TRACHEOTOMY. 



lermined to make an opening in the trachea, below the wound, 

 oppofitc the upper part of the larynx. The refpiration was 

 immediately eftablidied again, and the wound was kept open 

 with a grooved tent, until the tumefaftion of the larynx 

 was diminiihed. The cure was complete in three months. 

 M. Louis was of opinion, that, in thefe two cafes, the can- 

 nulse only ferved to keep the lips of the wound in the fkin 

 apart, becaufe, in the firft, the thyroid cartilage was broken 

 fo extenfively, that it could hardly be fuppofed to form an ob- 

 ilacle to the pafTage of the air ; and becaufe, in the fecond, the 

 wound of the trachea had allowed the air to enter and come 

 out again with eafe, without the affiftance of any tube. 



We find in Habicot's eflay a third inftance in which tra- 

 cheotomy was fuccefsfuUy performed. " A lad, fourteen 

 years of age, who had heard that gold, when fwallowed, 

 did no harm, having fold fome merchandize at Paris, for 

 which he had received about nine piftoles, wrapped them 

 up in a piece of cloth and fwallowed them, for fear of being 

 robbed. But as they could not pafs through the narrow 

 part of the pharynx or osfophagus, his face became fo fright- 

 ful and deformed with fwelling and blacknefs, that his com- 

 panions could not recoUeft him. Hence, having caufed him 

 to be brought to my houfe, and not being able to make 

 him void, nor get the obftacle into his ftomach, fo clofely 

 was it fixed by the fwelling of the throat ; and confidering 

 that he would be fuffocated, I firft made a favourable prog- 

 nofis, and then performed bronchotomy, which being finifhed, 

 he revived fo rapidly from the violence of the air, that the 

 byeftanders were alarmed ; but the tumour and unfavourable 

 colour of the face having difappeared, I affured them that 

 he would recover," &c. The foreign bodies were then 

 pufhed down into the ftomach with a leaden probe, and 

 thefe were difcharged about a week afterwards at different 

 times with the ftools. As the patient was fo promptly re- 

 lieved, probably Habicot never thought of keeping the 

 wound open with a cannula, but endeavoured to heal it as 

 expeditioufly as poffible. In the two other cafes, he em- 

 ployed this inftrument, which he has defcribed in the laft 

 chapter of his treatife. 



Since Habicot, and before the end of the feventeenth cen- 

 tury, the teftimonies to be found in favour of tracheotomy 

 are very numerous ; but no one did any thing to perfeft the 

 operation until Decker, who, in 1675, proposed to praftife it 

 with a fmall trocar, armed with a cannula. The method is 

 more fimple, more eafy, and fubjeft, as fome have conceived, 

 to fewer inconveniences, if the trachea be not pierced until 

 this tube is expofed by an incifion made in the anterior and 

 inferior part of the neck, betwixt the mufcles deftined to de- 

 prefs the os hyoides and larynx. Paulus, in his notes on 

 Van Hornc, imputes the preceding method to Sanftorins, 

 who recommends the trachea to be pierced in the operation 

 of tracheotomy, with the fame inftrument which he had 

 invented for the paracentefis of the abdomen. By this 

 means the trachea is opened, and the cannula placed, at the 

 fame time, a circumftance which prevents the bleeding, which 

 might otherwife efcape from the edges of the wound, and 

 occafion an inconvenient and perhaps fatal cough. Dionis, 

 who only propofes bronchotomy in the cafe of inflammatory 

 quinfey, thinks that it may be done in a more expeditious 

 manner, with lefs pain, and in a way more calculated to 

 procure a fpeedy cure, than the mode which was previoufly 

 in ufe. This plan confifts in performing the operation by 

 «ne punfture, fo that the lancet at once opens the integu- 

 ments and the interfpace of the cartilages of the trachea, 

 and the inftrument is not withdrawn before the introduftion 

 of the probe, which is to ferve as a conduftor for the can- 

 nula. The advantages which Dionis afcribes to this method 

 Vol. XXXVI. 



