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NOTE ON A CASE OF JACKSONIAN EPILEPSY TREATED BY TREPHINING.
1249 sputum which contains numerous micro-organisms and their products in addition to the tubercle bacillus. In the absence of other distinctive signs a uniform redness of both vocal cords should not be diagnosed as tuberculous, but if one cord be affected markedly in excess of the other tuberculosis may be strongly suspected. The subjects of active phthisis often complain of much dryness and discomfort in the throat, especially at night, even when there is no obvious nasal obstruction. This appears to be the result of the nocturnal pyrexia and the consequent rapid respiration which makes nasal breathing insufficient. A drink of hot milk or a demulcent lozenge diminishes the sense of disPatients in quite an early stage of phthisis sometimes complain of painful sensations about the throat which The cause of this on examination appears perfectly normal. is obscure ; it may, perhaps, be that the pain is referred from the pulmonary disease to the most sensitive part of the respiratory system. Be that as it may, the symptom is not very uncommon, and I would suggest that the patient who complains of pain about the larynx for which no cause can be found should be submitted to a careful examination of the chest. Pachydermia laryngis is also disproportionately common indeed, among the subjects of pulmonary phthisis ; Gougenheim] considered the majority of cases of pachydermia to be tuberculous. I personally consider the affecBrook-street, W. tion as an extreme form of chronic laryngitis and due to the same causes; it is therefore natural that it should be frequent in the larynges of consumptives exposed to the mechanical irritation of coughing and the chemical irritation of the sputum without, of necessity, any entrance of the AND MEDICAL, bacillus tuberculosis into the tissues. The firm white, THERAPEUTICAL. almost cornified, appearance of a typical case is very different from the soft semi-translucent granulations of tuberculous laryngitis. On several occasions I have removed A NOTE ON SOME NON-TUBERCULOUS THROAT the pachydermatous thickening from the posterior commissure COMPLICATIONS OF PHTHISIS. of consumptive patients and have failed to find any sign of BY HAROLD S. BARWELL, M.B. LOND., F.R.C.S. ENG., tuberculosis on microscopical examination. SURGEON FOR DISEASES OF THE THROAT, ST. GEORGE’S HOSPITAL; It is well known that in cases of tuberculous laryngitis the SURGEON TO THE THROAT AND EAR DEPARTMENT, HAMPSTEAD voice is readily lost and is generally much weaker than it GENERAL HOSPITAL; LATE LARYNGOLOGIST, MOUNT VERNON HOSPITAL FOR CONSUMPTION, ETC. would be with a similar extent of lesion due to another cause, such as syphilis. But apart from any laryngeal affecTUBERCULOUS laryngitis is by far the most important of tion, functional aphonia is very common among consumptive those complications of phthisis which affect the upper patients. The feeble respiration, the general weakness, and respiratory tract, so much so, indeed, that it is apt to over- the tendency to catarrh and discomfort of the throat all shadow all the others and to receive the exclusive attention conduce to this affection, which is found in male as well as of the laryngologist as well as of the physician. Never- female consumptives, though more frequently in the latter. theless, other complications are very frequently encountered It is so frequent that an examination of the chest is and are of sufficient importance to claim some consideration. advisable in every case of intractable functional aphonia. A " pre-tuberculous " condition of the larynx has often been True paralysis of a vocal cord is also a recognised complicadescribed, and this expression seems to mean an abnormal tion of pulmonary phthisis. It is due to pressure on the condition, consisting of anaemia, congestion, or swelling of recurrent laryngeal nerve, and is therefore of the abductor the larynx of a phthisical patient but without as yet any type. Paralysis of the left cord is the result of pressure on true tuberculous deposit, and it is implied that this is the left recurrent laryngeal nerve by enlarged bronchial or a precursor of tuberculous infiltration. The use of this tracheal glands, but the right nerve passes very close to the for there are no apex of the right pleura and is thus sometimes directly expression appears highly unscientific, grounds for the view that there is any distinctive state involved in an infiltration of the lung on this side. This is, of the larynx which is always, or frequently, followed perhaps, the commonest cause of paralysis of the right vocal by tuberculosis. There is also a very general opinion cord, therefore the possibility of pulmonary phthisis should that pallor