ON LARYNGOTOMY IN HYDROPHOBIA.

ON LARYNGOTOMY IN HYDROPHOBIA. BY J. B. SCRIVEN;

ESQ.,

FIRST ASSISTANT-SURGEON PRESIDENCY GENERAL HOSPITAL, CALCUTTA.

to feel the

I sent for a it on his head.; but it had little or no effect, except to increase distress and excitement when the water went into his mouth. I tried to give him some brandy-and.water and some small lumps of ice; but they did not appear to do good, and the greater part of both he,

placed

my hand

on

the

temples

bag of water (a bheesty’s mussick),

and

artery.

poured

managed to spit out.

MANY years have elapsed since Dr. Marshall Hall proAfter this, about eleven P.M., I removed him to a quiet and the attendants ceased to hold him. He now struggled of the the medical to place, performance tracheotomy profession posed for the relief of the urgent symptoms dependent on closure of much less, but still continued to talk in the same strain, though less occasionally spitting out with apparent difficulty the glottis in diseases in which that affection forms a prominent someloudly, viscid saliva. At this time his pulse was found small to character. His suggestions were directed more especially and wiry-160; skin hot, but moist; great sensibility of surthe treatment of epilepsy and children’s convulsions, probably face ; he started even when touched. The abdomen seemed because these formed the widest field for investigation and to be the most sensitive part. The pupils were dilated, and benefit to mankind; but not less confident was his hope that insensible to light. Respirf1tions were principally thoracic, He had no movements which could be distinctly called 41 in, some rarer yet more fatal affections the advantage to be he swallowed a little brandy-and-water that was derived would prove equally great. In all he looked forward voluntary; into his mouth. He continued in this state for half dropped to one thing as certain-viz., the removal of the symptoms an hour; after which, without evident cause, he became greatly caused by the laryngismus, which, in the immense majority of excited, bawled so as to he heard all over the compound, and such cases, as in hydrophobia and poisoning by strychnine, is required to be held in bed by several men, at whom he the cause of death, while he left for future experiment to de- frequently. Suddenly, it appears, he became sensible (about When spoken to by the wardmaster, he stood ttp cide how far the diseases would wear themselves out when de- midnight). to have his bed put to rights, and then lay down, took a little prived of these more immediate dangers. brandy-and-water, and went to sleep. He was awake at four The following case will, I think, be found interesting to all o’clock on the morning of the 9th, when I went over to see who have followed the great investigator of the nervous system him; quite cool and rational, but complaining of feeling very in his inquiries :weak. I put a silver bent tube into the larynx, the quill J. M-, seaman, aged nineteen, admitted into the General having come out. He went to sleep again, and was comfortHospital, Calcutta, July 23rd, 1858. On admission, had been ably sleeping when seen at six A.M. At half past eight he one month in India, and was suffering from slight choleraic was awake; skin cool and moist; pulse 100, soft; respirations 28. Complained of weakness and difficulty of coughing from diarrhoea, which yielded to simple treatment, sulphuric acid, &c. On August 8th, was recovering-in fact, feeling well, and ex- the opening in the windpipe; was perfectly collected, deto go out on the morrow; but about eight P.M. was scribed the sensations which were premonitory of the attack, pecting seized with a sudden feeling of "weakness, wind at stomach, as given at the commencement of this history. He said he and,difficulty of breathing," while on the stairs, and was obliged remembered the cut being made into his throat, but lost himto hold on by the balusters. The apothecary was sent for, and self entirely very soon after; remembered the pain in his gave him a dose of peppermint, which was said to have re- throat at the time of the operation, but did not know where lieved him temporarily. At a quarter to nine, however, I got he was, and was never in such a fright in his life. a note to the effect that a patient in the ward was complaining The patient has only been twice on shore in India this time "of choking." I went over at once, and found the man sitting (he was out here last year), with the exception of coming to on the bed, labouring for breath, yet taking deep sighs, and hospital. He is perfectly sure that no animal bit or licked filling his lungs completely; in great distress, with small rapid him on those occasions, and there were no animals