Lectures ON SOME OF THE MORE IMPORTANT POINTS IN SURGERY.

MARCH 5, 1853. six feet three inches high, broad and well-framed in proportion, had drank a gallon of rum during the afternoon, and ON very narrowly escaped, even with the loss of nearly as much his blood, abstracted in a few hours. His first bleeding was SOME OF THE MORE IMPORTANT of into the wash hand-basin, until he fainted, lying on his back, and the bleedings were repeated as soon as he again began to POINTS IN SURGERY. feel pain, and whenever he felt a return of the pain he used to put his arm out of bed to have the vein re-opened, for .Tack BY G. J. GUTHRIE, ESQ., F.R.S. Martin was a very gallant fellow. This is given as an extreme LATE PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND; case, to be borne in mind under circumstances somewhat THE WESTMINSTER TO SURGEON TO CONSULTING-SURGEON HOSPITAL, and particularly after injuries. In common cases of THE ROYAL WESTMINSTER OPHTHALMIC HOSPITAL ETC. pleuritis and pneumonia in strong and healthy persons, and particularly in pleuritis, it is now not unusual to abstract blood LECTURE X. with those who rely on its efficiency until the pain and difficulty IN the treatment of pleuritis and pneumonia, the first and of breathing are relieved, or fainting is about to take place. most essential remedy is bleeding, which should be resorted The patient should be raised in bed, the opening in the vein to in every case, whenever the febrile excitement is really should be large, the flow of blood free. The quantity will inflammatory. All old people, under such circumstances, vary from sixteen ounces to three times that amount in unless in a cachectic state, bear at least one bleeding well, different people; but the important point is to repeat it as they often bear more; and no fact is more important, in oppo- soon as the pain or the difficulty in breathing returns. It sition to the opinions commonly entertained on this subject. rarely happens that one bleeding, to whatever extent it may In young people, the bleeding should be repeated until the be carried, will suffice to remove the symptoms; and recurdesired object is effected; and the quantity required to be rence should be had to this remedy as often as the pain and drawn in inflammations, particularly after injuries, is often oppression require, and the action of the heart will bear it, very great. It may almost become a question, in some cases, especially during the first two or three days. It will often be whether the patient shall be allowed to die of the disease, or necessary to have recourse to it in smaller quantities for the from loss of blood; for convalescence is rapid in proportion as next four or six days, and again in less quantity on any return the inflammation is of a small extent, and has been early sub- of the inflammatory symptoms. Where the patient is likely dued. As the first stage of pneumonia only lasts from twelve to faint, he should be bled in the recumbent position; and as it hours to three days before it passes into the second; and the is advisable to take away a sufficient quantity of blood, great second from one day to three before matter begins to be de- care should be taken, by arresting its flow for a time, by posited, no time should be lost to prevent these evils taking giving stimulants, by admitting fresh air, and sprinkling with place, if the patient is to be saved, without incurring a risk, cold water, to prevent syncope, which is sometimes dangerous from which few escape with health, even if life be ultimately in elderly persons, who may be subject to, and who are not preserved. Bleeding in inflammation of the pleura, in young readily recovered from it. In the second stage of the comand healthy persons, should, therefore, be effected with an plaint, profuse and repeated bleedings do not answer so well; unsparing hand, until an impression is made on the system- they do not remove the evil which has occurred, although until the pain and the difficulty of breathing are removed- they may prevent its increase. Blood should then be drawn until the patient can draw a full breath, or faints; and the in such quantity only as will relieve the action of the heart, operation should be repeated, from time to time, every three restless under its efforts to propel the blood through a hepatized or four hours, according to the intensity of the recurrence, or lung. The quickness of pulse, the cough, the difficulty of the persistence of the essential symptoms. The pulse does breathing, must now be aided and relieved by other means; not often indicate the extent or severity of the inflammation, for although the pulse is not a certain indication, on which although it often expresses the amount of constitutional