736 . SURGERY. 
greatest convexity of the bone. The surgeon should place 
his hand on the part where the patient complains of a prick¬ 
ing pain, or where the blow has been received; and then the 
latter should be desired to cough, in which action, the ribs 
must necessarily undergo a sudden motion, and a crepitus 
thereby be likely to be rendered perceptible. However, all 
the best practical surgeons are in the habit of adopting the 
same treatment when there is reason to suspect a lib to 
be fractured, as when the injury is actually known to 
exist. 
When the point of a fractured rib is beaten inward, a train 
of alarming symptoms may ensue, as for instance, extrava¬ 
sation of blood, emphysema, and inflammation of the pleura 
and lungs. 
Except when urgent symptoms arise, the treatment of 
fractured ribs is a business of great simplicity. The prin¬ 
cipal indication is to render the injured .bone or bones as 
motionless as possible, during the cure. For this purpose, 
a jacket of strong linen should be made, and tightly laced. 
Of the Throat and Face. 
“ There are several anatomical points,” observes Mr. 
Cooper, “ which should be remembered by the surgeon in 
all cases of wounds about the throat. First, that the arch of 
the aorta lies in the upper part of the chest, in front of the 
trachea, and that where the carotid arteries come out of the 
chest to run up the neck, they are scarcely at the sides of the 
trachea, but rather in front of it. As they get higher, how¬ 
ever, they incline more to the side of that tube ; and on their 
arrival near the angle of the jaw, where they begin to give 
off their branches to the head and neck, they even lie rather 
behind the side of the larynx. Hence, we see the reason 
why a wound at the lower part of the neck is very often 
fatal, while one higher up is generally less dangerous. The 
suicide rarely strikes at the lower part of the neck, and it is 
from the accidental circumstance of his cutting very high up, 
near the chin, that the carotids escape.” 
Secondly, as Mr. John Bell has explained, it should be 
remembered, that the carotid artery, the great jugular vein, 
and eighth pair of nerves, lie very closely connected with 
each other, being all inclosed in one mass of cellular sub¬ 
stance, which forms a kind of common sheath for them. 
Now,” says this author, “ since the eighth pair is one of 
the greatest nerves of the viscera, and since, from experi¬ 
ments on animals, we know that a wound of it is more fatal 
than a wound of the brain itself, this frequently puts an end 
at once to all questions about the way of managing wounds 
of the carotid artery, or of the great vein.” But that the 
internal jugular vein, or the carotid artery itself, may some¬ 
times be partially injured, without the par vagum being also 
hurt, or the patient instantly perishing, has now been fully 
proved. 
Mr. John Bell asserted, that it is impossible to cut through 
the trachea, without wounding the carotid artery, the jugular 
vein, and the eighth pair of nerves. It is true such an acci¬ 
dent cannot be frequent. “ The fact is tsays he),- that 
neither the oesophagus nor the trachea is touched in the least 
degree, but the wound is much above them, for a suicide 
always strikes immediately under the chin. This wound, as 
far as I have observed, commonly falls in the line which 
divides the neck from the chin, that is, the place where the 
os hyoides lies, and he commonly cuts the os hyoides away 
from its connection with the thyroid cartilage, or pomum 
Adami. In that case, the thyroid cartilage, forming the 
uppermost part of the larynx is not touched: the rima 
glottidis lies below the wound quite safe. It only separates 
the larynx from the root of the tongue; it is properly a 
wound in the root of the tongue; it is rather a wound of the 
mouth than of the throat; and when the food comes out 
along with spittle and froth, it is by rolling over the root of 
the tongue.” 
In these high wounds of the throat, it is the superior 
thyroid artery, which is most frequently cut. This vessel, 
after quitting the external carotid at the angle of the jaw, 
passes along the side of the upper part of the trachea, in¬ 
clining forwards the thyroid gland in its descent, and there¬ 
fore much exposed to the edge of the razor. The bleeding 
from this artery is profuse, and if not speedily stopped, is as 
fatal as hemorrhage from the carotid itself. In some of these 
cases, the bleeding also proceeds from the lingual artery, or 
its branches. 
Wounds of the trachea are either simple or complicated. 
In both descriptions of cases, the usual symptoms are, an 
emission of air from the wound, loss of the voice, and some¬ 
times emphysema. Such injuries of the windpipe, as are not 
complicated either with hemorrhage, emphysema, or loss of 
substance, may generally be easily cured by means analogous 
to those which are employed for the cure of wounds in gene¬ 
ral. The reunion is still more easily accomplished, when the 
trachea is divided longitudinally, than when it is cut trans¬ 
versely. If the wound be of a certain size, and attended 
with hemorrhage, the first indication is to tie the bleeding 
vessels, and, in particular, to obviate the inconvenience and 
danger which would result from the entrance of the effused 
blood into the windpipe; an occurrence which has some¬ 
times proved fatal. 
The greater sensibility of the larynx, its complicated struc¬ 
ture, and the number and size of its blood vessels, render 
wounds of it much more dangerous than those of the trachea. 
They produce a great deal more irritation, and are generally 
attended with a convulsive cough. In general, however, 
simple wounds of the thyroid cartilage heal very favourably. 
Transverse wounds, extending through only the anterior 
half of the upper part of the trachea, generally do well. 
Such injuries mostly leave nerves and vessels of consequence 
untouched. Loss of the voice; the entrance and exit of 
air through the wound, and sometimes an emphysematous 
swelling of the integuments, are the speedy consequences 
of the injury. Wounds of this description, made by gun¬ 
shot violence, are more dangerous; but even these not un- 
frequently terminate well. In most instances, transverse 
wounds of the trachea, which have not divided it com¬ 
pletely through, can be cured by the strict observance of a 
proper position. By bringing the patient’s chin downward 
and forward to the sternum, and maintaining the head in 
this posture by the support of pillows, the edges of the 
wound in the trachea may be placed, and kept in contact, 
until they have grown together. 
The manner in which sutures aggravate the cough, and 
inflame the wound, often necessitates the surgeon to with¬ 
draw them, when they have been employed. Besides the 
irritation, which, as extraneous bodies, they create in the 
trachea, they are in general unnecessary. Nothing prevents 
a wound of the trachea from uniting more than the dis¬ 
turbance of a convulsive cough; and the irritation of sutures 
always increases this hurtful symptom in a great degree. In 
fact, unless the greatest part of the trachea be divided, there 
never can be such a space between the edges of the wound 
that they cannot be brought into contact with the assistance 
of a judicious posture of the head. 
When the troublesome cough seems to be owing to an 
inflammatory state of the wound, the complaint may be 
mitigated by bleeding and soothing remedies. 
Many surgical writers recommend the patient to refrain 
from making forcible expirations, and drawing his head 
suddenly backward, for a certain time after the wound is 
healed. By such causes, it is asserted, the recent coalescence 
of the wound may be easily destroyed. 
When a wound has detached the upper portion of the 
trachea from the lower one, and it is not immediately fatal 
by the injury of other important parts, the bleeding vessels 
are first to be tied, and the two ends are then to be brought 
into contact. In this sort of case, the employment of a 
suture is warrantable. A flat broadish ligature should be 
employed; the needle should not be introduced through 
the lining of the trachea; and one stitch will be quite 
enough, when the chin is kept properly approximated to the 
breast. 
In 
