Frederic Francis Burghard

OPERATIONS UPON THE LARYNX AND TRACHEA
BY
W. DOUGLAS HARMER, M.C. (Cantab.), F.R.C.S. (Eng.)
Surgeon to the Throat and Nose Department, St. Bartholomew’s Hospital

CHAPTER I
ENDOLARYNGEAL OPERATIONS

Indications. (i) Tumours. Tumours of the larynx are more often innocent than malignant. Sir F. Semon5 collected 12,297 cases seen between 1862 and 1888 by 107 laryngologists, and of these 10,747 (or 88%) were benign and 1,550 (or 12%) were malignant. Of the innocent forms, papilloma, either simple or multiple, occurred in 39%; fibroma, sessile or pedunculated, was next in frequency; cystic tumours were not nearly so common; and other forms, including myxoma, angeioma, adenoma, lipoma, and enchondroma, were rare. The period during which these tumours are most common is between the ages of 20 and 40 years, but they are also frequent during childhood.

Malignant growths occur at a later age, mostly between the ages of 40 and 60, and attack males more than females. Carcinoma is far more common than sarcoma, and is generally of the squamous-celled variety. Endothelioma has not often been discovered.

The importance of distinguishing innocent from malignant tumours is greater now than in former years, since it is agreed that endolaryngeal operations are preferable for the eradication of the former, while the latter are better treated by extra-laryngeal methods. Moreover, the differential diagnosis has steadily improved, owing to the more general use of the laryngoscope and the introduction of recent methods of examination. Thus, by direct laryngoscopy it is possible to investigate children as easily as adults. Microscopical examination of fragments removed with laryngeal forceps is of great value in confirming the clinical diagnosis; the sections can be made by freezing, or in paraffin, the latter method requiring, with recent improvements, not more than twenty-four hours. Semon, who has done more than any other man to improve the early diagnosis of malignant disease of the larynx, is strongly in favour of such examinations. It must be remembered, however, that the result is sometimes inconclusive, for it is difficult to be certain that the actual growth has been removed. In cases that are thought to be malignant, it is better to open the thyreoid6 cartilage than to rely upon endolaryngeal operation, as there is a danger of stimulating the growth to greater activity, especially by repeated interference. When the thyreoid cartilage has been opened, the whole disease can be explored thoroughly and a fragment selected from which to make a frozen section. In the majority of cases a definite diagnosis can thus be arrived at, and even when it is necessary to examine several fragments the amount of time lost is small.

As regards the value of skiagraphy, Walsham and myself have found that photographs can be made of tumours of the larynx which in some instances determine accurately the position and extent of the disease.

Fig. 254 is a photograph showing a cancer of the upper opening of the larynx, lying above the vocal cords, the position of which was proved to be accurate by later operation upon the patient. It is, however, doubtful whether the method will eventually assist in the differential diagnosis between innocent and malignant growths.

(ii) Tuberculosis. Endolaryngeal operations are successfully performed for chronic conditions such as ulceration or tumour, and, rarely, in acute forms such as abscess, necrosis, and the like. Removal of a portion of the epiglottis occasionally gives great relief to a patient who is suffering from dysphagia.

(iii) Strictures resulting from trauma, from the ulcerations of syphilis, diphtheria, and other inflammatory diseases, or caused by congenital webs.

(iv) Foreign bodies impacted in the larynx.

(v) Œdema of the mucous membrane due to trauma or inflammation, local abscess, necrosis, and other allied conditions, in which obstruction is likely to supervene.

The operation may be performed either by indirect or by direct laryngoscopy.

OPERATION BY INDIRECT LARYNGOSCOPY

It being essential that the patient should be tolerant, this method is chiefly applicable in the case of adults. The operation may require a course of instruction, but this presents no difficulty if given with discretion. The employment of cocaine, novocaine, and adrenalin is of the greatest importance to both surgeon and patient. Cocaine, which is generally to be preferred, may be used in strong solutions—10 or even 20%—if applied to the mucosa by a small swab of wool; but, if used as a spray, weaker solutions are employed (4%). With neurotic patients cocaine must be applied cautiously, as a sense of suffocation is sometimes produced. It is necessary first to treat the soft palate, the uvula, base of the tongue, pharynx, and epiglottis; secondly, with the help of a laryngeal mirror, the interior of the larynx must be cocainized; this can be accomplished by expelling a few drops of the solution from a laryngeal syringe or by means of a swab attached to a suitable wool-carrier. Fifteen to twenty minutes must be allowed to gain the full effect of anÆsthesia. The patient must be instructed on no account to swallow the saliva. The secret of successful intralaryngeal operations lies in the thorough application of these principles, and in not attempting the operation until the patient is able to tolerate the presence of an instrument within the larynx. The surgeon must be experienced in the use of laryngeal instruments, and must be provided with a complete equipment, including forceps (Mackenzie’s, Whistler’s, Grant’s, &c.), which must be of different lengths to suit the patient, snares, galvano-cautery, curettes, probes, and other instruments for the application of drugs. Proper illumination is also very important.

When removing an intralaryngeal growth, the surgeon sits facing the patient. The mouth is opened to the fullest extent, and the tongue drawn well forward and held by the patient’s right hand. The mirror is introduced in such a way that the tumour is distinctly seen. If the epiglottis overhangs, it can be drawn forward with the forceps; or, in rare instances, a special instrument (Fig. 255) can be used for transfixing its upper margin with a thread, the latter being grasped by a pair of pressure forceps, which, being allowed to hang, will automatically raise the obstruction.

The forceps, having been warmed, are taken in the right hand when the tumour is on the right side of the larynx and in the left hand when the tumour is on the left, thus allowing a clearer view than when the same hand is employed irrespective of the position of the disease. It is introduced as follows: firstly, the handle is directed towards the patient’s left ear until the point of the forceps has passed beyond the back of the tongue and lies behind the epiglottis; secondly, the instrument is quickly rotated so that the handle lies below the chin; thirdly, the hand is raised so that the point is directed forwards; fourthly, the whole instrument is quietly lowered and the beak of the forceps directed towards the growth. This manipulation is made more difficult by the laryngeal image being reversed in an antero-posterior direction.

When the point is seen to rest upon the growth, the instrument is opened, and the tumour grasped and avulsed: with careful manipulation there is little danger of wounding the normal mucosa, and hÆmorrhage is insignificant. When dealing with multiple growths the patient must understand that it may be necessary to repeat the operation, either immediately or after an interval. Given suitable instruments, sufficient experience, and a tolerant patient, it is possible to remove, with the help of cocaine, the majority of simple tumours. Operations upon cysts, the scarification of mucous membrane with a guarded knife, the curettement of tuberculous ulcers, and cauterization of the larynx, are all conducted upon similar lines. Foreign bodies can generally be removed with forceps; thus, F. A. Rose7 reported a case in which part of the breastbone of a chicken, measuring 1 inch in length and over ¾ of an inch in width, was removed after having been impacted in the larynx for nearly forty-eight hours. In rare instances such an operation is not successful; e.g. with a foreign body firmly impacted, multiple papillomata, or an intolerant patient, general anÆsthesia may be required, and removal may have to be effected through a tube-spatula or by external incision.

After-treatment. Intralaryngeal wounds generally heal well, but every effort should be made to prevent infection of the parts, to allay any inflammation that may arise, and to avoid catarrh and swelling of the mucosa. It is advisable to order complete vocal rest until the redness has subsided, and the patient should refrain from coughing; the sucking of ice, or the inhalation of benzoin or other medicated steam, has a sedative action upon the parts. If the larynx becomes septic or filled with irritating discharge, the use of sprays or powders is indicated; in such a case the patient may be given a parolein spray, with menthol, eucalyptus, or other antiseptic, for constant use; or a powder such as orthoform, the latter being sucked into the larynx through a warmed glass tube (Leduc’s insufflator), or applied by the surgeon. In the later stages the patient may be treated by the local application of caustic fluids, or by galvano-cautery, as occasion requires. The success of such operations depends largely upon the skill of the surgeon; if attention be given to the after-treatment the results are very good, and the voice is generally recovered. As Semon has shown conclusively, there is no practical danger of the occurrence of malignant degeneration through the influence of instrumentation.

OPERATION BY DIRECT LARYNGOSCOPY

(Killian’s Method)

Indications. (i) Multiple papillomata. These tumours occur most commonly during the early years of life, and operations for their removal present great difficulties, first, in their removal, and, secondly, owing to their inveterate tendency to recurrence whatever operation is performed; moreover, in some instances operation seems to stimulate the growths to greater activity. The case reported by Stoker is a well-known instance. He was consulted by a man thirty years of age who had suffered from papilloma for twenty-three years, during which period one surgeon had performed 100, and a second 120 operations.

(ii) Benign tumours other than papillomata, which are not amenable to operation by indirect laryngoscopy.

(iii) Foreign bodies. Direct laryngoscopy is advised for patients who are intolerant (e.g. young children), or when the object is firmly impacted, or when other methods of treatment have failed. Thus in one of my cases a man presented himself with a long pin impacted transversely above the vocal cords; it was found impossible to remove it by indirect laryngoscopy without serious injury to the parts. An anÆsthetic was therefore given and a large tube-spatula passed into the larynx: with strong forceps the pin was bent upwards and removed with ease.

(iv) Granulations, ulcers, necrosis, and other inflammatory conditions such as are caused by diphtheria, tubercle, syphilis, and many other diseases.

(v) For diagnostic purposes. There can be little doubt that direct laryngoscopy has a great future before it as a means of determining the nature of doubtful laryngeal conditions. If the upper parts of the larynx be swollen, if there be any stenosis such as follows ulceration, or if the patient be intolerant, the air-passages cannot be thoroughly examined with the laryngoscope alone. With the newer method many of these difficulties have disappeared, and it is now possible for the surgeon to diagnose with certainty many conditions which would otherwise have remained doubtful.

The apparatus required consists of:

(a) The tube-spatulÆ. The tube originally suggested by Killian was made of straight metal and circular in section, the distal end being cut obliquely with the projecting portion fashioned like a spatula. A strong handle, at right angles to the tube, was used for manipulation. Different sizes were required for children and adults. Various modifications of these tubes are now in use, notably those of Mosher and Bruenings: the instrument recommended by the latter is easier to manipulate and gives a better view than the earlier forms described.

(b) The lamp for illumination. Different forms of head-lamp (Killian’s, Kirstein’s) and hand-lamp (Caspar’s) have been devised for illumination from the outside, and Chevalier Jackson has invented a lamp which is sufficiently small to pass to the distal end of the tube, where it lies in a compartment of its own lest it should be broken and fall into the trachea. Recently these electroscopes have been improved upon by Bruenings, in whose instrument (Fig. 257) the lamp is more powerful and is attached to the handle in such a manner that it can be easily swung into position when required. A condensing lens has also been added and the light can be focused to any desired distance. If preferred, an ordinary forehead-mirror reflecting the light from a powerful Nernst lamp (100 c.p.) can be employed.

(c) The instruments for operation. Various forms of forceps for removal of tumours have been devised by Killian, von Eicken, Bruenings, Patterson, and others. In any form that is employed it is necessary, in order to allow of clear vision, that the handle should be set at an angle with the shaft. For foreign bodies, hooks of different shapes are also useful. Other requirements include a gag for opening the mouth, a tongue depressor, tongue forceps, suitable cotton-wool carriers, the requisites for tracheotomy, and a darkened room.

Operation. The operation can be performed with local or general anÆsthesia. With patients who are intolerant chloroform is more reliable, and is preferable to other drugs, which tend to excite secretion. Chloroform should always be employed for children. It should be given slowly and in the smallest possible quantity, the head of the patient being kept lower than the body to allow blood and mucus to drain away from the trachea. To make the parts more tolerant, cocaine can also be applied to the vocal cords, or a dose of morphine (codeine is advised in children) can be given half an hour before the operation. The importance of a skilled anÆsthetist cannot be too strongly emphasized. With chloroform, the patient should lie upon the back or right side, with the head projecting beyond the end of the table, so that the neck can be extended as required. With cocaine the upright position is often preferred, and the patient should sit on a low stool facing the surgeon. When the patient is recumbent, the surgeon should sit or kneel behind the head (Fig. 258). He should observe the strictest antiseptic precautions, and should introduce no instrument which has not been properly sterilized; further, the tubes should be previously warmed to prevent ‘fogging’, and oiled with sterilized liquid paraffin before introduction. There should be two assistants, one (the chloroformist) to support the head and watch the respiration and pulse, the other to help with instruments.

In order to examine the larynx, the mouth is opened by a gag, and the tube-spatula is passed to the upper border of the epiglottis; when this has been inspected the spatula is pushed behind it, and the upper portion of the cricoid plate is examined; the tongue is then pulled forward and the tube tilted so that the larynx can be seen. The examination should be methodical, and should include the vocal cords, ventricular bands, and openings of the ventricles. The whole manipulation can be performed with great delicacy, and is entirely guided by the eye, so that there is little fear of injury even in young children.

In this and the further technique the chief difficulties are caused by: (a) The prominence of the upper teeth. This may seriously interfere with the easy passage of a straight tube, even when the neck is fully extended. The difficulty can be overcome by turning the head laterally, so that the tube passes through the opposite angle of the mouth. (b) The mucus, which collects in the tube and obstructs the vision. This must be overcome by using a secretion aspirator, by frequent sponging, or, as suggested by Ingals, by giving a previous dose of atropin[e]. (c) Intolerance of the parts, which can be counteracted by the judicious use of cocaine (10%). It may be noted that this combination of chloroform and cocaine is not dangerous, even in young children, so long as the cocaine is prevented from running into the pharynx.

The condition of the larynx having been thoroughly examined, the operation can proceed. The method of removing multiple papillomata will first be described. In some cases it will be found that better exposure of the tumours is obtained if the end of the tube is placed above the epiglottis rather than in the larynx itself. The position of the growths having been determined, a suitable forceps is selected and introduced through the tube. The papillomata are seized and avulsed separately, without injury to the normal tissues. To arrest the bleeding it may be necessary to apply cocaine and adrenalin mixture, and to raise the foot of the table so that the blood drains away from the field of operation. As far as possible, all the growths should be removed; it may be difficult to attack those which are situated in the anterior commissure or subglottic region, but this difficulty may be overcome by the use of specially devised instruments; thus, von Eicken has invented a tube which is long enough to pass through the larynx and into the trachea, the portion lying in the larynx being provided with a lateral window which can be turned in any direction, so that a growth can be made to project into the tube, where it can be easily removed.

At any moment during this operation the surgeon may be called upon to perform tracheotomy.

After-treatment. This must be carried out upon the same lines as those already suggested; everything must be done to relieve congestion and irritation. Killian advises internal administration of arsenic for a period of several months, and, if this fails, potassium iodide in large doses. It should be remembered that in some instances syphilis seems to play an important part in the causation of these conditions. Ingersole suggests that X-rays prevent recurrence, and may even cause shrinkage of existing growths.

Recurrence occurs in most cases in some degree, and requires further operation; this may be carried out after an interval of a week or longer, according to the case. At these secondary operations it may not be necessary to use the forceps; local applications such as absolute alcohol, salicylic acid in absolute alcohol (2–10%), solutions of silver nitrate or chromic acid, and many other drugs, have been advised by different surgeons. Wylie is strongly in favour of the galvano-cautery, and is of opinion that the technique is more reliable and the liability of local infectivity diminished. If the latter method be employed, very little should be done at one sitting, otherwise great inflammatory reaction may be set up, entailing tracheotomy. A tracheotomy tube may be required for a short time while such treatment is being carried out; some surgeons, with whom the author does not agree, always perform preliminary tracheotomy, and claim that the papillomata are less likely to recur if complete rest is thus given to the larynx.

Results. In discussing the value of the above method it is necessary to refer to the results obtained by other operations, such as—

(i) Tracheotomy (see p. 522). This operation has been advocated as a method of curing papillomata. It has been noted that by giving rest to the larynx the congestion is relieved, the papillomata decrease in size, and in some cases completely disappear. Mackenzie8 published seven cases which he had had under observation for a minimum of two years, with four recoveries, the canula having been worn for periods varying from six to fifteen months. He also mentioned thirteen other cases in which good results had been obtained by other surgeons, and was of opinion that the method was most successful with ‘virgin’ cases. There are, however, many objections to this form of treatment. For instance, it is often necessary to retain the tube for a prolonged period, two years or longer, and even then the result is doubtful; moreover, the prolonged use of a canula is disastrous to the larynx, not only in retarding development, but also in the production of stenosis; there is also a danger of bronchitis, of broncho-pneumonia, and possibly of tuberculosis. In regard to the last, G. A. Wright,9 in reporting a case in which tubercle supervened, argues that ‘presumably there is more risk of this happening to the wearer of a tracheotomy tube than when breathing in a normal way through the mouth or nose’. Further, the line of treatment is difficult to enforce on account of the aversion shared by most parents to the performance of tracheotomy.

(ii) Laryngo-fissure (see p. 487). Under this head are included thyrotomy, or complete division of the thyreoid cartilage; partial thyrotomy, where a small portion of the upper or lower part of the thyreoid cartilage is left intact (an operation which does not give a good exposure of the larynx); infrathyreoid laryngotomy, which is only applicable to adults; cricotomy, with division of the cricoid cartilage and crico-thyreoid membrane; and subhyoid pharyngotomy. Of the above, thyrotomy is the most satisfactory operation, because it gives the best exposure of the parts and facilitates removal of the growths; recurrence, however, is frequent, permanent injury to the voice is common, and stenosis may result.

The results of these operations, especially during childhood, are by no means satisfactory. In the statistics carried up to 1896, collected by Rosenberg and von Bruns,10 laryngotomy was performed 143 times on 109 children; 11 were operated upon twice, 3 children three times, and 1 child seventeen times. 52 of the children were under four years of age; 20 died, principally from suffocation with recurrent papillomata; 43 showed recurrences after repeated operation; 40 were cured (i.e. 36%), and of these 10 showed disturbance of voice.

It must be admitted that operations for the treatment of papillomata do not meet with any great measure of success. It seems probable, however, that the results obtained by endolaryngeal removal are better than those obtained by either tracheotomy or laryngo-fissure. To quote Killian11: ‘Formerly, and especially from the standpoint of the surgeon, laryngotomy for laryngeal papillomata was very frequently done in little children in whom removal was impossible by endolaryngeal methods. In my judgment, direct laryngoscopy renders such a surgical procedure unnecessary. We can in all cases, with the aid of a tube-spatula under narcosis, remove papillomata, and the operation can be repeated as often as seems necessary.’ These remarks express the general feeling of the present day, and the most important factor in determining the success of operative treatment is early diagnosis. Such diagnosis divides the cases into two classes: those in which the growths are localized, and those in which they are diffuse. The first class is easy to treat by endolaryngeal methods, and, given careful after-treatment, the prognosis is satisfactory. The second class is serious, and far more difficult to treat; when Killian’s method fails the prognosis is very bad. Finally, it must be borne in mind that, as recurrence may not occur for several months, a guarded prognosis must be given in every case.

The removal of other benign tumours and of foreign bodies, and the treatment of granulations, are conducted upon similar lines, and are attended with excellent results.

CHAPTER II
EXTRA-LARYNGEAL OPERATIONS

THYROTOMY

Indications. This operation is performed for two purposes:

(i) To obtain access to the cavity of the larynx when the diagnosis is uncertain, or as a preliminary to other operations.

