XXVI. THE NECK
Surgical Anatomy--Malformations: Cervical auricles; _Thyreo-glossal cysts and fistulae_; Lateral fistula--Cervical ribs--Wry-neck: Varieties; Cicatricial contraction--Injuries: Contusions--Fractures of hyoid, larynx, etc.: Cut-throat--Infective conditions: Diffuse cellulitis; Actinomycosis; Boils and Carbuncles--Tumours: Cystic: Branchial cysts; Cystic lymphangioma; Blood cysts; _Bursal cysts_--Solid: Lipoma; Fibroma; Osteoma; Sarcoma; Carcinoma--The thymus gland--The carotid gland.
#Surgical Anatomy.#--In the middle line the following structures may be recognised on palpation: (1) the hyoid bone, lying below and behind the body of the lower jaw, on a level with the fourth cervical vertebra; (2) the hyo-thyreoid membrane, behind which lies the base of the epiglottis and the upper opening of the larynx; (3) the thyreoid cartilage, to the angle of which the vocal cords are attached about its middle; (4) the crico-thyreoid membrane, across which run transversely the crico-thyreoid branches of the superior thyreoid arteries; (5) the cricoid cartilage, one of the most important landmarks in the neck. It lies opposite the disc between the fifth and sixth cervical vertebrae, and at this level the common carotid artery may be compressed against the carotid tubercle on the transverse process of the sixth cervical vertebra. The cricoid also marks the junction of the larynx with the trachea, and of the pharynx with the oesophagus; at this point there is a constriction in the food passage, and foreign bodies are frequently impacted here. At the level of the cricoid cartilage the omo-hyoid crosses the carotid artery--a point of importance in connection with ligation of that vessel. The middle cervical ganglion of the sympathetic lies opposite the level of the cricoid. (6) Seven or eight rings of the trachea lie above the level of the sternum, but they cannot be palpated individually. The isthmus of the thyreoid gland covers the second, third, and fourth tracheal rings. As the trachea passes down the neck, it gradually recedes from the surface, till at the level of the sternum it lies about an inch and a half from the skin. The thyreoidea ima artery--an inconstant branch of the anonyma (innominate) or of the aorta--runs in front of the trachea as far up as the thyreoid isthmus. The inferior thyreoid plexus of veins also lies in front of the trachea. In the superficial fascia, cross branches between the anterior jugular veins cross the middle line.
In children under two years of age the thymus gland may extend for some distance into the neck in front of the trachea and carotid vessels, under cover of the depressors of the hyoid bone.
Cervical Fascia.--This fascia completely envelops the neck, and from its deep aspect two strong processes--the prevertebral and pretracheal layers--pass transversely across the neck, dividing it into three main compartments. The posterior or vertebral compartment contains the muscles of the back of the neck, the vertebral column and its contents, and the prevertebral muscles. This compartment is limited above by the base of the skull, and below is continued into the posterior mediastinum. The middle or visceral compartment contains the pharynx and oesophagus, the larynx and trachea with the thyreoid gland, and the carotid sheath and its contents. These different structures derive their special fascial coverings from the processes that bound this compartment. The middle compartment extends to the base of the skull and passes into the anterior mediastinum as far as the pericardium. The connective tissue space around the subclavian vessels is continued into the axilla. The anterior or muscular compartment contains the sterno-mastoid muscle and the depressor muscles of the hyoid bone. It extends upwards as far as the hyoid bone and base of the mandible, and downwards as far as the sternum and clavicle. The arrangement and limits of the different layers of the cervical fascia explain the course taken by inflammatory products and by new growths in the neck.
#Malformations of the Neck.#--Various congenital deformities result from interference with the developmental processes which take place in and around the fore-gut. These malformations are associated chiefly with imperfect development of the visceral or branchial arches and clefts, or of the hypoblastic diverticula from which the thyreoid and thymus glands are formed.
The term cervical auricles is applied to small outgrowths, composed of skin, connective tissue, and yellow elastic cartilage, found usually along the anterior border of the sterno-mastoid. These appendages are usually unilateral, and are derived from the second visceral arch. Sometimes they are situated near the orifice of a lateral fistula. When, on account of their size, or their situation on an exposed part of the neck, they give rise to disfigurement, they should be removed.
