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better than in the words of its great advocate, M. Trousseau,* who forbids the performance of the operation in any cases where the danger to the child appears to depend on disease of the general system rather than on the affection of the larynx or trachea.' But in cases where no such contraindication exists, it is yet evident that the issue of the operation must be in a great measure controlled by the age of the patient, by the fact of the disease being idiopathic or secondary, by the extent of the disease of the respiratory organs generally, and that this influence must be of a kind which no surgical dexterity or medical skill can do much to control or to modify.

Some circumstances may, however, be borne in mind as influencing the result of tracheotomy, while at the same time they are not beyond the control of the medical attendant.

The first of these concerns the size of the tracheal tube, a point the importance of which was first insisted on by M. Trousseau. He explains the occasional speedy and apparently causeless disappearance of the amendment that at first succeeds the operation of tracheotomy by the inadequate size of the canula which is frequently employed, and which does not provide for the permanent admission of a sufficient quantity of air. The air admitted through even a small canula is enough to afford temporary relief, but not enough for the continued discharge of the functions of the organism; and the return of hurried breathing, and the re-appearance of the livid hue of the surface, betoken the imperfect depuration of the blood. 'Take,' says he in illustration of this fact, a quill, and, closing your nostrils, endeavour to breathe entirely through it: at first you breathe easily enough, but soon your respiration becomes laborious; and at length you are fain to throw away the quill, and with open mouth once more to fill your lungs completely. Now precisely this is what happens when an opening of inadequate size is made into the trachea; air enters readily, and without the interruption which the spasm of the glottis occasioned; but it does not enter in sufficient quantity, and hence the return of the symptoms, and the patient's death.' Acting on this principle, M. Trousseau makes a larger opening into the trachea, and introduces a larger canula than had previously been customary; and this practice I believe to be now gaining ground among persons who have omitted to acknowledge their obligation to M. Trousseau for the suggestion.

The second of these precautions has reference to the necessity of

* Archives Gén, de Médecine,-March 1855, p. 257.

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surrounding the child after the operation with a warm, moist atmosphere, such as alone it ought to be allowed to respire; though, unfortunately, this is very much neglected, not in hospitals only, but also in private practice. The importance of attention to this point, and also to surrounding the neck with several folds of muslin, so as to cover the orifice of the tube, as well as to keeping the canula free, cannot be overstated; and yet these little things are overlooked or entrusted to unskilful hands, because they seem too trivial for such large issues to be dependant on them.

The third caution which I would urge is, that medical treatment must not be suspended, nor necessarily modified, after tracheotomy has been performed. The operation, indeed, seems so heroic a measure, and when it yields relief, the relief is so speedy and so striking as to occasion some risk of its being forgotten that the disease has not been removed by it, that its danger has only been postponed, and that the indications for treatment continue the same after tracheotomy as they were before.

A word or two with reference to the after-management of cases of tracheotomy will comprise all that I have to say on this subject. My own patients have rarely lived long enough after the operation for me to become practically familiar with the difficulties which arise some few days after its performance. These, however, apart from such as are the consequences of the supervention or increase of the disease of the respiratory organs, are two-fold, and arise from the condition of the wound, and from the occasional supervention of difficulty of swallowing.

One of the reasons for seeking to remove the canula as early as possible is supplied by the irritation of the edges of the wound which its long-continued presence is apt to produce. I saw the death of a child take place from this cause on the 11th day after the otherwise successful performance of tracheotomy by my colleague, Mr. Athol Johnson; and it was ascertained after death that, in addition to the destruction of several rings of the trachea, an abscess had formed in the anterior mediastinum which communicated with the external wound by sinuses that burrowed between the trachea and œsophagus. In fat children the unhealthy state of the edges of the wound is partly produced by the canula remaining deeply sunk in the flesh; an evil which would perhaps be lessened by the use of a long canula with a very broad shield ; or else by the employment of one à lorgnette,' as it has been termed by its inventor, M. Paul Guersant; that is to say, capable of being lengthened by pulling it out, like a telescope or an opera

glass. Besides this, the covering the wound with lint thickly spread with spermaceti ointment, and placing over that a piece of oiled silk so as to defend it as far as may be from irritation, and from the external air, as well as the touching its edges daily with the nitrate of silver, are the most important means of maintaining its healthy condition.

Another of the dangers of the operation depends on the abrasion of the mucous membrane of the trachea by the end of the canula, and its consequent ulceration. This danger, however, is almost, although perhaps not quite invariably, prevented by M. Lüer's modification of the canula, which was introduced to general notice by M. Roger. This modification consists in the canula being moveable on the shield, so that its position shifts with the varying attitudes of the child.

