Debate on Tracheotomy in Epilepsy at the Medical Society of London.
—Dr. Radcliffe read a paper 44 On the Questionable Utility of Tracheo-
tomy in the Treatment of any kind of Epilepsy.”—In order to arrive at
the object of his paper, the author depended chiefly upon a critical ex-
amination of the cases of epilepsy in which tracheotomy has been prac-
tised, and to this examination he at once proceeded :
Mr. Cane’s Case.—The patient was a boatman, aged twenty-four,
who had been epileptic for seven or eight years. The fits were severe
and frequent. The operation was performed during a fit, in consequence
of a state of asphyxial-coma that had lasted nineteen hours. The relief
was immediate, and no fits have followed the operation. The habits of
the patient were very irregular and intemperate, and he was discharged
from his employment on this account about ten months ago. The tube
is still worn, and curiously enough, it is worn with a cork in the opening.
Mr. Anderson’s Case.—The patient in this case was a stout, thick-
set, muscular female, aged thirty-six, the daughter of an epileptic father,
and herself epileptic for twenty-four years. Her complexion was ruined
by the former use of nitrate of silver. The operation was performed in
March, 1851, and the tube was worn until her death, which happened
in a fit about four months ago. After the operation the fits continued
as before—possibly a little less frequently and severely, but decidedly
of the same character. Her health and spirits also are said to have un-
dergone some slight improvement, and she lost a numbness in the right
arm which had previously distressed her, but those who knew her best
doubt the existence of any appreciable change of this kind until about
two or three months before her death—sixteen months after the opera-
tion. The following notes of the final seizure are from Mr. Anderson :
44 Eight A. M. : Had been up and dressed; heard to fall heavily. A
woman removed the inner tube from the trachea as she was in a fit ap-
parently more severe than usual. She 4 snorted loudly;’ nails of a
deeper color. She was placed on the bed, as the woman thought she
would recover as usual.” The woman here referred to says the patient
was black in the face and violently convulsed, and that death must have
taken place within ten minutes. The body was examined twenty-four
hours after death, and the following are the particulars supplied by Mr.
Anderson :—44 Body extremely muscular; cadaverous rigidity still pre-
sent ; not much fat. Head: Vessels of scalp much congested ; skull
thick, and dura mater so universally adherent that the skull-cap could
not be removed until the dura mater was divided. The sinuses were
filled with dark blood, and on the removal of the brain an unusual quan-
tity of dark blood flowed from the spinal canal. On either side of the
longitudinal sinus, and on the inner side of the frontal bone, two or
three growths of bone were found, and to these the dura mater was so
firmly adherent that, on attempting to separate it, it was torn through,
and portions remained attached. The largest of the exostoses was about
an inch and a half in circumference, and projected about half an inch
from the surface of the bone. No alteration was observed in the corres-
ponding portion of the cerebrum. The brain was softer than natural,
and the puncta were more than usually distinct. There was little fluid
in the ventricles, but the choroid plexuses were congested. Lungs :
These organs were collapsed, occupying but little more than a third of
the thoracic cavity, and somewhat congested at their posterior margin;
structure healthy. Heart: Larger than usual (perhaps a fourth ;) cavi-
ties, especially the left, distended with blood. It was surrounded with
fat, and its structure flabby ;* valves healthy. Liver, kidneys, and
spleen : Highly congested. Uterus natural, but cysts containing viscid
fluid in the ovaries. Small intestines (especially lower part of the ilium)
congested, and the mesenteric glands enlarged. Internal jugular, above
the level of the omohyoid, almost empty.”
•Dr. Jenner examined a portion of this heart microscopically and found some
slight degree of fatty degeneration.
Mr. Mackarsie’s Case.—R. W---------, aged forty, and epileptic for
twenty years. Latterly the fits had become much more frequent and
severe, the subsequent torpor much prolonged, and the mind much im-
paired. His complexion had- a congested, mahogany-like tint. Two
years previously he had had two attacks of paralysis, but his present
health, apart from the fits, is pretty good. Tracheotomy was performed
on the 24th of August, 1852, by means of the tracheotome. On the
day following the operation inflammatory action began in the lungs, and
continued until the 6th of August. Thus,—August 25th : “ A large
quantity of mucus has passed from the tube.” 26th : “ The patient
has been hot and feverish, and passed a restless night; tongue furred;
pulse 100 ; a large quantity of mucus passing through the tube.” 27th :
“Pulse 100, full and hard.” 28th: “Tongue still furred.” 31st:
“Violent haemoptysis.” Sept. 1st: “ Violent return of haemoptysis ;”
“left lung congested, dull on percussion, and respiratory murmur feeble.”
