that the pilot trocar is generally known. It certainly deserves to be universally adopted. The introduction of a cylindrical tube without the pilot must be a matter of very great difficulty. A sharp-pointed trocar is very dangerous, and should never be used. I cannot but hope that the adoption of some such modifications in the form and construction of the instrument as those I have thus suggested may aid in diminishing those dangers of tracheotomy which arise from ulceration produced by the canula. Canulas and trocars, such as those described, are made of various sizes by Messrs. Mayer and Meltzer.

Third, with regard to the danger of broncho-pneumonia caused by the inspiration of unwarmed, unmoistened air. The means by which this danger may be to a certain extent avoided are obvious enough, and should be duly provided in every case of tracheotomy. Such means consist in keeping the atmosphere of the room warm and moist, and in placing over the neck of the patient, when practicable, a small light cradle, on which two or three layers of moistened muslin are lightly placed.

Want of space prevents me from discussing the several classes of cases on which tracheotomy fails to save life, although it cannot be charged with causing death. The most frequent causes of such failure are, first, procrastination of the operation until the last moment; secondly, needless delay during the operation; and thirdly, want of perseverance in the after-treatment. With regard to the last mentioned cause of failure, I would simply say that I know from my own observation and experience that it is very common. It cannot be too constantly borne in mind that the performance of tracheotomy is like the first charge in a great battle; it may be to all appearance triumphant in its immediate effect, but it is rarely decisive in its result. The battle has to be fought out to the end; and any relaxation of vigilance, any want of energy or perseverance, any sign of giving way, is sure to be taken advantage of by the enemy.

The failure of tracheotomy from needless delay during the operation ought to be much more rare than it is. I cannot but think that such failure is often due to the method of operating ordinarily adopted. I therefore venture to describe and recommend the method which in my experience has proved alike sure, speedy, and safe.

Many surgical writers of eminence advise that in every case a deliberate dissection should be made down to the trachea, the various tissues being cut or torn through layer by layer and carefully hooked aside, and that the operator should pause from time to time to arrest any hemorrhage that may occur, however slight it be. Now such a process is all very well, and perhaps may be advantageously adopted when time is of no consequence, and skilled assistants are at hand. But it very often happens that there is not a minute to be lost, and the surgeon has to rely upon himself alone. In such case a deliberate dissection cannot be made, and unadroit attempts to hook aside the divided structures are more likely to embarrass than to aid the operator. The natural laxity of the tissues of the neck is increased by their division; and the various parts become capable of being moved so easily and to such an extent, that there is great danger of their being pulled more or less out of position. Thus the normal relations of parts may be so disturbed as to mislead the surgeon, or at any rate to hinder the accomplishment of his purpose. It has happened within my knowledge that the cervical vertebræ have been safely reached before the trachea has been found. In this case the trachea on the oue side and the large vessels on the other were held scrupulously apart by the assistants who had charge of the retractors. Mr. Marsh alludes to a similar case. The method of operating which I venture to advocate is as follows:

First, Chloroform having been administered, or not, according to circumstances, the patient is put into proper position. A good pillow is placed under the shoulders and upper part of the chest. The head is thrown well back. It must not be supported, nor propped forward by any pillow. The chin is drawn up. The shoulders are drawn downwards--in the adult by traction upon the upper extremities, in the child by means of a towel or shawl placed behind the shoulders-then carried on each side over the acromion and upper

extremity, crossed over the thorax, and securely tied behind and below. The head is placed perfectly straight and firmly held in that position until the operation is completed. The middle points of the upper piece of the sternum, the thyroid cartilage, and the lower jaw give the line. By repeated observation I am convinced that, when the patient is in the position described, these points can be readily recognised even in very young children. A small pad may sometimes be advantageously placed under the nape of the neck in such a way as to maintain or increase as far as practicable the anterior convexity of the cervical spine. I have been thus particular in describing the proper position of the patient, because upon the absolute maintenance of such position the facility with which the operation may be performed very greatly depends.

