CHAPTER III

OPERATIONS UPON THE TRACHEA

TRACHEOTOMY

There is evidence to show that this operation was known to the ancients, and that it has been practised during at least two thousand years chiefly for the treatment of foreign bodies in the air-passages. From the sixteenth century to the present time it has been frequently performed, and the discovery of diphtheria in 1881 by Bretonneau opened up a new field for the operation.

It is uncertain when tubes were introduced in the after-treatment of tracheotomy, but Dr. George Martin in 1730 was the first to describe a double tube which allowed of the removal of the inner part for purposes of cleaning. The movable collar was invented by Luer, and the angular tube now generally used is associated with the name of R. W. Parker, to whose research we owe many of the recent improvements in connexion with this operation.

=Indications.= Obstruction to respiration is the most important, and must be distinguished carefully from the dyspnœa which is due to pulmonary affections, disease of the heart, or organic lesions in other parts of the body. Laryngeal obstruction may be due to--

(i) _Diphtheria._ The extent to which diphtheritic obstruction has to be taken into account is shown by the following table:--

TABLE SHOWING THE NUMBER OF CASES ADMITTED TO THE FEVER HOSPITALS OF LONDON (M.A.B.) DURING THE YEARS 1902-7, INCLUSIVE[25]

+----+------------------+-----------------+-----------------+ | | _All forms of | _Laryngeal | _Tracheotomy | | | Diphtheria._ | Cases._ | Cases._ | | +------+-----+-----+-----+-----+-----+-----+-----+-----+ | | _C | _D |_M p | _C | _D |_M p | _C | _D |_M p | | | a | e | o e | a | e | o e | a | e | o e | | | s | a | r r | s | a | r r | s | a | r r | | | e | t | t | e | t | t | e | t | t | | | s | h | a c | s | h | a c | s | h | a c | | | ._ | s | l e | ._ | s | l e | ._ | s | l e | | | | ._ | i n | | ._ | i n | | ._ | i n | | | | | t t | | | t t | | | t t | | | | | y ._| | | y ._| | | y ._| +----+------+-----+-----+-----+-----+-----+-----+-----+-----+ |1902| 6,839| 741| 10.8| 639| 134 | 20.9| 264| 86 | 32.5| |1903| 5,422| 504| 9.3| 560| 102 | 18.2| 223| 67 | 30.0| |1904| 4,639| 464| 10.0| 659| 116 | 17.6| 247| 79 | 32.0| |1905| 4,224| 346| 8.2| 706| 116 | 16.4| 255| 72 | 28.2| |1906| 4,937| 444| 9.0| 702| 127 | 18.1| 275| 101 | 36.7| |1907| 5,674| 544| 9.6| 981| 169 | 17.2| 432| 129 | 29.9| +----+------+-----+-----+-----+-----+-----+-----+-----+-----+ | |31,735|3,043| 9.6|4,247| 764 | 17.9|1,696| 534 | 31.5| +----+------+-----+-----+-----+-----+-----+-----+-----+-----+

[25] _Metropolitan Asylums Board’s Ann. Rep., Med. Supplement_, 1902-1907.

An examination of the above figures shows that in recent epidemics 13% of the cases developed symptoms of laryngeal affection; that about 40% of these laryngeal cases were treated by tracheotomy (in some cases preceded by intubation); and that the mortality in all the cases of tracheotomy was 31.5%. Tracheotomy in diphtheria, therefore, must still be regarded as a serious operation.

The operation is required chiefly during the early years of life, namely, from one to six (see table on p. 543). Although the larynx cannot be inspected in children, it is easy to determine whether mechanical obstruction is present; for inspiration is noisy and accompanied by stridor, the voice is lost or reduced to a whisper, and attempts to cough are frequent. The alæ nasi are dilated, the extra muscles of respiration are called into action, and laryngeal excursion is seen. On examining the chest, recession is evident; and during inspiration the supraclavicular fossæ, the intercostal spaces, and the epigastrium are all indrawn. The amount of recession depends more upon the muscles of the chest than upon dyspnœa, and is marked in weakly children. When dyspnœa becomes urgent the restlessness increases, and this is an important indication that an operation is required. In very serious cases the face is drawn, livid, or extremely pale; respiration is deficient, and the chest expansion feeble. An examination of the lungs shows the air entry to be imperfect; the bases are dull to percussion, and all sounds absent. The action of the heart is feeble, rapid, or intermittent; no nourishment can be swallowed. It is always difficult to determine how much of this collapse is due to toxin; but by relieving the obstruction the most distressing feature of the disease is removed, better aeration of the blood is obtained, and the heart is relieved from strain. The operation also drains the trachea, and the amount of poison absorbed is thus diminished. There is abundant evidence to show that the best results are obtained by early operation, especially in young children, in whom the larynx is comparatively small. It should be remembered that dyspnœa is often worse at night, and that at any moment there may be spasm.

(ii) _Infectious diseases_, such as (_a_) secondary diphtheria, by no means uncommon in the fever hospitals of London: in the five years 1902 to 1906, thirty cases are recorded, with sixteen deaths (53%), a very high mortality; (_b_) scarlet fever or measles, which provided 118 cases in which tracheotomy was performed, with eighty-seven deaths (74.3% mortality); (_c_) erysipelas, small-pox, typhoid fever, influenza and whooping-cough, which occasionally cause dyspnœa, calling for tracheotomy.

(iii) _Acute laryngitis_ (other forms) in which œdema supervenes as the result of septic infection, or of the inhalation of steam, boiling water, or irritating chemicals, or as the result of trauma with or without fracture of the cartilages, or in the course of renal or heart disease. Brandy in excess, and certain drugs such as iodide of potassium, may also cause œdema of the larynx, and two cases are recorded by Fournier where death occurred before tracheotomy could be performed, as the result of taking iodides.

For conditions such as these tracheotomy is better than intubation, and, as the swelling may extend into the trachea, the high operation is not advised. Although the operation should not be undertaken until other treatment has been tried, it is well to remember that collapse of the lung, broncho-pneumonia, and complications, are likely to arise when the obstruction is allowed to persist.

(iv) _Syphilis._ In the tertiary stages of either acquired or congenital syphilis (rare) the larynx may be affected, and in long-standing cases of over ten years, when the mucosa is much thickened, there is a danger of obstruction. Even when energetic antisyphilitic treatment has been advised the disease may become acute. Tracheotomy may be necessary for the relief of (_a_) œdema, likely to occur suddenly with necrosis, perichondritis, or the breaking down of gummata; (_b_) fibrous stenosis, which may cause a gradual increase of dyspnœa or become suddenly acute from spasm or œdema (iodides?); (_c_) adhesions, whether simple bands or webs; or (_d_) fixation of the vocal cords in the middle line, resulting from inflammation of the laryngeal joints or from paralysis of the abductor muscles.

