were papillomata; next in number come fibromata. Aside from these two
kinds of tracheal tumor, the cases recorded in literature are the
following: Rokitansky more than thirty years ago described tracheal
enchondromata found after death; and Cohen discovered in the corpse of
a phthisical patient a number of small enchondromata on the central
portions of the tracheal cartilages. Steudener, Demme, Wilks, Chiara,
and Eppinger have observed, post-mortem, tracheal osteomata. Gibbs has
described a tracheal cystic tumor[2] seen with the laryngoscope;
Müller, under the guidance of Gerhardt, a myxo-adenoma observed
tracheoscopically and carefully studied {141} during life and after
death; and Eppinger has recorded a case of post-mortem tracheal
adenomata and cysts, Simon having previously found three similar tumors
on dissecting a new-born tigress. Virchow speaks of the occurrence of
retro-tracheal retention-cysts, and Gruber has observed several; but
there can be no doubt that at least some of the tumors thus described
are nothing but circumscribed dilatations of the tracheal mucous
membrane--practically, dilated mucous glands. As to malignant tumors,
in addition to my two cases Schrötter has reported two cases of
sarcoma, and Labus one of fibro-sarcoma, while Rokitansky, Klebs, Koch,
Schrötter, Langhans, and Mackenzie have described cases of carcinoma.
[Footnote 2: Cohen questions whether this was a cyst or an abscess. It
burst spontaneously.]
Cases of cancer of the oesophagus, which involve the trachea--excluded,
as before stated, from present consideration--are, comparatively
speaking, by no means rare, and are apt to establish a fistulous
communication between the two tubes.
DIAGNOSIS.--The symptoms mentioned are those common to nearly all cases
of tracheal stenosis, and will be referred to again under that head.
Tracheoscopy alone makes the diagnosis certain; unless when the seat of
the disease is ascertainable without, its nature is shown by the
expectoration of portions of the tumor. The first case of tracheal
tumor ever diagnosed during the patient's life was observed by means of
the mirror by Tuerck in 1861; but it is very difficult in the mirror to
estimate distances as to depth, and unless the number of tracheal rings
above a tumor can distinctly be counted, a growth in the lower cavity
of the larynx may readily be mistaken for one in the trachea, and vice
versâ. Catheterism of the trachea shows the distance at which the tumor
is situated, sometimes very accurately, but it is dangerous unless
performed under the guidance of the mirror, and even then requires
great care. The introduction without the mirror of a probe or sound for
the same purpose is still more dangerous and unjustifiable, while with
the mirror it is perfectly safe in proper hands. Localized protrusion
of the mucous membrane into the interior is the condition which most
simulates tracheal tumor. (Compare Fig. 32.)
[Illustration: FIG. 31. Papilloma of Trachea.]
The pathological nature of a tracheal tumor can sometimes be determined
in situ with more or less probability. Without microscopical
examination it is not always possible to say whether a growth is benign
or malignant unless the mass has advanced to ulceration, and then
specific disease must be excluded by the history and concomitant
symptoms. Papillomata have a peculiarly uneven surface; fibromata are
usually more smooth. With equally good illumination, tumors of the
trachea resemble tumors of the larynx, and may be similarly
differentiated. The former are almost always non-pedunculated, or at
least none of those hitherto observed have had a long pedicle. Their
seat is generally the posterior wall, or the cicatrix of the anterior
wall after tracheotomy. In Fig. 31 is seen the tracheoscopic appearance
of one of my cases of tracheal papilloma.
PROGNOSIS.--The prognosis is always unfavorable in malignant cases, and
also in non-malignant when the tumor grows rapidly or has already
attained a large size. The introduction of the laryngoscope has
bettered the prognosis, inasmuch as in many cases early recognition
enables us, by performing tracheotomy, to prevent sudden death from
suffocation, and also because by the aid of the mirror removal has been
accomplished through the natural passages.
