1755. As foreign bodies in the esophagus produce the same symptoms as those in the windpipe, it is always necessary, by examination of the throat, by the introduction of a sound, with a piece of sponge upon its end, to be sure of the œsophagus (1). Foreign bodies are only in very rare instances, thrown out by violent coughing on this account a severe emetic or artificially excited sneezing increase the danger (2). The only remedy for the certain removal of the foreign body is opening the windpipe, (Bronchotomia, Tracheotomia,) or opening the larynx, (Laryngtomia.) This operation must be undertaken as quickly as possible, because if put off, such symptoms as violent inflammation of the lungs and windpipe, emphysema of the lungs and the like arise, which even after the removal of the body may cause death. The operation is in all cases required, where suffocation presses, or an asphictic condition has set in; further, if dangerous symptoms occur from time to time, and the foreign body be observed rolling up and down in the windpipe; or if fixed pain point out its exact seat. But if the patient be free from all these symptoms, and the seat of the foreign body cannot be discovered, we must wait till there are symptoms of change in its situation, and a possibility of its removal. [(1) In reference to this subject STOKES (a) mentions one instance in which a piece of money lodging in the esophagus produced croupy breathing and laryngeal symptoms. And in his Lectures he used to speak of another case in which such symptoms were produced by a foreign body (a plum-stone) in the esophagus, that his first impulse was to perform tracheotomy with his penknife. An oesophageal bougie was, however, introduced, and the substance having been pushed into the stomach, the symptoms ceased, and a day or two after the plum-stone, with which the child had been known to be playing previous to the accident, was voided by stool (b). (2) Occasionally it may happen that although violent fits of coughing having failed to expel the foreign body from the windpipe, yet by some accidental change in the patient's position, the foreign body is removed from its lodging place, and is then thrown up with little effort. Such seems to me the explanation of Cock's case (c) of a sixpence slipping down the throat, and at first lodging in the larynx;" violent coughing, wih the most distressing sense of suffocation, immediately took place, and during the paroxysm he threw up a quantity of blood. On his admission he was still struggling for breath, coughing incessantly, and suffering great pain and irritation, which he referred to the larynx, where the coin appeared to have lodged." Shortly after" the sixpence had left the larynx, and descended into the trachea; its change of position being immediately followed by an abatement of the previous urgent symptoms. He still coughed almost incessantly, stated that he could feel the sixpence moving up and down the windpipe, and complained of pain and soreness in the chest in the seat of the right bronchus, and also just below the larynx." Towards the end of the same evening the symptoms subsided, and he went to sleep. On the following day he was in much the same state, and "as long as he remained calm and quiet, he complained of nothing but a feeling of general soreness along the larynx and windpipe." The same evening the sixpence was thrown out without surgical aid. “I was asleep," said the patient, "and dreamed I was drinking a pot of porter, and the attempt to swallow it made me cough. I awoke, and found the sixpence in my mouth." Cock observes :"It is perhaps worthy of remark, and not destitute of practical interest, that the foreign body, which had retained its position during the most violent expiratory efforts, should at length be ejected, at a period when the muscles of the glottis were probably in a state of quietude, and being taken unawares, allowed its expulsion, under à gentle act of coughing." (pp. 554, 55.)] 