CONSTRUCTION OF LUNATIC ASYLUMS. σε diseased or disordered state of the encephalon, or from irritation applied to filaments of the eighth pair, which may be produced by enlarged glands in the neck, pressing upon the recurrent, or some part of the pneumogastric, and thus closing the glottis by "subverting the exact antagonism by which the glottis is automatically and involuntarily kept open, and allowing its margins to come together, and to occasion the peculiar kind of inspiration so much like that of croup." Again, he remarks, in substantiation of the opinion that glandular enlargement is the cause of this affection in PROVINCIAL 5491 Medical & Surgical Journal. WEDNESDAY, OCTOBER 6, 1847. It is of great importance to the attainment of the objects for which the erection of County Lunatic Asylums, where such do not already exist, has been determined upon, that the buildings to be constructed should be on the most approved plan. We take it for granted, that the enlightened views which have led to the modern improvements in the general management and treatment of the insane, are those which the Government authorities will be anxious to see carried out; and that while every requisite economy in the expenditure of public money... is practised, no miserable attempt at the saving, in the first instance, of some farthing in the pound to the county rates, will be suffered to interfere with their adoption in every particular. Looking also to the influence which many of the members of the Provincial Association must have, both as professional advisers and as per◄ sonal friends, with the Magistracy of the country, to which body also several of them belong, we deem the present a fitting opportunity to direct attention to the admirable letter on this subject from Dr. John Conolly, which has just been given to the public. The letter is addressed, children, when, he says, "scarcely an instance has occurred to me since my attention has been directed to the subject in which there has not been the strongest foundation for the belief that either the glandulæ concatenatæ of the neck, or the thoracic absorbent glands, had become morbidly enlarged." Professor Reid, of St. Andrews, has abundantly shewn, that pressure upon any of the chief branches of the par vagum, might close the chink of the glottis, especially upon the laryngeals. Dr. Watson thinks that irritation of the gastric ramifications might even close the fissure, and in corroboration of this opinion he cites from Dr. John Clark, who observes that the attacks in children are "very common after a full meal." It has also been said, that an irritating cause, located in the branches of the trifacial, would have the same effect; this, however, is more problematical than what is advanced with regard to the par vagum. The general doctrines expressed by Dr. Marshall Hall, who philo-to the Chairman of the Committee of Visitors sophically accounts on the principles of reflex action for these previously anomalous and ill-understood functions of the nervous system, are quite applicable, and very elucidatory in unravelling the special pathology of this affection. From what has been said it seems conclusive, that morbid impressions conveyed to the great nervous centres, or existing in these themselves, will give rise to a spasmodic condition of the glottis in the young. Hence, reasoning from these facts, and knowing that the functions of the cerebro-spinal system are inextricably blended, it may readily be imagined how irritation in one part of the spinal marrow might be transmitted to nerves given off at another, and more especially when it is recollected, that between the organs of generation and the larynx there is an intimate though unintelligible sympathy; therefore, in the instance of the above cases, particularly in that of the female, it is highly probable that the prima causa was located in the generative organs; in the boy, perhaps, this conclusion might not be quite so obvious. (To be continued.) of the additional Lunatic Asylum for the county of Middlesex, which is about to be erected at Colney Hatch, but its contents are of equal value and importance, and apply with equal force, to every similar body throughout the kingdom, and its recommendations ought to be carefully weighed and considered in every case, in which a similar establishment is contemplated. We therefore deem no apology necessary in bringing these recommendations before our readers, and shall esteem ourselves amply repaid if we can induce those who have both influence and knowledge, to exert themselves in guiding aright persons who may possess the one, but are, to a certain extent at least, wanting in the other. 1 M The first point insisted on is the importance of providing sufficient separate sleeping accommodation. This is a point on which some difference of opinion would seem to exist. The Commissioners in Lunacy consider that "one-third of the sleeping accommodation should be provided for in separate sleeping-rooms or cells, and the remainder in dormitories, each containing not less.. than three, nor more than twelve, beds." This proportion Dr. Conolly considers insufficient, and indeed incompatible with the full adoption of those principles of treatment which are now. 