practical importance, and should, therefore, not be forgotten; for were the surgeon to act upon the principle of tying every bleeding vessel before he opens the tube, most injurious, if not fatal, delay might be occasioned. The veins of the neck, both superficial and deep, are frequently distended to their utmost, in consequence of the obstruction of the air-passages, or the struggles which the patient makes during the operation; a condition which, as a general rule, vanishes the moment the air enters the tube at the artificial aperture, and re-excites the lungs to renewed action.

To arrest hemorrhage, whether unavoidable or otherwise, in these operations, is one thing; to prevent it, another. To favor this result, so desirable in all operations, but particularly in those under consideration, should be one of the principal aims of the surgeon. This object will seldom, if ever, be difficult, if we reflect upon the various sources of the hemorrhage. We have only to proceed cautiously and deliberately, dividing one part after another, and pushing such vessels as may present themselves away from the front of the windpipe, and there can be no possible chance of any thing like a copious loss of blood in one case out of fifty, if not in still greater proportion. In laying open the tube, it is a good rule always to carry the knife from below upwards with the back towards the sternum, as the danger of wounding the large vessels at the root of the neck is thus greatly diminished.

Secondary hemorrhage must be very rare after these operations, inasmuch as no mention is made of the circumstance in any of the cases that have fallen under my observation. The occurrence is, of course, possible, and should, therefore, be borne in mind by the surgeon. The bleeding may happen at a variable period after the operation, either in a few hours, or not under several days, just as in secondary hemorrhage in other parts of the body. The treatment consists in exposing the bleeding vessels, and securing them with the ligature; or, if this be impracticable, on account of the depth of the wound, or the peculiarity of the hemorrhage, in applying systematic compression. Styptics, if not wholly inadmissible, should be employed with great caution, otherwise they may pass into the trachea, and so become productive of severe irritation and eough.

The best compressing agent is the blunt-hook, used for separat ing the edges of the wound, or a silver canula, such as is generally

inserted for promoting respiration. The former should always, I think, have the preference in case the offending substance still remains in the windpipe.

SECTION XI.

DRESSING AND AFTER-TREATMENT.

The operation being completed, and the bleeding having been arrested, the next thing to be done is to dress the wound. The manner of doing this must depend upon circumstances. If the foreign body has been removed, and the respiration thoroughly reestablished, the edges of the wound may be lightly approximated by a few narrow adhesive strips; but if the reverse is the case, they should be kept asunder by means of two blunt-hooks secured to the back of the neck with two pieces of gum-elastic tape. These hooks (Fig. 37), which are composed of silver, and from four to six

lines in breadth, should be retained for at least thirty-six hours, or until the parts have become thoroughly glazed with lymph, when they may be dispensed with. Of course, they are removed sooner if the extraneous body should happen to be expelled before this period.

To obviate the necessity of employing blunt-hooks, some writers have recommended the removal of a small piece of the windpipe at each side of the incision. Although the operation has been performed successfully, and has been adopted by some of the most distinguished surgeons, both in this country and in Europe, I must confess I have a dislike to it, amounting almost to an aversion; for it strikes me not only as unscientific, but as being calculated to lead to injurious contraction of the tube. It is for this reason that the practice ought, in my judgment, to be discountenanced. Indeed, I am not certain that it is always necessary even to employ blunthooks, for where proper care has been taken to make a free external and internal opening, the offending substance will generally be able to escape at the wound without such precaution.

Where the wound has been kept open for several days, and the necessity of maintaining it in this condition has ceased, the best plan is to approximate the edges with the twisted suture, care being taken to pass the needles deeply through the substance of the wound, but not through the walls of the windpipe; a procedure which could not be otherwise than prejudicial, and which must, therefore, be scrupulously avoided.

Should emphysema arise after the application of the dressings, they must be instantly removed, to afford a free passage to the air at the artificial opening. The same course is to be adopted in the event of internal hemorrhage, a still more serious accident, but which will rarely happen if the precaution be used of delaying the dressing of the wound until all bleeding has ceased.

In several of the cases detailed in this monograph, the surgical attendant introduced a silver canula into the wound, the foreign body being still in the air-passages. It would be difficult to conceive what motive could have prompted such a practice; if the object were to prevent the escape of the offending substance, hardly anything better could be selected for the purpose, unless it were a cork-stopper!

