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RUPTURE OF SPLEEN; SPLENECTOMY; RECOVERY.
794
Lucas-Championniere seems to me to have clearly proved that abdominal cavity to examine the spleen. As this organ was prehistoric trephining was undertaken as a remedial measure. felt to be extensively lacerated another incision was made He writes : ’’ Not only do our recent therapeutic views at right angles to the last across the recti muscles in order justify the cranial therapy of the Neolithic savage, but the to bring into view the damaged viscus. This was found to observation of modern savages is well calculated to make us be ruptured into three parts ; a small piece was quite free in interpret in this way the operations of primitive man." the peritoneal cavity, another was held merely by a tag of The operation, he says, is carried out at the present day by the thickened capsule, while the remaining portion-the itinerant operators among the Kabyles of the hinterland of largest of the three-was attached to the pedicle. There Morocco, amongst the Montenegrins, and perhaps other was still some bleeding going on. The pedicle was clamped, peoples, as it was done in the Neolithic age. Thus we know the organ excised, and the stump tied with a silk ligature. that a decompressive craniectomy, which we have only quite There were no adhesions to complicate the operation. After recently learned to do, and the value of which, even now, irrigating the peritoneal cavity with hot salt solution until but few doctors appreciate, was an operation performed as a all trace of blood was removed, the abdominal wound was closed, about two pints of sterile salt solution being left in. therapeutic measure by our most remote ancestors. The spleen (three pieces) weighed 8 oz. ; it was firm, dark, Harley-street, W. and pigmented, indicating chronic malarial infection ; the capsule was thickened. RUPTURE OF SPLEEN; SPLENECTOMY; Immediately after the operation the temperature rose to, and the pulse ran up to 130 per minute. For six 101.2°, RECOVERY. the operation the temperature varied from 99.2° after days BY R. SEHEULT, M.D. EDIN., to 103 - 60, and the pulse from 76 to 136 per minute. On, RESIDENT
SURGEON, COLONIAL HOSPITAL,
PORT OF
SPAIN, TRINIDAD.
THE interest in this case attaches mainly to its history. which I think is instructive and worth recording. The patient, a rather sparely built boy, aged 13, was admitted to the Colonial Hospital, Port of Spain, Trinidad, on Jan. 16th, 1913, with the following history. On the morning of the 15th while climbing a tree he fell from a height of 16 feet ; immediately after the fall he was put into an open boat and taken to the district medical officer, who resides on an island (Cronstadt) about two miles from the fishing village (Teteron) where the accident occurred. The lad was prescribed for and sent back to his home. On the afternoon of the next day at about 4 o’clock, as there was no abatement of the abdominal pain, he was again rowed across to the district medical officer, who ordered him to hospital; this necessitated a further removal by sea-a distance of about 4kmiles. On reaching the landing place (Cocorite) he was transferred into a tramcar and conveyed to the Colonial Hospital, a further distance of some 3 miles, arriving there at 10.10 P.M. On admission the patient complained of slight abdominal pain and of some tenderness on deep pressure over the umbilical region ; the recti muscles were a little rigid, and the abdomen was slightly distended and tympanitic. There was apparently some diminution of the liver dulness; the pulse was 104 per minute and of poor tension ; the temperature was 100’ 6. F. There was no restlessness and there had been no nausea or vomiting. No external marks of injury were detected, and examination of the heart and lungs revealed nothing abnormal. The boy stated that he had passed very little urine since the accident, but his bladder was not distended; some urine was drawn off and found to be clear and free from albumin. As the symptoms did not appear urgent, and the patient complained of feeling tired and sleepy after his journey, it was decided to apply an ice bag to the abdomen and to watch carefully the progress of the case. On the following morning (Jan. 17th) there was apparently no change in his general condition ; the pulse-rate was 108 per minute and the temperature 100.20. In view, however, of the continuance of pain in the abdomen and the presence of dulness on percussion in the flanks-a condition which had not been looked for on the previous evening-I decided to
perform
an
exploratory laparotomy. having been administered
Chloroform
to the patient at 9.15 A.M.-i.e., more than 48 hours after the accident-an incision 2 inches long was made in the middle line between On opening the peritoneal the umbilicus and the pubes. cavity a moderately large amount of dark-coloured blood escaped. The intestines were pulled out and examined, but no evidence of injury was disclosed. As much as possible of the blood was washed out and the intestines were returned. The abdominal wound was closed, and
second opening was made above the umbilicus along the outer border of the right rectus to explore the liver, which was now suspected to be the seat of haemorrhage. as it was observed that blood continued to ooze from that direction after the peritoneal cavity had been flushed out in the first instance. The liver was found to be intact; the wound was extended, and the hand passed across in the
