compression causing protrusion of the mucous membrane into the interior, represented in Fig. 32, or else constricting bands are visible. As to the dyspnea, both inspiration and expiration are affected-frequently, however, the former more than the latter, as is shown by pneumatometry. The head is thrown forward and the chin up; the larynx moves up and down less energetically than in health (while the respiratory movements of the larynx are abnormally increased in laryngeal dyspnoea); the thorax is less expanded than normally, especially its upper portions. As to catheterization and probing, see the remarks under the head of Morbid Growths. The PATHOLOGY.—The pathological changes in cases of stenosis vary with its eause. In the great majority of cases of stricture from within, syphilisantecedent ulceration followed by cicatrization-has produced the stenosis; in compression thyroid disease, and next often aneurism, is the cause. stenosis is most frequently situated in the lower, next in the upper, and least in the middle, portion; more often than the latter alone the whole tube is affected. PROGNOSIS.-This is rather favorable with timely and proper treatment unless a continuing active cause be irremovable; without treatment, however, the cases almost invariably terminate fatally from pneumonia, tracheal spasm, apnoea as before explained, etc. TREATMENT.-When the symptoms are urgent and the stenosis is not too low down, tracheotomy must be performed. Sometimes a very long and flexible tube may be introduced with success in case of very low stenosis, but more often tracheotomy is disappointing on account of the stenosis extending too low down even when its beginning is higher up. Stricture, especially when the symptoms are not very urgent, may be relieved by dilatation through the natural passages, with, or if possible without, previous tracheotomy. The cure of compression implies removal of the compressing tumor or disease. Soothing inhalations, such as of hops, benzoin, etc., diminish irritation and give temporary relief. DILATATION (HERNIA, FISTULE). DILATATION of the trachea is either confined to the tube (when the synonym tracheaectasy is applied to it) or is diverticular. In the former case it may involve only a part or else the whole extent of the windpipe. Whenever free respiration, especially expiration, is chronically impeded, some portion of the air-tract below the obstruction is apt to become dilated; thus, a bottle-shaped dilatation is sometimes found immediately below an annular contraction. On the other hand, tracheaectasy may extend upward from bronchiectasy. It has been observed post-mortem to a slight extent in public eriers, trumpeters, etc., and in old coughers from laryngeal disease, chronic bronchitis, pulmonary emphysema, etc., but without giving rise to distinct symptoms during life. Diverticular dilatation forms an air-containing tumor which either looks into the esophagus or is discernible on the outside of the neck. Though rarely met with, it ought to be thought of in all appropriate cases, and when pointing externally ought always to be recognized by the careful practitioner. It is either hernial, glandular, or fistular-three pathological conditions which have hitherto been confounded. On account of the construction and position of the trachea there can be but little protrusion outward without previous dilatation. Unless there be a deficiency of the cartilaginous rings, only the posterior wall, which is always unsupported, and to a slight extent also the intercartilaginous membranous portions, are liable to tracheal hernia. This is properly called tracheocele; but the various terms aërial goitre, aërial bronchocele, pneumatocele, tracheal air-cyst, tracheal retention-cyst, internal tracheal fistule, subcutaneous or incomplete fistule of the trachea, have been indiscriminately used as synonyms of tracheocele, and have added all the more to the confusion, as some of them originated, no doubt, as correct appellations of the particular cases to which they were applied. Aside from the occasional occurrence, both congenital and acquired, of tracheo-cutaneous fistule, complete and incomplete, and the still more rare occurrence of hernia of entire portions of the mucous membrane, the cases of diverticular dilatation of the trachea-or saccular tracheaectasy, as it may be called-are glandular, as found by Rokitansky more than fifty years ago. Virchow seems to regard all such glandular dilatations as retention-cysts (see Morbid Growths), but although retro-tracheal retention-cysts doubtless do occur (Gruber has reported two unquestionable instances), and although the tumors now under consideration do in fact sometimes contain a little mucus in addition to air, they do not constitute cysts or adenomatous new growths, but are simply distended portions of the tracheal mucous membrane, respiratory glands, whether the dilatation be caused, as Rokitansky thought, by traction (Zerrung) and hypertrophy of the mucous glands, or, as Eppinger suggestsand which is more likely-mainly by increased intra-tracheal air-pressure. There must, however, I think, coexist some deficiency or weakness of the cartilaginous or other tissue, either congenital or acquired. When the dilatation is retro-tracheal only, the symptoms are very obscure, and diagnosis during life is at best uncertain. In one such case under my care, confirmed (death having occurred from another cause) by post-mortem examination, there was some dysphagia and slight alteration of the voice. In all other cases the characteristic and unmistakable sign of the disease is the peculiar intermittent, or, at all events variable, aërial