COUNTRY CLINIQUES.

By a North Carolina Physician.

Katie L., colored, æt. 40, an expert and industrious laundress, but a woman of lewd character, has been under observation for several years. A reliable history of her previous life I cannot give. According to her own account, she had suffered almost every ill to which flesh is heir, excepting gonorrhœa and syphilis. There was a marked systolic murmur over the base of the heart, which, since she showed no other symptom of anæmia, I considered indicative of structural lesion; but as will be seen, I was probably mistaken in this opinion.

The most interesting feature in her case, and for this I most often prescribed, was the concurrence of epileptiform convulsions with every menstrual epoch. For six years has this occurred with almost uniform regularity, an occasional intermission only, having been brought about as the result of medical treatment.

En passant, a word may here be said against the too generally accepted idea that albumen found in the urine of puerperal women, after convulsions, is an indication of a previously existing albuminuria. On five successive occasions, I examined the urine passed by this woman before the occurrence of convulsions, and within a few hours of the attack.

There was not a trace of Albumen.Invariably I found the urine which was passedafterthe epileptic seizure to behighly albuminous. It gradually resumed its normal character in from two to six days, in a direct ratio to the severity of the attack. Again, the severity of the convulsions maintained an inverse proportion to the quantity of the menstrual discharge. When this was profuse the attack was light, when scanty, more severe. The convulsions generally appeared just before, or at the beginning of the monthly flow. Latterly their occurrence has been somewhat irregular, as has also been the case with the menses. Elaterium in ¼ grain doses, frequently cut them short, but exhausted the patient to such an extent that it had to be discontinued. For several months past I have been controlling the convulsions with ½ grain doses of morphia perorem, repeating every hour until relieved. She has frequently taken two, and a few weeks ago took three such doses, without exhibiting symptoms of marked narcosis.

At 9 A. M., on February 25th, I was called to see her. She had had four most violent convulsions during the previous night, and was complaining of terrible pain in the head, with nausea and vomiting. She expressed the conviction that another convulsion was imminent, and begged for relief. I immediately and without hesitation introduced ½ grain of hydrochlorate of morphia under the skin of the forearm, and having other engagements, left her. At 12 M., I was sent for, and informed that shortly after my departure, she sank into a deep sleep with stertorous breathing. All efforts to rouse her, had failed. On examination, she presented the following symptoms: There was total insensibility, except a slight twitching of the eye-lids when the conjunctiva was touched. The pupils were contracted to the size of a pin’s head. Respiration was shallow, irregular and interrupted, and numbered ten to twelve per minute. The extremities were cool and the face somewhat cyanosed. The pulse beat regularly, though feebly, 110 per minute. To my surprise, auscultation showed theabsenceof all adventitious sounds over the region of the heart.

Despite the gravity of the symptoms, I felt only a slight degree of alarm, when I considered the improbability of so small a dose of morphia proving fatal. Being compelled to leave, I merely directed the attendants to keep up circulation, by friction of the extremities. At 3 P. M., the condition of patient was unchanged, except that the extremities were more difficult to keep warm. Temperature in the axilla was 97.4°. The breathing was not at all better, and insensibility was, if possible, even more profound than at my previous visit. I injected 1–20th grain sulph. of atropia under the skin of the forearm, and during the next hour I made frequent applications of a moderately strong galvano-faradic current, one pole being placed in the epigastrium and moved along the insertion of the diaphragm, while the other was pressed upon the middle of the neck just behind the sterno-mastoid muscle. The heart’s beat was temporarily strengthened, and respiration slightly increased in depth and frequency by each application. At 4 P. M., I injected 1–12th grain of atropia, continuing the use of electricity. At 5 P. M., thecirculation appeared to be failing, the pulse being decidedly weaker and the extremities cold. Respiration was about 15 per minute, irregular and shallow. The pupils were still obstinately contracted. I now injected 1–6th grain of atropia and placed a bottle of hot water under each arm, and a large jug to the feet, still employing electricity at intervals. At 6 P. M., the change in my patient was evidently for the worse. To be sure the body was warm (100° F.), but the pulse at the wrist could only irregularly be felt. The heart contracted feebly but regularly 115 times per minute. Respiration was more shallow, although now 18 to 20 per minute. The pupils were unchanged, and there was absolute insensibility of the conjunctiva. I now injected ¼ grain of atropia. In twenty minutes the effect of this dose was perceptible. The pupils were widely dilated, and respiration increased to 30 per minute; but alas, the heart, although it contracted 130 to 140 times per minute, failed to convey even the slightest impulse to the wrist. Cyanosis had disappeared but the insensibility continued.

