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ON THE OPERATION AND APPLICATION OF TRACHEOTOMY.
367 has a peculiar, greyish, leaden hue, and is very sensitive to the touch. The left labium and a considerable portion of the mons veneris upon this side are entirely gone, as well as both gracilis and adductor longus, having sloughed away for twothirds of their extent. Continue the remedies. 11th.—Eleven A.,11.: Symptoms increased; has not slept during the night; cough and expectoration moderated; her features retain a most miserable consciousness of severe constitutional suffering; nausea and sickness have again supervened, with more or less pain in the epigastrium; pulse 125, small and irregular; there is burning heat of skin, with hectic flush; thirst continues; tongue and lips coated with brown sordes; diarrhœa has set in. The sore becomes more painful, especially at its lower part; it continues to bleed with renewal of poultices; the discharge is profuse, dark, and sloughy. On examination this morning the phagedsenic excavation is rapidly extending along the cleft of the left buttock, and around the back part of the thigh, having already exposed to view the lower border of the gluteus maximus, and nearly the whole of upper part of semi-tendinosus and membranosus Repeat the pill every three hours, and increase muscles. wine to eight ounces, with arrowroot. 12th.-Eleven A.M.: Her symptoms have much increased in severity since yesterday; she appears to be sinking fast ; vomits everything she takes in the way of food; has been ’, delirious thoughout the night; takes little notice of surrounding objects. Mouth open; eyes sunken within their sockets; features very much collapsed; pulse slow, weak, and irregular; involuntary stools; has voided little or no urine during the last twelve hours. There have been repeated and copious bleedings with each renewal of the poultice since my last report; sore not examined to-day. Ordered brandy, an ounce. 13th.-Died about half-past nine last night. Since her death there has been considerable hæmorrhage from the sore. Upon examination this morning it measures nearly twelve inches and a half in length, and about nine and a half in
The sore upon the labium spreads rapidly, and presents the character which we have described as existing at the time of her admission into the hospital. With a constitution worn out by the vicissitudes of her peculiar life, and with a constant drain upon a system unsupplied with nutritious food; exhausted by fatigue, and want of rest; anxious, from the aspect of her desperate circumstances, she presented a subject in which the malignity of her malady might run its course with out a check, and where the hope of recovery was too faint to be fostered, and her condition too debilitated for a cure to be realized. The prominent character of her disease was a rapidly-destructive action, without power,—without power, because of the incapacity of the system to resist the progress of the ulceration, and destructive, from its tendency to disorganize the parts in its immediate vicinity. The indications of treatment, then, were clearly developed, and were steadily kept in view during her life. It was necessary that the system should be supported, the irritative symptoms conciliated, and the diseased surface destroyed. Now it was evident, from the girl’sprevious mode of life, that the constitution was habituated to the influence of the most powerful stimuli; consequently, ammonia, opium, &c., were strikingly indicated, and the destruction of the diseased part was judiciously attempted by the application of strong nitric acid. After the application of this acid to the sloughing surface, free and frequently-renewed poultices, with a dressing of treacle, wormwood, and cummin seeds, were employed. The sloughs separated kindly, the margins of the sore sank, the surface became covered with healthy-looking granulations, and there was a discharge of well-formed pus. At this time there were some hopes of a favourable termination, but so great was the destruction of parts, that the portion of thigh below the diseased surface seemed to be cut off from connexion with the source of its vitality. Hectic symptoms supervening, indicated the extremity of the case, and the patient gradually sank, till death released her from her sufferings.
