CLINICAL NOTES.

419 .

our views of the pathology of the disease, and we can admit of no deficiency in our knowledge of the symptoms; while the evidence we possess in the pre-

degree of obscurity in

I

clogged with mueus, by which, becoming viscid as efficacy of the operation must be endangered.

it does, the

I must add one observation more: the silver cage may be made to assume the size required, by placing round it a ring of thread of the proper dimension; and this may be varied at will. In this mode of operation, there is only a little more of di8traction than in that in which an incision only is made into the trachea, no portion of it being removed; and at the close of a month’s use of the cage, I am persuaded that the state of the parts will be in all cases very nearly similar, absorption having accomplished the remov,vl of the parts otherwise removed by the knife or the tracheotome. I think the operation of opening the trachea is thus reduced to its utmost simplicity and facility. It remains, however, for experience to give or withhold its sanction, both to the employment of the operation itself, in the cases in which I have suggested its adoption, and to the mode of performing that operation suggested. The patient may be cautiously subjected to the influence of chloroform, to insure as much immobility of the structures of CLINICAL NOTES. the neck and throat as possible during the operation, if this measure be deemed necessary. BY MARSHALL HALL, M.D., F.R.S., &c. The whole apparatus is so small that it might be packed in It must be inexpensive, and it ought a large walnut-shell. No. III. ON TRACHEOTOMY, A NEW MODE OF OPENING THE to be possessed by every surgeon. To show the importance of TRACHEA. this matter, I will, in the next LANCET, enumerate the series THE difficulty in the operation of tracheotomy consists in of cases in which it may be required. The operation itself may be rendered so simple as scarcely the division of the tissues so as to denude the trachea,. Arteries and veins are apt to be divided, and the operation is arrested to exceed, in difficulty or danger, that of opening a vein or or retarded by the necessity for tying those vessels. artery. It has occurred to me that these difficulties might be A slight gauze cravat may be worn loosely over the cage, obviated; and to effect this object I would suggest the follow- in situ; the projecting part of this will secure the orifice ing procedure :against any obstruction. In addition to all this, a conical A ring is to be made of steel, one inch in internal diameter, stopper might be contrived, so as to admit of being introduced one-sixth of an inch in width, and one-eighth in thickness. into the external orifice of the wire cage, and to enable the This ring is to be pierced in four opposite points, so as patient to speak. Are there not also other cases in which the principle of the to receive four screws, admitting of being turned at their outer extremity by means of a little wheel, and nearly meet- tracheotone might be used ?-as an explorer(?)-in dangerous ing at the centre of the ring. The central point of each of abscess, empyema, ascites ?-even calculus ? I may add that the term tracheotone is compounded of the these screws is to be made to penetrate the circular eye of each of four needles, which are so arranged, being flattened Greek word &tgr;∈&ggr;&ngr;&ohgr;,as the term tracheotome is of the word &tgr;∈µ&ngr;&ohgr;. on two sides, as to be in accurate contact with each other, and to meet accurately in a point. Or these pieces of steel may The great desiderata in the mere operation of opening the be of square form, but at right angles at the centre of the ring, the screw being on the edges only, and the nut loose and trachea, are safety and promptitude. I have sometimes so as to act upon it. The instrument itself may be seen at trembled to think of the possibility of wounding a large Mr. Weiss’s, 62, Strand. artery or vein, somewhat anomalous in its size and erratic in A vertical incision.being made through the skin, over the its course, and seated deeply, near the highest part of the part of the trachea chosen for the operation, this point is sternum. I have still more frequently experienced a similar made to pierce the subcutaneous tissues and the trachea; the feeling when I have thought of the necessity, in some urgent four screws are then to be gently turned, one by one, at short cases, for an instantaneous opening into the trachea. This is intervals of time, so as by dis-traction to make the required the occasion for citing that oft-cited passageopening into the trachea. °° horae In all this procedure not a drop of blood has been lost, and Momento aut cita mors venit, aut victoria laeta."-HOR. Sat. I. no obstacle has been met with which would intimidate the This consideration, and that of the extensive series of cases in most nervous operator. The instrument, the tracheotone, having thus made the re- which I believe tracheotomy may be required, have led me to quired opening into the trachea, my next object is to retain think much of the means of rendering this operation more that orifice freely patent, also in the simplest manner, and by simply, safely, and promptly practicable, and therefore more

monitory signs, whereby may recognise its approach, is of the very clearest. We acknowledge, also, nofailure in the I would gladly that the progress of means of treatment. science, in tracing the causes whence one of the most indispensable necessaries of life is often turned into an insidious bane, were as far advanceel. It would be presumptuous to affirm that room does not yet remain for pursuing and maturing knowledge in that branch of the subject which more especially belongs to us; but the chemist and the experimental natural philosopher have still more to effect in theirs; and I shall close my subject with the earnest hope that the attention which has been recently bestowed on the inquiry will not be allowed to slumber, but receive added energy, to accomplish all that lies within the scope of human intellect and tikill. we

even

.

the

simplest

means.