(v) _Tubercle._ This rarely causes true laryngeal obstruction, excepting in those acute cases where subglottic œdema, abscess, or sequestrum is present. Tracheotomy was at one time used in certain cases in order to give complete rest to the larynx, but this has been abandoned as unsatisfactory; it should not be performed unless there is urgent laryngeal obstruction, since ‘it has many and grave disadvantages. It materially diminishes the efficiency of the cough, the secretion from the lungs is apt to accumulate in the bronchi and alveoli, and set up miliary tuberculosis. Again, the patient can often ill withstand even this slight operation; his power of speaking is diminished or lost and his mental anxiety is increased. Not rarely also, the tracheotomy wound becomes infected with tubercle. For these reasons tracheotomy should never be performed in phthisis except for severe dyspnœa’ (Lack[26]).

[26] Cheyne and Burghard, _Manual of Surg. Treat._, 1901, Pt. v, p. 449.

(vi) _Certain nervous diseases_, such as abductor paralysis. Urgent dyspnœa may occur in (_a_) advanced bilateral abductor paralysis, or (_b_) unilateral abductor paralysis associated with pressure upon the trachea by tumours. In the bilateral form it is difficult to determine when to operate; but the danger of suffocation, increased during the night, makes it necessary to overrule the objections of the patient. Tracheotomy (or intubation) may be performed merely as a temporary relief where the paralysis results from diphtheria, syphilis, toxic neuritis, &c.; in more serious cases the tube must be worn permanently, unless total recurrent paralysis supervenes (as it may do, though rarely in tabes) accompanied by cadaveric position of the cords and the restoration of free breathing. This latter condition can be induced by total division of both recurrent laryngeal nerves, but the operation, which has been performed on one or two occasions, has not been attended with satisfactory results. In cases of long duration the tube may be plugged during the day, or a valve may be added to the canula, so that the patient can speak by expiration through the larynx.

(vii) _Tracheal compression_ by tumours of the neck or mediastinum, of the thyreoid or thymus, or by aneurism, or by tuberculous bronchial glands. In these conditions inspiration and expiration are equally affected, and if the obstruction is low down, a long canula (such as König’s, Kocher’s, or Salzer’s) will be required in order to relieve the dyspnœa. The pressure of such tubes may cause ulceration of the wall of the trachea, and hæmorrhage may occur. This danger is especially to be feared when an aortic aneurism presses upon the trachea (see p. 542).

Tracheotomy should, therefore, be reserved for extreme cases, where it is impossible to remove the cause of the obstruction: on the other hand, dyspnœa caused by tumours of the neck which are removable (_e.g._ thyreoid tumours) should be relieved by radical operation without tracheotomy.

(viii) _Congenital laryngeal stridor_, glottic spasm, laryngismus stridulus, epilepsy, congenital webs and diseases of the crico-arytenoid joint such as ankylosis (true or false) or luxation. In these cases tracheotomy is rarely necessary, but when the operation is advisably undertaken the dyspnœa may require a permanent tracheotomy tube or prolonged intubation unless a radical removal of the disease can be effected.

(ix) _Cut-throat._ Tracheotomy is advised as a preliminary to further plastic operations in all cases where any part of the air-passages has been opened, in order to avoid the danger of suffocation and to prevent hæmorrhage into the trachea.

(x) _Fracture_ of either the hyoid, thyreoid, or cricoid cartilage, that of the thyreoid being the most common, and of the cricoid the most serious. These fractures are always associated with hæmorrhage and œdema of the mucous membrane, sometimes with emphysema; and the swelling thus caused within the larynx may be so great that tracheotomy or laryngotomy becomes urgently necessary for the relief of dyspnœa. Theoretically it is advisable to expose the fracture, so that it may be sutured or wired in its proper position, but, even in those instances where this is attempted, it is advisable to retain the tracheotomy tube for a few days until all swelling has subsided.

(xi) _Sudden dyspnœa during surgical operations_, due to--

(_a_) Mechanical obstruction to respiration, such as is caused by impaction of foreign bodies within the larynx (tooth-plates, teeth, blood, pus, vomited food, &c.), by faulty position of the head or falling backwards of the tongue, by a swollen condition of the larynx, by tumours or abscesses (retropharyngeal) which obstruct the air-way, by cicatricial contraction of the pharynx or larynx, by paralysis of the vocal cords, or by spasm of the muscles of the jaws so often associated with a similar condition of the glottis and auxiliary muscles of respiration. In a case reported by Boyle, a well-nourished muscular man was anæsthetized for the operation of internal urethrotomy; considerable difficulty was encountered with his breathing, and only towards the end of the operation was it discovered that he had well-marked stenosis of the upper opening of the larynx.

The entrance into the larynx of vomited food or blood is certainly dangerous, and may occur during the simplest operations even when properly performed, as, for instance, during removal of tonsils or adenoids. It is more likely to occur if the patient has not been prepared for an anæsthetic, or if the latter be badly administered, if the laryngeal reflex be lost, if the patient be in a bad position or suddenly moves, or if the surgeon allows too much blood to collect in the pharynx.

(_b_) Failure of respiration from an overdose of chloroform or other anæsthetic. To remedy such conditions it is essential that the air should be expelled from the chest as rapidly as possible. Artificial respiration can only be successful when the air passes freely both into and out of the lungs: in rare instances there may be so much difficulty in maintaining a free passage that tracheotomy should be performed.

(xii) _Multiple papillomata of the larynx._ Here tracheotomy is required for the relief of dyspnœa and as a preliminary to other operations. It has also been suggested as a method of curing the papillomata by giving rest to the larynx. After the performance of tracheotomy the congestion is relieved and the growths decrease in size; in some cases they completely disappear, but the treatment is uncertain and not to be recommended (see p. 485).

(xiii) _Malignant disease of the pharynx or larynx which is too advanced for other forms of treatment._ Palliative tracheotomy may be employed in order to relieve dyspnœa or as a means of giving rest to the larynx. It is most commonly used for cases of extrinsic carcinoma of the larynx: thus C. Jackson reported twenty-nine such cases, in twenty-one of which he advised palliative tracheotomy and in only eight laryngectomy. Of the former, tracheotomy was actually performed in nine, but none of the patients lived for more than thirteen months. It seems doubtful whether tracheotomy has any marked effect in retarding the course of malignant disease, though it sometimes gives relief.

(xiv) _Foreign bodies in the air-passages._ It makes no difference what views are held as to the advisability of tracheotomy in the treatment of these cases. The fact remains that the first essential is the safety of the patient, and, if the dyspnœa is urgent, relief must be afforded. When a foreign substance has been inhaled the surgeon must always be prepared for tracheotomy, and it is not advisable for him to leave the patient, even for a short interval, without proper supervision. In addition, the operation has been advocated as the proper treatment for all cases of foreign bodies in the lower air-passages: nevertheless, removal by Killian’s method gives far better results (see p. 559).

(xv) _As a preliminary to operations upon the upper air-passages_ tracheotomy is rarely necessary, its place having been taken by infrathyreoid laryngotomy: it is, however, often performed before undertaking the larger operations upon the larynx (see p. 489).

