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that the swelling was extending rapidly upwards over the face and back of the head. At the same time blood began to flow pretty freely from his month.
All these circumstances conspired to alarm him very much, still with the assisstance of a man who had been working with him he walked to his house a distance of about two hundred yards. A messenger was at once dispatched for medical aid, and about twelve hours after the accident, I arrived at the patient's residence (which is about twenty miles distant) and found him in the condition I have already described.
On proceeding to manipulate the parts there was no difficulty in discovering that the thyroid cartilage (at least) was fractured, the pomum adami was absent, and crepitus could be distinctly felt ; over and above the crepitation of the emphysema, and by pressing on the left ala of the thyroid cartilage, respiration was entirely arrested, and acute pain felt. At this time I was of opinion that the cricoid cartilage also was fractured, but at subsequent examinations could never detect the abnormal prominence which on this occasion I supposed to have been produced by fracture of the cricoid. The emphysematous and otherwise unnatural state of the parts of course rendered precise manipulation impossible.
For the same reason I found it impossible to discover the exact extent and direction of the fracture of the thyroid.
At this time there appeared to be very little in the way of treatment, necessary or admissible. I attempted to restore the thyroid cartilage to its natural position and form, but with only very partial success.
A bandage was applied pretty firmly around the neck with the effect of facilitating respiration to some extent, and enemata were ordered, first laxative and afterwards nutritive. At an early hour, on the morning of the 16th I left him with instructions to keep me informed as to his progress.
On the 17th a very unfavourable report was received in consequence of which I revisited him early on the 18th, provided with a conveyance suitable for transporting him to Kingston. On this occasion I found him very much changed for the worse, respiration laboured and painful, pulse small and irregular, countenance intensely anxious and haggard, he had not slept since the accident occurred, nor had he attempted to swallow anything since my previous visit; his whole body was bathed in a cold clammy sweat, and altogether he appeared to be in immediate danger of sinking. On making the attempt he found that deglutition could now be performed with comparative ease and comfort, consequently a mixture of brandy and milk was freely administered with the effect of very rapidly improving his condition.
I now proposed his immediate removal to Kingston where his urgent case could receive the close attention which it required. On explaining to the patient and his friends my reasons for desiring his removal, they gladly conceded, and immediate preparations were made accordingly.
Patient complained somewhat of the shaking of the carriage, but on the whole he stood the journey well. He partook of brandy and milk and tea sev. eral times on the way, and on his arrival here stated that he felt stronger and better than when he left home.
On Monday and Tuesday (19th and 20th) patient complained a good deal of sleeplessness, in fact he had hardly slept at all since the accident occurred; otherwise everything seemed to be going on well.
On Tuesday night he became restless and anxious, complained of difficulty of breathing and pain in the neighbourhood of the larynx. He walked about the room nearly the whole of the night, and at day. light on Wednesday morning became suddenly much alarmed by the rapidly increasing dyspnoea, and what he described himself as "a sinking
a feeling. At this time he stated to me his conviction that he had not many hours to live-a conviction which I found it impossible altogether to remove.
At ten a.m., Dr. Dickson saw the case with me, and several unsuccessful efforts were made to obtain a view of the rima glottidis; the most cautious manipulation inducing violent reflex action.
The power of deglutition, though impaired, was not altogether lost, and fluid food, and stimulants were freely administered.
At 8 p.m., the dypsnoea had become very distressing, and it was evident that unless relief could be afforded in some way, very soon the man would die asphyxiated.
Dr. Dickson now revisited the case with me, and at last succeeded in obtaining a satisfactory view of the fauces and upper part of the windpipe, when it was seen that the glottis was all but occluded by ædema.
The course was now quite clear, and I proceeded at once to perform the operation of tracheotomy. It would indeed be difficult to imagine a more unfavourable case for the operation. Between emphysema and exudation, the trachea was very deep, the veins of the neck were of course distended to their utmost capacity, and the patient was struggling violently for air.
Having cut into the trachea and introduced the largest sized tracheotomy tube, we were disapointed to find that no air passed into the lungs, from which it was feared that an insurmountable obstacle existed lower down.
The case now appeared desperate, and the man was on the point of dying asphyxiated, when I seized a silver male catheter and at once passed it into the trachea and beyond the obstruction with the immediate effect of affording the patient an adequate supply of air.
I subsequently prolonged the incisions downwards, and introduced the tracheotomy tube, which now worked quite satisfactorily.
The tube having been tied in the usual way, and the patient comfortably propped up in the large arm chair in which the operation was performed, he fell into a sound and natural sleep for more than seven hours; this was the first good sleep he had had since the receipt of the injury.
Up to this time indeed he had never been asleep for more than five minutes at one time, and very seldom even for this short period.
On the morning of the 21st he felt, comparatively speaking, very well. Respiration was performed with perfect ease, the fear of impending dissolution no longer oppressed him, and he was able to partake freely of food and stimulants. Nevertheless, there was an evident tendency towards sinking, the pulse did not respond to the stimulants which were administered with the utmost liberality. He slept a great deal, and was frequently suffused with a cold sweat.
