Walter Hamilton Acland Jacobson.

The operations of surgery; a systematic handbook for practitioners, students and hospital surgeons .. online

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one substituted, and worn as short as possible, and cut obliquely so
that the end does not impinge upon the anterior wall of the trachea.
If it is necessary to dispense with all tubes, attempts may be made to
keep the edges of the tracheal wound stitched to that in the soft i^arts
for a few hours, or Mr. Golding Bird's dilator may be worn.

(e) Suppuration in MediaMina. — This is a rare complication. When
it does occur it is liable to be very rapid. It results from a descend-
ing cellulitis from the wound. The only treatment is prevention by a
well-performed operation and by attention to the wound.

Other complications which are not surgical may of course be pres-
ent — viz.. Extension of exudation downwards. General infection.
Paralysis. Albuminuria. Broncho-pneumonia, a very frequent one,
known by a rise of temperature with frequent respiration and dyspnoea,
dulness on percussion, bronchial breathing, with large bubbling and
crepitant r^les.

practical conclusions with which his pages abound: (1) Emphysema of the anterior
mediastinum, often associated with pneumothorax, occurs in a certain number of trache-
otomies. (2) The conditions favoring this are, division of the deep cervical fascia,
ob.struetion to the air-passages, and inspiratory efforts. (3) The incision in the deep
cervical fascia downwards should not be longer than needful ; it should on no account
be raised from the trachea, especially during inspiratory efforts. (4) The frequency of
emphysema probably depends much on the skill of the operator, especially in inserting
the tube. (5) The dangerous period during tracheotomy is the interval between the
division of the deep cervical fascia and the efficient introduction of the tube. (6) If
artificial respiration is necessary, the tissues should be kept in apposition with the
trachea, and any manipulations performed without jerks.



362 OPERATIONS ON THE HEAD AND NECK.

TUBAGE OF THE LARYNX AS A SUBSTITUTE FOR
TRACHEOTOMY IN MEMBRANOUS LARYNGITIS.

This is one of those new modes of treating an old disease about
which it is difficult to give a decided opinion, as the matter is still
sub jud'ice.

Attention was called to this subject by Dr. Macewen* in 1880. It
has been, recently, more prominently brought forward in America.f

The advantages claimed, if verified, will no doubt be very great.
Of these the chief are — (1) That objection on the part of friends is less
likely than in the case of tracheotomy ; (2) That the tubes are easily
and quickly introduced ; (3) That there is no severe and difficult
operation; (4) That the inspired air is warm and moist; (5) That the
tubes are self-cleansing ; (6) That there is no prolonged after-treat-
ment.

The tubes used have been mainly of two kinds — (a) Macewen's
long cylindrical tubes of the pattern of gum-elastic catheters, intro-
duced from the mouth into the trachea through the larynx, and
removed at intervals of about twelve hours for cleansing ; (6) O'D wyer's
short tubes (under 3 inches) of metal with the antero-posterior diam-
eter larger than the lateral. These are self-retaining, partly by an
enlarged head which rests upon the ventricular bands, and partly by
a fusiform enlargement a little lower down. They are introduced and
removed from the mouth by special instruments. A gag must be
used.

I am unable to recommend intubation. Within a few months of
the appearance of Dr. Macewen's paper I made use of his method in
three patients with membranous laryngitis at the wish of my friend
Dr. Goodhart. Every one of these came to tracheotomy, most of the
drawbacks enumerated below being most strongly present. I ought
to say that of Dr. O'Dwyer's tubes I have no personal experience, but
I am most strongly of opinion that, in children at least, they cannot
meet with a» large amount of general success. Their necessarily
narrow chink-like calibre appears to me to be certain to obstruct the
free expectoration of mucus, membrane, etc., which is so essential in

* Brit. Med. Journ., July 24 and 31, 1880. Dr. Macewen's cases were all four in
adults, the two acute ones being cases of oedema of the glottis.

t Dr. O'Dwyer's first paper is in the New York Med. Journ., August, 1885. Mr.
Symonds, in his summary alluded to at p. 363, gives the following references of papers
by followers of Dr. O'Dwyer— viz., Dr. Waxhara {Chicago Med. Journ., March, 1886;
Journ. Amer. Med. Assoc, October 24, 1885, and July 23, 1887) and Dr. Ingals {New
York Med. Journ., July 2 and 9, 1887). Dr. Waxham's results have no doubt im-
proved, but in the Chicago Med. Journ. and Exam., November, 1885, Ann. of Surg.,
January, 1886, four cases are given which were treated by him, after O'Dwyer's plan,
of which only one recovered.



