instrument, as so arranged, were several. In the first place, if the rubber bag was over-distended, which might easily happen, it might burst, or could force its way down so as to close the lower end of the tube. This latter accident occurred to me in one case, and gave considerable trouble. The tracheas of some patients do not bear well the lateral pressure of the bag, violent cough being induced when it is distended. This I have also seen occur. To remedy the first objection, as well as to get rid of the outer bulb, and to obtain greater nicety in filling the trachea, Dr. Friedrich Lange devised the instrument of which I have a model here. Dr. Lange has already shown this instrument to the Society. It seems to me to fulfil the indications for either temporarily or permanently tamponing the trachea better than any which I have seen.

Michael, of Hamburg, surrounds the cannula with compressed sponge. Over the cannula and sponge he places a sac of gold-beater's skin soaked in a solution of rubber. A little water having been thrown into this sac, the sponge swells and effectually closes the lumen of the trachea.

Dr. Foulis, of Glasgow, in extirpating the larynx, tamponed the upper end of the divided trachea with a lead cannula, which was surrounded with a rubber ring, thus completely closing the air tube and effectually preventing the passage of blood into it. Dr. Lange recommends. in similar cases a leaden cannula surrounded with punk, which material is light, and does not allow of the passage of fluids through it. These cases, however, hardly come under the head of preliminary tracheotomy the tamponing of the trachea being necessarily done in the course of the operation.

The objects of the preliminary operation are several. Firstly, to prevent the passage of blood down the trachea. Secondly, to facilitate the continuous and safe administration of the anæsthetic. Thirdly, to avoid the possibility of being called upon in the course of the operation to open the windpipe under forced and adverse circumstances. Fourthly, to permit of a continuous, rapid, and complete operative procedure, and thus avoid much unnecessary loss of blood. Fifthly, to secure to the patient after the operation an abundant supply of air which is not contaminated by the discharge from the seat of operation.

The prevention of the passage of blood down the trachea is a danger which always threatens in bloody operations about the upper air passages, and enough fatalities have occurred from this cause to make it worthy of consideration, death having been produced on the operating table, and pneumonia having been induced in other cases from the entrance of blood into the air cells. The unnoticed loss of blood is, I am sure, in some cases very great when the operator depends upon sponging out the

pharynx during the operation, blood passing down the trachea, and more especially down the oesophagus, in large quantities. When the trachea is tamponed so as to permit of a continuous administration of the anæsthetic through the cannula, this loss of blood can be largely avoided, for continuous pressure can be kept up upon bleeding points during the course of a long operation, which, of course, can not be done when the anæsthetic is being repeatedly administered through the mouth and

nose.

The continuous and safe administration of the anesthetic has also the great advantage of not only saving time in operating, and hence some exhaustion to the patient, but permits the operator to deliberately carry out his dissection. In cases of malignant disease, as of the upper jaw, tongue, and pharynx, I am sure that complete extirpation of the disease is far more likely to be attained when the tracheal tube is used than when it is not. Of course, a less rapid recurrence of the disease would then be expected.

The advantages claimed for this preliminary operation can be obtained in a manner somewhat different from, and, in my opinion, better than, that proposed by Trendelenburg. Instead of the long and heavy tube used by Trendelenburg, one very like an ordinary tracheal tube may be used, into the outer end of which the tube to conduct the anesthetic from the reservoir can then be fitted. It is not necessary to tampon the trachea itself, but this can be very efficiently done by packing the lower part of the pharynx with a sufficiently large sponge, to which a string is attached to facilitate its removal. Kocher recommends this plan, but I first saw this method made use of by Dr. George Peters, and I have seen it used by others, and have used it myself with complete success. It is not perfect, however, for sponge, no matter how tightly packed, will permit of the passage of fluid. I would suggest, as an improvement on the ordinary sponge packing, a sponge about half covered with thin rubber. The rubber side being pushed down and covering the whole lower surface of the sponge, would prevent any drainage through.

There are some questions in regard to this preliminary operation which I am not able to satisfactorily answer to myself:

Firstly, is there any advantage gained by doing the tracheotomy some time in advance of the primary operation? Max Schuller, in his "Monograph on Extirpation of the Larynx," recommends that the tracheotomy be done some weeks in advance, and claims that by so doing the risks of subsequent pneumonia and bronchitis are lessened. Out of fifteen cases of extirpation of the larynx which Schuller collected, five died of pneumonia, and one suffered from severe bronchitis. But I am

not able to satisfy myself that any real advantage would be gained by

doing the tracheotomy a long time beforehand, except in cases where the difficulty of breathing through the natural passages caused great impairment of health.

In answer to another question, I think a more positive reply can be made.

How long shall the tube be left in position after the operation?

It should, of course, be left in all cases where there is reason to fear that the upper orifice of the larynx may become occluded by inflammatory swelling. But another reason for retaining the tube in position is to enable the patient to obtain a supply of pure air during the suppurative stage. Kocher not only keeps the tracheal tube in, but also the sponge tampon in the pharynx, the sponge being soaked in a five-per cent. solution of carbolic acid, and removed only to allow the patient to be fed. This method also enables the surgeon to treat the wound nearly antiseptically, the nostrils being plugged, the mouth closed, though drained with a tube, and frequent washings of the whole cavity being resorted to. I am inclined to think that the comfort and safety of the patient would be increased by following this method in all extensive operations. Michael, Schuller, and others also claim that by keeping up for some time this permanent closure of the larynx, patients are much less likely to suffer from Schluckpneumonie, or foreign-body pneumonia. I have myself made use of a preliminary tracheotomy but three times. In one of these the Trendelenburg apparatus gave me great trouble, in consequence of the extreme elasticity of the rubber bag which folded over the end of the cannula when it was distended. In the other two cases for removal of naso-pharyngeal polypi, I made use of a simple cannula, and plugged the lower part of the pharynx with sponge. This method gave me great satisfaction.

