Pupils natural ; pulse 96, with By JOHN W. OGLE, M.D., F.R.C.P., fair power. The urine is passed in a stream now and then. He ASSISTANT-PHYSICIAN TO ST. GEORGE’S HOSPITAL. has taken for some hours past nothing but a little toast. The canula has been kept quite clear from mucus. Ordered to reo the turpentine enema. peat IN the postcript of the case of which at p. 58 of the present 17th.-He has had no fits since last note, till just now before volume I concluded the report, I spoke of appending certain the visit at two r.M., when he had a slight one, from which he notes of my epileptic patient’s condition whilst he was under is recovering. Bowels freely open from an enema yesterday. the charge of Dr. Ormerod, in the Brighton Hospital. This I Pulse 84, softer. Tongue moist, with a whitish far. He has quite regained his consciousness, and speaks again almost in am wishful to do, in order that every particular regarding a his natural voice; still his urine runs away from him involuncase bearing on so interesting a topic may be made known. tarily from time to time. He takes his food more readily. He For the purpose Dr. Ormerod kindly offered me the choice of is restless at night, disturbing the patients by walking about the entire daily notes taken under his own observation, or the the ward, and pulling their bedclothes off. Yesterday the out, and staying out for some hours, could not accompanying abstract, which latter I resolved to avail myself canula slipped be replaced, so a, smaller canula was substituted. of, thinking that perhaps I had already trespassed too much readily Ordered thirty minims of turpentine thrice a day. upon the pages of this journal by a somewhat prolix history of 18th.-Restless during the night, disturbing the other details. The clinical remarks of Dr. Ormerod are as follows :- patients by mischievous tricks, to such an extent that it was " Chas. E-, aged seventeen, a healthy-looking boy, with necessary to confine him to his bed. He has had no more fits; a fair complexion, was admitted under my care into the Sussex he is conscious, but laughs in an imbecile manner when spoken County Hospital, on July 30th, 1857. to, and cannot answer beyond " yes" and "no." Bowels not I learned thathe had been a healthy child till he was twelve open; tongue as yesterday; urine passed unconsciously in large years old ; then, having been much alarmed on occasion of a quantities. He takes his food readily, and breathes easily quarrel between his parents, he became epileptic and had so through the smaller canula which he wears. To continue. continued. He was becomingidiotic, when, at the suggestion 19th.-He had a very severe fit at four A.M., and one less of Dr. Ogle, three months ago, his trachea was opened. Since severe at six A.M.; he was not asleep at the time. He takes he has worn the canula in his trachea the symptoms have been his food readily, but there is great difficulty in getting him to greatly mitigated ; the fits, which used to recur six or seven take his medicine. Ordered three grains of calomel, with seven times each night, and with great severity, are now quite slight grains of compound colocynth pill immediately, and to con. and occur only once or twice, in the morning, generally on first tinue. 20th.-Yesterday afternoon hejerked the canula out, and it awaking. Taking food of any kind usually checks their more frequent recurrence at this time. He sleeps well, and eats andI has not been replaced. He has had seven or eight fits, all drinks well; the bowels usually act regularly without medi- very slight, since last note. He takes his medicine and his cine ; tongue moist and clean ; pulse78, soft. The canula re- food properly, and his bowels have acted freely. To continue. 2lst.-Hc has had two or three very slight fits; he complains quires to be cleared out not more than once or twice daily. The lad gave very clear answers and appeared quite intelli- of some pain in the top of his head. Ordered an aperient gent ; he spoke with great gratitude of the benefit he had de- draught at once, and to continue. 22nd.-The bowels haveacted freely; he has no pain in his rived from the operation, and added, besides what I had learned from other sources, that he had suffered from thread-worms. head, and he has resumed his usual manner. Two fits this One of the slighter fits occurred during my visit. It was a morning, one closely following on the other. 24th.-All passage of air through the tube ceased almost mere transient affection, unaccompanied by any apparent convulsion. His breathing was oppressed for a moment ; he sat from the hour that the canula was removed. He has two or up in bed, looked pale, and then in a moment recovered his three fits every morning of the same character, but slighter, than those which he had on admission. They occur generally calmness and full consciousness. He was put on the use of ferro-citrate of quinine, ten grains on his first rising in the morning, and at breakfast time. Yesthrice daily, which I understood he had been taking under terday he had a threatening of an attack shortly after his dinner. He is fatter, and has improved in his general appear. Dr. Ogle’s care. August 5th.-He continues to have a fit of the same kind ance since his admission. Pulse 96, soft; bowels regular. once or twice a day, usually in the morning. His bowels re- Ordered to continue the turpentine mixture. 26th.-Yesterday he had four fits before eight A.M., and one quire the use of fivegrains of compound scammony powder in the afternoon; and he had two this morning, though all preevery night. 8th. -The attacks are more numerous, five or six rather thanl cautions of letting him have food early were most carefully two or three daily, but are still of the same slight character. observed; but all these attacks were very slight. 29th.-He continues to have about two fits daily, distinctly Otherwise the bodily functions are quite regular. 12th.-The attacks are distinctly more frequent, more severe, slighter. His general health remains otherwise perfect. I regret to add, that just about this time this patient foland last longer. During the attacks, he is quite unconscious of what he is doing, only he feels excited ; he has a sensation1 lowed the example of most other patients of whom much notice of the wind blowing in his face; stretches out his hands with1 is taken. I could only anticipate his mother taking him out, on the pretext of unkind treatment at the hands of the patients a helpless imploring expression, and runs forward for two orr three yards, not, however, falling even when left to himself.. and nurses, by discharging him, when I found, on inquiry, that The restoration of consciousness is still as instantaneousas ever,, the pretext was entirely false." OF A