2d: “Expectorates bloody mucus;’’ “ dulness on percussion not so
marked ; respiratory murmur more audible.” 3d : “ Still bloody ex-
pectoration.” 4th : “ Pulse 90 and soft.” 6th : “ Pulse 75, soft; re-
spiration free; dulness on percussion gone.” Again, on the 20th Sep-
tember, and for some days afterwards, there was feverishness, attended
with bilious vomiting, requiring salines, calomel, and prussic acid. The
fits, however, kept away until the second week in October, when four
or five slight ones happened. After this true fits made their appearance,
and continued to recur with their usual frequency, though in a mitigated
form, until about two months ago, when the tube was withdrawn by the
patient’s wife, (who throughout has been greatly opposed to, and dis-
satisfied with the operation,) since which time the fits are as bad as ever,
and the mental condition worse than ever. Mr. Mackarsie is fully of
opinion that during the time the tube was in the trachea the mind was
more active, the complexion less congested, and the fits less severe.
Mr. J. A. Lockhart Clarke’s Case.—In this case the patient was a
female, twenty-three years of age, who had been epileptic for twelve
years. The fits were very violent and very frequent. Laryngotomy,
not tracheotomy, was performed about three months ago, and the tube
worn until recently, when it was removed, in consequence of their being
no perceptible alteration either in the frequency, or in the severity of
the fits.
Mr. Henry Thompson's Case.—The main facts of this case are sub-
stantially these : The patient was an epileptic of twenty years standing,
whose intellect had suffered considerably. Tracheotomy was performed
nearly three months ago. Before the operation the fits were frequent
and violent, and the subsequent sopor prolonged ; since the operation
the fits have altered little in frequency and violence, but the subsequent
torpor is greatly abridged. The general health also is improved, and the
mind much clearer than it was.
Dr. Tyler Smith's Case.—Sarah B--------, the wife of a gamekeeper at
Debden in Essex, and the mother of four children. She has been epi-
leptic since puberty, aud chiefly about the menstrual period. The num-
bers of the fits during the month were sometimes as many as twenty,
but generally not more than five or six. The fits themselves were
usually preceded by the scream and attended with much lividity of the
head and neck; the convulsions were very violent and the subsequent
sopor protracted. The mental state was one of groat inanity. There
had been several paroxysms of insanity, and twice the patient had been
in a lunatic asylum. During the month that she remained in the hos-
pital before the operation there were nine fits; during the month after
the operation there were five fits. The operation itself was performed
on the 13th of February by Mr. Lane. On the 15th, 16th and 17th
she was restless, wakeful and unruly, with heat of skin, raised pulse,
and furred tongue. She threw a glass at the nurse, and persisted in at-
tempting to withdraw the tube from the neck, and her state required
constant watching. Three weeks after this she was greatly depressed,
her pulse feeble and wretched, her countenance anxious, and much
viscid, foetid phlegm passed from the tube; and this state continued for
the greater part of a week. Since this time she has rallied, and now
her mental condition is much better than it was during the month be-
fore the operation; her fits also are much better, the period of sopor is
somewhat abbreviated, and the cry is lost; but still the convulsion is
violent, the venous turgescence of the head and neck considerable,
though less than it was, and once at least the tongue has been bitten.
Dr. Andrea Verga's Case.—This case cannot strictly be classed with
the former cases, for the operation was performed unintentionally, and
by the patient himself; but in all other respects it fulfils the required
predicaments. It was originally reported in one of the Lombard journals,
and copied thence into an early number of Schmidt’s Jahrbuch for 1852.
The main particulars are the following : A. B.------, aged twenty-five,
was admitted into the great hospital at Milan, with his throat cut and
his genitals severely mutilated, in consequence of a determined attempt
at suicide. Six months afterwards the wounds had healed, with the ex-
ception of a free fistulous opening in the trachea ; but the fits and des-
pondency had undergone no change. The breath passed freely in and
out of the artificial opening, and the fits recurred with equal frequency
and force whether that opening were closed or not. In this state he was
removed to a madhouse, and there he remained for three years, when
he died of tabes, the fistula continuing open and the fits unabated up to
the end. After death the brain and skin were found congested and the
bowels somewhat ulcerated.
