TRACHEOTOMY.
BY GEORGE M. LEFFERTS, A.M., M.D.
The operation of tracheotomy, or the artificial opening of the air-passage—using the term in its modern acceptation as including all of the five incisions that are both anatomically and surgically possible, either singly or in combination, between the lower border of the thyroid cartilage and the upper edge of the sternum (incisura jugularis sterni), and reserving the term laryngotomy to denote the division of the thyroid cartilage alone—fulfils two important and usually urgent indications: First, in allowing the respiratory current free access to the lungs in cases where the laryngeal obstruction is of such a sudden or of so progressive a character as to either immediately or remotely threaten the life of the patient; and, secondly, in affording a ready means of direct access to those portions of the air-tract which lie below the level of the glottis, and thus permit not only of the direct extraction of such foreign bodies as may accidentally have found their way within the air-passage, but of neoplasms here located and of occluding diphtheritic membranes. Catheterization and aspiration of the trachea are likewise both rendered not only possible, but easy of execution. Both general indications mentioned often coexist, and are met by the operation in a large class of cases; the first alone plays its important life-saving rôle in many.
The disease or accident which renders the operation necessary varies greatly, and upon this variation depends not only the surgeon's decision as to the precise time at which the opening into the air-tube must be made, but also the precise point at which the operation should be performed. These general questions I treat of in detail. The special indications may conveniently, but somewhat arbitrarily, be arranged as follows, in groups, which I have attempted to make complete, although some of the conditions, being purely surgical, do not strictly come within the compass of this essay:
A. Acute inflammatory diseases of the larynx and trachea:
1. Acute oedema of the larynx.
2. Erysipelatous and exanthematous laryngitis.
3. Acute perichondritis, with abscess.
4. Diphtheritic croup.
B. Chronic affections of the larynx and trachea:
1. Syphilitic laryngitis.
2. Phthisical laryngitis.
3. Chorditis vocalis inferior hypertrophica.
4. Carcinoma of the larynx or trachea.
5. Non-malignant growths of the larynx or trachea.
6. Tumors overlying the superior aperture of the larynx.
7. External compression of the trachea by tumors of the neck or chest.
8. Strictures of the larynx or trachea.
C. Neurotic diseases:
1. Paralysis of the abductors of the vocal cords.
D. Traumatic conditions:
1. Foreign bodies in the larynx or trachea.
2. Impaction of foreign bodies in the pharynx or oesophagus.
3. Fracture of the larynx. Rupture of the trachea.
4. Scalds and burns of the larynx.
5. Incised and gunshot wounds of the throat.
6. Poisonous bites inflicted by certain insects about the mouth or neck.
7. Suffocation from the passage of blood, fluids, etc. into the air-passages (tracheotomy, with aspiration of the windpipe and artificial respiration).
8. Suffocation from the acute collection of either mucus or serum in the bronchia (ditto).
9. Suffocation from the inhalation or development of poisonous gases (tracheotomy, with artificial respiration).
Finally, although it pertains alone to the province of the surgeon, I may allude to the temporary tracheotomy and "tamponing of the trachea" which has been recommended—and certainly found efficient—in preventing the entrance of blood to a dangerous degree into the lower trachea and lungs during the performance of certain operations in the neighborhood of or upon the air-passages, such as resection of the upper jaw, the extirpation of large nasal and naso-pharyngeal polypi, removal of the tongue, subhyoidean pharyngotomy, laryngotomy, and extirpation of the larynx.1
1 For the details of this procedure consult Schüller, Die Tracheotomie, etc., Stuttgart, 1880.
All-important as a preliminary to the operation itself is a thorough knowledge of the surgical anatomy of the region upon which it is proposed to operate; and this not alone in the adult, but especially in the child, where essential differences often exist. Possible anomalies also are not to be forgotten.2 The assurance of the surgeon depends upon this knowledge: mere, manual skill will not compensate for its want; the success, both immediate and remote, of the operation is in great measure the reward of its possession.
2 See Pilcher, "The Anatomy of the Anterior Median Region of the Neck," Ann. of Anat. and Surgery, Brooklyn, April, 1881.
It will be remembered that the trachea commences at the inferior border of the cricoid cartilage, directly opposite to the lower edge of the fifth cervical vertebra, and reaches thence downward, in the median line of the neck, until it bifurcates opposite to the third dorsal vertebra. In its upper part it is nearly subcutaneous, and is surmounted by the prominent ring of the cricoid cartilage (easily identified, even in the young child), above which, in turn, lies a slight depression (the crico-thyroid space) between the cricoid and thyroid cartilages. As the trachea descends in the neck it recedes gradually, lying at the episternal notch about one and three-eighths of an inch from the surface. Throughout the whole of this course it is in relation with important structures. In its cervical portion it is covered by the sterno-hyoid and sterno-thyroid muscles, and in the median space, which is usually distinct between them, by layers of the deep cervical fascia. It is also crossed by the isthmus of the thyroid gland, which lies between the second and fourth tracheal rings; by the arteria-thyroidea ima, when present, and below by the plexus formed of inferior thyroid veins with their tributary and communicating branches. In the latter region, but more superficially, are some communicating branches between the anterior jugular veins. The innominate and left carotid arteries are also anterior to it in the episternal notch as they diverge from their origin. Laterally, the trachea is in relation with the common carotid artery, the lateral lobes of the thyroid body, the inferior thyroid veins, and the recurrent laryngeal nerves. The thoracic portion of the trachea is covered by the manubrium sterni, with the origins of the sterno-hyoid and sterno-thyroid muscles, by the left innominate vein, and by the commencement of the innominate and left carotid arteries. Still lower, the transverse portion of the arch of the aorta crosses, and the deep cardiac plexus of nerves lies in front of it. Posteriorly, throughout its length, it rests upon the oesophagus.
In performing, then, either the superior or inferior operation of tracheotomy, after cutting through the skin and superficial cervical fascia—which is really loose areolar tissue containing fat—the superficial layer of the deep cervical fascia is reached, and immediately below it more or less adipose tissue and the two anterior jugular veins lying in an inferior tracheotomy to either side of the wound, which is always made in the median line. As a matter of fact, these various layers are rarely demonstrable, and the surgeon proceeds irrespective of them until he reaches this point in his operation—viz. the muscles which overlie the trachea. These may overlap in the median line, and have to be retracted after having been separated; or, again, a thin line of connective tissue marks a slight interval between their inner edges, and is readily seen and dissected through if the operator has kept his incision vertical and strictly in the median line of the neck—a matter so important to the success of his operation that I do not hesitate to again allude to it. The muscles separated and gently retracted, together with the overlying tissues, toward the sides of the wound, the upper edge of the isthmus of the thyroid gland overlying the second and third, perhaps fourth, rings of the trachea, is always seen in a superior tracheotomy—its lower edge very frequently in the inferior operation. The isthmus is adherent to the trachea and to the larynx through the deep layer of the deep cervical fascia, but is capable of being slightly displaced or pushed upward or downward as the case may be, and thus kept from obscuring the operative field. This being done, the deep layer of the deep cervical fascia is seen covering and strongly adherent to the tracheal wall together with the thyroid veins. A few touches of the knife, carefully avoiding the blood-vessels, serve to clear it away, and the tracheal rings are clearly exposed.
