By CHARLES DUFFY, SR., M. D., Catherine Lake, N. C.
Read before the Onslow County Medical Society, September, 1878.
_Gentlemen of the Onslow County Medical Society:—_
I was written to sometime ago, by a member of the State Medical Society,
asking my views in regard to operating on the windpipe. My experience in
such operation has been very limited, six times being the maximum of my
labors in that direction. My first was a failure, done for the relief of
cynanche trachealis, the operation being performed too late.
The other five cases succeeded admirably; four of the patients ranging
from eight months to three years old, the other a woman of middle age.
The first of these cases was operated on for the removal of a watermelon
seed. The child was less than 2½ years old, and was very fat, so much so
that the depth from the surface, would seem to forbid approach to the
external surface of the trachea, still less to the internal, but by
patience and perseverance these difficulties were both overcome, and
respiration rendered comparatively easy. The next idea, was to get out
the seed, and one attempt after another was made to no purpose, the
wound inclined to close at the same time. I next lengthened the
incision, and the sides of the wound were well drawn apart. My next step
was to trim off the sides or edges of the cartilages; this being done,
gave the seed a fine opportunity to present itself, and the child was
placed in a cradle and diligently watched, with orders to take him in
the arms and walk about with him, in case of difficulty of breathing
coming on, which had to be done from time to time. The seed was expelled
through the aperture to our great joy and gratification, several hours
after the last step of the operation. The child was a son of Mr. Thomas
Holland, of this county. He grew to adult age, and was killed by a horse
running away.
From this case I learned that the removal of foreign substances by
forceps or other instruments, except they are metallic substances is
seldom necessary, there would be much more difficulty in retaining them
or preventing their escape. As soon as the windpipe is cut into there is
a rush of wind that follows, that moves the substance by the double
ability or means of respiration, caused or provided by the operation,
and the next we know the substance is expelled. Certain it is, it is not
going to stay there, if there is room for its escape and the patient is
rightly attended to. When certain that all has come away, apply adhesive
plaster drawing the parts together, a stitch or two might be necessary
in some cases, it soon gets well.
My next case was the woman alluded to, the wife of Mr. Amos Wooten, of
New Hanover county. A piece of beef gristle got into the wrong passage.
After several spasms, and vain attempts to get it out she sent for me. I
got to her as soon as possible—the distance being sixteen or seventeen
miles. On enquiry I learned the particulars of her case. I found her
composed. I told her it might not be in the windpipe, and we had better
be certain about it. I passed a probang down the œsophagus and found
that it was not there. After waiting a little longer, she had a violent
spasm that hurried and increased her determination to have it out. So
violent was the spasm, that it created doubts on her mind as to her
chances of living, or of being able to bear up under the operation. She
next turned her head toward me and remarked that she was ready. I had no
medical assistant with me. I operated without chloroform—the woman
fainted. There was camphorated spirits close by, and I sprinkled it
heavily and forcibly in her face and over her chest, and rubbed some in
her mouth. She revives with a vim and sends the gristle forcibly, not
only out of her mouth, but nearly out of doors, rejoicing all hands
around.
I applied sticking plaster and left; saw her in a few days; she was
well.
My next operation was on the child of Mr. Enoch Foy, who had the
misfortune to get a watermelon seed in his windpipe. The usual symptoms
occurring, he came on with his little boy and had him relieved—the seed
coming out several hours after the operation.
The next was a child of Mr. Marshall, (another fine boy), another case
of watermelon seed, which was operated on with like success.
My last case was a child 8 or 9 months old, a very pretty and fine
little girl, the daughter of a Mr. Padjet of this county. She had been
playing with an ear of corn, given to amuse her; some of the grains
coming off and one and a half getting into the windpipe, as shown by the
sequel. She was operated on, assisted by Drs. Cox and Nicholson. The
foreign substance did not come out as soon after the operation as the
other cases. The wound was not kept open by the attendants, and in
consequence I had to re-visit, reöpen and somewhat enlarge the incision
which was attended with the usual good results. The child was very fat,
and the space for operating in so young a child, was necessarily very
limited. One grain of corn and the part of another was expelled. I will
next give my “modus operandi,” or rather my imperfect manner of
operating.
