ootol THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF SAN FRANCISCO COUNTY MEDICAL SOCIETY rrv 'fri.UL^ JVU/Lae-iryv. ll^i^i^'>^ . > km::hjx CROUP, IN ITS RELATIONS TO TRACHEOTOMY. BY J. SOLIS COHEN, M.D., LECTURER ON LARYNGOSCOPY AND DISEASES OF THE TUKUAT AND CHEaT IN JEFFERSON MEDICAL COLLEaE. PHILADELPH lA: LINDSAY & BLAKISTON 1874 REPRIXTED FROM THE TRAXS!ACTIOXS OF THE MEDICAL SOCIETY OF THE STATE OF PEXXSYLVANIA. PHILADELPHIA ! COLLI. VS, PRINTER, 705 Jayne Street. Biomedical Library Tnrs essay was read before the Philadelphia County Medical Society, .lanuar}' 14, 1874 ; referred by that Society to the Medical Society of the State of Pennsylvania ; and b}- the latter Society, ordered to be printed in their Transactions for the current year. It is based on a careful study of the published records of more than live thousand cases of Tracheotomy in Croup, performed in various portions of the world. 624198 CROUP, IN ITS RELATIONS TO TEACHEOTOMY. By Croup I mean exudative injiammation of the air-passages. Its relations to tracheotomy, as portra3'ed in this paper, include sthenic croup, or croup proper, and systemic croup, or the croup of diphtheria ; but take no cognizance of traumatic croup, or that variety of exudatiA-e inflammation wliich ensues on the contact of ammonia, hydrochloric acid, and other vesicants. These three spe- cies of croup have one manifestation in common: the deposition of a pseudo-membrane, which appears to be identical physically, chem- ically, and microscopically. The demand for aid to respiration is as urgent in diphtheritic as in sthenic croup ; though, for obvious reasons, the ultimate success from an operation cannot be as great. Tracheotomy for croup is generally regarded with much disfavor in this city. Its results in Philadelphia have been less encouraging than almost anywhere else ; probably because, as a rule, the opera- tion is postponed too long ; possibly because our medicinal treat- ment of croup cures a number of cases which, under less efficient management, would become subjects for tracheotomy ; but, what- ever the cause, the results, in the comparative!}' few instances in which the operation has been performed, have been so dishearten- ing, that many practitioners refuse to sanction tracheotomy in croup under any circumstances. This radical feeling is wrong. Not only should our individual experience be utilized in judgment, but the recorded experience of others also. Early failures may be followed by ultimate successes. Barthez, in a letter to Rilliet' on the comparative results of the treatment of croup by tracheotomy and by medication during the years 1854-1858, ' Gaz. hebd., Dec. 2, 1859; Brit and For. Med.-Chir. Rev., April, 1860; Am. Journ. Med. Sci., July, i860. 6 CROUP IN ITS RELATIONS TO TRACHEOTOMY, stated" that the first year the Hopital Sainte-Eugfenie was opened, 13 croup patients were submitted to tracheotomy, of whom the first died during the operation, and 11 others in succession after the operation ; the first recovery taking place in the thirteenth case. Yet Barthez had many successes after- wards ; for in a letter published in 1868,' he stated that in the same hospital, between the years 1861-1867, 785 cases were operated upon, with 222 recov- eries. Guersant lost his first 23 cases, between 1834-184] ; but after that saved 17 out of 82. ^ Trousseau, up to 1842, had operated 119 times, with but 25 recoveries ; but at a later date (1854) he reported 222 operations with 127 recoveries." Similar examples of early want of success followed by re- sults truly gratifying are on record. But there have been results even worse than these. Thus Trousseau, in a discussion on tracheotomy in croup, be- fore the Academy of Medicine, in 1858, mentioned,^ that in the earlier days of the operation, Gosselin, Deguise, Huguier, Jarjavay, and Monod, Jr., of Paris, performed 95 operations successively without a single recovery ; that Alphonse Guerin, Michon, Laugier, Robert, Nelaton, Lenoir, and Depaul saved but 11 cases out of 117 operations ; and Velpeau, Jobert, and Desor- meaux but 16 out of 84. He attributed much of this want of success to the idea then prevalent that the surgeon's duty ended when he had opened the trachea. That tracheotomy saves many cronp-patients from death other- wise inevitable, and that, too, even under unfavorable circum- stances, there has long been no reason to doubt: there is little doubt, either, that patients are occasionally tracheotoraized unne- cessarily ; but the proportionately small number of such instances, whether errors of judgment or errors of prudence, is, in all proba- bility, insignificant in comparison with the number of patients saved by the operation from certain death ; life being preserved in the one instance, while it is not sacrificed in the other. Tracheotomy, in itself, docs not cure croup. It affords a possi- bility' of recovery by postponing, or insures it by averting death. The course of the disease is continued until all its attendant phe- nomena have undergone evolution. The surgeon's knife merely cuts a path for air to reach the bronchi in quantity sufficient for the requirements of the respiratory process, and saves the muscular force, exhausted in futile efforts at respiration through the glottis. Is it not possible that the freedom of breathing, and consequent ' Gaz. m^d. de Paris, 1868, p 449 : in reply to a statement of VacLer. 2 Bouvier ; Bull. Acad, de med., xxiv., 1858-9, pp. 188 and 192. In his Chi- rurgie des Enfants, Paris, 1864-7, Guersant says he saved but 2 out of his first 33 cases. Friedreich, in Virc-how's Handbuch der speciellen Pathologie uud Therapie ; Erlangen, 1858, Bd. v., states that Guersant saved 31 out of 91 cases operated on iu hospital and private practice. 3 Fried reicli, op. cit., p. 454. < Bull. Acad, de med., xxiv., 1858-9, p. 230. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 7 conservation of strength, would aid the system to resist the full effects of the development of the disease, in the further production of exudation, or its plastic deposition upon the bronchial mucous membrane? Then the artificial opening affords a better ilieans of escape for the false membrane, whether dispelled by cough or re- moved by instruments inserted through the wound ; it enables a more efficient application of local remedies to retard the congelation of the exudation into iBcmbranes or casts; and thus fticilitates the discharge of the plastic material by cough. In short, it gives the patient a chance, offered by no other means, to live and fight through the development and decline of the disease. On the other hand, in some unhappy examples tracheotoni}'^ has been only a prelude to the post-mortem examination; while a number of instances are on record in which death occurred during its per- formance, even under the hands of skilful and experienced ope- rators. The chief objections to tracheotomy, apart from its infrequent success, — which, nevertheless, is as proportionately great as that in many so-called capital operations considered fully justifiable, — are certain accidents incident to the operation itself, and the methods of treatment after it. To these, attention will be given in a subse- quent portion of this paper. Modern medical literature teems with statistics as to the results of tracheotomies for croup ; some presented in units, some in tens, some in hundreds, and some in thousands. Hundreds of individual cases have been recorded, with more or less detail. Their study leads but more and more to the conclusion that in croup, as in many more purely surgical affections, the decision as to the pro- priety of the operation must be made with reference to the indi- vidual case in question, rather than with regard to the proportionate number of recoveries reported in the journals. Though the operation had been suggested by Asclepiades, it was not until 1782 that the first successful tracheotomy for croup was per- formed by John Andree,* in London. The second was by Thomas Chevalier, of London, in 1814." Bretonneau followed in France, and after two unsuccessful cases in 1818 and 1820 respectively, per- formed a successful tracheotomy in 1825. In 1829 Prof. Stolz per- ' Farre ; Appendix to a paper on Cynanche laryngea, Med.-Chir. Trans., iii. 1812, p. 335. (Borsieri ; tome iv. Angina trachealis, § ccccxsxvi.) Trousseau ; Clin. Med., Sydenham Soc. Trans., vol. ii. p. 594. ^ Account of a case of Croup in which the operation of brouchotomy was suc- cessful, Med.-Chir. Trans., vi. 181G, p. 151. 8 CROUP IN ITS RELATIONS TO TRACHEOTOMY. formed the first operation in Strasbourg.^ Trousseau reported his first successful case in 1833 f and remained the most zealous advo- cate of the operation during his entire life. Success prior to 1850 was comparatively infrequent. About that period a greater amount of care began to be taken in the performance of the operation, and in the details of the after-treatment; in con- sequence of which, the ratios of success soon became much larger. A number of collections of statistics, culled from various duly acknowledged sources, and comprising several thousand cases, is herewith presented. Most of them deal with generalities only ; but some of them are accompanied with references to recorded details which can be consulted with more or less satisfaction. The writer will be glad if any of his readers, who have facilities for so doing, would perfect these statistics and publish them. A complete record from the two Parisian Hospitals for Children, if officially correct, would be of great value. The notes appended to some of these statistics, referring to other figures representing the same sources, show how little they can be depended upon for rigid investigation. It is not an easy matter to estimate the comparative value of sta- tistics. Isolated records of individual operators do not represent the full number of scattered recoveries, and still less the full number of scattered deaths; but, inasmuch as successes are more apt to be heralded than failures, the actual proportion of recoveries in the hands of those who are only occasionally called upon to perform the operation, is perhaps less than would appear from an exhibit of statistics of this class of records. The private statistics of operating surgeons who keep records of all their cases, and the statistics of hospitals, when officially correct, are the onl}^ ones of real value in this connection, taking cognizance of figures merely. Hospital cases in themselves, as a rule, offer less chance of recovery than cases in private practice, though the opei-ation is frequently performed better, and the after-treatment is much more assiduous. The general character of the run of cases has a like influence on both classes of cases ; but the hygienic condition of the patient, the period of the disease at which it comes under observation, and the character of the previous treatment, considerations of great importance with reference to results of tracheotomy, are much less favorable in hos- pital practice. Hence we find the percentage of mortality varying from 60 per cent, in some seasons, to 90 per cent, in others. » Gaz. med. de Strasbourg, Dec. 31, 1867, p. 295. 2 Journal des Connaissances medico-chirurgicales, 1 Sept. 1833. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 9 Bartliez says,' '• AVhat gives great value to the results obtained in hospitals is, that the greatest number are brought to the hospitals after the failure of medical treatment; and many of them in such a condition that death is nearly or quite imminent. Sometimes our assistants have hardly time enough to prepare their instruments for operation: there is great emergency ; and all those saved by the operation under such circumstances are simply snatched from certain death." But how are we to estimate the percentage of recoveries in despe- rate cases without tracheotom}' ? how estimate the percentage that die for want of tracheotomy ? how estimate the number of awkward tracheotomies ? how estimate the number of deaths due directly to the operation itself, or to untoward circumstances that follow it? how estimate the number operated upon when half dead, or in articulo-mortis ? how separate the causes of death after tracheotomy; whether incident to the disease, to previous exhaustive treatment, to the operation itself, to inefficient after-treatment of the wound or of the disease ? These are important questions in connection with a correct ap- preciation of the value of tracheotomy ; but they cannot be satis- factorily answered. Statistics from French Sources. In a discussion which took place in the Parisian Academy of Medicine in 1839,^ the following results were presented : — Operators. Araussat No. of Tracheotomies. . 6 Recoveries. Baudelocque Blandin . 15 . 5 Bretonneau^ . 18 4 Gerdy . Roux . . G . 4 4 Trousseau* . . 80 20 Yelpeau* . 6 140 28 A still less favorable exhibit was alluded to by Malgaigue in another famous discussion before the Academy in 1858 : — ^ ' Gaz. med. Paris, 1868, p. 449. 2 Bull, de I'Acad. de med. for that year ; and again for 1858-9. 3 Later statistics concerning Bretonneau give 20 operations and recoveries. Am. Journ. Med. Sci., April, 1849, p. 335, Meigs. Bouchut ; Slade on Diph- theria, 1861, p. 72. ' Meigs, Am. .Journ. Med. Sci., April, 1849,p. 331, quotes Trousseau as having at that time (1849) saved 27 out of 119 ; and p. 335, Velpeau, 2 out of 10. 5 Bull, de I'Acad. de med., xxiv. 1858-9, p. 168. 2 10 CROUP IN ITS RELATIONS TO TRACHEOTOMY. Operators. Gosselin No of Tracheotomies. . 23 Recoveries Michon , , 20 2 Laugier 8 1 N61aton | before 1848, I after " 23 I 13 1 gg f before 1848 1 after " l]^ Monod, Jr. . . . (about) Theirry . . (in children) " . . .(in adults) Malgaigne 40 37 3 8 (or 10) 3 1 heotomief. Recoveries. 57 17 6 3 13 4 17 8 21 8 3 2 3 1 6 3 2 1 9 ft 4 3 5 2 175 10 During this latter discussion, Trousseau presented the following additional statistics ;' — Operators. No. ofTri Bardinet (and confreres at Limoges) Saussier (Troyes) . Beylard (Paris) Moynier^ (Paris) Archarabault^ (Paris) Perrochaud (Boulogne) Delarue (Paris) Lalois (Belleville) . Yiard (Montbard) . Petel^ (Gateau) Baudin (Nantua) Dubarry (Condom) . And Trousseau adds as a separate list showing results better than those achieved at an earlier date.* ' Bull, de I'Acad. med., xxiv. p. 231. See also Gaz. hebd., Dec. 3, 18.58, p. 844. 2 Dr. Eugene Moynier, in a monograph entitled "Compte rendu des fails de diplitheiie observes dans le service de M. le Professeur Trousseau, pendant le premier semestre de I'anne 1859," reprinted from tlie Gaz. des hop., states that he had performed the operation 25 times with 11 recoveries ; 20 times with 8 recoveries in hospital, and 5 times with 3 recoveries in private practice. See Union med., Jan. 1866. 3 Later statistics furnished by Archambault in discussions at the Societe medicale des hopitaux de Paris, in 1867 (Bulletins at Memoires de la Societe, etc., t. 4, 2me ser. 1867, p. 185), sum up two unsuccessful cases in adults, and 22 recoveries out of 65 tracheotomies in children ; all in private practice ; 55 of them operated upon in the period of asphyxia ; most of them at the last ex- tremity ; some of them sufficiently insensible to enable him to operate without assistance. The details are exhibited at p. 201. See also Gaz. des hop., 1867 ; Ed. Med. Jouru., Nov. 1867 ; Am. Journ. Med. Sci., April, 1868. " Concerning 6 of these cases with 3 recoveries, consult Journ. des Conn, med.-chir., Oct. 1841 ; Am. Journ. Med. Sci., April, 1842, p. 472. 5 Bull, de I'Acad. med., xxiv. p. 233. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 11 Operators. No. of Tracheotomies. Recoveries. Richet . 9 5 Follin . 7 2 Broca . 12 6 Richard . . 5 2 Deraarquay . 6 2 185 74 HoPITAL DES EnPANTS MaLADES. Previous to 1849 the operation had been performed 49 times in this hospital, with only one recovery.^ The success immediately after 1849 was in remarkable contrast, as will be seen by the following exhibit: — ^ Years. 1850 1851 1852 1853 1854 1855 18563 1857^ 1858 1859 1860 1861 (10 months) 1862 . acheotomies. No. of Recoveries. 20 6 31 12 59 11 61 < 44 11 48 10 55 14 71 15 90 30 164 40 130 23 82 25 136 29 991 233 ' Trousseau, Union niedicale, Aout, 1851. See Nos. 2, 5, 19, 21, 23. 2 The statistics for 1850-1857 are from H. Chaillou, Am. Journ. Med. Sci., July, 1858, p. 251; for 1858 from Bouvier, Bull Acad, med., xxiv, 1858-9, p. 191 ; for 1859-1861 from Haughtou, Trans. Indiana State Med. Soc. 1867, p. 125 ; and for 1862 from Barthez,Gaz. med. Paris, Aug. 1, 1868, p. 449. ? For details concerning this year, see thesis of Andre, Du traitemeut des cas de croup observes k I'hopital des Enfans en 1856, Paris, 1857, which gives 15 re- coveries out of 54 operations. His observations were made in the male wards. See, also, Bull, de Therap., May 30, 1857, p. 471, with table ; Brit, and For. Med.-Chir. Rev., July, 1857; Amer. Journ. Med. Sci., Oct. 1857. * Millard, in a thesis, " De la tracheotomie dans le cas de croup," Paris, 1858, based on observations in the female wards during his service, made between January, 1857, and July, 1858, gives a result during that period of 21 recover- ies among girls out of 62 operations, and 8 recoveries among boys out of the same number; the sum total being 124 operations and 29 recoveries. Of 20 operated upon under 2 years of age, none recovered ; of 36 between 2 and 3 years, only 5 recovered ; the remaining 24 recoveries being in children between 3 and 9 years of age. In a letter in answer to some strictures of Malgaigne (see No. of Operations. No. of Recoveries. . 539 131 . 474 133 12 CROUP IN ITS RELATIONS TO TRACHEOTOMY. MM. Fischer and Brichetau' give the following table as the re- sults in this hospital for the 12 years, 1851-1863: — On boys On girls 1013 264 HopiTAL Sainte-Eugenie. Barthez, in a letter'- to Rilliet on tlie comparative results of the treatment of croup by tracheotomy and by medication, during the years 1854-1858, states that the first year after the Hopital Sainte- Eugenie was opened, 13 cases were operated on with but one suc- cess, and that the last of the series. Meanwhile 4 cases recovered that were not operated upon: 13 operations, 1 recovery. The next 3'ear, of 18 cases 4 recovered; in two of which the operation had been performed: operations 16, recoveries 4.* In 1856 there were 18 cases and 4 recoveries, of which 3 had been operated ou. In 1857 there were 33 cases with 9 recoveries, 7 of Avhich had not been operated on ; and of these, two had been sent back from the ope- rating table to await further result from medical treatment; while of 22 operated on, only 2 recovered : operations 22, recoveries 2. In 1858 there were 124 operations with 18 recoveries, and 30 recover- ies out of 62 cases not operated on: ojierations 124, recoveries 18. The following statistics are from Bouchut,* and are not in ac- cord witli this letter of Barthez as far as they go : — Bull, de I'Acad. med. 1858-9, and Gaz. hebd., Nov. 26, 1858, p. 826) he states that in but one of the.se cases was there no evidence of false membrane. Messrs. H. Roger and G. See, physicians to the same hospital, reported (see Gaz. hebd., Nov. 12, 1858, p. 789 ; Nov. 26, p. 817; and Bull, de I'Acad. med., xxiv. pp. 115 and 125) some observations based upon nine years' practice in the hospital, from June 1, 1850, to Oct. 15, 1858. The whole number of croup cases was 562 ; the number of operations 466 (incorrectly stated in many jour- nals as 446); recoveries after operations 126 ; recoveries without operation 49. They mention that 25 cases were saved out of 39 operated on before complete asphyxia had occurred. The proportion of recoveries in children between 6 and 12 years of age was 44 in 100. In several articles I have read, these statistics of operations and recoveries are incorrectly attributed to the personal experience of Trousseau. ' Traitement du Croup, ou Angiue laryngee diptheritique. Second edition. Paris, 1863. Giirlt's Jahresbericht, p. 563, in vol. viii. Arch. klin. Chir. 2 Gaz. hebd. Dec. 2, 1859; Brit, and For. Med. -Chir. Rev., Apl. 1860; Am. Journ. Med. Sci., July, 1860. ' Bouvier, Bull. Acad, med., xxiv. p. 192. •• Traite Pratique des Maladies des Enfants, etc. Paris, 1862, p. 277. CROUP IN ITS RELATIONS TO TRACHEOTOMY, 13 Years. No . of Tracheotomies. No. of Eecoveries 1854 (March 15 to December 31) 6 1855 . 9 3 1856 . 13 5 1857 . 25 6 1858 ..... . 119 21 1859 . 123 20 1860 . 55 7 1861 (January 1 to April 30) . 24 2 374 64 Then we have the following figures' from Bourdillat,'^ the house surgeon of Bergeron : — Years. No. of Tracheotomies. 1860 . . 55 1861 . . 76 18623 , . Ill 1863 . . 112 1864 . . 121 1865 . . 147 1866 . . 129 1867 (first 6 months) . 62 1867 (second 6 months ') . 40 853 Barthez' gives the following figures: — Operations. For 1861-1867 . . . .785 And for 1866 and 1867 . . 223 Taking Bouchut's list from 1854 to 1859 Boiu-dillat's list from 1860 to 1867 . Sanne's« list for 1868 . And Vaslin's list for 1869? . We have a total for 15 years of . As the results of Sainte-Eugenie. No. of Recoveries. 8 13 22 34 15 46 45 25 8 216 Recoveries, 222 79 Operations Recoveries . 295 55 . 853 216 . 83 18 . 30 10 1261 299 ' Statisque pour servir a I'histoire de la tracheotomie. Gaz. des hop. Paris, 1867, No. 89. 2 Bourdillat had operated himself 16 times with 10 successes. These cases are described in the Bull, et Mem. de la Soc. med. des hop., Paris, 1867, p. 221. 3 Barthez, Gaz. med., Paris, 1868, p. 449, gives the following results: opera- tions 113, recoveries 24. * Bull, et Mem. Soc. med. hop. 1868, p. 38. 6 Gaz. med., Paris, 1868, p. 449. ^ Etude sur le croup apres la tracheotomie. Paris, 1869, p. 8. 7 Gaz. des hop., Mch. 5, 1870. Bergeron's wards. 14 CROUP IN ITS RELATIONS TO TRACHEOTOMY. of Operations. No. of Recoveries , 9 2 14 3 73 11 76 20 34 7 37 7 62 19 54 18 292 27 64 29 39 10 . 82 17 But it will be seen elsewhere, as in these exhibits, that the figures drawn by different observers from the same sources are by no means identical ; and therefore it is impossible to know what the correct figures are. It is for this reason that they have been displayed, with references for detailed informa- tion, without any attempt to add up the entire number of cases tabulated in this paper, which, however, without any doubling, amount to upwards of 5000. Sanne' gives quite a different list for some of these years, as follows : — Year. 1855 1856 1858 1859 1860 1861 1862 1863 1865 1866 1867 1868" Fischer and Brichetau* give the following schedule as the expe- rience at the hospital for the years 1854-1861: — No. of Operations. No. of Recoveries. On boys 225 38 " girls 171 29 396 67 To these may be added further statistics from French sources : — Operator. No. of T Trousseau^ (1851-4, private practice) Tsnard^ Baizeau' (Paris) .... BoeckeP (Strasbourg) Schcellhammer^ (Haut Rhin) . ' fetude sur le croup apr^s la tracheotomie, Paris, 1869, p. 49. 2 An uucorrected typographical error evideutly. * In his introductiou, p. 8, the figures for the year are 83 operations, and 18 recoveries, being the cases on the individual observation of which his volume is based. » Op. cit. 5 Arch. gen. de med., March, 1858, p. 259 ; of these, in 1854, 9 operations, 7 recoveries. 6 Union med. 1859, 47. ^ Gaz. des hop., 1867, p. 397. 8 De la tracheotomie dans le croup. Strasbourg, 1867. Reviewed in Gaz. med. de Strasbourg, Dec. 31, 1867, p. 295 ; with details of these 33 personal cases. 3 Boeckel, op. cit. acheot omies. No. of Recoveries. 24 14 4 2 12 4 33 12 7 6 43 16 23 13 8 4 CR0T3P IN ITS RELATIONS TO TRACHEOTOMY. 15 Operator. No. of Tracheotomies. No. of Recoveries. (Other operators)! .... Calvet* (Castres) .... Henriette' (Brussels) 154 71 Dr. P. M. Braidwood, in an article on " Tracheotomy in the Treatment of Croup and Diphtheria,"* sums up, but without giving any references, 922 cases with 345 recoveries, at the hands of various operators whose names are given. They are all included in the exhibits in this paper, with the excep- tion of a result accredited to Barthez (Paris) of 110 recoveries in 142 cases. It is likely that these cases, or most of them, are included in the statistics presented from the Sainte-Eugfenie Hospital ; though the unusually large proportionate number of recoveries would rather indicate operations in private practice. In an extensive course of research, I have not elsewhere come across this series of Barthez, and am, therefore, unable to verify it ; though as far as my memory serves, all the remaining statistics have been verified by my own researches, which would indicate that these figures are correct also; but being so disproportionate to anything else I have seen, it has not, for the reason intimated, been included in any of the lists. Guersant^ stated in 1864, that he had performed in all 156 opera- tions with 28 recoveries; but that previous to 1845, up to which time he had used a single tube and had not employed a cravat, lie had saved but 2 cases out of 32 operations. His results would be as follows : — Between 1834 and 1845 No. of Operations. . 32 No. of Recoveries. 2 After 1845 . . 124 26 156 28 He also stated that he and his assistants had performed, in hospital between the years 1850 and 1861, 781 operations with 191 recoveries. ' Boeckel, op. cit. 2 Reflexions suivies de quelqnes observations de traclieotomie dans la derniere periode du croup. La Revue medicale de Toulouse. 8 successes out of 15 opera- tions performed between May, 1864, and April, 1866. See remarks by Arruand Key ; Le raouvemeut medical, March 29, 1868, p. 151. Also a report (verbal) by Giraldes ou the whole number, Gaz. hebd. 1868, No. 43, p. 685. 3 Presse med. Beige, No. 34; Med. Times and Gaz., Sept. 18, 1860, p. 247. ^ Liverpool Med. and Surg. Rep., iii., Oct. 1869, p. 9-16. 5 Gaz. des hop., 1864, p. 99. See also Med. and Surg. Rep., Philada., 1864, p. 9, from Brit. Med. Jouru. 16 croup in its relations to tracheotomy. Statistics from Spanish Sources. Operator. No. of Tracheotomies. No. of Recoveries. daSilva' 14 4 Barbosa' In 6 Carvalho' ..... 3 1 (Other operators)' ... 6 1 38 12 Only one child under 4 years of age was saved, and none between the ages of T and IT years. Statistics from Germanic Sources. Operators. No. of! Uhde^ and others (Braun- schweig) .... Klihn^ and his collected statistics .... Fock^ and others (Magdeburg) 1856-1861 .... Simon^ (Rostock) Burow^ (Kbnigsberg) . ' Barbosa ; Memoria sobre a Tracheiotomia uo Garrotilho ; Lisbon, 1S63. Brit, and For. Med.-Chir. Rev., 1864, p. 63; Union m6d., 1864, p. 362; Giirlt's Jahresbericht, p. 564, in vol. viii. Arch. klin. Chir. 2 Zusaiumenstellunf!: der in F^erzogthum Braunschweig vom Nov. 23, 1720, bis zum Apl. 18t!9, ausgefiihrten Luftrohrenschuitte. Arch, fiir klin. Chir., xi. 1869, p. 743. Death occurred during the operation in 5 cases ; in a few min- utes, in 7 cases ; within twenty-four hours, in 18 cases ; between the second and third day, in 18 cases ; and between the fifth and eighth day, in 4 cases. 3 In Giinther's Lehre von den blutigen Operationen ; Leipzig and Heidelberg, 1864, vol V. These are collected from individual reports, and include French and other records ; and doubtless a large number of them represent cases in- cluded in other tables in this exhibit. Tlie proportionate number of recoveries is much larger than a promiscuous collection of individual and other records would show in my own hands. * Deutsche Klinik, 1861, p. 134. Of these cases 16 operations with 8 recov- eries were personal. Giirlt's Jahresbericht, p. 312, in Arch, fiir klin. Med. iii. See also for 24 operations and 10 recoveries, Deutsche Klinik, 1859, Nos. 23, 24, 25 ; Canstatt's Jahresbericht, iv. p. 391 ; Kiihn, op. cit. ; Brit, and For. Med.- Chir. Rev., July, 1860 ; Am. Journ. Med. Sci., Oct. 1860. It is likely that these statistics include among others those of Sendler, of Magdeburg, 5 operations and 2 recoveries, detailed in the Prilger Vierteljahrschrift, 1859, iv. p. 57. 5 Schmidt's Jahrblicher, 1868, Bd. 140, p. 238. 6 Deutsche Klinik, 1862, p. 382 ; Gurlt, op. cit., p. 226, Arch. klin. Chir., v. 1864. racheotomies. No. of Recoveries. 81 21 277 125 43 18 22 f 1 in an I fatal adult, 1 g 51 7 CROUP IN ITS RELATIONS TO TRACHEOTOMY. Operators. No. of Tracheotomies. Roser' (Marburg-) Burow, Jr.,21863(Kunigsberg) 7 infants and 1 adult Schmidt^ (Leipzig) Symwrhid* [St. Petersburg ?) Ebert,5 1859-1865 (Berlin) . Widerhofer,^ reported by, (Vienna) .... Hauner^ (Munich) Rinecker* (Wurzburg) At the Kinderspitale^(Prague) Busch'o (Berlin) . Molendzinski" (Lemberg) . Oelschloeger'2 (Danzig, 1856-1869) Billroth'^ (Zurich) Reiffer'^ (Frauenfeld) . Gliterbock,'* report (Berlin) 1861-1867 . Heuter"^ (Rostock) Steiner,'^ 4 years (Prague) [Jaffe,'^ report ? (Germany) Titanus'® (Amsterdam) Muller,2" 1862-1869 (Cologne) 42 15 4 13 19 17 ? 24 72 2 (1 adult) 12 12 18 100 29 52 I boys 33, 1 girls 19, 294 80 45 No. of Kecoveries. 19 2 2 6 2 2 6 10 1 I 34 7 18 j boys 11, I erirls 7. 65] 28 15 ' Sydenham Soc. Year Book, 1863, p. 278; GiJrlt, op. cit., 1861-2, p. 306, Arch. klin. Chir., iii. 2 Deutsche Kliuik, 1863, p. 58 ; Giirlt, op. cit. 3 Kiihn, op. cit. * Gurlt's Jahresbevicht, p. 562, in Arch. klin. Chir., viii. 5 Berlin klin. Woch., 1865, pp. 474-482 ; Giirlt, op. cit., p. 565. Results in the Kinderklinik der Charite, Berlin, from June, 1859, to March, 1865. See al.so Jaffe, Schmidt's Jahrb., 1868, Bd. 140, p. 210. ^ Giirlt, op. cit. Results in St. Annen-Kinderspitale, Wien, to Jan. 1864. ^ Giirlt, op. cit. Miinchen Kiuderspltale. ^ Ibid. Julius-spitales. ^ Ibid. '0 Ibid. Universitats-Klinikum, 1869. » Ibid. 12 Arch. klin. Chir., xi. 1869, p. 841 '•5 Arch. klin. Chir., 1869, x. p. 191. '^ Billroth, loo. cit., p. 193. '5 Arch, d Heilk., 1867, viii. No. 6, p. 516; Jaffe, loo. cit., 149, p. 222. '5 Zur Lehre von der Tracheotoraie, resp. cricotomie, und ihre Erfolge bei Diphtheritis ; Berlin, klin. Woch., 1869, No. 30 et seq. '7 Jahrb. d Kinderheilkunde, 1868, No. 1 ; Priiger Vierteljahr., 1868, iii. ; Am. Journ. Med. Sci., Oct. 1868. The details have been translated into English by Dr. John C. Jay, Am. Journ. Obstet., 1871, p. 583. '8 Braidwood, Liverpool Med. and Surg. Rep., iii., Oct. 1869. '9 Ibid. ^ Beitrag zur Statistik der Tracheotomie bei Croup. Arch. klin. Chir., 1871, p. 432. The general results are detailed with great oare. 18 CROUP IN ITS RELATIONS TO TRACHEOTOMY. Operators. No. Wilms/ 1861-1872 (Berlin) Frb'belius^ (St. Petersburg) Balassa' (Pesth) Pletzer'' (Bremen) Bartelss (Kiel) von Kopl^ Mcirath'' Stelzner^ (Dresden) f Tracheotomies No. of Recoveries . 