In carrying out this dissection, which has been described as occurring in an ordinary and uncomplicated adult case, several matters must be borne in mind; and especially is this true if the operation concerns infants. In them, for instance, the thymus gland rises half an inch above the level of the sternum, and is frequently to be found as late as the sixth or seventh year. In both adults and children the innominate artery occasionally comes into view in an inferior tracheotomy, obliquely crossing the lower portion of the right half of the trachea. It is relatively higher in the child than in the adult. The left innominate vein is also often observed when the trachea is opened low down.
Certain abnormalities of the blood-vessels have been alluded to above. The commonest consists in the existence of a thyroidea ima artery, which when present usually arises from the innominate trunk, but sometimes from the right common carotid or the aorta: it passes to the thyroid body directly in the median line of the neck and close to the trachea; again, the place of the anterior jugular veins may be taken by a single central vessel, almost sure to be wounded during the operation if it exist (Mackenzie).
In performing the operation through the thyro-cricoid membrane (thyro-cricotomy) or through the cricoid cartilage alone (cricotomy), the same tissues are met with, and the same dissection is necessary in the earlier stage of the operation, as have been described in the operation of superior or inferior tracheotomy; but the parts are more superficial, adipose and cellular tissue less abundant, blood-vessels much less numerous, and the operation very much simpler. The thyroid gland of course does not come into view, and the crico-thyroid artery, a very small vessel, needs no attention in the dissection.
I have here and elsewhere included under the general term tracheotomy five distinct operations, having for their object the opening of the air-passages, which are surgically possible between the lower border of the thyroid cartilage and the upper edge of the sternum. In this classification I have followed that of Schüller, and its simplicity, but exactness, and the avoidance of the old confusion of different terms which results from the use of one intelligently employed, seem to me to commend it. These five operations are—1. Thyro-cricotomy, or the opening made through the crico-thyroid membrane alone. 2. Cricotomy, or the division of the cricoid cartilage alone. 3. Superior tracheotomy, the incision being made above the point where the isthmus of the thyroid gland crosses the trachea and below the cricoid cartilage. 4. Median tracheotomy, when, the isthmus being displaced or torn through, the trachea is opened immediately below its site. And 5. Inferior tracheotomy, the incision being made below the point of crossing of the isthmus of the thyroid gland, and at varying distances, dependent mainly upon the age of the patient and size of the parts, above the sternal notch.
Rarely, I am bound to admit, is the field of all of these operations as distinctly limited in practice as is here indicated, and one, perhaps two, are rarely selected. Thyro-cricotomy (old term laryngotomy) is often indicated, and cricotomy and median tracheotomy are sometimes performed as here described. Superior tracheotomy is commonly a combination of at least two of the methods—viz. the division of the upper rings of the trachea and the cricoid cartilage as well. It may even, probably frequently does, trench also upon the thyro-cricoid membrane (thyro-cricotomy) and upon the field of a median tracheotomy, the isthmus being pushed downward or even cut or torn through. The latter operation and cricotomy are, I believe, rarely if ever done from choice. Finally, inferior tracheotomy is a common method. As here described, it meets a large number of indications, and, despite its superior difficulties over the higher operations, is therefore necessarily often chosen; not infrequently, however, does it invade the median region, the isthmus of the thyroid being pushed upward.
Which of these operations shall be selected in a given case depends upon the particular conditions which render it necessary, and likewise, to some extent, upon the age of the patient. Durham summarizes the question very fairly. Thyro-cricotomy (old term laryngotomy) is by far the easiest operation to perform, and its execution is attended by least risk; therefore it is the operation to be preferred in any sudden emergency when suffocation threatens, and especially where the surgeon is alone with the patient. Generally, it is not as applicable as the others, especially in early childhood, on account of the limited dimensions of the thyro-cricoid space. It cannot be recommended in cases of acute or extensive diseases or injuries of the larynx, nor is it likely to be of much service if a foreign body is in the trachea or bronchus. On the other hand, it is probably the best operation to adopt in cases in which foreign bodies are impacted in the larynx, in cases of limited chronic disease or contractions of the superior laryngeal parts—usually the result of syphilitic ulceration—and in cases in which respiration is impeded by intra-laryngeal growths which cannot be removed by the natural passages.
Cricotomy, combined with superior tracheotomy (old term laryngo-tracheotomy), is not a difficult operation, and may be advantageously practised, especially in children; in the adult it meets many indications. Holmes recommends it the more urgently, in preference to an inferior tracheotomy, the earlier the age of the subject may be.
Inferior tracheotomy is comparatively difficult to perform, and during its performance dangers may have to be encountered greater and more numerous than those met with in either of the other operations. This is true certainly of children. As regards young children, Holmes states that after the age of five or thereabouts the surgeon can, if he prefer it, open the trachea below the isthmus of the thyroid gland. He himself does not recommend the operation before puberty. In the case, however, of a foreign body loose in the windpipe of a child, where a large opening is required, it can hardly be obtained above the thyroid body and below the cricoid. To cut through the isthmus of the thyroid (median tracheotomy) is, in early life at least, a doubtful proceeding when it is of large size, on account of its vascularity, and the incision must be made below it—in other words, an inferior tracheotomy.
When the operation of tracheotomy shall be performed is a question which the experience and individual views of the surgeon, based on experience, must decide in each case. The doubt always arises in the mind of the inexperienced operator whether the symptoms are sufficiently urgent to render the operation necessary. To him these general rules may be given: The immediate indication for the operation is to be looked for in the thorax. It is the recession of the lower part of the sternum and contiguous ribs and the retraction of the intercostal spaces and clavicular fossæ at each act of inspiration. He must not wait until lividity of the lips and blueness of the fingernails prove that the blood is being imperfectly oxygenated (Mackenzie). Let him remember also that, aside from the immediate and imminent danger of sudden suffocation, a remote one exists and increases the longer he postpones his operation and allows the struggle for air to continue—viz. vascular engorgement and oedema of the lungs, especially in young children; the production of all those conditions which allow, and even predispose, the lung after the operation to fall an easy prey to the inflammatory processes.
The instruments necessary for the performance of the operation of tracheotomy are few and simple, and are such as may ordinarily be found in any small operating-case. A scalpel, a probe and sharp-pointed bistoury, dissecting and artery forceps, a tenaculum, a grooved director, two small retractors, scissors, and a dilator for the tracheal wound, are necessary. To these may be added the needles and thread, waxed ligatures, sponges, and tape. The tracheal tube is elsewhere described. A faradic battery, good suction syringe, and a large flexible catheter may render good and timely service if at hand.
It is true that many other and more or less complicated instruments have been devised for the purpose of facilitating the operation; and other methods, aside from that of the knife, have come of recent years into vogue; but, still, simplest means, as above given, have in the experience of most surgeons been proven to be the best. This statement, undeniably true for all surgical measures, is especially so for the operation under consideration, which is often necessarily undertaken without opportunity for elaborate preparation and under the most adverse and inconvenient circumstances. The more familiar, therefore, the surgeon is with his instruments, the better and more certain will be his work.
