thicknesses of blanket and of suitable height, which has been placed
sideways in front of a window if the operation is done by daylight. (At
night several candles tied together afford a better and safer light
than a kerosene or oil lamp.) The surgeon stands at the right side of
his patient and facing the window. Of his two assistants--and the value
of trained assistance in this operation is inestimable--one faces him,
without obscuring the light, and is prepared to use the sponges, hand
the instruments, manipulate the retractors, and render such direct
assistance as may be required. The second sits at the head of the table
and holds the head of the patient steadily, the neck being well
extended and thrown backward over a small round pillow (or, better, a
wine-bottle wrapped in a towel) which has been placed beneath it. The
head must be held directly in the median line of the patient's body,
and even in that of the operating-table. The assistant's attention must
never waver from this important duty. In certain cases too great
inclination of the head backward serves to increase the urgent
dyspnoea, or even to check respiratory efforts. This effect he must
watch for, and be prepared to relieve instantly by raising the head.
His duties also include the preliminary administration of an
anæsthetic, and its use during the operation if required. That such use
is safe in this class of operations is now generally admitted, but it
is not always necessary. The operation is not an exceedingly painful
one, and I have often performed it, with the adult patient's consent,
without using any anæsthetic (sometimes freezing the skin over the site
of the incision before making it), he submitting rather than undergo
any addition to the sense of urgent dyspnoea from which he is already
suffering. In children anæsthetics--ether being more commonly employed,
although chloroform is often used--are much more necessary, often
indispensable. Their effects are speedily manifested when asphyxia is
present in any marked degree, and but little of the vapor need be
inhaled. The administration, always to be carefully watched and
profound anæsthesia avoided, renders breathing easier in many
instances, certainly lessens laryngeal spasm, and may be discontinued
early in the operation when the air-tube is or has been nearly reached
by dissection. Any slight risk attending their use is more than
outweighed by the safety and precision which they ensure in the more
difficult and delicate steps of the operation (Sands). If the patient
be already insensible or if death be imminent, their use, of course, is
contraindicated.
The operator having previously decided which operation he will perform,
and after carefully identifying the position of the various parts, the
larynx especially, marking them with ink upon the skin if he chooses,
now steadies the loose skin over the site of his intended incision, and
then makes it, freely, firmly, cleanly, and exactly in the median line.
If it be for a superior tracheotomy, combined or not with cricotomy,
the operation I shall first describe, it must extend from just at the
notch of the thyroid cartilage downward for about four inches. A free
external incision is very desirable in all cases. The subcutaneous
tissue now rapidly dissected through by the careful use of the knife,
the veins as met with either being pushed to one side or, if they cross
the line of incision, cut if small, then twisted or immediately
ligated, or if large doubly ligated and then cut between the ligatures,
the interval between the sterno-hyoid muscles is sought for and found,
then separated by the blade or handle of the knife and held apart by
retractors at the side of the wound. It is important that the faint
whitish line of connective tissue which marks the interval between the
muscles be recognized, otherwise it happens that the operator passes
through the body of one of them, deviates at once from the median line,
and approaches the side of the trachea {154} instead of the front. The
ring of the cricoid cartilage above and the upper edge of the isthmus
of the thyroid gland below can now be either seen or felt by the finger
in the wound between them; and about the latter lies more or less
connective tissue and numerous small veins. As a rule, careful touches
of the point of the knife, or, as some operators prefer at this stage,
its handle or the use of a blunt director, serves to dissect up
piecemeal or tear through and clear this away, the veins again being
pushed out of the way, or if necessary cut and tied, and all parts held
aside by removing and replacing freshly the retractors from time to
time as the dissection proceeds, until the ring of the cricoid and the
upper rings of the trachea come plainly into view; that is, are seen,
not alone felt. During this dissection, especially if the handle of the
scalpel be used, too much pressure must not be made upon the trachea.
