there were occasional violent expirations and attempts to cough, and a quantity of bloody mucus was shot out of the tube, but generally drawn in again. No hemorrhage came on. 8 P. M. Much the same. He has had four fits, the first one with slight lividity (as observed by the nurse), but not nearly so bad as most previous ones. Mr. Wilbe, the resident dispensary officer, saw him in one, but although severe, he said there was no lividity, no foaming, and no biting of the tongue or lips, &c. The patient took a little beef-tea, and swallowed as well as usual. There was no hemorrhage. He had been crying once or twice, and again did so whilst Mr. Holmes, Mr. Wilbe, and myself were present, at the thought of his mother being away at night. We left him, seeming to be, on the whole, very comfortable. 66 18th.-Quarter to eight A. M.: Found that he had had a very bad night, and the nurse stated that he had had twenty-five fits between the hours of two and eight o'clock this morning. These were very bad, but were not attended by any blackness of the face. The face was very red in color, and the upper part of the left eyeball quite blood-red. At one time, the patient appeared violent, and wanted to bite things. The last fit was twenty minutes before my visit. The pulse was 85, and he had taken beef-tea. The skin was warm, but the feet rather cold. The tongue was furred. No thirst was complained of, but the boy cried much. The respiration was noticed to be rather difficult, and as the inner of the tracheal tubes could not be removed, owing to coagulum, &c., both of the tubes were taken out, and much bloody mucus and coagulum found within. There was well-marked emphysema of the neck on both sides.Half-past nine P. M.: The boy seems tranquil and easy. Pulse natural, and no thirst. Tongue very furred, and bowels not open. The face was natural, and at times smiling. The feet were warmer. The respiration was the same as my own in number. He had had milk and eggs and bread and butter. When lying on the left side, he seemed inclined to cough, but not on the other, according to his mother's statement. The string of the tracheal tube had been tightened as the neck had shrunk. Since the morning, he had had four fits, the first being the worst, but in no case was any blackness observed, although the face got very red. Much clotted mucus came out of the tube. "19th.-Reported to have had five or six hours of comfortable sleep, and this morning had been removed down into his former room, which was a cellar (much to my annoyance). Had only had three fits in the night, which were very mild, excepting the first one, when the conjunctiva at the upper part of the left eye was very blood-shot. The nurse said that the mouth had not been put out of shape.' Slight bronchial mucous râles were observed in the fore part of the chest by auscultation, but no pain or thirst was complained of. The tube had been frequently removed from the trachea in the night to be cleaned. The pulse was 85, and rather sharp. The bowels not open. Ordered a draught with rhubarb and magnesia. The milk, eggs, and bread and butter to be continued.-Half-past eight P. M.: Rather fretful, as he has been every day towards evening, according to the nurse. Pulse quiet. Breathing a little troubled, but eased on removing and cleaning the tube, which contained some thick mucus, though it had been cleaned one hour before. Tongue furred. Smiles and tries to speak when told. Thumb-nail very sore from biting. Wound suppurating healthily. Since morning, he has had three fits, of which the first was the worst, and the face became dark red, but by no means black; the others were very mild. The mother repeats that after the fit the breathing was very violent, both inspiration and expiration; but whilst in the fit, he could not breathe generally. To go on with eggs and milk and beef-tea, &c. "20th.-Quarter to twelve A. M.: Has had six hours' good sleep, but had five fits in the night, but in none was he more than very red in the face. As before, the right side was chiefly affected. Has also had two fits this morning, but they were very slight indeed, simply transient redness of the face. Pulse 80, weak. Rather depressed countenance. Tongue, as before, rather furred. Bowels not opened with draught yesterday. Wound suppurating; redness around not so great. Rather thirsty. To go on with eggs, milk, beef-tea, and one ounce of wine diluted; raspberry vinegar. An ounce and a half of com pound senna draught immediately.-Half-past nine P. M.: Seems quite tranquil. Pulse 85, with tolerable firmness and fulness. Tongue cleaner. Bowels open three times; motions rather offensive and watery; the first motion, two hours after the draught; had slight abdominal pain at the time. Skin warmer. Not very thirsty. Liked the raspberry vinegar much. Had the nourishment and wine diluted at intervals. The nurse says he is more refreshed and better with the wine. Breathing comfortable. Feet warm. Had no fits since morning. "21st.