made of straight metal and circular in section, the distal end being cut
obliquely with the projecting portion fashioned like a spatula. A strong
handle, at right angles to the tube, was used for manipulation.
Different sizes were required for children and adults. Various
modifications of these tubes are now in use, notably those of Mosher and
Bruenings: the instrument recommended by the latter is easier to
manipulate and gives a better view than the earlier forms described.
[Illustration: FIG. 256. MULTIPLE PAPILLOMATA OF THE LARYNX. (_From
Specimen No. 1647 in the Museum of St. Bartholomew’s Hospital._)]
(_b_) The _lamp_ for illumination. Different forms of head-lamp
(Killian’s, Kirstein’s) and hand-lamp (Caspar’s) have been devised for
illumination from the outside, and Chevalier Jackson has invented a lamp
which is sufficiently small to pass to the distal end of the tube, where
it lies in a compartment of its own lest it should be broken and fall
into the trachea. Recently these electroscopes have been improved upon
by Bruenings, in whose instrument (Fig. 257) the lamp is more powerful
and is attached to the handle in such a manner that it can be easily
swung into position when required. A condensing lens has also been
added and the light can be focused to any desired distance. If
preferred, an ordinary forehead-mirror reflecting the light from a
powerful Nernst lamp (100 c.p.) can be employed.
(_c_) The _instruments_ for operation. Various forms of forceps for
removal of tumours have been devised by Killian, von Eicken, Bruenings,
Patterson, and others. In any form that is employed it is necessary, in
order to allow of clear vision, that the handle should be set at an
angle with the shaft. For foreign bodies, hooks of different shapes are
also useful. Other requirements include a gag for opening the mouth, a
tongue depressor, tongue forceps, suitable cotton-wool carriers, the
requisites for tracheotomy, and a darkened room.
[Illustration: FIG. 257. TUBE-SPATULÆ USED FOR LARYNGOSCOPY. A,
Killian’s. B, Bruenings’. A, Handle; B, Collar to allow rotation; C,
Fixation spring; D, Switch; E, Socket for lamp; F, Focus; G, Lamp; H,
Lens; I, Aperture for eye; K, Reflector.]
=Operation.= The operation can be performed with local or general
anæsthesia. With patients who are intolerant chloroform is more
reliable, and is preferable to other drugs, which tend to excite
secretion. Chloroform should always be employed for children. It should
be given slowly and in the smallest possible quantity, the head of the
patient being kept lower than the body to allow blood and mucus to drain
away from the trachea. To make the parts more tolerant, cocaine can also
be applied to the vocal cords, or a dose of morphine (codeine is advised
in children) can be given half an hour before the operation. The
importance of a skilled anæsthetist cannot be too strongly emphasized.
With chloroform, the patient should lie upon the back or right side,
with the head projecting beyond the end of the table, so that the neck
can be extended as required. With cocaine the upright position is often
preferred, and the patient should sit on a low stool facing the surgeon.
When the patient is recumbent, the surgeon should sit or kneel behind
the head (Fig. 258). He should observe the strictest antiseptic
precautions, and should introduce no instrument which has not been
properly sterilized; further, the tubes should be previously warmed to
prevent ‘fogging’, and oiled with sterilized liquid paraffin before
introduction. There should be two assistants, one (the chloroformist) to
support the head and watch the respiration and pulse, the other to help
with instruments.
In order to examine the larynx, the mouth is opened by a gag, and the
tube-spatula is passed to the upper border of the epiglottis; when this
has been inspected the spatula is pushed behind it, and the upper
portion of the cricoid plate is examined; the tongue is then pulled
forward and the tube tilted so that the larynx can be seen. The
examination should be methodical, and should include the vocal cords,
ventricular bands, and openings of the ventricles. The whole
manipulation can be performed with great delicacy, and is entirely
guided by the eye, so that there is little fear of injury even in young
children.
In this and the further technique the chief difficulties are caused by:
(_a_) _The prominence of the upper teeth._ This may seriously interfere
with the easy passage of a straight tube, even when the neck is fully
extended. The difficulty can be overcome by turning the head laterally,
so that the tube passes through the opposite angle of the mouth. (_b_)
_The mucus_, which collects in the tube and obstructs the vision. This
must be overcome by using a secretion aspirator, by frequent sponging,
or, as suggested by Ingals, by giving a previous dose of atropin[e].
(_c_) _Intolerance of the parts_, which can be counteracted by the
judicious use of cocaine (10%). It may be noted that this combination of
chloroform and cocaine is not dangerous, even in young children, so long
as the cocaine is prevented from running into the pharynx.
[Illustration: FIG. 258. REMOVAL OF MULTIPLE PAPILLOMATA BY DIRECT
LARYNGOSCOPY]
The condition of the larynx having been thoroughly examined, the
operation can proceed. The method of removing multiple papillomata will
first be described. In some cases it will be found that better exposure
of the tumours is obtained if the end of the tube is placed above the
epiglottis rather than in the larynx itself. The position of the growths
having been determined, a suitable forceps is selected and introduced
through the tube. The papillomata are seized and avulsed separately,
without injury to the normal tissues. To arrest the bleeding it may be
necessary to apply cocaine and adrenalin mixture, and to raise the foot
of the table so that the blood drains away from the field of operation.
As far as possible, all the growths should be removed; it may be
difficult to attack those which are situated in the anterior commissure
or subglottic region, but this difficulty may be overcome by the use of
specially devised instruments; thus, von Eicken has invented a tube
which is long enough to pass through the larynx and into the trachea,
the portion lying in the larynx being provided with a lateral window
which can be turned in any direction, so that a growth can be made to
project into the tube, where it can be easily removed.
At any moment during this operation the surgeon may be called upon to
perform tracheotomy.
=After-treatment.= This must be carried out upon the same lines as those
already suggested; everything must be done to relieve congestion and
irritation. Killian advises internal administration of arsenic for a
period of several months, and, if this fails, potassium iodide in large
doses. It should be remembered that in some instances syphilis seems to
play an important part in the causation of these conditions. Ingersole
suggests that X-rays prevent recurrence, and may even cause shrinkage of
existing growths.
Recurrence occurs in most cases in some degree, and requires further
operation; this may be carried out after an interval of a week or
longer, according to the case. At these secondary operations it may not
be necessary to use the forceps; local applications such as absolute
alcohol, salicylic acid in absolute alcohol (2-10%), solutions of silver
nitrate or chromic acid, and many other drugs, have been advised by
different surgeons. Wylie is strongly in favour of the galvano-cautery,
and is of opinion that the technique is more reliable and the liability
of local infectivity diminished. If the latter method be employed, very
little should be done at one sitting, otherwise great inflammatory
reaction may be set up, entailing tracheotomy. A tracheotomy tube may be
required for a short time while such treatment is being carried out;
some surgeons, with whom the author does not agree, always perform
preliminary tracheotomy, and claim that the papillomata are less likely
to recur if complete rest is thus given to the larynx.
=Results.= In discussing the value of the above method it is necessary
to refer to the results obtained by other operations, such as--
(i) _Tracheotomy_ (see p. 522). This operation has been advocated as a
method of curing papillomata. It has been noted that by giving rest to
the larynx the congestion is relieved, the papillomata decrease in size,
and in some cases completely disappear. Mackenzie[8] published seven
cases which he had had under observation for a minimum of two years,
with four recoveries, the canula having been worn for periods varying
from six to fifteen months. He also mentioned thirteen other cases in
which good results had been obtained by other surgeons, and was of
opinion that the method was most successful with ‘virgin’ cases. There
are, however, many objections to this form of treatment. For instance,
it is often necessary to retain the tube for a prolonged period, two
years or longer, and even then the result is doubtful; moreover, the
prolonged use of a canula is disastrous to the larynx, not only in
retarding development, but also in the production of stenosis; there is
also a danger of bronchitis, of broncho-pneumonia, and possibly of
tuberculosis. In regard to the last, G. A. Wright,[9] in reporting a
case in which tubercle supervened, argues that ‘presumably there is more
risk of this happening to the wearer of a tracheotomy tube than when
breathing in a normal way through the mouth or nose’. Further, the line
of treatment is difficult to enforce on account of the aversion shared
by most parents to the performance of tracheotomy.
[8] _Brit. Med. Journ._, 1901, vol. ii, p. 883.
[9] Ashby and Wright, _Dis. of Child._, 4th ed., p. 350.
(ii) _Laryngo-fissure_ (see p. 487). Under this head are included
thyrotomy, or complete division of the thyreoid cartilage; partial
thyrotomy, where a small portion of the upper or lower part of the
thyreoid cartilage is left intact (an operation which does not give a
good exposure of the larynx); infrathyreoid laryngotomy, which is only
applicable to adults; cricotomy, with division of the cricoid cartilage
and crico-thyreoid membrane; and subhyoid pharyngotomy. Of the above,
thyrotomy is the most satisfactory operation, because it gives the best
exposure of the parts and facilitates removal of the growths;
recurrence, however, is frequent, permanent injury to the voice is
common, and stenosis may result.
The results of these operations, especially during childhood, are by no
means satisfactory. In the statistics carried up to 1896, collected by
Rosenberg and von Bruns,[10] laryngotomy was performed 143 times on 109
children; 11 were operated upon twice, 3 children three times, and 1
child seventeen times. 52 of the children were under four years of age;
20 died, principally from suffocation with recurrent papillomata; 43
showed recurrences after repeated operation; 40 were cured (_i.e._ 36%),
and of these 10 showed disturbance of voice.
[10] Bergmann, E. von, _Sys. Pract. Surg._, vol. ii, p. 231.
