Chapter III: Operations Upon the Trachea (1)

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 dyspnœa 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, INCLUSIVE[25]

+----+------------------+-----------------+-----------------+
| | _All forms of | _Laryngeal | _Tracheotomy |
| | Diphtheria._ | Cases._ | Cases._ |
| +------+-----+-----+-----+-----+-----+-----+-----+-----+
| | _C | _D |_M p | _C | _D |_M p | _C | _D |_M p |
| | a | e | o e | a | e | o e | a | e | o e |
| | s | a | r r | s | a | r r | s | a | r r |
| | e | t | t | e | t | t | e | t | t |
| | s | h | a c | s | h | a c | s | h | a c |
| | ._ | s | l e | ._ | s | l e | ._ | s | l e |
| | | ._ | i n | | ._ | i n | | ._ | i n |
| | | | t t | | | t t | | | t t |
| | | | y ._| | | y ._| | | y ._|
+----+------+-----+-----+-----+-----+-----+-----+-----+-----+
|1902| 6,839| 741| 10.8| 639| 134 | 20.9| 264| 86 | 32.5|
|1903| 5,422| 504| 9.3| 560| 102 | 18.2| 223| 67 | 30.0|
|1904| 4,639| 464| 10.0| 659| 116 | 17.6| 247| 79 | 32.0|
|1905| 4,224| 346| 8.2| 706| 116 | 16.4| 255| 72 | 28.2|
|1906| 4,937| 444| 9.0| 702| 127 | 18.1| 275| 101 | 36.7|
|1907| 5,674| 544| 9.6| 981| 169 | 17.2| 432| 129 | 29.9|
+----+------+-----+-----+-----+-----+-----+-----+-----+-----+
| |31,735|3,043| 9.6|4,247| 764 | 17.9|1,696| 534 | 31.5|
+----+------+-----+-----+-----+-----+-----+-----+-----+-----+

[25] _Metropolitan Asylums Board’s Ann. Rep., Med. Supplement_, 1902-1907.

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 dyspnœa, and is marked in weakly children. When dyspnœa 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 dyspnœa 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 dyspnœa, calling for tracheotomy.

(iii) _Acute laryngitis_ (other forms) in which œdema 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 œdema 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_) œdema, likely to occur suddenly with necrosis, perichondritis, or the breaking down of gummata; (_b_) fibrous stenosis, which may cause a gradual increase of dyspnœa or become suddenly acute from spasm or œdema (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 œdema, 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 dyspnœa’ (Lack[26]).

[26] Cheyne and Burghard, _Manual of Surg. Treat._, 1901, Pt. v, p. 449.

(vi) _Certain nervous diseases_, such as abductor paralysis. Urgent dyspnœa 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 dyspnœa. 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, dyspnœa 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 dyspnœa 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 œdema 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 dyspnœa. 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 dyspnœa 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 dyspnœa 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 dyspnœa 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 dyspnœa 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 4-1/2 inches, of which 2-1/2 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’ (Parker[27]). 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.

[27] _Tracheotomy in Laryngeal Diphtheria_, 2nd ed., p. 42.

TABLE SHOWING SIZE OF TRACHEA AND OF TUBE REQUIRED AT DIFFERENT AGES

+--------------+------------+------------+---------------------+
| |_Approximate|_Approximate| _Number of tube._ |
| _Age._ | diameter of| diameter of+----------+----------+
| | trachea._ | tube._ |_Parker’s_|_Durham’s_|
+--------------+------------+------------+---------------------+
|6 months | 4 mm. | 4 mm. | 16 | -- |
|1-1/2--2 years| 6-8 mm. | 7 mm. | 20 | 1 |
|2-4 years | 8-10 mm. | 8 mm. | 24 | 2 |
|4-10 years | 10-12 mm. | 9 mm. | 28 | 3 |
|10-20 years | 12-19 mm. | 10 mm. | 30 | 4 |
+--------------+------------+------------+----------+----------+

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 dyspnœa. 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 dyspnœa; 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 1/2-5/8 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, 1-1/2 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 œsophagus, 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 dyspnœa 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 dyspnœa 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 œdema 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 œsophagus, 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.