cervical tumor. It increases and diminishes with forcible expiration and inspiration, and attains its largest size during violent coughing, hawking, blowing of the nose, or other expiratory effort. Occasionally the voice is considerably affected. The tumor, especially by the manner in which it can be made to temporarily disappear and reappear, can usually be easily differentiated from subcutaneous emphysema and goitre, the only two conditions with which it might be confounded. In the fistular variety the opening into the trachea can sometimes be seen by means of tracheoscopy. Aside from the deformity which the tumor may cause, it sometimes induces laryngeal spasm and dyspnoea; otherwise it is of no gravity. As to TREATMENT, methodical and continued compression by applications of astringent collodion or by mechanical means is the only palliative measure applicable; when suffocatory attacks call for it, tracheotomy must be performed. TRACHEOTOMY. BY GEORGE M. LEFFERTS, A. M., M. D. THE operation of tracheotomy, or the artificial opening of the air-passageusing the term in its modern acceptation as including all of the five incisions that are both anatomically and surgically possible, either singly or in combination, between the lower border of the thyroid cartilage and the upper edge of the sternum (incisura jugularis sterni), and reserving the term laryngotomy to denote the division of the thyroid cartilage alone-fulfils two important and usually urgent indications: First, in allowing the respiratory current free access to the lungs in cases where the laryngeal obstruction is of such a sudden or of so progressive a character as to either immediately or remotely threaten the life of the patient; and, secondly, in affording a ready means of direct access to those portions of the air-tract which lie below the level of the glottis, and thus permit not only of the direct extraction of such foreign bodies as may accidentally have found their way within the airpassage, but of neoplasms here located and of occluding diphtheritic membranes. Catheterization and aspiration of the trachea are likewise both rendered not only possible, but easy of execution. Both general indications mentioned often coexist, and are met by the operation in a large class of cases; the first alone plays its important life-saving rôle in many. The disease or accident which renders the operation necessary varies greatly, and upon this variation depends not only the surgeon's decision as to the precise time at which the opening into the air-tube must be made, but also the precise point at which the operation should be performed. These general questions I treat of in detail. The special indications may conveniently, but somewhat arbitrarily, be arranged as follows, in groups, which I have attempted to make complete, although some of the conditions, being purely surgical, do not strictly come within the compass of this essay: A. Acute inflammatory diseases of the larynx and trachea: 1. Acute oedema of the larynx. 2. Erysipelatous and exanthematous laryngitis. 3. Acute perichondritis, with abscess. 4. Diphtheritic croup. B. Chronic affections of the larynx and trachea: 1. Syphilitic laryngitis. 2. Phthisical laryngitis. 3. Chorditis vocalis inferior hypertrophica. 4. Carcinoma of the larynx or trachea. 5. Non-malignant growths of the larynx or trachea. 6. Tumors overlying the superior aperture of the larynx. 7. External compression of the trachea by tumors of the neck or chest. 8. Strictures of the larynx or trachea. C. Neurotic diseases: 1. Paralysis of the abductors of the vocal cords. 2. Spasm of the adductors of the vocal cords. VOL. III.-10 145 D. Traumatic conditions: 1. Foreign bodies in the larynx or trachea. 2. Impaction of foreign bodies in the pharynx or oesophagus. 4. Scalds and burns of the larynx. 5. Incised and gunshot wounds of the throat. 6. Poisonous bites inflicted by certain insects about the mouth or neck. 7. Suffocation from the passage of blood, fluids, etc. into the airpassages (tracheotomy, with aspiration of the windpipe and artificial respiration). 8. Suffocation from the acute collection of either mucus or serum in the bronchia (ditto). 9. Suffocation from the inhalation or development of poisonous gases (tracheotomy, with artificial respiration). Finally, although it pertains alone to the province of the surgeon, I may allude to the temporary tracheotomy and "tamponing of the trachea " which has been recommended and certainly found efficient-in preventing the entrance of blood to a dangerous degree into the lower trachea and lungs during the performance of certain operations in the neighborhood of or upon the air-passages, such as resection of the upper jaw, the extirpation of large nasal and naso-pharyngeal polypi, removal of the tongue, subhyoidean pharyngotomy, laryngotomy, and extirpation of the larynx." All-important as a preliminary to the operation itself is a thorough knowledge of the surgical anatomy of the region upon which it is proposed to operate; and this not alone in the adult, but especially in the child, where essential differences often exist. Possible anomalies also are not to be forgotten. The assurance of the surgeon depends upon this knowledge: mere manual skill will not compensate for its want; the success, both immediate and remote, of the operation is in great measure the reward of its possession. It will be remembered that the trachea commences at the inferior border of the cricoid cartilage, directly opposite to the lower edge of the fifth cervical vertebra, and reaches thence downward, in the median line of the neck, until it bifurcates opposite to the third dorsal