It must be admitted that operations for the treatment of papillomata do
not meet with any great measure of success. It seems probable, however,
that the results obtained by endolaryngeal removal are better than those
obtained by either tracheotomy or laryngo-fissure. To quote Killian[11]:
‘Formerly, and especially from the standpoint of the surgeon,
laryngotomy for laryngeal papillomata was very frequently done in little
children in whom removal was impossible by endolaryngeal methods. In my
judgment, direct laryngoscopy renders such a surgical procedure
unnecessary. We can in all cases, with the aid of a tube-spatula under
narcosis, remove papillomata, and the operation can be repeated as often
as seems necessary.’ These remarks express the general feeling of the
present day, and the most important factor in determining the success of
operative treatment is early diagnosis. Such diagnosis divides the cases
into two classes: those in which the growths are localized, and those in
which they are diffuse. The first class is easy to treat by
endolaryngeal methods, and, given careful after-treatment, the prognosis
is satisfactory. The second class is serious, and far more difficult to
treat; when Killian’s method fails the prognosis is very bad. Finally,
it must be borne in mind that, as recurrence may not occur for several
months, a guarded prognosis must be given in every case.
[11] _Trans. Amer. Laryng. Assoc._, 1907, p. 127. Discussion of paper by
C. G. Coakley on ‘Removal of papillomata of larynx by direct
instrumentation with the aid of Killian’s tubes.’
The removal of other benign tumours and of foreign bodies, and the
treatment of granulations, are conducted upon similar lines, and are
attended with excellent results.
CHAPTER II
EXTRA-LARYNGEAL OPERATIONS
THYROTOMY
=Indications.= This operation is performed for two purposes:
(i) To obtain access to the cavity of the larynx when the diagnosis is
uncertain, or as a preliminary to other operations.
(ii) As a method of eradicating certain diseases, of which the following
are important:--
1. _Malignant tumours_, both carcinoma and sarcoma, in which an early
diagnosis has been made, and so long as they remain intrinsic.
It is advisable to follow Krishaber in the separation of all forms of
laryngeal cancer into two classes, the _Intrinsic_ and the _Extrinsic_.
The term ‘intrinsic’ implies a growth springing from the vocal cords,
the ventricular bands, the ventricles, or the subglottic space, and the
growth must lie entirely within the laryngeal cavity. ‘Extrinsic’ is the
term used for a growth affecting the arytenoids, the posterior part of
the cricoid cartilage, the aryteno-epiglottidean fold, or the
epiglottis. Such a growth is not entirely limited to the larynx, but
also involves some part of the pharynx.
2. _Extrinsic localized malignant tumours_ which are attached to the
epiglottis, or to the aryteno-epiglottic fold.
3. _Innocent tumours_ which are too extensive for endolaryngeal
operation or of a doubtful character. In either of these cases it is
justifiable to perform an external operation, which may be thyrotomy, or
occasionally, an atypical operation: thus Semon[12] removed a large
fibromatous tumour of the larynx by submucous resection, without opening
the cavity of the larynx.
[12] _Brit. Med. Journ._, 1905, vol. i, p. 6.
4. _Stenosis_ following syphilis, trauma, acute exanthemata, scleroma,
and other rare diseases. C. Jackson has reported twenty-four cases
falling under this head, nineteen of which lived for more than a year
after the operation with useful voices. If the surgeon is satisfied that
the disease is quiescent, he should point out to the patient that it may
be possible to cure the obstruction by thyrotomy. It must, however, be
remembered that tertiary syphilitic lesions may again become active as
the result of operative interference. It is probable that slight cases
of stenosis can be treated better by intubation than by thyrotomy.
Thyrotomy has also been suggested to relieve stenosis caused by double
abductor paralysis of the vocal cords, but such cases are better treated
by tracheotomy or intubation.
5. _Foreign bodies._ Thyrotomy is rarely necessary, and should be
reserved for irregular or sharp-pointed bodies, such as tooth-plates or
bones, which are so firmly jammed that removal by other methods is
impracticable. If there has been much laceration of the soft parts, a
tracheotomy tube should be retained for a few days until the swelling
has subsided.
[Illustration: FIG. 259. INTRINSIC TUMOUR OF THE LARYNX. (_From Specimen
No. 1649 in the Museum of St. Bartholomew’s Hospital._)]
[Illustration: FIG. 260. EXTRINSIC TUMOUR OF THE LARYNX. (_From Specimen
No. 1653 in the Museum of St. Bartholomew’[s] Hospital._)]
6. _Tubercle._ Thyrotomy has been successfully performed in such cases,
mostly under the impression that the disease was malignant. The
differential diagnosis between tuberculous and malignant growths is
sometimes very difficult until the tumour has been explored. In cases
that are known to be tuberculous, the feeling prevails that thyrotomy
is not to be recommended. It should be remembered that the external
wound is liable to become tuberculous.
=Instruments.= Scalpel, curved scissors, dissecting forceps, pressure
forceps, aneurism needles, double hook retractors, bone shears
(Waggett’s) or bone scissors, tenaculum forceps, needles on handles,
catgut in various sizes, a Hahn’s tube, and tracheotomy equipment. A
head-light is required for illumination of the deeper parts during
removal of tumours.
=Operation.= In England, owing to the fact that the administration has
been in skilled hands, chloroform is not considered dangerous, and the
operation is well tolerated even for three or four hours (_e.g._ in
laryngectomy). On the Continent, however, Kocher, von Bruns, and others
advocate local anæsthesia with cocaine or novocaine. Jackson suggested
rectal etherization as an alternative, but this has many dangers. In my
opinion a general anæsthetic should be given, as it enables the
operation to be performed more thoroughly and is followed by less shock.
It must nevertheless be borne in mind that, if the growth is intrinsic
and of large size, it is difficult to administer chloroform, and the
patient is liable to suffer from urgent dyspnœa. In such a case i[t] is
advisable to perform preliminary tracheotomy with novocaine alone (see
p. 544).
As regards the operation, the important question arises whether
tracheotomy ought to be performed several days prior to the main
operation, in order to accustom the patient to the tube and the new
method of breathing. The following reasons are advanced in favour of
this: the main operation is shortened, and relief is given to the larynx
and lungs, so that congestion subsides and broncho-pneumonia is less
likely to supervene. The objections are also important, namely, that
there are two operations instead of one, and perhaps two anæsthetics
(though this can be avoided if local anæsthesia is used for the
tracheotomy); that the tracheotomy wound becomes septic, and infection
of the trachea and bronchi is apt to occur, with consequent bronchitis;
that the air which passes into the lungs is devoid of moisture and heat;
that the trachea becomes surrounded by adhesions; and that it is
altogether unnecessary. The objections in my opinion outweigh the
advantages claimed; it is better to perform tracheotomy as a first stage
in the operation of removal, except in cases where there is great
laryngeal obstruction, where dyspnœa is present, or where bronchitis
fails to yield to other forms of treatment. In such cases tracheotomy
should be performed first, and the second operation should be carried
out a week or ten days later when all the conditions are favourable.
When operating upon the larynx the surgeon must use every precaution to
prevent blood from running into the lower air-passages, and this may be
accomplished by a tampon in the trachea or by keeping the head of the
patient lower than the body. The former method appears to me to be more
reliable than the latter; and I prefer to use a Hahn’s canula, although
the sponge requires from ten to fifteen minutes to swell. This canula is
more reliable than Trendelenburg’s, whose inflated bag is apt to slip or
collapse suddenly. As soon as the thyreoid cartilage has been opened, a
second sponge should be inserted above the canula, and by this means the
air-passages are completely blocked.
If an ordinary tracheotomy tube be used, the operation must be performed
either with the head lower than the body (Rose’s position), or with the
whole body inclined (Trendelenburg’s position), or with a combination of
the two; and in any case a sponge should be placed in the upper part of
the trachea after the thyreoid has been opened. Many surgeons prefer the
combined method. Under no conditions must blood be allowed to pass below
the tube. Whatever form of canula is used, it should be fitted with a
Hahn’s tube and funnel (Fig. 266), so that the anæsthetist can give the
chloroform without interfering with the surgeon. The patient should lie
upon the back on a flat table, the head extended slightly over a small
cushion in the position for tracheotomy.
_First stage._ A vertical incision is made in the middle line from the
hyoid almost to the sternum, so as to expose the thyreoid cartilage and
the pretracheal muscles; these are retracted, so that the anterior
aspect of the trachea is exposed; the isthmus of the thyreoid gland is
completely divided, and search made for bleeding points until the wound
is quite dry. A large opening is made accurately in the middle line of
the trachea; this will be at least two rings below the cricoid cartilage
in order that the tube may be well away from the region of the growth.
In adults, if a Hahn’s tube be employed, the section should include at
least three rings of the trachea.
