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PARALYSES AND PSYCHOSES FOLLOWING PROLONGED ANÆSTHESIA.
1508
PARALYSES AND PSYCHOSES FOLLOWING PROLONGED ANESTHESIA.
tNsmorrhage occurred which must have come from the unferior mesenteric vein or one of its branches. The
existing arterio-sclerosis or atheromatosis and that it takes the form of hemorrhage or softening which may be brcught about in the following way. The anaesthetic acts in the first instance by producing relaxation of the cerebral vessels (vascular dilatation and atony) during the preliminary period of excitation from the chloroform or ether vapour, while efforts on the part of the patient, such as cries and struggles, and in some cases vomiting, provoke further vascular congestion followed by rupture (bsemorrhage) or by thrombosis or embolism. It is found that Trendelenburg’s
position in gynaecological operations favours the occurrence of cerebral paralysis owing to its proneness to bring
mentioned. 3. The toxic action of the the nerve-centres also plays probably a anesthetic minor part in determining some of the less known The subjects who suffer, and more obscure paralyses. however, from psychoses and serious mental disturbanaesthesia have a hereditary ances following surgical predisposition to mental derangement. In such cases there may be a more or less marked loss of memory (amnesia) lasting some days, while in others again the cerebral disease takes the form of delirium and mental confusion. In these cases and in cases of an hysterical nature local paralyses may PARALYSES AND PSYCHOSES FOLLOWING also appear with motor signs comparable to hystero-traumatic PROLONGED ANÆSTHESIA. palsies. Such troubles are never observed in children THE paralyses and psychoses of limited extent which follow (according to Professor Joffroy of Paris)and indicate the prolonged anaesthesia are infrequent but of great practical probable"hysterical"" nature of the paralysis. Finally, it is importance. Louis Moret1 gives an interesting study and to be noted in regard to the last class of post-operative record of paralyses following general anaesthesia produced psychoses that Dr. Granjux of Paris,4 an army medical by chloroform or ether, having no relation to the region officer, has not observed any such psychoses among soldiers, operated on, and being dependent upon effects produced on and this immunity is probably due to the special care the nervous system, peripheral or central. Garrigues2 was exercised in the selection of soldiers which eliminates one of the earliest to study and record cases of peripheral predisposition. paralyses following anesthesia, and Schwartz at the Annual SANITATION IN YUCATAN. French Surgical Congress at Lille, 1897, gave a ’l’ésumé of all the facts then known. It is necessary to discriminate IN Merida, the capital of Yucatan, a city possessing 45,550 between true paralysis and that from compression of peri- inhabitants, the sanitary problem is one of exceptional diffidheral nerves during the operation. Compression may be culty on account of the extreme flatness of the locality and brought about by elastic bands-e.g., Esmarch’s bandage- the perennially saturated condition of the subsoil. Situated or from pressure of nerves between bones-e.g., between the some 20 miles from the coast Merida stands only about davicle and the first rib-in which latter case a paralysis of 25 feet above sea-level in the centre of a vast plain of which the arm may result. These are peripheral paralyses. The the exact geological character has not been determined. other class comprises central paralyses. These may occur There are no rivers or streams of any kind throughout the under the form of facial paralysis, hemiplegia with or entire province, but so porous is the surface that storm water without aphasia, or some other focal paralysis from almost instantly sinks out of sight without, however, perIn some of these cases cerebral lesion. lesions, ceptibly affecting the height of the underlying aqueous of in the forms generally hemorrhage or softening, stratum which is said to remain pretty much at the same have been found in the cerebral hemispheres. A third class level all the year round. The city covers a considerable area includes indeterminate paralyses. 1. Of the three kinds, and is subdivided into squares and parallelograms by wide the first (peripheral paralysis) follows ansesthesia of long but unpaved and very ill-kept streets. The houses of well- duration where the patient’s body and limbs have been placed to-do citizens are for the most part spacious, single-storeyed, in’forced or strained attitudes and subjected to compression flat-topped edifices, built of calcareous stene, but the poor against the operating-table or by the use of Esmarch’s live in what are described as "veritable hovels, containbandage. When the anxsthesia is over the paralysis shows ing each one room only, which has to serve the family as itself and usually in a single limb or affecting a segment of kitchen, dining-hall, and dormitory." Every habitation, a limb only. No sensorial troubles are found nor is there large or small, has more or less curtilage and garden, and evidence of persistent peripheral neuritis. The reflexes are i hitherto it has been the custom to deposit slops and nightI soil in a small yard or enclosure where percolation and solar preserved, but where the brachial plexus has been upon, an ocular symptom-viz., myosis-may be present on desiccation are relied on for their innocuous dispersal. Such the affected side. 2. The central paralyses are rarer than those from time immemorial has been the universal practice in of the type just described and generally occur in women. Merida, for in the eyes of the multitude what was good Thus, out of a total of 12 recorded cases 11 were those of the enough for their fathers is likewise good enough for them; female sex. There is a partial ictus or stroke found to occur but a short time ago it occurred to an enlightened municiduring the anesthesia, and on recovering from the anaes- pality that although the subsoil of their city was unthetic or shortly after and within a few hours the paralysis doubtedly long-suffering there was possibly, if not probably, makes its appearance. The clinical types are monoplegic, a limit beyond which its continual befouling could not be facial, hemiplegic, or disseminated. Necropsies generally carried without disastrous consequences. A commission of - show that the central lesion is associated with a pre3 Proceedings of the Congress of French Alienists and Neurologists 1 Thèse de held at Angers, August, 1898. Paris, December, 1898. 2 American Journal of the Medical 4 Ibid. Sciences, 1897, p. 81. about the
causes on
-
pressed
PARALYSES AND PSYCHOSES FOLLOWING PROLONGED ANESTHESIA.
