- 3> >^> ' VW-£' j >fts> :> > » > > >» *i .•!''.'.'•'•' ■•'Xv-«'■. 1 §r^^;*x '.'«•■■'•'•'' Bfc. •.:•■;'.:!*.« s 37 V ? r?^ >»^ >>*t .3 >3 ^5> o :> 3 > > > >> 3> £ > >. )3 33 3J>3 -> > > > js>>»» > >>>?>> y 3mtE* » ■> > i»_> > !'-> -> » ^ 3 3 j»»5» > o ) >3 >z :•< ={ ->^ > 3» > 3>» ?> >> > > o >: ,^ > > > > > > *>> '' '> ^ v>»J" ■•'•-5* -* i i> "» ^,i0* '' > 5 »^J > i> > > 1» » o ^ > j^ -> •> > x> - >' J> i 3> -> > ) v> ■ 5 3>/' 3> ^> 1.. ■> •> >-y > ) )V.) O )»3> >> > >j -y .1.1 ^>-» ^> £> > > 3. o > 'J ^ > > y > 3 » > > > :-a>.>-vx> «-» >> . ^> > '»> . ^> -> > > a, > » » ^ •> > > " •» > j. * . > > > >■ ag > j > 3>)^^J> } ;> :> ^ > ^ >>>J> »^ > > ^> > > > >> > >x» > > a ~3 > ~2^fc > > > •_> ^ •■"> "~> ^ -^ -> ^3^^ ji / > >, . J —~ ~* -* ■> ■> ~r^~^> t^^ 3 "> >~> ' -> > ^3> ":^ ^ ^ > ? '3> ^> > > >> '^3 2 V> 3 5 ^^ * j» >' > •». j > * ^» S"^>S ^* ^k < * ' » » o> > ^7 •'/';■> ^ ^^> .^^* ■' > > ) > :^^ ^^> > > ^>- >>>> -*< ^^ ^ -* •> J» > > ^ ^> » >T! 9 ->■>•>> -1 •*» S ^ -1 . ^> 3 3 > >^ ^>3 >J^ > > > > > * »^i ^* -> > > > > ^ :> ^^>-> -* * « 3 ^ > ^ > > ' * r > ^ > «> > * >j > • • •^ ^ ; ,)3 3> > > ->>,>> j» -> > > j > :»• 0 > > ^> > ^ > . / Surgeon General's Office *':W UQ $ isec/ebn/./J •■■ No/^. r -.,,-,-,vu^-—-ill,-;.Vi,-l;,^ryl|-M Hi i St. 4 R E V S E W '^y-"& **&-f £^-^^ DR. RITPPAXTER'S CASE OP LARYNGO-TRACHEOTOMY. BY LEWIS A. SAYRE, M. D. W-- ** ■-■■'v NEW YORK: D. APPLETOX A COMPANY 90, 92 & 94 GUAM) STREET. 1870. THE './ NEW YORK MEDICAL JOURNAL, EDITED BT E. S. DUNSTER, M. D., Professor of Obstetrics and Diseases of Women and Children in the University of Vermont, Is published monthly; each number contains 112 pages, making two large octavo volumes yearly, of nearly 700 pages each. THE VOLUMES BEGIN IN APRIL AND OCTOBER. Terms, $4 per annum. Specimen numbers sent by mail on reoeipt of 25a Since its Enlargement, the New York Medical Journal contains more Reading Matter than any Monthly Medical Journal published in this Country. " One of the best Medical and Surgical Journals published on the American Continent." —London Medical Times and Gazette. " The editor and the contributors rank among our most distinguished medical men, and each number contains matter which does honor to American medical literature."—Boston Journal of Chemistry. "Full of valuable original papers abounding in scientific ability."— Chicago Medical Times. " Taking it all through, its beauty of paper and print, its large-sized type, the high char- acter of its contributors, its general usefulness, we know no other periodical that we would rather present as a specimen of American skill and intelligence than the New York Medical Journal."—Franklin Repository. CLUB RATES. N. Y. Medical Journal and Appletons' New Weekly Journal. .. .$7.00 Psychological " " " " ___8.00 N. Y. Medical Journal and Psychological Journal............ 8.00 PREMIUM PORTRAIT. As a premium to new subscribers to either of our Medical Journals at the regular sub- scription rate, wo will send a magnificent line and stipple engraving, size 19x24 inches, of the distinguished physician, the late Dr. John W. Francis. This engraving io eminently adapted to adorn the parlor of the physician. The price of the portrait alone is $3. Payment in all cases must be hi advance. Remittances should be made by postal money order or check to the Publishers, D. APPLETON & CO., 90, 92 & 94 Grand St., New Fork. 285 Fifth Avenue, February 10, 1870. To the Editor of the New York Medical Journal? Dear Sir : In the January number of your valuable jour- nal, is an article headed " Contributions to Practical Laryngo- scopy. Four Cases of Morbid Growths within the Larynx. Reported by A. Euppaner, M. D., Physician to the New York Dispensary for Diseases of the Throat and Chest," One of the above cases is most inaccurately reported, and, ;is it is a case in which I have a personal interest, it becomes my duty to give it a passing notice, in order to correct the doc- tor's errors. The case is that of Captain Bigelow, of New Braintree, Mass. Dr. R. requested me to see Captain B., in consulta- tion with him, some time in June or July, 1869. He had a tumor in the larynx, which the doctor has very accurately de- scribed, and which he was trying to remove by local applica- tion of various escharotics. On hearing the history of the case, and becoming satisfied that the tumor was increasing more rapidly than escharotics could destroy it, I advised its immediate removal by external incision, if he (Dr. R.) was satisfied that it was not malignant. Dr. Ruppaner assured me that he had repeatedly exam- ined, by the microscope, pieces that he had pulled off with the forceps, and could find no trace of cancer, and, although it bled 1 This letter was received too late for insertion in the March number of the Journal.