_Second stage._ The anterior aspect of the thyreoid cartilage, and the
crico-thyreoid membrane, are freely exposed, the infrahyoid muscles
being separated by at least one inch and, if necessary, retracted. Ten
minutes after the tube has been inserted, the crico-thyreoid membrane is
punctured, exactly in the middle line, in order to admit the inner blade
of the bone forceps; the latter is pushed upwards, slowly and without
force, between the posterior portions of the vocal cords, until the
whole length of the thyreoid cartilage is included between the blades;
the forceps are then forcibly closed, great care being taken that the
outer blade is cutting exactly in the middle line. By quickly opening
the cartilage in this manner, there is practically no danger of
destroying the anterior attachments of the vocal cords, or cutting
through the substance of one of them. The two halves of the larynx are
forcibly separated and retained in this position by hooked retractors,
so that the interior of the larynx is exposed. In order to give a free
exposure, it is necessary, as a rule, to divide with a knife the
crico-thyreoid membrane; but the thyreo-hyoid membrane should not be
touched, nor should the attachments of the epiglottis be disturbed. The
separation must be performed carefully in order to avoid a fracture of
the cartilages. The pharynx is plugged with gauze, so that no saliva can
enter the wound, and after all secretion has been removed from the
larynx a small sponge or plug is inserted into the upper end of the
trachea. Cocaine, 20%, is freely applied with a swab of wool to every
part of the larynx in order to constrict the vessels; persistent
hæmorrhage can be controlled by plugging the cavity with wool soaked in
cocaine; ‘this fully suffices ... and the employment of adrenalin, as I
have personally experienced in one case, increases the risk of secondary
parenchymatous hæmorrhage’ (Semon). Further, and this is of importance,
by the use of cocaine the irritability of the larynx and the laryngeal
reflex are destroyed. The tumour can now be inspected; it must be
thoroughly exposed by cutting through the soft or hard structures
(cricoid if necessary) so that its limits can be determined, thus
enabling the surgeon to decide whether it is possible to obtain a
satisfactory result by local removal.
[Illustration: FIG. 261. THYROTOMY. Showing exposure of the larynx, and
tube for the anæsthetic.]
_Third stage._ In the words of Butlin[13]: ‘an incision is carried
around it (the tumour) with knife or scissors, including more than half
an inch of the surrounding apparently healthy tissues, without respect
to the after use of the voice or any other consideration except the
complete removal of the disease. The included area is cut out right down
to the cartilage, which is laid bare and finally scraped absolutely bare
with Volkmann’s sharp spoon.’ The cavity is then plugged for a few
moments until the bleeding has been controlled. The hæmorrhage is never
serious, and can be controlled by catgut ligature if necessary. The
wound must be completely dry. It is then dusted with a powder such as
orthoform; the retractors are removed, and the alæ of the thyreoid
cartilage allowed to fall together. In relation to the removal of the
tumour, Butlin has shown that there is ‘little liability of malignant
disease infiltrating the cartilage of the larynx’, so that, as a general
rule, the latter can be left if all the soft tissues, including the
perichondrium, are removed from its surface; this is comparatively easy
to accomplish in the case of the thyreoid, but more difficult with the
arytenoids and cricoid cartilage. C. Jackson has criticized the use of a
sharp spoon as likely to cause infection of the cartilage.
[13] _Op. Surg. Malig. Dis._, 2nd ed., p. 191.
_Fourth stage._ In some instances it is possible partially to unite the
divided mucous membrane, and so to lessen the granulating area: when
this is done it is of the utmost importance that the lumen of the larynx
should not be constricted, as any constriction will increase the danger
of stenosis. In many instances it is not advisable to attempt to repair
the wound that has been produced.
In suturing the external wound the alæ of the thyreoid are brought
accurately into the position which they occupied before division, in
order that the anterior attachments (if left) of the vocal cords should
heal at their proper level. In some instances the cartilages fall
naturally into the desired position, especially if one or two catgut
sutures are inserted into the thyreo-hyoid membrane; in other cases it
may be advisable to insert one or two similar sutures through the
cartilage itself and thus obtain correct apposition. These sutures
should lie on the outer aspect of the mucosa, so as not to traverse the
cavity of the larynx itself. In cases where only the anterior portion of
a vocal cord has been removed, Semon recommends that the divided end be
sutured to the ventricular band; it is reasonable to suppose that, by
attention to this detail, a better voice will be afterwards obtained.
The infrahyoid muscles are approximated with one or two catgut sutures
in the upper part of the wound; the skin is united with a continuous
silk suture, as far downwards as the lower part of the thyreoid
cartilage. The lower part of the wound is left open, to procure free
drainage through the crico-thyreoid and tracheal openings. The whole of
this lower wound is packed very loosely with gauze, so that discharges
are not retained. It is necessary to emphasize the importance of not
plugging the cavity of the larynx. The Hahn’s tube is removed as soon
as the operation is completed, and replaced by a tracheotomy canula; the
whole wound is covered by a loose pad of antiseptic gauze, which is kept
in position by tapes or loosely applied bandages. No dissection for
removal of lymphatic glands is required.
The above may be called the typical operation for malignant disease in
which the growth is intrinsic; it gives a better exposure of the parts
than other operations such as transverse laryngotomy (division of the
thyreoid cartilage at the level of the ventricles), subhyoid
pharyngotomy, partial thyrotomy, cricotomy, and crico-tracheotomy; the
removal of tumours is therefore easier, and better after-results are
obtained. If the growth be found more extensive, it may be necessary to
modify the procedure. For example:
(_a_) When the epiglottis is involved, an extensive dissection of the
thyreo-hyoid membrane can be made in order to expose and remove the
growth thoroughly together with any soft parts or cartilage which appear
to be involved. Branches of the superior thyreoid arteries, or the hyoid
branch of the lingual artery, will be ligatured. The superior laryngeal
nerves should always be preserved whenever possible, as loss of
sensation increases the liability of food passing into the larynx.
(_b_) When the aryteno-epiglottidean fold is involved, a transverse
incision can be made through the thyreo-hyoid membrane, immediately
above the thyreoid cartilage on the same side, and the wound enlarged
until the tumour is exposed. In this manner I was able to remove the
large carcinoma shown in Fig. 254, including the soft parts of the right
half of the larynx, the right half of the epiglottis, the right
arytenoid, and the wall of the pharynx in relation to the right pyriform
fossa: the lymphatic glands were not removed. One year later the patient
continued to enjoy good health with no signs of any recurrence. In this
connexion it is important to emphasize that when the disease is very
extensive, and particularly when the posterior portion of the cricoid
and arytenoids is involved, such an operation is useless, and the
surgeon must decide whether partial or complete laryngectomy should be
performed. In rare instances the operation should be abandoned in favour
of tracheotomy (palliative).
(_c_) When the tumour extends downwards into the subglottic region, it
is necessary to split the cricoid anteriorly and divide the upper rings
of the trachea, after which the tumour can be removed with as much of
the structures as may be desirable.
(_d_) When the growth extends across the middle line in the anterior
commissure, or when a second growth is situated directly opposite on the
other side of the larynx, the whole disease must be removed regardless
of damage to the tissues which are not affected.
(_e_) When the operation is performed for stenosis, it is necessary to
remove freely all the fibrous tissue without attempting to preserve any
part that is diseased. The hæmorrhage is generally severe and
necessitates preliminary plugging of the trachea with a Hahn’s canula.
=After-treatment.= This must be conducted so as to prevent the chance of
broncho-pneumonia and sustain the strength of the patient. With Butlin’s
method the patient is placed on his side, or face downwards, with the
head low and with only a small pillow, so that all secretions pass out
of the air-passages through the external wound. This undoubtedly gives
better drainage to the wound, and is less exhausting than the upright
position during the early stages of convalescence. The dressings on the
wound must be changed, especially in the early days, as often as they
become soaked; it is also an advantage to insufflate an orthoform
powder, or an antiseptic parolein preparation, with the object of
cleansing the larynx. The tracheotomy tube should be retained, usually
from ten to twenty days, until the patient can swallow well and as long
as there is a flow of pus from the wound.
‘During the day of the operation nothing is swallowed, although
fragments of ice may be kept in the mouth for the comfort of the
patient. If there is fear of collapse and the patient is feeble and very
old, brandy and beef-tea may be administered by the rectum. On the
following morning the first attempt is made to swallow. The patient
leans far forwards with the head down, and the dressing is taken off the
wound, beneath which a basin is placed. Cold water is drunk out of a
glass. If the experiment is successful, all the water passes down into
the stomach; if it is only partially successful, some escapes into the
larynx; but the posture of the patient ensures that the liquid runs out
through the wound and does not pass into the air-passages. As soon as
water can be readily swallowed, milk, beef-tea, and other liquids may be
drunk, for the fear of “Schluck-pneumonie” is practically at an end. The
wound is generally closed within ten or twelve days of the operation,
and the patient is rarely confined to the house for more than ten days’
(Butlin). It is probable that the healing by this, which is called the
‘open’ method, is as rapid as with Moure’s, in which the whole length of
the incision is closed; the open method would also appear to be safer
and less often attended by complications.
=Complications.= (1) _Broncho-pneumonia_ is most to be dreaded. Death
from shock or collapse, from hæmorrhage, from septic conditions of the
wound, or from iodoform poisoning, is now rarely met with and can more
easily be prevented. Even pneumonia is uncommon, owing to more
scientific methods of treatment. It is still to be feared in very old
patients; in those who already suffer from bronchial catarrh at the time
of the operation; in alcoholics; and in cases with old-standing renal,
pulmonary, or heart affections. The improvement in this direction is due
to greater antiseptic precautions, and to the prevention of aspiration
of blood and septic secretion during and after the operation by free
drainage of the wound.
(2) _Stenosis._ It sometimes happens that a considerable mass of
granulation tissue appears in the anterior commissure, or upon the
surface of the cartilage that has been bared by the operation; if this
be left untreated it may gradually enlarge in size until a prominent
cushion is produced, which reaches to the opposite side and thus causes
stenosis with definite laryngeal obstruction. Such a swelling may be
mistaken for recurrence, but is nearly always of inflammatory character.
