Part 49

In other instances, the difficult breathing recurs soon after withdrawal of the tube, the morbid state of the laryngeal mucous membrane having not been wholly removed. In such circumstances, the tube must be replaced and continued, but a smaller one suffices, less mucus is secreted, and a considerable quantity of air passes through the larynx; in short, the patient requires merely a small tube to obviate the danger which might arise from complete closure of the artificial opening, and to compensate for the narrowness of the natural canal. He speaks tolerably well, on placing his finger over the orifice of the tube. In course of time, the larynx may recover, and the tube be no longer necessary.

In some cases, a tube of a certain size must be worn during the remainder of life; and it does not generally cause much inconvenience. Attempts to discontinue its use give rise to dreadful suffering; the difficult breathing, threatened suffocation, and horrible feelings during the night, all recur. The box of the larynx has fallen in, as it were, in consequence of having been long disused, and is unable to resume its functions to their full extent. Besides, great, though gradual, change of structure has in all probability taken place. In several such cases, I have attempted to restore the natural dimensions of the passage, by the occasional introduction of bougies, gradually increased in size; but in none have I completely succeeded, except in the case of attempted suicide which has been already detailed shortly. In all, my attempts were at first followed by encouraging amelioration, but untoward symptoms occurring forced me to abandon them, though repeatedly persevered in. In one man, I succeeded in restoring natural respiration and closing the opening in the neck, but this was not of long continuance; a fresh accession of difficult breathing made renewal of the artificial opening absolutely necessary within a few months. Still the results are not such as to forbid further trials; and at any rate, it is now well understood that much greater freedom may be safely used with the air-tube than was formerly imagined; yet it must be acknowledged that little benefit can be expected to follow such, or any treatment, in many cases of contraction of the canal, from long-continued disease. The larynx and trachea obtained from the patient whose case is alluded to above are here represented. The poor fellow had worn a small silver tube in an opening in his windpipe for many years. It was originally introduced on account of long-continued disease of the larynx, with dreadful suffering and constant sense of impending suffocation. He could not be made to dispense with the tube entirely, as he felt immediately on the wound closing a threatening of return of his painful and dangerous symptoms. A small one was substituted for that at first used. He led a very irregular life, used a vast quantity of opium, and no small amount of spirituous liquors. He used to be out in the open air occasionally all night, and suffered repeatedly under attacks of bronchitis. He was under treatment again and again in the hospital, on account of rheumatic affection and deranged digestive organs. He used occasionally to present himself, complaining of difficult breathing, and stating that his silver tube was too short. He could articulate tolerably well when he stopped with his finger the orifice of the silver tube; at all times a part of the respired air passing through the natural channel. Latterly, he used to suffer from threatening of suffocation, and he used to relieve himself of the cause of this, viz., the inspissated and ropy mucus which got entangled in the trachea, then not suspected to be in a diseased state, by pushing through the opening in his neck and into the bronchi, long turkey’s feathers; of these he carried a good store, and some are now in my possession. This feat he performed without causing the slightest excitement or coughing. Ultimately, and about twelve years after the operation had been performed, he died, principally from diseased viscera. His liver was enormously enlarged and altered in structure; the larynx is seen to be very much contracted at two points. The tube is observed to be considerably dilated below the contractions.

The introduction of tubes into the larynx has been supposed likely to supersede bronchotomy in some cases; and it is said that their presence does not produce so much irritation as has been stated. But the practice must, in all cases, be most troublesome to the surgeon, and painful to the patient; and, in my opinion, continuance of it is in the great majority of cases impracticable. Besides, it is difficult, and not unattended with danger. Bronchotomy is quite safe, and not likely to be followed by such suffering to the patient, or by any other unpleasant consequence, to which the other method is liable.

_Pharyngitis._—Inflammation of the pharynx is of rare occurrence. The inflammation may extend from neighbouring parts, or be produced by the direct application of an irritating or stimulating cause, as the lodgement of foreign bodies, of pins, fish-bones, seeds, portions of hard food; or by the application of acrid fluids to the membrane, acids, hot water, &c. In one instance which I met with, it occurred in a very violent form, in consequence of a large and sharp portion of an earthenware plate having been swallowed so far by the patient whilst eating his porridge, and becoming firmly impacted in the lower part of the pharynx. I have seen a considerable number of instances in which the disease was produced by the swallowing of soap lees, a fluid, it would appear, highly acrid, occasioning a severe degree of inflammation, and even destroying a portion of the parietes.