Holding this view, it is unnecessary for me to more than briefly mention such instrumental aids as the grooved tenaculum of Chassaignac, the groove serving to guide the operator's knife into the trachea; the sharp double hooks of Langenbeck, which, after being caught in the tracheal walls to either side of the site of the intended incision, are sprung apart after the latter is made, thus dilating the wound and rendering the introduction of the tube easy; the tracheotome of Thompson, a pair of curved cutting forceps, the blades of which are caused to open by a screw after they have been plunged through the tracheal walls; that of Garin, a forceps with curved blades—one, the longest and sharpest-pointed, being made to penetrate the trachea, the instrument then opened, and both blades cut their way to the desired extent of incision; finally, the tracheotome of Maisonneuve, a curved dilating hook with cutting inner edges. Its point is entered between the first and second rings of the trachea and brought out again between the fourth and fifth; the handle is then carried under the chin, so that the blades are made to cut through the trachea and the skin between the points of insertion and exit, after which, upon pushing a spring, the two halves of the hook separate, and the canula is introduced between them (Thornton). And the trachea-stretcher of Marshall Hall, by means of which a portion of the trachea is cut out and the opening kept patent.
None of these instruments have been proven to possess any practical worth; on the contrary, their use, especially that of the latter forms, has in more than one instance been attended with disastrous results.
To obviate the danger of serious hemorrhage during the performance of tracheotomy, both the galvano-cautery knife and the thermo-cautery instrument of Paquelin have been recommended within the past few years, and a number of operations placed upon record. The procedure is the same whichever means be used. The skin and soft parts overlying the trachea are usually alone cut through by means of the cautery-knife, the cartilaginous rings of the tube, when reached, being divided with the ordinary knife. This fact alone speaks against the thoroughness attainable by means of these methods; but, still more important, neither has been found reliable in checking hemorrhage, and in several instances the operator has been obliged in haste to lay aside his cautery apparatus and turn to the ordinary and better-known means to complete his operation. The healing of the tracheal wound made by the cautery is slow: erysipelatous inflammation may attack the wound as the result of the burn, and extensive sloughing of the edges is not unknown, while the resulting cicatrix is large, strong, and contractile, and has caused, in one case at least, a stenosis of the trachea. In the face of these facts he must indeed be an enthusiastic advocate who would recommend the procedure. Mackenzie justly remarks that the use of the thermo-cautery for opening the air-passage merely introduces an unnecessary complication into the operation.
The choice of a proper tube, one suited to meet the special indications in a given case and specially adapted to the age of the patient and the calibre and position of his trachea, is no unimportant matter, and may do much not only to facilitate the immediate success of the operation, but likewise prevent the occurrence of those possible unfortunate results, ulceration, fatal hemorrhage, abscess, pneumonia, and pyæmia, no lack of which are recorded in our literature.
Although the number and variety of mechanical devices and forms of tracheal tubes that have from time to time been devised by the inventive ingenuity of operators is large, the choice practically centres upon one of two forms. The first, and the one most commonly used, is but the original canula of Trousseau, modified by Roger, in that the tracheal portion of the tube is detached from the collar or neck-piece, and moves freely with the movements of the patient; and by Obré, by the important device of an inner tube to prevent clogging of the outer or original tube by mucus. Starting upon this essential basis, the instrument-maker has perfected the instrument of to-day. It is a silver tube, double throughout, the inner tube projecting at the lower or tracheal end beyond the outer—an important point, as it prevents any possible permanent occlusion by mucus or blood-crusts, membranes, and the like at this point, removal of the inner tube at once clearing the end of the outer one. The curve of both tubes should correspond to the arc of a quadrant, and the outer is fastened to a transverse collar or shield by means of two small projections or pins upon its sides which lie under small wire bridges upon the shield after it has passed through an opening in the transverse neck-collar large enough to permit of its free movement during the respiratory movements of the trachea, as well as during the forcible action caused by cough. The ends of this collar or shield curve slightly backward to correspond with the curve of the neck, and are perforated by, preferably, large oval openings, instead of the usual small, inconvenient slit, through which the tapes are passed which hold the tube in position by encircling the neck. To this same shield is fastened, by means of a small turn-screw or a revolving collar, the end of the inner tube, which is thus prevented from being forced out of the outer tube by coughing or any motion of the patient. Upon the upper or convex surface of the outer tube a small ovoid opening is usually made for the purpose of permitting the expiratory current to pass upward (the inner tube being removed) into the larynx and render phonation possible; also, the free opening of the outer tube being closed, to allow of respiration being carried on through the larynx and natural passages—often an important matter, as the case progresses toward recovery, in instances where the operation of tracheotomy has been performed on account of laryngeal obstruction.
A set of these tubes, which can now be readily obtained, should consist of four, with the following diameters: No. 1, one centimeter; No. 2, nine millimeters; No. 3, seven millimeters; No. 4, five millimeters: their length is of course in relative and fixed proportion to these measurements. A tube should always be selected less in diameter than the trachea operated upon: to seek to introduce one of the same calibre is not only unnecessary, but cannot fail to be dangerous. Tubes constructed upon the same principles as that just described (Lüer's) are made of hard rubber instead of silver (Leiter): their lessened cost is their principal recommendation, added to the one that they are more easily kept clean and sweet than the silver tubes. The fact that they are necessarily made much heavier and thicker than the latter is a disadvantage, the lumen of a hard-rubber tube being smaller than that of a silver tube of corresponding external diameter. The objection urged against them, of their great danger of breakage, I have not found borne out by experience. Tracheal tubes are also constructed of platinum, and recommend themselves on the score of lightness.
The main objection to any of the forms of tube just described exists in the nature and shape of their curve, which not infrequently causes the lower or tracheal end to lie in contact with the anterior tracheal wall, or its convexity with the posterior, and irritate, even ulcerate, them. This misfortune is entirely obviated by the canula of Durham, the second of the two forms to which I have called special attention, and which is essentially a right-angled tube, made of four sizes, with a long horizontal portion, varying from 7 to 4 centimeters, and short vertical portion, of from ½ to ¾ of an inch in length and slanting slightly backward. The former portion is capable of being lengthened or shortened in any sized tube by means of a screw arrangement attached to it as it passes through the usual neck-collar or shield; and the vertical tube can thus be correctly adapted to the particular depth at which the trachea naturally lies in a given case from the surface; and not alone this, but also to the condition of the overlying parts, whether thin or fat, swollen or otherwise. Once in position, the vertical portion of the tube remains in the long axis of the trachea, and does not touch its walls to any injurious degree. Owing to its right-angled shape, the angular and descending portions of the inner tube of this canula are necessarily made upon the lobster-tail principle, with joints—a possible disadvantage, as they can become clogged with mucus and may become detached. Other modifications and improvements exist in this Durham canula over the older one first described, which add to its utility, but need not here be dwelt upon. Suffice it to say that the tube is an excellent one for its purpose, and is deservedly highly spoken of and recommended by those who have had experience in its use. Its cost is an objection.