蜜 on the officers and attendants, but the vigilance and frequency of inspection, so important to the well-being of the patients, and so needful as a check upon the attendants, are greatly interfered with, There are many other points of much importance to the efficient working of a well-ordered asylum, which it is necessary to keep in view in the original construction of the building. Among these are the providing of due accommodation for the resident medical officers, the matron, and superintendent; of appartments also for a steward, a housekeeper, a dispenser, and other chief officials, required to preside over the respective departments in a large establishment; and of a room for giving the occasional entertainments to the patients, which have been found so advantageous at Hanwell and elsewhere. These, however, we must pass over, but there is another subject which, although not immediately connected with the erection or arrangements of the building, is one on which so intimately depends the value and fitness of the entire institution, that we cannot but allude to the observations which the letter of Dr. Conolly contains on the subject. so justly estimated. A deficiency in the number | additional amount of trouble necessarily entailed of separate sleeping apartments must inevitably interfere with the due classification of the patients; the safety of some must be compromised; ventilation interfered with; the tranquil will be annoyed and endangered by the violent; the clean greatly annoyed by being placed with the dirty; or, if these latter are to be thus congregated together, the air of the rooms in which they are placed will become most offensive, and cannot but be injurious to the health of all exposed to it. The application of the non-restraint system during the night in such cases must be greatly interfered with, if not altogether incompatible with the safety of the patients, and of course its moral effect on the entire body of patients in a great measure counteracted. Dr. Conolly maintains, that in a well-managed asylum, "every violent and dangerous patient, and every dirty patient, must have a separate sleeping room; that many of the epileptics who are not habitually violent, must be similarly provided for; that many helpless and imbecile patients are unsafe at night except in separate rooms; and that consequently, for all these, who will amount always to at least one half of the whole number of patients in a county asylum, single sleepingrooms are indispensable." He also states it as his conviction, that for a considerable proportion of newly-admitted patients a separate sleeping-room is essential to the cure; while the comfort to the more sensible and quiet patients, of having an apartment of their own, to which they can retire for reading or working, for tranquillity, and for private devotion, must be at once apparent. Another most important point as concerns the general safety of the patients is, that the building should be fire-proof. The occurrence of fire in a lunatic asylum, in which the entire building is not sufficiently protected from its spreading, would be a most fearful calamity. The Commissioners recommend that the staircases should be of stone, the store-rooms for inflammable stores thoroughly fire-proof, and other judicious precautions; but Dr. Conolly is of opinion that the entire building should be fire-proof throughout, each story being separated by a stone-floor and roof, so as to make it impossible for any accidental fire to spread. The advantage of absolutely complying with the recommendation of the Commissioners that "those portions of an asylum which are intended to be occupied by patients, shall in no case have more than two stories, that is to say, those on the ground and first floors" is evident; and it is well observed, that when a third story is added, not only is a great The appointment of a qualified superintendent to a county asylum, is certainly the highest duty, in reference to the proper management of the insane, which can devolve upon those with whom it rests; and it is most earnestly to be desired, that in every case in which such appointment may be made, no private or interested motive will be allowed to influence the decision. No favoritism, no family or other connection, should be allowed the least weight. The professional, intellectual, and moral fitness of the candidates for the appointment should alone be taken into consideration; and to an officer of such responsibility, with the requisite qualifications, the salary should be liberal, and everything like the Dutch-auction proceedings, which have disgraced certain other public medical appointments, should meet with most deserved and undisguised reprobation. To a medical superintendent, duly qualified and equitably selected, the utmost authority