=Anatomy.= The length of the trachea of an adult is about 4-1/2 inches, of which 2-1/2 inches lie above the level of the sternum; the cervical portion, which consists of eight or more rings, extends from the cricoid cartilage above to the suprasternal notch below. In order to determine the upper limit of the trachea it is advisable to palpate the following structures, which lie in the middle line, from above downwards: namely, the hyoid bone with its greater cornua, the thyreoid cartilage which forms the greatest prominence on the front of the neck, and the cricoid cartilage; in this manner it is possible to detect whether there is any deflexion of the trachea from the middle line as the result of a tumour lying in one side of the neck.

The anterior border of the sterno-mastoid muscle on each side is also an important landmark; the two muscles approach each other as they descend to their attachments to the sterno-clavicular joints, thus forming an angle the position of which corresponds to the notch in the manubrium sterni. By drawing a line transversely across the cricoid cartilage to the anterior borders of the sterno-mastoid muscles, a triangular space is marked off which may be described as the _tracheotomy triangle_ (Fig. 264).

Beneath the skin and superficial fascia lie the two anterior jugular veins; these run from above downwards, to communicate with a branch which crosses the middle line of the neck, commonly in the lower part of the tracheotomy triangle, and there is an interval between them which is, in most cases, sufficiently large to prevent their being injured by a central incision. The pretracheal muscles, namely, the sterno-hyoids and sterno-thyreoids, are closer together; but the interval can be recognized by the greater thickness of the deep fascia which passes between them. When the latter is incised, these muscles can be separated, and the trachea is exposed, together with the structures that lie on its anterior aspect. These are the following:--

(_a_) _The isthmus of the thyreoid gland_, which varies greatly in size. It may be either a thin band with few vessels of importance, covering the second, third, and fourth tracheal ring; or hypertrophied and vascular, extending higher in the neck even to the front of the cricoid or thyreoid cartilage. This condition also results when a pyramidal lobe is present.

(_b_) _The pretracheal fascia_, which encloses the isthmus of the thyreoid gland and, when traced upwards, finds attachment to the anterior aspect of the cricoid cartilage, thus forming the suspensory ligament of the isthmus. Passing downwards it covers the anterior surface of the trachea, and, though somewhat indefinite, can easily be traced behind the sternum as far as the pericardium, with which it blends. This is a point of great practical importance in determining the extension of inflammation into the mediastinum.

(_c_) _Veins._ Small transverse branches of the superior thyreoid veins run upon the upper border of the isthmus between the layers of the fascia which surround this structure. The inferior thyreoid veins, larger in size, run from the lower border of the isthmus vertically downwards in front of the trachea to communicate with the left innominate; in their upper part they may consist of several small veins which join together to form two main branches, of which the left may lie directly in the middle line; small communicating branches of these veins run transversely across the lower border of the isthmus. The left innominate vein crosses the front of the trachea somewhat obliquely, and may lie at least half an inch above the suprasternal notch.

(_d_) _Arteries._ The crico-thyreoid artery runs transversely across the crico-thyreoid space, being placed in front of the suspensory ligament, and gives off numerous branches, which enter and supply the interior of the larynx, as well as small descending branches which run to the isthmus of the thyreoid gland. A small branch of the inferior thyreoid artery is also constantly found behind the isthmus, and in rare instances a thyreoidea ima branch of the innominate, varying greatly in size, may pass upwards in front of the trachea.

In young children the same relations are found, but with certain differences. Owing to the larynx being relatively high in the early years of life, the length of the cervical portion of the trachea is almost 2 inches when the head is extended, and the bifurcation is considerably higher than in the adult; further, the trachea is more movable and is smaller in diameter. The laryngeal cartilages are difficult to distinguish, but a mass composed of the thyreoid and cricoid cartilages can always be felt, and its position determined by careful inspection. It is very important to remember that, even when the head is extended, the cricoid cartilage lies rather less than 2 inches above the upper margin of the sternum. In very young children it is common to find two transverse creases in the skin, of which the upper usually lies over the upper border of the thyreoid and the lower over the cricoid cartilage. The lower crease thus assists in determining the upper limit of the trachea.

The anterior jugular veins in young children are comparatively large; the infrahyoid muscles are less defined and more difficult to recognize; and the isthmus of the thyreoid gland is very broad, appears to be part of the lateral lobes, and occupies a higher position in the neck, often passing in front of the crico-tracheal membrane as well as the first and second tracheal rings. The inferior thyreoid veins are larger, more numerous, and more difficult to separate; the left innominate vein is somewhat higher in the neck; the thymus gland, which gradually decreases in size with the increase of age, may extend into the neck, in front of the trachea, and may even reach as high as the isthmus of the thyreoid; the fasciæ are softer and less definite, and the fascia which covers the trachea is easily stripped from its surface.

TRACHEOTOMY IN DIPHTHERIA

=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.

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.

[27] _Tracheotomy in Laryngeal Diphtheria_, 2nd ed., p. 42.

TABLE SHOWING SIZE OF TRACHEA AND OF TUBE REQUIRED AT DIFFERENT AGES

+--------------+------------+------------+---------------------+ | |_Approximate|_Approximate| _Number of tube._ | | _Age._ | diameter of| diameter of+----------+----------+ | | trachea._ | tube._ |_Parker’s_|_Durham’s_| +--------------+------------+------------+---------------------+ |6 months | 4 mm. | 4 mm. | 16 | -- | |1-1/2--2 years| 6-8 mm. | 7 mm. | 20 | 1 | |2-4 years | 8-10 mm. | 8 mm. | 24 | 2 | |4-10 years | 10-12 mm. | 9 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.

There are four varieties of the operation, viz.:

1. _Crico-tracheotomy_ (with division of the cricoid cartilage).

2. _High tracheotomy_ (involving section of the trachea above the isthmus of the thyreoid gland).

3. _Low tracheotomy_ (section of trachea below the isthmus of the thyreoid gland).

4. _Median tracheotomy_ (section of trachea through the isthmus of the thyreoid gland).

=Crico-tracheotomy= is an easy operation owing to the superficial position of this portion of the air-passage, but is inadvisable for the following reasons:--

(1) The larynx being narrower than the trachea, a smaller tube is required; (2) the swelling of the mucosa often extends downwards and causes constriction of this region; (3) the tube is not well tolerated; (4) pressure ulcers, necrosis of the cricoid, and granulations are frequent complications; and (5) retained tube is more common than with other operations, this really being the most important consideration. The comparative value of the remaining operations is largely a matter of opinion.

It is not uncommonly stated that tracheotomy is better done by touch than by sight: the object to be achieved is to find the trachea, and there are two methods of doing this. The first is the _deliberate method_, suitable for patients in good condition when there is no urgent dyspnœa; it can be performed entirely by sight, and the greater the experience of the surgeon the fewer his difficulties. In such cases skilful technique is of far greater value than haste. The high operation is preferred, because the trachea is more superficial, less movable, and easier to find; it has less complicated relations, the blood-vessels are less numerous, the fasciæ are not so loose, the tube is easier to fit and unlikely to slip out, healing of the wound is more rapid, and complications seldom occur. In cases where the isthmus is very broad or highly placed, so that the upper parts of the trachea and cricoid are covered, a median operation is recommended. Low tracheotomy is rarely necessary.