The other forms of tracheal tube need but passing mention. The bivalve canula of Fuller is made in two lateral segments, fastened to a collar and tapering when closed to a point, so that introduction of the apparatus through the tracheal wound is made easy. Once introduced, an inner complete canula is slid into its place, thus separating the two outer halves and rendering the whole round and compact. It has been criticised unfavorably on account of the danger of hemorrhage that it is likely to cause through pressure on the tracheal walls by the sharp edges of the outer canula. In Gendron's canula the same lateral blades are separated after introduction by means of a screw fastened on a transverse bar.
Soft-rubber canulas were introduced to the profession not long since by Morrant Baker for subsequent use after the operation of tracheotomy, the usual tube having been worn meanwhile for a few days. Being soft and flexible, they are certainly safe and comfortable for the patient, but their thickness and the absence of any inner tube are, especially the latter, serious disadvantages. They are not, I believe, generally used. Finally, the long, flexible tracheal tube of König was devised by its author to meet the indications in cases where the trachea is compressed from without by tumors, and where a long canula that is flexible, but at the same time rigid enough to resist pressure, becomes a necessity. It is made in the form of the ordinary tracheal canula, only larger, some three or more inches of the centre of the descending portion of the tube being constructed of spirally-twisted silver wire.
It may not be out of place to remind at this point that a tracheotomy is not infrequently performed, of necessity, very hastily, and in the absence not only of a tracheal tube, but likewise of other and even more essential instruments. The lack of the former need never be a barrier to the prompt performance of the operation, for the ready wit of the true surgeon will show him various ways out of his temporary difficulty. A thick goosequill fastened by threads passed through its outer end makes an efficient improvised canula. A bit of elastic catheter answers the same purpose. Retractors for the edges of the tracheal wound, made of wire—silver if it be at hand, a couple of hairpins if it be not—and connected together by an elastic tape which passes around the neck, will not only answer a good temporary purpose in holding the tracheal wound dilated, but have been recommended by Martin—in a more elegant form, it is true—as a proper method of treatment after opening the trachea. Finally, one or more stitches passed through the cartilaginous edges of the wound, and attached to the soft parts beyond it, will serve to secure its patency, at least temporarily.
If a patient be doomed to wear a tube constantly in his trachea, the instrument described above can be removed at a suitable interval after the operation and its place supplied by a single tube of the same size and form as has been found adapted in the case. In the convexity of this permanent tube an ovoid opening should be made to allow of the passage to the larynx of the respiratory current, in part at least, and to its mouth a pea-valve may be fitted which shall admit air on inspiration, and not allow it to escape on expiration, thus doing away with the necessity of the patient's closing the opening of his tube with his finger each time that he requires to speak. Several forms of these valves have been devised, but practically they are of little use, are annoying to the patients, and, as a rule, not tolerated by them.
How shall the operation of tracheotomy be performed? An answer to this question necessitates a short description of the operative steps of the different procedures that is given in the order in which, I believe, the operations are, as a matter of experience, found to occur in practice—viz. 1st, superior tracheotomy, combined or not with cricotomy; 2d, thyro-cricotomy and, 3d, inferior tracheotomy. Certain preliminaries are common to all.
The patient should be extended upon a table covered with one or two thicknesses of blanket and of suitable height, which has been placed sideways in front of a window if the operation is done by daylight. (At night several candles tied together afford a better and safer light than a kerosene or oil lamp.) The surgeon stands at the right side of his patient and facing the window. Of his two assistants—and the value of trained assistance in this operation is inestimable—one faces him, without obscuring the light, and is prepared to use the sponges, hand the instruments, manipulate the retractors, and render such direct assistance as may be required. The second sits at the head of the table and holds the head of the patient steadily, the neck being well extended and thrown backward over a small round pillow (or, better, a wine-bottle wrapped in a towel) which has been placed beneath it. The head must be held directly in the median line of the patient's body, and even in that of the operating-table. The assistant's attention must never waver from this important duty. In certain cases too great inclination of the head backward serves to increase the urgent dyspnoea, or even to check respiratory efforts. This effect he must watch for, and be prepared to relieve instantly by raising the head. His duties also include the preliminary administration of an anæsthetic, and its use during the operation if required. That such use is safe in this class of operations is now generally admitted, but it is not always necessary. The operation is not an exceedingly painful one, and I have often performed it, with the adult patient's consent, without using any anæsthetic (sometimes freezing the skin over the site of the incision before making it), he submitting rather than undergo any addition to the sense of urgent dyspnoea from which he is already suffering. In children anæsthetics—ether being more commonly employed, although chloroform is often used—are much more necessary, often indispensable. Their effects are speedily manifested when asphyxia is present in any marked degree, and but little of the vapor need be inhaled. The administration, always to be carefully watched and profound anæsthesia avoided, renders breathing easier in many instances, certainly lessens laryngeal spasm, and may be discontinued early in the operation when the air-tube is or has been nearly reached by dissection. Any slight risk attending their use is more than outweighed by the safety and precision which they ensure in the more difficult and delicate steps of the operation (Sands). If the patient be already insensible or if death be imminent, their use, of course, is contraindicated.
The operator having previously decided which operation he will perform, and after carefully identifying the position of the various parts, the larynx especially, marking them with ink upon the skin if he chooses, now steadies the loose skin over the site of his intended incision, and then makes it, freely, firmly, cleanly, and exactly in the median line. If it be for a superior tracheotomy, combined or not with cricotomy, the operation I shall first describe, it must extend from just at the notch of the thyroid cartilage downward for about four inches. A free external incision is very desirable in all cases. The subcutaneous tissue now rapidly dissected through by the careful use of the knife, the veins as met with either being pushed to one side or, if they cross the line of incision, cut if small, then twisted or immediately ligated, or if large doubly ligated and then cut between the ligatures, the interval between the sterno-hyoid muscles is sought for and found, then separated by the blade or handle of the knife and held apart by retractors at the side of the wound. It is important that the faint whitish line of connective tissue which marks the interval between the muscles be recognized, otherwise it happens that the operator passes through the body of one of them, deviates at once from the median line, and approaches the side of the trachea instead of the front. The ring of the cricoid cartilage above and the upper edge of the isthmus of the thyroid gland below can now be either seen or felt by the finger in the wound between them; and about the latter lies more or less connective tissue and numerous small veins. As a rule, careful touches of the point of the knife, or, as some operators prefer at this stage, its handle or the use of a blunt director, serves to dissect up piecemeal or tear through and clear this away, the veins again being pushed out of the way, or if necessary cut and tied, and all parts held aside by removing and replacing freshly the retractors from time to time as the dissection proceeds, until the ring of the cricoid and the upper rings of the trachea come plainly into view; that is, are seen, not alone felt. During this dissection, especially if the handle of the scalpel be used, too much pressure must not be made upon the trachea. More than once I have known it to cause sudden suspension of the respiration, probably by exciting reflex spasm of the larynx. If the isthmus of the thyroid gland extend far upward, it must be pressed downward, its facial attachments to the cricoid and trachea cut or torn through, and may require to be held downward in the lower angle of the wound by an additional retractor. The upper rings of the trachea having been thus well cleared of their overlying parts, the next step of the operation follows. I am in the habit of now removing the retractors and allowing the trachea, which may have become displaced by them, to resume its normal position, the head of the patient being meanwhile readjusted. All this takes but a few seconds. A tenaculum is then implanted in the median line, either just below the edge of the thyroid or the cricoid cartilage, if the latter is not to be severed, and held firmly by the assistant at the head of the table, thus steadying and elevating slightly the trachea and rendering the incision into it certain. The retractors are now reintroduced at the sides of the wound, and the operative field is clear and steady. A glance having shown that all bleeding has ceased, another that the tracheal dilator and tracheotomy-tube lie ready at hand, the operator plunges a straight-pointed bistoury through the tracheal wall at the level of the third or fourth ring in the median line, and cuts quickly upward until the cricoid cartilage is reached, if he proposes, as in the adult can usually be done, to limit his operation to a superior tracheotomy. If not, as in the child, and the cricoid cartilage must be cut through to gain sufficient space for the introduction of the tube, it also is severed by prolonging the incision upward to the thyro-cricoid membrane. A hissing of escaping air, with the bubbling of a little blood and paroxysms of cough, follows the incision and shows that the trachea has been fairly opened. The tracheal dilator is now introduced, the lips of the tracheal wound separated, and the canula slipped neatly into the windpipe (unless in the case of a foreign body), and secured a moment or two later, when respiration is fairly established, by tapes passing around the neck. The tenaculum and retractors are removed at the same moment that the tube is slipped into place.