A silver wire of due strength having been so bent alternately eight times and united at its extreme points, as to form a tube-like cage, this cage is introduced within and down the space formed by the four needles through the orifice into the trachea, and the tracheotone is withdrawn. Two opposite parts of the cage, within the trachea, left oneeighth or one-sixth of an inch longer than the other two for this purpose, are bent to a right angle. These being pressed together during their introduction, expand outwardly when that introduction is accomplished, and act as a sort of button, retaining the cage in its position, preventing its falling out of the orifice. The cage itself is of a slightly conical form, being wider at its external than its inserted part, and so, tends to move outwardly, and prevent its passing into the centre of the trachea. By a slight compression the cage is reduced in its diameter, and readily removed for the purpose of being washed. By the same simple manoeuvre it is as readily replaced. This cage is light, occupies the least possible space in the trachea, and leaves the freest space for the ingress and the egress of the respired air; and I may here remark that the usual tracheal tubes are, generally speaking, far too small to insure the perfect efficacy of the operation. Their form and their size are also such as to admit of their being readily

extensively available.

I have described such a mode of tracheotomy, or rather of tracheotony, in the present Note, and I propose to give the series of cases in which that operation may be appropriate in the next. It will be seen that these cases admit of being arranged in several classes or orders; and it will especially be evident, that whilst in some of them the surgeon may take time and select his opportunity, in others the utmost promptitude is requisite to save life. It is in the last case that my proposition of tracheotony is peculiarly opportune; and I beg, in this place, to suggest that even without the tracheotone this operation might, in a case of emergency, be readily performed. Let the incision be made through the skin, and then let four long needles be introduced at one and the same point, in succession, into the trachea; then let these needles be separated by means of a piece of cork cut into the proper cone-like form, and a tube, which might even consist in a scroll of writing-paper, until something better be procured, be introduced; or, to save life, one or two pairs of pointed scissors might be made to divide the skin, to act as a tracheotone, and even to retain the opening patent for a time. I was once summoned to the late Professor A. T. Thomson. He had, at his lecture, inhaled the vapour of the hydrochloric acid. He suffered from attacks of urgent laryngismus and suffocative dyspnoea. I remained with him some time, and

420 to rescue him from the danger of asphyxia, should that become imminent! There is no better exercise of the medical or surgical mind than to reflect earnestly as to what we would do in any given emergency, deprived of the usual appliances of our art. I once saved a lady’s life, who had just, by mistake, swallowed an enormous dose of Battley’s solution, by the providential fact of possessing the stomach pump. The tracheotone which I have recommended, is so simple and so little costly, and the necessity for an opening in the trachea is so frequent and so urgent, that I think it ought to be in 1’ectclines8 in every surgery, and indeed in every consulting-room.

prepared myself

,

.

,

Grosvenor-street, Oct., 1852. P. S.-I forgot to mention, in my

last, that in the peculiar occurring in apopleptic and epileptic cases from paralysis of the pneumogastric, the excitability of the larynx, and the sensibility of the trachea and bronchia, are diminished, and that there is little or no cough. When this state of things arses from an irremediable cause, it is the " death-rattle," and it exists in the bronchia, as well as trachea, as may be ascertained by the stethoscope. bronchial affection described

as

OBSERVATIONS

ON THE STRUCTURE CONNEXIONS OF THE VALVES OF HUMAN HEART. BY W. S. TUTOR AT ST.

THE

AND THE

SAVORY,

BARTHOLOMEW’S HOSPITAL,

ETC.

