Enlargement of the tongue occasionally takes place in young subjects, a sort of simple hypertrophy, which often proceeds to a very great extent. The increase goes on in a remarkable manner after the organ is extruded beyond the lips, so that the patient is incapable of covering it. Portions of the swelling of a V shape have been removed in such cases, and the edges of the wound put together. But by well managed and continued pressure the absorption of the swelling has been brought about, the organ has been reduced within the oral aperture, and a cure has then rapidly followed.
Division of the Frænum Linguæ is sometimes, though rarely, required. Division can be necessary only when the frænum is so short as to confine the point of the tongue, prevent free motion of the organ, and thereby cause indistinctness of articulation. Infants are often supposed by anxious mothers to have their tongues unduly confined, when no such malformation exists; in such circumstances, it is almost needless to observe that the part ought not to be interfered with. And even when there is confinement, division should not be had recourse to, unless the child is prevented from taking nourishment. The operative procedure is simple and safe. The tongue is raised towards the palate, either by a spitula or split card—or, what is better, by the fingers—and the frænum is cut across to a sufficient extent by blunt-pointed scissors.
Ranula is a swelling produced by accumulation in, and distention of, the extremity of the combined ducts of the sublingual and submaxillary glands. The extremity of the duct contracts, or is completely closed, and in consequence of the saliva and mucus (the one the secretion of the gland, the other of the duct) collect, distend the canal, and cause thickening of the parietes. Thereby a tumour is formed, which, in some instances, attains a very large size, displacing in some measure the neighbouring parts, and incommoding the tongue in particular. Indistinct utterance and impeded deglutition result.
The orifice of the duct, if discovered, is to be dilated gradually by occasional introduction of variously sized probes. Often it is necessary to make a small incision in the situation of the orifice, and introduce a bit of gum-elastic bougie, by continuing the use of which for some time, permanency of the opening may be obtained.
Deposition of Earthy Matter—principally phosphate of lime—not unfrequently takes place in the extremity of the submaxillary and sublingual ducts, and the concretion so formed is often of considerable size; some are larger than an almond. The colour is either white or yellowish, and the surface either smooth or roughened by nodules; in all the calcareous matter is friable, and disposed in concentric layers. They are of the same nature as the earthy deposits, called tartar, which form on those teeth opposite to the extremities of the salivary ducts. The foreign body produces uneasiness in the mouth, swelling, and indistinctness of speech; occasionally painful swelling of the salivary gland and surrounding parts takes place. Concretions also form, though very rarely, in the extremity of the parotid duct, and are attended with like inconvenience; of this I have seen only two cases.
The foreign body is easily removed; an incision is made through the membrane of the mouth, and the concretion dislodged by forceps, a scoop, or the fingers. The saliva regains its course, and irritation subsides. Sometimes the foreign body is exposed by ulceration, and might ultimately escape from its bed spontaneously.
A figure of a salivary calculus of considerable size is here given. When the concretion is small, its extraction is not so easily accomplished as might be supposed. It is apt to slip back out of reach, so that it cannot be seized, brought forward and extracted either by scoops or forceps. The flow of saliva must be promoted by giving the patient something to masticate; the probability is, that the foreign body will then be presented, and perhaps expelled, if the opening of the duct has been previously dilated. A young lady was brought to me lately suffering great uneasiness from the presence of a concretion, not larger than a millet-seed. She complained of great pain under the jaw on seeing anything savoury, that, as the vulgar phrase is, made her mouth water. Various unsuccessful attempts had been made to remove it. A small incision of the surface of the duct was made, but the foreign body eluded the grasp of the forceps, and completely disappeared. The patient was given a bit of bread to chew, and almost immediately the concretion was expelled.
Tumours, unconnected with the salivary ducts, occasionally form in the loose cellular tissue under the tongue. They may be either sarcomatous or encysted; the former are rare. I have removed several solid tumours, principally adipose, from this situation. They were loosely connected, and taken away without almost any dissection; indeed they were lifted out with the fingers, after division of the membrane of the mouth and of the cellular cyst which surrounded them. One was as large as an orange, and of a flattened form. The tongue had been displaced by the swelling, and articulation, deglutition, and breathing impeded. The patient, an old lady, had a good recovery. The case had been by some mistaken for ranula; and I mention this circumstance, lest others may reckon more on the situation of a swelling, than on its feel and other external characters. A sketch of the tumour is given at page 137.
Encysted tumours below the tongue are common. The cysts are generally thin and adherent, the contents albuminous and glairy. They attain a large size, and prove very inconvenient. Occasionally the cysts are thick and more loosely attached; such usually contain atheromatous matter. I removed one uncommonly large, from the inner surface of which numerous hairs were growing.
Encysted tumours here can seldom be removed by dissection; the depth of their situation, their firm connexion, the awkward situation in which the patient is necessarily placed, and the risk of hemorrhage, forbid the surgeon from attempting regular extirpation. A more simple and equally effectual procedure is as follows:—The membrane of the mouth and the cyst are divided by the point of a bistoury; and if the tumour be large, and the distention great, an oval portion of the parietes may be cut out. The contents are thus evacuated. The bleeding is allowed to cease, and the cavity having been wiped out clean, a stick of caustic potass is applied to the surface, so as to annihilate the cyst effectually. This I believe to be the only radical and safe mode of removal; after any other, the tumour is certain to be reproduced. It has been recommended to pass a seton, so as to excite inflammatory action, and lead to obliteration of the cyst. I have made trial of this practice, but most dangerous swelling ensued, the mouth was rapidly filled, and the system alarmingly shaken; after all the disease was not eradicated.
Tumours beneath the tongue, however originating, occasionally inflame, and become the seat of unhealthy abscess. A large and painful swelling forms, and projects under the chin. The matter gradually approaches the surface, and perhaps evacuates itself imperfectly into the mouth, or the integuments give way, and afford an external issue. In such cases, an early incision from the mouth may prevent the internal mischief, and the disfiguration of the countenance which would otherwise ensue may, in short, limit the suppuration; at a later period a free opening requires to be made below the chin, in the mesial line, and in the direction of the muscular fibres. A ready drain is thus obtained for the matter, and the cavity of the abscess gradually contracts.
Tumours of the Gums are usually hard, and not inclined to increase rapidly. They are of the same consistence as the parts to which they are attached, and grow either inwardly, outwardly, or both. They surround one or more teeth, which at last become loose, the alveolar processes then soften, and form part of the swelling.
These may degenerate, and grow rapidly, or the tumour may be soft (tumor mali moris) from the first. The attention of the patient is directed to the part by the occurrence of discharge from about the teeth, which loosen one after another. A soft tumour arises from the sockets after either extrusion or extraction of the teeth, it grows rapidly, and involves more and more of the gums and alveolar processes. Angry ulceration attacks the prominent parts of the swelling; the bone is softened to a considerable extent around; the discharge is thin, bloody, and profuse. Ultimately the lymphatics become affected, neighbouring parts are contaminated, malignant action acquires a firm footing, and extends, the patient becomes hectic, and dies.
