within the cavity of the larynx, as in the following case, which,
though unsuccessful, shows the advantages to be expected from similar
procedure adopted at a more early period. T. C., aged 22, had laboured
under the symptoms of phthisis laryngea for five months previous to his
application. He was much emaciated, and experienced great difficulty in
swallowing, on account of the irritation induced in the region of the
glottis; he had occasional cough, purulent sputa, and aphonia almost
complete. The larynx was painful when pressed, the epiglottis was seen
to be œdematous, and the general symptoms were of a hectic character.
The œdema of the epiglottis was reduced by scarification.
The symptoms increased, notwithstanding counter-irritation and tonic
remedies. The stethoscopic indications regarding the chest were so far
favourable.
Tracheotomy was performed, and the patient felt very much relieved in
consequence. On the tenth day after the operation, the inner surface
of the larynx was touched with a strong solution of the nitrate of
silver, applied by means of a bit of lint wrapped round the end of
a probe slightly bent, and introduced upwards from the wound. The
solution was applied every second or third day, and under its use the
patient was remarkably benefited. He swallowed, spoke, slept, and
looked better; the purulent sputa diminished, and the cough abated.
He complained of less pain in the larynx, and seemed to be regaining
strength, though slowly.
But after the lapse of several weeks, from imprudent exposure to
cold, evident symptoms of bronchitis supervened, under which his
constitution already shattered, speedily sank. The larynx was found
extensively ulcerated, but at a number of points there were distinct
marks of recent cicatrisation. The state of the lungs clearly showed
that phthisis pulmonalis had not only commenced, but made considerable
progress. The practice here detailed has been repeated again and again
with good success.
[Illustration]
Dyspnœa is caused by other circumstances besides those already
mentioned; some rare cases are met with in which warty excrescences
have grown from the seat of the vocal chords: a beautiful specimen from
the collections of my friends, Messrs. Grainger and Pilcher, is here
delineated. Dyspnœa frequently arises from paralysis of the muscles of
the larynx, in consequence of effusion at the base of the brain, from
long-continued irritation, as from an irritating cause seated in the
mouth, and in old people from a general decay of the animal powers. In
the last case, it is generally a symptom of approaching dissolution, as
is the dysphagia which often attends it.
Severe dyspnœa is sometimes caused by external violence. A fine
healthy child, aged eight, in running across the street, fell, and
struck the larynx with great force upon a large stone. She was taken
up quite lifeless, and some time elapsed before respiration was at all
established. A gentleman finding her face livid, opened the temporal
artery, and applied leeches to the throat, with some relief. I saw her
about three hours after the accident. The breathing, inspiration more
particularly, was exceedingly difficult; and this appeared to proceed
not only from the injury to the larynx, probably occasioning loss of
power in the muscles, but from the collection of some fluid in the
trachea and its ramifications. The child was evidently in such a state
that, unless active measures were resorted to, and that speedily, a
fatal termination would soon take place. Tracheotomy was performed; a
quantity of coagulated blood and bloody mucus was evacuated from the
opening; and when the discharge and coughing had ceased, a tube was
introduced. In eight days the tube was withdrawn, the aperture closed;
and no unfavourable symptom recurred. In the museum at Chatham is a
larynx showing fracture of the thyroid cartilage from the kick of a
horse. The immediate consequence was great difficulty of breathing and
rapid general emphysema. The patient, a young soldier, died soon after
the injury.