—[Ed. N. Y. Med. Jour. <■) very freely, he could find no evidence of the tumor being ma- lignant. In his published statement he says: " Pieces the size of a pin's-head were removed with the forceps,"' etc. . . . "Ex- amined under the microscope, these lobules were found to con- sist of cancer-cells, varying in type,'"' etc. I leave it to the doctor to explain this discrepancy between his statement to me, in the presence of Captain Bigelow, and in his published report. Presuming on the doctor's knowledge of the microscope, and on the accuracy of his statements, I again urged the im- mediate removal of the tumor by external incision, as the cap- tain was in danger of impending suffocation. This advice I certainly would not have given if I had not been assured that the growth was not cancerous, but would have advised trache- otomy, simply as a means of prolonging life, and making the patient as comfortable as possible under the circumstances. The operation of removal was not performed at the time, on account of the captain's business arrangements, which he stated would require a few weeks to put in such order as to allow him to lay up the required time for the operation. The doctor was to continue his local applications to keep the tumor in check, and the captain was informed that he might require the operation of tracheotomy at any moment, to prevent suffocation. I heard nothing more of this case until the 15th of August, about eleven o'clock at night, when I received, at Long Branch, the following telegram : " The captain is dying. Come im- mediately ; he must be operated on at once. A. Ruppaner." I came up in the six o'clock train the following morning, and arrived at the Fifth Avenue Hotel, about 10| a. m. ; found the doctor and several other physicians anxiously waiting for me. As I went into the hotel, I met Dr. Yance going to the telegraph-office, and told him that Dr. Ruppaner was going to perform tracheotomy, and, if he would like to see the opera- tion, I would try and get him an invitation. Dr. Ruppaner very courteously acceded to my request, and I went back for Dr. Yance, but on our return we found the doctor and the other gentlemen hurrying down the Fifth 3 Avenue to Twenty-second Street; on following them, we found the captain in his quarters over Goupil's picture-gallery. He was lying half-recumbent on a sofa, fanned by an as- sistant ; was quite purple in the face and fingers, and evidently in great danger of suffocation. I suggested that there was no time to lose, when the doc- tor asked some of the gentlemen present to arrange the table for the operation, and to administer the chloroform, and asked me into an adjoining room to look at the various instruments arranged for the operation. There was a very large assort- ment of instruments on the two tables in the room, but I had no time to inspect them, as, looking back through the door and seeing the man in a dangerous condition, I suggested to the doctor that he had better hurry, or the man would die before he could finish the operation. He then for the first time requested me to perform the operation, stating that he was tired and nervous from want of sleep, having watched all night with the captain. I remarked that this was rather short notice for an opera- tion of such magnitude, and that I preferred my own instru- ments and assistants. He replied in a hurried manner, " Every thing is all right. I have every instrument all prepared, and Dr. Zolknowski was a pupil of Turck and Troltsch, etc., and is the best assistant you could have." While we were talking, some one came to the door saying, " Hurry, doctor! the captain is dying." Of course, there was no time for further discussion, and I immediately took the scalpel and performed the operation. Intending to open at the laryngotracheal junction (which could have been done