It is by no means certain what is the causation of this condition, which
appears to occur more with some surgeons than with others; it has been
suggested that the presence of sutures in the region of the anterior
commissure may cause an irritation, especially if silk is used. It
appears to me, having in mind similar conditions in other surgical
wounds, that the cause is to be found in some form of sepsis, and that
it can be prevented to a great extent by precautions at the operation
and by proper after-treatment. If there be any obstruction to breathing,
the larynx is inspected and the projecting granulations are removed by
intralaryngeal forceps. The remainder of the mass generally shrinks and
disappears. If the stenosis be troublesome (chiefly in syphilitic
cases), the prolonged use of a laryngo-tracheal canula (Fig. 540), or of
an intubation tube, or dilatation with bougies, may be necessary. In
rare instances a permanent tracheotomy tube is required, with a valve to
encourage expiration through the mouth.
HEMI-LARYNGECTOMY
This operation is suitable for certain cases of malignant disease which
is strictly limited to one half of the larynx. The requirements and
_first and second_ stages of the operation are similar to those for
thyrotomy (see pp. 490, 491).
_Third stage._ A transverse incision is made on the side affected along
the upper border of the thyreoid cartilage, through the skin and fasciæ;
and, if necessary, a second transverse incision is made at the level of
the lower border of the cricoid so that a skin flap can be turned back.
The affected half of the larynx must now be considered as a tumour to be
removed. The infrahyoid muscles are dissected away from the ‘tumour’ and
retracted; the upper part of the lateral lobe of the thyreoid gland (the
isthmus having been previously divided) is displaced outwards by blunt
dissection, and the soft tissues above the thyreoid are similarly
treated: the larynx should be pulled well over to the opposite side
while this is being effected, great care being necessary to avoid
wounding the carotid artery in the deeper part of the dissection. The
branches of the superior thyreoid artery, the crico-thyreoid artery, and
the veins of this region are ligatured with catgut. In some instances,
when the growth has not perforated the cartilage, the separation can be
performed subperiosteally. Superiorly, the thyreo-hyoid membrane is
completely divided on the same side, and the mucosa is cut through above
the upper limit of the growth. If the growth extends upwards, the
epiglottis may be removed either totally or partially. Inferiorly, a
transverse incision must be made through the crico-thyreoid or
crico-tracheal membrane, or lower in the trachea. The inferior
constrictor of the pharynx is divided as close to the attachment to the
thyreoid as possible, and the cavity of the pharynx is opened behind the
growth. The cricoid plate is split with bone scissors in the
interarytenoid interval, and the final attachments are rapidly divided
with a few touches of the knife.
In this operation, as with other operations for cancer, the main thought
of the surgeon must be to remove the tumour thoroughly, including the
soft tissues of the neck when these are diseased, the lateral wall of
the pharynx, and the cervical glands upon the same side, whether they
are known to be affected or not. In this respect the operation differs
materially from thyrotomy; and I agree with Semon that, if
hemi-laryngectomy is necessary, the lymphatic glands of the same side
should in all cases be removed. The two dissections may be accomplished
at the same time, or one may be performed later at a second operation;
in the latter event an incision along the anterior border of the
sterno-mastoid muscle is preferred. The operation must be very complete
in order to be successful, and requires a knowledge of the anatomy of
the lymphatics.
THE ANATOMY OF THE LARYNGEAL LYMPHATICS.
The following description is Cuneo’s[14] and has been confirmed by de
Santi.[15]
[14] Poirier and Cuneo, _Lymphatics_, Eng. ed., 1903, p. 286.
[15] De Santi, _Malignant Disease of the Larynx_, 1904, p. 10.
The lymphatics which drain the mucous membrane of the larynx are divided
into two distinct regions, namely, the supraglottic and the infraglottic
zones. These regions are separated by the inferior vocal cords, and
injection of the cords themselves generally passes into the upper zone.
The upper region is most densely supplied, and covers the epiglottis,
the aryteno-epiglottidean folds, the superior vocal cords, and the
ventricles.
The lymphatics communicate freely in the posterior wall of the larynx
(not in the anterior commissure), but though an injection into one half
of the larynx easily passes into the mucous membrane of the other side,
it is exceptional for it to pass as far as the corresponding glands of
that side. The lymphatics of the larynx anastomose to a large extent
with the networks of the adjacent organs (tongue, pharynx, trachea).
The supraglottic lymphatics perforate the thyreo-hyoid membrane where
the superior laryngeal arteries enter, and end in (1) a
substerno-mastoid gland under the posterior belly of the digastric; (2)
glands on the internal jugular vein opposite the bifurcation of the
carotid artery; and (3) glands on the same vein opposite the middle of
the lateral lobes of the thyreoid gland. The glands in the front of the
thyreo-hyoid membrane receive lymphatics from the pharynx, but none from
the larynx.
The subglottic lymphatics perforate the crico-thyreoid membrane in two
places (_a_) anteriorly, near the middle line, ending in (1) a
prelaryngeal gland which lies in the V-shaped space between the
crico-thyreoid muscles or under one of the same (a gland above the
isthmus of the thyreoid gland is rarely present), and (2) a pretracheal
gland (or glands) below the isthmus; (_b_) laterally, to end in (1) the
glands which lie parallel to the recurrent laryngeal nerve, from which
trunks run to (2) the substerno-mastoid group and (3) the
supraclavicular glands.
It is important also to consider the question from the clinical aspect.
With ‘intrinsic’ growths, involvement of glands is very uncommon unless
the posterior (cricoid) zone is affected; it seems to be equally rare
with tumours of both supra- and infraglottic zones; extension to the
lymphatics of the opposite side is likewise improbable. With ‘extrinsic’
growths, the glands are rapidly involved; tumours that were originally
intrinsic follow this rule as soon as they begin to affect the
cartilages and extrinsic lymphatics of the larynx. These facts must be
remembered because palpation of the neck may be quite misleading in
early stages of the disease. On the other hand, in many advanced cases,
such as those requiring palliative tracheotomy, the glands become
massive and form definite tumours. The substerno-mastoid chain is,
clinically, the situation that is specially affected; and any of its
glands, from the digastric muscle above to the supraclavicular region
below, may be involved. The prelaryngeal gland is rare, as are likewise
the pretracheal and recurrent forms; nevertheless, the recurrent glands
become attacked by advanced disease, affecting the upper part of the
trachea.
TOTAL LARYNGECTOMY
=Indications.= This operation is performed for malignant tumours which
have affected (_a_) the whole of the interior of the larynx, including
the cartilages, or (_b_) the posterior portion of the larynx, including
the arytenoid cartilages and pharyngeal aspect of the cricoid plate. In
other words, it is employed in cases of extrinsic cancer in which the
growth is not too advanced to render the prospect of its eradication
hopeless. The operation should not be performed for tuberculosis.
It is essential that the patient should be in good health; one who is
emaciated or who has organic disease, especially incurable bronchitis,
is quite unsuitable for laryngectomy. On no account ought the operation
to be undertaken unless the diagnosis of malignant disease has been
confirmed, and unless the growth is known to be too extensive for
thyrotomy. In many instances, therefore, thyrotomy is the first stage in
the operation of total laryngectomy.
=Operation.= The instruments, anæsthetic, and position require the same
consideration as with thyrotomy (see p. 489).
_First stage._ A vertical incision is made, in the middle line, from the
hyoid to a point one inch above the sternum, and the anterior aspects of
the thyreoid cartilage and trachea are exposed, with complete division
of the isthmus of the thyreoid gland. The infrahyoid muscles are
dissected from the larynx and widely retracted. By blunt dissection the
upper part of the lateral lobes of the thyreoid gland is separated and
bleeding arrested. The trachea, having been isolated in this manner, is
divided obliquely from the front, upwards and backwards, as close to the
cricoid cartilage as the disease allows without injury to the œsophagus;
the lower end is carefully freed from the œsophagus, and two strong
catgut sutures are passed through it with which the divided stump can be
drawn forwards. If possible, a small transverse incision is made through
the skin immediately above the suprasternal notch and made to
communicate with the upper incision; the trachea is brought beneath the
bridge of skin into the button-hole thus formed, and firmly attached by
means of sutures. In some cases the trachea is sewn into the lower part
of the original incision. A tracheotomy tube is inserted, through which
the anæsthetic is continued. By this means the lower air-passages are
completely cut off from the region of the tumour, and no blood or septic
matter can pass into the lungs.
[Illustration: FIG. 262. TOTAL LARYNGECTOMY. A, Crico-thyreoid muscle;
B, Attachment of inferior constrictor of pharynx to thyreoid cartilage;
C, Cut edge of inferior constrictor; D, Thyreo-hyoid membrane; E,
Œsophagus; F, Trachea.]
_Second stage._ The lateral aspect of the larynx is freely separated so
that the attachment of the inferior constrictors is defined. The
superior laryngeal artery is ligatured on each side, and divided,
together with the internal laryngeal nerves. The thyreo-hyoid membrane
is transversely divided, and the pharynx is opened so as to expose the
upper limit of the growth; this may necessitate a transverse incision
through the skin, or a vertical division of the hyoid bone in the middle
line with retraction of its two halves. The larynx having been isolated
above, below, and laterally, its removal can be completed according to
the situation of the growth, in most cases from below. The lower end of
the larynx is hooked forward, and dissected away from the œsophagus by
means of scissors or a sharp scalpel (Fig. 262). While this is being
effected, the extent of the growth must be constantly examined by
inspection and palpation, so that the whole mass is removed, including,
if necessary, the pharynx and upper part of the œsophagus. It is
important not to drag upon the œsophagus; C. Jackson has shown
experimentally that this causes severe shock by affecting the depressor
fibres of the vagus, which may result in death. It follows, therefore,
that this part of the operation, though easy in the dead body, requires
the utmost care and detailed technique. The division of the
constrictors should be as close to their attachment as possible, and
the final division of the pharyngeal mucosa should be half an inch
beyond the limit of the growth. The epiglottis should generally be
removed.