This critical condition, lasted for two days, after which he gradually recovered his strength. The emphysema disappeared and the neck and face resumed their normal appearance. On Saturday June 29th, I removed the tube, and stitched up the wound with metallic sutures. Since then the patient has been working in his harvest field, and when last seen (a week ago) was in perfeet health.
Fracture of the cartilages of the larynx is extremely rare, still a few well authenticated cases have been recorded by M. M. Sodoly, Oliver, Margolin, Plenck, Morgagni, Remer, and Dr. Frank H. Hamilton of New York.
In all these cases the effects of the injury were either so slight as to require no surgical interference or else so serious as to be fatal.
Dr. Hamilton's case is, so far as I am aware, the only one in which tracheotomy was performed; in this and in several other respects the most striking resemblance will be observed between that case and the one I have just described.
The principal difference between the two cases consists in the fact that Dr. Hamilton's case died of exhaustion seventy-two hours after this accident, and thirty-four after the operation. (Hamilton on Fractures and Dislocations, page 135.)
Kingston, August, 1865.
A case of Perineal Thrombus, following labour. By DEWITT H. MAR
TYN, M.D., University of Toronto. I am induced to publish the following case, because I believe it to be of very rare occurrence ; I have been engaged in an active country practice for five years, and this is the first case of the kind with which I have met; I have never heard of one, nor can I find any account of such a
of the medical works to which I have access. On Sunday, the 16th of July, 1865, I was called to visit Mrs. J. McT., about ten miles from town : I arrived there about one o'clock, p.m., and found her suffering intensely from pain which she referred to the perineum. The history which I received of the case was as follows:
She had been delivered of a healthy male child, at about 4 o'clock, a.m., after, as the old women said who had been with her, a very fair average labour of about five hours' duration, though she had been suffering from slight labour pains for a couple of days before. About twenty minutes or half an hour after the completion of the labour, she complained of very severe, sharp pain in the perineum, about midway between the anus and fourchette of the labii pudendi and immediately to the left of the medial line; upon feeling with her hand, a small, sound tumour was found in this locality, about the size, when first observed, of a robin's egg; this swelling rapidly increased in size, and the pain in intensity. Upon making an examination, soon after my arrival, I found the swelling as large, I should think, as the head of the child, occupying the whole of the left labium, as high, nearly, as the pubis, closing the vagina and anus, and forcing the left wall of the vagina over against the right wall of the pelvis ; I could not reach past the tumour either per vaginam or per anum; per anum a small artery could be felt pulsating across the tumour; the pain had somewhat subsided, and the tumour was not swelling so rapidly as it had done; the woman had made water plentifully, but with considerable difficulty owing to the pressure of the tumour on the urethra.
As I had never heard of or seen a similar post-partum occurrence, I deemed it advisable to have another opinion, and therefore at once despatched a messenger to Kincardine for Dr. H. M. Ross; giving the patient in the meantime, pretty free doses of Dover's powder and acetate of lead, for the purpose of relieving the pain, and because I suspected that the tumour arose from extravasated blood.
By the time of Dr. R's arrival (whom I found quite as ignorant on the subject as myself), the swelling had, by its colour, &c., clearly declared itself to be the result of extravasated blood. We did not deem it advisable to open the tumour at that time lest we should renew the bleeding, for the swelling had now ceased to increase; we therefore applied pressure, by means of the T bandage, with astringent lotions, and cold applications, giving at the same time Dover's powder with acetate of lead. With the exception of the tumour, the woman was in as good health as could be expected or wished for under the circumstances.
On Wednesday, the 19th, Dr. R. and myself again visited Mrs. McT. and found the tumour somewhat smaller than when we left on Sunday. We decided that it should be opened, and I accordingly opened it by means of a sharp pointed curved bistoury, making a cut between four and five inches in length, over the most prominent part of the swelling: the sensibility of the skin was so completely destroyed that the patient did not feel the knife at all, except when dividing about one half an inch at one extremity of the cut; and where I first entered the instrument there appeared to be no more than the cuticle between my hand and the clot, which was found very firm. A probe, being introduced through the clot, from about the middle of the cut towards the centre of the upper strait of the pelvis, passed freely up for about five inches, and latterally it passed about two to three inches, which will give some idea of the enormous size of the tumour.
No further local treatment was necessary, except warm water dressings and poultices, and the woman's general health was so good that systemic treatment was quite needless.
I have heard from the patient frequently since, the last time being August 29th, and she has been steadily progressing towards a cure. The Found is now very nearly healed. There has been no bleeding, nor, far as I can learn, a single bad symptom.
The woman's age is about twenty-four; this was her first pregnancy, and a head presentation.
I think there can be no reasonable doubt that this tumour was the result of the rupture of one or more of the small vessels forming the vaginal plexus of veins, but what may have been the cause of this rupture does not seem, to my mind, quite so clear; my opinion is, that it was caused by the pressure of the child's head on a, perhaps, already weakened vein.
Kincardine, County of Bruce, August 30th, 1865.