breadth. Remarks.-In the case just detailed, we have a striking illustration of the fact, that a disease comparatively mild and i curable in the majority of cases, may, under circumstances ON THE OPERATION AND APPLICATION OF
TRACHEOTOMY. tending to its aggravation, assume a severe and fatal character. I A woman, in the vigour of youth, and, until lately, stout and BY MARSHALL HALL. M.D., F.R.S. robust, after having passed a few months in unusual excess, is THERE are three classes of cases in which the operation of thrown into prison. She there receives some treatment for the disease under which she is labouring; but the mental de- tracheotomy may be required. The,first of these is that of any disease of the larynx itself, pression attending the seclusion of a gaol, the coarseness of her food, the regularity of habit enjoined in contrast with her or the immediately adjacent structures, by which its orifice previously loose mode of life, and, above all, the sudden change or course may be obstructed physically or mechanically. The second is that of reflex action, or spasmodic closure of from an existence in excitement and intemperance to the opposite condition, quickly produce a state of constitution the glottis, induced through the irritation of the superior favourable to the spread of diseased action. Indeed, perhaps laryngeal, or some remoter incident nerve, and the recurrent, there is nothing more important to be remembered, than that or of the medulla oblongata—spasmodic laryngismus. the sudden alteration of a habit of body or mind, even should The third is catalysis of the pneumogastric nerve, or, it may such habit be of a pernicious nature, will modify the efforts of be, of the medulla oblongata-a condition attended by colthe system to repel the progress of a disease which has been lapse, and partial closure of the glottis or larynx—paralytic or contracted, and while the constitution was under the influence catalytic laryngismus. of such habit. Thus we find persons who reside in the Of the first of these cases we have an example in laryngitis; vicinity of a constant noise-near a forge, for instance-when of the second, in the irritation of the rima glottidis by the such noise ceases, are unable to rest; and the case of a suf- accidental contact of a drop of water, or a particle of bread; fering miller is recorded by Dr. Pereira, who, when the mill of the third, in the experiment of dividing the pneumogastric was stopped, became restless and sleepless, and continued so nerve, and in the cases attended by stertor in general. In all these cases, when danger is imminent, it may be until the mill was put in motion again. The effects of the sudden disuse of an accustomed stimulus also are familiar to averted by the operation of tracheotomy. This enlarged view of the application of this remedy may excite a little surprise. us in many of the diseases which we meet with among the inhabitants of large towns. Such manifest themselves, for I trust it will be justified by the observations which I am the most part, in the nervous system, (as in the form of about to lay before the profession. In this case, it will become delirium tremens, or some allied disease,) and more commonly of the most essential importance to render the operation itself as easy and as safe as possible. To this point I have occur during the collapse succeeding a debauch than during the debauch itself. We find many local diseases either therefore devoted much attention. arising from or having their character much modified by the 1. On the Mode of Operation. same cause. And others, again, we find, which, although not It would be presumptuous in me to obtrude any observations called into action by any peculiaritv of habit, require, nevertheless, their treatment to be based upon a knowledge of the on the best mode of performing any operation. This is not patient’s previous mode of life. Thus, we often observe pneu- therefore my intention. But I have been witness to great monia and others of the phlegmasiæ, when occurring to per- apparent difficulty in the performance of tracheotomy-I have even seen one little patient expire on the operation: sons whose constitutions have suffered in the way we are alluding to, not only forbidding the employment of antiphlo- table. It may, therefore, be quite permissible for me to suggistic treatment, but offering no prospect of being benefited, gest any simplification of the mode of operating which may except by supporting means, and perhaps by the exhibition of have occurred to me, for the sake of those practitioners whose the accustomed stimulus also. position does not lead them to perform the greater operations In the case before us, the patient, after having passed some frequently. My object is to make the operation of tradays in prison, and leaving it with the disease still upon her, cheotomy at once safe and easy in inexperienced hands, beat once plunges into a state of life more unfortunate. House- lieving, as I do, that it may have a much more extensive apless, cold, and famished, she passes three or four days in the plication in practice than at present. In the operation of tracheotomy, tavo modes and instruopen streets, during which time she tastes little else than gin.
368 For this purpose either an eye-probe may be used, or the double-acting forceps closed. Either of these being introduced, and gently moved in different directions, the trachea is at length laid bare, and this part is kept exposed by applying expanding the forceps.
ments may be adopted: the first is double-acting forceps; the second, a tenaculum within a canula, with a cutting edge. The double-acting forceps is represented. in the subjoined wood-cut :-
and moment, trachea, by
either an incision may be made into the of a minute scalpel, such as is used in operations on the eye, and this incision may be kept open, by means of the double-acting forceps, whilst a silver tube is introduced ; or the tenaculum eanula may be applied, and a portion of the trachea removed, and the tube may be inserted, or not, according to the views of the operator. In one case, in which the operation was performed by Mr.. Hilton, and the subsequent treatment was conducted by Mr Stevens, of Great Percy-street, Lloyd-square, such a tube has been worn for nineteen months, without inconvenience. The patient is a female of five-and-twenty, and probably labours under contraction of the rima glottidis, from the healing of a syphilitic ulcer. In another case, that of a man aged sixty, suffering under chronic laryngitis, on whom Mr. Fergusson performed. the operation of tracheotomy, a tube has been so worn for half a year. In no part of all this operation, after the division of the integuments, will a drop of blood escape: there will be neither haemorrhage externally, nor blood drawn by the acts of inspiration into the trachea. This operation becomes almost as easy, almost as safe, as phlebotomy. At this
means
2. On
Physical Lesion of the Larynx. It is unnecessary for me, in this place, to do more than advert to those cases of physical lesion of the larynx, in which tracheotomy is the remedy. My object is rather to adduce other examples, and examples of a different nature, of ita. utility. It will be obvious from this sketch, that this forceps may 3. On Spasmodic Laryngismus. be opened or closed by pressing on the little projections a and The next case to be mentioned here, as requiring the opeb, or c and d. ration of tracheotomy, is that of spasmodic closure of the The tenaculum canula is represented in this second sketchglottis or larynx-or spasmodic Laryngismus. An eminent medical professor sent for me, in haste, on account of a feeling of imminent suffocation, the effect of having inhaled, during an experiment, chlorine gas. Every one remembers the public interest attached to the* ’.