Each kind of tumour should be removed freely and early; the untoward results of the latter have been already mentioned; and I believe that, if the former be allowed to proceed unchecked, the tumour may ultimately extend to the bone, and osteosarcoma of the jaw, more or less extensive, be established. The disease must be attacked at an early period of its existence, and teeth, sockets, and soft parts taken freely away, by means of a strong knife and saw, or cutting forceps. After excision, the actual or potential cautery should be applied, otherwise the disease is apt to recur. Portions of involved bone, which may have escaped the knife, are by the caustic made to exfoliate. When the potassa fusa is used for the purpose of destroying what cannot be readily reached by the knife, and when it is pushed into the alveoli and applied to the altered gum, its action must be limited by the immediate use of vinegar, diluted or not.
Inflammation of the gums and neighbouring parts is attended with violent pain, swelling, and throbbing, difficulty in opening the mouth, headache, and fever. Inflammation of the soft parts runs its course speedily, and, as the cause is seldom removed during the existence of the inflammatory action, generally terminates in suppuration, so giving rise to what is termed parulis or gumboil. Frequently the inflammation extends to the sockets of the teeth, which seldom resist the action long, but from their low degree of vitality soon become necrosed; and by the presence of the dead portions of bone, a fresh accession is given to the disease. Severe pain is experienced on touching the teeth whose alveoli are affected; they project and become loose; purulent matter is secreted, and oozes out between the loosened teeth and diseased gums. Abscesses form, and point in different situations; the gums are tumid and spongy; through the openings in them the bone can be felt bare, and the purulent matter is situated within or around the alveoli, and under the mucous membrane and cellular tissue which invest them.
When the inflammation has been either intense from the first, or of long duration, it not unfrequently happens that abscesses form within the substance of the jawbone, and occasionally to a considerable extent—a portion of the bone having become inflamed, and the action terminating in suppuration and partial caries. This is more apt to occur in the inferior than in the superior maxillary bone; and, if allowed to proceed, the osseous cyst containing the purulent matter gradually enlarges, the plates of the bone are separated and expanded, the parietes become attenuated, and the affection is termed spina ventosa. Purulent collections in this situation also seem, in many instances, to arise from, or at least to be preceded by, the formation of a cyst around the decayed root of a tooth. Such cysts are generally of small size, and pyriform shape; externally they are smooth, membranous, and of rather a delicate texture; internally, they are lined by lymph of soft consistence, and contain purulent matter. In fact, they are purulent depôts, which form in consequence of inflammation around the fangs of the teeth, and from which the matter is occasionally discharged through a small aperture at the upper part of the cyst, and by the side of the affected tooth. They sometimes attain a very considerable size.
Mercury is perhaps the most common cause of this disease; but it is also produced by certain operations on the teeth, and by the presence of carious teeth or of stumps.
Caries of the teeth is an extremely common affection, and in some instances seems to arise from an unhealthy state of the constitution; but it is most frequently produced by the teeth having suffered from chemical agents, as when the mineral acids have been taken for a considerable time as medicines, or when the individual is in the habit of consuming sweetmeats, and confections. Sometimes the disease remains almost stationary, and may give little or no annoyance for a number of years; in other instances, its progress is very rapid. A portion of the tooth gradually decays, and this is at first unattended with any uneasy sensation; but when, from continuance of the destructive process, the central cavity has been exposed, the pain is excruciating, attended with headache, and swelling of the surrounding soft parts. In general, the progress of the disease may be arrested by removing the diseased portion, and stuffing the cavity, before any pain has been felt. But after the central cavity of the tooth has been exposed, filled with fungous mass, as here seen, or from their growing in a faulty direction, and pain consequently experienced, the most effectual remedy is extraction. The patient from whom the specimen below was obtained, perished in consequence of the extensive abscesses of the mouth and neck, consequent upon the awkward position of the wisdom tooth.
From the presence of carious teeth, or decayed portions of teeth, many evils both local and general ensue, besides inflammation and abscess. They are frequently the cause—and the sole cause—of violent and continued headaches; of glandular swellings in the neck, terminating in, or combined with abscess; of inflammation and enlargement of the tonsils, either chronic or acute; of ulcerations of the tongue or lips, often assuming a malignant action from continued irritation; of painful feelings in the face, tic doloureux, pains in the tongue, jaws, &c.; of disordered stomach, from affection of the nerves, or from imperfect mastication; and of continued constitutional irritation, which may give rise to serious diseases.
Along with abscess of the gums, purulent matter often collects in the cellular tissue of the cheek or of the chin. In the latter situation, the inflammation and suppuration are often caused by the teeth in the front or side of the lower jaw being too much crowded together. When the teeth are crowded together, the patient, of course, cannot be effectually benefited till one or more of them are extracted, and sufficient space allowed for development of the others. The abscess gives way, and discharges its contents often both externally and internally, and a fistula remains, which cannot be got rid of, unless, as in most other affections, the cause be removed. The cavity of the abscess must be opened into either from without or within, and after the subsequent irritation has subsided, the cause must be removed; carious teeth or stumps are not to be taken away during the inflamed state of the parts, but after the pain and inflammation has subsided in consequence of free evacuation of the purulent matter. After these have abated, and not till then, the offending bodies are to be extracted, both in order to procure a more speedy and effectual cure, and with a view to prevent recurrence of the disease. If a portion of the jaw has become necrosed, the sequestra are to be extracted as they become loose, and openings and counter-openings must be made, according to circumstances, so as to afford a free outlet to the matter.
The extraction of teeth, the crowns of which have not been destroyed, is accomplished most readily by the dexterous use of variously shaped forceps. Stumps may be occasionally extracted also by forceps, but the lever is generally required to loosen them from their sockets. The old key instrument and pelicans are now superseded by those above mentioned.37
Spina Ventosa of the Jaw often originates, as before mentioned, in a small cyst at the root of a decayed or dead tooth. An enormously large one extracted along with the stump attached is here shown: it is sketched from a specimen in the collection of Mr. Nasmyth, of Edinburgh.
The disease is usually situated on one side of the lower jaw; but sometimes occurs in the upper, and is at first unconnected with the cavity of the antrum. Inflammation has taken place in the internal structure of the bone; matter is secreted by the medullary vessels, and collects in the cancellated texture. Purulent formation advances, the cancelli are broken down, the external laminæ of the jaw are extended, protruded, and attenuated; and then the internal cavity enlarges, containing pus, perhaps mixed with other fluids, and with disorganised particles of bone. Sometimes the collection proceeds slowly, and the expansion of the bone is gradual and uniform; in other instances, the swelling rapidly attains a large size. As the disease advances, the bony parietes become remarkably thin and delicate, particularly at the more prominent parts of the tumour; and at many points bone is deficient, and its place supplied by membranous expansion. Occasionally alteration of structure takes place in the cyst; solid matter is added, either bony or fibro-cartilaginous, and morbid action proceeds in the new deposit. In acute cases, in which the secretion and distension are rapid, severe pain is felt in the part at the first, and usually continues but little unabated; when the swelling is slow and gradual, considerable pain is experienced during the inflammatory stage, but soon diminishes, or ceases entirely. In every instance, the features are deformed, and the functions of the mouth more or less impeded.
