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SUCCESSFUL CASE OF TRACHEOTOMY IN A CHILD TWO YEARS OLD.
834 insertion of the temporal muscles into the coronoid process was thus brought into view. The process was nipped through with bone forceps, and the muscle lifted up and dissected out. A hard dense structure was found in the centre of the muscle, which was freely removed. Four vessels
required ligature.
Great improvement followed this operation, though I was myself disappointed with the results. The hard mass in
the masseter continued, but the man could eat meat cut was himself satisfied with his condition, and left the house on June 1st. He again presented himself on June 24th with his jaws firmly closed, in the same condition as when he first applied for assistance. The temporal region presented a flattened appearance from the removal of the muscle, but the hard substance was still felt in the belly of the masseter. I determined to remove the masseter, and, if necessary, to disarticulate the bone and remove the whole ascending ramus. On the 26th June, chloroform having been administered, an incision was made from the angle of the jaw to the cicatrix of the old incision over the zygoma, which The flaps having been dissected back, was again laid open. the masseter muscle was dissected away from the bone and removed. The ramus was thus laid bare, but it was found irremovably fixed by numerous strong fibrous connexions with the neighbouring bones. It seemed as if every part of the temporal muscle which had escaped excision had been converted into fibrous or tendinous structure, which held the bone firmly in its place. Under these circumstances I determined to remove the bone, which was done by dividing it from the last molar tooth to the angle by means of saw and bone forceps, then freeing it from its connexions, and disarticulating its head from the glenoid cavity. The wound healed favourably. He could open the mouth well, and left the hospital in a few weeks able to masticate freely on the right side. I saw the man lately, and he continues quite well. Mr. Plaxton, the pathologist to the infirmary, made several microscopic examinations of the tumour and muscular substance, and the following is his report : -‘ The tumour on section showed that it was not distinctly marked off from the healthy muscle, the greater part of masseter and temporal muscles being converted more or less perfectly into a hard creaking mass. The microscopic examination showed that the muscles were in process of conversion into fibrous tissue; isolated muscular fibres were to be seen between thick bundles of wavy fibrous tissue." The muscular substance is not often the seat of disease. Though recurring fibroid is said to be frequently reproduced, it does not often originate in it. Mr. Tatum mentions a case in which he removed two recurring fibroids from the masseter and temporal muscles, but there was no train of symptoms such as I have related ; neither was there anything of a recurring nature in these tumours, there having been no previously existing tumour, as in Mr. Tatum’s case.* I consider, therefore, that this is a specimen of a very rare form of disease, and in the absence of any precedent to guide us as to treatment, I believe that nothing short of the extreme measure finally taken would have afforded relief. The man masticates only with the right side of his mouth, but he can open the jaws perfectly, and is now healthy and in good condition.
small, and
SUCCESSFUL CASE OF TRACHEOTOMY IN A CHILD TWO YEARS OLD. NEW
FORM
OF
BY W. E.
TRACHEOTOMY
TUBE.
PALEY, M.R.C.S., &c.,
HOUSE-SURGEON TO THE EVELINA HOSPITAL FOR SICK CHILDREN.
THE following case seems worthy of record, partly on account of the tender age of the patient (two years), and because a new form of tracheotomy tube was used, which appears likely to be beneficial in many cases. Ada L-- was admitted October 5th, 1875, into the Evelina Hospital, under the care of Dr. F. Taylor. A week *
pp.
For Mr. Tatum’s case,
639, 640.