(ii) As a method of eradicating certain diseases, of which the following are important:—

1. Malignant tumours, both carcinoma and sarcoma, in which an early diagnosis has been made, and so long as they remain intrinsic.

It is advisable to follow Krishaber in the separation of all forms of laryngeal cancer into two classes, the Intrinsic and the Extrinsic. The term ‘intrinsic’ implies a growth springing from the vocal cords, the ventricular bands, the ventricles, or the subglottic space, and the growth must lie entirely within the laryngeal cavity. ‘Extrinsic’ is the term used for a growth affecting the arytenoids, the posterior part of the cricoid cartilage, the aryteno-epiglottidean fold, or the epiglottis. Such a growth is not entirely limited to the larynx, but also involves some part of the pharynx.

2. Extrinsic localized malignant tumours which are attached to the epiglottis, or to the aryteno-epiglottic fold.

3. Innocent tumours which are too extensive for endolaryngeal operation or of a doubtful character. In either of these cases it is justifiable to perform an external operation, which may be thyrotomy, or occasionally, an atypical operation: thus Semon12 removed a large fibromatous tumour of the larynx by submucous resection, without opening the cavity of the larynx.

4. Stenosis following syphilis, trauma, acute exanthemata, scleroma, and other rare diseases. C. Jackson has reported twenty-four cases falling under this head, nineteen of which lived for more than a year after the operation with useful voices. If the surgeon is satisfied that the disease is quiescent, he should point out to the patient that it may be possible to cure the obstruction by thyrotomy. It must, however, be remembered that tertiary syphilitic lesions may again become active as the result of operative interference. It is probable that slight cases of stenosis can be treated better by intubation than by thyrotomy. Thyrotomy has also been suggested to relieve stenosis caused by double abductor paralysis of the vocal cords, but such cases are better treated by tracheotomy or intubation.

5. Foreign bodies. Thyrotomy is rarely necessary, and should be reserved for irregular or sharp-pointed bodies, such as tooth-plates or bones, which are so firmly jammed that removal by other methods is impracticable. If there has been much laceration of the soft parts, a tracheotomy tube should be retained for a few days until the swelling has subsided.

6. Tubercle. Thyrotomy has been successfully performed in such cases, mostly under the impression that the disease was malignant. The differential diagnosis between tuberculous and malignant growths is sometimes very difficult until the tumour has been explored. In cases that are known to be tuberculous, the feeling prevails that thyrotomy is not to be recommended. It should be remembered that the external wound is liable to become tuberculous.

Instruments. Scalpel, curved scissors, dissecting forceps, pressure forceps, aneurism needles, double hook retractors, bone shears (Waggett’s) or bone scissors, tenaculum forceps, needles on handles, catgut in various sizes, a Hahn’s tube, and tracheotomy equipment. A head-light is required for illumination of the deeper parts during removal of tumours.

Operation. In England, owing to the fact that the administration has been in skilled hands, chloroform is not considered dangerous, and the operation is well tolerated even for three or four hours (e.g. in laryngectomy). On the Continent, however, Kocher, von Bruns, and others advocate local anÆsthesia with cocaine or novocaine. Jackson suggested rectal etherization as an alternative, but this has many dangers. In my opinion a general anÆsthetic should be given, as it enables the operation to be performed more thoroughly and is followed by less shock. It must nevertheless be borne in mind that, if the growth is intrinsic and of large size, it is difficult to administer chloroform, and the patient is liable to suffer from urgent dyspnoea. In such a case i[t] is advisable to perform preliminary tracheotomy with novocaine alone (see p. 544).

As regards the operation, the important question arises whether tracheotomy ought to be performed several days prior to the main operation, in order to accustom the patient to the tube and the new method of breathing. The following reasons are advanced in favour of this: the main operation is shortened, and relief is given to the larynx and lungs, so that congestion subsides and broncho-pneumonia is less likely to supervene. The objections are also important, namely, that there are two operations instead of one, and perhaps two anÆsthetics (though this can be avoided if local anÆsthesia is used for the tracheotomy); that the tracheotomy wound becomes septic, and infection of the trachea and bronchi is apt to occur, with consequent bronchitis; that the air which passes into the lungs is devoid of moisture and heat; that the trachea becomes surrounded by adhesions; and that it is altogether unnecessary. The objections in my opinion outweigh the advantages claimed; it is better to perform tracheotomy as a first stage in the operation of removal, except in cases where there is great laryngeal obstruction, where dyspnoea is present, or where bronchitis fails to yield to other forms of treatment. In such cases tracheotomy should be performed first, and the second operation should be carried out a week or ten days later when all the conditions are favourable.

When operating upon the larynx the surgeon must use every precaution to prevent blood from running into the lower air-passages, and this may be accomplished by a tampon in the trachea or by keeping the head of the patient lower than the body. The former method appears to me to be more reliable than the latter; and I prefer to use a Hahn’s canula, although the sponge requires from ten to fifteen minutes to swell. This canula is more reliable than Trendelenburg’s, whose inflated bag is apt to slip or collapse suddenly. As soon as the thyreoid cartilage has been opened, a second sponge should be inserted above the canula, and by this means the air-passages are completely blocked.

If an ordinary tracheotomy tube be used, the operation must be performed either with the head lower than the body (Rose’s position), or with the whole body inclined (Trendelenburg’s position), or with a combination of the two; and in any case a sponge should be placed in the upper part of the trachea after the thyreoid has been opened. Many surgeons prefer the combined method. Under no conditions must blood be allowed to pass below the tube. Whatever form of canula is used, it should be fitted with a Hahn’s tube and funnel (Fig. 266), so that the anÆsthetist can give the chloroform without interfering with the surgeon. The patient should lie upon the back on a flat table, the head extended slightly over a small cushion in the position for tracheotomy.

First stage. A vertical incision is made in the middle line from the hyoid almost to the sternum, so as to expose the thyreoid cartilage and the pretracheal muscles; these are retracted, so that the anterior aspect of the trachea is exposed; the isthmus of the thyreoid gland is completely divided, and search made for bleeding points until the wound is quite dry. A large opening is made accurately in the middle line of the trachea; this will be at least two rings below the cricoid cartilage in order that the tube may be well away from the region of the growth. In adults, if a Hahn’s tube be employed, the section should include at least three rings of the trachea.

Second stage. The anterior aspect of the thyreoid cartilage, and the crico-thyreoid membrane, are freely exposed, the infrahyoid muscles being separated by at least one inch and, if necessary, retracted. Ten minutes after the tube has been inserted, the crico-thyreoid membrane is punctured, exactly in the middle line, in order to admit the inner blade of the bone forceps; the latter is pushed upwards, slowly and without force, between the posterior portions of the vocal cords, until the whole length of the thyreoid cartilage is included between the blades; the forceps are then forcibly closed, great care being taken that the outer blade is cutting exactly in the middle line. By quickly opening the cartilage in this manner, there is practically no danger of destroying the anterior attachments of the vocal cords, or cutting through the substance of one of them. The two halves of the larynx are forcibly separated and retained in this position by hooked retractors, so that the interior of the larynx is exposed. In order to give a free exposure, it is necessary, as a rule, to divide with a knife the crico-thyreoid membrane; but the thyreo-hyoid membrane should not be touched, nor should the attachments of the epiglottis be disturbed. The separation must be performed carefully in order to avoid a fracture of the cartilages. The pharynx is plugged with gauze, so that no saliva can enter the wound, and after all secretion has been removed from the larynx a small sponge or plug is inserted into the upper end of the trachea. Cocaine, 20%, is freely applied with a swab of wool to every part of the larynx in order to constrict the vessels; persistent hÆmorrhage can be controlled by plugging the cavity with wool soaked in cocaine; ‘this fully suffices... and the employment of adrenalin, as I have personally experienced in one case, increases the risk of secondary parenchymatous hÆmorrhage’ (Semon). Further, and this is of importance, by the use of cocaine the irritability of the larynx and the laryngeal reflex are destroyed. The tumour can now be inspected; it must be thoroughly exposed by cutting through the soft or hard structures (cricoid if necessary) so that its limits can be determined, thus enabling the surgeon to decide whether it is possible to obtain a satisfactory result by local removal.

Third stage. In the words of Butlin13: ‘an incision is carried around it (the tumour) with knife or scissors, including more than half an inch of the surrounding apparently healthy tissues, without respect to the after use of the voice or any other consideration except the complete removal of the disease. The included area is cut out right down to the cartilage, which is laid bare and finally scraped absolutely bare with Volkmann’s sharp spoon.’ The cavity is then plugged for a few moments until the bleeding has been controlled. The hÆmorrhage is never serious, and can be controlled by catgut ligature if necessary. The wound must be completely dry. It is then dusted with a powder such as orthoform; the retractors are removed, and the alÆ of the thyreoid cartilage allowed to fall together. In relation to the removal of the tumour, Butlin has shown that there is ‘little liability of malignant disease infiltrating the cartilage of the larynx’, so that, as a general rule, the latter can be left if all the soft tissues, including the perichondrium, are removed from its surface; this is comparatively easy to accomplish in the case of the thyreoid, but more difficult with the arytenoids and cricoid cartilage. C. Jackson has criticized the use of a sharp spoon as likely to cause infection of the cartilage.

Fourth stage. In some instances it is possible partially to unite the divided mucous membrane, and so to lessen the granulating area: when this is done it is of the utmost importance that the lumen of the larynx should not be constricted, as any constriction will increase the danger of stenosis. In many instances it is not advisable to attempt to repair the wound that has been produced.

In suturing the external wound the alÆ of the thyreoid are brought accurately into the position which they occupied before division, in order that the anterior attachments (if left) of the vocal cords should heal at their proper level. In some instances the cartilages fall naturally into the desired position, especially if one or two catgut sutures are inserted into the thyreo-hyoid membrane; in other cases it may be advisable to insert one or two similar sutures through the cartilage itself and thus obtain correct apposition. These sutures should lie on the outer aspect of the mucosa, so as not to traverse the cavity of the larynx itself. In cases where only the anterior portion of a vocal cord has been removed, Semon recommends that the divided end be sutured to the ventricular band; it is reasonable to suppose that, by attention to this detail, a better voice will be afterwards obtained. The infrahyoid muscles are approximated with one or two catgut sutures in the upper part of the wound; the skin is united with a continuous silk suture, as far downwards as the lower part of the thyreoid cartilage. The lower part of the wound is left open, to procure free drainage through the crico-thyreoid and tracheal openings. The whole of this lower wound is packed very loosely with gauze, so that discharges are not retained. It is necessary to emphasize the importance of not plugging the cavity of the larynx. The Hahn’s tube is removed as soon as the operation is completed, and replaced by a tracheotomy canula; the whole wound is covered by a loose pad of antiseptic gauze, which is kept in position by tapes or loosely applied bandages. No dissection for removal of lymphatic glands is required.

The above may be called the typical operation for malignant disease in which the growth is intrinsic; it gives a better exposure of the parts than other operations such as transverse laryngotomy (division of the thyreoid cartilage at the level of the ventricles), subhyoid pharyngotomy, partial thyrotomy, cricotomy, and crico-tracheotomy; the removal of tumours is therefore easier, and better after-results are obtained. If the growth be found more extensive, it may be necessary to modify the procedure. For example:

(a) When the epiglottis is involved, an extensive dissection of the thyreo-hyoid membrane can be made in order to expose and remove the growth thoroughly together with any soft parts or cartilage which appear to be involved. Branches of the superior thyreoid arteries, or the hyoid branch of the lingual artery, will be ligatured. The superior laryngeal nerves should always be preserved whenever possible, as loss of sensation increases the liability of food passing into the larynx.

(b) When the aryteno-epiglottidean fold is involved, a transverse incision can be made through the thyreo-hyoid membrane, immediately above the thyreoid cartilage on the same side, and the wound enlarged until the tumour is exposed. In this manner I was able to remove the large carcinoma shown in Fig. 254, including the soft parts of the right half of the larynx, the right half of the epiglottis, the right arytenoid, and the wall of the pharynx in relation to the right pyriform fossa: the lymphatic glands were not removed. One year later the patient continued to enjoy good health with no signs of any recurrence. In this connexion it is important to emphasize that when the disease is very extensive, and particularly when the posterior portion of the cricoid and arytenoids is involved, such an operation is useless, and the surgeon must decide whether partial or complete laryngectomy should be performed. In rare instances the operation should be abandoned in favour of tracheotomy (palliative).

(c) When the tumour extends downwards into the subglottic region, it is necessary to split the cricoid anteriorly and divide the upper rings of the trachea, after which the tumour can be removed with as much of the structures as may be desirable.

(d) When the growth extends across the middle line in the anterior commissure, or when a second growth is situated directly opposite on the other side of the larynx, the whole disease must be removed regardless of damage to the tissues which are not affected.

(e) When the operation is performed for stenosis, it is necessary to remove freely all the fibrous tissue without attempting to preserve any part that is diseased. The hÆmorrhage is generally severe and necessitates preliminary plugging of the trachea with a Hahn’s canula.

After-treatment. This must be conducted so as to prevent the chance of broncho-pneumonia and sustain the strength of the patient. With Butlin’s method the patient is placed on his side, or face downwards, with the head low and with only a small pillow, so that all secretions pass out of the air-passages through the external wound. This undoubtedly gives better drainage to the wound, and is less exhausting than the upright position during the early stages of convalescence. The dressings on the wound must be changed, especially in the early days, as often as they become soaked; it is also an advantage to insufflate an orthoform powder, or an antiseptic parolein preparation, with the object of cleansing the larynx. The tracheotomy tube should be retained, usually from ten to twenty days, until the patient can swallow well and as long as there is a flow of pus from the wound.

‘During the day of the operation nothing is swallowed, although fragments of ice may be kept in the mouth for the comfort of the patient. If there is fear of collapse and the patient is feeble and very old, brandy and beef-tea may be administered by the rectum. On the following morning the first attempt is made to swallow. The patient leans far forwards with the head down, and the dressing is taken off the wound, beneath which a basin is placed. Cold water is drunk out of a glass. If the experiment is successful, all the water passes down into the stomach; if it is only partially successful, some escapes into the larynx; but the posture of the patient ensures that the liquid runs out through the wound and does not pass into the air-passages. As soon as water can be readily swallowed, milk, beef-tea, and other liquids may be drunk, for the fear of “Schluck-pneumonie” is practically at an end. The wound is generally closed within ten or twelve days of the operation, and the patient is rarely confined to the house for more than ten days’ (Butlin). It is probable that the healing by this, which is called the ‘open’ method, is as rapid as with Moure’s, in which the whole length of the incision is closed; the open method would also appear to be safer and less often attended by complications.

Complications. (1) Broncho-pneumonia is most to be dreaded. Death from shock or collapse, from hÆmorrhage, from septic conditions of the wound, or from iodoform poisoning, is now rarely met with and can more easily be prevented. Even pneumonia is uncommon, owing to more scientific methods of treatment. It is still to be feared in very old patients; in those who already suffer from bronchial catarrh at the time of the operation; in alcoholics; and in cases with old-standing renal, pulmonary, or heart affections. The improvement in this direction is due to greater antiseptic precautions, and to the prevention of aspiration of blood and septic secretion during and after the operation by free drainage of the wound.

(2) Stenosis. It sometimes happens that a considerable mass of granulation tissue appears in the anterior commissure, or upon the surface of the cartilage that has been bared by the operation; if this be left untreated it may gradually enlarge in size until a prominent cushion is produced, which reaches to the opposite side and thus causes stenosis with definite laryngeal obstruction. Such a swelling may be mistaken for recurrence, but is nearly always of inflammatory character. It is by no means certain what is the causation of this condition, which appears to occur more with some surgeons than with others; it has been suggested that the presence of sutures in the region of the anterior commissure may cause an irritation, especially if silk is used. It appears to me, having in mind similar conditions in other surgical wounds, that the cause is to be found in some form of sepsis, and that it can be prevented to a great extent by precautions at the operation and by proper after-treatment. If there be any obstruction to breathing, the larynx is inspected and the projecting granulations are removed by intralaryngeal forceps. The remainder of the mass generally shrinks and disappears. If the stenosis be troublesome (chiefly in syphilitic cases), the prolonged use of a laryngo-tracheal canula (p. 540), or of an intubation tube, or dilatation with bougies, may be necessary. In rare instances a permanent tracheotomy tube is required, with a valve to encourage expiration through the mouth.

HEMI-LARYNGECTOMY

This operation is suitable for certain cases of malignant disease which is strictly limited to one half of the larynx. The requirements and first and second stages of the operation are similar to those for thyrotomy (see pp. 490, 491).

Third stage. A transverse incision is made on the side affected along the upper border of the thyreoid cartilage, through the skin and fasciÆ; and, if necessary, a second transverse incision is made at the level of the lower border of the cricoid so that a skin flap can be turned back. The affected half of the larynx must now be considered as a tumour to be removed. The infrahyoid muscles are dissected away from the ‘tumour’ and retracted; the upper part of the lateral lobe of the thyreoid gland (the isthmus having been previously divided) is displaced outwards by blunt dissection, and the soft tissues above the thyreoid are similarly treated: the larynx should be pulled well over to the opposite side while this is being effected, great care being necessary to avoid wounding the carotid artery in the deeper part of the dissection. The branches of the superior thyreoid artery, the crico-thyreoid artery, and the veins of this region are ligatured with catgut. In some instances, when the growth has not perforated the cartilage, the separation can be performed subperiosteally. Superiorly, the thyreo-hyoid membrane is completely divided on the same side, and the mucosa is cut through above the upper limit of the growth. If the growth extends upwards, the epiglottis may be removed either totally or partially. Inferiorly, a transverse incision must be made through the crico-thyreoid or crico-tracheal membrane, or lower in the trachea. The inferior constrictor of the pharynx is divided as close to the attachment to the thyreoid as possible, and the cavity of the pharynx is opened behind the growth. The cricoid plate is split with bone scissors in the interarytenoid interval, and the final attachments are rapidly divided with a few touches of the knife.

In this operation, as with other operations for cancer, the main thought of the surgeon must be to remove the tumour thoroughly, including the soft tissues of the neck when these are diseased, the lateral wall of the pharynx, and the cervical glands upon the same side, whether they are known to be affected or not. In this respect the operation differs materially from thyrotomy; and I agree with Semon that, if hemi-laryngectomy is necessary, the lymphatic glands of the same side should in all cases be removed. The two dissections may be accomplished at the same time, or one may be performed later at a second operation; in the latter event an incision along the anterior border of the sterno-mastoid muscle is preferred. The operation must be very complete in order to be successful, and requires a knowledge of the anatomy of the lymphatics.

THE ANATOMY OF THE LARYNGEAL LYMPHATICS.

The following description is Cuneo’s14 and has been confirmed by de Santi.15

The lymphatics which drain the mucous membrane of the larynx are divided into two distinct regions, namely, the supraglottic and the infraglottic zones. These regions are separated by the inferior vocal cords, and injection of the cords themselves generally passes into the upper zone. The upper region is most densely supplied, and covers the epiglottis, the aryteno-epiglottidean folds, the superior vocal cords, and the ventricles.

The lymphatics communicate freely in the posterior wall of the larynx (not in the anterior commissure), but though an injection into one half of the larynx easily passes into the mucous membrane of the other side, it is exceptional for it to pass as far as the corresponding glands of that side. The lymphatics of the larynx anastomose to a large extent with the networks of the adjacent organs (tongue, pharynx, trachea).

