Trachea

“ The trachea then contracts to 4 twelfths 167 and presently enlarges to form the inferior larynx, which is large, ossified, but symmetrical. In this space there are 6 distinct rings, and 10 united. The entire length of the trachea is 7 1/2 inches, its rings are all osseous and strong. The contractor muscles are very strong, pass along the sides of the lower dilatation, on which are given off the cleido-tracheals, then continue to the commencement of the inferior larynx, where the sterno-tracheals come off. ”

“ If the body remains movable in the trachea, it is apt to be displaced when the patient moves or coughs, and it may be driven up and become impacted in the glottis, setting up violent attacks of coughing and spasmodic dyspnœa.
Tracheotomy should be performed at once, and the edges of the tracheal wound held widely open with retractors, the patient being inverted, or coughing induced by tickling the mucous membrane with a feather. The foreign body is usually expelled, but it may be inhaled into one of the bronchi. ”

“ 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 puberty, 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. ”

“ The trachea is a cylindrical tube originating at the posterior extremity of the larynx, and terminating within the chest cavity at a point just above the heart in the right and left bronchial tubes. It is formed by a series of cartilaginous rings joined together at their borders by ligaments and lined by a mucous membrane. ”

“ It is this that science has done for us: It has clogged up all these natural avenues to our existence by teaching that we breathe through the trachea alone, in consequence of the muscle of the diaphragm forming an air-tight partition between the upper and lower compartments of our bodies; being ignorant of the fact of that other great tube of the œsophagus, also opening into the oral cavity, performing the same functions for the abdomen which the trachea does for the thorax. ”

“ A dry character of the respiratory murmur some time after tracheotomy indicates the approach of death within from twelve to twenty-four hours from descent of the membrane; so does cyanosis, whatever be its degree of intensity. Diphtheria of the trachea, which ascends to the larynx, is positively fatal. It has a rapid course, and tracheotomy only postpones the end for a little while, if at all. The general health and strength of the little sufferer have no influence whatever. ”

“ A trachea is a vessel composed of a single, elongated cell or of several cells set end to end. The cells usually are of large caliber, with very heavy walls, which are variously thickened. In some cases the thickening consists of a spiral band, in others of distinct, encircling rings. Frequently the thickening of the walls leaves definite, thin spots, called dots or pits. ”

“ About the middle of the nineteenth century tracheotomy--that is, the surgical opening of the trachea, or wind-pipe, below the larynx, for the purpose of admitting air to the lungs through such artificial opening--had been introduced by Trousseau, of Paris. In many cases this afforded relief; {330} at least the little patients did not die the awful death by asphyxiation, though not many recovered from the diphtheria or the results of the operation. ”

“ The Respiratory System.—Growths in the trachea are rare. The lungs are frequently affected, either by the direct invasion at the root from the bronchial glands (Case V.) , or by numerous scattered nodules through the substance. They develop about the bronchi, and may reach the size of marbles. Intense bronchitis, oedema, and congestion may be secondary changes induced by pressure on the bronchi or trachea.
The serous membranes occasionally present lymphoid growths. Pleural effusion is not uncommon.
The heart presents no very constant changes. When the anæmia is profound it may be very fatty. ”

“ And this is very serious in a patient whose respiration has already been much impeded, whose lungs are probably engorged, and who has certainly, by the mere existence of a wound in his trachea, lost the power of coughing properly; it must never be forgotten that a quantity of blood so trifling as to be at once ejected by a single cough in the case of a healthy chest, may be a fatal obstacle to respiration in one already weakened by disease. Thus any well-marked arterial hæmorrhage from cut branches, or from the isthmus of the thyroid, must certainly be arrested prior to opening the trachea. ”

“ When inflammation is confined to the trachea there is no alteration of the voice, and, except in children, in whom the calibre of the windpipe is proportionately small, usually no or only very slight dyspnoea. In mild cases there are no constitutional disturbances. Severe cases are accompanied by [p. 134] the febrile symptoms of a bad cold. The disease runs its course in from a few days to a week or two.
Uncured or too frequently repeated attacks of acute catarrh of the windpipe lead to chronic tracheitis, occasionally with considerable hypertrophy of the mucous membrane. ”

“ In such cases skilful technique is of far greater value than haste. The high operation is preferred, because the trachea is more superficial, less movable, and easier to find; it has less complicated relations, the blood-vessels are less numerous, the fasciæ are not so loose, the tube is easier to fit and unlikely to slip out, healing of the wound is more rapid, and complications seldom occur. In cases where the isthmus is very broad or highly placed, so that the upper parts of the trachea and cricoid are covered, a median operation is recommended. Low tracheotomy is rarely necessary. ”

“ The superficial and deep cervical groups may be uniformly affected, the muscles lifted and wasted, and vessels and trachea surrounded by a solid mass. Sometimes all distinction between the tissues is lost, and the carotids run in the midst of the new growth, which may extend far out beneath the trapezius and down into the chest or over the clavicle on to the outside. When the neck is not primarily affected the groups are more isolated, and can be traced as chains of enlarged glands along the trachea and the carotids continuous with those of the axillæ and mediastinum. ”

“ If any one will perform Galen’s experiment of dividing the trachea of a living dog, forcibly distending the lungs with a pair of bellows, and then tying the trachea securely, he will find, when he has laid open the thorax, abundance of air in the lungs, even to their extreme investing tunic, but none in either the pulmonary veins, or left ventricle of the heart. ”