a
Jan. Z3rd the temperature fell to normal and remained so.. On the 21st and the following day the pulse was irregular. On the 26th there were sudden and well-marked variations. in its frequency, ranging from 60 to 92 ; this persisted forthree days. From Jan. 30th to Feb. lst the pulse-rate remained at 62-66 per minute, and from the latter date until the discharge of the patient on March 6th it varied between. 70 and 84 per minute. Apart from some suppuration which was observed in the second abdominal wound on Jan. 22nd and lasted a few days,. the patient made a good and satisfactory recovery. From the 23rd his convalescence was rapid and uninterrupted. On Feb. llth he weighed 83 lb. On Feb. 18th he had gained 1 lb. On Feb. 23rd he showed a further gain of 4lb., and on March 4th-two days before his discharge-he weighed 92 lb. His detention in hospital after three weeks was for purposes of observation. The after-effects of the removal of the spleen were carefully watched, but no special sign or symptom followed, except the condition of the pulse referred to above and the blood changes to be described presently. None of the postoperative symptoms which have sometimes followed splenectomy-viz., rapid emaciation and debility, great thirst, a persistently rapid pulse, intermittent elevation of temperature, great anasmia, drowsiness, peevishness and irritability of temper, griping pain in the abdomen, and enlargement of’ the lymphatic glands-have been observed, so far, in this case. I propose, however, to follow up the further history for some time, and to note any change which may show itself with reference to the enlargement of the lymphatic
glands. Dr. J. R. Dickson, the bacteriologist to the hospital, very. kindly made some blood examinations at various times during the patient’s stay in hospital and on two occasions afterHe reported as follows :-Blood counts:o his discharge. Feb. 1st-Red corpuscles, 3,850,000 ; white corpuscles, 10,000. Feb. 21st-Red corpuscles, 2,739,682 ; white corpuscles, 16,000. March 3rd-Red corpuscles, 2,968,182 ;;. white corpuscles, 20,000. March 26th-Red corpuscles, 4,384,000 ; white corpuscles, 18,000. May 7th-Red, corpuscles, 4,000,000 ; white corpuscles, 11,000. Differential count : May 7th-Polymorphonuclears, 50-8percent. ; small lymphocytes, 13.4per cent. ; large lympho-
cytes, 27-5 per cent. ; mononuclears and transitionals, 3.8 per cent. ; eosinophiles, 4.5 per cent.
Spleen ruptured transversely and longitudinally into pieces, one large and two small. The large portion measures 9 X 7’ 5 X 4. 5 cm., and comprises about one-half of the organ. The small pieces measure 5x5.2x3 cm., and 5.5x4.5x2 em. The smaller piece is very ragged, I
three
is not covered by capsule, and appears to have been torn out of the substance of the organ. On section the capsule was thickened ; the trabeculas were hypertrophied, and throughout the pulp were irregular masses of blackish pigment and a general infiltration of leucocytes ; the pulp was swollen, the Malpighian corpuscles were rather indistinct, and much of the pulp tissue stained badly and appeared to be "
degenerating."
-Remarks.-l. The absence of urgent syinptoms even after the lapse of 48 hours, considering the extent and gravity of the lesion, is worthy of note. 2. It seems remarkable that
795 death did not ensue from hoemorrhage, considering the fact that the patient was removed from place to place over a -considerable distance before his admission to hospital. .3. The condition of the pulse-viz., its irregularity, sudden variations, and slowness at various times - was an interesting feature in this case. 4. The absence of post-operative sequelse reported in other cases is also noteworthy. On looking up the literature at my disposal I find it is stated that removal of the spleen was practised for the first time by Zuccarelli (Saccharelli) in 1554; if so, it would .appear that the operation fell at once into disfavour, for there is no record of its repetition until more than three centuries later, when M. Pean, of Paris, successfullyextirpated a cystic spleen in 1867. Since that time the operation has been performed for various conditions and has become a well-established surgical procedure. Up to a few years ago, however the mortality rate was high ; in 1887 it seemed to have been as high as 73 per cent. ; Cecil in 1894 estimated it at 51-66 per cent. Since that date there have been decided improvements in the results, due largely, I think, to the abandonment of the operation for splenic leukaemia and other unfavourable conditions which proved almost invariably fatal. In 1906 B. B. Davis was able to place the mortality at 18 per cent. As regards the removal of the spleen for rupture Reigner recorded in 1893 the first successful case. In 1902 Berger had collected from the literature 69 cases of this nature, with 29 deaths-a mortality of 42 per cent. In 1906 Horz had obtained the reports of 35 additional cases with a mortality of 29 per cent. Splenectomy consecutive to wounds of the organ has therefore been attended with a fair measure of success ; in any case it is, beyond doubt, the most Tational and hopeful treatment, especially when it is borne in mind that the mortality in the unoperated cases has been computed to be more than twice that of the cases in which splenectomy has been performed. Port of Spain, Trinidad.