The supraglottic lymphatics perforate the thyreo-hyoid membrane where the superior laryngeal arteries enter, and end in (1) a substerno-mastoid gland under the posterior belly of the digastric; (2) glands on the internal jugular vein opposite the bifurcation of the carotid artery; and (3) glands on the same vein opposite the middle of the lateral lobes of the thyreoid gland. The glands in the front of the thyreo-hyoid membrane receive lymphatics from the pharynx, but none from the larynx.

The subglottic lymphatics perforate the crico-thyreoid membrane in two places (a) anteriorly, near the middle line, ending in (1) a prelaryngeal gland which lies in the V-shaped space between the crico-thyreoid muscles or under one of the same (a gland above the isthmus of the thyreoid gland is rarely present), and (2) a pretracheal gland (or glands) below the isthmus; (b) laterally, to end in (1) the glands which lie parallel to the recurrent laryngeal nerve, from which trunks run to (2) the substerno-mastoid group and (3) the supraclavicular glands.

It is important also to consider the question from the clinical aspect. With ‘intrinsic’ growths, involvement of glands is very uncommon unless the posterior (cricoid) zone is affected; it seems to be equally rare with tumours of both supra- and infraglottic zones; extension to the lymphatics of the opposite side is likewise improbable. With ‘extrinsic’ growths, the glands are rapidly involved; tumours that were originally intrinsic follow this rule as soon as they begin to affect the cartilages and extrinsic lymphatics of the larynx. These facts must be remembered because palpation of the neck may be quite misleading in early stages of the disease. On the other hand, in many advanced cases, such as those requiring palliative tracheotomy, the glands become massive and form definite tumours. The substerno-mastoid chain is, clinically, the situation that is specially affected; and any of its glands, from the digastric muscle above to the supraclavicular region below, may be involved. The prelaryngeal gland is rare, as are likewise the pretracheal and recurrent forms; nevertheless, the recurrent glands become attacked by advanced disease, affecting the upper part of the trachea.

TOTAL LARYNGECTOMY

Indications. This operation is performed for malignant tumours which have affected (a) the whole of the interior of the larynx, including the cartilages, or (b) the posterior portion of the larynx, including the arytenoid cartilages and pharyngeal aspect of the cricoid plate. In other words, it is employed in cases of extrinsic cancer in which the growth is not too advanced to render the prospect of its eradication hopeless. The operation should not be performed for tuberculosis.

It is essential that the patient should be in good health; one who is emaciated or who has organic disease, especially incurable bronchitis, is quite unsuitable for laryngectomy. On no account ought the operation to be undertaken unless the diagnosis of malignant disease has been confirmed, and unless the growth is known to be too extensive for thyrotomy. In many instances, therefore, thyrotomy is the first stage in the operation of total laryngectomy.

Operation. The instruments, anÆsthetic, and position require the same consideration as with thyrotomy (see p. 489).

First stage. A vertical incision is made, in the middle line, from the hyoid to a point one inch above the sternum, and the anterior aspects of the thyreoid cartilage and trachea are exposed, with complete division of the isthmus of the thyreoid gland. The infrahyoid muscles are dissected from the larynx and widely retracted. By blunt dissection the upper part of the lateral lobes of the thyreoid gland is separated and bleeding arrested. The trachea, having been isolated in this manner, is divided obliquely from the front, upwards and backwards, as close to the cricoid cartilage as the disease allows without injury to the oesophagus; the lower end is carefully freed from the oesophagus, and two strong catgut sutures are passed through it with which the divided stump can be drawn forwards. If possible, a small transverse incision is made through the skin immediately above the suprasternal notch and made to communicate with the upper incision; the trachea is brought beneath the bridge of skin into the button-hole thus formed, and firmly attached by means of sutures. In some cases the trachea is sewn into the lower part of the original incision. A tracheotomy tube is inserted, through which the anÆsthetic is continued. By this means the lower air-passages are completely cut off from the region of the tumour, and no blood or septic matter can pass into the lungs.

Second stage. The lateral aspect of the larynx is freely separated so that the attachment of the inferior constrictors is defined. The superior laryngeal artery is ligatured on each side, and divided, together with the internal laryngeal nerves. The thyreo-hyoid membrane is transversely divided, and the pharynx is opened so as to expose the upper limit of the growth; this may necessitate a transverse incision through the skin, or a vertical division of the hyoid bone in the middle line with retraction of its two halves. The larynx having been isolated above, below, and laterally, its removal can be completed according to the situation of the growth, in most cases from below. The lower end of the larynx is hooked forward, and dissected away from the oesophagus by means of scissors or a sharp scalpel (Fig. 262). While this is being effected, the extent of the growth must be constantly examined by inspection and palpation, so that the whole mass is removed, including, if necessary, the pharynx and upper part of the oesophagus. It is important not to drag upon the oesophagus; C. Jackson has shown experimentally that this causes severe shock by affecting the depressor fibres of the vagus, which may result in death. It follows, therefore, that this part of the operation, though easy in the dead body, requires the utmost care and detailed technique. The division of the constrictors should be as close to their attachment as possible, and the final division of the pharyngeal mucosa should be half an inch beyond the limit of the growth. The epiglottis should generally be removed.

Third stage. The toilet of the pharynx and oesophagus remains to be decided. In order to restore the cavity of the pharynx, the upper end of the oesophagus is brought upwards whenever possible and accurately united to the pharynx in the region of the hyoid bone, this being accomplished by a double layer of catgut sutures uniting the mucous membranes. The infrahyoid muscles are then brought together by a vertical row of stitches, so as to cover and support the line of union. The wound having been thoroughly packed with gauze, the skin is sutured, excepting the lower end, which remains open for drainage. In cases where the pharynx is thus completely closed, a tube must be passed previously through the nose into the oesophagus, and retained for purposes of feeding. This is preferable to sewing the tube into the wound itself, and is rarely troublesome if the tube is sufficiently stiff to prevent its displacement by retching. At the conclusion of the operation the tracheotomy tube is replaced by an ordinary silver canula, and the wounds are lightly dressed.

After-treatment. This is conducted upon similar lines to those adopted in the after-treatment of thyrotomy. During the first ten days, until the pharyngeal wound is firm, the patient must be fed through the tube and by rectal administration. Sterilized water may be sucked uphill, and, as swallowing improves, food may be administered by the mouth. In most cases a pharyngeal fistula results, which may require a later plastic operation. A second operation is necessary for the removal of lymphatic glands, probably on both sides of the neck.

The complications are similar to those following thyrotomy (see p. 494).

Modifications. The above operation, which in the main has been planned by surgeons in America (S. Cohen, Keen, &c.), is preferable to the numerous modifications, of which the following may be mentioned as examples:—

Gluck’s operation. In this there is no preliminary tracheotomy. A large rectangular flap is turned to one side to expose the front of the larynx and trachea, the latter being isolated laterally and the thyreoid isthmus divided. A transverse incision is made through the thyreo-hyoid membrane in order to expose the upper aperture of the larynx thoroughly. By plugging the pharynx and adopting a low position for the head, saliva and blood are prevented from running into the air-passages. The interior of the larynx having been cocainized, a tracheotomy tube is inserted between the vocal cords. This is sutured in position in such a manner that the cavity of the larynx is completely shut off from the pharynx. If a general anÆsthetic be employed, it can be continued through the canula by a Hahn’s adjustment (Fig. 266). The larynx, and any part of the pharynx or oesophagus which is diseased, are separated from above downwards, the trachea being severed transversely as a final stage and sewn into a button-hole immediately above the sternum. A soft rubber tube having been introduced through the nose into the oesophagus, the walls of the latter are united over the tube by a double row of catgut sutures, completely isolating the gullet. The cavity is covered with gauze, and the skin flap is partially sutured into its original position. An ordinary canula is placed in the trachea and the wounds are dressed.

In cases where the pharynx has been extensively removed a fistula remains, but Gluck has devised a plastic operation by means of which this can afterwards be closed. In some cases this fistula may be obliterated by the natural falling in of the parts, without further operation, and in the meantime the patient is provided with a funnelled tube for feeding, placed in the oesophagus with the upper end below the base of the tongue.

The advantages claimed by Gluck for this operation are the avoidance of preliminary tracheotomy, the prevention of blood from passing into the trachea, the complete separation of the trachea from the gullet, and the early feeding through the mouth. These, however, are chiefly met by the former operation.

Chiari and le Bec perform the operation in two stages. In the first, the trachea is isolated and divided transversely, the lower end being sutured above the sternum. The second operation, undertaken one or two weeks later, consists of a complete removal of the disease.

FÖderl suggests the possibility of uniting the lower end of the trachea (after laryngectomy is completed) to the tissues beyond the hyoid bone, and thus restoring the air-passages; but the method is not free from danger, and the trachea is apt to slough.

S. Handley16 performed a complete transverse resection of the pharynx, with laryngectomy, for malignant growth in the following manner: Preliminary gastrostomy was performed; a week later, when the patient had recovered, a low tracheotomy was effected, the trachea being plugged with gauze above the tube. The whole of the larynx and a complete section of the pharynx were then removed as described in Gluck’s method; and, the trachea having been brought into the lower part of the wound, the pharynx and oesophagus were closed by sutures. The patient recovered with a pharyngeal fistula through which the saliva passed, the latter being led to the stomach through the gastrostomy opening. In a second similar case the result was fatal. ‘The patient died on the table, apparently from irritation of the vagus, after the operation was practically complete.’ Handley believed that the failure was due to a defect in his technique, and that, if he had frozen the two vagi below the point at which he was working, death would not have occurred.

COMPARATIVE RESULTS OF THE DIFFERENT EXTRA-LARYNGEAL OPERATIONS

In order to obtain a trustworthy idea of the value of the various operations for malignant disease, it is necessary to refer to the history of the operations.17 Czerny, in 1870, was the first to demonstrate by experiments on dogs the possibility of removing the entire larynx, and various attempts were afterwards made by different surgeons, notably by Billroth, to accomplish the same in man. In 1881 Foulis was able to collect twenty-five cases of total laryngectomy, and found that not one of them was alive twelve months after the operation. Partly in consequence of this, thyrotomy was given a trial, and in 1887 P. Bruns collected nineteen cases, with two deaths and sixteen local recurrences. He therefore concluded that ‘attempts to extirpate the disease by means of thyrotomy have shown themselves to be altogether insufficient and useless’; and so it came about that all external operations, at this date, were considered by most authorities to be unsatisfactory. Much attention was, however, drawn to the subject by the illness of the German Emperor, and Semon particularly emphasized the great importance of early diagnosis. The result of this was marvellous. The importance of Krishaber’s division of carcinoma of the larynx into two forms, intrinsic and extrinsic, was recognized by Butlin, to whom the greatest credit is due for having first shown that thyrotomy ought to be reinstated. Butlin and Semon have since perfected this operation, which has rightly been described as the English operation. It is now recognized throughout this country as the operation which gives perfectly ideal results, so long as it is restricted to early stages of intrinsic malignant disease (in which an early diagnosis is indispensable) and is thoroughly carried out. As Semon concludes, ‘if these demands be complied with, the position of thyrotomy, as being the operation in the early stages of malignant disease of the larynx, will remain impregnable, so long as we have to fight malignant disease by operation.’ That this is true will be seen by the results mentioned later.

It is also necessary to refer to the other side of the question, namely, the position of laryngectomy. Many well-known surgeons in Europe and the United States have been convinced that laryngectomy, partial or complete, is the only possible treatment for cancer in this region. Gluck18 says:

‘As showing the progress that has been made during the last fifteen years in this subject, I may mention that in my first series of ten cases only two were successful, and in nine cases of another series I had four deaths. Since then I have performed many operations with ever improving results. Thus in one series of thirty-five hemi-laryngectomies I had three deaths: one twenty-four days after the operation, of heart failure, when the wound was already healed; another independently of the operation, of phlegmon of the right gluteal muscle; the third of pneumonia five days after operation.

‘My most recent results show a series of twenty-two complete laryngectomies with one death, that of a man of seventy, who died on the eleventh day of iodoform poisoning. Of the partial extirpations of the larynx and pharynx, generally combined with removal of infected glands, I can point to a series of twenty-seven cases with only one death. This was a case in which the carotid had been tied, and death occurred from hemiplegia five days after the operation.

‘At present I could show you thirty-eight living patients who have been cured by these operations; the oldest case was operated on thirteen years ago. Of those already dead, a number have lived 11, 8, 6½, 5½, 4½ and 3½ years after the operation in good health, and some have died of other illnesses, not of recurrence. One man, nine years after hemi-laryngectomy, had recurrence in the other half of the larynx and in the glands; after the second operation he lived over two years, and died at seventy-six. The operations lengthened his life for eleven years.

‘A man of seventy-six had the larynx and pharynx extirpated, and lived 11½ years after the operation. Twice I have performed complete laryngectomy for tubercle; one case died in spite of that of consumption; the other was done four years ago and the patient is perfectly well.

‘In all I have performed 125 of these operations since the year 1888, and the record is one of great progress, both in technique and also in the elaboration of plastic operations and mechanical appliances for the improvement of the post-operative condition.’

Many large operations of this description have undoubtedly been performed because of the statement that it is impossible to obtain a lasting cure by performance of thyrotomy. Even at the present day this opinion holds its ground, and so long as there is a general grouping of the cases, progress cannot be made.

Thyrotomy. I shall attempt to show that thyrotomy is the best operation for early malignant disease, whether carcinoma or sarcoma, so long as it remains intrinsic. No attempt will be made to separate the different forms of these diseases. The points to be considered are the following:—

The mortality of the operation itself has been greatly reduced; von Bruns19 states that ‘between 1890 and 1898 there was an immediate fatality of 15%’ in sixty cases collected by Schmiegelow and himself. In comparison with these figures, the recent results of English surgeons have been very favourable. Thus Butlin and Semon have performed forty-eight thyrotomies for malignant disease since 1890 with only two deaths. In Butlin’s case the patient was over seventy years of age, very obstinate, very intractable, and persisted in sitting up from the time of the operation. He died, in the course of three or four days, of septic pneumonia. The results of other surgeons have been excellent, but are not included for three reasons: There is still considerable confusion in the selection of cases suitable to this operation; the operation is often performed by those who are not conversant with the difficulties and dangers that may arise; and it has sometimes to be undertaken for a patient who is also suffering from bronchitis or constitutional disease. Moreover, the above figures are sufficient to show that the immediate mortality from this operation under favourable circumstances is not large.

Recurrence, in Semon’s cases, occurred in 13.6%, which is not a large proportion. It usually occurs early or not at all. Semon and Jackson noted that none of their patients suffered from recurrence after the lapse of the first year. This is a point of great importance; and in this connexion Semon points out, as an additional advantage of thyrotomy, ‘that even in the cases in which either the operation has not been complete, or in which unfortunately genuine recurrence has taken place, the operation does not bring us to the end of our resources; but that, on the contrary, by a repetition of the operation, or by hemi-laryngectomy, or by total extirpation of the larynx, a lasting cure may still be obtained, where the minor operation has failed.’

Cures. I hope it will soon become generally recognized that the radical operation of thyrotomy for removal of early intrinsic malignant disease is attended by a remarkable number of complete cures, and compares favourably with almost any other operation for similar conditions in other parts of the body. Butlin (see Table, p. 507), Semon, and C. Jackson have all obtained, in recent years, from 60 to 80% of lasting cures. In Semon’s twenty-five cases,20 one died of the operation, three cases recurred within a year, and one was too recent to be included, the remaining twenty were cured for varying periods, namely:

1 case over 15 years.

4 cases between 10 and 15 years.

4 cases between 5 and 10 years.

2 cases over 4 years.

3 cases over 3 years.

2 cases over 2 years.

1 case just 2 years.

1 case 1 year and 10 months.

1 case died 5 years after operation from pulmonary embolism.

1 case died 4 years after operation from pneumonia.

In both the last cases recurrence was excluded.

The condition of the patient after thyrotomy. The voice results are often surprisingly good even when a free excision of soft parts, including one or both vocal cords, has been required. In from 40 to 60% of cases that are cured, the voice is practically normal, though rough and reduced in volume and range. Of the remainder, the majority recover sufficiently to produce a considerable whisper, and only a few suffer complete loss of voice. The causes of a complete loss of voice, when it occurs, are chronic inflammation, cicatricial contractions, or improper union of the cartilage. Further, a loss of voice is probable in the event of a recurrence of the growth.

The breathing is not affected unless the operation is followed by stenosis. The power of swallowing is soon regained, and the general condition of those who are cured is one of complete happiness and general excellence of health.

These results may now be briefly compared with those obtained by laryngectomy, whether partial or complete.

Hemi-laryngectomy. The immediate mortality of this operation also has been greatly reduced. Sendziak collected 108 cases, up to 1894, showing a mortality of 26.3%; von Bruns 106 cases, between 1890 and 1898, with a mortality of 17%; Gluck has performed thirty-five such operations with only three deaths—8.1%. The number of cases reported in England is too small to be of value, chiefly because thyrotomy or total extirpation has been considered better. Taking, therefore, the best published results, it appears that the mortality is at least twice as great as with thyrotomy.

The danger of recurrence is also greater, partly because the glands are affected. Statistics show that recurrence occurs in at least one-fourth of the cases, possibly more, and is generally fatal. It is impossible to give a prognosis as to cure in the early stages after operation, but there are instances of life being prolonged for many years; a case of Gluck’s lived for eleven years.

The after-condition is not unsatisfactory. The permanent wearing of a tracheotomy tube is rarely necessary. Swallowing is soon recovered, and the voice is often good.

Total laryngectomy. Although the mortality of this operation has been greatly reduced by many improvements in recent years, it still remains higher than that of thyrotomy. As far as can be judged from the small number of cases that have been reported by English surgeons, there seems to be a direct mortality of at least 20% from these operations. C. Jackson21 has, however, performed eight consecutive total laryngectomies without a death in the first thirty days. He writes: ‘Of eight total laryngectomies done by me, three were hemi-laryngectomies followed by recurrence and the total operation. Of the eight laryngectomies, one lived seven years. I felt justified in claiming a cure, but upon inquiry a few weeks ago I was informed by relatives that he died of cancer of the stomach. One case lived three years without recurrence, dying of cerebral hÆmorrhage, and one eight months, dying of alcoholism. Of the remaining five, three recurred within a year, one apparent cure was lost to observation after a year, and one is too recent to record: one of the three prompt recurrences had metastases in the lungs, liver, and pancreas. Thus, of eight laryngectomies, no absolute ultimate cures can be claimed, though three were apparent cures at the end of one year.’

Butlin has performed total laryngectomy upon seven patients, only one of whom died from the operation. He says: ‘I first removed a large mass of glands on both sides, and later took out the larynx, which was so diseased, that the surrounding parts were infiltrated for a considerable distance. He lived six weeks after the second operation, and then died of double pneumonia, which was attributed to an attack of influenza when he was up and about his room. I do not know whether the pneumonia was due to that cause or to sepsis of the lungs, for we had on several occasions some difficulty in feeding him, and in getting a tube properly down his oesophagus.’

The following is a table showing Butlin’s operations since the year 1890, from a paper which was read at the Second Congress of the International Surgical Society at Brussels in 1908:—

¹ In two patients the operation was repeated.

² In one patient thyrotomy was followed by laryngectomy, but the patient was included amongst the thyrotomies only.

³ This was regarded as a second attack of cancer, for the disease of the tongue was some distance from the larynx, and there was no sign of cancer of the intervening parts. Also more than a year elapsed before he began to suffer from cancer of the tongue.

⁴ Periods during which patients remained well lasted from 3 to 15 years.