of Mr. Brunel. No one would hesitate, in such cases, to perform the operation of tracheotomy. In some cases of choking, too, the same necessity for this operation may exist. The specific effect of strychnine is spasmodic laryngismus.. The case therefore requires tracheotomy, if time be given. Tracheotomy has also appeared a justifiable measure in certain cases of tetanus, and in hydrophobia. But besides these cases there are several others, in which tracheotomy would appear to be an appropriate measure. The violence of the general convulsion in epilepsy, and in’ puerperal convulsion, seems to be essentially linked with closure of the larynx. Without such closure no such violent and general convulsion could take place; and without such convulsion the cerebrum could not become the seat of violent congestion; and as a further consequence, no danger to-life or intellect could exist. But the epileptic coma, and especially the coma of puerperal convulsion, may prove fatal. And if there were no danger to life, the repetition of the attack of epilepsy may damage the memory, and, finally, the judgment. Now if all this can be prevented by the operation of tracheotomy, and the insertion and permanent retention of a silver tube in the wind-pipe, surely the remedy is incomparably lighter than the disease, than which, indeed, nothing can be case
deplorable. each epileptic attack leaves, after the first effect of exhausted excitability is over, augmented disposition to renewed attack, the effect probably of congested medulla oblongata. more
Besides,
It will be obvious that the trachea may be readily fixed by the tenaculum. The canula being then made to revolve by the thumb and finger, it descends with this revolving motion along the screw, and removes a cylindrical portion of the trachea. In every case, the first thing to be done is to make an incision of appropriate length through the integuments merely. All the other tissues down to the trachea are to be pushed aside without further incision, which may be done without the slightest haemorrhage.
To obviate such havoc in the cerebrum and medulla—to obviate the repetition of the paroxysm, and the injury to intellect, I venture to propose to the profession the adoption of tracheotomy and the tracheal air-tube.
4.-On Paralytic Laryngismus. The late Dr. Hugh Ley mistook the laryngismus which is so frequently observed in infants, for a paralytic affection, and argued for the error in the most ingenious and elaborate manner. This affection is spasmodic. But there is apa2-alytic laryngismus, and it greatly resembles ,
369 painful I congestion
that condition produced by division of the pneumogastric nerves to which Dr. Hugh Ley adverted. Every case of stertor is in fact, I believe, of this kind,-an important generalization, if correct. This stertor is usually associated with coma. It occurs after the severe epileptic, and the puerperal convulsion, in apoplexy, It induces slow asphyxia. as an effect of narcotic poisons. Now so far as this stertor and its attendant asphyxia are the source of danger, this danger may be averted by tracheotomy. This, therefore, is the final application of this important procedure which I have to propose. In such a case,—acase of deep intoxication,-it Mas employed by Mr. Sampson, as I have mentioned in my work on the " Diseases and Derangements of the Nervous System," page 280, and the patient’s life was saved by it-a trophy of modern surgery. 5.-On the Subsequent Treatment. I havelittle to say on this subject. But I may observe that every means should be adopted to render the silver tube and the inhaled air as little irritating as possible. With these objects, the form and bulk of the tube should be well considered, and the room of the patient should be kept at an agreeable and moderate temperature, and its air should be well supplied with moisture. These precautions are more essential immediately after the operation than more remotely. In time the parts involved become accustomed to the new stimulus, which thenceforth ceases to be a source of irritation. It is quite possible for the operation to prove fatal, either from the mental shock or agitation, or from the presence and irritation of the tracheal tube. I have witnessed such an in-
menstruation in all the cases I have since had of and ulceration of the neck of the uterus, and in those where the uterine passages were most concerned, this. symptom was prominent. Such being the case, might not many of the most obstinate cases of dysmenorrhoaa that we meet with be thus accounted for ? and thus relief obtained for that, ’the frequent return of which,’ as Dr. Mason Good says, ’ embitters the life of the patient.’ Certain it is, the case I
of
just spoke of I at first treated as a case of dysmenorrhcea, thus mistaking a symptom for the disease. In this fifth case at thedispensary, I should assuredly have done so too, had not my attention been previously aroused. These observations seem to confirm the views of the late Dr. Macintosh and Professor Simpson, relative to the cause of some cases of dysmenorrhœa - viz.,anaturally contracted uterine passage; the same effects are thus seen to arise from the passage contracted by disease.* The cause I then considered arose alone from mere congestion of the uterine neck, as a consequence of external ulceration ; but several cases I have since treated provo that