A man employed by the police in fumigating houses during the prevalence of cholera, had given to him as a practical joke a glass of sulphuric acid instead of whiskey. He suffered at the time, as may be supposed, most excruciating pain, violent inflammation supervened, followed by a bad stricture of the gullet.

Deglutition is difficult and painful; an exquisite degree of pain is occasioned by pressure on the sides of the neck, and the circulation is more or less excited. Redness and swelling of a portion of the mucous membrane can be observed on looking into the fauces. The changes which occur in the membrane are similar to those produced in the windpipe by inflammation.

Resolution will generally be effected by the application of leeches to the neck, the exhibition of purgatives and diaphoretics, and strict observance of the antiphlogistic regimen.

If the inflammation does not soon subside, it sometimes happens that constriction of the passage occurs, either from thickening or œdematous swelling of a portion of the mucous membrane, or from effusion of lymph, and adhesion of the opposed surfaces. The common seat of stricture, as in other mucous canals, is that portion of the tube which is naturally the narrowest, the lower part of the pharynx and commencement of the œsophagus, immediately behind the cricoid cartilage: occasionally it takes place in other parts of the canal. In general, the contraction is of small extent, and unaccompanied with much thickening around. The tube immediately above the constricted point is more or less dilated, and often to so enormous a size as almost to resemble a first stomach. In the majority of cases, the parietes of this pouch are attenuated; but occasionally they are much thickened, and the seat of a purulent collection, which subsequently opens into the general cavity. In cases of long standing, ulceration often occurs, usually limited to the neighbourhood of the stricture. When the parts immediately below the stricture are ulcerated, the circumstances is often attributed to the retching which generally attends the disease; but it appears to be the result of morbid action, seated in the parts themselves, similar to the ulcerative process in the larynx following inflammatory affection. But ulceration occurs as frequently above the stricture as below it; and, besides the natural cause to which it is referable, is often produced, or at least aggravated, by injudicious or unskilful attempts to remove the constriction. Though the ulcers seldom enlarge to any great extent, yet, in some rare cases, a portion of the parietes of the canal is perforated, and a communication thus established with the trachea, or with the cellular substance amongst the muscles of the neck. Or the ulcers, from either long continuance, or inherent disposition, may assume a malignant action, extend rapidly in both width and depth, throw out fungous and unhealthy granulations, form sinuous false passages, and produce a most horrible and intractable disease. But strictures are often of temporary duration, and appear to depend on spasmodic contraction of the circular muscular fibres of the tube. And dysphagia may also arise from an opposite condition of the fibres—from paralysis, in consequence of cerebral affection, a fatal symptom in any disease.

The prominent symptom of stricture of the œsophagus is difficult deglutition. Some patients can swallow only liquids; and when an attempt is made to get over any solid substance, this is stopped at the contraction, and completely obstructs the passage. In such cases patients will frequently apply for relief, in order that the portion of food may be pushed through the narrow portion of the canal; with the accomplishment of this many are quite satisfied, and are unwilling to submit to farther treatment, obstruction to solid matter being the only inconvenience experienced. But when contraction is great, and the involved portion of the canal almost obliterated, little food of any kind can pass into the stomach, the patient becomes feeble and emaciated, and ultimately dies from inanition. The subjects of this affection are generally far advanced in years, and in them it often occurs without any evident cause.

If pharyngitis have subsided, either spontaneously or after antiphlogistic treatment, and symptoms of stricture supervene, the existence or non-existence of this latter disease must be ascertained by gentle and cautious introduction of a gum-elastic bougie or ivory-ball probe. If stricture exist, the descent of the instrument will be resisted at the contracted point, and most frequently at the lower part of the pharynx: this, in the adult, will be at a distance of about nine inches from the incisor teeth. When the seat of the stricture is ascertained, a bougie is to be introduced, sufficiently small to pass through it; and when this has been pushed beyond, the disease, if unattended with malignant disposition or action, is completely in the power of the surgeon. After sufficient time has been allowed for the irritation following the first introduction to subside, a larger bougie is to be passed, and retained as long as its presence can be endured. This practice must be continued, till, by gradual increase of the bougie, the canal is dilated so as to admit readily an instrument sufficient to distend the gullet in its healthy state. Thus the passage will be gently and gradually dilated, till it regain its original calibre. The process is partly mechanical, but also greatly dependent on vital action; by the presence of the bougie the parts are stimulated, the fluid, which may be effused beneath the mucous membrane or into its substance, is absorbed, and the new solid matter is also gradually removed by increased action of the absorbents. But if the bougie be rudely and forcibly introduced, or too long retained, the absorbent action from being salutary becomes morbid, and ulceration is established, which may proceed to destroy the parietes of the canal, so producing an additional and equally formidable disease; or if the ulcerative action subside, the parts will cicatrise and consequently contract, so giving rise to a new stricture, and narrowing the canal to an equal or greater extent than formerly. Before introducing the bougie, the head must be thrown as far back as possible, as here seen, and brought to a horizontal position, that the natural curve of the upper part of the canal may be lessened, and the passage of the instrument thus facilitated. It is of consequence also to keep the point of the bougie pushed back towards the vertebræ (the patient being desired to make an effort to swallow), and to grasp the larynx with the left hand and pull it gently forwards, that there may be no risk of the instrument passing into the windpipe, instead of into the gullet; if such a mistake should happen, the surgeon will soon be apprised of it by the violent and convulsive coughing which is generally induced, though not always. Bougies armed with caustic have been recommended, but are unnecessary, the simple bougie being sufficient to remove the disease, if skilfully employed; besides, their use is not unattended with danger, ulceration being frequently produced. In very bad cases, in which the stricture is long in yielding to the means already mentioned, and the nutriment which the patient is able to swallow is necessarily small,—when the canal is altogether obliterated either at one point or to a considerable extent, as has sometimes happened, and when there is consequently little hope of success from any treatment—the strength of the patient may be supported, and life prolonged for some time by the use of nutritive enemata.

