- Email: [email protected]
ADDITIONAL REMARKS UPON THE NEW OPERATION OF TRACHEOTOMY BY DILATATION OF A SMALL INCISION, AND PARTICULARS OF A CASE IN WHICH IT WAS PERFORMED.
5 of these, two were admitted on the fifth day of the disease, and were free from fever on the fifth day of treatment; one admitted on the eighth day of the fever was free from it on the tenth. Thirteen cases in which the quinine was given proved fatal: of these five died within forty-eight hours after admission. Of the remaining eight, one was admitted on the eighth day of fever, and died on the eighth of treatment. One was admitted on the fifth day of fever,and died on the sixth of treatment : this man had persistent hiccough, congestion of lungs, and had had a severe attack of fever seven months before. One was admitted on the seventh day of fever, and died on the tenth of treatment: this patient had been allowed nothing but barley-water previous to admission; tubercles in the right lung. One was admitted on the fourteenth day of fever, and died
on
the fifth of treatment: the
quinine
seemed to
produce
effects. One was admitted on the ninth day of fever, and died on the sixth of treatment: this patient had two kinds of
mo
the one disappearing, the other unaffected, by pressure; had been a hard drinker. One was admitted on the fifth day of fever, and died on the eighth of treatment: a woman seventy-six years old; this was the only fatal case where the pulse was reduced below 100. One was admitted on the fourteenth day of fever, and died on the fourth of treatment: the quinine did no good. One was admitted on the eighth day of fever, and died on the third of treatment: had involuntary motions when admitted. The effect of the quinine on the pulse is, in favourable cases, sometimes very remarkable: in one case it fell from 104 to 72 in twenty-four hours; in another, from 140 to 84 in seventysix hours; but generally speaking the reduction is gradual and steady. In cases which terminated fatally the quinine, with one exception, never reduced the pulse below 100; it sometimes fell from 148 to 124, from 112 to 108, from 140 to 114, but not below 100. None of the fatal cases were under treatment before the fifth day. In complicated cases the effect on the pulse is less marked than in those which are free
spots,
from
complication.
lower margin of the cricoid cartilage, when the upper rings of the trachea will be plainly distinguished beneath it, and the thumb and second finger of the same hand should be placed one on each side of the trachea, in order to steady and support it. Then the blades of the tracheotome (which of course are closely applied to each other) are to be introduced in a direction across the tracheal tube, to the depth of about half an inch, at the point just indicated, and, therefore, as near as may be between the first and second rings. A very small amount of force is necessary to accomplish this, as the blades slip in with great ease, no cartilage being divided. The points being felt free in the trachea, the shoulders of the blades, which are external to the wound, should be held between the fingers of the left hand, while the dilating-screw is gradually turned with the right, until an opening is made sufficiently large to introduce the tube. This should be previously oiled, fitted with its tape, and placed within reach. Then, without moving the tracheotome, the tube is to be slipped into the opening between the blades, after which the dilating-screw is turned backwards two or three times, and the instrument is withdrawn. The tube must of course be carefully held in its place until the tape is fastened behind the neck. I have had the opportunity, through the kindness of Mr. Thomas Carr Jackson, of the Royal Free Hospital, of seeing a case in which he was suddenly called upon about three weeks ago to perform tracheotomy for urgent laryngeal disease, with the advice of Dr. Peacock. Mr. Jackson happening to have one of my tracheotomes by him, performed the operation with it. He expresses himself as exceedingly pleased with the facility and rapidity with which the object was attained, and having performed the old operation several times, states that he shall never do it again in any case in which the new one can be substituted for it. He informed me of the circumstance in the following note, which, with his permission, I have appended to these remarks, and as it contains the unbiassed opinion of a practical and experienced surgeon, must be regarded as a valuable testimony on the subject. It should be added, that Mr. Jackson had not previously tested the method by any practice upon the dead body :-
Hamilton-place, NeA,. road, May 21, 1853. ADDITIONAL REMARKS UPON THE NEW MY DEAR SiR,—Having occasion on Wednesday evening last OPERATION OF TRACHEOTOMY BY DILA- ,to perform the operation of tracheotomy, you will doubtless TATION OF A SMALL INCISION, be gratified to hear that I took the opportunity of using the