TREATMENT.--Removal of a tracheal tumor through the natural passages
{142} by means of either cutting or cautery instruments requires so
much special ability on the part of the operator that it need not be
described in detail in a work designed for general medical
practitioners. When the tumor is situated above a point at which
tracheotomy can be judiciously performed, no physician worthy of the
name should hesitate to lay open the trachea in any case in which
suffocation is impending. Removal of the tumor by surgical operation
after opening the windpipe may be attempted or not according to
circumstances, but in all cases palliative measures by sedative
inhalation and otherwise may be resorted to, and the patient's general
health, especially in malignant cases, must be kept up as much and as
long as possible.
STENOSIS.
DEFINITION AND PROXIMATE ETIOLOGY.--Stenosis is narrowing or more or
less occlusion of the windpipe. It is either stricture or constriction
from within, or compression from without, or both combined.
Constriction within the trachea is due to swelling or thickening or
cicatricial displacement of the mucous membrane or other tissue,
inversion of its walls, or morbid growth or foreign body in its
interior. Compression from without is due to goitre (which has in some
cases prevented viability) or other disease of the thyroid body;
aneurism; abscess; enlarged bronchial glands or cervical lymphatics;
disease of the sternum, clavicle, or vertebræ; mediastinal tumor;
cystic, emphysematous, or other tumor of neighboring tissue; or foreign
body. According to Rose's observations of goitre,[3] compression of the
trachea leads to fatty degeneration of the cartilages and their
subsequent softening and absorption; after which, the windpipe having
become membranous throughout and no longer patulous, death can
easily--in some positions or flexion of the body, etc.--take place.
[Footnote 3: _Der Kropftod und die Radicalcur der Kröpfe_, Berlin,
1878.]
In acute tracheitis, though there is swelling of the mucous membrane,
the large size of the tube usually obviates stenotic symptoms, while
chronic tracheitis does occasionally lead to sufficient contraction to
interfere with respiration; but generally stenosis is the result of
syphilis, and frequently follows ulceration and cicatrization. In a
case recorded in the _Bullétin des Sciences médicales_ for January,
1829, the lumen of the trachea was reduced to two lines.
[Illustration: FIG. 32. Involution of Trachea, due to aneurism.]
SYMPTOMS AND DIAGNOSIS.--The main symptom is the peculiar, gradually
increasing dyspnoea; once observed, it is recognized without much
difficulty. There may also be mucous râles; cough rough and sibilant;
attempts at clearing the throat without expectoration, or occasionally
with some expectoration, which is at first light-colored, then streaked
with blood, and at last purulent, but never abundant (unless
accidentally complicated by catarrh), and always difficult to eject;
perhaps occasional pain, but constant disagreeable sensation
(tightness) in the trachea just above the sternum. Tracheoscopy
settles the diagnosis. The tracheal rings are seen either as diminished
circles or arcs--sometimes concentrically placed, sometimes in two
different directions, as shown in a case of tracheal stenosis from
{143} compression causing protrusion of the mucous membrane into the
interior, represented in Fig. 32, or else constricting bands are
visible.
As to the dyspnoea, both inspiration and expiration are
affected--frequently, however, the former more than the latter, as is
shown by pneumatometry. The head is thrown forward and the chin up; the
larynx moves up and down less energetically than in health (while the
respiratory movements of the larynx are abnormally increased in
laryngeal dyspnoea); the thorax is less expanded than normally,
especially its upper portions.
As to catheterization and probing, see the remarks under the head of
Morbid Growths.
PATHOLOGY.--The pathological changes in cases of stenosis vary with its
cause. In the great majority of cases of stricture from within,
syphilis--antecedent ulceration followed by cicatrization--has produced
the stenosis; in compression thyroid disease, and next often aneurism,
is the cause. The stenosis is most frequently situated in the lower,
next in the upper, and least in the middle, portion; more often than
the latter alone the whole tube is affected.
PROGNOSIS.--This is rather favorable with timely and proper treatment
unless a continuing active cause be irremovable; without treatment,
however, the cases almost invariably terminate fatally from pneumonia,
tracheal spasm, apnoea as before explained, etc.
TREATMENT.--When the symptoms are urgent and the stenosis is not too
low down, tracheotomy must be performed. Sometimes a very long and
flexible tube may be introduced with success in case of very low
stenosis, but more often tracheotomy is disappointing on account of the
stenosis extending too low down even when its beginning is higher up.