The second is the _rapid method_, to be applied in cases of emergency. Turner, of the South Eastern Hospital, strongly advocates such an operation without an anæsthetic. The incision made is from 1/2-5/8 of an inch in length, this being repeated without attention to the bleeding until the trachea is reached. The latter is opened in the usual manner. The tip of the finger is placed in the wound in order to control the hæmorrhage, and as a guide to the dilators. When these have been introduced, the child is at once drawn beyond the end of the table so that the head hangs downwards. The bleeding usually ceases in a few moments, though in some cases the tube is inserted to control it. The advantages claimed for this method are that the operation is quicker, and that no distinction between ‘high’ and ‘low’ is required. The wound is smaller, there is less danger of sepsis, and the eventual scar is hardly visible; no hooks or retractors are used, so that the trachea cannot be displaced. If the wound be in the middle line it is impossible to miss the trachea. This operation is performed entirely by touch, and the bleeding is not considered. Its adoption may be necessary to save the patient’s life, but in the hands of an inexperienced surgeon the operation is attended with great difficulties.

=High tracheotomy.= The incision must be exactly in the middle line; this can be accomplished easily if the surgeon keeps in mind two important landmarks, namely, the point of the chin, and the suprasternal notch. To determine the upper end of the incision, a point is chosen midway between the anterior borders of the sterno-mastoid muscles at the level of the cricoid cartilage. The thyreoid cartilages being steadied between the fingers and thumb of the left hand, a bold incision is made from the upper point, 1-1/2 inches in length, extending in a young child almost to the suprasternal notch. A long incision is generally preferable, and, when the neck is fat, should commence over the middle of the thyreoid cartilage. The skin and superficial fascia are divided between the two anterior jugular veins, and any bleeding is controlled. The incision is repeated so as to divide the deep fascia lying between the sterno-hyoid muscles, close to one another in the upper part of the incision, and these are separated with the knife. It is now advisable to pause and to seize the bleeding points, allowing the pressure forceps to fall on both sides of the wound to act as retractors. The infrahyoid muscles are separated by at least an inch, and, if retractors are necessary, care must be taken that the muscles alone are included and that the retraction is equal on the two sides. If there has been no ‘tailing’ of the wound the following structures are then exposed from above downwards: the lower border of the thyreoid cartilage, and the front of the cricoid, both easily seen or felt; and a vascular mass, namely, the isthmus of the thyreoid gland, covered by fascia and completely concealing the trachea. The landmark that is required at this stage is the cricoid arch; this should be found, and a small transverse incision should be made along its lower border to divide the suspensory ligament; the handle of the scalpel or a blunt hook is introduced beneath the pretracheal fascia, and the isthmus dragged downwards into the lower portion of the wound, an operation which can be accomplished easily if done without hesitation. The upper rings of the trachea are now exposed; and, unless the superficial veins have been divided, there should be no bleeding. The trachea should not be opened until it has been exposed completely and all bleeding has been arrested. It is unnecessary to ligature the vessels at this stage unless the forceps have been so placed as to interfere with the part of the trachea chosen for section, or an artery of considerable size is encountered; in the latter instance there is a danger of subsequent hæmorrhage if the ligature is applied close to the tube. While the trachea is being opened, it is necessary to overcome the movements of the larynx by grasping the cricoid with the finger and thumb of the left hand. The scalpel should be gently stabbed into the middle of the trachea to ensure puncturing the mucous membrane as well as the outer wall, and the opening should be quickly enlarged in an upward direction until three rings have been divided, preferably the first, second, and third. It is imperative that this incision should be in the middle line, should not be too small, and should only pass through the anterior tracheal wall; if force be used there is danger of puncturing the œsophagus, or even of striking the bodies of the vertebræ.

At the moment when the trachea is opened there is a sudden rush of air out of the lungs. This is reassuring to the surgeon, and at this point the dilator should be introduced and the anæsthetic abandoned. Temporary cessation of breathing is common after the first inspiration, but the great improvement in colour shows that there is no cause for alarm; with the return of consciousness the child begins to cough, and this has two results, partly clearing the tubes of mucus, pus, or membrane, and partly promoting deeper inspiration and better expansion of the lungs. Cyanosis is thus speedily removed, unless membrane is abundant; and even where this is the case, it is advisable to encourage coughing in order to dislodge the membrane, which can be grasped with forceps or caught with a sponge as it appears in the wound. The use of a feather or a soft rubber catheter for irritation of the trachea to promote coughing should be abandoned, as such instruments often displace the membrane downwards. As soon as breathing is regular and the cough allayed, the vessels can be ligatured.

A tube of suitable size having next been selected, the opening in the trachea is widely dilated and the point of the canula quickly inserted into position, the outer tube alone being used, with tapes for tying attached. Unless the tube ‘sits’ well without tilting, different sizes should be tried until the breathing becomes easy, a sure sign that the lower opening of the canula is pointing in the right direction. The tapes are tied firmly on the right side of the neck, after which the inner tube is introduced and fixed in position.

The wound remains to be treated. Various methods have been recommended to guard against infection: the use of antiseptic watery solutions, such as perchloride of mercury, chloride of zinc, carbolic acid, and perchloride of iron, is dangerous; insufflation of powders, on the other hand, such as orthoform, aristol, and the like, is certainly effective in keeping the wound clean, and is better than the employment of an oil emulsion; suturing the wound is unnecessary and is not recommended. A dry antiseptic gauze is applied to the wound and kept in position by the pressure of the shield. Lastly, a thin covering of gauze is placed over the front of the neck, and the patient returned to bed.

=Low tracheotomy.= The incision should be rather longer than in the ‘high’ operation and should reach almost to the suprasternal notch. The fasciæ, anterior jugular veins, and infrahyoid muscles are treated as before, and there must be no ‘tailing’ of the wound. The landmark required is the isthmus of the thyreoid gland, and its lower border must be determined and dragged upwards by a blunt hook. It is important to remember that the lower part of the trachea lies deeper in the neck and is more difficult to expose owing to the blood-vessels that lie anterior to it; the thymus gland, also, may extend upwards and require to be retracted. Whereas in high tracheotomy practically the whole operation is best done by clean cutting, in the lower operation this is more dangerous, and the deep dissection must be performed partly with forceps or blunt director; if an artery be divided or venous bleeding occurs, it should be controlled immediately. No attempt should be made to perform this operation rapidly owing to the relations of the parts; nor should the trachea be opened before its rings are exposed thoroughly, as complications may arise after imperfect division of the pretracheal fascia. In the opening of the trachea and the further stages, the operation is similar to high tracheotomy.

=Median tracheotomy.= The child being placed in the required position as before, an incision is made, from the lower border of the thyreoid cartilage almost to the sternum, through the skin and superficial fascia. With a series of cuts, exactly in the line of the original incision, the fascia lying between the pretracheal muscles is divided; the bleeding points are seized with pressure forceps, and retractors are introduced to expose the isthmus. The isthmus itself is treated in one of two ways: in urgent cases it is boldly divided by one or two cuts of the knife; but if time can be spared, a threaded aneurysm needle may be passed under it, first on one side and then on the other, after which the needle is withdrawn, and the two ligatures can be tied so as to leave between them a space of one-third of an inch in which a cut can be made without hæmorrhage. The tracheal rings are thus exposed and can be divided as before.