335 103 2 2 2 3 1 . 61 17 . 17 11 1 1 . 12 4 Statistics from British Sources. Spence^ (Edinburg) Buchanan'" (Glasgow) . Cruickshank" H. W. Fuller'2 (report of) Vo. of Tracheotomies. No. of Recoveries . 87 28 . 39 13 . 11 8 7 3 • Bartels, Jahrb. f. Kinderheil. ; The Medical Record, N. Y., Sept. 1, 1873, p. 428. 2 Fetersb. med. Ztschr., xii. 4, 1867, p. 356 ; Jaffe, Schmidt's Jahrb., 1868, Bd. 140, p. 215. » Wieii. med. Woch., xiv. 1864, 18 and 19 ; Jaffe, Schmidt's Jahrb., 1871, Bd. 149, p. 217. « Hauuov. ZtscUr. 5, 1865 ; Jaffe, Schmidt's Jahrb. 149, p. 218. 5 Jaffe, ibid., p. 219, from Deutsches Arch. klin. Med., 1866, ii. 4 and 5. s Sitzungsberichteu des Vereins der Aerzte in Steiermark, Graz., 1870; Jaffe, loc. cit., 149, p. 332. ^ Ibid, 8 Jaffe, Schmidt's Jahresbericht, 1870, Bd. 149, p. 335. 8 Braidwood's table. Liverpool Med. and Surg. Reports, 1869, iii. p. 15. See also James Speuce, Cases of Tracheotomy in Croup, with clinical remarks. Ediu. Med. Journ., Feb. 1860, p. 693. Tracheotomy in Diphtheritic Croup. Ibid., March, 1864, p. 777. >" Brit. Med. Journ., March 4, 1871, p. 217. Also St. Andrew's Medical Graduates' Association Transactions, 1867, p. 161. During the seven years in which 31 of these cases with 11 recoveries had occurred, Dr. Buchanan had been called to 40 cases as an operating surgeon ; all of those not operated upon died. Dr. Buchanan, Brit. Med. Journ., March 25, 1871, p. 310, tabulates his 39 cases, of which 19 were under 4 years of age, two of whom recovered. This is an answer to a note from Vincent Jackson, Brit. Med. Journ., March 18, 1871, p. 278, uondeuiniug tracheotomy in patients under 4 years of age. See also note from C. E. Saunders, Brit. Med. Journ., April 1, 1871, p. 337. " Reynold's System of Medicine, vol. i. p. 101. Aitken's Practice, Philada., 1868, 1, p. 533. '2 Med. -Chir. Trans., 1857, xl. p. 39. Five (with postscript seven) cases of Tra- cheotomy in Croup, with remarks. See also Am. Journ. Med. Sci., April 1857, p. 525, from Med. Times and Gaz., Feb. 7, 1857. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 19 Conway Evans' . Henry Smith'^ (London) Eansom* (Nottingham) London Hospitals.* No. of Tracheotomies. No. of Recoveries. 5 1 . 3 . 3 Hospital. No. of Operations. No. of Recoveries. St. George's Hospital^ Dreadnought Hospital-Ship Metropolitan Free Hospital Hospital for Sick Children^ King's College Hospital The Middlesex Hospital St. Mary's Hospital Addenbrooke's Hospital (Cambridge) 1 1 170 57 6 3 1 1 3 1 1 1 Statistics FROM American Sources. Operators. No of Tracheotomies. No. of Recoveries. Physick^ (Philada.) 2 Pancoast^ " 9 4 Page'" 1 Smith" 1 Goddard'2 " 2 Hewson"' " 1 1 Edin. Med. Jouru., Nov. 1859, p. 397 ; Jan. 18(50, p. 618 ; May, 1860, p. 1008. On Tracheotomy in Croup. One death during operation. Am. Jouru. Med. Sci., Oct. 1859, p. 548. 2 Med. Times and Gaz., March 5, 1853, p. 244 (Ibid. Jan. 26, 1856) ; Am. Jouru. Med. Sui., April, 1856, p. 495. » Brit. Med. Journ., Sept. 17, 1864. * For details see Med. Times and Gaz., Oct. 15, 1859, p. 379. No. of opera- tions incorrectly summed up as 14. 5 One of the unsuccessful cases was 16 years of ajie. f" Mr. Holmes (Surgical Treatment of Diseases of Children, Philada., 1869, p. 302) states " that at the children's hospital, out of fifty recorded cases of opera- tions for diphtheria and croup, performed by several different operators durinp: the last twelve years, five only have recovered. In 31 cases the causes of death have been noted ; and in very few of these cases was the cause of death connected in any way with the operation. 7 Brit. Med. Journ., Feb. 17, 1866. 6 cases, 1 in an adult ; all fatal. ^ Meigs and Pepper. 9 H. H. Smith, Operative Surgery, Philada., 1863, p. 271. In 1848, Pancoast operated in three cases for Dr. Meigs, two of which were successful, one at 19 months. Am. Journ. Med. Sci., April, 1849. '° Ibid. " 1852, Ibid. Philada. Med. Exam., viii., N. S., p. 222. '2 Meigs and Pepper. "^ Ibid. 20 CROUP IN ITS RELATIONS TO TRACHEOTOMY, Operatoi-s. No. of Tracheotomies. No. of Recoveries Levis' (Philada.) . 12 1 Packard^ 1 Hodge" " 4 3 Drysdale"* " 4 1 Boiling^ " an adult 1 Grove'^ " 1 1 Cohen " 1 Bache^ 1 KeenS I Allis9 I (Other operators)'" 8 Thompson" . i E. Atlee'^ (Lancaster Pa.) . 1 Townsend'^ (Boston) 1 Bigelow'^ " . 1 Gay'5 " . 13 7 Cabot'6 " . 2 2 Cheever'^ " . 9 6 Buck'8 (New York) 2 2 Ayers'9 . 1 1 Van Buren^" " 1 Minor2' " . 6 2 C. K. Briddon22 (New York) 5 (1 in an adult) Jacobi'» (New York) . 67 13 ' Verbal cominuuication. See also Meigs and Pepper, On Diseases of Children. 2 Am. Journ. Med. Sci., Jan. 1870, p. 95. 3 Verbal communication. See also Meigs and Pepper ; and Cleeman ; Aui. Joiirn. Med. Sci., April, 1870, p. 567. < Verbal communication. ' Ibid. ^ Ibid. ' Am. Journ. Med. Sci., July, 1869, p. 112. » Philada. Med. Times, April 15, 1871, p. 263. 9 Ibid , June 1, 1871, p. 322. '" Verbal communications. 1' Smith, Operative Surgery; Philada. 1863, p. 271 ; 1816, N. E. Journ. Med. and Surg., vol. v. p. 318. '2 1831, Ibid. West. Journ. Med. and Phys. Sci., iv. p. 23. '3 1849, Ibid. Am. .Journ. Med. Sci., xvii., N. S., p. 28. '» 1853, Ibid. Am. Journ. Med. Sci., xxvi., p. 80. '5 Boston Med. and Surg. Rep., Jan. 27, 1858. 16 Ibid., Feb. 1861 ; Am. Journ. Med. Sci., April, 1861, p. 608. " Boston City Hospital Reports, 1870. 18 1851, H. H. Smith, op. cit. N. Y. Journ. Med., N. S., vii. p. 269. 18 1852, Ibid. N. Y. Journ. Med., N. S., ix. p. 69. ^o Hjjd. 2' N. Y. Journ. Med., 1860, p. 242. 22 Am. Med. Times, 1863, p. 227. ^3 ^m. Journ. Obstet., May, 1868. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 21 Operators. No. of Tracheotomies. No, of Recovpries. Voss' (New York) 43 6 before 1858, .36 alter '• ^^ ' 1 5 before 1858. [ 5 after Krackowitzer^ (New York) 55 16 von Roth'' (New York) . 48 11 Johnson, C. P.^ (Rich- mond, Va.) 1 Johnson^ 1 Burgess^ 2 1 Mcllvaine^ (Charlotte, N. C.) ... 1 Pitney^ (Moorestown, N.J.) 1 1 Haughton^ (Richmond, Indip,na) 5 1 Prentiss'" (Washington) 1 Lincoln" 1 Fenner'^ (Memphis, Teun.) 5 1 325 84 The age of the patient, taking an extensive range of statistics, lias an important influence on the success of tracheotomy for croup. Yer}^ few children under two years are saved ; verj- few^ over eight or nine; and adults seldom or never. In an important discussion upon tracheotoni}'^ in croup which occurred at the Parisian Societe des hopitaux in 186*7, Isambert stated'^ that during his two j'ears of service (1853-1855) in the Hopital des Enfants Malades, under Guersant and Blache, it was almost a rule that no case under two years of age, or at least under twent}' months, should be ope- rated upon, because of the insuccess that attended them. Indeed, it was erroneously stated by one member that no case under two years of age had ever recovered after the operation in the public hospitals of Paris. Several cases of recovery at an early age were ' .Tacobi,loc. cit. 2 Ibid. » Ibid. ' 1651, H. H. Smith, op. rit. Stethoscope, vol. i. p. 670. Am. .loum. Med. Sci., .Ian. 1852, p. 286. s ibid. 6 1824, Ibid. Am. Med. Recorder, vii. p. iii. ■ 1851, Ibid. Am. Journ. Med. Sui., xxi., N. S., p. 387. s 1852, Ibid. N. J. Med. Rep., v. p. 332, 9 Trans. Indiana State Med. Soc, 1867, p. 126. •0 Am. Journ. Med. Sci., April, 1868, p. 412. " Prentiss, loc. cit. '2 N. A. Med.-Chir. Rev., 1860, p. 854. 1 have a personal knowledge of the successful case, and believe it to have been croup, though Dr. Fenner lias doubts on the subject. '3 Bull, et Mem. de la Soc. med des hop. de Paris, t. iv 2me sen, anuee 1867. 22 CROUP IN ITS RELATIONS TO TRACHEOTOMY. mentioned during the course of that discussion which occupied several sessions. These are included in a table of successes at an early age which has been compiled in this connection. Vincent Jackson,' in a note published in 1871, condemned tra- cheotomy in children under four 3'ears of age. This note was an- swered by Dr. Buchanan,'^ in which he tabulates his 39 cases of tra- cheotomy for croup, showing that of 19 operations performed by him in children under four 3'ears of age, recovery took place in two instances. Roger and See, in their reports of 1851-8 (126 recoveries in 466 opei'ations), state'' that 44 out of 100 were saved between six and twelve years of age; and Roger asserted, in the discussion above referred to, that patients did not recover well after nine years of age, and that there was not a case on record of recovery in the adult. In the course of these pages there are a number of references to operations in the adult; not one of them resulted in recovery. Trousseau attributed the want of success in the adult to the fact that asphyxia, owing to the large size of the larynx, is retarded until the exudation has invaded the bronchi. Trousseau, in his Clinical Medicine, endorses tlie following quo- tation from Dr. Michel Peter: — * " Children below two, and up to two and a half years of age, seem to sink under the influence of traumatic fever ; and it is generally during the twenty- four or thirty-six hours which immediately follow the operation, that death occurs. Scarcely have two hours elapsed after the operation, when the number of pulsations and respirations increase in a remarkable manner, and the temperature of the skin rises in the same ratio. Then, little by little, the face becomes red, and there is burning thirst, while the heat of the body is dry and intolerable. The child sinks into a slumber, which is occasionally disturbed by some convulsive movements, and then he dies." In the table of Prof. Wilms, of Berlin (103 recoveries in 335 cases), six cases were operated on at less than two 3-ears of age, and six between the ages of eleven and fourteen years inclusive. Not one of these recovered. Thierry has reported three unsuccess- ful cases in the adult, and Archambault two. At St. George's Hos- pital, London, a fatal case occurred at sixteen years of age, in a girl operated on just before death.^ Prof Billroth has reported® an ' Brit. Med. Journal, March 18, 1871, p. 278. 2 Ibid., March 25, 1871, p. 310. » Gaz. hebd., Nov. 12, 1858, p. 789. * Relation d'une Epid^mie de diphtherie observee a I'hopital des Enfauts en 1858. Menioire couronnee par la Facnlte en 1859. 5 Med Times and Gaz., Oct. 15, 1859, p. 379. 6 Arch kiln. Chir., 1869, p. 191. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 23 operation in a female over twenty years of age, who died on the fourth day fi'ora mediastinitis, pleuritis, and septicaemia. From an examination of the records of a period of ten years, com- prising some 1300 croups, Bourdillat' found that the average re- covery after tracheotomy had been as follows : — Under 2 years .... 3 out of the 100. At 2 " .... 12 " From 2i to 3 years . . . 17 " " " 3^ to 4 " . . . 30 '* 41 to 5 " . . . 35 " 5^ to 6 " . . . 38 " Above 6 years . . . . 41 " " Sex did not appear to have any influence on mortality,- This ex- hibit, sa3's Bourdillat, comprises the law laid down by Millard, that, " all things being equal, the chances of recovery are in direct ratio with the age of the patient." Deaths had been more frequent pro- portionately during the months of November, December, and Janu- ar}^, doubtless as the effect of cold weather in inducing pulmonary complications. Jacobi, of New York, in his article on this subject,^ gives the fol- lowing statement of the ages of the recoveries in his cases (13 out of 67):— 1 at 2^-3 years, out of 5 operations 3 at 3 -4 " 16 7 at 4 -5 " 23 2 at 5 -6 " 7 20 per cent. 19 " 30 " 28* " Bartels* gives the following details of the cases occurring in Ber- lin (1861-1872) in the department of Prof. Wilms:— Age. No. 'Tracheotomies. No. of Eecovevies Up to 2 years 6 Between 2 and 3 years 56 15 " 3 4 " 69 22 " 4 5 " 74 18 " 5 6 " 57 20 " 6 1^ it i 33 15 " 7 8 " 21 5 •' 8 14 " 19 * 335 8 103 ' Bull, et Mem. Sec. med. hdp., Paris, 1867, p. 39. 2 The theses of Millard, and of Richet and Brichetau, and the report of Steiner, however, exhibit a remarkable preponderance of recoveries in the cases of female infants. 3 Am. Journ. Obstet., May, 1868. * Loc. cit. Operator. Thierry No. 3 Result. D Archambault 2 D Biirow, Jr. . 1 I) Simon . 1 D Billroth . . 1 D 24 CROUP IN ITS RELATIONS TO TRACHEOTOMY. Of six of these cases under two years, and of six between eleven and four- teen years of age inclusive, not one recovered. Inferior tracheotomy was performed under the influence of choloroform, and all bleeding vessels secured before the trachea was incised. Guersant reported in 1847' a case of recovery at fourteen years of age. Table of Operations on Adults. Operator. No. Result. Molendzinski 1 D HulUe^ . . 1 D Boiling . . 1 D Briddon . . 1 D 12, all fatal. Table of Successes at an Early Age. Age at Operation. Operator. 6 weeks .... Scoutetten'' (Strasbourg), 1840. Mr. Aniiandale has reported^ a case operated upon at three months, which lived seven weeks. . Bell5 (Edinburgh), 18G1. . Lawson Tait^ (Birmingham). . Baizeau^ (Algiers). . Dujardin.^ . Bourdillat^ (Paris), (under 11 months) J. Cooper Porster.'" . Trousseau" (Paris), 1834. . Barthez'2 (Paris). 1 Gaz. des hop. Feb. 23,1847; Am. Journ. Med. Sci , Oct. 1847, p. 491. This was Guersaiit's fifth success out of forty-one operations. 2 At Middlesex Hospital; Brit. Med. Journ. Feb. 17, 1866. ■3 For details see Am. Journ. Med. Sui. April, 1844, p. 466 ; from Med. Times, Jau. 20, 1844. Also Gaz. lued. 1845, p. 707 ; Gaz. hebd. 186ii,Nov. 14, p. 723 ; Bull, et Mem. Soc. med. hop., Paris, 1867. This was an operation on his own child, the emergency being so great that the father could not wait for the friend who was to have performed it. Doubts have been expressed as to whether it was real croup. * Ed. Med. Journ. 1862, p. 1121. 5 Syme, Ed. Med. Journ. 1861, p. 956. 6 Brit. Med. Journ. April 15, 1871, p. 391. 7 Gaz. des hop. 1867, p. 397. - Union med. 1872, No. 18. Canula worn eight mouths. A small fistule still remained at the end of four years. 8 Gaz. des hop. 1872, No. 64. Recovery slow ; membranes expelled several times ; canula retained fifteen days. '0 Brit. Med. Journ., March 27, 1871, p. 309. " Journ. des Conn, med.-chir., Sept. 1834. Clinical Medicine, London Trans., ii. p. 614. '2 Gaz. hebd. 1862, Dec. 19, p. 806. 4 months . 7 '• 10 " , 10 10 10 " (unt 13 13 ** , X 1 u 18 lUUlUS 18 11 19 i( 21 i( 22 << 22 " 23 « 23 (( CROUP IN ITS RELATIONS TO TRACHEOTOMY. 25 Age at Operation. Operator. 13 months . . . . Archambault' (Paris) 15 " .... Baizeau^ (Algiers). 1.5 " ... . .a colleague of Baizeau." 16 " .... Isambert^ (Paris), 1867. Potain reported a case at sixteen months which lived four weeks, and died from results of broncho-pneumonia, and tracheal ulceration from prolonged sojourn of canula. Bull. et M6m. Soc. med. hop. 1867. . Vigla.5 . Moutard-Martin.^ . Potain.'' . Pancoasts (Philadelphia), 1848. . Sendler^ (Magdeburg). . Labord,'" 1862. . Isambert" (Paris), 1868. . Labord,'^ 1862. . Malshieurat-Legrand,"' 1841. These examples prove that there are exceptions to the rule, that tracheotom}'^ for croup is not successful in children under two years of age. Croup supervening upon the exanthemata is not, as a rule, amen- able to tracheotomy. Three cases of recovery after measles are re- ported by Millard,^* and Labord'^ has reported one at twenty-three months (see above table) complicated with scarlatina. Selecting the best individual series of statistics from those repro- ' Bull, et Mem. Soc. med. des hop. 1867. 2 Cxaz. des h6p. 1867, p. 397. ^ Ibid. * Evenement med., Jan. 1863. Bull, et Mem. Soc. med. hop. 1867, p. 181. 5 Ibid. 6 Ibid. ; the only successful case out of seven performed during his sojourn at Saint-Antoine, on children under ten years of age. 7 Ibid. * Meigs, Am. Journ. Med. Sci., April, 1849, p. 316. 9 Prager Vierteljahr. 1859, iv. p. 70. In this case the tube could not be re- moved definitely until the fifth month after the operation. Gaz. hebd. 1862, p. 807. " Gaz. hebd. May 27, 1868, p. 348. '2 There was intercurrent scarlatina in this case. Labord also reports two successful cases at twenty-eight and twenty-nine months respectively. Loc. cit. p. 808. '3 In this case crico-tracheotomy was performed ; no tube was introduced ; the edges of the incision into the cricoid cartilage were held asunder by hooks extemporized from pins, and fastened with threads. In another case performed by the same operator, a similar extemporaneous apparatus became displaced the day after the operation, and death from suffocation occurred on the instant. Am. Journ. Med. Sci., April, 1842, p. 470; from Dub. Med. Press, Deo. 28, 1841. w Op. cit. '5 Gaz. hebd. 1862, p. 808. 3 26 CROUP IN ITS RELATIONS TO TRACHEOTOMY. ducecl in this paper, all of them exhibiting a success of more than 50 per cent.,' most of them results in private practice, we obtain the following table : — Operator. N Buck ). of Tracheotomies. . 2 No. of Eecoveries 2 Cabot . 2 2 Balassa . 2 2 Schcellhammer . 7 6 Voss (before 1858) . Trousseau (1854)^ . 6 . 9 5 7 Baudin . . . . . 4 3 -Hodge Cruickshank . 4 . 11 3 8 Gerdy Bardinet . 6 . 6 4 4 Perrochaud . 3 2 Pancoast (1848) . Cheever . 3 . 9 2 6 von Kopl . IT 11 Bourdillat . . 16 10 Moynier Petel .... 5 . 9 3 .5 Eichet . . ' . . 9 5 Calvet . 23 13 Gay .... . 13 7 Thus affording a very remarkable result in contrast with the en- tire list. Man}' fortuitous circumstances may have been (jpmbined in these instances to favor better results than have been obtained in other series of operations. A favorable age in the patient, a good selec- tion of cases, a happy recognition of the proper moment for surgical interference, skilful operation, and assiduous after-treatment may have been the causes leading to such excellent results. These are the elements of success ; and it is, in a measure, to assist in a better appreciation of these elements of success that this paper has been compiled. Attention is invited to four main topics to be discussed in suc- cession. These are : — 1. The indications for the operation; 2. The points of importance in connection with the operation it- self; ■ There are a few other series exhibiting exactly 50 per cent. 2 His results, 1851-1854, were 24 operations aud 14 recoveries, •med., March, 1858, p. 259. Arch. Gen. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 2Y 3. The after-treatment of the disease and of the surgical wound ; and 4. The casualties which prevent recovery. The Indications for the Operation. The indication for the operation exists whenever it is apparent that death from suffocation cannot be averted by an^-^ other means, it being borne in mind that the very condition suggesting the pro- priety of an operation in a given case is, in itself, an intimation that should not be disregarded. It is not only the existence of membrane at the glottis that gives an indication for the operation. There may be persistent spasmodic constriction of the glottis as a reflex manifestation of the inflamma- tor}^ affection per se as in other inflammatory affections of the air- passages in children, or as a reflex influence of the irritation caused by the presence of exudative products in its vicinity ; and there may be a permanent paralytic constriction from loss of power in the dilating muscles of the larynx, so that the air cannot pass through the glottis in sufficient quantity, but even presses the re- laxed vocal cords towards each other at every inspiration. It has been stated by Niemeyer' that he has observed this paralytic condi- tion in croup, on laryngoscopic inspection. It has frequently been observed in the adult, the attendant physical phenomena of inspira- tion being similar to those of some cases of croup. In either case, a continuance of the paralytic condition, or a threatening persist- ence or reproduction of the spasmodic contraction would be an in- dication for the operation, which, under such circumstances, ought to be followed by a successful result, if the blood had not become charged with a poisonous overplus of carbonic acid gas, rendering it unfit for the purposes of nutrition and repair; the more so, as instances are on record of death by laryngeal suffocation, which on examination have not revealed any anatomical or pathological lesion in the larynx. In a report to the Parisian Society Medicale des HSpitaux,^ concerning the pseudo-membranous affections observed in the hospitals .during October and November, 1868, several cases of false croup were mentioned, of which one, in the service of Roger, shows how guarded the prognosis should be even in this affection, so much more serious in appearance than in reality. An infant laboring under false croup was attacked with excesses of suffoca- tion sufficiently violent to necessitate tracheotomy, and it died. ' Flint's Practice of Medicine, 1868, p. 260. 2 Gaz. liebd. No 2, 1869, p. 25. 28 CROUP IN ITS RELATIONS TO TRACHEOTOMY. The objection made to tracheotomy, "as being unnecessary when there is spasmodic closure of the larynx, and as useless when false membrane exists in the windpipe without spasmodic closure," is well answered by Dr. Conway E^'ans, in an article on tracheotomy in croup,' by the recital of the following case : — A girl aged three years : croup treated by the warm bath and by tartar emetic, in spite of which the case progressed from bad to worse until the third day, when, while symptoms of asphyxia were being gradually developed and signs of exhaustion were becoming well marked, the patient suddenly fell back in bed and died, with scarcely a struggle. After death, but before the post-mortem examination, tracheotomy was performed. A mass of false membrane was found, almost filling the larynx, and quite occluding the rima; and extending downwards to the third ring of the trachea ; but the lotoest part of the croupous exudation was just above the top of the tracheotomy incision. No false membrane existed in any other part of the trachea. Even the existence of exudative products in the bronchi, at least in their larger divisions, is not an insuperable contraindication against the operation. Casts of the bronchi have been expectorated in cases which have recovered without operation ; proving that the}'- can be detached and expelled. Why not, then, give the patient the advantage of an opening through which surgical assistance can be rendered to facilitate their extrusion ? And, what is more to the point are cases, such as that reported by Moneretj^in which, although the vesicular murmur was extremely pure and heard everywhere, yet during the operation a false membrane was thrown out which represented the trachea and division of the bronchi. A similar case was reported hy Dr. Pepper, of Philadelphia.' Althougli tracheotomy, when postponed to the last minute, can lead to ultimate recovery only in rare instances, it should be per- formed, under certain circumstances, even in extremis^ or even im- mediately after apparent death ; for it has happened, in the experi- ence of several operators, that fleeting life has been recalled under such circumstances by the institution of artificial respiration ; though, unless the suffocation has been sudden, death from asthenia usually follows in a few daj^s, or sometimes in a few hours, as a result of the prolonged deficiency in hsematosis. Mr. James Spence states* that in eight of his operations the patients were in extremis, and three of them recovered. Dr. Drysdale,^ of this city, has ' Brit. iMed. Journ., Aug. 27, 1859 ; Am. Journ. Med. Sci., Oct. 1859, p. 549. 2 H. H. Smith's Operative Surgery, Phila. 1863, p. 270, from Meigs on Dis- eases of Children, Phila. 1853, p. iii. 3 Ibid. Summary Trans, Coll. Phys. Phila., iii. p. 106. * Edinburgh Med. Journ., 1860. ^ Verbal communication. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 29 operated four times, with only one recovery ; but the case which recovered was to all appearances the worst of the four at the time of the operation, for it was apparently dead, having actually ceased breathing and was pulseless, and required the institution of artificial respiration. Other cases, few in number, it is true, are on record. Dr. B. W. Richai-dson' has called attention to the fact that the excess of fibrin in the blood may give rise to deposit in the right cavities of the heart, and thus to death by syncope ; and he gives directions for the recognition of cases complicated in this way, stating that if symptoms of cardiac obstruction are detected, "whether complicated or not with constriction in the windpipe, the operation is worse than useless ; and will, of necessit}', fail, because there are other fatal influences at work which the knife cannot aflfect. Two distinct varieties of impediment to respiration are recognized in croup, apart from paroxysmal spasm, which, though by no means always present, is very frequent in all affections of the respiratory apparatus in children. In one, there is continuous and usually augmenting dyspnoea with slow asphyxia, air reaching the lungs, but in restricted quan- tity. There is great general restlessness, but no violent respira- tory efforts ; there is no sinking in of the tissues above the sternum, and little or none at the base of the thorax. The respirations are frequent and shallow ; the pulse small and rapid ; the face is swollen ; the eyes are listless, and their pupils dilated ; the skin is livid, cold, and covered with a clamm}'^ sweat ; the finger tips are blue at the nails ; the mucous membranes of the tongue, gums, etc., are pale ; sensation is dulled. Here, the membranous exudation has been thrown out over more or less of the entire bronchial tract, plug- ging some of the passages or occluding others, so that the air cannot reach the pulmonary vesicles in quantity sufficient to keep up the interchange essential to due hsematosis. Tracheotomy cannot afford immediate relief to the troubles of respiration except so far as the larjnix and trachea are concerned ; though it may be of immense secondary benefit ; its value in the case being greatly dependent on the condition of sj^stem which attends the affection. Many authori- ties regard this form of asphyxia as a contraindication for tracheo- tomy ; though the operation has occasionally succeeded even when the s3'mptoras have been at their worst. In the other variety of impeded respiration, the symptoms are ' On the Diagnosis of Fibrinous Concretions in the Heart in cases of Inflam- matory Croup. Med. Times and Gaz., March 8, 1856, p. 230. 30 CROUP IN ITS RELATIONS TO TRACHEOTOMY. those of more rapid suffocation with paroxysmal apnoea. There is great anxiety and agitation ; orthopncea is marked ; there are vio- lent respirator}' efforts ; the sub-thoracic tissues are deeply indented with each inspiration, and at a later date, the supra-sternal tissues also ; inspiration is noisy and stridulous ; the pulse is small and frequent; the face is turgid, flushed at first, and c^-anosed after- wards; the ej'^es are suffused and prominent; the cervical veins are swollen ; the skin is warm and moist ; the mucous membranes are blue; the vesicular murmur cannot be recognized. Here the exu- dation is limited to the larynx, or larynx and trachea. Cases of this kind are considered favorable for the operation ; and on its performance the morbid respiratory phenomena cease. Intermittent asph3'xia is a much less positive indication. " Guersant' has met with children breathing only with violent efiForts, and who appeared exposed to impending death. False membranes had been re- jected, and no doubt of the nature of the complaint could exist. The neces- sity of opening the trachea was pointed out to the parents, who objected to the operation. In such cases, emetics, calomel, alum, chlorate of potass were resorted to, and two of these children recovered." Mr. Henry Smith, in an article on Tracheotomy in Croup and other inflam- matory affections,'^ in which he mentions having performed the operation many times in children from eleven months to six years of age, writes : " It is im- possible to decide, except in the very last stage of croup, whether the patient will die or not. Almost every practitioner must have met with some remark- able cases of recovery where a fatal result was imminent, and this is the rea- son why tracheotomy is not used at an earlier period of the disease." He then mentions a case concerning which it had been remarked in consultation that to do it any justice the operation of tracheotomy should be performed at once, but at the same time the case was not so bad as not to leave scope for milder measures. Amendment began, in a few hours, under the continu- ance of leeches, counter-irritation, and calomel, and the child recovered. He then remarks, " Now, if the operation had been done here, the patient would probably have recovered ; but we have the certain proof that in this case, at least, it was not required." Trousseau,^ in 1855, wrote as follows, having at that date operated more than two hundred times: " If the diphtheritic infection has profoundl}^ impressed the econom}' ; if the skin, and especially if the nasal fossae are occupied by the special phlegmasia ; if the frequence of pulse, delirium, and prostration indicate a profound poisoning; if the peril is rather in this general condition than in the local lesion of the larynx or the trachea, the operation should never he attemj:)ted ; it 1 Chaillu, Am. Journ. Med. Sci., July, 1858, p. 25.3. 2 Med. Times and Gaz., Jan. 26th ; Am. Journ. Med. Sci., April, 1856, p. 495. 3 Arch. Gen. de med., March, 1855, and subsequently in his Clinical Medi- cine, which is essentially the same article with little alteration or additions. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 31 is invariably followed by death : while, if the local lesion constitutes the principal danger of the disease to such a degree that asphyxia is imminent, the infant having but a few more moments to live, trache- otomy is nearly as effectual as if it had been practised three or four hours earlier." Guersant, basing his opinions on more than two hundred cases operated on between the j^ears 1850 and 1857, considered trache- otomy absolutely indicated whenever voice is extinct ; and con- tinuous and increasing difficulty of respiration exists and has lasted two, three, or four hours. He does not consider extreme childhood an insuperable objection, though the chances for recoA^ery are slight. He does not consider pneumonia as a contraindication, as its reso- lution will be facilitated b}'^ the increased freedom of respiration; nor does he consider excessive aspln'xia a contraindication, if the difficulty of breathing is permanent, and has lasted continuousl}^ at least one hour. He recognizes but one express contraindication, and that is diphtheritic infection or general diphtheritis.' Prof. Stromeyer- considers that there are no positive contra- indications to the operation ; that although it is seldom successful in children under two j'ears of age, or in cases where pneumonia exists, successes do sometimes occur under such unfavorable cir- cumstances; and that therefore the operation is fully justifiable. He believes Baum, of Gottingen, to have laid down the safest indi- cations ; limiting tracheotomy to cases in which asphyxia is com- mencing, where the patient is worn out and sleep}', the skin becoming livid, the lips blue, the extremities cold, the subthoracic tissues sunken in ; in which state he saA^es one-third of his cases. Prof. Roser, of Marburg,^ operates earlier, when suffocation is threatened, respiration being effected only with the greatest effort, the face being red and covered with perspiration ; when there is great un- easiness and anxiety, so that the child throws itself about, tries to leave the bed, and clutches at its attendants for relief; if delayed longer, though breathing may be relieved, the resulting bronchitis cannot be averted. In discussing this subject, Prof. Heuter* reasons as follows: " When, however, the physician follows the course of the disease from da}^ today, or from hour to hour; when he sees the stenosis of the glottis increase, what S3nnptom gives him the right to invoke ' Am. .Tourn. Mt^d. Sci., July, 185^, from Journ. med. et chir. Prat. 2 Haiidbuch der Chirurgie ; Freiburg im Breisgau, 1865, vol. ii. p 361. 3 Sydenham Soc. Year Book, 1863, p. 276, from An-li. d. Heilk. ii. * von Pitlia and Billroth's Handbuch der allgemeinen und speciellen Chi- rurgie, Erlangen, 1872, vol. iii., Art. Tracheotomie uud Laryngotoiuie, p. 27. 32 CROUP IN ITS RELATIONS TO TRACHEOTOMY. the influence of tracbeotom}^ ? One symptom seems of special im- portance in answering this question. It is the energetic sinking in of the anterior wall of the thorax, especiall}^ of the lower end of the sternum. As soon as the want of oxygen in the blood, that is to say, the want of oxygenated air in the lungs of the croupous child, becomes very perceptible, the diaphragm and all the other in- spiratory muscles make violent contractile efforts to draw as mucli air as possible into the thoracic cavity. If now the glottis permits but little air to enter, the diaphragm does not descend as in ordi- nary respiratory contraction ; its central tendon becomes, on account of the limited expansibility of the lungs, a fixed point, towards which its peripheral insertions are forced by the contraction of its muscular fibres. Of these, the insertions of the diaphragmatic muscle on the lower end of the sternum, and on the adjacent costal cartilages are the most movable, and therefore these portions are drawn powerfully inwards by the inspiratory effort. Finally, there is produced at this place, b}' each inspiration, a deep sulcus into which one can sometimes almost hide the fist. A remarkable sinking in at the jugulum sterni also occurs at each inspiration, because the atmosphere presses forcibly upon the thoracic walls in consequence of the inspiratory rarefaction of the air in the lungs, and the impossibility of a sufficient carriage of the air through the bronchi and trachea. This characteristic depression sets in some- what later, as a rule, than the depression at the epigastrium, and indicates also a more advanced state of dj'spnoea. The well-known abnormal action of the nostrils which alwaj's occurs in marked diffi- culty of respiration, is an additional symptom of the difficulty of the respiratory act. Finall}', the general integrity of the respiratory muscles is to be taken into consideration. Their extreme labor always indicates that but little air reaches the respiratory surfaces. I hold the observation of these phenomena more important than that of the harsh and stridulous sounds with which the air passes to and fro through the contracted glottis. The character of these sounds, which naturally are not absent in marked stenosis of the glottis, is nevertheless ver}'^ variable and indeterminable. A great deal of dyspnoea may go hand in hand with little stridor, and little dyspnoea with great stridor. Observation of the entire respiratory act affords a much safer estimate of the impediment to breathing. "The coloring of the blood by the retained carbonic acid gas is best examined in the color of the lips. The lips gradually become dark blue, while the cheeks appear, as a rule, very pale and as though swollen b}' oedema; which strengthens the contrast of the color in the lips to that of the neighboring parts. This symptom CROUP IN ITS RELATIONS TO TRACHEOTOMY. 33 exhibits the altered texture of the blood in the distinctest manner. So, for my part, I consider that the hour for tracheotomy has come as soon as the substernal tissues sink in a marked manner on inspiration, and the blue color appears in the lips. At this period I propose the operation, and if it is declined, death by suffocation follows. The combination of symptoms just described are a safe indication of the greatest danger to life ; but I will not deny that cases in which the operation was undertaken by myself are not very numerous, and that I deem it very possible to have erred in esti- mating the condition of dyspnoea. It may be a mortifying experi- ence to propose an operation, and, after it is declined, to see the case recover, perhaps spontaneously, perhaps under the influence of some empiric remedy. But I believe that, even in such a case, the physician has no reason to reproach himself. A few tracheotomies which were not absolutely necessary for the preservation of life, are not so culpable as neglect of the operation and its postponement to the latest stage. Only think how we govern ourselves in the indications for other operations, by the results of comparative statistics. We feel justified in performing primary amputation in every comminuted fracture with opening into the knee-joint, not because the injury is absolutely fatal, but because we know that without primary ampu- tation a colossal percentage of such cases die, while the percentage is much less if primary amputation is performed. We sacrifice limbs and save human lives. If now, in the afore-described stage of dyspnoea from croup we tracheotomize all our cases, the operation may perhaps be superfluous in ten or twenty cases, but we will save man}'^ lives that would have been lost b}'^ postponing the operation. Ordinarily, tracheotomy does not entail any permanent injury, and we have to dread only the danger presented in executing the opera- tion and during tlie healing of the wound. But we will see tliat we have learned by instituting rational rules to reduce to a minimum the dangers of the operation and those of the progress of the wound." These views are a fair sample of the opinions held by men who, after considerable personal experience in tracheotomy for croup, remain partisans of the operation. More or less argumentative reasoning of the same kind will be found in most of the essays referred to in different portions of this paper. Rupture of the trachea from cough in croup, and tlie consequent production of emphysema, may give an indicafion for tracheotomy independently of any other condition. Latour mentions a case' in which such a rupture occurred between the first and second tracheal > Voss, N. Y. Med. Journal, Jan. 1860, p. 37. 34 CROUP IN ITS RELATIONS TO TRACHEOTOMY. cartilages in a child 2^ years of age;' and Dr. Yoss, quoting this case, in calling attention to the subject, reports a similar one from tiie practice of Dr. Gescheidt, of New York, in which the emphysema was stayed by promptly opening the trachea, thereby saving the life of the patient, a girl 4 years of age. The Points of Importance in Connection with the Operation ITSELF. The Use of Ansesthetics. — It is a question with some surgeons whether ansesthetics may be safely used in performing tracheotomy for croup. In Germany, Great Britain, and the United States, an anaesthetic is used as a rule ; in France the operation is more generally performed without it. The danger of wounding a vessel by an unlucky touch of the knife is not to be underrated ; and it is an important matter to control the child's movements, if struggling cannot be averted. If the operation is performed comparativel}'^ earlj'^, there seems to be little doubt as to the propriety' of using an anaesthetic, especially when assistants are few and unskilled. /It is generally said to be well borne, not impeding respiration even in some cases of advanced asphyxia. It usually calms the violence of the respiratory efforts and quiets spasm ; and thus certainly facilitates the operation. Cases have been narrated, however, in which the symptoms of asph^'^xia were notably increased by the anaesthetic, so as to render the propriet}' of its further use doubt- ful. Anaesthesia need not be pushed to its full extent ; for in many instances, especially when respiration has been impeded for a long time, the carbonization of the blood has alreadj^ pi'oduced an anaesthetic influence, which will permit the performance of the operation witliout much struggling of the patient; indeed, without any, in some cases, the child seeming to recognize the intention of the operation, and su])mitting to it without a murmur. Kiihn mentions" an instance in which he performed laryngotomy, without a cry of pain, upon a child whom he had been unable to induce to open the mouth to permit the introduction of an instrument for diagnosis. He has also used chloroform in operating for ci'oup, and has seen great quiet produced after a few inhalations. Prof. Bffickel, of Strasbourg, in an excellent thesis,'' based upon .S3 personal cases, and a careful study of the entire subject, believes that chloroform should be employed with great prudence; and only 1 Manuel sur le Croup. Orleans, 1808. « Op. cit., p. 147. 3 De la Traclieotomie dans le Croup, 1867. Reviewed in detail in the Gaz. med. de Strasbourg, Dec. 31, 1867. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 35 at the commencement, in order to control the agitation. The skin once incised, he considers it useless to continue the anaesthetic. Dr. F. Howard Marsh writes :' " It has been thought that it would be dangerous to give chloroform to a patient partly asplu'x- iated, because it would render his blood still more unfit for circu- lation ; but I have seen it employed in at least twenty-five cases, and when it has been carefully and slowly given, instead of being mischievous, it has been most beneficial. It is most useful where dj-spnoea is recent, and where the child is still vigorous and full}'' conscious. In such cases the difficulty of breathing is generally in great part spasmodic, and the child is very restless and struggles very much. Here chloroform, b}' relieving the laryngeal spasm, allows more air to enter the chest, so that the general condition is •improved, while there is the great gain that the movements of the trachea are lessened, and the child lies quietl}^, neither fatiguing himself nor interrupting the operator. Some of the chief author- ities in London, Dr. West, Dr. Jenner, and Mr. Paget, as well as those who see or do the operation frequently at the Hospital for Sick Children, Mr. Holmes, Mr. Smith, and Dr. Gee, employ chlo- roform during its performance. It may, however, be added that it is not required, and should not be given in cases in which the child is so unconscious that he will not struggle." Dr. Buchanan, of Glasgow,^ in relating a case of tracheotomy — the twenty-fourth on which he had operated — speaks of chloroform in tracheotomy as follows : " For the first time I gave chloroform in this case, and I was so much pleased with its effect that I would not hesitate to use it in future, although I have hitherto had some doubts of its applicability to tracheotomy. The operation was rather tedious, owing to the great depth of the trachea and some bleeding from small vessels ; but I adhered to my rule not to open the trachea till I exposed at least half an inch, which I could see clearly at the bottom of the wound. The chloroform was a great help in this careful dissection." In a subsequent case (the twenty- sixth), related in the same paper, Dr. Buchanan had equally' favor- able experience of chloroform.^ Prof.Roser, of Marburg, recommends chloroform in the suffocative agony, when children are very restless; but considers it inadmissible in asphj-^xia.* ' On Tracheotomy in Children ; its methods, its dangers, and its diflBculties. St. Bartholomew's Hospital Reports, vol. iii. 1867, p. 333. Principally from ob- servations at the Hospital for Sick Children. ^ Tracheotomy in Croup and Diphtheria ; Additional Cases. Glasgow, ISfJG. * Holmes, Surgical Treatment of Children's Diseases. Phila., 1869, p. 319. * Sydenham Society Year-book, 1863, p. -77, from Arch, der Heilk., ii. 36 CROUP IN ITS RELATIONS TO TRACHEOTOMY. Dr. Yoss, of New York,* was at first inclined to avoid anaes- thesia, and did not use it in his earlier operations ; but feeling en- couraged to do so by the favorable accounts of others, he at length resorted to it, and had had no cause to regret it. At the time of writing he was disposed to continue to use it. Dr. P. M. Braidwood saj^s :^ " Chloroform does not render the condition of the patient any worse as regards the constitutional affection, and it assists the surgeon greatly by keeping the patient quiet. One further advantage I have found to result from the exhibition of chloroform is, that the child by this means is forcibly sent to sleep, and receives refreshing rest, which he has not had for some daj's previously. This artificially induced sleep is very often followed, after some food has been taken, by a natural slumber." Dr. Braidwood precedes this paragraph by. the following remarks: "It is of the utmost importance that tracheotom}' should never be per- formed in a hurry. If this operation is to be of service in the class of cases we have been considering, it can only be useful in a com- paratively early stage of the disease ; and it is quite useless to thrust a knife hurriedly into the trachea when the child is uncon- scious and livid. There should be no unnecessary haste shown in the performance of the operation ; and, if so, why not relieve pain b}' giving chloroform ?" The perusal of numerous opinions on this topic has not furnished any views materially differing from those quoted, the majority of authors expressing themselves in favor of the use of an anaesthetic. The emesis which often follows the exhibition of an anaesthetic would in croup — unless, as in one instance I have read of, the matters vomited. enter the trachea — be advantageous in promoting the dis- lodgment of the membrane. Indeed the use of inhalations of ether has been suggested as a means of getting rid of the membrane in the medicinal treatment of croup, and several undoubted cases of suc- cess have been reported,^ and M. Passavant at one time entertained hopes of similar benefit from chloroform.* If, as remarked by Bojc- kel, it is necessar}^ to avoid the pain caused bj- the incision of the skin, it might be well to anaesthetize the line of incision by a streak of pure carbolic acid, as suggested by Surgeon Bill of the U. S. Army for other operations. Local anaesthesia by freezing might be ' Loc. cit. 2 Tracheotomy in the Treatment of Croup and Diplitheria ; Liverpoot Med. and Surg. Rep., iii. 1869, p. 14. * Livingston, Amer. Joiirn. Med. Sci., April 1867, p. 376. * Arch. Phys. Heilk. ; N. 0. Med. and Surg. Journ. ; Amer. Med. Monthly, 1857, p. 48. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 3t dangerous, though, perhaps not, as ice is used locally' in Europe, in the treatment of croup. I have heard of some cases of tracheotomy^ in adults for other affections performed under its influence, but do not know that it has ever been used in croup cases. The 3Iethods of Operating. — Two principal methods of operating are employed. The best, safest, and most usual method involves a careful dissection down to the trachea. The other method con- sists in transfixion of the parts and cutting through coverings and "windpipe in a single stroke — puncture and incision — by a knife, or puncture by a trocar-like instrument, the tracheotome.'^ Chassaignac fixes the trachea with a grooved tenaculum passed directly beneath the cricoid cartilage, and then penetrates the tra- chea by a direct puncture, along the groove, though the skin and subjacent tissues.^ Isambert operated in this manner in his success- ful case at sixteen months, and expressed the opinion that it was the preferable method to adopt in very young children.' After reading his report he was severely taken to task, for this assertion, by several of his auditors ; among them M. Peter, who stated' that he had been present at an operation of this kind, practised with a brilliant rapidity ; but the oesophagus was incised and the tube introduced into it ; the patient dying asphyxiated on the spot. This does not appear to have intimidated Isambert, for he operated in this manner again in his successful case at twenty-two months.^ Prof. Trousseau has stated," that Lenoir* and Millard" sensibly call attention to the danger, in fixing the larynx, of impeding move- ments connected with the exercise of a function already threatened, and thus running the risk of accelerating asphyxia and death. Dr. Marsh has stated,'" that he has known " of three cases in which the canula was not placed in the windpipe at all. In one, it lay in a cul-de-sac in the cellular tissue in front of the trachea ; in another it was thrust also in front of the trachea, and towards the medias- tinum, and in the third, it lay by the side of the trachea." Dr. Thomas Green, in an article on accidents during operations," mentions a case in which tracheotomy had been performed by a ' Niemeyer and others. 2 Many varieties of tracheotomes have been devised. Those who are curious on the subject are referred to Kiihn (op. cit.). 3 Wells, Med. Times and Gaz., Feb. 28, 1857, p. 209. * Bull, et Mem. Soc. med. des hop., Paris, 1867, p. 183. ^ Ibid., p. 198. 6 Gaz. hebd.. May 29, 1868, p. 348. ' Clin. Med. London Trans., ii. p. 601. * Da la Bronchotomie, These, Paris, 1841. s Op cit. '" St. Bartholomew's Hosp. Reports, 1867. >' Brit. Med. Journ., Dec. 17, 1870, p. 649. 38 CROUP IN ITS RELATIONS TO TRACHEOTOMY. skilful surgeon, on a child with ci'oup ; but no relief followed it, and death ensued. The trachea had not been entered ; the canula lay in front and close on the rings of the trachea. The plan pur- sued had been to push a lancet through the coverings into the tube ; hence the failure. Dr. Marshall Hall suggested the performance of the operation, in an emer- gency, with a pair of pointed scissors.' " The integument, being taken up horizontally by the thumb and fingers of the left hand, should be divided lon- gitudinally by the scissors ; these should then be promptly forced into the trachea, to the proper depth, and opened horizontally to the just extent ; the scissors must then be turned, being kept in their place, and opened in the direction longitudinally ; the operator has thus made, in little more than a moment of time, an opening through which the patient may breathe until fur- ther appliances can be obtained. Life or death depends meanwhile upon his steady hold of the instrument." There is no necessity for hurrying the operation, except in a case of emergency that admits of no choice. In the majority of cases there is ample time to proceed carefully and cautiously. Fifteen minutes, more or less, which is a liberal estimate for the difference of time between a hurried operation and a deliberate one, can cer- tainly be spared for tracheotomy, if the patient has an hour or two to live without it. Besides this, an accidental hemorrhage pro- duced in an operation of a minute, may require more minutes to control it than would have sufficed for the most careful operation. Prof. Trousseau, in all his articles, strongl}'- repudiated haste, and speaking on this point during that famous discussion to which allu- sion hasalreadj' been made, spoke words to this effect: "A certain surgeon (naming him) has reproached me with operating like a physician and not like a surgeon. Well, he had an opportunity, on one occasion, to operate like a turgeon, and with one stroke of his knife he divided the oesophagus as well as the trachea. Some time afterwards he lost another patient by hemorrhage during his brilliant operation. Since then Mr. has operated more like a physician ; and after a while he will become a very fair ti'acheo- tomist." The Arrest of Hemorrhage. — It has been laid down as a rule, by some surgeons, that all hemorrhage from division of vessels dur- ing the preliminary incisions should be controlled before the air- tube is opened. It is asserted by many operators, on the other hand, that there is no reason to fear hemorrhage into the air-pas- sages during the operation or immediately after it ; that as soon as ' Lancet, April 11, 1857 ; Tanner on the Diseases of Infancy and Childhood, Phila., 18(J6, p. 343. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 39 an opening is made, so that respiration may be freely established, the venous circulation resumes its wonted course, and the blood from the turgid veins in the neck passes freely into the veins of the thorax, and the hemorrhage ceases at once. That this is often the case there is no doubt ; but, on the other hand, the very first inspi- ration through the artificial opening may draw so much blood into the trachea as to produce complete asphyxia, before the veins are unloaded by the freedom of respiration. In some cases, too, respira- tion ceases for a few moments after the first inspiration, it seeming as though it took unusual time for the lungs to exhaust the in- creased supply of oxygen suddenly supplied. An amount of hemor- rhage, then, which would be insignificant in the health^^ condition, as in many operations for the removal of foreign bodies, may prove fatal here, on account of the serious impediment to respiration already present in croup cases. A deep inspiration, too, may suck the blood into the respiratory surface of the lung tissue itself, and produce suffocation without any blocking up of the bronchial tract. It is l)est, therefore, unless the emergency admits of no choice in the matter, to follow the advice of those who recommend waiting until hemorrhage has ceased, either spontaneousl}^ or b}' artificial aid, be- fore making the tracheal incision. Bleeding from small vessels can be restrained by holding them for a few moments in the grasp of the forceps, and it is a good plan to secure by spring forceps any ves- sel that seems likely to give any trouble as it is cut, and when the forceps are removed the bleeding will have been arrested. When the bleeding into the air-passages is profuse, an elastic catheter must be placed in the trachea, and the blood sucked out. Prof. Henter lays gi'eat stress on this employment of the catheter, which he considers one of the most indispensable appurtenances of the tracheotomy case; and he does not think that the use of the mouth can be superseded by any artificial suction apparatus which has been devised. Prof Roser also states that an elastic catheter should always be kept in the tracheotomy case. Mr. Arthur Durham,' of London, calls attention to the fact that this hemorrhage is more likely to occur in sudden obstruction than in slowly increasing asphyxia, and that in four tracheotomies which he performed (though not for croup), his patients would have died had he waited for bleeding to cease before he opened the trachea. He says: "Until the tube is introduced, a considerable proportion of the blood and comparatively little air will certainl^^ be drawn in by each inspiratory effort through any opening made into the trachea; ' The rractitioiier, 1869, p. 217. 40 CROUP IN ITS RELATIONS TO TRACHEOTOMY. but when the tube is in position the air passes freely through it, and the blood which has alread}' entered is in great part quicklj^ expelled by the violent expiratory efforts which ensue ; and little or no more blood is drawn in, because air enters more readily, and rapidly fills the expanding lungs; and also because, during inspiration, the edges of the tracheal wound and other divided structures are, by atmospheric pressure, kept in more or less close contact with the tube and with one another." " It cannot be too strongly insisted upon, nor too constantly borne in mind, that there is far greater danger of death occurring from want of air than from the presence of blood in the lungs." Prof. Heuter states that he has several times performed ten crico- iracheotomies (the operation he recommends in croup) one after another without the necessity for securing a vessel ; and his practice has always been, not to make the incision into the tube before the bleeding has ceased. Prof. Roser' considers it an important rule not to open the trachea till all bleeding has stopped. He himself, after much experience in the operation, and with practised assistants, had the misfortune to see a child suddenly die from the passage of Ijlood into the trachea, a ligature on the middle jugular vein liaving been accidentally pulled off. He feels himself bound to oppose the most earnest warning to the carelessness with which this subject is treated by most authors. He is aware of quite a series of cases in which children have perished on the operating table in the same manner; and he has become con- vinced, from experiments on rabbits, of the reality of the danger which arises from sudden coagulation of the blood in the bronchial ramifications. Some operators are so fearful of hemorrhage that they have endeavored to open the trachea by cauterization. Kiihn states^ that the proposition was suggested by Le Clerc (in the Revue m^d., v. 1851), and that Dujardin opened the trachea without hemorrhage in this way, in a case of oedema of the larynx, by the use, during two days, of a caustic paste. This method would be too slow for croup or any other case of emergency, even were there no other objection to it. Dujardin's case of oedema of the larynx must have been a very accommodating one, or the effusion must have been controlled by the counter-irritation. Amussat, in 1870, used the galvano-cautery in a case of foreign body." It has also been used by Verneuil,'' Yoltolini,^ and ' Loc. cit. ^ Op. cit., p. 150. a Lancet, May 18, 1872, p. 688 ; Bull, de Therap, 1872, p. 472. " Bull, de I'Acad., 26me ser. i., 1872, p. 299 ; Bull, de Therap, 1872, p. 472. 5 Berlin klin. Woch., 1872, ix. 41. See, also, Arch. Gen , June, 1872, p. 734-6; Gurlt's Jahresbericht fur 1863-1865 in Arch, fur klin. Chin, 1867, pp. 559-566. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 41 others. Prof. Bardeleben is inclined to think well of the galvano-cautery.' MM. de Rause and Muron have proposed the actual cautery.'' Chaissaignac has proposed the ^craseur;'' and Gu6riu a subcutaneous tracheotomy.* One might picture to himself an energetic practitioner summoned at mid- night to perform tracheotomy, and hurrying with his patent chloroform in- haler, his magneto-electric machine, his pneumatic aspirator, his galvano- cautery, and his bellows for artificial respiration ! A canula surrounded with a tubular rubber obturator, as devised by Trendelenburg,* might be of great service, in cases of severe hemor- rhage, to prevent the flow into the windpipe. It has been used for this purpose with great satisfaction in operations for other affections. The Incision into the Windpipe The operation most frequently practised is vertical incision of the trachea in the median line for a space comprising two or more of its rings. Some surgeons incise the trachea as high up as possible, others as low down as possible ; some divide the cricoid cartilage; others the cricoid cartilage and a ring or so of the trachea; some excise a portion of the anterior wall of the trachea, the incision being elliptical, oval, rectangular, or diamond-shaped ; others excise the anterior wall of the cricoid cartilage, with or without preservation of its perichondrium. Di- vision or excision of the crico-thjn'oid membrane is rarely practised in croup cases. The majority of operators introduce a rigid curved tube or canula of some sort into the trachea, whether incision or excision has been practised. Others dispense with a tube alto- gether, and, if a portion of the trachea has not been excised, resoi't to some other contrivance, such as hooks or ligatures, to keep the artificial opening patulous. The recommendation of cutting a piece out of the trachea is attributed to Mr. liawrence (or Laurence), of London. This operation was successfully practised by Mr. R. Carmichael, of Dublin, in 1820^ and in 1823,^ on adults ; in the latter instance he removed with scissors a diamond-shaped section comprising two tracheal rings and three interspaces, and found the delicate pair of scissors he employed a better instrument for the purpose than the knife. John Andree,^ of London, in 1782 found it necessary to dispense with the use of the tube. His operation is described in his own words as follows : — " The child being laid on his back, and kept as quiet as his great restless- ' Lelirb. der Chir., 1872, iii. p. 496. 