_Third stage._ The toilet of the pharynx and œsophagus remains to be
decided. In order to restore the cavity of the pharynx, the upper end of
the œsophagus is brought upwards whenever possible and accurately united
to the pharynx in the region of the hyoid bone, this being accomplished
by a double layer of catgut sutures uniting the mucous membranes. The
infrahyoid muscles are then brought together by a vertical row of
stitches, so as to cover and support the line of union. The wound having
been thoroughly packed with gauze, the skin is sutured, excepting the
lower end, which remains open for drainage. In cases where the pharynx
is thus completely closed, a tube must be passed previously through the
nose into the œsophagus, and retained for purposes of feeding. This is
preferable to sewing the tube into the wound itself, and is rarely
troublesome if the tube is sufficiently stiff to prevent its
displacement by retching. At the conclusion of the operation the
tracheotomy tube is replaced by an ordinary silver canula, and the
wounds are lightly dressed.
=After-treatment.= This is conducted upon similar lines to those adopted
in the after-treatment of thyrotomy. During the first ten days, until
the pharyngeal wound is firm, the patient must be fed through the tube
and by rectal administration. Sterilized water may be sucked uphill,
and, as swallowing improves, food may be administered by the mouth. In
most cases a pharyngeal fistula results, which may require a later
plastic operation. A second operation is necessary for the removal of
lymphatic glands, probably on both sides of the neck.
The complications are similar to those following thyrotomy (see p. 494).
=Modifications.= The above operation, which in the main has been planned
by surgeons in America (S. Cohen, Keen, &c.), is preferable to the
numerous modifications, of which the following may be mentioned as
examples:--
Gluck’s operation. In this there is no preliminary tracheotomy. A large
rectangular flap is turned to one side to expose the front of the larynx
and trachea, the latter being isolated laterally and the thyreoid
isthmus divided. A transverse incision is made through the thyreo-hyoid
membrane in order to expose the upper aperture of the larynx thoroughly.
By plugging the pharynx and adopting a low position for the head, saliva
and blood are prevented from running into the air-passages. The interior
of the larynx having been cocainized, a tracheotomy tube is inserted
between the vocal cords. This is sutured in position in such a manner
that the cavity of the larynx is completely shut off from the pharynx.
If a general anæsthetic be employed, it can be continued through the
canula by a Hahn’s adjustment (Fig. 266). The larynx, and any part of
the pharynx or œsophagus which is diseased, are separated from above
downwards, the trachea being severed transversely as a final stage and
sewn into a button-hole immediately above the sternum. A soft rubber
tube having been introduced through the nose into the œsophagus, the
walls of the latter are united over the tube by a double row of catgut
sutures, completely isolating the gullet. The cavity is covered with
gauze, and the skin flap is partially sutured into its original
position. An ordinary canula is placed in the trachea and the wounds are
dressed.
[Illustration: FIG. 263. TOTAL LARYNGECTOMY. GLUCK’S METHOD. Tracheotomy
canula with rubber tube for Hahn’s adjustment tied into the upper
opening of the larynx. A, Epiglottis; B, Superior cornu of thyreoid
cartilage; C, Posterior surface of cricoid with crico-arytenoid muscles;
D, Trachea; E, Œsophagus.]
In cases where the pharynx has been extensively removed a fistula
remains, but Gluck has devised a plastic operation by means of which
this can afterwards be closed. In some cases this fistula may be
obliterated by the natural falling in of the parts, without further
operation, and in the meantime the patient is provided with a funnelled
tube for feeding, placed in the œsophagus with the upper end below the
base of the tongue.
The advantages claimed by Gluck for this operation are the avoidance of
preliminary tracheotomy, the prevention of blood from passing into the
trachea, the complete separation of the trachea from the gullet, and the
early feeding through the mouth. These, however, are chiefly met by the
former operation.
Chiari and le Bec perform the operation in two stages. In the first, the
trachea is isolated and divided transversely, the lower end being
sutured above the sternum. The second operation, undertaken one or two
weeks later, consists of a complete removal of the disease.
Föderl suggests the possibility of uniting the lower end of the trachea
(after laryngectomy is completed) to the tissues beyond the hyoid bone,
and thus restoring the air-passages; but the method is not free from
danger, and the trachea is apt to slough.
S. Handley[16] performed a complete transverse resection of the pharynx,
with laryngectomy, for malignant growth in the following manner:
Preliminary gastrostomy was performed; a week later, when the patient
had recovered, a low tracheotomy was effected, the trachea being plugged
with gauze above the tube. The whole of the larynx and a complete
section of the pharynx were then removed as described in Gluck’s method;
and, the trachea having been brought into the lower part of the wound,
the pharynx and œsophagus were closed by sutures. The patient recovered
with a pharyngeal fistula through which the saliva passed, the latter
being led to the stomach through the gastrostomy opening. In a second
similar case the result was fatal. ‘The patient died on the table,
apparently from irritation of the vagus, after the operation was
practically complete.’ Handley believed that the failure was due to a
defect in his technique, and that, if he had frozen the two vagi below
the point at which he was working, death would not have occurred.
[16] _Proc. Roy. Soc. Med._, London, vol. i, No. 4, 1908, Clin. Sect.,
p. 66.
COMPARATIVE RESULTS OF THE DIFFERENT EXTRA-LARYNGEAL OPERATIONS
In order to obtain a trustworthy idea of the value of the various
operations for malignant disease, it is necessary to refer to the
history of the operations.[17] Czerny, in 1870, was the first to
demonstrate by experiments on dogs the possibility of removing the
entire larynx, and various attempts were afterwards made by different
surgeons, notably by Billroth, to accomplish the same in man. In 1881
Foulis was able to collect twenty-five cases of total laryngectomy, and
found that not one of them was alive twelve months after the operation.
Partly in consequence of this, thyrotomy was given a trial, and in 1887
P. Bruns collected nineteen cases, with two deaths and sixteen local
recurrences. He therefore concluded that ‘attempts to extirpate the
disease by means of thyrotomy have shown themselves to be altogether
insufficient and useless’; and so it came about that all external
operations, at this date, were considered by most authorities to be
unsatisfactory. Much attention was, however, drawn to the subject by the
illness of the German Emperor, and Semon particularly emphasized the
great importance of early diagnosis. The result of this was marvellous.
The importance of Krishaber’s division of carcinoma of the larynx into
two forms, intrinsic and extrinsic, was recognized by Butlin, to whom
the greatest credit is due for having first shown that thyrotomy ought
to be reinstated. Butlin and Semon have since perfected this operation,
which has rightly been described as the English operation. It is now
recognized throughout this country as the operation which gives
perfectly ideal results, so long as it is restricted to early stages of
intrinsic malignant disease (in which an early diagnosis is
indispensable) and is thoroughly carried out. As Semon concludes, ‘if
these demands be complied with, the position of thyrotomy, as being the
operation in the early stages of malignant disease of the larynx, will
remain impregnable, so long as we have to fight malignant disease by
operation.’ That this is true will be seen by the results mentioned
later.
[17] An account of the history of these operations will be found in a
paper by Sir F. Semon, _Brit. Med. Journ._, 1903, vol. ii, p. 1113.
It is also necessary to refer to the other side of the question, namely,
the position of laryngectomy. Many well-known surgeons in Europe and the
United States have been convinced that laryngectomy, partial or
complete, is the only possible treatment for cancer in this region.
Gluck[18] says:
[18] _Brit. Med. Journ._, 1903, vol. ii, p. 1123.
‘As showing the progress that has been made during the last fifteen
years in this subject, I may mention that in my first series of ten
cases only two were successful, and in nine cases of another series
I had four deaths. Since then I have performed many operations with
ever improving results. Thus in one series of thirty-five
hemi-laryngectomies I had three deaths: one twenty-four days after
the operation, of heart failure, when the wound was already healed;
another independently of the operation, of phlegmon of the right
gluteal muscle; the third of pneumonia five days after operation.
‘My most recent results show a series of twenty-two complete
laryngectomies with one death, that of a man of seventy, who died on
the eleventh day of iodoform poisoning. Of the partial extirpations
of the larynx and pharynx, generally combined with removal of
infected glands, I can point to a series of twenty-seven cases with
only one death. This was a case in which the carotid had been tied,
and death occurred from hemiplegia five days after the operation.
‘At present I could show you thirty-eight living patients who have
been cured by these operations; the oldest case was operated on
thirteen years ago. Of those already dead, a number have lived 11,
8, 6-1/2, 5-1/2, 4-1/2 and 3-1/2 years after the operation in good
health, and some have died of other illnesses, not of recurrence.
One man, nine years after hemi-laryngectomy, had recurrence in the
other half of the larynx and in the glands; after the second
operation he lived over two years, and died at seventy-six. The
operations lengthened his life for eleven years.
‘A man of seventy-six had the larynx and pharynx extirpated, and
lived 11-1/2 years after the operation. Twice I have performed
complete laryngectomy for tubercle; one case died in spite of that
of consumption; the other was done four years ago and the patient is
perfectly well.
‘In all I have performed 125 of these operations since the year
1888, and the record is one of great progress, both in technique and
also in the elaboration of plastic operations and mechanical
appliances for the improvement of the post-operative condition.’
Many large operations of this description have undoubtedly been
performed because of the statement that it is impossible to obtain a
lasting cure by performance of thyrotomy. Even at the present day this
opinion holds its ground, and so long as there is a general grouping of
the cases, progress cannot be made.