see
IMmes’s System of Surgery, vol, iii.,
previously she was taken suddenly ill with sore-throat and There had been, however, no difficulty of feverishness. breathing until the day before admission. When admitted there was evidence of considerable laryngeal obstruction. The respiration was noisy, and there was marked laryngeal cough, with sucking-in of the intercostal spaces. Air could be heard entering both lungs fairly well, and the chest was resonant throughout. No diphtheritic membrane could be seen, nor did the urine contain albumen. The patient was at once placed in a steam tent, but towards evening the symptoms became more urgent, and it This I accordingly was decided to perform tracheotomy. did, without chloroform, introducing an ordinary silver tube. Great relief of all symptoms was immediately afforded, nor was there any recurrence of the dyspnoea,. The details of the progress of the case for the few days immediately succeeding the operation present nothing worthy of special note. Subsequently several attempts were made to dispense with the tube, but without success. At the expiration of a fortnight the silver tube was changed for a new kind of tube suggested by Mr. Morrant Baker, the details of which were carried out under my direction by Mr. Millikin, of St. Thomas’s-street. The tube is single, of ordinary tracheotomy shape, and constructed entirely of flexible india-rubber. It could be inserted easily without a pilot, and did not require to be changed As far as could be more than once in every two days. judged from a single case, it was introduced with less pain, was more comfortable to the patient, and caused far less irritation than a metal one; and with some slight modifications now being made it will, probably, prove a useful instrument. I may add that the tube was worn for one month, during ten days of which the child was running about the ward; and we were able to discontinue its use altogether on Nov. 22nd, since which date the patient has left the hospital well. So far the tube is not proposed by Mr. Baker as a substitute for a metal one at the time of operation, but to obviate the many well-known disadvantages the latter has when required to be worn for more than a few days. But it is not unlikely that, in many cases, the elastic tube might be used with advantage throughout, as there would probably be little or no difficulty in its introduction, at the time of operation, with the help of a proper pilot or forceps.
A Mirror OF
HOSPITAL PRACTICE, BRITISH
AND
FOREIGN.
Nnlla autem est alia pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, turn aliorum, turn proprias collectas habere, et inter se comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv. Procemium.
ST. THOMAS’S HOSPITAL. ANEURISMAL VARIX OF LEFT COMMON ILIAC COMPRESSION OF AORTA; GANGRENE OF INTESTINE.
VEIN ;
(Under the care of Mr. SIMON.) THE previous history of the following interesting case, for which we are indebted to Mr. S. Osborn, surgical registrar, was published in THE LANCET of March 6th, 1875. Thomas K, aged thirty-eight, a driver in the Royal Engineers, was admitted into Albert ward on 1’eb. 16tb, suffering from aneurism within the abdomen. On the 3rd of March, after the patient’s bowels had been thoroughly cleared out by castor oil, compression of the abdominal aorta by tourniquet was commenced at 10 A.M., preceded by the subcutaneous injection of half a grain of morphia at 9.30, which was repeated at 10 A.M. Mr. Simon not being satisfied with the instrument, which failed to control completely the pulsation without digital assistance, it was discontinued at 11 A M., but recommenced at 11.30, the same
required ligature.
Great improvement followed this operation, though I was myself disappointed with the results. The hard mass in
the masseter continued, but the man could eat meat cut was himself satisfied with his condition, and left the house on June 1st. He again presented himself on June 24th with his jaws firmly closed, in the same condition as when he first applied for assistance. The temporal region presented a flattened appearance from the removal of the muscle, but the hard substance was still felt in the belly of the masseter. I determined to remove the masseter, and, if necessary, to disarticulate the bone and remove the whole ascending ramus. On the 26th June, chloroform having been administered, an incision was made from the angle of the jaw to the cicatrix of the old incision over the zygoma, which The flaps having been dissected back, was again laid open. the masseter muscle was dissected away from the bone and removed. The ramus was thus laid bare, but it was found irremovably fixed by numerous strong fibrous connexions with the neighbouring bones. It seemed as if every part of the temporal muscle which had escaped excision had been converted into fibrous or tendinous structure, which held the bone firmly in its place. Under these circumstances I determined to remove the bone, which was done by dividing it from the last molar tooth to the angle by means of saw and bone forceps, then freeing it from its connexions, and disarticulating its head from the glenoid cavity. The wound healed favourably. He could open the mouth well, and left the hospital in a few weeks able to masticate freely on the right side. I saw the man lately, and he continues quite well. Mr. Plaxton, the pathologist to the infirmary, made several microscopic examinations of the tumour and muscular substance, and the following is his report : -‘ The tumour on section showed that it was not distinctly marked off from the healthy muscle, the greater part of masseter and temporal muscles being converted more or less perfectly into a hard creaking mass. The microscopic examination showed that the muscles were in process of conversion into fibrous tissue; isolated muscular fibres were to be seen between thick bundles of wavy fibrous tissue." The muscular substance is not often the seat of disease. Though recurring fibroid is said to be frequently reproduced, it does not often originate in it. Mr. Tatum mentions a case in which he removed two recurring fibroids from the masseter and temporal muscles, but there was no train of symptoms such as I have related ; neither was there anything of a recurring nature in these tumours, there having been no previously existing tumour, as in Mr. Tatum’s case.* I consider, therefore, that this is a specimen of a very rare form of disease, and in the absence of any precedent to guide us as to treatment, I believe that nothing short of the extreme measure finally taken would have afforded relief. The man masticates only with the right side of his mouth, but he can open the jaws perfectly, and is now healthy and in good condition.
small, and
SUCCESSFUL CASE OF TRACHEOTOMY IN A CHILD TWO YEARS OLD. NEW
FORM
OF
BY W. E.