Osteosarcoma may supervene on spina ventosa—morbid action occurring in the parietes, and morbid deposit ensuing, as in the following instance:—The patient was a male, aged twenty-one. Swelling had existed for a considerable time at the posterior part of the lower jaw on the left side. The wisdom tooth and last large grinder, their pulps probably having been blighted, never appeared, and the swelling occupied their situation. The bone was expanded on each side; the upper surface of the tumour was soft, its growth had been gradual, and no great pain or uneasiness was experienced. I cut out an oval portion of the cyst where it projected into the mouth, and well-digested matter was evacuated; a seton was then passed out near the angle of the jaw, and worn for some weeks. The plates of the bone approximated, the cavity contracted, and the discharge ceased. Two years afterwards rapid swelling took place in the same situation, suppuration occurred, and the matter was again discharged by incision; the tumour then subsided. Again inflammatory swelling occurred twelve months afterwards; the same course was followed and the patient relieved. A hard swelling now occupies the jaw from its angle to the canine tooth, it is increasing in size; the necessity for its removal is apparent, and has been decided upon. Very shortly after writing the above, the patient submitted to the disarticulation and removal of fully half of the jaw, represented here. He made a rapid recovery, and showed himself to me and the pupils at the hospital a short time since, and fully five years from the time of the operation, in remarkably good health, and very little deformed by his loss. His whisker effectually conceals the mark of the incisions.
But in general, after free evacuation of the purulent matter from a bony cavity, even of very large size, the space between the parietes diminishes rapidly, the distended and attenuated bone contracts and is condensed, the new deposition is absorbed, and the parts regain their natural and healthy appearance.
In the slighter cases of spina ventosa, removal of the offending teeth or portions of teeth, is generally sufficient; the matter escapes freely enough from the sockets, and the discharge soon ceases. When the cavity is considerable and its parietes thin, a counter-opening at the base of the jaw is required; and it is often of advantage to introduce a small cord from the opening in the mouth through the counter-opening, and to continue its use for a short time, drawing it backwards and forwards in the cavity occasionally. For making the counter-opening and placing the seton at the same time, a strong needle in a fixed handle is most convenient. This practice I have employed in a good many instances, and can confidently recommend as successful. In a large spina ventosa, not complicated with solid growth, the parietes may be removed freely and with safety; the cavity is dressed to the bottom, and gradually fills up by granulation. The division of the integuments to expose the tumour must vary according to the circumstances of the case; the incision of the bone will generally be accomplished by a strong bistoury. Such procedure will seldom fail in procuring a cure, and is less severe, less dangerous, and productive of less deformity, than division of the jaw and entire removal of the diseased portions, an operation which can very seldom be warranted for spina ventosa. In the following case, the tumour was the largest of this kind which I have met with in the jaw, and yielded to the treatment just noticed. The patient was a male, æt. 48; he applied to me in 1821. The tumour had been of three or four years’ duration, equalled a large fist in size, and involved the left side of the lower jaw at the junction of the ramus with the body of the bone. The sac extended behind the coronoid process, and downwards, through the substance of the jaw, amongst the hyoid muscles. Several carious teeth and stumps were imbedded in the swelling; the projection was chiefly lateral, the parietes were yielding, and the line of the jaw could be traced from below. There was occasional slight discharge of purulent matter from the neighbourhood of the involved teeth. The cheek was laid open, and the bony and cartilaginous parietes of the cavity completely removed; the bleeding from the bony surface was arrested by cautery and pressure.
The soft parts united kindly, and the patient obtained a rapid, perfect, and permanent cure, returning home with the cheek united in ten days after the operation.
Solid Tumour of the Lower Jaw—Osteosarcoma—commences in the internal structure of the bone, frequently in the neighbourhood of stumps. The origin may be traced to external injury of the part; or the disease may take place in the jaw, either along with osteosarcomatous tumours of other bones, or subsequently to their development; in such circumstances a peculiar disposition of the system is the only cause that can be assigned. The tumour generally occupies the lateral parts of the bone. Its growth may be either slow or rapid, and is attended with dull uneasiness, rather than acute pain. At first the morbid deposit is confined to the cancellated texture, but as it increases the external laminæ are distended, and at last give way at one or more points, and the tumour protrudes fungous into the mouth. The consistence of the mass is various, it may be soft and brain-like, or cartilaginous, mixed with bone and fibrous matter in various proportions; but the anatomical characters of these tumours have been already detailed, and need not be here repeated. The features are much deformed, the swelling seriously incommodes the neighbouring parts; the teeth loosen and drop away, and fungi arise from the sockets; a fetid, thin, sometimes bloody discharge is secreted copiously, and the health declines. The part protruding around the gums is deeply indented by the teeth of the upper jaw; it separates the jaws to a greater or less extent, prevents closure of the lips, induces salivation, and impedes the taking of nourishment. The tumour is one of those which are apt to be reproduced, and if unmolested, gradually undermines the system, and ultimately the patient perishes very miserably. At one time every instance of it was regarded as hopeless; but of late a great many tumours, in various stages of advancement, have been removed successfully by British and foreign surgeons. In some instances, the portion of the jaw containing the morbid growth has been sawn out; in others, one half of the bone, or more, has been removed by disarticulation, after being divided beyond the diseased part. A very few weeks ago, I had occasion to remove fully three-fourths of this bone, from the site of the first large molar on the left side to the condyle of the right. The patient, an elderly female, is convalescent. The operation is severe, and to a spectator shocking enough; but it can be undertaken with safety, and in most cases with almost a certainty of favourable termination. In no other way, assuredly, can the disease be eradicated. Partial excisions, applications of the cautery, &c., only hasten the malignant process.
To expose the tumour and admit of the bone being readily divided, incision of the soft parts requires to be extensive. And previously to determining on the plan of operation, the extent of the disease must be ascertained accurately. If, for example, the tumour is included between the lateral incisor tooth and last molar on the same side—these teeth must be extracted to permit division at these points. A semilunar incision may then be made along the base of the jaw, the horns of the incision pointing upwards and passing over the space which was occupied by the extracted teeth. The flap is dissected up, and the membrane of the cheek divided along the line of incision. The bistoury is then carried along the inside of the bone so as to divide the membrane of the mouth and separate the attachments of the muscles. The tongue is pushed aside, and a copper spitula placed under the jaw at the part to be divided, in order that the soft parts may not be injured during the sawing. A small narrow saw, or one commonly known by the name of Hey’s, is applied to the bone at the points where the teeth were extracted, and by a few motions of this instrument a notch is made of no great depth; a pair of strong cutting pliers are placed in the track, and by them division of the bone is accomplished with equal neatness, and much more rapidly than if the use of the saw had been continued. The pliers should be strong in every point, and the handles long, to afford the advantage of a powerful lever. In edentulous subjects, as the one alluded to above, there is no necessity for using the saw at all: the bone is at once and easily cut by the forceps. The chain saw has been recommended for performing the section of the bone, but I have not yet seen one to be depended on; it is not only slow, but uncertain, in its operation.
The incisions may be made otherwise. The cheek may be divided by passing through it a long narrow bistoury, close to the anterior edge of the masseter muscle, and carrying the instrument forwards and through at the angle of the mouth. From each extremity of this incision another is made downwards, the anterior one inclining forwards, the other backwards. By reflection of the flap thus formed, the bone is exposed more easily, rapidly, and perfectly, than by the former mode of incision. The objection to this mode of procedure is the deformity occasioned by the scars, though, if care is taken in putting the edges together, this is very slight indeed, and not remarkable.