Stricture, especially when the symptoms are not very urgent, may be
relieved by dilatation through the natural passages, with, or if
possible without, previous tracheotomy. The cure of compression implies
removal of the compressing tumor or disease. Soothing inhalations, such
as of hops, benzoin, etc., diminish irritation and give temporary
relief.
DILATATION (HERNIA, FISTULE).
Dilatation of the trachea is either confined to the tube (when the
synonym tracheaectasy is applied to it) or is diverticular. In the
former case it may involve only a part or else the whole extent of the
windpipe. Whenever free respiration, especially expiration, is
chronically impeded, some portion of the air-tract below the
obstruction is apt to become dilated; thus, a bottle-shaped dilatation
is sometimes found immediately below an annular contraction. On the
other hand, tracheaectasy may extend upward from bronchiectasy. It has
been observed post-mortem to a slight extent in public criers,
trumpeters, etc., and in old coughers from laryngeal disease, chronic
bronchitis, pulmonary emphysema, etc., but without giving rise to
distinct symptoms during life.
Diverticular dilatation forms an air-containing tumor which either
looks into the oesophagus or is discernible on the outside of the neck.
Though rarely met with, it ought to be thought of in all appropriate
cases, and when pointing externally ought always to be recognized by
the careful practitioner. It is either hernial, glandular, or
fistular--three pathological conditions which have hitherto been
confounded. On account of the construction and position of the trachea
there can be but little protrusion outward without previous {144}
dilatation. Unless there be a deficiency of the cartilaginous rings,
only the posterior wall, which is always unsupported, and to a slight
extent also the intercartilaginous membranous portions, are liable to
tracheal hernia. This is properly called tracheocele; but the various
terms aërial goitre, aërial bronchocele, pneumatocele, tracheal
air-cyst, tracheal retention-cyst, internal tracheal fistule,
subcutaneous or incomplete fistule of the trachea, have been
indiscriminately used as synonyms of tracheocele, and have added all
the more to the confusion, as some of them originated, no doubt, as
correct appellations of the particular cases to which they were
applied. Aside from the occasional occurrence, both congenital and
acquired, of tracheo-cutaneous fistule, complete and incomplete, and
the still more rare occurrence of hernia of entire portions of the
mucous membrane, the cases of diverticular dilatation of the
trachea--or saccular tracheaectasy, as it may be called--are glandular,
as found by Rokitansky more than fifty years ago. Virchow seems to
regard all such glandular dilatations as retention-cysts (see Morbid
Growths), but although retro-tracheal retention-cysts doubtless do
occur (Gruber has reported two unquestionable instances), and although
the tumors now under consideration do in fact sometimes contain a
little mucus in addition to air, they do not constitute cysts or
adenomatous new growths, but are simply distended portions of the
tracheal mucous membrane, respiratory glands, whether the dilatation be
caused, as Rokitansky thought, by traction (Zerrung) and hypertrophy of
the mucous glands, or, as Eppinger suggests--and which is more
likely--mainly by increased intra-tracheal air-pressure. There must,
however, I think, coexist some deficiency or weakness of the
cartilaginous or other tissue, either congenital or acquired.
When the dilatation is retro-tracheal only, the symptoms are very
obscure, and diagnosis during life is at best uncertain. In one such
case under my care, confirmed (death having occurred from another
cause) by post-mortem examination, there was some dysphagia and slight
alteration of the voice. In all other cases the characteristic and
unmistakable sign of the disease is the peculiar intermittent, or, at
all events variable, aërial cervical tumor. It increases and diminishes
with forcible expiration and inspiration, and attains its largest size
during violent coughing, hawking, blowing of the nose, or other
expiratory effort. Occasionally the voice is considerably affected. The
tumor, especially by the manner in which it can be made to temporarily
disappear and reappear, can usually be easily differentiated from
subcutaneous emphysema and goitre, the only two conditions with which
it might be confounded. In the fistular variety the opening into the
trachea can sometimes be seen by means of tracheoscopy.
Aside from the deformity which the tumor may cause, it sometimes
induces laryngeal spasm and dyspnoea; otherwise it is of no gravity.
As to TREATMENT, methodical and continued compression by applications
of astringent collodion or by mechanical means is the only palliative
measure applicable; when suffocatory attacks call for it, tracheotomy
must be performed.
