103. I give Mr. Sampson's case without abridg. ment: Mr. Andrews, under whose care, as surgeon for the week, the patient was now placed. 104. "Abraham Harris, aged thirty-one, was 107. "The trachea was no sooner opened than brought to my house on the 31st of March last, the distention of the veins about the head and in a state of complete insensibility from intoxica-neck subsided, the violent efforts of the extration, the pupils being largely dilated, the breathing respiratory muscles ceased, and in about half an stertorous, and all voluntary motion having been hour regular and easy respiration through the lost for at least four hours before I saw him. The account given by those who came with him was, that he had attended a convivial meeting in the course of the day, at which he had drunk freely both of beer and brandy; his companions admitted that he had taken more than a pint of the latter; but it has since been ascertained that his glass was repeatedly filled up, without his knowledge, with white brandy instead of water, so that it is impossible to calculate what quantity of spirit he had actually taken. wound was completely established; at the same time, the pupils became slightly sensible to the stimulus of light, and the pulse returned to the wrist. The immediate result of the operation being thus far satisfactory, nothing remained to be done but to give directions for the frequent removal of the mucus which appeared at the wound, and to keep the surfaces of the incision asunder until the integuments and muscular layers had become agglutinated to each other: this latter object was effected by means of a piece of strong spring-wire, with a bow at each end of it, which, being introduced in a bent state, was allowed to expand, and the opening in the trachea was thus prevented from being covered by the muscles, even during the efforts of deglutition. 108. (( 105. "I immediately used the stomach-pump, and drew off between three and four pints of fluid, a great part of which appeared to consist of brandy; after which, tepid water with ipecacuanha diffused in it was several times injected into the stomach, and after a while withdrawn again, with He continued perfectly quiet during the a view to excite vomiting, and thus rouse the night, but had no return of consciousness until the energies of the brain. Finding, however, that following morning, when he gave us to understand, these means failed, a strong solution of salt in by signs, that he suffered from headache and water, and afterwards the sulphate of zinc, were soreness at the pit of the stomach; there was a repeatedly tried, without any better result; he tendency to sickness, and the tongue was coated became, if possible, more comatose, the coun- with a peculiar whiteness, as if rubbed over with tenance turgid, the breathing more and more chalk. Moderate purgatives, followed by mild difficult; the pulse grew fainter, and was at last alkaline medicines, soon removed these symptoms, scarcely perceptible; at the same time, the whole and a few leeches were applied to the throat for surface of the body was cold and clammy, and he the purpose of checking too high a degree of was insensible to every kind of stimulus. As he inflammation; after which, no further treatment was some miles from his home, I had him removed was required; but the wound being healed in to the Infirmary, and called a consultation of the about three weeks, he was discharged cured, and other medical attendants, who arrived in the has continued up to this time in the enjoyment of course of half an hour; but as, in addition to perfect health." the above symptoms, he had lost the power of swallowing, and every appearance indicated the rapid approach of death, nothing was ordered for him but a turpentine injection, there being no ground to justify a reasonable hope of re covery. 109. To Mr. Cane's case I shall have to refer hereafter, in its relation to the treatment of epilepsy: for, as I have already stated, it possesses a double and an extraordinary claim to our attention and admiration. I give it in Mr. Cane's own. words, as addressed to myself: "Uxbridge, May 17, 1951. 