A system of practical medicine. By American authors. Vol. 3

by Unknown

Inferior tracheotomy is comparatively difficult to perform, and during its performance dangers may have to be encountered greater and more numerous than those met with in either of the other operations. This is true certainly of children. As regards young children, Holmes states that after the age of five or thereabouts the surgeon can, if he prefer it, open the trachea below the isthmus of the thyroid gland. He himself does not recommend the operation before puberty. In the case, however, of a foreign body loose in the windpipe of a child, where a large opening is required, it can hardly be obtained above the thyroid body and below the cricoid. To cut through the isthmus of the thyroid (median tracheotomy) is, in early life at least, a doubtful proceeding when it is of large size, on account of its vascularity, and the incision must be made below it—in other words, an inferior tracheotomy.

When the operation of tracheotomy shall be performed is a question which the experience and individual views of the surgeon, based on experience, must decide in each case. The doubt always arises in the mind of the inexperienced operator whether the symptoms are sufficiently urgent to render the operation necessary. To him these general rules may be given: The immediate indication for the operation is to be looked for in the thorax. It is the recession of the lower part of the sternum and contiguous ribs and the retraction of the intercostal spaces and clavicular fossæ at each act of inspiration. He must not wait until lividity of the lips and blueness of the fingernails prove that the blood is being imperfectly oxygenated (Mackenzie). Let him remember also that, aside from the immediate and imminent danger of sudden suffocation, a remote one exists and increases the longer he postpones his operation and allows the struggle for air to continue—viz. vascular engorgement and oedema of the lungs, especially in young children; the production of all those conditions which allow, and even predispose, the lung after the operation to fall an easy prey to the inflammatory processes.

The instruments necessary for the performance of the operation of tracheotomy are few and simple, and are such as may ordinarily be found in any small operating-case. A scalpel, a probe and sharp-pointed bistoury, dissecting and artery forceps, a tenaculum, a grooved director, two small retractors, scissors, and a dilator for the tracheal wound, are necessary. To these may be added the needles and thread, waxed ligatures, sponges, and tape. The tracheal tube is elsewhere described. A faradic battery, good suction syringe, and a large flexible catheter may render good and timely service if at hand.

It is true that many other and more or less complicated instruments have been devised for the purpose of facilitating the operation; and other methods, aside from that of the knife, have come of recent years into vogue; but, still, simplest means, as above given, have in the experience of most surgeons been proven to be the best. This statement, undeniably true for all surgical measures, is especially so for the operation under consideration, which is often necessarily undertaken without opportunity for elaborate preparation and under the most adverse and inconvenient circumstances. The more familiar, therefore, the surgeon is with his instruments, the better and more certain will be his work.

Holding this view, it is unnecessary for me to more than briefly mention such instrumental aids as the grooved tenaculum of Chassaignac, the groove serving to guide the operator's knife into the trachea; the sharp double hooks of Langenbeck, which, after being caught in the tracheal walls to either side of the site of the intended incision, are sprung apart after the latter is made, thus dilating the wound and rendering the introduction of the tube easy; the tracheotome of Thompson, a pair of curved cutting forceps, the blades of which are caused to open by a screw after they have been plunged through the tracheal walls; that of Garin, a forceps with curved blades—one, the longest and sharpest-pointed, being made to penetrate the trachea, the instrument then opened, and both blades cut their way to the desired extent of incision; finally, the tracheotome of Maisonneuve, a curved dilating hook with cutting inner edges. Its point is entered between the first and second rings of the trachea and brought out again between the fourth and fifth; the handle is then carried under the chin, so that the blades are made to cut through the trachea and the skin between the points of insertion and exit, after which, upon pushing a spring, the two halves of the hook separate, and the canula is introduced between them (Thornton). And the trachea-stretcher of Marshall Hall, by means of which a portion of the trachea is cut out and the opening kept patent.

None of these instruments have been proven to possess any practical worth; on the contrary, their use, especially that of the latter forms, has in more than one instance been attended with disastrous results.