In either method, no artery, except the facial, requires to be secured by ligature. After division of the bone, the attachments of the tumour, which may not have been separated previously, are cut with the bistoury, the cavity is filled lightly with charpie, and the incisions are carefully and neatly put together, and retained by points of interrupted and twisted suture; the latter form of suture being adopted at those points where accurate coaptation is most important.
The symphysis of the lower jaw has been removed, and its extirpation may again be rendered necessary, either on account of tumour commencing in its internal structure, or from disease of the sockets extending deeply and approaching the base. I removed it in a case of malignant disease, by which, and by the applications used as remedies, great ravages had been made on the under lip; the gums and alveoli were involved, as also the bone, to a considerable extent, without any apparent affection of the lymphatics. Nothing untoward occurred in the operation, and the case was proceeding favourably; but after some weeks the patient was seized with violent erysipelas of the face and head, and perished. One objection to the operation is, that the muscular attachments of the tongue to the symphysis cannot be divided without some risk; the antagonist muscles are unrestrained; the os hyoides and root of the tongue may be drawn backwards upon the forepart of the vertebræ, so as to close the air-passage, and cause suffocation. This is guarded against by the introduction of a thick ligature. The disposition to retraction soon ceases.
Disarticulation of one side of the jaw is not unfrequently necessary; it is absolutely required when the tumour encroaches upon and involves the angle and ramus. It is a more severe operation than excision of part of the bone, and attended with greater risk; yet it may be advised and undertaken with a very fair and probable chance of ultimate success. The incision of the cheek is made to incline more upwards than those recommended for partial excision, and is extended to over the articulation of the jaw; from this point, another is made in the direction of the ramus, and prolonged an inch or more beyond the angle. A third incision is made perpendicular to the first, or to the lower lip, over that part of the bone in front which is to be divided. The flap is turned down, and the muscles and membrane of the mouth separated from the bone opposite to the last incision; after which, the finger is passed through to complete the detachment. A preferable form of incision along the posterior border of the ramus and under the base of the jaw and tumour to over the point at which the bone is to be sawn, but without division of the lip, is recommended in the Practical Surgery. This method I have practised repeatedly; the cicatrix is then completely out of sight, and in the male is entirely covered and concealed. During the cure, also, the discharges escape more readily, the opening being quite dependent. The bone is then divided at that point by the saw and pliers, the tooth in the line of the track having been extracted previously to the commencement of the operation. The cut end of the jaw is laid hold of by the left hand, and depressed, and the bistoury carried backwards along the internal surface, to effect detachment as far as the angle. The bone is still more depressed, and the temporal muscle cut from the coronoid process. The mass is thus loosened, and forced downwards and backwards on the neck; the forepart of the capsule is then cut, and the bone twisted out. Separation of the remaining attachments is completed by a few rapid strokes of the knife, and the whole mass removed. Hemorrhage is then to be permanently arrested, but instead of immediately tying every open mouth which presents itself, it is sometimes better to expose the common trunk of the internal maxillary and temporal arteries—which is easily effected, as it emerges from under the digastric muscle—and to pass a ligature beneath it, by means of an aneurism needle. This is more quickly done than the applying of ligatures to the many branches of this trunk which have been divided. The other vessels—the facial, branches of the lingual, &c.—are then tied, the cavity is filled with charpie, and the incisions of the soft parts are carefully closed. In these, union by the first intention usually takes place nearly throughout the whole extent; suppuration occurs from the deep wound; the charpie is dislodged gradatim, and removed; granulations spring up; and, after some time, the cavity is obliterated. The cheek must necessarily fall inward very considerably, but the deformity is not to be compared to that caused by the tumour. During granulation, the patient is made comfortable by the frequent use of tepid gargles, lodgement of pus in the mouth being thereby diminished. Articulation and mastication are not so perfect as when the jaw was entire and sound; but the patient gradually becomes accustomed to the want, and these functions improve. A contrivance described in the Practical Surgery is used to prevent the remaining portion of jaw from being drawn towards the mesial line, and to keep the teeth opposite to those of the corresponding side of the upper jaw. Partial paralysis of the side of the face necessarily follows, for there is no possibility of accomplishing disarticulation of the jaw without dividing many branches of the portio dura.
Supposing that the portion of the jaw between the angle and symphysis had been removed on account of osteosarcoma, and that the ramus subsequently became affected, it is no easy matter to effect disarticulation, as I have experienced.—The patient was a female, aged 30, of delicate constitution, and subject to toothache from infancy. I removed an osteosarcomatous tumour, extending from the angle to the canine tooth, on the right side. Division was made wide of the existing disease, and the sawn surfaces appeared quite healthy; but about five months afterwards, symptoms of return occurred in the ramus, and ten months after the first operation disarticulation was indispensable. The operation was accomplished with very considerable difficulty, on account of there being no lever to overcome the action of the temporal muscle. After separating the attachments as much as possible, an attempt was made to force down the coronoid process, from under the zygoma, by pushing the lower end of the bone backwards, in order to divide the insertion of the temporal muscle; but this proved ineffectual. The capsular ligament of the joint was then divided, and the bone with difficulty turned over from behind, forwards. It was then detached underneath the coronoid process, pulled down from under the zygoma, and the temporal muscle at length divided at its insertion.
In none of these operations is there a necessity for preliminary exposure and ligature of either the carotid artery or its branches; by so doing, a great addition is made to the patient’s sufferings, the real operation is only commenced when the patient supposes it should have been finished, and he is thus annoyed and worn out. The flow of blood is easily moderated, or altogether arrested, by the pressure of an assistant’s fingers against the forepart of the vertebræ, below the angle of the jaw.
The position of the patient is either recumbent, with the face turned from the operator, or sitting with the head supported and steadied.
The instruments required are, a very strong, sharp-pointed bistoury, for division of the soft parts; saws, of which Hey’s is to be preferred for notching the bone; strong and long pliers, for completing its section; an aneurism needle, for securing the common trunk of the temporal and internal maxillary artery; dissecting and artery forceps, hooks blunt and sharp, narrow copper spatulæ, ligatures, &c.
Wounds of the Face and Neck.—Accidental wounds of the face may involve the more important blood vessels and nerves, and interfere with the eye or its appendages, with the nose, or with the mouth. Injury of these parts is to be avoided in incisions premeditated for the removal of disease or deformity; and, in such premeditated wounds, the line of incision should always be, if possible, in the direction of the muscular fibres. The bleeding seldom proves troublesome; pressure on the vessels, as they pass over the bones, arrests it temporarily; and ligature is seldom required, accurate adaptation of the divided surfaces proving sufficient for effecting permanent closure of the divided branches. Paralysis, more or less extensive, follows division of the nerves and muscles. But paralysis of the face also arises from a variety of other causes; it often remains after injuries of the head, probably in consequence of extravasation on the brain; it attends on morbid formations in the substance of the brain, or in its membranes, and follows long-continued irritation in the neighbourhood of the nerves. Paralysis from the last-mentioned causes is not likely to be recovered from; that following simple division of nerve, may disappear after a considerable time, the nervous tissue reuniting, and resuming its functions. When there is reason to suppose that the nervous function is alone deranged, while the structure remains sound and the continuity undissolved, advantage may follow the application of strychnine to a raw surface over the course of the affected nerves.