66 106. At this period, it occurred to me, whilst standing by his bed side, that the comatose state 110. "MY DEAR SIR,-I was called suddenly in which he lay might not arise from apoplexy, to attend A. B. aged twenty-four, on Feb. 1, but from torpor of the brain, in consequence of 1851. I was told that he had been taken out of that organ being supplied with blood not duly a canal-boat the day before, apparently in a dyingoxygenated; for the shrill tone and extreme state. On entering the house, I found the patient difficulty of respiration showed the existence of in convulsions, with a most turgid face, with collapse of the glottis, and imperfect transmission extravasated blood on the conjunctivæ, which of air into the lungs, which might be accounted were of a perfectly livid colour, with cold exfor by a paralyzed state of the eighth pair of tremities, and a pulse imperceptible at the wrist, nerves and recurrent branches. With this view his heart acting most feebly. Respiration was of the case, I again appealed to my colleagues, impeded to such an extent, that I concluded that and strongly urged that a trial should be given to the operation of tracheotomy; for I could not but hope, that, if mechanical respiration were carried on for a time, the blood might regain its proper stimulant properties, and restore the energies of the brain and nervous system. Upon their consenting to give him this chance, the operation was performed, without loss of time, by the whole mass of his blood was becoming rapidly of a venous character, and quickly losing the properties necessary to support life. The platysma nyoides and the sterno-mastoidei were in powerful action, but most so on the right side, throwing the chin, which was kept in constant motion by spasm, nearly to the shoulder on the left. Inspiration was only accomplished by seldom and short 116. "He has done well from the first day, the ligatures coming away on the fourth and fifth days and the wound uniting by the first intention, and closing round the canula. catches. The veins of the head and neck were the integuments together with strips of plaster, everywhere visible, and greatly distended. I was until it exactly fitted the silver tube. The two told by the bystanders that he had been in the ligatures were brought out at the upper and lower same state for nineteen hours, with some inter- extremities of the incision. missions, but without any return of sensibility. I 115. "On my next visit, on the following day, looked upon this as a ease commencing with the pulse was about 90, and he was, in every spasm of the larynx and muscles of the neck in respect, doing well; and on my placing my finger general-the insensibility being produced in the on the mouth of the canula, he was able to tell first instance by obstruction to the return of blood me that he had been the subject of epilepsy for from the brain by this state of spasm, and kept seven or eight years, and that lately the attacks up and brought to a state of coma by spasm of had been more frequent and more violent, and the arytenoid muscles preventing free access of that he did not think he had passed two days air to the lungs, or even enough to arterialize the together, during the last two years, without an blood sufficiently to support life. With respect attack. to the exciting cause of the spasm, I could learn nothing at the time; but if acidity in the stomach, or dyspepsia, will (as it frequently does) produce cramp in the legs, how readily can we understand how the same thing may happen with the muscles of the larynx, particularly when we remember the origin and distribution of the gastric and recurrent laryngeal branches of the pneumogastric nerves. 111. "Feeling convinced that the patient must shortly expire, and that the root of the evil was in the closure of the larynx, I at once proceeded to open the trachea-a matter of no small difficulty on account of the twisted state of the neck, the engorged state of the vessels, and the constant action of the muscles. However, I felt it must be done, and I directly made an incision from the upper border of the sternum, extending in the median line upwards for about two inches. After separating the edge of the sterno-hyoidei muscles, a large and much-distended vein protruded forwards (the middle thyroid,) which, in its engorged state, was so troublesome, that I at once put two fine ligatures round it at each extremity of the wound, and removed the part between them. After this, the rings of the trachea were soon reached and divided, and the cut ends of the rings were then seized with a tenaculum, and small pieces removed from each. 112. "The immediate effect of the entrance of the air into the chest was to relieve all spasm. I was enabled to place the man's head straight, and in a remarkably short space of time the turgescence of the head was relieved. The face assumed a mottled appearance at first, then became red, and, in the course of ten minutes, pale; but, during these changes, the pulse had again become perceptible at the wrist, and means were used to induce circulation in the legs and feet. 113. I proceeded to convert the stilet of a female catheter into hooks, which were placed in the wound, and fastened behind the neck so as to keep the trachea open. This I was obliged to do, from being thrown in the way of the case with only my pocket instruments at hand. 114. "By the time I had done this, the patient was sufficiently sensible to try to speak, and I was able to tell him what had been done, and to induce him to be quiet. In an hour I left him, and shortly after returned with a canula, which 1 placed in the trachea, drawing the wound with 117. "He remained under my care until the 15th of the month, without any return of his fits. He then went with his boat into Staffordshire, and has not yet returned; but I hear that he has remained quite well up to this time." "To Dr. Marshall Hall." 118. No one can read the accounts given by Mr. Sampson and by Mr. Cane, of the immediate effect of the operation of tracheotomy on the circulation in the neck, without feelings of the deepest interest. 