RECORD OF MEDICAL SCIENCE.
SURGERY.
Self-inflicted wound of the throat, laying open the (Esophagus-
Recovery. (Under the care of Mr. Adams.)—Wounds of the throat in
persons who attempt to commit suicide, may be of a trifling kind, or
cause death instantaneously, either by hsemorrhage or suffocation.
There are between these two extremes a great variety of lesions result-
ing from self-inflicted wounds of the throat, placing the patient in a
more or less dangerous situation ; among these, the complete division
of the thyroid and cricoid cartilages, with a subsequent wound of the
oesophagus, are looked upon as extremely hazardous, and the manage-
ment of such cases requires great care and nicety. It is, however, satis-
factory to notice, that an enlightened and close attention to the treatment
may triumph over the numerous difficulties which lie in the way of
recovery when the wound is of the above mentioned destructive descrip-
tion ; and it is our pleasing duty to record a case, lately under the care
of Mr. Adams, where favourable results were obtained.
From the notes of Mr. Ball, the house-surgeon, who very courteously
afforded us frequent opportunities of seeing the patient, we are enabled
to give the following details. On the 28th of February, 1850, a man,
about twenty-five years of age, of thin, spare make, and a salesman by
trade, was admitted into the hospital with an oblique incision in the
anterior part of the throat, extending from above the thyroid cartilage
to the fourth ring of the trachea. Both the thyroid and cricoid carti-
lages, and the three first rings of the trachea, were divided ; the knife
had passed between the sterno-hyoid and sterno-thyroid muscles, and
had slightly lacerated them at their inner edges; the isthmus of the
thyroid body was laid bare, but not divided. This desperate wound
was inflicted by the patient’s own hand while under considerable excite-
ment, with a common table-knife, about an hour previous to admission.
The hemorrhage had been considerable, but had ceased when the patient
entered the hospital; the lungs, however, [contained a large quantity of
blood, which had passed into the trachea, and this fluid, excited by its
presence in the lungs, constant cough, with expectoration of the blood
through the wound in the throat.
This fact again proves how seldom the suicide succeeds in wounding
the common carotid artery or jugular vein, the haemorrhage mostly pro-
ceeding from some of the primary branches of the external carotid.
Here it would appear, that the violence used was expended upon the
division of the hard bodies above mentioned, viz., the thyroid and cricoid
cartilages, the rings of the trachea, and, as will be seen below, part of
the oesophagus, these organs being probably rendered prominent by the
head having been thrown backwards. The cut was likewise an oblique
one, and was therefore less likely to reach to a greater distance posteriorly.
The patient, under these circumstances, was immediately put to bed,
his head and shifulders were raised by means of pillows ; a silver tube
was passed into the trachea to facilitate the ejection of the blood; and
lint, wet with cold water, applied to the wound. Mr. Adams saw the
patient a few hours after admission, when the breathing was much
easier, a large quantity of blood having been expectorated through the
tube. Mr. Adams approved of what had been done, and ordered thirty
drops of tincture of opium to be given to the patient without a vehicle,
so as not to tax the powers of deglutition; but he swallowed this small
quantity of fluid with great difficulty, and the attempt excited a violent
fit of coughing. The patient made, towards the evening, several unsuc-
cessful attempts to swallow small quantities of milk, but the greater por-
tion of it passed into the trachea and caused violent cough; the milk,
at the same time, escaping by the wound in the windpipe.
These phenomena confirmed Mr. Adams in the previous suspicion of
wound of the oesophagus; the canula was therefore removed from the
wound in the trachea, and an attempt made to pass a flexible tube into
the stomach; this was, however, found impracticable, for the tube
invariably passed through the wound in the trachea, instead of gliding
down from the pharynx into the oesophagus, and excited an alarming
amount of irritation. No doubt now remained regarding the wound
having reached the oesophagus ; and as no tube could be passed into the
stomach, Mr. Adams had recourse to enemata for nourishing the patient.
A pint of beef-tea was therefore injected ; the man was allowed to mois-.
ten his mouth with a wet rag, and as he breathed quite freely through
the wound, it was not thought advisable to replace the canula into it.
This method of administering food by the rectum is invaluable in such
cases, and the patient owes his life to this measure ; it is a pity that it is
not invariably adopted in analogous circumstances. The case of a child,
for instance, was lately mentioned at the Surgical Society of Paris, who
had died of inanition. The little patient had had tracheotomy performed
upon him to ward off impending suffocation from croup ; as the food
subsequently passed through the opening in the trachea, the oesophageal
tube was thought of, but could not be used, owing to the inflamed state
of the larynx; the child died. It is not too much to suppose that the
child might perhaps have been saved by nourishing enemata.
The difficulty of deglutition in Mr. Adams’s patient went on increas-
ing on the second day ; even the swallowing of his saliva gave him great
pain ; he was therefore ordered half a pint of beef-tea to be injected into
the rectum three times daily. In the night the patient spoke once or
twice in a whisper; but strict silence was enjoined, as the effort of speak-
ing excited fits of coughing, which left him greatly exhausted. The
bowels having been relieved on the next day after admission, Mr. Adams
ordered thirty drops of the tincture of opium to be administered in a
starch enema of one ounce, towards the evening, to procure rest. The
patient was likewise removed into a private room, as the cold air excited
cough. This change to a higher temperature proved very beneficial;
the irritation about the air passages diminished considerably ; there was
much less cough; and a very evident improvement was noticed in the
patient’s countenance. He, however, was much tormented with thirst,
to satisfy which, Mr. Adams ordered an enema composed of a pint of
cold milk, and directed a small piece of ice to be placed in the patient’s
mouth. The wound, in the meantime, went on very favorably, and was
dressed solely with lint dipped in cold water.
On the fifth day the patient was able to speak in a whisper without
pain or exciting cough, and there was great improvement; he was
nourished entirely by beef-tea and milk enemata, with the administra-
tion of thirty drops of tincture of opium by the same means every night,
the bowels being kept regular. Oil the eleventh day after admission,
he began to take a small quantity of bread and milk by the mouth,
which he succeeded in swallowing without any difficulty. The wound
had in the meantime rapidly filled up, and was now about one-fourth
of its original size. Beef-tea, milk, rice-pudding, and porter, were soon
taken by the mouth, and the patient improved rapidly up to the twenty-
third day after the rash act, when symptoms of constitutional distur-
bance appeared, and pain was complained of both in the head, neck,
and shoulders. A purge of calomel and rhubarb, and a blister to the
temples, did not succeed in removing these symptoms; the tongue became
tremulous and the pulse weak; the patient was therefore prescribed
bark with half a grain of hydrochlorate of morphia at night, and by the
assistance of wine, porter, &c., he regained his strength; the wound
healed completely, and the patient was discharged in a very satisfactory
condition forty-one days after admission. He was still holding his head
rather erect, however, and his voice was somewhat indistinct; but it is
to be supposed that with the eventual perfect consolidation of parts within
the trachea, and subsequent absorption of exuberant fibrinous deposits,
the voice will regain its former tone. It will be noticed that no vessel
required tying, and that no secondary haemorrhage took place ; and as
certain, not unimportant, branches of the external carotid must have
been divided, the fact of the cessation of the bleeding will be an addi-
tional illustration of the retracting power of arteries, when completely
divided. Nor should it be passed unnoticed how well was exemplified
in the foregoing case the propriety of avoiding plaster and sutures, as
is generally advised by systematic writers when treating of wounds of
the thorax.—Lancet.