A Manual of the Operations of Surgery by Joseph Bell (shoe dog free ebook .txt) 📖
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The edges must be carefully united by various points of metallic suture, and the fissure of the soft palate closed at the same sitting, unless the patient has lost much blood, or is very much exhausted with the pain. The stitches may be left in for a week, or even ten days, unless they are exciting much irritation. The patient must exercise great self-control and caution in the character of his food and his manner of eating for ten days or a fortnight after the operation.
Excision of Tonsils.—To remove the whole tonsil is of course impossible in the living body, the operation to which the name of excision is given being only the shaving off of a redundant and projecting portion. When properly performed it is a very safe, and in adults a very easy operation, but in children it is sometimes rendered exceedingly difficult by their struggles, combined with the movements of the tongue and the insufficient access through the small mouth. Many instruments have been devised for the purpose of at once transfixing and excising the projecting portion; some of them are very ingenious and complicated. By far the best and safest method of removing the redundant portion is to seize it with a volsellum, and then cut it off by a single stroke of a probe-pointed curved bistoury; cutting from above downwards, and being careful to cut parallel with the great vessels.
The ordinary volsellum is much improved for this purpose by the addition of a third hook in each tonsil placed between the others, with a shorter curve, and slightly shorter; this ensures the safe holding of the fragment removed, and prevents the risk of its falling down the throat of the patient.
If both tonsils are enlarged they should both be operated on at the same sitting, and the pain is so slight that even children frequently make little objection to the second operation. Bleeding is rarely troublesome if the portion be at once fairly removed, but if in the patient's struggles the hook should slip before the cut is complete, the partially detached portion will irritate the fauces, cause coughing and attempts to vomit, and sometimes a troublesome hæmorrhage.
The plentiful use of cold water will generally be sufficient to stop the bleeding, though cases are on record in which the use of styptics, or even the temporary closure of a bleeding point by pressure, has been necessary.
M. Guersant has operated on more than one thousand children, with only three cases of any trouble from hæmorrhage, while four or five out of fifteen adults required either the actual cautery or the sesqui-chloride of iron.[126]
CHAPTER IX. OPERATIONS ON AIR PASSAGES.Operations on the Larynx and Trachea.—The great air passage may be opened at three different situations, and to the operations at these different places the following names have been given:—
Laryngotomy, when the opening is made in the interval between the cricoid and thyroid cartilages, through the crico-thyroid membrane.
Laryngo-tracheotomy, when the cricoid cartilage and the upper ring of the trachea are divided.
Tracheotomy, when the trachea itself is opened by the division of two, three, or more rings.
Of these the last, tracheotomy, is by far the most frequent, important, difficult, and dangerous, and requires a very detailed description. Chassaignac[127] says "the only really rational operation for the opening of the air passages by the surgeon is tracheotomy."
Tracheotomy.—Anatomy.—Between the cricoid cartilage and the level of the upper border of the sternum, the middle line of the neck is occupied by the upper portion of the trachea. Its depth from the surface varies, gradually increasing as the trachea descends, and varying very much according to the fatness, muscularity, and length of the neck. It is, however, almost subcutaneous at the commencement below the cricoid, and on the level of the sternum it is in most cases at least an inch from the surface, in many much deeper. Again, its length varies, even in the adult, from two and a half to three, or even four inches. This is important, as affecting the simplicity of the operation, which, as a rule, is easier the longer the neck is.
The trachea has most important and complicated anatomical relations—some constant, others irregular.
1. The carotid arteries and jugular veins lie at either side, but, where these are regular in their distribution, do not practically interfere in a well-conducted operation.
2. The thyroid gland lies in close relation to the trachea, one lobe being at each side (Fig. xxxi. B B), and the isthmus of the thyroid crosses the trachea just over the second and third cartilaginous rings. In fat vascular necks, or where the thyroid is enlarged it may occupy a much larger portion of the trachea. The position of the isthmus practically divides the trachea into two portions in which it is possible to perform tracheotomy. Both have their advocates, but the balance of authority tends to support the operation below the thyroid. A separate notice of each will be required immediately.
Fig. xxxi. [128]
3. The muscles in relation to the trachea are the sterno-hyoid and sterno-thyroid of each side. The latter are the broadest, are in close contact across the trachea by the inner edges below, but gradually diverge as they ascend the neck. In thick-set, muscular necks, however, they are in close contact for a considerable distance, and require to be separated to give access to the trachea.
The arteries are in most cases unimportant; no named branch of any size ought to be divided in the operation. However, occasionally very free bleeding may result from the division of an abnormal thyroidea ima running up the trachea to the thyroid body from the innominate, or even from the aorta itself.