Thyreo-glossal Cysts and Fistulae.--The thyreo-glossal cyst is developed in relation to the thyreo-glossal tract of His, which in early embryonic life extends from the foramen caecum at the base of the tongue to the isthmus of the thyreoid. Those that form in the upper part of the tract, in relation to the base of the tongue, have already been described (p. 538). Those arising from the lower part form a swelling in the middle line of the neck, usually above, but sometimes below the hyoid bone. They have to be diagnosed from other forms of cyst occurring in the middle line of the neck--sebaceous and dermoid cysts--and when giving rise to disfigurement they should be excised.
Such a cyst may rupture on the surface, usually as a result of superadded infection, and give rise to a thyreo-glossal or median fistula of the neck. As a rule the external opening of the fistula is above the hyoid bone, only the upper part of the duct having remained pervious. When the whole length of the duct has persisted, the fistula extends from the skin to the foramen caecum, passing usually in front of, but sometimes through the substance of, the hyoid bone. Occasionally the fistula only extends as high as the hyoid.
The part of the tract near the tongue is lined by squamous epithelium; the lower part by columnar epithelium, which, below the level of the hyoid, is usually ciliated. Lymphoid tissue and mucous glands are found in its wall.
The treatment consists in excising the duct and the connections, and it is usually necessary to resect the central portion of the hyoid bone to ensure complete removal.
The lateral fistula of the neck--formerly described as a branchial fistula--according to Weglowski, usually takes origin from the remains of the hypoblastic diverticulum, which arises from the pharyngeal part of the third visceral cleft and extends downwards to form the thymus gland. The internal opening is situated in the lateral wall of the pharynx in the region of the posterior palatine arch close to the tonsil, and the fistula passes out above the hypoglossal nerve, and runs downwards and laterally between the carotids and along the medial border of the sterno-mastoid muscle. When the fistula is complete, the external opening is situated a short distance above the sterno-clavicular joint. As the lower part of the thymus canal most often persists, an incomplete external fistula is the form most frequently met with. It is lined with ciliated columnar epithelium.
The fistula may be present at birth, or may result from the rupture of a cystic swelling, which has become infected. Clear viscous fluid exudes from it, and, when the fistula is complete and the lumen sufficiently wide, particles of food may escape. As the track is tortuous, it is seldom possible to pass a probe along it, but its extent and course may be recognised by injecting an emulsion of bismuth and taking an X-ray photograph.
The treatment consists in excising the fistula in its whole length, but, owing to its long and tortuous course, and its relations to important structures, the operation is a tedious and difficult one. Less radical measures, such as scraping with the sharp spoon, cauterising, or packing, are seldom successful.
#Cervical Ribs.#--Supernumerary ribs are not infrequently met with in connection with the seventh cervical vertebra, and in the majority of cases the condition is bilateral. The extra rib may be thin and pointed, and project straight out from the transverse process terminating in a free end, in which case, as it passes above the subclavian artery and the brachial plexus, it gives rise to no trouble. In other cases it arches downwards and forwards, and is attached by dense fibrous tissue to the first thoracic rib about the level of the scalene tubercle, or to the sternum by cartilage like an ordinary rib. When it encroaches upon the posterior triangle the scalene muscles are attached to it, and the subclavian artery and the lower trunk and medial cord of the brachial plexus pass over it in a groove behind the scalenus anterior. The pleura may reach as high as the medial border of the rib.
Clinical Features.--The condition, which is more common in women than in men, is seldom recognised before the age of twenty, and is often discovered accidentally, for example after some emaciating illness, or by a tight collar causing pain. The diagnosis is established by the X-rays.
When symptoms arise, they may be referable either to pressure on the artery or on the nerve roots. When the subclavian artery is displaced upwards it may be recognisable as a prominent pulsatile swelling, and as the part of the vessel distal to the rib is sometimes dilated and yields a systolic bruit, it may simulate an aneurysm (Sir William Turner). The pulse beyond is weakened while the arm hangs by the side, but may be restored by raising the hand above the head. Gangrene of the tips of the fingers has been observed in rare instances, but it is probably nervous rather than vascular in origin.
Symptoms referable to pressure on the nerve roots usually affect the right arm, and may be either neuralgic or paralytic in character (Wm. Thorburn). In the neuralgic group there is tingling pain, a feeling of numbness, and sensations of cold in the limb, most marked along the ulnar border of the forearm; the arm is weak, and susceptible to cold. This condition may be mistaken for brachial neuritis; it is relieved, however, by holding the arm above the head, for example, during sleep.
In the paralytic group, the pressure symptoms are referred to the first dorsal, or first dorsal and eighth cervical roots. The paralysis is most marked in the muscles of the thumb, and becomes less towards the ulnar side; the affected muscles atrophy, especially those forming the thenar eminence, and the finer movements of the thumb and fingers are impaired.
