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 by the 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 soon after 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 slit upward 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.