The veins are very numerous and irregularly distributed. There is generally a large transverse communicating branch between the superior thyroid veins just above the isthmus. The isthmus itself has a large venous plexus over it. Below the isthmus the veins converge into one trunk (or sometimes two parallel ones) lying right in front of the trachea.
4. The last anatomical point which may give trouble in normal necks is the thymus, which is present in children below the age of two, and covers the lower end of the trachea just above the level of the sternum. Where this is not only not diminished, but enlarged, as it sometimes is in unhealthy children, it may give a very great deal of trouble, rolling out at the wound and greatly embarrassing proceedings.
Abnormalities are very various and sometimes very dangerous: vessels crossing the trachea, as the innominate did in Macilwain's case,[129] or where two brachiocephalic trunks are present, as recorded by Chassaignac.[130] One of the most frequent dangers to be guarded against is a possible dilatation of the aorta or aneurism of the arch. This may very possibly, as happened in one case to the author, give rise to suffocative paroxysms from its pressure on the recurrent laryngeal nerves. Tracheotomy may be deemed necessary, and there is a great risk, unless proper precautions be taken, of wounding the aorta, where it passes upwards in the jugular fossa. In the author's case the vessel had actually to be pushed downwards by the pulp of the forefinger while the trachea was opened, the knife being guided on the back of the nail of the same finger.
The Operation.—In a work of this kind it would be utterly impossible to go at all into the subject of what diseases, injuries, etc., warrant or require the operation. It is enough to describe the various methods of operating, their dangers and difficulties.
1. The operation above the isthmus of the thyroid.—A spot about a quarter or half of an inch in vertical diameter between the cricoid cartilage (Fig. xxxi.) and thyroid isthmus.
Advantages.—It is near the surface, the vessels are few and comparatively small. It is most suitable in cases of aneurism.
Professor Spence[131] gives his sanction to the high operation in adults with thick short necks when the operation is performed for ulceration or papilloma of larynx or for spasm from aneurism, the low operation being still best in cases of croup or diphtheria.
Disadvantages.—The space is too small, requires very considerable disturbance of the thyroid isthmus, or actual division of it. It is too near the point where the disease is; so much so, that in most cases of croup or diphtheria it would be perfectly useless. However, if required, or if the operation lower down be contra-indicated, this may be performed easily enough. A straight incision being made in the middle line about one inch and a half in length, expose the upper ring by careful dissection, if possible draw aside the veins, and depress the thyroid isthmus, divide the rings thus exposed, and introduce the tube.
The operation below the isthmus.—This, though more difficult in its performance, is a much more scientific and satisfactory operation. Considerable coolness and a thorough knowledge of the anatomy of the part are absolutely required.
The patient being in the recumbent posture, the shoulders should be well raised, and the head held back so as to extend the windpipe, and thus bring it as near as possible to the surface. A pillow, or the arm of an assistant, behind the neck will be of service.
N.B.—Be careful lest too great extension by an anxious assistant, accompanied by closure of the mouth, should choke the patient (whose breathing is of course already much embarrassed) before the operation be begun.
Chloroform may occasionally be given, and, if well borne, renders the operation very much easier than it would otherwise be. An incision must then be made exactly in the median line of the neck, from a little below the cricoid cartilage, almost to the upper edge of the sternum; at first it should be through skin only, then the veins will be seen, probably turgid with dark blood; the larger ones should be drawn aside, if necessary divided, the bleeding stopped by gentle pressure. The deep fascia must then be cautiously divided, great care being taken to keep exactly in the middle line, and the contiguous edges of sterno-thyroid muscles separated from each other by the handle of the knife. A quantity of loose connective tissue, containing numerous small veins, must now be pushed aside, the thyroid isthmus pressed upwards, still with the handle of the knife. The forefinger must then be used to distinguish the rings of the trachea. If there is much convulsive movement of the larynx and trachea, they should be fixed by the insertion of a small sharp hook with a short curve, just below the cricoid cartilage, and this should be confided to an assistant. The surgeon should then, with the forefinger of his left hand, fix the trachea, and open it by a straight sharp-pointed scalpel, boldly thrusting it through the rings with a jerk or stab, the back of the knife being below, and divide two or three of the rings from below upwards. Any attempt to enter the trachea slowly with a blunt knife or trocar will probably be unsuccessful, as the rings, especially in children, give way before the knife, which merely approximates the sides of the trachea without opening it.
Question of Hæmorrhage.—It is often a question of some importance, and one which sometimes it is not easy to settle, how far attempts should be made completely to arrest the venous hæmorrhage before opening the trachea.
On the one
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