When pressure symptoms are present, the extra rib should be removed through an incision which exposes the posterior triangle sufficiently to admit of the bone and its periosteum being excised, without damage being inflicted on the brachial plexus, the subclavian artery, or the pleura.
Similar clinical features to those of cervical rib may be caused by a prominent transverse process of the first thoracic vertebra and similarly got rid of by its removal.
Branchial cysts and branchial tumours are described with tumours of the neck (p. 598).
WRY-NECK OR TORTICOLLIS.--The term wry-neck or torticollis is applied to a condition in which the head assumes an abnormal attitude, which is usually one of combined lateral flexion and rotation.
The most important form is due to faulty action of the cervical muscles, and three varieties of muscular wry-neck are recognised--(1) the acute or transient; (2) the chronic or permanent; and (3) the spasmodic.
#Acute# or #transient wry-neck#--so-called "rheumatic torticollis"--comes on suddenly, usually after the patient has been exposed to a draught of cold air or to damp. The condition is popularly known as "stiff neck," and is probably associated with fibrositis of the affected muscles. The sterno-mastoid, and often the trapezius, are contracted, and pull the head to one side, twisting the face slightly towards the opposite side (Fig. 270). There is tenderness on pressing over the affected muscles, and sometimes over the vertebral spines, and in the lines of the cervical nerves, and severe pain on attempting to move the head. Usually in the course of a few days the condition passes off as suddenly as it came on, but in some cases a certain amount of wasting of the affected muscles ensues.
In the diagnosis of this form of wry-neck it is necessary to exclude such conditions as cellulitis, inflammation of the cervical glands, and disease of the cervical spine, in which the head may assume an abnormal attitude, the position being that which gives the patient greatest comfort.
The treatment consists in ensuring free action of the bowels and kidneys, in inducing hyperaemia by means of heat, and applying gentle massage. Salicylates and similar drugs are useful in relieving the pain.
#Permanent# or #true wry-neck# is due to an organic shortening of the sterno-mastoid muscle. The trapezius, the splenius, the scaleni, and the levator scapulae muscle may also undergo shortening, along with their investing sheaths derived from the cervical fascia.
The sternal head of the sterno-mastoid is always markedly shortened, and stands out as a tight cord; sometimes the clavicular head is also prominent.
There is evidence that in the majority of cases the deformity results from some interference with the development of the muscles during intra-uterine life. This is probably the effect of undue pressure on the foetus diminishing the arterial supply to the central part of the muscle, with the result that the muscle fibres undergo degeneration with subsequent sclerosis and contraction. It may result also from cicatricial contraction of the muscle following rupture of its fibres during delivery. In such cases there is a history that the birth was a difficult one, the presentation having been abnormal; and that a swelling was observed in the sterno-mastoid shortly after birth. This swelling--a haematoma of the sterno-mastoid--is at first soft, later becomes smaller, and eventually disappears. In course of time, sometimes months, sometimes years after the disappearance of the swelling, shortening of the muscle takes place, and the deformity is established.
Clinical Features.--Although the condition is usually described as "congenital," it is the common experience in practice that the child has reached the age of from seven to ten years before advice is sought. The appearance of the patient is characteristic (Fig. 271). The shortening of the sterno-mastoid pulls the head towards the affected side, usually the right, so that the ear is approximated to the shoulder. At the same time the head is rotated towards the opposite side and slightly tilted backwards, with the result that the chin is directed towards the opposite side, and is somewhat raised. The shortened sterno-mastoid stands out prominently, and, on any attempt to straighten the head, can be felt as a firm, fibrous band. The skin of the affected side of the neck may be thrown into transverse folds. The patient is unable to correct the deformity, but it is usually possible to diminish it by manipulation.
If the condition is not corrected, all the structures on the affected side of the neck undergo organic shortening, with the result that the deformity becomes accentuated. In advanced cases a lateral curvature, with the convexity towards the normal side, occurs in the cervical region, the vertebrae becoming wedge-shaped from side to side, and a compensatory curve may develop in the thoracic region (Fig. 272).
There is also asymmetry of the head and face, the affected side being the smaller. The eye on this side lies on a lower level, and is more oblique than its neighbour, the cheek is flattened, and the mouth asymmetrical. Instead of the eyebrows and the lips forming parallel lines, their axes converge towards the side of the contracted muscles and fasciae.
Treatment.--While it may be possible when the condition is recognised during infancy to counteract the tendency to contraction and deformity by manipulations, massage, and exercises alone, it is usually necessary to divide the shortened structures as a preliminary to orthopaedic measures.