=Accidents.= The accidents that occur are less numerous than might be expected when it is considered how often this operation is performed by those who are quite unpractised in surgery; many of them are the direct result of inexperience or arise because the operator becomes confused. If the patient be in a bad position, or if a wrong incision be made, the trachea is difficult to find, and it is better to expose the thyreoid cartilage and prolong the incision downwards until the windpipe has been discovered.

Hæmorrhage, however, is the chief difficulty, and is sometimes unavoidable; it may be arterial or venous. The arteries of this region are generally small, being branches of the superior or inferior thyreoids, and this accounts for the fact that severe arterial bleeding is rare. Nevertheless, the smaller vessels may at times be very troublesome: for instance, the crico-thyreoid artery or one of its branches may be divided, in which case the cut ends will retract and will be difficult to seize; and if the trachea has been opened, blood may continue to enter in sufficient quantity to cause troublesome coughing. Abnormal arteries, such as the thyreoidea ima, are not of great practical importance.

Venous hæmorrhage is far more common, and, taking into account the anatomical relations of the veins, and their great size (increased by cyanosis) in children, it seems remarkable that bleeding is so seldom fatal; in desperate cases a very small amount of blood is sufficient to cause suffocation. Venous bleeding will stop only when respiration becomes free, and this is not possible so long as blood is being sucked into the air-passages. Every effort should be made, therefore, to prevent blood from passing into the trachea, either by hanging the head over the end of the table as soon as the dilators have been introduced, or by introducing a canula against which the walls of the trachea can be compressed.

Failure to breathe, after an opening has been made, is due to either obstruction or collapse and requires rapid treatment. The trachea must be widely dilated, and forceps used to remove any membrane which presents itself in the wound; the assistant must then slowly compress the ribs two or three times to empty the chest and encourage respiration. If consciousness returns, the patient begins to cough and mucus or membrane is expelled from the air-passages. On the other hand, it is useless to continue artificial respiration if the obstruction is not relieved; aspiration must be employed if special instruments are at hand. The fact that a number of surgeons have lost their lives as the result of sucking through a catheter in the attempt to save the child is sufficient to condemn this practice; but good results have been obtained by passing a catheter low down into the trachea and blowing through it with a syringe or even with the mouth. As soon as the trachea has been emptied by one of these methods, artificial respiration should be continued, and collapse treated by injections of strychnine, brandy, or ether. No attempt should be made to introduce a canula until the breathing is restored. As Turner remarks: ‘Heart failure during operation generally recovers with artificial respiration, and twelve hours later the condition is indistinguishable from that of a case who has not so closely approached death. The real remedy against such an accident is never to postpone operation until the heart is exhausted.’

=After-treatment.= Although this is a subject which has produced a great deal of discussion, there is a widespread impression among the younger members of the profession that it is of little importance. Much has been said about the dangers of interference, and any suggestion put forward has been criticized by those who have had large experience, with the result that confusion is prevalent. As a matter of fact, the subject is one of the greatest importance, for there is no operation in surgery in which the after-treatment can be neglected. Care should be exercised in choosing a nurse who has special knowledge of children and of the after-treatment of tracheotomy. Great discretion is required in the management of such cases, and there is little doubt that harm may result where too much attention is shown. At many of the hospitals a special nurse is appointed for attendance on the more desperate cases only. The main duty of the nurse is to watch the child, for any difficulty in breathing requires immediate attention. It is necessary that she should understand the proper management of the tube; she must see that the inner tube never becomes clogged, and if the tube slips out of the trachea it must be reintroduced or a dilator inserted; she must also be responsible for the feeding of the child. The difficulties that arise during the first few days after operation call for much tact and experience.

It is unnecessary to enter here into the discussion about food, stimulants, or general treatment, except to point out that swallowing may be very difficult. The food must be nourishing, fluid being in most cases preferred; occasional sips of water should be administered to find out whether coughing is produced, in which case nasal feeding can be advised without hesitation. A short rubber catheter should be passed through the nose at regular intervals according to the nature of the case. As a general rule a small quantity of nourishment should be given every two hours, studying, as far as possible, the likes and dislikes of the patient. By the observance of these principles the child soon becomes tolerant, and proper nourishment can be administered, thus removing one of the great difficulties of after-treatment.

_The atmosphere of the room._ The value of steam for producing warmth and moisture is undoubted; the amount required depends on the case. The main object to be kept in view is to encourage secretion from the mucous membranes, and so to prevent the formation of crusts. When secretion is scanty a large amount of moisture is required, and _vice versa_; also, when much pus is present, extra moisture is of value to prevent it from becoming dried and to allow it to be expectorated. The value of disinfectants is doubtful, but on general principles it may be said that the more septic the secretion the greater the indication for their use: tincture of benzoin, oil of eucalyptus, and thymol act as sedatives; carbolic acid, creosote, and numerous other drugs are useful disinfectants; soda and potash, recommended by R. W. Parker, tend to liquefy the exudations. Steam, however, is more important than all these, and should be advised as being likely to encourage the quicker healing of the wound: even in catarrhal conditions improvement is more rapid when this practice is adhered to.

The most important point in the after-treatment, however, as far as the surgeon is concerned, is to prevent recurrence of the obstruction. Obstruction is most often due to the blocking of the inner tube by secretions, a condition easy to recognize from the symptoms which are produced. The inner tube should be removed, thoroughly cleaned, and reintroduced. This usually suffices to allow the child a period of quiet breathing, and sleep may be obtained. To keep the tube free it is very necessary to repeat the removal at regular intervals. In those cases where the secretion is tenacious, the tube constantly becomes blocked, but it is better to remove it again than to allow a feather to be passed. Nothing is gained by attempting to hurry the separation of crusts, and the passage of a feather tends to force downward far more than can be extracted, and so to increase the danger of broncho-pneumonia. If dyspnœa continues after removal of the inner tube, a spray should be used, or a small amount of fluid should be dropped into the trachea to moisten the secretions.

Changing the outer tube rarely presents any difficulty because the tissues of the neck soon become matted together, a funnel being thus produced along which the canula is introduced with ease. A new tube should be prepared before removal of the old, and dilators should be at hand for use if the child is frightened, struggles, or coughs: the canula should be introduced quickly and without hesitation, sufficient force being employed to overcome any obstruction. Unless the original opening in the trachea was too small, it should be possible to introduce a tube equal in size to that which was removed. Frequent changing of the outer tube should be avoided.

_The time for removing the outer tube._ In every case of diphtheria there is a certain amount of catarrh, with swelling of the mucosa, increased secretion, and some difficulty of breathing. In addition, the habit of breathing through a canula is difficult to alter; the child shows an aversion to breathing through the natural air-passages, and is often frightened or bad-tempered. As soon as the secretion becomes small in amount and serous rather than purulent in consistence, an attempt should be made to discard the tube: the canula should not be retained a day longer than is necessary, the usual period varying from five to fifteen days. Various methods may be adopted:--

1. If the outer tube be provided with a window, the tip of the finger can be placed on the opening to compel the child to breathe through the larynx; breathing may be difficult, but by this means an indication can be obtained as to whether it is advisable to persist.