More than once I have known it to cause sudden suspension of the
respiration, probably by exciting reflex spasm of the larynx. If the
isthmus of the thyroid gland extend far upward, it must be pressed
downward, its facial attachments to the cricoid and trachea cut or torn
through, and may require to be held downward in the lower angle of the
wound by an additional retractor. The upper rings of the trachea having
been thus well cleared of their overlying parts, the next step of the
operation follows. I am in the habit of now removing the retractors and
allowing the trachea, which may have become displaced by them, to
resume its normal position, the head of the patient being meanwhile
readjusted. All this takes but a few seconds. A tenaculum is then
implanted in the median line, either just below the edge of the thyroid
or the cricoid cartilage, if the latter is not to be severed, and held
firmly by the assistant at the head of the table, thus steadying and
elevating slightly the trachea and rendering the incision into it
certain. The retractors are now reintroduced at the sides of the wound,
and the operative field is clear and steady. A glance having shown that
all bleeding has ceased, another that the tracheal dilator and
tracheotomy-tube lie ready at hand, the operator plunges a
straight-pointed bistoury through the tracheal wall at the level of the
third or fourth ring in the median line, and cuts quickly upward until
the cricoid cartilage is reached, if he proposes, as in the adult can
usually be done, to limit his operation to a superior tracheotomy. If
not, as in the child, and the cricoid cartilage must be cut through to
gain sufficient space for the introduction of the tube, it also is
severed by prolonging the incision upward to the thyro-cricoid
membrane. A hissing of escaping air, with the bubbling of a little
blood and paroxysms of cough, follows the incision and shows that the
trachea has been fairly opened. The tracheal dilator is now introduced,
the lips of the tracheal wound separated, and the canula slipped neatly
into the windpipe (unless in the case of a foreign body), and secured a
moment or two later, when respiration is fairly established, by tapes
passing around the neck. The tenaculum and retractors are removed at
the same moment that the tube is slipped into place.
Many different methods have been recommended for the dilatation of the
tracheal wound and to assist the introduction of the canula. The
dilator (Trousseau) which has been mentioned surely answers all
purposes, and is simple and easily used. An ordinary dressing forceps
will likewise do the work if introduced closed and afterward opened.
More complicated procedures are unnecessary.
Thyro-cricotomy requires that the superficial incision be so made over
the larynx that the thyro-cricoid space shall lie in the centre of one,
about two inches long, made in the median line. Following now the
dissection just described, the thyro-cricoid membrane is easily reached
and quickly seen as soon as the sterno-hyoid muscles are retracted. It
should then be divided transversely close below the lower edge of the
thyroid cartilage, the wound dilated, and the tracheotomy-tube slipped
into place.
{155} Inferior tracheotomy demands that the external incision be free.
In children, and in adults with a short neck, it should extend from the
cricoid cartilage to just above the sternum. The subsequent steps of
the operation are as for superior tracheotomy, with but slight
differences. The anterior jugular veins may come into view, but can
generally be avoided. If they are joined by a transverse branch, this
is necessarily cut through after being doubly ligated. After the
thyro-hyoid muscles are separated, the rings of the trachea are much
less distinctly felt at first than in superior tracheotomy, being
covered by more connective tissue and numerous veins. These inferior
thyroid veins, especially if large, are the great obstacle in the way
of this operation, and much care is necessary in order to avoid them,
which should be done if possible. The lower edge of the isthmus of the
thyroid gland, which presents to a variable extent above in the wound,
does not, as a rule, offer any obstruction. The thymus gland present in
infants is easily pulled downward and out of the way. The trachea at
length fairly exposed and all bleeding controlled, the left fore finger
of the operator is placed in the lower angle of the wound to securely
protect the large blood-vessels here located, and the incision made
through some three tracheal rings from below upward.
It may happen that in either a superior or inferior tracheotomy no time
will be allowed for careful and slow dissection as here described. In
such instances Durham advises that the surgeon grasp the trachea
between the fore finger of his left hand on the left side and the thumb
on the right, and make uniform, steady, deep pressure, thus firmly
securing it and at the same time protecting the large vessels of the
neck. The fingers thus placed are not to be moved until the trachea is
reached, which is accomplished by rapid incisions confidently made. The
pressure of the fingers causes the wound to gape and the trachea to
advance. The latter reached, it is caught by the tenaculum and the
operation completed as before described.
