except a proposal made by M. Malgaigne* 
for reaching the larynx through it, which 
has not yet received the sanction of practice. 
2. Theangle,in which the ale of the thyroid car- 
tilage meet, having—under the quaint name of 
um Adami—its extreme prominence above. 
Within it are the essential organs of voice, 
which, buckler-like, it protects: the inward 
aspect of its angle attaches the vocal ligaments ; 
its outward jutting marks their length, and mea- 
sures the development of the larynx. Hence 
the pomum Adami, as indicating by its promi- 
mence that matured growth of the organs of 
_ voice, which belongs to male puberty, is a phy- 
_ siognomical character of sex. Desault’s mode 
of laryngotomy consists in a vertical division 
_ of this angle from below upward, and has the 
_ recommendations of easy performance and of 
efficiency for the extraction of a foreign body. 
That it invades parts of high functional endow- 
_ ment and extreme irritability, —that ossification 
of the cartilage may unexpectedly prevent its 
‘completion—that perfect reunion of the di- 
‘yided structure is uncertain—are alleged as 
objections to it, and perhaps over-estimated 
‘as such; for to the first may be answered, that 
‘the operation is of relief, and hence little 
ae to aggravate an irritation, the cause of 
a ich it removes; to the second may be con- 
ceeded, that the mode of operation is not eligible 
for cases likely to present the bony deposit 
referred to; and against the third may be ad- 
duced the evidence of the French surgeons, 
_ by whom chiefly the operation has been per- 
formed, that the parts are as quickly repaired, 
__ and their functions as completely recovered, as 
after any other mode of operative procedure. 
__ As regards its anatomy, nothing can be easier 
than to lay bare the pomum Adami; a division 
of the skin, of the superficial and proper fascie, 
with some lateral displacement of the sub-hyoid 
muscles, will suffice for its exposure: and, for 
its division,—the closest following of the me- 
dial line, in order that the knife may pass be- 
tween the vocal ligaments, leaving both unin- 
geet, is the chief precaution to be observed. 
The upper edge of the glottis is on a level just 
below that of the superior thyroid notch. The 
prominence of the thyroid cartilage and the 
unyielding support which the borders of its 
arched surface receive from the bony column 
behind it, render it liable to be crushed by any 
considerable, direct, antero-posterior violence. 
Such has, more than once, been the cause of 
immediate death where a straightforward blow 
hhas reached the larynx in prize-fighting ; and 
Such, too, isa not infrequent effect in death by 
hanging, especially where, as in the English 
Mode of judicial execution, the rope is made 
to tighten itself jerkingly. The thyroid carti- 
lage is sometimes partially divided in attempts 
at self-destruction, which it commonly frus- 
trates by defending more important parts. 
3. A depression which answers to the crico-thy- 
roid ligament: it is here that the usual opera- 
tion for urgent glottic dyspnea is performed. 
The common integuments and the fascial raphe 
—————————————— 
* Médecine Opératoire, 1840, p. 517. 
NECK. 
573 
cover the little interspace in question, which is 
safely reached—hetween the crico-thyroidei— 
by displacing in a slight extent \he sub-hyoid 
muscles. It has about half an inch of trans- 
verse breadth, and about a third of an inch of 
height,—is bounded by the inferior thyroid 
notch and by the anterior part of the circum- 
ference of the cricoid cartilage; which borders 
give attachment to the strong yellow elastic 
membrane that closes the space. This depres- 
sion is so readily felt through the integuments 
—its boundaries are so definite and its relations 
so simple, as to render it a peculiarly eligible 
spot for bronchotomy, when suddenly and ur- 
gently required. A small artery sometimes 
forms, with its fellow of the opposite side, a 
transverse communication across this mem- 
brane, and its presence has been much insisted 
on as a circumstance of practical importance : 
it is of extreme minuteness, and by no means 
constantly present : it is the erico-thyroid, and 
arises from the thyroid branch of the external 
carotid, near the upper angle of the thyroid 
body, and runs across the membrane toward 
the median line. The necessity for haste is 
commonly of too urgent a character to admit of 
any deliberate, layer-by-layer, dissective opera- 
tion : a single steady puncture with a canulated 
trocar, or with a bistoury—directly followed by a 
tube—is the usual mode of conducting it. In 
such instances the minute artery can hardly be 
avoided with certainty, but neither can its 
division be injurious, since the closely fitting 
canula will secure the cavity of the air-tube 
against its trifling hemorrhage. In the rarer 
cases, where time is allowed for a slower divi- 
sion of the tissues, it would be desirable not to 
puncture the membrane till the artery, if pre- 
sent, had been disposed of. It usually lies 
near to the border of the cricoid cartilage, and 
might easily be drawn downward away from 
injury; or its division might be rendered harm- 
less by torsion, or by a fine ligature. In the 
more extemporaneous mode of laryngotomy the 
bistoury should be guided flatly, close beneath 
the thyroid cartilage; in so making a transverse 
division of the membrane, it is parallel to the 
line of the artery, but above its usual position. 
4. The slight prominence of the cricoid car- 
tilage, and the series of tracheal rings—be- 
coming progressively deeper toward the ster- 
num,—are next felt. In some subjects their 
chain is seemingly interrupted by a transverse 
fleshy eminence (which, however, is in health 
generally imperceptible through the skin), 
the isthmus of the thyroid gland. To the la- 
teral portions of this body I shall presently 
return: the isthmus is its only part having re- 
lations in the median line, which it crosses to 
a very variable extent. Most frequently it 
measures about half an inch in breadth, and 
corresponds by its middle to the second ring 
of the trachea: but from this, its normal ex- 
tent may vary on the one hand to the ex- 
treme of entire absence—on the other to that 
of being an uncontracted, flattened union 
of the lateral lobes, which it may so equal in its 
vertical dimension. Downward from its lower 
edge, in front of the remaining rings of the 