TRACHEOTOMY
TUBE.
PALEY, M.R.C.S., &c.,
HOUSE-SURGEON TO THE EVELINA HOSPITAL FOR SICK CHILDREN.
THE following case seems worthy of record, partly on account of the tender age of the patient (two years), and because a new form of tracheotomy tube was used, which appears likely to be beneficial in many cases. Ada L-- was admitted October 5th, 1875, into the Evelina Hospital, under the care of Dr. F. Taylor. A week *
pp.
For Mr. Tatum’s case,
639, 640.
see
IMmes’s System of Surgery, vol, iii.,
previously she was taken suddenly ill with sore-throat and There had been, however, no difficulty of feverishness. breathing until the day before admission. When admitted there was evidence of considerable laryngeal obstruction. The respiration was noisy, and there was marked laryngeal cough, with sucking-in of the intercostal spaces. Air could be heard entering both lungs fairly well, and the chest was resonant throughout. No diphtheritic membrane could be seen, nor did the urine contain albumen. The patient was at once placed in a steam tent, but towards evening the symptoms became more urgent, and it This I accordingly was decided to perform tracheotomy. did, without chloroform, introducing an ordinary silver tube. Great relief of all symptoms was immediately afforded, nor was there any recurrence of the dyspnoea,. The details of the progress of the case for the few days immediately succeeding the operation present nothing worthy of special note. Subsequently several attempts were made to dispense with the tube, but without success. At the expiration of a fortnight the silver tube was changed for a new kind of tube suggested by Mr. Morrant Baker, the details of which were carried out under my direction by Mr. Millikin, of St. Thomas’s-street. The tube is single, of ordinary tracheotomy shape, and constructed entirely of flexible india-rubber. It could be inserted easily without a pilot, and did not require to be changed As far as could be more than once in every two days. judged from a single case, it was introduced with less pain, was more comfortable to the patient, and caused far less irritation than a metal one; and with some slight modifications now being made it will, probably, prove a useful instrument. I may add that the tube was worn for one month, during ten days of which the child was running about the ward; and we were able to discontinue its use altogether on Nov. 22nd, since which date the patient has left the hospital well. So far the tube is not proposed by Mr. Baker as a substitute for a metal one at the time of operation, but to obviate the many well-known disadvantages the latter has when required to be worn for more than a few days. But it is not unlikely that, in many cases, the elastic tube might be used with advantage throughout, as there would probably be little or no difficulty in its introduction, at the time of operation, with the help of a proper pilot or forceps.
A Mirror OF
HOSPITAL PRACTICE, BRITISH
AND
FOREIGN.
Nnlla autem est alia pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, turn aliorum, turn proprias collectas habere, et inter se comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv. Procemium.
ST. THOMAS’S HOSPITAL. ANEURISMAL VARIX OF LEFT COMMON ILIAC COMPRESSION OF AORTA; GANGRENE OF INTESTINE.
VEIN ;
(Under the care of Mr. SIMON.) THE previous history of the following interesting case, for which we are indebted to Mr. S. Osborn, surgical registrar, was published in THE LANCET of March 6th, 1875. Thomas K, aged thirty-eight, a driver in the Royal Engineers, was admitted into Albert ward on 1’eb. 16tb, suffering from aneurism within the abdomen. On the 3rd of March, after the patient’s bowels had been thoroughly cleared out by castor oil, compression of the abdominal aorta by tourniquet was commenced at 10 A.M., preceded by the subcutaneous injection of half a grain of morphia at 9.30, which was repeated at 10 A.M. Mr. Simon not being satisfied with the instrument, which failed to control completely the pulsation without digital assistance, it was discontinued at 11 A M., but recommenced at 11.30, the same