on board pulse, perspiring profusely, crying out that he was dying for his ship. Was bitten by a dog on the inside of the right thigh want of breath, and requesting me to do something for him im- nine years ago, and the dog was afterwards killed for biting mediately. Presently a decided spasm of the glottis came on, people, but was not mad: was never bitten by any other with crowing inspiration, like laryngismus stridulus in the animal, and never had a dog of his own but one, which he child. J gave him a cup of tea, which he drank with apparent I gave away when he went to sea four years ago. The cicatrices avidity, though at first be said it would choke him. A mustard of wounds formed by two teeth are still distinctly visible. plaster also was applied to the chest. After taking the tea he Ordered, sago diet; beef-tea, two pints; port wine, eight seemed somewhat relieved, having lost the crowing inspiration, ounces. but still labouring for breath as at first. In a very few seconds, Aug. 10th.-Seems pretty well; pulse 100, feeble. To have however, the spasm and crowing returned, and were again ap- meat diet. Got the tube out yesterday evening, and did not parently relieved by a draught of water. This was repeated breathe through the wound in the night, as the skin overlapped three or four times, when, finding the relief only momentary, it. It was introduced again, and tied by strings placed round I sent for a mustard emetic, (a teaspoonful of mustard and four the neck. Particular inquiries were made to-day about other This took a few minutes to prepare, during possible causes of his symptoms. He never had epilepsy or ounces of water.) which I did nothing except try to pacify the patient, and paralysis. The glands of the neck are not enlarged, but there feel the larynx, in order that I might be ready to perform is one small superficial abscess just below the jaw, which, he laryngotomy if necessary. When the mustard emetic came he says, he has had since he first got the cholera. Never had any drank some of it, and then by a movement, apparently half laryngeal affection before, nor difficulty of breathing. Bowels convulsive, threw the cup containing the remainder of the regular, and stools solid and healthy, as they were also before liquid on the ground, and fell back upon his bed, unable to the attack. Prsecordial region very slightly prominent, but breathe from spasm of the glottis; there was now no crowing, he never had palpitation; the heart-sounds are healthy, and for the glottis was completely closed. I had my penknife the organ in natural position and apparently of natural dimenready, and plunged its small blade into the larynx through the sions. No murmurs along the arteries in the chest, nor other crico-thyroid membrane. The man was struggling so much at signs of aneurism. Liver of natural dimensions; spleen likethe time, that I only succeeded in making a small opening cor- wise. A slight murmur over the abdominal aorta (not proresponding to the width of the blade, through which, however, duced by pressure of the s ethoscope), but.no pain, palpitation, the air whistled, and the spasm of the glottis, at least the dis- or tumour. No abdominal disease detected. Has had no illtress consequent on it, was at once removed. Now he began ness since the scarlatina, when he was six years old. Sayshe to talk very fast and loud, and to express excessive fear of had a little irritability of the bladder on the voyage home last death, calling upon God to have mercy upon him, at the same year, which he attributed to drinking bad water; this got time struggling, so that it required about six men to hold him. well, and he had no return of it. The urine now is strawBy seizing opportunities, I gradually managed to enlarge the coloured, clear, 1016; no albumen; no deposit, seen under the opening into the larynx by cutting through the cricoid carti- microscope; very slightly acid. His sensations on taking the mustard, on the evening of the lage, and to insert a quill, through which he breathed freely. He still continued talking in the same rapid way, and soon be- 8th, he thus describes: " tt caused a burning in my stomach, 40-Ame decidedly incoherent, calling upon the devils to come and which seemed to come up into my throat, and stopped my take him away, and inquiring what he had done " on this 19th breath." He does not remember throwing away the cup conday of June" to, deserve such punishment. It was impossible taining the remainder of the liquid. Says he had difficulty in to quiet him or arrest his attention; but any sudden movement drinking the water during the attack before the laryngotomy, or impression made him start and talk the louder, as when I but drank it because I told him.