instrument described by you in THE LANCET of March 5 of this year. It was completed most satisfactorily in a very BY H. THOMPSON, ESQ., M.B. Lond., M.R.C.S, short space of time, and with the loss of but very few drops SURGEON TO THE ST. MARYLEBONE AND BLENHEIM DISPENSARIES, ETC. of blood. In this case I prefer red making a small preliminary incision, (transverse,) which I think facilitates the introTHE object of the present paper is to describe the details of duction of the blades of your instrument. the operation of tracheotomy, as performed by means of an With no previous knowledge of the case, I was hastily instrument which I figured in a paper upon the subject, pub- called in, and found the patient in a slate bordering on aslished in THE LANCET of March 5,1853. I have felt called phyxia, and I presumed that this was caused by the pressure upon to do so, because it has been suggested to me by nume- of some disease in or around the glottis. Accordingly I had rous inquirers, that the directions there given were not quite no alternative but to afford relief to the urgent dyspnoea as so explicit as are necessary to enable a person hitherto totally as possible. The operation was done in the presence unacquainted with the operation to perform it, at all events speedily of Mr. Lane, house-surgeon of the Royal Free Hospital, and in that manner which experience indicates as the best. In Dr. Peacock, who very kindly gave the benefit of his valuable attempting to supply the desired information as briefly asI opinion and sanction to the measure. possible, I will premise that the objects to be attained are,- , Perfect relief to the agonizing symptoms was the immediate first, the making of a transverse incision between the first andi effect; and the patient, who had not slept from the previous second rings of the trachea, and, therefore, between the cricoid Friday, now fell into a refreshing sleep for five hours, and has cartilage and the isthmus of the thyroid body; and, since progressed favourably. It is my intention to publish the by dilating that opening, to render it capable of admitting a details of this interesting case when the result is fully known, full-sized trachea tube. but I shall be very glad to show you the patient if you think I have befc..’e stated, that it is not necessary to make any it worth the trouble to visit him.-I am, dear Sir, yours truly, preliminary incisions through the skin and cellular tissue. THOMAS CARR JACKSON. Henry Thompson, Esq. Generally speaking, however, it may be advantageous to make I have not a small one before opening the trachea itself. I saw the patient on the following day with Mr. Jackson done so, but others have, and say that they prefer that mode. and Dr. Peacock, and again in a day or two after, when the At all events the slight incision can do no harm, and it may tube was changed for a double one. Ten days afterwards he render the subsequent application of the instrument to the died of pulmonary haemorrhage. The post-mortem examitrachea more easy. nation revealed extensive tubercular disease in both lungs, First step in the operation.-Supposing the patient to be and ulceration of the larynx, with a considerable portion of placed on his back, and the neck to be moderately extended, one of the alae of the thyroid cartilage necrosed, detached and the operator should stand on the left side of the patient,-and lying loose in the diseased structures around. Here was the first clearly define with his left forefinger the projection of cause of the dyspno3a, which would have been speedily fatal the cricoid cartilage; he may then with a common scalpel had not the trachea been opened, and by means of which act, make an incision about an inch long through the integuments, therefore, a short extension of life was afforded to the patient. from that projection downwards in the direction of the long The opening in the trachea was made between the first and axis of the trachea. If preferred, a transverse fold of skin second rings, exactly in the centre of the tube. Lymph had may be pinched up and transfixed with a bistoury: in either been thrown out around the margins of the opening, and no case the same result is produced. mark of injury resulting from it appeared in its vicinity. The Step the second.-Next, taking the tracheotome in the parts form a preparation which is now in my possession, and right hand, the tip of the left forefinger should be placed in well illustrates the foregoing remarks. the wound, not more than a quarter of an inch below the Wimpole-street, Cavendish-square, June, 1833. AND PARTICULARS OF A CASE IN WHICH IT WAS PERFORMED.
secondly,I’
on
the fifth of treatment: the
quinine
seemed to
produce
effects. One was admitted on the ninth day of fever, and died on the sixth of treatment: this patient had two kinds of
mo
the one disappearing, the other unaffected, by pressure; had been a hard drinker. One was admitted on the fifth day of fever, and died on the eighth of treatment: a woman seventy-six years old; this was the only fatal case where the pulse was reduced below 100. One was admitted on the fourteenth day of fever, and died on the fourth of treatment: the quinine did no good. One was admitted on the eighth day of fever, and died on the third of treatment: had involuntary motions when admitted. The effect of the quinine on the pulse is, in favourable cases, sometimes very remarkable: in one case it fell from 104 to 72 in twenty-four hours; in another, from 140 to 84 in seventysix hours; but generally speaking the reduction is gradual and steady. In cases which terminated fatally the quinine, with one exception, never reduced the pulse below 100; it sometimes fell from 148 to 124, from 112 to 108, from 140 to 114, but not below 100. None of the fatal cases were under treatment before the fifth day. In complicated cases the effect on the pulse is less marked than in those which are free
spots,
from
complication.