irri- dependance can be placed in the early stage of this complaint, tability of the person. It is sometimes exceedingly illusory as the breathing generally is; and as long as the respiration is a guide, and is never to be depended upon in the earlier stages oppressed, blood should be carefully abstracted, until it beof disease, when accompanied by pain and great oppression of comes manifest that the effect has been to quicken the pulse, breathing. Whenever the pulsations of the heart are propor. whilst it materially diminishes its power. A cupped and buffy state of the blood, together with a firm tionally much stronger than those of the arteries, we may is a of bleeding bleed without fear, and with the certainty of finding the pulse proof of the rise; but if the heart and pulse are both weak, the abstraction in the first stage of the disease; but after the effect of mercury of blood will almost always occasion complete prostration of on the system has been produced, it cannot be depended upon with the same degree of certainty. When the propriety of strength. When many years ago in charge of a regiment of infantry, further venesection is doubtful, the greatest advantage may be obtained from the use of leeches and from cupping, partion the top of the Berry Head, the outermost point of Torbay, the men were attacked by pneumonia. According to the cularly in cases of injury of the chest. Leeches may be practice taught in London, I bled my patients three and four applied’ by tens and twenties at a time; and when they have times in the first forty-eight hours. I first drew sixteen ceased to bleed into a warm bread and water or evaporating ounces, then fourteen, then twelve, then abstracted as the poultice, they may be replaced by as many more, until the complaint continued, eight ounces; gave tartar emetic, so as pain and the oppression have been removed. Cupping is to keep up nausea; then calomel, antimony, and opium, and always to be had recourse to when leeches cannot be obtained, lost my patients. I examined the bodies of all, and found that and when well done, it is frequently to be preferred; cupping they had lived to what is now called the third stage of pneu- to sixteen ounces will usually be found equivalent to forty or monia, combined in almost all with pleuritis, with effusion, and more leeches. Both these means often relieve to a greater the formation of false membranes. The disease was essentially extent, with less general depression, than a smaller quantity of blood taken from the arm, and are therefore, at such times a pleuro-pneumonia, varying in different degrees, as the pleura more advisable. When blood cannot be obtained from the or the lungs were principally affected; and I saw with regret that the disease had not in any way been arrested; that the veins, the arteries must furnish it; and both temporal arteries means employed had been insufficient. My sixteen ounces of have been opened with the best effect, when blood could not blood were increased to thirty, but it would not do. It was be obtained from the arm, or from the external jugular vein. The effects of bleeding were of old found to be different evident that, to succeed, no limit should be placed to the abstraction of blood in the first instance, but the decided incapa- under different circumstances and in different climates. bility of bearing its further loss. Everyman was therefore bled Asclepiades remarks that whilst phlebotomy was fatal at when he came into the hospital, until he fainted, and the Rome and at Athens, it was beneficial in the Hellespont. bleeding was repeated every four hours, or even oftener, as Nevertheless, at a much later period, Baglivi says,‘= In long as pain or difficulty of breathing remained; and under Romano, phlebotomia est princeps remedium in pleuritide." The remedy first to be administered, and most to be dethe improved practice all recovered. The lesson learned at Berry Head was not forgotten during pended upon in the first stage, is tartar emetic, which usually the five subsequent years passed in British North America. gives rise to vomiting, purging, and possibly sweating, and The men were as healthy, the winds were sharper and colder, should not be omitted, because such effects are produced in the vicissitudes of all kinds greater. Rum was cheaper, newer, the first instance. After a few, perhaps three or four doses, and stronger than the gin of Torbay. The local inflammations the vomiting usually ceases, the stomach tolerates its introwere often as severe, whether of the pleura or of the lungs, duction, and its gradual increase from six to nine, twelve, and by no means less so of the bowels. A grenadier, some twenty, or more grains, in twenty-four hours, is often borne

