Elements of Surgery

by Robert Liston

The disease has been frequently produced by mercury, when the abuse of that mineral was common; its abuse is still far from uncommon.

The symptoms may be mitigated by counter-irritation. The parts covering the trachea should not be subjected to counter-irritation; in consequence of repeated blistering, the application of irritating ointments, effusion and thickening of the cellular tissue is caused, and this may prove a serious obstacle in the performance of tracheotomy, should that afterwards, as is too likely, be required. Setons may be inserted on the sides of the neck, and applications made over the box of the larynx. But tracheotomy affords the only hope of permanent relief; and if performed at an early period, if the lungs are not the seat of tubercular disease, as they too frequently are, there is every reason to expect that it will prove successful. It is followed by the beneficial results mentioned when speaking of the preceding disease, and the nitrate of silver can be applied to the more external ulcers, along with the internal use of sarsaparilla, &c. Ulcers, which there is every reason to suppose had been both extensive and deep, have healed even after the discharge of portions of dead, sometimes ossified, cartilage. The symptoms abate; the patient recovers, though in general with imperfect voice, as might be expected.

It may even be practicable to employ topical applications to the ulcers 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.

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.