of the larynx is a characteristic feature always occur to the mind of the observer who discovers this of tuberculous laryngitis, but this opinion requires qualifica- lesion on laryngoscopic examination. Thus, other complications of pulmonary phthisis occur in tion. Many consumptives are anaemic, and in such cases the throat besides tuberculous laryngitis, and deserve rethe as well as the fauces and other mucous membranes, larynx, are, of course, pale ; in other cases the colour is quite normal, cognition ; and in a few cases where the first complaint is of and very frequently the tuberculous larynx is in a state of the throat a correct estimate of their significance may direc hypersemia as the result of coughing and irritation ; in fact, the attention to the pulmonary disease. it may be stated that tuberculous larynges are reddened Wimpole-street, W. quite as frequently as unduly pale. lt is true that the swollen infiltrated arytenoids are often pallid, and that the NOTE ON A CASE OF JACKSONIAN EPILEPSY margins of tuberculous ulcers are characteristically anasmio, TREATED BY TREPHINING. and this may have given rise to some misconception ; but BY BERNARD W. SECRETAN, M.B. LOND., F.R.C.S. ENG. very often tuberculous infiltration is decidedly red and congested, especially on the cords, ventricular bands, and THE following are notes of a somewhat unusual case of epiglottis. Simple chronic pharyngitis and laryngitis are extremely Jacksonian epilepsy, in which cessation of the fits was common among consumptive patients and not infrequently brought about by operation. The patient was an anaemic woman, aged 24 years. Her give rise to mistakes in diagnosis, for there is naturally a tendency to diagnose tuberculous laryngitis in a phthisical occupation was that of a clerk. About 16 years ago she fell patient who complains of hoarseness and discomfort down a flight of steps on to her head. She was not stunned The frequency of simple inflamma- at the time and was apparently able to get up by herself and in the throat. tion of the larynx may be explained by the strain of 1 Atlas de constant coughing and by the contact with irritating Laryngologie et de Rhinologie, p. 16. S 3
and two holders, and while I am using one holder, the other, with tubing attached, is being sterilised. I use a fresh needle for each case, and the needle will slip into the vein with ease if lubricated with a little sterile vaseline, and for this purpose I use a five cubic centimetre serum flask, filled to the shoulder with vaseline, which is autoclaved at 120, and after the vaseline has solidified a few drops of izal are introduced into the neck of the flask, which is then covered with a sterilised rubber teat. The needle, immediately after removal from the steriliser, is dipped into the vaseline before use. After use the holder and tubing should be washed through with a small glass urethral syringe to remove the blood before placing in steriliser. If the patient objects to venipuncture, which is seldom the case, I use the glass tube depicted in Fig. 2 with which I can easily collect one cubic centimetre from the finger. The tube is made from No. 4 glass-tubing with one end drawn out into a capillary tube and the other end sealed and a bulb blown near the drawn-out end with a small hole blown in its side ’(see Fig. 2). The tube is held with the hole in the bulb uppermost and the blood will flow into the bulb by capillary attraction and then collect in the sealed end, the displaced air escaping through the hole in the bulb. After filling, the drawn-out end is sealed in the flame and the hole in the bulb is sealed with wax.
Clinical Notes:
SURGICAL, OBSTETRICAL,
.
comfort.
1250 go home.
Eight days after, however, she developed a very headache, which was followed the same night by three convulsions affecting the left arm and leg. Each convulsion lasted only a short time. The next day the left arm and leg were found to be paralysed. The arm recovered after ROYAL SOCIETY OF MEDICINE. about five months ; the leg remained more or less useless for a year, and weak for much longer, necessitating the wearing of supporting irons. The growth of the leg was also imMEDICAL SECTION. paired, so that it is now considerably shorter than the right. Arterial Blood-pressure Readings. Since the paresis passed away the patient up to the date of A MEETING of this section was held on April 27th, the present illness had always enjoyed good health with the T. H. GREEN being in the chair. exception of"a nervous breakdown"in the spring of last Dr.Dr. 0. K. WILLIAMSON said that observations by the a week. have lasted seems to year. This, however, only of circular compression were made on the leg and method The present illness followed a spell of extra work at bookin 21 of arterial blood severe
Medical Societies.
