This operation may also be performed from above, downwards, with a sharp pointed bistoury, holding it not far from the point; the forefinger on the back of the knife—taking care to help the cricoid artery out of the way, which I have always been able to control when cut, by the application of nitrate of silver. The patient may be, if necessary, turned on the side to prevent blood from passing into the windpipe.
I begin close by the lower edge of the thyroid cartilage, and carry it so far as the second ring of the trachea; but in either case, whether I open upward or downward, the tenaculum can materially assist in the operation, by drawing down the tube when cutting upward, or by drawing upward when cutting downward—the hook to enter behind the knife in either case.
The use of the hook is most necessary when operating on young children. The object in pushing the knife, holding it steadily, is from knowing that it long since has been found, that an artery will give way before a knife when carried in this way that might otherwise have been cut immediately by a “see-saw” motion.
After the operation is performed, I direct the attendants to keep the opening clear of obstruction—bloody froth, &c., or anything that may make its appearance in the wound. Artificial respiration must be kept up until the foreign substance is expelled or removed. A probe or knitting needle will suffice for that purpose, one or the other must be used several times a day and night, in fact as often as needed; I use no gauze, it might get sucked to, or drawn into the opening, and thereby defeat the intent of the operation. In cases needing the use of the canula I make no reference.
I prefer laryngo-tracheotomy, sometimes denominated circo-tracheotomy, which I have been endeavoring to describe, to any other, for all ordinary purposes. We have less risk, and more room, and it is more adapted to the relief of children and might with propriety be called the higher operation to distinguish it from tracheotomy, which rightly speaking is the lower operation. This would draw a distinction between the two, and it is necessary that line should be observed, and that when these operations are spoken of, we should know what importance to attach in either case, and give to either operation the degree of approbation it may deserve.
I cannot close this subject without giving the opinion of a very able anatomist regarding it, Harrison, of Dublin. In the first place he speaks of an irregular artery, which he has seen running along the front of the trachea to the thyroid gland and cellular membranes beneath it. He had seen this so frequently in this situation, that he describes it under the name of the middle thyroid artery. “This is” he says “so common an occurrence that it should be remembered by the practitioner of tracheotomy.” He further goes on to say, “in children the space for tracheotomy is very limited,” and directly that “particular attention be paid to the inconsiderable portion of the trachea that can be exposed between the thyroid gland above, the arteria innominata, the left carotid artery, the remainder of the thymus gland below. The deep thyroid veins also descending to the vena innominata obscure the trachea very much, these together with the great mobility of this tube, add to the danger and difficulty of this operation.” Pancoast says: “The checking of hemorrhage from the veins and arteries divided in tracheotomy requires particular attention; from six to eight ligatures are usually employed. They should be applied in general as the vessels are cut and before the opening of the trachea as there must be blood drawn by respiration into the trachea and thereby endanger life.”
These dangers constitute shoals and quicksands to the anatomist and surgeon, that has made many a one shudder at their approach. The six or eight vessels to tie, before daring to open the trachea, causes delay dangerous to life, as well as to the success of the operation, and brings into question the propriety of the operation, and sometimes the skill of the physician. In the upper operation, laryngo-tracheotomy, you can enlarge the opening upward whenever necessary, with but little risk, by cutting through the thyroid cartilage. In fact, it may be opened above or below, one or both, with but little risk; whereas in the lower operation it is almost impossible to do so. When it becomes necessary, the safest plan is to enlarge the opening upward, as much as is practicable, and downward as little as we are able to get along with. The space taken up by the lower operation on children is very limited, and the operator must necessarily be cramped for want of room. The cervical portion of the adult trachea is laid down at from two to two and one half inches long. It is composed 18 or 20 fibro cartilages, this makes the space between each ring 1–8th of an inch. According to that measurement, allowing the 20 rings for 2½ inches makes the space taken up by cutting three rings 3–8ths of an inch long in the adult, if no more is divided, and proportionately less in the child. We can readily understand that those operating in this region do as little cutting as possible, and although the operation so far as the outside incision, may begin at the cricoid cartilage, and terminate as at a little distance from the fossa at the top of the sternum. I have no idea that the trachea is often laid open to that extent. Pancoast directs, “that after separating the two sterno-thyroid muscles, partly with the point and partly with the handle of the knife, and finding no large vessels in the way, pushes up, or if necessary divides the isthmus of the thyroid gland.” The next cutting he speaks of, is, “that of the third, fourth and fifth rings, puncturing the tube, with the point of the knife below the fifth ring.” He then speaks of running the scalpel upwards with the handle inclined to the sternum, so as to avoid injuring the posterior wall of the trachea. It is easy to perceive in the practice of the present day, that this operation is done for, and best suited to the insertion of the canula, and that the opening of the third, fourth and fifth rings of the trachea can, when divided, answer by binding the canula, a much better purpose than a larger opening, which would allow it to move about, thereby incurring the danger of displacement.
The word tracheotomy as a general term does harm. We ought rather to particularize, and make known on what part of that tube we operate, and not speak of tracheotomy as though it were of little moment in the performance, and that one part of the windpipe cut into, was as much a tracheotomy as another; not by any means should this be thought. I consider that tracheotomy strictly, and according to the definitions of anatomy and surgery, is one of the most dangerous that come within the province of the surgeon; and, on the contrary, I consider laryngo-tracheotomy, or crico-tracheotomy as it is sometimes denominated, a very simple operation, and only requiring ordinary tact in the performance.
Since the above article was written, this operation has been successfully performed by Dr. J. L. Nicholson, assisted by myself and Dr. C. Thompson.