the string has yielded good results in the hands of some operators.
The string may be used to pull up dilators in increasing sizes,
introduced through a gastrostomic fistula. The string stretched across
the stomach from the cardia to the pylorus, is fished out with the
author's pillar retractor, or is found with the retrograde
esophagoscope (Fig. 43). The string is attached to a dilator (Fig.
35), and a fresh string is pulled in to replace the one pulled out.
This is the safest of the blind methods. It is rarely possible to get
a child under two years of age to swallow and tolerate a string. It is
better after each treatment to draw the upper end of the string
through the nose, as it is not so likely to be chewed off and is less
annoying. With the esophagoscope, the string is not necessary, because
the lumen of the stricture can be exposed to view by the
esophagoscope.
_Retrograde esophagoscopy_ through a gastrostomy wound offers some
advantages over peroral treatment; but unless the gastrostomy is high,
the procedure is undoubtedly more difficult. The approach to the
lowest stricture from below is usually funnel shaped and free from
dilatation and redundancy. It must be remembered the stricture seen
from below may not be the same one seen from above. Roentgenray
examination with barium mixture or esophagoscopes simultaneously in
situ above and below are useful in the study of such cases.
_Impermeable strictures_ of the cervical esophagus are amenable to
external esophagotomy, with plastic reformation of the esophagus.
Those in the middle third have not been successfully treated by
surgical methods, though various ingenious operations for the
formation of an extrathoracic esophagus have been suggested as means
of securing relief. Impermeable strictures of the lower third can with
reasonable safety be treated by the Brenneman method, which consists
in passing the esophagoscope down to the stricture while the surgeon,
inserting his finger up into the esophagus from the stomach, can feel
the end of the esophagoscope. An incision through the tissue barrier
is then made from below, passing the knife along the finger as a
guide. A soft rubber stomach-tube is pulled up from below and left in
situ, being replaced at intervals by a fresh one, pulled up from the
stomach, until epithelialization of the new lumen is complete.
Catheters are used in children. In replacing the catheter or stomach
tube the fresh one is attached to the old one by stitching in a loop
of braided silk. Frequent esophagoscopic bouginage will be required to
maintain the more or less fistulous lumen until it is epithelialized,
and in occasional cases, for a long time thereafter.
In cases of absolute atresia the saliva does not reach the stomach. No
one realizes the quantity of normal salivary drainage, nor its
importance in nutritive processes. Oral insalivation is of little
consequence compared to esophagogastric drainage. Gastrostomized
children with absolute atresia of the esophagus do not thrive unless
they regurgitate the salivary accumulations into the funnel of the
gastrostomic feeding tube. This has been abundantly proven by
observations at the Bronchoscopic Clinic. My attention was first
called to this clinical fact by Miss Frances Groves who has charge of
these cases.
_Intubation of the esophagus_ with soft rubber tubes has occasionally
proven useful.
[260] CHAPTER XXXIII--DISEASES OF THE ESOPHAGUS (_Continued_)
DIVERTICULUM OF THE ESOPHAGUS
Diverticula may, and usually do, consist in a pouching by herniation,
of the whole thickness of the esophageal wall; or they may be
herniations of the mucosa between the muscular layers. They are
classified according to their etiology, as traction and pulsion
diverticula.
[FIG. 99.--Traction diverticulum of the esophagus rendered visible in
the roentgenogram by a swallowed opaque mixture. Case of H. W.
Dachtler, Am. Journ. Roentgenology.]
_Traction diverticulum of the esophagus_ (Fig. 99) is a rare
condition, usually occurring in the thorax, and as a rule constituting
a one-sided enlargement of the gullet rather than a true pouch
formation. It is supposed to be formed by the pulling during cough,
respiration, and swallowing, on localized adhesions of the esophagus
to periesophageal structures, such as inflammatory peribronchial
glands.
_Diagnosis_ is often incidental to examination of the gastrointestinal
tract for other conditions, because traction diverticula usually cause
no symptoms. Unless a very large esophagoscope be used, a traction
diverticulum may easily be overlooked in the mucosal folds. Careful
lateral search, however, will reveal the dilatation, and the localized
periesophageal fixation may be demonstrated. The subdiverticular
esophagus is readily followed, its lumen opening during inspiration
unless very close to the diaphragm, which is very rare. Perhaps most
cases will be discovered by the roentgenologist. It has been said that
traction diverticula are more readily demonstrated in the
roentgenologic examination, if the patient be placed with pelvis
elevated.
_Pulsion diverticulum of the esophagus_ is an acquired hernia of the
mucosa between the circular and oblique fibers of the inferior
constrictor muscle of the pharynx. A congenital anatomic basic factor
in etiology probably exists. The pouching develops in the middle part
of the posterior wall, between the orbicular and oblique fibers of the
cricopharyngeus muscle, at which point there is a gap, leaving the
mucosa supported only by a not very resistant fascia (Fig. 100). When
small, the sac is in the midline, but with increase in size, it
presents either to the right or the left side, commonly the latter.
The sac may be very small, or it may be sufficiently large to hold a
pint or more, and to cause the neck to bulge when filled. When large,
the pouch extends into the mediastinum. It will be seen that
anatomically the pulsion diverticulum has its origin in the pharynx;
the symptoms, however, are referable to the esophagus and the
subdiverticular esophagus is stenosed by compression of the pouch;
therefore, it is properly classified as an esophageal disease.
[FIG. 100.--Schema illustrative of the etiology of pressure
diverticula. O, oblique fibers of the cricopharyngeus attached to the
thyroid cartilage, T. The fundiform fibers, F, encircle the mouth of
the esophagus. Between the two sets of fibers is a gap in the support
of the esophageal wall, through which the wall herniates owing to the
pressure of food propelled by the oblique fibers, O, advance of the
bolus being resisted by spasmodic contraction of the orbicular fibers,
F.]
_Etiology_.--Pressure diverticula occur after middle life, and more
often in men than in women. The hasty swallowing of unmasticated food,
too large a bolus, defective or artificial teeth, flaccidity of
tissues, and spasm of the cricopharyngeus muscle, are etiologic
factors. Cicatricial stenosis below the level of the inferior
constrictor is a contributory cause in some cases.
_Prognosis_.--After the pouch is formed, it steadily increases in
size, since the swallowed food first fills and distends the sac before
the overflow passes down the esophagus. When a pendulous sac becomes
filled with food, it presses on the subdiverticular esophagus, and
produces compression stenosis; so that there exists a "vicious
circle." The enlargement of the sac produces increasing stenosis with
consequent further distension of the pouch. This explains the
clinically observed fact, that unless treated, pulsion diverticula
increase progressively in size, and consequently in distressing
symptoms. The sac becomes so large in some cases as to contribute to
the occurrence of cerebral apoplexy by interference with venous
return. Practically all cases can be cured by radical operation. The
operative mortality varies with the age, state of nutrition, and
general health of the patient. In general it may be said to have a
mortality of at least 10 per cent, largely due to the fact that most
cases are poor surgical subjects. Recurrences after radical operation
are due to a persistence of the original causes, i.e., bolting of
food; stenosis, spasmodic or organic, of the esophageal lumen; and
weakness in the support of the esophageal wall, which, unsupported,
has little strength of its own.
_Symptoms_.--Dysphagia, regurgitation, a gurgling sound and subjective
bubbling sensation on swallowing, sour odor to the breath, and cough,
are the chief symptoms. With larger pouches, emaciation, pressure
sensation in the neck and upper mediastinum, and the presence of a
mass in the neck when the sac is filled, are present. Tracheal
compression by the filled pouch may produce dyspnea. The sac may be
emptied by pressure on the neck, this means of relief being often
discovered by the patient. The sac sometimes spontaneously empties
itself by contraction of its enveloping muscular layer, and one of the
most annoying symptoms is the paroxysm of coughing, waking the
patient, when during the relaxation of sleep the sac empties itself
into the pharynx and some of its contents are aspirated into the
larynx. There are no pathognomonic symptoms. Those recited are common
to other forms of esophageal stenosis, and are urgent indications for
diagnostic esophagoscopy.
_Diagnosis_.--Roentgenray study with barium mixtures, is the first
step in the diagnosis (Fig. 101). This is to be followed by diagnostic
esophagoscopy. Malignant, spasmodic, cicatricial, and compression
stenosis are to be excluded by esophagoscopic appearances. Aneurysm is
to be eliminated by the usual means. The Boyce sign is almost
invariably present, and is diagnostic. It is elicited by telling the
patient to swallow, which action imprisons air in the sac. The
imprisoned air is forced out by finger-pressure on the neck, over the
sac. The exit of the air bubble produces a gurgling sound audible at
the open mouth of the patient.
_Esophagoscopic Appearances in Pulsion Diverticulum_.--The
esophagoscope will without difficulty enter the mouth of the sac which
is really the whole bottom of the pharynx, and will be arrested by the
blind end of the pouch, the depth of which may be from 4 to 10 cm. In
some cases the bottom of the pouch is in the mediastinum. The walls
are often pasty, and may be eroded, or ulcerated, and they may show
vessels or cicatrices. On withdrawing the tube and searching the
anterior wall, the subdiverticular slit-like opening of the esophagus
will be found, though perhaps not always easily. The esophageal
speculum will be found particularly useful in exposing the
subdiverticular orifice, and through this a small esophagoscope may be
passed into the esophagus, thus completing the diagnosis. Care must be
exercised not to perforate the bottom of the diverticular pouch by
pressure with the esophagoscope or esophageal speculum. The walls of
the sac are surprisingly thin.
[FIG. 101.--Pulsion diverticulum filled with bismuth mixture in a man
of fifty years.]
