CASE OF TRACHEOTOMY. By
Surgeon-Major F. Odevaine, F.R.C.S.,
^
Bengal Medical Service. Mahomedan, aged about 45, presented himDispensary with symptoms of laryngitis,
A tall spare self at the Sehore
few
days
before he came to my notice, when he of pain referred to the larynx increased by pressure ; his voice was husky and feeble, he had some cough and well marked dyspnoea, which at times became some
complained very
urgent.
Percussion showed chest
tolerably resonant, but respiratory murmur feeble, inspiration prolonged and stridulus, pulse quick and weak. Ordered a mild aperient as his bowels were constipated, and afterwards three grains of Calomel every fourth hour ; liquor lyttse to be applied the larynx, and steam inhalations frequently. over
Should much difficulty of breathing ensue, to get four grains of Sulphate of Copper as an emetic, and the Hospital Assistant was requested to send forme should dyspnoea continue urgent. The emetic had been given, and acted, yefc he got frequent paroxysms of dyspnoea, and I was accordingly asked to see the patient again, in the afternoon of the day I had first seen him at the dispensary. On my arrival he was a little easier, but, no doubt, considerable spasm is superadded to the laryngeal disease, as is generally the case ; some cyanosis existed, and it was just an instance in which delay would prove dangerous, by allowing of pulmonary congestion taking place, resulting in that seini-comatose condition due to insufficient aeration of the blood, and in which urgent dyspnoea no longer forms such a prominent symptom as in the earlier stage of
In fact, the patient was obstruction of the glottis. precisely in that condition in which we might hope that operative interference would relieve all his distress, and delay?even of an hour or less?prove most dangerous
if not fatal.
I accordingly placed the man lying down high operating table opposite a good light, putting a well rolled blanket under his neck, throwing the head well back, and thus drawing up the trachea. I next, with an ordinary scalpel, made an incision two and a half inches long in the median line, from a little on a
above the sternum to the lower edge of the thyroid the skin, exposing the superficial fascia of the neck, which was divided on a director to the extent of the wound ; the sterno-thyroid and hyoid muscles of each side were separated, and by clearing away some loose cellular tissue with the handle of the scalpel, the rings of the trachea could be distinctly felt at the lower part of the wound. The trachea having been fixed, I quickly plunged the point of the knife into it, prolonging the incision directly upwards, the back of the scalpel being of course directed towards the sternum. At the moment of opening the trachea, very violent came on, and the patient coughed paroxysms of dyspnoea a quantity of viscid bloody mucus. up through the wound There was some difficulty in introducing the tube, owing to the restlessness of the patient and the violence of the dyspnoea, his face and lips being at the time quite blue ; by however passing an aneurism needle into the tracheal wound on each side, I had the edges of the opening held apart, and then passed the double tracheotomy canula; when I had done so, very distressing dyspnoea again ensued, and some mucus and blood were forcibly ejected through the tube ; when, however, this was tied in and the man put sitting up, he soon began to breathe
cartilage, through
quite naturally.
I directed that the inner tube should he removed every
second hour and carefully washed with hot water, to prevent its becoming blocked by discharges, and as the
weather water
was
placed
attendant
cold,
on
it,
to look
a
fire with
was
to be
after the
a
shallow pan of ; with an during the night
large
kept in his
patient
room
September 2,
A MIRROR OF HOSPITAL PRACTICE.
1878.]