Lectures

similar,

eoagulum,

’

No. 1540.

satisfactory

propriety

218 not only with impunity, but with great advantage. Vomiting of the pleura, over which, as well as inflammation of serous and purging are not desirable, as the effects of tartar emetic membranes in other parts of the body, it exercises a remarkare more rapid and beneficial, when they give rise to no parable influence. ticular evacuations beyond that of general perspiration. The Blisters are never useful during the continuance of acute most valuable remark of Laennec on its use, is,"that by inflammation of the chest, although their use is indicated bleeding we almost always obtain a diminution of the fever, when the patient is much exhausted, the pulse weak, and the of the oppression, and of the bloody expectoration, so as to breathing continues difficult; or in cases in which the disease lead the patients and the attendants to believe that recovery proceeds slowly, or is becoming chronic, when they often do is about to take place; after a few hours, however, the un- much good. The same may be said of dry cupping, mustard favourable symptoms return with fresh vigour; and the same poultices, and other cutaneous rubefacients, which often do much good in the commencement and termination of slight scene is renewed often five or six times after as many venesections. On the other hand, I can state that I have never attacks, or of their supervention on chronic disease, as after witnessed these renewed attacks under the use of tartar injuries. In the acute stages simple drinks only should be allowed. emetic." He further says, that the same favourable results do not occur from its use in pleurisy, or in inflammation of serous As soon as the inflammatory action has subsided, the lightest farinaceous nourishment, gradually augmented by the addition membranes, as in pneumonia. Mercury is a remedy of the greatest importance in serous of broths, jellies, eggs, fish, and lastly animal food, should be inflammations, such as pleuritis, although of less value than substituted. The temperature of the room ought to be moderate tartar emetic in the first stage of pneumonia, than which it and equal. Inflammation of the lungs frequently terminates by the dewould appear to be more efficient in the later period of the stages of hepatization and infiltration, though some physicians position of a white or lateritious sediment in the urine, which place entire confidence on its efficacy in all. It is of most is considered a critical evacuation, not however to be relied value when combined with opium. Some suppose that the upon, unless accompanied by a remission of the important opium merely prevents the irregular action of the mercury; symptoms. A moderate diarrhoea and a profuse perspiration others, as far back as 1801, believed that the opium has a are also signs of a favourable crisis. distinct curative effect, being capable, when given in large Inflammation of the chest has been hitherto considered as doses, of subduing inflammation, and more particularly of accompanied by inflammatory fever as an essential character, allaying pain, relieving the cough and irritation, and of pro- but this is by no means always the case. In large cities, and curing sleep, in which opinion I fully concur. Opium is highly amongst troops, after hard service, in which they have been advantageous in irritable and nervous persons, and will fre- subjected to much privation, and in certain epidemics, the quently relieve the nervous pain-the pleurodynia which re- accompanying fever often partakes of a low or typhoid chamains after pleuritis, when nothing else succeeds. Calomel racter, and becomes infinitely more dangerous. This modifica. in large doses is usually preferred to all other forms, but a tion of disease I have known from my earliest years, in different difference of opinion has occurred as to what is a large dose, climates, in all of which it proved most fatal. It is a disease whether two, three, four, six, ten, or twelve grains are large formed of a local inflammation accompanied by general sympdoses, and whether they shall be given every one, two, three, toms of a low asthenic type of fever, combined with those of six, or twelve hours. It has been attempted to solve this marked derangement of the stomach, intestines, or liver, as question by supposing that in highly iuflammatory cases in shown by a dry black, or red black, or brown tongue, offensive healthy persons, from three to six and even to twelve grains breath, diarrhcea, vomiting of a dark-coloured or greenish fluid, may be given twice or three times a day, with better effect watery or sanious expectoration, great thirst, headache, a feeble and quick pulse, low delirium,and great prostration of strength. than smaller ones more frequently repeated. In cases less inflammatory or complicated with gastric de- It was marked, on the banks of the Guadiana, bv the discharge rangement, the disease assuming more of a general than of a of lumbrici by the mouth and by the anus. This disease has local