cases high the absence of one of her fellow clerks. arm of the same patient home one week end complaining of intense pressure. In all of the cases in which the arteries of the headache ; this continued and on the following Monday she leg and foot could be felt these were found to be He abnormally resistant and more so than those of the upper was seen by her own medical man, Dr. C. G. S. Leeds. found her in a dazed, dreamy condition, every now and then extremity; and in nearly all the cases there was also thickening in the arteries of the upper extremity. crying out with the pain, which was not localised to any one marked Ten cases of normal or low blood pressure, in which the her whole head. She was but affected given bromide, spot phenazone, and later aspirin, and appeared to improve some- arteries presented no clinical evidences of disease, were what, so that on the following Thursday the pain was investigated in the same manner, so as to afford a basis of’ decidedly better. On the Friday night, however, she had 11 comparison. The observations were made on the calf and convulsive attacks. The convulsions were limited to the left arm, the patient observed being recumbent, and the part of the limb on which the observation was made was at the level arm and leg, affecting the former more than the latter. They lasted from two to five minutes and apparently there was no of the heart. Oliver’s compressed air hæmomanometer was complete loss of consciousness. On the Saturday morning used with his 12 centimetre armlet. These observations showed there was a temporary cessation of fits, but they recommenced that the resistance due to the arterial wall might markedly in the afternoon so that by the following day (Sunday) the influence the readings, for the following reasons : 1. In the patient had had another 20. By this time the convulsive high blood-pressure cases the leg systolic readings were movements were more violent and in some of the worst in nearly all cases markedly higher than the corresponding attacks there was complete loss of consciousness. Clonic arm readings (average difference 32 millimetres), and the movements of the muscles of the face and of the eyeballs cases of highest blood pressure yielded distinctly greater also occurred. The patient was able to tell when a fit was differences than the cases of somewhat lower blood pressure. about to occur and would cry out to this effect about a minute On the other hand, the leg diastolic readings in these cases were, on the average, practically identical with the arm before the actual onset. I saw her with Dr. Leeds, and as she was obviously going diastolic readings (average difference less than 2 mm. downhill and becoming more and more exhausted we de- Hg). 2. In the case of normal or low blood pressure the cided to trephine the next morning. By that time (Monday) systolic arm and leg readings were found, on the average, to she had had another 29 attacks, and so frequent were they be identical (average difference less than 2 mm. Hg). the blood pressure in the leg could becoming that no less than four occurred whilst we were in 3. Inasmuch as than that in the arm (either limb the house making our preparations. I turned down the usual not be higher scalp flap and removed an inch and a quarter disc of bone being at the level of the heart), and seeing that the influence of the tissues superficial to the artery might over the right fissure of Rolando, having its centre about one and a half inches from the upper end of the fissure. (when a sufficiently wide armlet was used) be neglected, it I could find no depression or thickening of the bone, necessarily followed that the difference between the arm and The brain leg readings could only be due to resistance of the arterial nor was the dura adherent to the skull. a into the dura was wall. 4. The conclusion that the abnormal condition of the deal The bulged good opening. incised for about three-quarters of an inch, without, arterial wall was a direct result of the increased blood however, throwing any further light on the case, and pressure would seem to be inevitable, for the only obvious finally the scalp was sutured in position over the hole in difference between the conditions to which the arteries of the skull. The night following the operation the patient the legs and those to which the arteries of the arms are had altogether six fits, but these were not nearly so severe exposed in daily life was that, owing to the action of gravity, The next day she had none. That night the former were subjected to greater hydrostatic pressure as her former ones. she had three very slight attacks. Since then up to from a higher column of blood than were the latter. again Dr. GREEN said that it was very important to deterthe present time (six months) she has had none. The headache ceased the day following operation. The woman mine how far the pressure readings were influenced by the to-day is fit and fell. She has only been allowed to do easy condition of the vessel wall, and on that point there seemed work, but is very anxious to do more. She says that her head to be no definite agreement amongst various workers on the is much clearer than formerly and that she is much quicker subject. A great deal had been done in the matter during at figures and less easily fatigued by them than before her the last few years, but much remained to be done. While attack. waiting for that further information physicians had to be The case is remarkable on account of the long period of largely guided by their own unaided senses. When the time which elapsed between the initial injury and previous blood pressure was largely increased and when the arteries attack and the present one. Also on account of the benefit were markedly thickened those facts were evident to the resulting from trephining, although nothing abnormal wastrained finger. There seemed to be danger at the present found at the time of operation. I am not, of course, at thetime of relying too much on instrumental aids. Even with end of only six months so bold as to call the patientthe best instruments if there was not clinical skill physicians cured. Time alone will show that. I see no reason thoughmight fall far short of what they ought to achieve. Dr. W. P. HERRINGHAM said that he had been making exwhy the fits should recur provided the woman can be induced to lead a placid, quiet life. Anyhow, the operation un- periments on arteries that had been removed from the body 24 hours, and on arteries that had been three days out of the doubtedly saved her life at the time. room, being kept during those three days in a post-mortem Reading. 1 per cent. solution of sodium chloride. He found that those arteries still gave in some cases high resistance readings just IRISH MEDICAL SCHOOLS AND GRADUATES’ Asso- as other arteries did. The figures he obtained were 8, 13, CIATION.—A special meeting of this association will be held 5, 4, 6, 12, 15, and 22 millimetres, showing that there was at Harrogate on Saturday, May 22nd. Arrangements have something in the artery itself quite apart from contractility. been made with the Majestic Hotel to allow of members He had also been experimenting on simultaneous readings remaining until Monday to visit places of interest in the from the arm and leg, testing two places at the same moment, neighbourhood. Full particulars may be obtained from the and his results confirmed those of Dr. Williamson. Dr. T. D. SA. VILL asked whether the author of the paper ! honorary secretary, 30, Myddelton-square, London, E.C.
