Part 79 (1/2)
This table shows that nearly half the cases were treated by laryngotomy.
In sixty-three of these, where the tongue or floor of the mouth was concerned, no preliminary ligature of the lingual artery was performed; of the seventy-three similar cases treated without laryngotomy there was preliminary ligature of one lingual in thirty-one cases (42.5%), and of both arteries in twelve cases (16.4%).
From this it is apparent that lary[n]gotomy has to some extent taken the place of preliminary ligature of one or both linguals. The operation is simple, rapid in execution, and meets all requirements; it is not surprising to find, therefore, that in recent years the number of laryngotomies has proportionately increased.
TABLE SHOWING OPERATIONS AS PERFORMED IN DIFFERENT YEARS
+---------+----------+---------------+---------------+
_With
_Without
_Year._
_Cases._
Laryngotomy._
Laryngotomy._
+---------+----------+---------------+---------------+
1902
39
19
20
1903
35
5
30
1904
31
16
15
1905
32
18
14
1906
29
18
11
1907
21
14
7
+---------+----------+---------------+---------------+
Total
187
90
97
+---------+----------+---------------+---------------+
=Operation.= In cases of extreme emergency the operation can be performed with almost any kind of knife, but the following instruments are preferred: a sharp-pointed bistoury or tenotome, a sharp-pointed dilator (Fig. 265, B), a tube and introducer. The tube should be small, short, with a fixed collar, and made of silver; an introducer such as Butlin's is a great advantage (Fig. 265, A). As bleeding may occur, it is necessary to prepare dissecting forceps, retractors, pressure forceps and catgut.
[Ill.u.s.tration: FIG. 265. INSTRUMENTS FOR LARYNGOTOMY. A, Tube and introducer (Butlin's); B, Sharp-pointed dilator (Bailey's).]
A general anaesthetic is usually employed when infrathyreoid laryngotomy forms the first stage of the main operation, but it should be remembered that the amount of chloroform required is less when given through a tube.
The preparation of the skin and the position of the body are the same as for tracheotomy. A transverse incision one inch in length is recommended, and this should lie directly over the crico-thyreoid interval, which is easy to determine in the adult. The incision can be made quickly by pinching up a vertical fold of skin, transfixing immediately above the cricoid, and cutting outwards: with this method the anterior jugular veins are rarely wounded, but if any vessel has been p.r.i.c.ked it should be seized and tied at once.
The sharp dilator, placed exactly in the middle line immediately above the cricoid, is pushed backwards between the infrahyoid muscles until the resistance caused by the crico-thyreoid membrane is reached. It is then firmly stabbed into the larynx and widely dilated so as to tear open the membrane: the dilator having been withdrawn, the tube, with tapes attached and mounted upon the introducer, is rapidly inserted, a proceeding which is made easier by first smearing the instrument with a small amount of glycerine. The whole operation can be performed in less than a minute, and is rarely attended by serious haemorrhage; moreover, when the original puncture is immediately above the cricoid there is less danger of wounding the crico-thyreoid artery. The operation is attended by few difficulties, and is superior to one in which dissection or cutting is employed.
[Ill.u.s.tration: FIG. 266. LARYNGOTOMY CANULA FITTED WITH INNER TUBE.
Funnel for administration of anaesthetic.]
At this stage a prolonged period of apna is usually encountered, and this symptom is more marked than with tracheotomy; when seen for the first time it may be alarming, and it is therefore of practical importance. In a few moments, however, the patient settles down to the altered conditions of respiration; coughing may be excited but soon disappears. When the breathing becomes regular, the tapes are tied round the neck and a rubber tube is attached (Fig. 266) similar to that used with Hahn's apparatus, and through the tube the chloroform is continued.
This method has the following advantages: it gives far more room to surgeon and anaesthetist, and enables the latter to manipulate the laryngotomy tube and to prevent it from tilting in such a way that the lower end impinges against the front of the trachea with consequent obstruction; further, the opening into the larynx is completely blocked, blood and lotion being unable to enter from outside.
As soon as true anaesthesia with regular automatic breathing has been obtained, the lower part of the pharynx should be plugged with a soft marine sponge to which a piece of tape or silk is attached, this being pushed down behind the tongue and firmly wedged in position; it is advisable to use a large sponge, as this blocks the pharynx and pushes forward the tongue, an advantage to the surgeon when operating upon that structure. If the mouth be obstructed by a tumour, the same result can be obtained by two or more smaller sponges pa.s.sed in succession; or, as suggested by Bond, a small sponge may be pulled down into the larynx. As soon as the pharynx has been completely shut off, the main operation can proceed, and those who have once used this method can appreciate how much more quickly it can be performed and how much more comfortably for all concerned.
At the conclusion of the operation, when all bleeding has been controlled, the laryngotomy tube should be removed. The wound should not be sutured or plugged, and only a light dressing should be applied: the latter can be kept in place by a bandage, which, however, must on no account be tight, owing to the danger of emphysema.
=Complications= may arise--(_a_) _During the operation._ There may be troublesome bleeding owing to p.r.i.c.king of a vein, superficial or deep, or of the crico-thyreoid artery; this occurred in eight of the cases mentioned above, and in four was severe. In one of the latter the bleeding continued for thirty minutes before the vessel was finally secured. The condition is simple to treat: the wound must be enlarged, and the infrahyoid muscles separated so that the crico-thyreoid membrane is thoroughly exposed; the bleeding vessel can then be seized and tied, after which the tube is inserted. This is preferable to attempting to stop the bleeding by the introduction of the tube.