{145}
TRACHEOTOMY.
BY GEORGE M. LEFFERTS, A.M., M.D.
The operation of tracheotomy, or the artificial opening of the
air-passage--using the term in its modern acceptation as including all
of the five incisions that are both anatomically and surgically
possible, either singly or in combination, between the lower border of
the thyroid cartilage and the upper edge of the sternum (incisura
jugularis sterni), and reserving the term laryngotomy to denote the
division of the thyroid cartilage alone--fulfils two important and
usually urgent indications: First, in allowing the respiratory current
free access to the lungs in cases where the laryngeal obstruction is of
such a sudden or of so progressive a character as to either immediately
or remotely threaten the life of the patient; and, secondly, in
affording a ready means of direct access to those portions of the
air-tract which lie below the level of the glottis, and thus permit not
only of the direct extraction of such foreign bodies as may
accidentally have found their way within the air-passage, but of
neoplasms here located and of occluding diphtheritic membranes.
Catheterization and aspiration of the trachea are likewise both
rendered not only possible, but easy of execution. Both general
indications mentioned often coexist, and are met by the operation in a
large class of cases; the first alone plays its important life-saving
rôle in many.
The disease or accident which renders the operation necessary varies
greatly, and upon this variation depends not only the surgeon's
decision as to the precise time at which the opening into the air-tube
must be made, but also the precise point at which the operation should
be performed. These general questions I treat of in detail. The special
indications may conveniently, but somewhat arbitrarily, be arranged as
follows, in groups, which I have attempted to make complete, although
some of the conditions, being purely surgical, do not strictly come
within the compass of this essay:
A. Acute inflammatory diseases of the larynx and trachea:
1. Acute oedema of the larynx.
2. Erysipelatous and exanthematous laryngitis.
3. Acute perichondritis, with abscess.
4. Diphtheritic croup.
B. Chronic affections of the larynx and trachea:
1. Syphilitic laryngitis.
2. Phthisical laryngitis.
3. Chorditis vocalis inferior hypertrophica.
4. Carcinoma of the larynx or trachea.
5. Non-malignant growths of the larynx or trachea.
6. Tumors overlying the superior aperture of the larynx.
7. External compression of the trachea by tumors of the neck or
chest.
8. Strictures of the larynx or trachea.
C. Neurotic diseases:
1. Paralysis of the abductors of the vocal cords.
2. Spasm of the adductors of the vocal cords. {146}
D. Traumatic conditions:
1. Foreign bodies in the larynx or trachea.
2. Impaction of foreign bodies in the pharynx or oesophagus.
3. Fracture of the larynx. Rupture of the trachea.
4. Scalds and burns of the larynx.
5. Incised and gunshot wounds of the throat.
6. Poisonous bites inflicted by certain insects about the mouth or
neck.
7. Suffocation from the passage of blood, fluids, etc. into the
air-passages (tracheotomy, with aspiration of the windpipe and
artificial respiration).
8. Suffocation from the acute collection of either mucus or serum in
the bronchia (ditto).
9. Suffocation from the inhalation or development of poisonous gases
(tracheotomy, with artificial respiration).
Finally, although it pertains alone to the province of the surgeon, I
may allude to the temporary tracheotomy and "tamponing of the trachea"
which has been recommended--and certainly found efficient--in
preventing the entrance of blood to a dangerous degree into the lower
trachea and lungs during the performance of certain operations in the
neighborhood of or upon the air-passages, such as resection of the
upper jaw, the extirpation of large nasal and naso-pharyngeal polypi,
removal of the tongue, subhyoidean pharyngotomy, laryngotomy, and
extirpation of the larynx.[1]
[Footnote 1: For the details of this procedure consult Schüller, _Die
Tracheotomie, etc._, Stuttgart, 1880.]
All-important as a preliminary to the operation itself is a thorough
knowledge of the surgical anatomy of the region upon which it is
proposed to operate; and this not alone in the adult, but especially in
the child, where essential differences often exist. Possible anomalies
also are not to be forgotten.[2] The assurance of the surgeon depends
upon this knowledge: mere, manual skill will not compensate for its
want; the success, both immediate and remote, of the operation is in
great measure the reward of its possession.