Subcutaneous tenotomy--at one time the favourite method of treatment--has been entirely replaced by the open operation, which admits of all the structures at fault, including the cervical fascia, being thoroughly divided, without risk of injuring other structures in the neck. The result of division of the shortened tissues is seen at once in a marked increase in the interval between the sterno-clavicular joint and the mastoid process. As in other deformities, the operation is only a preliminary, although an essential one, to the treatment by massage, movement, and exercises which must be persevered with for months, and it may be for years. When the torticollis attitude has been corrected in childhood, the asymmetry of the skull disappears.
#Spasmodic wry-neck# is the term applied to a condition in which clonic contractions of certain muscles produce jerkings of the head. The muscles most frequently at fault are the sterno-mastoid and trapezius of one side, and the posterior rotators of the opposite side. By these muscles the head is pulled into the wry-neck position, and is at the same time retracted, and there is more or less constant nodding or jerking of the head.
The condition is usually met with in adults of a neurotic disposition who are in a depressed state of health, and is due to some lesion, as yet undiscovered, in the nerve mechanism of the affected muscles--most probably in their cortical centres. It would appear that in some cases the spasmodic jerkings are originated by certain movements habitually made by the patient in the course of his work. In others, as a result of astigmatism and other errors of refraction, the patient has acquired the habit of repeatedly tilting his head to enable him to see clearly, and these movements have become continuous and uncontrollable.
The affection tends to become progressively worse until the patient is incapacitated for work or enjoyment. Sleep even may be interfered with.
Treatment.--In well-marked cases the use of drugs, electricity, or restraining apparatus is never curative, but these measures combined with massage have been temporarily beneficial in milder cases.
Of the operative procedures, resection of portions of the accessory nerve on one side, and of the posterior primary divisions of the first five cervical nerves on the opposite side, seems to offer the best prospect of recovery. Simple division of these nerves or resection of the accessory alone has not proved permanently curative. Open division of the offending muscles without interfering with the nerves has given good results, and is a much simpler operation (Kocher).
Spasmodic wry-neck must be distinguished from the #hysterical# variety, which after lasting for weeks, or even months, may pass off completely, but, like other hysterical affections, is liable to recur.
Deviations of the neck simulating torticollis may occur in cervical caries, and in unilateral dislocation of the spine.
The #cicatricial contraction# of the integument of the neck that results from extensive burns, abscesses, or ulcers, may cause unsightly deformity and fixation of the head in an abnormal attitude, and call for surgical treatment. The contraction which follows the disappearance of a gumma of the sterno-mastoid may also produce a deformity resembling wry-neck.
INJURIES
#Contusion# of the neck may result from a blow or crush, as, for example, the passage of a wheel over the neck, or from throttling, strangling, or hanging. In medico-legal cases the distribution of the discoloration should be carefully noted. When due to throttling, the marks of the fingers may be recognisable, and nail-prints may be present. In cases of strangling, the mark of the cord passes straight round the neck, while in suicidal hanging it is more or less oblique and is higher behind than in front. When due to a direct blow, for example by a fist, the discoloration is limited, while it is usually diffused over the neck when due to the passage of a wheel over the part.
The clinical importance of these injuries depends on the complications that may ensue; for example, extravasation of blood under the cervical fascia may press upon the air-passage and oesophagus to such an extent as to cause interference with breathing and swallowing; the larynx or the trachea may be so grossly damaged that death results immediately from suffocation, or later from gradually increasing oedema causing obstruction of the glottis. If the mucous membrane of the air-passage or the apex of the lung and its investing pleura is torn, emphysema of the connective tissue may develop and spread widely over the body. In contusions of the lower part of the neck the cords of the brachial plexus may be injured.
#Fractures of the Hyoid, Larynx, and Trachea.#--The hyoid bone, on account of its mobility and the protection it receives from the body of the mandible, is seldom fractured, except in old people in whom the great cornu has become ossified to the body of the bone. It is usually broken either by a direct blow, or by transverse pressure as in garrotting. The fracture is almost always at the junction of the great cornu with the body, and there is marked displacement of the fragments, which may injure the pharyngeal mucous membrane.
The thyreoid and cricoid cartilages are also liable to be fractured in run-over accidents, particularly in old people after calcification or ossification has taken place.
The trachea may be lacerated, or even completely torn from the larynx, by the same forms of injury as produce fracture of the laryngeal cartilages.