=Thyrotomy.= I shall attempt to show that thyrotomy is the best
operation for early malignant disease, whether carcinoma or sarcoma, so
long as it remains intrinsic. No attempt will be made to separate the
different forms of these diseases. The points to be considered are the
following:--
The _mortality_ of the operation itself has been greatly reduced; von
Bruns[19] states that ‘between 1890 and 1898 there was an immediate
fatality of 15%’ in sixty cases collected by Schmiegelow and himself. In
comparison with these figures, the recent results of English surgeons
have been very favourable. Thus Butlin and Semon have performed
forty-eight thyrotomies for malignant disease since 1890 with only two
deaths. In Butlin’s case the patient was over seventy years of age, very
obstinate, very intractable, and persisted in sitting up from the time
of the operation. He died, in the course of three or four days, of
septic pneumonia. The results of other surgeons have been excellent, but
are not included for three reasons: There is still considerable
confusion in the selection of cases suitable to this operation; the
operation is often performed by those who are not conversant with the
difficulties and dangers that may arise; and it has sometimes to be
undertaken for a patient who is also suffering from bronchitis or
constitutional disease. Moreover, the above figures are sufficient to
show that the immediate mortality from this operation under favourable
circumstances is not large.
[19] Bergmann, E. von, _Sys. Prac. Surg._, vol. ii, p. 245.
_Recurrence_, in Semon’s cases, occurred in 13.6%, which is not a large
proportion. It usually occurs early or not at all. Semon and Jackson
noted that none of their patients suffered from recurrence after the
lapse of the first year. This is a point of great importance; and in
this connexion Semon points out, as an additional advantage of
thyrotomy, ‘that even in the cases in which either the operation has not
been complete, or in which unfortunately genuine recurrence has taken
place, the operation does not bring us to the end of our resources; but
that, on the contrary, by a repetition of the operation, or by
hemi-laryngectomy, or by total extirpation of the larynx, a lasting cure
may still be obtained, where the minor operation has failed.’
_Cures._ I hope it will soon become generally recognized that the
radical operation of thyrotomy for removal of early intrinsic malignant
disease is attended by a remarkable number of complete cures, and
compares favourably with almost any other operation for similar
conditions in other parts of the body. Butlin (see Table, p. 507),
Semon, and C. Jackson have all obtained, in recent years, from 60 to 80%
of lasting cures. In Semon’s twenty-five cases,[20] one died of the
operation, three cases recurred within a year, and one was too recent to
be included, the remaining twenty were cured for varying periods,
namely:
1 case over 15 years.
4 cases between 10 and 15 years.
4 cases between 5 and 10 years.
2 cases over 4 years.
3 cases over 3 years.
2 cases over 2 years.
1 case just 2 years.
1 case 1 year and 10 months.
1 case died 5 years after operation from pulmonary embolism.
1 case died 4 years after operation from pneumonia.
In both the last cases recurrence was excluded.
[20] _Trans. Med. Soc._, London, 1907, vol. xxx, p. 130.
The _condition_ of the patient after thyrotomy. The voice results are
often surprisingly good even when a free excision of soft parts,
including one or both vocal cords, has been required. In from 40 to 60%
of cases that are cured, the voice is practically normal, though rough
and reduced in volume and range. Of the remainder, the majority recover
sufficiently to produce a considerable whisper, and only a few suffer
complete loss of voice. The causes of a complete loss of voice, when it
occurs, are chronic inflammation, cicatricial contractions, or improper
union of the cartilage. Further, a loss of voice is probable in the
event of a recurrence of the growth.
The breathing is not affected unless the operation is followed by
stenosis. The power of swallowing is soon regained, and the general
condition of those who are cured is one of complete happiness and
general excellence of health.
These results may now be briefly compared with those obtained by
laryngectomy, whether partial or complete.
=Hemi-laryngectomy.= The immediate _mortality_ of this operation also
has been greatly reduced. Sendziak collected 108 cases, up to 1894,
showing a mortality of 26.3%; von Bruns 106 cases, between 1890 and
1898, with a mortality of 17%; Gluck has performed thirty-five such
operations with only three deaths--8.1%. The number of cases reported in
England is too small to be of value, chiefly because thyrotomy or total
extirpation has been considered better. Taking, therefore, the best
published results, it appears that the mortality is at least twice as
great as with thyrotomy.
The danger of _recurrence_ is also greater, partly because the glands
are affected. Statistics show that recurrence occurs in at least
one-fourth of the cases, possibly more, and is generally fatal. It is
impossible to give a prognosis as to cure in the early stages after
operation, but there are instances of life being prolonged for many
years; a case of Gluck’s lived for eleven years.
The _after-condition_ is not unsatisfactory. The permanent wearing of a
tracheotomy tube is rarely necessary. Swallowing is soon recovered, and
the voice is often good.
=Total laryngectomy.= Although the mortality of this operation has been
greatly reduced by many improvements in recent years, it still remains
higher than that of thyrotomy. As far as can be judged from the small
number of cases that have been reported by English surgeons, there seems
to be a direct mortality of at least 20% from these operations. C.
Jackson[21] has, however, performed eight consecutive total
laryngectomies without a death in the first thirty days. He writes: ‘Of
eight total laryngectomies done by me, three were hemi-laryngectomies
followed by recurrence and the total operation. Of the eight
laryngectomies, one lived seven years. I felt justified in claiming a
cure, but upon inquiry a few weeks ago I was informed by relatives that
he died of cancer of the stomach. One case lived three years without
recurrence, dying of cerebral hæmorrhage, and one eight months, dying of
alcoholism. Of the remaining five, three recurred within a year, one
apparent cure was lost to observation after a year, and one is too
recent to record: one of the three prompt recurrences had metastases in
the lungs, liver, and pancreas. Thus, of eight laryngectomies, no
absolute ultimate cures can be claimed, though three were apparent cures
at the end of one year.’
[21] _Brit. Med. Journ._, 1906, vol. ii, p. 1480.
Butlin has performed total laryngectomy upon seven patients, only one of
whom died from the operation. He says: ‘I first removed a large mass of
glands on both sides, and later took out the larynx, which was so
diseased, that the surrounding parts were infiltrated for a considerable
distance. He lived six weeks after the second operation, and then died
of double pneumonia, which was attributed to an attack of influenza when
he was up and about his room. I do not know whether the pneumonia was
due to that cause or to sepsis of the lungs, for we had on several
occasions some difficulty in feeding him, and in getting a tube properly
down his œsophagus.’
The following is a table showing Butlin’s operations since the year
1890, from a paper which was read at the Second Congress of the
International Surgical Society at Brussels in 1908:--
_Operations._
23 Thyrotomy[1] 21 patients
1 Hemi-laryngectomy 1 patient
7 Laryngectomy[2] 6 patients
-- --
31 operations on 28 "
Died of the operation (1 thyrotomy, 1 laryngectomy) 2
Died of recurrence 4
Died of intrathoracic disease, probably cancerous glands,
within 2 years 1
Died of cancer of tongue[3] 1
Lost sight of after operation 1
Alive after operation for recurrence 2
Well within 3 years 3
Died of other disease after 3 years 1
Well after 3 years[4] 13
--
28
[1] In two patients the operation was repeated.
[2] In one patient thyrotomy was followed by laryngectomy, but the
patient was included amongst the thyrotomies only.
[3] This was regarded as a second attack of cancer, for the disease of
the tongue was some distance from the larynx, and there was no sign of
cancer of the intervening parts. Also more than a year elapsed before he
began to suffer from cancer of the tongue.
[4] Periods during which patients remained well lasted from 3 to 15
years.
Recurrence after laryngectomy is, therefore, more frequent than after
thyrotomy, and it is difficult to estimate the proportion of cases that
are cured by this operation. Butlin writes: ‘Of the six patients who
survived the operation, one died of probable cancerous glands in the
mediastinum, one had inoperable recurrence in the cervical glands, three
were alive within three years, and one was well three years after the
operation.’ He says: ‘I began to perform laryngectomy three years ago on
account of Gluck’s success, and of the excellent modification due to
Solis Cohen. I wish I had begun to perform it earlier. I am sure that
several of the cases on which I performed thyrotomy were much better
fitted for laryngectomy, and I cannot help thinking I might have saved
one or two patients in whom recurrence took place if I had then removed
the larynx. I think the glands ought to be removed in every case in
which there is extensive carcinoma of the larynx, even if it be
intrinsic, unless the disease is limited to the middle zone of the
interior of the larynx. Even in these cases it would probably be a wise
precaution to remove the glands. I have never removed the glands and the
larynx at one sitting.’ Von Bruns,[22] from statistics of all total
operations since 1890, gives the following proportions:--
Cure, over 3 years 8.6%
Cure, 1 to 3 years 17.4%
Cure, under 1 year 32.0%
Recurrence 23.4%
Death due to operation 18.5%
[22] Bergmann, E. von, _Sys. Pract. Surg._, vol. ii, p. 245.
_The voice_ after laryngectomy. Many efforts have been made to replace
the lost voice. The artificial larynx, as first devised by Gussenbauer,
consisted of three distinct parts: a tube for the trachea through which
the patient inspired; a tube communicating with the pharynx so as to
allow of expiration through the mouth; and a phonation canula which
fitted into the former. This canula was supplied with a valve which
closed during expiration so as to allow of breathing through the mouth,
and a phonation apparatus for production of the voice. A large number of
modifications of this larynx have been made at different times but have
rarely been successful. The irritation and pain caused by the pharyngeal
portion, the difficulty in swallowing and in keeping the tubes clean,
and the exhaustion caused by prolonged use, have combined to make the
apparatus unsatisfactory.