Recurrence after laryngectomy is, therefore, more frequent than after thyrotomy, and it is difficult to estimate the proportion of cases that are cured by this operation. Butlin writes: ‘Of the six patients who survived the operation, one died of probable cancerous glands in the mediastinum, one had inoperable recurrence in the cervical glands, three were alive within three years, and one was well three years after the operation.’ He says: ‘I began to perform laryngectomy three years ago on account of Gluck’s success, and of the excellent modification due to Solis Cohen. I wish I had begun to perform it earlier. I am sure that several of the cases on which I performed thyrotomy were much better fitted for laryngectomy, and I cannot help thinking I might have saved one or two patients in whom recurrence took place if I had then removed the larynx. I think the glands ought to be removed in every case in which there is extensive carcinoma of the larynx, even if it be intrinsic, unless the disease is limited to the middle zone of the interior of the larynx. Even in these cases it would probably be a wise precaution to remove the glands. I have never removed the glands and the larynx at one sitting.’ Von Bruns,22 from statistics of all total operations since 1890, gives the following proportions:—

The voice after laryngectomy. Many efforts have been made to replace the lost voice. The artificial larynx, as first devised by Gussenbauer, consisted of three distinct parts: a tube for the trachea through which the patient inspired; a tube communicating with the pharynx so as to allow of expiration through the mouth; and a phonation canula which fitted into the former. This canula was supplied with a valve which closed during expiration so as to allow of breathing through the mouth, and a phonation apparatus for production of the voice. A large number of modifications of this larynx have been made at different times but have rarely been successful. The irritation and pain caused by the pharyngeal portion, the difficulty in swallowing and in keeping the tubes clean, and the exhaustion caused by prolonged use, have combined to make the apparatus unsatisfactory.

As the result of recent improvements in laryngectomy, most surgeons isolate the trachea as already described, and thus entirely shut off all communication with the mouth. The patient then has a choice of two methods—(1) the bucco-pharyngeal voice, or (2) a phonetic apparatus such as that described by Gluck, consisting of (a) an external tracheotomy canula for breathing, (b) an internal canula, possessing a valve which closes during expiration and causes the air to pass upwards to another compartment containing a small rubber band or tongue, the vibration of which forms the voice, and (c) a third tube of rubber, which is easily fitted to the upper part of the inner canula and is of sufficient length to reach the mouth. When the patient wishes to speak, the upper end of the last-mentioned tube is either placed in the angle of the mouth or passed through the nose to the back of the pharynx, and the air which has been made to vibrate in the inner tube is thus carried to the mouth. This instrument is easy to adjust and clean, produces remarkable phonetic effects, and is much the most ingenious and serviceable device that has so far been invented. In some cases, however, a patient can make himself understood without an instrument of any kind. ‘A whispered voice remains even after the pharynx has been completely shut off from the air-passages and, as shown by experience, may be developed by practice until it is quite sufficient for the demands of the patient. Hans Schmidt’s case has become more or less celebrated, in which, under conditions of this sort, a loud though rough and monotonous voice was developed. One of Mikulicz’s patients was even able to sing. Gottstein explains the development of a pseudo-voice by the formation of an air-chamber in the pharynx and oesophagus, which is voluntarily inflated and emptied by the patient’ (von Bruns).

Swallowing after laryngectomy is satisfactory, and the general health in many cases improves. The mental condition of the patient is often disappointing. ‘Even in favourable cases, when the tumour does not recur after laryngectomy, the patient finds himself in such a condition of inferiority to his fellows, that he may, with some reason, ask himself (at least in certain cases) whether death would not have been preferable to such an existence as is left to him’ (Moure23). With recurrence of the disease the patient’s life is terribly sad.

It must therefore be admitted that laryngectomy is at present an operation of necessity, suitable for certain cases only, capable of prolonging life, and, rarely, of curing the patient. It is difficult to foreshadow the future of this operation; but, in the words of Gluck, ‘our first object must be to save life; our next, to leave the patient in such a physical condition that the life so saved is worth living.’

The above statistics are sufficient to show that the results of laryngectomy for extrinsic disease compare unfavourably with the results obtained by thyrotomy in intrinsic forms of cancer. In this country there have not been sufficient cases to estimate accurately the percentage of recoveries. The disease may recur at any period after the operation, and the prospect of a cure is always doubtful.

It is, however, to be hoped that, with improved methods of examination, earlier diagnosis, and a careful selection of the cases, better results will in future be obtained. Authorities such as Butlin and Semon support this view, and agree that further attempts must be made to make this operation successful.

INFRATHYREOID LARYNGOTOMY

In order to avoid confusion with other operations included under laryngotomy, this term is used to denote the operation in which the larynx is opened through the crico-thyreoid membrane. The operation is an easy one in adults, but in children the crico-thyreoid space is so small that it is almost impossible to introduce a tube without division of the cricoid cartilage (see Crico-tracheotomy, p. 529).

A tube introduced through the crico-thyreoid membrane lies in the subglottic space well below the vocal cords, and the latter should not be injured when the operation is performed with care. If inflammation supervenes, there may be a swelling of the subglottic region, making the tube difficult to manipulate; and for this reason the operation is particularly suited to cases which require a tube for a short period only, such as—

Indications. (i) Sudden laryngeal obstruction due to impaction of food or other foreign body. This is more common in adults: in children dyspnoea is rarely so urgent as to necessitate an operation.

(ii) Sudden oedema of the larynx caused by trauma, fracture, or acute inflammation, when the equipment for tracheotomy is not obtainable; or,

(iii) As a preliminary to major operations upon the upper air-passages, in order to prevent blood from passing down into the trachea.

This last method of treatment marks a distinct advance in the surgery of the throat. Attention was first directed to it by Bond24, who has used the method for the past sixteen years with intent to make such operations less dangerous to life, and to increase, therefore, the number of cases that could be operated upon. His objects were to prevent respiration through the pharynx, thus obviating the coughing and struggling due to imperfect anÆsthesia and making the anÆsthetic easier and safer to administer; to shorten the operation and make it easier for the surgeon; and to get rid of preliminary tracheotomy whenever possible.

The value of this practice is well recognized by many surgeons. Butlin writes: ‘I do not know how many times I have employed this preliminary laryngotomy, but certainly more than a hundred times, so that I am now in a position to urge the importance of it on the profession.’ It has now been adopted at many of the hospitals in England before removal of tumours in the naso-pharynx, the upper and lower jaw, the tongue, palate, floor of mouth, and tonsil, in those cases where bleeding is likely to be severe.

In order to ascertain the feeling of my colleagues on this subject I have collected, with the assistance of Mr. Boyle, all the major operations performed upon the upper air-passages during the last six years at St. Bartholomew’s Hospital. These are tabulated below.

Table showing Operations upon the Upper Air-passages during the Years 1902–7 inclusive at St. Bartholomew’s Hospital

This table shows that nearly half the cases were treated by laryngotomy. In sixty-three of these, where the tongue or floor of the mouth was concerned, no preliminary ligature of the lingual artery was performed; of the seventy-three similar cases treated without laryngotomy there was preliminary ligature of one lingual in thirty-one cases (42.5%), and of both arteries in twelve cases (16.4%).

From this it is apparent that lary[n]gotomy has to some extent taken the place of preliminary ligature of one or both linguals. The operation is simple, rapid in execution, and meets all requirements; it is not surprising to find, therefore, that in recent years the number of laryngotomies has proportionately increased.

Table showing Operations as performed in different Years

Operation. In cases of extreme emergency the operation can be performed with almost any kind of knife, but the following instruments are preferred: a sharp-pointed bistoury or tenotome, a sharp-pointed dilator (Fig. 265, B), a tube and introducer. The tube should be small, short, with a fixed collar, and made of silver; an introducer such as Butlin’s is a great advantage (Fig. 265, A). As bleeding may occur, it is necessary to prepare dissecting forceps, retractors, pressure forceps and catgut.

A general anÆsthetic is usually employed when infrathyreoid laryngotomy forms the first stage of the main operation, but it should be remembered that the amount of chloroform required is less when given through a tube.

The preparation of the skin and the position of the body are the same as for tracheotomy. A transverse incision one inch in length is recommended, and this should lie directly over the crico-thyreoid interval, which is easy to determine in the adult. The incision can be made quickly by pinching up a vertical fold of skin, transfixing immediately above the cricoid, and cutting outwards: with this method the anterior jugular veins are rarely wounded, but if any vessel has been pricked it should be seized and tied at once.

The sharp dilator, placed exactly in the middle line immediately above the cricoid, is pushed backwards between the infrahyoid muscles until the resistance caused by the crico-thyreoid membrane is reached. It is then firmly stabbed into the larynx and widely dilated so as to tear open the membrane: the dilator having been withdrawn, the tube, with tapes attached and mounted upon the introducer, is rapidly inserted, a proceeding which is made easier by first smearing the instrument with a small amount of glycerine. The whole operation can be performed in less than a minute, and is rarely attended by serious hÆmorrhage; moreover, when the original puncture is immediately above the cricoid there is less danger of wounding the crico-thyreoid artery. The operation is attended by few difficulties, and is superior to one in which dissection or cutting is employed.

At this stage a prolonged period of apnoea is usually encountered, and this symptom is more marked than with tracheotomy; when seen for the first time it may be alarming, and it is therefore of practical importance. In a few moments, however, the patient settles down to the altered conditions of respiration; coughing may be excited but soon disappears. When the breathing becomes regular, the tapes are tied round the neck and a rubber tube is attached (Fig. 266) similar to that used with Hahn’s apparatus, and through the tube the chloroform is continued. This method has the following advantages: it gives far more room to surgeon and anÆsthetist, and enables the latter to manipulate the laryngotomy tube and to prevent it from tilting in such a way that the lower end impinges against the front of the trachea with consequent obstruction; further, the opening into the larynx is completely blocked, blood and lotion being unable to enter from outside.

As soon as true anÆsthesia with regular automatic breathing has been obtained, the lower part of the pharynx should be plugged with a soft marine sponge to which a piece of tape or silk is attached, this being pushed down behind the tongue and firmly wedged in position; it is advisable to use a large sponge, as this blocks the pharynx and pushes forward the tongue, an advantage to the surgeon when operating upon that structure. If the mouth be obstructed by a tumour, the same result can be obtained by two or more smaller sponges passed in succession; or, as suggested by Bond, a small sponge may be pulled down into the larynx. As soon as the pharynx has been completely shut off, the main operation can proceed, and those who have once used this method can appreciate how much more quickly it can be performed and how much more comfortably for all concerned.

At the conclusion of the operation, when all bleeding has been controlled, the laryngotomy tube should be removed. The wound should not be sutured or plugged, and only a light dressing should be applied: the latter can be kept in place by a bandage, which, however, must on no account be tight, owing to the danger of emphysema.

Complications may arise—(a) During the operation. There may be troublesome bleeding owing to pricking of a vein, superficial or deep, or of the crico-thyreoid artery; this occurred in eight of the cases mentioned above, and in four was severe. In one of the latter the bleeding continued for thirty minutes before the vessel was finally secured. The condition is simple to treat: the wound must be enlarged, and the infrahyoid muscles separated so that the crico-thyreoid membrane is thoroughly exposed; the bleeding vessel can then be seized and tied, after which the tube is inserted. This is preferable to attempting to stop the bleeding by the introduction of the tube.

Difficulty in introducing the tube may occasionally occur. It may be due to imperfect division of the membrane; thus in one case the tube was passed down between the coats of the larynx and not within its cavity; and another case is recorded where the mucous membrane was similarly pushed backwards owing to the dilator having split the cricoid cartilage. Care must be taken, therefore, that the membrane is properly punctured, and that the opening is thoroughly dilated before any attempt is made to introduce the tube. Replacement of the tube was necessary in only one case, on the second day, owing to recurrence of bleeding from the wound in the mouth.

(b) After the operation. Emphysema occurred in six of the ninety cases; in two it was slight; in three it was extensive and involved the chest, neck, and face; and in one, where death supervened twelve hours after the operation, there was emphysema of the mediastinum. In two of these cases the laryngotomy wound had been sutured; in two others the operation was attended with severe hÆmorrhage, and the mouth was plugged with gauze to control it. It is probable that emphysema is more likely to occur if there is any obstruction to breathing through the mouth after the operation, such as may be caused by the falling back of the remaining part of the tongue. The following precautions should be observed to prevent it: The laryngotomy wound must always be left open, and covered by a loose piece of gauze which does not press upon the neck; the patient must be nursed on his side, not upon the back; suturing the remaining part of the tongue is not sufficient; if plugging is left in the mouth, the tube must be temporarily retained, and removed after a few hours when breathing is not obstructed; early removal, however, is preferred.

Bronchitis is mentioned in two of the cases already quoted, pneumonia in one case, pneumonia and empyema in one, and purulent mediastinitis in one, with three deaths in all. Of these five cases, four had operations upon the tongue. On the other hand, without laryngotomy, bronchitis was rather more common (seven cases) and broncho-pneumonia occurred in two, both of which died. In order to throw more light upon the subject, we have examined the charts of all the cases after the operation, and have found that in most of them there was a rise of temperature to 99° F., or slightly higher, which lasted for periods varying from one to seven days; the pulse and respiration were little affected. In laryngotomy cases there were only eighteen instances of temperatures of over 100° F., as against twenty-five where no laryngotomy had been performed. Here again the pulse and respiration were only slightly affected, so that the condition was probably due to local inflammation and not to involvement of the lung. The results are by no means conclusive, but justify the general feeling that laryngotomy does not increase, but probably diminishes, the danger of infection of the lungs.

Healing of the wound may take place in normal conditions in about five days, but the period is frequently longer—from ten to twenty days; suppuration is uncommon, and was only mentioned in two instances where the wound had been sutured. The scar left after laryngotomy is often depressed for several months, but eventually becomes loosened and is then scarcely noticeable.

Death occurred in six cases, but there was no evidence to show that there was any connexion with the laryngotomy; on the contrary, the operations were more severe, and infrathyreoid laryngotomy was performed partly for the very reason that the condition of the patients was less favourable.

From my experience, the advantages which were originally claimed by Bond, Butlin, and others have been completely upheld; the larger operations upon the upper air-passages are easier to perform and can be more thoroughly completed; and it is very possible that the after-results may be improved by the greater facility which is thus afforded. I would strongly urge laryngotomy in all large operations of this region; the tube should be removed early, and the wound should not be sutured.

CHAPTER III
OPERATIONS UPON THE TRACHEA

TRACHEOTOMY

There is evidence to show that this operation was known to the ancients, and that it has been practised during at least two thousand years chiefly for the treatment of foreign bodies in the air-passages. From the sixteenth century to the present time it has been frequently performed, and the discovery of diphtheria in 1881 by Bretonneau opened up a new field for the operation.

It is uncertain when tubes were introduced in the after-treatment of tracheotomy, but Dr. George Martin in 1730 was the first to describe a double tube which allowed of the removal of the inner part for purposes of cleaning. The movable collar was invented by Luer, and the angular tube now generally used is associated with the name of R. W. Parker, to whose research we owe many of the recent improvements in connexion with this operation.

Indications. Obstruction to respiration is the most important, and must be distinguished carefully from the dyspnoea which is due to pulmonary affections, disease of the heart, or organic lesions in other parts of the body. Laryngeal obstruction may be due to—

(i) Diphtheria. The extent to which diphtheritic obstruction has to be taken into account is shown by the following table:—

Table showing the Number of Cases admitted to the Fever Hospitals of London (M.A.B.) during the Years 1902–7, inclusive25

An examination of the above figures shows that in recent epidemics 13% of the cases developed symptoms of laryngeal affection; that about 40% of these laryngeal cases were treated by tracheotomy (in some cases preceded by intubation); and that the mortality in all the cases of tracheotomy was 31.5%. Tracheotomy in diphtheria, therefore, must still be regarded as a serious operation.

The operation is required chiefly during the early years of life, namely, from one to six (see table on p. 543). Although the larynx cannot be inspected in children, it is easy to determine whether mechanical obstruction is present; for inspiration is noisy and accompanied by stridor, the voice is lost or reduced to a whisper, and attempts to cough are frequent. The alÆ nasi are dilated, the extra muscles of respiration are called into action, and laryngeal excursion is seen. On examining the chest, recession is evident; and during inspiration the supraclavicular fossÆ, the intercostal spaces, and the epigastrium are all indrawn. The amount of recession depends more upon the muscles of the chest than upon dyspnoea, and is marked in weakly children. When dyspnoea becomes urgent the restlessness increases, and this is an important indication that an operation is required. In very serious cases the face is drawn, livid, or extremely pale; respiration is deficient, and the chest expansion feeble. An examination of the lungs shows the air entry to be imperfect; the bases are dull to percussion, and all sounds absent. The action of the heart is feeble, rapid, or intermittent; no nourishment can be swallowed. It is always difficult to determine how much of this collapse is due to toxin; but by relieving the obstruction the most distressing feature of the disease is removed, better aeration of the blood is obtained, and the heart is relieved from strain. The operation also drains the trachea, and the amount of poison absorbed is thus diminished. There is abundant evidence to show that the best results are obtained by early operation, especially in young children, in whom the larynx is comparatively small. It should be remembered that dyspnoea is often worse at night, and that at any moment there may be spasm.

(ii) Infectious diseases, such as (a) secondary diphtheria, by no means uncommon in the fever hospitals of London: in the five years 1902 to 1906, thirty cases are recorded, with sixteen deaths (53%), a very high mortality; (b) scarlet fever or measles, which provided 118 cases in which tracheotomy was performed, with eighty-seven deaths (74.3% mortality); (c) erysipelas, small-pox, typhoid fever, influenza and whooping-cough, which occasionally cause dyspnoea, calling for tracheotomy.

(iii) Acute laryngitis (other forms) in which oedema supervenes as the result of septic infection, or of the inhalation of steam, boiling water, or irritating chemicals, or as the result of trauma with or without fracture of the cartilages, or in the course of renal or heart disease. Brandy in excess, and certain drugs such as iodide of potassium, may also cause oedema of the larynx, and two cases are recorded by Fournier where death occurred before tracheotomy could be performed, as the result of taking iodides.

For conditions such as these tracheotomy is better than intubation, and, as the swelling may extend into the trachea, the high operation is not advised. Although the operation should not be undertaken until other treatment has been tried, it is well to remember that collapse of the lung, broncho-pneumonia, and complications, are likely to arise when the obstruction is allowed to persist.

(iv) Syphilis. In the tertiary stages of either acquired or congenital syphilis (rare) the larynx may be affected, and in long-standing cases of over ten years, when the mucosa is much thickened, there is a danger of obstruction. Even when energetic antisyphilitic treatment has been advised the disease may become acute. Tracheotomy may be necessary for the relief of (a) oedema, likely to occur suddenly with necrosis, perichondritis, or the breaking down of gummata; (b) fibrous stenosis, which may cause a gradual increase of dyspnoea or become suddenly acute from spasm or oedema (iodides?); (c) adhesions, whether simple bands or webs; or (d) fixation of the vocal cords in the middle line, resulting from inflammation of the laryngeal joints or from paralysis of the abductor muscles.