2 Gaz. med., 1873, 48. Translated in Phila. Med. Times, Oct. 25, 1873, p. 54. 3 Med. Times and Gaz., May 25, 1872, p. 004. * Ibid. 5 Die Tamponade der Trachea, Berlin, klin. Wocli., 1871, No. 19. Arch. klin. Chir., xii. p. 121. 6 Trans. King's and Queen's Coll. Phys. Ireland, 1820, p. 170. ' Ibid., 1824, p. 311, with illustration of incision. 8 Fane, Med.Chir. Trans., iii. 1812, p. 336. 4 42 CROUP IN ITS RELATIONS TO TRACHEOTOMY. ness in struggling for breath would admit of, I commenced the operation by a straight incision from the thyroid gland towards the sternum, about one inch and a half in length. I then cautiously laid bare the anterior part of the trachea, without any material hemorrhage or difficulty, except what arose from the child's struggles, and then made a small transverse incision, or rather puncture, through the membrane which connects the second and third annu- lar cartilages, and then a similar incision between the fourth and fifth carti- laginous rings; the respiration was immediately relieved. I now proceeded, according to the rules laid down by the most approved authors, and as myself had taught in anatomical lectures, to introduce a silver canula into the trachea through one of the orifices. It instantly produced a most violent and incessant cough, until the instrument was withdrawn. A hollow bougie being introduced, produced the same effect. I then contented myself with dressing the wound superficially, cutting an orifice in the plasters to corre- spond with the openings iuto the trachea, and covering the wound with a piece of gauze laid loosely on the neck." Mr. Thos. Chevalier,' in his successful case in 1814. " exposed the trachea just below the cricoid cartilage, and divided two of the cartilaginous rings vertically, cutting afterwards transversely in the interstice between them." In concluding his account he states : " It would also follow, that the intro- duction of a canula or tube into the trachea after the operation, for the sake of securing the passage of air, is of less consequence than has been usually supposed, and might even be better omitted, as the presence of an extraneous body must irritate the internal membrane, and would thus be likely to increase that secretion of mucus from an accumulation of which the principal danger is to be apprehended. In the instance which I have related, I found no necessity for a tube, though I am sure little or no air entered the wound." This patient was a boy, seven years of age, who had discharged false mem- brane. The crucial incision in the tracheal wall permitted egress of the exudative products ; while respiration was carried on mainly through the natural passages. Prof. Pancoast, of this city, performed three tracheotomies for Dr. J. F. Meigs, in 1848,^ in all of which be cut out an elliptical portion of the anterior wall of the trachea, dispensing with the use of a tube; and two out of the three recovered, one of the patients being but nineteen months old. Dr. Marshall Hall, in a lecture on laryngismus and tracheotomy delivered before the class at the Pennsylvania Hospital in this city, in April, 18.53,^ exhibited a compressible wire dilator which he proposed as a substitute for a canula, and which he called a tracheotone, or trachea stretcher, because he proposed, after incising the skin, to simply pierce the trachea with a pointed, tapering instrument, introduce the tracheotone compressed, and let it stretch the tissues in dilating. The tissues, he asserted, would readily yield to stretching. This instrument was never used much, and is generally believed > Op. cit., Med.-Chir. Trans., 1816, p. 152. s Am. Journ. Med. Sci., April, 1849, p. 307. 3 Reported in Am. Journ. Med. Sci., July, 1853, p. 55. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 43 to be hazardous, on account of the danger of the wire cutting the tissues, and wounding vessels. In a discussion upon a paper on 'IVacheotomy in Diph- theria, by Dr. George Buchanan, of Glasgow, Dr. Davey stated that he knew of two deaths which were attributable to the use of Dr. Marshall Hall's tra- cheotone ;' and Mr. Arthur Durham, in his very excellent paper on Trache- otomy, alludes^ to a fatal case reported in the Medical Times for 18.59, and designates it as " clearly due to the use of an instrument, which to mention is to condemn." A vessel had been cut in the withdrawal of this instrument, producing fatal hemorrhage. In a case operated upon by Dr. Henry J. Bigelow, of Mass.,^ he cut a piece out of the trachea on the third day after the operation, on account of the mechanical interference of the tube to the discharge of false membrane ; and on the next day introduced two pieces of annealed wire to act as dilators ; and these were used to keep the wound open until the child's death, which occurred on the twelfth day, from pneumonia and debility. Diefifenbach cut out a four-cornered piece with a scalpel; and Blasius, in a child four years of age, an elongated strip, three lines long by two broad. Dumreicher proposed a dilator modelled on Snowden's eyelid speculum. Linhart states^ that it is not well borne, and recommends an elastic band with metallic hooks to keep the lips of the the incision apart. Heuter says* that this dilator of Dumreicher will produce necrosis if used for any length of time. Prof. Brainerd, of Chicago,^ avoids the use of the canula by making a val- vular or flap incision into the trachea. His directions for making this incision are : " Having denuded the trachea, insert a small suture needle, armed with a ligature, beneath two of its rings. Withdraw the needle, and, drawing gently on the thread, make a semicircular incision on one side, so as to form a valve, readily opened by drawing on the thread. The opening thus formed can be kept patent or be allowed to close at will." It is evident that when the flap is left to itself, the parts are acted upon somewhat as in the manner after Chevalier's crucial incision. Brainerd further states that " In trache- otomy for croup, the prolonged sojourn of the tube has been considered, by the most eminent surgeons, as a cause of the pneumonias which so frequently are the cause of death." Guillou proposes^ a sort of eyelet of flexible ivory, or of lead, to prevent the irritation and other deleterious consequences of the canula. ' St. Andrew's Medical Graduates' Association Transactions, 1867 ; Am. Journ. Med. Sci., April, 1869, p. 483. 2 Practitiouer, 1869, p. 217- s Am. Journ. Med. Sci., July, 1853, p. 81. * Compendium der Chirurgie, Operationslehre, Wien, 1856, p. 49. Heuter, op. cit. 5 Op. cit. 6 Chicago Med. Journ., March, 1859 ; Am. Journ. Med. Sci., July, 1859, p. 291. ' Reflexions sur Toperation de la tracheotomie dans le cas de croup. Modi- fication k apporter au precede ordinaire. Bull. gen. de therap., Sept. 1869, p. 267-272. 44 CROUP IN ITS RELATIONS TO TRACHEOTOMY. N6Iaton' loosened the perichondrium from the cricoid cartilage, leaving it in connection with the crico-thyroid membrane; and then excised a portion of the cartilage. If a tube were employed, this would hardly be necessary in croup cases, for the cricoid cartilage iu children yields ready entrance to the canula. Levis, of Philadelphia, in his successful case, did not use a tube.^ The objections urged against dispensing with the tube are that the swelling of the soft parts is often so great as to prevent free access of air to the arti- ficial opening ; that the movements of the trachea may draw the opening in that structure away from the superficial wound, unless the latter is very large; and that the formation of granulations may take place so rapidly as to close the defect in the trachea before the favorable course of the disease has over- come the occlusion of the larynx. Whenever an artificial opening has to be maintained for more than a very few days, the use of the canula seems to be indispensable. The tubes usually employed are made of silver ; but some surgeons prefer them made of hard rubber. Perhaps the use of a leaden tube for the first few days, or until the fistulous track is hardened, might prove less deleteri- ous to the parts than either hard rubber or silver. Prof. Roser," as soon as the first expectoration is over, after opening the trachea, passes a ligature through each edge of the tracheal wound; this is not tied, but only twisted a little, and then fastened on each side with adhesive plaster. The operator thus has full command over the trachea, and can readily dilate the wound ; a circumstance tliat much facilitates the insertion or the change of the canula. He keeps the ligatures in for three or four days ; and has not seen any injurious effect from them, in an experience of some forty cases. Prof. Trousseau urges that the incision be made in the trachea, and that the cricoid cartilage and crico-thyroid membrane be spared ; arguing that, if, as sometimes happens, the canula is to remain several weeks in the wound, it will produce partial necrosis of the cartilage. Prof. Heuter, of Greifswald,^ strenuously urges the division of the cricoid cartilage, from below upwards, — but avoiding the conoid lig- ament, — as the safest operation in children ; recommending the sub- sequent division of a tracheal ring or two, in case the opening prove insufficient. His arguments are that this locality is freer than any other from all anomalous anatomical complications; and that it permits the direct withdrawal of false membrane from the glottis. He has performed this operation man}' times, and has never en- countered any untoward results referable to the division of this cartilage. He has several times performed ten crico-tracheotomies in succession without any necessity to secure a single vessel, and ' Panas ; Gaz. des hop., 1871, No. 117. ^ Verbal coinuiunication. 3 Op. cit., p. 277. •* Op. cit. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 45 it lias always been his practice not to make the incision before the bleeding had ceased. The moment of making the incision is a very important one. The usnal method is to stab the trachea, as it were, with the point of the knife, and then to cut upwards or downwards as the case may be, or to remove the pointed knife and complete the incision with a probe-pointed bistoury. Care must be taken in penetrating the trachea that the force of the movement does not carr}' the knife too far, so as to wound the posterior wall, or make a counter-opening into the oesophagus. More than one case of this kind has already been mentioned on the authority of Trousseau, and others ; and the possibility of the accident is alluded to by a number of authors.* Sudden suffocation may ensue, with immediate death, from the flow of blood into the bronchial tract. Several cases of this kind are mentioned bjj^ Ktihn- from the obserA'-ations of Trousseau and others. When any danger of this kind is to be apprehended, it is customary to raise the child up, as soon as the incision is made, so as to prevent the blood from running down the trachea; and if this does not suffice, a finger is placed over the wound. Bleeding into the trachea may occur also, though in much more limited quantitj', from vascularity of the divided mucous membrane ; or if the crico- thyroid membrane is incised, which is rarely done in croup cases, from division of an artery in its substance. Prof. Billroth lost a case'' in an attempt to dilate the wound some hours after the ope- ration, in order to return the canula; though the cut he made was exceedingly small. Another untoward complication may arise, in cases where false membrane is present in the path of the knife, by pushing it over against the posterior wall of the trachea. Heuter* states that he has noticed, in several instances where false membrane existed upon the anterior surface of the cricoid cartilage or the trachea, that the point of the knife did not penetrate the false membrane, but merely loosened it and pressed it backwards, occluding the tube, and in this way rendering suffocation imminent. The forced respiration of the suffocative paroxysm would, as a rule, he sa3rs, ' Kiihn, op. cit., p. 149, cites cases of this kind from Barthez ; also one from Bacher, in which it is not distinctly staled whether a communication between the trachea and the oesophagus, found after death, was made during the opera- tion or not. Glas (Upsula lak for. forhande, Bd. v. p. 37 ; Virchow's Jahres, med. Wiss., 1870, Bd. ii. p. 369) describes a tracheotomy in which the trachea was transfixed and cut through. 2 Op. cit., p. 151. 3 Arch. klin. Chir., 1869, p. 192, * Op. cit., p. 46. 46 CROUP IN ITS RELATIONS TO TRACHEOTOMY. tear the membrane loose and force it out ; but he has never waited for this occurrence, which might be impossible in moribund children, but he has introduced an elastic catheter to tear the membrane loose, and blown into it to excite cough or supply air. Trousseau' records a very illustrative case in which the false membrane, being torn b}' the introduction of the canula, was impacted by the in- strument into the trachea, so as to obstruct the passage of air com- pletely. A fatal instance of this kind occurred in the practice of Dr. Jacobi, of New York,^ and is related by him in his admirable article on Croup, in which, as he graphically expresses it, " the child was strangled in the attempt to save her life." Another element of danger is the descent of loosened membrane upon the bronchi. This element of danger, says Heuter,^ is not to be underrated. As a rule, the false membrane is half-incised, half- torn by the point of the knife; and large fragments ma}' become loose enough, partly by their mere weight, and partly by the suc- tion power of the inspiratory current, to reach the bifurcation. He has seen several such cases on the operating table, and has alwa^'s overcome them by aspiration through the catheter. He believes that many cases of death from suffocation which other operators have encountered have been due to this cause. Inasmuch as this point has not received a great deal of atten- tion from other authors, the question naturally arises, whether Heuter's method of incising the cricoid cartilage is not more apt to bring his knife in contact with false membrane, in many in- stances, than an incision practised some distance below ? In pursuing this theme Heuter calls attention to the dangers of confounding the asph3'xia brought about by obstruction of the air- passages with membrane and blood, with the apnoea which some- times supervenes immediately on opening the trachea. When the stream of air rushes free into the lungs of the suffocating child, breathing is sometimes suspended for a moment. This causes the operator a good deal of anxiety when he sees it for the first time ; but it is void of danger, and he soon learns to distinguish apnoea from asphj^xia. Heuter strongly iirges in every operation for membranous croup, that, immediately after the opening is made into the trachea, an elastic catheter (from No. 8-12) should be introduced down to the bifurcation, and suction be made, as first recommended by Roux. The membrane and blood is thus drawn into the e3'es of the catheter, • Op. cit., p. 60]-2. 2 Am. Journ. Obstet., ISe-*, p. 59. s Op cit. CROUP IN ITS RELATIONS TO TRACHEOTOMY. i1 and when tlie latter is withdrawn the obstructing contents come with it. Even its simple introduction and withdrawal Avill cause the discharge of some of the membrane, and also of some of the blood ; and as there is some personal danger in aspiration, this ma}- suffice in slight cases. But when the respiration remains unfreed after the opening is made, or asphyxia supervenes, aspiration becomes neces- sary, for everything points to an obstruction low down, for the prompt relief of which there is nothing so useful. He says one soon learns to avoid receiving the contents of the catheter in the mouth. A small glass globe can be attached to the catheter to receive the contents. He has tried the suction sj'ringe, and the compressed rub- ber ball recommended by Stromeyer, but has not been satisfied with their action. The moutli enables him to appreciate the resistance; and to his fearless use of it, he attributes his good fortune in never having lost a patient on the operating table. Should artificial respiration be required, Heuter recommends again the use of the catheter to blow air into the lungs ; while ex- piration is to be effected by manual pressure on the hypochondrium, the movements being made alternately, and in the rhythm of normal respiration. Prof. Roser' also recommends that there should always be an elastic catheter in the tracheotomy case ; for he thinks that nothing promotes so conveniently and innoculously the discharge of false membranes, and excites respiratory movements, as the motion up and down of a catheter ; such an irritation being espe- cially required where asphyxia already exists. The incision being made into the trachea, its edges should be held apart by hooks or other contrivances, and search be made for false membrane as in a case of any extraneous foreign body. This is a point discussed by very few operators, most of whom, judging from their published records, introduce the canula as soon as pos- sible. If membrane is removed by forceps, by aspiration through a catheter, or simply by cough mechanically excited, before the canula is introduced, it must be a great gain ; l)ecause the membrane can otherwise be discharged only through the tube, against or within which it may become lodged in one of the paroxysms of cough. Cases have been recorded^ in which large portions of tracheal and bronchial membranous exudation were removed through the tracheal orifice. If the trachea is cleared of all the membrane it contains at the time of the operation, it is fair to infer, that, what with the subsidence of muscular exertion in breathing, due oxygenation of the blood, and refreshing slumber, the general ' Op. eit., p. 277. * One by Moneret is ah-eady alluded to iu these pages. 48 CROUP IN ITS RELATIONS TO TRACHEOTOMY. state of the system will be so far improved as to give an interval of many hours at least, before the exudation again accumulates in obstructing quantity. The false membrane is usuall}^ readily detached, often by the force of the cough alone ; in some instances, however, it is exceed- ingly adherent, requiring cousidei*able effort to detach it. In one of the cases operated upon by Prof. Pancoast,' "the inner circum- ference of the trachea was found lined with a false membrane of much density and toughness. This was so tough that in attempting to detach it from the side next the larynx by pulling on it with the forceps, the larynx was drawn downward before the membrane broke." The Canula. — Thecanula usually employed at the present day is a modification of the double tube originally devised by George Martin''' from the suggestion of one of his friends in 1730. As modified by Prof. Trousseau, the inner tube projects a little beyond the terminal extremit}' of the outer one, so as to free the latter ■when the former is removed or inserted. The proximal extremity of the outer tube should be suspended by movable joints in a per- forated plate to be fastened upon the neck by means of tapes or elastic bands tied behind. This arrangement, by allowing the tube to adjust itself to the movements of the trachea, avoids pressure against the mucous membrane to some extent; and, thus far, pre- vents ulceration of the trachea; a serious complication which some- times attends a prolonged use of the tube, though it sometimes occurs within 36 or 48 hours. The size of the tube should be as large as can be convenient!}" emploj^ed without touching the walls of the trachea. Trousseau^ thinks that the canula should be of larger calibre than the glottis. Others recommend that it should be about as large as the calibre of the cricoid cartilage, which is considerably less than that of the trachea, in some cases much less. By having a number of tubes of graduated sizes the nicety of ad- justment may be attained, whatever may be the age of the child; the same sized tube emploj'ed promiscuously for all cases, as is the habit, will not always be well adapted to the case in hand. Too short a canula may be coughed outside the trachea, rendering the patient liable to become asphj'xiated in a few moments by its pressure externall^^ Three times an accident of this kind occurred in Trousseau's practice.* In order to permit the easy introduction and withdrawal of the inner tube, the canulas are made in the form of a segment of an ellipse, or in that of a circle, a form in which the terminal extremity 1 Am. .Jonrn. Med. Sci., Apl. 1859, p. 315. 2 Philosophical Transactions, 1736. 8 Op. cit. < Cliu, med., ii. p. 604. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 49 is apt to graze the anterior wall of the trachea; and to avoid this, the terminal orifice is to be bevelled off from before backwards. Dr. Arthur Durham, of London,' has devised a canula turning into the trachea at right angles, and capable of being set, hy means of a movable collar, at an3^ distance from the surface. This avoids contact with the walls of the trachea ; but it necessitates the use of a jointed or lobster-tailed inner tube, which is likel}' to necessi- tate very frequent removal, an operation sometimes even difficult, in certain instances, from presenting so many projecting points for the detention of mucus, pus, blood, and other products. Dr. Fuller, in a paper^ read to the Royal Medico-Chirurgical Societ3'of London, January 27, 1857, recommended that both tubes be of the same diameter throughout, and that the outer one be di- vided longitudinall}' into two blades, flattened towards their inferior extremity so as to come into close apposition, and to admit of easy introduction into the trachea; being made to open like the blades of a bivalve speculum, and admitting, when full>' expanded, an inner tube of uniform diameter throughout. This arrangement, he claimed, could not only conduce to keep the inner tube clear of mucus, but Avould render serious obstruction to the resi)iration well nigh impossible, inasmuch as, if the inner tube were to be clogged in any wa}'^, and the extremity of the outer canula also were to be choked with mucus, the chink existing between its expanded blades would provide a free passage of air immediately on the withdrawal of the inner tube. This tube has not won the approval of many operators. Bourdillat, of Paris, more recently^ contrived a more elaborate outer tube on the same principle, which has proved more efficient; and which will often prove of great service* in dressing tracheotomy wounds, whenever any serious difficulty is presented in replacing the ordinary canula. The canula is confined to the neck hy tapes or elastic bands at- tached to the plate. The surface of the skin should be protected from the discharges which take place through the canula, by means of a piece of oiled silk or rubber cloth into which a hole has been cut for the passage of the canula, the whole having been prepared before the introduc- tion of the tube. Beneath this, if desired, a greased rag may be placed to prevent its becoming plastered to the skin. The wound is brought together by adhesive strips merely, sufficient room being ' The Practitioner, 1869. 2 Med. Times and Gaz., Feb. 7, 1857 ; Am. Journ. Med. Sci., Apl. 1857, p. 525. 8 Gaz. hebd., 1868, p. 154. •• Sanue, op. cit. 50 CROUP IN ITS RELATIONS TO TRACHEOTOMY. allowed below for drainage. Experience has shown that sutures are not well borne, and are often cut out by the strain exerted on them in the paroxysm of cough. Sometimes cases do very well without any dressing whatever. The introduction of the tube is facilitated by holding the lips of the tracheal incision apart either by tenaculum, forceps, blunt hooks, or special dilators; and still further by the temporary use within the tube of a conducting gum catheter or a special piloting blunt trocar, or a bit of gum bougie, so as to present a solid tapering ex- tremit}^ which is more readily manipulated. Dr. Guersant, who modified Trousseau's dilator b^^ substituting rectangular blades with i^lane extremities, and opening by pressure upon the handles, states,' as the result of personal experience in more than three hundred tracheotomies which he has performed, that he believes the best method is to use a dilator, and the elastic bougie as a conduc- tor. Laborde further modified this dilator by attaching a third blade, but, though a very admirable instrument, it is believed by Guersant and others to possess no special advantages. Mr. John Couper- inserts a flexible rod of gutta-percha into the trachea, and then runs the tube down on it, when there is any difficulty in intro- ducing the latter. The final removal of the canula is usually made at a period vary- ing between the 5th and 9th day after the operation. In occasional and rare instances it may be removed as early as the end of the first day; and in other instances it cannot be dispensed with for a number of weeks, or a number of months. In Jacobi's 13 success- ful cases,'' the canula was permanently removed as follows : — On the 17th day, in 2 cases. 18th " " 1 case. 20th " " 1 " 27th " " 1 " 29th " " 1 " 30th " 1—1 35th " " 2 cases, On the 42d day, in 1 case. " 44th " " 1 " " 46th " " 1 " " 54lh " " 1 " 13 cases. In four of these cases the protracted use of the canula was due to polypoid excrescences at the margins of the tracheal wound. In Steiner's cases the canula was permanently removed as follows : — ' La chirurgie des Enfants, Paris, 1864-7, p. 42. 2 London Hosp. Rep., 1808 ; Brit, and For. Med.-Chir. Rev., July, 1869, p. 41. 3 Am. Journ. Obstet., May, 1868. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 51 On the 10th day, in 2 cases. On the 34th day, in 1 case, " 35th " " I " At the end of one year and three months . . in 1 " 18 cases. Sanne' gives the following dates of the final removal of the canula in 108 cases : — At the end of the 1st day, in 1 case. At the end of the 16th day, in 2 cases. 17th " " 1 case. 20th " " 3 cases. 21st " : „ 2 '< 25th " 11 9 i( 28th " 1 '< 4 " 30 th ' ' " 1 case. 3d " " 3 cases. 4th " " 7 " 5th " " 14 " 6th " " 16 " 7th " " 10 " 8th " " 14 " 9th " " 5 " 10th " " ' 8 " nth " " 3 " 12th " " 3 " 13th " " 5 " 14th " " 1 case. 15th " " 3 cases. 17th " " 2 " 20th " " 2 " 23d " " 1 case. 24th " " 1 " 25th " " 1 " 30th '• u 1 t( 32 nd " il 1 X 34th " 11 1 11 35th " " 1 " 45th " 11 1 II 126th " 11 Y " 108 cases. In Max MUller's^ 15 successful cases, the tube was removed definitely : — On the 13th day. On the 69th day. 15th " " 70th " 25th " " 79th " 27th " " 105th " 42nd " " 112th " 44th " " 120th " " 51st " and 203rd days resp'ly. A most exceptional series. He mentions that in one of these cases febrile phenomena reappeai'ed on the 19th da^'^ after the opera- tion ; followed, three days later, by the expectoration of a tubular cast of membrane two inches in length, bifurcated at one extremity and bearing an impression of the primitive bronchi. The causes ivhich prevent the early removal of the canula^ are spasm, inflammatory products in the air-passages or in the wound, and diphtheritic paralysis. The spasmodic condition is sometimes independent of any ap- preciable cause. Sometimes it is due to fear of suffocation, on the ' Op. cit., p. 30. 2 Arch. kliu. Chir., 1871, p. 448. 52 CROUP IN ITS RELATIONS TO TRACHEOTOMY. part of the patient, requiring great circumspection, patience, and care to overcome. Millard relates a case in which the child, though able to breathe without the tube, would not lose sight of it for a minute, and became subject to a suffocative paroxysm if a threat was made, in pleasantry, to take it out of the ward. It became ne- cessary to let him carry it around his neck like a watch chain. Blachez' recounts a case of a child who, after having for six weeks resisted all attempts to dispense with the canula, passed an entire day without his tube. While playing, he pinched his finger in a doorway, and the emotion produced hy this accident brought on a paroxysm of suffocation which proved fatal in a few minutes. A patient of Bergeron''' was unable to dispense with the canula for more than a few minutes. At the end of fovty days he was able to pass a day and niglit without it, but had such a severe paroxysm of apnoea the next day that it was necessary to practise tracheotom\' anew. From this time forward he could not be de- prived of his canula for more than a quarter of an hour each day. On the 154th dav he died of a broncho-pneumonia, the sequel of measles. The autopsy did not reveal any lesion which could ex- plain the obstacle to respiration. M. Breckel reports a case in which he had to perform tracheotomy a second time, on account of spasm after the removal of the tube, on the 19th day. The canula was definiteh' removed on the 11th day after the second tracheo- toni}', the 31st da}' after the first tracheotomy. Dr. Rouzier-Joly^ relates a case in the person of his own son, in which the tube could not be removed for fourteen months, on account of spasm. Cau- terization of the deep parts of the wound was of great benefit. M. Paris relates* the following case : J. B., set. 5^ years, had a severe attack of croup in Nov. 1865, for which M. Paris performed tracheotomy. Recover^' was complete on the 14th daj'. On the 32d day, after many temporary removals, the canula was taken out, and the wound allowed to heal. Respiration gradually became so difficult, that in two days it had to be replaced. Other attempts were made at three and four montlis; but still without success. The boy was taken to Paris, and seen by M. Trousseau, who stated that he had met with several similar cases, in one of which the canula had to be retained for five j-ears, and yet eventually a cure was com- pleted. M. Marjolin confirmed this opinion. M. Ozanam made a 1 Sanne, op. cit., p. 145. 2 Saiuie, op. cit., p. 147, and in detail (obs. 28) p. 256. 