Cyanosis
can best be guarded against by giving the gas slowly mixed with air or oxygen, and by correcting it as soon as it begins rather than allowing a deep degree to occur. The position of the patient should be upright or leaning
forward, so that the moment the tooth is drawn or the cut made
be leaned more forward and the pus flow out of the In operating on a fang far back in the upper jaw with a mouth but partially open the dentist will like the head well back, but if he ask for it the anesthetist must strenuously oppose it. With these three precautions gas may be given in the majority of abscesses associated with the teeth. The last one mentioned is, however, different and must be ranked with the pathological conditions next to be mentioned. These include those abscesses which bulge into the respiratory tract behind the mouth or those inflammations of the cellular tissues which are associated with so much swelling of the mucous membrane that there is dyspnoea or some danger of it. In the former the danger lies in the abscess bursting into the respiratory tract ; in the latter in two things-first, that the dyspnoea will become most urgent during the administration of the anesthetic ; and, secondly, that heart failure may supervene. For these reasons in such cases an anesthetic should only be given when absolutely essential. It may be well, however, to epitomise the inflammatory lesions to which I refer : (1) The uncommon abscess of the tongue; (2) the common peritonsillar cellulitis or quinsy;; (3) the retro-pharyngeal abscess bulging forward into the pharynx ; (4) the diffuse cellulitis of the fascial planes of the floor of the mouth and mid-line of the neck; (5) the large deep-seated abscess of the neck in relation with larynx, pharynx, and carotid vessels. These last two I believe most usually to be due to the teeth and to be a further stage of the abscess internal to the jaw which I have mentioned above. Lastly, there is the acute septic inflammation of the pharynx, which sometimes calls for tracheotomy. In all of these conditions an anesthetic is dangerous. A tracheotomy can be done under a local anesthetic; ANÆSTHESIA IN ACUTE INFLAMMATIONS similarly can a deep-seated abscess be opened by the smallincision method or a cellulitis be incised. With regard to OF THE MOUTH AND PHARYNX. the abscesses bulging into the pharynx, a quinsy should never be opened under an anesthetic; it presents no BY T. B. LAYTON, M.S. LOND., F.R.C.S. ENG., difficulties which call for one, and the risk is too great to SURGEON IN CHARGE OF THE THROAT AND EAR DEPARTMENT, GUY’S HOSPITAL; LATE ANÆSTHETIST TO GUY’S HOSPITAL AND TO give one solely for the relief of pain. Nor should a retroGUY’S HOSPITAL DENTAL SCHOOL. pharyngeal abscess need one ; they usually point in such a position that they can be opened through the mouth. I WILL first consider what are the operations likely to be General surgeons have, I believe, recently been opening performed and the conditions under which they must be these through the neck under anesthesia. While I cannot done. The operations are those for the incision of abscesses think this route a good one, they should at least be opened under a local anesthetic. Abscess of the tongue is a rare or other inflammatory conditions, for the removal of teeth, and tracheotomy. The pathological conditions include those condition and my experience is limited to two cases ; in both definitely arising from disease of the teeth and those where an anesthetic was necessary because of the extreme tenderthe infective agent has gained an entrance presumably ness of the organ. When general anesthesia is given the choice of anesthetic through the mucous membrane, though here, also, the teeth is no easy one. Ether stimulates secretion and makes still are possibly the original cause. The inflammations definitely associated with the upper greater the risk of cyanosis, chloroform is more toxic if teeth are abscess and suppuration of the maxillary air sinus. heart failure be imminent. I think that this last is the ’The abscess usually forms to the outer side of the alveolus, lesser of the two evils, if the chloroform be given slowly bulges out the cheek, and causes cedema of the lower eye- and carefully. A preliminary injection of atropine is of lid ; from the lateral incisor and from the palatal fangs of advantage, both by diminishing secretion and by lessening the first pre-molar and of the molar teeth a palatal abscess the danger of