In Tic Doloureux, division of the nerves of the face, as they pass out of the foramina, is seldom resorted to; nor ought it to be practised, unless at the urgent request of the patient, and after all other means have failed to afford relief; and even then the operation is scarcely warrantable, since it may be said never to have succeeded in affording permanent relief. We must trust to milder measures, to the removal of local irritations, to paying strict attention to the digestive organs, to the administration of purgatives, tonics, and anodynes; occasionally benefit has resulted from the external use of the nitrate of silver, applied so as to cause very slight vesication. Ointments containing veratria and aconitine have been used with advantage, and the endermic application of the salts of morphia has also been found useful.
Spasmodic action of the muscles of the face, without pain, sometimes follows wounds and other injuries of the nerves which supply them; and sometimes no cause can be assigned for the occurrence. In this affection also, the application of nitrate of silver to the integuments over the nerves may sometimes be made with advantage.
Division of the parotid duct, or wound of the gland itself, is occasionally followed by the formation of a fistulous aperture, discharging saliva over the cheek. We endeavour to prevent this by accurate union of the recent wound. After the fistula has formed, an opening is to be made from it into the mouth, and kept pervious; the external aperture is then closed by suture after excision of the smooth edges, or is made to contract by the repeated application of a heated wire; pressure alone is of little use.
All wounds of the face are to be put into the most favourable state for healing without granulation, so that deformity may be prevented as much as possible. The twisted suture is best adapted for this purpose; more accurate coaptation being thereby obtained than by the interrupted form. In extensive wounds, the parts may be brought somewhat into their proper position by a few points of interrupted suture; twisted sutures are then placed in the intervals, and the isinglass plaster is of use in closing those points which may still gape slightly; in many cases, the greater part of the approximation may be accomplished by isinglass plaster alone.38
Deep wounds behind the angle of the jaw, and at the lateral and lower parts of the neck, are highly dangerous; indeed they are almost certainly and immediately fatal, as can readily be understood when the large bloodvessels and important nerves are considered which have their course in these parts, and which must be either wounded or completely divided. The bleeding has in some cases been arrested by immediate ligature of the divided extremities of the vessel, by firm and permanent pressure, or by pressure at first, and ligature of the trunk of the vessel on the recurrence of hemorrhage after the lapse of many days; of these methods immediate ligature of each extremity is certainly the safest and best. In lacerated wounds violent hemorrhage may take place some time after the infliction of the injury, from ulceration or sloughing of a large artery; in such circumstances either permanent pressure may be resorted to, or ligature applied to the vessel above and below the open point.
Dissections for the removal of morbid growths in the situations just mentioned must be conducted with much caution, and with a full recollection of the relative anatomy. Unless the tumour be tolerably loose and defined, it ought not to be interfered with. But it is to be recollected that tumours of these parts are bound down by their condensed coverings—the platysma myoides and cervical fasciæ; and that after division of these, the tumour, if not intimately incorporated with the neighbouring tissues, is loosened, and often enough can be readily detached.
From constant external pressure, tumours growing rapidly spread amongst the deep parts, and often form firm attachments. The parotid is displaced, and almost entirely absorbed, by the pressure of tumours growing out of the lymphatic glands which are lodged on its anterior surface. Such tumours attain a large size, and occupy the exact situation of the parotid; on their removal, the space betwixt the angle of the jaw and the mastoid process is completely exposed, and the styloid and pterygoid processes can be distinctly felt. From these circumstances many have been led to believe that they have dissected out the parotid; but this and the other salivary glands seldom if ever degenerate. And if the parotid do become the seat of carcinoma or medullary sarcoma, it is impossible to remove it with either safety or advantage. Even in the healthy state, removal of the parotid is a troublesome dissection; and the difficulty must be greatly increased when enlargement has taken place from disease, when neighbouring parts are involved, when firm and deep connections have been formed, and important structures encroached upon. I have taken away many tumours from the site of the parotid, and some of large size, but would scarcely attempt, or boast, as some have done, of having removed the diseased gland itself.
The incisions, for the removal of the tumours of which we have been speaking, are to be made in the direction of the fibres of those muscles which are interposed betwixt them and the integuments, in the direction of the bloodvessels and nerves, and towards those points where the vessels are expected to enter the diseased mass. Attention to the last recommendation is important in order to save blood. For when the trunks of the arteries are divided at the commencement of the dissection, they are easily secured temporarily by the fingers of an assistant: the operation is proceeded in and accomplished with scarcely any further hemorrhage, and in many instances no other vessels require ligature; whereas, if an opposite course be pursued, the same vessels will be divided three or four different times; the hemorrhage will be greater, and the operation delayed. By cutting also in the direction of the vessels and nerves, fewer arteries are divided, and nerves are less apt to be injured, than if the incisions were made across.
Wounds inflicted with the view of effecting suicide are generally on the fore and upper part of the neck, and their severity depends on the resolution of the individual. Some penetrate the integuments merely, and are consequently of slight extent; there is little bleeding, and the edges are easily brought together, after the cessation of bleeding and when the surfaces are glazed, by inclining the head forwards, and introducing a few points of suture. Others divide the muscles, and branches of the lingual or of the superior thyroid arteries; such wounds are gaping, more extensive than the former, and accompanied with smart hemorrhage. Some penetrate the mouth, separating the os hyoides, tongue, and epiglottis from the thyroid cartilage. Occasionally the wound is lower, through the thyroid, or betwixt that cartilage and the cricoid; and sometimes through these into the gullet; it is seldom lower. Such are truly horrible; the countenance is contorted, and presents a frightful expression; inspiration is difficult, hurried, and noisy, and at each expiration blood frothed with air is forcibly ejected from the wound. I have seen wounds of the trachea, near the top of the sternum, but without extensive division of the lateral parts; large wounds, such as are usually made at the upper part of the neck, could not be inflicted here without division of the large vessels, and instant death. Some determined suicides reach the vessels even high in the neck, dividing everything down to the vertebræ; immediate dissolution takes place from loss of blood. But, in general, mere opening of the air-passage is all that is aimed at, there being a vulgar notion that this is sufficient for the extinction of life. A considerable quantity of blood is lost, though the branches only of the external carotid are wounded, and the loss may prove fatal; but the hemorrhage generally ceases on syncope taking place; and if the patient be then discovered, means should be immediately adopted for permanently arresting it. Its recurrence may cause death, on the patient recovering from the first faint; or he may die some days after, from the effects of loss of blood. Hemorrhage, though to no very alarming extent, is always to be dreaded in those advanced in life; though in most cases the fatal result is not attributable solely to the bleeding, but is expedited by other circumstances, as defective supply of proper nourishment, and an unfavourable state of the mind.
Some patients seem to be going on most favourably towards a cure, but, within two days after the injury, are suddenly seized with difficult breathing, and die in a few minutes. On the examination of such, blood is sometimes found in the ramifications of the bronchial tubes, and the lungs can contain little or no air; or the bronchial tubes and ramifications are loaded with adherent mucus; in either case the patients die from asphyxia. In others, nothing remarkable is observed; perhaps passage of the air may have been prevented by inspissated mucus lodging in the windpipe around the wound, and closing the aperture, or by faulty adaptation of the divided surfaces. Likewise, during motion of the head, or attempts to swallow, either the upper or lower part of the windpipe may change its relative position; the continuity of the tube will be thereby destroyed, either partially or wholly, and suffocation ensue. When the wound is large and transverse, as the majority of such wounds are, there is difficulty in freeing the air-passage from mucus. This result becomes evident, when we consider how coughing is effected in the healthy state of parts—that the upper part of the windpipe is contracted by its own muscles, and the air driven through, by sudden action of the muscles of the chest, in a forcible and small stream, so as to carry the mucus along with it. This process cannot be accomplished when the muscles employed in contracting the orifice of the larynx are injured, or when an opening is formed below the glottis, through which the patient breathes, either wholly or in part.