3 Croup, traclieotomie, etouflfemeuts provoques par I'ablation momentanee de la canule. Gaz. des hop., 1867, No. 75, p. 297. * Gaz. des hop., April 13, 1867 ; Am. .Journ. Med. Sci., Jan. 1868, p. 273. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 53 laryngoscopic examination, but after twenty examinations, assisted by tlie little patient with good will and courage, could discover nothing, but that the larynx and vocal cords were healthy. At the date of the report, sixteen months after the operation, the boy was healthy, but was still wearing the canula. During the day he closed it with a plug, which he had to take out at niglit. The curious point is, that although he could breathe quite well with the canula com- pletely plugged, he could not breathe wlien it v/as removed. Dr. Ehrmann, of Strasbourg, presented to the Societe Medicale du Haut-Rhin, at its session. May 10th, 1868,' a little girl 4 years of age, whom he had tracheotomized for croup, on June 14th, 186*7, and who could not dispense with the tube, the removal of which was followed by suffocative phenomena. Dr. Ehrmann had en- countered two other cases of this nature, mentioned in the thesis of Dr. Edouard Boeckel. The explanation of these phenomena seemed to reside in the fact that the laryngeal muscles had lost the habit of contracting harmoniously for the needs of respiration ; the patients being somewhat in the condition of those with paralysis of the vocal cords. The j:)resence of false membrane in the larynx may retard the removal of the canula. False membranes are seldom observed longer than a week after the operation ; sometimes not after the first day; occasionally for a much longer period. One or two instances of the latter kind are incidentally alluded to in this paper; and Sanne reports one in which false membranes appeared until the thirty-second day, having necessitated a second tracheotomy four- teen days previously. Tumefaction of the mucous membrane of the larynx may be an- other cause. Sanne- states, that in two cases in which the canula could not be removed without embarrassment of respiration, threat- ening suffocation, the patients died of broncho-pneumonia; and the autopsy revealed that the tracheal mucous membrane was red and hypertrophied, forming, at the level of the vocal cords, prominent projections which obstructed the glottis. In another case,'^ there was a veritable oedema of the glottis, a very rare occurrence in children. Barthez observed, at Sainte-Eug^nie Hospital/ a case of oedema of the glottis occurring without known cause and terminating fatally in an access of suffocation which did not afford time to perform tracheotomy. ' Gaz. rat'd. de Strasbourg, Aug. 10 1868, p. 177. 2 Op. cit., p. 153. 3 Op. cit., recorded iu detail at p. 208, * Gaz. hebd., 1869, No. 2, p. 25. 54 CROUP IN ITS RELATIONS TO TRACHEOTOMY. The presence of exuberant granulations or polypoid excrescences in the track of the wound or in the larynx itself may prevent re- moval of the canula. Dr. Jacobi' states that in four of bis cases of recovery, removal of tbe tube was rendered impossible by "polypoid excrescences, sometimes numerous, of the size of a pin's head to that of a pea or more, originating on the margin of the tracheal wound, in one case on the lower portion of the sore larynx itself. It required a great many applications of nitrate of silver, or sub- sulphate of iron, to destroj' them. Their disappearance would in- stantly relieve the symptoms, and allow of the final removal of the tube from the trachea." Steiner^ mentions luxuriant granulations at the edge of the tra- cheal incision, forming a tongue-shaped projection within the re- spiratory tube. M. Bergeron^ reported a case in which death from pneumonia occurred on the twent3'-third day, after numerous ineffectual attempts to remove the tube. The autopsy revealed the presence of a pedunculated laryngeal polyp about one centimetre above the incision in the trachea. It is doubtful if this polyp had anything to do with the croup. Dr. Gigon, of Angouleme, has published* a case in which the canula was removed on tlie fifteenth day, but respiration did not become re-established satisfactorily. Paroxj'sms of suffocation supervened, necessitating a second tracheotomy forty-five days after the first. There was then seen, in the neighborhood of the tracheal cicatrix, some roundish, red, movable bodies, the size of peas, which obstructed the calibre of the tube ; and they were excised. The canula was then removed on the third day, and there was no further difficulty. Catarrhal affections of the air passages will retard the removal of the canula, on account of the difficulty of expulsion for the pro- ducts of secretion. Finally, diphtheritic paralysis may render the larynx insubser- vient to the purposes of respiration, and necessitate the prolonged use of the canula. The cause of difliculty in removal of the canula being recognized, the appropriate treatment, medicinal and surgical, suitable for the same condition under other circumstances, would be employed in cases occurring after tracheotomy for croup. > Am. Journ. Obstet., May, 1868. ^ Op. cit. 3 Union med., 1868, p. 624; Gaz. med., 1869, p. 253. * Saune ; op. cit., p. 154 ; Union med., 1862, p. 272, CROUP IN ITS RELATIONS TO TRACHEOTOMY. 55 The period of death after tracheotomy for croiq? varies, as we see from the tables presented, from a few moments to several months. Mr. Spence' states that, as a general rule, death occurs in croup proper two, three, or four days after tracheotomy, and in cases of diphtheria two or three weeks after the operation. Cicatrization of the Wound. — The canula being permanently re- moved, the wound, as a rule, gradually contracts, and cicatrization is completed, without interference, within a fcAV days. If cicatriza- tion progresses favorably, the prognosis is good as to ultimate re- covery ; if it is retarded, it indicates, in the absence of local disease, the approach of some complication. Exuberant granulations are repressed witli nitrate of silver. If cicatrization is too slow, the edges of the wound maj- be touched witli some gently stimulating application. Sanne speaks "well of carbolic acid, one part in a- hun- dred. The following table from Sanne'^ is instructive : — Date of Cicatrization in Sixty-eight Cases. At the end of 9 days in 1 case At the end of 24 days in 1 case 10 ' ' 1 " 11 ' ' 2 cases 12 ' 4 u 13 ' ' 3 " 14 * ' 2 " 1.5 ;< 5 .. 16 • 5 " 17 ' 2 " 18 ' ' 4 " 19 ' 2 " 20 ' 6 " 21 ' 4 " 22 ' 5 " 23 ' ' 1 case 25 " 4 cases 26 " 3 " 27 " 3 " 29 " 1 case 30 " 1 i( 33 1 " 35 " 1 " 36 1 " 38 " 1 <( 40 1 " 43 1 " 80 " 128 " 1 " 68 ( cases. The After-treatment of the Disease and of the Surgical Wound. A great deal of the success to follow tracheotomy for croup will depend upon the after-treatment of the case. It was a "want of recognition of the importance of this fact, that rendered success so infrequent previous to 1850 or thereabouts. Great stress has been laid upon this point by all recent writers on the subject. The most valuable work I have seen in this connection is from the pen of Dr. Sannd, of Paris,^ based upon his year of service (1868) in the Hopi- 1 Edinb. Med. .Journ., March, 1S64. 2 Op. cit., p. 33. * Etude sur ie croup apres la tracbeotomie, Paris, 1869. 56 CROUP IN ITS RELATIONS TO TRACHEOTOMY. tal Sainte-Eugenie, which afforded him many opportunities to ope- rate, and to study the results of operations, and the subsequent course of the disease. During that year 102 cases of croup were received into the wards of M. Barthez, of which 83 were subjected" to tracheotomy with a result of 18 recoveries. M. Barthez placed records of other cases at the service of the author, so that his vol- ume is the result of an analj'sis of 662 cases of croup subjected to tracheotomy. Dr. Sanne has made good use of this material, and has discussed the subject of after-treatment, accidents, and compli- cations with great detail and circumspection. Much that follows has been chiefly derived from his pages, which present partly much the same conclusions as are expressed by most authors ; the simi- larity of argument, and often of language in many articles, indica- ting a common source, that of the great Parisian tracheotomists. The operation being completed, and its immediate dangers over, the patient should be replaced in bed and be well covered up. His apartment should be kept at a comfortable iieat (70° F. at least), the temperature being regulated b}' a thermometer. These precautions are necessary, because more or less well-marked chilliness almost always follows the operation, varjang, usually, with the previous degree of dyspnoea and the amount of blood lost in the operation. The external opening should be covered by a bit of stiff gauze, to protect it from exti'aneous matters, as employed by Andree in the very first operation ; best applied above the wound, straddled upon a strip of adhesive plaster. In addition to this. Trousseau' strongly recommended " covering the neck with a knitted comforter, or a large piece of muslin, so arranged as to compel the child to respire into its folds, and thus inspire air warm and impregnated with the warm vapor furnished by the expiration. In this manner several un- toward circumstances are avoided : drying of the cavity of the canula and of the trachea, irritation of the mucous membrane, and the formation of coriaceous crusts, which, becoming detached in complete tubes or fragments of tubes, cause terrific fits of suffoca- tion, and sometimes death by occlusion of the canula." Before Messrs. Trousseau and Paul Guersant had adopted this practice, they lost many of their patients by catarrhal pneumonia ; but this accident liad become rare since, and they thought it probable that the introduction into the bronchi of a warm and humid air was a very favorable circumstance. The use of this woollen cravat renders less essential another prac- tice much in vogue for the same purpose of warming and moisten- 1 Arch. Gen. de uied., 1855, p. 265, CROUP IN ITS RELATIONS TO TRACHEOTOMY. 5Y ing the inspired air; and that is keeping up an evolution of steam- from boiling water, so that its vapor can be mingled with the in- spiratory current, either by means of some special contrivance for conveying a current of warm vapor of water directly in front of the opening, or by allowing it to be generally diffused in the patient's vicinity. From personal experience of this practice in the medicinal treatment of croup, I would not feel disposed to forego it even with the use of the cravat. It appears to replace, in part, the moisture evaporated or absorbed from the exudative products in their trans- formation into the semi-solid or membranous form, and thus to keep them in a condition favoring their detachment and expulsion. Some operators keep the temperature of the room about 65'^ F., others, as Sayre, of New York, as high as 90°. That a high temperature is well borne in croup I have had ample evidence at a temperature of 80° to 85°, with an evolution of steam sufficient to cause the paper to loosen from the walls. Some of the German authors recom- mend keeping a sponge wrung out of hot water in front of the opening so that the air shall pass through its pores ; a plan also recommended by Gerdy and Nelaton.^ If the patient does not react well from the chill, warm aromatic drinks should be freely given, and fljung sinapisms be applied to various parts of the skin; the evidence being that under these in- fluences the face gradually resumes its normal color, the pulse in- creases in force, and the respiration becomes quieter, so that the vesicular murmur can be heard in all portions of the lungs, except, perhaps, anteriorly, where interv^esicular emphysema has taken place. At the end of a few minutes the child usually sinks into a calm, sweet sleep which lasts sometimes for several hours. In some in- stances indeed the child goes to sleep on the operating table, within a few minutes after the introduction of the tube. With regard to details such as these, and others to be mentioned in connection with the dressings. Trousseau himself asserted that the older he became, the more convinced he remained of their importance. The diphtheritic manifestations of croiqy are usually abandoned to themselves after tracheotomy. Trousseau's opinion was that the disease had exhausted all its action in the air-passages ; and that if the patient could be prevented from dj'ing by tracheotomy, re- covery ensued in the natural manner. Inasmuch as the diphtheritic manifestations frequently, exist in the bronchi, endeavors are often made to aid in their destruction and removal, and to prevent their further deposition. Inhalations ' Boucluit, op. cit. p. 255. 58 CROUP IN ITS RELATIONS TO TRACHEOTOMY. of steam, sometimes charged with lime, volatile and other substances, are used to this end Sanne endorses the opinion of Millard that the use of the cravat or comforter has rendered this practice more embarrassing than useful. Dr. H. Trideau has suggested the utilization of the elimination of cubebs and copaiba by the respiratory mucous membrane.' He considers that the false membrane is susceptible of being attacked by remedies which are eliminated from the surface on which it has been deposited. Trousseau, iJarthez, and Bergeron'^ have been favorably' impressed with this view, and have employed these sub- stances in numerous instances, and with varying results; some of them, however, highly satisfactory. Cubebs is preferred to copaiba on account of its not affecting the digestive organs ; and the best form of administration has been found to be the oleo-resinous ex- tract in doses of half a gramme to a gramme every two hours, in a mucilaginous emulsion. Bergeron prefers to give the extract of cubebs in the form of a saccharate. Its use is continued until no more false membranes are expelled, and the larynx seems free. Isambert, Andre, and Millard recommend the administration of chlorate of potassa after tracheotomy. Dr. Labat' recommends the use of acetate of potassa in large doses, 5ij in the twenty-four hours, administered in sweetened water. When expectoration is tardy and the tube becomes dr}^, he gives 10 grammes in 120 gr. of water; and at the end of two hours finds tliat the expectoration has become easy and abundant. Bartliez'' at one time found great advantage from instillation into the trachea of a rather concentrated tepid solution of chlorate of soda. The evacuations should be carefully watched. Diarrhoea and vomiting sometimes occur a few hours after tracheotomy has been performed, principally in children to whom emetics, particularly antimon}^, have been administered ; and chiefly in those cases where, on account of the susi^ension of the function of absorption during the period of asphj^xia, they have operated very little or not at all. J Nouveau traitemeut de I'aiigine couenneuse, du croup, et des autres localisa- tions de la diphtlierie par le baume de copaliu etle poivre cubebe. Paris, 1866. Gaz. des hop., 2, 1866. 2 Gaz. hebd., 1869, 16, p. 253, 26, p. 44; Gaz. des hop., March 5, 1870. 3 .Jonrn. de med., Bordeaux, 1869: Bull, de therap , 1869, 1, p. 190; Practi- tioner, June 1869, p. 377. 4 Bull. g6n. de therap., May 30, 1858 ; Brit, and For. Med.-Chir. Rev., Jan. ,1859 ; Amer. Journ. Med. Sci., April, 1859. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 59 The resumption of normal function on the re-establisliraent of re- spiration, promotes the absorption of the contents of the intestinal canal ; hence the catharsis and emesis. It is, therefore, unwise to continue the emploj^ment of this class of medicines long after they have ceased or failed to act; for even a spontaneous ejection of false membrane would be followed b}' similar consequences. Traumatic fever sets in soon after the operation, at a period which may vary from a quarter of an hour to several hours, this variation being in accordance with the state of the patient at tlie time of the operation ; the greater the depressing influences, such as dyspnoea and hemorrhage, have been, the later, other things being equal, will be the febrile reaction. This fever, in a favorable case, should subside in tlie course of one or two days, or coalesce into that attendant upon the diphtheritic affection itself Its longer per- sistence is due to some impending complication. In some cases the violence of the reaction proves fatal within twenty-four hours ; the slight extent of membrane, and the absence of evidence of other lesions on post-mortem examination, permitting no other conclusion. The respirations^ afteojsubsidence of the fever, should not exceed forty in the minute, in a case progressing fiivorably, counted during sleep ; though they will become more frequent under emotional influence, or cough. As the case progresses towards recovery the respirations gradually resume their normal frequence. Sometimes when respiration appears perfectly calm, and without effort, it will be found to be short and rapid. This is usually indicative of some pulmonary or other complication. The circulation is proportionate to the respiration. During the febrile movement the pulse will vary between 120 and 140 beats in the minute; and it will subside as the patient progresses towards recovery. If it becomes much accelerated, say to 160-180 in the minute, the temperature of the skin rising at the same time, it is almost certain evidence of some impending complication. Bartels^ states that with a pulse over 110, the patient is sure to be lost; that 152 a few hours after the operation makes the diagnosis unfavor- able, wliile less than 130 is favorable ; that a temperature of 39° (]. (102° F.) is unfavorable, and a normal temperature the day after the operation is favorable ; while sudden rise of temperature indicates complications or a relapse. The expectoration at first contains more or less blood, according to the quantity which has passed down the trachea. In a short time it becomes mucous, thick, and opaque, sometimes forming large ' Loc. cit. 60 CROUP IN ITS RELATIONS TO TRACHEOTOMY. irregular masses. In other cases it remains transparent and more fluid, though still viscid. These are the characteristics of laudable expectoration. If the expectoration is purulent or serous, grayish, fetid, non-aerated; and trickles out instead of being coughed out, it is an unfavorable symptom. If the patient does not cough after tracheotomy, the prognosis is bad ; for the mere drainage of fluids is insuflicient to prevent gradual asphyxia. The removal of false membranes is probably attended with more or less excoriation of the mucous membrane from loss of epithelium, and it is in part to the reparative processes here that the discharges occur, which, on desiccation, form the coriaceous crusts that so often appear shortly after the operation. The inspiration of warm and moistened air tends to retard this desiccation and facilitate the removal of the discharges by cough. Should these matters accumulate in threat- ening quantitj'^, it would be good practice, as recommended by Prof. Heuter,' to endeavor to remove them by aspiration, a method more certain and powerful than the action of medicinal expectorants. Some authors contend that the false membranes are eventually lifted from their seat by serous exudati^ ; others contend that they are loosened b}^ suppuration beneath thera.'^ In the latter case the presence of large quantities of pus in the expectoration would be readily accounted for. The nutrition of the tracheotomized patient is a point of the highest importance. The appetite is usually satisfactory^ for the first two or three days; after wliich it often diminishes, sometimes to such a degree that the patient refuses nourishment. Complica- tions of all kinds tend to diminish the appetite. Every effort should be made to sustain the child. From the very first day, in the French hospitals, thin soups are given, and red wine or vinous lemonade as a common drink. The following day soup and milk are given; and one or two fresh eggs are soon added to the diet. The use of solid food is approached as rapidly as possible, ordinary diet being allowed, and care taken to make it as nutritious as possible. From the second day a little generous wine (de Baguols, at Sainte- I^ugenie) is given diluted with a little water. In some cases fear, caprice, dread of the accidents attendant on deglutition when diphtheritic paralj'sis is appearing, cause difli- culty of feeding. In some cases it is simple repugnance; in othei's a resistance sufficient to inspire grave disquiet. A great deal of care, tact, and humoring is necessarj' under these circumstances to induce the patient to take food. Delicacies and confectionery may be J Op. cit., p. 62. 2 Flint's Practice, 1868, p. 259. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 61 allowed, rather than to permit the patient to remain without eating. An artifice will sometimes convince the child that it can eat. The return of appetite is almost a certain promise of recovery. (Sanne.) Sometimes liquid nourishment alone is taken. If paral3'sis ensue, liquids cannot be taken as well as semi-solid food. To assist nour- ishment and rouse appetite, cinchona is often given, in the form of wine or extract suspended in mucilage, or in an infusion of sweetened coffee. When the patient cannot swallow, or does not take food in sufficient quantit}^, we must resort to artificial nourish- ment by the stomach or by the rectum. Trousseau, and others after him, recommend the use of the stomach tube for conveying nourishment in cases of inability or unwillingness to swallow. A small tube passed through the nostril and guided along the posterior wall of the pharynx until two or more inches had passed down the oesophagus, would probably be preferable to one passed through the mouth, as it would avoid the epiglottis; while it would easily permit the passage of milk and other thin liquid nourishment. Diphtheritic Paralyais. — Sanne states that diphtheritic paralysis at the end of a variable period attends nearly all the cases operated upon for croup ; and he considers this complication sufficiently habitual to entitle it almost to be considered among the phenomena of normal evolution ; belonging essentially to the diphtheritic affection itself, however, and not to tracheotomy. It occasionally necessi- tates the retention of the canula when other croupous or diphtheritic phenomena have ceased. In this condition milk and other fluids will not be thoroughly swallowed, but will pass down the larynx and trachea, exciting cough, or they will trickle through tlie wound without reaching the trachea. These phenomena will also occur from other impediments to deglutition independent of diphtheritic paralysis. Mr. Spence' is of the opinion that the passage of aliment by the tube is peculiar to diphtheria ; for in a very large experience of tracheotomy performed for different kinds of disease or accident, he has never seen the fluid food ejected by the tube, except in that disease ; and he asks, " Is it not probable that the same paralyzed state of the glottis ma}^ allow portions of fluid nutriment to pass into the air-passages in other cases of diphtheria in which tracheo- tomy had not been performed ?" The care of the canula is a consideration of the gravest moment. ' Tracheotomy in Diplitheritic Croup. Edinb. Med. Jouru., March, 1864, p. 782. 62 CROUP IN ITS RELATIONS TO TRACHEOTOMY. The tube is apt to become obstructed by retention of expectorated products, whether mucous, purulent, sanguineous, or membranous; and, if not freed from them, the patient will become suffocated. Cases of death from this cause are by no means infrequent. It is, therefore, of the greatest importance that a competent attendant, by preference a medical, man of some judgment, and familiar with the nature of the accidents which follow tracheotomy and the use of a tube, be at the side of the patient, or, at least, within immediate call, until all danger from this source has passed. Kelief must be im- mediate, in case the artificial passage becomes occluded. Obstruc- tion in the tube will be indicated by peculiar moist sounds in respi- ration, or by the restlessness of the patient. The inner tube should then be removed and cleansed, and the outer tube be swabbed out with a soft mop or a feather, after which, if the passage is clear, the inner tube may be replaced. The removal and replacement of the inner tube, and the cleansing of the outer tube usually excite effec- tual cough with more or less discharge. Partial or complete occlu- sion of the artificial opening by the finger during the explosive movement of cough will render it more effective. A soft sponge, mop, or cloth should be at hand to catch any secretions or discharges that present at the external extremity of the canula, and prevent them from being drawn back b}' the current of inspiration. A shred of false membrane presenting at the extremity of the tube produces a characteristic flapping, sometimes accompanied by harsh and stridulous sounds ; cough is excited by the impediment to respiration, and after more or less effort the membrane is usually driven through the canula. If this does not take place promptly, the inner tube should be removed, and if the membrane is not driven through the outer tube, an attempt should be made to catch it with curved for- ceps. Should this be unsuccessful, cough should be excited b}^ passing a feather or delicate mop through the tube into the trachea. If this fail, a little warm water should be dropped gutfatim into the tube, and be repeated every ten or fifteen minutes ; or an elastic catheter be introduced and aspiration made. It is an important matter to excite cough. If the obstructions continue in spite of all these measures, the entire canula should be removed, but, on account of the difficulty of reintroduction, this should not be done, the first da}^ at least, by an unskilled hand. Yery often the mere reintroduc- tion of the canula will excite effectual cough. Where the canula is not well borne, when it cannot be replaced, or when it prevents ex- pulsion of matters from the trachea, some other means must be em- ploj^ed to maintain the potency of the artificial respiration. Care must be taken to recognize a necessity' for these and similar mani- CROUP IN ITS RKLATIONS TO TRACHEOTOMY. 63 pulations, so that the parts be not irritated unnecessarilj', or sleep disturbed without cause. The character of the respiration will art'ord the proper indication for interference. The condition of the inner canula should be observed every two or three hours, to make sure that viscid secretions have not adhered in serious quantity upon its surface ; and whenever it is I'emoved, the nature of its contents should be carefully examined in water, so as to assist the judgment as to the progress of the case. Changing the Tube. — At the end of twenty-four hours or there- abouts the tube should be changed, a clean one being inserted to replace the tube introduced at the operation, and now soiled with blood and sputa ; as well as to permit an early inspection and dress- ing of the wound, an important point in many instances, in view of impending diphtheritic deposit, gangrene, erysipelas, etc. It is best to make the first change by good daylight, and the usual time stated may be anticipated or postponed a few hours accordingly. Trous- seau and manj^ others do not approve of the early dressing, but it is recomended by Barthez, Millard, Sanne, and others. The inflam- mation excited by the presence of the tube is sufficient, in the course of twenty-four hours, to pour out enough plastic lymph to give the tissues a certain amount of resistance, and the sides of the opening in the soft parts are sufficiently firm, except in very rare instances, to permit the safe passage of the tube ; though not as firm as they become subsequently. At the first withdrawal of the tube it is desirable to have efficient assistants at hand to control the movements of the child, who should be placed with the neck in a good light, and somewhat in the position for tracheotomy itself. The removal is immediately followed by cough, with the discharge of sputa, blood, false mem- brane, or whatever products may be in the trachea. If everything is going on well, the tube, supposing it is of silver, though soiled by mucus, blood, or pus, will be otherwise perfectly white; if blackened, it denotes some unfavorable complication. The wound should be care- fully cleaned with soft sponge, charpie, or cotton, moistened with warm water. If healthy, the parts will be normal in color, pliable, and the edges everted. In some instances the parts will be so soft that thej' will turn inwards and close the wound. It is then neces- sary to insert the dilator and keep the wound open until the fresh tube has been inserted; and it is here, I think, that the dilator of Trousseau, or one of its substitutes, is most serviceable, much more indispensable than in the first introduction of the tube. It permits great freedom of respiration, and, exciting cough, gives greater exit to accumulations in the air passages, or permits the use of tlie for- ceps for the extraction of false membrane. The state of the larynx 64 CROUP IN ITS RELATIONS TO TRACHEOTOMY. should be examined before the tube is replaced. If permeable to air, and no contraindications exist, there ma}'^ be no further neces- sity for the tube. Several cases of this kind are on record. If the diflHculty of respiration has been due to paralj'sis of the dilators of the glottis, rather than to false membrane, or inflammatory swelling which has subsided, it will not be safe to close the wound even though the patient breathe readily by the natural passages when the artificial opening is occluded by the finger ; for if the disease be not receding, the paralytic condition may recur and necessitate a second operation. If the canula is replaced, the external parts should be first covered with a layer of olive oil, cold cream, or collodion. Dr. Sanne speaks very highly of collodion as a preferable application ; it secures the skin from contact with the fluids of the wound, and diminishes the inflammatory tumefaction. Each morning the layer of collodion is found in part detached, and can be readily removed to give place to a fresh application. If adherent in places, the denuded parts onl}' are covered. In most cases the skin beneath is healthy; in some rare cases there is a slight miliary eruption. The canula is then changed once every day, the state of the larynx being examined, and the wound dressed. When air begins to pass through the larynx, the tube maj'^ be left out for a few moments each day, but should be replaced on the appearance of any difficulty of respiration. Such difficulty may arise from incomplete permea- bility of the larj-nx, and contraction of the wound; or occlusion by inward pressure of soft exuberant granulations ; the lodgment of false membranes in the wound or in the larynx; spasm of the larynx ; fear of dyspnoea, etc. If the granulations block the pass- age, it would be well in many cases to insert a blunt catheter and slide the tube down over it, rather than to force the tube through this vascular tissue and run the risk of hemorrhage. From da}' to day this period of withdrawal of the tube may be lengthened until it is left out all the time. One of the most favorable indications is the passage of sub-glottic sputa by the mouth. When the tube has been definitely withdrawn, the wound usuallj- closes spontaneously; cicatrization being completed within a few days. If the cicatriza- tion does not take place promptly, and there be no disease of tlie wound itself to retard it, it may be taken as evidence of some ap- proaching complication, — pneumonia, bronchitis, paralj- sis, eruptive fever. There is no necessity for any dressing to hasten cicatrization in a normal wound. If covered with an impermeable dressing, asphyxia may ensue as the result of some sudden impediment to respiration, whether spasmodic from emotion or from access of cold air, or from CROUP IN ITS RELATIONS TO TRACHEOTOMY. 