eleventh day after the operation, the report states that she slept well, the respirations were only twenty in a minute, and the pulse 104, soft. Mr. Hilton then ordered quinine, and good diet, with a continuance of the wine.

On July 11th, twenty-one days after tracheotomy, she began walking about the ward without fatigue, and was pronounced convalescent. Her progress from this time was most satisfactory; she gradually lost the sallow, unhealthy hue of skin, and gained flesh rapidly; the wound contracted firmly around the canula, the latter requiring, however, occasional cleansing. No topical applications were used to the palate and larynx, but the ulcerations did not extend; they gradually assumed a healthier appearance, and about three weeks after the operation the throat was quite well.

With Mr. Hilton it was a question as to the propriety of removing the original canula, and substituting a broad one; but on considering the subject, as there was a probability of much inconvenience resulting from the change, it was decided that the canula should remain untouched. By the patient's own desire she was discharged on Aug. 10, 1847, seven weeks after the operation, and was earnestly enjoined to be careful of exposure to cold, and to wear constantly two or more folds of muslin over the mouth of the canula.

This patient stayed away for about six years, when she was re-admitted May 12, 1853, for a slight bronchial affection, much emaciated, and suffering more from want than from actual disease. She was still wearing her canula, and Mr. Stevens, who had been attending to her for a long time at her residence, was kind enough to put the following memoranda at our disposal:

"Since the period that this patient left the hospital in 1847 to the present time, I have constantly seen her. She has been living in Spitalfields, and has had three children since the operation was performed. Her husband has frequently during these years been out of work for days, sometimes for weeks, together, so that her living, at the best of times hardly sufficient, has very often been totally inadequate, and she has consequently endured much privation. Her different places of residence in Spitalfields have all been characterized by darkness, dirt, and utter cheerlessness; she has been exposed continuously to all the vicissitudes of the weather (to some extent perhaps unavoidably), her clothing being inappropriate and insufficient, and she has moreover entirely disregarded all our entreaties and injunctions relative to the tube being lightly covered with a fold or two of muslin; frequent and sometimes rather severe attacks of bronchitis have been the result of this imprudence and carelessness.

"The tube has required removal and cleansing four or five times in the year, of course oftener when there has been bronchial disturbance present; the secretion has at all times passed freely and easily through the canula, and never through the mouth. Carefully repeated trials have failed to detect the smallest passage of air through the larynx and mouth till about four months ago, when a very slight stream was found to pass, so small that even now (June, 1853) it is only sufficient to bend the flame of a candle. There has been no appreciable voice, and it requires the greatest possible attention in observing the movements of the lips to be enabled to recognise the enunciation of a word. Further to demonstrate the impervious condition of the larynx, I may mention that when the finger has been applied over the end of the canula, or, the canula being absent, over the external orifice, complete incapability of breathing has been the result,

"Generally speaking, I have had no difficulty in removing the canula, and substi tuting another, during the cleansing of the original one. On the last occasion, however, Feb. 23, 1853, there was great difficulty in the re-introduction of the tube, owing to a very relaxed state of the tracheal mucous membrane, and towards the close of this nearly fatal operation, I was compelled to use considerable force to overcome the sphincter-like contraction of the external orifice. On three or four occasions, small abscesses have formed in front, but independent, of the trachea, and these have occurred more often below than above the canula.

"The form of tracheal tube through which this patient has breathed for six years is here introduced, for the purpose of adducing the strongest evidence of its aptitude as regards the purpose for which it was intended. It should be also noticed that it is a curve through which a trocar can be introduced with facility; indeed the tube here represented is the very one which was employed with the trocar at the time of operation, and has been used by the patient during at least four years out of the six."

Mr. Hilton treated this patient, upon her re-admission, on the tonic and restorative plan, and she left the hospital in a month, greatly improved, and in what might be considered, for her, good health. It is thus clear that a canula can be worn for years under the most unfavourable circumstances, and it is also evident that this patient could not have lived without the performance of the operation, seeing that the larynx is now almost completely closed. This case might also allay the fears of those who advocate tracheotomy in epilepsy, as it is proved that a canula can be worn without danger for a considerable length of time.-Lancet, July 16, 1853, p. 57.

