The commonest consists in the existence of a thyroidea ima artery,
which when present usually arises from the innominate trunk, but
sometimes from the right common carotid or the aorta: it passes to the
thyroid body directly in the median line of the neck and close to the
trachea; again, the place of the anterior jugular veins may be taken by
a single central vessel, almost sure to be wounded during the operation
if it exist (Mackenzie).
In performing the operation through the thyro-cricoid membrane
(thyro-cricotomy) or through the cricoid cartilage alone (cricotomy),
the same tissues are met with, and the same dissection is necessary in
the earlier stage of the operation, as have been described in the
operation of superior or inferior tracheotomy; but the parts are more
superficial, adipose and cellular tissue less abundant, blood-vessels
much less numerous, and the operation very much simpler. The thyroid
gland of course does not come into view, {148} and the crico-thyroid
artery, a very small vessel, needs no attention in the dissection.
I have here and elsewhere included under the general term tracheotomy
five distinct operations, having for their object the opening of the
air-passages, which are surgically possible between the lower border of
the thyroid cartilage and the upper edge of the sternum. In this
classification I have followed that of Schüller, and its simplicity,
but exactness, and the avoidance of the old confusion of different
terms which results from the use of one intelligently employed, seem to
me to commend it. These five operations are--1. Thyro-cricotomy, or the
opening made through the crico-thyroid membrane alone. 2. Cricotomy, or
the division of the cricoid cartilage alone. 3. Superior tracheotomy,
the incision being made above the point where the isthmus of the
thyroid gland crosses the trachea and below the cricoid cartilage. 4.
Median tracheotomy, when, the isthmus being displaced or torn through,
the trachea is opened immediately below its site. And 5. Inferior
tracheotomy, the incision being made below the point of crossing of the
isthmus of the thyroid gland, and at varying distances, dependent
mainly upon the age of the patient and size of the parts, above the
sternal notch.
Rarely, I am bound to admit, is the field of all of these operations as
distinctly limited in practice as is here indicated, and one, perhaps
two, are rarely selected. Thyro-cricotomy (old term laryngotomy) is
often indicated, and cricotomy and median tracheotomy are sometimes
performed as here described. Superior tracheotomy is commonly a
combination of at least two of the methods--viz. the division of the
upper rings of the trachea and the cricoid cartilage as well. It may
even, probably frequently does, trench also upon the thyro-cricoid
membrane (thyro-cricotomy) and upon the field of a median tracheotomy,
the isthmus being pushed downward or even cut or torn through. The
latter operation and cricotomy are, I believe, rarely if ever done from
choice. Finally, inferior tracheotomy is a common method. As here
described, it meets a large number of indications, and, despite its
superior difficulties over the higher operations, is therefore
necessarily often chosen; not infrequently, however, does it invade the
median region, the isthmus of the thyroid being pushed upward.
Which of these operations shall be selected in a given case depends
upon the particular conditions which render it necessary, and likewise,
to some extent, upon the age of the patient. Durham summarizes the
question very fairly. Thyro-cricotomy (old term laryngotomy) is by far
the easiest operation to perform, and its execution is attended by
least risk; therefore it is the operation to be preferred in any sudden
emergency when suffocation threatens, and especially where the surgeon
is alone with the patient. Generally, it is not as applicable as the
others, especially in early childhood, on account of the limited
dimensions of the thyro-cricoid space. It cannot be recommended in
cases of acute or extensive diseases or injuries of the larynx, nor is
it likely to be of much service if a foreign body is in the trachea or
bronchus. On the other hand, it is probably the best operation to adopt
in cases in which foreign bodies are impacted in the larynx, in cases
of limited chronic disease or contractions of the superior laryngeal
parts--usually the result of syphilitic ulceration--and in cases in
which respiration is impeded by intra-laryngeal growths which cannot be
removed by the natural passages.
Cricotomy, combined with superior tracheotomy (old term
laryngo-tracheotomy), is not a difficult operation, and may be
advantageously practised, especially in children; in the adult it meets
many indications. Holmes recommends it the more urgently, in preference
to an inferior tracheotomy, the earlier the age of the subject may be.
Inferior tracheotomy is comparatively difficult to perform, and during
its performance dangers may have to be encountered greater and more
numerous {149} than those met with in either of the other operations.