TRACHEOTOMY. 363

these cases. Even when this is liquid and abundant, I fear thcat the
tubes will be plugged ; when the expectoration is dry, thick, and
tenacious, its escape must surely be impossible.

Drawbacks : (1) The tubes are likely to become plugged ; (2) There
is very great difficulty in getting children to take sufficient food, as
swallowing is, in them certainly, much embarrassed. The importance
of getting sufficient food down in these cases has already been alluded
to, p. 367 ; (3) Part of what liquids are taken now easily finds its way
into the trachea and lungs; (4) The tube may be coughed out ; (5)
The facilities for extracting membrane, spraying the trachea, etc., are
much fewer than after tracheotomy.

Mr. Symonds, in a summary* of the results of O'Dwyer's method,
states that in passing the tubes membranes may be pushed down, thus
increasing the dyspnoea, and, with this difficulty before us, he points
out that it will be wise, when making use of intubation, to be prepared
for immediate tracheotomy ; while I feel, I trust sufficiently, that the
results of tracheotomy for croup admit of very great improvement, I
doubt if intubation will be more successful. I venture to think that
this is one of those diseases in which sufficient attention has not been
paid to some of the anatomical surroundings. I shall, perhaps, be
condemned as holding a j)essimist's views when I say that, consid-
ering the narrowness of the glottis, its proneness to spasm, the ready
downward extension of the disease, the age and rapid exhaustion of
the patients, I doubt much if it is not expecting too much when a
larger proportion of cures are looked for here, either by tracheotomy
or, still less, I think, by tubage. And while I allow that I have not
myself had personal experience of the recent modification of tubage,
I would add that I have very lately seen two cases in which the im-
proved method was made use of with much temporary edat, followed
by tracheotomy, deferred, but ultimately called for, and by fatal results.

OTHER INDICATIONS FOR TRACHEOTOMY.

(i.) Syphilitic and Tubercular Ulceration.— Tracheotomy is
more frequently called for in the first of these, in which also it is
decidedly more useful. The conditions which demand it temporarily,
are cedema of the glottis setting in on old mischief, fibroid thickenings,
which may, later, yield to treatment, and more permanently, prob-
ably, deep ulceration, necrosis, and cicatricial contraction.

In tubercular mischief tracheotomy rarely gives much relief, dysp-
noea being now a rarer misery than cough and difficulty of swallowing,
both of which are conditions which may be intensified by the pres-
ence of a tube.



* Brit. Med. Journ., November 19, 1887.



364 OPERATIONS ON THE HEAD AND NECK.

(ii.) Malignant Disease of the Larynx. -Here tracheotomy
is often called for. Till statistics of extirpation of the larynx are more
complete, the question which of these modes of operative interference
has the soundest basis must remain uncertain. One difficulty alone
which besets this matter is scarcely to be surmounted, and that is that
an increasing number of cases shows that, to be really successful,
extirpation of the larynx must be performed early, but how many
patients will submit to it at this stage ? (p. 370).

In deciding between advising a palliative tracheotomy and extirpa-
tion of the larynx the surgeon will be guided by the condition of the
disease and that of the patient. The latter operation can alone be
justified when the disease is strictly localized. Enlargement of the
lymphatic glands, extension of the disease, especially in cases of car-
cinoma, to the pharynx, back of the tongue or tonsil, should put this
operation aside. Again, the condition of the patient, how far he is
exhausted, how far his strength is sufficient for such an operation as
extirpation, how far he gains ground after a prehminary tracheotomy,
have all to be considered.

(iii.) Acute Laryngitis.— The rapidity with which this may run"
a fatal course, especially after exposure to cold in reduced consti-
tutions, is well known. If treatment, including application of strong
solution of silver nitrate and scarification of the aryteno-epiglottidean
folds and adjacent parts fails to relieve the dyspnoea, tracheotomy
should be performed at once to meet the increasing exhaustion.

(iv.) Certain Spasmodic Affections,— e..^.. Aortic Aneurism
and Tetanus.— Owing to these diseases destroying life, usually in
other ways, tracheotomy is rarely called for here. Occasionally, how-
ever, the laryngeal dyspnoea which they bring about calls for this
operation.

Probably there is no form of dyspnoea more agonizing to the patient
or more distressing to the friends, than that which may accompany
thoracic aneurism. The surgeon, however, when called upon to per-
form tracheotomy in one of these terrible cases, must remember that
the dyspncea may be tracheal as well as laryngeal in its origin, and
that it is in the latter only that operation will give relief.

