The diagnosis of these conditions is now comparatively easy, and with the help of direct laryngoscopy and X-ray photography the exact condition can, in many cases, be determined. In some instances the tumour may be removed by endotracheal operation, especially if the growth is innocent.
Tracheo-fissure is more reliable, and should always be performed when there is any suspicion of malignancy. The preliminary stages are similar to those of tracheotomy. A section of the trachea is first made in the region of the tumour, and the opening is enlarged so that the growth can be thoroughly explored; this can be better accomplished when the trachea is illuminated by a good electric lamp, in some instances a Killian’s tube being required. When possible, a tampon canula is inserted into the lower part of the trachea. When the growth is low down, the patient is placed in the Trendelenburg position in order to prevent the inspiration of blood. Should the diagnosis be uncertain, a portion of the tumour can be excised and a frozen section made. If proved to be innocent, the growth can then be freely excised with scissors or galvano-cautery. The bleeding is arrested, and the tracheotomy tube is retained for several days. The after-treatment must be conducted on lines similar to those laid down for laryngectomy, the patient being turned on the face in order to prevent pneumonia. ‘Up to the present time about two dozen operations of this sort have been reported. The author has removed in this manner four intratracheal thyreoids with permanent result’ (von Bruns).[35]
Resection. If the tumour be malignant, the surgeon must first decide whether its removal is practicable or whether palliative tracheotomy is preferable. In the former case the trachea is isolated laterally and divided transversely well below the growth. Whenever possible the lower end is then brought outwards and temporarily attached to the lower part of the incision above the sternum. The resection of the trachea is then carried out, so that the growth is freely removed, care being taken to preserve the recurrent laryngeal nerves. ‘Where the section of the trachea to be removed is limited to 4 centimetres or less, the two ends can generally be approximated and united, restoring the calibre of the tube and normal mouth respiration’ (Brewer).[36] This is accomplished by numerous catgut sutures some of which include the entire thickness of the tube. The muscles can be approximated so as to cover the incision, and the wound can be drained freely. On the other hand, the lower end of the trachea may be permanently fixed in the wound as described under laryngectomy (see [p. 498]). Von Bruns has removed a cancer on the posterior wall of the trachea with six tracheal rings, thus giving the patient six years of life. He remarks: ‘operative treatment in tumours of the trachea shows brilliant results. Untreated the condition leads to death from suffocation. In seven cases operated upon by me, the results were all favourable.’
CHAPTER IV
INTUBATION OF THE LARYNX
Intubation, or ‘tubage’, was first recommended by Loiseau and Bouchut in France; in 1880 attention was drawn to the subject by Sir W. Macewen in England, and soon afterwards O’Dwyer[37] of New York published articles which resulted in its being extensively tried in America; since that time it has continued to be popular in that country for the treatment of laryngeal diphtheria. ‘The good results which American physicians have secured by intubation may be explained, perhaps, by the circumstance that according to their reports diphtheria takes a milder form in America’ (Tillmanns).[38] Intubation has been extensively used in Europe, especially in Germany, but never to the same extent as tracheotomy, and in England it has been practised at only a small number of hospitals; thus, of the nine M. A. B. fever hospitals in London only three used it regularly during 1906–7, and none of them so often as tracheotomy.
Intubation versus Tracheotomy in Diphtheria. Since the introduction of the newer method of treatment in 1880 the subject has been widely discussed in America, on the continent of Europe, and in England. There is no evidence to show that treatment with antitoxin has been beneficial to one operation more than to the other.
The advantages claimed for intubation are:
1. No anæsthetic is required.