CLINICAL NOTES.

437 "Sept. 12th.-Mr. Ililton endeavoured to find the puncture in CLINICAL NOTES. the bladder by means of a speculum in the rectum, so as to reintroduce the catheter, but without success. On Sept. 13th, as BY MARSHALL HALL, M.D., F.R.S., &c. no progress could be made with the cure of the stricture, the rectum the was again performed. puncture of the bladder through CASES IN WHICH TRACHEOTOMY OR At ten P.M., the patient passed some blood of a venous character NOTE IV.—THE SERIES OF TRACHEOTONY MAY BE REQUIRED. kind has the of the flowed the nothing through penis; through canula." You should here notice, that on this second puncturing, To the Editor of THE IANCET. hardly six ounces of urine were drawn from the bladder-all it contained, no doubt, but it is a small quantity, and involves the extent to which the operation of tracheotomy SIR,-The necessity of extreme care in performing the puncture into the may be required will be best appreciated by your readers by it is The was from when so small. bladder, haemorrhage, then, them with a classified list of cases in which this presenting It is left vas the urethra, not from the bladder. possible that the measure be appropriate or necessary. I beg therefore to deferens was wounded in the second operation; its occurrence call theirmay particular attention to the following Table :would explain the appearance of blood coming from t’.e penis, whilst the water discharged from the bladder through the canula TABLE OF CASES REQUIRING TRACHEOTOMY. was free from blood; the wounded vas deferens might conduct 1. Cases qf Para7ytic Laryngi .smus.the blood into the prostatic portion of the urethra, at the termi1. Apoplexy of Inorganic Origin; nation of the ejaculatory duct. 2. Coma after Epilepsy; As regards the possibility to avoid wounding bloodvessels during 3. Deep Intoxication; the operation, it is not possible for the operator to foretell the ex4. Severe Narcotism;-each combined with f,)2,midable istence of pretty large veins upon the track of the trocar, but an stertor threatening life. artery may be felt by its pulsations, and avoided-at least, I cerII. Cases of Spasmodic Laryngismus : tainly did so myself in one instance. 14th.-No fever of any kind ; pulse quiet, and of moderate 1. Epilepsia Laryngea, threatening life or intellect; 2. Epilepsy with Torticollis, with the danger of suffocapower; tongue clean ; blood still drains from the penis; the bladder is washed out through the canula. Two ounces of wine tion; 3. Infantile, and daily. 16th.-Less blood from the penis ; the patient looks rather ex» 4. Puerperal Convulsion; 5. Hydrophobia; sanguine; the bladder is still washed out two or three times daily. 18th.-The bleeding has quite ceased ; an elastic catheter is 6. Tetanus; 7. Pertussis threatening Convulsion or Hydrocephctlus, passed into the canula, and the latter taken out. There is great 8. Laryngitis; pain and swelling in the left testicle, most likely associated with the suspected injury to the vas deferens; the discharge from the 9. Ulcercation of the Larynx; urethra is more profuse ; the urine passes occasionally by the 10. Certain Cases of Cut-throat; 11. Diseases adjacent to the Larynx, as and certainly in a better stream than before the operation. Health good. The veins of the scrotum were punctured, and the 1. Tumour, bladder washed out with warm water, as heretofore. 2. Aneurism, 27th.-All inflammation of the testicle has subsided; a fine 3. Cynaozc7ae Tonsillaris, 4. Scarlatina, Variola,- with paroxysms of gutta percha catheter was tried without the stilette, but could not be passed through the stricture. Nothing now was done, except Laryngismus; 12. Choking, from washing out the bladder, until October 12, when Mr. Hilton introduced into the urethra a No. 7 elongated, conical-shaped sound 1..A Foreign Body in the Larynx or Trachea; down to the stricture, and ordered it to be kept firmly pressed 2. A Foreign Body in the Pharynx; 3. A Mass offood in the Pharynx; against it for two hours daily. At the same time the perinseum This was freely leeched, thirty being applied in three days. 4. Inhalation of Acrid Vapour; 5. The Attempt to Drink Boiling Water; plan of treatment was continued for four days, and on the fifth 6. Swelling following the Attempt at Suicide by day, Mr. Hilton passed the instrument quite into the bladder. A No. 4 catheter was then introduced, and kept in. The elastic Strangulation; &c. &c. catheter was now of course taken from the rectum ; the urethral 13. The Poisonous Effects of Strychnia, &c., threatening discharge became less, the thickening of the prepuce likewise Suffocation. diminished, and the swelling of the testicle had quite disappeared; III. Cases of Permanent Laryngismus. the health improved, and a succession of catheters were now 1. Œdema of the Glottis; introduced at an interval of three or four days (up to No. 7), 2. Laryngitis; until November 12, when the patient left the hospital. 3. Other Diseases ofthe Larynx, or I would have you finally notice that the elastic catheter was 4. Oftheadjacent Tissues. removed from the bladder through the rectum on the twentyninth day from its introduction, without any fistulous opening To these cases may perhaps be added,persisting, or important incrustation at the end of the instrument (IV. Cases of Asp7ayxia. being noticed. This patient was directed to pass for himself, 1. Drowning; once a week or a fortnight, according to his condition, a No. 7 2. Hanging; bougie. He was seen in the summer of 1849, and was then, and 3. Suffocation from Mechanical Causes, had been, in every respect quite well since quitting the hospital. 4. From Breathing Irrespirable Gases, &c. &c.,-t7te I must, however, not be misunderstood as to the operation object being efficient artificial respiration.) which was performed in this case. I do not, in fact, advise From this table it will be sufficiently apparent that the subpuncturing the bladder through the rectum for all cases of stricture. All kinds of means short of an operation should be tried; ject of tracheotony or tracheotomy is one of vast and vital and when the time for operating arrives, balance in your minds importance, requiring the utmost attention from our best the operation I am advocating against the others which have physicians and surgeons, and not likely to be exhausted by been proposed. This is the right way for arriving at a satisfac- the superficial observer and thinker. I commend it to the earnest inquirer. tory solution and a safe practice. I will conclude this note by a question or two :(To be concluded in the next LANCET.) 1. What is the abortive form of malady left by tracheotomy in the various convulsive diseases ? BOURN v. Cox.-A special general meeting of the 2. What would be the abortive form of malady left by Bath and Bristol Branch of the Provincial Association was held at tracheotomy in formidable cases of pertussis? &c. &c. &c. Bristol on the 27th ult., when the above case was taken into con. It is scarcely necessary to repeat, that it is not for apoplexy, sideration. A discussion of considerable length ensued, in which nor even for epilepsy, that I have recommended tracheotomy: several influential members of the Association took part. Great but-for laryngismus. I have now shown that the recomdifference of opinion prevailed as to the best mode of meeting mendation is of vast extent, as it is also of vital interest. Time, this really painful case. Resolutions were proposed, seconded and great experience and observation, will be required to despoken on, and withdrawn, but eventually it was determined fine the limits and the precise circumstances of its just appli"that the whole subject with regard to Mr. Cox be referred to cation. But it will be admitted already, that a new field of the council, with a request to them to report on it to the next medicine and surgery has been opened to the physiological

penis,

quarterly meeting."

and

practical physician.