The clinical features common to all these injuries are swelling and discoloration; and if the mucous membrane is torn, air may escape into the tissues and produce emphysema. There is always more or less difficulty in breathing, which may amount to actual suffocation, and this may come on immediately, or in the course of a few hours from oedema of the glottis. Blood may pass into the lungs and be coughed up. Swallowing is usually difficult and painful, especially in fracture of the hyoid bone. There is also pain on speaking, the voice is husky and indistinct, and spasmodic coughing is common. When blood has entered the air-passages there is considerable risk of septic pneumonia.
Treatment.--As the immediate risk to life is from suffocation, it is usually necessary to perform tracheotomy at once. In fracture of the hyoid the fragments may be replaced by manipulation through the mouth, after which the head and neck are immobilised by a poroplastic collar.
#Wounds--Cut-throat.#--The most important variety of wound of the neck met with in civil practice is that known as "cut-throat"--an injury usually inflicted with suicidal, less frequently with homicidal intent.
Suicidal wounds are usually directed from left to right (if the patient is right-handed), and they run more or less obliquely from below upwards across the neck; the wound being deepest towards its left end, that is where the weapon enters, and gradually tailing off towards the right. In most cases the would-be suicide throws his head so far back at the moment of inflicting the wound, that the main vessels are carried backward under cover of the tense sterno-mastoid muscles, and so escape injury. The knife may even reach the vertebral column without damaging the contents of the carotid sheath.
Homicidal wounds are usually more directly transverse, and are of equal depth throughout. The main vessels are generally divided, the oesophagus and trachea opened into, and in some cases the vertebral canal is opened and the cord and its membranes injured.
Clinical Features.--The clinical features vary with the level of the wound and with its depth. In all cases the contraction of the platysma causes the wound to gape widely, and its edges tend to be turned in.
In a large proportion of suicidal attempts the patient only succeeds in inflicting one or more comparatively superficial wounds across the front of the neck. In many cases the haemorrhage from these is trifling, but if the external jugular and other large superficial veins are divided, it may be fairly profuse, although it is seldom immediately fatal, unless the blood is sucked in to the wounded air-passage.
Occasionally, but rarely, the wound is made above the hyoid bone, and opens directly into the mouth. There may then be sharp haemorrhage from the base of the tongue or from the lingual and external maxillary (facial) arteries or their branches in the submaxillary region, and asphyxia may result from the base of the tongue and the epiglottis falling back and obstructing the larynx.
The hyo-thyreoid membrane is frequently divided, and the pharynx thus opened. As the depressor muscles of the hyoid are divided, there is interference with deglutition and phonation, but respiration is not affected. In such cases the upper portion of the epiglottis is often cut off, and the base of the tongue, the tonsil or the soft palate may be injured. The lingual, external maxillary and superior thyreoid arteries, and the hypoglossal nerve are also liable to be divided at this level, but the main vessels of the neck usually escape. There is pain and difficulty in swallowing, and food and saliva tend to escape through the wound. Particles of food may pass into the air-passages and cause violent fits of coughing.
In more severe cases the knife enters the larynx or the trachea. Sometimes the thyreoid cartilage is divided--as a rule only partly--and the vocal cords are injured; in other cases the trachea is opened, or it may be completely cut across. The bleeding is serious, as the superior thyreoid arteries are usually damaged. If the common carotid and the internal jugular vein also are wounded, the haemorrhage usually proves fatal. The fatal issue may be contributed to by blood entering the air-passages and causing asphyxia, or by air being sucked into the open veins and causing air embolism. The laryngeal branches of the vagus may be divided and paralysis of the larynx ensue.
In all cases there is more or less dyspnoea and persistent coughing. The voice is husky, and the patient can only express himself in a hoarse whisper. There is difficulty in swallowing, and the food may enter the trachea. When the external wound is small, there may be a considerable degree of emphysema of the cellular tissue.
The prognosis depends largely on the general condition of the patient. The majority of those who attempt to take their own lives are in a low state of health from alcoholic excess, mental worry, privation or other causes, and many succumb even when the wound in the neck is comparatively slight. Shock, loss of blood, asphyxia from blood entering the air-passages, and oedema of the glottis are the most frequent causes of death soon after the injury. Cellulitis, inhalation, pneumonia, and delirium tremens are later complications that may prove fatal.
Treatment.--The first indication is to arrest haemorrhage, and this may be done by applying digital compression over the bleeding points. The bleeding vessels are then sought for and ligated, the wound being enlarged if necessary.
If the food and air-passages are intact, any muscles that have been divided should be sutured.