The operation of median tracheotomy may require a word. As has been
stated, that part of the trachea covered by the isthmus of the thyroid
gland is very commonly encroached upon in performing either or both
superior and inferior tracheotomy, the isthmus being slightly displaced
from its site. Other than this the site here mentioned would rarely be
selected as the point for opening the trachea. Certain conditions, it
is true, might render it necessary, but they would be rare. The danger
lies in the hemorrhage which, theoretically at least, is to be expected
when the isthmus of the thyroid gland is either torn or cut through;
but opinions vary very greatly as regards this danger. With a thin,
narrow isthmus in children I have frequently, in performing superior
tracheotomy, cut my way through to a sufficient extent to clear a
suitable space upon the trachea through which to introduce a tube
without difficulty or danger. I should not recommend the procedure,
however, were the isthmus to be seen to be, when reached, thick, wide,
and exceedingly vascular, but at the same time believe that the danger
even here of cutting into it is much overestimated.[3] Roser's
recommendation to apply a ligature to the isthmus on either side of the
median line previous to its division is not generally applicable.
Hueter has shown that the fibrous capsule of the thyroid gland
enclosing it and its blood-vessels is firmly attached to the trachea
and sides of the larynx, and that from the isthmus this fascia extends
upward over the larynx (fascia laryngo-thyroidea), and thus prevents,
in a measure, attempts at displacing the gland downward. Bose[4]
recommends that this fascia be divided transversely over the anterior
convexity of the cricoid cartilage, when a director can be passed
behind the isthmus, to lift it from the trachea and depress it far
enough to expose three or four of the {156} rings: the capsule of the
gland thus remains unbroken and no hemorrhage occurs. The procedure
certainly merits trial; twice it has succeeded well in my hands.
[Footnote 3: See Foulis, "Some Points on Tracheotomy," _Glasgow Med.
Journ._, vol. xv. No. 2, p. 123.]
[Footnote 4: _Archiv für klin. Chirurgie_, vol. xiv. p. 137.]
Cricotomy, the division of the cricoid cartilage alone, is an operation
which, as far as I am aware, is rarely ever performed. The objection
urged against it, however, that in the adult the elasticity of the
cricoid cartilage is so great that a wound through its ring cannot be
made to gape sufficiently to allow of the introduction and retention of
a canula without discomfort and danger of necrosis of the cartilage, is
not borne out by experience. In children the objection cannot of course
be urged.
The description of the operative steps which has been given, and which
comprises the routine in an ordinary and easy cure, should not mislead.
The operation is not always as simple and safe as would appear from
what has been said. At times complicated and difficult, at times
dangerous in practice from the delay involved, it demands in all, but
especially in certain urgent cases, a trained hand and eye, sound
anatomical knowledge, coolness, self-reliance and presence of mind on
the part of the operator. Despite the greatest caution, and even in
apparently favorable cases where time for dissection and deliberation
is allowed, certain mishaps may occur which complicate the operation to
a serious, dangerous, or even fatal degree. Some of these, as will be
seen, are avoidable with care, but others may happen that are not only
unavoidable, but totally unforeseen, and from their very suddenness all
the more embarrassing.
Accidents may occur during the dissection of the soft parts overlying
the larynx and trachea, and the importance of carefully determining by
palpation the location of the various parts prior to making the
preliminary incision, and of studiously preserving their relation and
location during the dissection, cannot be overestimated. Neglect of
this precaution has in more than one instance led to the air-passages
being opened through the thyroid cartilage or thyro-hyoid membrane,
instead of at the intended point. It should not be forgotten also that
the natural laxity of the several layers of connective tissue of the
neck is much increased by their division, and that the trachea, being
naturally freely movable, is thus very easily displaced from its normal
position during the act of dissection; especially will this happen when
unskilful attempts are made to hook aside or retract the divided
structures during the operation. Thus it may easily occur that the
entire trachea is drawn to one side and entirely lost, or, more
commonly, is turned upon its vertical axis, and finally opened at the
side instead of anteriorly in the median line. It may not be opened at
all, either being altogether missed by the surgeon in his dissection,
which is continued past it, even down to the vertebral column, or the
tracheal tube may be passed into the tissues lying in front of the
trachea, under the mistaken idea that the latter has been incised.