-Ten A. M.: Had eight or nine fits in the night whilst asleep, two or three being rather severe, and three this morning, which were very slight; was not dark in the face in any, and there were no contortions of the face, the right side of the body being chiefly affected. The nurse and mother both consider the fits since the operation to differ from those before it, by the want of any noise at the throat both before and in the fit, the want of contortion, the want of any lividity of the face, or of any very deep redness of the eyeball, which often were like balls of blood, as they describe it, and by the rapid convalescence after the attack. The patient is reported as being stronger this morning. Pulse not so strong as last evening. He was restless in the night, and had about three hours' sleep; somewhat thirsty; tongue rather furred, but not much; has slight cough at times, and then gets up thick mucus.' Has had an ounce of wine along with other things in the night.--Ten P. M.: Has been much more cheerful all day. Pulse natural, 85; tongue clean; skin warm; appetite good, and had an ounce and a half of wine and part of mutton chop, with eggs and milk; something every half hour. Nurse says the tube requires more frequent cleaning; the mucus is more tenacious. Had only one very slight fit since morning, in which no lividity or contortion of the face existed; only the limbs were affected, and he was out of the fit almost directly. Seen by Mr. Holmes in the attack. Not very thirsty; bowels not open since last night. 66 22d.-Half-past 11 A. M.: Had a very bad night, and ten or twelve fits; some very strong; in one he forced the tube out about 12 o'clock, and Mr. Wilbe had to be sent for to return it. He has had also three this morning, and I found him just recovering from one; the face was entirely suffused, but nothing more. He seemed very heavy and stupid afterwards, and inclined to sleep. Pulse natural; bowels not opened, and had taken an ounce and a half of compound senna mixture; had had wine, &c., in the night. In no case was there lividity of the face. The mother and the nurse feel assured that the boy did not pull the tube out in any way, but that it was forced out during the convulsive efforts.-Half-past 9 P. M.: Had two slight fits only since visit, and has taken wine, two ounces of mutton, two eggs, milk, and beef-tea. Bowels open twice; tongue clean; pulse quiet, soft; much thick mucus passed during the day. Can speak in a low tone, which he says he could not at first do at all. Smiles, and is cheerful. Face with a healthy florid look, and natural and lively expression. Protrudes tongue promptly. 66 23d.-Half-past 10 A. M.: Had not so good a night, and had ten or twelve fits; none with lividity or alteration of the facial muscles. Bowels not again open; tolerably cheerful. Repeat the senna mixture, wine, &c. "24th.-12 A. M.: Had the best night which he has had since the operation, having had only five fits, and these not very severe; but he had one lately, and is now very inactive and heavy, and will hardly put out the tongue. (Has never bitten his tongue or lips since the operation.) Lies half asleep, with the right eyeball rather everted; face slightly suffused. After about five or eight minutes, during my visit, he gradually recovered. He had been very excited two hours before, requiring great force to hold him down, owing to the pain and difficulty attending the nurse's attempt to get the tube out, which she had not done since yesterday early. She had only cleaned it out by means of the probe, &c. Whilst present I saw him in a fit; it began by his raising himself in bed; he quickly became quite bright red over all his face, but was not the least black; he stared violently, with very dilated pupils, but did not seem to know any one; the pulse was very quick; breathing still going on. After about four minutes the attack gradually subsided, and he lay rather up heavy, and yawned; the pulse became natural, and he had some wine and water. The cleft of the operation is so deep and so closing, that the inner tube can apparently not be got out. Mr. Holmes wishes it to be left in, and to be cleansed by the probe, &c.-9 P. M.: Very cheerful, and sits up in bed; wound suppurating; tube very clogged up; speaks freely, but not nearly so well when the tube is somewhat cleansed; pulse and skin natural; had meat twice, with wine and other things; bowels open once freely with senna draught to-day; the draught yesterday had no effect. Several thread-worms were seen to-day. I had ordered a tubal dilator at Savigny's-one which I had had constructed, and wished to have tried, but it had not yet come. A much longer tube was required than the one used, as alluded to in Mr. Holmes' note, to prevent the fluids from the outer wound getting down into the tube, in order that the inner one may freely be removed. Thinking that the tube might be cleansed by forced expiration, the mouth and nostrils being stopped, I wished the patient to adopt this method, but for some reason or other he was unable. "25th.-10 A. M.: Appears very cheerful; had only three light fits in the night when asleep, and again three of a similar description this morning. The mother declares he was not unconscious in any of them, and that in coming out of them he says 'Oh, dear!' He has slept five or six hours in the night, and again an hour and a half this morning; bowels open twice this morning. To go on with wine and other things. "26th.