TRACHEOTOMY.--_Anatomy._--Between the cricoid cartilage and the level of the upper border of the sternum, the middle line of the neck is occupied by the upper portion of the trachea. Its depth from the surface varies, gradually increasing as the trachea descends, and varying very much according to the fatness, muscularity, and length of the neck. It is, however, almost subcutaneous at the commencement below the cricoid, and on the level of the sternum it is in most cases at least an inch from the surface, in many much deeper. Again, its length varies, even in the adult, from two and a half to three, or even four inches. This is important, as affecting the simplicity of the operation, which, as a rule, is easier the longer the neck is.

The trachea has most important and complicated anatomical relations--some constant, others irregular.

1. The carotid arteries and jugular veins lie at either side, but, where these are regular in their distribution, do not practically interfere in a well-conducted operation.

2. The thyroid gland lies in close relation to the trachea, one lobe being at each side (Fig. x.x.xI. B B), and the isthmus of the thyroid crosses the trachea just over the second and third cartilaginous rings.

In fat vascular necks, or where the thyroid is enlarged it may occupy a much larger portion of the trachea. The position of the isthmus practically divides the trachea into two portions in which it is possible to perform tracheotomy. Both have their advocates, but the balance of authority tends to support the operation below the thyroid. A separate notice of each will be required immediately.

[Ill.u.s.tration: FIG. x.x.xI.[128]]

3. The _muscles_ in relation to the trachea are the sterno-hyoid and sterno-thyroid of each side. The latter are the broadest, are in close contact across the trachea by the inner edges below, but gradually diverge as they ascend the neck. In thick-set, muscular necks, however, they are in close contact for a considerable distance, and require to be separated to give access to the trachea.

The _arteries_ are in most cases unimportant; no named branch of any size ought to be divided in the operation. However, occasionally very free bleeding may result from the division of an abnormal _thyroidea ima_ running up the trachea to the thyroid body from the innominate, or even from the aorta itself.

The _veins_ are very numerous and irregularly distributed. There is generally a large transverse communicating branch between the superior thyroid veins just above the isthmus. The isthmus itself has a large venous plexus over it. Below the isthmus the veins converge into one trunk (or sometimes two parallel ones) lying right in front of the trachea.

4. The last anatomical point which may give trouble in normal necks is the thymus, which is present in children below the age of two, and covers the lower end of the trachea just above the level of the sternum.

Where this is not only not diminished, but enlarged, as it sometimes is in unhealthy children, it may give a very great deal of trouble, rolling out at the wound and greatly embarra.s.sing proceedings.

Abnormalities are very various and sometimes very dangerous: vessels crossing the trachea, as the innominate did in Macilwain's case,[129] or where two brachiocephalic trunks are present, as recorded by Cha.s.saignac.[130] One of the most frequent dangers to be guarded against is a possible dilatation of the aorta or aneurism of the arch. This may very possibly, as happened in one case to the author, give rise to suffocative paroxysms from its pressure on the recurrent laryngeal nerves. Tracheotomy may be deemed necessary, and there is a great risk, unless proper precautions be taken, of wounding the aorta, where it pa.s.ses upwards in the jugular fossa. In the author's case the vessel had actually to be pushed downwards by the pulp of the forefinger while the trachea was opened, the knife being guided on the back of the nail of the same finger.

THE OPERATION.--In a work of this kind it would be utterly impossible to go at all into the subject of what diseases, injuries, etc., warrant or require the operation. It is enough to describe the various methods of operating, their dangers and difficulties.

1. _The operation above the isthmus of the thyroid._--A spot about a quarter or half of an inch in vertical diameter between the cricoid cartilage (Fig. x.x.xI.) and thyroid isthmus.

_Advantages._--It is near the surface, the vessels are few and comparatively small. It is most suitable in cases of aneurism.

Professor Spence[131] gives his sanction to the high operation in adults with thick short necks when the operation is performed for ulceration or papilloma of larynx or for spasm from aneurism, the low operation being still best in cases of croup or diphtheria.

_Disadvantages._--The s.p.a.ce is too small, requires very considerable disturbance of the thyroid isthmus, or actual division of it. It is too near the point where the disease is; so much so, that in most cases of croup or diphtheria it would be perfectly useless. However, if required, or if the operation lower down be contra-indicated, this may be performed easily enough. A straight incision being made in the middle line about one inch and a half in length, expose the upper ring by careful dissection, if possible draw aside the veins, and depress the thyroid isthmus, divide the rings thus exposed, and introduce the tube.