When the epiglottis is cut across in wounds opening into the pharynx, it should be united, preferably with fine silk sutures, as catgut is absorbed before healing has time to take place. The wall of the pharynx and the muscles should then be sutured layer by layer.
When the air-passage is opened, it is usually advisable to introduce a tracheotomy tube (Fig. 273), and pack gauze round it to avoid the risk of oedema of the glottis and to prevent blood entering the lungs. The soft tissues may then be brought together layer by layer.
In all cases the superficial part of the wound should be drained, and in applying the bandage the head should be flexed on the chest to take all tension off the stitches. The patient must be kept under constant supervision lest he should interfere with the dressings, or make a further attempt on his life. In some cases it is necessary to feed him through a tube passed into the stomach either through the mouth or through the nose; when this is not feasible, nourishment must be given by the rectum, or by a gastrostomy tube (Fig. 273).
Wounds of the thoracic duct have been described with affections of the lymphatics (Volume I., p. 324), and wounds of the brachial plexus with injuries of individual nerves (Volume I., p. 360).
INFECTIVE CONDITIONS
#Cellulitis# may occur in any of the cellular planes in the neck, the most important form being that which occurs under the cervical fascia, for example in the course of acute infective diseases, such as scarlet fever, measles, or pyaemia. The pus tends to spread widely throughout the neck, infiltrating the connective-tissue spaces around the blood vessels, the air-passages, and the oesophagus. The density and tension of the cervical fascia cause the pus to burrow downwards towards the mediastinal spaces of the thorax, where it may give rise to such complications as empyema, infective pericarditis, or gangrene of the lung. The pus may also reach the axilla by spread of the infection along the subclavian vessels.
An acute phlegmonous peri-adenitis sometimes occurs in the loose cellular tissue around the submaxillary gland, and spreads with great rapidity through the cellular planes of the neck. The condition--which goes by the name of angina Ludovici--is usually met with in adults, and appears to originate in some infective focus in the mouth.
Clinical Features.--In all forms the process spreads rapidly, and the neck becomes swollen, brawny, and of a dusky red colour. The head is flexed towards the affected side, and there is pain on movement and on palpating the swelling. Pus forms early, but, as it is under great tension, fluctuation can seldom be detected. Respiration may be interfered with by pressure on the air-passages, or by the onset of oedema of the glottis, and tracheotomy may be urgently called for. Swallowing may also be affected by pressure on the pharynx and oesophagus. Pressure on the important nerves traversing the neck may give rise to irritative or paralytic symptoms. The main vessels may become thrombosed or eroded--particularly when the cellulitis is associated with scarlet fever--and in the latter case copious haemorrhage may follow incision of the abscess.
There is always marked constitutional disturbance, as evidenced by rigors, high temperature, a small, rapid pulse, and delirium; and death may result within a few days from toxaemia.
Treatment.--In the earliest stages hot fomentations or ichthyol and glycerine should be applied, but if the process does not begin to abate within twenty-four hours, and if the swelling becomes brawny in character, one or more incisions should be made through the deep fascia where the signs of inflammation are most intense, and the deeper planes of the neck opened up by dissection. Drainage is secured by tubes or strips of rubber tissue. If profuse haemorrhage occurs it may be necessary to ligate the main artery lower in the neck.
#Actinomycosis# manifests itself in the neck as a diffuse, painless swelling, which slowly infiltrates the superficial structures, becoming brawny at some places, and at others breaking down and forming sinuses from which the ray fungus escapes in the discharge.
#Boils and carbuncles# frequently occur on the back of the neck, where the skin is thick and coarse and is rubbed by the collar.
The affections of the cervical lymph glands have already been described (Volume I., p. 330).
TUMOURS
#Cystic Tumours.#--A great variety of cystic tumours is met with in the neck.
#Branchial cysts# are formed by the distension of an isolated and unobliterated portion of one of the branchial clefts. They usually form in connection with the third cleft, and are met with in the region of the great cornu of the hyoid bone, to which the wall of the cyst is almost always attached. Less frequently they take origin in the second cleft, and lie below the mastoid process, in which case the cyst is adherent either to the mastoid or to the styloid process. In some cases these cysts project towards the floor of the mouth. When near the skin they are of the nature of dermoid cysts, being lined with squamous epithelium and filled with sebaceous material. When deeply placed, they are lined by cylindrical or ciliated epithelium and contain a glairy mucoid fluid.
Although of congenital origin, these cysts do not usually attract attention till about the age of puberty, when they are noticed as small, soft, fluctuating tumours over which the skin moves freely. They grow slowly, but may attain great dimensions. The only treatment that yields satisfactory results is complete excision.