_Treatment of Pulsion Diverticulum_.--If the pouch is small, the
subdiverticular esophageal orifice may be dilated with esophagoscopic
bougies, thus overcoming the etiologic factor of spastic or organic
stenosis. The redundancy remains, however, though the symptoms may be
relieved. Cutting the common wall between the esophagus and the sac by
means of scissors passed through the endoscopic tube, has been
successfully done by Mosher.
Various methods of external operation have been devised, among which
are: (1) Freeing the sac through an external cervical incision and
suturing its fundus upward against the pharynx, which has proved
successful in some cases. (2) Inversion of the sac into the pharynx
and suture of the mouth of the pouch. In a case so treated the pouch
was blown out again during a fit of sneezing eight months after
operation. (3) Plication of the walls of the sac by catgut sutures, as
in the Matas obliterative operation for aneurysm. (4) Freeing and
removing the sac, with suture of the esophageal wound. (5) Removal of
the sac by a two-stage operation, in which method the initial step is
the deliverance of the sac into the cervical wound, where it remains
surrounded by gauze packing until adhesions have walled off the
mediastinum. The work is completed by cutting off the sac and either
suturing the esophageal wound or touching it with the cautery, and
allowing it to heal by granulation. External exposure and amputation
of the sac has been more frequently done than any other operation.
Unless the pouch is large, it is extremely difficult to find after the
surgeon has exposed the esophagus, for the reasons that at operation
it is empty and that when the adhesions about it are removed the walls
of the sac contract. After removal, the sac is disappointingly small
as compared with its previous size in the roentgenogram, which shows
it distended with opaque material. It has been the chagrin of skilled
surgeons to find the diverticulum present functionally and
roentgenographically precisely the same as before the performance of
the very trying and difficult operation. The time of operation may be
shortened at least by one-half by the aid of the esophagoscopist in
the Gaub-Jackson operation. Intratracheally insufflated ether is the
anesthesia of choice. After the surgeon has exposed the esophagus by
dissection, the endoscopist introduces the esophagoscope into the sac,
and delivers it into the wound, while the surgeon frees it from
adhesions. The esophagoscope is now withdrawn from the pouch and
entered into the esophagus proper, below the diverticulum, while the
surgeon cuts off the hernial sac and sutures the esophagopharyngeal
wound over the esophagoscope. The presence of the esophagoscope
prevents too tight suture and possible narrowing of the lumen (Fig.
102).
[FIG. 102.--Schematic representation of esophagoscopic aid in the
excision of a diverticulum in the Gaub-Jackson operation. At A the
esophagoscope is represented in the bottom of the pouch after the
surgeon has cut down to where he can feel the esophagoscope. Then the
esophagoscopist causes the pouch to protrude as shown by the dotted
line at B. After the surgeon has dissected the sac entirely loose from
its surroundings, traction is made upon the sac as shown at H and the
esophagoscope is inserted down the lumen of the esophagus as shown at
C. The esophagoscope now occupies the lumen which the patient will
need for swallowing. It only remains for the surgeon to remove the
redundancy, without risk of removing any of the normal wall. The
esophagoscope here shown is of the form squarely cut off at the end.
The standard form of instrument with slanted end will serve as well.]
_After-care_.--Feeding may be carried on by the placing of a small
nasal feeding tube into the stomach at the time of operation.
Gastrostomy for feeding as a preliminary to the esophageal operation
has been suggested, and is certainly ideal from the viewpoint of
nutrition and esophageal rest. The decision of its performance may
perhaps be best made by the patient himself. Should leakage through
the neck occur, the fistula should be flushed by the intake of sterile
water by mouth. Oral sepsis should, of course, be treated before
operation and combated after operation by frequent brushing of the
teeth and rinsing of the mouth with Dakin's solution, one part, to ten
parts of peppermint water. A postoperative barium roentgenogram should
be made in every case as a matter of record and to make certain the
proper functioning of the esophagus.
[268] CHAPTER XXXIV--DISEASES OF THE ESOPHAGUS (_Continued_)
PARALYSIS OF THE ESOPHAGUS
The passage of liquids and solids through the esophagus is a purely
muscular act, controlled, after the propulsive usually voluntary start
given to the bolus by the inferior constrictor, by a reflex arc having
connection with the central nervous system through the vagus nerve.
Gravity plays little or no part in the act of deglutition, and alone
will not carry food or drink to the stomach. Paralysis of the
esophagus may be said to be motor or sensory. It is rarely if ever
unassociated with like lesions of contiguous organs.
_Motor paralysis of the esophagus_ is first manifested by inability to
swallow. This is associated with the accumulation of secretion in the
pyriform sinuses (the author's sign of esophageal stenosis) which
overflows into the larynx and incites violent coughing. Motor
paralysis may affect the constrictors or the esophageal muscular
fibers or both.
_Sensory paralysis of the esophagus_ by breaking the continuity of the
reflex arc, may so impair the peristaltic movements as to produce
aphagia. The same filling of the pyriform sinuses will be noted, but
as the larynx is usually anesthetic also, it may be that no cough is
produced when secretions overflow into it.
_Etiology_.--1. Toxic paralysis as in diphtheria.
2. Functional paralysis as in hysteria.
3. Peripheral paralysis from neuritis.
4. Central paralysis, usually of bulbar origin.
Embolism or thrombosis of the posterior cerebral artery is a
reported cause in two cases. Lues is always to be excluded as the
fundamental factor in the groups 3 and 4. Esophageal paralysis is not
uncommon in myasthenia gravis.
_Esophagoscopic findings_ are those of absence of the normal
resistance at the cricopharyngeus, flaccidity and lack of sensation of
the esophageal walls, and perhaps adherence of particles of food to
the folds. The hiatal contraction is usually that normally
encountered, for this is accomplished by the diaphragmatic
musculature. In paralysis of sensation, the reflexes of coughing,
vomiturition and vomiting are obtunded.
_Diagnosis_.--Hysteria must not be decided upon as the cause of
dysphagia, until after esophagoscopy has eliminated paralysis.
Dysphagia after recent diphtheria should suggest paralysis of the
esophagus. The larynx, lips, tongue, and pharynx also, are usually
paralyzed in esophageal paralysis of bulbar origin. The absence of the
cricopharyngeal resistance to the esophagoscope passed without
anesthesia, general or local, is diagnostic.
_Treatment_.--The internist and neurologist should govern the basic
treatment. Nutrition can be maintained by feeding with the
stomach-tube, which meets no resistance to its passage. Should this be
contraindicated by ulceration of the esophagus, gastrostomy should be
done.
LUES OF THE ESOPHAGUS
_Esophageal syphilis_ is a rather rare affection, and may show itself
as a mucous plaque, a gumma, an ulceration, or a cicatrix. Cicatricial
stenosis developing late in life without history of the swallowing of
escharotics or ulcerative lesions is strongly suggestive of syphilis,
though the late manifestation of a congenital stenosis is a
possibility.
_Esophagoscopic appearances_ of lues are not always characteristic. As
in any ulcerative lesion, the inflammatory changes of mixed infections
mask the basic nature. The mucous plaque has the same appearance as
one situated on the velum, and gummata resemble those seen in the
mucosa elsewhere. There is nothing characteristic in luetic
cicatrices.
_The diagnosis_ of luetic lesions of the esophagus, therefore, depends
upon the history, presence of luetic lesions elsewhere, the serologic
reaction, therapeutic test, examination of tissue, and the
demonstration of the treponema pallidum. The therapeutic test by
prolonged saturation of the system with mercury is imperative in all
suspected cases and no other negative result should be deemed
sufficient.
_The treatment_ of luetic esophagitis is systemic, not local. Luetic
cicatrices contract strongly, and are very resistant to treatment, so
that esophagoscopic bouginage should be begun as early as possible
after the healing of a luetic ulceration, in order to prevent
stenosis. A silk-woven endoscopic bougie placed in position by ocular
guidance, and left _in situ_ for from half to one hour daily, may
prevent severe contraction, if used early in the stage of
cicatrization. Prolonged treatment is required for the cure of
established luetic cicatricial stenosis. If gastrostomy has been done
retrograde bouginage (Fig. 35) may be used.
TUBERCULOSIS OF THE ESOPHAGUS
_Esophageal tuberculosis_ is not commonly met, but is probably not
infrequently associated with the dysphagia of tuberculous laryngitis.
It may rarely occur as a primary infection, but usually the esophagus
is involved in an extension from a tuberculous process in the larynx,
mediastinal lymphatics, pleura, bronchi, or lungs.
Primary lesions appear as superficial erosions or ulcerations, with a
surrounding yellowish granular zone, or the granules may alone be
present. The mucosa in tuberculous lesions is usually pallid, the
absence of vascularity being marked. Invasion from the periesophageal
organs produces more or less localized compression and fixation of the
esophagus. The character of open ulceration is modified by the mixed
infections. Healed tuberculous lesions, sometimes resulting from the
evacuation of tuberculous mediastinal lymph nodes into the esophagus
may be encountered. The local fixation and cicatricial contraction may
be the site of a traction diverticulum. Tuberculous esophago-bronchial
fistulae are occasionally seen.
_Diagnosis_, to be certain, requires the demonstration of the
tubercule bacilli and the characteristic cell accumulation of the
tubercle in a specimen of tissue removed from the lesion.
Actinomycosis must be excluded, and the possibility of mixed luetic
and tuberculous lesions is to be kept in mind. Post-tuberculous
cicatrices have no recognizable characteristics.
_Treatment_.--The maintenance of nutrition to the highest degree, and
the institution of a strict antituberculous regime are demanded. Local
applications are of no avail. Gastrostomy for feeding should be done
if dysphagia be severe, and has the advantage of putting the esophagus
at rest. The passage of a stomach-tube for feeding purposes may be
done, but it is often painful, and is dangerous in the presence of
ulceration. Pain is not marked if the lesion be limited to the
esophagus, though if it is present orthoform, anesthesin, or
apothesin, in powder form, swallowed dry, may prove helpful.