Secondly, The operator, standing upon the right side of the patient, selects the spot at which he intends to open the trachea, and makes a careful preliminary examination of the parts. Then placing the forefinger of his left hand on one side of the trachea and the thumb on the other, so as to include between them the spot at which the trachea is to be opened, he makes uniform, steady, deep pressure, until he is able distinctly to feel the pulsation of both carotid arteries. The security of the great vessels is thus ensured, and the surgeon has the satisfaction of feeling that the trachea is safely and firmly held between his finger and thumb. Moreover the skin and superficial tissues are rendered tense, and prevented from moving downwards with the knife, as from their great elasticity and mobility they otherwise might do. The finger and thumb thus placed are not to be moved until the trachea is reached.

Thirdly, By a succession of careful incisions strictly in the middle line the surgeon confidently cuts down on to the trachea. The forefinger of the right hand may from time to time be passed into the wound "to make assurance doubly sure" that there is no important vessel in the way. The pressure of the finger and thumb on either side causes the wound to gape, and the trachea to advance. When the trachea is reached, it may either be opened at once by the knife guarded, lancet-like, to within a quarter or a third of an inch from the point by the forefinger of the hand which holds it; or a sharp hook may be used to seize the trachea, and hold it firmly until the opening is made.

Fourthly, When the opening into the trachea is satisfactorily made (and there is no mistaking the moment at which the trachea has been opened), the outer tube, mounted on the blunt-pointed pilót trocar, and already armed with tapes for fixing, is introduced. If the pilot trocar is used, there is rarely any difficulty about this part of the operation; but, as I have already said, the introduction of an open-ended tube must be difficult in the extreme. If the surgeon should not possess a trocar, the tube may be mounted upon an elastic catheter or bougie, as a substitute. But the long firm handle of the trocar renders the manipulation of this instrument much more easy. The withdrawal of the trocar, the tube being held in position, enables the surgeon at once to judge whether the trachea has been properly entered or not.

As a rule, the pressure of the finger and thumb serves to a great extent, if not entirely, to prevent venous hemorrhage during the conduct of the operation. If, however, such hemorrhage should occur to any alarming extent, it is better to introduce the index finger of the left hand into the wound, and apply it firmly to the front of the trachea before the opening is made. The opening, when made, is easily closed at once by the point of the finger, so as to prevent the entrance of blood. And the finger-nail placed on the edge of the opening serves as a guide to the introduction of the trocar.

By the method thus described the trachea is firmly fixed throughout the operation, and the violent convulsive up and down movements which commonly give fise to so much difficulty and embarrassment are effectually prevented. The whole operation from the first use of the knife to the insertion of the canula occupies so brief a period of time that the necessary interference with respiration need give rise to no anxiety.

I wish it to be distinctly understood that I do not suggest this method on

theoretical grounds, but I recommend it because I have tested it and found it good. I have operated in this way in fifteen cases, and in no instance have I had the slightest reason to regret the course pursued. I cannot say the same of other methods which I have tried or seen tried by others.

I have thus endeavoured to show that tracheotomy is not necessarily the fatal operation it is sometimes represented to be; and I have also endeavoured to point out the means by which, so far as I am able to judge, some of the chief difficulties and dangers really attending it may be best encountered and overcome.-Practitioner, April, 1869, p. 221.

61.-CASE OF TRACHEOTOMY.

By T. R JESSOP, Esq., Lecturer on Physiology at the Leeds School of Medicine, Surgeon to the Leeds Public Dispensary.

[The following case occurred during Mr. Jessop's house-surgeoncy at the Leeds General Infirmary.]

Case. Mary M'G., aged 14, a street-dancer and stilt-walker, from Manchester, was admitted into the Leeds General Infirmary, under the care of the late Mr. Samuel Smith, on the 30th of May, 1862, in consequence of hypertrophy of the thyroid body, attended by some dyspnoea which at times assumed a somewhat violent character, and was then accompanied by noisy inspiration. A careful examination failed to elicit any other cause for the paroxysms of difficult breathing than the enlargement of the thyroid body. The hypertrophy, though marked, was not excessive, was of the usual simple character, unaccompanied by exopthalmos or heart-murmur, involved all three lobes equally, and the middle one lay apparently in its usual position across the front of the upper part of the trachea. The disease had commenced about a year lefore her admission, and had steadily advanced, the difficulty of breathing keeping pace with the enlargement of the neck.

