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the top of the sternum." When both carotid arteries originate from the arteria innominata there is considerable danger in performing the operation of tracheotomy. These varieties. should teach the surgeon to be fully on his guard and not use the knife more than necessary.
THE LINE TO OPERATE.
In many cases, such as diphtheria in young children, three distinct stages are observed: 1. The child is flushed, hot and restless; sits erect, distressed for fear of suffocation. 2. He is fatigued and half-unconscious, caused, doubtless, by the circulation through the nervous centres of blood imperfectly oxyaised. 3. He lies nearly or quite insensible; perspiring most profusely; a pale and bluish color encircling the lips and eyes. The exact duration of the different stages is somewhat uncertain in many cases. Two or three hours elapse between each change. When death takes place it is by coma and exhaustion, and not, as some might suppose, by a sudden closure of the glottis. The time for operating is in first and second stage. There is no denying the fact that tracheotomy is the best and only chance for success, more especially in children. when afflicted with croup or diphtheria, when the pseudomembrane is confined to the larynx, when it reaches the trachea, and still less when it extends so far as the bifurcation of the bronchi. In such condition it is the only chance left for the patient. If the patient survives the shock it usually follows that directly after the operation has been performed the breathing becomes fully established. If a child is the patient it frequently resumes its usual habits and appears almost well again. This state of things, however, does not last long. In one case in which I operated, asphyxia returned twenty-four or thirty hours afterward as bad as ever. The tube was kept clean; still, however, the poor little fellow succumbed. A constant current of steam had been kept supplied. Doubtless the false membrane had formed below the point where the tube was inserted, and in all probability, too near the bifurcation of the trachea. In operating on children about to expire we run a risk-first, of finding the false membrane; second, an
inability to remedy congestion, engorgment-inflammation and pulmonary emphysema, which are common in the last stage of asphyxia; and third, the operation is rendered far more dif ficult in consequence of the great swelling of the cervical vessels and the surrounding tissues, causing a greater trouble to respiration.
ACCIDENTS DURING THE OPERATION.
Asphyxia, hemorrhage, shock and convulsions sometimes follow an operation. A case is reported in which the jugular vein was cut, owing to the operator not making his incision in the median line. A case is reported by Dr. Woods in which the tracheotomy-tube caused an ulceration downward, reaching the coats of the innominate artery, into which a small opening occurred producing fatal hemorrhage.
There is in St. George's Hospital, London, No. 52, in which the artery innominatar crossed high up in the neck and so near to the thyroid body that to have performed tracheotomy would have been impossible. Dr. H. A. Martin, of Boston, has adopted a plan in which the tube or canula is relinquished. The operation is as follows: "A silk ligature is introduced on either side of the wound at about one-eighth of an inch from the edge and through the skin at a corresponding point, and at a quarter of an inch from the line of incision. The two edges of the trachea and the skin are brought together by tying the ligature,which is left uncut and with needle still attached. Next, a strip of adhesive plaster is applied to each side of the wound. The ends of the plaster next to the incision are doubled on themselves so that the adhesive surfaces come in contact through the strengthened portion, the ligature is passed and secured in such a manner as to open the tracheal wound." The great advantage of this operation is that the surgeon is always prepared with instruments in pocket-case. Tubes have been known to produce trouble by their misfits and causing irritation and inflammation. Dr. Durham has invented a vertebrated or "lobster-tail" canula in which the tracheal portion will adapt itself to the various curves.
Dr. Bryant, of London, has invented one with a ball-andsocket joint, which join the neck-plate to the tracheal portion. This does away with the tracheotomy-tubes altogether.
By L. E. RUSSELL, M. D., Springfield, Ohio.
For the last ten years I have been engaged by the different railroad systems centering here as "Railroad Surgeon," and during these years I have had to care for persons maimed in every conceivable way. I have found that the practice differed enough from ordinary surgery to warrant me in offering an essay on the subject.
Two trains, freighted with human beings and running at great speed, suddenly and without warning, collide. The consequences are fearful, yet cannot be appreciated except by those who have surgically attended the injured.