82.-ON TRACHEOTOMY ABOVE THE THYROID ISTHMUS, ILLUSTRATED BY A CASE.

By DR. CHARLES EDWARDS, A.B., Cheltenham.

The space operated in, which I shall term subcricoid, is bounded above by the cricoid cartilage, and below by the isthmus of the cricoid thyroid gland. It is about one-fourth of an inch in extent. Ink a line precisely over this space, and draw it up over the thyroid cartilage, upon which incise the retracted integuments; you thus obtain a strictly rectilinear and median incision.

Next, get clearly the cricoid cartilage and a ring of trachea below; take now a steel director grooved throughout, one extremity of which passes off from the open groove, with a short tenaculum curve, as figured in the diagram; pass this curve beneath the lower margin of the cricoid cartilage, and hook the latter well forward and upwards, in this way, rather than by "pressing the larynx" as advised by Mr. Maclise, steadying the trachea.

Now pass into the groove of director the point of a strong narrow scalpel, which thus cannot slip to either side during any convulsive movements of the trachea, but immediately pierces it, thus rendered tense. Should the thyroid isthmus or any pulsating vessel be in the way below, the puncture should barely admit the extremity of a probe-pointed bistoury, in which case introduce the bistoury on the grooved tenaculum into the trachea with its back to the cricoid cartilage, and in a subcutaneous fashion you can divide as many rings of the trachea from within outwards, underneath the isthmus, as may be necessary to admit the tracheal tube without carrying it so far forward as to wound the isthmus, or even drawing it down. The introduction of the tube in this limited space will be much facilitated by the same directing and fixing tenaculum, and the distension of the more superficial parts, by its introduction, will prevent a drop of blood entering the trachea.

Finally, with respect to the shape of the canula, it is well apprehended that a straight tube will press and irritate the posterior wall of the trachea; but I would here especially observe that curved tubes, if short, are easily displaced by coughing, &c.; or else secured by a ligature so tight round the neck as to obstruct the cervical circulation. If sufficiently long to be retained by moderate fastening, they alike objectionably press against the anterior wall. (See illustrative diagram.) A further

A

B

A. Lateral view of directing tenaculum.

B. Posterior view of ditto, showing the groove.

objection, common to both the straight and ordinarily curved, is, that from the position of their extremities against the tracheal parietes, neither air nor mucus can freely pass through either tube.

All these difficulties may be met by using an elbow-shaped, obtuse-angled tube, the angle being at the juncture of the upper with the middle third, which, as shown in the engraving, will simply lie in the axis of the trachea.

B

EA. Straight canula.
EDC. Curved tube.

D

E

EDB. My obtuse angled ditto.

I will now subjoin my case of operation, so far as it has gone, trusting that the above practical points may be use ful to parties called, as I was, to operate without a moment's warning.

On Sunday night, at nine p.m., Mr. Groves, a respectable tradesman, had a rapid succession of epileptic fits up to eleven o'clock; had, it appears, been left by his then medical attendant. At eleven I was summoned to take charge of the case. The laryngismus was terrific; and he, being a Roman Catholic, now in a short comatose interval, had I received the last rite of his church.

In consultation with Dr. Allendyce, after trying every possible expedient till one a.m., I proposed tracheotomy. The only question was, whether, after the measures already adopted, it was worth while to risk the character of the operation on a case so utterly hopeless. I operated by candlelight, at half-past one a.m., during a short comatose interval of regularly cumulative-shall I say culminating?-laryngismus tending to asphyxia.

For the entertainment of Dr. Radcliffe, I now enumerate the following facts:1st. The fits, the recurrence of which we could have predicted almost to a minute, immediately ceased. Whatever congestion might have caused them, there was no inflammation to remove them. But there was the shock of the operation! Would Dr. Radcliffe's physiology propose to the profession any operation equivalent in shock and sequelae in any other part of the body as equally anti-epileptic? If the locality establishes the difference, that local operation-tracheotomy-is the cure.

2ndly. He was operated upon in a state of insensibility; ergo, the cessation of the fits was not, at least, the result of HIS FAITH.