Persistence in keeping to the median line during dissection--a golden
rule in the operation of tracheotomy--will render the first accident
impossible; the second may be avoided by hooking up the trachea, as has
been described, before incising it. If the opening into the trachea has
not been made large enough to receive the tube, as often happens to the
young operator, and even to the experienced when he fears to extend his
incision on account of the proximity of the thyroid isthmus, no
resource remains but to carefully enlarge it, pushing the thyroid
isthmus or veins from before the course of the knife. If the opening be
small, and be lost both to touch and sight, a second should at once be
made, especially in urgent cases, and no time lost in searching for the
first. This opening must be made directly in the median line, otherwise
the canula will stand awry in the wound and be easily dislodged from
its position in the trachea. If the first opening made is faulty in
this respect, it is better to at once make a second. It may seem
unnecessary to {157} warn the surgeon against thrusting his
sharp-pointed bistoury too far inward at the moment of incising the
trachea; but as a matter of fact it has been driven through both
anterior and posterior walls, and even through the oesophagus, until it
has struck the spine. The converse, or a too superficial incision, is
an accident more likely to occur, the point of the knife not being made
to penetrate the mucous membrane of the trachea, which is probably
swollen and thickened. No relief in such cases follows the incision,
and an attempt to introduce a tracheal tube may cause it to pass
between the mucous membrane and tracheal walls into the submucous
tissue, thus stopping up the tube as it progresses. The disastrous
result of such an accident can readily be foreseen unless the
complication be quickly appreciated as to its nature, the tube
withdrawn, and the incision completed. Much more frequently will a
somewhat similar accident occur in the operation of tracheotomy for
croup or diphtheria. The pseudo-membrane overlying the walls of the
air-passage is not penetrated, but pushed before the knife, which has
properly incised the walls of the tube; the introduction of the canula
now crowds this membrane still farther back toward the posterior
tracheal wall, and a complete tracheal stenosis is added to the
pre-existing laryngeal one; sudden and urgent dyspnoea follows, and
prompt relief alone wards off fatal suffocation. Fortunately, in such
instances the forcible efforts at respiration and struggles of the
patient are often sufficient to break through the occluding membrane
and allow the respiratory current to pass. Violent cough often follows,
and more or less of the membrane is forced out through the tube. Should
these events not come instantly to pass, the surgeon must not wait for
the efforts of the patient, he being often cyanosed and unconscious at
this point, but by passing an elastic catheter down through the
tracheal tube break through the occluding membrane forcibly. The
occurrence of such an accident is always denoted by absence of
respiration through the canula and by alarming asphyxia, and its cause
needs but little reflection to be appreciated.
Much the same train of events happens if during the introduction of the
canula large portions of the false membrane are completely detached and
drawn down into the lower trachea by the violent inspiratory efforts of
the patient, or stripped up from the mucous membrane and pushed
downward into the air-tube. No time should be lost in either case in
removing the tracheal tube, dilating the tracheal wound by forceps or
otherwise, and in endeavoring to clear the trachea by seizing the
obstructing membrane with forceps. If this be unavailing, the
suction-syringe must be adapted to the mouth of the canula and the
trachea cleared by aspiration. A large elastic catheter may take the
place of the canula. Sands recommends in such instances as the
foregoing that another opening should be freely made below the first
one in the trachea, when respiration will probably be re-established.
The success of this procedure of course depends upon the depth to which
the false membrane has been drawn in the trachea.
Schüller regards the moment at which the trachea is opened as the most
important and most dangerous of the whole operation. Certain of the
accidents which may occur at this period have been detailed; others
remain to be spoken of, one of which at least--viz.
hemorrhage--requires special mention. Even before the tube is cut into
it may cause an important question to arise for the surgeon's decision.
A bleeding, often copious and persistent, which arises during the
course of the operation from the accidental or unavoidable wounding of
the thyroid veins, especially when they are large and numerous, the
patient unruly, and perhaps with a short fat neck, and the fact that
having wounded one the blood flows so over the parts as to obscure and
increase the chance of wounding others, constitutes one of the
commonest difficulties met with in the operation of tracheotomy.
