is liable to be wounded which would bleed sufficiently to cause any embarassment. There is, however, a little artery on the crico-thyroid membrane which runs in a transverse direction, and which would be inevitably divided if the membrane were cut in a longitudinal direction; this danger may be avoided by making the division of this part transverse.

In TRACHEOTOMY, on the contrary, though the trachea is only covered by the skin, and by the sterno-hyoid and sterno-thyroid muscles, it is much more deeply situated than the larynx. There is no arterial branch before this canal which could produce hemorrhage to any extent, if we except the rare instance of a branch of considerable size, running to the thyroid gland. But the case is very different with the veins: those called the inferior thyroid, are placed a little obliquely in front of the trachea, so that it is almost impossible to expose it, without wounding them, or some of their branches. This hæmorrhage is not dangerous from its amount, but by obscuring the parts, it renders the incision of the trachea more difficult, and by running into this canal when it is opened, threatens the patient with suffocation.

From this comparison, it is evident that the operation of LARYNGOTOMY is more simple, and more easy, than that of tracheotomy, and that it ought to be preferred in all those cases in which it is likely to answer the end proposed in the operation. Thus M. Boyer decides, that the incision of the crico-thyroid membrane is sufficient for the purpose of restoring the passage of air, when it is intercepted by a cause such as cynanche, situated above this membrane, though as we conceive it admits of considerable doubt, if this situation be not objectionable on account of its proximity to the seat of the disease. Laryngotomy is exclusively proper when a foreign body is lodged in one of the ventricles of the larynx. When the obstacle which impedes the passage of air is situated below the crico-thyroid membrane, as for instance a foreign body fixed in the upper part of the oesophagus, and which does not admit of being pushed down into the stomach, tracheotomy is exclusively applicable. It is to this latter operation that we should have recourse when the trachea is obstructed by a foreign body; but in this case, in order to avoid the inconveniences attendant on tracheotomy, M. Boyer recommends the adoption of laryngo-tracheotomy, that is to say the incision of the cricoid cartilage, and of the two or three first rings of the trachea. The only part of any consequence injured in this operation is the middle portion of the thyroid gland; but this is in general so thin, so narrow, and its vessels so small, that there is little chance of any inconvenience resulting from it,

We are at a loss to understand the reasons which induce many practitioners to consider tracheotomy as the operation exclusively proper for the extraction of a foreign body from the trachea. It is admitted that laryngotomy is infinitely more easy in the performance than tracheotomy, and we have already quoted M. Boyer in illustration of the circumstances which render the latter more dangerous, though he has omitted to mention two occurrences which materially add to the risk and embarrassment of that operation,-we mean the not unfrequent ascent of the arteria innominata upon the lower part of the trachea; and the convulsive action of the muscles of the neck, as described by Messrs. A. Burns and Bell. The only objection which we can anticipate to the employment of laryngotomy in such cases, is that it is less likely to answer the object in view, namely, the extraction, or rather the expulsion of the foreign body. But the experiments of Favier on living animals, recorded in the Memoirs of the Academy of Surgery, have proved that foreign bodies introduced into the trachea are drawn towards the bronchiæ during inspiration, and driven towards the glottis during expiration; that they are expelled and driven out by expiration, as soon as an opening has been made in the trachea large enough to admit of their passage. M. Boyer alludes to these experiments for the purpose of proving that the fear of being unable to meet with, and extract the foreign body, cannot be a sufficient motive for declining the operation of bronchotomy; but surely they will also prove, that the object proposed may be effected by means of an opening of sufficient size in any part of the respiratory passage, and allow us to choose between the difficulties and dangers of tracheotomy, and the comparative facility and safety of laryngotomy.

Systematic writers on surgery, in general, scem not to have taken sufficient pains in discriminating the particular cases requiring the performance of these two operations. Notwithstanding the indications for each appear to be pretty decidedly marked, at least in the greater number of cases. Thus tracheotomy is exclusively called for in the instance of a foreign body fixed in the œsophagus and impeding respiration by its pressure on the trachea. In cynanche laryngea too, and other affections of this part, tracheotomy is preferable to laryngotomy, as it would of course be desirable that the seat of the operation should be as remote as possible from that of the disease. On the other hand, in inflammations of the mouth and throat, either primary or consequent upon wounds, &c. (provided always that the larynx be unaffected); for the purpose of inflating the lungs in

suspended animation; and for extracting a foreign body lodged in the trachea, as our object is merely to make an opening into some part of the air-passages, it would be a matter of indifference, as far as the purpose of the operation is considered, whether we selected the larynx or the trachea; but as we know that the incision of the former is less hazardous to the patient, and more easy to the operator, every motive combines to direct our choice to it.

It only remains to say a few words of the case of CROUP, which some have supposed likely to be relieved by making an artificial opening for respiration. We may safely say, that when this disease really exists with the exudation of lymph into the trachea, and most probably with a simultaneous affection of the lungs, it is sufficient to produce death,-the result of any ope-: ration for the purpose of restoring respiration must be more than doubtful. This is a disease, as every one is aware, only to be relieved by active treatment in its early stages. But as it is our duty to do every thing that affords a shadow of hope, bad as the prognosis must always be, it is better to attempt something than allow the patient to perish unrelieved. In such cases nothing would be gained by opening the larynx, which is above the seat of the impediment to respiration. We must cut into the trachea at the lowest point of it that can be reached, consistent with the security of the important parts placed in its vicinity.We say the lowest point, because there is a chance that the disease, at least its greatest intensity, might be confined to the upper portion of the tube, though, we believe, it will be more commonly found to extend downwards to the lungs. We may repeat, in conclusion, the assertion with which we commenced on this point, that there is little prospect of relief in true croup,' from making an artificial opening for respiration.