VARIX AND ANGIOMA OF THE ESOPHAGUS
These lesions are sometimes the cause of esophageal hemorrhage, the
regurgitated blood being bright red, and alkaline in reaction, in
contradistinction to the acid "coffee ground" blood of gastric origin.
Esophageal varices may coexist with the common dilatation of the
venous system in which the veins of the rectum, scrotum, and legs are
most conspicuously affected. Cirrhosis and cancer of the liver may, by
interference with the portal circulation, produce dilatation of the
veins in the lower third of the esophagus. Angioma of the esophagus is
amenable to radium treatment.
ACTINOMYCOSIS OF THE ESOPHAGUS
_Esophageal actinomycosis_ has been autoptically discovered. Its
diagnosis, and differentiation from tuberculosis, would probably rest
upon the microscopic study of tissue removed esophagoscopically,
though as yet no such case has been reported.
ANGIONEUROTIC EDEMA
_Angioneurotic edema_ involving the esophagus, may produce
intermittent and transient dysphagia. The lesions are rarely limited
to the esophagus alone; they may occur in any portion of the
gastrointestinal, genitourinary, or respiratory tracts, and
concomitant cutaneous manifestations usually render the diagnosis
clear. The treatment is general.
DEVIATION OF THE ESOPHAGUS
_Deviation of the esophagus_ may be marked in the presence of a
deformed vertebral column, though dysphagia is a very uncommon
symptom. The lack of esophageal symptoms in deviation of spinal
production is probably explained by the longitudinal shortening of the
spine which accompanies the deflection. Compression stenosis of the
esophagus is commonly associated with deviations produced by a
thoracic mass.
[PLATE IV
A, Gastroscopic view of a gastrojejunostomy opening drawn patulous by
the tube mouth. (Gastrojejunostomy done by Dr. George L. Hays.) B,
Carcinoma of the lesser curvature. (Patient afterward surgically
explored and diagnosis verified by Dr. John J. Buchanan.) C, Healed
perforated ulcer. (Patient referred by Dr. John W. Boyce.)
Drawn from a case of postdiphtheric subglottic stenosis cured by the
author's method of direct galvanocauterization of the hypertrophies.
A, Immediately after removal of the intubation tube; hypertrophies
like turbinals are seen projecting into the subglottic lumen. B, Five
minutes later; the masses have now closed the lumen almost completely.
The patient became so cyanotic that a bronchoscope was at once
introduced to prevent asphyxia. C, The left mass has been cauterized
by a vertical application of the incandescent knife. D, Completely and
permanently cured after repeated cauterizations. Direct view;
recumbent patient.
PHOTOPROCESS REPRODUCTIONS OF THE AUTHOR'S OIL-COLOR DRAWINGS FROM
LIFE]
[273] CHAPTER XXXV--GASTROSCOPY
The stomach of any individual having a normal esophagus and normal
spine can be explored with an open-tube gastroscope. The adult size
esophagoscope being 53 cm. long will reach the stomach of the average
individual. Longer gastroscopes are used, when necessary, to explore a
ptosed stomach. Various lens-system gastroscopes have been devised,
which afford an excellent view of the walls of the air-inflated
stomach. The optical system, however, interferes with the insertion of
instruments, so that the open-tube gastroscope is required for the
removal of gastric foreign bodies, the palpation of, or sponging
secretions from, gastric lesions. The open-tube gastroscope may be
closed with a window plug (Fig. 6) having a rubber diaphragm with a
central perforation for forceps, when it is desired to inflate the
stomach.
_Technic_.--Relaxation by general anesthesia permits lateral
displacement of the dome of the diaphragm along with the esophagus,
and thus makes possible a wider range of motion of the distal end of
the gastroscope. All of the recent gastroscopies in the Bronchoscopic
Clinic, however, have been performed without anesthesia. The method of
introduction of the gastroscope through the esophagus is precisely the
same as the introduction of the esophagoscope (q.v.). It should be
emphasized that with the lens-system gastroscopes, the tube should be
introduced into the stomach under direct ocular guidance, without a
mandrin, and the optical apparatus should be inserted through the tube
only after the stomach has been entered. Blind insertion of a rigid
metallic tube into the esophagus is an extremely dangerous procedure.
The descriptions and illustrations of the stomach in anatomical works
must be disregarded as cadaveric. In the living body, the empty
stomach is usually found, on endoscopic inspection, to be a collapsed
tube of such shape as to fit whatever space is available at the
particular moment, with folds and rugae running in all directions, the
impression given as to form being strikingly like searching among a
mass of earth worms or boiled spaghetti. The color is pink, under
proper illumination, if no food is present. Poor illumination may make
the color appear deep crimson. If food is present, or has just been
regurgitated, the color is bright red. To appreciate the appearance of
gastritis, the eye must have been educated to the endoscopic
appearances under a degree of illumination always the same. The left
two-thirds of the stomach is most easily examined. The stomach wall
can be pushed by the tube into almost any position, and with the aid
of gentle external abdominal manipulation to draw over the pylorus it
is possible to examine directly almost all of the gastric walls except
the pyloric antrum, which is reachable in relatively few cases. A
lateral motion of from 10 to 17 cm. can be imparted to the
gastroscope, provided the diaphragmatic musculature is relaxed by deep
anesthesia. The stomach is explored by progressive traverse. That is,
after exploring down to the greater curvature, the tube-mouth is moved
laterally about 2 centimeters, and the withdrawing travel explores a
new field. Then a lateral movement affords a fresh field during the
next insertion. This is repeated until the entire explorable area has
been covered. Ballooning the stomach with air or oxygen is sometimes
helpful, but the distension fixes the stomach, lessens the mobility of
the arch of the diaphragm, and thus lessens the lateral range of
gastroscopic vision. Furthermore, ballooning pushes the gastric walls
far away from the reach of the tube-mouth. A window plug (Fig. 6) is
inserted into the ocular end of the gastroscope for the ballooning
procedure.
[275] Like many other valuable diagnostic means, gastroscopy is very
valuable in its positive findings. Negative results are entitled to
little weight except as to the explorable area.
The gastroscopist working in conjunction with the abdominal surgeon
should be able to render him invaluable assistance in his work on the
stomach. The surgeon with his gloved hand in the abdomen, by
manipulating suspected areas of the stomach in front of the tube-mouth
can receive immediately a report of its interior appearance, whether
cancerous, ulcerated, hemorrhagic, etc.
_Lens-system ballooning gastroscopy_ may possibly afford additional
information after all possible data from open-tube gastroscopy has
been obtained. Care must be exercised not to exert an injurious degree
of air-pressure. The distended portion of the stomach assumes a
funnel-like form ending at the apex in a depression with radiating
folds, that leads the observer to think he is looking at the pylorus.
The foreshortening produced by the lens system also contributes to
this illusion. The best lens-system gastroscope is that of Henry
Janeway, which combines the open-tube and the lens system.
_Gastroscopy for Foreign Bodies_.--The great majority of foreign
bodies that reach the stomach unassisted are passed per rectum,
provided the natural protective means are not impaired by the
administration of cathartics, changes in diet, etcetera. This,
however, does not mean that esophageal foreign bodies should be pushed
into the stomach by blind methods, or by esophagoscopy, because a
swallowed object lodged in the esophagus can always be returned
through the mouth. Foreign bodies in the stomach and intestines should
be fluoroscopically watched each second day. If an object is seen to
lodge five days in one location in the intestines, it should be
removed by laparotomy, since it will almost certainly perforate.
Certain objects reaching the stomach may be judged too large to pass
the pylorus and intestinal angles. These should be removed by
gastroscopy when such decision is made. It is to be remembered that
gastric foreign bodies may be regurgitated and may lodge in the
esophagus, whence they are easily removed by esophagoscopy. The
double-planed fluoroscope of Manges is helpful in the removal of
gastric foreign bodies, but there is great danger of injury to the
stomach walls, and even the peritoneum, unless forceps are used with
the utmost caution.
[277] CHAPTER XXXVI--ACUTE STENOSIS OF THE LARYNX
_Etiology_.--Causes of a relatively sudden narrowing of the lumen of
the larynx and subjacent trachea are included in the following list.
Two or more may be combined.
1. Foreign body.
2. Accumulation of secretions or exudate in the lumen.
3. Distension of the tissues by air, inflammatory products, serum,
pus, etc.
4. Displacement of relatively normal tissues, as in abductor
paralysis, congenital laryngeal stridor, etcetera.
5. Neoplasms.
6. Granulomata.
_Edema of the larynx_ may be at the glottic level, or in the
supraglottic or subglottic regions. The loose cellular tissue is most
frequently concerned in the process rather than the mucosal layer
alone. In children the subglottic area is very vascular, and swelling
quickly results from trauma or inflammation, so that acute stenosis of
the larynx in children commonly has its point of narrowing below the
cords. Dyspnea, and croupy, barking, cough with no change in the tone
or pitch of the speaking voice are characteristic signs of subglottic
stenosis. Edema may accompany inflammation of either the superficial
or deep structures of the larynx. The laryngeal lesion may be primary,
or may complicate general diseases; among the latter, typhoid fever
deserves especial mention.
_Acute laryngeal stenosis_ complicating typhoid fever is frequently
overlooked and often fatal, for the asthenic patient makes no fight
for air, and hoarseness, if present, is very slight. The laryngeal
lesion may be due to cordal immobility from either paralysis or
inflammatory arytenoid fixation, in the absence of edema.
Perichondritis and chondritis of the laryngeal cartilages often follow
typhoid ulceration of the larynx, chronic stenosis resulting.