This is true certainly of children. As regards young children, Holmes
states that after the age of five or thereabouts the surgeon can, if he
prefer it, open the trachea below the isthmus of the thyroid gland. He
himself does not recommend the operation before puberty. In the case,
however, of a foreign body loose in the windpipe of a child, where a
large opening is required, it can hardly be obtained above the thyroid
body and below the cricoid. To cut through the isthmus of the thyroid
(median tracheotomy) is, in early life at least, a doubtful proceeding
when it is of large size, on account of its vascularity, and the
incision must be made below it--in other words, an inferior
tracheotomy.
When the operation of tracheotomy shall be performed is a question
which the experience and individual views of the surgeon, based on
experience, must decide in each case. The doubt always arises in the
mind of the inexperienced operator whether the symptoms are
sufficiently urgent to render the operation necessary. To him these
general rules may be given: The immediate indication for the operation
is to be looked for in the thorax. It is the recession of the lower
part of the sternum and contiguous ribs and the retraction of the
intercostal spaces and clavicular fossæ at each act of inspiration. He
must not wait until lividity of the lips and blueness of the
fingernails prove that the blood is being imperfectly oxygenated
(Mackenzie). Let him remember also that, aside from the immediate and
imminent danger of sudden suffocation, a remote one exists and
increases the longer he postpones his operation and allows the struggle
for air to continue--viz. vascular engorgement and oedema of the lungs,
especially in young children; the production of all those conditions
which allow, and even predispose, the lung after the operation to fall
an easy prey to the inflammatory processes.
The instruments necessary for the performance of the operation of
tracheotomy are few and simple, and are such as may ordinarily be found
in any small operating-case. A scalpel, a probe and sharp-pointed
bistoury, dissecting and artery forceps, a tenaculum, a grooved
director, two small retractors, scissors, and a dilator for the
tracheal wound, are necessary. To these may be added the needles and
thread, waxed ligatures, sponges, and tape. The tracheal tube is
elsewhere described. A faradic battery, good suction syringe, and a
large flexible catheter may render good and timely service if at hand.
It is true that many other and more or less complicated instruments
have been devised for the purpose of facilitating the operation; and
other methods, aside from that of the knife, have come of recent years
into vogue; but, still, simplest means, as above given, have in the
experience of most surgeons been proven to be the best. This statement,
undeniably true for all surgical measures, is especially so for the
operation under consideration, which is often necessarily undertaken
without opportunity for elaborate preparation and under the most
adverse and inconvenient circumstances. The more familiar, therefore,
the surgeon is with his instruments, the better and more certain will
be his work.
Holding this view, it is unnecessary for me to more than briefly
mention such instrumental aids as the grooved tenaculum of Chassaignac,
the groove serving to guide the operator's knife into the trachea; the
sharp double hooks of Langenbeck, which, after being caught in the
tracheal walls to either side of the site of the intended incision, are
sprung apart after the latter is made, thus dilating the wound and
rendering the introduction of the tube easy; the tracheotome of
Thompson, a pair of curved cutting forceps, the blades of which are
caused to open by a screw after they have been plunged through the
tracheal walls; that of Garin, a forceps with curved blades--one, the
longest and sharpest-pointed, being made to penetrate the trachea, the
instrument then opened, and both blades cut their way to the desired
extent of {150} incision; finally, the tracheotome of Maisonneuve, a
curved dilating hook with cutting inner edges. Its point is entered
between the first and second rings of the trachea and brought out again
between the fourth and fifth; the handle is then carried under the
chin, so that the blades are made to cut through the trachea and the
skin between the points of insertion and exit, after which, upon
pushing a spring, the two halves of the hook separate, and the canula
is introduced between them (Thornton). And the trachea-stretcher of
Marshall Hall, by means of which a portion of the trachea is cut out
and the opening kept patent.
None of these instruments have been proven to possess any practical
worth; on the contrary, their use, especially that of the latter forms,
has in more than one instance been attended with disastrous results.