when I first saw the patient, I think), we were surprised to find the tumor projecting on the left side of the trachea for some distance down, and were compelled to extend the incision below the sixth tracheal ring be- fore we reached the lower border of the tumor. As there was no haemorrhage, I told the doctor to have his retractors ready, and I would open the trachea. I cut the sixth and seventh rings, but unfortunately found the tumor filled the anterior portion of the trachea, and extended still farther down. It was then proposed to plunge through, the tumor with a curved knife, and instantly to insert the tube so as to stop. 4 by its pressure, any haemorrhage that might occur. I passed the knife through the tumor, which was very vascular, and intend- ed to insert the tube immediately on the withdrawal of the knife, but the captain gave a deep, full, whistling inspiration. completely invaginating and closing the external wound, and of course inhaling a large quantity of blood, and almost in- stantly he apparently expired. As there was but one tenacu- lum used, and no other retractor present, I had to take out my pocket-case, open it (which, of course, took some time), and get a tenaculum, which, on being used, proved too deli- cate to hold the wound open. Dr. Dudley seized the scissors out of my pocket-case, which happened to have a hook on one of the handles, and, using this hook as a tenaculum, gaped open the wound, and I inserted the tube. But the captain still remained apparently dead and without respiration. Pull- ing off a feather from a fan some one was using, I ran it sud- denly down the tube into the trachea, and removed some clots of blood. This was done several times while other gentlemen present were trying to keep up artificial respiration. At last, in a paroxysm of coughing, he forcibly expelled several clots of blood, when his respiration became normal, and his life was saved. Dr. Ruppaner, in his published account, says, page 349 : " No untoward event happened when the incision was made and the tube inserted." The doctor may possibly think that death by inhalation of blood is not an " untoward event," but I am certain that no gentleman who saw the operation will agree with him. We often learn lessons for future application, from our errors or mistakes, of more practical value than from our most brilliant successes, and it is our duty to record them honestlv for the benefit of our professional brethren. So here was a striking case showing the necessity of being prepared to keep open a trachea which we are about to open for a person who is dying for want of breath, and, in fact, unless we are thus prepared and promptly act, the very desire for air will cause the patient to inspire so forcibly as to close the very opening by which we had hoped to save his life. I regret to appear before the profession in this manner 5 and presumed from the following letter that I should have been spared the trouble: [Copy.] , Fifth Avenue Hotel, ) December 31, 1869. \ My dear Doctor: "When I wrote the report of my case I had not the remotest intention to claim for myself any credit in my case that right- ly belongs to you. If there is any doubt as to who performed the opera- tion, I will clear up that doubt in a supplementary note to the Journal, as well as in reference to the hemorrhage, which latter fact I acknowl- edge I overlooked in ray report. Very respectfully. Your friend and servant, A. Ruppaner, M. D. Dr. L. A. Sayre, Fifth Avenue. As the February number of the Journal is out, without the promised explanation, I have, in compliance with the wishes of many friends, and in obedience to the duty I owe the profession, made these facts public. The sentence in the doctor's letter, u If there is any doubt as to who performed the operation, etc.," refers to his ambigu- ous mode of expression, which is probably owing to his want of knowledge of the language. Of course, there can be no doubt, in the minds of those present, as to who performed the operation, but I will quote the doctor's description, and the reader will then see that he is correct in thinking that his description is liable to deceive. On page 348 he says: kt Au- gust 16th, operation for laryngo-tracheotomy. My friend Dr. L. Sayre, who had seen, at my request, the patient at a former