contains the results of various observathe anatomy of the auriculo-ventricular and arterial valves. It has been my endeavour to avoid all useless repetition of that which is already generally known and accurately described. Previous observations are repeated or alluded to only so far as they appear necessary to the explanation of my own. The dissections have not been entirely limited to the human heart, but have been extended only to illustrate and determine any points that were otherwise doubtful or obscure. The two auriculo-ventricular orifices are situated upon the same plane at the posterior portion of the base of the ventricles; they are directed obliquely downwards and backwards, the walls of the ventricles extending higher in front than behind. They are separated from each other by the upper border of the septum of the ventricles. In the angle formed between these orifices in front, the aortic aperture is situate, more closely connected, however, with the antero-lateral portion of the left auricnlo-ventricuiar ring, and separated from the right by a thin border of muscular tissue. Its close connexion with the left side will be presently more particularly examined. This orifice is placed horizontaliy.* Lastly, in front of the aorta, the pulmonary artery arises. This orifice lies obliquely, looking upwards and to the left, and is on a plane superior to the aortic aperture. This is the result of the infundibuliform prolongation of the muscular fibres of the right ventricle upwards, and this disposition is especially marked in the human heart, the muscular tissue being continued upwards to the pulmonary artery higher in man than in any of the animals whose hearts I have more particularly examined, as the horse, otherwise the relative position of the four orifices ox, sheep, &c.; corresponds very exactly with the arrangement above described. the aorta and pulmonary artery Although at the first appear to arise in close connexion with each other, yet if we dissect down between the two vessels, we shall find them separated at the base by an interval of muscular tissue. The same arrangement occurs between the adjacent portions of the aorta and right auricle; and by a careful dissection continued downwards, weat last arrive at the thin border of the right ventricle between them. Between the adjacent surfaces of the aorta and left auricle, however, no such separation can be effected. The relative situation of the four orifices is easily seen by removing the fat and coronary vessels from the base of the heart, and then cutting off the auricles and great vessels on a level with the base of the ventricles. The two arterial orifices are circular; the auriculo-ventricular apertures are oval, their long diameters being at right angles to each other-i. e., in the left transverse, and in the right from before backwards. After prolonged boiling,the fat and coronary vessels will separate from the base and the grooves in which the of the heart with great

tions

following paper

on

vessels lay are well seen. The arrangement to which their existence is due will be presently examined. With very little care we can separate the auricles from the ventricles ; and it is safer to use the handle than the blade of the scalpel for this purpose, for we then run no risk of dividing any fibres; a little more difficulty will usually occur at the septum, especially in front, where the auricular fibres are more abundantly attached. The separation being completed, it will be observed that in the auricles the margins of the orifices are rough and uneven; the extremities of the fibres appear as if torn, presenting a decided contrast to the smooth, well-defined border of the ventricular orifices. This is fully explained by the mode in which the auricles are attached. Occasionally, if the operation be hastily performed, the valves will separate with the auricles, but more generally remain connected with the ventricles; but their attached borders are always more or less torn in the separation, and for a very obvious reason. If we now proceed to the arteries, we shall find (provided the heart has been sufficiently boiled) that these vessels and their valves, together with the whole of the tendinous structures connected with them, will separate from the muscular fibres, the inner lining membrane of the ventricles only requiring division; some difficulty occurs at the posterior part of the aorta, from which a portion of tough fibrous tissue must be separated. In detaching the auricles, we cannot fail to remark the c’ose connexion that subsists between the base of the anterior wall of the left one, and the posterior surface of the commencement of the aorta. Now, having completed the separation of all these parts from the ventricles, we shall see that there remain indeed only three orifices; that the aortic has become continuous with the leftauriculoventricular, the posterior part of the one, opening as it were, into the anterior part of the other; (a portion of the anterior mitral valve only sometimes iiitervening,-,vhich maybe removed,)theoutof the two together somewhat resembling the figure 8, (Fig. 1.)

line

glance

facility,

*

In the above downwards.

description, the apex of the heart is supposed to be directed

t From one to two hours for a human or sheep’s heart, and four or five hours for the heart of a horse or ox. It is a good plan to fill the cavities previously with cotton woo]. The heart is prevented from shrinking, (which otherwise it will do,) and preserves its shape. ’

The general outline of the base of the ventricles is irregularly triangular, with the apex at the origin of the pulmonary artery; and from the arrangement of the four, or rather three orifices, it

that while the auriculo-ventricular, as well as the arterial are separated from one another by a rounded ridge of muscular tissue, the posterior portion of the pulmonary orifice is separated from the anterior border of the right auriculo-ventricular ring by a more considerable interval occupied by fibres forming the base of the right ventricle, and having a general direction from the septum and aortic orifice obliquely outwards to the right.* The margins of the apertures are smooth and well defined; that bounding the pulmonary orifice is thin, but the others are much thicker and convex, and this especially applies to the left auriculo-ventricular border. A close inspection and careful examination of the general arrangement and direction of the muscular fibres (which are well seen in a heart after prolonged boiling) will enable us to understand the formation of these thick convex borders ; and it is important, as they are closely con-

is

seen

apertures,

*

The terms

left and right, &c.,

apply to the heart.