should be conceded in the management of the patients committed to his care, with full powers to carry out his plans, free from all vexatious interference, whether of Committees of Management, Visitors, or subordinate officers. The utmost care should be bestowed in making the appointment; but once fully assured that the appointment has been a judicious one, the duties of inspection should be directed chiefly to the general economy of the establishment, and to carefully watching, (with full confidence in and with the physician,) BIRMINGHAM PATHOLOGICAL SOCIETY. the effects of judicious treatment on the general comfort and welfare of the patients, without any attempt to interfere with its progress, or otherwise regulate the manner in which it is carried out. Proceedings of Societies. BIRMINGHAM PATHOLOGICAL SOCIETY. May 1st, 1847. Dr. MACKAY in the Chair. SYPHILITIC ULCERATION OF THE LARYNX: TRACHEOTOMY. Dr. Fletcher exhibited to the Society a specimen of syphilitic ulceration of the larynx, taken from a female, for which the operation of tracheotomy had been performed, which had been sent to him to be brought before the Society, by Mr. Thomas Chavasse, under whose care the patient had been, and with whom Dr. Fletcher had attended in consultation. Dr. Fletcher first saw the case February 14th, 1847. She was then labouring under difficult and whistling respiration, which had been gradually getting worse for some time. The seat of the obstruction was evidently in the larynx; the lungs did not present physical signs of disease, the respiration was scarcely to be heard in any part, percussion was healthy, and the voice being destroyed by the disease in the larynx, its value as a sign of disease was of course done away with. The history of the disease was such as to render it certain that it was of syphilitic origin. The patient had had four children, and was then pregnant at the seventh month. Dr. Fletcher proposed that mercury and iodine should be actively employed, and the case closely watched, in order that the operation of tracheotomy should be immediately performed if any symptoms of increased difficulty of breathing presented themselves, and requested that Mr. Chavasse, under whose care the patient had been for some years, should meet him in consultation in three or four day's time, to see the effect of the remedies, feeling that should there be no improvement, the case as it already stood, justified the recommendation of the operation of tracheotomy, both as a means of giving the larynx a better chance of undergoing a process of cure, by relieving it from the irritation of the air pasing through it in respiration, and also as preventing impending asphyxia. On the 28th, Dr. Fletcher met Mr. Chavasse in consultation; the patient was better in every respect, the breathing less difficult. The treatment was continued, and a blister applied to the region of the trachea, which was to be dressed with mercurial ointment. Dr. Fletcher continued seeing the case with Mr. Chavasse, every third or fourth day, until the 9th of March,during which time the improvement was such as to lead to the treatment being persevered in, and to the operation of tracheotomy being deferred, but if any indication of asphyxia should come on, the operation of tracheotomy was to be immediately performed, as the only means likely to prolong the life of the patient. The treatment was continued until the 24th of March, when an attack 551 of asphyxia threatened the life of the patient, and Mr. Chavasse urged the performance of tracheotomy. The friends wished Mr. Hodgson to see the case, who coincided in the opinion already given, and on the 25th of March, the operation was performed by Mr. Chavasse, with great relief to the patient, who went on well for several days; but on the 7th of April, having been for three days previously much worn down, and harrassed by attacks of difficult breathing, obliging her sometimes to wear the tube, and at others to take it out, as the quantity of mucus from time to time accumulated, she was seized in labour. The child appears to have been born almost before labour-pains commenced, and immediately on the birth of the child she expired. Very little blood was lost, and the child and after-birthwere expelled almost together. Mr. Hodgson considered this a case of syphilitic disease; it had been introduced in some unfortunate way into the family, and every member seemed to suffer from it in some way or other. This patient had suffered from the disease for some years, and he thought her case illustrated a fact which had not been noticed hy authors, that syphilitic disease affects the cartilages of the larynx in a similar manner to that in which it affects the bones,—namely, the cartilage or its perichondrium becomes the seat of the disease in the same way as a node is produced by it upon the bone, and that disease does not always commence by ulceration of the mucous lining of the cartilage, as generally supposed. In this case, a portion of the thyroid cartilage was necrosed, which