119. Mr. Sampson observes-"The trachea was no sooner opened, than the distention of the veins about the head and neck subsided." 120. Mr. Cane states that-" the veins of the head and neck were everywhere visible and greatly distended;" that--" the immediate effect of the entrance of air into the chest was to relieve all spasm;" and that "the face assumed a mottled appearance at first, then became red, and, in the course of ten minutes, pale." 121. I leave these facts to my readers' attentive consideration. I write for the candid lover of our profession and of truth. On Laryngismus in relation to the Epilepsia 122. Observation teaches us that laryngismus, more or less severe, intervenes as the essential cause of all that is convulsive and most formidable in epilepsy. 123. In the year 1841, before the relation of laryngismus to epilepsy, or rather to epileptic convulsion, was known to me, I wrote the following paragraph : 124. "The other day, the mother of a most intelligent lady, whose husband is liable to epilepsy, was suddenly choked: the phenomena were precisely those which precede or commence the epileptic attack! This remark was made by the lady in question, who was but too well acquainted with the terrible appearances in that morbid affection."* 125. To this paragraph, I must add the follow * See Derangements of the Nervous System, p. 189. ing most interesting case from the able work of Dr. Stokes : 126. "A gentleman, aged twenty, who had previously enjoyed the best health, while conversing in the act of eating a piece of cheese after a hearty dinner, suddenly fell from his chair in a state of insensibility. On the supposition that a foreign body had become fixed in the oesophagus, a probang was speedily passed, and after about ten minutes he partially recovered. Soon, however, the attack recurred with great violence, the face was strongly congested, and the breathing spasmodic and stertorous. He was then freely bled; but no impovement followed. Stimulating injections and a second bleeding were employed, but still without relief, the situation of the patient becoming every moment more critical. A loud rattling in the throat now supervened. The patient tossed himself on the bed, and threw his arms about so as to extend the chest as much as possible. All the muscles of inspiration were in the most violent action; and the surface of the body became pale and cold. Hours had now elapsed: the failure of all means employed led to the suspicion that the case might be one of asphyxia from tracheal obstruction; and a stethoscopic examination having been made, the following circumstances were observed : had no return of the disease. The treatment consisted in small bleedings, cold to the head, and the use of turpentine."* 130. Laryngismus, in its simplest form, proved the exciting cause of epilepsy, and of that condition of the spinal nervous centre which led to future attacks of epilepsy! 131. We have all witnessed the condition of the face and of the neck in pertussis; and we have all met with cases of Convulsion induced by this strange and violent laryngeal affection. Would not tracheotomy supersede both the first and the second phases of this malady? 132. The following note will be read with the deepest interest : "7 Pembridge Villas, Westbourne Grove, 1st March, 1850. "DEAR SIR,-I venture to trouble you with some particulars of the following case, thinking it tends to confirm some important views which you have lately made known to the profession on the pathology of apoplexy and epilepsy. "The subject, a son of mine, a healthy boy, four years old, has been suffering for the last five weeks with hooping cough. The symptoms during the first and second stages, were mild, as compared with those of three others attacked on the same day; but, during the last fortnight, when all inflammatory symptoms have passed off, and 127. "The chest sounded everywhere clear, the disease has become purely nervous or spasbut the vesicular murmur could scarcely be per modic, he has had ten or a dozen convulsive atceived in any portion of the