chloroform. Since writing the above I have had a case which shows the may arise. From the lower teeth the abscess may form on the outside of the alveolus, where it causes the swollen face value of Killian’s suspension laryngoscope in applying these most often seen ; or more rarely it forms internal to the principles. The patient was a man, aged 50, who complained ramus in the floor of the mouth. In all these conditions that he had had some symptoms of abnormal sensation on ,extraction of the offending tooth is the operation,"’ which swallowing for eight weeks, which had become an actual must first be done, and often the only one necessary. difficulty during the past three weeks. At the back of the If sufficient precautions be taken gas may safely-be given pharynx was a swelling three inches long by one and a half in all these conditions with the exception of the last. The across, smooth, tense, and resistant to the touch. He was precautions to be taken are three : the anaesthesia must be prepared in the usual way by an injection of scopolamine short, cyanosis must be prevented, and the position of the 1/200 gr. and morphine 1/8 two hours previously, and patient carefully chosen. The dentist or surgeon must repeated one hour before the examination, and by painting realise that time is only given for one manipulation-one the base of the tongue and epiglottis with cocaine. He was incision and search with the director for the surgeon, one then suspended, and the ease with which the exact site, tug only at the tooth for the dentist ; the latter will not have appearance, and dimensions of the lump could be determined time to take a second grip of his tooth, nor to remove a was most pleasing. The surface was painted with novocaine, second if the first is the wrong one. Cyanosis must carefully and an exploring syringe being introduced pus was drawn off. be guarded.against, because it is specially likely to occur. The abscess was opened by a small incision and sinus forceps, In addition to the swelling in the mouth the whole mucous and when the pus had mostly escaped he was sat up. All membrane of the respiratory tract is inflamed with an ( of anethesia was eliminated, no vestige of pus attendant swelling and increased exudation of reached the larynx, and the incision was efficiently made he
can
mouth.
danger
mucus.
Lucas-Championniere seems to me to have clearly proved that abdominal cavity to examine the spleen. As this organ was prehistoric trephining was undertaken as a remedial measure. felt to be extensively lacerated another incision was made He writes : ’’ Not only do our recent therapeutic views at right angles to the last across the recti muscles in order justify the cranial therapy of the Neolithic savage, but the to bring into view the damaged viscus. This was found to observation of modern savages is well calculated to make us be ruptured into three parts ; a small piece was quite free in interpret in this way the operations of primitive man." the peritoneal cavity, another was held merely by a tag of The operation, he says, is carried out at the present day by the thickened capsule, while the remaining portion-the itinerant operators among the Kabyles of the hinterland of largest of the three-was attached to the pedicle. There Morocco, amongst the Montenegrins, and perhaps other was still some bleeding going on. The pedicle was clamped, peoples, as it was done in the Neolithic age. Thus we know the organ excised, and the stump tied with a silk ligature. that a decompressive craniectomy, which we have only quite There were no adhesions to complicate the operation. After recently learned to do, and the value of which, even now, irrigating the peritoneal cavity with hot salt solution until but few doctors appreciate, was an operation performed as a all trace of blood was removed, the abdominal wound was closed, about two pints of sterile salt solution being left in. therapeutic measure by our most remote ancestors. The spleen (three pieces) weighed 8 oz. ; it was firm, dark, Harley-street, W. and pigmented, indicating chronic malarial infection ; the capsule was thickened. RUPTURE OF SPLEEN; SPLENECTOMY; Immediately after the operation the temperature rose to, and the pulse ran up to 130 per minute. For six 101.2°, RECOVERY. the operation the temperature varied from 99.2° after days BY R. SEHEULT, M.D. EDIN., to 103 - 60, and the pulse from 76 to 136 per minute. On, RESIDENT
SURGEON, COLONIAL HOSPITAL,
PORT OF
SPAIN, TRINIDAD.
