degree of obscurity in 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 premonitory signs, whereby we may even recognise its approach, is of the very clearest. We acknowledge, also, no failure in the means of treatment. I would gladly that the progress of science, in tracing the causes whence one of the most indispensable necessaries of life is often turned into an insidious bane, were as far advanced.

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 skill.

CLINICAL NOTES.

BY MARSHALL HALL, M.D., F.R.S., &o.

No. III. ON TRACHEOTONY, A NEW MODE OF OPENING THE TRACHEA.

THE difficulty in the operation of tracheotomy consists in the division of the tissues so as to denude the trachea. Arteries and veins are apt to be divided, and the operation is arrested or retarded by the necessity for tying those vessels.

It has occurred to me that these difficulties might be obviated; and to effect this object I would suggest the following procedure:

A ring is to be made of steel, one inch in internal diameter, one-sixth of an inch in width, and one-eighth in thickness. This ring is to be pierced in four opposite points, so as to receive four screws, admitting of being turned at their outer extremity by means of a little wheel, and nearly meeting at the centre of the ring. The central point of each of these screws is to be made to penetrate the circular eye of each of four needles, which are so arranged, being flattened 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 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 so as to act upon it. The instrument itself may be seen at Mr. Weiss's, 62, Strand.

A vertical incision being made through the skin, over the part of the trachea chosen for the operation, this point is made to pierce the subcutaneous tissues and the trachea; the four screws are then to be gently turned, one by one, at short intervals of time, so as by dis-traction to make the required opening into the trachea.

In all this procedure not a drop of blood has been lost, and no obstacle has been met with which would intimidate the most nervous operator.

The instrument, the tracheotone, having thus made the required opening into the trachea, my next object is to retain that orifice freely patent, also in the simplest manner, and by 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

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

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 distraction 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 removal 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 the neck and throat as possible during the operation, if this measure be deemed necessary.

The whole apparatus is so small that it might be packed in a large walnut-shell. It must be inexpensive, and it ought to be possessed by every surgeon. To show the importance of this matter, I will, in the next LANCET, enumerate the series of cases in which it may be required.

The operation itself may be rendered so simple as scarcely to exceed, in difficulty or danger, that of opening a vein or artery.

A slight gauze cravat may be worn loosely over the cage, in situ; the projecting part of this will secure the orifice against any obstruction. In addition to all this, a conical stopper might be contrived, so as to admit of being introduced into the external orifice of the wire cage, and to enable the patient to speak.

Are there not also other cases in which the principle of the tracheotone might be used?-as an explorer (?)—in dangerous abscess, empyema, ascites ?-even calculus?

I may add that the term tracheotone is compounded of the Greek word revw, as the term tracheotome is of the word reuve.

The great desiderata in the mere operation of opening the trachea, are safety and promptitude. I have sometimes trembled to think of the possibility of wounding a large artery or vein, somewhat anomalous in its size and erratic in its course, and seated deeply, near the highest part of the sternum. I have still more frequently experienced a similar feeling when I have thought of the necessity, in some urgent cases, for an instantaneous opening into the trachea. This is the occasion for citing that oft-cited passage

"" horse

Momento aut cita mors venit, aut victoria læta."-HOR. Sat. I. This consideration, and that of the extensive series of cases in which I believe tracheotomy may be required, have led me to think much of the means of rendering this operation more simply, safely, and promptly practicable, and therefore more 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

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prepared myself 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 readiness in every surgery, and indeed in every consulting-room.

By W. S. SAVORY,

TUTOR AT ST. BARTHOLOMEW'S HOSPITAL, ETC.

THE following paper contains the results of various observations on the 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 auriculo-ventricular 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 horizontally.* 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, ox, sheep, &c.; otherwise the relative position of the four orifices corresponds very exactly with the arrangement above described. Although at the first glance the aorta and pulmonary artery 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, we at 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 of the heart with great facility, and the grooves in which the

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 shall find (provided the heart has been sufficiently boiled) that very obvious reason. If we now proceed to the arteries, we these vessels and their valves, together with the whole of the muscular fibres, the inner lining membrane of the ventricles only tendinous structures connected with them, will separate from the 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 close connexion that subsists between the base of the anterior wall of the left one, and the posterior surface of the commence

ment of the aorta.