I would refer my readers on this point to one of Dr. Bristowe's in-
teresting Lumleian Lectures,* and especially to this passage : " De-
struction of the functional activity of one recurrent laryngeal nerve is
attended with, of course, paralysis of the corresponding vocal cord
(which can be recognized by means of the laryngoscope), with impair-

* Lancet, May 10, 1879. Dr. Bristowe goes on to show that the exacerbations of
dyspnop.a in narrowing of the trachea may be due partly to spasm of the muscular
fibres, but mainly to accumulation of mucus below the narrowing, and to the difficulty
of dislodging it by coughing.



TRACHEOTOMY. 365

ment of the musical quality of the voice, and apparently with some
difficulty of swallowing, owing to the tendency of food to slip into the
trachea, but is certainly not necessarily attended with stridor or
dyspnoea; in the second place, compression of the trachea involves
stridor and dyspnoea, which is often paroxysmal and is liable to end
in sudden death, but does not itself interfere with intonation or pho-
nation, excepting in so far as it may render the voice weak by
diminishing the supply of wind to the vocal organ." As the paryox-
ysmal nature of the dyspnoea may then be met with in cases of press-
ure on the air-tube below the larynx as well as in laryngeal dyspnoea,
the chief points to rely on will be the result of a laryngoscopic exami-
nation, and the freedom of the lungs and air-tube from pressure. Dr.
Hall* thinks that "the absence of respiratory excursions of the
larynx points to the chief impediment being below the glottis."

With regard to tracheotomy in tetanus, the same warning has to be
given. In the rarer cases in which tetanus threatens life by asphyxia
and not by exhaustion, the surgeon, before performing tracheotomy,
must decide where lies the seat of the asphyxia. In the few cases
which I have seen in which asphyxia closed life in this disease, the
asphyxia was due to spasm of the muscles of respiration, including
the muscles of inspiration and those of expiration — e.g., the ab-
dominal muscles also. The fatal spasm thus, usually, not lying
in the larynx, tracheotomy seems contraindicated, unless it were
done with the object of relieving, with the aid of artificial respiration,
that congested, gorged condition of the lungs which is due to the con-
tinued spasm of the muscles of respiration. And it is to be feared that
if these steps were taken, the gentle violence of artificial respiration
would, as has happened with tracheotomy itself in this disease, only
bring on a final and fatal spasm.

(v.) Scalds of the Upper Aperture of the Larynx.— Tra-
cheotomy is here usually deferred till late, and its want of success is
well known. This is not, however, an instance of cause and effect, the
mortality in these cases being rather due to the shock, pain, and ina-
bility to take sufficient food. Unless the case is seen late, tracheotomy

* Clin. Soc. Trans., vol. xix. p. 82. Quoting from Gerhardt (Lehrh. d. Ausc, Tubin-
gen, 1871), Dr. Hall points ont that in a case of aortic aneurism the following causes
for dyspnoea (Dr. Powell, Reynolds's Syst. of Med., vol. v. p. 32) may all be present
together: (1) Undoubted paresis of the abductors of the cords. (2) Though the post-
mortem may "not show any very distinct bulging inwards of the trachea, the aorta
and sac being emptied of blood, yet I can readily believe that during life, when these
parts were distended with blood, considerable pressure was exerted on the trachea, and
that this narrowing led to accumulation of the tough mucus which so bothered the
patient." (3) Gairdner (Clin. Med., p. 486) states thai paroxysms of dyspncea, closely
resembling those of asthma, may be occasioned by compression of one of the pulmonary
plexuses.



366 OPERATIONS ON THE HEAD AND NECK.

should not be performed in these cases till a trial has been made of
scarification, or rather of acupuncture, by means of a guarded bistoury
point, of the mucous membrane of the epiglottis and the glosso-epi-
glottidean and aryteno-epiglottidean folds, the left fore-finger guiding
the point of the instrument. In doing this, the surgeon must remem-
ber the amount of dyspnoea which is already present, and the cer-
tainty that this will be increased by the struggles of the child, by the
finger coming in contact with these inflamed parts, and at any moment
the child must be turned on its side, artificial respiration performed,
or even tracheotomy resorted to.

(vi.) Foreign Bodies in the Air-passages.— We will suppose
a child brought to the surgeon with a history of having swallowed one
of the usual foreign bodies. Two questions now call for an answer.