The cystic lymphangioma, hygroma, or hydrocele of the neck (Fig. 274), has been described with affections of lymphatics (Volume I., p. 327); and thyreo-glossal cysts in the neck at p. 583.
Blood Cysts.--These may originate in a diverticulum of a vein that has become isolated, or in a cavernous angioma; or they may be due to haemorrhage taking place into a branchial or thyreo-glossal cyst. The diagnosis is often only possible by exploratory puncture; and the treatment consists in complete excision.
Cystic Bursae.--Cystic degeneration may occur in the supra-hyoid and thyreo-hyoid bursae, and give rise to a rounded swelling which moves with the thyreoid on swallowing, and is only troublesome from the disfigurement it causes. It is treated by excision.
#Solid Tumours#, apart from the common enlargements of lymph glands, and the various forms of goitre, are not often met with in the neck.
The circumscribed lipoma usually occurs over the nape of the neck or in the supra-clavicular region. It may attain considerable size, and from its weight become pedunculated and hang down over the back or shoulder.
Diffuse lipomatosis usually begins over the nape and spreads more or less symmetrically till it completely surrounds the neck. As the new-formed fat is not encapsulated, extirpation of the mass is difficult and is seldom called for.
Fibroma originating in the ligamentum nuchae, or the periosteum of the vertebral processes, is of slow growth, but it may attain considerable size, and on account of its deep attachments the operation for its removal may be difficult.
Mixed tumours like that described as occurring in the vicinity of the parotid, and taking origin from branchial rests, are sometimes met with in the upper part of the anterior triangle.
Osseous and cartilaginous tumours occasionally grow in connection with the transverse processes of the lower cervical vertebrae.
Sarcoma and fibro-sarcoma of the slowly growing type may develop from any of the fascial structures in the neck, or from the connective tissue surrounding the blood vessels. In those taking origin beneath the sterno-mastoid, there is difficulty in removing them completely on account of their deep attachments, and when they are found to infiltrate the surrounding tissues the attempt should be abandoned. This rule may be relaxed in view of the aid that may be afforded by the insertion of a tube of radium, which is capable of rendering inert such portions of the growth as are not capable of being removed. Sacrifice of the common carotid artery is attended with the risk of hemiplegia and cerebral softening, especially in persons over fifty; resection of a portion of the vagus is less dangerous to life than stimulation by irritation of its fibres; resection of the internal jugular vein and of the cervical sympathetic cord are factors which add to the shock of the operation but do not carry with them any special risk.
Carcinoma.--The commonest form of primary cancer is the branchial carcinoma, a squamous epithelioma which originates in connection with the second visceral cleft (Fig. 276). It appears as a rule under the sterno-mastoid at the level of the hyoid bone, and extends towards the submaxillary region, infiltrating the muscles and the sheath of the vessels.
It is more common in men than in women, and there is often a history of a small swelling having been present for many years, or even since birth. About middle life more active growth begins, the swelling becomes more fixed and is painful, and once it begins to grow, it increases rapidly and within a month or two may reach the size of a child's head. In spite of its size, however, it seldom causes interference with breathing or swallowing, and it has comparatively little effect on the general health. Clinically, the induration and fixation of the tumour suggest its epitheliomatous character, but the absence of a primary growth in the mouth or pharynx excludes its being a metastasis in the lymph glands.
Unless completely removed at an early stage, recurrence inevitably takes place.
Primary carcinoma may also occur in a supernumerary thyreoid, and in the para-thyreoid glands.
We have met with a case of paraffin epithelioma on the neck, and a similar type of epithelioma may be met with in a lupus or a burn of long standing.
#The Thymus Gland.#--The thymus gland begins to diminish in size towards the end of the second year, and by the time puberty is reached it has entirely disappeared. In some cases, however, the process of involution fails to take place, and the gland may even undergo hyperplasia and exert pressure on the trachea, the great blood vessels, or the left vagus nerve and its recurrent branch. The enlargement of the thymus may be part of a general lymphatic hyperplasia--known as the status lymphaticus.
The pressure effects may be entirely referable to the trachea--thymus stenosis of the trachea--giving rise to progressive dyspnoea accompanied by stridor, with paroxysmal exacerbations during which the child becomes asphyxiated. It is only expiration that is interfered with, as with each inspiratory effort the gland is sucked in towards the mediastinum and so frees the air-passages, while with expiration it rises again, and, becoming jammed in the upper opening of the thorax, exerts pressure on the trachea, and during expiration a soft swelling is sometimes recognisable in the episternal notch. The paroxysms occur at irregular intervals, and any one of them may prove fatal. In some cases the symptoms seem to be associated with pressure on the blood vessels and nerves rather than on the air-passages, and in these there is distension of the veins and a tendency to syncopal attacks.
