tached portions retracted within the uterus. He very candidly stated what he had done, and it was easily remedied; and I merely mention the occurrence as further evidence of the attention necessary to be observed even in the performance of so simple an operation as removing, from the uterus and vagina, an unattached placenta.

1, KEPPEL STREET, BEDFORD SQUARE,

January 1823.

A CASE

OF

CUT THROAT,

SUCCESSFULLY TREATED.

BY CHARLES THOMAS HADEN,
Surgeon to the Chelsea and Brompton Dispensary, &c.

THE writer publishes this case because he thinks it involves some peculiar principles of surgical practice important in such accidents. He deems it necessary to state, however, that as he wholly derived the peculiarity of these principles from his friend Mr. Alcock, he is disappointed to find these observations will not, as at first arranged, appear as a supplement to a paper containing an extensive series of similar cases which have occurred in Mr. Alcock's practice. He the more regrets this because the case was in reality only treated by him under the direction of that gentleman, who fortunately happened to be at the author's house when the accident occurred.

CASE.

Mrs. Savons, aged forty-two, cut her throat in July 1822, after suffering for some days from pain in her head. She was not in bad circumstances, nor had she any particular reason for the deed; her forehead was low, her cranium small, and

she had much of the moody appearance of insanity. She had also, on a former occasion, attempted to drown herself.

She had divided the thyroid cartilage and adjacent parts, so as to lay open the larynx and expose to view the posterior surface of the pharynx. The wound of the thyroid cartilage was very jagged and irregular, having evidently been inflicted by repeated incisions: a portion of the cartilage was so far detached, except at one of its extremities, as to vibrate like a reed, and to be drawn inwards at each inspiration. She coughed almost incessantly, and with a degree of violence rarely witnessed, except when the larynx suffers great irritation. She lost a large quantity of blood; but none of the vessels required a ligature except one near the surface. The wound was made by means of a razor, and it extended from one sternocleido-mastoideus muscle to the other. Although her appearance was so alarming as to render the persons with whom she lived most anxious to have her removed, on any terms, fearing she would immediately expire; yet in a little time after she was visited, she was in a state of tolerable quietude; but occasional attacks of suffocation came on, which were relieved by keeping the loose portion of cartilage from being drawn into the larynx, and by the expulsion or extraction of large lumps of ropy and almost inspissated mucus, which arose from the trachea.

The blood which continued to flow, or rather to ooze rapidly from the divided surfaces, for a considerable time, was prevented from being carried into the windpipe during the inspirations (which were, as might be expected, much more violent than natural), by inclining the body forwards, and by the constant and cautious application of soft sponges, frequently renewed, immediately after being squeezed from hot

water.

After the hæmorrhage had ceased, the wound was cleaned thoroughly, by the removal of every particle of coagulated blood; the hanging portion of cartilage, which, as before mentioned, was drawn into the larynx at every inspiration, and one

or two jagged edges of skin, &c. were removed. Two ligatures were introduced, leaving a space between them of about an inch; but as the arteries of the part were in considerable action, and as the expectoration of sticky mucus was almost incessant, the ligatures were not drawn tight, nor were the parts attempted to be closed, except occasionally, for more than two hours after the accident. An assistant was left to remove the protruded lumps of mucus by means of a small piece of sponge rapidly and skilfully applied, so as to prevent them from being drawn into the trachea when the cough ceased, on the recurrence of inspiration.

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When the patient drank fluid, almost all of it ran through the wound, producing cough, and threatening suffocation. Cough too was produced whenever she attempted to speak, even though the external wound was closed, in which case she spoke in a faint whisper. When the wound was open, of course she could not speak at all. Cough was induced also whenever the parts were irritated by being kept closed or otherwise.

After a lapse of two hours the wound put on quite a different appearance. It was pale and free from blood, and abundantly less irritable, so that the neighbouring arteries no longer beat so violently as to make the wound pulsate. The cough and sticky expectoration had also materially abated, and the patient was very tranquil. The ligatures were therefore drawn so that the lips of the wound were lightly but accurately closed; two compresses of lint were placed diagonally, with one across the bottom of them, as is expressed below by the outline*. Slips of sticking plaster were placed in like manner

* As it is scarcely practicable to convey an accurate idea by a mere sketch, of the manner in which the compresses should support divided parts, the outline is omitted. The principle may, however, be plainly stated. Let the surgeon bring the divided parts accurately into contact, by regulating the position, and by supporting with his fingers those parts which are disposed to retract. Let him

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diagonally and across, so as to keep the compresses on, and thus to support the lower lip of the wound in its closed state. It was also intended to steady the head in a position reclined forwards, but the patient was so quiet, and the wound so accurately closed, that it was found to be unnecessary. When the wound was in this state the sputa were forced out of the middle aperture as before, when the patient coughed (for it will be remarked that the middle point was not covered by the plaster), and therefore a sponge was applied and supported by a single turn of roller passed round the neck*. After some hours, however, this sponge was removed, and a bandage applied formed of two slips of roller sewed together, so as to resemble a pair of diminishing compasses, the crossed part being placed on the wound, the longer ends passed under the armpits and tied across the back, and the shorter ones tied at the back of the neck. The sponge was taken away merely to keep the attendants at work to remove the expelled sputa, and thus to ensure their constant attention to the patient.

observe towards what points the retraction takes place, and the direction and extent of the support necessary to counteract it. Having carefully determined these circumstances, the support previously given by the fingers, must be supplied by compresses and bandage. Mere strips of plaster close only the edges of the skin, and are liable, if too tightly applied, to fold the edges inwards, and thereby prevent union. The deeper parts require the aid of compresses and roller. Few of the younger members of the profession conceive, although many of ample experience are fully aware, how much the successful treatment of severe and dangerous wounds depends upon the efficient use of bandages.

* Few cases of wound penetrating into the larynx or trachea admit of the attempt to close the opening, until after the irritation consequent on the wound has subsided. The accumulation of tenacious mucus is so great, in many instances, as not only merely to endanger, but actually to produce suffocation, unless precautions be taken to moderate it by allaying irritation, and to remove it whenever it is protruded; and thus prevent its being carried back again into the trachea.