Many different methods have been recommended for the dilatation of the tracheal wound and to assist the introduction of the canula. The dilator (Trousseau) which has been mentioned surely answers all purposes, and is simple and easily used. An ordinary dressing forceps will likewise do the work if introduced closed and afterward opened. More complicated procedures are unnecessary.
Thyro-cricotomy requires that the superficial incision be so made over the larynx that the thyro-cricoid space shall lie in the centre of one, about two inches long, made in the median line. Following now the dissection just described, the thyro-cricoid membrane is easily reached and quickly seen as soon as the sterno-hyoid muscles are retracted. It should then be divided transversely close below the lower edge of the thyroid cartilage, the wound dilated, and the tracheotomy-tube slipped into place.
Inferior tracheotomy demands that the external incision be free. In children, and in adults with a short neck, it should extend from the cricoid cartilage to just above the sternum. The subsequent steps of the operation are as for superior tracheotomy, with but slight differences. The anterior jugular veins may come into view, but can generally be avoided. If they are joined by a transverse branch, this is necessarily cut through after being doubly ligated. After the thyro-hyoid muscles are separated, the rings of the trachea are much less distinctly felt at first than in superior tracheotomy, being covered by more connective tissue and numerous veins. These inferior thyroid veins, especially if large, are the great obstacle in the way of this operation, and much care is necessary in order to avoid them, which should be done if possible. The lower edge of the isthmus of the thyroid gland, which presents to a variable extent above in the wound, does not, as a rule, offer any obstruction. The thymus gland present in infants is easily pulled downward and out of the way. The trachea at length fairly exposed and all bleeding controlled, the left fore finger of the operator is placed in the lower angle of the wound to securely protect the large blood-vessels here located, and the incision made through some three tracheal rings from below upward.
It may happen that in either a superior or inferior tracheotomy no time will be allowed for careful and slow dissection as here described. In such instances Durham advises that the surgeon grasp the trachea between the fore finger of his left hand on the left side and the thumb on the right, and make uniform, steady, deep pressure, thus firmly securing it and at the same time protecting the large vessels of the neck. The fingers thus placed are not to be moved until the trachea is reached, which is accomplished by rapid incisions confidently made. The pressure of the fingers causes the wound to gape and the trachea to advance. The latter reached, it is caught by the tenaculum and the operation completed as before described.
The operation of median tracheotomy may require a word. As has been stated, that part of the trachea covered by the isthmus of the thyroid gland is very commonly encroached upon in performing either or both superior and inferior tracheotomy, the isthmus being slightly displaced from its site. Other than this the site here mentioned would rarely be selected as the point for opening the trachea. Certain conditions, it is true, might render it necessary, but they would be rare. The danger lies in the hemorrhage which, theoretically at least, is to be expected when the isthmus of the thyroid gland is either torn or cut through; but opinions vary very greatly as regards this danger. With a thin, narrow isthmus in children I have frequently, in performing superior tracheotomy, cut my way through to a sufficient extent to clear a suitable space upon the trachea through which to introduce a tube without difficulty or danger. I should not recommend the procedure, however, were the isthmus to be seen to be, when reached, thick, wide, and exceedingly vascular, but at the same time believe that the danger even here of cutting into it is much overestimated.3 Roser's recommendation to apply a ligature to the isthmus on either side of the median line previous to its division is not generally applicable. Hueter has shown that the fibrous capsule of the thyroid gland enclosing it and its blood-vessels is firmly attached to the trachea and sides of the larynx, and that from the isthmus this fascia extends upward over the larynx (fascia laryngo-thyroidea), and thus prevents, in a measure, attempts at displacing the gland downward. Bose4 recommends that this fascia be divided transversely over the anterior convexity of the cricoid cartilage, when a director can be passed behind the isthmus, to lift it from the trachea and depress it far enough to expose three or four of the rings: the capsule of the gland thus remains unbroken and no hemorrhage occurs. The procedure certainly merits trial; twice it has succeeded well in my hands.
3 See Foulis, "Some Points on Tracheotomy," Glasgow Med. Journ., vol. xv. No. 2, p. 123.
4 Archiv für klin. Chirurgie, vol. xiv. p. 137.
Cricotomy, the division of the cricoid cartilage alone, is an operation which, as far as I am aware, is rarely ever performed. The objection urged against it, however, that in the adult the elasticity of the cricoid cartilage is so great that a wound through its ring cannot be made to gape sufficiently to allow of the introduction and retention of a canula without discomfort and danger of necrosis of the cartilage, is not borne out by experience. In children the objection cannot of course be urged.
The description of the operative steps which has been given, and which comprises the routine in an ordinary and easy cure, should not mislead. The operation is not always as simple and safe as would appear from what has been said. At times complicated and difficult, at times dangerous in practice from the delay involved, it demands in all, but especially in certain urgent cases, a trained hand and eye, sound anatomical knowledge, coolness, self-reliance and presence of mind on the part of the operator. Despite the greatest caution, and even in apparently favorable cases where time for dissection and deliberation is allowed, certain mishaps may occur which complicate the operation to a serious, dangerous, or even fatal degree. Some of these, as will be seen, are avoidable with care, but others may happen that are not only unavoidable, but totally unforeseen, and from their very suddenness all the more embarrassing.
