LARYNGO-TRACHEOTOMY.
By Charles Duffy, Sr., M. D., Catherine Lake, N. C.
Read before the Onslow County Medical Society, September, 1878.
Gentlemen of the Onslow County Medical Society:—
I was written to sometime ago, by a member of the State Medical Society, asking my views in regard to operating on the windpipe. My experience in such operation has been very limited, six times being the maximum of my labors in that direction. My first was a failure, done for the relief of cynanche trachealis, the operation being performed too late.
The other five cases succeeded admirably; four of the patients ranging from eight months to three years old, the other a woman of middle age. The first of these cases was operated on for the removal of a watermelon seed. The child was less than 2½ years old, and was very fat, so much so that the depth from the surface, would seem to forbid approach to the external surface of the trachea, still less to the internal, but by patience and perseverance these difficulties were both overcome, and respiration rendered comparatively easy. The next idea, was to get out the seed, and one attempt after another was made to no purpose, the wound inclined to close at the same time. I next lengthened the incision, and the sides of the wound were well drawn apart. My next step was to trim off the sides or edges of the cartilages; this being done, gave the seed a fine opportunity to present itself, and the child was placed in a cradle and diligently watched, with orders to take him in the arms and walk about with him, in case of difficulty of breathing coming on, which had to be done from time to time. The seed was expelled through the aperture to our great joy and gratification, several hours after the last step of the operation. The child was a son of Mr. Thomas Holland, of this county. He grew to adult age, and was killed by a horse running away.
From this case I learned that the removal of foreign substances by forceps or other instruments, except they are metallic substances is seldom necessary, there would be much more difficulty in retaining them or preventing their escape. As soon as the windpipe is cut into there is a rush of wind that follows, that moves the substance by the double ability or means of respiration, caused or provided by the operation, and the next we know the substance is expelled. Certain it is, it is not going to stay there, if there is room for its escape and the patient is rightly attended to. When certain that all has come away, apply adhesive plaster drawing the parts together, a stitch or two might be necessary in some cases, it soon gets well.
My next case was the woman alluded to, the wife of Mr. Amos Wooten, of New Hanover county. A piece of beef gristle got into the wrong passage. After several spasms, and vain attempts to get it out she sent for me. I got to her as soon as possible—the distance being sixteen or seventeen miles. On enquiry I learned the particulars of her case. I found her composed. I told her it might not be in the windpipe, and we had better be certain about it. I passed a probang down the œsophagus and found that it was not there. After waiting a little longer, she had a violent spasm that hurried and increased her determination to have it out. So violent was the spasm, that it created doubts on her mind as to her chances of living, or of being able to bear up under the operation. She next turned her head toward me and remarked that she was ready. I had no medical assistant with me. I operated without chloroform—the woman fainted. There was camphorated spirits close by, and I sprinkled it heavily and forcibly in her face and over her chest, and rubbed some in her mouth. She revives with a vim and sends the gristle forcibly, not only out of her mouth, but nearly out of doors, rejoicing all hands around.
I applied sticking plaster and left; saw her in a few days; she was well.
My next operation was on the child of Mr. Enoch Foy, who had the misfortune to get a watermelon seed in his windpipe. The usual symptoms occurring, he came on with his little boy and had him relieved—the seed coming out several hours after the operation.
The next was a child of Mr. Marshall, (another fine boy), another case of watermelon seed, which was operated on with like success.
My last case was a child 8 or 9 months old, a very pretty and fine little girl, the daughter of a Mr. Padjet of this county. She had been playing with an ear of corn, given to amuse her; some of the grains coming off and one and a half getting into the windpipe, as shown by the sequel. She was operated on, assisted by Drs. Cox and Nicholson. The foreign substance did not come out as soon after the operation as the other cases. The wound was not kept open by the attendants, and in consequence I had to re-visit, reöpen and somewhat enlarge the incision which was attended with the usual good results. The child was very fat, and the space for operating in so young a child, was necessarily very limited. One grain of corn and the part of another was expelled. I will next give my “modus operandi,” or rather my imperfect manner of operating.
The patient being laid on a suitable table, with the chest elevated, by placing a pillow or folds of cloth underneath. The head is next laid back neatly observing the direction of the mesial line strictly, and throughout the operation. The instruments previously got ready, and those which I prefer, are a scalpel with a sharp handle, a director and probe, two bistouries, one sharp and the other button pointed, a forceps, tenacula, sponge and ligatures. But so far I have never needed the ligatures. I have always stopped any little bleeding that occurred by applying a pencil of nitrate of silver. All these ready, also a basin of cold water, standing on the right of my patient, I place the finger and thumb of my left hand, one on each side of the thyroid cartilage, and commence my first incision from its lower third if a child, and from its lower edge if an adult, for obvious reasons, namely: In the child we want room, and if necessary can enlarge the incision in that direction, with but little difficulty, the cartilage affording no resistance. In the adult we have more room, and the cartilage is often found hard, and unyielding in persons of advanced life, and it is therefore necessary when enlargement is required in the adult, to cut an additional ring or more of the trachea. I continue my incision below the cricoid cartilage, so far as one or more of the rings of the trachea. The track of the operation being now laid off, I proceed cautiously, an assistant sponging, and applying caustic, as may be necessary to arrest any little bleeding that may ensue, whilst I, with the handle of my knife, push aside any vessel likely to bleed—cricoid artery or otherwise. I next lay hold on the cellular sheath of the trachea, at the lower edge of the track of my operation, and at this point I enter with a sharp pointed bistoury, holding it close to the point, and cutting upward not more than one-eighth of an inch and withdraw it in favor of the button pointed bistoury, with which I slit upward the windpipe, as far as the starting point of the first incision—not moving the instrument back and forth, but holding it perfectly steady, carrying it or rather pushing it, aided by the other hand from below upward, with the handle of the knife inclined downward. The operation now done, is made known by a whizzing which it is necessary to look after, and as all-important. I consider it the safety valve of the patient.