As the result of recent improvements in laryngectomy, most surgeons
isolate the trachea as already described, and thus entirely shut off all
communication with the mouth. The patient then has a choice of two
methods--(1) the bucco-pharyngeal voice, or (2) a phonetic apparatus
such as that described by Gluck, consisting of (_a_) an external
tracheotomy canula for breathing, (_b_) an internal canula, possessing a
valve which closes during expiration and causes the air to pass upwards
to another compartment containing a small rubber band or tongue, the
vibration of which forms the voice, and (_c_) a third tube of rubber,
which is easily fitted to the upper part of the inner canula and is of
sufficient length to reach the mouth. When the patient wishes to speak,
the upper end of the last-mentioned tube is either placed in the angle
of the mouth or passed through the nose to the back of the pharynx, and
the air which has been made to vibrate in the inner tube is thus carried
to the mouth. This instrument is easy to adjust and clean, produces
remarkable phonetic effects, and is much the most ingenious and
serviceable device that has so far been invented. In some cases,
however, a patient can make himself understood without an instrument of
any kind. ‘A whispered voice remains even after the pharynx has been
completely shut off from the air-passages and, as shown by experience,
may be developed by practice until it is quite sufficient for the
demands of the patient. Hans Schmidt’s case has become more or less
celebrated, in which, under conditions of this sort, a loud though rough
and monotonous voice was developed. One of Mikulicz’s patients was even
able to sing. Gottstein explains the development of a pseudo-voice by
the formation of an air-chamber in the pharynx and œsophagus, which is
voluntarily inflated and emptied by the patient’ (von Bruns).
_Swallowing_ after laryngectomy is satisfactory, and the general health
in many cases improves. The mental condition of the patient is often
disappointing. ‘Even in favourable cases, when the tumour does not recur
after laryngectomy, the patient finds himself in such a condition of
inferiority to his fellows, that he may, with some reason, ask himself
(at least in certain cases) whether death would not have been preferable
to such an existence as is left to him’ (Moure[23]). With recurrence of
the disease the patient’s life is terribly sad.
[23] _Brit. Med. Journ._, 1903, vol. ii, p. 1148.
It must therefore be admitted that laryngectomy is at present an
operation of necessity, suitable for certain cases only, capable of
prolonging life, and, rarely, of curing the patient. It is difficult to
foreshadow the future of this operation; but, in the words of Gluck,
‘our first object must be to save life; our next, to leave the patient
in such a physical condition that the life so saved is worth living.’
The above statistics are sufficient to show that the results of
laryngectomy for extrinsic disease compare unfavourably with the results
obtained by thyrotomy in intrinsic forms of cancer. In this country
there have not been sufficient cases to estimate accurately the
percentage of recoveries. The disease may recur at any period after the
operation, and the prospect of a cure is always doubtful.
It is, however, to be hoped that, with improved methods of examination,
earlier diagnosis, and a careful selection of the cases, better results
will in future be obtained. Authorities such as Butlin and Semon support
this view, and agree that further attempts must be made to make this
operation successful.
INFRATHYREOID LARYNGOTOMY
In order to avoid confusion with other operations included under
laryngotomy, this term is used to denote the operation in which the
larynx is opened through the crico-thyreoid membrane. The operation is
an easy one in adults, but in children the crico-thyreoid space is so
small that it is almost impossible to introduce a tube without division
of the cricoid cartilage (see Crico-tracheotomy, p. 529).
[Illustration: FIG. 264. INFRATHYREOID LARYNGOTOMY. Position of the
incision.]
A tube introduced through the crico-thyreoid membrane lies in the
subglottic space well below the vocal cords, and the latter should not
be injured when the operation is performed with care. If inflammation
supervenes, there may be a swelling of the subglottic region, making the
tube difficult to manipulate; and for this reason the operation is
particularly suited to cases which require a tube for a short period
only, such as--
=Indications.= (i) Sudden laryngeal obstruction due to impaction of food
or other foreign body. This is more common in adults: in children
dyspnœa is rarely so urgent as to necessitate an operation.
(ii) Sudden œdema of the larynx caused by trauma, fracture, or acute
inflammation, when the equipment for tracheotomy is not obtainable; or,
(iii) As a preliminary to major operations upon the upper air-passages,
in order to prevent blood from passing down into the trachea.
This last method of treatment marks a distinct advance in the surgery of
the throat. Attention was first directed to it by Bond[24], who has
used the method for the past sixteen years with intent to make such
operations less dangerous to life, and to increase, therefore, the
number of cases that could be operated upon. His objects were to prevent
respiration through the pharynx, thus obviating the coughing and
struggling due to imperfect anæsthesia and making the anæsthetic easier
and safer to administer; to shorten the operation and make it easier for
the surgeon; and to get rid of preliminary tracheotomy whenever
possible.
[24] _Brit. Med. Journ._, 1907, vol. i, p. 7.
The value of this practice is well recognized by many surgeons. Butlin
writes: ‘I do not know how many times I have employed this preliminary
laryngotomy, but certainly more than a hundred times, so that I am now
in a position to urge the importance of it on the profession.’ It has
now been adopted at many of the hospitals in England before removal of
tumours in the naso-pharynx, the upper and lower jaw, the tongue,
palate, floor of mouth, and tonsil, in those cases where bleeding is
likely to be severe.
In order to ascertain the feeling of my colleagues on this subject I
have collected, with the assistance of Mr. Boyle, all the major
operations performed upon the upper air-passages during the last six
years at St. Bartholomew’s Hospital. These are tabulated below.
TABLE SHOWING OPERATIONS UPON THE UPPER AIR-PASSAGES DURING THE
YEARS 1902-7 INCLUSIVE AT ST. BARTHOLOMEW’S HOSPITAL
-----------------------------+------------------+------------------
| _With | _Without
| Laryngotomy._ | Laryngotomy._
+--------+---------+--------+---------
|_Cases._|_Deaths._|_Cases._|_Deaths._
-----------------------------+--------+---------+--------+---------
Excision of Tongue | 20 | 3 | 13 | 2
-----------------------------+--------+---------+--------+---------
" " half Tongue | 25 | 2 | 46 | 1
-----------------------------+--------+---------+--------+---------
" " Floor of Mouth | 13 | | 13 | 1
-----------------------------+--------+---------+--------+---------
" " Tongue and Floor | 5 | 1 | 1 | 1
of Mouth | | | |
-----------------------------+--------+---------+--------+---------
" " Palate | 8 | | 1 |
-----------------------------+--------+---------+--------+---------
" " Upper Jaw | 12 | | 13 |
-----------------------------+--------+---------+--------+---------
" " Lower Jaw | 1 | | 9 |
-----------------------------+--------+---------+--------+---------
" " Tumour of Gums | 1 | | |
-----------------------------+--------+---------+--------+---------
" " Tonsil | 2 | | 1 |
-----------------------------+--------+---------+--------+---------
" " Naso-pharyngeal | 3 | | |
Tumour | | | |
-----------------------------+--------+---------+--------+---------
Total | 90 | 6 | 97 | 5
-----------------------------+--------+---------+--------+---------
This table shows that nearly half the cases were treated by laryngotomy.
In sixty-three of these, where the tongue or floor of the mouth was
concerned, no preliminary ligature of the lingual artery was performed;
of the seventy-three similar cases treated without laryngotomy there was
preliminary ligature of one lingual in thirty-one cases (42.5%), and of
both arteries in twelve cases (16.4%).
From this it is apparent that lary[n]gotomy has to some extent taken the
place of preliminary ligature of one or both linguals. The operation is
simple, rapid in execution, and meets all requirements; it is not
surprising to find, therefore, that in recent years the number of
laryngotomies has proportionately increased.
TABLE SHOWING OPERATIONS AS PERFORMED IN DIFFERENT YEARS
+---------+----------+---------------+---------------+
| | | _With | _Without |
| _Year._ | _Cases._ | Laryngotomy._ | Laryngotomy._ |
+---------+----------+---------------+---------------+
| 1902 | 39 | 19 | 20 |
| 1903 | 35 | 5 | 30 |
| 1904 | 31 | 16 | 15 |
| 1905 | 32 | 18 | 14 |
| 1906 | 29 | 18 | 11 |
| 1907 | 21 | 14 | 7 |
+---------+----------+---------------+---------------+
| Total | 187 | 90 | 97 |
+---------+----------+---------------+---------------+
=Operation.= In cases of extreme emergency the operation can be
performed with almost any kind of knife, but the following instruments
are preferred: a sharp-pointed bistoury or tenotome, a sharp-pointed
dilator (Fig. 265, B), a tube and introducer. The tube should be small,
short, with a fixed collar, and made of silver; an introducer such as
Butlin’s is a great advantage (Fig. 265, A). As bleeding may occur, it
is necessary to prepare dissecting forceps, retractors, pressure forceps
and catgut.
[Illustration: FIG. 265. INSTRUMENTS FOR LARYNGOTOMY. A, Tube and
introducer (Butlin’s); B, Sharp-pointed dilator (Bailey’s).]
A general anæsthetic is usually employed when infrathyreoid laryngotomy
forms the first stage of the main operation, but it should be remembered
that the amount of chloroform required is less when given through a
tube.
The preparation of the skin and the position of the body are the same as
for tracheotomy. A transverse incision one inch in length is
recommended, and this should lie directly over the crico-thyreoid
interval, which is easy to determine in the adult. The incision can be
made quickly by pinching up a vertical fold of skin, transfixing
immediately above the cricoid, and cutting outwards: with this method
the anterior jugular veins are rarely wounded, but if any vessel has
been pricked it should be seized and tied at once.
