Vol. 60, 1909 - University of North Carolina at Chapel Hill

184 THE CHARLOTTE MEDICAL JOURNAL.
death recorded as the cosnequence of the to become nasal. This can be easily demoperation,
and the results appear on the onstrated; if nitrous oxide is given by the
whole to be very good. In all the published face piece method, when one is near the end
casesgeneralansestbesiaseems to have been of the administration the face piece is still
used, on the whole without much trouble, kept on, and at the same time the nose is
The operation need not last more than a compressed, unless the palate is of the short
few minutes and no very profound degree variety, it gives rise to obstruction to exof
anaesthesia is necessary, so that if the piration. Besides the condition of the fauces
patient has been kept at rest for some time causing obstruction and giving rise to cyapreviously
there seems no great objection nosis, cyanosis in itself gives rise to obstructo
the use of chloroform. If it were neces- tion of free breathing in the later stages,
sary, however, to do the operation at a time the swelling and falling back of the tongue
when the heart was in an unsatisfactory giving rise to false stertor: he has noticed f
condition there can be little doubt that a that this trouble occurs to a marked degree
local anaesthetic should be preferred. As in patients with receding chins. Cyanosis
is well known, the chest wall can be very causes distension of the large veins of the
satisfactorily infiltrated with eucaine and neck; and, as is well known, a collar or
adrenalin, and one has been able, for ex- piece of tape, which was quite loose at the
ample, to open the pericardium very freely beginning is, if the administration is pushed
under it in a child with purulent pericarditis until the patient jactitates, found to be
without causing pain. The technical de- pressing tightly round the neck, the meas-
tails of the operation are very simple. A urement of the neck having increased J4 in.
horseshoe shaped flap should be marked in circumference. This is clearly due to
out, having its base above at the third rib distention of the superficial veins of the
and its apex at the seventh. The inner neck, as it is not likely that a structure like
edge should be over the sternum and the the cervical fascia can stretch much. In
outer in the region of the nipple line. The cases of oedema or suppuration beneath the
flap is turned up with the pectoralis and all deep cervical fascia, one is struck by the
the structures external to the ribs. The severe dyspncEa that occurs from pressure
fourth and fifth ribs are those most com- beneath this structure without any apparent
monly excised, but the extent of the rib re- general swelling of the neck. If the supersection
will, of course, depend on what is ficial veins external to the cervical fascia
found. A length of at least three or four are compared with the deep veins of the
inches of combined rib and cartilage must neck, one realizes what the pressure in
be removed. The third, the sixth, and these huge veins must be, on the soft tissue,
even the seventh rib must also be dealt with beneath a fixed structure like the cervical
if it appears necessary, and even the left fascia. The parts likely to be affected are
edge of the sternum lias been excised when the laryngeal opening, which may get
the heart was obviously fixed to it. There pressed back against the wall of the phahas
been but one subject of disagreement in rynx, and the space just above the larynx,
the matter of technique, and that is the where the tissue is extremely vascular, and
question of the removal of the costal perios- it is quite easy to imagine how, with the
teum. But it was shown by Koenig that increased tension within the cervical fascia
the anterior periosteum only should be re- occurring in asphyxia, the air way here
moved. The possibility of leaving the peri- may be completely obliterated,
osteum without damaging the usefulness of
the treatment makes the operation still more Prostatic Enlargement.— Herring, in
simple and removes the only serious risk it The Dublin Medical Journal, states that
could be supposed to have. prostatectomy should not be undertaken
The Causes ol Obstruction Producing
Cyanosis During the Nasal Admlnistra-
Hon ot Nitrous Oxide.—Trewby, according
to The London Medical Lancet, has
observed some thousands of nitrous oxide
administrations and states that cyanosis in
unless the symptoms present are definitely
ascertained to arise from that organ, and
from nothing else. Urinary symptoms are
very frequently artributed to the gland when
in fact they come from quite a different
cause. Forinstance—and this, perhaps, is
the most common mistake— a patient comordinary
cases in merely mechanical, being plains of occasional retention, haemorrhage,
mainly due to the size and shape of the
palate and tongue. Whether nitrous oxide
pain, etc.; a rectal examination is made;
the prostate is found to be enlarged and is
is given by the nasal or ordinary methods, straightway accused, without furthersearch,
the fact remains that the oropharyngeal of being the cause of the trouble. What is
aperture is always obliterated before the theresult? During the operation for removnasopharyngeal
aperture is in any way af- ing the offending member a stone is found
fected, and the breathing gradually tends in the bladder, which could easily have