[Footnote 2: See Pilcher, "The Anatomy of the Anterior Median Region of
the Neck," _Ann. of Anat. and Surgery_, Brooklyn, April, 1881.]
It will be remembered that the trachea commences at the inferior border
of the cricoid cartilage, directly opposite to the lower edge of the
fifth cervical vertebra, and reaches thence downward, in the median
line of the neck, until it bifurcates opposite to the third dorsal
vertebra. In its upper part it is nearly subcutaneous, and is
surmounted by the prominent ring of the cricoid cartilage (easily
identified, even in the young child), above which, in turn, lies a
slight depression (the crico-thyroid space) between the cricoid and
thyroid cartilages. As the trachea descends in the neck it recedes
gradually, lying at the episternal notch about one and three-eighths of
an inch from the surface. Throughout the whole of this course it is in
relation with important structures. In its cervical portion it is
covered by the sterno-hyoid and sterno-thyroid muscles, and in the
median space, which is usually distinct between them, by layers of the
deep cervical fascia. It is also crossed by the isthmus of the thyroid
gland, which lies between the second and fourth tracheal rings; by the
arteria-thyroidea ima, when present, and below by the plexus formed of
inferior thyroid veins with their tributary and communicating branches.
In the latter region, but more superficially, are some communicating
branches between the anterior jugular veins. The innominate and left
carotid arteries are also anterior to it in the episternal notch as
they diverge from their origin. Laterally, the trachea is in relation
with the common carotid artery, the lateral lobes of the thyroid body,
the inferior thyroid veins, and the recurrent laryngeal nerves. The
thoracic portion of the trachea is covered by the manubrium sterni,
with the origins of the sterno-hyoid and {147} sterno-thyroid muscles,
by the left innominate vein, and by the commencement of the innominate
and left carotid arteries. Still lower, the transverse portion of the
arch of the aorta crosses, and the deep cardiac plexus of nerves lies
in front of it. Posteriorly, throughout its length, it rests upon the
oesophagus.
In performing, then, either the superior or inferior operation of
tracheotomy, after cutting through the skin and superficial cervical
fascia--which is really loose areolar tissue containing fat--the
superficial layer of the deep cervical fascia is reached, and
immediately below it more or less adipose tissue and the two anterior
jugular veins lying in an inferior tracheotomy to either side of the
wound, which is always made in the median line. As a matter of fact,
these various layers are rarely demonstrable, and the surgeon proceeds
irrespective of them until he reaches this point in his operation--viz.
the muscles which overlie the trachea. These may overlap in the median
line, and have to be retracted after having been separated; or, again,
a thin line of connective tissue marks a slight interval between their
inner edges, and is readily seen and dissected through if the operator
has kept his incision vertical and strictly in the median line of the
neck--a matter so important to the success of his operation that I do
not hesitate to again allude to it. The muscles separated and gently
retracted, together with the overlying tissues, toward the sides of the
wound, the upper edge of the isthmus of the thyroid gland overlying the
second and third, perhaps fourth, rings of the trachea, is always seen
in a superior tracheotomy--its lower edge very frequently in the
inferior operation. The isthmus is adherent to the trachea and to the
larynx through the deep layer of the deep cervical fascia, but is
capable of being slightly displaced or pushed upward or downward as the
case may be, and thus kept from obscuring the operative field. This
being done, the deep layer of the deep cervical fascia is seen covering
and strongly adherent to the tracheal wall together with the thyroid
veins. A few touches of the knife, carefully avoiding the
blood-vessels, serve to clear it away, and the tracheal rings are
clearly exposed.
In carrying out this dissection, which has been described as occurring
in an ordinary and uncomplicated adult case, several matters must be
borne in mind; and especially is this true if the operation concerns
infants. In them, for instance, the thymus gland rises half an inch
above the level of the sternum, and is frequently to be found as late
as the sixth or seventh year. In both adults and children the
innominate artery occasionally comes into view in an inferior
tracheotomy, obliquely crossing the lower portion of the right half of
the trachea. It is relatively higher in the child than in the adult.
The left innominate vein is also often observed when the trachea is
opened low down.