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ber roller-bandage of Martin's or Bulkley's, or in the absence of any of these, an elastic suspender will do. The band is laid lengthwise upon the splint and tacked in the centre.

A padding of cotton is adapted to fill the irregularities between the splint and leg, care being taken to fill the space under the knee.

The splint is now applied with the rubber-band between the board and leg. The loops are caught and brought around the ends of the splint, and while the body is flexed upon the thigh and the fragments are pushed together by an assistant, a muslin roller-bandage is thrust through the loops (the upper one first), the loops held upon a stretch, the fragments are secured by several turns of the roller, as in Fig. 7.

The bands are drawn sufficiently tense during the adjustment to stretch the loops, in order to compensate for the

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FIG. 7.

relaxation of the muslin roller and to keep the fragments from separating. Upon the amount of tension rests the judgment of the surgeon. A compress of folded cotton may be placed beneath the bandages at the top of the knee to prevent friction and undue pressure upon the skin. The leg may now be bolstered up to form an incline plane.

My patient, James Cochran, upon whom I first applied this apparatus, made a good recovery, with no evidences of a ligamentous union. If we obtain an osseous union in any case of fracture of the patella, it will be by the firm juxtaposition of the fragments.


By W. R. G. SAMUELS, M. D., F. A. S., San Francisco, Cal.

Bronchotomy is derived from two Greek words signifying the "cutting of the wind-pipe," or larynx, for the admission of air. The operation has subsequently taken the name of laryngotomy, and more recently still, tracheotomy.

The operation is intended to allow the free passage of air into the lungs of the patient when obstructed. So soon as the child is born into the world one of the first evidences of life manifested is caused by the passage of air into its lungs, which is usually followed by a good loud cry, very much to the satisfaction of all persons around.

The amount of air taken into the lungs during each twentyfour hours varies in different individuals and different conditions. Thus, for example, one writer estimates about four hundred cubic feet. Nevertheless, it undergoes a marked degree of muscular effort. With the ordinary exercise of the unoccupied man the inspiration will be as high as four hundred and sixty-six cubic feet; in more active life, about six hundred, in the case of the hard-worked laborer about nine hundred, and in Alpine climbing for about twelve hours some one thousand feet. A soldier carrying weight in marching order was found to increase the amount of air passing through the lungs at the rate of seven cubic inches for every pound of weight carried. In consumption and other emaciating disorders the person dies worn out and completely broken down, the lung-tissue having undergone a change and no longer capable of performing its functions of sanguification.

The subject, however, for which this paper was intended, is Tracheotomy, or, more properly speaking, making an opening into the wind-pipe. There are three methods by which this can be done, namely: 1. Cricotomy, made by dividing the cricordcartilage an operation seldom performed in the present day. 2. Laryngotomy, made by dividing the crico-membrane horizontally. Care must be taken not to injure or wound the muscles. Hemorrhage is very apt to occur by the wounding of

the crico-thyroid arteries. Access of air into the lungs is readily effected by this operation. 3. Tracheotomy. This is the next and most frequent operation performed at the present day. In fact, the others are obsolete. This operation is made by dividing the rings of the trachæ either above or below the thyroid body."

Laryngotomy was first proposed by Vicq d' Azry. It was afterward recommended by Desault, and at one time was preferred to tracheotomy. Dr. Lawrence, an English surgeon of note, says: "Of the three situations proposed to make an opening in the thyroid cartilage, between that and the cricord, I consider the first, namely, cricotomy, the least eligible." Besides the objection frequently arising from the ossification of the cartilage and the danger of wounding or otherwise injuring the chordæ vocales, there is the inconvenience of the liability that angina larynga may arise from the swollen and thickened state of the membrane, impeding the passage of air into the lungs. Very many of the various diseases described by the ancients, including those of the throat, were thought to be due to a diseased liver. When suffocation threatened from any cause whatever, it was advised by Hippocrates to insert a pipe into the throat so us to give admission of air. It would appear, however, that Asclepiades was the first to discover bronchotomy: at least he is the first to give a clear and accurate description of the operation. He directs the operator to make the incision in the trachea under the larynx about the third or fourth ring. This point is the most eligible because it is not covered with muscle and no vessels are near it. The patient's head must be kept backward in order that the trachea may project forward. A transverse cut is then to be made between the two rings with great care, so as not to wound the cartilage, but only the membrane.