_Laryngeal stenosis in the newborn_ may be due to various anomalies of
the larynx or trachea, or to traumatism of these structures during
delivery. The normal glottis in the newborn is relatively narrow, so
that even slight encroachment on its lumen produces a serious degree
of dyspnea. The characteristic signs are inspiratory indrawing of the
supraclavicular fossae, the suprasternal notch, the epigastrium, and
the lower sternum and ribs. Cyanosis is seen at first, later giving
place to pallid asphyxia when cardiac failure occurs. Little air is
heard to enter the lungs, during respiratory efforts and the infant,
becoming exhausted by the great muscular exertion, soon ceases to
breathe. Paralytic stenosis of the larynx sometimes follows difficult
forceps deliveries during which stretching or compression of the
recurrent nerves occur.
_Acute laryngeal stenosis in infants, from laryngeal perichondritis_,
may be a delayed result of traumatism to the laryngeal cartilages
during delivery. The symptoms usually develop within four weeks after
birth. Lues and tuberculosis are possible factors to be eliminated by
the usual methods.
_Surgical Treatment of Acute Laryngeal Stenosis_.--Multiple puncture
of acute inflammatory edema, while readily performed with the
laryngeal knife used through the direct laryngoscope, is an uncertain
measure of relief. Tracheotomy, if done low in the neck, will
completely relieve the dyspnea. By its therapeutic effect of rest, it
favors the rapid subsidence of the inflammation in the larynx and is
the treatment to be preferred. Intubation is treacherous and
unreliable except in diphtheritic cases; but in the diphtheritic cases
it is ideal, if constant skilled watching can be had.
[279] CHAPTER XXXVII--TRACHEOTOMY
_Indications_.--Tracheotomy is indicated in dyspnea of laryngotracheal
origin. The cardinal signs of this form of dyspnea are:
1. Indrawing at the suprasternal notch.
2. Indrawing around the clavicles.
3. Indrawing of the intercostal spaces.
4. Restlessness.
5. Choking and waking as soon as the aid of the voluntary
respiratory muscles ceases in falling to sleep.
6. Cyanosis is a dangerously late symptom.
As a therapeutic measure in diseases of the larynx its place has been
thoroughly established. Marked improvement of the laryngeal lesions
has been observed to follow tracheotomy in advanced laryngeal
tuberculosis, and in cancer of the larynx. It has proven, in some
cases, a useful adjunct in the treatment of luetic laryngitis, though
it cannot be regarded as indicated, in the absence of dyspnea.
Perichondritis and other inflammations are benefited by tracheotomy. A
marked therapeutic effect on multiple laryngotracheal papillomata in
children has been noted by the author in hundreds of cases.
_Tracheotomy for foreign body_ is no longer indicated either for the
removal of the intruder, or for the insertion of the bronchoscope.
Tracheotomy may be urgently indicated for foreign body dyspnea, but
not for foreign body removal.
_Subcutaneous rupture of the trachea_ from external trauma may produce
dyspnea and generalized emphysema, both of which will be relieved by
tracheotomy.
[280] _Acromegalic stenosis of the larynx_ is a rare but urgent
indication for tracheotomy.
_Contraindications_.--There are no contraindications to tracheotomy
for dyspnea.
_The instruments_ required for an orderly tracheotomy are:
Headlight
Scalpels
2 Retractors
Trousseau dilator
6 Hemostats
Scissors (dissecting)
Tracheal cannulae (six sizes)
Curved needles
Needle holder
Hypodermic syringe for local anesthesia
No. 1 plain catgut ligatures
Linen tape
Gauze sponges
These are sterilized and kept in a sterile copper box ready for
instant use. Beside the patient's bed following the tracheotomy the
following sterile materials are placed:
Sterile gloves
1 Hemostat
Sterile new gauze
Trousseau dilator
Scissors
Duplicate tracheotomy tube
Silver probe
Basin of Bichloride of mercury solution, 1 : 10,000
Tracheotomy is one of the oldest operations known to surgery, yet
strange to say, it is probably more often improperly performed today,
and more often followed by needless mortality, than any other
operation. The two chief preventable sequelae are death from improper
routine surgical care and wrongly fitted tube, and stenosis from too
high an operation. The classical descriptions of crico-thyroidotomy
and high and low tracheotomy have been handed down to generations of
medical students without revision. Every medical graduate has been
taught that there are two kinds of tracheotomy, high and low, the low
operation being very difficult, the high operation very easy. When he
is suddenly called upon to do an emergency tracheotomy, this erroneous
teaching is about all that remains in the dim recesses of his memory;
consequently he makes sure of doing the operation high enough, and
goes in through the larynx, usually dividing the cricoid cartilage,
the only complete ring in the trachea. As originally made the
distinction between high and low as applied to tracheotomy referred to
operations above and below the isthmus of the thyroid gland, in a day
when primitive surgery attached too much importance to operations upon
the thyroid gland. The isthmus is entitled to absolutely no
consideration whatever in deciding the location at which to incise so
vital a structure as the trachea. Students are taught different short
skin incisions for these two operations, and it is no wonder that
they, as did their predecessors, find tracheotomy a difficult, bloody,
and often futile operation. The trachea is searched for at the bottom
of a short, deep wound filled with blood, the source of which is
difficult to find and impossible to control.
_Tracheotomic cannulae_ should be made of sterling silver. German
silver plated with pure silver is good enough for temporary use, but
the plating soon wears off under the galvanic action set up between
the two metals. Aluminum becomes roughened by boiling and contact with
secretions, and causes the formation of granulations which in time
lead to stenosis. Hard rubber tubes cannot be boiled, the walls are so
thick as to leave too little lumen, and the rubber is irritating to
the tissues. All tracheotomy tubes should be fitted with pilots. Many
of the tubes furnished to patients have no pilots to facilitate the
introduction, and the tubes are inserted with somewhat the effect of a
cheese tester, and with great pain and suffering on the part of the
patient. Most of the the tubes in the shops are too short to allow for
the swelling of the tissues of the neck following the operation. They
may reach the trachea at the time of the operation, but as soon as the
reactionary swelling occurs, the end of the tube is pulled out (Fig.
103) of the tracheal incision; the air hissing along the tube is
considered by the attendant to indicate that the tube is still in
place, and the increasing dyspnea and accelerated respiratory rate are
attributed to supposed pneumonia or edema of the lungs, under which
erroneous diagnosis the patient is buried. In all cases in which it is
reported that in spite of tracheotomy the dyspnea was only temporarily
relieved, the fault is the lack of a "plumber." That is, an attendant
who will make sure that there is at all times a clear airway all the
way down to the lungs. With a bronchoscope and aspirator he will see
that the airway is clear. To begin with, a proper sized cannula must
be selected. The series of different sized, full curved tubes, one of
which is illustrated in Fig. 104, will under all conditions reach the
trachea. If the tube seems to be too long in any given case, it will
usually be found that the tracheotomy has been done too high, and a
lower one should be done at once. If the operation has not been done
too high, and the cannula is too long, a pad of gauze under the shield
will take up the surplus length. In cases of tracheal compression from
new growth, thymus or other such cases, in which the ordinary tube
will not pass the obstruction, the author's long cane-shaped cannula
(see Fig. 104) can be inserted past the obstruction, and if necessary
into either bronchus. The fenestrum placed in the cannula in many of
the older tubes, with the supposed function of allowing partial
breathing through the larynx, is a most pernicious thing. A properly
fitted tube should not take up more than half of the cross section of
the trachea, and should allow the passage of sufficient air for free
laryngeal breathing when it is completely corked. The fenestrum is,
moreover, rarely so situated that air can pass through it; the
fenestral edges act as a constant irritant to the wound, producing
bleeding and granulation tissue.
[FIG. 103.--Schema showing thick pad of gauze dressing, filling the
space, A, and used to hold out the author's full-curved cannula when
too long, prior to reactionary swelling, and after subsidence of the
latter. At the right is shown the manner in which the ordinary cannula
of the shops permits a patient to asphyxiate, though some air is heard
passing through the tracheal opening, H, after the cannula has been
partially withdrawn by swelling of the tissues, T.]
[FIG. 104.--The author's tracheotomic cannulae. A, shows cane-shaped
cannula for use in intrathoracic compressive or other stenoses. B,
shows full curved cannula for regular use. Pilots are made to fit the
outer cannula; the inner cannula not being inserted until after
withdrawal of the pilot.]
_Anesthesia_.--No dyspneic patient should be given a general
anesthetic; because any patient dyspneic enough to need a tracheotomy
for dyspnea is depending largely upon the action of the accessory
respiratory muscles. When this action is stopped by beginning
unconsciousness, respiration ceases. If the trachea is not immediately
opened, artificial respiration instituted, and oxygen insufflated, the
patient dies on the table. Skin infiltration along the line of
incision with a very weak cocaine solution (1/10 of 1 per cent),
apothesine (2 per cent), novocaine, Schleich's fluid or other local
anesthetic, suffices to render the operation painless. The deeper
structures have little sensation and do not require infiltration. It
has been advocated that an interannular injection of cocaine solution
with a hypodermic syringe be done just prior to incision of the
trachea for the purpose of preventing cough after the incision of the
trachea and the insertion of the cannula. It would seem, however, that
this introduces the risk of aspiration pneumonia and pulmonary
abscess, by permitting the aspiration and clotting of blood in small
bronchi, followed by subsequent breaking down of the clots. As the
author has so often said, "The cough reflex is the watch dog of the
lungs," and if not drugged asleep by local or general anesthesia can
safely be relied upon to prevent all possibility of the blood or the
pus which nearly always is present in acute or chronic conditions
calling for tracheotomy, being aspirated into the deeper air-passages.
Cocaine in any form, by any method, and in any dosage, is dangerous in
very young children.
_Technic_.--The patient should be placed in the recumbent position,
with the extended head held in the midline by an assistant. The
shoulders, not the neck, should be slightly raised with a sand bag.