THE interest in this case attaches mainly to its history. which I think is instructive and worth recording. The patient, a rather sparely built boy, aged 13, was admitted to the Colonial Hospital, Port of Spain, Trinidad, on Jan. 16th, 1913, with the following history. On the morning of the 15th while climbing a tree he fell from a height of 16 feet ; immediately after the fall he was put into an open boat and taken to the district medical officer, who resides on an island (Cronstadt) about two miles from the fishing village (Teteron) where the accident occurred. The lad was prescribed for and sent back to his home. On the afternoon of the next day at about 4 o’clock, as there was no abatement of the abdominal pain, he was again rowed across to the district medical officer, who ordered him to hospital; this necessitated a further removal by sea-a distance of about 4kmiles. On reaching the landing place (Cocorite) he was transferred into a tramcar and conveyed to the Colonial Hospital, a further distance of some 3 miles, arriving there at 10.10 P.M. On admission the patient complained of slight abdominal pain and of some tenderness on deep pressure over the umbilical region ; the recti muscles were a little rigid, and the abdomen was slightly distended and tympanitic. There was apparently some diminution of the liver dulness; the pulse was 104 per minute and of poor tension ; the temperature was 100’ 6. F. There was no restlessness and there had been no nausea or vomiting. No external marks of injury were detected, and examination of the heart and lungs revealed nothing abnormal. The boy stated that he had passed very little urine since the accident, but his bladder was not distended; some urine was drawn off and found to be clear and free from albumin. As the symptoms did not appear urgent, and the patient complained of feeling tired and sleepy after his journey, it was decided to apply an ice bag to the abdomen and to watch carefully the progress of the case. On the following morning (Jan. 17th) there was apparently no change in his general condition ; the pulse-rate was 108 per minute and the temperature 100.20. In view, however, of the continuance of pain in the abdomen and the presence of dulness on percussion in the flanks-a condition which had not been looked for on the previous evening-I decided to
perform
an
exploratory laparotomy. having been administered
Chloroform
to the patient at 9.15 A.M.-i.e., more than 48 hours after the accident-an incision 2 inches long was made in the middle line between On opening the peritoneal the umbilicus and the pubes. cavity a moderately large amount of dark-coloured blood escaped. The intestines were pulled out and examined, but no evidence of injury was disclosed. As much as possible of the blood was washed out and the intestines were returned. The abdominal wound was closed, and
second opening was made above the umbilicus along the outer border of the right rectus to explore the liver, which was now suspected to be the seat of haemorrhage. as it was observed that blood continued to ooze from that direction after the peritoneal cavity had been flushed out in the first instance. The liver was found to be intact; the wound was extended, and the hand passed across in the
a
Jan. Z3rd the temperature fell to normal and remained so.. On the 21st and the following day the pulse was irregular. On the 26th there were sudden and well-marked variations. in its frequency, ranging from 60 to 92 ; this persisted forthree days. From Jan. 30th to Feb. lst the pulse-rate remained at 62-66 per minute, and from the latter date until the discharge of the patient on March 6th it varied between. 70 and 84 per minute. Apart from some suppuration which was observed in the second abdominal wound on Jan. 22nd and lasted a few days,. the patient made a good and satisfactory recovery. From the 23rd his convalescence was rapid and uninterrupted. On Feb. llth he weighed 83 lb. On Feb. 18th he had gained 1 lb. On Feb. 23rd he showed a further gain of 4lb., and on March 4th-two days before his discharge-he weighed 92 lb. His detention in hospital after three weeks was for purposes of observation. The after-effects of the removal of the spleen were carefully watched, but no special sign or symptom followed, except the condition of the pulse referred to above and the blood changes to be described presently. None of the postoperative symptoms which have sometimes followed splenectomy-viz., rapid emaciation and debility, great thirst, a persistently rapid pulse, intermittent elevation of temperature, great anasmia, drowsiness, peevishness and irritability of temper, griping pain in the abdomen, and enlargement of’ the lymphatic glands-have been observed, so far, in this case. I propose, however, to follow up the further history for some time, and to note any change which may show itself with reference to the enlargement of the lymphatic
glands. Dr. J. R. Dickson, the bacteriologist to the hospital, very. kindly made some blood examinations at various times during the patient’s stay in hospital and on two occasions afterHe reported as follows :-Blood counts:o his discharge. Feb. 1st-Red corpuscles, 3,850,000 ; white corpuscles, 10,000. Feb. 21st-Red corpuscles, 2,739,682 ; white corpuscles, 16,000. March 3rd-Red corpuscles, 2,968,182 ;;. white corpuscles, 20,000. March 26th-Red corpuscles, 4,384,000 ; white corpuscles, 18,000. May 7th-Red, corpuscles, 4,000,000 ; white corpuscles, 11,000. Differential count : May 7th-Polymorphonuclears, 50-8percent. ; small lymphocytes, 13.4per cent. ; large lympho-
cytes, 27-5 per cent. ; mononuclears and transitionals, 3.8 per cent. ; eosinophiles, 4.5 per cent.