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The operation was performed for angina strangulans, croup, quinsy, foreign substances lodged in the throat; although for the former affection it was common that the patient should be bled, and even blistered, before operating. In cases of suffocation, caused by bronchial emphysema, Desault advised the insertion of a gum-elastic catheter from the nose into the

trachea so as to allow the patient to breathe. I have not heard of this having ever been done by English or American surgeons. Although the French are said to have performed this operation, Pliny spoke disparagingly of it. Galen believed Asclepiades the inventor of Bronchotomy. Cœlius Aurelinus despised all that came from Asclepiades. Paulus Ægineta, who lived in the seventh century, states the best surgeons of his day had disliked the operation. The late Dr. Liston was of the opinion that Tracheotomy had, in most cases, superseded this operation.

Tracheotomy is no new invention. It is performed as follows: The head is thrown back and an incision made of about two inches long in the adult in the median line near the top of the sternum to the cricoid cartilage. The integument and fascia are cut with the point of the bistoury. The sternothyroid muscle is to be divided with the point of the knife together with a few fibres. All the loose tissues and veins are to be removed from the front of he trachea with the handle of the scalpel. If the thyroid gland gives trouble it is to be pushed up, and the trachea drawn up with the hook of the tenaculem. While the trachea is stretched the surgeon thrusts in his knife, with a slight jerk into the bottom of the wound, and carries it upward, dividing two or three rings of the trachea. The canula should not be inserted till a few moments after the operation. This operation has been modified by several surgeons, who make use of newly-invented instruments. In morbid conditions of the trachea it is much more safe to cut into the sound part if possible. For example, in laryngitis the effused lymph is more often confined to the larynx; therefore, to make the incision below the thyroid gland gives a better chance for the patient. Whereas, to cut through the crico-thyroid membrane, it very frequently happens that the opening is into the diseased part.

Bronchotomy has been proposed when the tongue is enlarged so as to exclude air from passing into the lungs. A case is recorded where the patient had taken a large dose of mercury, causing the tongue to swell. The operation was suc

cessful. It has also been proposed for enlarged tonsils, polypus, drowning and small-pox in the trachea.

The operation of Bronchotomy in whatever way performed is not so dangerous an undertaking as many imagine. The real danger, however, consists in the above-named condition and position of the arteries, the time and place of the patient's location, and the attendance bestowed after the operation has has been performed. Such cases occur more frequently in the middle of the night than otherwise. The patient is halfasphyxiated, reduced by medicine and disease, struggling for breath, perhaps a very young child with short, fat neck, veins distended. Dr. Holmes found flatness of thyroid cartilage, the trachea drawn up and down with every inspiration and expiration, child half strangled, the doors and windows closed, every one excited and agitated, anxious to do something, a small room, bad lights, poorly ventilated, the persons who are to act as assistants nervous and agitated, the surgeon fatigued from over-work at night. Under such a state of things and conditions it behooves to have a steady hand, cool head and sound judgment. There is no time to reflect on this or that mode of operating or a life may be lost. Even then if the patient should die before the tube is inserted into the throat he is apt to be considered slow and guilty of the fatal result. If on the other hand the patient succumbs after the operation the surgeon is sometimes said to have operated improperly; so you see the dilemma. For my own part I do whatever I consider best, not heeding or fearing any reproach that may be cast upon me.

Desault has reported a case in which the carotid artery was wounded. W. A. Burns has given the following caution: "The arteria innominata is a risk in some subjects. I have seen it mounting so high on the forepart of the trachea as to reach the lower border of the thyroid gland. Even the right carotid artery is not always safe. I am in possession of a cast taken from a boy twelve years of age, which shows the right carotid artery crossing the trachea in an oblique direction. In that subject the vessel did not reach the lateral part of the trachea till it had ascended two inches and a quarter above

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