In other cases, death is more slow. The patient is seized with dyspnœa, great anxiety, and occasional spasmodic action of the muscles of respiration, which symptoms gradually become more urgent and alarming. They are attributable to awkward position of the parts, to swelling around the wound, inflammatory or œdematous and rapid or slow, or to bronchitis. To the latter affection patients breathing through artificial openings in the larynx or trachea are peculiarly subject, probably from the inspired air not being heated, as in natural respiration, before it enters the bronchial tubes. A view from behind is here introduced of the larynx of a patient who some weeks previously attempted suicide by wounding the forepart of the neck. By some mismanagement the edges of the incision were kept asunder, and they cicatrised. The patient was seized with difficult breathing, the inspirations were rare, long, and laborious; he had threatening of suffocation during his disturbed sleep. These symptoms were disregarded. He started up suddenly in the night, caught hold of the patient in the next bed, and fell down in a state of asphyxia, from which he could not be recovered. The œdematous swelling of the rima glottidis is remarkable; beyond that is seen the rounded opening betwixt the thyroid cartilage and epiglottis, which is in a normal state.
The bleeding is to be arrested as speedily as possible by ligature, and the patient placed in bed with the head and shoulders raised. The edges of the wound are brought together by attention to the position of the head; but, provided the patient breathes easily with the wound open, closure should not be attempted till after eight, ten, or twelve hours—that is, not until all oozing of blood has ceased; the time depends on the extent to which the air-tube has been divided. There is little chance of immediate union taking place; and the wound not being approximated when recent and bleeding, does not diminish the chance, but on the contrary augments it. Adhesion is prevented by the insinuation of air and mucus betwixt the edges, by frequent motion of the edges on each other, by the slightest change in the position of the head, either rotatory or nodding, by the action of the muscles of the os hyoides, and by attempting to swallow food or saliva. Every circumstance is opposed to complete approximation and immediate union of transverse wounds of the throat.
Plasters and bandages surrounding the part are inapplicable, and unwarrantable from the interruption thereby caused to breathing and circulation; they likewise prevent the escape of mucus and air. Emphysema is apt to occur in consequence, and may prove troublesome; the cellular tissue of the neck becomes filled, so as to interfere with free respiration, and the infiltration of air extends over the face and chest. Neither can many stitches be used without bad effects. The corners of an extensive wound may be kept together by points of suture; and one may be placed at the middle, through the integuments only, to prevent overlapping or inversion of the edges. The head is placed in a comfortable position, inclined forwards, and secured by a bandage passed round it, with the ends brought down and fixed to a band round the chest. In many cases the patient requires to be watched attentively, to have the motions of his hands restrained by proper means, in order to prevent him from interfering with the wound, or committing other insane acts which might prove dangerous. The state of the breathing and of the pulse must be strictly attended to; inflammatory symptoms must be actively combated, and swelling prevented from gaining a dangerous extent, by bleeding, general and local. But depletion is indeed very seldom necessary, the loss of blood in the first instance proving a pretty effectual preventive of inflammation; it is more frequently requisite to administer nourishment or even stimulants; but these must be given gradually in those advanced in life, and in those who have lost much blood.
The slightest difficulty or noisiness of breathing must be closely watched, and on the occurrence of any alarming symptoms, energetic measures adopted. Swelling about the wound, producing difficult expectoration and a diminished current of air, may require the making of a longitudinal opening into the trachea below the wound, and the insertion of a tube. Thus the respiration is quickly relieved; and the patient is soon able to regulate the size of the aperture; he is readily taught to apply his finger over part of the orifice of the tube, when it is wished to clear the passage from mucus. The operation of tracheotomy should be had recourse to in such cases without hesitation or delay; there is no danger from its performance, but much from its being withheld.
If the mouth or gullet have not been opened by the cutting instrument, or only slightly, the patient may be allowed to swallow naturally; though it is true that even the slightest motion of the parts affects the wound injuriously. But, as already observed, immediate union is not to be expected; swallowing, or attempting to swallow, saliva, produces an involuntary action of the muscles, quite as prejudicial as the swallowing of liquids in large quantity does; and these motions cannot be prevented, since the patient has no control over them. If the wound of the mouth or gullet is extensive, portions of the ingesta are apt to interfere with the air-tube, particularly if the wound is high, and the epiglottis cut away or difigured. In such cases, soups and other nutritious fluids are conveyed through an elastic tube, passed by the mouth over the root of the tongue to beyond the injured part, and introduced only when it becomes necessary to administer food; or a small tube may be passed by the nostril, and retained. If the wound is very severe, and the necessity for thus conveying nourishment likely to continue long, the latter method is adopted; it is more difficult in execution than the former, but when the instrument is once passed, no further trouble is given to either the patient or surgeon. Small quantities of nourishment are to be given frequently, of such strength as the symptoms indicate; many patients have died from inattention on this score.
Many have died suddenly and unexpectedly (though this should not be, if symptoms and circumstances were attended to) from the effects of apparently slight wounds; whilst others have recovered, when recovery was unlooked for, after dreadful injuries, and these perhaps not treated in the most approved manner. In illustration, I shall briefly detail, though it did not fall under my own observation, an interesting and remarkable case of recovery. A criminal under confinement attempted suicide by transverse wound of the throat. The larynx was severed at the upper part of the cricoid cartilage, and the cut extremities had retracted at least three inches; the œsophagus was also cut across, but the extent to which it had receded was not ascertained. A large quantity of blood had been lost; attempts were made to bring the parts together, but were abandoned on account of the violent dyspnœa which was induced. The attendant endeavoured in vain to pass an elastic gum tube into the gullet, from the nose and from the mouth. The patient was kept alive by nutritious enema. On the second day after the accident, the cut extremities of the larynx were approximated by two ligatures; and, the retraction being thereby diminished, it was then discovered that there was another wound between the cricoid cartilage and the trachea. All ingesta by the mouth passed through the upper wound. On the fifth day, the ligatures separated, and the larynx again retracted. On the sixth, an elastic gum catheter was passed into the inferior cut extremity of the gullet, and through this nutritious fluids were regularly administered. The wound granulated, and filled up in some measure; the patient continued to receive both air and nourishment through tubes introduced downwards from the wound in the throat. Whilst pouring in food, saliva was secreted in the mouth in great profusion. The sense of smelling remained tolerably acute, and he also possessed the power of imperfect whispering articulation.