lower margin of the cricoid cartilage, when the upper rings of the trachea will be plainly distinguished beneath it, and the thumb and second finger of the same hand should be placed one on each side of the trachea, in order to steady and support it. Then the blades of the tracheotome (which of course are closely applied to each other) are to be introduced in a direction across the tracheal tube, to the depth of about half an inch, at the point just indicated, and, therefore, as near as may be between the first and second rings. A very small amount of force is necessary to accomplish this, as the blades slip in with great ease, no cartilage being divided. The points being felt free in the trachea, the shoulders of the blades, which are external to the wound, should be held between the fingers of the left hand, while the dilating-screw is gradually turned with the right, until an opening is made sufficiently large to introduce the tube. This should be previously oiled, fitted with its tape, and placed within reach. Then, without moving the tracheotome, the tube is to be slipped into the opening between the blades, after which the dilating-screw is turned backwards two or three times, and the instrument is withdrawn. The tube must of course be carefully held in its place until the tape is fastened behind the neck. I have had the opportunity, through the kindness of Mr. Thomas Carr Jackson, of the Royal Free Hospital, of seeing a case in which he was suddenly called upon about three weeks ago to perform tracheotomy for urgent laryngeal disease, with the advice of Dr. Peacock. Mr. Jackson happening to have one of my tracheotomes by him, performed the operation with it. He expresses himself as exceedingly pleased with the facility and rapidity with which the object was attained, and having performed the old operation several times, states that he shall never do it again in any case in which the new one can be substituted for it. He informed me of the circumstance in the following note, which, with his permission, I have appended to these remarks, and as it contains the unbiassed opinion of a practical and experienced surgeon, must be regarded as a valuable testimony on the subject. It should be added, that Mr. Jackson had not previously tested the method by any practice upon the dead body :-
Hamilton-place, NeA,. road, May 21, 1853. ADDITIONAL REMARKS UPON THE NEW MY DEAR SiR,—Having occasion on Wednesday evening last OPERATION OF TRACHEOTOMY BY DILA- ,to perform the operation of tracheotomy, you will doubtless TATION OF A SMALL INCISION, be gratified to hear that I took the opportunity of using the
instrument described by you in THE LANCET of March 5 of this year. It was completed most satisfactorily in a very BY H. THOMPSON, ESQ., M.B. Lond., M.R.C.S, short space of time, and with the loss of but very few drops SURGEON TO THE ST. MARYLEBONE AND BLENHEIM DISPENSARIES, ETC. of blood. In this case I prefer red making a small preliminary incision, (transverse,) which I think facilitates the introTHE object of the present paper is to describe the details of duction of the blades of your instrument. the operation of tracheotomy, as performed by means of an With no previous knowledge of the case, I was hastily instrument which I figured in a paper upon the subject, pub- called in, and found the patient in a slate bordering on aslished in THE LANCET of March 5,1853. I have felt called phyxia, and I presumed that this was caused by the pressure upon to do so, because it has been suggested to me by nume- of some disease in or around the glottis. Accordingly I had rous inquirers, that the directions there given were not quite no alternative but to afford relief to the urgent dyspnoea as so explicit as are necessary to enable a person hitherto totally as possible. The operation was done in the presence unacquainted with the operation to perform it, at all events speedily of Mr. Lane, house-surgeon of the Royal Free Hospital, and in that manner which experience indicates as the best. In Dr. Peacock, who very kindly gave the benefit of his valuable attempting to supply the desired information as briefly asI opinion and sanction to the measure. possible, I will premise that the objects to be attained are,- , Perfect relief to the agonizing symptoms was the immediate first, the making of a transverse incision between the first andi effect; and the patient, who had not slept from the previous second rings of the trachea, and, therefore, between the cricoid Friday, now fell into a refreshing sleep for five hours, and has cartilage and the isthmus of the thyroid body; and, since progressed favourably. It is my intention to publish the by dilating that opening, to render it capable of admitting a details of this interesting case when the result is fully known, full-sized trachea tube. but I shall be very glad to show you the patient if you think I have befc..’e stated, that it is not necessary to make any it worth the trouble to visit him.-I am, dear Sir, yours truly, preliminary incisions through the skin and cellular tissue. THOMAS CARR JACKSON. Henry Thompson, Esq. Generally speaking, however, it may be advantageous to make I have not a small one before opening the trachea itself. I saw the patient on the following day with Mr. Jackson done so, but others have, and say that they prefer that mode. and Dr. Peacock, and again in a day or two after, when the At all events the slight incision can do no harm, and it may tube was changed for a double one. Ten days afterwards he render the subsequent application of the instrument to the died of pulmonary haemorrhage. The post-mortem examitrachea more easy. nation revealed extensive tubercular disease in both lungs, First step in the operation.-Supposing the patient to be and ulceration of the larynx, with a considerable portion of placed on his back, and the neck to be moderately extended, one of the alae of the thyroid cartilage necrosed, detached and the operator should stand on the left side of the patient,-and lying loose in the diseased structures around. Here was the first clearly define with his left forefinger the projection of cause of the dyspno3a, which would have been speedily fatal the cricoid cartilage; he may then with a common scalpel had not the trachea been opened, and by means of which act, make an incision about an inch long through the integuments, therefore, a short extension of life was afforded to the patient. from that projection downwards in the direction of the long The opening in the trachea was made between the first and axis of the trachea. If preferred, a transverse fold of skin second rings, exactly in the centre of the tube. Lymph had may be pinched up and transfixed with a bistoury: in either been thrown out around the margins of the opening, and no case the same result is produced. mark of injury resulting from it appeared in its vicinity. The Step the second.-Next, taking the tracheotome in the parts form a preparation which is now in my possession, and right hand, the tip of the left forefinger should be placed in well illustrates the foregoing remarks. the wound, not more than a quarter of an inch below the Wimpole-street, Cavendish-square, June, 1833. AND PARTICULARS OF A CASE IN WHICH IT WAS PERFORMED.
secondly,I’