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 is seen that while the auriculo-ventricular, as well as the arterial apertures, 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

The terms left and right, &c., apply to the heart.

nected with the construction and functions of some of the valves. It may now be plainly observed that the fibres forming the walls of the ventricles converge around the rings. We can easily trace them up from the walls of the ventricles, curving obliquely Over the convex border, and having their extremities fixed around the orifices. We may remove them layer after layer, and still find the same arrangement to obtain; the deeper layers lying more transversely, and obliquely intersecting those above and below. It is unnecessary now to enter more at length into the arrangement of these fibres, and perhaps enough has been said with regard to the formation of these thick and convex borders. A vertical section through some portion of the circumference of one of the apertures (through the aorta or left auriculo-ventricular) will convey the best idea of the shape and thickness of these borders, both of which vary considerably at different parts, the outer and inner walls being in some situations, as around the aortic orifice, (Fig. 2,) almost equally convex, while around the auriculo-ventricular apertures, especially the left, (figs. 8 & 9,) the outer wall forms almost the entire convexity, the direction of the inner being nearly straight.

The tendinous circles (fibrous zones, framework of the heart, &c.) surrounding the orifices are generally described as "firm rings;" structures quite distinct from, although closely connected with, the surrounding parts, which, besides serving as points of attachment to the base of the tricuspid and mitral valves, afford origin and insertion to all the fibres of the auricles and ventricles. Beyond the thickened and attached bases of the auriculo-ventricular valves, there does not exist, around the entire circumference of the rings, a sufficient quantity of fibrous structure to justify the descriptions and terms applied, or the uses ascribed to it. After removing the auricles as before described, there remain delicate fibrous rings surrounding the margins of the auriculo-ventricular apertures, and closely connected with the muscular fibres of the ventricles, denser and more plainly marked on the left side. In the anterior half of the border of the ventricular septum, a considerable portion of dense fibrous tissue is found closely connected at its anterior extremity with the adjacent posterior portion of the commencement of the aorta, and causing the difficulty in its separation, as also of the auricles at this part before noticed. Spreading out posteriorly between the ventricles, but especially curving round to the posterior portion of the left auriculoventricular ring, this fibrous band adds considerably to its thickness. In structure it possesses all the characters of the densest fibrous tissue. On the opposite side also, a thin but dense portion of fibrous tissue extends from the aorta round the left margin of the ring. More delicate processes of the same structure are generally connected with the aorta, and extend into the muscular substance of the ventricle between the pulmonary artery and left auriculo-ventricular orifice. In separating the vessels, however, from the ventricles, we find that with them we can remove all fibrous structure, leaving an edge of muscular tissue.

Of the three pulmonary valves, one is posterior, one forwards and to the right, and one forwards and to the left. Of the three aortic valves, one is opposite the ventricular septum, one to the left, and one anterior, inclining to the right, and corresponding to the muscular substance of the ventricle between the pulmonary and right auriculo-ventricular apertures. Of the tricuspid valves, one corresponds to the ventricular septum, one lies to the right, and the other forwards and to the left. Lastly, of the two mitral valves, one is anterior and somewhat to the right, the other posterior and to the left. The three semilunar valves of each artery are of tolerably uniform size; this, however, is by no means the case with the auriculo-ventricular valves. The posterior mitral valve is smaller and thinner than the anterior, and is more or less deeply cleft in its centre; the division in some cases extends almost to the base, and this valve then consists of two segments. Of the tricuspid valves, the anterior is generally the largest, and the right the smallest segment. The form and arrangement of these valves have been frequently described, and the smaller portions also which are found between the principal segments. Indeed, towards their attached border the valves are continued into each other, so as to form an uninterrupted membranous ring.

Notwithstanding the time and attention which have been bestowed in investigating the structure of the valves of the heart, one very important means of obtaining a clear insight into their construction appears to have been entirely unheeded or overlooked-viz. the plan of making vertical sections through various parts of the four rings. I do not remember to have seen a preparation, or even a representation of such a section made with a view to exhibit their structure. Dr. Reid* has given a detailed description of the valves, and has illustrated his remarks by many diagrams, and yet no representation of, or even refer

* Cyclopædia of Anatomy and Physiology, art. "Heart."

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ence to, a vertical section is given; and this seems the more remarkable, as such drawings would illustrate at a glance many points which can scarcely be rendered clear by the most graphic description.

