A System of Operative Surgery Part 79

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

+---------+----------+---------------+---------------+ _With _Without _Year._ _Cases._ Laryngotomy._ Laryngotomy._ +---------+----------+---------------+---------------+ 1902 39 19 20 1903 35 5 30 1904 31 16 15 1905 32 18 14 1906 29 18 11 1907 21 14 7 +---------+----------+---------------+---------------+ Total 187 90 97 +---------+----------+---------------+---------------+

=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.

[Ill.u.s.tration: FIG. 265. INSTRUMENTS FOR LARYNGOTOMY. A, Tube and introducer (Butlin's); B, Sharp-pointed dilator (Bailey's).]

A general anaesthetic 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 p.r.i.c.ked 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 haemorrhage; 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.

[Ill.u.s.tration: FIG. 266. LARYNGOTOMY CANULA FITTED WITH INNER TUBE.

Funnel for administration of anaesthetic.]

At this stage a prolonged period of apna 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 anaesthetist, 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 anaesthesia 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 pa.s.sed 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 p.r.i.c.king 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 pa.s.sed 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 haemorrhage, 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-pa.s.sages 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-pa.s.sages. 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 a.s.sociated 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 dyspna 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.

[Ill.u.s.tration: FIG. 267. SKIAGRAM SHOWING AN ANGULAR TRACHEOTOMY TUBE IN THE TRACHEA. H, Body of hyoid; PH, Pharynx; CR, Posterior plate of cricoid; L, Larynx; OE, sophagus; T, Trachea.]

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 alae 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 fossae, the intercostal s.p.a.ces, and the epigastrium are all indrawn. The amount of recession depends more upon the muscles of the chest than upon dyspna, and is marked in weakly children. When dyspna 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 dyspna 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 dyspna, calling for tracheotomy.

(iii) _Acute laryngitis_ (other forms) in which dema 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 pota.s.sium, may also cause dema 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_) dema, likely to occur suddenly with necrosis, perichondritis, or the breaking down of gummata; (_b_) fibrous stenosis, which may cause a gradual increase of dyspna or become suddenly acute from spasm or dema (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 dema, 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 acc.u.mulate 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 dyspna' (Lack[26]).

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

(vi) _Certain nervous diseases_, such as abductor paralysis. Urgent dyspna may occur in (_a_) advanced bilateral abductor paralysis, or (_b_) unilateral abductor paralysis a.s.sociated 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 Konig's, Kocher's, or Salzer's) will be required in order to relieve the dyspna. The pressure of such tubes may cause ulceration of the wall of the trachea, and haemorrhage 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, dyspna 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 dyspna 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-pa.s.sages has been opened, in order to avoid the danger of suffocation and to prevent haemorrhage 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 a.s.sociated with haemorrhage and dema 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 dyspna. 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.