The head should be somewhat lower than the feet, to lessen the danger
of aspiration of blood. A midline incision dividing the skin and
fascia is made from the thyroid notch to just above the suprasternal
notch. The cricoid is now located, and the deeper dissection is
continued from below this point. The ribbon muscles are separated with
dissecting scissors or knife, and held apart with retractors. If the
isthmus of the thyroid gland is in the way, it may be retracted
upward; if large, however, it should be divided and ligated, for it is
apt to slip over the tracheal incision afterward, and render difficult
the quick finding of the incision during after-care. This covering of
the tracheal incision by the slipping back of the drawn-aside
thyroidal isthmus is one of the most frequent avoidable causes of
mortality, because it deflects the cannula off into the tissues when
it is replaced after cleaning during the early postoperative period.
The corrugated surface of the trachea can be felt, and its exact
location can be determined by the index finger. If the tracheotomy is
proceeding in an orderly manner, all bleeding points should be caught
and tied with plain catgut (No. 1) before the trachea is opened.
Because of distension of vessels during cough, all but the tiniest
vessels should be ligated. Side-cut veins are particularly
treacherous. They should be freed of tissue, cut across and the
divided ends ligated.
The _incision in the trachea_ should be as low as possible, and should
never be made through the first ring. The incision should be through
the third, fourth and fifth rings. Only in cases of laryngoptosis will
it be necessary to incise the trachea higher than this. The incision
must be made in the midline, and in the long axis of the trachea, and
care must be exercised that the point of the knife does not perforate
the posterior tracheal wall. Stab incisions are always to be avoided.
If the incision in the trachea is found to be of insufficient length,
the original incision must be found and elongated. A second incision
must not be made, for the portion of cartilage between the two
incisions will die and will almost certainly make a site of future
tracheal stenosis. The cricoid should never be cut, for stenosis is
almost sure to follow the wearing of a cannula in this position. A
Trousseau dilator should now be inserted in the tracheal incision, its
blades gently separated. With the tracheal lumen thus opened, a
cannula of proper size is introduced with absolute certainty of its
having entered the trachea. A quadruple-folded square of gauze in the
form of a pad about four inches square is moistened with mercuric
chloride solution (1:10,000) and is slit from the lower border to its
midpoint. This pad is slipped from above downward under the tape
holder of the cannula, the slit permitting the tubal part of the
cannula to reach the central part of the pad (Fig. 108), and
completely covers the wound. No attempt should be made to suture the
skin wound, for this tends to form a pocket in which lodge the
bronchial secretions that escape alongside the tube, resulting in
infection of the wound. Furthermore it renders the daily changing of
the tube much more difficult. In fact it prevents the attendant from
being certain that the tube is actually placed in the trachea.
Suturing of the skin to the trachea should never be done, for the
sutures soon tear out and often set up a perichondritis of the
tracheal cartilages, with resulting difficult decannulation.
[FIG. 105.--Schema of practical gross anatomy to be memorized for
emergency tracheotomy. The middle line is the safety line, the higher
the wider. Below, the safety line narrows to the vanishing point VP.
The upper limit of the safety line is the thyroid notch until the
trachea is bared, when the limit falls below the first tracheal ring.
In practice the two-dark danger lines are pushed back with the left
thumb and middle finger as shown in Fig. 106, thus throwing the safety
line into prominence. This is generally known as Jackson's
tracheotomic triangle.]
[FIG. 106.--Schema showing the author's method of rapid tracheotomy.
First stage. The hands are drawn ungloved for the sake of clearness.
The upper hand is the left, of which the middle finger (M) and the
thumb are used to repress the sterno-cleido-mastoid muscles, the
finger and thumb being close to the trachea in order to press backward
out of the way the carotid arteries and the jugular vein. This throws
the trachea forward into prominence, and one deep slashing cut will
incise all of the soft tissues down to the trachea.]
_Emergency Tracheotomy_.--Stabbing of the cricothyroid membrane, or an
attempted stabbing of the trachea, so long taught as an emergency
tracheotomy, is a mistake. The author's "two stage, finger guided"
method is safer, quicker, more efficient, and not likely to be
followed by stenosis. To execute this promptly, the operator is
required to forget his textbook anatomy and memorize the schema (Fig.
105). The larynx and trachea are steadied by the thumb and middle
finger of the left hand, which at the same time push back the
important nerves and vessels which parallel the trachea, and render
the central safety line more prominent (Fig. 106). A long incision is
now made from the thyroid notch almost to the suprasternal notch, and
deep enough to reach the trachea. This completes the first stage.
[FIG. 107.--Illustrating the author's method of quick tracheotomy.
Second stage. The fingers are drawn ungloved for the sake of
clearness. In operating the whole wound is full of blood, and the
rings of the trachea are felt with the left index which is then moved
slightly to the patient's left, while the knife is slid down along the
left index to exactly the middle line when the trachea is incised.]
Second stage. The entire wound is full of blood and the trachea cannot
be seen, but its corrugations can be very readily felt by the tip of
the free left index finger. The left index finger is now moved a
little to the patient's left in order that the knife shall come
precisely in the midline of the trachea, and three rings of the
trachea are divided from above downward (Fig. 107). The Trousseau
dilator should now be inserted, the head of the table should be
lowered, and the patient should be turned on the side to allow the
blood to run away from the wound. If respiration has ceased, a cannula
is slipped in, and artificial respiration is begun. Oxygen
insufflation will aid in the restoration of respiration, and a pearl
of amyl nitrite should be crushed in gauze and blown in with the
oxygen. In all such cases, excessive pressure of oxygen should be
avoided because of the danger of producing ischemia of the lungs. Hope
of restoring respiration should not be abandoned for half an hour at
least. One of the author's assistants, Dr. Phillip Stout, saved a
patient's life by keeping up artificial respiration for twenty minutes
before the patient could do his own breathing.
The _after-care_ of the tracheotomic wound is of the utmost
importance. A special day and night nurse are required. The inner tube
of the cannula must be removed and cleaned as soon as it contains
secretion. Secretion coughed out must be wiped away quickly, but
gently, before it is again aspirated. The gauze dressing covering the
wound must be changed as soon as soiled with secretions from the wound
and the air-passages. Each fresh pad should be moistened with very
weak bichloride of mercury solution (1:10,000). The outer tube must be
changed every twenty-four hours, and oftener if the bronchial
secretion is abundant. Student-physicians who have been taught my
methods and who have seen the cases in care of our nurses have often
expressed amazement at the neglect unknowingly inflicted on such cases
elsewhere, in the course of ordinary routine surgery. It is not
unusual for a patient to be sent to the Bronchoscopic Clinic who has
worn his cannula without a single changing for one or two years. In
some cases the tube had broken and a portion had been aspirated into
the trachea.
[FIG. 108.--Method of dressing a tracheotomic wound. A broad
quadruple, in-folded pad of gauze is cut to its centre so that it can
be slipped astride of the tube of the cannula back of the shield. No
strings, ravellings or strips of gauze are permissible because of the
risk of their getting down into the trachea.]
If the respiratory rate increases, instead of attributing it to
pulmonary complications, the entire cannula should be removed, the
wound dilated with the Trousseau forceps, the interior of the trachea
inspected, and all secretions cleaned away. Then the tracheal mucosa
below the wound should be gently touched with a sterile bent probe, to
induce cough to rid the lower air passages of accumulated secretions.
In many cases it is a life-saving procedure to insert a sterile long
malleable aspirating tube to remove secretions from the lower
air-passages. When all is clear, a fresh sterile cannula which has
been carefully inspected to see that its lumen has been thoroughly
cleaned, is inserted, and its tapes tied. Good "plumbing," that is,
the maintenance at all times of a clear, clean passage in all the
"pipes," natural and artificial, is the reason why the mortality in
the Bronchoscopic Clinic has been less than half of one per cent,
while in ordinary routine surgical care in all hospitals collectively
it ranges from 10 to 20 per cent.
_Bronchial Aspiration_.--As mentioned above, bronchial aspiration is
often necessary. When the patient is unable to get up secretions, he
will, as demonstrated by the author many years ago, "drown in his own
secretions." In some cases bronchoscopic aspiration is required
(Peroral Endoscopy, p. 483). Occasionally, very thick secretions will
require removal with forceps. Pus may become very thick and gummy from
the administration of morphin. Opiates do not lessen pus formation,
but they do lessen the normal secretions that ordinarily increase the
quantity and fluidity of the pus. When to this is added the
dessicating effect of the air inhaled through the cannula, unmoistened
by the upper air-passages, the secretions may be so thick as to form
crusts and plugs that are equivalent to foreign bodies and require
removal with forceps. Diphtheritic membrane in the trachea may require
removal with bronchoscope and forceps. Thinner secretions may be
removed by sponge-pumping. In most cases, however, secretions can be
brought up through an aspirating tube, connected to a bronchoscopic
aspirating syringe (Fig. 11), an ordinary aspirating bottle, or
preferably, a mechanical aspirator such as that shown in Fig. 12. In
this, combined with bronchoscopic oxygen insuflation (q.v.), we have a
life-saving measure of the highest efficiency in cases of poisoning by
chlorine and other irritant and asphyxiating gases. An aspirating tube
for insertion into the deeper air passages should be of copper, so
that it can be bent to the proper curve to reach into the various
parts of the tracheobronchial tree, and it should have a removable
copper-wire core to prevent kinking, and collapse of the lumen. The
distal end should be thickened, and also perforated at the sides, to
prevent drawing-in of the mucosa and trauma thereto. A rubber tube may
be used, but is not so satisfactory. The one shown in Fig. 10 I had
made by Mr. Pilling, and it has proved very satisfactory.