Large or irregular _foreign bodies_, as coins, pebbles, portions of
stone or of coal, seeds of fruit, &c., put heedlessly into the mouth,
are apt to become impacted in the rima glottidis, and give rise to
severe and dangerous dyspnœa, or even cause sudden dissolution. Smaller
and smooth substances pass through into the trachea. Such accidents
happen most frequently to children. Peas, beans, small shells, &c.,
slip into the air-passage, are obstructed for a short time in the rima,
but are soon forced by the convulsive actions of the patient into the
trachea, and frequently lodge in the right bronchus, it being more
capacious, and more a continuation of the trachea than the left; or
they remain loose in the trachea, and are moved up and down by the
passage of the air. Immediately on their introduction, most violent
coughing takes place, respiration is convulsive and imperfect, the
patient writhes in agony, and is in dread of instant suffocation;
the countenance becomes inflated and livid, and most strenuous
efforts are made by nature to expel the foreign body. At length he
is exhausted, and an interval of perfect quiet ensues; but this is
soon interrupted by renewed attempts at expulsion. After a time, the
intervals of repose increase in duration, and in many cases are so
long continued, as to lull the patient and his friends into a belief
that the windpipe contains no extraneous substance. But still violent
fits of coughing supervene from time to time, and the dyspnœa is very
alarming; on attentive examination, the presence of this foreign body
may be ascertained beyond doubt by the peculiar noise produced by its
movements in the passage; at the same time, thin mucus is copiously
discharged from the lining membrane. Occasionally the foreign body
becomes so placed in the canal as to form a complete valve, and then
the labours of the patient to dislodge it are most painfully severe;
if they fail, he is suffocated. During laborious breathing the neck
sometimes becomes emphysematous. The parts may at length get accustomed
to the presence of the foreign body, and all uneasiness subside. But
danger, though not immediate, still remains. Foreign bodies have
remained for years without causing much inconvenience; but in such
cases they have generally settled in some remote ramification of the
bronchial tubes; abscess commonly, sooner or later, takes place around,
purulent expectoration follows, all the symptoms of pulmonary phthisis
are established, the patient becomes hectic, and dies.
The existence of the foreign body, when suspected, is to be ascertained
by accurate and attentive examination along the forepart of the neck,
and by listening carefully to the sounds which may be present in the
trachea; but the urgency and continuance of the symptoms will seldom
leave the surgeon to entertain a doubt. If he attentively watch the
patient, he can scarcely be mistaken. It has been recommended to
examine the œsophagus previously to adopting active measures, a large
foreign body impacted in that passage being capable of materially
obstructing respiration by compression of the trachea; and it is
safe and prudent to follow this recommendation whenever the least
uncertainty exists regarding the real nature of the case.
When a foreign body has lodged in the windpipe, tracheotomy should be
had recourse to without delay. In general, the offending substance
presents itself immediately after the division of the trachea, and
is expelled by a strong current of air. But in some cases it may
be necessary to introduce instruments—probes, scoops, or small
forceps—upwards or downwards, to dislodge and extract the body. A case
in which a foreign body, which had lodged in the right bronchus for
about six months, was successfully extracted, is detailed fully in the
_Lancet_, and noticed shortly in the _Practical Surgery_, p. 416. A
little blood from the wound may cause coughing for some minutes, but
this soon ceases; the wound is closed after a few hours, respiration is
completely reëstablished, and all that the surgeon has then to combat
are the evil effects on the mucous membrane which the contact of a
foreign body may have occasioned.
Tracheotomy is, in nearly all cases, preferable to laryngotomy. In
disease of the windpipe, as formerly stated, it is better to cut into
a sound part of the passage, or at least as far as possible from the
seat of the disease. When an adult, for example, labours under acute
laryngitis, the effused lymph is generally confined to the larynx, as
was already mentioned; an opening below the thyroid gland is removed
from the effusion, and by means of it the patient breathes through
the natural tube yet sound; whereas, if the opening is made in the
crico-thyroid membrane, the surgeon frequently cuts into the middle of
the diseased part; little or no benefit follows, and, if the danger
is not increased, equivocal good is all that can be expected from
such an operation. Tracheotomy is also preferable for the removal of
foreign bodies, unless it is certain that the body is impacted in the
rima, for in such circumstances laryngotomy is much more suitable. In
tracheotomy, the incision of the tracheal rings can be extended with
much less injury than can division of the laryngeal cartilages, when
the largeness of the foreign body, its being firmly fixed, or other
circumstances, require that the wound be of considerable size. The
risk or danger in the one operation is not much greater than in the
other. Division of the crico-thyroid membrane and skin is effected
by one incision; there is nothing important in the way of the knife.
In very young children, when suffocation is threatened, as from the
effects following upon the attempt to swallow very hot fluids, and
the inhalation of steam, this operation may with great propriety be
performed. Tracheotomy, on the contrary, requires to be proceeded in
more carefully, particularly in children, in whom the neck is short,
and the trachea deep. The tube is moreover very small, and not easily
steadied. I had occasion, not long since, to open the passage in a
child under sixteen months old, who had tried to swallow the contents
of a teapot recently filled with boiling water. The difficulty
experienced in such cases is often very great. Obstacles may also be
presented by the thyroid and other veins being distended, and the soft
parts are perhaps tumid and infiltrated with serum.
