SURGERY. 737 
In cases in which the whole diameter of the trachea is cut 
through, the French surgeons have proposed the introduc¬ 
tion of a flexible catheter, from one of the nostrils, into the 
larynx and trachea, in order to insure a passage for respira¬ 
tion, which, they say, without this means, is liable to be 
intercepted when the outer wound is closed, in consequence 
of the two portions of the windpipe being separated and 
not corresponding. This, however, is not the practice to 
which we should give a preference; first because the intro¬ 
duction of a flexible catheter is a thing which is not always 
easy of accomplishment; secondly, because its use in this 
way is constantly productive of considerable irritation; and, 
thirdly, because the employment of a suture appears a better 
way for preserving a passage for the air, by keeping the ends 
of the trachea together. 
A flexible catheter should be introduced through one of 
the nostrils into the oesophagus, for the purpose of giving 
food and medicines to the patient, without disturbing the 
wounded parts. 
A total division of the oesophagus may be considered as 
fatal. The inevitable injury of other important parts, at the 
same time, would render such a case at once mortal. The 
celebrated Prussian surgeon Schmucker, has treated small 
wounds of the pharynx and upper part of the oesophagus 
with success. Wounds dividing half, or even two-thirds of 
the tube, are also stated to have been cured. 
The tying of the carotid artery when divided in wounds 
of the neck, is of course the same process as tying any other 
artery in any other wound. When this vessel is to be tied 
for the cure of aneurism, the following operation is per¬ 
formed :— 
Begin the incision at the lower edge of the thyroid car¬ 
tilage ; continue it upwards and outwards through the inte¬ 
guments and platysma myoides for two inches and a half, 
immediately on the inner side of the sterno mastoid muscle, 
so as to form an angle with the thyroid cartilage: dissect 
very carefully by the edge of the muscle, drawing it a little 
outwards, and the artery is found where it emerges from 
beneath that muscle and the omo-hyoideus. Be careful not 
to wound the internal jugular vein, which is situated on the 
outer side of the artery, and rather auteriorly; the nervus 
vagus is behind, and to its outer side, and the descendens 
noni runs down the front of the artery: the whole is sur¬ 
rounded by condensed cellular membrane, forming a kind 
of sheath. 
The windpipe is cut into in various parts, to prevent 
suffocation. When surgeons make an opening into the 
trachea, the operation is called tracheotomy; when into 
the larynx, laryngotomy. These operations are only per¬ 
formed, when we have in view to [make a passage for the 
air, or to extract foreign bodies from the oesophagus. La¬ 
ryngotomy is thus performed:— 
The skin being made tense, and the larynx fixed, the skin 
and cellular substance are to be divided to the extent of 
an inch, from the lower part of the thyroid to the cricoid 
cartilage, between the sterno-thyroidei and hyoidei muscles. 
The surgeon is then to place on the membrane his finger, 
with which he is to guide the point of the knife. The 
puncture should be made rather towards the cricoid car¬ 
tilage, in order to avoid an arterial branch, which usually 
runs along the lower edge of the thyroid cartilage. Should 
any vessel happen to bleed, it must be tied. Lastly, the 
silver tube is to be introduced, and being covered with a bit 
of gauze, is to be fixed in its place with ribands. Care 
must be taken to withdraw and clean the canula as often 
as it may become obstructed with mucus, during the neces¬ 
sity for continuing its employment. 
The following is the common method of performing 
tracheotomy:— 
When a free incision into the trachea is requisite, the 
surgeon may make an incision in the integuments, which 
should begin just below the inferior lobes of the thyroid 
gland, and be carried straight downwards about two inches. 
The sterno-thyroidei muscles are then to be pushed a little 
Vol. XXIII. No. 1604. 
towards the side of the neck, and a longitudinal wound, of 
the necessary size, is next to be made in the front of the 
trachea. The knife must not be carried either to the right 
or left hand, in order to avoid all risk of injuring the large 
blood-vessels; and the incision ought never to extend too 
near the first bone of the sternum, lest the subclavian vein 
should unfortunately be cut. 
The treatment of bodies in the oesophagus.—If possible 
they should be extracted, and if this cannot be done and 
they are not such as are likely to be pushed through the 
vessels of the pharynx and produce worse consequences, 
they may be propelled down the oesophagus with a pro¬ 
bang. 
The operation of extracting the thyroid gland, is one that 
rarely requires to be performed: Desault’s method is reckoned 
the best; it was conducted in the following manner:—An 
incision was made along the middle of the swelling, begin¬ 
ning about an inch above, and ending at the same distance 
below it. This extent was given to the wound for the 
purpose of having plenty of room for the continuance of 
the dissection. The inner edge of the incision being drawn 
to the left by an assistant, the tumour was next separated 
from the sterno-cleido-mastoideus by the operator cutting 
the cellular substance that connected these parts. In doing 
this, two small arteries were divided, and immediately tied. 
The next object was to detach the inner part of the swelling 
from the trachea. While this was performed, the assistant 
drew the tumour outwards with a hook. In this part of the 
operation, several branches of the thyroid arteries were tied 
as soon as cut. 
The assistant with the hook, then pulled the gland inwards 
and forwards, while Desault finished the dissection outwards 
and above and below. This part of the operation was the 
most difficult, and it was necessary every instant to wipe 
away with a sponge the little blood that was effused, in 
order that the parts might be distinctly seen. The operator 
only ventured to divide a very little at a time, and every 
part was carefully examined with the fingers before it was 
cut. With these precautions, Desault succeeded in exposing 
the superior and inferior thyroideal arteries, without wound¬ 
ing them, and a ligature was immediately put under them 
by means of a curved blunt needle. The vessels were then 
divided, and the detachment of the swelling from the trachea 
completed. The patient was discharged from the Hotel- 
Dieu, quite well, on the 34th day after the operation. 
The tumour which was removed was nearly five inches 
in circumference. The wound made in the operation was 
almost three inches in depth, being bounded externally by 
the sterno-cleido-mastoideus, internally by the trachea and 
oesophagus, and behind by the common carotid, and par 
vagum, which were visible. 
That the extirpation of the thyroid gland is a delicate 
and difficult operation, must be evident to every body at ail 
acquainted with anatomy. Above, are the superior thy¬ 
roideal arteries; below, the inferior ones; at the sides, the 
common carotids, and internal jugular veins; in front, an 
extensive plexus of veins; and the trachea, oesophagus, 
recurrent nerves, and par vagum, all close to the tumour. 
Wounds of the face, though they involve important parts, 
and are extremely frightful to behold, are not generally 
attended with danger, and heal up in a surprising manner. 
There is nothing peculiar in their treatment, unless in cuts 
of the cheek, when the parotid duct sometimes becomes di¬ 
vided, and the disease called salivary fistula is formed. In 
this complaint the saliva, instead of taking its natural course 
into the mouth, flows out on the cheek. The treatment of 
the salivary fistula is as follows:—an opening should be 
made into the mouth with a trocar as close to the open ori¬ 
fice of the duct as possible, and this being withdrawn, a 
seton introduced. 
Desault’s method of applying the seton is the most eli¬ 
gible. When the trocar had been introduced, he used to 
withdraw the stilette, and pass through the canula a 
thread into the mouth. The tube was then taken out, and 
9 B the 