1756. Opening the larynx or windpipe is also required to assist the entrance of the air into the lungs, when it is obstructed under any other circumstances, and suffocation is dreaded; in great swelling or other (a) Above cited, p. 265. (b) WELLS; in Dict. of Pract. Surgery, vol. i. p. 516. (c) Medical Gazette, vol. i. New Series, 1845. degeneration of the structures about the throat; in diseased changes of the epiglottis; in great swelling of the tongue, if the danger cannot be relieved by bleeding, scarification, and the like; in fracture of the thyroid cartilage, if the dislocated pieces cannot be otherwise brought into place; in inflammation of the epiglottis (Angina laryngea); when foreign bodies are in the esophagus, and cause suffocation; in compression of the windpipe by tumours; in gun-shot wounds of the throat, which, on account of the great swelling, are attended with danger and suffocation; in drunken or suffocated persons; in croup, if the membrane be loose and cannot be coughed up. According to DESAULT (a), in the greater number of these cases in which it is only necessary to assist the entrance of the air, the introduction of an elastic tube_through the nostril renders the operation superfluous. No other person, however, but DESAULT holds this notion. SAMUEL COOPER (b) objects to it in drunkards and suffocated persons, and considers opening the windpipe to inflate the lungs, most efficient. However, the benefit of cutting into the windpipe, undertaken in this spirit, is not supported by precise reasoning. In Angina laryngea, which is characterized by difficult breathing, with pressing suffocation, very hoarse and only whispering voice, and frequently accompanied with pain in the esophagus and difficulty in swallowing, without apparent swelling and redness of the throat, the operation must not be long delayed, if relief be not soon afforded by general and local blood-letting, blisterings, and the like (c). In Angina membranacea, laryngotomy and tracheotomy are generally useless, because the mass blocking up the air-tube, is not merely in the larynx, but extends through the whole windpipe and even into the bronchi (d). In more modern times, however, many cases have been published in which this operation has been successful. NEVERMANN (e) has collected all the cases of laryngitis and tracheitis, in which tracheotomy has been performed; and the result is that out of one hundred and forty cases, twenty-eight have been cured, and one hundred and twelve died. BRETONNEAU (f) considers that tracheotomy can only terminate favourably, if the opening be made moderately large between the thyroid gland and the breast-bone, and the free entrance and escape of the air maintained by a sufficiently large and wide canula. At the same time he introduces calomel dry, or moistened with water, through the wound into the windpipe. In one case he succeeded. TROUSSEAU (g) also recommends the introduction of a thick catheter, and scraping out the windpipe with a probang, and dropping in a watery solution of nitrate of silver, four grains to a dram of water. GERDY (h) also advises the introduction of a weak solution of lunar caustic. [KIRBY (i) is decidedly opposed to bronchotomy for croup; he says:-"I have performed the operation myself on the child, and have seen it frequently done by others, and in no one case has the life of the patient been saved." (p. 63.)] 1757. The proceedings vary in laryngotomy and tracheotomy, in reference to the special object desired, according as the entrance of the air is to be assisted, or a foreign body removed. 1758. In laryngotomy, after placing the patient's head in such a position as that his uneasiness shall be least, and the front of the neck free and accessible, the skin is to be moderately stretched on both sides with the fingers of the left hand, and the larynx at the same time fixed; a cut is then made lengthways, about an inch in length, the middle (a) Above cited. (b) Dictionary of Practical Surgery, p. 1262. (c) FARRE; in Med.-Chir. Trans., vol. iii. p. 84. —PERCIVAL, E.; Ibid., vol. iv. p. 29.-WILSON, THOMAS; Ibid., vol. v. p. 155. ARNOLD; Ibid., vol. ix. p. 31.-HALL, MARSHALL; Ibid., vol. x. p. 166.-PORTER; Ibid., vol. xi. p. 114-WEDEMEYER; in VON GRAEFE und voN WALTHER'S Journal, vol. ix. p. 107. (d) SACHSE, vol. ii. p. 277; the best writer on Croup (e) Berliner Med. Centralzeitung, 1836, July.Also, CULLEN, V., On the Causes of the Fatal Termination of certain cases of Bronchotomy; in Edinb. Med. and Surg. Journal, vol. xxix. p. 75, 1828.-BECQUEREL; Bulletin de Therapeutie, 1842, Jan., Feb. (f) Des Inflammations spéciales du Tissu muqueux et en particulier de la Diptherite, ou inflammation pelliculaire, connue sur le nom de Croup, d'Angine maligne, d'Angine gangrèneuse, p. 217395. Paris, 1826. 8vo. (g) Journal des Connaissances Med.-Chirurg., 1834, June. (h) Archives générales de Médecine, vol. v. p. 577, 1834.