Dysphagia may also be caused by tumours in the œsophagus; but as these are generally of a medullary structure, and consequently endowed with malignant action, the treatment can only be palliative—there is no hope of a radical cure.

Dysphagia may arise from an aneurismal tumour of the arch of the aorta, or of the large arterial trunks passing off from it, pressing on the œsophagus, and so narrowing its calibre. In such cases, also, no hope of success from any treatment can be entertained; often the case terminates fatally in a very sudden manner, in consequence of the aneurismal tumour giving way at the point which protrudes on the gullet; the contents are discharged into the stomach, or ejected by the mouth. If treatment by bougies be attempted in dysphagia arising from such a cause, the practitioner not being aware of the nature of the disease, the fatal issue will be fearfully hastened—a very unpleasant consequence of any practice.

_Foreign bodies_ lodged in the œsophagus produce difficult deglutition, and, if large, may obstruct the passage completely; much irritation is also caused to the parts with which they are in contact, and inflammatory action kindled in them. A large substance firmly impacted likewise creates difficulty of breathing, by compressing the posterior part of the trachea. Indeed every consequence is of such an annoying nature, as to render dislodgement and removal of the offending substance necessary, though there were no apprehension of danger from its long-continued presence. The proceedings must be varied according to the consistence, form, size, and situation of the foreign body. There are a great many instruments for effecting dislodgement and extraction, but the great majority of them are more curious and ingenious than applicable to the purpose intended; few are of any use. A probang, mounted with a bit of sponge, or with an ivory-ball—a blunt flat hook attached to a whalebone probe—and long curved forceps, constitute the whole useful apparatus. The feelings of the patient are generally sufficient to mark the position which the body occupies; he is made to throw the parts into action, by attempts to swallow the saliva, and during the attempt to point to the seat of pain. But by this both patient and surgeon may be deceived, for pain and a feeling of foreign matter being lodged often remain at a fixed point, after the body has passed down; similar deception occurs in other situations, as in regard to extraneous substances in the eye, urethra, &c.

Small and sharp substances seldom remain long in the œsophagus, but readily descend into the stomach and intestines; they then either escape along with the feces, or, as sometimes happens, penetrate the parietes of the alimentary canal, generally near its termination. On leaving the stomach or the intestines, by gradual perforation, they frequently travel great distances in the trunk or limbs, without causing much inconvenience,—effusion of lymph surrounding them, and filling up their track. They will appear, long after their insertion, at a far distant point, approach the surface, and gradually make their way through the integument, or be readily extracted. When they enter from the surface, also, they often come within reach long afterwards, and far from their point of entrance. Needles, thus travelling, become oxidised. They are easily removed, on coming near the surface, by fixing them with the fingers, and making a small incision over the more superficial extremity. A needle may sometimes be taken out, by making pressure on both ends, and so forcing the point through the integument.

