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Show or Bnoncnoronx. 8 out. will be no bleeding to interrupt the further operation of ting into the trachea, and introducing the canula. The cut. into the trachea is made betwixt two of the rings, with the same knife which is used for the first part of the operation, or with a lancet. It is recommended by some to push in a sharp stilette and canula, without a previous incision of the trachea. The intention of pushing a trocar and canula into the trachea without making a cut, is, that the canula may so {team mum ‘- 9 or anoncnoromr. exactly fill the opening in the trachea that no drop of blood may fall into it. Authors speak on this subject, as if a drop of blood end . tering the wind-pipe at this place, would irritate and excite the lungs, as an excoriating humour, or a hard substance does the glottis or epiglottis. Bleeding is if possible to be avoided, and I believe it always will be possible; but this dread of bleeding is not to make us defer this operation under the idea, that it requires a very particular apparatus. As we have the tube in the hand, cannot the incision be adapted to it, and if there is an oozing of blood, can we not tie a dos~ sil of lint round the canula, and which pressing upon the trachea around the opening, may either suppress the bleeding, or at least hinder the blood from falling into the wind-pipe, should the opening be twice the size required to pass the tube .9 Hurry and confusion however in this operation, and inattention to this subject, will lead to the most terrible consequences. A friend of mine and a very celebrated surgeon, told me he saw a gentleman die of loss of blood, and the falling of the blood into the trachea; I suppose the opera‘ tor must have cut upon the substance of the thyroid gland. In a child the trachea is very small, and operating with canula and stilette it has happened that the trachea was transfixed ! The tube being introduced, the surgeon will naturally hold it with his fingers until the respiration is fully restored, it may be then fixed and the process is this : folding a large piece of lint together, it is cut into a circular form, then it canula. This compress (now consisting of distinct pieces) is to be put betwixt the wound and guard of the canula, so as to keep the end of the canula its due length, inserted into the wind-pipe. Now a band put round the neck may be fixed to the tube and compress it suliiciently, without forcing it too far into the wind~pipe. IVhen the skin and perhaps the thyroid gland swell in consequence of the operation, then may several of the pieces of cloth be taken from betwixt the wound and‘the guard of the canula; so as to allow the extremity of the canula still to keep its place in the wind-pipe. Having secured the present safety of the patient, our attention will be naturally called in the next place, to remove the cause of the obstructed respiration, whether it be a toreign body sticking in the glottis, or something in the pharynx, or an inflammatory swelling. I have been several times on the eve of performing the operation of bronchotomy, but I have never done it. And this is the case with many surgeons. I cannot therefore speak with the same certainty on this subject that other authors have done. But to bring the subject into as short and practical a View as possible, I have thus concerted it on these occasions: viz. first to introduce a flexible tube into the trachea through the glottis, and if this should not be attended with the desired eiTect of establishing a free respiration, then to perform the operation of bronchotomy. I introduce the tube through the glottis, because in every case I have yet seen, the occasion of the difficulty of breathing was to be found in the spasmodic closing of the glottis, and if the tube is introduced into the rims. glottidis so as to secure the passage of the air, the play of the lungs will be free. The only question which remains is, whether the presence of the tube in the larynx will not (in the intimate connexion which exists betwixt this part and the respiratory muscles) produce such irritation, as still to cause a spasmodic coughing. But I believe that it will not be found to have this effect. is slit up to the middle and a part cut out to answer to the VOT . Il‘. |