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TRACHEOTOMY TUBES
596
potassium acts as a sedative to the vaso-motor system (see for chronic cases, and one which I would gladly see abolished article by Dr. Russell Reynolds, The Practitioner, July, altogether. Finally, I would draw attention to the general outline of the tube for reasons which I have detailed at 1868), hence its action in the class of cases just referred to. I am. Sir. vours- Jf length in my little work on tracheotomy. I think such a W. B. MOIR, M.D. tube should never be used. I am. Sir. vours. &c.. Belford
Hospital,
Fort William,
ROBERT WM. PARKER.
N.B., Sept. 10th, 1885.
To the Editor of THE LANCET. "DIGITAL TENOTOMY IN PIANISTS." would not trouble you with any reply to Dr. SiB,—I To the Editor of THE LANCET. Notley did riot his theory lead to practical conclusions which, SiR,-Your remarks upon this subject seem to me I believe, are erroneous. My paper was intended to be very opportune, for the introduction of the above operaclinical. I pointed out the symptom and the way to cure tion into this country has excited a good deal of it. Compound rhubarb powder and calomel cure gastric interest among pianists, and is likely to lead to innot cure disorder, but do ansemia; hence I attribute the discriminate at its performance. The operaattempts disease to some gastric disturbance, which is often, but not tion is not so simple in all cases as might be thought, the If Dr. is iron always, obviously present. Notley right, the accessory slips should cure these cases; but that has not been my expe- great variety in the arrangement of giving rise sometimes to difficulty in their isolation, rience. I would ask that my method should have a trial. With respect .to its success, I may quote from a letter especially in hands in which none of the tendons are pro- of a medical correspondent-a stranger to me, personally- mment. Certainly, in the case which I recently published, who writes : " The treatment you recommended in THE there was no difficulty whatever, a single accessory slip was LANCET in Mrs. W——’s case was as successful as could be divided at once, and the result has remained perfectly satisdesired. The numbness has already disappeared." He goes factory. But it is not always so easy to single out and divide the slips with the limited subcutaneous cut to which on to say how much better her digestion is-a tribute of it judicious to restrict myself. As to the praise which I would accord to the plan of treatment pur- I have thought whether the operation ought to be performed at sued,-which is as good now as it was when Abernethy questionare in the first instance naturally disinclined to all, we practised it, though abandoned by too many in favour of undertake any operation, however slight, for other than a more fashionable means. surgical purpose; but it is another question whether we I am. Sir. vours faithfullv. ought to withhold our services when a distinct advantage ROBERT SAUNDBY. accrues to the person operated upon, provided of course that no great danger is incurred. The bare possibility of the To the Editor of THE LANCET. wound not healing by first intention should, of course, be SiR,-With reference to Dr. Robert Saundby’s article stated to every "would-be"patient, but the risks of the operation are surely infinitesimal. As to the result involving ’on the above subject, which appeared in THE LANCET loss of power, this is certainly a mistaken idea. The fact is of Sept. 5th, I should like to be allowed to point out quite the reverse: the restriction to free movement causes that a similar, if not identical, form of numbness is men- the finger to be weak; when the latter is freed from this tioned by Dr. Liveing1 as a phenomenon of the paroxysm restriction, it strength. The likelihood of "cicaof megrim. It is even possible that some of the cases trical union ofgains the several ends leading to a distinct mentioned in Dr. Saundby’s article were megrim with crippling of the finger"is negatived by the fact that a some of its phenomena absent or modified ; though, if in similar result has never been known to occur among the their previous history there was no record of chronic and thousands of tenotomies performed in other parts ot the recurring headache, this diagnosis could hardly be sustained. body by skilled operators. Dr. Forbes of Philadelphia has mentioned The symptoms by him, however, especially in operated upon the ring fingers of fourteen persons since the Cases 3 and 5, are by no means unsuggestive of megrim, and year 1857, and he reports that "in not one of them did any even the drugs on the use of which he lays stress-viz., accident follow the operation." He further states that"the rhubarb and calomel-are perhaps of all others the most operation does not lessen in the least the power of the comuseful in the dyspepsia of megrim, as a good many years mon extensor muscle." of experience in my own case have convinced me. It would In conclusion, I would recommend (1) that the operation doubtless be too much to claim that all similar cases of be only performed in cases where the tendon slips can be numbness are megrim or some modification of it, but I defined ; (2) that the patient be first warned that no clearly think that those of your readers who will now look for this wound can be made without some danger; and (3) that no numbness in the light of Dr. Saundby’s article, will do well one should undertake it who is not practically experienced to bear in mind the possibility of megrim. in dividing tendons. I am. Sir. vours truly. I am. Sir, vours faithfullv. NOBLE SMITH, Queen Anne-street, Sept. 21st, 1885. A. HAIG, M.B.
fair
"CHOLERA MALIGNA." To the Editor of THE LANCET.