_Decannulation_.--When the tracheal incision is placed below the first
ring, no difficulty in decannulation should result from the operation
per se. When by temporarily occluding the cannula with the finger it
is evident that the laryngeal aperture has regained sufficient size to
allow free breathing, a smaller-sized tracheotomic tube should be
substituted to allow free passage of air around the cannula in the
trachea. In doing this, the amount of secretion and the handicap of
impaired glottic mobility in the expulsion of thick secretions must be
borne in mind. Babies labor under a special handicap in their
inefficient bechic expulsion and especially in their small cannulae
which are so readily occluded. If breathing is not free and quiet with
the smaller tube; the larger one must be replaced. If, however, there
is no trouble with secretions, and the breathing is free and quiet,
the inner cannula should be removed, and the external orifice of the
outer cannula firmly closed with a rubber cork. If the laryngeal
condition has been acute, decannulation can usually be safely done
after the patient has been able to sleep quietly for three nights with
a corked cannula. If free breathing cannot be obtained when the
cannula is corked, the larynx is stenosed, and special work will be
required to remove the tube. Children sometimes become panic stricken
when the cannula is completely corked at once and they are forced to
breathe through the larynx instead of the easier shortcut through the
neck. In such a case, the first step is partially to cork the cannula
with a half or two-thirds plug made from a pure rubber cord fashioned
in the desired shape by grinding with an emery wheel (Fig. 112). Thus
the patient is gradually taught to use the natural air-way, still
feeling that he has an "anchor to windward" in the opening in the
cannula. When some swelling of the laryngeal structures still exists,
this gradual corking has a therapeutic effect in lessening the
stenosis by exercising the muscles of abduction of the cords and
mobilizing the cricoarytenoid articulation during the inspiratory
effort. The forced respiration keeps the larynx freed from secretions,
which are more or less purulent and hence irritating. After removing
the cannula, in order that healing may proceed from the bottom upward,
the wound should be dressed in the following manner: A single
thickness of gauze should be placed over the wound and the front of
the neck, and a gauze wedge firmly inserted over this to the depths of
the tracheotomic wound, all of this dressing being held in place by a
bandage. If the skin-wound heals before the fibrous union of the
tracheal cartilages is complete, exuberant granulations are apt to
form and occlude the trachea, perhaps necessitating a new tracheotomy
for dyspnea.
It is so important to fix indelibly in the mind the cardinal points
concerning tracheotomy that I have appended to this chapter the
teaching notes that I have been for years giving my classes of
students and practitioners, hundreds of whom have thanked me for
giving them the clear-cut conception of tracheotomy that enabled them,
when their turn came to do an emergency tracheotomy, to save human
life.
RESUME OF TRACHEOTOMY
_Instruments_.
Headlight
Sandbag
Scalpel
Hemostats
Small retractors
Tenaculum
Tracheotomic cannulae (proper kind)
Long.
Half area cross-section trachea.
Proper curve: Radius too short will press ant. tracheal wall; too
long, post. wall.
Sterling Silver
Tracheobronchial aspirator.
Probe.
Tapes for cannulae
Trousseau dilator
Sponges
Infiltration syringe and solution
Oxygen tank.
_Indications_: Laryngeal dyspnea.
(Indrawing guttural and clavicular fossae and at epigastrium.
Pallor. Restlessness. Drowning in his own secretions.)
Do it early. Don't wait for cyanosis.
[294] Never use general anesthesia on dyspneic patient.
Forget about "high" and "low" distinctions until trachea is exposed.
Memorize Jackson's tracheotomic triangle.
Patient recumbent, sand bag under shoulders or neck. Nose to zenith.
Infiltration, _Intra_dermatic.
Incise from Adam's apple to guttural fossa.
Hemostasis.
Keep in middle line.
Feel for trachea.
Expose isthmus of thyroid gland.
Draw it upward or downward or cut it.
Ligature, torsion, etc. before incising trachea.
Hold trachea with tenaculum.
Incise trachea below first ring.
Avoid cutting cricoid or first ring. Cut 3 rings vertically. Don't
hack. Don't cut posterior wall which almost touches the anterior wall
during cough. Spread carefully, with Trousseau dilator.
Insert cannula; _see_ it enter tracheal lumen; remove pilot; tie
tapes.
Don't suture wound. Dress with large squares.
Don't give morphine.
Decannulation by corking partially, after changing to smaller
cannula.
Do not remove cannula permanently until patient sleeps without
indrawing with corked cannula.
RESUME OF EMERGENCY TRACHEOTOMY
The following notes should be memorized.
1. Essentials: Knife and pair of hands (but full equipment better).
[295] 2. Don't do a laryngotomy, or stabbing.
3. "Two stage, finger guided" operation better.
4. Sand bag or substitute.
5. Press back danger lines with left thumb and middle finger, making
safety line and trachea prominent.
6. Memorize Jackson's tracheotomic triangle.
7. Incise exactly in middle line from Adam's apple to sternum.
8. Feel for tracheal corrugations with left index in pool of blood,
following trachea with finger downward from superficial Adam's apple.
9. Pass knife along index and incise trachea (not too deeply, may
cut posterior wall).
10. Don't mind bleeding; but keep middle line and keep head
straight; keep head low; don't bother about thyroid gland.
11. Don't expect hiss when trachea is cut if patient has stopped
breathing.
12. Start artificial respiration.
13. Amyl nitrite. Oxygen.
14. Practice palpation of the neck until the tracheal landmarks are
familiar.
15. Practice above technic, up to point of incision, at every
opportunity.
16. _Jackson's tracheotomic triangle_: A triangulation of the front
of the neck intended to facilitate a proper emergency tracheotomy.
Apex at suprasternal notch.
Sides anterior edge sternomastoids.
Base horizontal line lower edge cricoid.
RESUME OF AFTER-CARE OF A TRACHEOTOMIC CASE
1. Always bear in mind that tracheotomy is not an ultimate object.
The ultimate object is to pipe air down into the lungs. Tracheotomy is
only a means to that end.
2. Sterile tray beside bed should contain duplicate (exact)
tracheotomy tube, Trousseau dilator, hemostat, thumb forceps, silver
probe, scissors, scalpel, probe-pointed curved bistoury. Sterile
gloves ready.
3. Special nursing necessary for safety.
4. Laxative.
5. Sponge away secretions before they are drawn in.
6. Cover wound with wide large gauze square slit so it fits around
cannula under the tape holder. Pull off ravelings. Keep wet with
1 : 10,000 Bichloride solution.
7. Change dressing every hour or oftener.
8. Abundance of fresh air, temperature preferably about 70 degrees.
9. _Nurse should remove inner cannula as often as needed and clean
it with pipe cleaner before boiling._
10. Outer cannula should be changed every day by the surgeon or
long-experienced tracheotomy nurse. A pilot should be used and care
should be taken not to injure the cut ends of the tracheal cartilage.
11. A sterile, bent probe may be inserted downward in the trachea
with both cannulae out to excite cough if necessary to expel
secretions. An aspirating tube should be used, when necessary.
12. A patient with a properly fitted cannula free of secretions
breathes noiselessly. Any sound demands immediate attention.
13. If the respiratory rate increase it is much more likely to be
due to obstruction in, malposition of, or shortness of the cannula
than to lung complications.
14. Be sure that:
(a) The cannula is clear and clean.
(b) The cannula is long enough to reach well down into the
trachea. A cannula that was long enough when the operation was done
may be too short after the cervical tissues swell.
(c) The distal end of the cannula actually is deeply in the
trachea. The only way to be sure is, when inserting the cannula, to
spread the wound and the tracheal incision with a Trousseau dilator,
then _see_ the interior of the tracheal lumen and _see_ the cannula
enter therein.
15. If after attending to the above mentioned details there are
still signs of obstructive dyspnea, a bronchoscopy should be done for
finding and removal of the obstruction in the trachea or main bronchi.
16. If all the "pipes," natural and instrumental, are clear there
can be no such thing as obstructive dyspnea.
17. Pneumonia and pulmonary edema may exist before tracheotomy, but
they are rare sequelae.
18. Decannulation, in cases of tracheotomy done for temporary
conditions should not be attempted until the patient has slept at
least 3 nights with his cannula tightly corked. A properly fitted
cannula (i.e. one not larger than half the area of cross section of
the trachea) permits the by-passage of plenty of air. A partial cork
should be worn for a few days first for testing and "weaning" a child
away from the easier breathing through the neck. In cases of chronic
laryngeal stenosis a prolonged test is necessary before attempting
decannulation.
19. A tracheotomic case may be aphonic, hence unable to call for
help.
20. The foregoing rules apply to the post-operative periods. After
the wound has healed and a fistula is established, the patient, if not
a child, may learn to care for his own cannula.
[298] 21. Do not give cough-sedatives or narcotics. The cough reflex
is the watch dog of the lungs.
NOTES ON NURSING TRACHEOTOMIZED PATIENTS
Bedside tray should contain:
Duplicate cannula
Scalpel
Trousseau dilator
Hemostat
Dressing forceps
Sterile vaseline
Scissors
Tape
Probe
Gauze sponges
Gauze squares
Probe-pointed curved bistoury.
1. Room should be abundantly ventilated, as free from dust and lint
as possible, and the air should be moistened by steam in winter.
2. Keep mouth clean. Tooth brush. Rinse alcohol 1:10.
3. Sponge away secretion after the cough before drawn in.
4. Remove inner cannula (not outer) as often as needed. Not less
often than every hour. Replace immediately. Never boil a cannula until
you have thoroughly cleaned it.
5. Obstruction of cannula calling for cleaning indicated by:
Blue or ashy color.
Indrawing at clavicles, sternal notch, epigastrium.
Noisy breathing. (Learn sound.)
6. Surgeon (in our cases) will change outer cannula once daily or
oftener.
7. Duplicate cannulae.
8. Be careful in cleaning cannulae not to damage.
9. Watch for loose parts on cannula.
10. Change dressing (in our cases) as often as soiled. Not less
often than every hour. Large squares. Never narrow strips.
11. Watch color of lips and ears and face.
[299] 12. Report at once if food or water leaks through wound.
(Coughing and choking).
