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tissue. Free bleeding occurred, so that, owing to this circum-- ..’stance and to the extreme depth of the trachea, the knife was’ Very sparingly used in the latter part of the operation. ’When’the windpipe was reached and opened, a long bivalve tube wasintroduced; the relief to his distress was very manifest, and
’the bleeding was speedily controlled without the use of liga-tures. Considerable emphysema occurred in the surroundingtissues, and it became evident that a longer tube would be re--quired. The longest that could be procured was then insertedwithout much difficulty; but it still became necessary to fit a- second tube into the upper aperture of the inner tube, so as’to increase its length and permit it to be secured in the wound.
Wrapped in blankets, and breathing steam, the patient hada comfortable night, and in the morning could swallow without:much trouble beyond occasional cough. His progress for sometime was satisfactory, the erysipelas’steadily subsiding. Forthe next forty-eight hours he was sensible, could take’abun-dance of fluid nourishment, and slept-fairly with the assistance
- of morphia injected beneath the skin.On the morning of the 24th, a densely foggy one, he flagged;
had much cough, with a considerable increase of thick mucusdischarged’ through the tube. During a fit of coughing, somebleeding.occurred from the wound ; its source was not evident,and, as he was breathing to some extent -through the larynx,the tubes were removed. For a time he rallied and improved,but again failed, and in spite of nourishment; which he tookseagerly and without difficulty, he slowly sank, dying appa-rently from mere exhaustion, just one hundred hours-after theoperation.
Having lost his left arm five years’since by a machineryaccident, throughout his illness he invariably lay on his rightside; but up to the last, as far as could be ascertained, hislungs remained sound.Autopsy twenty six hours after death.-The wound looked
sloughy and discoloured. The surrounding parts were infil-trated with a dirty, puriform fluid, which had completelyencircled the trachea, separating it from the eesophagus, andhad then made its way down .into the posterior mediastinum,almost to the roots of the lnngs. The upper lobe of the rightlung was tightly bound down by old adhesions; the posteriorportion of this lobe was congested, but, with this exception,the lungs were throughout sound. There was no distinct evi-dence of the recent congestion about the fauces or larynx. Theknife had divided the fourth; fifth, and sixth tracheal cartilages.The edges of the aperture were irregular and ulcerated. Theentire length of the trachea was of a vivid red colour, from in-tense inflammation. Immediately below the incision were somesmall patches of inflammation, clearly due to the pressure of.the end of the tube.
ABSCESS OF THYROID GLAND, WITH ŒDEMA OF ONE SIDEOF THE GLOTTIS, IN A CASE OF BRIGHT’S DISEASE OFTHE KIDNEYS; TRACHEOTOMY; FATAL RESULT.
(Under the care of Dr. REES.)
JOHN B-, aged twenty-one, was admitted into Job wardon the 30th May, 1862, for albuminuria &c. On the morningof the 15th June he was taken with difficulty of breathing,accompanied by a stridulous noise. This increased until the
evening, when the noise made on inspiration was much greater,and the voice nearly gone. At the same time he was some-what drowsy, as if under the influence of uraemia. Althoughthe breathing was quick, the air appeared to enter the lungsfreely. It might thus have been a question as to the proprietyof tracheotomy; but as the man was sinking fast, and it ap-peared to hold out a faint chance, it was performed about teno’clock P.M. It was thought that he rallied somewhat, but heafterwards sank into a lethargic condition, and died at half-past three r.M. on the 16th.
A utopsy, twenty -four hours after deat7t.-The body wasslightly œdematous at the lower part. On examining the
larynx, the first thing noticeable was suppuration of the thy-roid body and neighbouring glands. The left lobe was full ofsmall abscesses, so that, when cut through, fluid purulentmatter flowed out. In the right lobe there were scatteredyellow deposits of lymph, in the midst of which was purulentmatter. These deposit? appeared somewhat like tubercle, buton close examination showed merely lymph and pus. Some
lymphatic glands near also contained lymph, and in one or twothis was softening. The pharynx was healthy, also the tonsilsand epiglottis. The glottis on the left side was cedematous,but not sufficiently so, as then seen, to cause much impedimentto respiration. The opening made at the operation was in theusual position. Both above and below it the membrane wasacutely inflamed, the surface having mucus upon it and alsoflakes of lymph. (It was a question whether or not all thishad arisen since and in consequence of the operation.) Theinflammation extended down the bronchial tubes; these.beingfull of dirty purulent mucus. The lungs were full of air, andin parts highly congested ; the blood having burst through thetissue, producing an apoplectic condition. The kidneys wereof usual size, quite white, and full of deposit of advanceddisease.
CASE OF SUCCESSFUL REMOVAL OF A LARGE STONE FROM
THE TRACHEA, WITHOUT ANY OPERATION.
(Under the care of Mr. HENRY POWER.)THE details of the following most interesting case tell-their
own story; but we may remark, that it is rare indeed thatsuch a large foreign body is removed,or ejected’spontaneouslyfrom the trachea without the usual operation :-Henry.N-, aged forty-five, a robust Irish labourer, was
in the habit of sucking a small stone whilst he was at work tokeep his mouth moist. On Thursday, the 23rd of July, atfive P.M., whilst stooping,.he made a sudden inspiration, andimmediately felt that the stone had passed into his windpipe.It gave him little or no uneasiness; but he was sufficientlyalarmed to apply to several medical practitioners at Dartford.’By one of these gentlemen he was inverted, and an- emetic-wasordered for him. On inversion, which he also several timestried, by himself, violent coughing came-on, and he felt thestone rise up to a certain point, and then fall back. Fearingsuffocation, he came to town, and applied at Guy’s Hospital.He was here again inverted, though with an unsuccessful result.An operation was suggested, and he was told to return. Heapplied amongst the out-patients of the Westminster Hospitalon the 25th of July, when he was breathing quite naturally,and-at once said he wished the windpipe to be opened.On auscultation, the respiratory sounds were natural, except
that on coughing, which was of a spasmodic character, thesharp blow of a hard body was distinctly perceived by thestethoscope pressed on the trachea in the interclavicular depres-sion. This sound was clearly heard both by Mr. Power andDr. Wallis. There were no bronchitic symptoms. Mr. Powerlaid him on his belly on a couch, with his head and chest de-pendent, directed him to take a full breath, and then to cough.At the moment of coughing, a sharp blow was struck on theback, when, to the infinite joy of the patient, who expressedhis gratitude with truly national fervour, the large stone, ofwhich the annexed woodcut is an exact copy, was projected
with considerable force upon the floor, after having been lodgedfor forty-five hours in his trachea. Its dimensions are-length,nineteen-twentieths of an inch; breadth, fifteen-twentieths ofan inch; thicknecs, five-twentieths of an inch : thus almostexactly equalling a shilling in circumference, but with aboutone-fifth chipped off, which was probably the circumstance thatprevented suffocation ; whilst its thickness is rather greaterthan five shillings placed one upon the other. It is a perfectlysmooth water-worn pebble. It is somewhat surprising that astone whose diameter cannot have been far short of that of theman’s trachea should have produced so little embarrassment ofthe breathing. It probably rested, during the greater part ofthe time, on the bifurcation of the trachea, and only partiallyoccluded each of the bronchi.
In conclusion, it may be observed, that in similar cases whereinversion is tried, it is wise to have the insfruments for tracheo-tomy at hand in case of the impaction of the foreign body in
! the-rima glottidis.