65 retention of sputa in the larynx; and death may follow in the absence of an attendant capable of rendering the proper service. In conse- quence of several accidents of this kind, M, Barthez abandoned this system, and simply covered the wound with a light compress to prevent irritation from the clothing. By this plan there is no danger from retention of sputa in the larynx ; one opening supplementing the other in case of necessity ; while b}'^ the time the wound has closed, the larj'nx has become accustomed to a resumption of its functions. If there is delay in cicatrization, it may be hastened by astringent or stimulating applications. Nitrate of silver is used most fre- quently for this purpose. Exuberant granulations are repressed in like manner; or, if too large for cauterization, are snipped oflf, and then their stumps are cauterized. The canula can usually be dispensed with in from five to nine days. The Casualties which Prevent Recovery. Inasmuch as this paper is limited to the subject of croup in its relations to tracheotomy, the casualties which are incident to the disease, independently of the operation, will not be discussed. These are : extension of the exudation, general systemic infection, diphthe- ritic paralysis, albuminuria, pneumonia, and fibrinous deposits in the cardiac cavities. In considering the casualties attendant on the operation, Sanne's volume is here closel}^ followed. Complicating lesions are verj- fre- quent, though manifested in greater proportion at different seasons. We extract from Sanne' the following table of frequency of compli- cations attending the successful cases of tracheotom}'^ in the Sainte- Eugenie Hospital for the years indicated. Tear. No. of successes. No. in which there were complications. 1855 ....... 2 1 1856 3 1 1858 11 1 1859 20 3 1860 7 1 1861 7 2 1862 19 14 1863 18 10 . 1865 27 22 1866 22 12 1867 10 5 1868 17 12 163 84 » Op. cit., p. 48. 66 CROUP IN ITS RELATIONS TO TRACHEOTOMY. Hemorrhage after the operation is most frequent in the hours immediately following, being often a continuance of hemorrhage at- tending tlie operation. In some instances it occurs when the outer tube is removed for the first time; and sometimes it recurs for days in succession at each withdrawal of the tube ; and this even in cases unattended with much hemorrliage at the operation. In other cases it occurs for the first time several days after the operation. Cases of this kind are cited by Andre,' Boeckel,- Sanne,* and others. Andre mentions a case in which secondary hemorrhage occurred on the 4th, and again on the 7th day. In Sanne's cases the hemorrhage occurred in one case on the 1st day and continued to recur until the 11th, in one on the 4th da}^, in one on the 5th daj'^, in two on the 6th day, and in another on the 7th day. When a moderate hemorrhage occurs during the operation, it is usuall}' arrested almost immediately upon the introduction of the tube. This is by no means alwvnys the case. The compression ex- ercised 1)3' the tube upon the divided tissues and the divided vessels is insufficient if a vessel of some size has been divided, and the hemorrhage may persist to an alarming extent. In some cases the blood escapes at the inferior angle of the wound or by the tube, and suitable means can be emplo^'ed to stanch it. In other cases the blood may flow externally and internally at the same time. It then provokes cough, by which some of it is discharged through the canula; but, at the same time, the net of coughing keeps up the hemorrhage. Usually the cough soon becomes quieted, and the bleeding is arrested ; but sometimes it may continue to such an extent as to eventuate in ultimate death b}- anaemia or by asphyxia. The mere presence alone of blood in the tube may occasion asphyxia. Three personal observations recounted by Sann6 give an idea of the dan- gers incurred by such an accident. 1st Case. He had occasion to perform tracheotomy on an infant in the wards of M. Bergeron. Everything had gone well during the operation, the hemorrhage having been very moderate; some cough had taken place and blood had escaped through the canula, but the patient had rallied. While sitting up well covered, about to be removed to bed, he made violent efforts of inspiration, became cyanosed, and fell upon the table. Sann6 attempted to remove the inner tube, thinking it was blocked up, but found that the san- guineous flow, which had persisted after the operation, had covered the plate with a viscous mass which had agglutinated the surfaces of the different pieces of the canula. He immediately removed the entire concern, but • Du traitement des cas de croup observes k I'hopital des Enfants en 1856, p. 38. 2 De la tracheotomie dans le croup, Strasburg, 1867, p. 45. ^ Op. cit. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 6*1 although the whole scene occupied less time than it has taken to narrate it, respiration had ceased. He introduced the dilator into the wound, and prac- tised artificial respiration while an assistant flapped the face vigorously with a wet towel. Finally, at the end of several seconds an inspiration took place; others followed, at first at rare intervals, then more frequently, and finally regularly. A second canula was introduced ; the patient rallied, and was put to bed. The first canula was found completely occluded by a plug of clotted blood and fibrin which had been forced into the tube by the efforts of cough. This case, h6 adds, shows with what care the minutest details should be observed after the operation. If blood flows from the canula, the tube should be frequently cleansed both internally and externally. 2d Case. An infant, 3 years of age, had been tracheotomized in the third stage of croup. The operation was a long one, and was attended by a hem- orrhage which persisted after the introduction of the canula, and resisted all measures for its arrest. Blood flowed into the trachea and provoked a violent cough which projected it through the canula to the floor of the apartment. From time to time a click was heard behind the canula, indicating the presence of false membrane. Some debris of false membranes were removed by forceps introduced through the tube, but the hemorrhage was not arrested ; the child sank rapidly, became cold, the integuments paled, the pulse dimin- ished. The canula was withdrawn and a dilator introduced into the wound to favor the expulsion of the membranes. Some fragments were rejected; but the hemorrhage continued, and the patient succumbed in spite of all that could be done. In the 3d case (obs. 6 in detail) recovery ensued, notwithstanding accidents of extreme gravity ; in spite of abundant hemorrhage which persisted con- tinuously more than five hours, and which brought the patient several times to the verge of death. The first canula was replaced by a larger one, but this proved insufficient, though effectual at the first. Compression of the wound with agaric was of no greater service. The patient really owed his life to the employment of large doses of alcohol (about 80 grammes of rum), under the influence of which the blood was arrested almost instantaneously. The hemorrhages which appear at a later period are habitually less abundant and less grave. They are not always recurrences of losses which have already complicated the operation. Sanne col- lected 19 observations of secondary hemorrhage; in eight of them the operation had not been bloody, in three others the detail as to hemorrhage is not given. In one case (obs. t) the loss of blood continued from the first time of changing the tube until the 11th day. The patient could not be disembarrassed of his canula with- out the blood spui'ting in a jet; in the intervals between the dressings a slight discharge from the canula was sometimes observed. This case recovered. Of the whole 19, death occurred in 11, either directly from the hemorrhage, or by the ansemic state it bnuight on. The expectoration will continue tinged with blood for twenty-four 68 CROUP IN ITS RELATIONS TO TRACHEOTOMY. or thirty-six hours after the cessation of the hemorrhage. If the loss of blood has been slight, it is not to be regarded as a matter of great moment, but if it has been at all copious, it may produce sufficient ansemia to prevent recovery. On the other hand, though the dyspnoea may cease, in great measure, in a comparatively short time, death may occur from pulmonar}'^ inflammation excited b}'^ the blood which has remained for some time in contact with the ulterior divisions of the bronchi. The causes of hemorrhage are:' — 1. Division of a vessel during the operation. If the operation is rapidly executed, the loss of blood is insignificant and may usually be arrested by the compression of the canula when introduced, the occlusion of the end of the vessel being permanent as a rule ; but in some instances the vessel is ruptured when the canula is removed, and bleeds again ; and this accident may occur sevei*al days in succession. 2. The necessary manipulations of the dressing, either in ex- tracting eschars or false membrane ; or a vessel momentarily occluded may be ruptured by the reintroduction of the canula. 3. The pressure exercised hy the canula may ulcerate the walls of vessels not divided in the operation. 4. The condition of the blood itself in diphtheritic cases may be a predisposing cause to excite hemorrhage by the accidents already mentioned. To this list I would add another cause, and that is the vascularity of the delicate granulations that are formed in the track of the wound. Treatment. — Hemorrhage may be repressed, if slight, by the ap- plication of small pieces of cotton, one laid upon another as they become saturated, in succession. The magma thus formed exer- cises a gentle compression. It is well, if the hemorrhage is severe, to premise these applications b}^ compression with the finger at the lower angle of the wound to diminish the flow, but this is too fatiguing to the patient to be continued for any length of time. If these eff'orts do not suffice, a plug of charpie saturated with per- chloride of iron may be used ; but this is very painful, and it may become a point of departure for an inflammation of the wound. The local contact of bits of ice inclosed in a cloth should be of service. Sanne states that the advice to remove the canula and search for the bleeding vessel should not be followed ; because it abandons 1 Sanne, op. cit., p. 54. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 69 the only compressing agent which can be of any service, for a search often fruitless, at any rate very protracted, and during which the patient may die of the hemorrhage. Should the canula be removed, however, the bottom of the wound may be painted over with a brush dipped in perchloride of iron ; though on account of the inconveniences of this agent, it should not be employed except as a dernier resort. Sanne recommends very strongly the internal administration of alcohol in large quantities ; by means of which he has seen hemor- rhage arrested several times when all ordinary means failed. He saj^s we need not fear to give too much alcohol ; large doses are the most certain, and the patient may be allowed to drink as much as he will take. When the hemorrhage has moderated, the patient should sit on the bed supported upon the bolsters, so as to avoid the penetration of the liquid in^ the bronchi. If syncope seems imminent, he is to be laid down, and sinapisms are to be applied to the surface, and at the same time the face is to be slapped with a wet towel. Syn- cope is to be prevented at all hazards, although under other circum- stances it is considered favorable for the arrest of hemorrhage. Injiammation of the Wound. — The mechanical injury done to the soft tissues during the operation, to the peri-tracheal connective tissue in the introduction of the canula, the exposure of the surfaces of the wound to sputa, pus, false membranes, and alimentary mat- ters which pass by the sides of the tube, and the constant presence of the foreign bodj', pi-oduce more or less inflammation of the wound in nearly every instance. Sometimes this inflammation exceeds what is necessary for cicatrization, and it becomes phlegmonous. The inflammation takes place about the end of the first twenty-four or thirty-six hours. The tumefaction may be of such extent as not onh'- to require loosening of the cords which confine the canula, but it may so deepen the wound as to render the canula too short, and tluis expose the patient to emph^^sema and its suff'ocative accidents. The skin may fail to cover the subcutaneous tissues completely, and these exposed structures ma^^ become affected with erysipelas or with diphtheritic exudation. The skin becomes tense, firm, and immovable, and inflamed for a considerable extent around the edges of the wound. It is frequently covered with little miliary vesicles filled with a white opaline fluid ; sometimes very few in number, often very numerous; sometimes situated above the wound, but more frequently below it. It is not rare to see them form a sort of crescent following the contour of TO CROUP IN ITS RELATIONS TO TRACHEOTOMY. the protecting layer of gum or oiled silk, over all the surface ex- posed to the contact of the fluids discharged through the tube. When the inflammation is simple, the A^esicles dry up and the epi- dermis reforms beneatli them. In contrary cases they terminate in ulcerations, the bottoms of which very often exhibit a tendency to become covered with diphtheritic exudation. Simple inflammation rarely terminates in suppuration ; but often in ulceration, the lesion being usuall}'^ limited to the angles and borders of the wound, especially in its inferior portion. Sometimes it implicates the parts around, and may produce extensive loss of substance ; but this is infrequent. The ulcerated surfaces usually present a rose-colored bottom, rarel}"^ a gray one, and the edges are regular and not much elevated. The metallic lustre of the tube is not altered by the discharges. If recovery is to take place, these disorders, after having persisted for several days, subside ; the redness fades, the induration is re- solved, the ulcerated portions close, the wound becomes smaller, and resumes its progress towards cicatrization, which had been corapletel}' arrested during the period of phlegmasia. The inflammatory complication is never A'ery grave by itself; it is almost inevitable, and is perfectly cured when no accident of an- other nature is produced. Treatment. — In moderate inflammation it suffices to cleanse the parts frequently and cover and recover them with some mild un- guent, as sweet oil or cold cream. If there is slight tumefaction, applications of collodion are of great service. If more extensive, the same means are employed, and the canula is removed from time to time for as long a period as possible, so as to get rid of the main factor of irritation. The induration of the edges of the wound makes a tolerably rigid tract, so that the patient can readily get enough air. While the canula is out the patient must be carefully watched, for he supports the deprivation with great difficulty the first few daj's ; respiration becomes impeded; suflfocation ma^'^ rapidly ensue ; and the canula has to be replaced at the end of half an hour, fifteen minutes, or even earlier. If there is much tumefaction of the connective tissues, a longer canula is substituted to prevent its being forced out of the wound and thus producing serious acci- dents. Ulcerative tendencies are combated locally by a solution of carbolic acid, and in case of need, b}^ the nitrate of silver. Erysipelas is not a frequent complication. It may occur inde- pendently of the vicinity of erj'sipelatous patients. The only pre- monitor}^ signs are diminution of appetite and augmentation of fever ; the pulse becoming more frequent, the temperature increas. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 71 in g, and the skin becoming dry. Vomiting does not occur; nor even chill, unless it passes off nnperceived. It is sometimes at- tended with considerable and extended tumefaction. It may be confined to the vicinity of the wound, or it may take the serpiginous form and run over the whole body. The prognosis is grave, as most of the cases in which erysipelas occurs die, even though it may be of moderate extent. Sanne relates, in detail,' one exceptional case in which recovery took place, although erj'sipelas had spread over all the surface of the body. Treatment. — The treatment requires the local use of bland and unirritating unguents. Sanne' thinks very highly of the use of col- lodion, — renewed daily, or several times a da}^, — which modifies the local inflammation, and rapidly diminishes the redness and tumefac- tion. If tlie canula can be dispensed with, it is well to remove it, as a considerable source of irritation is thus gotten rid of. The general treatment requires the use of tonics. Emetics and cathartics can exert only an unfavorable influence. Gangrene. — Gangrene is, perhaps, the most frequent complication. Even cases of recover}^ ai-e not exempt from it. Sanne recognizes two species of gangrene : — 1. Superficial gangrene of the internal surface of the wound ; fre- quent, benign, almost always the result of compression of the in- flamed tissue l)y the canula. 2. Extensive and deep gangrene of the tract of the wound, with or without extension to the skin, enlarging the opening and tract of the wound, and caused both by compression and diplitheritic infec- tion ; a form graver and moi'e rare. Superficial gangrene usuall^r appears about the third or fourth day after the operation. Although the general evidences of the condition may not be recognizable at this early date, there is one sign which Sanne says has never deceived him, and that is blacken- ing of the canula; it being understood that a silver canula has been employed. The extent of the discoloration is an indication of the extent of the gangrenous process. It rarely reaches the posterior third of the tube unless there is an ulceration of the trachea at the same time. If the gangrene is extensive it entails considerable loss of substance. The wound becomes filled with fragments of eschars, shreds of cellular tissue or muscular tissue, sometimes cartilaginous debris from the tracheal rings ; the whole enveloped in a serous, brown, and fetid pus. If the patient survives, tliese eschars are discharged, and suppuration becomes normal ; but the wound is en- ' Op. cit., obs. X. p. 205. T2 CROUP IN ITS RELATIONS TO TRACHEOTOMY. larged and its walls irregular, perhaps penetrated by sinuses ; the denuded surfaces being covered with a la^^er of health}^ granula- tions. The deformity of the cicatrix will be proportionate to the loss of substance. The general condition of system is nsuall}^ pro- portion atel}'^ affected, and when amendment takes place the gangrene is arrested. The absence of gangrene, Sanne affirms, is an almost infallible pledge of recovery. Treatment — Sanne does not think that gangrene can be prevented. He counsels removal of the tube for as long a time as possible when- ever an inflamed condition of the parts and tumefaction of the tissues indicate undue pressure. Applications, such as cold cream, sweet oil, and glycerole of starch, should be applied upon the skin. If this is insufficient, and the blackening of the canula announces mortification of the tissues, it will be well to cauterize the wound freely with nitrate of silver. If the mortification continues, the wound will become covered with an extensive brown eschar : cau- terization is then no longer of value, nor any other topical measures either. The onl}^ resource left is to keep the tube out of the wound as long as possible, and to sustain the system b}^ the use of tonics. When the eschar becomes detached, the wound should be bathed frequently to free it from fetid pus and debris of mortified tissue ; and after each cleansing it should be touched with a solution of car- bolic acid, one part to one hundred. This destroj-s the putrid pro- ducts at the. surface of the wound, and excites the vitality of the tissues, thus accelerating the discharge of the eschars, and prevent- ing systemic infection by absorption of these pi'oducts. Alimentation, quinine, and generous wines are indispensable com- plements of the treatment. Diphtheria of the Wound. — Sanne states that false membrane is not apt to appear upon the surfaces of a deep wound, but is rather manifested upon the superficies where the skin has been incised, and theuce extends to the surrounding parts. He insists upon it, that eschars of the wound are often confounded with plastic exudation. Diphtheria of the wound appears from the second to the fourth da}' after the operation. It is part of the anatomical characteristics of the disease, and is, of itself, to be considered as a matter of gravity onl}- when persistent or frequently reproduced; being, in fact, an evidence of the intensity and tenacity of the general affection. Treatment. — Cleanliness, frequent and lengthened removal of the tube, are here the principal elements of treatment, the same as for all other complications concerning the wound. Sanne does not favor the use of topical agents to destroy the membrane, as most other writers do, unless it is of such great extent as to threaten OROUP IN ITS RELATIONS TO TRACHEOTOMY. T3 serious accidents bj- its mere presence. He prefers the use of alum or tannm in powder with equal quantities of starch, or tannin with gl3^cerole of starch, which is of excellent service in superficial exu- dation. For the walls of the wound itself he has found the appli- cation of lemon-juice of benefit. Emphysema is not a very frequent complication. Sometimes it begins during the operation ; more frequentl}^, it comes on during the first few hours after ; sometimes not until the next day. Of 662 observations studied by Sannc, he could collect only eighteen in- stances, six of which had occurred during the same year, while in many other ^^ears there had been no cases. Millard cites four cases. Emphysema, in the great majority of instances, is the result of faulty operations ; the most frequent cause being denudation of the trachea during ineffectual efl^orts to introduce the tube. If the tube remains for sevei*al instants in a false route, the air is forced both by inspiration and expiration, into the lax cellular tissue, and em- phj^sema soon commences. In such cases, it is not rare to find at the autopsy, an abscess of the mediastinum in addition to the em- physema.* , An incorrect incision of the trachea is a no less powerful cause of emphysema. The vicious incision may be lateral ; it may be double ; it may be too long ; it may be too short ; it may be too low down. The incision in the trachea may not be in the same line as the in- cision through the integuments, but be to one side. If the tube is promptly and securely introduced under such circumstances, em- phj'sema will not occur ; but if, as is usuall}'- the case, several in- effectual attempts precede its introduction, some denuding of the trachea inevitably takes place, and rapid emph^^sema is the conse- quence. The trachea maj' be perforated through and through, the second or accidental incision being posterior or else lateral. Sometimes the tube may be pushed through this second incision into the tissue surrounding the trachea, and thus produce emph^'sema; but this additional form of the accident is rare. Moi'e frequently the tube is placed in the cavit}' of the trachea ; but a certain amount of air escapes through the second incision, and thus produces emphysema. Emphysema is much more cer- tain to result in this way than tlie other, for if the tube passes through the second opening, only a small quantity of air can pass ' Satine details several cases of this kind. Kiibn, op. cit., p. 149, cites one from Barthez. 6 74 CROUP IN ITS RELATIONS TO TRACHEOTOMY. through it ; but when the tube is in the trachea, the air passes readily, and easily issues in part by the fissure left by the bistoiny. If the incision is too long, the tube is soon forced out of the trachea into the' connective tissue, or it may rest on the inferior angle of the tracheal wound, so that the inspiratory current is divided into two routes, in either instance producing emphysema. If the incision is too short, or a mere puncture, there will be em- physema into the connective tissue during the time lost in finding the incision and enlarging it. If the incision is too low down, the tube may not be long enough to reach the cavity of the trachea, which is here at a greater distance from the external surface, and thus emphysema will take place while another tube is being procured. The tube should be long enough to reach into the trachea ; too short a tube is an inevitable source of emphysema. Tumefaction of the tissues may force a tube out of the trachea and thus produce emphysema. Emphj'sema itself may give rise to additional emphysema in the same manner. Improper fastening of the hands which confine the tube may render it liable to be forced out by cough, and thus produce emphysema. If the bevel of the extremity of the tube is too long, a portion of the orifice may rise above the lower edge of the wound, and thus occasion emphysema. Another cause is insuflflation through the tube to resuscitate a patient apparently dead ; the effoi'ts at which may be too energetic, and thus rupture some of the pulmonary vesicles. Sann§ reports a case of this kind in detail" in which insufflation ruptured the pulmonary vesicles and forced the air into the mediastinum, thence into the tissues of the neck, whence it reached the face, and the chest as far as the level of the nipple. The patient died the next day. If the tube or catheter used for insufflation is not placed within the trachea, the cellular tissue will be blown up. Emphysema is sometimes limited to the vicinity of the wound; sometimes it reaches the angle of the jaw ; it rarely extends upon the face, but it may descend over the neck and chest reaching the shoulders, the arms, and the back. I have seen it extend from the zygomatic process of the temporal bone down over the chest, as far as the second or third rib. In some instances it will become general. If limited to the vicinitj' of the wound, and of moderate extent, it is of little consequence. If extensive it may produce ' Op. cit., obs. XV., f. 222. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 15 dyspnoea; and even force the tube out of the trachea, necessitating the substitution of a longer tube. Its duration depends on its ex- tent and its cause. It sometimes disappears in the course of a day or two, and sometimes lasts a week or more. Treafment. — If due to too short a tube, a longer one should be employed. If this is not at hand, a catlieter may be substituted until a suitable tube can be obtained, the edges of the tracheal wound being kept separated meanwliile by the dilator, forceps, or blunt hooks of lead wire, hair-pins, or any other extemporaneous temporary contrivance. Gentle frictions will sometimes succeed in forcing out a good deal of the air. Dr. Watson relates a case in which death occurred in a child 10 months of age, 38 hours after the operation, in which there was found an " emphysematous distension of the anterior mediastinum, by which the head was partially dis- placed towards the left side. This appeared to have resulted from the air- finding a more ready access to the expanding thorax through the wound, and external to the trachea, than through the obstructed bronchi." {Ed. Med. Journ., Jan. 1861).