_The operation below the isthmus._--This, though more difficult in its performance, is a much more scientific and satisfactory operation.

Considerable coolness and a thorough knowledge of the anatomy of the part are absolutely required.

The patient being in the rec.u.mbent posture, the shoulders should be well raised, and the head held back so as to extend the windpipe, and thus bring it as near as possible to the surface. A pillow, or the arm of an a.s.sistant, behind the neck will be of service.

_N.B._--Be careful lest too great extension by an anxious a.s.sistant, accompanied by closure of the mouth, should choke the patient (whose breathing is of course already much embarra.s.sed) before the operation be begun.

Chloroform may occasionally be given, and, if well borne, renders the operation very much easier than it would otherwise be. An incision must then be made exactly in the median line of the neck, from a little below the cricoid cartilage, almost to the upper edge of the sternum; at first it should be through skin only, then the veins will be seen, probably turgid with dark blood; the larger ones should be drawn aside, if necessary divided, the bleeding stopped by gentle pressure. The deep fascia must then be cautiously divided, great care being taken to keep exactly in the middle line, and the contiguous edges of sterno-thyroid muscles separated from each other by the handle of the knife. A quant.i.ty of loose connective tissue, containing numerous small veins, must now be pushed aside, the thyroid isthmus pressed upwards, still with the handle of the knife. The forefinger must then be used to distinguish the rings of the trachea. If there is much convulsive movement of the larynx and trachea, they should be fixed by the insertion of a small sharp hook with a short curve, just below the cricoid cartilage, and this should be confided to an a.s.sistant. The surgeon should then, with the forefinger of his left hand, fix the trachea, and open it by a straight sharp-pointed scalpel, boldly thrusting it through the rings with a jerk or stab, the back of the knife being below, and divide two or three of the rings from below upwards. Any attempt to enter the trachea slowly with a blunt knife or trocar will probably be unsuccessful, as the rings, especially in children, give way before the knife, which merely approximates the sides of the trachea without opening it.

_Question of Haemorrhage._--It is often a question of some importance, and one which sometimes it is not easy to settle, how far attempts should be made completely to arrest the venous haemorrhage before opening the trachea.

_On the one hand_, if not arrested, besides the risk of weakening the patient, we have to dread the much more serious complication of the admission of blood into the wound. And this is very serious in a patient whose respiration has already been much impeded, whose lungs are probably engorged, and who has certainly, by the mere existence of a wound in his trachea, lost the power of coughing properly; it must never be forgotten that a quant.i.ty of blood so trifling as to be at once ejected by a single cough in the case of a healthy chest, may be a fatal obstacle to respiration in one already weakened by disease. Thus any well-marked arterial haemorrhage from cut branches, or from the isthmus of the thyroid, must certainly be arrested prior to opening the trachea.

Besides this, blood once having entered the bronchi is apt to extend into their smaller ramifications and prove a cause of death, by acting as a local irritation, and setting up intra-lobular suppurative pneumonia. The author has found this to be the case both after tracheotomy and still more frequently in suicide by cut throat.

But, _on the other hand_, it is equally true that there is almost always a considerable amount of oozing from small venous radicles divided during the operation, which depends simply on the great venous engorgement resulting from the obstruction to the respiration, so that while to attempt to tie every point would be simply endless, we may be almost certain that the oozing will cease whenever the trachea is opened, and respiration fairly improved. Slight pressure on the wound is generally sufficient to stop the bleeding till the venous engorgement has disappeared.

Of late years many tracheotomies have been done bloodlessly by use of the thermo-cautery, for division of the soft parts, but the subsequent sloughing of the wound is a great objection to this method.

In cases of extreme urgency, all such minor considerations as suppression of venous oozing must be ignored, and the trachea simply opened as rapidly as possible. I had once to perform the operation after respiration had entirely ceased, and no pulse could be felt at the wrist, with no a.s.sistance except that of a female attendant. Merely feeling that no large arterial branch was in the way, I cut straight through all the tissues, opened the trachea, and commenced artificial respiration. The patient eventually recovered.

_Question of Tubes, etc._--Once the trachea is opened, the next question is, How is the opening to be kept pervious? For the moment the handle of the scalpel is to be inserted in the wound, so as to stretch it transversely; this will probably suffice to allow of the escape of any foreign body. But where, to admit air, the wound is to be _kept_ open, how is this to be done? It used to be advised that an elliptical portion of the wall of the trachea be removed; this, though succeeding well enough for a time, was unscientific, as the wound always tended to cicatrise, and ended of course in permanent narrowing of the ca.n.a.l of the trachea. It may be necessary thus to excise a portion of the trachea, in cases where it is very intolerant of the presence of a tube. Such a case is recorded by Sir J. Fayrer of Calcutta.[132] Not much better is the proposal to insert a silk ligature in each side of the wound, and by pulling these apart thus mechanically to open the wound. This also is evidently a merely temporary expedient.