Accidents may occur during the dissection of the soft parts overlying the larynx and trachea, and the importance of carefully determining by palpation the location of the various parts prior to making the preliminary incision, and of studiously preserving their relation and location during the dissection, cannot be overestimated. Neglect of this precaution has in more than one instance led to the air-passages being opened through the thyroid cartilage or thyro-hyoid membrane, instead of at the intended point. It should not be forgotten also that the natural laxity of the several layers of connective tissue of the neck is much increased by their division, and that the trachea, being naturally freely movable, is thus very easily displaced from its normal position during the act of dissection; especially will this happen when unskilful attempts are made to hook aside or retract the divided structures during the operation. Thus it may easily occur that the entire trachea is drawn to one side and entirely lost, or, more commonly, is turned upon its vertical axis, and finally opened at the side instead of anteriorly in the median line. It may not be opened at all, either being altogether missed by the surgeon in his dissection, which is continued past it, even down to the vertebral column, or the tracheal tube may be passed into the tissues lying in front of the trachea, under the mistaken idea that the latter has been incised. Persistence in keeping to the median line during dissection—a golden rule in the operation of tracheotomy—will render the first accident impossible; the second may be avoided by hooking up the trachea, as has been described, before incising it. If the opening into the trachea has not been made large enough to receive the tube, as often happens to the young operator, and even to the experienced when he fears to extend his incision on account of the proximity of the thyroid isthmus, no resource remains but to carefully enlarge it, pushing the thyroid isthmus or veins from before the course of the knife. If the opening be small, and be lost both to touch and sight, a second should at once be made, especially in urgent cases, and no time lost in searching for the first. This opening must be made directly in the median line, otherwise the canula will stand awry in the wound and be easily dislodged from its position in the trachea. If the first opening made is faulty in this respect, it is better to at once make a second. It may seem unnecessary to warn the surgeon against thrusting his sharp-pointed bistoury too far inward at the moment of incising the trachea; but as a matter of fact it has been driven through both anterior and posterior walls, and even through the oesophagus, until it has struck the spine. The converse, or a too superficial incision, is an accident more likely to occur, the point of the knife not being made to penetrate the mucous membrane of the trachea, which is probably swollen and thickened. No relief in such cases follows the incision, and an attempt to introduce a tracheal tube may cause it to pass between the mucous membrane and tracheal walls into the submucous tissue, thus stopping up the tube as it progresses. The disastrous result of such an accident can readily be foreseen unless the complication be quickly appreciated as to its nature, the tube withdrawn, and the incision completed. Much more frequently will a somewhat similar accident occur in the operation of tracheotomy for croup or diphtheria. The pseudo-membrane overlying the walls of the air-passage is not penetrated, but pushed before the knife, which has properly incised the walls of the tube; the introduction of the canula now crowds this membrane still farther back toward the posterior tracheal wall, and a complete tracheal stenosis is added to the pre-existing laryngeal one; sudden and urgent dyspnoea follows, and prompt relief alone wards off fatal suffocation. Fortunately, in such instances the forcible efforts at respiration and struggles of the patient are often sufficient to break through the occluding membrane and allow the respiratory current to pass. Violent cough often follows, and more or less of the membrane is forced out through the tube. Should these events not come instantly to pass, the surgeon must not wait for the efforts of the patient, he being often cyanosed and unconscious at this point, but by passing an elastic catheter down through the tracheal tube break through the occluding membrane forcibly. The occurrence of such an accident is always denoted by absence of respiration through the canula and by alarming asphyxia, and its cause needs but little reflection to be appreciated.
Much the same train of events happens if during the introduction of the canula large portions of the false membrane are completely detached and drawn down into the lower trachea by the violent inspiratory efforts of the patient, or stripped up from the mucous membrane and pushed downward into the air-tube. No time should be lost in either case in removing the tracheal tube, dilating the tracheal wound by forceps or otherwise, and in endeavoring to clear the trachea by seizing the obstructing membrane with forceps. If this be unavailing, the suction-syringe must be adapted to the mouth of the canula and the trachea cleared by aspiration. A large elastic catheter may take the place of the canula. Sands recommends in such instances as the foregoing that another opening should be freely made below the first one in the trachea, when respiration will probably be re-established. The success of this procedure of course depends upon the depth to which the false membrane has been drawn in the trachea.
Schüller regards the moment at which the trachea is opened as the most important and most dangerous of the whole operation. Certain of the accidents which may occur at this period have been detailed; others remain to be spoken of, one of which at least—viz. hemorrhage—requires special mention. Even before the tube is cut into it may cause an important question to arise for the surgeon's decision. A bleeding, often copious and persistent, which arises during the course of the operation from the accidental or unavoidable wounding of the thyroid veins, especially when they are large and numerous, the patient unruly, and perhaps with a short fat neck, and the fact that having wounded one the blood flows so over the parts as to obscure and increase the chance of wounding others, constitutes one of the commonest difficulties met with in the operation of tracheotomy. Hemorrhage arising from a wound of the thyroid isthmus is much rarer, and neither, as a rule, need be feared if due care and promptitude be exercised. But should it occur in a case in which the urgency of the dyspnoea allows of no time in which to employ the ordinary methods by ligature, torsion, pressure, or otherwise of checking it, shall the incision be made and the risk boldly incurred of blood passing to a dangerous degree into the trachea, and this in the face of the oft-repeated advice—the, in some quarters, absolutely given rule—that the trachea is never to be opened until all hemorrhage has ceased? I hold that it unquestionably should be, and that he who waits in many instances until the former moment will have to wait until his patient is dead. Durham truly says that it is useless to let the patient die from suffocation while attempting to prevent death from loss of blood; and yet this has been done.
In any case, then, where there is great venous congestion, marked venous bleeding, and little time, the patient being on the point of suffocation, the surgeon should carefully but boldly proceed and complete his operation in spite of the hemorrhage, opening the trachea and introducing the canula even though the entire field of his operation be obscured by blood. The tracheal opening once made under such circumstances, the patient, if the blood which enters the windpipe be not coughed up again, may be turned upon his face, so that the blood will gravitate toward the tracheal opening and the lips of the latter compressed about the rigid tube; or the blood may be aspirated from the trachea by means of the suction-syringe through an elastic catheter in the wound or the tracheotomy-tube by the operator's mouth, according to the urgency of the case. These measures answer for the slighter cases, but where the patient has suffered from urgent impending suffocation before the opening of the trachea, the entrance of the blood and its suction downward by the first inspiration may make it complete, and the danger is great. Still, the choice lies between the two evils, and the advice given above holds good. To the treatment there recommended will now have probably to be added artificial respiration and faradization. Comfort in any case may be taken in the fact that the re-establishment of respiration through the tracheotomy wound quickly relieves the pulmonary capillaries and the right heart of their distension, the venous circulation resumes its natural course, and the venous bleeding, perhaps alarmingly free, ceases almost immediately or is readily checked by pressure.
Where time is afforded and despatch in the operation is not a necessity, the trachea should not be opened until all hemorrhage has ceased. This, as a rule, is readily controlled by the usual measures, and in a large percentage of operations is not excessive. A direct fatal hemorrhage is very rare; likewise an arterial hemorrhage of any extent, especially if the possible anomalous position of certain arteries, such as the thyroidea ima, be borne in mind and care in making the incision exercised. Nothing but gross carelessness on the part of the surgeon and entire loss of presence of mind can account for the opening of the carotid or innominate arteries, as has been done. During the performance of the low operation of tracheotomy the finger of the operator must more or less frequently be pressed into the lower angle of the wound, and his anatomical sense constantly on the alert.
The entrance of air into a vein during the operation is a possible accident, especially when it is much enlarged and imbedded in dense tissue, as sometimes occurs in malignant disease of the throat or when large tumors of the parts exist. Should such an unfortunate complication occur, the proper treatment, according to Erichsen, should be compression of the wounded vein with the finger and its immediate ligation if possible; compression of the axillary and femoral arteries and a recumbent position for the patient to favor cerebral circulation; and, lastly, artificial respiration.