During the next seven hours, I injected into the bowel ½ oz. of whiskey every half hour. All of it was retained. During this time, the patient occasionally made an unconscious effort to swallow the mucus which accumulated in the fauces, and succeeded so far as to diminish temporarily the rattling and gurgling which now accompanied every respiration. Several times after this effort at swallowing, respiration had to be stimulated by the electrical current. At midnight there was a slight convulsion, after recovery from which the patient again lapsed into the same condition. Gradually there was an increase in the rate both of circulation and respiration, until at 4 A. M., the heart beat 150, and the breathing was 36 per minute. There was no dicrotism, but the heart’s contraction was steadily becoming more feeble and imperfect. The pupils were still widely dilated, the extremities warm, and the temperature 101°. Fifteen minutes later the heart ceased to beat, and death supervened without a struggle.

For my own sake, as well as for the good of the profession, I invite the most rigid criticism of the above report. The case in many ways is both interesting and instructive. Was this a case of opium poisoning? The symptoms appear to answer this question in the affirmative. I have so frequently given a similar, andeven a larger dose in pressing emergencies, without the least unpleasant effect, that I find it difficult to realize the fact that this patient was fatally poisoned by ½ grain of morphia. Such an unlooked for result has given a terrible shock to my confidence in the safety of large doses of morphia under any circumstances. The heart lesion of it before existed, evidently did not influence the result, as all signs of it were gone when I examined, three hours after the administration of the morphia, and they were not reproduced, even under the stimulation of electricity, atropia and whiskey.

Did I give too little atropia? Three doses of 1–12th grain each, sufficed to counteract the poisonous influence of 1½ ozs. tinct.opii, in a case which presented much graver symptoms of poisoning, (vide pp. 65 and 66 N. C.Med. Jour., Feb., 1879). Was I too slow in administering the antidote? In the present case the use of atropia was commenced six hours after the morphia was exhibited,—in the case above cited five hours elapsed before any atropia was given. In the case I previously reported, an aggregate of ¼ grain was given within seven hours after the opiate was taken, in the present case ½ grain within eight hours. Did I give too much atropia? At a single dose, Dr. Fothergill gave 1 grain in a similar case, and the patient recovered.[3](Antagonism of Medicines, p. 133). Should I have given digitalis or strychnia hypodermically to further stimulate the heart? That poor organ appeared to be doing its best, and to tell the truth, I felt that I had had enough of hypodermic medication for one day, and felt unwilling to risk anything more, after being so disappointed in my expectation of relief from atropia. I am open to conviction upon any one or all of the questions I have propounded.

In the light of our present knowledge of laceration of the cervix uteri, Dr. Whitehead’s article on “Hypertrophic Elongation of the Cervix Uteri” (Trans. N. C. Medical Society, 1875, p. 90), has peculiar significance.

LARYNGO-TRACHEOTOMY.

ByCharles Duffy, Sr., M. D., Catherine Lake, N. C.Read before the Onslow County Medical Society, September, 1878.

ByCharles Duffy, Sr., M. D., Catherine Lake, N. C.

Read before the Onslow County Medical Society, September, 1878.

Gentlemen of the Onslow County Medical Society:—

I was written to sometime ago, by a member of the State Medical Society, asking my views in regard to operating on the windpipe. My experience in such operation has been very limited, six times being the maximum of my labors in that direction. My first was a failure, done for the relief of cynanche trachealis, the operation being performed too late.