13. Never leave a tracheotomized patient unwatched during the first
days or weeks, according to case.
14. Remember Trousseau dilator or hemostat will spread the tracheal
wound or fistula when cannula is out.
15. Remember life depends on a clear cannula if the patient gets no
air through the mouth.
16. Remember it takes very little to clog the small cannula of a
child.
17. Remember a tracheotomized patient cannot call for help.
18. Decannulation. Testing by corking partially. Watch corks
not too small, or broken. Attach them by braided silk
thread. Pure rubber cord ground down makes best cork.
[300] CHAPTER XXXVIII--CHRONIC STENOSIS OF THE LARYNX AND TRACHEA
The various forms of laryngeal stenosis for which tracheotomy or
intubation has been performed, and the difficulties encountered in
restoring the natural breathing, may be classified into the following
types:
1. Panic
2. Spasmodic
3. Paralytic
4. Ankylotic (arytenoid)
5. Neoplastic
6. Hyperplastic
7. Cicatricial
(a) Loss of cartilage
(b) Loss of muscular tissue
(c) Fibrous
_Panic_.--Nothing so terrifies a child as severe dyspnea; and the
memory of previous struggles for air, together with the greater ease
of breathing through the tracheotomic cannula than through even a
normal larynx, incites in some cases so great a degree of fear that it
may properly be called panic, when attempts at decannulation are made.
Crying and possibly glottic spasm increase the difficulties.
_Spasmodic stenosis_ may be associated with panic, or may be excited
by subglottic inflammation. Prolonged wearing of an intubation tube,
by disturbing the normal reciprocal equilibrium of the abductors and
adductors, is one of the chief causes. The treatment for spasmodic
stenosis and panic is similar. The use of a special intubation tube
having a long antero-posterior lumen and a narrow neck, which form
allows greater action of the musculature, has been successful in some
cases. Repeated removal and replacement of the intubation tube when
dyspnea requires it may prove sufficient in the milder cases. Very
rarely a tracheotomy may be required; if so, it should be done low.
The wearing of a tracheotomic cannula permits a restoration of the
muscle balance and a subsidence of the subglottic inflammation.
Corking the cannula with a slotted cork (Fig. 111) will now restore
laryngeal breathing, after which the tracheotomic cannula may be
removed.
[PLATE V--PHOTOPROCESS REPRODUCTIONS OF THE AUTHOR'S OIL-COLOR
DRAWINGS FROM LIFE--LARYNGEAL AND TRACHEAL STENOSES:
1, Indirect view, sitting position; postdiphtheric cicatricial
stenosis permanently cured by endoscopic evisceration. (See Fig. 5.)
2, Indirect view, sitting position; posttyphoid cicatricial stenosis.
Mucosa was very cyanotic because cannula was re-moved for laryngoscopy
and bronchoscopy. Cured by laryngostomy. (See Fig. 6.) 3, Indirect
view, sitting position; posttyphoid infiltrative stenosis, left
arytenoid destroyed by necrosis. Cured by laryngostomy; failure to
form adventitious band (Fig. 7) because of lack of arytenoid activity.
4, Indirect view, recumbent position; posttyphoid cicatricial
stenosis. Cured of stenosis by endoscopic evisceration with sliding
punch forceps. Anterior commissure twice afterward cleared of
cicatricial tissue as in the other case shown in Fig. 15. Ultimate
result shown in Fig. 8. 5, Same patient as Fig. 1; sketch made two
years after decannulation and plastic. 6, Same patient as Fig. 2;
sketch made four years after decannulation and plastic. 7, Same
patient as Fig. 3; sketch made three years after decannulation and
plastic. 8, Same patient as Fig. 4; sketch made one year after
decannulation, fourteen months after clearing of the anterior
commissure to form adventitious cords. 9, Direct view, recumbent
patient; web postdiphtheric (?) or congenital (?). "Rough voice" since
birth, but larynx never examined until stenosed after diphtheria. Web
removed and larynx eviscerated with punch forceps; recurrence of
stenosis (not of web). Cure by laryngostomy. This view also
illustrates the true depth of the larynx which is often overlooked
because of the misleading flatness of laryngeal illustrations. 10,
Direct laryngoscopic view; postdiphtheric hypertrophic subglottic
stenosis. Cured by galvanocauterization. 11, Direct laryngoscopic
view; postdiphtheric hypertrophic supraglottic stenosis. Forceps
excision; extubation one month later; still well after four years. 12,
Bronchoscopic view of posttracheotomic stenosis following a "plastic
flap" tracheotomy done for acute edema. 13, Direct laryngoscopic view;
anterolateral thymic compression stenosis in a child of eighteen
months. Cured by thymopexy. 14, Indirect laryngoscopic (mirror) view;
laryngostomy rubber tube in position in treatment of post-typhoid
stenosis. 15, Direct view; posttyphoid stenosis after cure by
laryngostomy. Dotted line shows place of excision for clearing out the
anterior commissure to restore the voice. 16, Endoscopic view of
posttracheotomic tracheal stenosis from badly placed incision and
chondrial necrosis. Tracheotomy originally done for influenzal
tracheitis. Cured by tracheostomy.]
_Paralysis_.--Bilateral abductor laryngeal paralysis causes severe
stenosis, and usually tracheotomy is urgently required. In cadaveric
paralysis both cords are in a position midway between abduction and
adduction, and their margins are crescentic, so that sufficient airway
remains. Efforts to produce the cadaveric position of the cords by
division or excision of a portion of the recurrent laryngeal nerves,
have been failures. The operation of _ventriculocordectomy_ consists
in removing a vocal cord and the portion or all of the ventricular
floor by means of a punch forceps introduced through the direct
laryngoscope. Usually it is better to remove only the portion of the
floor anterior to the vocal process of the arytenoid. In some cases
monolateral ventriculocordectomy is sufficient; in most cases,
however, operation on both sides is needed. An interval of two months
between operations is advisable to avoid adhesions. In almost all
cases, ventriculocordectomy will result in a sufficient increase in
the glottic chink for normal respiration. The ultimate vocal results
are good. Evisceration of the larynx, either by the endoscopic or
thyrotomic method, usually yields excellent results when no lesion
other than paralysis exists. Only too often, however, the condition is
complicated by the results of a faultily high tracheotomy. A rough,
inflexible voice is ultimately obtained after this operation,
especially if the arytenoid cartilage is unharmed. In recent bilateral
recurrent paralysis, it may be worthy of trial to suture the recurrent
to the pneumogastric. Operations on the larynx for paralytic stenosis
should not be undertaken earlier than twelve months from the inception
of the condition, this time being allowed for possible nerve
regeneration, the patient being made safe and comfortable, meanwhile,
by a low tracheotomy.
_Ankylosis_.--Fixation of the crico-arytenoid joints with an
approximation of the cords may require evisceration of the larynx.
This, however, should not be attempted until after a year's lapse, and
should be preceded by attempts to improve the condition by endoscopic
bouginage, and by partial corking of the tracheotomic cannula.
_Neoplasms_.--Decannulation in neoplastic cases depends upon the
nature of the growth, and its curability. Cicatricial contraction
following operative removal of malignant growths is best treated by
intubational dilatation, provided recurrence has been ruled out. The
stenosis produced by benign tumors is usually relieved by their
removal.
_Papillomata_.--Decannulation after tracheotomy done for papillomata
should be deferred at least 6 months after the discontinuance of
recurrence. Not uncommonly the operative treatment of the growths has
been so mistakenly radical as to result in cicatricial or ankylotic
stenoses which require their appropriate treatments. It is the
author's opinion that recurrent papillomata constitute a benign
self-limited disease and are best treated by repeated superficial
removals, leaving the underlying normal structures uninjured. This
method will yield ultimately a perfect voice and will avoid the
unfortunate complications of cicatricial hypertrophic and ankylotic
stenosis.
_Compression Stenosis of the Trachea_.--Decannulation in these cases
can only follow the removal of the compressive mass, which may be
thymic, neoplastic, hypertrophic or inflammatory. Glandular disease
may be of the Hodgkins' type. Thymic compression yields readily to
radium and the roentgenray, and the tuberculous and leukemic
adenitides are sometimes favorably influenced by the same agents.
Surgery will relieve the compression of struma and benign neoplasms,
and may be indicated in certain neoplasms of malignant origin. The
possible coexistence of laryngeal paralysis with tracheal compression
is frequently overlooked by the surgeon. Monolateral or bilateral
paralysis of the larynx is by no means an uncommon postoperative
sequel to thyroidectomy, even though the recurrent nerves have been in
no way injured at operation. Probably a localized neuritis, a
cicatricial traction, or inclusion of a nerve trunk accounts for most
of these cases.
_Hyperplastic and cicatricial chronic stenoses_ preventing
decannulation may be classified etiologically as follows:
1. Tuberculosis
2. Lues
3. Scleroma
4. Acute infectious diseases
(a) Diphtheria
(b) Typhoid fever
(c) Scarlet fever
(d) Measles
(e) Pertussis
5. Decubitus
(a) Cannular
(b) Tubal
6. Trauma
(a) Tracheotomic
(b) Intubational
(c) Operative
(d) Suicidal and homicidal
(e) Accidental (by foreign bodies, external violence, bullets,
etc.)
Most of the organic stenoses, other than the paralytic and neoplastic
forms, are the result of inflammation, often with ulceration and
secondary changes in the cartilages or the soft tissues.
[304] _Tuberculosis_.--In the non-cicatricial forms, galvanocaustic
puncture applied through the direct laryngoscope will usually reduce
the infiltrations sufficiently to provide a free airway. Should the
pulmonary and laryngeal tuberculosis be fortunately cured, leaving,
however, a cicatricial stenosis of the larynx, decannulation may be
accomplished by laryngostomy.
