Elements of Surgery

by Robert Liston

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.

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.