lungs, the feebleness tacks, of a rather peculiar kind, which appeared being equal and universal, notwithstanding that in part to take the place of the ordinary paroxthe patient made the most violent efforts of inspi- ysms. He is aware when the cough is coming on, ration. A loud sonorous-mucous rattle, every moment increasing, was heard in the trachea, while the slight dilatation of the chest, compared with the respiratory efforts, clearly pointed out some obstruction in the windpipe. dreads it much, and gives intimation to those about him; but, on these occasions, instead of coughing, he suddenly loses all power, and falls, if not supported; every muscle becomes rigid, the countenance and neck suffused, the eyes and lids 128. "The question then arose, what was the convulsed; he foams at the mouth; the respiranature of this obstruction? Had a morsel of food tion is entirely suspended at the larynx for several passed into the trachea, or were the symptoms moments; evacuations pass involuntarily; and produced by a spasm of the glottis, consequent there is distinct torticollis. The paroxysm lasts on cerebral irritation? The failure of treatment from one to two or three minutes, and is succeedcalculated to relieve the brain, and the evident ed by some cough and hooping, but much less than secretion into the trachea, as shown by the loud on the ordinary occasions. He afterwards sleeps rattle at the top of the sternum, were strongly in heavily for half an hour or an hour, and awakes favour of the first opinion; and it was obvious tolerably well. There has been a slight ecchythat, as the patient was dying of laryngeal or tra- mosis of the eyelids, and considerable swelling, so cheal obstruction, something should be done to much so as to lead, with some oedema of the feet, give immediate relief. The operation of trache- to a suspicion of renal disease. The latter eviotomy was then performed, and a crucial incision dently arises from debility, as he has lost much made through the tube; and on the angular por- flesh and strength during the last ten days. tions between the incisions being removed, a mass "I look upon this as a case of epilepsy, caused of pultaceous matter was forcibly ejected through by the perfect closure of the glottis, and as giving, the opening, with complete and instantaneous re- in a very marked manner, support to your original lief to the symptoms. Respiration became easy, view of the seat of the disease. the expansion of the lung full and audible, the patient breathed through the glottis, and recovered without a bad symptom. 129. "In about four weeks, however, he was attacked with symptoms of cerebral irritation, and had a fit resembling epilepsy; during the next three months, these attacks recurred several times, becoming gradually less severe. They then altogether subsided; and for the last four years he has "I am, dear Sir, very faithfully yours, "Dr. Marshall Hall," "W. H. ALLCHIN, M.B. This case is a beautiful illustration of the following remarkable observations on pertussis, of Heberden: Puer advenientem præsentit, et ad matrem, vel famulam, accurrit; at adulti, accessione victi, momento temporis, velut attoniti con A Treatise on the Diagnosis and Treatment of Diseases of the Chest, Part I., by W. Stokes, M. D.; 1837; p. 288. cidunt; illico vero resipiscunt; atque hoc est 141. "The attack occurred about an hour after proprium hujus affectus signum in adultis. Qui his dinner. We were quietly seated, talking of enim præter solitum tussiunt, et nuper versati something I had just read in the Times, when I fuerunt inter aliquos tusse convulsiva laborantes, observed him turn his head very oddly towards siquidem morbo concidant, nullum relinquunt his left shoulder, which is always observed in the locum dubitandi de natura ægrotationis. Egri commencement of an attack. On this occasion I de quibis sermo est, majorem in modum querun- was enabled to watch every symptom, the attack tur inflationes."* having occurred whilst he was reclining on a large easy chair. It evidently commenced with complete laryngismus, with evident efforts of expiration. I immediately applied the candle to his mouth and nose, and I am positive that he was unable to expire for one or two minutes; and, during the spasmodic state of the muscles, his neck measured, as well as I could ascertain from a very loose shirt-collar becoming perfectly tight, rather more than an inch and a half more in circumference than before. 133. Such too is precisely the effect of strangulation, when it does not prove fatal, as in a case detailed by the late Mr. Hey, of Leeds:† 134. "May 18th, 1782, in the evening, Mr. being greatly distressed, rashly hanged himself. He was discovered and cut down. A surgeon was sent for, and, finding him lying insensible and frothing at the mouth, took about a pound of blood from the arm. Soon after, Mr. was seized with convulsions." 