when healed, sometimes produces a permanently contracted or strictured condition of the uterine passage, which is capable of giving rise to painful menstruation. With an exception of one case, I have clearly been able to . trace this contracted state of the passage to inflammation* and ulceration having previously existed, the painful menstruation not making its appearance until after the symptoms of the uterine mischief had existed for some time. To Dr. Macintosh we are indebted for first pointing out the fact of dysmenorrhoea being frequently produced by mechanical. obstruction; but no author seems since to have met with either the like cause or like success from the treatment by stance. Every device, therefore, for rendering tracheotomy (if ever they have fairly tried it,) most considering will received and doubtless be with more easy " safe, avidity by bougies, if a cause at all," a rare one. it, the profession. From much observation with the sneculum. I am convinced Manchester-square, March, 184g. that this cause of the disease is not the rare one Capuron. and others would seem to think; and if careful inquiries be made of our patients, we shall, I think, in the great number PRACTICAL REMARKS ON of cases, without the speculum, meet prior to, or simultaneous DYSMENORRHŒA, AND ITS TREATMENT BY with, the coming on of the disease, all those symptoms which CAUSTIC TO, AND DILATATION OF, THE recent or long-continued ulceration of the " os" or " cervix uteri" do not fail to produce-e. g., pain or weakness in the UTERINE NECK. lumbar region, a sense of burning or heat over the pubis, BY SAMUEL EDWARDS, M.D., leucorrhoea, more or less profuse, sometimes streaked with FORMERLY HOUSE-SURGEON TO THE EDINBURGH LYING-IN HOSPITAL, AND blood, a bearing-down, loss of appetite, with various dyspeptic LATE PHYSICIAN TO THE EASTERN DISPENSARY OF BATH, AND BATH symptoms; languor on exertion, together with sometimes more EAR AND EYE INFIRMARY. or less of spinal irritation, when the affection has continued. AT the annual meeting of the Bath and Bristol branch of the any length of time. Dr. Ashwell, in treating of the causes of dvsmenorrhoea, . Provincial Medical and Surgical Association, held at Bristol, " The history usually brings to light some symptoms July 22nd, 1847, I had the honour of reading a paper upon the remarks: irritation more or less acute." In this stage of the subject ofUlceration of the Cervix and Os Uteri, and its of uterine Occasional Cause of Dysmenorrhoea." Since that period I disease leucorrhcea. becomes profuse, if it has not habitually have had many opportunies, both in private and dispensary existed." He also remarlis: ‘’ During the intervals of congespractice, of testing the truths of the observations therein con- tivedysmcnorrhcea, where false membranes are constantly tained relative to the not infrequent result of this latter dis- expelled, there is generally abundant leucorrhceal discharge, Such a ease, consequent upon a contraction of the uterine passage, the health becomes increasingly disordered," &c. from previous or existing ulceration. Cases having thus been case I have detailed below, where there was no ulceration on uteri, brought before me, I am desirous of recording them, and of the cervix, but a narrow, congested ring around the osmucous. seen, however, the inducing attention to a disease-namely dysmenorrhoea, often- on everting the lips of which were and the slightest touch of.. times alike difficult of relief, as it is painful and distressing to membrane, rough and granulated, the patient. At the period of writing the paper above the probe instantly occasioning bleeding; and on carrying it-, referred to, my attention had only practically been drawn to forward beyond five-eighths of an inch a difficulty was found. this connexion a few months previously, and few opportunities with even this, a very fine silver probe." The recital will had occurred of investigating the circumstance to any extent; show that the introduction of increasing-sized bougies, together with the free use of the nitrate of silver, put an end to however, I find the following remarks made :-" I have related the disease, and its distressing symptom, dysmenorrhnea. The it (the previous case) to show peculiarly a connexion between ulceration of the neck and dysmennorrheea. I have for some cases 1, 2, and 3, show a condition of parts, the effect of premonths noticed this connexion in several cases which have vious or existing ulceration, where the " os" and cervix uteri. fallen under my observation, but especially so in the case be- have become indurated, and the passage extremely contracted, fore me, and also in one other, which I regret to say I kept by deposits in the tissue of the organs. My experience has no notes of. It was in a lady of twenty-seven years of age, led me to believe, that the majority of cases of painful menwho had suffered from dysmenorrhosa, in an extreme degree, struation arise from a preternaturally contracted condition of for six years. Many and various had been the remedies ad- the uterine passage, either from original formation, a permavised by almost as many medical men, when I proposed the nent stricture, from prior inflammation and ulceration, or inflammatory congestion, with or without uleeration employment of the means recommended by the late Dr. Macintosh,—of dilating the os uteri by the aid of bougies,- of the uterus and its neck, this latter taking on that peculiar which I had long desired to put in practice. An examination, form of action, at the periodical mstrum, which, in some cases,however, with the fingers, discovered to me an irregularity andI believe in the majority of this character, produce that and tenderness about the os uteri, the whole cervix appearing effusion of organized lymph which has caused some authors swollen. The symptoms, which she certainly had, of ulcera- to divide dysmenorrhœa merely intoFirst. Dysmenorrhoea, with membranous formation. tion, were all saddled by me upon dysmenorrhoea. This being the case, I had a small speculum made, and on introducing it Second. Dysmenorrhoea, without membrane. found the margin and neighbourhood of the os superficially I have now made several careful examinations of individuals ’ ulcerated. I applied lunar caustic, and had the satisfaction of from the disease under consideration, with mem; in her about of three cured her dysmenorrhaea seeing entirely notice to the *Vide Provincial Medical and Surgical Journal, Sept. 8, 1847, No. 18. I led months. was thus particularly symptom
ulceration,
..