To obviate the danger of serious hemorrhage during the performance of
tracheotomy, both the galvano-cautery knife and the thermo-cautery
instrument of Paquelin have been recommended within the past few years,
and a number of operations placed upon record. The procedure is the
same whichever means be used. The skin and soft parts overlying the
trachea are usually alone cut through by means of the cautery-knife,
the cartilaginous rings of the tube, when reached, being divided with
the ordinary knife. This fact alone speaks against the thoroughness
attainable by means of these methods; but, still more important,
neither has been found reliable in checking hemorrhage, and in several
instances the operator has been obliged in haste to lay aside his
cautery apparatus and turn to the ordinary and better-known means to
complete his operation. The healing of the tracheal wound made by the
cautery is slow: erysipelatous inflammation may attack the wound as the
result of the burn, and extensive sloughing of the edges is not
unknown, while the resulting cicatrix is large, strong, and
contractile, and has caused, in one case at least, a stenosis of the
trachea. In the face of these facts he must indeed be an enthusiastic
advocate who would recommend the procedure. Mackenzie justly remarks
that the use of the thermo-cautery for opening the air-passage merely
introduces an unnecessary complication into the operation.
The choice of a proper tube, one suited to meet the special indications
in a given case and specially adapted to the age of the patient and the
calibre and position of his trachea, is no unimportant matter, and may
do much not only to facilitate the immediate success of the operation,
but likewise prevent the occurrence of those possible unfortunate
results, ulceration, fatal hemorrhage, abscess, pneumonia, and pyæmia,
no lack of which are recorded in our literature.
Although the number and variety of mechanical devices and forms of
tracheal tubes that have from time to time been devised by the
inventive ingenuity of operators is large, the choice practically
centres upon one of two forms. The first, and the one most commonly
used, is but the original canula of Trousseau, modified by Roger, in
that the tracheal portion of the tube is detached from the collar or
neck-piece, and moves freely with the movements of the patient; and by
Obré, by the important device of an inner tube to prevent clogging of
the outer or original tube by mucus. Starting upon this essential
basis, the instrument-maker has perfected the instrument of to-day. It
is a silver tube, double throughout, the inner tube projecting at the
lower or tracheal end beyond the outer--an important point, as it
prevents any possible permanent occlusion by mucus or blood-crusts,
membranes, and the like at this point, removal of the inner tube at
once clearing the end of the outer one. The curve of both tubes should
correspond to the arc of a quadrant, and the outer is fastened to a
transverse collar or shield by means of two small projections or pins
upon its sides which lie under small wire bridges upon the shield after
it has passed through an opening in the {151} transverse neck-collar
large enough to permit of its free movement during the respiratory
movements of the trachea, as well as during the forcible action caused
by cough. The ends of this collar or shield curve slightly backward to
correspond with the curve of the neck, and are perforated by,
preferably, large oval openings, instead of the usual small,
inconvenient slit, through which the tapes are passed which hold the
tube in position by encircling the neck. To this same shield is
fastened, by means of a small turn-screw or a revolving collar, the end
of the inner tube, which is thus prevented from being forced out of the
outer tube by coughing or any motion of the patient. Upon the upper or
convex surface of the outer tube a small ovoid opening is usually made
for the purpose of permitting the expiratory current to pass upward
(the inner tube being removed) into the larynx and render phonation
possible; also, the free opening of the outer tube being closed, to
allow of respiration being carried on through the larynx and natural
passages--often an important matter, as the case progresses toward
recovery, in instances where the operation of tracheotomy has been
performed on account of laryngeal obstruction.
A set of these tubes, which can now be readily obtained, should consist
of four, with the following diameters: No. 1, one centimeter; No. 2,
nine millimeters; No. 3, seven millimeters; No. 4, five millimeters:
their length is of course in relative and fixed proportion to these
measurements. A tube should always be selected less in diameter than
the trachea operated upon: to seek to introduce one of the same calibre
is not only unnecessary, but cannot fail to be dangerous. Tubes
constructed upon the same principles as that just described (Lüer's)
are made of hard rubber instead of silver (Leiter): their lessened cost
is their principal recommendation, added to the one that they are more
easily kept clean and sweet than the silver tubes. The fact that they
are necessarily made much heavier and thicker than the latter is a
disadvantage, the lumen of a hard-rubber tube being smaller than that
of a silver tube of corresponding external diameter. The objection
urged against them, of their great danger of breakage, I have not found
borne out by experience. Tracheal tubes are also constructed of
platinum, and recommend themselves on the score of lightness.