tNsmorrhage occurred which must have come from the unferior mesenteric vein or one of its branches. The
existing arterio-sclerosis or atheromatosis and that it takes the form of hemorrhage or softening which may be brcught about in the following way. The anaesthetic acts in the first instance by producing relaxation of the cerebral vessels (vascular dilatation and atony) during the preliminary period of excitation from the chloroform or ether vapour, while efforts on the part of the patient, such as cries and struggles, and in some cases vomiting, provoke further vascular congestion followed by rupture (bsemorrhage) or by thrombosis or embolism. It is found that Trendelenburg’s
position in gynaecological operations favours the occurrence of cerebral paralysis owing to its proneness to bring
mentioned. 3. The toxic action of the the nerve-centres also plays probably a anesthetic minor part in determining some of the less known The subjects who suffer, and more obscure paralyses. however, from psychoses and serious mental disturbanaesthesia have a hereditary ances following surgical predisposition to mental derangement. In such cases there may be a more or less marked loss of memory (amnesia) lasting some days, while in others again the cerebral disease takes the form of delirium and mental confusion. In these cases and in cases of an hysterical nature local paralyses may PARALYSES AND PSYCHOSES FOLLOWING also appear with motor signs comparable to hystero-traumatic PROLONGED ANÆSTHESIA. palsies. Such troubles are never observed in children THE paralyses and psychoses of limited extent which follow (according to Professor Joffroy of Paris)and indicate the prolonged anaesthesia are infrequent but of great practical probable"hysterical"" nature of the paralysis. Finally, it is importance. Louis Moret1 gives an interesting study and to be noted in regard to the last class of post-operative record of paralyses following general anaesthesia produced psychoses that Dr. Granjux of Paris,4 an army medical by chloroform or ether, having no relation to the region officer, has not observed any such psychoses among soldiers, operated on, and being dependent upon effects produced on and this immunity is probably due to the special care the nervous system, peripheral or central. Garrigues2 was exercised in the selection of soldiers which eliminates one of the earliest to study and record cases of peripheral predisposition. paralyses following anesthesia, and Schwartz at the Annual SANITATION IN YUCATAN. French Surgical Congress at Lille, 1897, gave a ’l’ésumé of all the facts then known. It is necessary to discriminate IN Merida, the capital of Yucatan, a city possessing 45,550 between true paralysis and that from compression of peri- inhabitants, the sanitary problem is one of exceptional diffidheral nerves during the operation. Compression may be culty on account of the extreme flatness of the locality and brought about by elastic bands-e.g., Esmarch’s bandage- the perennially saturated condition of the subsoil. Situated or from pressure of nerves between bones-e.g., between the some 20 miles from the coast Merida stands only about davicle and the first rib-in which latter case a paralysis of 25 feet above sea-level in the centre of a vast plain of which the arm may result. These are peripheral paralyses. The the exact geological character has not been determined. other class comprises central paralyses. These may occur There are no rivers or streams of any kind throughout the under the form of facial paralysis, hemiplegia with or entire province, but so porous is the surface that storm water without aphasia, or some other focal paralysis from almost instantly sinks out of sight without, however, perIn some of these cases cerebral lesion. lesions, ceptibly affecting the height of the underlying aqueous of in the forms generally hemorrhage or softening, stratum which is said to remain pretty much at the same have been found in the cerebral hemispheres. A third class level all the year round. The city covers a considerable area includes indeterminate paralyses. 1. Of the three kinds, and is subdivided into squares and parallelograms by wide the first (peripheral paralysis) follows ansesthesia of long but unpaved and very ill-kept streets. The houses of well- duration where the patient’s body and limbs have been placed to-do citizens are for the most part spacious, single-storeyed, in’forced or strained attitudes and subjected to compression flat-topped edifices, built of calcareous stene, but the poor against the operating-table or by the use of Esmarch’s live in what are described as "veritable hovels, containbandage. When the anxsthesia is over the paralysis shows ing each one room only, which has to serve the family as itself and usually in a single limb or affecting a segment of kitchen, dining-hall, and dormitory." Every habitation, a limb only. No sensorial troubles are found nor is there large or small, has more or less curtilage and garden, and evidence of persistent peripheral neuritis. The reflexes are i hitherto it has been the custom to deposit slops and nightI soil in a small yard or enclosure where percolation and solar preserved, but where the brachial plexus has been upon, an ocular symptom-viz., myosis-may be present on desiccation are relied on for their innocuous dispersal. Such the affected side. 2. The central paralyses are rarer than those from time immemorial has been the universal practice in of the type just described and generally occur in women. Merida, for in the eyes of the multitude what was good Thus, out of a total of 12 recorded cases 11 were those of the enough for their fathers is likewise good enough for them; female sex. There is a partial ictus or stroke found to occur but a short time ago it occurred to an enlightened municiduring the anesthesia, and on recovering from the anaes- pality that although the subsoil of their city was unthetic or shortly after and within a few hours the paralysis doubtedly long-suffering there was possibly, if not probably, makes its appearance. The clinical types are monoplegic, a limit beyond which its continual befouling could not be facial, hemiplegic, or disseminated. Necropsies generally carried without disastrous consequences. A commission of - show that the central lesion is associated with a pre3 Proceedings of the Congress of French Alienists and Neurologists 1 Thèse de held at Angers, August, 1898. Paris, December, 1898. 2 American Journal of the Medical 4 Ibid. Sciences, 1897, p. 81. about the
causes on
-
pressed