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478 four hours, and five grains of mercury and chalk and of Dover’s powder at bed-time. On the 16th he was better, and the same treatment was continued. On the 18th he required a tonic mixture; after which, con- valescence-was gradually restored. Remarks.—Without requiring many special remarks, the cases will speak for themselves. I would only add, that it is shown in Case 2, that the abstraction of blood during the first stage, in cases of this sort-as was proposed in the late unfortunate occurrences-in the Kenilworth-street sewer, is likely to be followed by injurious, and perhaps fatal conse- quences. The treatment most appropriate in cases where re- spiration is suspended, seems to be the introduction, by arti- ficial means, of atmospheric air into the lungs, seconded by treatment generally pursued, where collapse has occurred. West Bromwich, Nov. 27, 1849. Hospital Reports. MIDDLESEX HOSPITAL. Reported by W. B. CLAPHAM, Esq, House-surgeon. Two Cases of Laryngotomy. CASE 1.-James D-,aged thirty, was admitted into Handel ward, under Mr. Shaw, Jan. 7th, 1850, with an abscess on the left side of the vertebral column, opposite to about the sixth or seventh dorsal vertebras, supposed to be connected with caries ’, of one of those bones, or the contiguous ribs, but of which no evidence could be obtained, either by probing or external examination. Tolerably healthy pus was oozing from it at the time of his admission, from one or two small openings which had been made iri its most superficial part by his sur- geon in the country. On Tuesday, Jan. 22nd, he first complained to me of slight soreness and smarting of the throat, which he attributed to his medicine. (He was taking, liquor potassœ, twenty minims; tincture of hyoscyamus, half a drachm; compound mixture of gentian, an ounce and a half,—three times a day.) There was nothing unusual in his appearance; he had no difficulty of breathing or of deglutition, excepting the medicine, which, he said, gave him pain in swallowing. On questioning him the next day, the soreness was still persistent; and on exa- mining his throat, nothing could be discovered to account for it. There was slight redness of the velum and arches of the palate, but the tonsils and posterior part of the pharynx were natural. He was directed to wash the back of his mouth, three or four times a day, with alum gargle. He made no further complaints until the following evening, when he ob- served to the nurse that he thought " the gargle did not reach the sore part, as it was deeper down;" but he swallowed his tea with ease. I saw nothing more of him until half-past six the next morning, when the sister called me to him, to say that he was choking. I went to the ward immediately, and found him struggling for breath, propped up in bed, scarcely able to articulate, with stridulous breathing, which accompanied both expiration and inspiration, the air being drawn in by gasps through the opened mouth. On looking into the throat, nothing unusual presented itself, excepting the slight redness above alluded to. On sweeping the finger round the pharynx, the glottis felt unusually large, as if swollen from oedema. He evinced pain on handling the larynx externally, and it appeared somewhat enlarged, although there was no general swelling of the parts about the neck. His lips were dry and livid, and his face congested, evidently from imperfect oxy- genization of the blood; and his pulse was quick and small. According to the night-nurse, his breathing first became more difficult between two and three A.M.; but no distress or urgent symptoms manifested themselves until about six. At five o’clock he swallowed half a pint of milk with tolerable facility. He expectorated nothing, but a watery fluid flowed from his mouth-no doubt saliva-and he made several attempts to vomit. Fifteen leeches were applied to the throat, and the bleeding encouraged by a warm linseed poultice, covered with oil-silk; and he was ordered to take half a grain of tartrate of antimony every half-hour. The nature of the case now became evident-one of acute laryngitis, with oedema glottidis; and suspecting what it must soon come to, I prepared a trocar and canula ready for the emergency, which was not long in showing itself; for soon after eight the nurse came running to me, to say that he was choked. I ran up to the ward, taking Dr. Corfe with me, whom I met in the passage. The man was then apparently dead, for respiration had ceased, and the sister exclaimed, " It is too late, sir; he is gone." His pulse was still beating. I’ directed her to take the poultice off immediately, and at once- made an incision down to the crico-thyroid membrane, and