No lint should be placed over the wound, lest it should be drawn into the windpipe, and thus induce dangerous consequences. The fact is the dressings should be of the most simple character.

As long as the wound is open it must be protected with a piece of gauze, to prevent the ingress of flies, and of particles of matter floating in the air, or attached to the bed, body, or clothes of the patient. It should be arranged in the form of a bag, and be carefully

secured to the neck by pieces of tape or strips of adhesive plaster. It will be readily perceived that, if it were applied flat over the wound, it might effectually prevent the escape not only of blood and mucus but also of the foreign substance. A gauze covering is particularly necessary in warm weather, when the air is liable to be filled, both day and night, with all kinds of insects, almost any of which might be entrapped by the wound.

Some of the above directions may appear trivial, if not useless; but they can be so only in the opinion of those who place little estimate upon the results of surgical operations, and the value of human life. To the true surgeon and philanthropist, nothing is unimportant that has for its object the prevention of suffering and the preservation of existence.

The treatment after the operation, whether followed by the removal of the extraneous body or not, is a matter of paramount importance, and should, therefore, always receive the special consideration of the professional attendant. The operation itself is not without danger, and although it rarely proves fatal, yet, when it is recollected that it is performed for the purpose of getting rid of an offending substance in the air-passages, it will be readily perceived how injurious it may prove, both to the parts and to the system at large; how seriously, in short, it may affect the former, and how easily it may destroy the latter. The foreign body may have been retained for days before the windpipe is opened; but, even where this has not been the case-where, indeed, it has been expelled even within a comparatively short period after its introduction-there is always danger of severe inflammation of the lungs and air-tubes; and it is for this reason that the practitioner should always be on the alert, carefully watching his patient, lest the disease, thus awakened, should progress, and finally, perhaps before he is conscious of it, gain the ascendency.

The fact that the patient is not always safe, even after the removal of the offending body, cannot be too often repeated or too strongly impressed upon the mind of the practitioner. To conclude that an individual is no longer in danger of his life because he has been relieved of an extraneous substance in the lungs, is as absurd as it is in an ostrich to suppose that he is free from the pursuit of his enemy because he has buried his head under his wing. Taking into consideration the result of my experience, personal and collected, upon this subject, I assume that no person

is safe after an occurrence of this kind until the wound is perfectly healed, and until all laryngeal, tracheal, bronchial, and pulmonary symptoms have disappeared. Even then he should be carefully watched for some time, lest he should take cold or commit some dietetic indiscretion, and thus incur the risk of lighting up disease in structures which, when once irritated, are always peculiarly prone to morbid action.

The following case, reported more fully under the head of laryngotomy, while it illustrates the truth of my remarks, will place this subject in a more forcible light than any language which I can employ.

A boy, eight years old, having inhaled a grain of corn, was laryngotomized by Dr. Winlock and Dr. Moore, of Shelbyville, Kentucky, on the fourth day after the accident, after having in vain tried the effects of emetics. The breathing was much improved by the operation, but the foreign body failed to make its appearance. After a few days, during which the lad had occasional paroxysms of partial strangulation, he was brought to Louisville, and placed under my charge. He reached town about 11 o'clock in the morning, and in a few hours afterwards he ejected the grain of corn in a violent fit of coughing. A careful examination of the chest revealed the existence of a high grade of pneumonia, for the relief of which he was copiously bled and purged, and subjected to the use of tartrate of antimony and potash. Under this treatment, he so far recovered, in the course of a few days, that his friends, contrary to my most strenuous opposition, carried him home, a distance of thirty miles. The rest of the story is soon told. The disease, aggravated by premature exposure, rapidly increased in violence, a portion of the right lung became hepatized, and in a fortnight after he left Louisville, he threw up, in a fit of coughing, a large quantity of fetid matter, which he continued to expectorate until the time of his death, which, as Dr. Miller, one of his attendants, informed me, happened on the forty-fifth day after the accident.

The treatment necessary after these operations is, of course, the antiphlogistic, and it need hardly be stated that the time and manner of its employment must vary with each individual case. Purgatives, having mercury for their basis, are generally highly beneficial, and can seldom be dispensed with. A dose should always be given within a few hours after the patient has been put to bed, and, where the symptoms are at all urgent, it should be