To obviate the danger of serious hemorrhage during the performance of tracheotomy, both the galvano-cautery knife and the thermo-cautery instrument of Paquelin have been recommended within the past few years, and a number of operations placed upon record. The procedure is the same whichever means be used. The skin and soft parts overlying the trachea are usually alone cut through by means of the cautery-knife, the cartilaginous rings of the tube, when reached, being divided with the ordinary knife. This fact alone speaks against the thoroughness attainable by means of these methods; but, still more important, neither has been found reliable in checking hemorrhage, and in several instances the operator has been obliged in haste to lay aside his cautery apparatus and turn to the ordinary and better-known means to complete his operation. The healing of the tracheal wound made by the cautery is slow: erysipelatous inflammation may attack the wound as the result of the burn, and extensive sloughing of the edges is not unknown, while the resulting cicatrix is large, strong, and contractile, and has caused, in one case at least, a stenosis of the trachea. In the face of these facts he must indeed be an enthusiastic advocate who would recommend the procedure. Mackenzie justly remarks that the use of the thermo-cautery for opening the air-passage merely introduces an unnecessary complication into the operation.

The choice of a proper tube, one suited to meet the special indications in a given case and specially adapted to the age of the patient and the calibre and position of his trachea, is no unimportant matter, and may do much not only to facilitate the immediate success of the operation, but likewise prevent the occurrence of those possible unfortunate results, ulceration, fatal hemorrhage, abscess, pneumonia, and pyæmia, no lack of which are recorded in our literature.

Although the number and variety of mechanical devices and forms of tracheal tubes that have from time to time been devised by the inventive ingenuity of operators is large, the choice practically centres upon one of two forms. The first, and the one most commonly used, is but the original canula of Trousseau, modified by Roger, in that the tracheal portion of the tube is detached from the collar or neck-piece, and moves freely with the movements of the patient; and by Obré, by the important device of an inner tube to prevent clogging of the outer or original tube by mucus. Starting upon this essential basis, the instrument-maker has perfected the instrument of to-day. It is a silver tube, double throughout, the inner tube projecting at the lower or tracheal end beyond the outer—an important point, as it prevents any possible permanent occlusion by mucus or blood-crusts, membranes, and the like at this point, removal of the inner tube at once clearing the end of the outer one. The curve of both tubes should correspond to the arc of a quadrant, and the outer is fastened to a transverse collar or shield by means of two small projections or pins upon its sides which lie under small wire bridges upon the shield after it has passed through an opening in the transverse neck-collar large enough to permit of its free movement during the respiratory movements of the trachea, as well as during the forcible action caused by cough. The ends of this collar or shield curve slightly backward to correspond with the curve of the neck, and are perforated by, preferably, large oval openings, instead of the usual small, inconvenient slit, through which the tapes are passed which hold the tube in position by encircling the neck. To this same shield is fastened, by means of a small turn-screw or a revolving collar, the end of the inner tube, which is thus prevented from being forced out of the outer tube by coughing or any motion of the patient. Upon the upper or convex surface of the outer tube a small ovoid opening is usually made for the purpose of permitting the expiratory current to pass upward (the inner tube being removed) into the larynx and render phonation possible; also, the free opening of the outer tube being closed, to allow of respiration being carried on through the larynx and natural passages—often an important matter, as the case progresses toward recovery, in instances where the operation of tracheotomy has been performed on account of laryngeal obstruction.

A set of these tubes, which can now be readily obtained, should consist of four, with the following diameters: No. 1, one centimeter; No. 2, nine millimeters; No. 3, seven millimeters; No. 4, five millimeters: their length is of course in relative and fixed proportion to these measurements. A tube should always be selected less in diameter than the trachea operated upon: to seek to introduce one of the same calibre is not only unnecessary, but cannot fail to be dangerous. Tubes constructed upon the same principles as that just described (Lüer's) are made of hard rubber instead of silver (Leiter): their lessened cost is their principal recommendation, added to the one that they are more easily kept clean and sweet than the silver tubes. The fact that they are necessarily made much heavier and thicker than the latter is a disadvantage, the lumen of a hard-rubber tube being smaller than that of a silver tube of corresponding external diameter. The objection urged against them, of their great danger of breakage, I have not found borne out by experience. Tracheal tubes are also constructed of platinum, and recommend themselves on the score of lightness.