A System of Operative Surgery Part 82

TABLE SHOWING TOTAL DIPHTHERIA TRACHEOTOMIES PERFORMED AT THE FEVER HOSPITALS IN LONDON DURING 1902-6, INCLUDING THOSE IN WHICH INTUBATION WAS PREVIOUSLY PERFORMED AND THOSE IN WHICH NO ANt.i.tOXIN WAS USED

+---------+----------+-----------+----------------+ _Age._ _Times._ _Deaths._ _Percentage of Deaths._ +---------+----------+-----------+----------------+ Under 1 62 40 64.5 1-2 256 123 48.0 2-3 272 87 31.9 3-4 231 54 23.3 4-5 196 45 22.9 5-6 119 19 16.0 6-7 67 18 26.9 7-8 22 5 22.7 8-9 12 3 25.0 9-10 9 3 33.3 Over 10 16 6 37.5 +---------+----------+-----------+----------------+ Total 1,262 403 31.9 +---------+----------+-----------+----------------+

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

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

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

In so-called haemorrhagic diphtheria the result is always fatal.

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

TRACHEOTOMY IN CONDITIONS OTHER THAN DIPHTHERIA

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

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

The following solution will be found effective:

'Novocaine, 4% solution ? x = 1.3% Sodium chloride, 4% solution ? vj = 0.8% Adrenalin, 1-1,000 ? i = 0.003% Distilled water to ? x.x.x

[Transcriber's note: ? (approximation to symbol in the text) is thought to mean drops, minims, or parts by volume; hence ? x = 10 parts/drops, ? vj = 6 parts/drops, ? i = 1 drop made up to a total of 30 parts/drops with distilled water]

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

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

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

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

Complications are less common than with tracheotomy for diphtheria.

Under favourable conditions there is little danger of pneumonia unless the wound becomes infected, as may happen when the operation is undertaken for the relief of septic inflammations.

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

TRACHEO-FISSURE AND RESECTION OF THE TRACHEA

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

=Indications.= (i) _Tumours of the trachea._ These are uncommon.

Thiesen[34] in 1906 collected from literature 135 cases, of which 89 were innocent and 46 malignant. The majority of the former were papilloma (25), fibroma (24), enchondroma (17), and intratracheal struma (10). Of the latter, carcinoma (28) was more common than sarcoma (18).

More than half of these tumours were situated high up in the trachea.

These cases were collected from a period covering seventy-five years, which proves that they are extremely rare as compared with tumours of the larynx.

[34] _Trans. Amer. Laryng. a.s.soc._, 1906, p. 264, 'Tumours of the Trachea.'

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

(iii) _Cut-throat, or injury._ An operation may be necessary after crus.h.i.+ng or bullet wounds, or, in later stages, owing to the development of stenosis.

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

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

[35] Bergmann, E. von. _Sys. Pract. Surg._, vol. ii, p. 249.

[Ill.u.s.tration: FIG. 275. SARCOMA OF THE TRACHEA. (_From Specimen No.

1658a in the Museum of St. Bartholomew's Hospital._)]

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

[36] _Keen's Surgery_, 1908, p. 510.

CHAPTER IV

INTUBATION OF THE LARYNX

Intubation, or 'tubage', was first recommended by Loiseau and Bouchut in France; in 1880 attention was drawn to the subject by Sir W. Macewen in England, and soon afterwards O'Dwyer[37] of New York published articles which resulted in its being extensively tried in America; since that time it has continued to be popular in that country for the treatment of laryngeal diphtheria. 'The good results which American physicians have secured by intubation may be explained, perhaps, by the circ.u.mstance that according to their reports diphtheria takes a milder form in America' (Tillmanns).[38] Intubation has been extensively used in Europe, especially in Germany, but never to the same extent as tracheotomy, and in England it has been practised at only a small number of hospitals; thus, of the nine M. A. B. fever hospitals in London only three used it regularly during 1906-7, and none of them so often as tracheotomy.

[37] _New York Med. Journ._, 1885, vol. xlii, p. 145.

[38] _Text Book of Surgery_, 1900, vol. ii, p. 625.

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

The _advantages_ claimed for intubation are:

1. No anaesthetic is required.

2. Consent of friends is easily obtained.

3. No cutting: great rapidity.

4. No wound to heal.

5. Tube worn more easily than the tracheotomy tube.

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

7. Its earlier performance.