existing
B suffering
The sore upon the labium spreads rapidly, and presents the character which we have described as existing at the time of her admission into the hospital. With a constitution worn out by the vicissitudes of her peculiar life, and with a constant drain upon a system unsupplied with nutritious food; exhausted by fatigue, and want of rest; anxious, from the aspect of her desperate circumstances, she presented a subject in which the malignity of her malady might run its course with out a check, and where the hope of recovery was too faint to be fostered, and her condition too debilitated for a cure to be realized. The prominent character of her disease was a rapidly-destructive action, without power,—without power, because of the incapacity of the system to resist the progress of the ulceration, and destructive, from its tendency to disorganize the parts in its immediate vicinity. The indications of treatment, then, were clearly developed, and were steadily kept in view during her life. It was necessary that the system should be supported, the irritative symptoms conciliated, and the diseased surface destroyed. Now it was evident, from the girl’sprevious mode of life, that the constitution was habituated to the influence of the most powerful stimuli; consequently, ammonia, opium, &c., were strikingly indicated, and the destruction of the diseased part was judiciously attempted by the application of strong nitric acid. After the application of this acid to the sloughing surface, free and frequently-renewed poultices, with a dressing of treacle, wormwood, and cummin seeds, were employed. The sloughs separated kindly, the margins of the sore sank, the surface became covered with healthy-looking granulations, and there was a discharge of well-formed pus. At this time there were some hopes of a favourable termination, but so great was the destruction of parts, that the portion of thigh below the diseased surface seemed to be cut off from connexion with the source of its vitality. Hectic symptoms supervening, indicated the extremity of the case, and the patient gradually sank, till death released her from her sufferings.
breadth. Remarks.-In the case just detailed, we have a striking illustration of the fact, that a disease comparatively mild and i curable in the majority of cases, may, under circumstances ON THE OPERATION AND APPLICATION OF
TRACHEOTOMY. tending to its aggravation, assume a severe and fatal character. I A woman, in the vigour of youth, and, until lately, stout and BY MARSHALL HALL. M.D., F.R.S. robust, after having passed a few months in unusual excess, is THERE are three classes of cases in which the operation of thrown into prison. She there receives some treatment for the disease under which she is labouring; but the mental de- tracheotomy may be required. The,first of these is that of any disease of the larynx itself, pression attending the seclusion of a gaol, the coarseness of her food, the regularity of habit enjoined in contrast with her or the immediately adjacent structures, by which its orifice previously loose mode of life, and, above all, the sudden change or course may be obstructed physically or mechanically. The second is that of reflex action, or spasmodic closure of from an existence in excitement and intemperance to the opposite condition, quickly produce a state of constitution the glottis, induced through the irritation of the superior favourable to the spread of diseased action. Indeed, perhaps laryngeal, or some remoter incident nerve, and the recurrent, there is nothing more important to be remembered, than that or of the medulla oblongata—spasmodic laryngismus. the sudden alteration of a habit of body or mind, even should The third is catalysis of the pneumogastric nerve, or, it may such habit be of a pernicious nature, will modify the efforts of be, of the medulla oblongata-a condition attended by colthe system to repel the progress of a disease which has been lapse, and partial closure of the glottis or larynx—paralytic or contracted, and while the constitution was under the influence catalytic laryngismus. of such habit. Thus we find persons who reside in the Of the first of these cases we have an example in laryngitis; vicinity of a constant noise-near a forge, for instance-when of the second, in the irritation of the rima glottidis by the such noise ceases, are unable to rest; and the case of a suf- accidental contact of a drop of water, or a particle of bread; fering miller is recorded by Dr. Pereira, who, when the mill of the third, in the experiment of dividing the pneumogastric was stopped, became restless and sleepless, and continued so nerve, and in the cases attended by stertor in general. In all these cases, when danger is imminent, it may be until the mill was put in motion again. The effects of the sudden disuse of an accustomed stimulus also are familiar to averted by the operation of tracheotomy. This enlarged view of the application of this remedy may excite