S.B. Birch
1869 The Lancet  
492 extremely ill. I could not detect any sign of phthisis on examining his chest; but his symptoms pointed unmistakably, as I thought, to that disease. He was almost aphonic, and yet the vocal cords appeared healthy. In the following month (June) I observed, by means of the laryngoscope, a swelling posterior to, and on the right of, the larynx, which displaced that organ towards the left of the middle line; and, on examining the neck externally, a distinct thickening could be felt deeply
more » ... e felt deeply situated on the right side of the larynx. From this time the growth rapidly enlarged, projecting outwardly at the side and on the front of the neck, and encroaching upon the cavity of the larynx within. His strength daily diminished, and his breathing became more and more impeded. On the 23rd of July, about six weeks after the first detection of the disease, immediate death by suffocation was averted by my opening the trachea. The relief to the urgent symptoms was of course decided; and for some weeks he positively gained flesh and strength, was able to sit up, and passed his time in tolerable comfort. Meantime the tumour rapidly enlarged ; and towards the end of October his strength visibly failed. He died from exhaustion on Nov. 9th, having survived the operation nearly sixteen weeks. The tumour, which was found to consist of encephaloid infiltration of all the tissues in the neighbourhood of the larynx, and formed a very large and prominent mass on the side and front of the neck, was exhibited by me before the Pathological Society in 1866. CASE 3.-Richard D-, aged fifty-two, applied to me on the 31st day of August, 1865, on account of difficult breathing, which had for some months been gradually increasing. He was spare and sallow. On laryngoscopic examination the epiglottis and borders of the larynx were found to be thickened and ulcerated, and to the touch they felt hard and rigid. The vocal cords were not implicated in the disease, but were much limited in their movements. Inasmuch as he stated that he had contracted syphilis ten years before, although I felt convinced, from the situation, the appearance, and the feel of the diseased parts, that the affection would prove to be epithelioma, I deemed it right to put him at once under treatment suited to that disease. I accordingly prescribed mercurial ointment to the arms, and ten grains of iodide of potassium in two-ounce doses of the syrup of sarsaparilla three times daily, and swabbed the parts on alternate days with a strong solution (ten grains to the ounce) of nitrate of silver. The disease continued to advance, and the breathing became daily more embarrassed, until the 26th of September, when, as suffocation became evidently imminent, I opened the trachea. He rapidly improved, and at the end of a week was able to sit up. He now, however, began to experience considerable difficulty in swallowing food, and more especially liquids, which almost invariably found their way into the trachea, and were expelled in astonishingly large quantity through the tube. Whilst taking some broth on the 18th of October-twenty-two days after the operationhe suddenly died. A post-mortem examination could not be obtained, but on removing the tube it was found partially blocked up with a piece of meat. Widely different from the last are the cases where a foreign body has accidentally slipped into the windpipe. In these, the surgeon does not hesitate, after having failed to extract the offending substance by other means, to open the trachea without delay. The following case presents some points of interest: the somewhat unusual length of time which elapsed between the entrance of the foreign body into the larynx and the operation, and again between the operation and the escape of the foreign body; the little mischief set up by the long sojourn of the nutshell in so delicate an organ as the larynx, when that organ was no longer being made use of; and, lastly, the advantage of making a large opening when operating for the removal of foreign substances. CASE 4. -own the 4th of June, 1867, I was asked by Dr. Young, of Headingley, near Leeds, to see with him George R-, aged four years, who, on the afternoon of the 2nd of June, whilst laughing at play, had accidentally drawn into the larynx a portion of nutshell. A violent paroxysm of difficult breathing was the immediate consequence; but as this gradually passed off, and the little fellow resumed his play, little was thought of it. During the night and day following, occasional attacks of dyspnoea occurred, but always passed away in a short time. Early on the morning of the 4th of June, however, he was seized with a paroxysm of more than usual severity, and his voice dropped to a whisper-a condition of things which hourly increased, and was evidently about to culminate in complete suffocation when I saw him at midday. With Dr. Young's assistance, I made a large opening into the trachea, and inserted a correspondingly large tube. Immediately after the operation the child's condition seemed to be so critical that we deemed it prudent not to make any attempt to remove the nutshell, which had evidently stuck fast in the larynx, and offered, therefore, no obstruction to the ingress and exit of air. On the following day the child rapidly improved, and suffered little apparently from the effects of the operation. On closing the orifice of the tube he was unable to breathe or speak, and as it was evident, from the resistance he offered to anyexamination, that it would be necessary to administer chloro-form before making any attempt at the removal of the foreign substance, I preferred waiting, in the absence of any sign of irritation in the larynx, until he was quite convalescent. On the afternoon of June 22nd-eighteen days after the operation-he was seized with a violent fit of coughing, which terminated in the expulsion through the tube of the nutshell-a piece consisting of about one-fourth of the shell of an ordinary Barcelona nut. Immediately after the expulsion of the foreign body he was able to speak with a rough voice on closing the orifice of the tube. In order to facilitate the recovery of the larynx from any damage it might have sustained from the long irritation to which it had been subjected, I kept the tube in until the 2nd of July. The child's recovery was afterwards uninterrupted. In conclusion, I have two suggestions to offer for the improvement of tracheotomy tubes as ordinarily constructed. A remark commonly made after performing the operation is, 11 How much deeper the trachea is than it seems to be!" We may go further with our reflections, and add, "How much deeper the trachea is in the living than in the dead !" In private practice, where the patient resides at a distance from the surgeon, it is no unusual circumstance to be told, on making the morning visit, that the patient, especially if & p o u n d ; it be a child, has died after a violent fit of coughing during the night. And if the throat be examined, it will not unfrequently be found that the tube has been forced out of the trachea, and is lying irregularly in the wound; that, in faet, the child has died suffocated, because the tube was only just long enough to reach the trachea, and has therefore become readily displaced during the act of coughing, or in swallowing. The ordinary tracheotomy tubes would seem to be made to correspond with the apparent, and not with the actual depth of the trachea-to reach the trachea of the dead and not of the living. Those I am in the habit of using are nearly half as long again as the ordinary tubes, and I find them very advantageous. I had them made after losing two children in the way I have described above. My second suggestion-the principle of which is, I believe, recognised, but is not sufficiently appreciated by instrument makers,-is, that the two blades of the outer canula should be made so that they lie in close apposition at their distal extremities, and are separated only by the introduction between them of the inner canula. By the adoption of this means the most difficult step in the operation of tracheotomy-viz., the introduction of the canula through the slit in the trachea will be much facilitated.
doi:10.1016/s0140-6736(02)66126-4 fatcat:5ibbi62rbngutoxdhrpzdwklrm