Spleen ruptured transversely and longitudinally into pieces, one large and two small. The large portion measures 9 X 7’ 5 X 4. 5 cm., and comprises about one-half of the organ. The small pieces measure 5x5.2x3 cm., and 5.5x4.5x2 em. The smaller piece is very ragged, I
three
is not covered by capsule, and appears to have been torn out of the substance of the organ. On section the capsule was thickened ; the trabeculas were hypertrophied, and throughout the pulp were irregular masses of blackish pigment and a general infiltration of leucocytes ; the pulp was swollen, the Malpighian corpuscles were rather indistinct, and much of the pulp tissue stained badly and appeared to be "
degenerating."
-Remarks.-l. The absence of urgent syinptoms even after the lapse of 48 hours, considering the extent and gravity of the lesion, is worthy of note. 2. It seems remarkable that
795 death did not ensue from hoemorrhage, considering the fact that the patient was removed from place to place over a -considerable distance before his admission to hospital. .3. The condition of the pulse-viz., its irregularity, sudden variations, and slowness at various times - was an interesting feature in this case. 4. The absence of post-operative sequelse reported in other cases is also noteworthy. On looking up the literature at my disposal I find it is stated that removal of the spleen was practised for the first time by Zuccarelli (Saccharelli) in 1554; if so, it would .appear that the operation fell at once into disfavour, for there is no record of its repetition until more than three centuries later, when M. Pean, of Paris, successfullyextirpated a cystic spleen in 1867. Since that time the operation has been performed for various conditions and has become a well-established surgical procedure. Up to a few years ago, however the mortality rate was high ; in 1887 it seemed to have been as high as 73 per cent. ; Cecil in 1894 estimated it at 51-66 per cent. Since that date there have been decided improvements in the results, due largely, I think, to the abandonment of the operation for splenic leukaemia and other unfavourable conditions which proved almost invariably fatal. In 1906 B. B. Davis was able to place the mortality at 18 per cent. As regards the removal of the spleen for rupture Reigner recorded in 1893 the first successful case. In 1902 Berger had collected from the literature 69 cases of this nature, with 29 deaths-a mortality of 42 per cent. In 1906 Horz had obtained the reports of 35 additional cases with a mortality of 29 per cent. Splenectomy consecutive to wounds of the organ has therefore been attended with a fair measure of success ; in any case it is, beyond doubt, the most Tational and hopeful treatment, especially when it is borne in mind that the mortality in the unoperated cases has been computed to be more than twice that of the cases in which splenectomy has been performed. Port of Spain, Trinidad.
Cyanosis
can best be guarded against by giving the gas slowly mixed with air or oxygen, and by correcting it as soon as it begins rather than allowing a deep degree to occur. The position of the patient should be upright or leaning
forward, so that the moment the tooth is drawn or the cut made
be leaned more forward and the pus flow out of the In operating on a fang far back in the upper jaw with a mouth but partially open the dentist will like the head well back, but if he ask for it the anesthetist must strenuously oppose it. With these three precautions gas may be given in the majority of abscesses associated with the teeth. The last one mentioned is, however, different and must be ranked with the pathological conditions next to be mentioned. These include those abscesses which bulge into the respiratory tract behind the mouth or those inflammations of the cellular tissues which are associated with so much swelling of the mucous membrane that there is dyspnoea or some danger of it. In the former the danger lies in the abscess bursting into the respiratory tract ; in the latter in two things-first, that the dyspnoea will become most urgent during the administration of the anesthetic ; and, secondly, that heart failure may supervene. For these reasons in such cases an anesthetic should only be given when absolutely essential. It may be well, however, to epitomise the inflammatory lesions to which I refer : (1) The uncommon abscess of the tongue; (2) the common peritonsillar cellulitis or quinsy;; (3) the retro-pharyngeal abscess bulging forward into the pharynx ; (4) the diffuse cellulitis of the fascial planes of the floor of the mouth and mid-line of the neck; (5) the large deep-seated abscess of the neck in relation with larynx, pharynx, and carotid vessels. These last two I believe most usually to be due to the teeth and to be a further stage of the abscess internal to the jaw which I have mentioned above. Lastly, there