During the first fortnight of her stay in the hospital an iodine lotion was applied to the neck, and the tincture of iodine given internally, without any apparent result. The size of the thyroid was undiminished, and the dif ficulty of inspiration remained the same. As the attacks had never been of an alarming character, no extraordinary precautions were taken.

About half-past six on the morning of June 13th, exactly a fortnight after the patient's admission, the night nurse came to my room-in compliance with my requirement, that every nurse should inform me when any of her patients died, whether expectedly or unexpectedly-and, rousing me, said: "Mary M'G. has just died in a fit, Sir." I lost no time in reaching the ward in which the patient was. My bedroom, however, was at one end of the building and the patient was at the opposite end, and on the floor above me. On arriving at the bedside, I found the girl duly “laid out," and surrounded by the large screen, which was made use of for isolating the dead. The face was livid, and no sign of life was manifest. Feeling certain that the patient must have been suffocated, I ran to the operation room, which is situated in the centre of the building, and on the floor above that on which the patient lay, procured the necessary instruments, ran back to the ward, had the body lifted from the bed on the floor, which had been made there owing to the crowded state of the house, and placed on another patient's bed; and I then opened the trachea. The depth of the wound was so great that the ordinary tubes were found to be of no use. I therefore held the wound open by means of a pair of long forceps introduced, while assistants, who had in the mean time been summoned, performed the movements for artificial respiration, as directed by Dr. Marshall Hall. Air entered, and was expelled freely with each set of movements. The body remained quite warm, and every now and then, at very long intervals of many minutes, I thought I could detect a slight fluttering of the heart; but, with these exceptions, no sign of life was manifested until a few minutes before 8 o'clock-nearly an hour and a half after I was called, and, according to the nurse's statement, fully an hour and three quarters after the girl was supposed to have died-when a single distinct and convulsive

inspiration was observed. Shortly, in from forty to sixty seconds, another followed; and subsequently breathing became by slow degrees established, and with it a pulsation at the heart and wrist. The artificial respiration was continued until about 8.30, when it was no longer needed. The patient remained perfectly unconscious all that day and the next, and became able to recognize those around her only at about the end of forty-eight hours.

As soon as the immediate danger was over, a silversmith was directed to make a special tube, of twice the ordinary length; and in the mean time the wound was kept open by an assistant with a pair of long forceps. Her recovery was uninterrupted. At the end of a week, without any further treatment having been adopted, the enlargement of the thyroid had diminished very considerably. In three weeks she sat up, and at the end of two months the thyroid body was only slightly larger than natural; and yet the trachea was so deep that the long special canula alone would reach it.

When the canula was removed to be cleaned, the opening contracted so rapidly that it was found necessary to have a second tube made, in order that it might be introduced immediately on the withdrawal of the first. On August 30th, the introduction of the clean canula having been neglected on the withdrawal of the obstructed one, the wound was found to have contracted so much that it became necessary to enlarge it with a bistoury before the tube could be reintroduced. In consequence of the difficulty experienced each time the tube was cleaned it became necessary that the girl should be kept in the hospital; and accordingly she was hired as a cleaner, the duties of which office she continued to perform until the end of 1865, when, after a sojourn of three years and a half she left the hospital, still wearing the tube. I often tried to induce her to give up the use of the tube, but in vain, as the distress of breathing invariably recurred when in a very few minutes the opening narrowed, and then it became a matter of some difficulty to reintroduce the tube. There was no appearance of disease on laryngoscopic examination, and on closing the orifice of the tube the patient could speak with a bass voice and breathe with tolerable facility.

I have two suggestions to offer for the improvement of tracheotomy tubes as ordinarily constructed. A remark commonly made after performing the operation is, "How much deeper the trachea is than it seems to be!" We may go further with our reflections, and add, "How much deeper the trachea is in, the living than in the dead!" In private practice, where the patient resides at a distance from the surgeon, it is no unusual circumstance to be told, on making the morning visit, that the patient, especially if it be a child, has died after a violent fit of coughing during the night. And if the throat be examined, it will not unfrequently be found that the tube has been forced out of the trachea, and is lying irregularly in the wound; that, in fact, the child has died suffocated, because the tube was only just long enough to reach the trachea, and has therefore become readily displaced during the act of coughing, or in swallowing. The ordinary tracheotomy tubes would seem to be made to correspond with the apparent, and not with the actual depth of the trachea to reach the trachea of the dead and not of the living. Those I am in the habit of using are nearly half as long again as the ordinary tubes, and I find them very advantageous. I had them made after losing two children in the way I have described above.