In a heart from the base of which the fat, cellular tissue, and coronary vessels have been carefully and completely removed, the walls of the auricles are observed to pass down on to the inner surface of the ventricular borders surrounding the orifices, so that the greater portion of their breadth projects externally beyond the outer wall of the auricles, (especially on the left side, where the border is much thicker;) and thus is the deep groove formed in which the coronary vessels of the heart are lodged. (Figs. 8 & 9.) The gradual increase in the size of the arteries towards their termination, the three pouch-like dilatations corresponding to the situation of the valves, and to the sinuses of Valsalva, and the great diminution in the thickness of the arterial coats behind the valves, commencing rather abruptly opposite their upper margin, may now be plainly seen; but as all these characters have been frequently described, it is unnecessary now to dwell upon them. They are all more strongly marked in the aorta. The outline of the arterial tendinous rings may also be observed. These rings, which are plainly seen when the arteries are laid open, are generally described as "formed by a fibrous band or zone, one edge of which is even, and gives attachment to the muscular fasciculi of the ventricle, whilst the other is scalloped into three deep semilunar notches, and is firmly fixed to the middle coat of the large artery. The semilunar margins of the notches just mentioned are much thicker and stronger than the rest of the tissue; and from the small depth of the tendinous zones, the notches descend nearly through to its ventricular edge, almost reaching the muscular substance, which, indeed, is attached to the middle of the stout, tendinous, semilunar margins. The middle coat of the artery presents a festooned border, divided into three convex, semicircular segments, which are received into, and attached to, the corresponding notches of the tendinous ring."* Dr. Reidt has given a detailed account of these festooned rings, and describes their appearance differently. He is disposed to regard them as distinct and independent structures, closely indeed connected with, but separable from, the surrounding parts. He says: "Each of these arterial rings appears as if composed of three semilunar portions, placed on the same plane, the convexities of which are turned towards the ventricle, and the concavity towards the vessels. Each of these semilunar portions has its projecting extremities intimately blended at their termination with the corresponding projecting extremities of those next to it, so that the three form a complete circle, with three triangular portions projecting from its upper edge. The semilunar portions approach fibro-cartilage in their structure, and have the intervals left between their convex edges filled with a texture more decidedly fibrous, and which is considerably weaker than the semilunar portions, more particularly on the left side of the heart." repeated observation, it appears to me that what has been described as the upper and thickened festooned border is the result of the attachment of the bases of the valves to the arterial coat, and is formed by an intimate union of the fibrous tissue composing the valves with the elastic coat of the artery. 1. These festooned bodies correspond exactly with the attached bases of the valves, and hence their shape. 2. They are thickest and most strongly marked at the angle formed by the junction of two valves, to which points the bands of fibrous tissue in the valves converge. 3. The microscope shows these festooned rings to be composed of a mixture of the white fibrous with the yellow elastic tissue-an arrangement naturally to be expected from an intimate union of the tendinous tissue of the valve with the arterial coat. The proper tissue of the arterial walls terminates indeed in these festooned rings, below which it is not found. The muscular fibres of the ventricles are attached to the lowest portion of their convexity, and extend upwards for a short distance into the intervals left between the convex margins of the festoons; thus presenting an undulating border around the base of the vessels, while the upper portion of the space forming the apex of the angle between two valves, which is destitute of muscular fibres, is occupied by a thin layer of white fibrous tissue, containing some few yellow elastic fibres scattered irregularly through it.

From

If we now make a section through the anterior aortic valve, the view represented in figure 2§ is obtained. The aorta and pulmonary artery, (Figs. 2 and 3,) expanding towards their termination, are situated upon the outer edge of the ventricular Quain and Sharpey's Anatomy and Physiology, p. 1118.

↑ Cyclopædia of Anatomy and Physiology, art. "Heart." Op. cit., vol. ii. p. 588.

These sketches are purposely made somewhat diagramically, in order to show more clearly the relations of parts.

422

FIG. 2.

FIG. 3.

of the anterior aortic valve is especially broad, and is formed by the anterior extremity of the upper border of the septum of the ventricles; and it is the corresponding portion of the aorta which is especially dilated; the posterior wall descending nearly verti cally. The contrast is well shown in an antero-posterior vertical section of the vessel. This arrangement obtains in all three pulmonary valves, but as the walls of the right ventricle are considerably thinner than those of the left, the muscular floor of these valves is much narrower than in the anterior aortic valve. All this is of course much more plainly seen in the hearts of the larger animals, as the horse and ox; and here, where the muscalar floor of the valves, more especially the anterior aortic, is of very considerable breadth, the tendinous tissue of the valve may be traced over the muscular surface to join the wall of the vessel.

(To be concluded.)