-Half-past 10 A. M.: Sitting up; he seems very comfortable; has only had two fits in the night, and they were small. Nurse says he was not unconscious in any of them. The tracheal tube was quite patent, as shown by the probe passed down, also by fine air coming out of it, and mucus likewise on his coughing, but yet he can speak in a half whisper. Cough rather troublesome.-8 P. M.: The boy walked to my house, a distance of threequarters of a mile, which he ought not to have done. He said he felt poorly, and seemed weak; had only one slight fit since the morning "27th.-Has had rather a bad night, with eight or ten fits, but none very strong; several to-day, but his mother declares that he is out of them directly (in a minute). The tube very full of mucus, but the air passes through; cough bad; bowels not open; tongue clean. Senna draught, with tincture of senna. To be repeated if necessary. "28th.-4 P. M.: Had eight or nine fits in the night, and several to-day, but out of them in a minute. The tube was taken out by Mr. Holmes, and nothing left in the aperture, until a longer tube, to lie with its shield on the skin, be made by his directions. Never passes urine in his fits since the operation; bowels opened twice with a second draught; appetite indifferent today; cough not quite so troublesome all day as it was in the night. 29th.-12, mid-day: Had two or three small fits in the course of yesterday afternoon, and eight or nine in the night of the same character; seems stronger, and is going out to see the people come up for the illumination.' Mr. Blaise is making a single large tube, to be ready in the morning. "30th.-Half-past 9 A. M.: Nurse says he had only two fits since I saw him yesterday, and they were slight ones. The large tube was brought and introduced into the tracheal opening by Mr. Holmes. “31st.—Did not see him for above a week from this date, as I was out of London; but the following list of fits which the boy had was kept by the mother by my directions. The fits were all of the slight kind:' 66 June 2d.-In the day, two fits; in the night, three fits. "3d. In the day, one fit; in the night, four fits. "4th. In the day, three fits; in the night, five fits. "5th.-In the day, one fit; in the night, four fits. "9th. In the night, four fits; in the day, six fits. "10th. In the night no fit; but this morning had one of the slight form. Recommended the occupation of netting to him. Going on with large doses of quinine and iron, purgatives, and at times turpentine injections, as plenty of worms were passed. "12th.-Two capital nights, and no fits since Tuesday morning. "13th. The tube was removed, but could not be returned (though it had only been out for half a minute) without chloroform. During the administration of chloroform the boy had a slight attack of convulsions (doubtful whether from chloroform or not). "14th. The tube was replaced with the greatest ease. No fits since Tuesday, 10th. Fit in the course of the day. 66 15th.-One fit. "16th.-Two fits. "17th.-One fit. Worms seen. Ordered turpentine enema. "18th.-No fit. "19th.-One fit. Worms came away in a lump. Repeat enema. "20th.-One fit. "21st. No fit. No worms seen. Sleeps at night, and never wakes. The mother says she does not know what to make of herself when she gets up in a morning, now that she gets so much sleep; she is so delighted.' "22d and 23d.-No fits. "All the above fits were very slight, as the mother says he only goes white for a moment, and is then all right.' Nothing more decided than this. His mother calls the attacks 'faintnesses,' which last generally about two minutes, during which he says 'mother,' and heaves a sigh, but does not lose consciousness, and then says 'I'm better.' If he be on the other side of the room when the fit comes on, he is generally about right by the time his mother gets to him. The fainting attacks are generally in the morning when he gets up; never at night. The boy says he always feels better when wind and air and heat' is coming to him. Pulse better; no cough; tube in trachea all right; no worms seen in the evacuations. "24th.-One fit. Repeat mixture and turpentine enema. "25th.-No fit. “26th.-No fit. Repeat mixture. "27th.-One fit and two faints directly after turning the mangle.' No worms with injection. Bowels not open; slept from half-past 10 to 8 without waking. His mother says she now lives another life.' Repeat mixture and powder. '28th, 29th, and 30th.-No fits. "July 1st.-No fit; no worms; 'feels he's getting much stronger.' Always feels uncomfortable and sinking when the tube is out for cleaning. Repeat mixture. "4th.-One fit. Rode yesterday to Camden Town, and walked part of the way back. Had another injection. 8th.-No fit. "15th.-One fit; occasional worms. Got up this morning and went out without food, and 'fainted right off.' Pulse good; no wine and very little meat of late. "16th.-One fit. "17th.