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.
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