The almost instantaneous stopping of heavy machinery and rolling material is attended with crashing sounds, splintered timber, broken car-furniture, fractured bones and lacerated flesh. The passengers lose self-control and behave like maniacs. All are shocked and few are unhurt. In the fright and confusion the panic-stricken wretches in hurrying to and fro not unfrequently hurt each other. In cold weather not a few get burned by being thrown against hot stoves. Sometimes an excited individual will leap down an embankment, or over a bridge, and thus sustain injuries that might have been avoided if presence of mind had been retained.
Nowhere, except in battle, are such ghastly sights presented as in a railroad wreck. The facilities for treating the wounded are often more defective than those of a camp. The surgeon has to view or examine the victims hastily, and then attend to the wants of those most in need. Often only a temporary dressing is employed-a "fixing up," which is to do service till a better application can be made. All at once a poor stunned creature cries out from the depths of a mass of
disjointed timbers, and he must be rescued by the free use of the ax, and the fence-rail.
Here lies a man breathing heavily under the depressing influence of a fractured skull; and there is a body literally transfixed with a splintered piece of lumber. One is calling for water or morphia, and another for a dose that will end an unbearable misery.
It is not uncommon for the injured to be very cold though the weather is warm. The shock sustained has produced congestion, or arrested respiration and circulation. Such need wrappings and alcoholic stimulants. Occasionally a brisk hemorrhage is to be arrested; hence the surgeon in railroad accidents should have with him the means most useful in emergencies.
I can best illustrate the nature of some of my experiences by referring in brief to exciting cases that have come under my care. A fireman running to get on his locomotive slipped and fell under the moving wheels. A leg and an arm were literally mashed to pulp. He was taken to his home, and into a small room where there was poor light and no ventilation. He complained of being very cold, though the place was stifling hot. The pulse was scarcely felt, the face was pallid and clammy sweat exuded from every pore. Whiskey was given and morphia administered, and in a little while the patient appeared easy and sleepy. Friends think these symptoms are favorable, but the professional man, who has seen many similar cases, does not like the heavy breathing, livid lips, and actual pulselessness. He knows that these signs are fatal.
A brakeman fell between moving cars and the wheels pass over both legs, one limb being crushed above and the other below the knee. He was picked up and brought to our office. We, myself and partner, gave the chilly victim a quantity of whiskey and placed him upon an operating table. There was very little pain complained of, and the pulse forbade immediate amputation. In a half-hour some reaction is apparent. This is encouraging and a few breaths of chloroform are administered to see if the anesthetic impression will not be favorable, as it sometimes is. The patient coughs a little,
rolls the eyes upward, appears stolid and soon dies. Did the chloroform kill the patient? "Not a bit of it." Death came from the profundity of the shock. The impression upon the nerve-centres was too great to be survived.
I was called to a man with a leg crushed above the knee. I found him with a cold sweat all over the body, and the pulse was scarcely perceptible at the wrist. An amputation was inevitable; hence an anæsthetic was administered, and a severence of the mangled parts took place. The femoral artery is looked for, but no spurting blood indicates its location. The tourniquet is loosened, but no arterial blood flows. The heart is evidently flagging; it has not power to force the blood to the extremities, and by the time the real state of things is comprehended the patient is dead.
A passenger crossing the platforms between two cars while they were in motion was toppled from the train. In the fall he sustained a compound fracture of an arm and leg. I conjectured that the limbs might be saved and cured. I dressed them nicely, gave an anodyne, and left him with the expectation of seeing him the next day. Before I made the second visit a messenger brought the news that my patient was dead.
Thus it goes in severe railroad accidents. The forces are so violent that they kill. Any medical man who has patients from railroad accidents will do well to give a doubtful prognosis.
I have encountered two accidents of great similarity in a single wreck. Each victim had a broken arm and leg. I dressed and treated both alike. On the fifth day a peculiar sickly suspicious smell was detected in the room of one of my patients. There was evidence of blood-poisoning and perhaps gangrene. All was done to counteract the evil tendency, but unmistakable death of a limb was apparent on the day following the suspicion. Amputation was performed, but did not arrest the dying process. A second amputation was followed by death. The cause of the fatal issue was thrombus of the femoral near the iliac artery. The plugging may have occurred from a direct injury, or from shock. The other patient recovered without an untoward symptom.