The other five cases succeeded admirably; four of the patients ranging from eight months to three years old, the other a woman of middle age. The first of these cases was operated on for the removal of a watermelon seed. The child was less than 2½ years old, and was very fat, so much so that the depth from the surface, would seem to forbid approach to the external surface of the trachea, still less to the internal, but by patience and perseverance these difficulties were both overcome, and respiration rendered comparatively easy. The next idea, was to get out the seed, and one attempt after another was made to no purpose, the wound inclined to close at the same time. I next lengthened the incision, and the sides of the wound were well drawn apart. My next step was to trim off the sides or edges of the cartilages; this being done, gave the seed a fine opportunity to present itself, and the child was placed in a cradle and diligently watched, with orders to take him in the arms and walk about with him, in case of difficulty of breathing coming on, which had to be done from time to time. The seed was expelled through the aperture to our great joy and gratification, several hours after the last step of the operation. The child was a son of Mr. Thomas Holland, of this county. He grew to adult age, and was killed by a horse running away.

From this case I learned that the removal of foreign substances by forceps or other instruments, except they are metallic substances is seldom necessary, there would be much more difficulty in retaining them or preventing their escape. As soon as the windpipe is cut into there is a rush of wind that follows, that moves the substance by the double ability or means of respiration, caused or provided bythe operation, and the next we know the substance is expelled. Certain it is, it is not going to stay there, if there is room for its escape and the patient is rightly attended to. When certain that all has come away, apply adhesive plaster drawing the parts together, a stitch or two might be necessary in some cases, it soon gets well.

My next case was the woman alluded to, the wife of Mr. Amos Wooten, of New Hanover county. A piece of beef gristle got into the wrong passage. After several spasms, and vain attempts to get it out she sent for me. I got to her as soon as possible—the distance being sixteen or seventeen miles. On enquiry I learned the particulars of her case. I found her composed. I told her it might not be in the windpipe, and we had better be certain about it. I passed a probang down the œsophagus and found that it was not there. After waiting a little longer, she had a violent spasm that hurried and increased her determination to have it out. So violent was the spasm, that it created doubts on her mind as to her chances of living, or of being able to bear up under the operation. She next turned her head toward me and remarked that she was ready. I had no medical assistant with me. I operated without chloroform—the woman fainted. There was camphorated spirits close by, and I sprinkled it heavily and forcibly in her face and over her chest, and rubbed some in her mouth. She revives with a vim and sends the gristle forcibly, not only out of her mouth, but nearly out of doors, rejoicing all hands around.

I applied sticking plaster and left; saw her in a few days; she was well.

My next operation was on the child of Mr. Enoch Foy, who had the misfortune to get a watermelon seed in his windpipe. The usual symptoms occurring, he came on with his little boy and had him relieved—the seed coming out several hours after the operation.

The next was a child of Mr. Marshall, (another fine boy), another case of watermelon seed, which was operated on with like success.

My last case was a child 8 or 9 months old, a very pretty and fine little girl, the daughter of a Mr. Padjet of this county. She had been playing with an ear of corn, given to amuse her; some of the grains coming off and one and a half getting into the windpipe, as shown by the sequel. She was operated on, assisted by Drs. Cox and Nicholson. The foreign substance did not come out as soonafter the operation as the other cases. The wound was not kept open by the attendants, and in consequence I had to re-visit, reöpen and somewhat enlarge the incision which was attended with the usual good results. The child was very fat, and the space for operating in so young a child, was necessarily very limited. One grain of corn and the part of another was expelled. I will next give my “modus operandi,” or rather my imperfect manner of operating.