my instructions were easily carried out. I did not see the case for five days after the operation, as I was obliged to leave the station on duty ; on my return, I found
man breathing freely through the tube ; cough not troublesome, but had some hiccup which annoyed him ; this was relieved by a subcutaneous injection of morphia ; sleeps tolerably well ; takes his food ; pulse normal ; lungs free from signs of congestion. Ordered chlorate of potash in ten grain doses, three times a day, and iodine inhalations, through the glottis, by making the
the
patient close the mouth of the tracheotomy tube with the tip of his finger ; this he cannot, however, do for any length of time, as the breathing becomes oppressed accompanied by stridor at each inspiration, indicating that laryngeal swelling and thickening of mucous lining still exist. He can speak plainly enough even though the canula remains patent, but when closed, his voice is much louder and more distinct. About a fortnight after the operation, he implored me to remove the tube, as he said he could not rest with it in the wound as it was hurting the trachea. I stopped its mouth with a cork, and he breathed tolerably well, but not so freely as with the open tube ; at the patient's earnest solicitation, I removed it, leaving directions with the Hospital Assistant to replace the canula at once should any dyspnoea come on. In about three hours he was suddenly seized with spasm and great and most urgent difficulty of breathing ; the tube was immediately re-introduced into the trachcea, when he once more breathed easily. The subsequent difficulty of breathing, whenever the mouth of the canula was closed, even for a short time, prevented the possibility of his dispensing with its use, and I was obliged to get him a double silver canula made in the Bazaar, which I may here say, was well and very cheaply done. I attribute this inability to breathe through the glottis and increasing aphonia, to the growth of some form of benign tumor or tumors on the chord? vocales, likely of papillomata, arising from the chronic state of hyperajmia of the mucous lining of the larynx, due to the previous inflammation. I regret that owing to the want of a laryngoscope, and my shortly after leaving the station, I was prevented satisfying myself on this point, and adopting means for the enucleation of any tumor, should I have discovered one within reach. Remarks.
\
The violent spasm and urgent dyspnoea when the trachea was incised, and also on the first introduction of the canula. were most distressing, and although well known to take place generally at this part of the operation, yet, might make one unprepared for their occurrence hesitate to proceed further, and this at a stage when expedition is called for to establish free respiration and thus check venous hannorrhage, so embarrassing in these cases. Another point worth notice is that, though a few days after the operation the patient was able to keep the tube closed for a considerable time and yet breathe tolerably well, still, its removal for a few hours a fortnight afterwards, very nearly cost the man his life ; and had he not been detained in the dispensary and the canula kept in readiness for immediate re-introduction, he would probably have died asphyxiated. Sehore, C. I., March 1878.
245
Surgeon-Major F. Odevaine, F.R.C.S.,
^
Bengal Medical Service. Mahomedan, aged about 45, presented himDispensary with symptoms of laryngitis,
A tall spare self at the Sehore
few
days
before he came to my notice, when he of pain referred to the larynx increased by pressure ; his voice was husky and feeble, he had some cough and well marked dyspnoea, which at times became some
complained very
urgent.
Percussion showed chest
tolerably resonant, but respiratory murmur feeble, inspiration prolonged and stridulus, pulse quick and weak. Ordered a mild aperient as his bowels were constipated, and afterwards three grains of Calomel every fourth hour ; liquor lyttse to be applied the larynx, and steam inhalations frequently. over
Should much difficulty of breathing ensue, to get four grains of Sulphate of Copper as an emetic, and the Hospital Assistant was requested to send forme should dyspnoea continue urgent. The emetic had been given, and acted, yefc he got frequent paroxysms of dyspnoea, and I was accordingly asked to see the patient again, in the afternoon of the day I had first seen him at the dispensary. On my arrival he was a little easier, but, no doubt, considerable spasm is superadded to the laryngeal disease, as is generally the case ; some cyanosis existed, and it was just an instance in which delay would prove dangerous, by allowing of pulmonary congestion taking place, resulting in that seini-comatose condition due to insufficient aeration of the blood, and in which urgent dyspnoea no longer forms such a prominent symptom as in the earlier stage of
In fact, the patient was obstruction of the glottis. precisely in that condition in which we might hope that operative interference would relieve all his distress, and delay?even of an hour or less?prove most dangerous
if not fatal.