The sharp dilator, placed exactly in the middle line immediately above
the cricoid, is pushed backwards between the infrahyoid muscles until
the resistance caused by the crico-thyreoid membrane is reached. It is
then firmly stabbed into the larynx and widely dilated so as to tear
open the membrane: the dilator having been withdrawn, the tube, with
tapes attached and mounted upon the introducer, is rapidly inserted, a
proceeding which is made easier by first smearing the instrument with a
small amount of glycerine. The whole operation can be performed in less
than a minute, and is rarely attended by serious hæmorrhage; moreover,
when the original puncture is immediately above the cricoid there is
less danger of wounding the crico-thyreoid artery. The operation is
attended by few difficulties, and is superior to one in which dissection
or cutting is employed.
[Illustration: FIG. 266. LARYNGOTOMY CANULA FITTED WITH INNER TUBE.
Funnel for administration of anæsthetic.]
At this stage a prolonged period of apnœa is usually encountered, and
this symptom is more marked than with tracheotomy; when seen for the
first time it may be alarming, and it is therefore of practical
importance. In a few moments, however, the patient settles down to the
altered conditions of respiration; coughing may be excited but soon
disappears. When the breathing becomes regular, the tapes are tied round
the neck and a rubber tube is attached (Fig. 266) similar to that used
with Hahn’s apparatus, and through the tube the chloroform is continued.
This method has the following advantages: it gives far more room to
surgeon and anæsthetist, and enables the latter to manipulate the
laryngotomy tube and to prevent it from tilting in such a way that the
lower end impinges against the front of the trachea with consequent
obstruction; further, the opening into the larynx is completely blocked,
blood and lotion being unable to enter from outside.
As soon as true anæsthesia with regular automatic breathing has been
obtained, the lower part of the pharynx should be plugged with a soft
marine sponge to which a piece of tape or silk is attached, this being
pushed down behind the tongue and firmly wedged in position; it is
advisable to use a large sponge, as this blocks the pharynx and pushes
forward the tongue, an advantage to the surgeon when operating upon that
structure. If the mouth be obstructed by a tumour, the same result can
be obtained by two or more smaller sponges passed in succession; or, as
suggested by Bond, a small sponge may be pulled down into the larynx. As
soon as the pharynx has been completely shut off, the main operation can
proceed, and those who have once used this method can appreciate how
much more quickly it can be performed and how much more comfortably for
all concerned.
At the conclusion of the operation, when all bleeding has been
controlled, the laryngotomy tube should be removed. The wound should not
be sutured or plugged, and only a light dressing should be applied: the
latter can be kept in place by a bandage, which, however, must on no
account be tight, owing to the danger of emphysema.
=Complications= may arise--(_a_) _During the operation._ There may be
troublesome bleeding owing to pricking of a vein, superficial or deep,
or of the crico-thyreoid artery; this occurred in eight of the cases
mentioned above, and in four was severe. In one of the latter the
bleeding continued for thirty minutes before the vessel was finally
secured. The condition is simple to treat: the wound must be enlarged,
and the infrahyoid muscles separated so that the crico-thyreoid membrane
is thoroughly exposed; the bleeding vessel can then be seized and tied,
after which the tube is inserted. This is preferable to attempting to
stop the bleeding by the introduction of the tube.
Difficulty in introducing the tube may occasionally occur. It may be due
to imperfect division of the membrane; thus in one case the tube was
passed down between the coats of the larynx and not within its cavity;
and another case is recorded where the mucous membrane was similarly
pushed backwards owing to the dilator having split the cricoid
cartilage. Care must be taken, therefore, that the membrane is properly
punctured, and that the opening is thoroughly dilated before any attempt
is made to introduce the tube. Replacement of the tube was necessary in
only one case, on the second day, owing to recurrence of bleeding from
the wound in the mouth.
(_b_) _After the operation._ Emphysema occurred in six of the ninety
cases; in two it was slight; in three it was extensive and involved the
chest, neck, and face; and in one, where death supervened twelve hours
after the operation, there was emphysema of the mediastinum. In two of
these cases the laryngotomy wound had been sutured; in two others the
operation was attended with severe hæmorrhage, and the mouth was plugged
with gauze to control it. It is probable that emphysema is more likely
to occur if there is any obstruction to breathing through the mouth
after the operation, such as may be caused by the falling back of the
remaining part of the tongue. The following precautions should be
observed to prevent it: The laryngotomy wound must always be left open,
and covered by a loose piece of gauze which does not press upon the
neck; the patient must be nursed on his side, not upon the back;
suturing the remaining part of the tongue is not sufficient; if plugging
is left in the mouth, the tube must be temporarily retained, and removed
after a few hours when breathing is not obstructed; early removal,
however, is preferred.
Bronchitis is mentioned in two of the cases already quoted, pneumonia in
one case, pneumonia and empyema in one, and purulent mediastinitis in
one, with three deaths in all. Of these five cases, four had operations
upon the tongue. On the other hand, without laryngotomy, bronchitis was
rather more common (seven cases) and broncho-pneumonia occurred in two,
both of which died. In order to throw more light upon the subject, we
have examined the charts of all the cases after the operation, and have
found that in most of them there was a rise of temperature to 99° F., or
slightly higher, which lasted for periods varying from one to seven
days; the pulse and respiration were little affected. In laryngotomy
cases there were only eighteen instances of temperatures of over 100°
F., as against twenty-five where no laryngotomy had been performed. Here
again the pulse and respiration were only slightly affected, so that the
condition was probably due to local inflammation and not to involvement
of the lung. The results are by no means conclusive, but justify the
general feeling that laryngotomy does not increase, but probably
diminishes, the danger of infection of the lungs.
Healing of the wound may take place in normal conditions in about five
days, but the period is frequently longer--from ten to twenty days;
suppuration is uncommon, and was only mentioned in two instances where
the wound had been sutured. The scar left after laryngotomy is often
depressed for several months, but eventually becomes loosened and is
then scarcely noticeable.
Death occurred in six cases, but there was no evidence to show that
there was any connexion with the laryngotomy; on the contrary, the
operations were more severe, and infrathyreoid laryngotomy was performed
partly for the very reason that the condition of the patients was less
favourable.
From my experience, the advantages which were originally claimed by
Bond, Butlin, and others have been completely upheld; the larger
operations upon the upper air-passages are easier to perform and can be
more thoroughly completed; and it is very possible that the
after-results may be improved by the greater facility which is thus
afforded. I would strongly urge laryngotomy in all large operations of
this region; the tube should be removed early, and the wound should not
be sutured.
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.
[Illustration: FIG. 267. SKIAGRAM SHOWING AN ANGULAR TRACHEOTOMY TUBE IN
THE TRACHEA. H, Body of hyoid; PH, Pharynx; CR, Posterior plate of
cricoid; L, Larynx; OE, Œsophagus; T, Trachea.]
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:--
[Illustration: FIG. 268. ANATOMY OF THE LARYNX AND TRACHEA AND THE
POSITION OF INCISIONS FOR THE OPERATIONS IN THIS REGION. A, Subhyoid
pharyngotomy; B, Thyrotomy; C, Infrathyreoid laryngotomy; D, ‘High’
tracheotomy; E, ‘Median’ tracheotomy; F, ‘Low’ tracheotomy; 1, Platysma;
2, Crico-thyreoid muscle; 3, Sterno-hyoid muscle; 4, Isthmus of thyreoid
gland; 5, Sterno-thyreoid muscle; 6, Sterno-mastoid muscle; 7,
Crico-thyreoid artery; 8, Anterior jugular vein; 9, Inferior thyreoid
vein; 10, Innominate artery; 11, Right innominate vein; 12, Left
innominate vein.]
(_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.
[Illustration: FIG. 269. TUBES FOR TRACHEOTOMY. A, Parker’s; B,
Durham’s; C, Baker’s rubber tube.]
Tracheotomy tubes may be made of silver, rubber, vulcanite, celluloid,
or a gum-elastic material, but most surgeons prefer a silver tube in the
early stages of treatment. An angular form should be used, for ‘with the
ordinary quarter circle tube, the lower extremity tends to impinge on
the anterior wall of the trachea, and this is attended with many
inconveniences and even with grave risks’ (Parker[27]). A movable shield
is equally important, and this should be flush with the neck in order to
avoid the possibility of its being removed by the patient. Further, the
tube should consist of two parts--an outer tube to which the shield is
attached, and an inner tube which projects slightly beyond the outer and
can be removed for purposes of cleaning. To encourage breathing through
the larynx, a window may be added in the upper part of the tubes.
Parker’s tube, which meets all the above requirements, is the one most
commonly used in England. When longer tubes are necessary, either
Durham’s or Stewart’s is recommended: in these, the position of the
shield can be altered, and the length of the tube arranged, to suit the
patient. In cases of long duration the use of rubber tubes such as
Morrant Baker’s is indicated. An introducer is rarely necessary except
for rubber or long tubes. As taper and bivalve tubes are liable to
injure the trachea, their use is not advised. The tube chosen should fit
loosely, and should project far enough into the trachea to be secure
from slipping out during coughing or struggling. Short tubes are
preferable, and the wider the tube the easier the breathing and the
better the drainage. The approximate diameter of the trachea varies at
different ages, and the size of tube suitable in each case varies
chiefly according to the trachea, but partly also according to the
fatness of the neck. The accompanying table indicates the appropriate
dimensions.
[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.