2. If the above method be successful, the tube may be removed. A small pad of gauze is placed over the wound and the child further encouraged to breathe through the larynx. Expiration is generally easier than inspiration, and older children should be encouraged to blow out a candle or to sound a whistle, this process being continued so long as the child can endure it, but not to the stage of exhaustion. It is often possible to remove the tube at the first attempt.

3. The canula may be plugged with a cork which the nurse removes when necessary: it is often possible to replace the plug while the child is asleep without his becoming conscious of the fact, thus showing that the dyspnœa is largely mental.

4. In some children breathing is easy so long as the tube is simply plugged and is not removed; in such cases the canula can be replaced by a shield and a plug which does not pass into the trachea. This may completely deceive the child.

5. The silver tube can be changed for one of rubber, and this can be shortened daily until nothing remains but the shield.

If these various methods have been tried with no success it is probable that the case is abnormal, but before this can be conceded it is necessary to repeat that, in the large majority of cases, the difficulty of removing the tube is due not so much to definite stenosis of the larynx as to the bad habit acquired by the patient.

=Complications= arising after tracheotomy and preventing removal of the tube:--

1. _Wound infection._ This rarely occurs at the present time, and diphtheritic wounds are seldom seen. Some inflammation of the wound is natural under the conditions, and may be associated with œdema of the surrounding tissues; this generally yields to antiseptic treatment in a few days. In very weakly children suffering from a virulent form of disease the healing of the wound may be slow, and septic conditions are apt to arise ending in cellulitis of the neck or even typical erysipelas. Owing to the disposition of the fasciæ there is a tendency for the infection to spread in a downward direction, and for mediastinal inflammation or suppuration to occur: this appears to be more common after low tracheotomy. The prognosis in such cases is not good, and every endeavour should be made to prevent the possibility of their occurrence by absolute cleanliness at the operation and by suitable after-treatment of the wounds.

2. _Septic conditions_ of the trachea are less common since the introduction of antitoxin, but occur in cases where false membrane is abundant. There may be swelling of the mucosa, or copious discharge which persists for long periods.

3. _Ulceration_ may be due to sepsis or to pressure from a badly fitting tube, especially when the latter has been worn for a protracted period (Fig. 270). It may cause perforation and localized abscess either in front of the trachea or in the neighbourhood of the œsophagus, and may result in a communication with the latter. In the region of the cricoid, ulcers are liable to cause necrosis. The signs of such ulceration are: continuance of purulent discharge, discoloration of the tube, bleeding from the wound, and, above all, difficulty in removing the tube.

At the first indication of ulceration the cause of irritation should be removed. It is advisable to discard a metal in favour of a rubber tube, or, if possible, to remove the tube altogether. Strenuous efforts must then be made to disinfect the trachea by the insufflation of antiseptics, either as powders or in solution. The healing of such ulcers is very slow, and granulations are apt to form resulting in obstruction and preventing removal of the tube. In later stages contraction of fibrous tissue causes stenosis; this is more common in the neighbourhood of the cricoid, especially when the latter has been divided at the time of the operation.

4. _Granulations._ The possible presence of granulations must always be borne in mind. I believe this condition is far less common than is generally supposed, and that in many cases the granulations are entirely limited to the neighbourhood of the wound, where they can be seen. It is doubtful whether they are responsible for the dyspnœa which occurs. Great ingenuity and patience are required for the treatment of this condition. The wound must be kept scrupulously clean and all source of irritation removed. A rubber canula should be substituted in place of a metal one; if it were possible it would be advisable to discard the tube altogether, but as yet no form of dilator has been devised which will take the place of the canula. If the granulations be large they should be removed either with a sharp spoon or with suitable forceps, the area having been anæsthetized previously by a small quantity of the novocaine and adrenalin mixture. When small, the use of silver nitrate is preferable. It may be necessary to repeat this after a few days, and as soon as seems advisable a further attempt should be made to dispense with the tube. At this stage time must be allowed for the various tissues to regain their normal condition. Should this treatment prove unsuccessful, a thorough investigation must be made under chloroform. The wound is enlarged as far upwards as the cricoid, bleeding being arrested with the mixture just described. By throwing a strong light into the wound, the condition of the mucous membrane can be inspected and granulations removed. If there be no granulations in the trachea, a tube speculum can be passed through the mouth to ascertain the condition of the larynx (see p. 480). Such a method of procedure is preferable to the passage of probes, forceps, sponges, and other articles through the larynx, in the hope that any obstruction may be removed. If ulceration or necrosis of cartilage be discovered, it is impossible to relieve the condition by surgical means without prolonged treatment with tubes and the constant use of antiseptics. Under these conditions it is advisable to consider the removal of the tracheotomy tube in favour of intubation. In the hands of many foreign authorities the use of intubation tubes covered with gelatine, in which antiseptic is introduced, has been attended with such conspicuous success that further attempts should be made in this country; there is little doubt that, as our knowledge of the treatment of such wounds improves, better results are daily attained. Whatever treatment is considered it is important first of all that the actual cause should be distinguished. This is now possible owing to the great advances made in methods of examining the larynx.

5. _Stenosis_ of the larynx or trachea occurs in old-standing cases, as the result of ulceration, after some cases of crico-tracheotomy, and especially where a tube has been worn for a very protracted period. Breathing through a tube, if continued for a long time, interferes with the natural growth of the air-passage above it. The child grows, but the larynx remains stationary. This condition is aggravated by the fact that some inflammation is constantly present, especially in the neighbourhood of the wound, so that the tissue become fibrous and hard. The fibrous tissue contracts and stenosis is caused. According to von Bruns, Kohl,[28] and others, constrictions of the trachea may in rare instances result from some kinking of its wall. Such conditions as a bulging of the posterior wall due to the approximation of the posterior ends of the cartilage secondary to the spreading of the anterior portions, inversion of the tracheal margins from too small an incision, overlapping of the tracheal wound, and cicatricial union between the thyreoid and cricoid, must be exceedingly rare. Here, again, a definite diagnosis can always be made by proper investigation, but treatment is more difficult. Dilatation must be attempted by either continuous or intermittent methods. If preferred, a short piece of rubber tubing can be passed upwards from the tracheotomy wound into the larynx and kept in place for several hours by two silk sutures, one passing out of the tracheal wound, the other out of the mouth; or a stenosis canula can be inserted with some form of hollow plug which passes upwards into the larynx (Fig. 272). The question whether the tracheotomy wound should be kept patent is difficult to answer. When stenosis is extreme there is no alternative, and the open wound allows of the constant passage of graduated bougies, which is more easily accomplished from below than from above. If treatment be persistent the prospect of a good result is not unfavourable, and there is every reason to believe that in the future the number of cases which require a permanent tracheotomy tube will be reduced to a minimum.

[28] Bergmann, E. von, _Sys. Pract. Surg._, vol. ii, p. 270.