Tracheotomy and not laryngotomy is the operation required for the relief of the inflammation of the glottis and larynx, caused by an accident that sometimes happens to children-drinking boiling water from the mouth of a tea-kettle, supposing it to be cold (See Quart. Journ. For. Med. ii. 235. ; and for MR. WALLACE's interesting case, iv. 299.) After what we have already said, and looking to the parts affected in this case, it is unnecessary to assign the causes of this preference, and the reasons of our dissent from the recommendation of laryngotomy as above quoted.

We have already expressed our opinion of the value of the volume before us, and we feel much pleasure in adding, that it does equal credit to the author, and to the school of surgery of which he is the greatest ornament.

M. KERGARADEC ON AUSCULTATION IN PREGNANCY.*

No arguments are required to prove the uncertainty of the symptoms on which all attempts to ascertain the state of pregnancy are founded. Those who are most conversant with the subject will at once assent to this proposition, and disclaim a precision to which, whatever some individuals may suppose, we have at present no title. Such being the case, every attempt to improve our knowledge merits attention and impartial experiment. The name of M. Laennec, and the peculiar means adopted by him for extending the diagnosis of thoracic diseases, are perfectly familiar to the profession in this country. (See Quart. Journ. For. Med. ii. 51.) M. Kergaradec's Memoir is founded on the application of this plan to a subject not originally contemplated by the discoverer. The circumstances which led him to his researches on this subject, were the following.

Being in attendance on Madam L, a young woman who had been some months pregnant, he resolved to assure himself if it was possible to hear the noise caused by the agitation of the fluid of the amnios when the foetus moved in the uterus. His investi. gations on this point gave him no satisfactory result, though in other respects they were more successful. One day, when Ma dame L had nearly gone her full time, M. Kergaradec, whilst attending to the motions of the foetus, was struck by a sound to which he had not until then attended, and which resembled the ticking of a watch placed very near his ear. On removing his ear from the abdomen the noise altogether ceased. The experiment frequently repeated gave the same result. By attention he recognized a double pulsation recurring at regular periods, like the contractions of the heart. On counting them, they varied from 143 to 148 in a minute, whilst the pulse of Madame Lwas but 70 in the same time. This difference in the number and the situation of the pulsations rendered it impossible to confound them with the pulse of the mother. The practical and theoretical consequences of this discovery immediately presented themselves to the author, and led him to repeat his experiments during a fortnight which elapsed before Madame

* Memoire sur L'Auscultation appliquée à l'etude de la Grossesse, ou Recherches sur deux nouveaux signes propres a faire reconnoitre plusieurs circonstances de l'etat de Gestation. Par M. J. A. Lejumeau de Kergaradec, D. M. P. &c. 8vo. Paris, 1822.

L was delivered.

the following:

The principal facts he observed were

The double pulsations in question were heard in the left part of the abdomen; they extended about a foot in a vertical direction from a few inches below the umbilicus to a little above the crural arch; they were much more limited in a transverse direction. Their greater or less intensity afforded the means of judging of the proximity or remoteness of the point at which they were situated: this point varied a little. The foetus appeared to be inclined to the right side, where a projection could be felt through the integuments corresponding to the lower extremities. During the fortnight the mother's pulse varied from -54 to 72 in a minute; that of the child also varied from 123 to 160. There was no constant relation between them as to their frequency; on one morning, however, after some very brisk motions of the foetus, its pulsations attained the maximum of 160, and at the same time Madame L's pulse reached the maximum of 72.

But besides these pulsations, M. Kergaradec derived some additional information from the employment of auscultation. One day, whilst endeavouring to hear the beating of the heart of the fœtus on the right side of the abdomen, he distinguished simple, regular pulsations, perfectly isochronous with the pulse of the mother. Their force was such that they seemed to arise from very large vessels, or from several vessels at once. They were accompanied by a particular noise, which resembled the rustling (souffle) observed in certain diseases of the heart and great vessels. They were confined to a very narrow space on the right side below the umbilicus: they were not sensible in any part of the left side. It was evident that they were not owing to the pulsations of the heart of the foetus. The conclusion which M. Kergaradec drew was, that from their situation and other circumstances they bore some relation to the point of insertion of the placenta. These pulsations were not sensible at all times; they frequently disappeared and returned after a suspension of some days, a circumstance which the author attributed to the variations in the position of the fœtus with relation to the placenta. During the pains of labour, and when the os uteri was dilated to the size of a three livre piece, the pulse of the mother was 85, that of the child 136 to 189, and situated lower than usual, quite at the bottom of the abdomen, almost in the median line. The simple pulsations with the rustling, were also very perceptible, and altogether confined to the right side. Three hours afterwards, labour had made considerable progress, the child having entered the hollow of the pelvis, the pulsations