character, the excretions being vitiated, the skin dry always appeared to arise from peculiar circumstances, and to and hot, and the tongue loaded, from gr. iss. to grs. iij. of disappear when they ceased to exist; such as great privations calomel, combined with three grains of Dover’s powder, may and exposure to cold and fatigue, the use of ardent spirits withbe advantageously given every second or third hour, the great out sufficient food, bad air, or other depressing causes. It is being to affect the gums as quickly as possible. This sometimes epidemic. The fever is typhoid, the local inflammais not effected in some cases by any of the quantities given tion latent, and the symptoms of it masked. It may be comuntil after a considerable lapse of time, whilst in others it is plicated with inflammation of the stomach and intestines; it accomplished by less than half-a-dozen grains of the remedy. may occur in cases of erysipelas, or after wounds or injuries It has not been ascertained that twenty-four or forty grains attended with large secretions of purulent matter, or other given in two or four doses in twenty-four hours will affect the ’complaints. Whilst the symptoms of low fever are general mouth more rapidly than three grains every two hours for the and well marked, those of the latent affection of the lung are same time, neither is it less liable to cause irritation; whilst not so prominent or even observable. The patient complains the third or half-a-grain of opium given every two hours but little, and sometimes not at all of his chest, until attention is drawn to it by a slight cough, and difficulty of respiration, seems to keep up the effect of that remedy with great advanIt does not materially signify which method is adopted attended by a character of countenance which usually inditage. in strong and healthy persons, although the smaller doses are cates embarrassment in the functions of the lung. It may be most satisfactory to all parties when the patient is weak and brought on by a common non-penetrating injury of the chest. In typhoid pneumonia, general bleeding, if admissible, is to irritable, whilst the large and less frequent doses often excite great apprehension. It is argued that calomel in large doses be had recourse to with extreme caution, even in young and never causes the dysentery nor the severe ptyalism produced robust persons. Local depletion is oftentimes useful, and by smaller doses; that it acts more quickly, and that after perhaps ought alone to be relied upon. The great dependance giving twenty grains, and repeating it in six hours, any other is on calomel and opium, and after such local depletion as medicines may be given without interfering with it, although may be thought advisable, counter-irritation by blistering, the strictest attention must be paid to diet, generally con- and the administration of stimulants, such as camphor, fining it to very small sups of warm whey. Very serious de- ammonia, and wine, in small and repeated quantities. Mild rangements do, however, follow the exhibition of the large as aperients only should be employed, and anodyne injections well as of the small doses, inasmuch as it is impossible to are frequently useful. Whilst auscultation has thrown a clear know beforehand what quantity will cause a severe salivation and steady light on the nature of the mischief which is going or diarrhoea which it may be difficult to arrest. on, it has added little or nothing dissimilar to the practice It may be concluded, that of the two heroic internal pursued some forty years ago. The nature of the hepatization remedies, tartar emetic and calomel, recommended for the or solidification which takes place in the lung in typhoid cure of inflammation of the chest, tartar emetic is the more pneumonia has given rise to some difference of opinion among appropriate fGr inflammation of the lungs or pneumonia, pro morbid anatomists, who incline to believe, from the rapidity vided it is not accompanied by symptoms of gastric inflamma- with which it takes place, and with which it is sometimes reo tion; in which case its use should be superseded by leeches to moved, that it depends more on passive congestion, and on a the epigastrium, and saline aperients, lest the irritation, typhoid alteration of the state of the blood, than on an altered vomiting, and purging should increase the evil. But care action in the vessels of the part. This opinion does not seem that one inflammation shall not be allowed to to be fully supported by dissection, unless it be generally admust be taken increase, whilst attention is principally paid to the other, and mitted that grey hepatization, and the third stage of disease symptoms of irritation, the ga6tro-enterite of the French phy- of the lungs in pneumonia, mean simply congestion. When the patient survives the imminence of danger in sicians, are not to be mistaken for gastritis. Mercury, in the form of calomel, is more to be depended upon in inflammation which he is placed by the attack of the disease, and the ex-