Comments.—Such are the chemical data upon which as yet the reme-
dial value of tracheotomy in epilepsy has to be tested, and the question
is whether or not they realize Dr. Hall’s expectations, and justify the
comments which have been passed upon them.
What of Mr. Crane’s case? Here undoubtedly the results seem most
marked, but do they not prove too much ? There are no fits whatever
after the operation, and this is not to be expected even on Dr. Hall’s
own premises. Moreover, fits do happen in all the other cases, and in
some of them very severe fits, and this fact gives a probabilty of at least
seven to one that the fits in this case did not keep away in consequence
of the operation. It is to be remembered also, that the wearing of the
cork in the tracheal tube did in. fact place the patient in the same pre-
dicament as that in which he was before the windpipe was opened. Why
the fits kept away it is not necessary to inquire, for nothing is more
certain than that epilipsy may suddenly disappear and keep away for a
long time, without any apparent cause.
What of Mr. Anderson’s case ? Here the main questions are as to
the character of the fits, the state of the general health, and the cause
of death. Were the fits improved in character? Possibly, but not
probably. Dr. M. Hall, in his lectures at the College of Physicians,
allowed that a fit had followed very shortly after the operation, in which
the tongue had been bitten. A Mrs. Dwellie, living in the adjoining
garret to the patient’s, and who frequently went to the patient’s assist-
ance when she heard the noise and struggle of the fit, states explicitly
that the convulsions were as frequent and violent, and the subsequent
sopor as prolonged, after the operation as before it. A Mrs. Smith,
also, an aunt of the patient, who had known, her from childhood, and
who saw her several times a week during the whole of her life, makes
the same statement. Miss Lewis, on the contrary, who lives on the
first floor of the house in the garret of which the patient lived, thinks
the fits, after the operation, were not so severe or frequent as before it;
but why she thinks so is not very evident. She saw her in but few fits,
and in none (there is reason to believe) from the commencement. In-
deed it is to be understood that this witness was infirm and half-crippled,
and often quite an invalid; that she had to be fetched from the top of
the house, and then to mount up two flights of stairs before she could
get to the place where the patient was; so that the fit must have been
far from its commencement before she could see it. The last fit, also,
which was evidently of great violence, is spoken of only as “apparently
more severe than usual,” showing that the ordinary fits were severe, and
the patient was “ expected to recover as usual,” showing that death had
occurred unexpectedly in what was regarded as an ordinary fit. Con-
cerning the state of the general health there are two opinions. Miss
Lewis says this was better; Mrs. Dwellie and Mrs. Smith say there was
no perceptible improvement until within two or three months from
her death, fifteen or sixteen months after the operation. The cause of
death is very obscure. It could not be, however, from the strangulation
of laryngismus, for the inner tube was removed at the beginning of the
last fit, as it was in all the fits in which the patient was watched. Indeed
there was never any neglect or mismanagement about the tube, (which
reflects the highest credit on Mr. Anderson’s mechanical ingenuity,) and
the patient herself had so schooled herself to it that she could remove
and cleanse it, and did so remove and cleanse it many times a day. The
fatty state of the heart, as Dr. Hall supposes, might have had something
to do with death, for death happened shortly after the commencement of
the seizure; but, on the other hand, it is not to be forgotten that there
was stertorous breathing, blackness and turgescence of the head and
neck, with distended sinuses, distinct cerebral puncta, and other signs
showing that death might have been caused by coma.
