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Retropharyngeal abscess is a disease of early life; more than 80 per cent. of the cases occurring before the second year. Lennox Brown says it is a rare affection. He noted but 6 cases in a service of over twenty years. This seems to have been the general experience of nose and throat specialists, whereas the pediatricians seem to have observed many more cases. Holt and Rotch say it is almost always seen in infancy, and that it is rare after the first year. Bokai reported 60 cases ; 42 occurring during the first year, 11 during the second year, and only 7 at a later period.

Koplik says the disease is rare after the fifth year. Of his 70 cases, 4 occurred before the third month; 10 before the sixth month; 41 between the sixth and twelfth months; 19 between the first and fifth years; and only 3 after the fifth year.

The second case is a typical one, and is reported, as it affords a contrast to the first. It occurred in a seven-months-old breast-fed baby. The mother said it had always been a very healthy infant. It had a “cold” in the head, with some fever, for several days; and for three days had been very fretful and restless. The mother noticed that the child's breathing was somewhat labored during sleep, and that it did not nurse well. The difficulty in breathing and nursing was increasing, and when I saw the baby it had dyspnea, which seemed to be mostly inspiratory, and was worse in the recumbent position. It would nurse for only a few seconds at a time, and was growing weak evidently from lack of nourishment and from the labored breathing. The cry had a nasal twang. The head thrown back and the mouth was open. The breathing was rattling and snoring, at times stertorous. Inspection of the throat, owing to the diminutive size, was difficult, and rendered more so by the accumulation of mucus. On introducing the finger a tense fluctuating swelling was detected in the posterior wall of the pharynx, nearly in the median line, reaching down to the larynx.

Using a finger as a guide, an opening in the abscess was made, and a large amount of creamy pus was evacuated. Pressure with the finger on the walls of the abscess was necessary to thoroughly empty it. The infant began to breathe easily at once, and made a perfect recovery in a few days. There has been no return of the disease.

was

The injection into a ganglion of the wrist of phenol-camphor, two to ten minims, according to the size, and repeated once or twice if necessary, will cause its complete disappearance in most

No attempt at preliminary aspiration need be made. -American Journal of Surgery.

cases.

foreign Bodies in the Larynx and Trachea. M. McTyeire Cullom,

A.B., M.D., Surgeon to St. Thomas's Hospital; President Nashville
Academy of Medicine and Davidson County Medical Society,
Nashville, Tenn., in the International Journal of Surgery.

When a foreign body becomes lodged in the air passages nature gives instant and unmistakable assurance that a grave accident has occurred. In his great article on “Foreign Bodies in the Larynx and Trachea,” Roe quotes the immortal Gross as follows: “How many persons have perished, perhaps in an instant and in the midst of a hearty laugh, the recital of an amusing anecdote, or the utterance of a funny joke, from the interception at the glottis of a piece of meat, a crumb of bread, a morsel of cheese, or a bit of potato, without a suspicion of those around of the real nature of the case. Many a coroner's inquest has been held upon the bodies of the victims of such accidents and a verdict rendered that they died by the visitation of God, when the actual cause of death lay quietly and unobserved at the door of the windpipe of the deceased.”

Foreign bodies in the larynx constitute one of the rare conditions which the physician is called upon to relieve. It is the testimony of many laryngologists that out of many thousands of patients applying for treatment, only a very few are so afflicted. The articles which most commonly find lodgment in the throat are, first, fish bones, chicken bones, and the bones of game birds. Pieces of toothpick, perhaps, come next; then pins, needles, tacks, toothbrush bristles, false teeth, thread, coins, grains of corn, wheat, or seeds of various kinds, as well as small objects that are liable to be put into the mouth by children or grown persons. When we realize how well guarded the larynx is, it is not surprising that so few objects find lodgment in it.

The symptoms of a foreign body in the larynx may be classified as immediate and remote. The immediate symptoms are apt to be all those of a most distressing spasm of the glottis. Respiration is interrupted, the patient giving a gasp or two, followed by prolonged stridulous inspiratory efforts, accompanied by a crowing noise, which is peculiar to spasm. The patient has an anxious expression, wide open eyes, livid lips, and if the paroxysm is prolonged, extreme cyanosis sets in and the patient may drop to the floor unconscious. In such cases death may occur almost at once from asphyxia. As a rule, however, the spasm ceases and respiration is resumed; it may be with difficulty. There is, however, a constant effort of nature to expel the intruder, and the spasm is apt to recur at intervals. There are always more or less pain and discomfort referred to the larynx.

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The remote symptoms set up by foreign bodies in the larynx are inflammation, suppuration, or ulceration. If the foreign body becomes lodged in a bronchus a septic pneumonia is very apt to be set up, an d a fatal result is almost sure to follow. There are instances, however, of very remarkable toleration shown by the larynx for foreign bodies. Coins have been carried in the larynx for a long time, and a case is reported of a toy locomotive being lodged in the larynx and remaining for some time without producing death.