would merit the greateft attention, were they not counter- 

 balanced by the inconveniences which refult from it. There 

 are not many fubjefts, whofe necks are fo entirely deftitute 

 of fat, that the interfpace of the rings of the trachea can 

 be felt. This tube, whofe figure is cylindrical, eafily flips 

 under the fingers, and the change of pofition may render 

 Dionis's manner of operating extremely difficult. The 

 operation is not without danger of wounding the pofterior 

 parietes of the trachea, becaufe one cannot penetrate into 

 its cavity, through the thicknefs of the integuments 

 and cellular fubftance, without ufing a degree of force 

 which it is difficult to regulate with precifion. Laftly, 

 when the cannula is put into the wind-pipe, this canal rifes, 

 and defcends fo confiderably in various circumftances, and 

 efpecially in the aftion of deglutition, that the inftrument 

 muft be hable to flip out of it. Verduc, before Dionis, 

 had made fome remarks on the pofture of the patient during 

 the operation. His head was extended back, and the inte- 

 guments were pinched up into a tranfverfe fold before 

 being divided. Verduc obferved, that by inclining the 

 head back, the difficulty of breathing would probably be 

 increafed, and that when this pofition was adopted, the in- 

 teguments of the neck could not eafily be pinched up into 

 a fold. For fuch reafons, he thinks that pofture beft, in 

 which the patient breathes with moft freedom. 



Tracheotomy had been praftifed only with a view of re^ 

 lieving the fuffocation arifing from the quinfey, and that 

 which is produced by the prefTure of a foreign body in the 

 oefophagus upon the trachea. Detharding, profefFor of 

 medicine at Roftock, pubhfhed in 17 14 a differtation, en- 

 titled " De Methodo fubveniendi fubmerfis per Laryngoto- 

 mium ;" the objeft of which was to prove, that this oper- 

 ation is necefTary in order to reftore drowned perfons. The 

 principle with which he fets out is, that drowned perfons 

 cannot breathe when taken out of the water, becaufe the 

 epiglottis is in contaft with the glottis, and clofes this open- 

 ing fo clofely, as to leave no pafTage at all for the air. 

 But fome obfervations, carefully drawn up by M. Louis, 

 have proved that the glottis is open and free in drowned 

 perfons, as well as in perfons who have perifhed of any 

 other kind of death, and that their death is caufed by 

 the water which they have forcibly infpired, and which 

 mixing with the air and mucus with which the bronchise and 

 bronchial cells are naturally filled, obftrufts and blocks up 

 thefe organs, fo that the air can no longer enter them. 

 But if Detharding has been miftaken upon this point, he 

 has not been deceived in regard to the advantages of trache- 

 otomy in every other circumftance, and the little rifk there 

 is in praftifing it. He ftates, that the integuments, and 

 the membrane which unites the rings of the trachea, being 

 the only parts which ought to be cut, no vefFels nor nerves 

 of importance need be wounded. 



Though there are no nerves of confiderable fize in the 

 track which the incifion muft neceffarily follow, the fame 

 obfervation cannot be made in refpeft to the blood-velTels. 

 The thyroid gland fends down, to the left fubclavian, veins 

 which, after having ramified on its anterior furface, unite 

 into two trunks, the left of which moft commonly paffes in 

 front of the trachea, at the lower part of the interfpace, 

 which lies between the fterno-hyodei mufcles. In the 

 greater number of fubjeiEls, thefe trunks only form one at the 

 place of their infertion. Sometimes they continue feparate. 

 Sometimes, alfo, one of them terminates in the left fubcla- 

 vian vein, and the other in the right. The left may be 

 injured in dividing the cellular fubftance which covers the 

 trachea. This canal itfelf has likewife its own veffcls, 

 which may be cut, and bleed a good deal. This was 



N wh;(t 