My second suggestion—the principle of which is, I believe, recognised, but is not sufficiently appreciated by instrument makers,-is, that the two blades of the outer canula should be made so that they lie in close apposition at their distal extremities, and are separated only by the introduction between them of the inner canula.

By the adoption of this means the most difficult step in the operation of tracheotomy-viz., the introduction of the canula through the slit in the trachea will be much facilitated.-Lancet, April 3 and 10, 1869, pp. 458, 492.

62.—THE ÆSTHETIC TREATMENT OF HARE-LIP, WITH A DESCRIPTION OF A NEW OPERATION FOR THE MORE SCIENTIFIC REMEDY OF THIS DEFORMITY.

By Dr. MAURICE HENRY COLLIS, Surgeon to the Meath Hospital, and County Dublin Infirmary, &c. The natural condition of the upper lip in its perfect state is as follows:Its free margin has the waved outline to which the name of "Cupid's Bow” is given. Its depth is greatest in the centre. Its margin is connected with the inner margin of each nostril by a curved line. These curves, and those of the free margin, correspond, or have a relation to one another; thus, if the lip be full and freely curved, the lines which pass up to the nostrils will likewise be freely curved, and will include a larger portion of lip than when the margin of the lip is almost straight. In this latter case, the lines referred to are also straight or nearly so. The upper lip may, therefore, be fairly divided into a central, and two lateral portions, joined by curved lines.

The fissures of hare-lip always correspond to this division.

In the double hare-lip, the fissures cut off the central portion along the curved lines referred to. In the single hare-lip, the central portion remains attached to one side and detached from the other, the curved line being still traceable on the larger portion.

These are anatomical facts of some importance, both in a surgical and asthetic point of view. Almost from the time of my student days I have considered the ordinary operation for hare-lip to be deficient in a due regard to the natural condition of parts, and I have followed with interest many efforts made by distinguished surgeons to improve it. Let me first state wherein it is deficient.

The ordinary directions are-first, to divide the frena, true and false, to the fullest extent. Secondly, with knife or scissors to pare the edges, cutting away the rounded corners freely. Some surgeons make these incisions straight, others make them curved with the concavities facing each other.

The evil of dividing the true frenum is that the lip is thrown out of gear, and one of the best means of bringing the distorted nostril into its proper place is sacrificed.

The incisions, whether straight or concave, must result in a straight cicatrix, whereas there can be no doubt that the cicatrix ought, if possible, to follow the curved line which runs, in the natural condition, from the nostril to the margin of the lip. Further, the loss of substance along the margin of the lip is considerable by this method. Hence the resulting lip has a tight margin, which is drawn up by the gradual contraction of the cicatrix, so that ultimately its outline, instead of a graceful wavy line is made up of two straight lines, which at their point of junction allow a tooth to be seen. The contraction of the cicatrix not only tucks up the lip at that point, but it also renders the lip thin along the line of cica trix, whereas it ought to be thicker and more full along that line than elsewhere. In fact, in place of a curved ridge, we got by the ordinary operation a short depressed straight line, with a lip tucked up in or near the centre.

Such are my objections to the common operation.

One of these is remedied by the operation known as Malgaigne's or Sédillot's, which I learned twenty-one years ago from a fine old English surgeon, the late Samuel Smith, of Leeds. He told me then that he had devised it some twenty or thirty years previously. Whether he ever published it I do not know. This improvement consists in reserving the lower portion of the parings at each side, and turning them downwards so as to form a prominence along the margin. This manifest improvement gave me the first idea of my operation. For some years I was content with it, but by degrees I have added one thing and another to it until I have brought it to a point of perfection, that I am not afraid to challenge attention to.

The rules for my operation are:

1st. Never to interfere with the true frenum. It is not only unnecessary to divide it, but most pernicious.