THE Operation of Bronchotomy, is an Incision made in the Aspera Arteria, to make way for the Air into the Lungs, when Respiration is obstructed by any Tumour compressing the Larynx, or some other Disorder of the Glottis and Aspera Arteria, without any apparent Tumour. These are the Cases in which it is supposed to be useful; but I am inclined to think it hardly ever can be of service, but where the Complaint is attended with some Swelling, since I cannot find any Instance to my satisfaction of good done by this Operation in the other Species of Angina; nor has it appeared upon the Examination of several who have died of it, that the Air was obstructed by any Stricture of the Glottis, or Aspera Arteria: If then the Passage remains open, and Respiration be disturbed from other Causes, the making a new Orifice can be but of little advantage: I once performed it under this circumstance, but it gave no sort of Relief.
Upon the whole then, I imagine the practice of this Operation useful only in that Species of Angina, where the Throat is exceedingly enlarged by the swelling of the Thyroid Gland, and Parts adjacent, called Bronchocele, which by their weight may press upon the Trachea, so as to make it in some degree narrower, and prevent the free course of the Air to and from the Lungs. But should any one judge it proper in the Instance I object to, the Operation is so easy to perform, and so utterly void of any Danger whatsoever, notwithstanding the frightful Cautions laid down by Writers, that I would not altogether discourage the Trial, 'till I have farther Proof of its Insignificance.
The manner of doing it, is by making a longitudinal Incision through the Skin, three quarters of an Inch long, opposite to the third and fourth Ring of the Trachea, if you have the choice of the Place; and when you cannot make it so high, the Rule will be to wound a little below the Tumour: It is always advised to pinch up the Skin for this Process, which however may be left to the Discretion of the Surgeon. When the Skin is cut through, you must make a small transverse Incision into the Wind-pipe, and immediately introduce a Silver crooked Canula near half an Inch long, with a couple of little Rings at the top of it, through which a Ribband may be passed round the Neck, to keep it fixed in the Wound.
Some have prescribed making an Incision through the Skin and Trachea at once, with a Lancet or Knife, as the more easy and expeditious Method; and I once saw it performed in that manner, but it proved very inconvenient; for the Windpipe in Respiration moving up and down, slipped from the Orifice of the Skin, and made it very difficult to introduce the Canula, and afterwards to maintain it in its Situation: Wherefore I think it absolutely necessary, to make the external incision longitudinal, and even pretty large, as I have directed above.
The Caution laid down of raising the Sternohyoidei and Sternothyroidei Muscles, before cutting the Windpipe, is not to be regarded; and as to the Division of the recurrent Nerves and great Blood-Vessels, so much apprehended in this Operation, 'tis not in the least to be feared; since they are quite out of the reach of the Instrument, as any one skilled in the Anatomy of those Parts must very well know.
The Method of Dressing will be easily understood, since after the Patient can breathe by the natural Passage, if you withdraw the hollow Tent, the Wound will become a a simple one, and notwithstanding its Penetration through a Cartilage into a large Cavity, require a superficial Application only.