6. _Paralysis._ In the larynx there may be paralysis of the sensory or of the motor nerves. In the former case food may enter into the trachea and cause troublesome coughing and possibly ‘Schluck-pneumonie’. When the motor nerves are affected, the paralysis is commonly abductor and may be unilateral or bilateral, the latter associated with inspiratory dyspnœa. ‘Complete paralysis of the recurrent laryngeal nerve may also occur, but is nearly always confined to one side’ (C. A. Parker[29]). Such paralyses may last from a few days to several months, and are very troublesome when associated with the passage of food into the trachea; when severe, nourishment should consist of fluids which can be administered by a nasal tube.

[29] _Nose and Throat_, 1906, p. 94.

Further complications arising during the after-treatment of tracheotomy:

7. _Broncho-pneumonia._ This occurs in the worst forms, and is accompanied by high temperature with definite signs in the lungs. The absence of septic discharge, the restlessness of the patient, and the rapidity of the breathing (in many instances accompanied by ‘recession’ not caused by obstruction in the tube) make the condition easy to recognize. There is no satisfactory treatment for septic broncho-pneumonia which has already developed, but it may be prevented. Within recent years it has become less common. This is due to better technique in the operation, and to careful attention during the after-treatment. The habit of passing feathers into the trachea has been abandoned with advantage to the patient. When possible the child should be removed from septic influences which are liable to infect the throat, for the occurrence of tonsil[l]itis as a sequel to tracheotomy is always to be feared in wards containing septic cases.

8. _Emphysema_ may occur in the neighbourhood of the wound, or in rare cases may be extensive and involve the whole of the face, neck, and chest. Champneys[30] was the first writer to call attention to this complication of tracheotomy. After a large number of observations and experiments, he was of opinion that emphysema of the anterior mediastinum occurs in a certain proportion of tracheotomies and is of frequent occurrence in cases that are fatal; that it may be associated with pneumothorax; and that the conditions which favour its production are a low division of the deep cervical fasciæ in the neighbourhood of the sternum, combined with obstruction of the air-passages and strong inspiratory efforts; artificial respiration, especially if improperly performed; and want of skill on the part of the operator; further, that the dangerous period of the operation is between the division of the deep cervical fascia and the efficient introduction of the tube. To this may be added those cases in which the tube slips out of the trachea into the cellular tissue above the sternum and thus causes more or less obstruction to breathing. It seems probable that the air is sucked into the cellular tissues beneath the pretracheal fascia, rather from the outside than from the trachea, and that with forced expansion of the chest it finds its way beneath the fascia into the mediastinum.

[30] _Trans. Med. Chirurg. Soc._, vol. lxv, p. 85; vol. lxvii, p. 102.

9. _Hæmorrhage_ may occur as the result of slipping of a ligature during an attack of vomiting or struggling after the operation; it is usually venous and requires nothing but passing notice. Secondary hæmorrhage may result from ulceration into one of the larger arteries or veins. Kocher[31] states that ‘the number of cases recorded is now about eighty-seven, of which fifty-six are associated with the innominate artery. Unfortunately it is not known how often in these cases inferior tracheotomy had been performed. Low tracheotomy was performed in my case because an excision of the larynx for cancer had been undertaken. Doubtless the danger of these fatal complications is much greater with inferior tracheotomy owing to the pressure of the canula.’ Von Bruns[32] also agrees that ‘the vast majority of fatal hæmorrhages were in cases of inferior tracheotomy. Of thirty-six cases in which the source of hæmorrhage was given, twenty-eight were traced to the innominate vein, two to the right carotid, and one each to the superior thyreoid, the left innominate, the right jugular and the left jugular.’ Bleeding is also recorded in cases of aneurism of the aorta, in which tracheotomy has been performed, as the result of erosion of the tracheal wall and the bursting of the sac. Further, troublesome oozing may take place from the mucous membrane of the trachea when this is inflamed, or when granulations are present, or when there is much sloughing of tissues, and especially after a metal tube has been worn for a considerable period. Hæmorrhage from an enlarged thyreoid isthmus is also described. When due consideration is given to the septic condition of the wounds and the close relation of large vessels, it is surprising to find that hæmorrhage proves so seldom fatal.

[31] _Chirurg. Operat._, 1907, p. 631.

[32] Bergmann, E. von, _Sys. Pract. Surg._, vol. ii, p. 265.

10. _Cardiac paralysis_ may also complicate tracheotomy. When supervening in the acute stages of the disease, the patient becomes prostrate and vomiting is persistent, while the heart gradually fails. In other cases death occurs suddenly and unexpectedly, in mild as well as in severe disease; this may happen at any period, during the first days or later, during convalescence. Heart failure is more common in diphtheria than in any other infectious disease which is met with in this country.

=Prognosis.= It may be said that all cases of laryngitis caused by diphtheria are of a serious nature, and especially those which require tracheotomy (see Table, p. 517). The mortality amongst tracheotomized patients during five years was 31.5%, and the variations in each separate year were slight. Such results are far from satisfactory, but it must be remembered that in pre-antitoxin days less than 30% recovered after tracheotomy (Goodall[33]). The use of antitoxin, first suggested by Behring, is undoubtedly responsible for this remarkable decrease in the mortality. The sooner the serum is injected the better the prognosis with tracheotomy. A large dose should be given, 8,000 to 18,000 units, irrespective of age, and the dose may be repeated on the second day if required. Improvement generally commences between twelve and twenty-four hours after injection; the swelling of the mucosa subsides, and secretion is diminished; false membrane is not so copious, and rarely extends to the trachea and bronchi; crusts become less adherent, and are expelled by the patient. In this manner the whole area of the disease becomes clean, and there is less absorption of toxins. It is now generally agreed that serum should be used in all suspicious cases, and some authorities inject at once not only the patient, but also other children living in the same house. It is hoped by early injection to avoid the necessity for tracheotomy.

[33] _Brit. Med. Journ._, 1899, vol. i, p. 199, ‘On the Value of the Treatment of Diphtheria by Antitoxin.’

The age of the patient is very important, as the following table shows:

TABLE SHOWING TOTAL DIPHTHERIA TRACHEOTOMIES PERFORMED AT THE FEVER HOSPITALS IN LONDON DURING 1902-6, INCLUDING THOSE IN WHICH INTUBATION WAS PREVIOUSLY PERFORMED AND THOSE IN WHICH NO ANTITOXIN WAS USED

+---------+----------+-----------+----------------+ | _Age._ | _Times._ | _Deaths._ | _Percentage of | | | | | Deaths._ | +---------+----------+-----------+----------------+ | Under 1 | 62 | 40 | 64.5 | | 1-2 | 256 | 123 | 48.0 | | 2-3 | 272 | 87 | 31.9 | | 3-4 | 231 | 54 | 23.3 | | 4-5 | 196 | 45 | 22.9 | | 5-6 | 119 | 19 | 16.0 | | 6-7 | 67 | 18 | 26.9 | | 7-8 | 22 | 5 | 22.7 | | 8-9 | 12 | 3 | 25.0 | | 9-10 | 9 | 3 | 33.3 | | Over 10 | 16 | 6 | 37.5 | +---------+----------+-----------+----------------+ | Total | 1,262 | 403 | 31.9 | +---------+----------+-----------+----------------+

From these figures it is apparent (1) that children less than one year of age rarely recover after tracheotomy; this is especially true of diphtheria, although in other forms of laryngeal obstruction cases of recovery have been reported in children of six months; (2) that in the early years of life tracheotomy is most commonly needed, especially between the ages of one and five years; (3) that the death-rate gradually decreases between the ages of one and six years, after which there is a rise.

