Operation. As local anæsthetics are of little practical value in the case of children, the surgeon must decide whether a general anæsthetic shall be used; for any nervousness on his part increases the danger of death upon the table. A general anæsthetic is not necessary, but undoubtedly has certain advantages: the operation is easier and can be performed more rapidly; the patient is more likely to fall asleep; and any vomiting that occurs is beneficial rather than harmful. On the other hand, children suffering from diphtheria are apt to die suddenly under chloroform; and it should never be administered when there is any sign of heart failure, when obstruction is very marked, when cyanosis is present, or when the patient is prostrate. The danger has probably been exaggerated, and depends more upon the experience of the anæsthetist than upon the actual disease; in my opinion it is as a rule safer to employ a small quantity of chloroform, which should be given on the operating table after everything has been prepared. The child should be allowed to choose its own position, generally curled up on one side, and the administration must be slow. By observing these precautions it usually happens that the child becomes quiet, and that with the loss of consciousness the breathing improves; the child can then be placed in the proper position, and the more difficult part of the operation can be completed before restlessness returns.
The instruments required are: a small scalpel, scissors, two dissecting forceps, three or more fine-pointed pressure forceps, two double hook retractors, one blunt hook, an aneurysm needle, and a suitable dilator for the wound; some form of aspiration apparatus may also, in rare instances, be necessary ([Fig. 278]). Three or four tracheotomy tubes such as described by Parker, and a small tube containing sterilized catgut, which is eminently suitable for the tying of vessels, and for that purpose preferable to silk, should also be in readiness. All the instruments should be kept together in a metal case, as well for private as for hospital practice, so as to be ready in case of emergency. They should be boiled for at least twenty minutes both before and after each operation, and should be laid out separately upon a dry sterilized towel in the position selected by the surgeon.
Fig. 269. Tubes for Tracheotomy. A, Parker’s; B, Durham’s; C, Baker’s rubber tube.
Tracheotomy tubes may be made of silver, rubber, vulcanite, celluloid, or a gum-elastic material, but most surgeons prefer a silver tube in the early stages of treatment. An angular form should be used, for ‘with the ordinary quarter circle tube, the lower extremity tends to impinge on the anterior wall of the trachea, and this is attended with many inconveniences and even with grave risks’ (Parker[27]). A movable shield is equally important, and this should be flush with the neck in order to avoid the possibility of its being removed by the patient. Further, the tube should consist of two parts—an outer tube to which the shield is attached, and an inner tube which projects slightly beyond the outer and can be removed for purposes of cleaning. To encourage breathing through the larynx, a window may be added in the upper part of the tubes. Parker’s tube, which meets all the above requirements, is the one most commonly used in England. When longer tubes are necessary, either Durham’s or Stewart’s is recommended: in these, the position of the shield can be altered, and the length of the tube arranged, to suit the patient. In cases of long duration the use of rubber tubes such as Morrant Baker’s is indicated. An introducer is rarely necessary except for rubber or long tubes. As taper and bivalve tubes are liable to injure the trachea, their use is not advised. The tube chosen should fit loosely, and should project far enough into the trachea to be secure from slipping out during coughing or struggling. Short tubes are preferable, and the wider the tube the easier the breathing and the better the drainage. The approximate diameter of the trachea varies at different ages, and the size of tube suitable in each case varies chiefly according to the trachea, but partly also according to the fatness of the neck. The accompanying table indicates the appropriate dimensions.
Table showing Size of Trachea and of Tube required at Different Ages
| Age. | Approximate diameter of trachea. | Approximate diameter of tube. | Number of tube. | |
|---|---|---|---|---|
| Parker’s | Durham’s | |||
| 6 months | 4 mm. | 04 mm. | 16 | — |
| 1½–2 years | 6–8 mm. | 07 mm. | 20 | 1 |
| 2–4 years | 8–10 mm. | 08 mm. | 24 | 2 |
| 4–10 years | 10–12 mm. | 09 mm. | 28 | 3 |
| 10–20 years | 12–19 mm. | 10 mm. | 30 | 4 |
Tracheotomy, even under favourable circumstances, is attended by many difficulties; the urgency of the case, the restlessness of the patient, the movements of the larynx, the frequent absence of a proper operating table and equipment, the importance of a good light, of sensible assistants, of a trained nurse, and, above all, of a calm disposition, make this one of the most anxious and difficult operations in surgery, yet there is no medical man who may not be called upon to perform it.
It is important to make the best possible preparations. A table of suitable height can usually be improvised and placed in a good light. If the operation be at night, gas lamps or candles can be used, and the illuminant should be placed in a definite position rather than held by the parents. The child should be wrapped in a large towel in order to control the movements of the arms, body, and legs, and should then be placed upon the table; it is advisable to leave him in ignorance of the operation, whatever his age, until the last moment. The skin of the neck should be rapidly washed or sponged with ether, and the head extended over a small pillow or rolled towel. The operation must never be commenced until the proper position is obtained; on the other hand, extension of the head should not be too great for fear of increasing the dyspnœa. Three assistants are preferred—one to hold the head firmly in the middle line so that the point of the chin is exactly in line with the suprasternal notch (this is probably the anæsthetist), a second to hold the body at the opposite end of the table, and a third to assist the surgeon with sponges or retractors. It should be the duty of the last named to prevent any membrane or pus from being coughed over the principals after the trachea has been opened.