Solis Cohen introduced a method of treating these cases by fastening the trachea to the external wound and permitting the cavity above to close as rapidly as possible. In this way the trachea is permanently terminated in the middle of the neck and patients breathe through this opening. It has been found that with practice they can retain sufficient air in the mouth and pharyngeal cavity to permit them to whisper several words at a time. This simplifies the procedure, and is now usually adopted after extirpation of the larynx.
Partial laryngectomies have been practised through external openings, one lateral half or more of the larynx being removed. These operations have been few in number and often unsatisfactory. They should be reserved for cases with favorable indications. When required they are performed on the same principles as those already outlined, only the extirpation is incomplete. Certain modifications have been proposed by individuals, as, for instance, the suggestion made by Gluck, to suture the opening in the trachea to a buttonhole opening made in the overlying skin, by which means he thought to prevent inspiration pneumonia.
OPERATIONS UPON THE TRACHEA.
Tracheotomy is the general term made to cover any opening into the lower air passages between the larynx proper and the upper end of the sternum. Laryngotomy, cricotracheotomy, tracheotomy, etc., may be described as implying by these names the exact location of the opening. The principle is, however, the same, and the details of the operation vary but little.
Fig. 482
Position of patient for tracheotomy. (Wharton.)
Tracheotomy as a deliberate operation is different from tracheotomy as it was formerly practised for diphtheria, and as it is yet done in emergencies, some cases being so serious that suffocation will occur if the opening be not promptly afforded. In the former case preparations can be made; in the latter, operation may have to be done with the blade of a penknife. It makes considerable difference also whether an anesthetic can be used. To administer chloroform to a child with a heart already weakened by the toxins of diphtheria is almost to invite disaster, and yet to do the operation without an anesthetic is perhaps impossible.
The middle line is the line of safety in all of these operations. The danger of heart failure from the anesthetic, or of suffocation from tardiness of relief, being passed, the other principal danger is that of hemorrhage. The isthmus of the thyroid may be divided, but always with preliminary ligatures, or it should be caught between the blades of pressure forceps on either side before dividing it. A patient with a short, fat neck, whose cervical veins are dilated and engorged with venous blood owing to partial asphyxia, makes a difficult and undesirable subject. The trachea lies nearer the surface at its laryngeal end than in its lower portion—i. e., if the operation be low in the neck deep search will have to be made for the tube. The first incision should be made sufficiently long, never less than two inches, and should be so planned as to bring the operator down upon the tracheal rings. By this time sufficient engorged veins may have been divided to cause a serious oozing of dark, venous blood, by which the field of vision is much obscured. Except in emergencies the surgeon may wait for this engorgement to be relieved. The trachea, being recognized by the finger-tip, is seized with a tenaculum, by which it may be held forward, and then at least two of its rings divided with the knife-blade. The instant the opening is made, if the patient be still breathing, bloody foam and frothy blood will be ejected, and for a moment or two the bleeding may be uncontrollable. Under these circumstances the normal blood color soon returns. Artificial respiration should be practised at the same time. Supposing this to be an emergency case, with little or almost nothing at hand, sutures should be passed through the tracheal opening and through the skin margin on either side. If no other retractor be at hand the suture materials may be left long and tied behind the back of the neck, sufficient tension being made to prevent the wound edges from coming together. Formerly when the surgeon was called to do this operation with little or no help the writer has extemporized a couple of retractors out of hair-pins, bent for the purpose, hooked into the tracheal wound, then tied with tapes, which were united behind the neck, while the wires were kept from being pulled out of place by a skin suture on each side. There is now less occasion for these crude methods since the introduction of O’Dwyer’s intubation.
With tracheotomy done deliberately, and at the point of election, usually above the thyroid isthmus, with or without division of the cricoid, the vessels may be secured as they are exposed or bleed, and the trachea should not be opened until all oozing from its exterior has been checked. For this purpose the patient is placed upon the back, the shoulders raised, the head thrown backward, and the neck exposed, a pillow being placed beneath. (See [Fig. 482].) The operation may be done under cocaine local anesthesia or with a general anesthetic. Incision in the middle line, below the lower border of the thyroid cartilage, is made two inches or so downward, the fascia beneath being divided in the same line and the tissues retracted to either side from this median exposure. Thus one makes access to the cricothyroid membrane, the cricoid, the upper tracheal rings, and the thyroidal isthmus. According to the size and location of the latter (it usually lies in front of the second tracheal ring) it may be retracted or doubly ligated and divided in the middle. The difficulty now afforded is from the upward and downward play of the larynx, which may occur during forced efforts at respiration. To steady it a tenaculum should be introduced just above the cricoid, a little to one side of the middle line, firmly fastening it. With this held in the left hand, thus steadying the parts, a sharp-pointed knife is so employed as to divide the cricoid and one or two upper rings of the trachea, being cautious not to wound the posterior wall. The opening thus made should be about one-half inch in length. Through it a second hook is now passed into the other side of the cricoid and the incision held open by their agency while the trachea tube is introduced.