(1) Is there a foreign body at all in any part of the air-passages ? and

(2) if so, where is it? In regard to the first tjuestion, it is well to
remember that the history is often far from clear, especially in children,
and the symptoms by no means as obvious as they are often described
to be. Thus, the chief aids in distinguishing the entrance of a foreign
body from such a disease as membranous laryngitis are the sudden
onset and, not unfrequently, the well-marked intermissions. The
symptoms characteristic of the entrance of a foreign body into the
larynx — viz., the urgent dyspnoea, the cyanosis, the struggling against
impending death — may not be got at on account of the youth of the
patient, or because no one saw the onset; while if the body has passed
from the larynx into the trachea, or into one bronchus, the dyspnoea,
brassy cough, and alteration in the voice, may all have disappeared
before the surgeon sees the child, and yet he will be expected to give
a definite opinion. Again, the body may have been coughed up, and
perhaps swallowed. Again, in adults, usually hysterical and egotis-
tical women, who come with a history of cancer, dysphagia, owing to
a pin which they aver to be in their throats, the diagnosis will be far
from easy.*

Having settled that a foreign body is really present, the surgeon,
unless tracheotomy is urgently called for, tries to decide where the
body is lodged. A careful examination should be made with a good
light and with the finger in the fauces, and with the laryngoscope when
feasible, any information about the size and nature of the body having
been previously obtained.

(a) A large or irregular body, such as bolted — i.e., unmasticated —
food, or artificial teeth, usually lodge above the upper aperture of the
larynx, and cause urgent and often fatal dyspnoea. If, however, the

* I would refer my readers to some instructive remarks by Mr, Lund on tlie delusive
impressions which may arise from the imagined swallowing of false teeth, etc. (Hunt,
Lect, 1885, p. 34.)



FOREIGN BODIES IN THE BRONCHI. 367

first attack be survived, bodies of considerable size— e.g., a plate with
one or two false teeth, or halfpennies — have been known to lodge near
the base of the epiglottis and aryteno-epiglottideon folds for a very
considerable time.

Such cases should be treated by laryngotomy to meet the urgent
dyspnoja, and extraction of the bodies either by the finger, or appro-
priate forceps, or probangs.

(/?) A small and light body — e.g., a bead, a pea, or more likely an
irregular one, as a bit of nutshell — may stick in the rima or ventricle
of the larynx. If the first urgent symptoms pass off without opera-
tion,* the position of the body will be pointed to by the shortness of
the intermissions between the attacks of spasm, and by the pain and
the marked alteration of the voice.

The treatment, here, would be first to perform a high tracheotomy,
and to dislodge the body from below with a female catheter or bougie
of appropriate size, the cricoid cartilage being divided if needful.f If
the body cannot be dislodged in this way, a partial or complete thy-
rotomy (p. 345) must be performed.

(j) If the body pass through the larynx it will depend mainly on its
outline and weight whether it remain in the trachea or pass into one
of the bronchi. Thus, if it is light and smooth — e.g., a cherry-stone —
it may frequently shift its position, and then, from time to time rising
into the larynx, cause spasm, and thus attacks of urgent dyspnoea,
with paroxysmal cough and temporary aphonia.

In such cases tracheotomy should be performed with a free opening
into the air-tube, this being kept open by wire ligatures passed through
the edges of the wound and tied behind the neck, or a dilator such as
Mr. Golding Bird's may be inserted.

(5) If the body is smooth and heavier it will probably fall into one
of the bronchi. This subject is next dealt with separately.

FOREIGN BODIES IN THE BRONCHI.

Amongst these may be tracheotomy tubes,! especially ill-made ones,
tubes worn too long, particularly if a low operation has been done

* Occasionally, when the body is in the ventricle, the consequences may be very
slight for a long time, especially if it is smooth and soon coated with mucus and partly
encapsuled. Mr. Durham {Syst. Surg., vol. i. p. 760) mentions a case of Dfesault's, in
■which a patient, with a cherry-stone in one of the ventricles, refused operation and lived
for two years, death then taking place from laryngeal disease.

t In adults, attempts at removal with the laryngoscope and laryngeal forceps, aided
by a 20 per cent, solution of cocaine may be successful.

% Dr. Cohen {Inter. Emycl. Surgery, vol. v. p. 665) thus speaks of the frequency with
•which th«se bodies have slipped in when ill- made or corroded : "This source of the
accident, so readily avoided by proper circumspection and admonition, is so inex-
cusable that I desire to emphasize the point with quite an array of references : Porter,



368 OPERATIONS ON THE HEAD AND NECK.

(p. 351) ; pebbles ; fruit stones ; part of toy-whistles ; pieces of nut-
shells; etc., etc.