135. In this point of view nothing can be more interesting than the following sketch of a case by Mr. Martin Coates, of Salisbury 142. "I should like, were it possible, to see the effects of your valuable suggestion-viz., Tracheotomy; for my decided impression is, that 136. "My dear Sir,-I have had a very in- it would obviate the evil. On the day previous teresting case of puerperal laryngismus. I was to the attack, I observed that the pitch or keycalled to a rather corpulent, very indolent woman, note of his voice had fallen more than a note." who had had several natural labours. I arrived 143. In effect, the state of convulsion is attended just in time to support the perinæum during the by violent and ineffectual respiratory, and espepassage of the head of the foetus. At this moment cially expiratory, efforts; and every kind of effort she complained of oppression of breathing, accom- implies laryngismus. The acts of vomiting and panied by a short cough, and, before I could tie of defecation imply closure of the larynx. Many and divide the funis, the dyspnoea was urgent, and years ago, I investigated the nature of the act of she was soon in a state resembling that of a child vomiting, and found that it was rendered impossible who has sucked boiling water from a tea kettle; by tracheotomy! The patient on whom Mr. Anderand, in a very short space of time, her lips and son performed this operation (see § 147,) face become blue, her eyeballs protruded and when suffering from an attack of epilepsy,—now fixed, and she was becoming unconscious. I felt happily limited to the epilepsia mitior!-on one her pulse, and found it full and bounding. I occasion blew out a candle brought near the desired the persons in the room to raise her to a tracheal orifice. Mr. Cane's patient inserts a sitting posture, and opened a vein in both arms, cork into the tracheal tube when he wishes to having previously relieved the throat from any speak loud, or lift a heavy object. One day he pressure from her dress. When I had allowed will, I fear, in this manner bring on a fit of epileptic twenty ounces of blood to flow she became sensible, convulsion! and her breathing free, and in a quarter of an hour she was, and continued, quite well. 137. "The case so much resembled those above alluded to—that is, of closure of the glottis from injury-that, had she not been relieved at the moment, I should have taken my bistoury and opened the trachea. 138. "In this case there were-1, Spasm, and almost complete closure of the glottis ; 2, A state approaching to apoplexy, or convulsion. "Believe me to remain, my dear Sir, "Dr. Marshall Hall." 144. But the Proof of the justice of these views is afforded by the successful issue of two cases of tracheotomy, instituted as a preventive of epileptic convulsion. I must here adduce two notes from Mr. Cane, written subsequently to that given, §110. "Uxbridge, April 1st, 1851. 145. "My dear Sir,-I have inquired after my patient, and find that he has been laid up with variola, but has not, up to this time, had any return of epilepsy. I wish now to close the canula, and observe whether there be any disposition to a return of his malady. I will, when he next comes this way, detain him for a week or two, and watch him, and give you the opportunity of seeing him. "Believe me, my dear Sir, yours faithfully, 147. To these notes I add the following ob- to use her own expressions. Oftentimes the servations made by me at the Harveian Society, startings of the limbs have come on, and no fit on the evening of Thursday, the 20th of Novem- has supervened. Beyond this account, but little ber, 1851, in reference to a case of Mr. Anderson, history concerning the character of the attacks of York-place, Portman-square, in which he had can be elicited from the patient. performed the operation of tracheotomy, with the view of preventing epileptic convulsion: 148. It is impossible not to feel deeply interested in Mr. Anderson's admirable case; and I beg to make a few remarks upon it. แ 149. The poor woman, who is thirty-six years of age, has been fearfully epileptic during twentyfour years, and her father had been afflicted with the same dire malady. Her seizures were of the most terrible character; she would frequently present herself at the dispensary, cut and bruised, and even burnt, in her convulsive falls and convulsions, and her face still bears the marks of these injuries. Her case is one, therefore, calculated to test the value of any remedy. 