At the moment of opening the windpipe two conditions may suddenly supervene, both of which need, as may usually be easily done, differentiation from the asphyxia produced by the entrance of blood into the trachea. The first of these is the apnoea which not unfrequently arises in children suffering from urgent dyspnoea the moment that a free opening is made and the air-stream rushes unimpeded into the lungs. The condition lasts but a moment or two, and need excite no alarm. The second is based upon the fact that the operation itself not seldom excites an alarming asphyxia, probably by provoking laryngeal spasm. The introduction of the tube serves to promptly relieve it.
Finally, I may refer to those rare but unfortunate and unpreventable cases where the introduction of a tracheotomy-tube after a carefully conducted operation fails to give relief. Such instances are reported by several authors, and depend upon the existence of some unascertained pathological lesion, such as the presence of a stricture of the trachea below the site of the operation, compression of this tube from without or a tumor within, stricture of the primary bronchi, or some similar condition. A careful preliminary examination and study of the case will in the majority of instances do much to fix the indications for the operation and perhaps account for the surgeon's failure.
The operation itself having been practically completed with the introduction of the canula, the after-treatment of the case now becomes the important consideration. This naturally varies in accordance with the accident or disease which has rendered the opening of the trachea necessary. In the instance of a foreign body lodged in either larynx or trachea the tube may at once be removed as soon as the former is removed or expelled. Indeed, the introduction of the tube is often unnecessary, as the offending article flies out through the wound as soon as the trachea is opened. The only contraindication would be to this rule when the foreign body is of a sharp and irritating character, and has been impacted in the larynx, especially of a child, and consequent inflammation and swelling of the parts may confidently be looked for. Should the operation have been called for on account of laryngeal or tracheal obstruction due to syphilis, both constitutional and local treatment are indicated, the latter varying with the special conditions presented, and being fully described in the section of this work treating of that subject. The patient not infrequently is obliged to wear the tracheal tube permanently. In croup and diphtheria the first efforts of the surgeon after introduction of the tube should be directed toward the removal of such shreds of the membrane as present through the tube or may be reached by forceps introduced through it into the air-passage. Large quantities may thus often be gotten away, to the manifest relief of the patient. A pseudo-membrane covering the vocal cords and causing glottic stenosis has thus also more than once been removed through the wound. A feather carefully passed through the tube into the trachea, by exciting cough and through its mechanical effects, is of assistance in promoting the expulsion of membrane lodged in the trachea below the wound. The use of an elastic catheter and aspirating syringe for the same purpose is advised by Roux and Hueter. In any case, constitutional treatment as well is indicated, and other measures—viz. the inhalation of steam, direct local applications, and the like—such as may meet the views of the particular operator.
Granted that the operation has been performed to meet the indication in cases of sudden and urgent dyspnoea arising from the passage of blood into the trachea or the accumulation of serous fluids in the lower air-passages, as well as in cases of dangerous intoxication from the effects of poisonous gases and narcotics, aspiration of the trachea in the former instances, followed by artificial respiration in all, and perhaps the catheterization of the trachea in the latter, as advised by several recent writers, will tax the surgeon's energies as the primary consideration after his operation. The catheter may be first used for the purpose of aspiration in the former cases, if necessary, then for the injection of air, it here taking the place of the natural upper air-passages.
In cases of acute laryngeal oedema, certain chronic inflammatory processes, neoplasms in the larynx or trachea, and injuries or wounds of the air-passages, the proper treatment, aside from that of the necessary tracheotomy, will suggest itself on ordinary surgical principles, or is elsewhere specially treated of in this work in connection with the subjects themselves.
Aside from these special indications for after-treatment, which must be met as they arise, there are certain general rules for the management of any case after the tracheotomy-tube has once been inserted: they relate mainly to the care of the patient, the dressing of the wound, and the care of the canula.
A variable period of intense and exhausting suffering from dyspnoea having probably preceded the operation, the sooner the patient is allowed to seek refreshing sleep the better; and this may be allowed if there be no danger of hemorrhage. Nourishment of a fluid character and stimulants, if necessary, are to be allowed in quantities and at times dictated by good judgment. The patient's first attempts at swallowing must be watched and directed, as the fluids frequently pass in part for a short time into the larynx, and may appear at the tracheal wound. If the condition persist, it may be, no other apparent cause existing, because the tracheal tube is too long and presses on the posterior wall of the trachea, thus interfering with deglutition. For the first day or two at least a competent nurse must be in attendance, and the care of the tube entrusted, after explicit directions, to her. For the first twenty-four hours the secretions usually need to be constantly cleared from the mouth of the inner tube as they are coughed up by the patient, and the tube itself occasionally removed and thoroughly cleaned in carbolized water (or water to which a little borax or potash has been added) by means of a bristle brush, such as is used for cleaning pipes. As the case progresses, the secretions are not as profuse or annoying, and the patient learns to assist himself, in caring for his tube and to remove and replace the inner one. Attempts at using the voice are to be abstained from, and a slate or pencil and paper used until, if the case progress favorably, the third day, when he may be shown how to produce it by closing the outer fenestrated tube (the inner being removed) with the finger. The outer tube does not require usually to be removed, except in diphtheria, for cleansing until the third or the fourth day, prior to this it being done by means of a feather. The removal of the tube should always be done by the surgeon himself, and the occasional danger of its difficult reintroduction, caused by the swelling of the parts, not forgotten. At the same date, the wound sutures may be cut and removed. After its first removal the outer tube is taken out, cleansed, and replaced at each daily dressing, which consists in the washing of the wound with carbolized solutions, the application of adhesive strips, if necessary, across it after the sutures have been removed, and the insertion between the neck-plate or collar of the tracheotomy-tube and the skin, upon which it presses, of a layer of sheet lint covered by a little simple cerate or like dressing. The tapes attached to the canula for fastening it about the neck need changing, and care must be taken to regulate each day their degree of tension about the neck in proportion to the amount of inflammatory swelling attendant upon the wound through the soft parts overlying the trachea.
The patient, during, especially, the first few days after the opening into the trachea has been made, should be kept in a well-ventilated room with a uniform temperature. There is rarely any occasion, except in cases of croup and diphtheria, when it may be advisable, to envelop him in steam. Some surgeons place a small wad, two or three layers of gauze, wrung out frequently in hot water, over the mouth of the tube for the first day or two. A large, coarse sponge answers the same purpose; and the precaution seems to me to be a good one, preventing, as it does, air of a low temperature from entering the lungs, and rendering it moist and free from adventitious particles. The difficulty is in keeping it in place.
