TRACHEOTOMY. 



what happened in a cafe iofeited by Hevin, in his memoir 

 on foreign bodies lodged in the cefophagus and trachea, 

 in the fiurll volume of the Memoires de I'Acad. de Chi- 

 rurgie. A Spanilh foldier, twenty-three years of age, was 

 nearly dying of fuffocation from quinfey. Tracheotomy 

 was deemed the only means by which his life could be 

 faved. The wind-pipe having been expofed by a longitu- 

 dinal incifion, ao opening was made between two of its car- 

 tilaginous rings ; but the patient derived no benefit from it, 

 becaufe the blood entered it, and occafioned a convullive 

 coagh, which hindered the cannula from keeping in its place. 

 The cafe appeared fo urgent, that M. Virgili determined to 

 divide the trachea longitudinally down to the fixth ring ; 

 and he then made the patient lean forward. The blood 

 foon ceafed, and the furgeon was enabled to place in the 

 wound a plate of lead, pierced with feveral holes, and 

 provided with two ihoulders, verv much hke what Bellofte 

 employed in the treatment of the wound after trepanning. 

 The nest day the fever was diminilhed, and deglutition 

 eafier. M. Virgili fufpecied that the patient would be 

 able to breathe without the aflulance of the plate, and he 

 therefore removed it. His hopes were not deceived. The 

 only thir^ which remained to be done, was to bring the 

 edges of the wound together, and endeavour to heal it, 

 which was accompliihed in a few days. 



Garengeot ftates, that in feparating the ftemo-thyroidei 

 mufcles, the thyroid glands are feparated, a circumftance 

 which produces a rifle of cutting them in the centre, and of 

 wcjning a great many of the vefTels which are either 

 diftributed upon them or the adjacent parts, fo that the 

 blood running into the trachea, the operation muft be ufe- 

 lefs. He allows that it is neceffary to operate thus upon 

 perfons who are inclined to be fat ; but in order to avoid 

 fo great an inconvenience, when the patients are thin, and 

 the interfpace betwixt the third and fourth ring of the tra- 

 chea has been felt with the index-finger of the left hand, 

 and the place marked, Garenge<^ recommends introducing 

 3 lancet into the trachea at once, before the finger has been 

 removed. The lancet is then to be moved gently towards 

 each fide, fo as to enlarge the opening. A flat tube is 

 afterwards to be introduced, the fides of which are fumilhed 

 with narrow ribbands. In this manner, the veffels of the 

 trachea are alone cut, and thefe are fmall and of no con- 

 fequence, fo that there is lefs danger of blood falling into 

 the wind-pipe : Garengeot adds, that tracheotomy was in 

 his days accounted a dangerous operation, and that there 

 were few v.-ho had praciiled it, or who mentioned their 

 having done it with fuccefs. This want of fuccefs ap- 

 peared to him to be lefs afcribable to the operation itfelf, 

 than to its having been undertaken too late. Such was 

 alfo the fentiment of M. Louis, who infills upon the necef- 

 fity of having recourfe to it as foon as the fuffocation ap- 

 pears at all urgent, fo as to prevent the effufions in the 

 lungs and brain, always brought on by an extreme difficulty 

 of refpiration. 



Garengeot's method was not original, fince it had been 

 defcribed by Dionis. It has alfo fome refemblance to 

 Dccker^s mode of operating, which cordiiled in opening 

 the trachea through the integuments, without espofing this 

 canal by a longitudinal incifion, in the ufual way. Sharp 

 records a cafe, which confirms the inconveniences which 

 have been attributed to it. A patient, who was in great 

 danger of dying fuffocated, was operated upon in the pre- 

 ceding manner. The mo-ion of the wind-pipe in refpiration 

 foon feparated the opening in the trachea from that in the 

 fldn, and occafioned the utmofk difficulty in introducing the 

 cannula, and keeping it in its place. Sharp rightly infejs 



10 



firom this hSt, that it is abfolutely neceffary to pra&ife a 

 longitudinal incifion, and make it of fufficient fize. Plat- 

 ner likewife recommends this incifion of the ikin, after 

 which, he fays, the trachea mav be opened with a lancet, 

 or with an inftrument analogous to what is employed for 

 tapping. But though this method feemed to him the moft 

 expeditious, he deemed it lefs fafe. 