object

219 becomes copious, with great emaciation, quick and hectic fever, a slight infusion of senega with ammopulse,or of cinchona, with a mild and well-regulated diet, and nia, change of air and climate, answer best in aiding recovery. A typhoid pleuritis is presumed to exist, as a distinct disease from typhoid pneumonia, although the analogy between them is admitted to be close; like it the disease is latent and oftener pointed out by the sinking of the powers of life tha i by any The signs of effusion may be discovered on new suffering. auscultation, and the treatment is essentially similar; blistering and counter-irritants, being perhaps more useful, if time be granted for their application.

pectoration

TRACHEOTOMY, WITH

A NEW METHOD PERFORMING THE OPERATION.

OF

BY HENRY THOMPSON, ESQ., M.B. Lond., M.R.C.S. &c. THE BLENHEIM-STREET DISPENSARY, FORMERLY SURGEON TO UNIVERSITY COLLEGE HOSPITAL.

SURGEON TO

HOUSE-

" The subject of tracheotomy or tracheotony is one of vast and vital importance, requiring the utmost attention from our best physicians and surgeons, and not likely to be exhausted by the superficial observer and thinker. I commend it to the earnest enquirer."—Clinical Notes, by Dr. MARSHALL HALL, THE LANCET, Nov. 13, 1852.

THE quotation placed at the head of this paper forms the single sentence of commentary appended to a list of terms descriptive of not less than about twenty-five distinct morbid conditions,

(diseases,) in each of which Dr. Marshall Hall suggests, that " this measure (tracheotomy) may be appropriate and necessary." The object of that list is to show that whatever may have been the practice hitherto, the operation of making an artificial opening into some part of the respiratory passages, for the purpose of permitting free access of air to the lungs, is one likely to be required by no means unfrequently, and it is conceived that Dr. Marshall Hall’s clearly expressed opinion on this point, renders it unnecessary to consider it a question for discussion: at all events it is not the object of the present paper to enter upon it. Under these circumstances, it has occurred to the writer to examine (not without a considerable degree of diffidence on his part) the present modes of fulfilling the indication just described, their relative value and applicability in different circumstances ; and lastly, to inquire whether some other method might not be adopted with advantage in certain cases. Three principal operations have been adopted for the purpose of opening the great air passage below the rima glottidis. Strangely enough, all these have been comprehended by systematic writers under the single term bronchotomy, although it is almost unnecessary to say, that the bronchus is never divided in any one of them. Regarded singly, they are known as tracheotomy, laryngotomy, and laryngo-tracheotomy. It is needless to describe these in detail. Tracheotomy consists in laying bare the trachea at some point by dissection through the superjacent structures, and cutting through one or more of its rings, usually from about the third to the sixth. This method has been practised by surgeons from a early period. Laryngotomy is

very

an incision into the membrane which interDesault between the thyroid and cricoid cartilages. divided the former also, from below upwards, to a certain extent. Larpngo-trac7teutomy, commencing by an incision in the membranous space described, divides the cricoid cartilage, and more or less of the trachea below. This was Boyer’s mthod. These operations have not been employed indifferently. Without quoting at length numerous authorities which have been consulted, it may be stated that it has been in the main a generallyreceived axiom among all surgeons, that when nothing more is indicated than the admission of air to the passages below the rima glottidis, laryngotomy is sufficient for the purpose, being also a much less difficult and serious proceeding than tracheotomy. But that when the removal of a foreign body is proposed, either tracheotomy, laryngo-tracbeotomy, or the laryngotomy of Desault must be resorted to. Further, that when it is intended that a tube should be worn subsequently, for any considerable period of time, tracheotomy is to be employed, the larynx being too sensitive to admit of its long-continued presence. After laryrgotracheotomy also, the tube has been found to give rise to much

venes

*

irritation.

Let us briefly compare these operations in relation to the difficulties and dangers which are encountered m each. The trachea above the sternum, by its anterior aspect, has the following structures in contact, or in close proximity with it :First, the isthmus of the thyroid body; the size and position of which varies somewhat, while it is also a little larger in the