The question as to the final removal of the canula is a difficult one to answer here, depending as it does upon the various causes for which the operation was originally performed. In certain cases, as will be seen from what has been said, its sojourn in the trachea will only be from a few moments to a few hours; while, on the other hand, in cases, for instance, of severe syphilitic disease of the larynx, with cicatricial stenosis of its cavity, the tube, once introduced, has to be worn during the lifetime of the patient. Between these extreme limits the period varies greatly. As a general rule—perhaps from the fourth or fifth day to the end of the first week—an attempt to cause the patient to breathe through the natural passages, the outer end of the outer fenestrated tracheal tube being closed, will partially succeed. Each day will now make success greater; the voice in part returns, and a period is soon reached when the outer tube may be closed with a cork (at first during the daytime only) and respiration carried on entirely through the larynx. The speedy removal of the tube and the closure of the tracheal wound then follow as a matter of course. I have never found it necessary to employ any of the various forms of after-treatment canulas, and believe them to be unnecessary. The original tube, preferably a fenestrated one, as heretofore described, is to be worn until convalescence is established, then permanently withdrawn.
The tube should be removed at the earliest safe and practicable moment. Its lengthened sojourn is not devoid of danger, as will be shown; and an atrophy of the laryngeal muscles, especially the abductors of the vocal cords, may follow their prolonged disuse, or at least inactivity, thus giving rise to a narrowing of the glottic opening perhaps inconsistent with respiration.
The wound, covered by granulation-tissue if the tracheotomy-tube has been worn for any length of time, quickly closes, when the latter is removed, and needs to ensure this but a few narrow strips of adhesive plaster to be passed across it and attached to the side of the neck, to prevent the air being forced out through it during the first day or two when the patient coughs or attempts to speak.
In cases where the tube has been worn for a long period, and the edges of the opening have firmly cicatrized, their freshening by the knife or scissors is a necessary preliminary to their being brought together by means of a suture or two.
The wound in the trachea closes not by the formation of a cartilaginous, but rather of a dense connective tissue, and the cicatrix is so smooth and small as to be with difficulty discernible. The cicatrix remaining externally upon the neck need be but slight and linear, and cause no disfigurement, especially if the wound have been properly treated and watched during the healing process.
Among the complications and accidents which may occur after a tracheotomy successfully performed,5 none is commoner, and none, perhaps, is more to be feared, than the broncho-pneumonia which may develop at any time within the first three or four days, and especially in those cases where the operation has been rendered necessary by a diphtheritic inflammation of the throat or air-passages. Bronchitis is common when much blood has escaped into the trachea during the operation. The periodical and careful auscultation of the chest is therefore desirable, in order that the earliest physical signs of these morbid conditions may be detected.
5 See Parker, "On Some Complications of Tracheotomy, with Illustrative Cases," Lancet, Jan. 24, Jan. 31, and Feb. 7, 1885.
Secondary hemorrhage is rare: should it occur, the wound must be opened, enlarged if necessary, and the bleeding vessel sought for and secured. A slight hemorrhage may be checked by pressing the parts firmly about the tracheal tube and the use of styptics locally.
When the pathological condition of the parts has demanded that the canula be worn for a long time, and in cases where sufficient care has not been taken to select one suited to the age of the patient or to the particular form of operation that has been chosen, perhaps to the needs of the special case, an ulceration of the anterior or posterior wall of the trachea, the result of the pressure of the lower edge of the tube or of its upper posterior and convex side, may occur. Usually, it happens on the anterior wall, rarely on both, and the main trouble to which they give rise lies in the repeated hemorrhages that proceed from the laceration of granulation-tissue, in changing the canula, for instance, and the descent of the blood into the trachea and lungs. Cases of extensive ulceration, with erosion of the large vessels at the root of the neck, and fatal hemorrhage, have been reported. Considerable care should then be exercised in so adapting a canula to a special case that it will lie as free as possible within the lumen of the trachea. Ulceration of the tracheal walls, it is claimed, never occurs with the right-angled canula of Durham. Occasional change of form in the canula or the use of canulas with rounded extremities (perforated with numerous slits) is often advisable when the tube is worn for a length of time.
Another complication following the prolonged sojourn of a tracheal tube—rare, it is true—is the development of a mass of granulation-tissue, a veritable tumor, which may occlude the lumen of the trachea and lead to serious disturbances of respiration. The growth usually occurs about the inner edges of the tracheal wound, extending thence inward and upward or downward, as the case may be, and is most frequently met with, perhaps, after tracheotomies undertaken for diphtheria, although it may occur as a result of the ulcerations mentioned above, and develop even from the cicatrix in an old and perfectly-closed tracheotomy wound. The size of the mass, its location, and the amount and manner of its interference with the respiratory current vary much, but the condition must ever be regarded as a troublesome, even dangerous, one, and may always be suspected when attempts at the removal of the canula temporarily or permanently are followed by sudden and urgent dyspnoea.
The exuberant granulation-tissue which forms about the outer edges of even a recent tracheotomy wound, and occasionally renders the reintroduction of the tube difficult, as well as closing the wound while it is out, is a much simpler matter, and is easily remedied by cutting it away with the scissors or checking its formation by caustic applications.
A subcutaneous emphysema not infrequently occurs as the result of poor surgery and delay at the time of introducing the tube into the windpipe, or may come on later when the tube fits the tracheal wound incompletely. In either case it need excite no apprehension, and usually quickly subsides. Cervical cellulitis is a more serious matter, but is fortunately rare if unconnected with disease of the cartilages of larynx or trachea. It probably depends upon injury to the tissues and a too extensive opening up of the intermuscular strata at the time of the operation. Should the complication arise, the tendency to the burrowing of pus must be prevented by free drainage and, if necessary, incisions. The other surgical indications are to be treated on general principles.
When the incision necessary for the introduction of a tracheotomy-tube has been made through healthy tissue, necrosis of the cartilage in contact with the tube belongs to the rarest of the complications of the operation. The simple traumatic perichondritis set up by the operation shows no tendency to eventuate in death of the parts. Equally rare is cicatricial contraction of the trachea as the direct result of the operation. That it may follow the healing of the extensive defects sometimes left by the syphilitic and other processes can readily be understood; and the same defects, involving as they occasionally do the loss of large amounts of tissue and destruction of important parts, may eventuate in the formation of an aërial fistula during or after the healing process is completed. The occurrence of such a fistulous opening as the result of a simple and uncomplicated tracheotomy wound could only be regarded as the evidence of unskilful surgery and after-treatment. The various plastic operations undertaken for the repair of such defects are described in the works on general surgery, notably in the able monograph of Schüller. Dislodgment of the canula out of the trachea as the result of an insufficiently long tube, or of neglect to fasten the tapes which hold it properly about the neck, so that it slips during coughing or the movements of the patient, is an accident which may not for the moment attract the attention of an inexperienced surgeon unless laryngeal dyspnoea is urgent. The patient breathes quietly, the air passing by the sides of the tube, which apparently is correctly placed. The simple test of ascertaining whether air be passing through the canula or not, or of making a trial whether the patient breathe as well when the finger closes the opening of the outer tube, as he will do if the tube is out of the trachea, will decide the question. Should the tube have slipped, it is of course at once to be replaced.
The breaking off of a portion of the inner canula, and the terminal piece falling down the trachea—several instances of which have been reported during recent years—is more apt to happen with the right-angled canula of Durham, the inner tube of which is necessarily made up of segments held by small rivets: these become in time loosened and the piece that they held detached. The outer tube of the hard-rubber canula also has become detached from its collar and dropped into the trachea. An occasional inspection of the condition of the tube is therefore desirable.