he believed was the cause of the very fœtid breath. He would take the liberty of relating another case, which illustrated the same fact. A gentleman, who had lived much abroad, had disease in the bones of the head, and his larynx was affected with the same disease; the symptoms were so urgent that tracheotomy was performed, and he breathed through the tube for fifteen months. Several attempts were made to do without the tube, but without success. The day before Mr. Hodgson saw him, in a violent fit of coughing, a bony substance was expelled. At length he died exhausted. The expelled substance was found to be a portion of the thyroid cartilage, which had fallen into the right bronchus. The larynx was nearly, if not entirely, grown up. Within the last fortnight, Mr. Hodgson saw a poor man in the General Hospital who had suffered from syphilitic disease of the larynx; he was thought not to be in a state sufficiently dangerous to require the operation. On the next day he died suddenly from asphyxia. In the larynx was found considerable ulceration, which also extended in patches down the trachea. In another case which seemed to be caused by the bite of a dog, which was succeeded by ulceration of the larynx, the attacks of asphyxia were very urgent. The operation of tracheotomy was performed, under which the patient died. No examination of the body took place. The performance of the operation of tracheotomy in cases of ulceration of the trachea, Mr. Hodgson said, required the deepest consideration. On the one hand he thought it ought to be done earlier than it was usually resorted to; and yet, on the other, the operation itself was one attended. with many dangers, both as to its performance, and as to the means used to keep the aperture, formed in the trachea, open by wearing tubes. In a woman upon whom the operation was performed in the General Hospital, death took place a week after, from abscess of the brain; but the operation was generally too late if delayed until asphyxia came on. In the case now before the Society, Mr. Hodgson thought death took place from the inflammation caused in the trachea by wearing the tube, in consequence of which the removal of the tube was required. Mr. Hodgson objected to the longitudinal incision, if the opening is required to be kept open some time after the operation; in such cases a transverse incision is much more desirable, as the former heals up so quickly that there is always difficulty in keeping it open, whilst in the latter the difficulty of healing it is so great that most commonly a fistulous opening remains after the greatest care having been taken to heal the wound, which is very well exemplified in cases of cutthroat. Mr. Hodgson knows a patient who cut his throat transversely some years since, and the wound is not healed yet. It would be still more effectual to take out a portion of the trachea. Mr. Ryland said that Mr. Hodgson's view of syphilitic disease, was to him quite new, but he thought that in all the cases of syphilitic disease of the larynx he had seen, they had commenced by ulceration. SCIRRHOUS PANCREAS. Dr. Fletcher exhibited a pancreas affected with scirrhus, especially at its head, by which the ductus communis was completely obstructed, so that no bile could flow into the duodenum. The patient, a male, about 45 years of age, applied to Dr. Fletcher on the 8th of last month, having suffered from jaundice above a year and a half; he was then very yellow. The region of the liver was some what enlarged; there was pain situated about midway between the ensiform cartilage and umbilicus. It appeared a case of jaundice from obstruction to the course of the bile. There was no sign of aneurism nor of any tumour, and none of the symptoms of disease of the pancreas were related by the patient, except the passing of white wax-like matter from the intestines, which had occurred several times during the progress of the case. The patient died on the 15th, rather suddenly, the day he was to have called upon Dr. Fletcher again, having tried very little of the remedies, which consisted of counter-irritation and alteratives. On the 16th, early in the morning, a post-mortem examination fully explained the cause of the jaundice from the scirrhus of the pancreas; the bile duct was completely obliterated, and above this the ductus communis was dilated so as to be large enough to allow four fingers to be passed into it. The gall-bladder was - capable of holding two-thirds of a pint, and the ductus hepaticus and its branches were all dilated so much, that a finger could be passed into any of the branches, in any part of the liver, and these were all distended with colourless bile. The liver was about half again as large as natural. All other organs in the body appeared healthy on examination. The brain was not ⚫ examined. ̈ (Translated for the Provincial Medical and Surgical Journal. J [Some difference of opinion still existing as to the chemical constitution of the blood in scurvy, and its importance as explanatory of