-STILLING; in Berlin Med. Centralzeitung, 1835, May 9. (i) Observations, cited at the head of article. of which corresponds to the crico-thyroid ligament. A second cut divides the cellular tissue between the sterno-hyoid and sterno-thyroid muscles, and lays bare the crico-thyroid ligament; the bleeding must be stanched with a sponge dipped in cold water. The larynx is then to be fixed with a finger on each side, and the forefinger of the same hand placed on the upper third of the ligament; after which a lancet is thrust in, and a wound of sufficient extent made, which is to be kept open by inserting lint between the angle of the skin and of the muscular wound, and the whole covered with gauze, and the patient allowed to bend his head towards the chest. This method appears preferable to using the tracheotome and introducing a tube into the aperture made in the crico-thyroid ligament, for the tube always excites inconvenient, and frequently unbearable irritation, is frequently stopped up, and cannot be properly fastened. The cases in which cutting into the windpipe is performed are urgent, and the tracheotome cannot be sufficiently commanded. If the opening into the crico-thyroid ligament be insufficient, the cut must be lengthened through the cricoid cartilage. For the purpose of effecting expectoration, if much tough mucus collect, the wound must occasionally be held with the fingers, and the patient allowed to cough. If a canula be used, it should always be sufficiently large. For the purpose of avoiding an often not inconsiderable arterial branch upon the crico-thyroid membrane, we must feel with the finger if the membrane be quite bare, and when it is exposed, we must endeavour to avoid it, for which purpose the membrane is to be divided transversely at the upper edge of the cricoid cartilage. [Some persons are in the habit of introducing a tube into the larynx after having opened it. This as a general rule is quite unnecessary, as if there be any fear of the wound closing before the air can recover its usual course through the rima glottidis, it is better to cut out a piece of either the laryngeal or tracheal cartilage, as may be, according to LAWRENCE'S recommendation. And it is also improper, as a fistulous opening will be formed, which on the subsequent removal of the canula, may contract so as to require a second operation, and often cannot be done without. If, however, such practice be adopted, it will be necessary that the instrument should be taken out from time to time to ascertain that it has not been corroded; for if not, it may break, and the part within drop down the windpipe, whilst that without falls from the wound, without notice. A case of this kind was admitted into St. Thomas's Hospital in December, 1844; a tube had been introduced about two and a half years previously, and on the morning of his admission whilst walking along the street, it slipped out broken. No symptoms of consequence, however, appeared till towards evening, when the breathing became difficult, and attended with a whistling noise; the veins of his head and face distended, and the surface covered with cold perspiration. My colleague and assistant, the younger TRAVERS, therefore, thought it necessary to pare the edges of the opening, and dilate it upwards and downwards upon a director. Some blood running into the windpipe caused violent expirations, and in one of them two fragments, which formed the remainder of the canula, were expelled, surrounded with a clot of blood, and the relief was immediate. Another canula was introduced. The patient did well; and the broken corroded instrument is in St. Thomas's Museum. Occasionally it happens that after a severe cut throat, the aperture remains, from some cause or other, fistulous; and as the scar contracts, the passage for the air is so narrowed as to cause great difficulty of breathing, and require surgical aid. I had a case of this kind some years ago, in a Hindoo woman, who, in her voyage to this country, had attempted suicide, and nearly cut through the larynx, between the thyroid and cricoid cartilages. She had been very refractory, and the skin had turned over the lower edge of the wound, and become connected with the back of the organ, so as materially to diminish the passage, and cause her breathing to be very laborious, and with a loud hiss. As from the account given, these symptoms were daily becoming worse, I cut through the front of the cricoid cartilage vertically, and inserted a short but pretty wide tube, through which she breathed freely and did well, leaving the house some time after to return home.-J. F. S.] 1759. If laryngotomy be undertaken for the removal of a foreign body, the crico-thyroid ligament is, after the bleeding has been stanched, to be cut through its whole length, from the thyroid to the cricoid cartilage; and if this be insufficient to allow the foreign body to be removed or withdrawn through it, a director somewhat curved is to be introduced, by means of which a button-ended bistoury is passed in, and the thyroid cartilage sufficiently divided upwards in its centre, or the cricoid cartilage, and the upper part of the air-tube so far cleft as the removal of the foreign body may seem to require. 