_Lues_.--Active and persistent antiluetic medication must precede and
accompany any local treatment of luetic laryngeal stenosis. Prolonged
stretching with oversized intubation tubes following excision or
cauterization may sometimes be successful, but laryngostomy is usually
required to combat the vicious contraction of luetic cicatrices.
_Scleroma_ is rarely encountered in America. Radiotherapy has been
advocated and good results have been reported from the intravenous
injection of salvarsan. Radium may be tried, and its application is
readily made through the direct laryngoscope.
_Diphtheria_.--Chronic postdiphtheritic stenosis may be of the panic,
spasmodic or, rarely, the paralytic types; but more often it is of
either the hypertrophic or cicatricial forms. Only too frequently the
stenosis should be called posttracheotomic rather than
postdiphtheritic, since decannulation after the subsidence of the
acute stenosis would have been easy had it not been for the sequelae
of the faulty tracheotomy. Prolonged intubation may induce either a
supraglottic or subglottic tissue hyperplasia. _The supraglottic type_
consists in an edematous thickening around the base of the epiglottis,
sometimes involving also the glossoepiglottic folds and the
ventricular bands. An improperly shaped or fitted tube is the usual
cause of this condition, and a change to a correct form of intubation
tube may be all that is required. Excessive polypoid tissue
hypertrophy should be excised. The less redundant cases subside under
galvanocaustic treatment, which may be preceded by tracheotomy and
extubation, or the intubation tube may be replaced after the
application of the cautery. The former method is preferable since the
patient is far safer with a tracheotomic cannula and, further, the
constant irritation of the intubation tube is avoided. _Subglottic
hypertrophic stenosis_ consists in symmetrical turbinal-like swellings
encroaching on the lumen from either side. Cautious galvanocauterant
treatment accurately applied by the direct method will practically
always cure this condition. Preliminary tracheotomy is required in
those cases in which it has not already been done, and in the cases in
which a high tracheotomy has been done, a low tracheotomy must be the
first step in the cure. Cicatricial types of postdiphtheritic stenosis
may be seen as webs, annular cicatrices of funnel shape, or masses of
fibrous tissue causing fixation of the arytenoids as well as
encroachment on the glottic lumen. (See color plates.)
As a rule, when a convalescent diphtheritic patient cannot be
extubated two weeks after three negative cultures have been obtained
the advisability of a low tracheotomy should be considered. If a
convalescent intubated patient cough up a tube and become dyspneic a
low tracheotomy is usually preferable to forcing in an oversized
intubation tube.
_Typhoid Fever_.--Ulcerative lesions in the larynx during typhoid
fever are almost always the result of mixed infection, though
thrombosis of a small vessel, with subsequent necrosis is also seen.
If the ulceration reaches the cartilage, cicatricial stenosis is
almost certain to follow.
_Trauma_.--The chief traumatic factors in chronic laryngeal stenosis
are: (a) prolonged presence of a foreign body in the larynx (b)
unskilled attempts at intubation and the wearing of poorly fitting
intubation tubes; (c) a faulty tracheotomy; (d) a badly fitting
cannula; (e) war injuries; (f) attempted suicide; (g) attempted
homicide; (h) neglect of cleanliness and care of either intubation
tubes or tracheotomic cannulae allowing incrustation and roughening
which traumatize the tissues at each movement of the ever-moving
larynx and trachea.
_Treatment of Cicatricial Stenosis_.--A careful direct endoscopic
examination is essential before deciding on the method of treatment
for each particular case. Granulations should be removed. Intubated
cases are usually best treated by tracheotomy and extubation before
further endoscopic treatment is undertaken. A certain diagnosis as to
the cause of the condition must be made by laboratory and therapeutic
tests, supplemented by biopsy if necessary. Vigorous antiluetic
treatment, especially with protiodide of mercury, must precede
operation in all luetic cases. Necrotic cartilage is best treated by
laryngostomy. Intubational dilatation will succeed in some cases.
[FIG. 109.--Schema showing the author's method of laryngostomy. The
hollow upward metallic branch (N) of the cannula (C) holds the rubber
tube (R) back firmly against the spur usually found on the back wall
of the trachea. Moreover, the air passing up through the rubber tube
(R) permits the patient to talk in a loud whisper, the external
orifice of the cannula being occluded most of the time with the cork
(K). The rubber tubing, when large sizes are reached may extend down
to the lower end of the cannula, the part C coming out through a large
hole cut in the tubing at the proper distance from the lower end.]
_Laryngoscopic bouginage_ once weekly with the laryngeal bougies (Fig.
42) will cure most cases of laryngeal stenosis. For the trachea,
round, silk-woven, or metallic bougies (Fig. 40) are better.
[307] _Laryngostomy_ consists in a midline division of the laryngeal
and tracheal cartilages as low as the tracheotomic fistula, excision
of thick cicatricial tissue, very cautious incision of the scar tissue
on the posterior wall, if necessary, and the placing of the author's
laryngostomy tube for dilatation (Fig. 109). Over the upward branch of
the laryngostomy tube is slipped a piece of rubber tubing which is in
turn anchored to the tape carrier by braided silk thread.
Progressively larger sizes of rubber tubing are used as the laryngeal
lumen increases in size under the absorptive influence of the
continuous elastic pressure of the rubber. Several months of wearing
the tube are required until dilatation and epithelialization of the
open trough thus formed are completed. Painstaking after-care is
essential to success. When dilatation and healing have taken place,
the laryngostomy wound in the neck is closed by a plastic operation to
convert the trough into a trachea by supplying an anterior wall.
_Intubational treatment of chronic laryngeal stenosis_ may be tried in
certain forms of stenosis in which the cicatrices do not seem very
thick. The tube is a silver-plated brass one of large size (Fig. 110).
A post which screws into the anterior surface of the tube prevents its
expulsion. Over the post is slipped a block which serves to keep open
the tracheal fistula. Detailed discussion of these operative
treatments is outside the scope of this work, but mention is made for
the sake of completeness. Before undertaking any of the foregoing
procedures, a careful study of the complete descriptions in Peroral
Endoscopy is necessary, and a practical course of training is
advisable.
[FIG. 110.--The author's retaining intubation tube for treatment of
chronic laryngeal stenosis. The tube (A) is introduced through the
mouth, then the post (B) is screwed in through the tracheal wound.
Then the block (C) is slid into the wound, the square hole in the
block guarding the post against all possibility of unscrewing. If the
threads of the post are properly fitted and tightly screwed up with a
hemostat, however, there is no chance of unscrewing and gauze packing
is used instead of the block to maintain a large fistula. The shape of
the intubation tube has been arrived at after long clinical study and
trials, and cannot be altered without risk of falling into errors that
have been made and eliminated in the development of this shape.]
[309] CHAPTER XXXIX--DECANNULATION AFTER CURE OF LARYNGEAL STENOSIS
In order to train the patient to breathe again through the larynx it
is necessary to occlude the cannula. This is best done by inserting a
rubber cork in the inner cannula. At first it may be necessary to make
a slot in the cork so as to permit some air to enter through the tube
to supplement the insufficient supply obtainable through the
insufficiently patulous glottis, new corks with smaller grooves being
substituted as laryngeal breathing becomes easier. Corking the cannula
is an excellent orthopedic treatment in certain cases where muscle
atrophy and partial inflammatory fixation of the cricoarytenoid joints
are etiological factors in the stenosis. The added pull of the
posterior cricoarytenoid muscles during the slight effort at
inspiration restores their tone and increases the mobility of all the
attached structures. By no other method can panic and spasmodic
stenosis be so efficiently cured.
[FIG. 111.--Illustration of corks used to occlude the cannula in
training patients to breathe through the mouth again, before
decannulation. The corks allow air leakage, the amount of which is
regulated by the use of different shapes. A smaller and still smaller
air leak is permitted until finally an ungrooved cork is tolerated. A
central hole is sometimes used instead of a slot. A, one-third cork;
B, half cork; C, three-quarter cork; D, whole cork.]
Following the subsidence of an acute laryngeal stenosis, it is my rule
to decannulate after the patient has been able to breathe through the
larynx with the cannula tightly corked for 3 days and nights. This
rule does not apply to chronic laryngeal stenosis, for while the lumen
under ordinary conditions might be ample, a slight degree of
inflammation might render it dangerously small. In these cases, many
weeks are sometimes required to determine when decannulation is safe.
A test period of a few months is advisable in most cases of chronic
laryngeal stenosis. Recurrent contractions after closure of the wound
are best treated by endoscopic bouginage. The corks are best made of
pure rubber cord, cut and ground to shape, and grooved, if desired, on
a small emery wheel (Fig. 112). The ordinary rubber corks and those
made of cork-bark should not be used because of their friability, and
the possible aspiration of a fragment into the bronchus, where rubber
particles form very irritant foreign bodies.
[FIG. 112.--This illustration shows the method of making safe corks
for tracheotomic cannulae by grinding pure rubber cord to shape on an
emery wheel. After grinding the taper, if a partial cork is desired, a
groove is ground on the angle of the wheel. If a half-cork is desired
half of the cork is ground away on the side of the wheel. Reliable
corks made in this way are now obtainable from Messers Charles J.
Pilling and Son.]
BIBLIOGRAPHY
The following list of publications of the author may be useful for
reference:
1. Peroral Endoscopy and Laryngeal Surgery, Textbook, 1914.
(Contains full bibliography to date of publication.)
2. Acromegaly of the Larynx. Journ. Amer. Med. Asso., Nov. 30, 1918,
Vol. LXXI, pp. 1787-1789.
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5. Amalgam Filling Removed from Lung after a Seven Months' Sojourn:
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June, 1916, p. 992.
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33. Intestinal Foreign Bodies. Editorial. The Laryngoscope, Vol.
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37. Mechanical Problems of Bronchoscopic and Esophagoscopic Foreign
Body Extraction, Journ. Am. Med. Assn., Jan. 27, 1917.
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