spat

409

llth.-At noon, I found him in a very excited state. Ever his clothes and money to his father. Took his draught at bedsince the operation he has had slight emphysema about the time, and slept almost the whole night. Passes urine freely, chest, which all along he has been inclined to exaggerate, but ’ but bowels not open; pulse more feeble than yesterday, only to-day he magnified it into something terrible, and filled up 72; skin moist and cool; tongue rather dry; is delirious, but the wound in the throat and his ears with cotton from his not noisy; was crossing himself, and muttering some kind of bedding, which he had torn to pieces; this was done with the prayer, when I saw him this morning; has had no chloroform idea of preventing the entrance of more air.-About three P.M. since three P.M. yesterday. Repeat castor oil, half an ounce,, he became decidedly delirious, and was in a great fright about immediately. himself: said that he thought I had cured him, but that now 17th.-Got his fingers upon the wound in the throat yesterday,, he was gone; the blood had come up into his head, his belly and made it bleed to a most surprising extent, most of the and testicles had burst, and his limbs were all swollen. He blood running into the windpipe, and being coughed up immewas asked to take some water, but he said it would choke him; diately. This weakened him considerably, and increased the yet he took it.-At six P.M. he was violently delirious and frequency of his pulse, but he nevertheless ate his dinner, and very abusive, talking very loud and fast, and spitting at every slept the whole night without any opiate. He is still delirious body; said I had killed him by opening his windpipe, and that this morning; says there is a bad smell from his body, which is-. I had done it because he was a Catholic and I a Protestant. injurious to other people; pulse soft, feeble, 88. He was a little feverish, and his tongue dry. Pupils dilated 19th.-Sleeps well at night, but is delirious during the day; and immovable. The tube was removed from the larynx, as he is melancholic; always fancies he is dying, but has no particular to make of uneasiness; wound in the throat open,. would not keep it in during this delirium, and the wound now remained freely open of itself. I administered chloroform by appetite good; tongue clean, moist; pulse 92;. inhalation; he took three drachms and a half, and fell into a bowels open. 25th.-The same wound in throat closed internally since yes-tranquil sleep, in which he continued for three hours. During the inhalation the pulse sank from 120 to 100. On awaking, terday. It is granulating. He does not breathe through it’ he was still delirious, but quiet; covered himself with the now. Pulse soft, 68 (lying) ; skin cool and moist; pupils bedclothes, and was apparently sleepy; yet he did not sleep, natural; tongue clean and moist; looks sad; still fancies he is iniuring other people. but continued in this drowsy state. 12th.-At one A.M., he expressed a wish to see me. I found Sept. 8th.-The remaining notes are but a repetition of this him more collected, though excited. He asked forgiveness for last. He has the same delusions, and refuses various articles having spit at the gentlemen, and inquired if it were really of diet in succession, in the hope of diminishing this smell from true that he had done so, as he thought he remembered doing his body, which he considers so injurious to all around him it during his dream. Thought he would be much better if he He sometimes tells me he knows he must die for the injury he got some of the same drug that put him to sleep before. I has thus produced, and the number of deaths he has caused. therefore gave him chloroform again. He took two drachms, He has become thin during his illness, but otherwise appears and again fell into a tranquil sleep, which continued till half- now to be in good bodily health. To give a name to this patient’s disease is more difficult than past five A.M. When I went to him, about six A. he was water and eating bread-and-butter, and said he was might at first sight appear. The throwing away of the liquid very hungry ; still talked about being swollen; slightly inco- and the convulsive closing of the glottis point to hydrophobia ;j herent ; manner a little excited; skin cool and moist; tongue and the fact of the man drinking, though with difficulty, before is by no means hostile to the idea, as the attack had but moist and clean. 13th.-He was somewhat incoherent all day yesterday; ate just commenced, he had had no complete closure of the glottis, and had not learnt to connect the spasm with the swallowing some food, but did not take his meat; became more excited towards evening, and began to spit a little as on the previous of fluids. It is probable that, had the larynx not been opened evening; was quieted by the inhalation of chloroform; took a when it was, he would strenuously have refused the next drachm and a half, and slept all night ; is known to have awoke draught of water. Hydrophobia cases are rarely seen so early only once, at nine Appears a little busy and excited, but by medical men, so that we lack the means of comparison;j does not talk incoherently at present; says he is much better, yet the absence of the peculiar horror of water in the early that the crackling (i. e., the emphysema) in his chest is almost stages is by no means without a parallel. Again, we lack the gone, and that he has now no swelling of the limbs. Tongue means of comparingthe course of the disease after the operamoist, slightly coated ; pulse soft, 84; skin perfectly cool and tion ; for, as far as I am aware, no cases of hydrophobia so moist; bowels not open since the night of the 10th. Ordered treated have been recorded; yet everything agrees with what six drachms of castor oil immediately ; port wine, sixteen Marshall Hall anticipated, viz. :-