The main objection to any of the forms of tube just described exists in
the nature and shape of their curve, which not infrequently causes the
lower or tracheal end to lie in contact with the anterior tracheal
wall, or its convexity with the posterior, and irritate, even ulcerate,
them. This misfortune is entirely obviated by the canula of Durham, the
second of the two forms to which I have called special attention, and
which is essentially a right-angled tube, made of four sizes, with a
long horizontal portion, varying from 7 to 4 centimeters, and short
vertical portion, of from ½ to ¾ of an inch in length and slanting
slightly backward. The former portion is capable of being lengthened or
shortened in any sized tube by means of a screw arrangement attached to
it as it passes through the usual neck-collar or shield; and the
vertical tube can thus be correctly adapted to the particular depth at
which the trachea naturally lies in a given case from the surface; and
not alone this, but also to the condition of the overlying parts,
whether thin or fat, swollen or otherwise. Once in position, the
vertical portion of the tube remains in the long axis of the trachea,
and does not touch its walls to any injurious degree. Owing to its
right-angled shape, the angular and descending portions of the inner
tube of this canula are necessarily made upon the lobster-tail
principle, with joints--a possible disadvantage, as they can become
clogged with mucus and may become detached. Other modifications and
improvements exist in this Durham canula over the older one first
described, which add to its utility, but need not here be dwelt upon.
Suffice it to say that the tube is an excellent one for its purpose,
and is deservedly highly {152} spoken of and recommended by those who
have had experience in its use. Its cost is an objection.
The other forms of tracheal tube need but passing mention. The bivalve
canula of Fuller is made in two lateral segments, fastened to a collar
and tapering when closed to a point, so that introduction of the
apparatus through the tracheal wound is made easy. Once introduced, an
inner complete canula is slid into its place, thus separating the two
outer halves and rendering the whole round and compact. It has been
criticised unfavorably on account of the danger of hemorrhage that it
is likely to cause through pressure on the tracheal walls by the sharp
edges of the outer canula. In Gendron's canula the same lateral blades
are separated after introduction by means of a screw fastened on a
transverse bar.
Soft-rubber canulas were introduced to the profession not long since by
Morrant Baker for subsequent use after the operation of tracheotomy,
the usual tube having been worn meanwhile for a few days. Being soft
and flexible, they are certainly safe and comfortable for the patient,
but their thickness and the absence of any inner tube are, especially
the latter, serious disadvantages. They are not, I believe, generally
used. Finally, the long, flexible tracheal tube of König was devised by
its author to meet the indications in cases where the trachea is
compressed from without by tumors, and where a long canula that is
flexible, but at the same time rigid enough to resist pressure, becomes
a necessity. It is made in the form of the ordinary tracheal canula,
only larger, some three or more inches of the centre of the descending
portion of the tube being constructed of spirally-twisted silver wire.
It may not be out of place to remind at this point that a tracheotomy
is not infrequently performed, of necessity, very hastily, and in the
absence not only of a tracheal tube, but likewise of other and even
more essential instruments. The lack of the former need never be a
barrier to the prompt performance of the operation, for the ready wit
of the true surgeon will show him various ways out of his temporary
difficulty. A thick goosequill fastened by threads passed through its
outer end makes an efficient improvised canula. A bit of elastic
catheter answers the same purpose. Retractors for the edges of the
tracheal wound, made of wire--silver if it be at hand, a couple of
hairpins if it be not--and connected together by an elastic tape which
passes around the neck, will not only answer a good temporary purpose
in holding the tracheal wound dilated, but have been recommended by
Martin--in a more elegant form, it is true--as a proper method of
treatment after opening the trachea. Finally, one or more stitches
passed through the cartilaginous edges of the wound, and attached to
the soft parts beyond it, will serve to secure its patency, at least
temporarily.
If a patient be doomed to wear a tube constantly in his trachea, the
instrument described above can be removed at a suitable interval after
the operation and its place supplied by a single tube of the same size
and form as has been found adapted in the case. In the convexity of
this permanent tube an ovoid opening should be made to allow of the
passage to the larynx of the respiratory current, in part at least, and
to its mouth a pea-valve may be fitted which shall admit air on
inspiration, and not allow it to escape on expiration, thus doing away
with the necessity of the patient's closing the opening of his tube
with his finger each time that he requires to speak. Several forms of
these valves have been devised, but practically they are of little use,
are annoying to the patients, and, as a rule, not tolerated by them.
How shall the operation of tracheotomy be performed? An answer to this
question necessitates a short description of the operative steps of the
different procedures that is given in the order in which, I believe,
the operations are, as a matter of experience, found to occur in
practice--viz. 1st, superior {153} tracheotomy, combined or not with
cricotomy; 2d, thyro-cricotomy and, 3d, inferior tracheotomy. Certain
preliminaries are common to all.