The patient being laid on a suitable table, with the chest elevated, by
placing a pillow or folds of cloth underneath. The head is next laid
back neatly observing the direction of the mesial line strictly, and
throughout the operation. The instruments previously got ready, and
those which I prefer, are a scalpel with a sharp handle, a director and
probe, two bistouries, one sharp and the other button pointed, a
forceps, tenacula, sponge and ligatures. But so far I have never needed
the ligatures. I have always stopped any little bleeding that occurred
by applying a pencil of nitrate of silver. All these ready, also a basin
of cold water, standing on the right of my patient, I place the finger
and thumb of my left hand, one on each side of the thyroid cartilage,
and commence my first incision from its lower third if a child, and from
its lower edge if an adult, for obvious reasons, namely: In the child we
want room, and if necessary can enlarge the incision in that direction,
with but little difficulty, the cartilage affording no resistance. In
the adult we have more room, and the cartilage is often found hard, and
unyielding in persons of advanced life, and it is therefore necessary
when enlargement is required in the adult, to cut an additional ring or
more of the trachea. I continue my incision below the cricoid cartilage,
so far as one or more of the rings of the trachea. The track of the
operation being now laid off, I proceed cautiously, an assistant
sponging, and applying caustic, as may be necessary to arrest any little
bleeding that may ensue, whilst I, with the handle of my knife, push
aside any vessel likely to bleed—cricoid artery or otherwise. I next lay
hold on the cellular sheath of the trachea, at the lower edge of the
track of my operation, and at this point I enter with a sharp pointed
bistoury, holding it close to the point, and cutting upward not more
than one-eighth of an inch and withdraw it in favor of the button
pointed bistoury, with which I slit upward the windpipe, as far as the
starting point of the first incision—not moving the instrument back and
forth, but holding it perfectly steady, carrying it or rather pushing
it, aided by the other hand from below upward, with the handle of the
knife inclined downward. The operation now done, is made known by a
whizzing which it is necessary to look after, and as all-important. I
consider it the safety valve of the patient.
This operation may also be performed from above, downwards, with a sharp
pointed bistoury, holding it not far from the point; the forefinger on
the back of the knife—taking care to help the cricoid artery out of the
way, which I have always been able to control when cut, by the
application of nitrate of silver. The patient may be, if necessary,
turned on the side to prevent blood from passing into the windpipe.
I begin close by the lower edge of the thyroid cartilage, and carry it
so far as the second ring of the trachea; but in either case, whether I
open upward or downward, the tenaculum can materially assist in the
operation, by drawing down the tube when cutting upward, or by drawing
upward when cutting downward—the hook to enter behind the knife in
either case.
The use of the hook is most necessary when operating on young children.
The object in pushing the knife, holding it steadily, is from knowing
that it long since has been found, that an artery will give way before a
knife when carried in this way that might otherwise have been cut
immediately by a “see-saw” motion.
After the operation is performed, I direct the attendants to keep the
opening clear of obstruction—bloody froth, &c., or anything that may
make its appearance in the wound. Artificial respiration must be kept up
until the foreign substance is expelled or removed. A probe or knitting
needle will suffice for that purpose, one or the other must be used
several times a day and night, in fact as often as needed; I use no
gauze, it might get sucked to, or drawn into the opening, and thereby
defeat the intent of the operation. In cases needing the use of the
canula I make no reference.
I prefer laryngo-tracheotomy, sometimes denominated circo-tracheotomy,
which I have been endeavoring to describe, to any other, for all
ordinary purposes. We have less risk, and more room, and it is more
adapted to the relief of children and might with propriety be called the
higher operation to distinguish it from tracheotomy, which rightly
speaking is the lower operation. This would draw a distinction between
the two, and it is necessary that line should be observed, and that when
these operations are spoken of, we should know what importance to attach
in either case, and give to either operation the degree of approbation
it may deserve.
I cannot close this subject without giving the opinion of a very able
anatomist regarding it, Harrison, of Dublin. In the first place he
speaks of an irregular artery, which he has seen running along the front
of the trachea to the thyroid gland and cellular membranes beneath it.
He had seen this so frequently in this situation, that he describes it
under the name of the middle thyroid artery. “This is” he says “so
common an occurrence that it should be remembered by the practitioner of
tracheotomy.” He further goes on to say, “in children the space for
tracheotomy is very limited,” and directly that “particular attention be
paid to the inconsiderable portion of the trachea that can be exposed
between the thyroid gland above, the arteria innominata, the left
carotid artery, the remainder of the thymus gland below. The deep
thyroid veins also descending to the vena innominata obscure the trachea
very much, these together with the great mobility of this tube, add to
the danger and difficulty of this operation.” Pancoast says: “The
checking of hemorrhage from the veins and arteries divided in
tracheotomy requires particular attention; from six to eight ligatures
are usually employed. They should be applied in general as the vessels
are cut and before the opening of the trachea as there must be blood
drawn by respiration into the trachea and thereby endanger life.”