,

434

Such is the summary of the boy’s state during his sojourn at the Brighton Hospital, exactly as I have received it; and here I would make one or two remarks upon some of the particulars therein given. Thus, I would draw attention to the fact, that at his admission into the hospital a note of the attacks, which

Sergeant R. Williams, an EcgHebBMB, aged twenty-seven sanguineous temperament. He has served in the army upwards of eight years. He was invalided from Hong Kong for dysentery in July, 1854, and having recovered his health in England, re-embarked for Hong Kong in April, 1857, on board

chiefly syncopal, was taken, corresponding very closely the steamer Transit. On the passage out in J nne, in bad by myself when previously I had last seen weather, he was thrown backwards off the mainhatch by a roll him, and stating also, as did my note, that the boy’s symptoms of the ship, and fell against the ship’s side, striking the periThe patient, it will be neum on a projecting piece of iron or wood; he could not ascerwere relieved by the taking of food. seen, continued much the same until August 12th, when the tain what it was, being dark at the time. Profuse haemorrhage attacks were described as being more severe, longer in dura- from the urethra followed, and continued for four days at intion, and attended by unconsciousness, from which, nevertheless, tervals. Pain and difficulty were then experienced on mictuhe recovered instantaneously. In like manner, also, as I had rition; the former ceased in a few days, the latter steadily stated, he is noticed as " running forwards" at the period of increased. Shortly afterwards, he noticed a hard swelling, the attack, but he did not fall down, even when left to himself. about the size of a hazel-nut, in the perinamm, at the seat of It is to the point to quote Esquirol in this place, who describes injury. On his arrival at Calcutta, in August, he was attacked with ophthalmia, and while in hospital eighteen days with an epileptic as running at full speed " a toutes jambes" even that complaint, frequent unsuccessful attempts were made to until she fell, immediately before the attack. On the 13th of August, Dr. Ormerod wrote to me a letter, introduce a catheter. The passage became daily more conin which he said that he thought the patient was worse than stricted, and the symptoms more urgent. On the 4th of November, he embarked for China, suffering he had been, having " five or six minor epileptic attacks every day." On the 14th, the boy, it will be seen, became worse, much during the voyage, and finally, the day before his arrival and during the intervals of the attacks did not completely re- at his destination, he was attacked with complete retention of Headache was complained of. On urine. He was brought to hospital on landing, and after oover his consciousness. the 15th, the seizures became more severe, but it may be con- various attempts to relieve the greatly distended bladder by cluded from the narrative how much in severity these increased the catheter, the recto-vesical operation was performed on the attacks came short of those to which, when tracheotomy was lth of December, by Surgeon M’Wharrie, 59th Regt., under resorted to, the patient was obnoxious. On the 17th, the the influence of chloroform. The canula was left in until the eanula is said to have fallen out of the trachea, and to have end of the month without causing any irritation, when it was remained out some hours, after which time attempts were withdrawn, and the urine flowed through the urethra in a small made in vain to re-introduce it, just as it had been previous stream. althoush the catheter could not be massed. to the exhibition of chloroform after the operation was On the 17th of January, retention of urine again attacked had recourse to. A smaller canula was accordingly intro him, and as the impermeability of the stricture had been so duced, but on the 19th, this smaller one is stated to hav long declared, Syme’s operation was decided on, and performed been jerked out by the patient, and was not replaced at all at eleven P.M., under chloroform. A staff was passed as far as but the fistulous communication was allowed to close anc the stricture, a free incision made in the mesian line, its point heal. It may be asked how it was that the attacks did n01 exposed, the strictured portion of the urethra, about half an again increase in intensity after that the artificial opening hac inch, divided, and No. 6 catheter passed into the bladder; the become partially, and then completely, closed ? The answei haemorrhage was trifling, and the operation perfectly satisfacis, I think, to be found in the supposition that the proneneSf tory. The catheter was lefc in for forty-eight hours, when to laryngismus and its calamitous results, and perhaps to even great irritation was experienced, and it was withdrawn. The some other forms of spasm, had been stayed during the rathei progress of the case has since been highly satisfactory. Catheters of gradually-increasing size have been passed, and more than thirteen weeks that the air..