thrust in the trocar, which was withdrawn, leaving in the canula. No voluntary respiration followed, although we blew a current of cold air on his face &c. The mouth was applied to the tube, and the lungs inflated, the air being gently pumped out again by pressing on the chest. After repeating this once more, he expelled it himself, and by degrees began to breathe naturally. The change in his countenance was perceptible- almost instantaneously; his face, which was before pale and livid, became perceptibly red; his lips regained their usual colour; and he breathed with tolerable ease, interrupted only by an occasional paroxysm of coughing, which expelled some bloody mucus through the tube. Some slight cerebral dis- turbance followed, in the space of a few minutes, manifested by the convulsive struggles of his body, his snapping at us with his teeth and hands, and by the dilatation of his pupils; but this passed off in from five to ten minutes, and he became collected. The tube was now fastened in, and a nurse directed to sit constantly by him, to keep it free; and he was to take, tartrate of antimony, a quarter of a grain; chloride of mer- cury, two grains,-in powder, every four hours. The operation was extremely simple, performed with ease, and unattended with bleeding. During the day he remained quiet, breathing tranquilly and naturally through the tube; lie experienced great difficulty in swallowing, and evinced extreme tenderness of the larynx on touching it; his skin was perspiring freely; his pulse 120, but not jerking; he vomited each powder about ten minutes after taking them. Jan. 26th.-Has passed a sleepless night, and his counte nance is more pallid and anxious than yesterday; he has been sweating very profusely, and his pulse is 130, and more feeble. The tube was changed about ten A.M. He coughed more mucus through it, and attempts at swallowing brought on spasmodic attacks of coughing. He was perfectly sensible, and not so much tenderness of the larynx as yesterday. On closing the tube with the finger, little or no air found its way to the lungs through the mouth. Speech was consequently lost. Ordered, mercury with chalk, ten grains; chloride of mercury, one grain, every six hours. Towards night he became more distressed and sinking, and his countenance livid and sunken; he breathed extremely quick, and a thin, watery, frothy sputa, came through the canula at each expira- tion. On applying the stethoscope to the chest, large crepi- tation was heard over the whole of its surface anteriorly, with small crepitation at the base of the left lung, indicating the presence of general bronchitis, mixed up with pneumonia, from which he was evidently sinking. Ordered, a blister to the chest; ice in mouth. He died at five A.M., forty-eight hours after the operation. Post-mortem examination, fifty hours afterwards.—On reflect- ing the skin and platysma from off the neck on either side, a deposition of purulent matter was seen in the cellular tissue, behind the sterno-mastoid on the left side, and extending beneath its posterior border. An extensive purulent deposit- of jelly-like pus was seated beneath the post-pharyngeal fascia, extending upwards beyond the level of the tonsils on either side and downwards as far as the middle of the oesophagus, the mucous membrane of which was reddened, and its upper part in a sloughy state. The tonsils were slightly enlarged, but contained no purulent matter. The mucous membrane uniting the epiglottis to the root of the tongue and arches of the palate was tumefied. The epiglottis itself was cede- matous, converted into a slough, its posterior free margin having a red, velvety edge. On opening the larynx its inner surface was throughout in a sloughy state, isolated patches of which occupied the posterior part of the trachea to within an inch of its bifurcation, slight attempts having been made to throw one or two of them off. Its mucous membrane was considerably reddened, but that of the bronchial tubes in- tensely injected, and filled with a thick, sanious, muco-puru lent fluid, containing no air-bubbles. A thin layer of concrete pus was likewise observed at the roots of both lungs, occu- pying a large extent of surface, and situated immediately beneath their serous covering. The pleurae were both in- flamed, and their cavities filled with fluid, but there were no adhesions. The lungs were greatly engorged and congested, but slightly crepitant, soft and friable in texture, and in- elastic, containing scattered patches of lobular pneumonia, these pieces being quite impermeable, and sinking in water. The heart was hypertrophied and flabby, its external surface , covered with large patches of recent lymph, jelly-like masses