consultation, consented to divide with me the responsibility, and to aid me with his skill and experience in performing the operation." Further comment on this part of the report is unnecessary. In the last part of the report, he says: u Nothing has been elicited from the captain since the above date, till a short time since, I came in possession of a statement of his case " (the ital- ics are mine). This statement is copied from a letter from Captain Bige- low to me, and which is still in my possession. This letter I did not like to give the doctor, as it contained some statements not very flattering to his veracity, and I did 6 not like to hurt his feelings. In fact, the captain charges him with having deceived him by telling him that u it was the most difficult and dangerous operation he (Ruppaner) ever performed in his life/1 And the captain, having learned from Dr. Swan and Mr. Hobert that Dr. Ruppaner had not per- formed the operation, felt indignant at the deception. I therefore had copied and sent to him the professional part of the letter, in order to prove to him the correctness of my first suspicions that the tumor was malignant. That there may be no possible doubt as to the accuracy of my description of the captain's case, I append the following letters from gentlemen who were present at the operation. The first is from Dr. B. W. Dudley, an intimate friend, and the present assistant of Dr. Ruppaner. It will be observed that he states, " As well as I remember, there were two tenacu- lums at hand, one of which was unavailable on account of its delicacy, and I used the open ring of the scissors from your pocket-case as a retractor instead." This delicate tenaculum referred to was the one taken from my pocket-case after the captain had suffocated from the haemorrhage, and therefore was not present at the time of the operation except in my pocket. He also says he has read Dr. R.'s report, and consid- ers it a correct account of the operation as far as I observed it, with the exception of his omitting to speak of the haemorrhage which interfered for a few moments with respiration (the ital- ics are mine), exactly how many minutes it is necessary to have respiration interfered with before an " untoward event " might happen, the doctor does not state. From Dr. B. W. Dudley: Xo. 6 Washington Place, ) December 30, 1869. \ Dr. L. A. Sayre— Dear Sir : Yours of the 27th instant is received, and in reply I beg leave to state that it will give me pleasure to furnish the facts, so far as I know them, connected with the operation on Captain Bigelow. I was invited by Dr. Ruppaner to be present at an operation of trache- otomy, but, at the time, I did not know upon whom. When I arrived at the house, being a little late, the preliminary ar- rangements for the operation had been made ; in a few moments you and 7 Dr. Ruppaner went into an adjoining apartment, I supposed, at the time, to hold a consultation, but not being acquainted with any of the particu- lars of the case, or those connected with it, I merely considered myself a spectator, and knew nothing positive, further than that an operation was about to be performed. I recognized both Dr. R. and yourself as the principals in the case, but was not aware upon which one rested the onus of responsibility, although you performed the operation. As well as I remember, there were two tenaculums at hand, one unsuitable on account of its delicacy, and I used the open ring of the scissors from your pocket-case as a retractor instead. I have read Dr. Ruppaner's report of Captain Bigelow's case, in the January number of the New York Medical Journal, and consider it a correct account of the operation as far as I observed it, with the exception of his omitting to speak of the haemorrhage which interfered for a few mo- ments writh respiration; this was unavoidable, as the tumor, which was very vascular, was found attached to the anterior wall of the trachea. After the haemorrhage had nearly ceased, the tube was introduced, and the blood which had accumulated in the trachea and bronchi was forced out by par- oxysms of coughing and forcible expiration, after which, and up to the time I left, the patient breathed very well. The above is all I can recall now in connection with the cnse, and hop- ing it may be entirely satisfactory, I remain, doctor, Respectfully yours, B. W. Dudley. 