a little surprise. us in many of the diseases which we meet with among the inhabitants of large towns. Such manifest themselves, for I trust it will be justified by the observations which I am the most part, in the nervous system, (as in the form of about to lay before the profession. In this case, it will become delirium tremens, or some allied disease,) and more commonly of the most essential importance to render the operation itself as easy and as safe as possible. To this point I have occur during the collapse succeeding a debauch than during the debauch itself. We find many local diseases either therefore devoted much attention. arising from or having their character much modified by the 1. On the Mode of Operation. same cause. And others, again, we find, which, although not It would be presumptuous in me to obtrude any observations called into action by any peculiaritv of habit, require, nevertheless, their treatment to be based upon a knowledge of the on the best mode of performing any operation. This is not patient’s previous mode of life. Thus, we often observe pneu- therefore my intention. But I have been witness to great monia and others of the phlegmasiæ, when occurring to per- apparent difficulty in the performance of tracheotomy-I have even seen one little patient expire on the operation: sons whose constitutions have suffered in the way we are alluding to, not only forbidding the employment of antiphlo- table. It may, therefore, be quite permissible for me to suggistic treatment, but offering no prospect of being benefited, gest any simplification of the mode of operating which may except by supporting means, and perhaps by the exhibition of have occurred to me, for the sake of those practitioners whose the accustomed stimulus also. position does not lead them to perform the greater operations In the case before us, the patient, after having passed some frequently. My object is to make the operation of tradays in prison, and leaving it with the disease still upon her, cheotomy at once safe and easy in inexperienced hands, beat once plunges into a state of life more unfortunate. House- lieving, as I do, that it may have a much more extensive apless, cold, and famished, she passes three or four days in the plication in practice than at present. In the operation of tracheotomy, tavo modes and instruopen streets, during which time she tastes little else than gin.
368 For this purpose either an eye-probe may be used, or the double-acting forceps closed. Either of these being introduced, and gently moved in different directions, the trachea is at length laid bare, and this part is kept exposed by applying expanding the forceps.
ments may be adopted: the first is double-acting forceps; the second, a tenaculum within a canula, with a cutting edge. The double-acting forceps is represented. in the subjoined wood-cut :-
and moment, trachea, by
either an incision may be made into the of a minute scalpel, such as is used in operations on the eye, and this incision may be kept open, by means of the double-acting forceps, whilst a silver tube is introduced ; or the tenaculum eanula may be applied, and a portion of the trachea removed, and the tube may be inserted, or not, according to the views of the operator. In one case, in which the operation was performed by Mr.. Hilton, and the subsequent treatment was conducted by Mr Stevens, of Great Percy-street, Lloyd-square, such a tube has been worn for nineteen months, without inconvenience. The patient is a female of five-and-twenty, and probably labours under contraction of the rima glottidis, from the healing of a syphilitic ulcer. In another case, that of a man aged sixty, suffering under chronic laryngitis, on whom Mr. Fergusson performed. the operation of tracheotomy, a tube has been so worn for half a year. In no part of all this operation, after the division of the integuments, will a drop of blood escape: there will be neither haemorrhage externally, nor blood drawn by the acts of inspiration into the trachea. This operation becomes almost as easy, almost as safe, as phlebotomy. At this
means
2. On
Physical Lesion of the Larynx. It is unnecessary for me, in this place, to do more than advert to those cases of physical lesion of the larynx, in which tracheotomy is the remedy. My object is rather to adduce other examples, and examples of a different nature, of ita. utility. It will be obvious from this sketch, that this forceps may 3. On Spasmodic Laryngismus. be opened or closed by pressing on the little projections a and The next case to be mentioned here, as requiring the opeb, or c and d. ration of tracheotomy, is that of spasmodic closure of the The tenaculum canula is represented in this second sketchglottis or larynx-or spasmodic Laryngismus. An eminent medical professor sent for me, in haste, on account of a feeling of imminent suffocation, the effect of having inhaled, during an experiment, chlorine gas. Every one remembers the public interest attached to the* ’.