In explanation of these facts it appears probable that after five years of age the larynx and trachea are increased in size, so that obstruction is only met with where there is a large amount of membrane, namely, in the worst cases; in patients over ten, the age which marks the change to the adult type of larynx, the air-passages become so large that obstruction seldom occurs even when much membrane is present; dyspnœa, in these cases, points to extension of the disease to the smaller tubes, and tracheotomy is unable to give the same relief.

In considering the prognosis, not only must the symptoms peculiar to the case be taken into account (as for instance the pulse, temperature, respiration and general condition), but also any complications that arise. It must be borne in mind that tracheotomy does not cure, although it can relieve, the patient; that nearly one-third of the cases die; that the disease, and not the operation, is responsible for most of the deaths. Moreover, the amount of toxæmia depends upon the virulence of the infection, which is variable in different epidemics; upon the area of mucous membrane infected; and upon the constitution of the patient. In so-called hæmorrhagic diphtheria the result is always fatal.

_The effect on after-life._ It was stated by Landouzy at the Berlin Tuberculosis Congress in 1899 that, judging by the rarity of the scar, few tracheotomized children reach adult life, but inquiries in Germany showed that this was incorrect. H. W. L. Barlow, in reviewing the literature of the subject, concludes that ‘in the large majority of cases the cure is permanent and complete’. In cases where a tracheotomy tube has been retained for a long period, however, complications are liable to arise; these include stenosis of the larynx or trachea, bronchitis, pneumonia, and possibly tuberculosis (see p. 485).

TRACHEOTOMY IN CONDITIONS OTHER THAN DIPHTHERIA

The indications for tracheotomy in conditions other than diphtheria have already been described. Although local anæsthetics are of little practical value in children, their use is much preferred where adults are concerned. The three drugs most commonly used at the present time are eucaine, cocaine, and novocaine, and of these novocaine is unquestionably to be preferred for subcutaneous injection as being less toxic, less irritant to the tissues, and at least as efficient in producing anæsthesia. Whichever drug is chosen, a small quantity of chloride of sodium should be added in order to make the solution isotonic with the blood serum, and thus to render it practically non-irritant. Many surgeons add adrenalin to contract the vessels in the injected area and so to prevent the drug from being absorbed into the general circulation: owing to the large size of the vessels and their proximity to the heart this is important, but it must also be remembered that with strong solutions there is great contraction of vessels, and that when the effects have disappeared there is a slight danger of recurrent hæmorrhage. Semon has drawn attention to this danger in connexion with operations upon the larynx, and after minor operations in other regions of the body it is not uncommon to find a small hæmatoma which necessitates reopening the wound.

In order to ensure the full effects of local anæsthesia with the least possible disadvantage, the drug should be used in weak solution, and the injection should be made at least a quarter of an hour before the operation is commenced. It is only necessary to prick the skin at one point, namely, at the upper end of the proposed incision; a small quantity of the fluid should be expelled, after which the needle may be withdrawn. After a short interval it is possible to reinsert the needle (or a larger one if preferred) and to push it deeper, until the whole length of the incision has been injected, without distress to the patient.

The following solution will be found effective:

‘Novocaine, 4% solution ɱ x = 1.3% Sodium chloride, 4% solution ɱ vj = 0.8% Adrenalin, 1-1,000 ɱ i = 0.003% Distilled water to ɱ xxx

[Transcriber’s note: ɱ (approximation to symbol in the text) is thought to mean drops, minims, or parts by volume; hence ɱ x = 10 parts/drops, ɱ vj = 6 parts/drops, ɱ i = 1 drop made up to a total of 30 parts/drops with distilled water]

‘These local anæsthetics are all, more or less, rapidly decomposed and rendered inactive in the presence of even traces of an alkali or alkaline carbonate. If boiling is resorted to in order to sterilize the syringe, great care must be taken that no soda is present.’--LANG.

Moreover, the finished solution cannot be boiled without decomposing the adrenalin, and it is customary therefore to add thymol or Ol. Gaultherii (0.1%), which keeps the solution antiseptic without being irritant.

The operation, which is often required in adults, must be carried out upon the lines already described. The enlargement of the thyreoid and cricoid cartilages, the small amount of fat, the small size of the thyreoid isthmus and of the pretracheal vessels after puberty, make the trachea easy to find. Difficulties, however, arise and are determined by the urgency of the case and the nature of the disease. Thus, with inflammation, the neck may be so swollen that the trachea is many inches from the surface; with tumours the trachea may be displaced, or the obstruction may be in the thorax. Under such conditions it is important to note the probable position of the trachea before the operation is commenced, and to be prepared for serious hæmorrhage.

The after-treatment also corresponds to that which is adopted in diphtheria. It is important to keep the tube clean and to prevent it from irritating the trachea. The time for removal of the canula varies according to the condition. Thus, when tracheotomy is performed for a foreign body, the tube may be removed as soon as the object has been extracted; on the other hand, when treating stenosis of the larynx it may be necessary to advise permanent wearing of the canula.

Complications are less common than with tracheotomy for diphtheria. Under favourable conditions there is little danger of pneumonia unless the wound becomes infected, as may happen when the operation is undertaken for the relief of septic inflammations.

Although tracheotomy is in itself a slight operation, it should be reserved for cases that demand it. The mortality of the operation under favourable conditions is probably very small; on the other hand, in acute septic conditions and in patients suffering from bronchitis there are grave dangers of complications.

TRACHEO-FISSURE AND RESECTION OF THE TRACHEA

Although these operations are very rarely performed, advance has been made in their technique during recent years.

=Indications.= (i) _Tumours of the trachea._ These are uncommon. Thiesen[34] in 1906 collected from literature 135 cases, of which 89 were innocent and 46 malignant. The majority of the former were papilloma (25), fibroma (24), enchondroma (17), and intratracheal struma (10). Of the latter, carcinoma (28) was more common than sarcoma (18). More than half of these tumours were situated high up in the trachea. These cases were collected from a period covering seventy-five years, which proves that they are extremely rare as compared with tumours of the larynx.

[34] _Trans. Amer. Laryng. Assoc._, 1906, p. 264, ‘Tumours of the Trachea.’

(ii) _Stenosis due to previous inflammation._ Stenosis may be caused by diphtheria or other fevers, syphilis, the presence of a foreign body, or the inhalation of corrosive acids or chemical fumes. Such cases are generally treated by endotracheal methods (see p. 559).

(iii) _Cut-throat, or injury._ An operation may be necessary after crushing or bullet wounds, or, in later stages, owing to the development of stenosis.

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]

[35] Bergmann, E. von. _Sys. Pract. Surg._, vol. ii, p. 249.

=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.’

[36] _Keen’s Surgery_, 1908, p. 510.