I

female than in the male. This is most commonly situated oppo. site to the third and fourth rings, reckoning from the top.* On each side it enlarges, forming a lobe, which is closely applied to the side of the tube. A very large arterial supply is afforded to this body by numerous branches of the superior and inferior thyroid arteries, of which the latter are distributed chiefly to its under surface, where a free anastomosis exists between the vessels of either side. Rarely, there exists a third lobe, formed by a small projection of glandular substance from either side of the middle line, generally from the left. Lower down some subcutaneous veins may be found of varying size; frequently a vessel, uniting the two anterior jugulars, crosses the region an inch or so above the sternum. Below the thyroid, the trachea is overlapped by the sterno-thyroid and sterno-hyoid muscles, and in the interval between these by the deep cervical fascia. On separating them, several veins, sometimes of large size, (inferior thyroid,) may be seen crossing the trachea to reach the innominate vein, which usually become more closely aggregated as they approach the sternum ; here also are a few tracheal branches from the inferior thyroid artery ; and on each side at this part the two carotid arteries are closely applied to it for a greater or less portion of its length, the innominate and left carotid having crossed obliquely in front of it at the episternal no’ch or there. abouts. An irregular arterial branch of considerable size is occasionally met with here, lying in front of the trachea, and ascending upon it to the thyroid body. This is the "thyroidea ima" of Neubauer and Erdmann;t other large vessels may be occasionally found in this situation, but such an occurrence is more exceptional than the preceding.* Next, respecting the relation of the trachea to the external surface. Immediately beneath the cricoid cartilage, at its commencement, it is subcutaneous, the distance at which it lies from the surface gradually increasing from this point, until, opposite the top of the sternum, it is usually found in the adult at a depth of about one inch to an inch and a quarter. This, however, is sometimes increased in fat subjects, although it may be less in those who are emaciated. In cases of acute inflammation of the larynx and of the neighbouring structures, there is sometimes so much ccdema of the external parts that the distance of the trachea from the surface is greatly increased. Mr. Macnamara, of the Meath Hospital, reports a case in which, when operating, he found the trachea at two inches and a half from the surface, in consequence of this condition of the integuments.§ Hitherto, most surgeons have fixed upon that part of the trachea which is immediately below the thyroid body as the most eligible spot for making an opening into it. Velpeau advises that the fourth, fifth, and sixth rings should be cut, and if necessary the third and seventh in addition.1I Some prefer the upper rings, considering that a division of the isthmus of the thyroid is less hazardous than an incision lower down, which incurs the probability of inflicting injury upon more important structures. Thus, Malgaigne, considering that the dangers increase in proportion as the wound approaches the sternum, prefers cutting the upper rings of the trachea and dividing the isthmus of the thyroid body, respecting which he says-‘‘ After having divided the isthmus of the thyroid gland, and the venous plexus below it, (if such cannot be pushed aside,) the trachea is exposed. Then the patient should be directed to make deep inspirations in order to lessen the venous haemorrhage ; and next, such vessels as continue to bleed should be tied.""i[ Mr. Lawrence adopted a similar method of operating in the cases which he reported in a paper read before the Medico-Chirurgical Society. (Transactions, vol.

vi.,

art,

xv.)

In reviewing the opinions which have been recorded by practical surgeons respecting the operation of tracheotomy, an almost unanimous admission that considerable difficulties frequently attend its performance is met with. Sir Charles Bell gives a graphic account of the difficulties which presented in a case in which he attempted to perform it. Having laid bare the trachea, he states that he was unable to make an opening, because, on *

Quain and Sharpey’s Elements of Anatomy, p. 1179. Not less than five examples of T Anatomy of the Arteries. Quain. this vessel are figured here. Vide Pl. vii. fig. 9, and Pl. xxiiv. figs. 7, 8, 9, and 10. It most commonly arises from the innominate artery. &Dag er; Mr. Macilwain states that he has seen " the arteria innominata rise so high in the neck before its division as to cross the trachea in the situation where the tube is opened in this operation," (tracheotomy,) in three cases. In one of them he abandoned an operation from the apparent impossibility of performing it there.—Diseases of Mucous Canals, pp. 327—37. Burns has also seen the same variety. In relation to the subject of tracheotomy, he records five cases in which the left carotid artery, and one in which the right, "crossed the trachea pretty high in the neck."—Surg. Anat. of the Head and Neck, p. 394. § THE LANCET, Nov. 20, 1830. Elements of Operative Surgery, part ii. chap. 3. ¶ Man. de Med. Oper. Second Edition. Paris, 1837. p. 487.