The patient being laid on a suitable table, with the chest elevated, by placing a pillow or folds of cloth underneath. The head is next laid back neatly observing the direction of the mesial line strictly, and throughout the operation. The instruments previously got ready, and those which I prefer, are a scalpel with a sharp handle, a director and probe, two bistouries, one sharp and the other button pointed, a forceps, tenacula, sponge and ligatures. But so far I have never needed the ligatures. I have always stopped any little bleeding that occurred by applying a pencil of nitrate of silver. All these ready, also a basin of cold water, standing on the right of my patient, I place the finger and thumb of my left hand, one on each side of the thyroid cartilage, and commence my first incision from its lower third if a child, and from its lower edge if an adult, for obvious reasons, namely: In the child we want room, and if necessary can enlarge the incision in that direction, with but little difficulty, the cartilage affording no resistance. In the adult we have more room, and the cartilage is often found hard, and unyielding in persons of advanced life, and it is therefore necessary when enlargement is required in the adult, to cut an additional ring or more of the trachea. I continue my incision below the cricoid cartilage, so far as one or more of the rings of the trachea. The track of the operation being now laid off, I proceed cautiously, an assistant sponging, and applying caustic, as may be necessary to arrest any little bleeding that may ensue, whilst I, with the handle of my knife, push aside any vessel likely to bleed—cricoid artery or otherwise. I next lay hold on the cellular sheath of the trachea, at the lower edge of the track of my operation, and at this point I enter with a sharp pointed bistoury, holding it close to the point, and cutting upward not more than one-eighth of an inch and withdraw it in favor of the button pointed bistoury, with which I slitupward the windpipe, as far as the starting point of the first incision—not moving the instrument back and forth, but holding it perfectly steady, carrying it or rather pushing it, aided by the other hand from below upward, with the handle of the knife inclined downward. The operation now done, is made known by a whizzing which it is necessary to look after, and as all-important. I consider it the safety valve of the patient.

This operation may also be performed from above, downwards, with a sharp pointed bistoury, holding it not far from the point; the forefinger on the back of the knife—taking care to help the cricoid artery out of the way, which I have always been able to control when cut, by the application of nitrate of silver. The patient may be, if necessary, turned on the side to prevent blood from passing into the windpipe.

I begin close by the lower edge of the thyroid cartilage, and carry it so far as the second ring of the trachea; but in either case, whether I open upward or downward, the tenaculum can materially assist in the operation, by drawing down the tube when cutting upward, or by drawing upward when cutting downward—the hook to enter behind the knife in either case.

The use of the hook is most necessary when operating on young children. The object in pushing the knife, holding it steadily, is from knowing that it long since has been found, that an artery will give way before a knife when carried in this way that might otherwise have been cut immediately by a “see-saw” motion.

After the operation is performed, I direct the attendants to keep the opening clear of obstruction—bloody froth, &c., or anything that may make its appearance in the wound. Artificial respiration must be kept up until the foreign substance is expelled or removed. A probe or knitting needle will suffice for that purpose, one or the other must be used several times a day and night, in fact as often as needed; I use no gauze, it might get sucked to, or drawn into the opening, and thereby defeat the intent of the operation. In cases needing the use of the canula I make no reference.

I prefer laryngo-tracheotomy, sometimes denominated circo-tracheotomy, which I have been endeavoring to describe, to any other, for all ordinary purposes. We have less risk, and more room, and it is more adapted to the relief of children and might with proprietybe called the higher operation to distinguish it from tracheotomy, which rightly speaking is the lower operation. This would draw a distinction between the two, and it is necessary that line should be observed, and that when these operations are spoken of, we should know what importance to attach in either case, and give to either operation the degree of approbation it may deserve.

I cannot close this subject without giving the opinion of a very able anatomist regarding it, Harrison, of Dublin. In the first place he speaks of an irregular artery, which he has seen running along the front of the trachea to the thyroid gland and cellular membranes beneath it. He had seen this so frequently in this situation, that he describes it under the name of the middle thyroid artery. “This is” he says “so common an occurrence that it should be remembered by the practitioner of tracheotomy.” He further goes on to say, “in children the space for tracheotomy is very limited,” and directly that “particular attention be paid to the inconsiderable portion of the trachea that can be exposed between the thyroid gland above, the arteria innominata, the left carotid artery, the remainder of the thymus gland below. The deep thyroid veins also descending to thevena innominataobscure the trachea very much, these together with the great mobility of this tube, add to the danger and difficulty of this operation.” Pancoast says: “The checking of hemorrhage from the veins and arteries divided in tracheotomy requires particular attention; from six to eight ligatures are usually employed. They should be applied in general as the vessels are cut and before the opening of the trachea as there must be blood drawn by respiration into the trachea and thereby endanger life.”