— ylwi. Journ. Med. Set., April 1861, p. 577. Abscess of the Mediastinum. — An abscess of the mediastinum has sometimes been found in post-mortem examinations of patientjS who have undergone tracheotomy for croup. Millard was tire first to call attention to this complication ; since which a number of cases have been recorded by others. Sann^, in his essay,' states that he has been able to collect ten cases which had been observed in the service of M. Barthez. Creqny, Pelletier, Roger, and Boeckel have also reported cases. It is likely, too, that some cases have existed in which the opportunity of verification by post-mortem was not allowed. The lesion, however, is rare. Sanne attributes this complication to the operator rather than to the operation. In all the observations which he had encountered, the causes had been of the same nature as those which occasion emphysema. All mechanical injury to the trachea by improper in- cisions, and in ffectual attempts to introduce the canula, favor phlegmonous inflammation of the wound, which, once set up, rapidly reaches the connective tissue of the mediastinum. He remarks that all lesions of the wound when unaccompanied with denudation of the trachea, remain limited to the wound and do not invade tlie mediastinum. He instances one case^ in which it appeared to have been produced by too deep a use of the actua cautery in an attempt to arrest deep gangrene of the wound, the patient dying on the following day; and answers an ' Op. cit,, p. 107. 2 Op. cit., obs. xix., p. 230, 76 CROUP IN ITS RELATIONS TO TRACHEOTOMY. objection which might be made as to the shortness of the interval in producing such a result, by mentioning another case in which the patient died the day after the operation, and in which, at the au- topsy, a purulent infiltration was found lodged in front of the trachea and descending two or three centimetres beneath the ster- num. The pus is sometimes collected in an abscess the size of an egg ; sometimes it extends from the wound in the integuments more or less deeply in the mediastinum ; and sometimes exists as a simple infiltration in this locality. It has been found on all sides of the trachea, and also enveloping the oesophagus. In all the cases the wound of the integuments was the point of departure. In two cases the sternum was denuded and necrosis had commenced. Emphy- sema of the mediastinum, of the adjacent subcutaneous tissues, and of the lungs frequently coexists with the abscess. The symptoms are obscure. General diphtheria, pneumonia, or broncho-pneumonia usually exist at the same time, and their symp- toms mask those of the abscess. In cases in which there were no such complications, intense fever with dyspnoea and agitation sud- denly supervened at a period when the patient appeared doing well. Treatment. — Sannd says if the abscess could be diagnosed, the only rational treatment would be to trephine the sternum ; but who, he asks, would dare adopt such a procedure upon an infant who had been tracheotomized for croup ? Ulceration of the Trachea. — M. Roger in 1859 published an article,^ based on an analysis of 21 cases of ulceration of the trachea produced by the presence of the canula after traclieotom}'. Dr. Sanne details the result of his own study of It cases, all of which occurred in the service of Barthez. The lesion may be superficial and consist simply of destruction of the epithelium ; but more frequently the mucous membrane is de- stroyed; and the cartilages are exposed whether healthy or diseased. In some cases the cartilages are completely destroyed and the tra- cheal wall is separated from the surrounding connective tissue by its fibrous layer only This, too, may give way, and the interior of the trachea may communicate with the exterior by one or more new apertures. In the greater number of instances, the ulceration exists upon » Des ulcerations de la trachee art6re produites par le sejour de la eanule apres la tracheototnie, Arch. gen. de med., ii., 1859 ; Bull, de I'Acad. de med., March, 1859 ; Bnll. de therap., 1859, p. 443 ; Actes de la Societe des hop,, Paris, 1861, p. 57. CROUP IN ITS RELATIONS TO TRACHEOTOMY. 77 tlie anterior wall below the inferior augle of the tracheal wound, at a point corresponding with the inferior extremity of the canula, the surface between the ulceration and the tracheal wound being healthy in most instances. In some cases the alteration commences at the inferior angle, extending in length or breadth to a greater or lesser degree. In one of Sanne's cases the lower angle had been destroj'ed and the wound was lengthened to the extent of one centimetre. In another case the borders of the tracheal wound were irregular and torn ; the rings were thinned, and on their surface were fragments of cartilage in course of elimination ; this lesion being accompanied, below the wound, by an ulceration, which had denuded and diseased the cartilages. The posterior wall was also interested. M. Roger had seen two cases of ulceration confined to the posterior wall, and four in which both walls were ulcerated. In one of these cases the trachea was perforated posteriorly. Dr. Sanne had never seen a case of this kind, but had seen several in which the ulceration had made the circuit of the trachea; and two in which the lateral walls were implicated. Roger cites four cases of perforation ; Sanne three, in one of which three perforations existed, placing the tra- cheal cavity in communication with the inferior portion of the wound in the integuments ; and in another were two large perforations the floors of which were formed bj' the brachio-cephalic trunk. Holmes," in discussing the subject of the ulceration of the trachea, refers to an instance in which the innominate artery had been opened by ulceration." Schneevogt^ saw a tracheotomized child die on tlie ninth day, from hemorrhage due to erosion of the innominate artery. The ulceration may be extensive without producing perforation. In four cases Sanne saw the mucous membrane and cartilage de- stroyed, nothing remaining but a fibrous or cellular layer sometimes very thin and transparent ; and, whatever the extent of the ulcera- tion, the thinnest portion of the tracheal wall was almost alwa^'s at a point corresponding to the lower extremity of the canula. Thus, in one of the four cases cited, a very thin cellular layer was all that separated the end of the canula from the brachio-cephalic trunk at its point of bifurcation. There do not appear to be any truly characteristic signs of the existence of this lesion; though many circumstances are mentioned by Barthez, Roger, Sanne, and others. Its possibility must be ' Op. cit., p. 326. 2 Path. Soc. Traus., xi. 20. 3 Kiilin, op. cit., p. 146. 18 CROUP IN ITS RELATIONS TO TRACHEOTOMY. borne in mind, in case of the appearance of any symptoms wliicb might be the probable result of such a lesion. The occurrence of the accident should be avoided as far as pos- sible by the selection of canulas of proper shape and curvature, and freely suspended on the supporting plate. If ulceration be sus- pected, the canula should be removed. If it is impossible to dispense with a tube, one of Durham's canulas should be employed which is so constructed that its two extremities are on rectangular planes ; the tube being movable within an outer collar so that it can be set at any depth and be thus lodged in the very centre of the windpipe. If the accident occur long after the operation, canulas of ditferent lengths and curvature could be substituted from time to time so as to avoid constant pressure on points already irritated. In one case which I saw treated abroad, in which nlceration was supposed to exist, a long elastic catheter had been substituted for the canula with so much comfort that the little patient would not consent to the use of any other appliance. Summing up the points discussed in the foregoing pages, we may, I think, with safety draw the following conclusions : — 1. That thei>e are no insuperable contra-indications to trache- otomy in croup; 2. That the administration of an anfesthetic for the purpose of controlling the child's movements is admissible in performing the operation ; but that it should be used with great caution ; 3. That a careful dissection should be made down to the wind- pipe, and hemorrhage be arrested before incising it, whenever there is at all time to do so ; 4. That the incision should be made into the trachea as near the cricoid cartilage as possible, to avoid excessive hemorrhage, and subsequent accidents which might occasion emphysema; 5. That a dilator should be used, or a piece of the trachea be ex- cised, whenever any difficulty is encountered in introducing the tube ; 6. That the tube should be dispensed with as soon as possible; or altogether if the case will admit of it ; 7. That assiduous attention should be bestowed npon the after- treatment, especially that of the wound ; and that a skilled attendant should be within a moment's call for the first twenty-four or forty- eight hours immediately following the operation. 1327 Geeen St., Philadelphia, January 14tli, 1874. NOW READY. THE PHYSICIAN'S VISITING LIST FOR 1875. For Various Styles and Prices, see .page 25 of this Catalogue. PHILADELPHIA, October, 1874. CATALOGUE OF LINDSAY & BLAKISTON'S MEDICAL, DENTAL AND PHARMACEUTICAL PUBLICATIONS. MESSRS. LINDSA Y &- BLAKISTON ask the attention of the Medical Profes- sion to the extensive list and varied character of their publications and to the Classified Index of thetn annexed. ALL THEIR PUBLICATIONS can be had from or throtigh BOOKSELLERS in any of the large cities of the United States or Canada. When, for any reason, it is inconvenieiit thus to procure them, they will be furnished direct by mail or express upon receipt of a Post-office order, draft or check for the ainoufit ordered. IN ADDITION to their own publications, they keep on hand a full and coinplete assortment of all Medical Books published in the United States; and, by special arrangement with Messrs. J. &= A. CHURCHILL and other Medical Pub- Ushers of London, they can supply many important English Medical Works at greatly reduced prices ; such as are ftot on hand they can import promptly to order. AS SPECIAL AGENTS OF THE SYDENHAM SOCIETY in the United States, they are prepared to receive Subscribers at Ten Dollars per Annum, and supply any of the back years. Complete lists of works published will be furnished upon application. DEALERS IN MEDICAL BOOKS will be supplied on the most favorable terms, and will be furnished with copies of this Catalogue, without charge, for distribution among their customers if desired. CLASSIFIED INDEX TO LINDSAY & BLAKISTON'S PUBLICATIONS. ANATOMY. Rindfleisch's Text-Book of Pathological Histology 28 Wilson's Anatomist's Vade Mecum 37 Handy's Text-Book of Anatomy 18 Hilles's Pocket Anatomist 19 Jones and Sievekiug's Pathological Anat- omy 20 Holden's Manual of Dissections 18 " Human Osteology 18 Wilks & Moxon's Pathological Anatomy- 3(3 BRAIN AND NERVOUS SYSTEM. Bucknill and Tuke's Psychological Medi- cine 9 Radcliff'e on Epilepsy, Paralysis, &c 29 Tuke's Influence of the Mind on the Body 35 Elam on Cerebria 15 Sheppard on Madness 32 Sankey's Lectures on Mental Diseases.... 31 Van der Kolk's Pathology and Therapeu- tics of Mental Diseases 63 CHEST, HEART, THROAT, ETC. Waters on the Chest 38 Fothergill on the Heart 15 Stokes on the Heart and xVorta 31 Cohen on Inhalation 11 Greenhow on Bronchitis 17 Mackenzie on the Throat and Nose Mackenzie on Growths in the Larynx 22 Mackenzie on theLaryngoscope inDiseases of the Throat 22 Mackenzie's Pharmacopoeia of the Hospi- tal for Diseases of the Throat 22 Thorowgood on Asthma 35 Barth and Roger on Auscultation and Percussion 7 Dobell on Winter Cough 13 Ruppaner's Laryngoscopy 30 Cohen on Croup 11 CHILDREN (DISEASES OF). Meigs and Pepper's Practical Treatise on Diseases of Children 23 Tanner andMeadows's Diseases of Infancy and Childhood 33 Ellis's Practical Manual of the Diseases of Children 15 Hillier's Clinical Treatise on Children ... 18 Holmes's Surgical Diseases of Children.. 19 CANCER. Marsden's New Mode of Treating Cancer 25 Arnott on Cancer 6 CHEMISTRY, BOTANY, ETC. Bloxam's Chemistry,Inorganic& Organic 8 " Laboratory Teaching 8 Murphy's Review of Chemistry 23 Reese's Syllabus of Chemistry 29 Darlington's Flora Cestrica 14 Beniley and Trimen's Medicinal Plants.. DEFORMITIES. Adams on Club-Foot 6 Brodhurst on Deformities 9 Prince's Plastic and Orthopedic Surgery. 27 " Galvano-Therapeuties 27 DENTAL SCIENCE. Harris'sPrinciples&Practice of Dentistry 18 " Dictionary of Dental Surgery... 18 Richardson's Mechanical Dentistry 29 Taft's Operative Dentistry 33 Tomes's Dental Surgery 35 " Dental Anatomy and Physiolog}' 35 Wedl's Dental Pathology 37 Leber and Rottenstein on Dental Caries.. 21 Coles's Mechanical Dentistry 12 " Deformities of the Mouth 12 Heath's Injuries and Diseases of the Jaws 19 Fox on the Human Teeth 16 Robertson on Extracting Teeth 29 British Journal of Dental Science 7 DICTIONARIES. Harris'sDictionary of Dental Surgery and Medical Terminology 18 Sweringen's Pharmaceutical Lexicon 32 Cooper's Surgical Dictionary 11 Cleaveland'sPronouncingMedicalLexicon 12 EYE AND EAR. Soelberg Wells on Diseases of the Eye... 38 " on Long, Short, and Weak Sight 38 Lawson's Diseases and Injuries of the Eye 21 Macnamara's Manual of Diseases of the Eye 22 Dixon's Guide to Diseases of the Eye 14 Walton's Surgery and Diseases of the Eye 38 Liebreich's Ophthalmoscopic Atlas 21 Jones on Defects of Sight and Hearing... 20 Power's Student's Guide to Diseases of the Eye 26 Dalby on Diseases and Injuries of the Ear 15 Toynbee on the Ear, by Hinton 34 Allen's Aural Catarrh ELECTRICITY. Tibbitts's Hand-Book of Medical Elec- tricity 35 Althaus's Medical Electricity 6 Reynolds's Clinical Uses of Electricity... 28 Pucheuiie's Localized Electrizatiou 14 FEMALES (DISEASES OF). Hewitt's Diagnosis, Pathology and Treat- ment of tlie Diseases of Women 17 By ford's Medical and Surgical Diseases of Women 9 Byford on tlie Uterus 9 Atthill's Clinical Lectures ou Diseases of Women 6 Dillenberger's Handy-Book of Women and Children's Diseases 14 Agnew's Liicerations of the Female Peri- neum C Tilt's Change of Life in Women 34 Savage's Female Pelvic Organs 32 " Nature of the Surgical Diseases of the Female Pelvic Organs 32 Scanzoni's Diseases of Women 31 Hodge on Foeticide and Abortiou 20 FEVERS. Stille's Epidemic Meningitis.....*. 31 Flint on Continued Fever 16 FORENSIC MEDICINE & TOXICOLOGY. Woodman and Tidy's Pland-Book of Fo- rensic Medicine 38 Tanner's Memoranda of Poisons 33 GENERATIVE & URINARY ORGANS, SYPHILIS, ETC. Acton on the Reproductive Organs 7 " on Prostitution 7 Black on the Functional Diseases of tlie Renal, Urinary & Reproductive Organs 10 Harley on the Urine & its Derangements 17 jjCgg on Examination of the Urine 21 Thompson on the Urinary Organs 34 " on Calculous Diseases 34 Lewin on the Treatment of Syphilis 22 Durkee on Gonorrhcea and Syphilis 14 Parker's Modern Treatment of Syphilis. 27 Gant's Irritable Bladder 16 Buzzard's Syphilitic Nervous Affections. 7 HYGIENE AND POPULAR MEDICINE. Parkes's Practical Hygiene 26 Wilson's Hand-Book of Hygiene 37 Hufeland's Art of Prolonging Life 19 Chavasse's Mental Culture and Training of Children 11 Pv)-an's Philosophy of Marriage 28 Walker on Intermarriage 38 Routh's Infant Feeding Veitch's Hand-Book for Nurses KIDNEYS AND THE LIVER, Beale on Kidney Diseases, Urinary Depos- its and Calculous Disorders 8 Basham's Diagnosis of Kidney Diseases.. 7 Ward on the IJver and Intestinal Canal, 37 Habershou ou the Liver 17. MATERIA MEDICA AND THERAPEU- TICS. Biddle's Materia Medica for Students 9 Waring's Practical Therapeutics 36 Headland on the Action of Medicines.... 19 Brunton's Experimental Investigation into the Action of Medicines ^ 10 Tliorowgood's Student's Guide to Materia Medica 34 Beasley's Book of 3000 Prescriptions 10 Pereira's Physician's Prescription Book.. 2^ Wythe's Pocket,Dose and Symptom Book 36 Fothergill on the Action of Digitalis...... 15 Bouchardat's Abstract of Thera})eutics,&c. 7 Philip's Materia Medica and Therapeutics. MICROSCOPICAL. Beale's How to Work the Microscope 8 Carpenter on the Microscope and its Reve- lations 11 Beale's Microscope in Medicine 8 Martin's Microscopical Mounting 24 MANUALS, ETC., FOR STUDENTS. Mendenhall's Manual of Examinations... 23 Chew on Medical Education 12 Cleaveland'sPronouncingMedical Lexicon 12 Pereira's Pocket Prescription Bosk 26 Wythes Pocket, Dose and Symptom Book 36 MISCELLANEOUS. Allingham on the Rectum 5 Basham on Dropsy 7 Bircli on Consti])ation 9 Clarke's Diseases of the Tongue 11 Carson's University of Pennsylvania 11 Cobbold on Worms .". 12 Dunglison's History of Medicine 15 Gross's Medical Biograpliy 16 Holden on the Sphygmograph 20 Liveing on Megrim, Sick-Headache, &c.. 21 Pennsylvania Hospital Reports 26 Physician's Visiting List 25 " Case Record and Prescription Blanks 27 Rib I and O'Conner's Physician's Account Book 30 Ross's Graft Theory of Disease 29 Reports on the Progress of Medicine, &c. 25 Sievekiug on Life Assurance 30 Sydenham Society's Publications (new).. 31 " " " (old)... 32 Wright on Headaches 38 OBSTETRICS. Cazeaux's Text-Book of Obstetrics 13 Meadows's Manual of Midwifery 24 Schultze's Lecture Diagrams 31 Hodge on Foeticide and Abortion 20 Rigby's Obstetric Memoranda 30 Roberts's Student's Guide to Midwifery... 29 Tyler Smith's Obstetrics 34 Clay's Hand-Book of Obstetric Surgery.. 12 PRACTICE OF MEDICINE. Aitken's Science & Practice of Medicine. 5 Roberts's Theory & Practice of Medicine. 28 Tanner's Practice of Medicine 33 Trousseau's Clinical Medicine 34 Fagge's Principles and Practice of do 15 Maxson's Practice of Medicine 23 Chambers's Clinical Lectures 12 Foster's Lectures and Essays on Clinical Medicine 16 PATHOLOGY. Paget's Surgical Pathology 26 Wedl's Dental Pathology 37 Virchow's Cellular Pathology 3G Stille's General Pathology 31 PHYSIOLOGY. Sanderson's Physiological Hand-Book ... 30 Marshall's Physiological Diagrams 23 " " Anatomy 23 Reese's Analysis of Physiology 29 Tyson's Cell Doctrine 33 Beale on Disease Germs 8 " Bioplasm, or Physiology of Life.... 8 " Protoplasm, or Matter and Life 8 Carpenter's Human Physiology 11 PHARMACEUTICAL. Sweringen's Pharmaceutical Lexicon 32 Beasley's Druggist's Receipt Book ;... 10 " Book of 3000 Prescriptions 10 " Pocket Formulary 10 Cooley's Cyclopedia of Practical Receipts 13 Branston's Hand-Book of do 10 Reese's American Medical Formulary.... 29 Lescher's Elements of Pharmacy 21 Squire's Companion to the British Phar- macopoeia 32 Proctor's Practical Pharmacy 27 Squire's Hospital Pharmacopoeias. RHEUMATISM, GOUT, ETC. Garrod on Gout and Rheumatic Gout Adams on Rheumatic and Strumous Dis- eases ,. Adams on Rheumatic Gout 6 Hood on Gout and Rheumatism 20 SURGERY. Harris's Dental Surgery : 18 Norris's Contributions to Surgery 25 Paget's Surgical Pathology 26 SAvain's Hand-Book for Surgical Injuries 30 Prince's Plastic and Orthopedic Surgery, 27 Clark's Outlines of Surgery and Surgical Pathology 13 Hewson's Use of Earth in Surgery 20 Druitt's Surgeon's Vade Mecum 14 Maunder's Operative Surgery 24 Heath's Minor Surgeiy 19 Cooper's Surgical Dictionary 11 Thompson's Lithotomy and Lithotrity ... 34 Hancock on the Foot and Ankle 20 STIMULANTS AND NARCOTICS. Anstie on Stimulants and Narcotics 7 Sansom on Chloroform 31 Miller on Use and Abuse of Alcohol 24 Lizar on Use and Abuse of Tobacco 22 SCIENTIFIC. Hardwich and Dawson's Photography ... 19 Overman's Practical Mineralogy 25 Ott on the Manufacture of Soap 25 Peisse's Whole Art of Perfumery 27 Piggott on Copper Mining, A MANUAL OF PRACTICAL HYGIENE. The Fourth Revised. and Enlarged Edition, for Medical Officers of the Army, Civil Medical Officers, Boards of Health, &c., &c. With many Illustrations. One volume Octavo. Price ....... ;^6.oo This work, previously unrivalled as a text-book for medical officers of the army, is now equally unrivalled as a text-book for civil medical officers. The first book treats in succes- sive chajaters of water, air, ventilation, examination of air, food, quality, choice, and cooking of food, beverages, and condiments; soil, habitations, removal of excreta, warming of houses, exercise, clothing, climate, meteorology, individual hygienic management, disposal of the dead, the prevention of some common diseases, disinfection, and statistics. The second book is devoted to the service of the soldier, but is hardly less instructive to the civil officer of health. It is, in short, a comprehensive and trustworthy text-book of hygiene for the scientilic or general reader. — London Lancet. POWER (henry), M.B., F.R.C.S., Senior Ophthalmic Surgeon to St. Bartholomew's Hospital. THE STUDENT'S GUIDE TO THE DISEASES OF THE EYE. With Engravings. Preparing. PENNSYLVANIA HOSPITAL REPORTS. EDITED BY A COMMITTEE OF THE HOSPITAL STAFF. J. M. Da Costa, M.D., and William Hunt, M.D. Vols, i and 2 ; each volume containing upwards of Twenty Original Articles, by former and present Members of the Staff, now eminent in the Profession, with Lithographic and other Illustrations. Price per volume . ^4.00 The first Reports were so favorably received, on both sides of the Atlantic, that it is hardly necessary to s})eak for them the universal welcome of which they are deserving. The papers are all valuable contributions to the literature of medicine, reflecting great credit upon their authors. Tlie work is one of which the Pennsylvania Hospital may well be proud. It will do much towards elevating the profession of this country. — American Journal of Obstetrics. PAGET (JAMES), F.R.S., Surgeon to St, Bartholomew's Hospital, &c. SURGICAL PATHOLOGY. Lectures delivered at the Royal Col- lege of Surgeons of England. Third London Edition, Edited and Revised by William Turner, M. D. With Numerous Illustrations. Price, in cloth, $7.50; in leather $8.50 A new and revised edition of Mr. Paget's Classical Lectures needs no introduction to our readers. Commendation would be as superfluous as criticism out of place. Every page bears evidence that this edition has been " carefully revised."— ^mmcaw Medical Journal. PEREIRA (JONATHAN), M.D., F.R.S., &c. PHYSICIAN'S PRESCRIPTION BOOK. Containing Lists of . Terms, Phrases, Contractions, and Abbreviations used in Prescriptions, with Explanatory Notes, the Grammatical Constructions of Prescrip- tions, Rules for the Pronunciation of Pharmaceutical Terms, a Proso- diacal Vocabulary of the Names of Drugs, &c., and a Series of Abbre- viated Prescriptions illustrating the use of the preceding terms, &c. ; to which is added a Key, containing the Prescriptions in an unabbreviated Form, with a Literal Translation, intended for the use of Medical and Pharmaceutical Students. From the Fifteenth London Edition. Price, in cloth, ^1.25; in leather, with Tucks and Pocket, . ^1.50 27 PROCTOR (BARNARD S.). PRACTICAL PHARMACY. A Course of Lectures comprising Descriptions of General Processes, Lessons in Dispensing, Pharmaco- poeial Testing, Qualitative and Quantitative, &c. With Illustrations. Octavo. Price . . . . . . . . . ^5.00 PARKER (langston), F.R.C.S.L. THE MODERN TREATMENT OF SYPHILITIC DISEASES. , Containing the Treatment of Constitutional and Confirmed Syphilis, with numerous CaseSjFormulas, &c., &c. Fifth Edition, Enlarged. $4.25 PRINCE (david), M.D. PLASTIC AND ORTHOPEDIC SURGERY. Containing i. A Report on the Condition of, and Advances made in. Plastic and Ortho- pedic Surgery up to the Year 187 1. 2. A New Classification and Brief Exposition of Plastic Surgefy. With numerous Illustrations. 3. Ortho- pedics : A Systematic Work upon the Prevention and Cure of Deformities. With numerous Illustrations. Octavo. Price . . . ^4.50 This is a good book upon an important practical subject; carefully written, and abun- dantly illustrated. It goes over the whole ground of deformities — from cleft-palate and club-foot to spinal curvatures and ununited fractures. Itappears, moreover, to be an original book. — Medical and jSionjicul Jicpoiter. SAME AUTHOR. GALVANO-THERAPEUTICS. A Revised reprint of A Report made to the Illinois State Medical Society. With Illustrations. Price, PIESSE (g. w. Septimus), Analytical Chemist. WHOLE ART OF PERFUMERY. And the Methods of Obtaining the Odors of Plants ; the Manufacture of Perfumes for the Handkerchief, Scented Powders, Odorous Vinegars, Dentifrices, Pomatums, Cosmet- ics, Perfumed Soaps, &c. ; the Preparation of Artificial Fruit Essences, &c. Second American from the Third London Edition. With Illus- trations. .......... $3.00 PIGGOTT (a. snowden), M.D., Practical Chemist, COPPER MINING AND COPPER ORE. Containing a full Descrip- tion of some of the Principal Copper Mines of the United States, the Art of Mining, the Mode of Preparing the Ore for Market, &c., &c. ^1.50 PHYSICIAN'S CASE RECORD & PRESCRIPTION BLANKS. Containing Blanks for Prescriptions and a Marginal Copy, also Blanks for noting Date, Name, Address, Diagnosis, Age, Physique, Pulse, Tem- perature, Respiration, Tongue, Urine, and Stools of Patients. Pocket Edition, price per copy, 40 centsj per dozen, ^3.75; Office Edition, 4to, price per copy, ^1.50. This book will be found an invaluable aid in the thorough study of Diseuse, and of in- finite relief to the overtasked memor^ . 28 RINDFLEISCH (dr. edward). Professor of Pathological Anatomy, University of Bonn. TEXT-BOOK OF PATHOLOGICAL HISTOLOGY. An Intro duction to the Study of Pathological Anatomy. Translated from the German, by Wm. C. Kloman, M.D., assisted by F. T. Miles, M.D., Professor of Anatomy, University of Maryland, &c., &c. Containing Two Hundred and Eight elaborately executed Microscopical Illustra- tions. Octavo. Price, bound in Cloth, .... ^6.00 *' *' Leather, . . . .7.00 This is now confessedly the leading book, and the only complete one on the subject in* the English language. 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Price ^5-o°- This work has been prepared mainly for the use of Students, and its object is to present in as condensed a form as the present extent of Medical Literature will permit, and in one volume, such information with regard to the Principles and Practice of Medicine, as shall be sufficient not only to enable them to prepare for the various examinations which they may have to undergo, but also to guide them in acquiring that Clinical Knowledge which can alone properly fit them for assuming the active duties of their profession. The work Is also adapted to the wants of very many members of tlie profession who are already busily engaged in general Practice, and consequently have but little leisure and few opportunities for the perusal of the larger works on Practice or of the various special monographs. REYNOLDS (j. russell). M. D., F. R. S., Lecturer on the Principles and Practice of Medicine, University College, London. LECTURES ON THE CLINICAL USES OF ELECTRICITY. 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The work is valuable not only to the dental student and practitioner, but also to the medical student and surgeon. — Dental Cosmos, REESE (JOHN J.), M.D., Professor of Medical Jurisprudence and Toxicology in the University of Pennsylvania, AN ANALYSIS OF PHYSIOLOGY. Being a Condensed View of the most important Facts and Doctrines, designed especially for the Use of Students. Second Edition, Enlarged. . . . ^1.50 SAME AUTHOR. THE AMERICAN MEDICAL FORMULARY. Price . ^1.50 A SYLLABUS OF MEDICAL CHEMISTRY. Price . ^i.oo RICHARDSON (joseph), D. D. S. Late Professor of Mechanical Dentistry, &c., &c. A PRACTICAL TREATISE ON MECHANICAL DENTISTRY. Second Edition, much Enlarged. With over 150 beautifully executed Illustrations. Octavo. Price, in leather .... $4.50 This work does infinite credit to its author. Its comprehensive style has in no way in- terfered with most elaborate details where this is necessary ; and the numerous and beautifully executed wood-cuts with which it is illustrated make the volume as attractive as its instruc- tions are easily understood. — Edmburgh 3Ied. Journal. ROBERTS (LLOYD D.), M.D., Vice-President of the Obstetrical Society of London, Physician to St. Mary's Hospital, Manchester. THE STUDENT'S GUIDE TO THE PRACTICE OF MID- WIFERY. With Engravings. In Preparation. ROSS (james), M.D. THE GRAFT THEORY OF DISEASE. Being an Application of Mr. Darwin's Hypothesis of Pangenesis to the Explanation of the Phenomena of the Zymotic Diseases. Price . . . ^4.00 30 •RIGBY AND MEADOWS. DR. RIGBY'S OBSTETRIC MEMORANDA. Fourth Edition, Revised and Enlarged, by Alfred Meadows, M.D., Author of "A Manual of Midwifery," &c. Price 50 RIHL AND O'CONNOR. THE PHYSICIAN'S DIARY. Monthly, Semi-Annual, and Annual Journal and Cash-Book Combined. The Fourth Revised Edition. A large folio volume, with printed Heads, Index, &c., &c. Bound in full leather. Price ......... $7.50 RUPPANER (antoine), M.D.. THE PRINCIPLES AND PRACTICE OF LARYNGOSCOPY AND RHINOSCOPY IN DISEASES OF THE THROAT, &c. Fifty-nine Illustrations. Price . . . . . . ^1.50 SANDERSON, KLEIN, FOSTER, and BRUNTON. A HAND-BOOK FOR THE PHYSIOLOGICAL LABORATORY. Being Practical Exercises for Students in Physiology and Histology, by E. Klein, M. D. , Assistant Professor in the Pathological Laboratory ot the Brown Institution, London; J. Burdon-Sanderson, M. D., F. R. S., Professor of Practical Theology in University College, Lon- don; Michael Foster, M.D., F.R.S., Fellow of and Praelector of Ph3's- iology in Trinity College, Cambridge; and T. Lauder Erunton, M.D., D.Sc, Lecturer on Materia Medica in the Medical College of St. Bar- tholomew's Hospital. Edited by J. Burdon-Sanderson. The Illus- trations consist of One Hundred and Twenty-three octavo pages, including over Three Hundred and Fifty Figures, with appropriate letter-press explanations attached and references to the text, and bound in a separate volume. Price of the two volumes, text and plates, ;^8.oo' We feel that we cannot recomraend this work too higlily. To those engaged in physiologi- cal work as students or teachers, it is almost indispensable ; and to those who are not, a perusal of it will by no means be unprofitable. The execution of the plates leaves nothing to be desired. They are mostly original, and their arrangement in a separate volume has great and obvious advantages. — Dublin Journal 0/ Medical Sciences, SIEVEKING (e. h.). M.D., F.R.C.S. THE MEDICAL ADVISER IN LIFE ASSURANCE. Price ;^2.25 This book supplies, in a concise and available form, such facts and figures as are required by the Physician or Examiner to assist him in arriving at a correct estimate of the many contingencies upon which life insurance rests. SWAIN (WILLIAM PAUL), F.R.C.S., Surgeon to the Royal Albert Hospital, Devonport. SURGICAL EMERGENCIES: A MANUAL CONTAINING CONCISE DESCRIPTIONS OF VARIOUS ACCIDENTS AND EMERGENCIES, WITH DIRECTIONS FOR THEIR IMME- DIATE TREATMENT. With numerous Wood Engravings. In one volume, i2mo. Cloth. Price ...... ^2.00 31 STILLE (ALFRED), M.D.. Professor of the Theory and Practice of Medicine in the University of Pennsylvania, &c. EPIDEMIC MENINGITIS; or, Cerebro-Spinal Meningitis. In one volume, Octavo. . . . . . . . . ^2.00 This monograph is a timely publication, comprehensive in its scope, and presenting witliin a small compass a f\ur digest of our existing Icnowledge of tlie disease, particularly accept able at the present time. It is just such a one as is needed, and may be taken as a model for similar works. — American Journal MedicaJ /Sciences. SAME AUTHOR. ELEMENTS OF GENERAL PATHOLOGY. A Practical Treat- ise on the Causes, Forms, Symptoms, and Results of Disease. Second Edition preparing. SCHULTZE (dr. b. s.), Professor of Midwifery at the University of Jena. LECTURE DIAGRAMS FOR INSTRUCTION IN PREG- NANCY AND MIDWIFERY. Twenty Plates of the largest Imperial size, printed in colors. Drawn and Edited with Explanatory Notes, and a 4to volume of letter-press. Prices, in sheets, $15.00. Hand- somely mounted on rollers for hanging up. . . . $30.00 SANSOM (ARTHUR ERNEST), M.B., Physician to King's College Hospital, &c. CHLOROFORM. Its Action and Administration. Price ^2.00 This work may be characterized as most excellent. Written not alone from a theoretical point of view, but showing veiy considerable exjjerimental study, and an intimate clinical acquaintance with the administration of these remedies, — passing concisely over the whole ground, giving the latest information upon every point. It is just the work for the student and practitioner. — American 31edical Journal. SCANZONI (f. w. von). Professor in the University of Wurzburff. A PRACTICAL TREATISE ON THE DISEASES OF THE SEXUAL ORGANS OF WOMEN. Translated from the French. By A. K. Gardner, M.D. With Illustrations. Octavo. . $5.00 STOKES ( WILLI am), Regius Professor of Physic in the University of Dublin. THE DISEASES OF THE" HEART AND THE AORTA. Octavo. . . . . . . . . . . g^.oo SYDENHAM SOCIETY'S PUBLICATIONS. New Series, 1859 to 1873 inclusive, 15 years, 56 vols. Subscriptions received, and back years furnished at ^10.00 per year. . Full prospectus, with the Reports of the Society and a list of the Books published, furnished free upon application. SANKEY (w. H. o.), M.D., F.R.C.R LECTURES ON MENTAL DISEASES. Octavo. . . ^3.25 32 SWERINGEN (hiram v.). Member American Pharmaceutical Association, &,c. PHARMACEUTICAL LEXICON. A Dictionary of Pharmaceu- tical Science. Containing a concise explanation of the various subjects and terms of Pharmacy, with appropriate selections from the collateral sciences. Formulae for officinal, empirical, and dietetic preparations; selections from the prescriptions of the most eminent physicians of Europe and America; an alphabetical list of diseases and their defini- tions; an account of the various modes in use for the preservation of dead bodies for interment or dissection; tables of signs and abbrevia- tions, weights and measures, doses, antidotes to poisons, &c., &c. Designed as a guide for the Pharmaceutist, Druggist, Physician, &c. Royal Octavo. Price in cloth . . . . . . ;^5.oo " leather ...... 