Site of Lodgment— li has been shown by Mr. Goodall that, owing to
the septum being a little to the left and the right bronchus the larger,
the foreign body usually lodges in this. According to M. Bourdillat's
statistics,* out of 156 cases of impaction 80 were in the trachea, 35 in
the larynx, 26 in the right bronchus, and 15 in the left. Out of 21 cases
analyzed by Prof. Gross,t in which death took place without operation,
and without expulsion of the foreign body, in 4 the foreign substance
was situated in the larynx; in 1 partly in the trachea, partly
in the larynx; in 3 in the trachea; in 1 in the right bronchial
tube; in 1 in the lung; in 9 in the right pleural cavity. Out of
42 cases subjected to operation and general treatment, the extraneous
substance was situated twice positively, and 11 times probably, in the
right bronchial tube, 4 times certainly, and 4 times probably, in the
left bronchus tube ; 7 times in the trachea and 14 times in the larynx.
From these statistics it would appear that the trachea, larynx, and
right bronchus are the most likely places in which a foreign body will
be arrested.

Evidence of a foreign Body having lodged in a Bronchus. — Perhaps
there may be a history of a foreign body in the mouth ; pain dull, and
heavy behind sternum, at about its junction with the second right
costal cartilage ; % shortness of breath, cough, expectoration ; more or
less diminution of breath sounds over a portion of the chest-wall ; §
rales ; increased breath sounds on the opposite side ; and, later on, evi-
dence of inflammation and destruction of lung-tissue.

On the Larynx and Trachea, p. 144 ; Gross, Foreign Bodies in the Air Passages, p. 325;
Albert, Arch. f. Clin. Chir., Bd. viii. s. 177 ; Waters, Brit. Med. Journ., vol. i. 1868, p.
141 ; Boston Med. and Surg. Journ., February 23, 1871; Buck, Trans. New York Acad.
Med., 1870; Pick, Trans. Path. Soc, 1870, p. 416; Ogle, Med. Times and Oaz., 1870,
vol. ii. p. 531 ; Holthouse, Lancet, 1872, vol. i. p. 113 ; Ogle and Lee, Lancet, 1872,
vol. i. p. 81 ; Hulke, Lancet, 1876, vol. ii. p. 785 ; Davy, Brit. Med. Journ., 1876, vol.ii.
p. 45; Burow, Berl. Klin. Woch., No. 36, 1876; Thornton, Tracheotomy, p. 36; Howse,
Lancet, April 17, 1877."

* Cohen, loc. supra cit., p. 668.

f Durham, Syst. of Sury., vol. i. p. 758.

X The division of the trachea is opposite the spine of the third, in some cases the
fourth, dorsal vertebra. In front, this division is on the level of the junction of the
first with the second bone of the sternum. The root of the spine of the scapula is on a
level with the third intercostal space. A stethoscope placed here would cover the
bronchus, more especially the right (Holden).

5 " Obstruction of the left bronchus usually produces absence of respiration over the
entire lung of that side, but occlusion of the right bronchus usually produces absence
of respiration over the lower lobe of that side only, the division of the bronchus taking
place much nearer the bifurcation, and the foreign body rarely lodging above the point
of division" (Dr. Cohen, loc. supra cit., p. 671).



FOEBIGN BODIES IN THE BRONCHI. 369

Treatment. — A low tracheotomy (p. 351) should be performed at
once, and with as free an opening as possible. The edges of the
incised trachea being held open with sutures of wire (not too tine),
inversion and succussion should be tried, and the mucous membrane
excited with a feather or probe in order to excite cough.

If provided with suitable instruments (see below), the surgeon may
at once proceed to attempts at extraction, but it is well to remember
the fact pointed out by Mr. Durham,* that in a large proportion of
the cases which have done well, expulsion has not been effected until
some time after the operation.f Whenever a fit of coughing brings
the body into view, the next inspiration will draw it back again, so
that careful watching and prompt use of forceps, etc., will be required.

If from its shape, or from the interval which has elapsed, the body
is too firmly impacted to be expelled by exciting coughing, the fol-
lowing instruments should be resorted to,viz. : Gross's flexible German-
silver tracheal forceps, long and slender and easily bent into any
curve ; or Durham's forceps, equally flexible and giving a better grip.

Failing the above, stout silver or copper wire should be bent into
the form of a blunt hook, or a long probe fashioned into the same
shape. J The above instruments are first used as sounds and searchers,
aided by the forefinger, which can be passed as far as the bifurcation
of the trachea, and the orifice of each primary bronchus, as pointed
out by Dr. Sands. §

The operation should not be too prolonged, especially if the parts
are inflamed : when this condition has subsided spontaneous expul-
sion will often take place. Annandale|| recommended that this be
promoted by the patient's taking a deep inspiration ; the surgeon then
closes the tracheotomy wound till expiration, thus rendered more



Online LibraryWalter Hamilton Acland JacobsonThe operations of surgery; a systematic handbook for practitioners, students and hospital surgeons .. → online text (page 38 of 112)