I accordingly placed the man lying down high operating table opposite a good light, putting a well rolled blanket under his neck, throwing the head well back, and thus drawing up the trachea. I next, with an ordinary scalpel, made an incision two and a half inches long in the median line, from a little on a
above the sternum to the lower edge of the thyroid the skin, exposing the superficial fascia of the neck, which was divided on a director to the extent of the wound ; the sterno-thyroid and hyoid muscles of each side were separated, and by clearing away some loose cellular tissue with the handle of the scalpel, the rings of the trachea could be distinctly felt at the lower part of the wound. The trachea having been fixed, I quickly plunged the point of the knife into it, prolonging the incision directly upwards, the back of the scalpel being of course directed towards the sternum. At the moment of opening the trachea, very violent came on, and the patient coughed paroxysms of dyspnoea a quantity of viscid bloody mucus. up through the wound There was some difficulty in introducing the tube, owing to the restlessness of the patient and the violence of the dyspnoea, his face and lips being at the time quite blue ; by however passing an aneurism needle into the tracheal wound on each side, I had the edges of the opening held apart, and then passed the double tracheotomy canula; when I had done so, very distressing dyspnoea again ensued, and some mucus and blood were forcibly ejected through the tube ; when, however, this was tied in and the man put sitting up, he soon began to breathe
cartilage, through
quite naturally.
I directed that the inner tube should he removed every
second hour and carefully washed with hot water, to prevent its becoming blocked by discharges, and as the
weather water
was
placed
attendant
cold,
on
it,
to look
a
fire with
was
to be
after the
a
shallow pan of ; with an during the night
large
kept in his
patient
room
September 2,
A MIRROR OF HOSPITAL PRACTICE.
1878.]
my instructions were easily carried out. I did not see the case for five days after the operation, as I was obliged to leave the station on duty ; on my return, I found
man breathing freely through the tube ; cough not troublesome, but had some hiccup which annoyed him ; this was relieved by a subcutaneous injection of morphia ; sleeps tolerably well ; takes his food ; pulse normal ; lungs free from signs of congestion. Ordered chlorate of potash in ten grain doses, three times a day, and iodine inhalations, through the glottis, by making the
the
patient close the mouth of the tracheotomy tube with the tip of his finger ; this he cannot, however, do for any length of time, as the breathing becomes oppressed accompanied by stridor at each inspiration, indicating that laryngeal swelling and thickening of mucous lining still exist. He can speak plainly enough even though the canula remains patent, but when closed, his voice is much louder and more distinct. About a fortnight after the operation, he implored me to remove the tube, as he said he could not rest with it in the wound as it was hurting the trachea. I stopped its mouth with a cork, and he breathed tolerably well, but not so freely as with the open tube ; at the patient's earnest solicitation, I removed it, leaving directions with the Hospital Assistant to replace the canula at once should any dyspnoea come on. In about three hours he was suddenly seized with spasm and great and most urgent difficulty of breathing ; the tube was immediately re-introduced into the trachcea, when he once more breathed easily. The subsequent difficulty of breathing, whenever the mouth of the canula was closed, even for a short time, prevented the possibility of his dispensing with its use, and I was obliged to get him a double silver canula made in the Bazaar, which I may here say, was well and very cheaply done. I attribute this inability to breathe through the glottis and increasing aphonia, to the growth of some form of benign tumor or tumors on the chord? vocales, likely of papillomata, arising from the chronic state of hyperajmia of the mucous lining of the larynx, due to the previous inflammation. I regret that owing to the want of a laryngoscope, and my shortly after leaving the station, I was prevented satisfying myself on this point, and adopting means for the enucleation of any tumor, should I have discovered one within reach. Remarks.
\
The violent spasm and urgent dyspnoea when the trachea was incised, and also on the first introduction of the canula. were most distressing, and although well known to take place generally at this part of the operation, yet, might make one unprepared for their occurrence hesitate to proceed further, and this at a stage when expedition is called for to establish free respiration and thus check venous hannorrhage, so embarrassing in these cases. Another point worth notice is that, though a few days after the operation the patient was able to keep the tube closed for a considerable time and yet breathe tolerably well, still, its removal for a few hours a fortnight afterwards, very nearly cost the man his life ; and had he not been detained in the dispensary and the canula kept in readiness for immediate re-introduction, he would probably have died asphyxiated. Sehore, C. I., March 1878.
245