keeping, owing to She
came
and two holders, and while I am using one holder, the other, with tubing attached, is being sterilised. I use a fresh needle for each case, and the needle will slip into the vein with ease if lubricated with a little sterile vaseline, and for this purpose I use a five cubic centimetre serum flask, filled to the shoulder with vaseline, which is autoclaved at 120, and after the vaseline has solidified a few drops of izal are introduced into the neck of the flask, which is then covered with a sterilised rubber teat. The needle, immediately after removal from the steriliser, is dipped into the vaseline before use. After use the holder and tubing should be washed through with a small glass urethral syringe to remove the blood before placing in steriliser. If the patient objects to venipuncture, which is seldom the case, I use the glass tube depicted in Fig. 2 with which I can easily collect one cubic centimetre from the finger. The tube is made from No. 4 glass-tubing with one end drawn out into a capillary tube and the other end sealed and a bulb blown near the drawn-out end with a small hole blown in its side ’(see Fig. 2). The tube is held with the hole in the bulb uppermost and the blood will flow into the bulb by capillary attraction and then collect in the sealed end, the displaced air escaping through the hole in the bulb. After filling, the drawn-out end is sealed in the flame and the hole in the bulb is sealed with wax.
Clinical Notes:
SURGICAL, OBSTETRICAL,
.
comfort.
1250 go home.
Eight days after, however, she developed a very headache, which was followed the same night by three convulsions affecting the left arm and leg. Each convulsion lasted only a short time. The next day the left arm and leg were found to be paralysed. The arm recovered after ROYAL SOCIETY OF MEDICINE. about five months ; the leg remained more or less useless for a year, and weak for much longer, necessitating the wearing of supporting irons. The growth of the leg was also imMEDICAL SECTION. paired, so that it is now considerably shorter than the right. Arterial Blood-pressure Readings. Since the paresis passed away the patient up to the date of A MEETING of this section was held on April 27th, the present illness had always enjoyed good health with the T. H. GREEN being in the chair. exception of"a nervous breakdown"in the spring of last Dr.Dr. 0. K. WILLIAMSON said that observations by the a week. have lasted seems to year. This, however, only of circular compression were made on the leg and method The present illness followed a spell of extra work at bookin 21 of arterial blood severe
Medical Societies.
cases high the absence of one of her fellow clerks. arm of the same patient home one week end complaining of intense pressure. In all of the cases in which the arteries of the headache ; this continued and on the following Monday she leg and foot could be felt these were found to be He abnormally resistant and more so than those of the upper was seen by her own medical man, Dr. C. G. S. Leeds. found her in a dazed, dreamy condition, every now and then extremity; and in nearly all the cases there was also thickening in the arteries of the upper extremity. crying out with the pain, which was not localised to any one marked Ten cases of normal or low blood pressure, in which the her whole head. She was but affected given bromide, spot phenazone, and later aspirin, and appeared to improve some- arteries presented no clinical evidences of disease, were what, so that on the following Thursday the pain was investigated in the same manner, so as to afford a basis of’ decidedly better. On the Friday night, however, she had 11 comparison. The observations were made on the calf and convulsive attacks. The convulsions were limited to the left arm, the patient observed being recumbent, and the part of the limb on which the observation was made was at the level arm and leg, affecting the former more than the latter. They lasted from two to five minutes and apparently there was no of the heart. Oliver’s compressed air hæmomanometer was complete loss of consciousness. On the Saturday morning used with his 12 centimetre armlet. These observations showed there was a temporary cessation of fits, but they recommenced that the resistance due to the arterial wall might markedly in the afternoon so that by the following day (Sunday) the influence the readings, for the following reasons : 1. In the patient had had another 20. By this time the convulsive high blood-pressure cases the leg systolic readings were movements were more violent and in some of the worst in nearly all cases markedly higher than the corresponding attacks there was complete loss of consciousness. Clonic arm readings (average difference 32 millimetres), and the movements of the muscles of the face and of the eyeballs cases of highest blood pressure yielded distinctly greater also occurred. The patient was able to tell when a fit was differences than the cases of somewhat lower blood pressure. about to occur and would cry out to this effect about a minute On the other hand, the leg diastolic readings in these cases were, on the average, practically identical with the arm before the actual onset. I saw her with Dr. Leeds, and as she was obviously going diastolic readings (average difference less than 2 mm. downhill and becoming more and more exhausted we de- Hg). 