When, from the untoward circumstances of the case, or from neglect, the opening in the windpipe remains long open, and becomes fistulous, the larynx contracts, and the voice is in a great measure lost, the patient breathes almost entirely by the unnatural opening, and all the respiratory functions are conducted imperfectly. But even this state of parts may admit of remedy, as is exemplified by the following case: Elizabeth Oswald, aged twenty-seven, attempted suicide in 1826, and wounded the larynx through the crico-thyroid ligament. She was under treatment for several months; but was at length abandoned with loss of voice, breathing entirely through a silver tube placed in the original wound. On her applying to me, I found the larynx had contracted; an exceedingly minute aperture, not capable of admitting a common dressing probe, extended from the wound towards the glottis, constituting all that remained of the upper part of the natural air-passage at this point. Small bougies were introduced from the wound into this diminutive canal; and by gradually increasing their size, the passage was brought to its natural diameter in less than three months. Part of the trachea below the wound had also contracted considerably, and was dilated by similar means.
A long œsophagus tube was introduced by the wound into the mouth, there laid hold of and drawn upwards, and then pushed down into the trachea, so that it extended from the mouth to some inches below the wound of the trachea. Its introduction was followed by a severe fit of coughing, which lasted about half an hour. The tube, nine inches long, and equal in diameter to the largest œsophagus tube, was retained in the windpipe for fifteen days, during which it caused great salivation; the teeth loosened, and the strength was extremely reduced.
The callous edges of the wound were removed by incision, and the opening closed by suture. The tube was removed on the tenth day thereafter, and the patient breathed well. Within a few hours, however, respiration became difficult, and tracheotomy (below the isthmus of the thyroid) was performed. A silver tube was introduced into this recent longitudinal opening, and retained for five days, when it was replaced by a smaller one. After twenty days, this tube was also removed, and in a short time afterwards the wound closed completely. The patient continued to breathe with ease through the larynx, and slowly recovered her voice. When agitated, or after sudden and violent exertion, her inspirations are a little longer than natural, but in other respects the cure is complete. She was in very good health some years after the restoration of the air-tube.
Laryngitis, cynanche trachealis, most frequently occurs in children, and in them it is termed croup; but it also, though rarely, attacks adults. The voice is brazen, hoarse, and croaking; the cough is barking, and the countenance suffused. Inspiration is long, painful, effected with much difficulty, and attended with a wheezing or rattling noise. Expiration, on the contrary, is easy.
Difficult inspiration is a symptom common to all affections of the larynx, and admits of ready explanation. The membrane lining the glottis is thickened, and covered also by a viscid mucus; the passage is thus much contracted; the muscles, by the action of which the rima is opened, participate in the inflammatory action, and are thereby incapacitated for the full performance of their functions. While inspiration is thus difficult, expiration is more easy, all the powerful muscles of the chest combining to empty the lungs of the little air which they receive.
In croup, there is confusion and pain of the head, the lips are of a livid hue, and the veins of the neck are much distended. Respiration is extremely laborious, the chest and nostrils heave, and all the auxiliary muscles of respiration are called into play. Sleep is broken and unrefreshing; the patient starts, much alarmed, from a feeling of impending suffocation, and catches at the nearest object. The circulation is accelerated, and becomes weak and irregular as the disease advances.
A common cause of croup is exposure to cold and damp; but the frequency of its occurrence in children is attributable to dentition. Dentition induces a long catalogue of infantile diseases, and is intimately connected with most cases of croup. Children are besides of a peculiarly irritable system; and in them disorder of the digestive organs may, in many instances, be considered as at least a predisposing cause, and in all cases it is a constant attendant on the disease. It may also be occasioned by inflammatory action extending to the larynx and trachea from a neighbouring surface; from the fauces, for instance. In some instances inflammatory swelling has been produced by the direct application of stimuli to the membrane; as by the patient inadvertently swallowing boiling water, and a portion of the hot fluid, or rather of the steam, being drawn into the windpipe. It is supposed that certain slight degrees of this affection are to be ascribed to spasm; in nervous and hysterical females, paroxysms of slight difficulty in breathing are not of unfrequent occurrence, and in them it may be ascribed, with much probability, to a spasmodic action. The expiration may be then performed with difficulty, and occasionally there is almost complete aphonia. In children, dyspnœa, apparently dependent on spasm, is produced by some affection of the base of the brain.
The most desirable termination of the disease is of course resolution—the cough, pain, and uneasiness subsiding, and the constitution gradually attaining its former state of composure. Too frequently, however, the inflammatory action proceeds unabated, and terminates in effusion of lymph, which is generally of great extent, adhering to the surface of the mucous lining, and forming what is termed a false or adventitious tubular membrane. On the occurrence of lymphatic formation, dyspnœa is much aggravated; and the second stage of the disease is then said to have commenced. Occasionally the patient sinks before effusion has taken place. The extent to which the pseudo-membranous deposit occurs is extremely various; in some cases it is confined to the larynx, or to the upper part of it; in others it lines the whole of the windpipe, and often is prolonged, either in flakes or tubes, into the ramifications of the bronchi. In general, it is not at every point adherent to the mucous membrane, but more or less detached, particularly at its inferior extremity, by a quantity of vitiated mucus which intervenes between it and the mucous surface, and is intimately adherent to the latter. The mucous membrane is also slightly elevated by effusion into the subjacent cellular tissue.
By the formation of false membrane, the symptoms may be so much increased as to cause speedy dissolution; but in many cases the patient’s strength is not altogether exhausted, and the extraneous substance by its irritation causes frequent and violent attempts to expectorate, by which the lymph is not unfrequently expelled either entire or in irregular portions; the relief thereby afforded, though considerable, is in general temporary, for lymph is speedily redeposited, or there is a profuse muco-purulent expectoration, and the patient succumbs. It has been already stated that a portion of the false membrane is usually detached from the lining membrane of the canal, and from this the existence of the membrane is in general easily recognised; for on its being moved by the passage of air in the canal, a peculiar sound is frequently audible, and has been compared to that made by the movement of the valve or clapper of a pump. When perceived during inspiration, it indicates that the membrane is detached at its superior extremity; when in expiration, that the separation has occurred inferiorly. A fatal termination may suddenly take place, in consequence of the detached extremity being so displaced by the passage of the air as to form a complete valve, obstructing respiration, and causing death by suffocation.
When the inflammation extends into the bronchi and substance of the lungs, laborious breathing and the mucous rattle occur. The bronchi are obstructed by vitiated mucus, or by lymph, and serum is effused at the base of the brain; and from either or both of these circumstances the patient soon perishes. In children the gums should be looked to, and if swollen or tender, they must be freely scarified; this always affords relief, and often forms the most important part of the treatment. The bowels must be completely freed from the fetid dark-coloured matter which they contain; and if this be effected at an early period, it will generally be sufficient to arrest the progress of the disease. Calomel is the medicine usually preferred, not only from its excellent qualities as correcting and purging out the vitiated secretions, but also on account of its supposed effect of preventing lymphatic effusion. To the procuring of copious evacuations from the stomach and bowels, the attention of the practitioner ought to be chiefly directed at the commencement. With the same view, emetics are of much service. The warm bath will be of use in promoting the cutaneous discharge, and assisting to allay irritation. When the inflammatory symptoms are violent, bleeding, both local and general, is indispensable, and must be had recourse to early; for during the commencement only of the disease can it be of service. The first, or acute, inflammatory stage is of but short continuance, speedily terminating in effusion; and when this has occurred, the symptoms all denote debility of the system, and will be irreparably aggravated by depletion. The most effectual mode of abstracting blood, is by opening the external jugular vein, and this may be followed by the application of leeches to the forepart of the neck; in the second stage of the disease, their place is to be supplied by blisters, and other counter-irritants. Much benefit will be derived from the continued use of nauseating doses of the tartrite of antimony; in the first stage the vascular action will be thereby subdued, and in the second the medicine acts as a powerful expectorant, determines to the surface, and promotes the evacuations from the bowels. Often, however, the disease defies all sanative measures, and advances unsubdued to a fatal termination.