vertebra. In its upper part it is nearly subcutaneous, and is surmounted by the prominent ring of the cricoid cartilage (easily identified, even in the young child), above which, in turn, lies a slight depression (the crico-thyroid space) between the cricoid and thyroid cartilages. As the trachea descends in the neck it recedes gradually, lying at the episternal notch about one and three-eighths of an inch from the surface. Throughout the whole of this course it is in relation with important structures. In its cervical portion it is covered by the sterno-hyoid and sterno-thyroid muscles, and in the median space, which is usually distinct between them, by layers of the deep cervical fascia. It is also crossed by the isthmus of the thyroid gland, which lies between the second and fourth tracheal rings; by the arteria-thyroidea ima, when present, and below by the plexus formed of inferior thyroid veins with their tributary and communicating branches. In the latter region, but more superficially, are some communicating branches between the anterior jugular veins. The innominate and left carotid arteries are also anterior to it in the episternal notch as they diverge from their origin. Laterally, the trachea is in relation with the common carotid artery, the lateral lobes of the thyroid body, the inferior thyroid veins, and the recurrent laryngeal nerves. The thoracic portion of the trachea is covered by the manubrium sterni, with the origins of the sterno-hyoid and For the details of this procedure consult Schüller, Die Tracheotomie, etc., Stuttgart, 1880. 2 See Pilcher, "The Anatomy of the Anterior Median Region of the Neck," Ann. of Anat. and Surgery, Brooklyn, April, 1881. sterno-thyroid muscles, by the left innominate vein, and by the commenceinent of the innominate and left carotid arteries. Still lower, the transverse portion of the arch of the aorta crosses, and the deep cardiac plexus of nerves lies in front of it. Posteriorly, throughout its length, it rests upon the esophagus. In performing, then, either the superior or inferior operation of tracheotomy, after cutting through the skin and superficial cervical fascia-which is really loose areolar tissue containing fat-the superficial layer of the deep cervical fascia is reached, and immediately below it more or less adipose tissue and the two anterior jugular veins lying in an inferior tracheotomy to either side of the wound, which is always made in the median line. As a matter of fact, these various layers are rarely demonstrable, and the surgeon proceeds irrespective of them until he reaches this point in his operation-viz. the muscles which overlie the trachea. These may overlap in the median line, and have to be retracted after having been separated; or, again, a thin line of connective tissue marks a slight interval between their inner edges, and is readily seen and dissected through if the operator has kept his incision vertical and strictly in the median line of the neck -a matter so important to the success of his operation that I do not hesitate to again allude to it. The muscles separated and gently retracted, together with the overlying tissues, toward the sides of the wound, the upper edge of the isthmus of the thyroid gland overlying the second and third, perhaps fourth, rings of the trachea, is always seen in a superior tracheotomy-its lower edge very frequently in the inferior operation. The isthmus is adherent to the trachea and to the larynx through the deep layer of the deep cervical fascia, but is capable of being slightly displaced or pushed upward or downward as the case may be, and thus kept from obscuring the operative field. This being done, the deep layer of the deep cervical fascia is seen covering and strongly adherent to the tracheal wall together with the thyroid veins. A few touches of the knife, carefully avoiding the blood-vessels, serve to clear it away, and the tracheal rings are clearly exposed. In carrying out this dissection, which has been described as occurring in an ordinary and uncomplicated adult case, several matters must be borne in mind; and especially is this true if the operation concerns infants. In them, for instance, the thymus gland rises half an inch above the level of the sternum, and is frequently to be found as late as the sixth or seventh year. In both adults and children the innominate artery occasionally comes into view in an inferior tracheotomy, obliquely crossing the lower portion of the right half of the trachea.. It is relatively higher in the child than in the adult. The left innominate vein is also often observed when the trachea is opened low down. Certain abnormalities of the blood-vessels have been alluded to above. The commonest consists in the existence of a thyroidea ima artery, which when present usually arises from the innominate trunk, but sometimes from the right common carotid or the aorta: it passes to the thyroid body directly in the median line of the neck and close to the trachea; again, the place of the anterior jugular veins may be taken by a single central vessel, almost sure to be wounded during the operation if it exist (Mackenzie). In performing the operation through the thyro-cricoid membrane (thyrocricotomy) or through the cricoid cartilage alone (cricotomy), the same tissues are met with, and the same dissection is necessary in the earlier stage of the operation, as have been described in the operation of superior or inferior tracheotomy; but the parts are more superficial, adipose and cellular tissue less abundant, blood-vessels much less numerous, and the operation very much simpler. The thyroid gland of course does not come into view, |