SECTION III.

LARYNGOTOMY.

Laryngotomy, as may be perceived from the preceding sketch of the anatomy of the windpipe, is, on the whole, a very simple and easy operation. The only structures that are divided are the skin, the cervical fascia, and the crico-thyroid membrane. If the patient is an adult, he may sit upon a chair, or, what is preferable, especially if he take chloroform, he lies upon a narrow table, the head and shoulders being properly elevated and horizontalized' by pillows. If, on the contrary, he is a child, he should be supported upon the lap of an assistant, and his body and limbs should be securely fastened with an apron, very much as in the operation for harelip. The head is thrown backwards and held by another assistant, in such a manner as to render the parts prominent and make the chin look directly forward in the direction of the middle line. Armed with a small, narrow scalpel, the surgeon, stationed in front of the patient, if he sits, or by his side, if he is recumbent, makes an incision directly along the centre of the larynx, commencing at the top of the thyroid cartilage and terminating at the base of the cricoid. In the adult, the length of this incision will be fully one inch and a half, and hardly any less in a thick, short-necked child. It embraces the skin and cervical fascia, and usually also the cricothyroid artery. Should this vessel bleed, it must either be forcibly twisted or secured with the ligature, lest the blood should find its way into the windpipe, and thus occasion severe cough, if not suffocation. All that now remains to be done is to divide the crico-thyroid membrane, in its whole extent, in the direction of the cutaneous wound. Should the opening not be sufficiently large, the incision may be prolonged into the contiguous cartilages, or a piece of the membrane may be cut away on each side of the wound. Some surgeons prefer making a crucial incision, and such a proceeding is quite proper where it is desirable to afford free play to the instruments without interfering with the thyroid and cricoid cartilages.

1 Such a term has long been needed in surgery, a circumstance which is my only warrant for employing it on this occasion.

SECTION IV.

TRACHEOTOMY.

If the operation of laryngotomy is simple and easy, it is far different with that of tracheotomy. This is particularly true with regard to tracheotomy in children with short, thick necks, to say nothing of the cries and struggles which they are sure to make if they are not under the influence of chloroform, or nearly choked by the foreign body. I know hardly an operation in all surgery that I would not rather undertake than this under such circumstances. The amputation of a limb, the extirpation of a glandular tumor, lithotomy, and even the perineal section are trifling matters in comparison with tracheotomy in a short, thick-necked, and restive child. I was not a little surprised, some years ago, at hearing a former colleague, the then professor of medicine in the University of Louisville, speak of this operation as the most simple thing in the world, which any one who is not even a surgeon might easily perform with a razor! I have not learned whether my friend ever opened the trachea; if he has, he would not, I am sure, have hazarded such an erroneous statement. The operation is easy enough on the dead body, and may be done with almost any instrument; but on the living subject it is a very different affair. Here, it requires not only a thorough knowledge of the anatomy of the parts, but the nicest care and the most delicate dissection. I am not singular in my views upon this subject; the difficulty in question has been experienced a thousand times, and that, too, by the most dexterous and accomplished operators. The use of anaesthetic agents will, undoubtedly, greatly facilitate the performance of this operation, and divest it of much of the dread which surgeons have always so justly entertained respecting it. Chloroform and chloric ether have been already employed with the happiest effect, in a considerable number of cases, and no one who has once administered these articles will be likely to dispense with them. My own experience, limited as it is, fully satisfies me of their value, and even of their indispensable importance in all operations of this kind; but as this is a subject to which I shall presently recur, I forbear any further remarks concerning it in this place.

Owing to the uncertainty of the diagnosis of foreign bodies in the larynx, this portion of the tube should, I think, seldom be opened if it be possible to employ tracheotomy. The latter operation, although much more difficult, has the advantage, in many instances, of enabling the lungs to expel the offending substance, however high it may be situated, and of affording the surgeon ample opportunity of dislodging it with his mop and other instruments when it occupies the larynx. Nothing can be more embarrassing to him than to be obliged to open the windpipe, first, at its superior, and afterwards at its inferior division. It is only, in fact, when he has the most indubitable evidence of the existence of the object in the larynx that he should open the crico-thyroid membrane. In no case, except of the most extraordinary character, ought he, in my judgment, to divide the thyroid and cricoid carti lages, particularly the former, on account of its intimate relation with the vocal cords, and the consequent risk of injuring the voice. The latter is so near the thyroid gland, and so far from the bronchial tubes, that an attempt should always be made, if practicable, to avoid it. An opening midway, or nearly midway, between the sternum and the larynx is, as a general rule, far preferable to any other, inasmuch as it puts the operator in sufficient proximity with each extremity of the canal, and thus affords him a favorable opportunity of dislodging the foreign body, whether situated in the larynx, floating about in the trachea, or impacted in one of the bronchial tubes.