TRACHEOTOMY TUBES. To the Editor of THE LANCET.
SiR,-Dr. Illingworth has impugned the accuracy of my SiB,—In your last week’s issue is figured an "improved statements, and has quoted a portion of my letter, which he tracheotomy tube" by Messrs. Salt and Sons. As considerable strives to show is inaccurate because incomplete. Dr, importance attaches to the construction of tubes, 1 ven- Illingworth has evidently quite lost sight of the sentence ture to say that I do not consider the present tube is in immediately following the quotation. He will see on
any way "improved" by the proposed alteration. It will ’*be remembered that the shape of the loops in Fig. A was - suggested by Trousseau, and had for their object to prevent inconvenience to respiration from the too close fitting of the muslin cravat which his patients were made to wear in order to protect them from too direct contact with the outer air. They serve also to keep away sponges, or the child’s dress, from the orifice of the tube, and allow free discharge of all secretions. I do not think anything will be gained by the change proposed in Fig. B. As for allowing the finger to close the tube more readily when the patient is speaking, I consider this a doubtful gain; for if a patient has need to wear his tube permanently, there are many contrivances of greater value and more suitable for the purpose. I notice, too, that the outer tube is a bivalve, a most unsuitable form 1 On Megrim, Sick-headache, and Churchill, 1873, pp. 15, 16, 64-85 et seq.
some
Allied Disorders.
J. &
A.
referring to my letter again that I quite admit his claim to treat successfully one and all cases of British cholera, but not necessarily those of the Asiatic disease. Dr. Illingworth asserts that the two diseases differ only in degree. What evidence has he to offer on this point ? Further on he savs that "it is difficult to see how they can be ’quite distinct from each other’ when they have many clinical features in common:" I confess I cannot
see the difficulty. Take for example due to cerebral apoplexy and that due to opium poisoning : these two resemble each other in many of their clinical features, and yet no one would ever maintain that cerebral apoplexy and opium poisoning are one and the same thing, and that they differ only in degree. Again, what has Dr. Illingworth to say to the late ravages of Asiatic cholera in Spain? Can Dr. Illingworth show anything approaching the epidemic nature of this disease in all his wide experience coma
potassium acts as a sedative to the vaso-motor system (see for chronic cases, and one which I would gladly see abolished article by Dr. Russell Reynolds, The Practitioner, July, altogether. Finally, I would draw attention to the general outline of the tube for reasons which I have detailed at 1868), hence its action in the class of cases just referred to. I am. Sir. vours- Jf length in my little work on tracheotomy. I think such a W. B. MOIR, M.D. tube should never be used. I am. Sir. vours. &c.. Belford
Hospital,
Fort William,
ROBERT WM. PARKER.
N.B., Sept. 10th, 1885.
To the Editor of THE LANCET. "DIGITAL TENOTOMY IN PIANISTS." would not trouble you with any reply to Dr. SiB,—I To the Editor of THE LANCET. Notley did riot his theory lead to practical conclusions which, SiR,-Your remarks upon this subject seem to me I believe, are erroneous. My paper was intended to be very opportune, for the introduction of the above operaclinical. I pointed out the symptom and the way to cure tion into this country has excited a good deal of it. Compound rhubarb powder and calomel cure gastric interest among pianists, and is likely to lead to innot cure disorder, but do ansemia; hence I attribute the discriminate at its performance. The operaattempts disease to some gastric disturbance, which is often, but not tion is not so simple in all cases as might be thought, the If Dr. is iron always, obviously present. Notley right, the accessory slips should cure these cases; but that has not been my expe- great variety in the arrangement of giving rise sometimes to difficulty in their isolation, rience. I would ask that my method should have a trial. With respect .to its success, I may quote from a letter especially in hands in which none of the tendons are pro- of a medical correspondent-a stranger to me, personally- mment. Certainly, in the case which I recently published, who writes : " The treatment you recommended in THE there was no difficulty whatever, a single accessory slip was LANCET in Mrs. W——’s case was as successful as could be divided at once, and the result has remained perfectly satisdesired. The numbness has already disappeared." He goes factory. But it is not always so easy to single out and divide the slips with the limited subcutaneous cut to which on to say how much better her digestion is-a tribute of it judicious to restrict myself. As to the praise which I would accord to the plan of treatment pur- I have thought whether the operation ought to be performed at sued,-which is as good now as it was when Abernethy questionare in the first instance naturally disinclined to all, we practised it, though abandoned by too many in favour of undertake any operation, however slight, for other than a more fashionable means. surgical purpose; but it is another question whether we I am. Sir. vours