-One fit. Repeat injection and mixture. "The above fits are only faintings, and he is quite out of them again in about five minutes. His mother says he does not lose his senses completely in them, and only sometimes knows of it beforehand. It would appear as if they were from not eating sufficient, as he scarcely touches anything to eat in the morning, and never has the fits in the other part of the day, when he eats more. Tongue clean; no worms; motions sometimes light, sometimes black. "24th.-Offensive motions brought away with injection, but no worms. Repeat mixture. "25th. On walking quickly for a time, fainting came on. "26th.-Pulse 29. Fainting again this morning. "Arrangements were made for the boy's going to Brighton Infirmary—the tube being still in the trachea―for general health. "29th.-Went to Brighton with his mother, and on the 30th into the infirmary. During his stay his mother visited him, and he sent home letters, two of which I have, dated August 1st and 5th, both speaking of his being comfortable, and getting well, &c. On the week following his admission into the infirmary, the mother went again to Brighton, saw him, and the tube in the trachea was then all right, and the boy much about the same, according to her account. Two weeks later the mother went down, and to her surprise found the wound healed (as I had told her it was still kept open), and the tube out. When she saw him he was then very ill, but better, she was told, than what he had been. He had several fits whilst his mother was with him, which was for four or five hours. These fits were very bad ones, the ears getting red and the face dark, and lasting about ten minutes; he also lost his senses during them. She understood from the patients that he had been delirious, and was strapped down two days and nights, and had had very severe fits. Previous to the removal of the tube, I had heard from Dr. Ormerod, under whose care in the infirmary the boy was, that he had five or six minor epileptic attacks every day.' Dr. Ormerod thought him worse than he was when he entered the infirmary. On hearing then that the tube had been removed, and that since then his mother had seen him in very bad attacks, I wrote to Dr. Ormerod, who very kindly sent me word again about him. He said that the tube was after a while evidently keeping up irritation, and a most striking improvement ensued on its withdrawal. Wishing to have the boy under my immediate notice, I sent the mother to Brighton to fetch him back, August 30th. It seems that on the day of return he had no fit; but on the evening of Sept. 1st he had a slight one, which lasted five minutes. His mother asserts that he did not completely lose his senses in it. "On September 2d I gave him again quinine and sulphate of iron. The voice was quite natural, and the wound in the neck firmly healed. The pulse was good, the tongue clean, but the appetite was still very bad in the morning. No worms were seen in his natural motions, but under further use of strong purgatives and enemata, they were passed. What the boy appeared to want, as no more very severe attacks came on, was regular employment. This, however, he could not get; for although one or two people took him as errand-boy, they were frightened by his slight attacks, and obliged to part with him. After that I lost sight of him altogether for some time. At last I saw his mother, who said he had had on several occasions heavy attacks, and wanted the opera tion to be again performed. However, as by acknowledgment on the patient's part, and by his description, I felt sure the attacks were not nearly so severe as they had been before the operation, although the tube was kept in so short a time, I could not consent to it. Indeed, there was no laryngismus threatening life, limb, or mental powers, which demanded our having recourse to tracheotomy. For several months I had again seen nothing of the patient except on one occasion, when I accidentally met him in the street, carrying a basket of vegetables. He then said he at times had severe fits, but he was a marvellously different being from what he was during the few days before the operation. Again I lost sight of him for several months, until November 26th last, when, having been seen by Mr. Holmes, he was sent to me with his mother. He had grown much, but was very thin. He had had two or three situations, but had been unable to retain them, by reason of the fits, which now were nearly all of the smaller kind. They lasted about five minutes, during which time he went as pale as a corpse,' and lost his consciousness. One always came on in a morning. Contrary to what took place some time ago, the attacks but seldom came on in the night. His mother had not seen any worms of late, but thought, from his ravenous appetite, that he must have them. She volunteered observations as to the good of the operation, and was willing to have it again performed; but as there was no laryngismus in the attacks, and apparently scarcely any convulsive movements, such a step could not be advised. The epilepsy had almost entirely assumed the syncopal form." ART. 38.-A case in which Death happened in an Epileptic Fit after Tracheotomy. Dy Dr. ORMEROD, Physician to the Brighton Hospital. The following case is appended to the preceding case by Dr. Ogle. It was |