In performing the operation of tracheotomy (Fig. 19), the same general rules are to be observed as in laryngotomy. The position of the patient and surgeon, the instruments and assistants, are all the same. An incision is made through the common integuments, directly along the middle plane, extending from the base of the cricoid cartilage to within a quarter of an inch of the top of the sternum. The sterno-hyoid and sterno-thyroid muscles of the opposite sides are next separated from each other at their raphé, by a cautious use of the handle of the knife, aided, if necessary, by the point of the instrument, when the cervical fascia and the thyroid plexus of veins will be fully brought into view. The former is divided in the same careful manner, while the latter is pushed aside, and protected by a blunt-hook. If the middle thyroid artery is cut, which, however, is a rare contingency, it must be instantly secured. The isthmus of the thyroid gland, even when it descends

considerably lower than usual, will seldom embarrass our progress; should it do so, it must be held out of the way, although it

has sometimes been divided with impunity. Professor Van Buren, of New York, informs me that he has completely divided this process on several occasions without the slightest loss of blood, mischief, or inconvenience. Generally, however, it will be well enough to avoid it, by holding it out of harm's way; should this, however, be impracticable, any bleeding that may be apprehended can be effectually avoided by embracing the part in two ligatures, the knife being afterwards carried between them. Under ordinary circumstances, however, such a proceeding will be quite unnecessary, as, in the event of hemorrhage, it would be very easy to apply the ligatures after the division has been effected.

Seeing that there is no bleeding, or any blood at the bottom of the wound, the surgeon steadies the trachea with the left indexfinger, or, what is more effective and more satisfactory, with a tenaculum, and divides at least three of its rings. In executing this step of the operation, the knife is entered at a right angle to the surface of the tube, with its back towards the sternum, care

being taken to cut from below upwards, lest injury be inflicted upon the great vessels at the root of the neck. The incision in the trachea must strictly correspond with the centre of the external wound, and should be at least from nine lines to an inch in length. If shorter than this, it will scarcely suffice for the spontaneous ejection of the foreign body, or, when this does not happen, for the proper play of the forceps.

One of my old friends and classmates, Professor Gilbert,' of Philadelphia, has recently, in several instances of tracheotomy, made the opening on the left side of the tube, about two lines from the middle plane, so that the orifice was completely closed by the overlaying muscles and fascia. He was led to adopt this method from the fact that, in the ordinary operation, the patient has occasionally perished from the introduction of blood into the trachea after the wound is closed externally. The aperture in the tube is thus protected as if by a valve, and the divided parts usually unite by the first intention. In one of Professor Gilbert's cases, secondary hemorrhage came on a few hours after closure of the wound, but the blood escaped outwardly, and the respiration consequently remained perfectly free.

Of the propriety of this operation I know nothing from personal experience; I should suppose, however, that it was ill calculated to answer the purpose where the object is to promote the extrusion of a foreign body, inasmuch as the valve-like character of the tracheal wound would necessarily oppose an irresistible barrier to its passage after the parts have resumed their natural position. Where the substance is expelled instantly, it would perhaps be preferable to the ordinary method. A similar operation was proposed about twenty-five years ago by Dr. Jones Quain, of London, but so far as I know was never performed by him on the living subject.2

No surgeon at the present day would think of opening the trachea transversely. Such a procedure was occasionally resorted to in former times, and an instance in which it was employed is narrated in the present treatise. It occurred in the practice of Dr. Peter P. Woodbury, by whom it has been reported in the fourteenth volume of the New England Journal of Medicine and Surgery. The operation was begun by opening the trachea transversely, but find

Amer. Journ. Med. Sciences, New Series, vol. xxi. p. 74, 1851. 2 Elements of Anatomy, first edition, London, 1829.