1760. After the opening is made, if the edges of the wound be gently drawn apart with blunt hooks by the assistants, the foreign body usually appears and is thrown out by coughing; but if this do not happen, its position must be sought with due care, and it must be removed with straight or curved forceps. The treatment, after removal of the foreign body, must be precisely similar to that already laid down for longitudinal wounds of the windpipe. (par. 467.) 1761. In tracheotomy, where the entrance of the air merely is to be assisted, a cut should be made through the skin and muscle on the mesial line of the windpipe, beginning below the cricoid cartilage and continued down to the edge of the breast-bone. The edges of the wound are to be held asunder with blunt hooks, the blood sopped up with a moist sponge, the cellular tissue and vascular net upon the third and fourth cartilaginous rings divided, and thus the windpipe laid bare. Bleeding is stanched by cold water, or, where possible, by tying the vessels; the lobes of the thyroid gland, which are a little in the way, are to be turned aside, and two or three rings of the windpipe divided vertically. The further treatment is the same as after opening the larynx. The same reasons against the use of the tracheotome and the introduction of a tube, which have been already given (par. 1758) also apply here. LAWRENCE (a) advises, if after opening the windpipe, the introduction of the tube cannot be effected, to cut off half an inch through the cartilage, and to remove a small slip from the edges of the wound, so that the opening may continue to gape. 1762. If tracheotomy be performed for the removal of a foreign body, the air-tube must be exposed and cut into in the way just described, only the size of the cut must be proportioned to that of the body to be removed. The removal itself must be managed as in laryngotomy. [When the foreign body is lodged in the bronchus its removal should be first attempted by reversing the patient's natural position, and placing him upright, or nearly so, with his head downwards, and then striking his back or shaking the body smartly, by which it may be hoped the foreign substance will move from its situation, and, dropping through the windpipe, be ejected at the rima glottidis. Of the two very interesting cases in which this practice was successfully adopted, BRODIE'S patient (b) had first attempted it on the sixteenth day after the accident, by "placing himself in the prone position, with his sternum resting on a chair, and his head and neck inclined downwards, and, having done so, he immediately had a distinct perception of a loose body slipping forward along the trachea. A violent convulsive cough ensued. On resuming the erect posture he again had the sensation of a loose body moving in the trachea, but in an opposite direction, that is, towards the chest." The experiment was repeated six days after, more completely; "he was placed, in the prone position, on a platform, made to be movable on a hinge in the centre, so that on one end of it being elevated, the other was equally depressed. The shoulders and body having been fixed by means of a broad strap, the head was lowered until the platform was brought to an angle of about 80 degrees with the horizon. At first no cough ensued; but on the back, opposite the right bronchus, having been struck with the hand, the patient began to cough violently; the half-sovereign, however, did not make its appearance. This process was twice repeated with no better result; and on the last occasion the cough was so distressing, and the appearance of choking was so alarming, it became evident it would be imprudent to proceed further with this experiment unless some precaution were used to render it more safe." Tracheotomy was therefore determined on two days after, and "in proposing this," says BRODIE, (a) Above cited, p. 249. (b) Above cited. 