(v) Tubercle. This rarely causes true laryngeal obstruction, excepting in those acute cases where subglottic oedema, abscess, or sequestrum is present. Tracheotomy was at one time used in certain cases in order to give complete rest to the larynx, but this has been abandoned as unsatisfactory; it should not be performed unless there is urgent laryngeal obstruction, since ‘it has many and grave disadvantages. It materially diminishes the efficiency of the cough, the secretion from the lungs is apt to accumulate in the bronchi and alveoli, and set up miliary tuberculosis. Again, the patient can often ill withstand even this slight operation; his power of speaking is diminished or lost and his mental anxiety is increased. Not rarely also, the tracheotomy wound becomes infected with tubercle. For these reasons tracheotomy should never be performed in phthisis except for severe dyspnoea’ (Lack26).

(vi) Certain nervous diseases, such as abductor paralysis. Urgent dyspnoea may occur in (a) advanced bilateral abductor paralysis, or (b) unilateral abductor paralysis associated with pressure upon the trachea by tumours. In the bilateral form it is difficult to determine when to operate; but the danger of suffocation, increased during the night, makes it necessary to overrule the objections of the patient. Tracheotomy (or intubation) may be performed merely as a temporary relief where the paralysis results from diphtheria, syphilis, toxic neuritis, &c.; in more serious cases the tube must be worn permanently, unless total recurrent paralysis supervenes (as it may do, though rarely in tabes) accompanied by cadaveric position of the cords and the restoration of free breathing. This latter condition can be induced by total division of both recurrent laryngeal nerves, but the operation, which has been performed on one or two occasions, has not been attended with satisfactory results. In cases of long duration the tube may be plugged during the day, or a valve may be added to the canula, so that the patient can speak by expiration through the larynx.

(vii) Tracheal compression by tumours of the neck or mediastinum, of the thyreoid or thymus, or by aneurism, or by tuberculous bronchial glands. In these conditions inspiration and expiration are equally affected, and if the obstruction is low down, a long canula (such as KÖnig’s, Kocher’s, or Salzer’s) will be required in order to relieve the dyspnoea. The pressure of such tubes may cause ulceration of the wall of the trachea, and hÆmorrhage may occur. This danger is especially to be feared when an aortic aneurism presses upon the trachea (see p. 542).

Tracheotomy should, therefore, be reserved for extreme cases, where it is impossible to remove the cause of the obstruction: on the other hand, dyspnoea caused by tumours of the neck which are removable (e.g. thyreoid tumours) should be relieved by radical operation without tracheotomy.

(viii) Congenital laryngeal stridor, glottic spasm, laryngismus stridulus, epilepsy, congenital webs and diseases of the crico-arytenoid joint such as ankylosis (true or false) or luxation. In these cases tracheotomy is rarely necessary, but when the operation is advisably undertaken the dyspnoea may require a permanent tracheotomy tube or prolonged intubation unless a radical removal of the disease can be effected.

(ix) Cut-throat. Tracheotomy is advised as a preliminary to further plastic operations in all cases where any part of the air-passages has been opened, in order to avoid the danger of suffocation and to prevent hÆmorrhage into the trachea.

(x) Fracture of either the hyoid, thyreoid, or cricoid cartilage, that of the thyreoid being the most common, and of the cricoid the most serious. These fractures are always associated with hÆmorrhage and oedema of the mucous membrane, sometimes with emphysema; and the swelling thus caused within the larynx may be so great that tracheotomy or laryngotomy becomes urgently necessary for the relief of dyspnoea. Theoretically it is advisable to expose the fracture, so that it may be sutured or wired in its proper position, but, even in those instances where this is attempted, it is advisable to retain the tracheotomy tube for a few days until all swelling has subsided.

(xi) Sudden dyspnoea during surgical operations, due to—

(a) Mechanical obstruction to respiration, such as is caused by impaction of foreign bodies within the larynx (tooth-plates, teeth, blood, pus, vomited food, &c.), by faulty position of the head or falling backwards of the tongue, by a swollen condition of the larynx, by tumours or abscesses (retropharyngeal) which obstruct the air-way, by cicatricial contraction of the pharynx or larynx, by paralysis of the vocal cords, or by spasm of the muscles of the jaws so often associated with a similar condition of the glottis and auxiliary muscles of respiration. In a case reported by Boyle, a well-nourished muscular man was anÆsthetized for the operation of internal urethrotomy; considerable difficulty was encountered with his breathing, and only towards the end of the operation was it discovered that he had well-marked stenosis of the upper opening of the larynx.

The entrance into the larynx of vomited food or blood is certainly dangerous, and may occur during the simplest operations even when properly performed, as, for instance, during removal of tonsils or adenoids. It is more likely to occur if the patient has not been prepared for an anÆsthetic, or if the latter be badly administered, if the laryngeal reflex be lost, if the patient be in a bad position or suddenly moves, or if the surgeon allows too much blood to collect in the pharynx.

(b) Failure of respiration from an overdose of chloroform or other anÆsthetic. To remedy such conditions it is essential that the air should be expelled from the chest as rapidly as possible. Artificial respiration can only be successful when the air passes freely both into and out of the lungs: in rare instances there may be so much difficulty in maintaining a free passage that tracheotomy should be performed.

(xii) Multiple papillomata of the larynx. Here tracheotomy is required for the relief of dyspnoea and as a preliminary to other operations. It has also been suggested as a method of curing the papillomata by giving rest to the larynx. After the performance of tracheotomy the congestion is relieved and the growths decrease in size; in some cases they completely disappear, but the treatment is uncertain and not to be recommended (see p. 485).

(xiii) Malignant disease of the pharynx or larynx which is too advanced for other forms of treatment. Palliative tracheotomy may be employed in order to relieve dyspnoea or as a means of giving rest to the larynx. It is most commonly used for cases of extrinsic carcinoma of the larynx: thus C. Jackson reported twenty-nine such cases, in twenty-one of which he advised palliative tracheotomy and in only eight laryngectomy. Of the former, tracheotomy was actually performed in nine, but none of the patients lived for more than thirteen months. It seems doubtful whether tracheotomy has any marked effect in retarding the course of malignant disease, though it sometimes gives relief.

(xiv) Foreign bodies in the air-passages. It makes no difference what views are held as to the advisability of tracheotomy in the treatment of these cases. The fact remains that the first essential is the safety of the patient, and, if the dyspnoea is urgent, relief must be afforded. When a foreign substance has been inhaled the surgeon must always be prepared for tracheotomy, and it is not advisable for him to leave the patient, even for a short interval, without proper supervision. In addition, the operation has been advocated as the proper treatment for all cases of foreign bodies in the lower air-passages: nevertheless, removal by Killian’s method gives far better results (see p. 559).

(xv) As a preliminary to operations upon the upper air-passages tracheotomy is rarely necessary, its place having been taken by infrathyreoid laryngotomy: it is, however, often performed before undertaking the larger operations upon the larynx (see p. 489).

Anatomy. The length of the trachea of an adult is about 4½ inches, of which 2½ inches lie above the level of the sternum; the cervical portion, which consists of eight or more rings, extends from the cricoid cartilage above to the suprasternal notch below. In order to determine the upper limit of the trachea it is advisable to palpate the following structures, which lie in the middle line, from above downwards: namely, the hyoid bone with its greater cornua, the thyreoid cartilage which forms the greatest prominence on the front of the neck, and the cricoid cartilage; in this manner it is possible to detect whether there is any deflexion of the trachea from the middle line as the result of a tumour lying in one side of the neck.

The anterior border of the sterno-mastoid muscle on each side is also an important landmark; the two muscles approach each other as they descend to their attachments to the sterno-clavicular joints, thus forming an angle the position of which corresponds to the notch in the manubrium sterni. By drawing a line transversely across the cricoid cartilage to the anterior borders of the sterno-mastoid muscles, a triangular space is marked off which may be described as the tracheotomy triangle (Fig. 264).

Beneath the skin and superficial fascia lie the two anterior jugular veins; these run from above downwards, to communicate with a branch which crosses the middle line of the neck, commonly in the lower part of the tracheotomy triangle, and there is an interval between them which is, in most cases, sufficiently large to prevent their being injured by a central incision. The pretracheal muscles, namely, the sterno-hyoids and sterno-thyreoids, are closer together; but the interval can be recognized by the greater thickness of the deep fascia which passes between them. When the latter is incised, these muscles can be separated, and the trachea is exposed, together with the structures that lie on its anterior aspect. These are the following:—

(a) The isthmus of the thyreoid gland, which varies greatly in size. It may be either a thin band with few vessels of importance, covering the second, third, and fourth tracheal ring; or hypertrophied and vascular, extending higher in the neck even to the front of the cricoid or thyreoid cartilage. This condition also results when a pyramidal lobe is present.

(b) The pretracheal fascia, which encloses the isthmus of the thyreoid gland and, when traced upwards, finds attachment to the anterior aspect of the cricoid cartilage, thus forming the suspensory ligament of the isthmus. Passing downwards it covers the anterior surface of the trachea, and, though somewhat indefinite, can easily be traced behind the sternum as far as the pericardium, with which it blends. This is a point of great practical importance in determining the extension of inflammation into the mediastinum.

(c) Veins. Small transverse branches of the superior thyreoid veins run upon the upper border of the isthmus between the layers of the fascia which surround this structure. The inferior thyreoid veins, larger in size, run from the lower border of the isthmus vertically downwards in front of the trachea to communicate with the left innominate; in their upper part they may consist of several small veins which join together to form two main branches, of which the left may lie directly in the middle line; small communicating branches of these veins run transversely across the lower border of the isthmus. The left innominate vein crosses the front of the trachea somewhat obliquely, and may lie at least half an inch above the suprasternal notch.

(d) Arteries. The crico-thyreoid artery runs transversely across the crico-thyreoid space, being placed in front of the suspensory ligament, and gives off numerous branches, which enter and supply the interior of the larynx, as well as small descending branches which run to the isthmus of the thyreoid gland. A small branch of the inferior thyreoid artery is also constantly found behind the isthmus, and in rare instances a thyreoidea ima branch of the innominate, varying greatly in size, may pass upwards in front of the trachea.

In young children the same relations are found, but with certain differences. Owing to the larynx being relatively high in the early years of life, the length of the cervical portion of the trachea is almost 2 inches when the head is extended, and the bifurcation is considerably higher than in the adult; further, the trachea is more movable and is smaller in diameter. The laryngeal cartilages are difficult to distinguish, but a mass composed of the thyreoid and cricoid cartilages can always be felt, and its position determined by careful inspection. It is very important to remember that, even when the head is extended, the cricoid cartilage lies rather less than 2 inches above the upper margin of the sternum. In very young children it is common to find two transverse creases in the skin, of which the upper usually lies over the upper border of the thyreoid and the lower over the cricoid cartilage. The lower crease thus assists in determining the upper limit of the trachea.

The anterior jugular veins in young children are comparatively large; the infrahyoid muscles are less defined and more difficult to recognize; and the isthmus of the thyreoid gland is very broad, appears to be part of the lateral lobes, and occupies a higher position in the neck, often passing in front of the crico-tracheal membrane as well as the first and second tracheal rings. The inferior thyreoid veins are larger, more numerous, and more difficult to separate; the left innominate vein is somewhat higher in the neck; the thymus gland, which gradually decreases in size with the increase of age, may extend into the neck, in front of the trachea, and may even reach as high as the isthmus of the thyreoid; the fasciÆ are softer and less definite, and the fascia which covers the trachea is easily stripped from its surface.

TRACHEOTOMY IN DIPHTHERIA

Operation. As local anÆsthetics are of little practical value in the case of children, the surgeon must decide whether a general anÆsthetic shall be used; for any nervousness on his part increases the danger of death upon the table. A general anÆsthetic is not necessary, but undoubtedly has certain advantages: the operation is easier and can be performed more rapidly; the patient is more likely to fall asleep; and any vomiting that occurs is beneficial rather than harmful. On the other hand, children suffering from diphtheria are apt to die suddenly under chloroform; and it should never be administered when there is any sign of heart failure, when obstruction is very marked, when cyanosis is present, or when the patient is prostrate. The danger has probably been exaggerated, and depends more upon the experience of the anÆsthetist than upon the actual disease; in my opinion it is as a rule safer to employ a small quantity of chloroform, which should be given on the operating table after everything has been prepared. The child should be allowed to choose its own position, generally curled up on one side, and the administration must be slow. By observing these precautions it usually happens that the child becomes quiet, and that with the loss of consciousness the breathing improves; the child can then be placed in the proper position, and the more difficult part of the operation can be completed before restlessness returns.

The instruments required are: a small scalpel, scissors, two dissecting forceps, three or more fine-pointed pressure forceps, two double hook retractors, one blunt hook, an aneurysm needle, and a suitable dilator for the wound; some form of aspiration apparatus may also, in rare instances, be necessary (Fig. 278). Three or four tracheotomy tubes such as described by Parker, and a small tube containing sterilized catgut, which is eminently suitable for the tying of vessels, and for that purpose preferable to silk, should also be in readiness. All the instruments should be kept together in a metal case, as well for private as for hospital practice, so as to be ready in case of emergency. They should be boiled for at least twenty minutes both before and after each operation, and should be laid out separately upon a dry sterilized towel in the position selected by the surgeon.

Tracheotomy tubes may be made of silver, rubber, vulcanite, celluloid, or a gum-elastic material, but most surgeons prefer a silver tube in the early stages of treatment. An angular form should be used, for ‘with the ordinary quarter circle tube, the lower extremity tends to impinge on the anterior wall of the trachea, and this is attended with many inconveniences and even with grave risks’ (Parker27). A movable shield is equally important, and this should be flush with the neck in order to avoid the possibility of its being removed by the patient. Further, the tube should consist of two parts—an outer tube to which the shield is attached, and an inner tube which projects slightly beyond the outer and can be removed for purposes of cleaning. To encourage breathing through the larynx, a window may be added in the upper part of the tubes. Parker’s tube, which meets all the above requirements, is the one most commonly used in England. When longer tubes are necessary, either Durham’s or Stewart’s is recommended: in these, the position of the shield can be altered, and the length of the tube arranged, to suit the patient. In cases of long duration the use of rubber tubes such as Morrant Baker’s is indicated. An introducer is rarely necessary except for rubber or long tubes. As taper and bivalve tubes are liable to injure the trachea, their use is not advised. The tube chosen should fit loosely, and should project far enough into the trachea to be secure from slipping out during coughing or struggling. Short tubes are preferable, and the wider the tube the easier the breathing and the better the drainage. The approximate diameter of the trachea varies at different ages, and the size of tube suitable in each case varies chiefly according to the trachea, but partly also according to the fatness of the neck. The accompanying table indicates the appropriate dimensions.

Table showing Size of Trachea and of Tube required at Different Ages

Tracheotomy, even under favourable circumstances, is attended by many difficulties; the urgency of the case, the restlessness of the patient, the movements of the larynx, the frequent absence of a proper operating table and equipment, the importance of a good light, of sensible assistants, of a trained nurse, and, above all, of a calm disposition, make this one of the most anxious and difficult operations in surgery, yet there is no medical man who may not be called upon to perform it.

It is important to make the best possible preparations. A table of suitable height can usually be improvised and placed in a good light. If the operation be at night, gas lamps or candles can be used, and the illuminant should be placed in a definite position rather than held by the parents. The child should be wrapped in a large towel in order to control the movements of the arms, body, and legs, and should then be placed upon the table; it is advisable to leave him in ignorance of the operation, whatever his age, until the last moment. The skin of the neck should be rapidly washed or sponged with ether, and the head extended over a small pillow or rolled towel. The operation must never be commenced until the proper position is obtained; on the other hand, extension of the head should not be too great for fear of increasing the dyspnoea. Three assistants are preferred—one to hold the head firmly in the middle line so that the point of the chin is exactly in line with the suprasternal notch (this is probably the anÆsthetist), a second to hold the body at the opposite end of the table, and a third to assist the surgeon with sponges or retractors. It should be the duty of the last named to prevent any membrane or pus from being coughed over the principals after the trachea has been opened.

There are four varieties of the operation, viz.:

1. Crico-tracheotomy (with division of the cricoid cartilage).

2. High tracheotomy (involving section of the trachea above the isthmus of the thyreoid gland).

3. Low tracheotomy (section of trachea below the isthmus of the thyreoid gland).

4. Median tracheotomy (section of trachea through the isthmus of the thyreoid gland).

Crico-tracheotomy is an easy operation owing to the superficial position of this portion of the air-passage, but is inadvisable for the following reasons:—

(1) The larynx being narrower than the trachea, a smaller tube is required; (2) the swelling of the mucosa often extends downwards and causes constriction of this region; (3) the tube is not well tolerated; (4) pressure ulcers, necrosis of the cricoid, and granulations are frequent complications; and (5) retained tube is more common than with other operations, this really being the most important consideration. The comparative value of the remaining operations is largely a matter of opinion.

It is not uncommonly stated that tracheotomy is better done by touch than by sight: the object to be achieved is to find the trachea, and there are two methods of doing this. The first is the deliberate method, suitable for patients in good condition when there is no urgent dyspnoea; it can be performed entirely by sight, and the greater the experience of the surgeon the fewer his difficulties. In such cases skilful technique is of far greater value than haste. The high operation is preferred, because the trachea is more superficial, less movable, and easier to find; it has less complicated relations, the blood-vessels are less numerous, the fasciÆ are not so loose, the tube is easier to fit and unlikely to slip out, healing of the wound is more rapid, and complications seldom occur. In cases where the isthmus is very broad or highly placed, so that the upper parts of the trachea and cricoid are covered, a median operation is recommended. Low tracheotomy is rarely necessary.

The second is the rapid method, to be applied in cases of emergency. Turner, of the South Eastern Hospital, strongly advocates such an operation without an anÆsthetic. The incision made is from ½-5/8 of an inch in length, this being repeated without attention to the bleeding until the trachea is reached. The latter is opened in the usual manner. The tip of the finger is placed in the wound in order to control the hÆmorrhage, and as a guide to the dilators. When these have been introduced, the child is at once drawn beyond the end of the table so that the head hangs downwards. The bleeding usually ceases in a few moments, though in some cases the tube is inserted to control it. The advantages claimed for this method are that the operation is quicker, and that no distinction between ‘high’ and ‘low’ is required. The wound is smaller, there is less danger of sepsis, and the eventual scar is hardly visible; no hooks or retractors are used, so that the trachea cannot be displaced. If the wound be in the middle line it is impossible to miss the trachea. This operation is performed entirely by touch, and the bleeding is not considered. Its adoption may be necessary to save the patient’s life, but in the hands of an inexperienced surgeon the operation is attended with great difficulties.