. Section of arterial coat. 2. Section of valve. 3. Section of ventricle. border before described; the consequence of which arrangement is, that the portion of valve adjacent to the vessel passes over, and rests upon the muscular substance-is supported upon the inner border of the free edge of the ventricles surrounding the arterial orifices. This arrangement, in consequence of the small size of the parts, is not so obvious at the first glance in the human heart, but can scarcely be overlooked in an examination of the heart of any one of the larger animals. Figures 4 and 5 are ac

curate sketches from preparations in the Museum of St. Bartholomew's Hospital, exhibiting vertical sections of the anterior aortic and pulmonary valves of the ox. Any doubt as to the nature of this disposition of parts in the human heart, is at once removed by an examination of the same parts on a larger scale. This arrangement appears of importance when viewed in connexion with the functions of the valves. Dr. Reid describes the reflux as sustained in part by the festooned rings at the base of the valves, but in fact they are thinnest at this very part, corresponding to the central portion of the convexity of the valve; and if the description previously given of the formation of the tendinous festooned rings be a correct one, it is obvious why it is so-the thicker portions being the projecting angle at the junction of two valves, to which points the tendinous fibres of the valves converge. Probably this arrangement will be better understood from the accompanying sketches than from any lengthened verbal description. Now, inasmuch as the posterior portion of the aortic orifice is continuous with the left auriculo-ventricular ring, no muscular tissue of the ventricle existing in this part, the posterior aortic valve and a portion of the adjacent one have no support of this kind, and here, indeed, "the force of the reflux is (entirely) sustained by the stouter and more tendinous part of the arterial valve;"+ but the muscular floor

Cyclopædia of Anatomy and Physiology, art. "Heart."

+ A. Retzius. Müller's Archiv.: Mr. Paget's Reports, 1843, p. 14.

ST. BARTHOLOMEW'S, GUY'S, AND ST. THOMAS'S HOSPITALS.

Cases of Gonorrhoea treated by M. Jozeau's Copahine-Mège; a
Peculiar Mode of Administering Copaiba.

(Under the care of Mr. LLOYD, Mr. POLAND, and
Mr. LEGROS CLARK.)

OUR readers have probably observed that we carefully put upon record the trials which are made in the hospitals of this metropolis, of the new therapeutical agents which are from time to time offered to the profession. Among these we may mention the sumbul, which was first used at King's College Hospital (THE LANCET, vol. i. 1850, p. 63). This root was recommended in cases of epilepsy and spasmodic diseases, and gave at first some satisfaction; but it has not kept its ground, and is, as far as nosocomial practice is concerned, put upon the shelf. It was in our columns that the wonderful effects obtained by kousso at King's College Hospital, were first mentioned, (THE LANCET vol. i. 1850, pp. 339, 483.) As to this remedy, we are happy to say that it still continues to do much good, and that it may be procured at a much lower price than at the period when our reports were first published. It should not, however, be concealed that the head is not always expelled together with the rest of the tape-worm, and that relapses have occurred, (THE LANCET, vol. ii. 1851, p. 270.) Nor should it be passed under silence that the oil of male fern has been found extremely efficacious in procuring the expulsion of the tænia solium, (THE LANCET, vol. ii., 1850, p. 676). We likewise have mentioned experiments which were instituted with Warburg's tincture for ague (THE LANCET, vol. i. 1851, p. 430,) the weak point in this remedy being the mystery which surrounds its composition. Another remedial agent has lately been tried at Guy's Hospital-viz. the fruit of the Bengal quince, or Bael, which is said to be of some value in dysentery. The experiments have not, however, been sufficiently numerous to allow of a conclusion; we shall revert to it, as well as to the good effects of sulphuric acid in diarrhea, which have been largely recorded from private practice, and which we saw principally used at King's College Hospital.

In the surgical department, we have been careful in noting the new mechanical contrivances which are being introduced: among these was Mr. Luke's elastic bed (THE LANCET, vol. i. 1850, p. 154); Mr. Thomas Wakley's new stricture instruments, (THE LANCET, vol. i. 1851, p. 178); Mr. John Wood's improved splint for fracture of the femur (THE LANCET, vol. ii. 1850, p. 578); Mr. Bourjeaurd's new belts for hernia, (THE LANCET, vol. ii. 1851, p. 33, and vol. i., 1852, p. 43). M. Boissonneau's artificial eyes, (THE LANCET, vol. ii., 1851, p. 130); Mr. Hilton's speculum ani, (THE LANCET, vol. i. 1850, p. 533); Mr. Clark's