153. "Until eight years ago, the patient resided with friends, having no home; but they having got tired of her, she has been in lodgings since that period, subject in the same way to the fits. The present attendant's account of them is as follows:-The fits have been wont to be very violent, and attended by strong convulsions. She has generally gone very dark,' and 'at times almost black' in the face, and been often dashed forcibly to the ground, cutting her face and biting her tongue. She has generally foamed at the mouth during the fits, which have lasted, for the most part, for a quarter of an hour; and when the fits have been less frequent, the startings and jumpings of the limbs have been most numerous. 150. "The operation of tracheotomy was per- Her general health has been tolerably good, and formed three months ago, and I think the opening she has maintained herself by her needle, and by into the trachea too small to be perfectly satis- the assistance of friends. For the last three factory her inspiration is heard through the years, however, she has been getting thinner. tube, and her speech is audible, and she can. 154. On the 26th of July, 1851, the opera'snuff up,' drawing in the alæ nasi, without tion of tracheotomy was resorted to; and since closing its orifice. None of these events occur that time the fits have been much less frequent when the orifice into the trachea is of sufficient and less strong in character. The patient said dimensions. The tube is also partly occupied by she had had four or five fits, but the attendant, an inner tube, which, though it admits of easy who is only with her occasionally, being within removal for the purpose of being cleaned, is apt call, had not seen a single one until December to become clogged with mucus, through neglect. 23rd. These four or five seem, however, from Nevertheless, this poor woman has had no for- the patient's account, to have been much milder midable fit since the tube was inserted. She has than previous ones. On the forementioned date, never bitten her tongue, which she used to do; December 23rd, the attendant saw her in a fit, once only has she fallen, and there was then no which was very bad and strong,' but not nearly convulsion, and she experienced no injury; her so much so, or so lengthy, as formerly;' and 'withfall was not convulsive. To use her own phrase, out blackness of the face,' foaming in the mouth,' and those of the person who accompanied her to or general convulsion as distinguished from partial the Society, she does not now turn black,' her spasms; and she thinks the benefit is owing to fits are not so ' strong,' and she is recovering the breath coming out of the tube.' During the from a state of apathy,' in which she was last week of December, and the first two weeks before. In a word, she has none of the formidable of January, 1852, the patient had three fits, but convulsions which were previously inducing havoc on her brain and mental faculties!" 151. Mr. Cane saw his patient on or about March 1, the tracheal tube having to be constantly worn during the interval of thirteen months since the operation. Not a symptom of his malady has recurred. On the 10th, Dr. J. W. Ogle was so kind as to visit Mr. Anderson's patient, who had worn the tube during half that period, and to take the following note: all of them were comparatively mild. One of them, stronger than the others, came on during the time (about ten P.M.) that they were searching for the tube, which had fallen out of the throat. She has since lost the tube out of the throat again, but nothing then took place. When seen, January, 1852, she came down stairs to open the door herself, and the re-ascent gave her much difficulty of breathing, and palpitation of the heart. Her countenance was very dusky, and had almost 152. "Ann Ross, aged thirty-six, a washer- the appearance of one who has been treated with woman, has been subject to 'fits' for twenty-four nitrate of silver. This aspect rather subsided, years. The only cause she can assign for them after a short time, but she always has somewhat is the fact of her father's being also liable to them. of a dingy-coloured skin. She has a slight squint, These fits, the patient says, have followed no rule and on her face there are various marks of former in their accession; at one time occurring many falls and injuries; the left eyelid was bruised, times in a week; at another time, having an and the conjunctiva ecchymosed from a recent interval of three weeks; but never any longer fall. She spoke in a very low whisper, and on interval. Neither has she been able to refer them to any irregularity of diet. They were generally but not invariably, preceded by 'shakings and jumpings of the limbs,' and 'confusion of ideas,' inspiration, a rushing noise was made by the air entering the trachea through the artificial aperture. Moreover, when she spoke with effort, not closing the canula with her finger, there were |