The difficulty of deglutition is an inconvenience which usually comes on about the fifth or sixth day after the operation: that is to say at the time when the larynx, though now free from the false membrane which before occluded it, has not completely recovered from the effects of the disease, but a state of partial paralysis of its muscles remains, which allows food, and especially liquids, to enter the air-tubes. This accident, which is by no means invariable in its occurrence, has probably little or no relation to the operation. It is a result of that paralysis of the soft palate and muscles of the pharynx which sometimes succeeds to diphtheria, and which from being a troublesome accident is converted by the previous tracheotomy into a dangerous complication. If the patient is sufficiently intelligent to admit of M. Archambault's suggestion* being adopted, and will place the finger on the opening of the tube, and endeavour to breathe quietly through the larynx when swallowing, it is very likely that the want of harmony between respiration and deglutition will be overcome in many instances, though, according to M. Trousseau's experience, by no means in all. In the majority of cases, however, we are compelled, by the tender age of our patients, to confine ourselves to feeding them as far as possible on solid, or at least on pultaceous food; rejecting all drink as far as possible, and giving it when absolutely necessary in small quantities, and either immediately before or a considerable time after food. In some instances M. Guersant has found the use

L'Union Médicale, Juillet 1854.

Archives Gén. de Médecine, Mars 1855.

Notices sur la Chirurgie des Enfants, 8vo. Paris, 1864, pp. 34-48.

DD

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AFTER-MANAGEMENT OF TRACHEOTOMY.

of the stomach-pump, or of a tube introduced through the nares, necessary to convey food safely into the stomach; though happily such are exceptional cases; while generally the larynx recovers itself in three or four days, and deglutition is then no longer attended with difficulty or danger.

In M. Guersant's remarks on tracheotomy, he mentions the occasional occurrence of cases in which it has been found impossible, after the lapse of the ordinary time, to remove the tube from the trachea, the larynx remaining still partially closed by the adhesion of false membrane to the vocal cords. I have met with a case in which, twelve months after the performance of tracheotomy, it was still impossible to remove the canula, owing to the constriction of the windpipe above the opening; and several such are on record in the annals of medicine.

M. Guersant recommends the sweeping out the larynx by a little pledget of lint introduced through the canula, and carried from below upwards, so as to detach from between the vocal cords any false membrane remaining there.

This means, however, he confesses, has not always been successful, and Dr. Steiner, of Prague,* found in the case of a little boy who died of acute hydrocephalus nine months after tracheotomy, and who had never been able to dispense with the canula, that the larynx was completely closed by firm cicatrix tissue, the result of previous deep ulcerations of its surface beneath the deposit.

In my case, after various unsuccessful measures, my colleague at the Children's Hospital, Mr. Thomas Smith, at length succeeded in permanently dilating the contracted opening with a piece of the sea tangle; the child now passes many hours daily without the canula, though she still wears it at night, and I look forward to her becoming able before long to dispense with it altogether.

I trust soon to be able to refer to a promised essay by Mr. T. Smith, on the various surgical questions involved in the performance of tracheotomy in children, and on their management surgically after the operation.

Jahrbuch der Kinderheilkunde, 1863, vol. vi. p. 79. Dr. Steiner was good enough to communicate to me personally the results of the post-mortem examination; the child having died subsequently to the publication of his paper.

LECTURE XXV.

DIPHTHERIA, or ANGINA MALIGNA.-Not a new disease.-Its anatomical charactersmode of extension of the disease.-Its relation to true croup.

Symptoms of diphtheria-in its milder form, insidious supervention of croupal symptoms-in its severer forms, frequently associated with albuminuria-peculiar depression which attends it-note showing date and cause of death in 34 cases-evidence of its affinity to the class of blood diseases-paralytic symptoms which follow it.Relation between it and scarlatina examined-evidence on both sides of the question stated that in favour of their non-identity considered to preponderate. Treatment-local applications-constitutional measures-necessity for tonics and stimulants. Modified form of the disease-usually a complication of measles-its symptoms and

treatment.

LARYNGITIS STRIDULA, or croup with predominance of spasmodic symptoms-not a distinct disease, but results from constitutional peculiarity.-Illustrative case. Instances of spasmodic cough and affection of larynx, from irritation in lungs-intestines-brain.-Note on thymic asthma.

REFERENCE was made in the last lecture to a second form of disease, resembling croup in some respects, though differing in others, alike but not the same, and calling therefore for a separate notice. This other disease, Angina Maligna, Diphtheritis, or more correctly Diphtheria, is no new malady, but one which, though always prevalent, forces itself occasionally upon general notice by the formidable symptoms that sometimes attend it, by the rapidity with which it then runs its course, and by its selection of several victims from one town, one village, or one family. At such seasons it wears a character which seems so different from that which it assumes in its milder forms as to render it almost impossible to believe that the slight sore throat which caused only a trivial inconvenience, and hardly required any medical treatment, is one with the malignant disease, whose local symptoms are often cast

* Starr's unpretending account of the disease at Liskeard, a century ago, details all the most characteristic features of diphtheria: the false membrane on the fauces, its extension to the air-passages, its appearance on blistered surfaces and upon the skin behind the ears, leave scarcely a symptom wanting to prove the identity of the two affections. Those who wish to pursue the question will find all necessary information in Fuchs' Historische Untersuchungen über Angina Maligna, 8vo. Würzburg, 1826.