of Mr. Brunel. No one would hesitate, in such cases, to perform the operation of tracheotomy. In some cases of choking, too, the same necessity for this operation may exist. The specific effect of strychnine is spasmodic laryngismus.. The case therefore requires tracheotomy, if time be given. Tracheotomy has also appeared a justifiable measure in certain cases of tetanus, and in hydrophobia. But besides these cases there are several others, in which tracheotomy would appear to be an appropriate measure. The violence of the general convulsion in epilepsy, and in’ puerperal convulsion, seems to be essentially linked with closure of the larynx. Without such closure no such violent and general convulsion could take place; and without such convulsion the cerebrum could not become the seat of violent congestion; and as a further consequence, no danger to-life or intellect could exist. But the epileptic coma, and especially the coma of puerperal convulsion, may prove fatal. And if there were no danger to life, the repetition of the attack of epilepsy may damage the memory, and, finally, the judgment. Now if all this can be prevented by the operation of tracheotomy, and the insertion and permanent retention of a silver tube in the wind-pipe, surely the remedy is incomparably lighter than the disease, than which, indeed, nothing can be case
deplorable. each epileptic attack leaves, after the first effect of exhausted excitability is over, augmented disposition to renewed attack, the effect probably of congested medulla oblongata. more
Besides,
It will be obvious that the trachea may be readily fixed by the tenaculum. The canula being then made to revolve by the thumb and finger, it descends with this revolving motion along the screw, and removes a cylindrical portion of the trachea. In every case, the first thing to be done is to make an incision of appropriate length through the integuments merely. All the other tissues down to the trachea are to be pushed aside without further incision, which may be done without the slightest haemorrhage.
To obviate such havoc in the cerebrum and medulla—to obviate the repetition of the paroxysm, and the injury to intellect, I venture to propose to the profession the adoption of tracheotomy and the tracheal air-tube.
4.-On Paralytic Laryngismus. The late Dr. Hugh Ley mistook the laryngismus which is so frequently observed in infants, for a paralytic affection, and argued for the error in the most ingenious and elaborate manner. This affection is spasmodic. But there is apa2-alytic laryngismus, and it greatly resembles ,
369 painful I congestion
that condition produced by division of the pneumogastric nerves to which Dr. Hugh Ley adverted. Every case of stertor is in fact, I believe, of this kind,-an important generalization, if correct. This stertor is usually associated with coma. It occurs after the severe epileptic, and the puerperal convulsion, in apoplexy, It induces slow asphyxia. as an effect of narcotic poisons. Now so far as this stertor and its attendant asphyxia are the source of danger, this danger may be averted by tracheotomy. This, therefore, is the final application of this important procedure which I have to propose. In such a case,—acase of deep intoxication,-it Mas employed by Mr. Sampson, as I have mentioned in my work on the " Diseases and Derangements of the Nervous System," page 280, and the patient’s life was saved by it-a trophy of modern surgery. 5.-On the Subsequent Treatment. I havelittle to say on this subject. But I may observe that every means should be adopted to render the silver tube and the inhaled air as little irritating as possible. With these objects, the form and bulk of the tube should be well considered, and the room of the patient should be kept at an agreeable and moderate temperature, and its air should be well supplied with moisture. These precautions are more essential immediately after the operation than more remotely. In time the parts involved become accustomed to the new stimulus, which thenceforth ceases to be a source of irritation. It is quite possible for the operation to prove fatal, either from the mental shock or agitation, or from the presence and irritation of the tracheal tube. I have witnessed such an in-
menstruation in all the cases I have since had of and ulceration of the neck of the uterus, and in those where the uterine passages were most concerned, this. symptom was prominent. Such being the case, might not many of the most obstinate cases of dysmenorrhoaa that we meet with be thus accounted for ? and thus relief obtained for that, ’the frequent return of which,’ as Dr. Mason Good says, ’ embitters the life of the patient.’ Certain it is, the case I
of
just spoke of I at first treated as a case of dysmenorrhcea, thus mistaking a symptom for the disease. In this fifth case at thedispensary, I should assuredly have done so too, had not my attention been previously aroused. These observations seem to confirm the views of the late Dr. Macintosh and Professor Simpson, relative to the cause of some cases of dysmenorrhœa - viz.,anaturally contracted uterine passage; the same effects are thus seen to arise from the passage contracted by disease.* The cause I then considered arose alone from mere congestion of the uterine neck, as a consequence of external ulceration ; but several cases I have since treated provo that