The patient, if adult, should be seated with the trunk erect, and by
throwing back the head, space in the neck is gained. In a female on
whom I operated some years since, this advantage could not be obtained
on account of induration in the belly of the sterno-mastoid muscle,
with contraction. The incision of the integument is commenced in the
mesial line over the cricoid cartilage, and carried downwards, an inch
in the adult, but proportionally shorter in children. The cellular
tissue is divided by a few touches with the point of the instrument (a
small scalpel or bistoury); the finger is then introduced to separate
the sterno-hyoid muscles, and to feel for any stray vessels which may
be in the way; for the thyroid arteries sometimes cross the line of
incision, and it may happen that some of the larger arteries of the
neck, by following an unusual course, become liable to injury, if the
operation were rashly performed. The plexus of veins on the forepart of
the neck is pushed downwards, and the isthmus of the thyroid gland, if
it exist, is displaced slightly upwards; thus the rings of the trachea
are cleared. The patient is desired to swallow his saliva, in order
to elongate and stretch the windpipe; and the surgeon, seizing the
favourable opportunity, pushes the point of the knife, with its back
towards the top of the sternum, into the tube at the lower part of the
incision. The instrument is carried steadily upwards, so as to divide
three or four rings. It is not at all necessary to cut out any part of
the rings of the trachea as recommended by some writers; contraction of
the tube may afterwards result; nor can any good purpose be served by
making the opening crucial.
If the operation has been undertaken for the removal of a foreign body,
its object is usually accomplished immediately on division of the
rings; if not, the substance must be dislodged by proper instruments,
as was previously remarked. The opening is allowed to close after
the oozing of blood has entirely ceased; but its edges must be kept
asunder till then, lest the blood be drawn into the bronchial tubes,
which occurrence, however slowly it take place, is always dangerous.
The union and cicatrisation of such longitudinal wounds are soon
accomplished; they close permanently in a few days, even after having
been open for many weeks with a foreign substance interposed between
their edges. The same obstacles do not interfere as in transverse
wounds; on the contrary, every circumstance is in favour of rapid union.
When the object of the operation is to relieve respiration, impeded by
disease in the superior part of the canal, a silver tube, of convenient
curve, length, and calibre, is introduced into the wound immediately
on the knife being withdrawn, and secured by tapes attached to the
rings at the orifice of the tube, and tied round the neck. Frequently
a violent fit of coughing, alarming to the patient, follows the
introduction, in consequence of some blood having entered the trachea.
But on the ejection of some frothy mucus, mixed with blood, the patient
becomes quiet and tranquil, breathes easily, and feels composed and
relieved. The form of the tube—the calibre gradually increasing from
below towards the orifice—completely prevents any farther ingress
of blood, by the uniform compression which it makes on the edges of
the wound. The secretion of mucus in the trachea is increased by the
presence of the foreign body, but the patient easily frees himself from
its annoyance, being instructed to place his finger on the orifice of
the tube, so as to narrow the aperture, when he wishes to cough and
expectorate. In those cases where the operation has been performed
without there being diminution of calibre of upper part by swelling or
otherwise, expectoration through the tube is more difficult. Mucus,
however, is apt to adhere to the inner surface of the tube, and thereby
obstruct breathing; to prevent this, it is necessary occasionally to
introduce a feather, or a probe wrapped round with lint, for some
hours after the operation; the attendance of an assistant may be
necessary for this purpose, but the patient readily undertakes the
duty himself, on being made aware of its necessity. A double tube has
been recommended, to facilitate the keeping of the passage clear, the
inner one being occasionally withdrawn, cleaned, and replaced. But
this is not in ordinary cases necessary. The frequent introduction of
a feather, or probe, is sufficient for some hours after the operation,
and in a very short time the patient finds that he breathes freely,
though the tube is removed for a few minutes, in order to be cleaned.
At first, a funnel-shaped tube is used, to compress the edges of the
wound and prevent oozing, as already mentioned; afterwards, one of
uniform calibre is more easily coughed through. The patient should be
kept in an atmosphere of warm and equal temperature, and it is also
prudent to place some cloth of very loose texture over the tube, that
the temperature of the respired air may resemble as much as possible
that passing through the whole track of the windpipe; thus bronchitis
may be averted.
In some cases, the necessity for continuing the tube speedily goes
off, the larynx, in consequence of rest, having recovered its healthy
state and action. After eight or ten days, on taking out the tube, and
closing the aperture in the trachea, the patient breathes and speaks
well, and continues to do so.
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.
[Illustration]
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.