A Manual of the Operations of Surgery / For the Use of Senior Students, House Surgeons, and Junior Practitioners

by Joseph Bell

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 quantity 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 assistant. 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 Hæmorrhage.—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 hæmorrhage 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 quantity 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 hæmorrhage 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 assistance 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 canal 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 canulæ 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.