A RARE CARDIAC CONDITION: MITRAL STENOSIS WITH BALL-THROMBUS IN LEFT AURICLE

Alex.Mills Kennedy
1909 The Lancet  
1315 forceps and gently drawn towards the middle line, so that the imbedded part of the gland bulges beneath its normal covering of the anterior pillar of the fauces. (Fig. 1. ) Immediately external to the internal margin of the anterior pillar, just where it blends with the surface of the tonsil, an incision is made with the fine-toothed forceps, parallel to and extending FiG. 2. Tonsil drawn inwards and incision made along dotted line. This line is close to the free margin of the anterior
more » ... ar of the fauces, which does not appear owing to the bulging of the imbedded portion of the tonsil during traction. for the whole length of the free margin of the anterior pillar. (Fig. 2.) This incision reveals the capsule of the tonsil which now appears as a glistening smooth bluishwhite surface. (Fig. 3.) (The ease and success of the operation depend upon this incision displaying the capsule FIG. 3. Anterior pillar of fauces drawn outwards and tonsil removed from its bed by dissection. The capsule of the gland appears as asmooth bluish-white surface. The real size of the gland is now seen and is a striking contrast with the amount visible in Fig. 1 , before the tonsil is drawn inwards. of the tonsil and not entering its substance. This mistake is easily made by keeping too near to the free surface of the tonsil, and it is the common cause of difficulty and failure for beginners.) The ring forceps is then readjusted so as to get a firm hold upon the tonsil and the anterior pillar is drawn outwards by means of the fine toothed forceps. The tonsil is then practically dislocated from its bed, and the separation of the rest of the layer of fine cellular tissue, intervening between the capsule of the tonsil and the muscular wall of the pharynx, is easily effected either by the fine toothed forceps or by a closed pair of curved bluntended scissors which fit in behind the whole of the tonsil and push the pharyngeal wall away from it. (Fig. 3.) Since the tonsillar vessels are thereby torn across and are able to retract within the muscular wall of the pharynx, there is practically no bleeding-in fact, the absence of bleeding forms a striking contrast to the sharp haemorrhage which ensues after the tonsil has been cut across by a guillotine. The time occupied in the complete removal of both tonsils and adenoids is, on an average, three minutes. A brief deep anaesthesia with chloroform is necessary, and the coughing reflex should be abolished. If it is present it adds a distinct danger to the operation, since coughing enormously increases the haemorrhage, and during the ensuing inspiration blood could easily be sucked into the larynx. Under the conditions detailed above there is no danger of this happening. During the operation traction upon the posterior pillar of the fauces must be avoided, since it gives rise to a troublesome spasm of the glottis. For the after-treatment a simple mouth'wash is provided and a mixture containing salicylate of soda and chlorate of potash, administered every few hours. The patients are kept in bed for about 48 hours and are allowed solid food when they feel inclined for it. With children this is frequently on the day after the operation. All the above 900 cases have been seen at the end of a week and at the end of five weeks from the date of operation. Their ages range from six weeks to 41 years. There have been no complications, such as haemorrhage or sepsis. As a rule the temperature seldom reaches 100° F. after the operation. Of the 126 cases who had been chiefly under the care of Dr. Hutchison, suffering from general debility, 12 showed no improvement after the operation. In the remainder of the cases rapid and complete recovery was made. Of those suffering only from throat symptoms 774 cases have been operated upon. Of these 143 had already had their tonsils I guillotined "-some of them as often as two or three times -at other hospitals with no relief to them. They all made an uninterrupted recovery. A typical case from this group may be quoted. The patient, aged nine years, had his tonsils guillotined at a London throat hospital in November, 1906, on account of sore throat. He continued to suffer from this affection until March, 1907, when he contracted scarlet fever. Since then, the attacks of sore throat had become more frequent. On examination, large imbedded masses of tonsillar material were seen to be present. Since the removal of these by dissection in July, 1907, he has remained quite well. e
doi:10.1016/s0140-6736(00)44600-3 fatcat:hu7mqguprzhfdn5cz7z6uqtkyi