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The operation may be performed by steadying the part, and then piercing with a knife, held with the middle finger applied to the blade one half inch from the point as a guard, all the tissues into the larynx. This puncture must be made a little below the thyroid cartilage in the median line, the blade of the knife being held crosswise. Turn the edge of the knife and cut downward, following the median line to or through the cricoid cartilage.

In the child the incision must be prolonged in the same line downward through two or three rings of the trachea (laryngo-tracheotomy).

The communicating branch between the crico-thyroid arteries may be divided below the thyroid cartilage. The superior thyroid veins communicate above the isthmus of the gland, and hence have their communicating branches divided in laryngo-tracheotomy.

Insert the tube and secure it in position by means of a tape encircling the neck. Stitch the upper and lower angles of the wound.

3. Tracheotomy.-Locate the cricoid cartilage with the left index-finger. Make an incision extending from above the cricoid cartilage downward two inches in the median line. Divide the integument and fasciæ and separate the sterno-hyoid muscles. Retract the sides of the wound. Cut the fascia transversely on the cricoid cartilage and strip it downward with the isthmus of the thyroid gland, (Bose). Hook the trachea below the cricoid cartilage with a tenaculum and draw it upward and forward.

Pierce the trachea with a scalpel held with its cutting edge upward in the lower angle of the wound,

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and divide it upward in the median line to the extent of three quarters of an inch.

Dilate the opening and insert a tracheotomy-tube with its convexity turned upward. Secure the tube by means of a tape, and stitch the angles of the wound.

In the child the incision reaches nearly to the upper border of the sternum. The trachea being small, avoid wounding its posterior wall.

If the isthmus of the thyroid gland can not readily be displaced downward, catch it with serrefines on each side and divide it in the median line.

The communicating branches between the superior thyroid veins are divided as they cross the median line above the isthmus of the thyroid gland.

It is seldom necessary to operate below the isthmus of the thyroid gland in the living, and the operation on the cadaver gives an inadequate idea of the difficulties encountered in this location. The incisions must be made in the median line through the integument and fasciæ. Separate the sterno-hyoid and sterno . thyroid muscles. Make the incisions from below upward, using the left index-finger to locate the trachea and to guide the incisions.

In the lower angle of the wound the left innomi. nate vein, the innominate artery, a plexus formed by the inferior thyroid veins, the thyroidea ima, and the thymus gland may be encountered.

When the trachea, which is deeply situated, is exposed, hook it forward and open it to the extent of an inch in the median line. The tube is now inserted and secured.

The operation of tracheotomy may be performed by bolder incisions. Include the trachea between the left index-finger on the left and the thumb on the right side. By approximating the fingers and press. ing backward, the trachea is made to bulge forward, and the tissues anterior to it are put on the stretch. Locate the cricoid cartilage. Make an incision in the median line two inches in length from the cricoid cartilage downward. Divide all the tissues until the trachea is exposed. Apply clamps to the divided isthmus of the thyroid gland. Hook the trachea forward, and complete the operation as before described.

Before inserting the tube in these operations, suck the mucus from the air-passage by means of a rubber tube attached to the nozzle of an ordinary syringe.

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EXTERNAL ESOPHAGOTOMY.

Place the subject on the back, with the shoulders slightly raised on a block. Turn the face to the right, as the æsophagus is most easily approached from the left side, to which it inclines. Operate from the left side.

Locate the cricoid cartilage, close below which the oesophagus is to be opened. Make an incision between the anterior border of the left sterno-mastoid muscle and the larynx, beginning at the level of the upper border of the thyroid cartilage, and continue this incision downward two inches between the same muscle and the trachea. Cut the integument, platisma, and fasciæ. Draw the sterno-mastoid muscle outward. Separate the omo-hyoid muscle, and either divide it or draw it outward with the sternomastoid.

Elevate slightly the head, to relax the tissues, so that the sides of the wound can be retracted. Divide on a director the deep fascia, and draw the carotid sheath outward. Separate the attachments of the thyroid lobe and turn it toward the right.

Pass a bulbous bougie through the mouth and pharynx into the wesophagus to the location where the opening is to be made. Draw the trachea for. ward, slightly twisting it over toward the right side. The bulb of the bougie can now be cut directly upon, or the wall of the wesophagus may be raised and a small opening made through it to admit the finger. Enlarge the opening vertically, either upward or downward.

In making the opening do not divide the recurrent laryngeal nerve, and in cutting downward guard against wounding the inferior thyroid artery.

In closing the wound into the esophagus, stitch the opening with a continuous suture and invert the edges. Bring together the separated muscles by means of buried sutures, providing for drainage. Stitch the integumentary wound.

Pharyngotomy is performed if the incision into the oesophagus is prolonged upward above the level of the cricoid cartilage into the pharynx.

If the external incision is continued upward, avoid cutting the superior thyroid artery and the superior laryngeal nerve.

CHAPTER V.

OPERATIONS ON THE TRUNK.

EXCISION OF THE MAMMARY GLAND.

THE removal of the areolar tissue of the axilla should be practiced in conjunction with this operation.

Place the subject on the back, with the thorax slightly raised on a block. The pectoralis major is made tense by the arm being abducted to a right angle with the body. Operate standing on the side from which the gland is to be removed.

Begin internal to the gland to make a curved incision, concave upward, following closely the direction of the fibers of the pectoralis major, and extending below the nipple external to the gland. Dissect the integument and fascia downward until the lower border of the pectoralis major is reached, which is the best guide to the lower border of the gland. Separate the lower and posterior connections of the gland.

Begin a second curved incision, concave downward, at the same point as the first, and extend it in the direction of the fibers of the pectoralis major above the nipple, joining the first incision at a point external to the gland. Dissect up the integument and fascia until the upper border of the gland is ex

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