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Thyrotomy, or laryngotomy, as it was formerly termed, was first proposed by Desault about a century ago, although he never had occasion to perform it. To Bauers, of Louvain, is due the honor of ha been the first to perform it. Gurdon Buck, of this city, did it in 185 1, his being the third case on record. Dr. Sands viagra brand thailand and Dr. Gouley, also viagra brand thailand of this city, performed it early in the '6o's. The introduction of the laryngosope into viagra brand thailand general practice, by which the cause of laryngeal obstruction to respiration can easily be diagnosticated, caused the operation to grow rapidly into favor with surgeons. I think it may safely be assumed that it was performed in many cases by those engaged in general surgery, in which a skilled laryngoscopist might viagra price men have operated by the intra-laryngeal method. In fact, thirty years ago, a contention arose between Dr. Morell Macken- zie and Mr. Durham, of Guy's Hospital, as to which was the preferable method for removing laryngeal growths, thyrotomy or the intra-laryngeal method through the mouth. It is not my purpose to discuss the relative merits of the two methods. The immense number of ca of growths viagra brand thailand that have been successfully removed per riiis nat viagra brand thailand urates, without involving life, settles the ques- tion as to the superiority of that method. But there are two classes of cases in which thyrot- omy will always be justifiable, if not absolutely neces- sary. First malignant growths, for which the radical surgical treatment must be either thyrotomy or exsec- tion of half or the entire larynx; secondly, cases of occlusion of the larynx in very young children, such as I will describe later on. I shall endeavor to show that although thyrotomy is not always a viagra price men simple, easy operation, still it is not dangerous to life if carefully performed, neither is it necessarily destructive to the vocal function in non-malignant cases. In performing the operation, the shoulders of the patient should be well raised, and the head thrown back, by which the skin covering the larynx is made tense, and that organ thrown prominently forward. An incision should then be made through the skin and fascia from a little above the thyroid notch downward, in the median line to the cricoid. W ith" a small probe- viagra price men pointed knife, the crico-thyroid membrane is divided, and then with a gentle sawing motion viagra price men the knife is carried upward through the thyroid cartilage. In young persons the section is made without difficulty, but in middle-aged or old persons ossification of the thyroid will have taken place, to divide which, the saw must be employed. I use a small file-cut saw 1 Read before the New York Academy of viagra brand thailand Medicine, Section Laryngology and Rhinology, November 27,'iSo,5. wheel, made to revolve by means of the electric motor. The section can be made in an incredibly short space of time. The incision is clean and can be maintained in the median line without difficulty. Malgaigne viagra brand thailand says of this operation, "ossification of the thyroid renders it absolutely impossible." But in his time the elec- tric motor did not form a part of the surgeon's arma- mentarium. The difficulties of the operation begin as soon as the larynx is penetrated. The introduction of the knife, together with the flow of blood, produce violent reflex action. The larynx rises and falls spas- modically and very rapidly. The employment of a sharp-pointed knife or scissors, at this stage of the operation, is highly fraught with danger. During the rapid movements of the larynx, its posterior wall might be penetrated, and thus cause a laryngo-cesopha- geal fistula. At this viagra brand thailand moment, the operator has need of all his coolness and presence of mind. During the spasmodic action of the larynx, in spite of all that may be done to prevent it, a certain amount of blood will find its way down the trachea and into the lungs. If the patient is not fully under the influence of the anaesthetic (and he should not be), it will excite fur- ther reflex action. Violent coughing will follow, and the blood will be expelled. I am always extremely careful in regard to the amount of anaesthetic administered. Coughing, under these circumstances, may be regarded as a danger signal. In deep or complete anaesthesia it will not take place. The blood will collect, and death on the table from asphyxia may suddenly take place. The divided edges of the viagra price men thyroid should now be kept widely apart by retractors, the anaesthetic care- fully pushed, and the removal of the growth, false membrane, or whatever the cause of the laryngeal oc- clusion may be, proceeded with. Except in cancerous growths the hemorrhage usually is not very great. In all my operations I have viagra price men never found it necessary to apply a ligature. Gentle compression has always been sufficient to arrest the bleeding, and I cannot conceive where a distinguished laryngologist, Fauvel of Paris, placed thirty-eight ligatures in one viagra price men of his thyrotomies, and I am not surprised that he should denounce it as " a severe and bloody operation." The only artery that lies in the course of the surgeon's knife is the crico-thyroid, which is very small and can easily be secured by compression. No evil effects follow the division of the cricoid cartilage. I usually cut down to the cannula viagra price men in the trachea, in order to gain more room. The cannula may be removed dur- ing the operation, if it is in the way, and it generally is. Silver sutures, as recommended by the earlier operators, passed through the thyroid for the purpose of maintaining the divided edges of the cartilage in apposition after the operation, are quite unnecessary. If the skin is brought together by a few sutures, aided by plaster, it will maintain the edges of the thyroid in firm apposition. Thyrotomy is not an operation for the display of brilliancy and clash on the part of the surgeon. It is a tedious operation in which, in order to secure safety, celerity should not be attempted. The larynx of viagra price men a child under five years of age is extremely small, the opening made for the play of instruments still MEDICAL RECORD.