It seems to combine all the dangers with none of the advantages of the other methods of operating. It is close to the disease, involves cutting a cartilage of the larynx, and almost certain wounding of the isthmus of the thyroid; and it is not easy to see what corresponding advantages it has over tracheotomy in the usual position.
Thyrotomy is an operation by which the larynx is opened in the middle line by a vertical incision, and its halves separated, while any morbid growths are excised from the cords or ventricles. The merits and dangers of this operation have been discussed at length by Mr. Durham[135] and Dr. Morell Mackenzie.[136]
Laryngectomy or Excision of the Larynx, first performed by Dr. Heron Watson in 1866, has been lately frequently performed for carcinoma and sarcoma. Each case presents its own difficulties, which vary according to the amount and extent of the disease for which it is done.
The trachea must be divided and tamponed by a Trendelenburg canula, after which the larynx must be carefully dissected out. The immediate mortality, i.e. in first ten days, is fifty per cent., and Dr. Gross holds that life has not been prolonged by the operation.[137]
Œsophagotomy.—This operation is very rarely required, and has as yet been performed only for the removal of foreign bodies impacted in the œsophagus, and interfering with respiration and deglutition. To cut upon the flaccid empty œsophagus in the living body would be an extremely difficult and dangerous operation, from the manner in which it lies concealed behind the larynx, and in close contact with the great vessels. When it is distended by a foreign body, and specially if the foreign body has well-marked angles, the operation is not nearly so difficult. It has now been performed in forty-three cases at least, of which eight or nine have proved fatal. Seven, along with another in which he himself performed it with success, were recorded by Mr. Cock of Guy's Hospital.[138] Three others were performed by Mr. Syme, with a successful result. Of the seven cases collected by Mr. Cock only two died, one of pneumonia, the other of gangrene of the pharynx.
Operation.—Unless there is a very decided projection of the foreign body on the right, the left side of the neck should be chosen, as the œsophagus normally lies rather on the left of the middle line. An incision similar to that required for ligature of the carotid above the omohyoid should be made over the inner edge of the sterno-mastoid muscle; with it as a guide, the omohyoid may be sought and drawn downwards and inwards, the sheath of the vessels exposed and drawn outwards, the larynx slightly pushed across to the right, the thyroid gland drawn out of the way by a blunt hook, the superior thyroid either avoided or tied. The œsophagus is then exposed, and if the foreign body is large, it is easily recognised; if the foreign body be small, a large probang with a globular ivory head should then be passed from the fauces down to the obstruction; this will distend the walls of the œsophagus, and make it a much more easy and safe business to divide them to the required extent. The wound in the œsophagus should be longitudinal, and at first not larger than is required to admit the finger, on which as a guide the forceps may be introduced to remove the foreign body, or, if necessary, a probe-pointed bistoury still further to dilate the wound.
For some days or even weeks the patient must be fed through an elastic catheter introduced through the nose and retained, or by an ordinary stomach-tube through the mouth. In introducing the latter there is always a risk of opening the wound. No special sutures for the wound in the œsophagus are required, nor is it advisable too closely to sew up the external wound.