High tracheotomy. The incision must be exactly in the middle line; this can be accomplished easily if the surgeon keeps in mind two important landmarks, namely, the point of the chin, and the suprasternal notch. To determine the upper end of the incision, a point is chosen midway between the anterior borders of the sterno-mastoid muscles at the level of the cricoid cartilage. The thyreoid cartilages being steadied between the fingers and thumb of the left hand, a bold incision is made from the upper point, 1½ inches in length, extending in a young child almost to the suprasternal notch. A long incision is generally preferable, and, when the neck is fat, should commence over the middle of the thyreoid cartilage. The skin and superficial fascia are divided between the two anterior jugular veins, and any bleeding is controlled. The incision is repeated so as to divide the deep fascia lying between the sterno-hyoid muscles, close to one another in the upper part of the incision, and these are separated with the knife. It is now advisable to pause and to seize the bleeding points, allowing the pressure forceps to fall on both sides of the wound to act as retractors. The infrahyoid muscles are separated by at least an inch, and, if retractors are necessary, care must be taken that the muscles alone are included and that the retraction is equal on the two sides. If there has been no ‘tailing’ of the wound the following structures are then exposed from above downwards: the lower border of the thyreoid cartilage, and the front of the cricoid, both easily seen or felt; and a vascular mass, namely, the isthmus of the thyreoid gland, covered by fascia and completely concealing the trachea. The landmark that is required at this stage is the cricoid arch; this should be found, and a small transverse incision should be made along its lower border to divide the suspensory ligament; the handle of the scalpel or a blunt hook is introduced beneath the pretracheal fascia, and the isthmus dragged downwards into the lower portion of the wound, an operation which can be accomplished easily if done without hesitation. The upper rings of the trachea are now exposed; and, unless the superficial veins have been divided, there should be no bleeding. The trachea should not be opened until it has been exposed completely and all bleeding has been arrested. It is unnecessary to ligature the vessels at this stage unless the forceps have been so placed as to interfere with the part of the trachea chosen for section, or an artery of considerable size is encountered; in the latter instance there is a danger of subsequent hÆmorrhage if the ligature is applied close to the tube. While the trachea is being opened, it is necessary to overcome the movements of the larynx by grasping the cricoid with the finger and thumb of the left hand. The scalpel should be gently stabbed into the middle of the trachea to ensure puncturing the mucous membrane as well as the outer wall, and the opening should be quickly enlarged in an upward direction until three rings have been divided, preferably the first, second, and third. It is imperative that this incision should be in the middle line, should not be too small, and should only pass through the anterior tracheal wall; if force be used there is danger of puncturing the oesophagus, or even of striking the bodies of the vertebrÆ.

At the moment when the trachea is opened there is a sudden rush of air out of the lungs. This is reassuring to the surgeon, and at this point the dilator should be introduced and the anÆsthetic abandoned. Temporary cessation of breathing is common after the first inspiration, but the great improvement in colour shows that there is no cause for alarm; with the return of consciousness the child begins to cough, and this has two results, partly clearing the tubes of mucus, pus, or membrane, and partly promoting deeper inspiration and better expansion of the lungs. Cyanosis is thus speedily removed, unless membrane is abundant; and even where this is the case, it is advisable to encourage coughing in order to dislodge the membrane, which can be grasped with forceps or caught with a sponge as it appears in the wound. The use of a feather or a soft rubber catheter for irritation of the trachea to promote coughing should be abandoned, as such instruments often displace the membrane downwards. As soon as breathing is regular and the cough allayed, the vessels can be ligatured.

A tube of suitable size having next been selected, the opening in the trachea is widely dilated and the point of the canula quickly inserted into position, the outer tube alone being used, with tapes for tying attached. Unless the tube ‘sits’ well without tilting, different sizes should be tried until the breathing becomes easy, a sure sign that the lower opening of the canula is pointing in the right direction. The tapes are tied firmly on the right side of the neck, after which the inner tube is introduced and fixed in position.

The wound remains to be treated. Various methods have been recommended to guard against infection: the use of antiseptic watery solutions, such as perchloride of mercury, chloride of zinc, carbolic acid, and perchloride of iron, is dangerous; insufflation of powders, on the other hand, such as orthoform, aristol, and the like, is certainly effective in keeping the wound clean, and is better than the employment of an oil emulsion; suturing the wound is unnecessary and is not recommended. A dry antiseptic gauze is applied to the wound and kept in position by the pressure of the shield. Lastly, a thin covering of gauze is placed over the front of the neck, and the patient returned to bed.

Low tracheotomy. The incision should be rather longer than in the ‘high’ operation and should reach almost to the suprasternal notch. The fasciÆ, anterior jugular veins, and infrahyoid muscles are treated as before, and there must be no ‘tailing’ of the wound. The landmark required is the isthmus of the thyreoid gland, and its lower border must be determined and dragged upwards by a blunt hook. It is important to remember that the lower part of the trachea lies deeper in the neck and is more difficult to expose owing to the blood-vessels that lie anterior to it; the thymus gland, also, may extend upwards and require to be retracted. Whereas in high tracheotomy practically the whole operation is best done by clean cutting, in the lower operation this is more dangerous, and the deep dissection must be performed partly with forceps or blunt director; if an artery be divided or venous bleeding occurs, it should be controlled immediately. No attempt should be made to perform this operation rapidly owing to the relations of the parts; nor should the trachea be opened before its rings are exposed thoroughly, as complications may arise after imperfect division of the pretracheal fascia. In the opening of the trachea and the further stages, the operation is similar to high tracheotomy.

Median tracheotomy. The child being placed in the required position as before, an incision is made, from the lower border of the thyreoid cartilage almost to the sternum, through the skin and superficial fascia. With a series of cuts, exactly in the line of the original incision, the fascia lying between the pretracheal muscles is divided; the bleeding points are seized with pressure forceps, and retractors are introduced to expose the isthmus. The isthmus itself is treated in one of two ways: in urgent cases it is boldly divided by one or two cuts of the knife; but if time can be spared, a threaded aneurysm needle may be passed under it, first on one side and then on the other, after which the needle is withdrawn, and the two ligatures can be tied so as to leave between them a space of one-third of an inch in which a cut can be made without hÆmorrhage. The tracheal rings are thus exposed and can be divided as before.

Accidents. The accidents that occur are less numerous than might be expected when it is considered how often this operation is performed by those who are quite unpractised in surgery; many of them are the direct result of inexperience or arise because the operator becomes confused. If the patient be in a bad position, or if a wrong incision be made, the trachea is difficult to find, and it is better to expose the thyreoid cartilage and prolong the incision downwards until the windpipe has been discovered.

HÆmorrhage, however, is the chief difficulty, and is sometimes unavoidable; it may be arterial or venous. The arteries of this region are generally small, being branches of the superior or inferior thyreoids, and this accounts for the fact that severe arterial bleeding is rare. Nevertheless, the smaller vessels may at times be very troublesome: for instance, the crico-thyreoid artery or one of its branches may be divided, in which case the cut ends will retract and will be difficult to seize; and if the trachea has been opened, blood may continue to enter in sufficient quantity to cause troublesome coughing. Abnormal arteries, such as the thyreoidea ima, are not of great practical importance.

Venous hÆmorrhage is far more common, and, taking into account the anatomical relations of the veins, and their great size (increased by cyanosis) in children, it seems remarkable that bleeding is so seldom fatal; in desperate cases a very small amount of blood is sufficient to cause suffocation. Venous bleeding will stop only when respiration becomes free, and this is not possible so long as blood is being sucked into the air-passages. Every effort should be made, therefore, to prevent blood from passing into the trachea, either by hanging the head over the end of the table as soon as the dilators have been introduced, or by introducing a canula against which the walls of the trachea can be compressed.

Failure to breathe, after an opening has been made, is due to either obstruction or collapse and requires rapid treatment. The trachea must be widely dilated, and forceps used to remove any membrane which presents itself in the wound; the assistant must then slowly compress the ribs two or three times to empty the chest and encourage respiration. If consciousness returns, the patient begins to cough and mucus or membrane is expelled from the air-passages. On the other hand, it is useless to continue artificial respiration if the obstruction is not relieved; aspiration must be employed if special instruments are at hand. The fact that a number of surgeons have lost their lives as the result of sucking through a catheter in the attempt to save the child is sufficient to condemn this practice; but good results have been obtained by passing a catheter low down into the trachea and blowing through it with a syringe or even with the mouth. As soon as the trachea has been emptied by one of these methods, artificial respiration should be continued, and collapse treated by injections of strychnine, brandy, or ether. No attempt should be made to introduce a canula until the breathing is restored. As Turner remarks: ‘Heart failure during operation generally recovers with artificial respiration, and twelve hours later the condition is indistinguishable from that of a case who has not so closely approached death. The real remedy against such an accident is never to postpone operation until the heart is exhausted.’

After-treatment. Although this is a subject which has produced a great deal of discussion, there is a widespread impression among the younger members of the profession that it is of little importance. Much has been said about the dangers of interference, and any suggestion put forward has been criticized by those who have had large experience, with the result that confusion is prevalent. As a matter of fact, the subject is one of the greatest importance, for there is no operation in surgery in which the after-treatment can be neglected. Care should be exercised in choosing a nurse who has special knowledge of children and of the after-treatment of tracheotomy. Great discretion is required in the management of such cases, and there is little doubt that harm may result where too much attention is shown. At many of the hospitals a special nurse is appointed for attendance on the more desperate cases only. The main duty of the nurse is to watch the child, for any difficulty in breathing requires immediate attention. It is necessary that she should understand the proper management of the tube; she must see that the inner tube never becomes clogged, and if the tube slips out of the trachea it must be reintroduced or a dilator inserted; she must also be responsible for the feeding of the child. The difficulties that arise during the first few days after operation call for much tact and experience.

It is unnecessary to enter here into the discussion about food, stimulants, or general treatment, except to point out that swallowing may be very difficult. The food must be nourishing, fluid being in most cases preferred; occasional sips of water should be administered to find out whether coughing is produced, in which case nasal feeding can be advised without hesitation. A short rubber catheter should be passed through the nose at regular intervals according to the nature of the case. As a general rule a small quantity of nourishment should be given every two hours, studying, as far as possible, the likes and dislikes of the patient. By the observance of these principles the child soon becomes tolerant, and proper nourishment can be administered, thus removing one of the great difficulties of after-treatment.

The atmosphere of the room. The value of steam for producing warmth and moisture is undoubted; the amount required depends on the case. The main object to be kept in view is to encourage secretion from the mucous membranes, and so to prevent the formation of crusts. When secretion is scanty a large amount of moisture is required, and vice versa; also, when much pus is present, extra moisture is of value to prevent it from becoming dried and to allow it to be expectorated. The value of disinfectants is doubtful, but on general principles it may be said that the more septic the secretion the greater the indication for their use: tincture of benzoin, oil of eucalyptus, and thymol act as sedatives; carbolic acid, creosote, and numerous other drugs are useful disinfectants; soda and potash, recommended by R. W. Parker, tend to liquefy the exudations. Steam, however, is more important than all these, and should be advised as being likely to encourage the quicker healing of the wound: even in catarrhal conditions improvement is more rapid when this practice is adhered to.

The most important point in the after-treatment, however, as far as the surgeon is concerned, is to prevent recurrence of the obstruction. Obstruction is most often due to the blocking of the inner tube by secretions, a condition easy to recognize from the symptoms which are produced. The inner tube should be removed, thoroughly cleaned, and reintroduced. This usually suffices to allow the child a period of quiet breathing, and sleep may be obtained. To keep the tube free it is very necessary to repeat the removal at regular intervals. In those cases where the secretion is tenacious, the tube constantly becomes blocked, but it is better to remove it again than to allow a feather to be passed. Nothing is gained by attempting to hurry the separation of crusts, and the passage of a feather tends to force downward far more than can be extracted, and so to increase the danger of broncho-pneumonia. If dyspnoea continues after removal of the inner tube, a spray should be used, or a small amount of fluid should be dropped into the trachea to moisten the secretions.

Changing the outer tube rarely presents any difficulty because the tissues of the neck soon become matted together, a funnel being thus produced along which the canula is introduced with ease. A new tube should be prepared before removal of the old, and dilators should be at hand for use if the child is frightened, struggles, or coughs: the canula should be introduced quickly and without hesitation, sufficient force being employed to overcome any obstruction. Unless the original opening in the trachea was too small, it should be possible to introduce a tube equal in size to that which was removed. Frequent changing of the outer tube should be avoided.

The time for removing the outer tube. In every case of diphtheria there is a certain amount of catarrh, with swelling of the mucosa, increased secretion, and some difficulty of breathing. In addition, the habit of breathing through a canula is difficult to alter; the child shows an aversion to breathing through the natural air-passages, and is often frightened or bad-tempered. As soon as the secretion becomes small in amount and serous rather than purulent in consistence, an attempt should be made to discard the tube: the canula should not be retained a day longer than is necessary, the usual period varying from five to fifteen days. Various methods may be adopted:—

1. If the outer tube be provided with a window, the tip of the finger can be placed on the opening to compel the child to breathe through the larynx; breathing may be difficult, but by this means an indication can be obtained as to whether it is advisable to persist.

2. If the above method be successful, the tube may be removed. A small pad of gauze is placed over the wound and the child further encouraged to breathe through the larynx. Expiration is generally easier than inspiration, and older children should be encouraged to blow out a candle or to sound a whistle, this process being continued so long as the child can endure it, but not to the stage of exhaustion. It is often possible to remove the tube at the first attempt.

3. The canula may be plugged with a cork which the nurse removes when necessary: it is often possible to replace the plug while the child is asleep without his becoming conscious of the fact, thus showing that the dyspnoea is largely mental.

4. In some children breathing is easy so long as the tube is simply plugged and is not removed; in such cases the canula can be replaced by a shield and a plug which does not pass into the trachea. This may completely deceive the child.

5. The silver tube can be changed for one of rubber, and this can be shortened daily until nothing remains but the shield.

If these various methods have been tried with no success it is probable that the case is abnormal, but before this can be conceded it is necessary to repeat that, in the large majority of cases, the difficulty of removing the tube is due not so much to definite stenosis of the larynx as to the bad habit acquired by the patient.

Complications arising after tracheotomy and preventing removal of the tube:—

1. Wound infection. This rarely occurs at the present time, and diphtheritic wounds are seldom seen. Some inflammation of the wound is natural under the conditions, and may be associated with oedema of the surrounding tissues; this generally yields to antiseptic treatment in a few days. In very weakly children suffering from a virulent form of disease the healing of the wound may be slow, and septic conditions are apt to arise ending in cellulitis of the neck or even typical erysipelas. Owing to the disposition of the fasciÆ there is a tendency for the infection to spread in a downward direction, and for mediastinal inflammation or suppuration to occur: this appears to be more common after low tracheotomy. The prognosis in such cases is not good, and every endeavour should be made to prevent the possibility of their occurrence by absolute cleanliness at the operation and by suitable after-treatment of the wounds.

2. Septic conditions of the trachea are less common since the introduction of antitoxin, but occur in cases where false membrane is abundant. There may be swelling of the mucosa, or copious discharge which persists for long periods.

3. Ulceration may be due to sepsis or to pressure from a badly fitting tube, especially when the latter has been worn for a protracted period (Fig. 270). It may cause perforation and localized abscess either in front of the trachea or in the neighbourhood of the oesophagus, and may result in a communication with the latter. In the region of the cricoid, ulcers are liable to cause necrosis. The signs of such ulceration are: continuance of purulent discharge, discoloration of the tube, bleeding from the wound, and, above all, difficulty in removing the tube.

At the first indication of ulceration the cause of irritation should be removed. It is advisable to discard a metal in favour of a rubber tube, or, if possible, to remove the tube altogether. Strenuous efforts must then be made to disinfect the trachea by the insufflation of antiseptics, either as powders or in solution. The healing of such ulcers is very slow, and granulations are apt to form resulting in obstruction and preventing removal of the tube. In later stages contraction of fibrous tissue causes stenosis; this is more common in the neighbourhood of the cricoid, especially when the latter has been divided at the time of the operation.

4. Granulations. The possible presence of granulations must always be borne in mind. I believe this condition is far less common than is generally supposed, and that in many cases the granulations are entirely limited to the neighbourhood of the wound, where they can be seen. It is doubtful whether they are responsible for the dyspnoea which occurs. Great ingenuity and patience are required for the treatment of this condition. The wound must be kept scrupulously clean and all source of irritation removed. A rubber canula should be substituted in place of a metal one; if it were possible it would be advisable to discard the tube altogether, but as yet no form of dilator has been devised which will take the place of the canula. If the granulations be large they should be removed either with a sharp spoon or with suitable forceps, the area having been anÆsthetized previously by a small quantity of the novocaine and adrenalin mixture. When small, the use of silver nitrate is preferable. It may be necessary to repeat this after a few days, and as soon as seems advisable a further attempt should be made to dispense with the tube. At this stage time must be allowed for the various tissues to regain their normal condition. Should this treatment prove unsuccessful, a thorough investigation must be made under chloroform. The wound is enlarged as far upwards as the cricoid, bleeding being arrested with the mixture just described. By throwing a strong light into the wound, the condition of the mucous membrane can be inspected and granulations removed. If there be no granulations in the trachea, a tube speculum can be passed through the mouth to ascertain the condition of the larynx (see p. 480). Such a method of procedure is preferable to the passage of probes, forceps, sponges, and other articles through the larynx, in the hope that any obstruction may be removed. If ulceration or necrosis of cartilage be discovered, it is impossible to relieve the condition by surgical means without prolonged treatment with tubes and the constant use of antiseptics. Under these conditions it is advisable to consider the removal of the tracheotomy tube in favour of intubation. In the hands of many foreign authorities the use of intubation tubes covered with gelatine, in which antiseptic is introduced, has been attended with such conspicuous success that further attempts should be made in this country; there is little doubt that, as our knowledge of the treatment of such wounds improves, better results are daily attained. Whatever treatment is considered it is important first of all that the actual cause should be distinguished. This is now possible owing to the great advances made in methods of examining the larynx.

5. Stenosis of the larynx or trachea occurs in old-standing cases, as the result of ulceration, after some cases of crico-tracheotomy, and especially where a tube has been worn for a very protracted period. Breathing through a tube, if continued for a long time, interferes with the natural growth of the air-passage above it. The child grows, but the larynx remains stationary. This condition is aggravated by the fact that some inflammation is constantly present, especially in the neighbourhood of the wound, so that the tissue become fibrous and hard. The fibrous tissue contracts and stenosis is caused. According to von Bruns, Kohl,28 and others, constrictions of the trachea may in rare instances result from some kinking of its wall. Such conditions as a bulging of the posterior wall due to the approximation of the posterior ends of the cartilage secondary to the spreading of the anterior portions, inversion of the tracheal margins from too small an incision, overlapping of the tracheal wound, and cicatricial union between the thyreoid and cricoid, must be exceedingly rare. Here, again, a definite diagnosis can always be made by proper investigation, but treatment is more difficult. Dilatation must be attempted by either continuous or intermittent methods. If preferred, a short piece of rubber tubing can be passed upwards from the tracheotomy wound into the larynx and kept in place for several hours by two silk sutures, one passing out of the tracheal wound, the other out of the mouth; or a stenosis canula can be inserted with some form of hollow plug which passes upwards into the larynx (Fig. 272). The question whether the tracheotomy wound should be kept patent is difficult to answer. When stenosis is extreme there is no alternative, and the open wound allows of the constant passage of graduated bougies, which is more easily accomplished from below than from above. If treatment be persistent the prospect of a good result is not unfavourable, and there is every reason to believe that in the future the number of cases which require a permanent tracheotomy tube will be reduced to a minimum.

6. Paralysis. In the larynx there may be paralysis of the sensory or of the motor nerves. In the former case food may enter into the trachea and cause troublesome coughing and possibly ‘Schluck-pneumonie’. When the motor nerves are affected, the paralysis is commonly abductor and may be unilateral or bilateral, the latter associated with inspiratory dyspnoea. ‘Complete paralysis of the recurrent laryngeal nerve may also occur, but is nearly always confined to one side’ (C. A. Parker29). Such paralyses may last from a few days to several months, and are very troublesome when associated with the passage of food into the trachea; when severe, nourishment should consist of fluids which can be administered by a nasal tube.