Difficulty in introducing the tube may occasionally occur. It may be due to imperfect division of the membrane; thus in one case the tube was pa.s.sed down between the coats of the larynx and not within its cavity; and another case is recorded where the mucous membrane was similarly pushed backwards owing to the dilator having split the cricoid cartilage. Care must be taken, therefore, that the membrane is properly punctured, and that the opening is thoroughly dilated before any attempt is made to introduce the tube. Replacement of the tube was necessary in only one case, on the second day, owing to recurrence of bleeding from the wound in the mouth.
(_b_) _After the operation._ Emphysema occurred in six of the ninety cases; in two it was slight; in three it was extensive and involved the chest, neck, and face; and in one, where death supervened twelve hours after the operation, there was emphysema of the mediastinum. In two of these cases the laryngotomy wound had been sutured; in two others the operation was attended with severe haemorrhage, and the mouth was plugged with gauze to control it. It is probable that emphysema is more likely to occur if there is any obstruction to breathing through the mouth after the operation, such as may be caused by the falling back of the remaining part of the tongue. The following precautions should be observed to prevent it: The laryngotomy wound must always be left open, and covered by a loose piece of gauze which does not press upon the neck; the patient must be nursed on his side, not upon the back; suturing the remaining part of the tongue is not sufficient; if plugging is left in the mouth, the tube must be temporarily retained, and removed after a few hours when breathing is not obstructed; early removal, however, is preferred.
Bronchitis is mentioned in two of the cases already quoted, pneumonia in one case, pneumonia and empyema in one, and purulent mediastinitis in one, with three deaths in all. Of these five cases, four had operations upon the tongue. On the other hand, without laryngotomy, bronchitis was rather more common (seven cases) and broncho-pneumonia occurred in two, both of which died. In order to throw more light upon the subject, we have examined the charts of all the cases after the operation, and have found that in most of them there was a rise of temperature to 99 F., or slightly higher, which lasted for periods varying from one to seven days; the pulse and respiration were little affected. In laryngotomy cases there were only eighteen instances of temperatures of over 100 F., as against twenty-five where no laryngotomy had been performed. Here again the pulse and respiration were only slightly affected, so that the condition was probably due to local inflammation and not to involvement of the lung. The results are by no means conclusive, but justify the general feeling that laryngotomy does not increase, but probably diminishes, the danger of infection of the lungs.
Healing of the wound may take place in normal conditions in about five days, but the period is frequently longer--from ten to twenty days; suppuration is uncommon, and was only mentioned in two instances where the wound had been sutured. The scar left after laryngotomy is often depressed for several months, but eventually becomes loosened and is then scarcely noticeable.
Death occurred in six cases, but there was no evidence to show that there was any connexion with the laryngotomy; on the contrary, the operations were more severe, and infrathyreoid laryngotomy was performed partly for the very reason that the condition of the patients was less favourable.
From my experience, the advantages which were originally claimed by Bond, Butlin, and others have been completely upheld; the larger operations upon the upper air-pa.s.sages are easier to perform and can be more thoroughly completed; and it is very possible that the after-results may be improved by the greater facility which is thus afforded. I would strongly urge laryngotomy in all large operations of this region; the tube should be removed early, and the wound should not be sutured.
CHAPTER III
OPERATIONS UPON THE TRACHEA
TRACHEOTOMY
There is evidence to show that this operation was known to the ancients, and that it has been practised during at least two thousand years chiefly for the treatment of foreign bodies in the air-pa.s.sages. From the sixteenth century to the present time it has been frequently performed, and the discovery of diphtheria in 1881 by Bretonneau opened up a new field for the operation.
It is uncertain when tubes were introduced in the after-treatment of tracheotomy, but Dr. George Martin in 1730 was the first to describe a double tube which allowed of the removal of the inner part for purposes of cleaning. The movable collar was invented by Luer, and the angular tube now generally used is a.s.sociated with the name of R. W. Parker, to whose research we owe many of the recent improvements in connexion with this operation.
=Indications.= Obstruction to respiration is the most important, and must be distinguished carefully from the dyspna which is due to pulmonary affections, disease of the heart, or organic lesions in other parts of the body. Laryngeal obstruction may be due to--
(i) _Diphtheria._ The extent to which diphtheritic obstruction has to be taken into account is shown by the following table:--
TABLE SHOWING THE NUMBER OF CASES ADMITTED TO THE FEVER HOSPITALS OF LONDON (M.A.B.) DURING THE YEARS 1902-7, INCLUSIVE[25]
+----+------------------+-----------------+-----------------+
_All forms of
_Laryngeal
_Tracheotomy
Diphtheria._
Cases._
Cases._
+------+-----+-----+-----+-----+-----+-----+-----+-----+
_C
_D
_M p
_C
_D
_M p
_C
_D
_M p
a
e
o e
a
e
o e
a
e
o e
s
a
r r
s
a
r r
s
a
r r
e
t
t
e
t
t
e
t
t
s
h
a c
s
h