These dangers constitute shoals and quicksands to the anatomist and
surgeon, that has made many a one shudder at their approach. The six or
eight vessels to tie, before daring to open the trachea, causes delay
dangerous to life, as well as to the success of the operation, and
brings into question the propriety of the operation, and sometimes the
skill of the physician. In the upper operation, laryngo-tracheotomy, you
can enlarge the opening upward whenever necessary, with but little risk,
by cutting through the thyroid cartilage. In fact, it may be opened
above or below, one or both, with but little risk; whereas in the lower
operation it is almost impossible to do so. When it becomes necessary,
the safest plan is to enlarge the opening upward, as much as is
practicable, and downward as little as we are able to get along with.
The space taken up by the lower operation on children is very limited,
and the operator must necessarily be cramped for want of room. The
cervical portion of the adult trachea is laid down at from two to two
and one half inches long. It is composed 18 or 20 fibro cartilages, this
makes the space between each ring 1–8th of an inch. According to that
measurement, allowing the 20 rings for 2½ inches makes the space taken
up by cutting three rings 3–8ths of an inch long in the adult, if no
more is divided, and proportionately less in the child. We can readily
understand that those operating in this region do as little cutting as
possible, and although the operation so far as the outside incision, may
begin at the cricoid cartilage, and terminate as at a little distance
from the fossa at the top of the sternum. I have no idea that the
trachea is often laid open to that extent. Pancoast directs, “that after
separating the two sterno-thyroid muscles, partly with the point and
partly with the handle of the knife, and finding no large vessels in the
way, pushes up, or if necessary divides the isthmus of the thyroid
gland.” The next cutting he speaks of, is, “that of the third, fourth
and fifth rings, puncturing the tube, with the point of the knife below
the fifth ring.” He then speaks of running the scalpel upwards with the
handle inclined to the sternum, so as to avoid injuring the posterior
wall of the trachea. It is easy to perceive in the practice of the
present day, that this operation is done for, and best suited to the
insertion of the canula, and that the opening of the third, fourth and
fifth rings of the trachea can, when divided, answer by binding the
canula, a much better purpose than a larger opening, which would allow
it to move about, thereby incurring the danger of displacement.
The word tracheotomy as a general term does harm. We ought rather to
particularize, and make known on what part of that tube we operate, and
not speak of tracheotomy as though it were of little moment in the
performance, and that one part of the windpipe cut into, was as much a
tracheotomy as another; not by any means should this be thought. I
consider that tracheotomy strictly, and according to the definitions of
anatomy and surgery, is one of the most dangerous that come within the
province of the surgeon; and, on the contrary, I consider
laryngo-tracheotomy, or crico-tracheotomy as it is sometimes
denominated, a very simple operation, and only requiring ordinary tact
in the performance.
* * * * *
Since the above article was written, this operation has been
successfully performed by Dr. J. L. Nicholson, assisted by myself and
Dr. C. Thompson.
MR. GRANT GIVES THE FOLLOWING RULES ABOUT FOREIGN BODIES IN THE EXTERNAL
EAR.
1. Be sure that the foreign body is _seen_. To attempt to extract a
foreign body without first seeing it is highly dangerous.
2. Determine what the body is, and, if possible, obtain a sample of the
body supposed to be in the ear.
3. Remember that a body which will not swell, and has no cutting edge,
will generally remain without causing any urgent symptoms.
4. Seeing the body, determine with a probe if it be movable. If easily
movable, concussion with a downward position of ear will often remove
it.
5. Warm water injection is the best of all methods of removing foreign
bodies.
6. If it be a vegetable substance, do not inject fluid unless you have
time to extract the body either at one operation, or shortly afterwards.
7. Injection failing, which is very exceptional, a surgeon, with the
necessary appliances, ought to be at once consulted, or should urgent
symptoms arise from the irritation in the attempted extraction, the
extraction by the incisions, galvano-cautery, boring out by trephine or
conical file the centre of substance, and so causing its collapse; or
even detachment of the auricle may be necessary.—_The Medical Press and
Circular._