when healed, sometimes produces a permanently contracted or strictured condition of the uterine passage, which is capable of giving rise to painful menstruation. With an exception of one case, I have clearly been able to . trace this contracted state of the passage to inflammation* and ulceration having previously existed, the painful menstruation not making its appearance until after the symptoms of the uterine mischief had existed for some time. To Dr. Macintosh we are indebted for first pointing out the fact of dysmenorrhoea being frequently produced by mechanical. obstruction; but no author seems since to have met with either the like cause or like success from the treatment by stance. Every device, therefore, for rendering tracheotomy (if ever they have fairly tried it,) most considering will received and doubtless be with more easy " safe, avidity by bougies, if a cause at all," a rare one. it, the profession. From much observation with the sneculum. I am convinced Manchester-square, March, 184g. that this cause of the disease is not the rare one Capuron. and others would seem to think; and if careful inquiries be made of our patients, we shall, I think, in the great number PRACTICAL REMARKS ON of cases, without the speculum, meet prior to, or simultaneous DYSMENORRHŒA, AND ITS TREATMENT BY with, the coming on of the disease, all those symptoms which CAUSTIC TO, AND DILATATION OF, THE recent or long-continued ulceration of the " os" or " cervix uteri" do not fail to produce-e. g., pain or weakness in the UTERINE NECK. lumbar region, a sense of burning or heat over the pubis, BY SAMUEL EDWARDS, M.D., leucorrhoea, more or less profuse, sometimes streaked with FORMERLY HOUSE-SURGEON TO THE EDINBURGH LYING-IN HOSPITAL, AND blood, a bearing-down, loss of appetite, with various dyspeptic LATE PHYSICIAN TO THE EASTERN DISPENSARY OF BATH, AND BATH symptoms; languor on exertion, together with sometimes more EAR AND EYE INFIRMARY. or less of spinal irritation, when the affection has continued. AT the annual meeting of the Bath and Bristol branch of the any length of time. Dr. Ashwell, in treating of the causes of dvsmenorrhoea, . Provincial Medical and Surgical Association, held at Bristol, " The history usually brings to light some symptoms July 22nd, 1847, I had the honour of reading a paper upon the remarks: irritation more or less acute." In this stage of the subject ofUlceration of the Cervix and Os Uteri, and its of uterine Occasional Cause of Dysmenorrhoea." Since that period I disease leucorrhcea. becomes profuse, if it has not habitually have had many opportunies, both in private and dispensary existed." He also remarlis: ‘’ During the intervals of congespractice, of testing the truths of the observations therein con- tivedysmcnorrhcea, where false membranes are constantly tained relative to the not infrequent result of this latter dis- expelled, there is generally abundant leucorrhceal discharge, Such a ease, consequent upon a contraction of the uterine passage, the health becomes increasingly disordered," &c. from previous or existing ulceration. Cases having thus been case I have detailed below, where there was no ulceration on uteri, brought before me, I am desirous of recording them, and of the cervix, but a narrow, congested ring around the osmucous. seen, however, the inducing attention to a disease-namely dysmenorrhoea, often- on everting the lips of which were and the slightest touch of.. times alike difficult of relief, as it is painful and distressing to membrane, rough and granulated, the patient. At the period of writing the paper above the probe instantly occasioning bleeding; and on carrying it-, referred to, my attention had only practically been drawn to forward beyond five-eighths of an inch a difficulty was found. this connexion a few months previously, and few opportunities with even this, a very fine silver probe." The recital will had occurred of investigating the circumstance to any extent; show that the introduction of increasing-sized bougies, together with the free use of the nitrate of silver, put an end to however, I find the following remarks made :-" I have related the disease, and its distressing symptom, dysmenorrhnea. The it (the previous case) to show peculiarly a connexion between ulceration of the neck and dysmennorrheea. I have for some cases 1, 2, and 3, show a condition of parts, the effect of premonths noticed this connexion in several cases which have vious or existing ulceration, where the " os" and cervix uteri. fallen under my observation, but especially so in the case be- have become indurated, and the passage extremely contracted, fore me, and also in one other, which I regret to say I kept by deposits in the tissue of the organs. My experience has no notes of. It was in a lady of twenty-seven years of age, led me to believe, that the majority of cases of painful menwho had suffered from dysmenorrhosa, in an extreme degree, struation arise from a preternaturally contracted condition of for six years. Many and various had been the remedies ad- the uterine passage, either from original formation, a permavised by almost as many medical men, when I proposed the nent stricture, from prior inflammation and ulceration, or inflammatory congestion, with or without uleeration employment of the means recommended by the late Dr. Macintosh,—of dilating the os uteri by the aid of bougies,- of the uterus and its neck, this latter taking on that peculiar which I had long desired to put in practice. An examination, form of action, at the periodical mstrum, which, in some cases,however, with the fingers, discovered to me an irregularity andI believe in the majority of this character, produce that and tenderness about the os uteri, the whole cervix appearing effusion of organized lymph which has caused some authors swollen. The symptoms, which she certainly had, of ulcera- to divide dysmenorrhœa merely intoFirst. Dysmenorrhoea, with membranous formation. tion, were all saddled by me upon dysmenorrhoea. This being the case, I had a small speculum made, and on introducing it Second. Dysmenorrhoea, without membrane. found the margin and neighbourhood of the os superficially I have now made several careful examinations of individuals ’ ulcerated. I applied lunar caustic, and had the satisfaction of from the disease under consideration, with mem; in her about of three cured her dysmenorrhaea seeing entirely notice to the *Vide Provincial Medical and Surgical Journal, Sept. 8, 1847, No. 18. I led months. was thus particularly symptom
ulceration,
..
existing
B suffering