the symptomatology of the disease, we have thought that the following researches upon the subject recently made at the Salpêtriére on more than 30 cases, might be interesting to the readers of the Provincial Medical and Surgical, Journal, in connection with the papers upon the same disease, which have already appeared.] The disease declared itself chiefly in females of an advanced age, the youngest of our patients being at least sixty-nine years of age, while three were upwards of eighty. There is not much to be said respecting the etiology of the disease, we are only able to state that the majority inhabited upper rooms, and that their food consisted chiefly of meat with bread, meat soups, and wine. All were apparently in good health previous to the attack. The disease declared itself with vague pains in the extremities, with a sense of general malaise, disagreeable taste in the mouth, and loss of appetite. In some, spots on the skin commenced simultaneously with the above symptoms. The chief symptoms when the patients were first seen, were a particular discolouration of the skin, hæmorrhagic spots and patches, a special alteration in the state of the gums, and general prostration of the vital powers. The discolouration of the skin consisted in a yellowish tint, sui generis, most marked on the face; it neither resembled exactly the icteric, chlorotic, nor cancerous hue, but was most like the colour left by the decline of an ecchymosis. This colour affected even the conjunctiva and gave an appearance to the patient which could not admit of misapprehension as to the nature of the disease, The hæmorrhagic spots varied in appearance, and consisted either of small points of a vivid red, scattered principally on the anterior aspect of the limbs, or of true petechiæ, the situation of which was the same. The most important and characteristic spots consisted of large ecchymoses or sanguineous infiltrations, situated in a subcutaneous cellular tissue. When the hæmorrhage was of an ancient date, its circumference was of a yellowish colour, indicative of the commencement of absorption. The pains of which the patients complained were of two kinds, the one spontaneous and deep-seated, the other more superficial and excited by pressure. The alteration in the gums was quite characteristic ; it did not consist of a general tumefaction and softening of their tissues, as is seen in certain forms of stomatitis," but of fungous vegetations, developed exclusively · around the neck of each tooth, so that the alveolar serum 63.1 1000. 7.3 811. 1000. Mastication was difficult or impossible, and the mouth exhaled a fœtid odour. Among the other general Inorganic matters of serum symptoms, prostration of strength was marked; and "there was anorexia from the first. Constipation occurred Water in most of the patients. Blood was never seen in the **'evacuations; neither was there any other hæmorrhage of consequence, with the exception of epistaxis in one 'case. 720The treatment consisted in the use of a drink acidu⚫lated with lemon juice, a gargle of alum, and a generous diet, of which green leguminous plants formed a considerable portion. [The analysis of the blood of five of M. Fauvel's e patients was undertaken by MM. Becquerel and Rodier, whose researches give the following results] CASE I.-Female, aged 76. Severe case: first bleeding, the clot much buffed; second bleeding, fifteen days later, clot dense, resisting, dark-red, and spotted with white striæ. CASE V.-Female, 72 years. Severe case; epistaxis. Defibrinized blood, 1038.3. From the study of the blood in these cases it appears : 1. That far from presenting that state of dissolution which has generally been admitted, the blood in scurvy coagulates firmly, and the serum is uncoloured by globules. 2. That the density of the defibrinized blood was 7.8 in all the cases below the normal standard, (1057.) 3. That the density of the serum is notably diminished, (1027.) 914.5 1000. CASE II.-Female, aged 74. Severe case; blood firmly coagulated. Density of defibrinized blood 1048.6. Analysis of 1000 parts of Organic matters of serum Inorganic matters Analysis of 1000 parts of Serum. Blood. Globules Fibrin 1108 Organic matters 73.8 7. 919.2 1000. clot CASE III.-Female, aged 73. Slight case; dark and loose. Density of defibrinized blood 1051.7. [The above memoir concludes with some observations on the complete subversion which the predominent theories of scurvy have received by these researches. It was thought the fibrin was diminished, and hence the profuse hæmorrhages, &c. It is proved by these analyses, as was previously ascertained by Mr. Busk, that it is, on the contrary, in excess. The theory of the alkalinity of the blood is equally opposed by the above facts, as is also another favourite theory of M. Andral, that when the albumen is diminished to a certain point dropsy is the necessary consequence, for it was found that though the number of albumen was low, anarsarca only appeared in one case, and that to a very trifling amount.] |