complaint suppurating;

drinking

ounces.

1st. The cessation of all

symptoms consequent

on

laryngis-

14th. -Continued much in the same state all day yesterday. mus, the absence of general convulsions and horror of water. Delirium increased in the evening; there seems to be always 2nd. The retention for a time of all the other symptoms of Last night, said some great fear of death connected with it. hydrophobia:the intense excitement, the wild delirium, the he was much worse; showed me his hand, remarking that the morbid sensibility of the surface, the spitting, the fear of impulse did not beat. Chloroform administered again. Took mediate death. two drachms, but the effect did not last. Went to sleep three 3rd. The gradual amelioration of the disease. times while inhaling this, but awoke in a few minutes; the The total absence of any other discoverable cause for the third sleep was rather a deep one, accompanied by puffing of the rarity of such symptoms from any other strange the the lips during expiration. He was ordered following: cause affection, their possibility is not denied), are all in favour Battley’s sedative solution, forty minims; peppermint water, of the(though view; while the obscure history of the inoculation is one ounce: to be taken at bed-time. After taking the is common in cases of the most unmistakable kindwhat only draught, he slept an hour and a quarter. With this exception, unmistakable from the non-performance of indeed, perhaps, has been awake all night, and about one A.M. became very and the consequent persistence and hitherto intracheotomy, threw the contents of over the the noisy; sergeant night-stool and coolies. Is still delirious this morning; no fever; skin variably fatal result of hydrophobia. Be the name of the discool and moist; pulse 100, soft; bowels freely opened yesterday; order what it may, it was a kindred one to hydrophobia. It did not eat his meat, but took the greater part of his beef-tea commenced with spasm of the glottis, which was followed by and port wine.-Two P.M.: Chloroform, half a drachm; all the characteristic symptoms. Laryngotomy did all that camphor mixture, one ounce: to be taken every two hours. was ever expected of it. It relieved the man from immediate In the evening, Battley’s sedative solution, one drachm; danger; it gave time for the blood poison to be gradually spent, and allowed the disease to terminate in melancholia instead of water, one ounce: to be taken at bed-time. 15th.-Took his medicine up to midnight; would not take it in death. Time alone can tell whether or not the patient will recover. afterwards; very delirious and troublesome all night; since eventually It to me that this case is scarcely less valuable as an appears has been midday yesterday perspiring freely; does not eat, but takes his beef-tea and port wine; is quiet and sensible this illustration of the correctness of the views of Dr. Marshall Hall if the history of its production by the bite of a rabid morning; pulse soft, 72; complains of headache. Repeat chlo- than animal had been more distinct. This is the only link in the roform draught; anodyne draught at bed-time. 16th.-Took his medicine yesterday regularly up to three chain of evidence that we want to prove it hydrophobia. The effect of chloroform (given by inhalation, and, w,ien that failed, P.M.; got a little sleep during the day, the pulse varying from the stomach) in quieting delirium, lowe;ing the frequency was and not at all to 72 excited, by 76; ate nearly all his food, the of pulse, and inducing sleep, is well worthy of remark. though not perfectly coherent. In the evening he was someJanuary, 1859. Calcutta, me to send and was he what worse; thought dying, requested ,

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