6.00 " We have received from publishers so many English reprints ill adapted to the needs of this country, that it is with pleasure we welcome a thorough American book, written for the uses of the American pharmaceutist. Besides, the work is well written, creditaljly arranged, dnd neatly printed. It will be found very useful to the druggist as well as to the physician. Being in the form of a dictionary, its aim is to give immediate information in a concise man- ner, and not a comj)lete treatise on each subject. So far as we have been able to see, the Pharmaceutical Lexicon is remarkably correct. " — Druggist's Circular. SHEPPARD (edgar), M. D. Professor of Psychological Medicine in King's College, London, MADNESS, IN ITS MEDICAL, SOCIAL, AND LEGAL AS- PECTS. A series of Lectures delivered at King's College, London. Octavo. Price ......... $2.50 SAVAGE (henry), M. D., F. R. C. S. Consulting Physician to the Samaritan Free Hospital, London, THE SURGERY, SURGICAL PATHOLOGY, and Surgical Anat- omy of the Female Pelvic Organs, in a Series of Colored Plates taken from Nature : with Commentaries, Notes, and Cases. Third Edition, greatly enlarged. A quarto volume. Price SAME AUTHOR. AN EXPOSITION OF THE NATURE OF THE SURGICAL DISEASES OF THE FEMALE PELVIC ORGANS. With a View to their Rational Treatment. Preparing. SYDENHAM SOCIETY. A COMPLETE SET OF THE PUBLICATIONS OF THE OLD SYDENHAM SOCIETY, in Thirty-nine Volumes Octavo, together with a Folio Volume of Plates.. Price .... ^60.00 SQUIRE (peter), F.L.S. A COMPANION TO THE BRITISH PHARMACOPOEIA. Com- paring the Strength of its Various Preparations with those of the Edinburgh, Dublin, United States, and other Pharmacopoeias. 9th Ed. Price ^4.50 33 TANNER (THOMAS hawkes), M.D., F.R.C.P., &c. THE PRACTICE OF MEDICINE. Sixth American from the last London Edition. Revised, much Enlarged, and thoroughly brought up to the present time. With a complete Section on the Diseases Pecuhar to Women, an extensive Appendix of Formulae for Medicines, Baths, &c., &c. Royal Octavo, over iioo pages. Price^ ip cloth, ^6.00; leather . . . . . . , . , . ^7.00 There is a common character about the writings of Dt. Tanner — a characteristic wliicK constitutes one of their cliief values : they are all essentially and thoroughly practical. Dr. Tanner never, for one moment, allows this utilitarian end to escape his mental view. He aims at teaching how to recognize and how to cure disease, and in this he is thoroughly suc- cessful. ... It is, indeed, a wonderful mine of knowledge. — Medical Times. SAME AUTHOR. A PRACTICAL TREATISE ON THE DISEASES OF IN- FANCY AND CHILDHOOD. Third American from the last Lon- don Edition, Revised and Enlarged. By Alfred Meadows, M.D., London, M.R. C.P., Physician to the Hospital for Women and to the General Lying-in Hospital, &c., &c. Price .... $3.50 This book of Dr. Tanner's has been much enlarged and the plan altered by Dr. Meadows. As it now stands, it is probably one of the most complete in our language. It no longer deals with children's diseases only, but includes the peculiar conditions of childhood, both normal and abnormal, as well as the therapeutics specially applicable to that class of patients. The articles on 8kin Diseases have been revised by Dr. Tilbury Fox, and those on Diseases of the Eye by Dr. Brudenell Carter, both gentlemen distinguished in these specialties. — Medical Times and Gazette. A MEMORANDA OF POISONS. A New and much Enlarged Edition. Price . . . . . . . . . .75 This manual is intended to assist the practitioner in the diagnosis and treatment of poison- ing, and especially to prevent his attributing to natural disease symptoms due to the admin- istration of deadly drugs. TYSON (jAMEs), M.D., Lecturer on Microscopy in the University of Pennsylvania, &c, THE CELL DOCTRINE. Its History and Present State, with a Copious Bibliography of the Subject, for the use of Students of Medi- cine and Dentistry. With Colored Plate, and numerous Illustrations on Wood. Price . . . . . . . . ;^2.oo Dr. Tyson furnishes in this work a concise and instructive rfsume of the origin and ad- vance of the doctrine of Cell Evolution. In it we find the theories of Virciiow, Robin, Huxley, Hughes, Bennett, Beale, and other distinguished men. It contains what could other- wise only be learned by a perusal of many works; and it supplies the reader with a con- tinuous, complete, and general knowledge of the history, progress, and peculiar phases of the Cell i)')Ctrine, accompanied by careful references and a copious bibliography. TAFT (Jonathan), D.D. S., Professor of Operative Dentistry in the Ohio College, &.c. A PRACTICAL TREATISE ON OPERATIVE DENTISTRY. Second Edition, thoroughly Revised, with Additions, and fully brought up to the Present State of the Science. Containing over 100 Illus- trations. Octavo. Price, in leather, .... $4- 50 Professor Taft has done good service in thus embodying, in a separate volume, a com]ire- hensive view of operative dentistry. This gentleman's position as a teacher must have ren- dered him familiar with the most recent views which are entertained in America on this matter, while his extensive experience and well-earned reputation in practice must have rendered hina a competent judge of their merits. We willingly commend Professor Taft's able aud useful work to the profession. — London Dental Jievlew. 3 34 TROUSSEAU (a.), Professor of Clinical Medicine to the Faculty of Medicine, Paris, &c. LECTURES ON CLINICAL MEDICINE. Delivered at the HStel Dieu, Paris. Translated from the Third Revised and Enlarged Edition by P. Victor Bazire, M.D., London and Paris; and John Rose Cor- MACK, M.D., Edinburgh, F.R.S., &c. With a full Index, Table of Con- tents, &c. Complete in Two volumes, royal octavo, bound in cloth. Price $10.00; in leather $12.00 Trousseau's Lectures have attained a reputation both in England and this country far greater than any work of a similar character heretofore written ; and, notwithstanding but few medical man could afford to purchase tlie expensive edition issued by the Sydenham Society, it has had an extensive sale. In order, however, to bring the work within the reach of aJl the profession, the publishers now issue this edition, containing all the lectures as contained in the five-volume edition, at one-half the price. The London Lancet, in speaking of the work, says: " it treats of diseases of daily occurrence and of the most vital interest to the practitioiier. And we should think any medical library absurdly incomplete now which did not have alongside of Watson, Graves, and Tanner, the ' L'linica"l Medicine' of Trousseau." The Sydenham Society's Edition of Trousseau can also be furnished in sets, or in separate volumes, as follows : Volumes I., II., and III., $5.00 each. Volumes IV. and V., $4.00 each. TILT (EDWARD John), M.D. THE CHANGE OF LIFE IN HEALTH AND DISEASE. A Practical Treatise on the Nervous and other Affections incidental to Women at the Decline of Life. From the Third London Edition. Price $2,-oo The work is rich in personal experience and observation, as well as in ready and sensible reflection ou the experience and observation of others. The book is one that no practitioner should be without, a.s the best we have on a class of disea.ses that makes a constant demand upon our care, and requires very judicious management on the part of the practitioner. — London Lancet. TOYNBEE (j.), F.R.S. ON DISEASES OF THE EAR. Their Nature, Diagnosis, and Treatment. A new London Edition, with a Supplement. By James HiNTON, Aural Surgeon to Guy's Hospital, &c. And numerous Illus- trations. Octavo. ^5- 00 THOMPSON (sir henry), F.R.C.S., &c. ON THE PREVENTIVE TREATMENT OF CALCULOUS DISEASE, and the Use of Solvent Remedies. Price . . $1.00 SAME AUTHOR. CLINICAL LECTURES IN DISEASES OF THE URINARY ORGANS. Third London Edition, with additional Lectures and Illustrations. ^2.50 PRACTICAL LITHOTOMY AND LITHOTRITY. Second Edi- tion, with Illustrations. ^4.00 THOROWGOOD (john c), M.D., Lecturer on Materia Medicaatthe Middlesex Hospital. THE STUDENT'S GUIDE TO MATERIA MEDICA. With Engravings on Wood. $2.50 TYLER SMITH (w.), M.D., Physician, Accouclieur, and Lecturer on Midwifery, &,c. ON OBSTETRICS. A Course of Lectures. Edited by A. K. Gardner, M.D. With Illustrations. Octavo. . . . ^5.00 35 THOROWGOOD (j. c), M. D. Physician to the City of London Hospital for Diseases of the Chest, and to the West London Hospital, &c, NOTES ON ASTHMA. Its various Forms, their Nature and Treatment, including Hay Asthma, with an Appendix of Formulae, &c. Second Edition. Price . . . . . . • $i-75 TOMES (JOHN), F.R.S. Late Dental Surgeon to the Middlesex and Dental Hospitals, &c. A SYSTEM OF DENTAL SURGERY. The Second Revised and Enlarged Edition, by Charles S. Tomes, M.A., Lecturer on Dental Anatomy and Physiology, and Assistant Dental Surgeon to the Dental Hospital of London. With 263 Illustrations. . Price . . $5.00 This book has been for some time out of print in this country. The material progress made in the science of Dental Surgery since its first publication has rendered large additions and many revisions necessary to the New Edition : in order to l)ring it fully up to the time; this has been done without increasing the size of the book more than possible. Many imjjrove- ments, however, will be found added to the Text, and some Sixty new illustrations are in- corporated in the volume. TOMES (c. s.), B.A. Lecturer on Anatomy and Physiology, and Assistant Surgeon to the Dental Hospital of London. A MANUAL OF DENTAL ANATOMY AND PHYSIOLOGY^ with Numerous Illustrations. Preparing. TROUSSEAU (a.), M. D. Professor of Clinical Medicine to the Faculty of Medicine, Paris j Physician to the Hotel Dieu, &c., Lc, LECTURES ON CLINICAL MEDICINE. Delivered at the Hotel Dieu, Paris. Sydenham Society's Edition. Price of Vols, i, 2, and 3, each, . . . . . . $5.00 " " 4 and 5 " 4 00 TUKE (DANIEL H.), M. D. Associate Author of "A Manual of Psychological Medicine," &c. ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON THE BODY. Octavo. Price . . . . ^4 00 The author shows very clearly in this book the curative influence of the mind, as well as its effect in causing disease, and the use of the imagination and emotions as therapeutic agents. iTis object is afso to turn to the use of legitimate medicine the means so Irequeatly employed ouccessfully in many systems of cjuackery. TIBBITS (HERBERT), M.D. Medical Superintendent of the National Hospital for the Paralyzed and Epileptic, die. A HANDBOOK OF MEDICAL ELECTRICITY. With Sixty- four large Illustrations. Small octavo. Price . . . $2.00 The author of this volume is the translator of Duchenne's great work on " Localized Elec- trization." Avoiding contested points in electro-physiology and therapeutics, he has pre- pared this handbook as containing all that is essential for the busy practitioner to know, not only when, but in EXPLICIT and full DETAIL, how to use Electricity in the treatment of disease, and to make tiie practitioner as much at home in the use of his electrical as his other medical instruments. 36 VIRCHOW (rudolphe), Professor, University of Berlin. CELLULAR PATHOLOGY. Translated from the Second Edition, with Notes and Emendations, by Frank Chance, B.A., M.A., 144 Illustrations. . . gi^.oo VAN DER KOLK (j. l. c. schroeder), THE PATHOLOGY AND THERAPEUTICS OF MENTAL DISEASES. Translated by Mr. RuDALL, F.R.C.S. Octavo. $3.00 WARING (EDWARD JOHN), F.R.C.S., F.L.S., &c., &c. PRACTICAL THERAPEUTICS. Considered chiefly with refer- ence to Articles of the Materia Medica. Third American from the last London Edition. Price, in cloth, ^5.00; leather . . . $6.00 There are many features in Dr. Waring's Therapeutics which render it especially valuable to the Practitioner and Student of Medicine, niucli important and reliable information being found in it not contained in similar works; also in its completeness, the convenience of its ar- rangement, and the greater prominence given to the medicinal application of the various articles of the Materia Medica in the treatment of morbid conditions of the Human Body, &c. It is divided into two parts, the alphabetical arrangement being adopted throughout. It contains also an excellent Index of Diseases, with a list of the medicines applicable as remedies, and a full Index of the medicines and j^reparatious noticed in the work. WYTHES (JOSEPH h), A.M., M.D., &c. THE PHYSICIAN'S POCKET, DOSE, AND SYMPTOM BOOK. Containing the Doses and Uses of all the PrincipalArticles of the Materia Medica, and Original Preparations; A Table of Weights and Measures, Rules to Proportion the Doses of Medicines, Common Abbreviations used in Writing Prescriptions, Table of Poisons and Antidotes, Classifi- cation of the Materia Medica, Dietetic Preparations, Table of Symptom- atology, Outlines of General Pathology and Therapeutics, &c. The Eleventh Revised Edition. Price, in cloth, ^1.25; in leather, tucks, with pockets, . . . . . . . . . $1.50 This manual has been received with much favor, and a large number of copies sold. It was compiled for the assistance of students, and as a vade niecum for the general practitioner, to save the trouble of reference to larger and more elaborate works. This edition has under- gone a careful revision. The therapeutical arrangement of the Materia Medica has been added, together with other improvements of value to the work. WILKS AND MOXON. LECTURES ON PATHOLOGICAL ANATOMY. By Samuel WiLKS, M.D., F.R.S., Physician to, and Lecturer on Medicine at, Guy's Hospital. Second Edition, Enlarged and Revised. By Walter Moxon, M.D., F.R.S., Physician to, and late Lecturer on Pathology at, Guy's Hospital. Preparing. WILSON (ERASMUS), F.R.S. HEALTHY SKIN. A Popular Treatise on the Skin and Hair, their Preservation and Management. Seventh Edition. . . ^1.25 37 WILSON (GEORGE), M. A., M. D. Mtdical Officer to the Convict Prison at Portsmouth. A HANDBOOK OF HYGIENE AND SANITARY SCIENCE. With Engravings. Second Edition, carefully Revised. C0NTENT8. tage, and Contagious Diseases Hospitals. Chap. 10. Removal of Sewage and Refuse Matter. " 11. Purification and Utilization of Sewage. " 12. Effects of Improved Sewerage and Drainage on Public Health. " 13. Preventive Measures; Disinfec- tion ; Management of Epidemics. " 14. Duties of Medical Officei"s of Health. Appendix I. Excerpts from the various Public Health and Sanitary Acts. II. List of Analytical Apparatus and Re- agents, with prices. Chap. 1. Introductory — Public Health and Preventable Disease. " 2. Food — Construction of Dietaries; Examination ; Effects of Un- wholesome Food. " 3. Air : its Impurities ; Unwholesome Trades. " 4. Ventilation and Warming. " 5. Examination of Air. " 6. Water, Waterworks, Water Analy- sis. " 7. Effects of Impure Water on Public Health. " 8. Dwellings, Structural Arrange- ments, Dwellings of the Poor. " 9. Hospitals; Plans of Pavilion, Cot- Price ........... ^2.50 WARD (STEPHEN H.), M.D., F. R. C. P. Physician to the Seaman's Hospital, &.c,, &.c. ON SOME AFFECTIONS OF THE LIVER and Intestinal Canal; with Remarks on Ague and its Sequelse, Scurvy, Purpura, &c. Price ........... ^3.00 "Dr. Ward's book is of a purely practical character, embodying the author's experience, from his long connection as physician to tlie Seaman's Hospital. His accurate description of the diseases treated will amply repay the reader." — Dablin Medical Journal. WILSON (ERASMUS), F. R. C. S., &c. CONTAINING THREE HUNDRED AND SEVENTY-ONE ILLUSTRATIONS. THE ANATOMIST'S VADE MECUM. A Complete System of Human Anatomy. The Ninth Revised and Enlarged London Edition. Edited and fully brought to the Science of the day by Prof. George Buchanan, Lecturer on Anatomy in Anderson's University, Glasgow^, with many New Illustrations, prepared expressly for this Edition. Price ^5.50 WEDL (CARL), M.D. Professor of Histology, &c., In the University of Vienna. DENTAL PATHOLOGY. The Pathology of the Teeth. With Special Reference to their Anatomy and Physiology. First American Edition, translated by W. E. Boardman, M.D., yvith. Notes by Thos. B. Hitchcock, M.D., Professor of Dental Pathology and Therapeutics in the Dental School of Harvard University, Cambridge. With 105 Illustrations. . . . Price, in Cloth, ^4.50 ; Leather, $5.50 This work exhibits laborious research and medical culture of no ordinary character. It covers the entire field of Anatomy, Phvsiolosry, and Pathology of the Teeth. The author, Prof. Wedl, has thoroughlv mastered the subject, using with great benefit to the book the very valuable material left by the late Dr. Heider, Professor of Dental Pathology in the Uni- versity of Vienna, the result of the life-long work of this eminent man. 38 WOODMAN AND TIDY. A HANDY-BOOK OF FORENSIC MEDICINE AND TOXI- COLOGY. By W. Bathurst Woodman, M. D. St. And., Assistant Physician and Lecturer on Pliysiology at the London Hospital; and C. Meymott Tidy, M.A., M.B.,- Lecturer on Chemistry, and Professor of Medical Jurisprudence and Public Health, at the London Hospital. With numerous Illustrations. Preparing. WELLS (j. scelberg), Ophthalmic Surgeon to King's College Hospital, &c. TREATISE ON THE DISEASES OF THE EYE. Illustrated by Ophthalmoscopic Plates and numerous Engravings on Wood. The Third London Edition. Cloth, $5.00; leather . . . $6.00 This is the author's own edition, printed in London under his supervision, and issued in this country by special arrangement with him. SAME AUTHOR. ON LONG, SHORT, AND WEAK SIGHT, and their Treatment by the Scientific Use of Spectacles. Third Edition Revised, with Ad- ditions and numerous Illustrations. Price .... ;^3.oo WRIGHT (henry g.), M.D., Member of the Royal College of Physicians, &c. ON HEADACHES. Their Causes and their Cure. From the Fourth London Edition. i2mo. Cloth. . . . . . ;^i.25 The author's plan is simple and practical. He treats of headaches in childhood and youth, in adult life and old age, giving in each their varieties and symptoms, and their causes and treatment. It is a most satisfactory monograph, as the mere fact that this is a reprint of the pmrth edition testifies. WALTON (haynes), Surgeon in Charge of the Ophthalmic Department of, and Lecturer on Ophthalmic Medicine and Surgery in, St. Mary's Hospital. A PRACTICAL TREATISE ON DISEASES OF THE EYE, with an Introductory Chapter on the Anatomy of the Eyeball. With nearly 300 Engravings on Wood and about 20 Chromo-Lithographs. Third Edition. Octavo. Nearly Ready. WATERS (a. t. h.), M.D., F.R.CP., &c. DISEASES OF THE CHEST Contributions to their Clinical His- tory, Pathology, and Treatment. Second Edition, Revised and Enlarged. With numerous Illustrative Cases and Chapters on Haemoptysis, Hay Fever, Thoracic Aneurism, and the Use of Chloral in certain Diseases of the Chest, and Plates. Octavo. Price . . . . ^5.00 WALKER (ALEXANDER), Author of "Woman," ".Beauty," &c, INTERMARRIAGE; or, the Mode in which, and the Causes why, Beauty, Health, Intellect result from certain Unions, and Deformity, Disease, and Insanity from others. With Illustrations. i2mo. ^1.50 "The leading feature of this book is its essentially practical characier.^- LoNDON Lancet. Tanner's Practice of Medicine. SIXTH AMERICAN. FROM THE LAST LONDON EDITION ENLARGED AND THOROUGHLY REVISED. JUST READY. THE PRACTICE OF MEDICINE, by Thomas Hawkes Tanneh, M.D., Fellow of the Royal College of Physicians, Author of Tanner''^ Practical Treatise on the Diseases of Children, &c., r&c. Sixth Ame- rican Edition, vjith a very Extensive Appendix of Formulae. In- cluding also Climates for Invalids, Baths, Mineral Waters, dc. Price, handsomely bound in Cloth, . . $6 00 " " Leather, . . 7 00 OOIsTTElSTTS. Part 1. General Diseases. '♦ 2. Fevers. " 3. Venereal Diseases. " 4. Diseases of the Nervous System. " 6. Diseases of the Organs of Respi- ration and Circulation. " 6. Diseases of the Thoracic Walls. " 7. Diseases of the Alimentary Canal. " 8. Diseases of the Liver. " 9. Diseases of the Pancreas and Spleen. Part 10. Diseases of the Abdominal Walls. " 11. Diseases of the Urinary Organs. " 12. Diseases of the Uterine Organs. " 13. Diseases of the Skin. " 14. Diseases of Cutaneous Append- ages. ** 15. Diseases of the Bloodvessels. " 16. Diseases of the Absorbent System. Appendix of Formulse General Index. "The rapidity with which edition after edition of this work has appeared and dis- appeared 13, on the whole, a true test of its merits. The fifth edition was, we believe, a very large one, yet the book was for some time out of print before the present one could be prepared. Dr. Tanner has chosen his title well ; his work is essentially one on the practice of medicine in its widest sense, and it is in what relates to pure prac- tice, as contradistinguished from the theory of medicine, that the book is strongest; for it has been the author's aim to collect everything he could think of which would aid the practitioner in the discharge of his duties. But it is not to men engaged in the active discharge of the duties of their profession alone to whom the book is wel- come. With the student, preparing himself to enter upon these duties, the book has long been a favorite, chiefly, we believe, from the lucidity of its style and the character of its substnnce. Other books there are, more eloquent and more recondite, but none excel Dr. Tanner's work in these important features. All that is necessary to know is here, di,>*posed in such a manner as to admit of the readiest reference, and of being most easily retained in the memory. Our limits will not admit of an extended review, which would be out of place with regard to a book practically established as a standard. It carries its own recommendation, and is its own best passport to general use. It has been the result of very great labor — labor well spent ; and it appears in a form which is creditable to its publishers as it is pleasing to those who have to use the book. — British and Foreign Medico- Chirurgical Review, April, 1870. "Dr. Tanner's works are all essentially and thoroughly practical, — he never for on« moment allows (his utilitarian end to escape his mental view. He aims at teaching how to recognize and how to cure disea.se, and in this he is thoroughly successful. It ii indeed a wonderful mine of knowledge." — Medical Times atid Oazetle, July, 1869. THE LATEST TEXT-BOOK ON THE PEACTICE OF MEDICINE. Uniformly Commended by the Profession and the Press. A HAND-BOOK OF THE THEORY AND PRACTICE OF MEDI- CINE. By Frederick T. Roberts, M.D., M.R.C.P., Assistant Pro- fessor and Teacher of Clinical Medicine in University College Hospital, Assistant Physician in BrompLon Consumptive Hospital, &c., &c. In One Volume, Octavo, of over 1000 pages. Price, iu cloth . $5.00 leather . $6.00 The Publishers are in receipt of numerous letters from Professors in the various Med- ical Schools, uniformly commending this book; wliilst the following extracts from the Medical Press, botli English and American, fully attest its superiority and great value not only to the student, but also to the busy practitioner. This is a good boob, yea, a very good book. It is not so fuli in its Pathology as " Aitken," so charming in its composition as " Watson," nor s.i decisive iu its treatment as " Tanner;" but it is more compendious than any of tliem, and therefore more useful. We know of no other worlv in the English language, or in any othex", for that matter, which conijjetes with this one. — Edinburgh Medical Journal. We have mncli pleasure in expressing our sense of the author's conscientious anxiety to make his work a faitliful representation of modern medical beliefs and practice. In this he has succeeded in a degree that will earn the gratitude of very many students and practition- ers: it is a remarkable evidence of industry, exi)erience, and research. — Practitioner. That Dr. Roberts's book is admirably fitted to supply the want of a good hand-book of medicine, so much felt by every medical student, does not admit of a question. — Uttidents' Journal and Hospital Gazette. Dr. Roberts has accomplished his task in a satisfactory manner, and has produced a work mainly intended for students that will be cordially welcomed by them ; most of the observa- tions on treatment are carefully written and worthy of attentive study; the arrangement is good, and the style clear and simple. — London Lancet. It contains a vast deal of capital instruction for the student, much valuable matter in it to commend, and merit enough to insure forit a rajjid sale. — London 3Iedicul Times and Gazette. There are great excellencies in this book, which will make it a favorite both with the accurate student and busy practitioner. The autiior has had ample experience. — Ridimond and, Louisville Journal. We confess ourselves most favorably impressed with this work. The atithor hasjierformed his task most creditably, and we cordially recommend the book to our readers. — Canada Medical and Stirf/ical Journal. A careful i-eading of the book has led us to believe that the author has written a work more nearly u|> to the times than any that we have seen ; to the student, it will be a gift of priceless value. —Detroit Review of Medicine. Our opinion of it is one of almost unqualified praise. The style is clear, and the amount of useful and, indeed, indispensable information which it eontiiins is marvellous. We heartily recommend it to students, teaciiers, and practitioners. — Boston Med. and Hurgicul Journal. It is of a much higher order than the usual compilations and abstracts placed in the hands of students. It embraces many suggestions and hints from a carefully cornpiled hospital experience ; the style is clear aiid concise, and the ])lan of the work very judicious. — 3Iedical and Hurgicdl Reporter. It is unsurpassed by any work that has fallen into our hands as a compendium for students preparingfor examination. It is thoroughly practical and fully up to the times. — The Clinic. We find it an admirable book. Indeed, we know of no hand-book on the subject just now to be preferred to it. We particularly commend it to students about to enter ujjou the practice of their profession. — St. Louis Medical and Surgical Journal. If there is a book in the whole of medical literature in which so much is said in so few words, it has never come within our reach. So clear, terse, and pointed is the style; so accurate the diction, and so varied the matter of this book, that it is almost a dictionary of practical medicine. — Chicago Medical Journal. The author's style is clear, concise, and methodical.— CAtcogro 3Iedical Examiner. Dr. Roberts has given us a work of real value, and especially for the use of students is the book a good one. — Lancet and Observer. ''^ UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. 'M DEC 16 JAN 6 1988 Form L9-42»n-8,'49 (B5573)444 TTT^JTVERSITY OF -LV-'UO <^roup in .i.LS Eolations to 1^74 lihr»ry Tracheotomy''. 1068 S686c 1874 lArnry 3 1158 01209 0113 1%^