PRELIMINARY LARYNGOTOMY
Authors: H. T. Butlin
Journal: BMJ (1907)

FOR the past 15 years I have prformed laryngotomy with plugging of the, air passage aboVe as-a preliminary.tolarger operations about the upper air passages, with the intent: (1) To make such operations less.dangerous to life; (2) to increase the number of cases which could be operated upon owing to the diminished danger; (3) to ,help surgically in tho operation by getting rid of the Tespiration through the pharynx during the time of opera- tion, and of the hindrance caused by perpetual sponging and coughing; (4)to give the chloroformist a clear field for his work away from the site of operation, 0o thkt he may do his wor-k uninterruptedly withou1t taking turns about with the surgeon; (5) to lessen the time needed to perform certain operations' attended by bl0eding difficult to control; (6) to get rid of tracheotomy as a preliminary operation-in all suitable cases, and so again to assist in -making the operations in question more easy, quick, and efficient in saVing life.With regaird'to tracheptomy 'high or low-all who have seen much Qf it in hog4itals must agree that it 'is often difficult to porfordi, that whether done hurriedly or slowly it is apt to'be associated with the suction of blood into the trachea and luhgs, and that the deep tissue of the neck is opened 'up in the operation, so that tracheotomy as a preliminary operation iritended to facilitate the operation required may unhappily increase danger and even be the cause of death.Laryngotomy, on 'the other hand, as a preliminary operation, can be done in a few seconds, without any haemorrhage of consequence, and with but slight opening up of the neck tissues.The wound can be-th6aled in a few hours, and the whole operation is without danger, and easy to perform.In most cases the method of operating is as follows:First, an assistant lifts up a vertical fold of skin, the centreof which should be at the level of the upper border of the cricoid cartilage when the' head is extended.Secondly, the, centre of the uplifted fold is transfixed and, cut through so.as to make a transverse cut -of 1 in. in length.'It will be,found that-the veins running vertically in this region have not been cut, and are exposed at the bottom of the wound.Thirdly, a pair of sharp closed scissors curved on the flat' are plunged through 'the crico-thyroid membrane downwards and backwards in the mid-line, keeping close to the upper border of the cricoid, so as to avoid the little artery.The scissors are then widely opened.Fourthly, t&e laryngotomy tube is inserted between the blades of the widely-opened scissors, or retractors can be used,after withdrawifg 'the scissors.,In' most cases it is quite easy to pass the tube with the left forefinger nail serving'as a'guide above, whilst an as'sistant holds the partly-o.xiednscissorsin position.The laryngotomy tube should ',ie a" little flatter than' a tracheotomy tube; it should be'fitted with a pilot with not' too blunt a point, 'and the tiabe should project beyond the plate externally, so that the chloroformist can easily fix an indiarubber' tube through which to give the anaesthetic.If need be, a smal'lor medium Durham's tracheoto'my tube will serve every purpose.Lastly,I the pharynx can be firmly packed with a large fliat ,sponge, a serie3 of which-should be in readiness, and the preliiiinary' operation preparations for some!griaver matte'r are there*ith ende4.