3rdly. This case does not "prove too much," as Mr. Cane has stated, as abortive fits have occurred every day, except Wednesday; nor yet too little, as they stand in strange contrast with the former, continue but for a few moments, are not even trachelean, and frequently allow the patient instantly after to resume his conversation- strictly as yet, and scarcely, the petit mal.

4thly. Their recurrence or absence concurs so regularly with the clogging or cleansed state of the canula, that their frequency or otherwise might be almost fixed beforehand by the amount of attention to the tube. This will account for Dr. Verga's case of fistula co-existing with epilepsy. Was the fistula always fully patent? And besides, "he died of tabes;" not, then, of epileptic laryngismus!

5thly. I have had as yet no consecutive fever to control or diminish the fits. His most tranquil and cordial days have been his least fitful.

Finally, I would observe that to attribute any one thing possibly to any other thing is probably easier to some minds than to offer a theory philosophically founded, and likely to issue in the saving many lives; nay, easier than even to wait till time and experience establish or otherwise the relation of cause and effect between laryngismus-not epilepsy-and its cure by tracheotomy.

P.S. Tuesday, May 17th, 1853.-Patient has had no fit, abortive or otherwise, since Saturday evening, seven o'clock; walks abroad and follows his usual employment. In fact, since a properly patent canula has been used and kept cleaned, up till last date, May 14th, his slight epileptic abortions were gradually yielding, and since gone.-Lancet, May 28, 1853, p. 492.

ALIMENTARY CANAL.

83. PERMANENT CURE OF REDUCIBLE HERNIA.

BY DR. GEORGE HAYWOOD, Boston, Massachusetts.

[A committee appointed to inquire into this subject, after a careful examination thereof, came to the following conclusions:]

1. That there is no surgical operation at present known, which can be relied on with confidence to produce in all instances, or even in a large proportion of cases, a radical cure of reducible hernia.

2. That they regard the operation of injection by the subcutaneous method as the safest and best. This will probably in some cases produce a permanent cure, and in many others will afford great relief.

3. The compression, when properly employed, is, in the present state of our knowledge, the most likely means of effecting a radical cure in the greatest number of cases.

[In an appendix to their report, one of the committee, DR. MASON WARREN, describes an operation proposed by DR. PANCOAST for the radical cure of hernia.]

The contents of the hernial sac being returned into the abdomen, and the ring explored to ascertain that no portion of the intestine protrudes, the pad of a wellfitting truss is slipped down so as to make pressure on the inguinal canal, and prevent any escape of the hernia. With the forefinger of the left hand the spermatic cord, as it passes out from the external inguinal opening, is pressed upwards on the pelvic bone, so as to prevent it from being injured. A delicate trocar and canula, the latter having fitted to it a small Anel's syringe, is now carefully but firmly forced through the integuments with a rotatory motion to facilitate its progress, and pushed forward till it enters the external inguinal ring or neck of the sac. The trocar being now withdrawn, the canula is kept firmly in place, and twenty or thirty drops of the tincture of iodine, tincture of cantharides, or sulphuric ether, thrown in and lodged in the neck of the sac, when this is practicable, or else in the vicinity of the external abdominal ring. Subsequently to the operation, a small compress is applied over the minute wound made by the trocar, the pad of the truss slipped down over it, and the patient directed, for a week or two, to maintain the recumbent position.

In addition to the injection, in some of the operations, a tenotomy knife was previously introduced, and the internal surface of the neck of the sac scarified. The wound made by the knife in these cases much facilitated the subsequent introduction of the trocar, which is with some difficulty worked through the integuments.

In no instance did any bad result follow the operation-the pain and inconvenience hardly amounting to that presented in a case of hydrocele treated by injection, or in any simple operation.

The following case, attended with success, will serve as an illustration of the course generally pursued:

A male child, three years of age, with congenital inguinal hernia of the right side, was brought to the Massachusetts General Hospital to obtain relief, if it was possible, as no truss had been found to retain the protruded intestine in the abdomen, and the pain and inconvenience from the infirmity was great. On examination, a tumour, the size of a small orange, was found to occupy the scrotum. By a little manipulation, the contents were ascertained to be a portion of omentum, a loop of intestine, and the testicle-the whole of which, by care, could be easily returned into the abdomen.