faithfullv. ought to withhold our services when a distinct advantage ROBERT SAUNDBY. accrues to the person operated upon, provided of course that no great danger is incurred. The bare possibility of the To the Editor of THE LANCET. wound not healing by first intention should, of course, be SiR,-With reference to Dr. Robert Saundby’s article stated to every "would-be"patient, but the risks of the operation are surely infinitesimal. As to the result involving ’on the above subject, which appeared in THE LANCET loss of power, this is certainly a mistaken idea. The fact is of Sept. 5th, I should like to be allowed to point out quite the reverse: the restriction to free movement causes that a similar, if not identical, form of numbness is men- the finger to be weak; when the latter is freed from this tioned by Dr. Liveing1 as a phenomenon of the paroxysm restriction, it strength. The likelihood of "cicaof megrim. It is even possible that some of the cases trical union ofgains the several ends leading to a distinct mentioned in Dr. Saundby’s article were megrim with crippling of the finger"is negatived by the fact that a some of its phenomena absent or modified ; though, if in similar result has never been known to occur among the their previous history there was no record of chronic and thousands of tenotomies performed in other parts ot the recurring headache, this diagnosis could hardly be sustained. body by skilled operators. Dr. Forbes of Philadelphia has mentioned The symptoms by him, however, especially in operated upon the ring fingers of fourteen persons since the Cases 3 and 5, are by no means unsuggestive of megrim, and year 1857, and he reports that "in not one of them did any even the drugs on the use of which he lays stress-viz., accident follow the operation." He further states that"the rhubarb and calomel-are perhaps of all others the most operation does not lessen in the least the power of the comuseful in the dyspepsia of megrim, as a good many years mon extensor muscle." of experience in my own case have convinced me. It would In conclusion, I would recommend (1) that the operation doubtless be too much to claim that all similar cases of be only performed in cases where the tendon slips can be numbness are megrim or some modification of it, but I defined ; (2) that the patient be first warned that no clearly think that those of your readers who will now look for this wound can be made without some danger; and (3) that no numbness in the light of Dr. Saundby’s article, will do well one should undertake it who is not practically experienced to bear in mind the possibility of megrim. in dividing tendons. I am. Sir. vours truly. I am. Sir, vours faithfullv. NOBLE SMITH, Queen Anne-street, Sept. 21st, 1885. A. HAIG, M.B.
fair
"CHOLERA MALIGNA." To the Editor of THE LANCET.
TRACHEOTOMY TUBES. To the Editor of THE LANCET.
SiR,-Dr. Illingworth has impugned the accuracy of my SiB,—In your last week’s issue is figured an "improved statements, and has quoted a portion of my letter, which he tracheotomy tube" by Messrs. Salt and Sons. As considerable strives to show is inaccurate because incomplete. Dr, importance attaches to the construction of tubes, 1 ven- Illingworth has evidently quite lost sight of the sentence ture to say that I do not consider the present tube is in immediately following the quotation. He will see on
any way "improved" by the proposed alteration. It will ’*be remembered that the shape of the loops in Fig. A was - suggested by Trousseau, and had for their object to prevent inconvenience to respiration from the too close fitting of the muslin cravat which his patients were made to wear in order to protect them from too direct contact with the outer air. They serve also to keep away sponges, or the child’s dress, from the orifice of the tube, and allow free discharge of all secretions. I do not think anything will be gained by the change proposed in Fig. B. As for allowing the finger to close the tube more readily when the patient is speaking, I consider this a doubtful gain; for if a patient has need to wear his tube permanently, there are many contrivances of greater value and more suitable for the purpose. I notice, too, that the outer tube is a bivalve, a most unsuitable form 1 On Megrim, Sick-headache, and Churchill, 1873, pp. 15, 16, 64-85 et seq.
some
Allied Disorders.
J. &
A.
referring to my letter again that I quite admit his claim to treat successfully one and all cases of British cholera, but not necessarily those of the Asiatic disease. Dr. Illingworth asserts that the two diseases differ only in degree. What evidence has he to offer on this point ? Further on he savs that "it is difficult to see how they can be ’quite distinct from each other’ when they have many clinical features in common:" I confess I cannot
see the difficulty. Take for example due to cerebral apoplexy and that due to opium poisoning : these two resemble each other in many of their clinical features, and yet no one would ever maintain that cerebral apoplexy and opium poisoning are one and the same thing, and that they differ only in degree. Again, what has Dr. Illingworth to say to the late ravages of Asiatic cholera in Spain? Can Dr. Illingworth show anything approaching the epidemic nature of this disease in all his wide experience coma