Small pointed bodies, needles, pins, fish-bones, &c., often get entangled in the root of the tongue or in the folds of the palate; on opening the mouth they can be seen, and are easily brought away. If lodged in the pharynx, they can be reached by the finger. The patient is seated with the head thrown back, and the jaws extended; the finger is introduced with determination, regardless of attempts to vomit, and swiftly passed into all the sinuosities by the side of the epiglottis, into the pouches betwixt the os hyoides and cornua of the thyroid cartilage, so that no part is left unsearched. The substance, when felt, may be extracted with the finger by entangling it in the point of the nail; or curved forceps may be introduced, and applied conveniently to the body by the guidance of the finger. Great care and caution is required in dislodging the foreign body, when both ends, as is often the case, have penetrated the parietes; if it be rudely grasped and pulled, the parts are lacerated; or it breaks, and the surgeon, after bringing out the portion held in the forceps, may find great difficulty in detecting and disentangling the other. I have often found it very troublesome to remove delicate needles entire. When they are beyond the reach of the finger, it is of no use to attempt their removal; the patient suffers great pain during the endeavour, and there is no chance of successful issue; besides, the surgeon is apt to bring discredit on himself.

Coins may be removed by the forceps, or by the hook, if lodged at the narrow part of the passage behind the cricoid cartilage; if lower, they generally defy attempts at extraction, and slip into the stomach gradually. Halfpennies, halfcrowns, &c., pass readily along the alimentary canal, and are voided in a short time.

Tendinous or cartilaginous portions of hard meat, when within reach of the finger, can be laid hold of by the curved forceps, and pulled up. Smaller and soft portions, if impeded in the passage, as when it has been narrowed by previous disease, are dislodged and pushed down by the cautious use of a small probang or œsophagus bougie. In the introduction of any instrument, attention should always be paid to the steps advised when treating of stricture of the gullet.

_Œsophagotomy_ is an operation that may, under some peculiar circumstances, be required. When a foreign body is of such a nature that, when once lodged in the gullet, it cannot be removed either upwards or downwards, without serious læsion of the parts, and, when breathing is impeded by its projection, incision of the œsophagus may be warrantable. The operation is easily accomplished. An incision of about three inches is made in the superior triangular space of the neck, on the left side,—the gullet usually inclining to the left of the mesial line. It is commenced opposite to the os hyoides, and carried downwards parallel with the trachea; the use of the knife is continued till by cautious dissection the wound is brought to the level of the common sheath of the large vessels. Assistants separate the edges by thin and broad copper spatulæ, and the cavity is frequently sponged. The larynx is pulled aside, and turned a little over on its axis; the pharynx is thus exposed. During the latter part of the dissection, the laryngeal nerves and thyroid arteries must be looked for and avoided. The foreign body is felt through the parietes, and these are laid open to an extent sufficient for its extraction. It is advisable to nourish the patient for some days afterwards through an elastic tube passed by the mouth or nares into the gullet, with its extremity one or two inches beyond the wound. Its introduction requires caution; an instance is on record of a tube being passed with the view of conveying nourishment, in which the surgeon did not discover that its extremity had slipped into the larynx till after the injection of some fluid. It is recommended to wait for some minutes before proceeding to inject, and that, if during that time no air pass through the tube, the instrument may be considered certainly in the œsophagus. It is seldom that the opening of the œsophagus will close by the first intention, and therefore accurate approximation of the external wound need not be attempted.

_Removal of noxious matter from the stomach_ is now successfully practised by the aid of instruments. This is required when the excitability of the organ has been impaired or destroyed, and emetics in consequence do not act.

It is unnecessary here to treat of the emetics which act most quickly, or which are most proper in different cases, nor of antidotes for various poisons. Many stomach-pumps have been contrived, and their merits have caused much rivalry; but they are all constructed on much the same principle. People, too, seem to indulge the inventors by swallowing deleterious substances much more frequently than before. There has been a demand for cases of poisoning, and the supply has kept pace pretty well with the demand. Now-a-days twenty seem to attempt suicide by poison for one that did so long ago.

Most vegetable narcotics—those which do not act with great rapidity, can be removed mechanically; but some of the mineral poisons are heavy and difficult of solution, and are not so readily extracted. Read’s apparatus appears to me the simplest and the best, for this and various other purposes. Ample directions for its use are given along with the instrument.

_Inflammation and Abscess of the Ear_ are either deep-seated, or confined to the external meatus. Suppurations in the internal parts—in the cavity of the tympanum, or in the mastoid cells—are often attended with the most violent symptoms, excruciating pain, fever, delirium. Such are highly dangerous in their consequences. Collections nearer the surface, under the membrane lining the meatus, are, though not so dangerous, also attended with great suffering and severe constitutional symptoms. The disease may occur at all ages, but is most common in children during dentition; in them it is often accompanied with convulsions and head symptoms, leading to a suspicion of hydrocephalus being established. The symptoms are all much relieved on the occurrence of copious purulent discharge.