Further complications arising during the after-treatment of tracheotomy:

7. Broncho-pneumonia. This occurs in the worst forms, and is accompanied by high temperature with definite signs in the lungs. The absence of septic discharge, the restlessness of the patient, and the rapidity of the breathing (in many instances accompanied by ‘recession’ not caused by obstruction in the tube) make the condition easy to recognize. There is no satisfactory treatment for septic broncho-pneumonia which has already developed, but it may be prevented. Within recent years it has become less common. This is due to better technique in the operation, and to careful attention during the after-treatment. The habit of passing feathers into the trachea has been abandoned with advantage to the patient. When possible the child should be removed from septic influences which are liable to infect the throat, for the occurrence of tonsil[l]itis as a sequel to tracheotomy is always to be feared in wards containing septic cases.

8. Emphysema may occur in the neighbourhood of the wound, or in rare cases may be extensive and involve the whole of the face, neck, and chest. Champneys30 was the first writer to call attention to this complication of tracheotomy. After a large number of observations and experiments, he was of opinion that emphysema of the anterior mediastinum occurs in a certain proportion of tracheotomies and is of frequent occurrence in cases that are fatal; that it may be associated with pneumothorax; and that the conditions which favour its production are a low division of the deep cervical fasciÆ in the neighbourhood of the sternum, combined with obstruction of the air-passages and strong inspiratory efforts; artificial respiration, especially if improperly performed; and want of skill on the part of the operator; further, that the dangerous period of the operation is between the division of the deep cervical fascia and the efficient introduction of the tube. To this may be added those cases in which the tube slips out of the trachea into the cellular tissue above the sternum and thus causes more or less obstruction to breathing. It seems probable that the air is sucked into the cellular tissues beneath the pretracheal fascia, rather from the outside than from the trachea, and that with forced expansion of the chest it finds its way beneath the fascia into the mediastinum.

9. HÆmorrhage may occur as the result of slipping of a ligature during an attack of vomiting or struggling after the operation; it is usually venous and requires nothing but passing notice. Secondary hÆmorrhage may result from ulceration into one of the larger arteries or veins. Kocher31 states that ‘the number of cases recorded is now about eighty-seven, of which fifty-six are associated with the innominate artery. Unfortunately it is not known how often in these cases inferior tracheotomy had been performed. Low tracheotomy was performed in my case because an excision of the larynx for cancer had been undertaken. Doubtless the danger of these fatal complications is much greater with inferior tracheotomy owing to the pressure of the canula.’ Von Bruns32 also agrees that ‘the vast majority of fatal hÆmorrhages were in cases of inferior tracheotomy. Of thirty-six cases in which the source of hÆmorrhage was given, twenty-eight were traced to the innominate vein, two to the right carotid, and one each to the superior thyreoid, the left innominate, the right jugular and the left jugular.’ Bleeding is also recorded in cases of aneurism of the aorta, in which tracheotomy has been performed, as the result of erosion of the tracheal wall and the bursting of the sac. Further, troublesome oozing may take place from the mucous membrane of the trachea when this is inflamed, or when granulations are present, or when there is much sloughing of tissues, and especially after a metal tube has been worn for a considerable period. HÆmorrhage from an enlarged thyreoid isthmus is also described. When due consideration is given to the septic condition of the wounds and the close relation of large vessels, it is surprising to find that hÆmorrhage proves so seldom fatal.

10. Cardiac paralysis may also complicate tracheotomy. When supervening in the acute stages of the disease, the patient becomes prostrate and vomiting is persistent, while the heart gradually fails. In other cases death occurs suddenly and unexpectedly, in mild as well as in severe disease; this may happen at any period, during the first days or later, during convalescence. Heart failure is more common in diphtheria than in any other infectious disease which is met with in this country.

Prognosis. It may be said that all cases of laryngitis caused by diphtheria are of a serious nature, and especially those which require tracheotomy (see Table, p. 517). The mortality amongst tracheotomized patients during five years was 31.5%, and the variations in each separate year were slight. Such results are far from satisfactory, but it must be remembered that in pre-antitoxin days less than 30% recovered after tracheotomy (Goodall33). The use of antitoxin, first suggested by Behring, is undoubtedly responsible for this remarkable decrease in the mortality. The sooner the serum is injected the better the prognosis with tracheotomy. A large dose should be given, 8,000 to 18,000 units, irrespective of age, and the dose may be repeated on the second day if required. Improvement generally commences between twelve and twenty-four hours after injection; the swelling of the mucosa subsides, and secretion is diminished; false membrane is not so copious, and rarely extends to the trachea and bronchi; crusts become less adherent, and are expelled by the patient. In this manner the whole area of the disease becomes clean, and there is less absorption of toxins. It is now generally agreed that serum should be used in all suspicious cases, and some authorities inject at once not only the patient, but also other children living in the same house. It is hoped by early injection to avoid the necessity for tracheotomy.

The age of the patient is very important, as the following table shows:

Table showing Total Diphtheria Tracheotomies performed at the Fever Hospitals in London during 1902–6, including those in which Intubation was previously performed and those in which no Antitoxin was used

From these figures it is apparent (1) that children less than one year of age rarely recover after tracheotomy; this is especially true of diphtheria, although in other forms of laryngeal obstruction cases of recovery have been reported in children of six months; (2) that in the early years of life tracheotomy is most commonly needed, especially between the ages of one and five years; (3) that the death-rate gradually decreases between the ages of one and six years, after which there is a rise.

In explanation of these facts it appears probable that after five years of age the larynx and trachea are increased in size, so that obstruction is only met with where there is a large amount of membrane, namely, in the worst cases; in patients over ten, the age which marks the change to the adult type of larynx, the air-passages become so large that obstruction seldom occurs even when much membrane is present; dyspnoea, in these cases, points to extension of the disease to the smaller tubes, and tracheotomy is unable to give the same relief.

In considering the prognosis, not only must the symptoms peculiar to the case be taken into account (as for instance the pulse, temperature, respiration and general condition), but also any complications that arise. It must be borne in mind that tracheotomy does not cure, although it can relieve, the patient; that nearly one-third of the cases die; that the disease, and not the operation, is responsible for most of the deaths. Moreover, the amount of toxÆmia depends upon the virulence of the infection, which is variable in different epidemics; upon the area of mucous membrane infected; and upon the constitution of the patient. In so-called hÆmorrhagic diphtheria the result is always fatal.

The effect on after-life. It was stated by Landouzy at the Berlin Tuberculosis Congress in 1899 that, judging by the rarity of the scar, few tracheotomized children reach adult life, but inquiries in Germany showed that this was incorrect. H. W. L. Barlow, in reviewing the literature of the subject, concludes that ‘in the large majority of cases the cure is permanent and complete’. In cases where a tracheotomy tube has been retained for a long period, however, complications are liable to arise; these include stenosis of the larynx or trachea, bronchitis, pneumonia, and possibly tuberculosis (see p. 485).

TRACHEOTOMY IN CONDITIONS OTHER THAN DIPHTHERIA

The indications for tracheotomy in conditions other than diphtheria have already been described. Although local anÆsthetics are of little practical value in children, their use is much preferred where adults are concerned. The three drugs most commonly used at the present time are eucaine, cocaine, and novocaine, and of these novocaine is unquestionably to be preferred for subcutaneous injection as being less toxic, less irritant to the tissues, and at least as efficient in producing anÆsthesia. Whichever drug is chosen, a small quantity of chloride of sodium should be added in order to make the solution isotonic with the blood serum, and thus to render it practically non-irritant. Many surgeons add adrenalin to contract the vessels in the injected area and so to prevent the drug from being absorbed into the general circulation: owing to the large size of the vessels and their proximity to the heart this is important, but it must also be remembered that with strong solutions there is great contraction of vessels, and that when the effects have disappeared there is a slight danger of recurrent hÆmorrhage. Semon has drawn attention to this danger in connexion with operations upon the larynx, and after minor operations in other regions of the body it is not uncommon to find a small hÆmatoma which necessitates reopening the wound.

In order to ensure the full effects of local anÆsthesia with the least possible disadvantage, the drug should be used in weak solution, and the injection should be made at least a quarter of an hour before the operation is commenced. It is only necessary to prick the skin at one point, namely, at the upper end of the proposed incision; a small quantity of the fluid should be expelled, after which the needle may be withdrawn. After a short interval it is possible to reinsert the needle (or a larger one if preferred) and to push it deeper, until the whole length of the incision has been injected, without distress to the patient.

The following solution will be found effective:

‘These local anÆsthetics are all, more or less, rapidly decomposed and rendered inactive in the presence of even traces of an alkali or alkaline carbonate. If boiling is resorted to in order to sterilize the syringe, great care must be taken that no soda is present.’—Lang.

Moreover, the finished solution cannot be boiled without decomposing the adrenalin, and it is customary therefore to add thymol or Ol. Gaultherii (0.1%), which keeps the solution antiseptic without being irritant.

The operation, which is often required in adults, must be carried out upon the lines already described. The enlargement of the thyreoid and cricoid cartilages, the small amount of fat, the small size of the thyreoid isthmus and of the pretracheal vessels after puberty, make the trachea easy to find. Difficulties, however, arise and are determined by the urgency of the case and the nature of the disease. Thus, with inflammation, the neck may be so swollen that the trachea is many inches from the surface; with tumours the trachea may be displaced, or the obstruction may be in the thorax. Under such conditions it is important to note the probable position of the trachea before the operation is commenced, and to be prepared for serious hÆmorrhage.

The after-treatment also corresponds to that which is adopted in diphtheria. It is important to keep the tube clean and to prevent it from irritating the trachea. The time for removal of the canula varies according to the condition. Thus, when tracheotomy is performed for a foreign body, the tube may be removed as soon as the object has been extracted; on the other hand, when treating stenosis of the larynx it may be necessary to advise permanent wearing of the canula.

Complications are less common than with tracheotomy for diphtheria. Under favourable conditions there is little danger of pneumonia unless the wound becomes infected, as may happen when the operation is undertaken for the relief of septic inflammations.

Although tracheotomy is in itself a slight operation, it should be reserved for cases that demand it. The mortality of the operation under favourable conditions is probably very small; on the other hand, in acute septic conditions and in patients suffering from bronchitis there are grave dangers of complications.

TRACHEO-FISSURE AND RESECTION OF THE TRACHEA

Although these operations are very rarely performed, advance has been made in their technique during recent years.

Indications. (i) Tumours of the trachea. These are uncommon. Thiesen34 in 1906 collected from literature 135 cases, of which 89 were innocent and 46 malignant. The majority of the former were papilloma (25), fibroma (24), enchondroma (17), and intratracheal struma (10). Of the latter, carcinoma (28) was more common than sarcoma (18). More than half of these tumours were situated high up in the trachea. These cases were collected from a period covering seventy-five years, which proves that they are extremely rare as compared with tumours of the larynx.

(ii) Stenosis due to previous inflammation. Stenosis may be caused by diphtheria or other fevers, syphilis, the presence of a foreign body, or the inhalation of corrosive acids or chemical fumes. Such cases are generally treated by endotracheal methods (see p. 559).

(iii) Cut-throat, or injury. An operation may be necessary after crushing or bullet wounds, or, in later stages, owing to the development of stenosis.

The diagnosis of these conditions is now comparatively easy, and with the help of direct laryngoscopy and X-ray photography the exact condition can, in many cases, be determined. In some instances the tumour may be removed by endotracheal operation, especially if the growth is innocent.

Tracheo-fissure is more reliable, and should always be performed when there is any suspicion of malignancy. The preliminary stages are similar to those of tracheotomy. A section of the trachea is first made in the region of the tumour, and the opening is enlarged so that the growth can be thoroughly explored; this can be better accomplished when the trachea is illuminated by a good electric lamp, in some instances a Killian’s tube being required. When possible, a tampon canula is inserted into the lower part of the trachea. When the growth is low down, the patient is placed in the Trendelenburg position in order to prevent the inspiration of blood. Should the diagnosis be uncertain, a portion of the tumour can be excised and a frozen section made. If proved to be innocent, the growth can then be freely excised with scissors or galvano-cautery. The bleeding is arrested, and the tracheotomy tube is retained for several days. The after-treatment must be conducted on lines similar to those laid down for laryngectomy, the patient being turned on the face in order to prevent pneumonia. ‘Up to the present time about two dozen operations of this sort have been reported. The author has removed in this manner four intratracheal thyreoids with permanent result’ (von Bruns).35

Resection. If the tumour be malignant, the surgeon must first decide whether its removal is practicable or whether palliative tracheotomy is preferable. In the former case the trachea is isolated laterally and divided transversely well below the growth. Whenever possible the lower end is then brought outwards and temporarily attached to the lower part of the incision above the sternum. The resection of the trachea is then carried out, so that the growth is freely removed, care being taken to preserve the recurrent laryngeal nerves. ‘Where the section of the trachea to be removed is limited to 4 centimetres or less, the two ends can generally be approximated and united, restoring the calibre of the tube and normal mouth respiration’ (Brewer).36 This is accomplished by numerous catgut sutures some of which include the entire thickness of the tube. The muscles can be approximated so as to cover the incision, and the wound can be drained freely. On the other hand, the lower end of the trachea may be permanently fixed in the wound as described under laryngectomy (see p. 498). Von Bruns has removed a cancer on the posterior wall of the trachea with six tracheal rings, thus giving the patient six years of life. He remarks: ‘operative treatment in tumours of the trachea shows brilliant results. Untreated the condition leads to death from suffocation. In seven cases operated upon by me, the results were all favourable.’

CHAPTER IV
INTUBATION OF THE LARYNX

Intubation, or ‘tubage’, was first recommended by Loiseau and Bouchut in France; in 1880 attention was drawn to the subject by Sir W. Macewen in England, and soon afterwards O’Dwyer37 of New York published articles which resulted in its being extensively tried in America; since that time it has continued to be popular in that country for the treatment of laryngeal diphtheria. ‘The good results which American physicians have secured by intubation may be explained, perhaps, by the circumstance that according to their reports diphtheria takes a milder form in America’ (Tillmanns).38 Intubation has been extensively used in Europe, especially in Germany, but never to the same extent as tracheotomy, and in England it has been practised at only a small number of hospitals; thus, of the nine M. A. B. fever hospitals in London only three used it regularly during 1906–7, and none of them so often as tracheotomy.

Intubation versus Tracheotomy in Diphtheria. Since the introduction of the newer method of treatment in 1880 the subject has been widely discussed in America, on the continent of Europe, and in England. There is no evidence to show that treatment with antitoxin has been beneficial to one operation more than to the other.

The advantages claimed for intubation are:

1. No anÆsthetic is required.

2. Consent of friends is easily obtained.

3. No cutting: great rapidity.

4. No wound to heal.

5. Tube worn more easily than the tracheotomy tube.

6. Breathing through natural passages, so that warmth and moisture are added to the air.

7. Its earlier performance.

8. Its better results in children under five.

9. Recovery is quicker.

The practical disadvantages are:

1. Quite unsuitable except at special hospitals, as great dexterity and constant practice are necessary.

2. Respiration is interfered with during introduction, so that celerity is indispensable, accidents are frequent, and failure is common.

3. Tube may be coughed up (28%, Goodall39), blocked (12%, Goodall), and does not provide good drainage for secretions.

4. Swallowing difficult.

5. Complications common: Broncho-pneumonia, ulceration, cicatrization.

6. After-treatment difficult and constant watching required.

7. Necessity for secondary tracheotomy (32.6%), which has a greater mortality (death in 46.1%, see table below).

8. Retained tube.

In considering the above it is the obvious duty of the surgeon to advise what he considers the better operation for the case, and this must depend largely upon the amount of his experience; the argument that the operation is superior because it can be previously practised on the cadaver is a bad one, and implies a failure to realize the many difficulties which will be encountered in the selection of cases, the operation itself, and its after-management.

I am strongly of opinion that the operation ought not to be tried indiscriminately by those who have no knowledge of these difficulties. In the hands of an expert it is a justifiable method of treatment which is suitable for selected cases, and it is one which can be used early; tracheotomy, on the other hand, is naturally delayed, or used for serious cases and those which have not derived relief from intubation.

Although intubation has received extensive trial, the published results show great variations and do not prove that intubation is superior to tracheotomy, but rather the reverse.

Table showing Details of Cases during 1906 and 1907 at the M. A. B. Hospitals where Intubation is favoured

Certain points in the table deserve attention:

1. In cases treated by intubation only, the results are excellent, namely, death in 10.4%.

2. In cases where tracheotomy was afterwards performed the mortality is high, i.e. 46.1%.

3. Where tracheotomy was the original operation the mortality is also high, i.e. 37.7%.

4. The total operations at these hospitals taken together show a rather higher mortality than appears in the table below.

As regards the first three points, the facts are the same as in any published statistics dealing with the relative advantages of the two operations. I wish to emphasize that the results obtained by intubation depend very largely upon the selection of the cases and I agree with Turner and Cuff that, in order to arrive at any conclusion in the matter, it is necessary to compare the total results of those hospitals where intubation is favoured with those of the hospitals where tracheotomy is chiefly employed.

Table showing Comparative Results at ‘Intubation’ and ‘Tracheotomy’ Hospitals

¹ No return.

² Of these more than 400 were intubations.

³ Of these 23 or more were intubations.

From these figures it will be seen that the total result for five years is a mortality of 27.9% as against 29.6%, in favour of tracheotomy. This serves, in my opinion, to strengthen the position of those hospitals which rely upon tracheotomy. Upon a comparison of this sort it would certainly appear that the results of intubation, at any rate in England, are not so good as has been stated. I am aware that this opinion is not shared by many authorities and that Stack40 writes, ‘taking everything into consideration, my impression is that under the most favourable conditions of operating, nursing, &c., the mortality is almost halved by doing intubation as a routine instead of tracheotomy.’

It has been claimed that intubation gives better results in children under five. This question has been worked out by H. W. L. Barlow,41 who concludes that ‘the younger the child, the longer will it require the tube, and the more frequently, therefore, has the latter to be inserted’, and ‘from the mortality alone, there is no indication that one operation is better suited for certain age periods than another, but since secondary tracheotomy appears to be rarest at three years old and the intubation fatality is least between four and six years, it follows that children from three to six are best adapted for intubation’.

Conclusions. Intubation is justifiable for diphtheria of a mild type if sufficient experience can be obtained and if the after-treatment can be personally carried out. The success of the operation depends largely upon a proper selection of the cases; in other words, it is not suitable for the worst types of this disease. It should never be performed upon a patient in whose case the question of tracheotomy does not arise.

In my opinion it is not a good operation for those general hospitals where there is constant change among the resident officers; it seems probable that it will remain the treatment of a small number of physicians who have frequent opportunities of practising their art.

Indications. (i) In diphtheria, intubation is justifiable when the disease is of a mild type without great toxÆmia, where early diagnosis has been made, and antitoxin has been administered. It is not recommended when there is great pharyngeal inflammation, or in cases with bronchitis or pneumonia, or when the patient is prostrate, nor for severe obstruction caused by excessive swelling or false membrane in the larynx or trachea. In the last-mentioned condition intubation is difficult to perform, and the patient may be choked by false membrane which has been pushed down: intubation should be abandoned in favour of tracheotomy when immediate relief is not obtained.

(ii) In other forms of septic laryngitis, there is evidence to show that with intubation the mortality is higher than with tracheotomy; in oedematous laryngitis, such as follows the inhalation of steam, every effort should be made to prevent laryngeal obstruction by other forms of treatment, for intubation is difficult to perform owing to the swollen condition of the tissues; moreover, injuries are common, and there is a danger that the upper opening of the tube will become obstructed. Again, the tube may be expelled by coughing, and the child suffocated without relief.