144 East Twenty-second Street, ) New York City, February 12, 1870. \ My dear Sir : In answer to yours of the 27th of December, 1869, I have to state that, according to the best of my recollection, the following are the facts in the case of Captain Bigelow, with which I am personally acquainted: On the 16th of August, 1869, you came to me at the telegraph-office in the Fifth Avenue Hotel, and inquired if I desired to witness an opera- tion for tracheotomy, which Dr. Ruppaner was about to perform. Upon my replying in the affirmative, you requested and obtained Dr. Ruppaner's permission for me to be present, and, in company with Drs. Ruppaner and Zolknowski, we proceeded to Captain Bigelow's rooms, over Goupil's pic- ture-gallery, on the corner of Twenty-second Street and Fifth Avenue. Dr. Zolknowski and myself remained in the anteroom, until the patient was anesthetized, and every arrangement for the operation completed. I was very much surprised wrhen I saw you proceed to operate, as I had been in- formed that the case was Ruppaner's, and that we were there to see him open the trachea. 8 Two points connected with the operation made a very deep impression on my mind. One was, that the haemorrhage, which ensued upon opening the windpipe, could have been prevented, had the proper instrument for dilating the opening in such cases been at hand ; and the other was, that the patient would certainly have died on the table, had it not been for your presence of mind, in passing a fragment from a fan deep into the trachea, thereby exciting such powerful reflex actions as to force the clotted blood from the air-passages. As to my opinion of the manner in which the operation was per- formed, I can say most emphatically that, considering the peculiar circum- stances under which you were placed, the operation was skilfully executed, and the result was far more favorable than I had any reason to anticipate. I remain, very respectfully, Your obedient servant, Reuben A. Vance. Dr. Lewis A. Sayre, Fifth Avenue and Thirtieth Street, N. Y. City. From Dr. Swan : Astor House, / December 30, 1869. ( My dear Doctor: Dr. Ruppaner's report conveys the idea that he (Dr. R.) was the operator, which surprises me greatly, as there were sev- eral present besides myself who saw you operate. After the operation, suffocation from haemorrhage was imminent. Cap- tain Bigelow will be shaken again if he sees this report. He will not know who to believe. In haste, yours truly, C. Y. Swan. Dr. Sayre, 285 Fifth Avenue. Apologizing for these tedious details, and assuring you that my only desire is to put myself right upon the record, and to give a truthful history of Captain Bigelow's case, in which I took so responsible a part, I remain, very respectfully, L. A. Sayre. AD VERTISEMENT8. THE JOURNAL OF Psychological Medicine: A QUARTERLY REVIEW OP Diseases of the Nervous System, Medical Jurisprudence, and Anthropology, EDITED BY WILLIAM A. HAMMOND, M. D., Professor of Diseases of the Mind and Nervous System in (he Bdlevue Hospital Medical College, la published quarterly, each number containing not less than 308 pages, making one large volume annually. THE VOLUME BEGINS WITH THE JANUARY NUMBER. Terms, $5.00 per annum. Specimen numbers, by mail, $1.00. 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As a premium to new subscribers to either of our Medical Journals at the regular sub- scription rate, we will send a magnificent line and stipple engraving, size 19x34 inches, of the di«Mnguished physician, the late Dr. John W. Francis. This engraving is eminently adapted to adorn the parlor of the physician. The price of the portrait alone is $3. Payment in all cases must be in advance. Remittances should be made by postal money order or check to the Publishers, D. APPLETON & CO., 90, 92 A 94 Grand St., New York. I / AC C© < cci < cc l cc $' «C Cc cc r > V CC CC . C*C CC CC < ? cc cc «ccc cc cc CC cCc t «. cc cc owe cc - « C < C c - C « *ft.i< CCCJLC- < < Cc <& cc - - 'C-..> c< i c CC C(< * <-jc/ <3- "CJ CCC « C cC C CT"4, .- -C" cC cc c CC t(.c v Ci C C C. cr '« C C C ' r O C C Cv ( O C ci c cc CC < i re CC ^ . cc CC €^* - <- cc. ' cc i cc < cc ». ■ c < . vc CC r cc cC -- c c< . 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