Tracheotomy has been both proposed and performed in this disease. Recourse to it is not warrantable till the later period of the affection, and then it will be found unavailing. If performed early, there is found no obstruction to respiration that can be removed; it can therefore be of no service, and is not required. If it be undertaken at a more advanced period, lymph will most probably be found to extend below the incision; the bronchial tubes and the substance of the lungs are then the principal seat of the disease, and consequently the operation is futile, at least in children. When first I entered on practice I was several times prevailed on to perform tracheotomy on children labouring under croup; the results were unsuccessful, and from my own experience I cannot recommend the practice.
The fauces and larynx of children are occasionally injured, as stated above, by the attempt to swallow by mistake boiling water, and inhaling the steam. The alarming symptoms follow in a very few hours, in consequence of the formation of numerous minute vesicles, with swelling, from effusion of serum into the submucous tissue. Great pain is generally experienced at the moment, but after crying violently the child may fall asleep and awaken croupy, and with threatened suffocation. By this time inflammatory action has been fairly established, the submucous effusion has begun to take place, and it is this that gives rise to the danger. The excited action is to be combated by leeching and exhibition of calomel in small doses, with or without opium frequently repeated, so as to arrest the lymphatic effusion, which is apt to supervene. When these means fail, tracheotomy must be resorted to without delay. The fauces and upper part of the larynx are only involved at first; this practice is sound, and good success may be expected from the operation. The breathing has been suddenly suspended in children by the attempt to swallow acrid fluids, such as alkaline solutions, or concentrated acids.
Cynanche laryngea, in adults, is of comparatively rare occurrence; at least that kind of inflammation of the windpipe, which in children is so rapid in its progress, and so prone to terminate in effusion of lymph, is not often met with in persons of an advanced age. Inflammatory affections of the larynx and trachea are, however, by no means unfrequent in adults; but are of a very different character, as to symptoms, progress, and termination, from that affection which is strictly denominated croup. Pain is felt in the region of the windpipe, and is aggravated by pressure on the forepart of the neck, by speaking, and by deglutition; expectoration is increased, and ultimately assumes a muco-purulent character. The voice is altered in tone and in strength, and occasionally there is complete aphonia. Frequently these symptoms, after having continued for a short time, gradually subside; if not, the mucous membrane, particularly in the upper part of the larynx, becomes thickened and considerably softened in texture, with effusion of serous fluid in the subjacent cellular tissue, and apparently in the substance of the membrane itself. In consequence of such effusion, the difficulty of breathing is much increased. Occasionally lymph is effused on the surface of the membrane; but this is seldom met with, and when it does take place, is generally confined to the upper part of the larynx. The larynx and trachea of an old lady of seventy years is here shown, with very extensive false membranes blocking up the bronchi; a large portion besides was coughed up. The specimen, a rare one, is in my collection.
The effusion of serum is often abundant, causing protrusion of the mucous membrane, and narrowing of the canal; and when it is limited to the upper part of the larynx, as frequently happens, the disease is termed Œdema Glottidis. In this affection, the majority of the symptoms, which have been already enumerated as attendant on laryngitis, are all present, and in an aggravated form. Inspiration is extremely difficult and sibilant, and occasionally the patient experiences a sensation, as if a foreign body were lodged in the passage, and had changed its position on the muscles of the part being put in motion. The symptoms of œdema come on gradually in some cases, in others with alarming rapidity. They often follow ulcerations of the soft palate, and of the root of the tongue, as shown in treating of diseases of that organ, occurring on the patient being exposed to cold or moisture, or supervening rapidly when discharge from the ulcerations is by any accident suddenly suppressed. The difficult breathing, with cough and violent attempts at expectoration, takes place in paroxysms, and often to so alarming a degree as to threaten immediate suffocation, especially during the night. The patient, if he has fallen asleep, often starts up suddenly, and catches at the nearest object, having dreamed probably of drowning or strangulation. Deglutition is seriously impeded, the strength is exhausted, the body is emaciated, the features become contracted, and evince great anxiety. As already stated, the serous effusion is chiefly situated in the upper part of the larynx, particularly on the lips of the glottis, and on the inferior surface of the epiglottis; and on introducing the finger, a soft swelling can be felt beneath this cartilage. Perhaps the following sketch exhibits the most complete instance of œdematous swelling of the rima glottidis to be found in collections of morbid anatomy. The patient was brought to the Royal Infirmary labouring under all the symptoms of the disease in a very aggravated form. Tracheotomy was performed without delay, and with instant relief. The patient fell into a quiet and profound sleep, which lasted for six or seven hours. He started up suddenly and fell down dead; probably the end of the tube had become obstructed by mucus. It is scarcely to be supposed that the patient could have breathed at all with such a state of parts at the top of the air-tube, as here represented. Could any of the swelling have come on in the interval betwixt the performance of the operation and his sudden death? In some instances, the disease rapidly proceeds to a fatal termination, the glottis being speedily and entirely shut by the swelling; in others, the patient lingers for weeks, or even months.
Depletion, local and general, especially the former, if employed on the first appearance of the inflammatory symptoms, will often arrest their progress; but if practised at a more advanced period, it can be productive of no benefit, and if any advantage does follow, it is merely temporary. Sometimes considerable benefit will be derived from the use of blisters, or from the unguentum tartritis antimonii being rubbed on the sides of the neck and over the larynx, so as to produce an eruption of numerous pustules. When all hopes of procuring resolution have passed, and when the urgent symptoms occasionally threatening suffocation supervene, tracheotomy should be performed without delay; and it ought to be borne in mind, that the more early this operation is resorted to, the greater is the chance of success. It has been repeatedly stated, that the disease is confined to the larynx, and, in most instances, to the upper part of it; so that, by making an opening in the windpipe below the thyroid gland, the disease is situated above the incision, the patient breathes through a canal which is in its healthy state, the affected parts are set at rest, and from their remaining comparatively motionless the disease often subsides spontaneously; if not, the various applications to the parts can be employed much more successfully than before; for when the parts remain subject to constant irritation from the movements necessary for respiration and nutrition, all medicines and all topical applications are generally productive of little or no benefit. But if the incision be made into the crico-thyroid membrane, we shall, in most instances, cut into the very middle of the disease; at any rate, the affected parts can be at no great distance from the incision, and the irritation of the tube will be a sufficient cause to excite inflammatory action in parts contiguous to the original disease, and already disposed to assume a similar action; thus the disease may be extended. I have performed tracheotomy on a very considerable number of patients afflicted with œdema glottidis, and I may say, with almost uniform success. The disease was speedily subdued, and in most of them there was no great difficulty in closing the artificial aperture, and restoring natural respiration. The relief afforded by the operation is almost instantaneous; the performance of it, if skilful, is attended with no danger; and want of success will generally be found to proceed from its having been too long delayed.