2 D VOL. II. "we had a twofold object; the one, that if the coin were lodged in any part from which it might be safely extracted by the forceps, this method might be had recourse to; and the other, that, if relief could not be obtained in this manner, the artificial opening might answer the purpose of a safety valve, and enable us to repeat the experiment of inverting the body on the movable platform without the risk of causing suffocation." The operation being completed, some attempts were made to reach the coin with the forceps introduced through the opening. The contact of the instrument with the internal surface of the trachea, however, induced on every occasion the most violent convulsive coughing. The coin was not seized, nor even felt." The attempt was therefore given up for the time, and repeated five days after with no better success. He was left quiet for ten days to recover from the exhaustion he suffered, and the probe was passed occasionally into the wound to keep it open. At the end of this period, on the thirtieth day after the accident," the patient having been placed on the platform, and brought into the same position as formerly, the back was struck with the hand; two or three efforts to cough followed, and presently he felt the coin quit the bronchus, striking almost immediately afterwards against the incisor teeth of the upper jaw, and then dropping out of the mouth. A small quantity of blood, drawn into the trachea from the granulations of the external wound, being ejected at the same time. No spasm took place in the muscles of the glottis, nor was there any of that inconvenience and distress which had caused no small degree of alarm on the former occasion. (p. 288-91.) The case did well. MACRAE (a) did not make any opening into the air-tube of his patient, but, on the third day after the mishap, had him "strapped securely to a common chair, that he might be easily suspended from the rafters of the roof, with his head downwards, in order that his chest might be conveniently shaken by a rapid succession of sudden smart jerks, and that the weight of the bullet might favour its escape from its seat in the lungs. He was kept depending as long as he could endure such an uncomfortable position, and then placed in the horizontal posture for a few minutes to rest. When sufficiently recruited he was hung up again. Upon being taken down the first time he described the pain in his breast as having moved nearer to the top of his chest; and during the third suspension he joyfully exclaimed, “thanig à! thanig à!" ("it has come ! it has come!" in the Gaelic language,) immediately after a smart shaking and a few convulsive retching coughs, and spat the little bullet from his mouth. The diameter of it is three eighth parts of an inch, having its surface ruffled by the chewing it underwent previously to slipping into the windpipe. He felt immediate relief from every uneasy feeling, except the dry cough and deep-seated pain in his breast, which continued rather sharp for two days, after which, and a dose of laxative medicine, he found himself restored to his former health, and by the end of the week pursued his usual avocations on the hill." (pp. 421, 422.) If this mode of treatment be insufficient to dislodge the foreign body from the bronchus, it will be necessary to attempt its removal by opening the windpipe and drawing it out with forceps. This operation was first performed, and successfully by LISTON in 1833 (b), on a female of thirty-eight years, who "got a piece of mutton bone entangled in the glottis, whilst eating some hashed meat. By a great effort, during a fit of threatened suffocation, she succeeded in dislodging it; but it passed downwards into the trachea," *** and lodged permanently under the right sterno-clavicular articulation. An attack of bronchitis supervened, followed by cough and expectoration, and the inflammatory attack was repeated several times; from one of these she had just recovered. ***The inspiration was somewhat noisy, and there was some degree of peculiar sonorous râle perceived on applying the ear to the chest at the point described as where the foreign body had become fixed. The operation was performed; one pair of forceps opening laterally were introduced; a hard substance could be felt, but not grasped; the patient was re-assured, and allowed to recover the effects of the exploration and attempt to seize it. Another instrument with the blades differently arranged, was then passed down the tube, at least three or three and a half inches, and the bone immediately seized and extracted. *** The result of the case was most satisfactory. The length of the forceps was seven inches. (pp. 415, 16.) The second operation was performed also successfully by DICKIN, of Middleton, near Manchester, in 1832 (c), on a boy of eight years, who having "found a bell button, which he placed in his mouth, and during the act of jumping, it passed backwards into the windpipe. He instantly fell down, to all appearance in a state of suffocation, and was taken home, a few yards distant, making the most violent efforts to respire; after which his breathing became easy, but with (a) LISTON'S Practical Surgery. Fourth Edition, 1846. (b) DUNCAN; in Lancet, 1833, 34, vol. ii. p. 419. -Also LISTON's own notice of it, in his Prac- |