This operation may also be performed from above, downwards, with a sharp pointed bistoury, holding it not far from the point; the forefinger on the back of the knife—taking care to help the cricoid artery out of the way, which I have always been able to control when cut, by the application of nitrate of silver. The patient may be, if necessary, turned on the side to prevent blood from passing into the windpipe.
I begin close by the lower edge of the thyroid cartilage, and carry it so far as the second ring of the trachea; but in either case, whether I open upward or downward, the tenaculum can materially assist in the operation, by drawing down the tube when cutting upward, or by drawing upward when cutting downward—the hook to enter behind the knife in either case.
The use of the hook is most necessary when operating on young children. The object in pushing the knife, holding it steadily, is from knowing that it long since has been found, that an artery will give way before a knife when carried in this way that might otherwise have been cut immediately by a “see-saw” motion.
After the operation is performed, I direct the attendants to keep the opening clear of obstruction—bloody froth, &c., or anything that may make its appearance in the wound. Artificial respiration must be kept up until the foreign substance is expelled or removed. A probe or knitting needle will suffice for that purpose, one or the other must be used several times a day and night, in fact as often as needed; I use no gauze, it might get sucked to, or drawn into the opening, and thereby defeat the intent of the operation. In cases needing the use of the canula I make no reference.
I prefer laryngo-tracheotomy, sometimes denominated circo-tracheotomy, which I have been endeavoring to describe, to any other, for all ordinary purposes. We have less risk, and more room, and it is more adapted to the relief of children and might with propriety be called the higher operation to distinguish it from tracheotomy, which rightly speaking is the lower operation. This would draw a distinction between the two, and it is necessary that line should be observed, and that when these operations are spoken of, we should know what importance to attach in either case, and give to either operation the degree of approbation it may deserve.
I cannot close this subject without giving the opinion of a very able anatomist regarding it, Harrison, of Dublin. In the first place he speaks of an irregular artery, which he has seen running along the front of the trachea to the thyroid gland and cellular membranes beneath it. He had seen this so frequently in this situation, that he describes it under the name of the middle thyroid artery. “This is” he says “so common an occurrence that it should be remembered by the practitioner of tracheotomy.” He further goes on to say, “in children the space for tracheotomy is very limited,” and directly that “particular attention be paid to the inconsiderable portion of the trachea that can be exposed between the thyroid gland above, the arteria innominata, the left carotid artery, the remainder of the thymus gland below. The deep thyroid veins also descending to the vena innominata obscure the trachea very much, these together with the great mobility of this tube, add to the danger and difficulty of this operation.” Pancoast says: “The checking of hemorrhage from the veins and arteries divided in tracheotomy requires particular attention; from six to eight ligatures are usually employed. They should be applied in general as the vessels are cut and before the opening of the trachea as there must be blood drawn by respiration into the trachea and thereby endanger life.”
These dangers constitute shoals and quicksands to the anatomist and surgeon, that has made many a one shudder at their approach. The six or eight vessels to tie, before daring to open the trachea, causes delay dangerous to life, as well as to the success of the operation, and brings into question the propriety of the operation, and sometimes the skill of the physician. In the upper operation, laryngo-tracheotomy, you can enlarge the opening upward whenever necessary, with but little risk, by cutting through the thyroid cartilage. In fact, it may be opened above or below, one or both, with but little risk; whereas in the lower operation it is almost impossible to do so. When it becomes necessary, the safest plan is to enlarge the opening upward, as much as is practicable, and downward as little as we are able to get along with. The space taken up by the lower operation on children is very limited, and the operator must necessarily be cramped for want of room. The cervical portion of the adult trachea is laid down at from two to two and one half inches long. It is composed 18 or 20 fibro cartilages, this makes the space between each ring 1–8th of an inch. According to that measurement, allowing the 20 rings for 2½ inches makes the space taken up by cutting three rings 3–8ths of an inch long in the adult, if no more is divided, and proportionately less in the child. We can readily understand that those operating in this region do as little cutting as possible, and although the operation so far as the outside incision, may begin at the cricoid cartilage, and terminate as at a little distance from the fossa at the top of the sternum. I have no idea that the trachea is often laid open to that extent. Pancoast directs, “that after separating the two sterno-thyroid muscles, partly with the point and partly with the handle of the knife, and finding no large vessels in the way, pushes up, or if necessary divides the isthmus of the thyroid gland.” The next cutting he speaks of, is, “that of the third, fourth and fifth rings, puncturing the tube, with the point of the knife below the fifth ring.” He then speaks of running the scalpel upwards with the handle inclined to the sternum, so as to avoid injuring the posterior wall of the trachea. It is easy to perceive in the practice of the present day, that this operation is done for, and best suited to the insertion of the canula, and that the opening of the third, fourth and fifth rings of the trachea can, when divided, answer by binding the canula, a much better purpose than a larger opening, which would allow it to move about, thereby incurring the danger of displacement.
The word tracheotomy as a general term does harm. We ought rather to particularize, and make known on what part of that tube we operate, and not speak of tracheotomy as though it were of little moment in the performance, and that one part of the windpipe cut into, was as much a tracheotomy as another; not by any means should this be thought. I consider that tracheotomy strictly, and according to the definitions of anatomy and surgery, is one of the most dangerous that come within the province of the surgeon; and, on the contrary, I consider laryngo-tracheotomy, or crico-tracheotomy as it is sometimes denominated, a very simple operation, and only requiring ordinary tact in the performance.
Since the above article was written, this operation has been successfully performed by Dr. J. L. Nicholson, assisted by myself and Dr. C. Thompson.