(iii) In chronic stenosis, intubation is now extensively employed. Fibrous contraction such as follows some cases of thyrotomy, or syphilis and other inflammatory diseases, can be treated successfully by this method. Short light tubes, of vulcanite or similar material, are inserted and retained in position for long periods, three months or longer; with the pressure so exerted the amount of fibrous tissue appears to be diminished, and the lumen of the larynx is dilated.

Operation (in diphtheria). The apparatus required consists of a gag for opening the mouth, a set of tubes with a gauge showing the size for each age, an instrument for intubation and extubation, and equipment for tracheotomy.

The tubes recommended by O’Dwyer are of gilded bronze, but other materials such as vulcanite or hard rubber are sometimes used. The tubes have undergone frequent modifications and those designed by Bayeux are shorter, lighter, and a great improvement (Goodall). In Thorner’s type (Fig. 276) the lower end has been cut off at an angle, so that it may pass more easily between the vocal cords; the intubator and extubator have been replaced by a single pair of beaked forceps with a ratchet attached to the handles, so that, when the beaks are separated, the tube is gripped firmly and cannot be disengaged until the trigger of the ratchet has been pulled; with these forceps the tube is not obstructed while it is being taken in and out of the larynx, and there is less need for hurry; further, the top of the tube has a funnel-shaped opening ‘which greatly facilitates the introduction of the beaks when the tube is in the larynx, inasmuch as it allows the beak to glide from any point of the rim almost automatically into the opening, and what this means can be appreciated by those who have had experience with the old extractor’ (Kyle).42

No preparation of the patient is required, but a blanket must be wrapped round the arms, body, and legs to control the struggling. Two assistants are required, one to hold the patient, the other to steady his head and manipulate a gag. The upright position is preferred by many surgeons because the patient is less frightened, and the breathing is easier; but the child may be laid upon a table, with the head slightly extended and exactly in the middle line of the body, or the head may be allowed to hang over the end of the table and the tube passed from behind, in a manner similar to that used for direct laryngoscopy. No anÆsthetic is necessary. The first assistant or nurse should sit on a low chair with the child on his knee, holding him so that he directly faces the surgeon; a second assistant stands behind with a gag in his hand. A tube of suitable size, with a thread attached, and mounted on the introducer, is taken in the right hand; the assistant introduces the gag, opens the mouth to the fullest extent, and steadies the head with his two hands; the surgeon now passes the left index-finger over the back of the tongue, so that the tip of it passes behind and below the epiglottis until the cricoid is felt; this is the most important landmark, and as soon as it is located the finger is drawn upwards and forwards in order to hook up the epiglottis, and the introducer and tube are rapidly passed over it; the method of introduction being that used for all laryngeal instruments. As soon as the end of the tube is level with the end of the finger, the handle of the introducer is raised so as to throw the point as far forward as possible; the instrument is then bodily lowered, so as to drive the tube downwards through the larynx until it rests firmly and securely against the ventricular bands, which prevent further passage of the collar; the tube is now held in place with the left index-finger until the introducer is removed. The whole operation in experienced hands should take from three to five seconds only, and must be performed without force.

If the tube has been properly introduced, it is usual for the child to begin coughing, and this may continue for a short time, accompanied by noisy and rattling inspiration; the cough gradually disappears and breathing becomes easy. The tube causes temporary aphonia, which may persist for a few days after its removal, but is otherwise well tolerated; the patient is not conscious of the presence of the canula unless it becomes blocked.

The operation is simple in the hands of those who are accustomed to the use of laryngeal instruments; in a normal larynx there is no difficulty in introducing a tube, but in diphtheria the parts are inflamed and obstruction is present. Children are often intolerant or frightened; they are liable to retch or choke during introduction, but the latter can sometimes be accomplished by waiting for an inspiratory effort; if the struggling is very troublesome a small quantity of chloroform (cocaine in adults) may be given with safety.

Difficulties of the operation. The difficulty of passing the tube over the base of the tongue can be avoided by pulling the tongue downwards and forwards and passing the introducer through the mouth with the hand to the left of the patient’s face and rotating downwards when the point is in the pharynx. Failure to find the opening of the larynx is often due to not keeping the instrument exactly in the middle line. The tube may be too large (even when it corresponds to the age of the child) owing to swelling either in the larynx or in the subglottic region; in such a case a smaller tube must be tried, and it is essential that no force should be used to drive the tube into place, or dangerous complications may arise. Even a smaller tube may not be passed on the first occasion, and the surgeon has to decide whether he will try the same tube again or one that is smaller; the latter may not be suitable for the age. The tube may be too small, and this may be recognized by the ease with which it passes; as a result, the first strong cough expels it out of the larynx, and another must be introduced. A tube of correct size may be in the larynx without relieving the dyspnoea; this may be due to one of the following causes: (a) some membrane may have been pushed in front of the tube, an event which is evidenced by the noisy and difficult respiration, and which requires that the tube shall be withdrawn with the thread and again introduced, after an interval; (b) the tube itself may become blocked with membrane, with the result that it is at once coughed out; or (c) the child may be asphyxiated so that tracheotomy becomes a necessity. This last is a point that must always be remembered: intubation should never be performed unless everything has been prepared for opening the trachea. The tube may pass into the oesophagus in spite of all care, and this may increase the dyspnoea by pressing upon the posterior part of the larynx, in which case it must be withdrawn by the thread and a further attempt made. It has frequently happened that the tube with its thread has passed down the oesophagus into the stomach, an accident which ought to be avoided. No serious consequences are likely to occur, as the tube will be passed per rectum, or in rare instances vomited.

The question arises as to how many attempts should be made before intubation is abandoned. This varies in each case and depends upon the amount of distress caused by the previous attempts. With each further trial the child becomes more and more restless, and if the third attempt fails, it is better to desist, or to allow at least an interval of half an hour. When the dyspnoea becomes urgent there must be no hesitation, and either the tube must be reintroduced or tracheotomy performed; both operations are difficult under these circumstances, and the surgeon should choose the method of which he has the greater experience.

It is very important to remember that tracheotomy is required in nearly a third of the cases at one stage or another; at the M. A. B. fever hospitals of London during 1902–6 there were 429 cases of intubation for diphtheria, and of these 117 required tracheotomy later, i.e. 27.2%. As Goodall says: ‘Every case that was intubated four or more times came to tracheotomy. I therefore lay down the rule that if three insertions, each of several hours’ duration, fail to cure the laryngeal obstruction, tracheotomy should be performed. Frequent expulsion of the tube by coughing a few minutes after its insertion is also an indication for tracheotomy.’

After-treatment. A case of intubation requires more personal attention than one of tracheotomy. It is essential that the doctor should remain within easy call, as the tube may be blocked or coughed out at any moment. This danger is not so great as it appears; when the tube is coughed out there is no immediate asphyxia, and a fatal result is uncommon; an interval of at least twenty minutes usually occurs before the dyspnoea becomes urgent, in which time the doctor can be called; it may even happen that the tube is not required again, and that the obstruction has disappeared. When the tube becomes blocked, the state is more serious; in most cases it will be coughed out of the larynx, but if the child is very weak or the tube very firmly fixed, the obstruction must be at once relieved. It is for this reason that some surgeons prefer to leave a thread attached so that the nurse can extract the tube, but the latter has a disadvantage, namely, that the child may pull the tube out. This can be prevented by tying up the hands of the child while the tube is being worn, but even then the child may bite the string; the general practice therefore is to remove the thread, and the tube is then expressed by lateral pressure on the sides of the trachea, or by passing the finger below and behind the larynx and so pushing out the tube. The method is termed ‘enucleation’,43 and where it fails the extubator must be used. A nurse must be chosen who has had previous experience of intubation; she must understand the symptoms which necessitate interference with the tube, and the feeding of the child. Swallowing is often difficult, and liquids tend to pass through the canula into the trachea; the patient chokes and may cough up the tube. The danger of pneumonia is also increased. To overcome the dysphagia the patient should be made to suck uphill through a tube, or semi-solids may be tried: in other cases nasal or rectal feeding can be ordered: temporary removal of the tube has also been recommended for purposes of feeding, but vomiting often occurs with reintroduction immediately after a meal. In very troublesome cases there is distinct danger in repeated intubation; tracheotomy should be performed if the child is becoming exhausted from want of nourishment.

Changing the tube. O’Dwyer recommends that the tube should be retained for forty-eight hours without change, after which it should be removed once a day: it must, however, be remembered that while the tube is retained coughing is greatly impeded, so that septic material collects in the trachea and is liable to cause pneumonia.

Extubation by the thread and by enucleation has already been mentioned, but these methods are not applicable in every case. Extubation is difficult to perform, especially if respiration is obstructed and the patient struggling; whenever necessary, chloroform should be given. The preparation required is similar to that for intubation; a table and tracheotomy instruments are made ready; the upright position is preferred, and two assistants are required to hold the child and the gag; expanding forceps are introduced as if intubation were being done, and the tube is grasped securely and rapidly extracted, the whole operation being carried out as quickly as possible and without any suggestion of force. In experienced hands no danger is to be feared, but if two or three attempts are unsuccessful, tracheotomy should be performed. The time for removal of the tube varies from a few hours to four or five days in favourable cases. The main object is to dispense with the tube as soon as possible, and to err on the side of too early removal even in spite of the fact that reintroduction may be necessary.

Complications may occur, but there is no evidence that they are more numerous than with tracheotomy. Injury to the larynx is liable to result, especially from inexperience of the method, and this may be followed by hÆmorrhage, emphysema, or abscess. In rare instances a false passage has been made, generally through the ventricle of the larynx: pressure ulcers may form, there may be necrosis of the cartilage, peritracheal abscess, or cicatricial contraction; or, as with tracheotomy, subglottic swelling may persist and granulations may be formed. When urgent dyspnoea follows the removal of the tube, one of these conditions must be suspected. O’Dwyer maintains that ‘the cause of persistent stenosis following intubation in laryngeal diphtheria can be summed up in a single word—traumatism,’ but ‘paralysis of the vocal cords may possibly furnish an occasional exception to this rule’ (Jacobson).44

‘Retained tube,’ which is the term applied to cases of more than five days’ duration, is certainly more common after injury, but does not occur more frequently than with tracheotomy; many cases have been reported where intubation tubes were used for long periods with ultimate recovery, but the method is uncertain unless the exact condition of the larynx can be determined (see p. 480).

Pneumonia. It has been shown that large numbers of bacilli are present in the lungs, where they may cause inflammation quite apart from any operation; in laryngeal cases the danger is increased owing to the obstruction which causes deficient aeration of, and improper expectoration from, the lung. Where tracheotomy is performed the dyspnoea is relieved and the expectoration easy; with intubation, on the other hand, there is no stage of apnoea after introduction, which seems to indicate that the air does not pass so easily through the smaller tube; coughing is more difficult and the amount of expectoration less; mucus, pus, or membrane in small pieces, can all be expelled through the tube, but not so freely as through the larger canula, and are more likely to be swallowed. For these reasons it would appear that pneumonia is less to be feared after tracheotomy; there is, however, considerable difference of opinion on this point, and statistics have not proved of great value.

CHAPTER V
TRACHEOSCOPY AND BRONCHOSCOPY

Indications. (i) Foreign bodies. Accidental inhalation of foreign bodies is more common in children than in adults in the proportion of about two to one. The character of the foreign body should be considered before treatment is advised, and for this purpose the inhaled bodies may be divided into three classes:

To these may be added pieces of necrosed cartilage from the larynx, trachea, or bronchi; and calcareous concretions from bronchial glands, which occasionally perforate the walls of the air-passages.

Any of the above may become impacted in the trachea or fall into one of the bronchi: the right bronchus is affected nearly twice as often as the left owing to its larger size, its direction (which is more nearly that of the trachea), and the inclination of the septum to the left of the middle line.

(ii) Tumours of the trachea (see p. 546).

(iii) Stricture of the trachea resulting from previous inflammation or trauma. Tracheoscopy is useful both for accurate diagnosis and for treatment of such conditions. The following case may be quoted as an illustration: A boy of 17 was admitted to my hospital on account of dyspnoea, caused by obstruction in the lower air-passages. The chest was examined and a skiagram taken, the latter showing a definite shadow in the position of the bifurcation of the trachea. This was possibly an enlarged gland which pressed upon the trachea. I decided to give the boy an anÆsthetic and perform tracheoscopy. On passing the tube a stricture was found in the trachea at the level of the suprasternal notch, which was so small that a large probe completely blocked its lumen, thus causing cessation of breathing. Under the condition it was impossible to dilate the stricture by endotracheal methods. The trachea was therefore exposed, but appeared to be normal. An opening was made into it above the stricture, and it was then seen that the latter was caused by a thickening of the anterior and lateral walls, involving two rings of the trachea and apparently of inflammatory nature. As no history of inflammation had been obtained the tissue was examined microscopically, and this confirmed the diagnosis. Division of the stricture completely relieved the dyspnoea, and after a few days the wound was allowed to heal. Three months later there was some return of the dyspnoea, and tracheoscopy was again performed. The stricture had to some extent returned, but was easily dilated through the tube, and two months later there had been no further dyspnoea. By the passage of bougies through a bronchoscope a stricture of the bronchus has been relieved in a similar manner.

(iv) For diagnostic purposes alone, to determine the cause of pressure upon the air-passages; as in tumours of the mediastinum, aneurism, and the like.

The instruments required correspond in the main to those used for direct laryngoscopy (see p. 480). The special instruments include (a) bronchoscopes, which are long circular tubes of dimensions suitable to the patient:

Length and Size of Tube required in Upper Bronchoscopy (Killian)

These should be marked externally in centimetres, measured from the distal end of the tube, and should be provided with a lateral window to allow of free breathing through the opposite bronchus when the tube is introduced into the one which is obstructed; of the various forms in use, the sliding tube of Bruenings appears to me superior; (b) instruments for extraction, including forceps and hooks according to the nature of the body to be removed; (c) aspirator for removal of mucus, and sponge-holders, the length of the bronchoscope.

Operations (see also p. 481). As regards the anÆsthetic, chloroform is preferable in children, but in adults cocaine may suffice. The operations are best performed in a room which can be made dark.

Tracheoscopy. The preliminary stages are similar to those of direct laryngoscopy. If the larynx be found normal, a smaller tube can be passed through the tube-spatula between the vocal cords, and the spatula can then be divided and removed in separate halves. In Bruening’s instrument the inner tubes are so constructed that they can be pushed through the outer tube and made to project like a telescope to any desired distance. In this way the subglottic region and trachea can be explored.

Upper bronchoscopy. The tubes are passed through the mouth, and the inner one is projected until the bifurcation of the trachea is visible. In order to avoid injury to the tissues, the operation should be performed entirely by sight and with great care. Three cases have been recorded where tracheotomy was needed for the relief of dyspnoea caused by oedema of the larynx which had followed traumatism.

The tube having been passed, cocaine (10%) is applied to the bifurcation of the trachea, and mucus is removed by sponging or by an aspirator. If the secretion be excessive, the foot of the table should be raised so that the mucus drains away from the part to be explored.

It is the duty of the anÆsthetist or some competent assistant to note that normal respiration is maintained, and the necessity for tracheotomy or artificial respiration must always be borne in mind.

If the operator be experienced, bronchoscopy can be performed without endangering the patient’s life even in the case of a young child. A baby of eight months has been successfully treated by this method.

Lower bronchoscopy. Preliminary tracheotomy (median or low) having been performed, a wide tube is introduced into the bronchus through the wound in the trachea. This method has the following advantages: It is easier to perform, and the surgeon requires less experience of technique; the tube, being wider, is more readily illuminated; there is little danger of asphyxia; in passing the tube no organisms are introduced from the mouth, and there is less danger of pneumonia. If these advantages are weighed, it becomes apparent that the lower operation is preferable for surgeons without experience. In all cases with urgent dyspnoea preliminary tracheotomy is practically essential.

By a combination of the above methods the diagnosis of foreign bodies can be positively determined in the majority of cases. As Killian said in 1902: ‘We have now reached a position in which, in many cases at least, one can not only obtain a positive result but with confidence can assert that the foreign body is not present.’ In support of this statement numerous cases have been reported, especially in Germany and America. Von Eicken, in 1904, collected 42 cases of bronchoscopy, in 35 of which a definite diagnosis of a foreign body was made; in 4 it was shown that none was present; and in 3 only were negative results obtained. Since that time the results have been equally good, for in 1907 Killian increased this number to 164 reported cases in which a foreign body had been actually discovered.

As soon as the foreign body is clearly seen, a pair of forceps is selected and introduced through the tube. The object is grasped and drawn through the tube, if this be possible, or the tube and forceps may be withdrawn together from the trachea. If the foreign substance be broken the operation can be repeated until all of it has been removed. If the patient becomes collapsed it may be necessary to postpone the continuation of the treatment until the following day. A second attempt is often successful when the first has proved a failure.

Bronchoscopy is comparatively easy to perform (a) when the foreign body lies in the trachea or main bronchus; (b) when the foreign body has been accurately located; or (c) when the operation can be performed early, before inflammation has supervened. In the rare instances where the body lies in one of the secondary or tertiary bronchi, or has penetrated the substance of the lung, the difficulties are much increased, and in such conditions the question of the advisability of lower bronchoscopy should be considered.

Complications seldom occur after removal of foreign bodies by these methods if the surgeon is careful to avoid injury when passing the tubes. There may be temporary hoarseness owing to congestion of the mucous membrane. Ingals has reported two cases in which death occurred soon after the operation, with symptoms like those of delayed poisoning from an anÆsthetic, and has raised the question whether it is advisable to use cocaine or atropin[e] in these operations. Delavan, on the other hand, suggests that injury to the pneumogastrics may account for such collapse. As stated above, the combination of chloroform and cocaine does not appear to be dangerous if used with discretion.

Results. Removal of foreign bodies by bronchoscopy gives far better results than the older methods of treatment such as tracheotomy, bronchotomy, and thyrotomy. With the last-named operations more than one-third of the cases have been fatal: while on the other hand, taking the 164 cases45 collected by Killian, it is found that in 159 (leaving out 5 with unknown result) only 21 (or 13%) died, viz. 2 from cocaine; 2 because it was impossible to remove the object on account of bronchial stenosis; 1 from suffocation in spite of upper and lower bronchoscopy; and the remaining 16 of pulmonary complications—5 with the foreign body in the lung, and the others in spite of its removal. Upper bronchoscopy was fully successful in 54 cases, and lower bronchoscopy in 63. The result of the remaining 21 operations is not stated.

Speaking of his own cases, Killian writes: ‘My own statistics give perhaps a better judgment for the future of cases of foreign bodies in the deeper air-passages than the general, since I have gradually acquired a larger experience and more practice. Nevertheless, I have the impression that in many cases my technic has not reached the highest mark, and I hope to obtain better results in the future. As shown by the list of cases, only one death resulted in the eighteen cases, and this was six months after the removal of the foreign body, caused by severe lung complication due to its long sojourn in the air-passages. In only two cases was I unable to find the foreign body and in only one was I unable to remove it on account of its being coughed up.

‘Upper bronchoscopy was performed in twelve cases, upper and lower in five, and lower tracheo-bronchoscopy in one. However, I hope in the future, with improved technic, to be successful with the upper method at the first sitting and to use the lower only in the severest cases.’

To Killian of Freiburg is due the chief credit for having introduced a safe method of treatment, the value of which is at last beginning to be generally recognized in England. As Paterson46 says, ‘it is earnestly to be hoped that the time has now come when workers in this country will recognize its enormous advantages.’