What of Mr. Mackarsie’s case ? Here it is not difficult to imagine
that the pulmonary inflammation and the subsequent febrile action may
have had something to do with the absence of the fits during the first
two months after the operation, for inflammation and fever are not only
uncongenial to, but incompatible with, epilepsy. This inflammation also,
even after its cessation, may have had something to do with the ameliora-
ation of the fits, by acting derivatively in regard to that mischief in the
brain, the existence of which is to be argued from the two former attacks
of paralysis. The fact, however, is not to be doubted—that the fits were
“ mitigated” and the mental state ameliorated after the operation. This is
undeniable. Still the fits were true fits, and not mere warnings, and
there is little if any reason for supposing that they gave up the charac-
ters of epilepsia gravior for those of epilepsia mitior; nor is it clear that
the mind was not invigorated by hope or some other psychical stimulus,
and that the fits were not subdued by the mind thus invigorated, the
tracheal tube all the while acting merely as a charm by which to propi-
tiate hope and her allies; nor is it clear that any diminished sopor after
the fit may not have been the consequence rather than the cause of the
mental invigoration. Time must elapse before these doubts can be re-
solved, and in the meantime it must not be forgotten that the wife of the
patient was opposed to and dissatisfied with the operation.
What of Mr. Clarke’s case ? Nothing favourable to the operation.
What of Mr. Henry Thompson’s case? In this case the fits recur as
frequently as before, but the subsequent sopor and intermediate stupor
are greatly diminished. Still it is by no means certain or even probable
that the fits after the operation were of the character of epilepsia mitior,
or that the diminished sopor and stupor were not the consequences of
faith in the operation rather than of the operation itself.
What of Dr. Tyler Smith’s case ? In this case it is more than im-
probable that the fits underwent that modification which they ought fo
have done, or that any improvement in the symptoms is really due to the
operation. All the fits after the operation were certainly not of the type
of epilepsia mitior, for the convulsions were severe, and once at least the
tongue was bitten. It is doubtful also whether the fits were really less
frequent. During the first month of hospital life there were, it is true,
nine fits, but this was a time when the patient was exposed to the agitat-
ing publicity of a hospital ward, with the fear of an operation before her
eyes. The usual number of fits during the month would also seem to be
from five to six, though occasionally ranging so high as twenty, and
these numbers correspond with the numbers after the operation. It is
clear also that as yet little can be said about mental improvement after
the operation, seeing that a paroxysm of insanity and a week of extreme
mental inanity form a part of this period. This being the case, it is not
necessary to speculate whether such improvement is psychically or so-
matically the result of the operation.
What of Dr. Andrea Verga’s case ? Possibly very little, but certainly
nothing in favour of the operation.
On looking over these cases, therefore, one conclusion is inevitable—
namely, that severe fits have followed the operation—fits in which the
tongue has been bitten, and one fit in which death has happened. Al-
most uniformly the convulsion has been as bad as ever. In Mr. Ander-
son’s, Mr. Clarke’s, Mr. Mackarsie’s, and possibly in Dr. Andrea Ver-
ga’s cases, the sopor after the fit, and the torpor between the fits were
unaffected; in Mr. Henry Thompson’s, and possibly in Dr. Tyler Smith’s
cases, they were relieved, though how they were relieved remains a mat-
ter of doubt. As judged, therefore, by the results of the cases in which
it .has been practically tested, the utility of tracheotomy in epilepsy
would seem to be extremely doubtful; so doubtful, indeed, as to render
it a matter of paramount and imperative necessity to pause and ponder
well upon the evidence before again resorting to it, and this all the more
because it is by no means certain that the remedy is not more dangerous
than the disease, and because the inevitable result of the operation is to
convert the patient into a dumb, whistling wretch, whose every breath
is an annoyance to himself and others. In order to do this it will be
necessary to examine epileptics, whose windpipes are sound as well as
those whose windpipes are not sound. It will be necessary to determine
how much of the epileptic asphyxia depends upon spasmodic “setting”
of the whole chest, and how far this “ setting” will negative the results
of an opening in the windpipe. It will be necessary to go to the root of
the matter, and determine whether, apart from organic disease, the la-
rynx does close spasmodically in epilepsy, and whether such closure can
exist at the time of life when epilepsy happens. In the meantime the
absence of any stridulous inspiration in epilepsy, such as is heard in la-
ryngismus stridulus, in the hooping-cough of children, and in certain
organic diseases of the larynx, would seem to be a serious, if not fatal
objection to the idea of laryngismus in epilepsy. The age of epileptics
—namely, youth and manhood—is also an objection to the same effect;
for judging from the history of laryngismus stridulus and hooping
cough, pure spasmodic closure of the larynx is usually confined to the
period antecedent to that at which epilepsy commences; indeed, as a
rule, laryngismus stridulus is an affection of teething, and hooping-
cough looses its characteristic hoop before puberty. This deduction is
also borne out by the results which follow the division of the laryngeal
nerves in the lower animals, as dogs and cats; for in these experiments
the young animal is immediately suffocated by the closure of the glotti-
dean chink, whereas the old animal goes on breathing without any evi-
dent diminution in the current of air.