These dangers constitute shoals and quicksands to the anatomist and surgeon, that has made many a one shudder at their approach. The six or eight vessels to tie, before daring to open the trachea, causes delay dangerous to life, as well as to the success of the operation, and brings into question the propriety of the operation, and sometimes the skill of the physician. In the upper operation, laryngo-tracheotomy, you can enlarge the opening upward whenever necessary, with but little risk, by cutting through the thyroid cartilage. In fact, it may be opened above or below, one or both, with but little risk; whereas in the lower operation it is almostimpossible to do so. When it becomes necessary, the safest plan is to enlarge the opening upward, as much as is practicable, and downward as little as we are able to get along with. The space taken up by the lower operation on children is very limited, and the operator must necessarily be cramped for want of room. The cervical portion of the adult trachea is laid down at from two to two and one half inches long. It is composed 18 or 20 fibro cartilages, this makes the space between each ring 1–8th of an inch. According to that measurement, allowing the 20 rings for 2½ inches makes the space taken up by cutting three rings 3–8ths of an inch long in the adult, if no more is divided, and proportionately less in the child. We can readily understand that those operating in this region do as little cutting as possible, and although the operation so far as the outside incision, may begin at the cricoid cartilage, and terminate as at a little distance from the fossa at the top of the sternum. I have no idea that the trachea is often laid open to that extent. Pancoast directs, “that after separating the two sterno-thyroid muscles, partly with the point and partly with the handle of the knife, and finding no large vessels in the way, pushes up, or if necessary divides the isthmus of the thyroid gland.” The next cutting he speaks of, is, “that of the third, fourth and fifth rings, puncturing the tube, with the point of the knife below the fifth ring.” He then speaks of running the scalpel upwards with the handle inclined to the sternum, so as to avoid injuring the posterior wall of the trachea. It is easy to perceive in the practice of the present day, that this operation is done for, and best suited to the insertion of the canula, and that the opening of the third, fourth and fifth rings of the trachea can, when divided, answer by binding the canula, a much better purpose than a larger opening, which would allow it to move about, thereby incurring the danger of displacement.

The word tracheotomy as a general term does harm. We ought rather to particularize, and make known on what part of that tube we operate, and not speak of tracheotomy as though it were of little moment in the performance, and that one part of the windpipe cut into, was as much a tracheotomy as another; not by any means should this be thought. I consider that tracheotomy strictly, and according to the definitions of anatomy and surgery, is one ofthe most dangerous that come within the province of the surgeon; and, on the contrary, I consider laryngo-tracheotomy, or crico-tracheotomy as it is sometimes denominated, a very simple operation, and only requiring ordinary tact in the performance.

Since the above article was written, this operation has been successfully performed by Dr. J. L. Nicholson, assisted by myself and Dr. C. Thompson.

1. Be sure that the foreign body isseen. To attempt to extract a foreign body without first seeing it is highly dangerous.

2. Determine what the body is, and, if possible, obtain a sample of the body supposed to be in the ear.

3. Remember that a body which will not swell, and has no cutting edge, will generally remain without causing any urgent symptoms.

4. Seeing the body, determine with a probe if it be movable. If easily movable, concussion with a downward position of ear will often remove it.

5. Warm water injection is the best of all methods of removing foreign bodies.

6. If it be a vegetable substance, do not inject fluid unless you have time to extract the body either at one operation, or shortly afterwards.

7. Injection failing, which is very exceptional, a surgeon, with the necessary appliances, ought to be at once consulted, or should urgent symptoms arise from the irritation in the attempted extraction, the extraction by the incisions, galvano-cautery, boring out by trephine or conical file the centre of substance, and so causing its collapse; or even detachment of the auricle may be necessary.—The Medical Press and Circular.

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