It does not appear to Sabatier, however, in what it is 

 more objecbonable than the other. On the contrary, he 

 thinks that it has the advantage of preventing bleeding 

 into the trachea, beeaufe the cannula immediately tills the 

 opening made in this tube. Platcer cites a cafe, which is 

 recorded in the Phdofophical Tranfaftions, and which the 

 celebrated commentator upon Boerhaave has alfo quoted. 

 Authors who had mentioned the cannula which was to be 

 introduced into the trachea, had contented themfelves with 

 ftating, that it ought not to be too long, left it fhould injure 

 the pofterior fide of that canal. Garengeot conceived, that 

 the dimenfions of the inftrument might be determined with 

 more precifion, and he calculated that its length fhould be 

 about twenty-feven millimetres. Dr. G. Martin, the author 

 of the cafe to which we have alluded, found this length in- 

 fufficient, and he was even obhged to ufe the cannula of a 

 trocar for the pa-acentefis of the abdomen, inftead of what 

 he was firft about to employ ; but as it was too long, he 

 was under the neceffity of making it pafs through an aper- 

 ture made in a thick linen comprefs. 



It has been apprehended, that the extraneous fubflances 

 in the air may pals through the cannula into the lungs, and, 

 confequently, it has been recommended to cover the mouth 

 of the inftrument with a bit of fponge, cotton, or gauze- ' 

 But Dr. Martin did not find this precaution neceffar)'. He ! 

 thicks it more ufeful to warm the air which the patient 

 breathes, fo that the lungs may not be hurt by it. There 

 is one ferious inconvenience which expenence taught him, 

 and which arifes from the mucus difcharged from the lungs. 

 By this the cannula becomes fo obftructed, that its prefence 

 affords no affiftance. Dr. Martin was feveral times com- 

 pelled to take out the tube in order to clean it. He received 

 a fuggeftion, that he might employ a double cannula, that 

 is to lay, two cannuLz, one within the other, fo that the in- 

 ternal one might be withdrawn as often as neceffary, without 

 difturbinc the outer one, into which it could be eafily put 

 again. In this manner, a free refpiration would be affiled ; 

 but Sabatier conceives, that fo thick a tube would be difficult 

 of introduction. He alfo doubts whether the tube, of which 

 all praaitioners have fpoken,is indifpenfably requifite. When 

 the trachea, or larynx, is opened in wounds of the neck, 

 the air makes its efcap-s with force, and the circumftance 

 needs to be checked by inclining the patient's head forward, 

 and confining it in this pofture vrith bandages. Meyffonnier, 

 who wrote towards the conclufion of the feventeenth cen- i 

 tury, and who praftifed tracheotomy three t:roes, put no 

 leaden cannula in the wound. He contented himfelf with I 

 applying dry hnt, a pledget, and bandage. Sabatier do- I 

 tices, that thefe cafes are detailed too briefly. They prove, j 

 however, that the cannula may be difpenfed with, and that 

 the making of an opening in the trachea will enable the pa- 

 tient to b.-eathe. 



Van Swieten, as well as Platner, rejects the plan of open- 

 ing the tnchea .'^ith a trocar. His reafon was, becaufe the 

 point of thisiofbrument being thick and (hort, it was difficult 

 to make it penetrate without ufing a great deal of force, 

 efpecially in confequence of the great mcveablenefs of the 

 part on which it has to acl. The trials which he made of 

 this method, both on the dead fubjeS and on Living a nim als, 

 convinced bun that it was difficult, ^.d that there W3S danger 