2. In the case of normal or low blood pressure the cided to trephine the next morning. By that time (Monday) systolic arm and leg readings were found, on the average, to she had had another 29 attacks, and so frequent were they be identical (average difference less than 2 mm. Hg). the blood pressure in the leg could becoming that no less than four occurred whilst we were in 3. Inasmuch as than that in the arm (either limb the house making our preparations. I turned down the usual not be higher scalp flap and removed an inch and a quarter disc of bone being at the level of the heart), and seeing that the influence of the tissues superficial to the artery might over the right fissure of Rolando, having its centre about one and a half inches from the upper end of the fissure. (when a sufficiently wide armlet was used) be neglected, it I could find no depression or thickening of the bone, necessarily followed that the difference between the arm and The brain leg readings could only be due to resistance of the arterial nor was the dura adherent to the skull. a into the dura was wall. 4. The conclusion that the abnormal condition of the deal The bulged good opening. incised for about three-quarters of an inch, without, arterial wall was a direct result of the increased blood however, throwing any further light on the case, and pressure would seem to be inevitable, for the only obvious finally the scalp was sutured in position over the hole in difference between the conditions to which the arteries of the skull. The night following the operation the patient the legs and those to which the arteries of the arms are had altogether six fits, but these were not nearly so severe exposed in daily life was that, owing to the action of gravity, The next day she had none. That night the former were subjected to greater hydrostatic pressure as her former ones. she had three very slight attacks. Since then up to from a higher column of blood than were the latter. again Dr. GREEN said that it was very important to deterthe present time (six months) she has had none. The headache ceased the day following operation. The woman mine how far the pressure readings were influenced by the to-day is fit and fell. She has only been allowed to do easy condition of the vessel wall, and on that point there seemed work, but is very anxious to do more. She says that her head to be no definite agreement amongst various workers on the is much clearer than formerly and that she is much quicker subject. A great deal had been done in the matter during at figures and less easily fatigued by them than before her the last few years, but much remained to be done. While attack. waiting for that further information physicians had to be The case is remarkable on account of the long period of largely guided by their own unaided senses. When the time which elapsed between the initial injury and previous blood pressure was largely increased and when the arteries attack and the present one. Also on account of the benefit were markedly thickened those facts were evident to the resulting from trephining, although nothing abnormal wastrained finger. There seemed to be danger at the present found at the time of operation. I am not, of course, at thetime of relying too much on instrumental aids. Even with end of only six months so bold as to call the patientthe best instruments if there was not clinical skill physicians cured. Time alone will show that. I see no reason thoughmight fall far short of what they ought to achieve. Dr. W. P. HERRINGHAM said that he had been making exwhy the fits should recur provided the woman can be induced to lead a placid, quiet life. Anyhow, the operation un- periments on arteries that had been removed from the body 24 hours, and on arteries that had been three days out of the doubtedly saved her life at the time. room, being kept during those three days in a post-mortem Reading. 1 per cent. solution of sodium chloride. He found that those arteries still gave in some cases high resistance readings just IRISH MEDICAL SCHOOLS AND GRADUATES’ Asso- as other arteries did. The figures he obtained were 8, 13, CIATION.—A special meeting of this association will be held 5, 4, 6, 12, 15, and 22 millimetres, showing that there was at Harrogate on Saturday, May 22nd. Arrangements have something in the artery itself quite apart from contractility. been made with the Majestic Hotel to allow of members He had also been experimenting on simultaneous readings remaining until Monday to visit places of interest in the from the arm and leg, testing two places at the same moment, neighbourhood. Full particulars may be obtained from the and his results confirmed those of Dr. Williamson. Dr. T. D. SA. VILL asked whether the author of the paper ! honorary secretary, 30, Myddelton-square, London, E.C.
keeping, owing to She
came