Three Cases of Thyreotomy; Recovery in each Case, with Excellent Voice. BY CLINTON WAGNER, M. D. REPRINTED PROW E\)e "Neto Fork fttetiical journal for October SO, 1886. Reprinted from the New York Medical Journo! for October 30, 1886. THREE CASES OF TIIYREOTOMY; RECOVERY IN EACH CASE, WITH EXCELLENT VOICE* By CLINTON WAGNER, M. D. Tiiyreotomy is indicated in all cases in which distressing dyspnoea is present from laryngeal obstruction, and for the relief of which the operation per vias naturales is impracti- cable. I have no suggestions to offer as to the method of performing the operation, except that I regard silver sutures through the thyreoid, for the purpose of maintaining the divided eges of the cartilage in apposition, after the opera- tion, as quito unnecessary. I employed them in my first two operations, but have since abandoned them. The skin should be brought together by sutures aided by plaster. If this is done carefully and properly, the divided edges of the carti- lage will be kept firmly in position, the skin serving as a splint. In subjects over forty-five years of age I have almost in variably found ossification of the cartilage. A small file-cut wheel, made to revolve by means of the dental engine, will be found in many respects better than the small convex saw generally used; the line of division will be smooth and clean and more easily maintained in the median line, and there will * Read before the American Laryngological Association at its eighth annual congress. _ 2 THREE CASES OF THYREOTOMY. he less difficulty in steadying or fixing the larynx during the sawing process. No evil effects follow the division of the crico-thyreoid membrane and cricoid cartilage ; I have usu- ally divided both in my operations; more room or space is gained thereby, especially in very young children, and the growth or membranous web can be removed more easily and thoroughly. I have performed the operation nine times; with the exception of the three cases which form the subject-matter of this paper, all were for the removal of malignant growths occurring in adults, and the destruction of the vocal cords was a necessary step in the operations. I do not regard thyreotomy as dangerous to life; haemor- rhage usually is very slight, and can be easily controlled by compression. I can not recall an instance in which I ap- plied. a ligature. Fauvel,* however, in one of his operations applied thirty-eight. Case I.—Georgie, aged five years, was admitted into the Metropolitan Throat Hospital suffering from alarming dyspnoea, with frequent attacks of spasm of the glottis. An examination revealed a large papilloma attached to the right cord and al- most completely filling the box of the larynx, and between the cords posteriorly could be distinctly seen what appeared to be a web of membrane stretched from cord to cord. As the child was greatly reduced in flesh and strength, thyreotomy was at once decided upon. Tracheotomy was first performed, followed immediately by the thyreotomy. The growth was removed, the membranous web cut away with the scissors, and the patient put to bed. The membranous web was the result of an attack of diphtheria or croup, which he had had some months before. The boy recovered perfectly and gained rapidly in strength and flesh; was discharged from the hospital five weeks after the operation. * Quoted by Mackenzie, “Diseases of the Pharynx, Larynx, and Trachea,” p. 241. THREE CASES OF THYREOrO.UY. 3 1 saw him six years after the operation. There had been no recurrence of the growth, the vocal cords appeared normal in appearance and action, and the voice was excellent. Case II.—A boy between three and four years of age was attacked with diphtheria at the Foundling Asylum. Tracbe- otomy was performed by Dr. G. M. Swift, at that time house surgeon of the institution. The child recovered from the diph- theria, and in due time an attempt was made to dispense with wearing the cannula. Dyspnoea followed and the tube was reinserted. Numerous attempts were subsequently made with the same result. Five months after the tracheotomy was per- formed, I was requested to give my opinion as to the cause of dyspnoea upon removing the cannula. Owing to the re- sistance made by the child, I was unable to obtain a very satisfactory view of the larynx. I gave as my opinion that there was laryngeal obstruction, probably a membranous web, the result of the ulceration of diphtheria. I suggested thyre- otomy, and was requested to take charge of the case and per- form the operation. I found below the vocal cords and just above the inferior border of the thyreoid a membranous web stretched across the larynx and occluding at least the anterior two thirds of its lumen. This was removed carefully by means of scissors and knife, after which I had no difficulty in carrying my index-finger through the glottis into the mouth. The wound healed kindly, twelve days after the operation; the cannula, which he had worn for nearly six months, was removed. Two years later the child, well and strong, with a good strong voice, was sent from the asylum to a home in the West which had been provided for him. Case III.—A girl child, aged three years, was admitted into the Metropolitan Throat Hospital suffering from alarming dysp- noea with frequent attacks of spasm of the glottis, caused by a large papilloma attached to the left vocal cord. Tracheotomy was performed, but during the operation a large vein wras cut, which bled profusely; the prostration from haemorrhage was so great that I was compelled to defer thyreotomy for two weeks; it was then performed in the usual manner. The patient was 4 THREE CASES OF THYREOTOMY. discharged from the hospital at the expiration of two months, but attended my clinic as an out-door patient, and was kept under observation for six months longer. I saw the patient last in October, 1885, nineteen months after the operation; she was at that time in perfect health, and her voice seemed clear and strong. Cases I and II were reported at length shortly after the operations (“Med. Record,” October, 1879, and “Archives of Laryngology,” July, 1883); they are again referred to, merely to show the improvement in the vocal functions after an interv al of several years. The membranous web is a sequel of healing from de- structive ulceration of the mucous membrane occurring simultaneously on opposite sides of the larynx. It is not infrequently found as a result of the deep-seated ulceration of tertiary syphilis. In my opinion, it occurs more fre- quently as a result of laryngeal diphtheria than is generally supposed, although the two cases above detailed are the only instances I have encountered in my practice. I have no doubt it would be frequently seen in laryngeal tubercu- losis and cancer could healing be brought about bg any means. In the adult the web may be destroyed by the galvano- cautery, the laryngeal knife, or Whistler’s ingenious cutting- dilator, but in very young children thyreotomy is our only means for affording radical relief. REASONS WHY Physicians should Subscribe -FOB- The NewYork Medical Journal, Edited by FRANK P. FOSTER, M. D., Published by D. APPLETON & CO., t, 3, & 5 Bond St. 1. BECAUSE : It is the LEADING JOURNAL of America, and contains more reading-matter than any other journal of its class. 2. BECAUSE : It is the exponent of the most advanced scientific medical thought. 3. BECAUSE : Its contributors are among the most learned medi- cal men of this country. 4. 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