&bgr;a.&.en1Jeret1-thetl’aclrea through the patulous artificial aperture, all the while general there is now no obstruction in their transit, the opening in the remedies being brought to bear upon the system, with the in- perinseum has perfectly healed, and the function of micturition tention of lessening the disposition to fits, or the excÜo-motor is restored in its integrity. jReH!CM’A.—The performance of two operations-viz., rectoStisoeptibility, and local remedies being adopted for the removal, albeit partial, of causes of irritation. This arrest of laryngismus, vesical puncture and perineal section, for the relief of so danAnd the amount of convulsive action dependent upon and gerous a condition as retention of urine, and the cure of so imequivalent to it, would necessarily be again interfered with, portant a disease as stricture of the urethra in the same indishould the local irritating causes again accumulate, or the vidual, in the short space of one month, is probably unique in peculiar excitability of the nervous system be again exalted. surgical practice, and invites a few observations which I beg In such a state of things, the artificial tracheal opening, for the to offer, simply with a view of exciting discussion on their compurpose of obviating the spasm of the glottis muscles, would be parative merits in similar cases. in demand. Hence the necessity for patency of this opening I witnessed the first (recto-vesical), in a case of retention of in such cases as the present for months or years, or even for urine, at Guy’s Hospital, last year, by Mr. J. Birkett, one of life. I purpose putting together and analyzing all those cases the present surgeons, an old friend and fellow-apprentice. I placed on record in which for any purpose a tracheal tube has was certainly fascinated by its rapid and satisfactory result, been worn for a length of time. This would be for the pur- and left the hospital with a strong bias in its favour, as a pose of showing with what impunity it can be worn and en- simple and expeditious mode of relieving a state of intense dured, and to prove, as I think will be evident, how much easier agony and danger, and one filling the patient with emotions of such a remedy can be borne, how much lighter an affliction gratitude, and covering the surgeon with eelcat and credit. it is, than those terrible, demoniac-like seizures of the " maladie The case of Serjeant Williams, however, induces reflection on the propriety of its indiscriminate application, and starts sacree." (To be concluded.) the question, whether, although the immediate object-viz., the relief of the bladder-is accomplished with such facility, is the ultimate and equally important end-viz., the cure of the stricture-so much advanced by this procedure as to give it ON A CASE OF a decided superiority over any other? In this case the stricSTRICTURE OF THE URETHRA, TREATEI ture was in no degree affected by the urine ceasing to enter the BY RECTO-VAGINAL PUNCTURE ANI urethra. The point of the smallest or the largest catheter appeared to impinge in the bulbous portion against a solid wall PERINEAL SECTION. or obstruction, which could neither be penetrated by justifiable force or entered by careful insinuation, although up to the BY EDWARD MENZIES, ESQ., M.R.C.S. period of each attack of retention the patient could micturate in a fine stream or gnttatim. It is, of course, impossible decidedly to affirm what was the exact condition of the canal, [DR. SMITH presents his compliments to the Editor of THE through which no one could pass an instrument, and which yet partial performance of the function of mictuLANCET, and at the request of Staff-Surgeon Menzies, who is permitted the stationed at Hong Kong, forwards, for publication the accom- rition ; my own conviction is that a false passage existed, forming a semicircle round the effused lymph, the result of the inpanying case of Sergeant Williams, 59th Regt., should it be jury, and that the point of the catheter was always brought thought worthy of a place in that periodical. 1 up sharp at the anterior entrance of this detour. I base this Medical were

with those taken

"

STAFF SURGEON SECOND CLASS.

Army

Department, April,

1858.

conclusion

on

my

having arrived, in the early steps of the

435