Dr. Crisp regretted the absence of Dr. Marshall Hall, and was dis-
posed to regard with favour the operation proposed by that gentleman.
He deemed the whole subject worthy of further inquiry. Many epilep-
tic patients are anaemic, but others are plethoric.
Dr. Barnes believed the subject to be very important, and the discus-
sion of it not premature. He gave credit to the author of the paper for
having recited the cases with fairness and candour, but inferred that
Dr. Radcliffe had misapprehended Dr. Hall’s views on the subject. He
affirmed that each of the cases recited had exhibited marked improve-
ment after the operation. Mr. Cane’s case had been very successful;
he admitted that. Mr. Anderson’s patient had not died from asphyxia;
but he did not admit Dr. Radcliffe’s explanation. Dr. Jenner had found
the heart in a state of fatty regeneration—a physical condition likely to
cause death. Laryngismus is not met with in every case of epilepsy,
neither is its presence essential.
Dr. Winn stated that epilepsy is not essentially accompanied by an
anaemic condition of system.
Dr. Tyler Smith, in reference to his own case, explained that the at-
tack of mania after the operation was probably to be attributed to the
influence of chloroform. The fits are slighter, and the condition of the
mind is clearly improved. He believed laryngismus to be essential to
the disease, and that it occurs in adults without the stridulous breathing,
except that the peculiar cry is a modification of that symptom. Lividity
of countenance may be induced by spasms of the muscles of the neck,
without the occurrence of laryngismus or closure of the glottis. Tra-
cheotomy is not a serious operation.
Mr. Dendy thought that Dr. Hall had not been hardly treated, and
that the cases had been fairly recited by Dr. Radcliffe. Tracheotomy is
proposed, not as a remedy for epilepsy, but to relieve one of its symp-
toms. It is not a dangerous operation; yet he doubted if medical men
would themselves submit to it. Laryngismus is neither the essence nor
the proximate cause of the disease, and when it occurs it may pass away
without the exhibition of any remedy. It is not important to decide
whether this disease be essentially anaemic or not, but the case must be
treated according to the nature of the patient’s constitution. Congestion
is not always productive of asphyxia, and may be relieved in some cases
without the operation, or indeed without any remedy whatever. He
believed that the good effects of the operation had been exaggerated.
Mr. II. Thompson, on referring to his own case, believed that the na-
ture of the fit had been well made out, and stated that the family were
unanimous in asserting that much benefit had followed the operation.
The mind is clearly improved. He had witnessed the occurrence of a
fit that morning, and found that loss of consciousness continued but
during three or four minutes, instead of four hours, as had usually been
the case previous to the operation. On that occasion the tube was not
in a clean condition, and the same fact had been noticed on the occur-
rence of all the fits subsequent to the operation. He had removed the
tube, and observed that respiration appeared to be suspended for a few
seconds, no sound indicating the passage of air through the trachea.
Mr. Bullock described the present improved condition of Dr. Tyler
Smith’s patient.
Dr. Camps approved the operation under the circumstances selected
by Dr. Marshall Hall. He considered that an attack of epilepsy is not
antagonized by existing inflammation or fever.
Mr. C. Clark mentioned a case which he had relieved by artificial
respiration.
Dr. Radcliffe, in reply, said that he had taken up the question under
consideration, not because it clashed with any of his own opinions
respecting convulsive diseases,—which it did not,—but simply as a
matter of fact that from its importance ought not to be passed over any
longer. He had frankly expressed his present convictions, but he was
perfectly willing and ready to change them whenever they were shown
to be wrong. He had, he trusted, acted with all honor and sincerity,
and his only regret was that Dr. Marshall Hall, (whom he and all the
profession highly honored) had not been present in person to hear and
reply to what he had ventured to say. In reply to an observation that
had been made in the discussion, he would only say that he could not
understand how the epileptic cry would be a proof of laryngismus.—
London Lancet, May 14th, 1853.