“ PHYSICAL SIGNS OF TRACHEAL FOREIGN BODY If fixed in the trachea the only objective sign of foreign body may be a wheezing respiration, the site of which may be localized with the stethoscope, by the intensity of the sound. Movable foreign bodies may produce a palpatory thrill, and the rumble and sudden stop can be heard with the stethoscope and often with the naked ear. The lungs will show equal aeration, but there may be marked dyspnea without the indrawing of the fossae, if the object be of large size and located below the manubrium. ”

“ Skiagram showing an Angular Tracheotomy Tube in the Trachea. H, Body of hyoid; PH, Pharynx; CR, Posterior plate of cricoid; L, Larynx; OE, Œsophagus; 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. ”

“ Compression Stenosis of the Trachea and Bronchi.—Compression of the trachea is most commonly caused by goiter, substernal or cervical, aneurysm, malignancy, or, in children, by enlarged thymus. Less frequently, enlarged mediastinal tuberculous, leukemic, leutic or Hodgkin's glands compress the airway. The left bronchus may be stenosed by pressure from a hypertrophied cardiac auricle. Compression stenosis of the trachea associated with pulmonary emphysema accounts for the dyspnea during attacks of coughing. ”

“ Accidental injuries to the trachea, particularly injuries produced by dogs biting sheep or goats, are always accompanied by local emphysema, unless the wounds in the skin and trachea correspond, which rarely happens. At every respiration a portion of the air expelled passes into the peritracheal tissue, from which it gradually invades neighbouring parts, and may attain the mediastinum, etc. The injured animal thus inflates its own tissues and dies from asphyxia. ”

“ By the trachea.—Medicines are injected into the trachea, or windpipe, in the treatment of some forms of diseases of the lungs, and especially in that form of bronchitis or pneumonia that is caused by lungworms. For this injection a large hypodermic syringe, fitted with a very thick, strong needle, is used. The needle is to be inserted about the middle of the neck and between the cartilaginous rings of the trachea. ”

“ The wound is smaller, there is less danger of sepsis, and the eventual scar is hardly visible; no hooks or retractors are used, so that the trachea cannot be displaced. If the wound be in the middle line it is impossible to miss the trachea. This operation is performed entirely by touch, and the bleeding is not considered. Its adoption may be necessary to save the patient’s life, but in the hands of an inexperienced surgeon the operation is attended with great difficulties. ”

“ Body well nourished; slight oedema of both legs; swelling at angles of jaws, most marked on left side. Vessels of brain moderately injected; otherwise appearance normal. Cicatrizing ulcers on both sides of fauces; a diphtheritic pseudo-membrane on septum of nose, larynx normal. Trachea, upper half apparently normal; a thin film of pseudo-membrane extends from just above the bifurcation upward to nearly the middle of trachea. About an ounce of fluid in each pleural cavity; on the right side a few loose flakes of fibrin floating in the serum, and consolidation of lung at apex ”

“ When it becomes necessary, the safest plan is to enlarge the opening upward, as much as is practicable, and downward as little as we are able to get along with. The space taken up by the lower operation on children is very limited, and the operator must necessarily be cramped for want of room. The cervical portion of the adult trachea is laid down at from two to two and one half inches long. ”

“ Stenosis of the larynx or trachea occurs in old-standing cases, as the result of ulceration, after some cases of crico-tracheotomy, and especially where a tube has been worn for a very protracted period. Breathing through a tube, if continued for a long time, interferes with the natural growth of the air-passage above it. The child grows, but the larynx remains stationary. This condition is aggravated by the fact that some inflammation is constantly present, especially in the neighbourhood of the wound, so that the tissue become fibrous and hard. ”

“ Examination after death showed slight injection of the cerebral membranes; the cellular tissue in the neighbourhood of the trachea contained in certain places extravasations of blood, varying from the size of a pea to that of a penny; the [515] mucous membrane of the larynx and trachea was swollen and covered with a thick croupous layer; the lungs were partially hepatised, and the pleura thickened; the crop as well as the true intestines still contained some food. ”

“ Surgical treatment alone suggests itself. Before attempting an operation tracheotomy should be performed and a metal canula inserted. The animal having been cast, and the upper laryngeal region anæsthetised by means of cocaine, a vertical incision is made in the median line below the larynx, passing through the skin, the vertical junction between the neck muscles and the three first circles of the trachea, and access is thus obtained to the larynx and subglottal region. ”

“ The trachea is 5 inches long, much flattened, its rings unossified, its diameter at the top 2 3/4 twelfths, towards the lower part 3 twelfths, having scarcely any appearance of dilatation at the part which is so excessively enlarged in the Golden-eyed Duck, which in form and habits is yet very closely allied. The lateral muscles are strong, and there are cleido-tracheal and sterno-tracheal muscles, as in other ducks. ”

“ Bleeding by leeches or cupping, over the region of the trachea, should be immediately had recourse to, when the symptoms are urgent; or violent local irritants, as pieces of lint dipped in strong acetic acid, or blisters, may be applied to the same part. In weakly subjects of irritable constitution bleeding should be avoided. ”

“ When the pathological condition of the parts has demanded that the canula be worn for a long time, and in cases where sufficient care has not been taken to select one suited to the age of the patient or to the particular form of operation that has been chosen, perhaps to the needs of the special case, an ulceration of the anterior or posterior wall of the trachea, the result of the pressure of the lower edge of the tube or of its upper posterior and convex side, may occur. ”