Dr. Post said he had performed preliminary tracheotomy three times; twice upon the same subject after a long interval. In two out of the three times the operation was performed without the introduction of the tube, according to the method of Dr. Martin, of Boston, which he had found very satisfactory. He introduced a large sponge into the fauces, and only a few drops of blood escaped into the trachea. With the open trachea he found it very easy to sponge out whatever blood might enter. He had found great facility in performing tracheotomy as a preliminary operation, and believed that all the advantages which Dr. McBurney had attributed to the operation were derived from it, and that there was no additional risk from performing it.

Dr. G. A. Peters had performed preliminary tracheotomy three times. In one case he had used Trendelenburg's tube. Having seen the difficulties which Dr. McBurney had mentioned concerning the use

of this tube, Dr. Peters had had the instrument modified, and supposed that he had got rid of the danger, but he then found that another troublesome symptom resulted, namely, a persistent coughing the moment the bag was distended, although he had taken pains to measure the exact amount of air which was necessary to distend the bag up to a certain point. After that he threw Trendelenburg's tube aside entirely, and had since used only an ordinary tracheal tube, stuffing the fauces with sponge. This method had given him much satisfaction. The anesthetic could be administered without interruption, and he had had no trouble from blood running into the stomach or trachea. In one of the cases where he used Trendelenburg's tube the patient had a cough which lasted for some time, but he attributed it rather to pressure from the instrument than to entrance of blood into the lungs. He had, however, concluded that the most satisfactory method was to use the ordinary tracheal tube and stuff the fauces with sponge.

Dr. Gerster had performed preliminary tracheotomy once, and in a case previous to exsection of half of the larynx. In that instance he used Trendelenburg's instrument, and just after the operation had been commenced the India-rubber bag ruptured. He was obliged to remove the cannula and replace the bag by folds of gauze bound in position by silk. The cannula was then reintroduced, and answered the purpose very well. With regard to one object mentioned by Dr. McBurney concerning tracheotomy as a preliminary operation, his own opinion was that preliminary tracheotomy, performed a good while before the secondary operation, afforded many advantages over its performance simultaneously with the operation for the removal of the disease. He recalled several instances where he had been present and in which considerable time was consumed in performing the preliminary operation; thus, in one instance, half an hour was occupied, and it could readily be seen that in an anæmic patient the performance of the preliminary operation would necessitate the longer continuance of the anesthetic, and therefore, an undesirable exposure to shock. Tracheotomy upon a grown subject was rather an indifferent operation if properly performed and the necessary care was bestowed upon the after-treatment, The operation was not very serious, and the patient's respiratory tract became accustomed to the tube, and he believed it to be advantageous to first dispose of this liability to accident before the operation power was to be performed.

Dr. W. T. Bull had had occasion to perform tracheotomy as a preliminary operation in four cases; three times for extirpation of a portion of the tongue, and once for removal of a recurrent growth from one side of the pharynx. In all instances he had used the ordinary tracheotomy

tube. He had not seen any advantage following the use of the tube with the rubber bag. On the contrary, he had thought that it interfered with expulsion of mucus from the trachea. He had not left the tube in more than forty-eight hours. He regarded the suggestion made by Dr. McBurney with reference to permanent tamponing the trachea after the operation as a very valuable one, and as an important addition in the after-treatment

Dr Briddon remarked that he had been prejudiced against Trendelenburg's tube, and had simply used an ordinary tracheal tube, packing the fauces with sponge. The operations which he had performed, however, had always been laryngotomies. He thought it unnecessary to make the operation for the introduction of the instrument a tedious one. He believed there was no danger from hæmorrhage, which always ceased after the introduction of the tube. He had been favorably impressed with Nussbaum's method of narcosis in these cases; that is, to precede the anaesthetic by the use of a large hypodermic injection of morphine, perhaps fifteen drops of Magendie's solution. This is to be followed by the use of an anaesthetic, and he had employed chloroform, administering it to the production of moderate narcosis, and then performing tracheotomy. He had been surprised at the small quantity of chloroform required to maintain insensibility. In one operation not more than three drachms and a half were consumed, and the patient was able to assist at the operation, was sufficiently conscious to be able to empty the mouth of blood, etc, and yet he was placed beyond sensitiveness to the knife. He had not seen Trendelenburg's tube used without the occurrence of some disagreeable accident.

Dr. Weir had performed preliminary tracheotomy in one case with advantage, using only the ordinary tracheal tube, packing the fauces with sponge, and maintaining anesthesia through the mouth of the tube. He was led to adopt this method because of having previously resorted to Rose's method in the removal of a naso-pharyngeal growth. It was found that the stretching of the neck unduly compressed the trachea and interferred with respiration. In the second case, of a similar nature, the use of tracheotomy permitted more satisfactorily the dependent position of the head. He was, however, loth to adopt preliminary tracheotomy, as a rule, because he believed the operation was associated with considerable risk in itself. He had been led to this conclusion from studying the case in which the operation had been performed for the relief of syphilitic diseases of the larynx without much dyspnoea, and for rest of that organ. In two such cases pneumonia had occurred. He had also seen several instances of cut throat where only the trachea had been incised, and where the patient's condition was good, and subsequently