Various canulae and tubes have been proposed. The ones recommended by the older surgeons had all one great fault; they were much too small, and were many of them straight, and thus liable to displacement. The smallness of their bore was their greatest objection, and Mr. Liston conferred a great benefit on surgery by his insisting upon the introduction of tubes with a larger bore, and with a proper curve, so as thoroughly to enter the trachea. The tube ought to be large enough to admit all the air required by the lungs, without hurrying the respiration in the least.

There is a mistake made in the construction of many of the tubes even of the present day; the outer opening is large and full, while for convenience of insertion the tube tapers down to an inner opening, admitting perhaps not one-half as much air as the outer one does.

It must be remembered that for some days there is great risk of the tube becoming occluded, by frothy blood or mucus, especially in cases of croup, and in children. To prevent this a double canula will be found of great service, providing only that it be remembered that the inner canula, not the outer merely, is to be made large enough to breathe through, and that the inner should project slightly beyond the outer one.

The inner one can thus be removed at intervals and cleansed, by the nurse, without any risk of exciting spasm or dyspnoea by its absence and reintroduction.

_After-treatment._--The after-treatment of a case in which tracheotomy has been performed demands great care and many precautions. For the first day or two the constant presence of an experienced nurse or student is always necessary to insure the patency of the tube. The temperature of the room should be equable and high, and it seems of importance that the air should be kept moist as well as warm by the use of abundance of steam.

A piece of thin gauze, or other light protective material, should be placed over the mouth of the tube, to prevent the entrance of foreign bodies.

In cases where the operation has been performed for some temporary inflammatory closure of the air pa.s.sage, retention of the tube for a few days may suffice. It may then be removed, but it must be remembered that the wound will generally close with great rapidity, so that it is as well to be quite sure of the patency of the natural pa.s.sage before the artificial one is allowed to close by the removal of the tube.

In cases where from long-standing disease or severe accident the larynx is rendered totally unfit for work, and the tube has to be worn during the rest of the patient's life, care must be taken (1.) lest the tube do not fit accurately, in which case it may ulcerate in various directions, even into the great vessels;[133] (2.) lest the tube become worn, and lest the part within the windpipe fall into the trachea and suffocate the patient.[134]

LARYNGOTOMY.--As a temporary expedient in cases of great urgency, where proper instruments and a.s.sistants are not at hand, laryngotomy is occasionally useful, though from the want of s.p.a.ce without encroaching on the cartilages of the larynx, and from its close proximity to the disease, laryngotomy is by no means a suitable or permanently successful operation.

In the adult, especially in males with long spare necks, the operation itself is exceedingly easy to perform. The crico-thyroid s.p.a.ce (Fig.

x.x.xI. A) is so distinctly shown by the prominence of the thyroid cartilage, and is so superficial that it is quite easy to open it in the middle line with a common penknife, there being merely the skin and the crico-thyroid membrane to be cut through, with very rarely any vessel of any size. The opening can then be kept patent by a quill or a small piece of flat wood. This simple operation has in many cases, where a foreign body has filled up the box of the larynx, succeeded in saving life, and even in cases of disease I have known it useful in giving time for the subsequent performance of tracheotomy.

Easy as it appears and really is, cases are on record in which the thyro-hyoid s.p.a.ce has been opened instead of the crico-thyroid, such operations being of course perfectly useless.

The incision is best made transversely.

LARYNGO-TRACHEOTOMY.--This modification consists in opening the air pa.s.sage by the division of the cricoid cartilage vertically in the middle line, along with one or two of the upper rings of the trachea.

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]

OESOPHAGOTOMY.--This operation is very rarely required, and has as yet been performed only for the removal of foreign bodies impacted in the oesophagus, and interfering with respiration and deglut.i.tion. To cut upon the flaccid empty oesophagus 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. c.o.c.k of Guy's Hospital.[138] Three others were performed by Mr. Syme, with a successful result. Of the seven cases collected by Mr. c.o.c.k 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 oesophagus 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 oesophagus 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 pa.s.sed from the fauces down to the obstruction; this will distend the walls of the oesophagus, and make it a much more easy and safe business to divide them to the required extent. The wound in the oesophagus 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.