This operation, though apparently easy, is by no means so in the first class of cases mentioned, owing to rapid per pendicular motions of the trachea when violent efforts at respiration are made. In the second class there is, as a rule, no dyspncea; hence the operation, in a thin subject especially, is less difficult, since the trachea is quiescent except when the patient swallows. The same may be said of the majority of cases included under the third class.
It is not always possible to anesthetize fully the patient when a stenotic dis order so compromises the respiration as to render expiration difficult, as is the case in tumors situated beneath the vocal cords; the residual air becomes so satu rated with the anesthetic that dangerous symptoms may appear if the agent used be pushed. A small amount of ether under such circumstances usually suf fices to dull sensation, this being further assisted by the imperfect oxygenation occurring as a result of improper breath ing.
The operation is performed as follows: The patient is placed on a table and the shoulders are raised on a pillow so as to cause extension of the neck. With a blue pencil, a line starting from the cricoid fire to seven centimetres down ward, exactly in median line, is drawn— the tracing for the incision. This should include the skin and platysma. Blood vessels should now be watched for, and. if any are met with, they should be tied if at all important, or pushed aside if possible. Working down, cutting only on the grooved director, and strictly fol lowing the axis of the trachea. the rings are soon reached. If the vessels have received proper attention, the wound should be comparatively dry. The tenac ulum is then used to steady the trachea. and. an assistant holding the lips of the wound apart with hooks, the three rings, including the cricoid, are cut, if need be. A violent inspiration then occurs, fol lowed by the sudden expulsion of mucus, blood, or diphtheritic membrane if any be present: a dangerous feature for the surgeon if he is not on his guard. At this time, the patient often ceases to breathe for several seconds. Though he practically always recovers, the opening should be carefully examined lest a mass of membrane, a plug of muco-pus, or a foreign body be the cause of the arrest of breathing. If it is prolonged, arti ficial breathing should be resorted to, or the patient should be slapped on the back and suspended by the heels. Finally, as a rule, the patient takes a deep breath and the respiration continues normal.
The cannula is immediately introduced, the sponges being taken off at the same time. The flow of blood ceases almost immediately upon the restoration of the normal breathing; for prudence's sake. however, the patient should be raised and leaned forward, so as to cause what blood might ooze from the wound to flow externally, instead of in the trachea. When the operation has been satisfac torily performed, the external wound above and below the tube is closed by adhesive strips, taking care to approxi mate and adjust the edges accurately. The lower end of the wound should re main open for drainage.
Keen introduces a silk suture into the trachea on each side of the incision and through the skin, ties the ends, and leaves them hanging long. This pro vides a permanent retractor with which the surgeon can at any time open the trachea. If no tracheotomy-tube is at hand, an elastic band tied around the neck can be used to connect the free ends of the ligatures, and so keep the trachea patent for free respiration.
Silver-tubes are to be preferred when the instrument is to be worn a long time; aluminium tubes are the best when they are to be removed soon, since the metal is corroded by the secretions. The hard rubber tubes are clumsy and become quickly saturated and foul. A double tube—the largest that can be easily ac commodated — should always be em ployed. It should also be carefully tied with tapes, around the neck, particularly in children.
During the operation, and as long as the patient is confined to his room, gen erally about a week, the atmosphere should be kept at a temperature of not less than SO° F., and maintained in a moist state by means of steam, obtained by boiling water in the apartment. In short, the object should be to furnish the lungs with air possessing as nearly as possible the properties it would pos sess if it were inhaled through the nose. To further attain this object, the foreign particles floating in the atmosphere can be arrested at the mouth of the cannula by straddling a piece of thin muslin over it; care should be taken, however, not to attach it so as to interfere with the free discharge of mucus. The best means is to tie a thin muslin hankerchief around the neck above the cannula, letting it overhang its orifice. This not only pre vents the ingress of dust during inspira tion, but also serves to prevent the re gurgitation of mucus, which often takes place without such a contrivance, when a coughing-spell forces the discharges up to the mouth of the tube.