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.
[Illustration]
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.
Suppuration in the organ of hearing often follows eruptive diseases;
and both ears, or one, may continue to discharge for a long time. There
is always more or less derangement of the functions of the parts. When
the disease is external, perhaps hearing may not be much affected; but
when, as often happens, the ossicula, nervous expansions, membrane,
parietes, are all destroyed or injured, hearing is lost, or rendered
at least very obtuse. Purulent discharge often continues for the
rest of the patient’s life, at one time scanty, at another profuse,
and preceded or accompanied by inflammatory symptoms. Openings form
over the mastoid process, communicating with the cells; and these are
often connected with abscess betwixt the dura mater and pars petrosa
of the temporal bone. Abscesses, too, of the middle lobe of the
cerebrum, or in the cerebellum, are sometimes evacuated through the
meatus auditorius. In all cases, but in the last more particularly,
the patient suffers extremely on the discharge being suppressed, and
is again relieved on its recurrence. At length, fever and delirium
may supervene, terminating in coma and death; I have dissected many
who have perished in this manner. Or, after long-continued discharge
from the meatus, perhaps with paralysis of one side of the face,
a soft tumour of the dura mater will be found lying over the pars
petrosa, having caused extensive absorption of the bone, and exposed
the semicircular canals, cochlea, tympanum, &c., filled with purulent
matter. Abscess of the tympanum itself discharges long; and large,
flabby, soft granulations fill up the meatus, very different in
appearance from the solid tumours which sometimes occupy that situation.
Ordinary earache—inflammation extending along the meatus externus, and
confined to the lining membrane—will be relieved by leeching behind
the auricle, and by assiduous and regular fomentation afterwards.
But suppuration is seldom prevented. The abscess may sometimes be
opened, with great relief. If deeply seated, the parts are soothed by
fomentation and poultice, till spontaneous evacuation of the matter
occurs; this is then to be washed away, from time to time, by the
injection of a warm and bland fluid; the abscess gradually closes, and
the discharge slowly disappears. In cases of long-continued discharge,
it is generally impossible to ascertain from what depth the matter
comes, and there is always great risk in using means to arrest its
flow. The patient must submit to the annoyance. The discharge can be
moderated, or altogether suppressed, by injections of astringent salts,
but the practice is unsafe, and in most cases unwarrantable. The parts
are to be kept clean by frequent ablution with tepid water, lime water,
or other bland fluids; and cotton or wool may be worn in the meatus to
take up the discharge, and prevent bad effects from cold. Discharge
from the external meatus, and about the auricle, is often kept up by
irritation in the mouth, in both children and adults; this should be
looked to, and the offending cause removed, if possible.
_Foreign bodies_ are frequently lodged by children in the meatus
auditorius externus—peas, beads, shells, shot, pins, &c. By awkward
attempts at removal they are pushed deep into the cavity; and the
membrane of the tympanum is sometimes broken, as indicated by effusion
of blood, and swelling of the parts. Violent inflammatory symptoms
may be caused by such substances, and will be seriously aggravated by
unsuccessful attempts at extraction. Sometimes they are allowed to
remain for days or weeks; in such circumstances seeds swell, separate,
and begin to throw out a germ, thus fixing themselves more firmly in
the passage. They are easily removed at first, by a small silver scoop,
of convenient size and form; and even at a later period, a determined,
though not forcible, attempt with the instrument will be followed with
success. The scoop is gently and gradually insinuated betwixt the
membrane and foreign body; and on its handle being then raised the body
is extruded. It is seldom that any excitement follows extraction by
this method: but if large and powerful instruments be introduced, and
force applied, the parts may sustain severe injury, and troublesome
consequences ensue: indeed such proceedings have proved fatal.
Foreign bodies are also occasionally impacted in the nostrils: the
procedure above described is to be adopted. Sometimes they are
discharged by the posterior nares during attempts at extraction.
_Polypus_ of the meatus auditorius externus is generally of pretty firm
consistence, pyriform, sometimes slightly lobulated and warty-looking;
it adheres by a narrow neck to the parietes of the tube near the margin
of the membrana tympani, is attended with slight discharge, and with
deafness to a greater or less extent.
Extraction is the only means of cure. The body of the tumour is
depressed and pulled outwards by the flat end of a probe slightly
bent; delicate forceps are introduced gently, and passed up to the
neck of the polypus, which is then firmly grasped; by combining slight
twisting with gentle extractive force, it is readily removed. Or a
flat scoop, with a sharp round edge, is passed along till obstructed,
and by slight rotatory motion of the edge, the neck of the tumour is
divided. After a day or two, a mild escharotic may be applied with
the view of preventing reproduction; a bit of charpie sprinkled with
the oxidum hydrargyri rubrum may be pushed up to where the tumour was
attached, and the application may be repeated several times, one or two
days intervening. Even after this the tumour sometimes returns, again
rendering extraction necessary.
_Deafness_ is attributable to various causes besides those already
mentioned. Accumulation of cerumen in the external meatus is the most
common. The cerumen is often mixed with wool, and other extraneous
substances, which the patient may have been in the habit of introducing
as preservatives from cold, and thus a large and firm plug is formed,
completely blocking the meatus. It is removable by the assiduous
injection of tepid water, the best solvent of cerumen. The whole may
not be brought away at the first sitting; but the injection must be
repeated again and again, till the membrane of the tympanum is free. A
powerful syringe is required. By the use of a speculum, the condition
of the external tube and membrane of the tympanum can be ascertained.
But it is perhaps unnecessary to enlarge farther here on this subject,
for such is the division of labour in these days, that a distinct
profession is founded on the operation of squirting water into the
external ear; it is true that other operations are talked of by these
Aurists, as they style themselves, but the advantage to be derived from
any of them is often very doubtful. They talk of deafness as arising
from a deficient secretion of cerumen, from dryness, or from eruptions
in the meatus; and heating stimulant applications are poured in—oils,
ointments, mercurial salts, acetic acid, garlic, &c., all combined.
They even go so far as to recommend mercurials to correct the state
of the general health, to improve or rectify the functions of the
chylopoietic viscera, the assistant chylopoietic, and the whole of
the digestive organs, upon derangement of which, say they, many cases
of deafness depend. The fools who apply to such charlatans certainly
deserve to have their pockets well drained, but ought scarcely to be
poisoned by them.