is the acute septic inflammation of the pharynx, which sometimes calls for tracheotomy. In all of these conditions an anesthetic is dangerous. A tracheotomy can be done under a local anesthetic; ANÆSTHESIA IN ACUTE INFLAMMATIONS similarly can a deep-seated abscess be opened by the smallincision method or a cellulitis be incised. With regard to OF THE MOUTH AND PHARYNX. the abscesses bulging into the pharynx, a quinsy should never be opened under an anesthetic; it presents no BY T. B. LAYTON, M.S. LOND., F.R.C.S. ENG., difficulties which call for one, and the risk is too great to SURGEON IN CHARGE OF THE THROAT AND EAR DEPARTMENT, GUY’S HOSPITAL; LATE ANÆSTHETIST TO GUY’S HOSPITAL AND TO give one solely for the relief of pain. Nor should a retroGUY’S HOSPITAL DENTAL SCHOOL. pharyngeal abscess need one ; they usually point in such a position that they can be opened through the mouth. I WILL first consider what are the operations likely to be General surgeons have, I believe, recently been opening performed and the conditions under which they must be these through the neck under anesthesia. While I cannot done. The operations are those for the incision of abscesses think this route a good one, they should at least be opened under a local anesthetic. Abscess of the tongue is a rare or other inflammatory conditions, for the removal of teeth, and tracheotomy. The pathological conditions include those condition and my experience is limited to two cases ; in both definitely arising from disease of the teeth and those where an anesthetic was necessary because of the extreme tenderthe infective agent has gained an entrance presumably ness of the organ. When general anesthesia is given the choice of anesthetic through the mucous membrane, though here, also, the teeth is no easy one. Ether stimulates secretion and makes still are possibly the original cause. The inflammations definitely associated with the upper greater the risk of cyanosis, chloroform is more toxic if teeth are abscess and suppuration of the maxillary air sinus. heart failure be imminent. I think that this last is the ’The abscess usually forms to the outer side of the alveolus, lesser of the two evils, if the chloroform be given slowly bulges out the cheek, and causes cedema of the lower eye- and carefully. A preliminary injection of atropine is of lid ; from the lateral incisor and from the palatal fangs of advantage, both by diminishing secretion and by lessening the first pre-molar and of the molar teeth a palatal abscess the danger of chloroform. Since writing the above I have had a case which shows the may arise. From the lower teeth the abscess may form on the outside of the alveolus, where it causes the swollen face value of Killian’s suspension laryngoscope in applying these most often seen ; or more rarely it forms internal to the principles. The patient was a man, aged 50, who complained ramus in the floor of the mouth. In all these conditions that he had had some symptoms of abnormal sensation on ,extraction of the offending tooth is the operation,"’ which swallowing for eight weeks, which had become an actual must first be done, and often the only one necessary. difficulty during the past three weeks. At the back of the If sufficient precautions be taken gas may safely-be given pharynx was a swelling three inches long by one and a half in all these conditions with the exception of the last. The across, smooth, tense, and resistant to the touch. He was precautions to be taken are three : the anaesthesia must be prepared in the usual way by an injection of scopolamine short, cyanosis must be prevented, and the position of the 1/200 gr. and morphine 1/8 two hours previously, and patient carefully chosen. The dentist or surgeon must repeated one hour before the examination, and by painting realise that time is only given for one manipulation-one the base of the tongue and epiglottis with cocaine. He was incision and search with the director for the surgeon, one then suspended, and the ease with which the exact site, tug only at the tooth for the dentist ; the latter will not have appearance, and dimensions of the lump could be determined time to take a second grip of his tooth, nor to remove a was most pleasing. The surface was painted with novocaine, second if the first is the wrong one. Cyanosis must carefully and an exploring syringe being introduced pus was drawn off. be guarded.against, because it is specially likely to occur. The abscess was opened by a small incision and sinus forceps, In addition to the swelling in the mouth the whole mucous and when the pus had mostly escaped he was sat up. All membrane of the respiratory tract is inflamed with an ( of anethesia was eliminated, no vestige of pus attendant swelling and increased exudation of reached the larynx, and the incision was efficiently made he
can
mouth.
danger
mucus.