The diagnosis is made with the laryngeal mirror, the x-ray, or from the history and symptoms. The diagnosis is a matter of the greatest importance, for it is in most cases an accident fraught with the gravest dangers to life. Many cases apply to us under the impression that they have a foreign body lodged in the throat when none can be found. The traumatism caused by its passage into the esophagus leaves an irritation which the patient mistakes for a foreign body. In Prof. Juaraz's clinic at Heidelberg, out of 4048 patients applying for throat treatment, 106 came under the impression that they had a foreign body in the throat, but in only four was one actually found. And, again, foreign bodies exist in children where none are suspected. The lodgment of a foreign body •in the air passages is always

Death may ensue immediately from suffocation, or inflammation and sepsis may occur as a result of retention, with death as a final result. Roe has collected 762 cases of foreign bodies in the larynx and trachea, of which 312 were in the larynx, and 450 in the trachea. In the 312 cases of foreign body in the larynx its removal by operation was undertaken in 124 cases with 17 deaths. Of the other 188 cases the foreign body was expelled spontaneously in 40 cases with 38 recoveries. In 101 cases it was removed by forceps through the mouth, all of which recovered. In 16 cases removal was accomplished by various means, such as inversion, the fingers, by emesis, etc., all of the patients recovering. In 31 cases no operation was attempted, and of these, 28 died. Of the 450 cases in which the foreign body was in the trachea it was removed by operation in 239 cases, with 201 recoveries. In 124 the foreign body was expelled spontaneously, with 112 recoveries ; in 14 it was removed by forceps, in 9 by inversion, in 2 by emesis ; all recoverd. In 58 cases no operation was undertaken, with 56 deaths. So that in 312 cases of foreign bodies in the larynx there were 265 recoveries, or 84.9 per cent.; of 450 cases of foreign bodies in the trachea, 343 recovered, or 77 per

Combining the statistics of a number of investigators, comprising about 2,650 cases, the recoveries are 78 per cent. The significant fact which these statistics bring out is the almost certain death

serious.

cent.

of the patient when the foreign body is not removed spontaneously or otherwise.

The diagnosis of a foreign body having been made, the urgent indications are for its prompt removal. The only question is by what means is it to be accomplished The means of removal are by expulsion through the natural passages; removal through the natural passages with instruments; removal with instruments or by expulsion through an artificial opening. It is needless to say that removal by the natural channels is the most desirable, and every effort should be made to accomplish it in this manner before resorting to operation, unless the urgency of the symptoms demands surgical interference. Perhaps the earliest effort made to relieve a patient with a foreign body in the air passages was to tickle the throat so as to induce coughing and emesis. This has no doubt been tried successfully in thousands of cases that have not been reported. Thought some authorities condemn it, it is the first thing to be thought of in the urgency of laryngeal spasms, and should be resorted to at once. No doubt many a life has been saved by some one inserting a finger or a feather into the throat in such a way as to provoke emesis or coughing. Foreign bodies have also been expelled by bringing on a paroxysm of sneezing.

The method of inversion and succussion has been successfully practised in many cases.

This is available in the case of objects which have weight enough to be acted on by the force of gravity, such as coins, bullets, metal objects, etc. The best way to accomplish this is to place the patient on a bench with his legs flexed over the end, and then elevate the bench at an angle of 45 degrees. Vigorously shaking the patient is supposed to aid the expulsion. The patient should avoid speaking, as this brings the vocal cords together and prevents the expulsion of the foreign body.

The ideal method for removing foreign bodies from the trachea is by means of bronchoscopy, which within a few years has been brought to a high state of perfection in technic. To Gustav Killian, of Freiburg, belongs the credit of placing this epoch-making method upon a practical basis. To those who have seen this modest, unassuming gentleman explore the deep recesses of the trachea and bronchi under direct inspection the method is a surprise and a revelation. The instruments consist of a tube-spatula, which is used in inspecting the larynx, and through which the bronchoscope may be used. The bronchoscope proper consists of a hollow tube carrying its own illumination in the shape of a small electric light within the lumen of the tube. The tube is passed directly into the trachea, whereby the trachea and bronchi may be directly inspected, and by means of suitable forceps foreign bodies may be removed without danger, without after-treatment, and without a scare, where available, and where indicated. It is the ideal method of extraction. In the comparatively small number of cases in which the method has been used the indicated mortality is 8 per cent., as against 22 per cent. for other methods. The instrument may also be inserted through the tracheotomy wound.

When attempts at removal of a foreign body through the natural channels have failed it is necessary to adopt surgical means, and the success of this treatment has been greatly facilitated by the use of the x-ray for diagnosing and locating the exact spot occupied by the foreign body. The character of the operation will be determined largely by the location and nature of the foreign body. When the trachea is opened, the foreign body is often expelled through the tracheal wound or through the larynx, or it may be thrown up into the trachea where it may be grasped with forceps. When it is not expelled at once, efforts should be made to extract it with forceps. Gross, Roe, and Cohen have devised flexible forceps, which can be bent at any angle for reaching into a bronchus.

I wish to report the following cases :

Case I. L. E., white, aged thirty-two, was brought to me by his physician June 19, 1904, with the following history: He was subject to a purulent discharge from the nose, which was characterized by an accumulation of crusts in the post-nasal space. These crusts were dislodged with great difficulty at times. Three days before, while hawking in an attempt to dislodge 'a crust, it was drawn into the larynx. He was seized with spasm, dyspnea, and all the symptoms of a foreign body in the larynx. His breathing had been very difficult ever since, with frequent attacks of urgent dyspnea. His distress was very apparent and his voice was practically gone. With the laryngeal mirror I discovered the crust in the treachea just below the vocal cords. I recognized the gravity of the condition, not only on account of the presence of the foreign body in the trachea, but also because being such a particularly foul one, I was unwilling to undertake its removal by endolaryngeal methods, for fear that I would dislodge it and cause it to drop into a bronchus with almost a certainty of septic pneumonia. I advised an immediate tracheotomy, which was agreed to. The patient was

removed

to St. Thomas's Hospital, and Dr. W. A. Bryan was called into the case. At four o'clock that afternoon Dr. Bryan did a high tracheotomy and removed the mass through the wound. The patient made an uneventful recovery.

Case II. I. M., female, white, aged eight. This patient was

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