Hemorrhage arising from a wound of the thyroid isthmus is much rarer,
and neither, as a rule, need be {158} feared if due care and
promptitude be exercised. But should it occur in a case in which the
urgency of the dyspnoea allows of no time in which to employ the
ordinary methods by ligature, torsion, pressure, or otherwise of
checking it, shall the incision be made and the risk boldly incurred of
blood passing to a dangerous degree into the trachea, and this in the
face of the oft-repeated advice--the, in some quarters, absolutely
given rule--that the trachea is never to be opened until all hemorrhage
has ceased? I hold that it unquestionably should be, and that he who
waits in many instances until the former moment will have to wait until
his patient is dead. Durham truly says that it is useless to let the
patient die from suffocation while attempting to prevent death from
loss of blood; and yet this has been done.
In any case, then, where there is great venous congestion, marked
venous bleeding, and little time, the patient being on the point of
suffocation, the surgeon should carefully but boldly proceed and
complete his operation in spite of the hemorrhage, opening the trachea
and introducing the canula even though the entire field of his
operation be obscured by blood. The tracheal opening once made under
such circumstances, the patient, if the blood which enters the windpipe
be not coughed up again, may be turned upon his face, so that the blood
will gravitate toward the tracheal opening and the lips of the latter
compressed about the rigid tube; or the blood may be aspirated from the
trachea by means of the suction-syringe through an elastic catheter in
the wound or the tracheotomy-tube by the operator's mouth, according to
the urgency of the case. These measures answer for the slighter cases,
but where the patient has suffered from urgent impending suffocation
before the opening of the trachea, the entrance of the blood and its
suction downward by the first inspiration may make it complete, and the
danger is great. Still, the choice lies between the two evils, and the
advice given above holds good. To the treatment there recommended will
now have probably to be added artificial respiration and faradization.
Comfort in any case may be taken in the fact that the re-establishment
of respiration through the tracheotomy wound quickly relieves the
pulmonary capillaries and the right heart of their distension, the
venous circulation resumes its natural course, and the venous bleeding,
perhaps alarmingly free, ceases almost immediately or is readily
checked by pressure.
Where time is afforded and despatch in the operation is not a
necessity, the trachea should not be opened until all hemorrhage has
ceased. This, as a rule, is readily controlled by the usual measures,
and in a large percentage of operations is not excessive. A direct
fatal hemorrhage is very rare; likewise an arterial hemorrhage of any
extent, especially if the possible anomalous position of certain
arteries, such as the thyroidea ima, be borne in mind and care in
making the incision exercised. Nothing but gross carelessness on the
part of the surgeon and entire loss of presence of mind can account for
the opening of the carotid or innominate arteries, as has been done.
During the performance of the low operation of tracheotomy the finger
of the operator must more or less frequently be pressed into the lower
angle of the wound, and his anatomical sense constantly on the alert.
The entrance of air into a vein during the operation is a possible
accident, especially when it is much enlarged and imbedded in dense
tissue, as sometimes occurs in malignant disease of the throat or when
large tumors of the parts exist. Should such an unfortunate
complication occur, the proper treatment, according to Erichsen, should
be compression of the wounded vein with the finger and its immediate
ligation if possible; compression of the axillary and femoral arteries
and a recumbent position for the patient to favor cerebral circulation;
and, lastly, artificial respiration.
At the moment of opening the windpipe two conditions may suddenly {159}
supervene, both of which need, as may usually be easily done,
differentiation from the asphyxia produced by the entrance of blood
into the trachea. The first of these is the apnoea which not
unfrequently arises in children suffering from urgent dyspnoea the
moment that a free opening is made and the air-stream rushes unimpeded
into the lungs. The condition lasts but a moment or two, and need
excite no alarm. The second is based upon the fact that the operation
itself not seldom excites an alarming asphyxia, probably by provoking
laryngeal spasm. The introduction of the tube serves to promptly
relieve it.
Finally, I may refer to those rare but unfortunate and unpreventable
cases where the introduction of a tracheotomy-tube after a carefully
conducted operation fails to give relief. Such instances are reported
by several authors, and depend upon the existence of some unascertained
pathological lesion, such as the presence of a stricture of the trachea
below the site of the operation, compression of this tube from without
or a tumor within, stricture of the primary bronchi, or some similar
condition. A careful preliminary examination and study of the case will
in the majority of instances do much to fix the indications for the
operation and perhaps account for the surgeon's failure.