The question which first presented itself was, whether the testicle could be separated from the other parts, the adhesions being quite intimate between them, so as to admit the return of the intestine and omentum into the abdomen, leaving the testicle in the scrotum. This being determined, the operation was performed as follows:-The intestine and omentum being returned into the abdomen, and the testicle prevented from following, the spermatic cord was held out of the way in the manner stated above. A subcutaneous incision was then made by a cataract knife, the point of which was carried into the sac, and the neck scarified in different directions. Through the aperture thus made, a small trocar and canula were intro

duced; the former being withdrawn, the syringe was adapted, and thirty drops of sulphuric ether were injected. The truss was now applied.

The operation was performed on October 28, 1847, and there was every prospect of success, when, from a violent paroxysm of crying, the hernia was forced down on December 9. On the 12th, the injection was repeated, and resulted, on the following day, in a swelling of the scrotum, such as is observed after the injection for hydrocele. On December 22, the report was made that the hernia came slightly down, and was returned with difficulty, "the aperture being apparently quite small." By the end of the month, it was stated that the hernia was perfectly retained.

I have been informed by an individual who saw the patient a year afterwards, that the cure was permanent.

During the treatment of this case, a slight suppuration took place under the pad of the truss, which, the patient being somewhat fractious, was necessarily applied pretty firmly to prevent the recurrence of the hernia after the operation.

In a large proportion of the other cases operated on, the patient experienced much relief, though still obliged to wear a truss. In one case, where the hernia was quite large, no relief was experienced. A female, with a double femoral hernia, on whom the scarification and injection were once or twice repeated, expressed herself much benefited by the operation, the hernia being retained, and the suffering previously experienced much relieved. Another patient, a labouring man, was seen by me six months after the operation; the rupture had not recurred, but he still wore a truss. Previous to this time he had not been able to work without forcing down the intestine under the pad, causing so much pain and ill health as to have induced him to come to Boston for relief.

Some allowance for the want of perfect success in the above operations must, of course, be made from the tentative mode in which they were performed through fear of a serious result.

From a comparatively limited experience, I derive the following conclusions : 1. That the operation, when carefully performed, is safe.

2. That in ruptures where the neck of the sac is small and the abdominal aperture not too much enlarged by repeated descents of the hernia, there is a prospect of a radical cure.

3. That, in most cases, the operation mitigates the infirmity, allowing the hernia to be more readily retained by the ordinary mechanical means.

[DR. SAMUEL PARKMAN stated that he had seen operated upon four cases of hernia for their permanent cure.]

The first case was in January, 1848; the second and third in September, 1849; and the fourth in October, 1851. The hernia were all inguinal. The method employed was scarification of the pillars of the ring and adjacent parts, with injection of tincture of iodine, by means of a syringe armed with a point at the nozzle. The precise situation where the fluid was thrown I believe it to be impossible to determine. It is clearly more probable that it should have been into the cellular tissue around the neck of the sac, than into the sac itself. In all the cases I compressed the canal to prevent communication with the peritoneal cavity. Rest in the horizontal position was enjoined, and a bandage applied. Some tenderness and swelling resulted in all the cases.

The first patient considered himself relieved, that is, he felt that the hernia descended with more difficulty.

The second and third cases presented no marked results.

The fourth case is worthy of note:

A healthy man, twenty-five years of age, stated that the right testicle did not descend until his tenth year, and was then followed by a hernia. This hernia had always been reducible, but the testicle was returned with it. A truss had but imperfectly retained the hernia, and he was desirous of relief if possible. On examination the ring appeared very large, and coughing or straining produced the descent of a mass the size of a goose-egg, on the front of which was the testicle, which could not be separated from the hernia proper. I proposed to retain the whole mass, and with this view, between the 29th October and 10th November, I did four separate operations, each time scarifying the pillars of the ring and injecting tincture of iodine. Each operation was followed by an effusion into the parts, and