The only way to afford relief is to expose the gland and withdraw it from behind the sternum by making traction on its capsule. If the breathing is not thereby improved, the capsule should be opened and the gland shelled out.
The term thymic asthma has been applied to another form of disturbed respiration due to a large thymus, which comes on suddenly in infants otherwise apparently healthy. Without warning, the child seems to choke, has great difficulty in breathing, with inspiratory stridor and indrawing of the epigastrium; he rapidly becomes cyanosed, and in the majority of cases dies in a few minutes--thymus death. No satisfactory explanation of the sudden onset of the symptoms is forthcoming, but it appears to be associated with something which suddenly narrows the mediastinal space, such as backward bending of the head, or venous engorgement of the thymus gland. Cases are recorded in which an attack has come on during the administration of a general anaesthetic; in some instances the patient has suffered from the generalised status lymphaticus.
#Tumours of the Carotid Gland or Glomus Carotica# (Potato-like tumour of the neck).--The carotid gland under normal conditions is about the size of a grain of corn, and lies to the posterior aspect of the bifurcation of the carotid. It is sometimes the seat of endothelioma. The tumour has a definite capsule, is moderately firm and elastic, increases in size slowly and gradually for a time, and then may grow more rapidly. Its relation to the vessels is characteristic: as it grows it envelops the common carotid and its branches, and becomes adherent to the internal jugular vein; and it may come to implicate the nerves in the neck, particularly the vagus and its recurrent branch, and the cervical sympathetic.
It gives rise to few symptoms, and in the majority of cases the surgeon is consulted on account of the disfigurement resulting from the presence of the swelling in the neck. This swelling is ovoid, smooth or slightly lobulated; it lies at the level of the bifurcation of the carotid, and tends to grow upwards rather than downwards; it is movable from side to side, but not up and down; it lies under the sterno-mastoid, and the skin is not implicated. There is transmitted pulsation in the tumour, but no expansion.
The diagnosis has to be made from lymphoma, adenoma, tuberculous glands, sarcoma, and carcinoma.
In a large proportion of the cases operated upon it has been necessary to ligate the carotids and to excise portions of the internal jugular vein, and as severe cerebral symptoms are liable to ensue the mortality has hitherto been high. Operation is therefore only to be recommended when the growth is rapid, or the symptoms have become urgent.
XXVII. THE THYREOID GLAND
Surgical Anatomy--Physiological hyperaemia--Acute thyreoiditis--GOITRE--Varieties: Parenchymatous; Adenomatous; Cystic; Malignant; Toxic.
#Surgical Anatomy.#--The thyreoid gland consists of two lateral lobes connected by an isthmus. The lateral lobes lie in contact with the side of the larynx up to the middle of the thyreoid cartilage, and with the sides of the first five or six rings of the trachea. The isthmus lies in front of the second, third and fourth rings of the trachea, and from it a process of gland tissue--the pyramidal lobe--passes up in the middle line towards the hyoid bone.
The gland lies under cover of the superficial muscles of the neck, and is surrounded by a process of the cervical fascia--the external thyreoid capsule of Kocher--which connects it with the larynx, trachea, and oesophagus, so that it moves with these structures on swallowing. In this capsule are numerous veins; and in the groove between the oesophagus and trachea the recurrent (laryngeal) nerve runs. Enclosing the gland substance is the capsule proper, which sends in processes to form its fibrous stroma. The arteries of supply--the superior and inferior thyreoids--are very large for the size of the gland, and enter it at its four corners. The thyreoidea ima, when present, goes to the isthmus. Isolated nodules of thyreoid tissue--accessory thyreoids--are sometimes met with in different parts of the neck; they are liable to the same diseases as the main gland.
The secretion of the gland is absorbed into the general circulation through the veins; it consists of a complex colloid substance which contains an iodine-albumin--iodothyrin--and plays an important part in maintaining the normal metabolism of the body, particularly of the central nervous and cutaneous tissues in adults, and of the bones in children. Disturbance of the function of the thyreoid gland plays a part in producing the symptoms characteristic of myxoedema, cretinism, and goitre.
The para-thyreoid glands--usually two on each side--lie in the external capsule along the posterior edge of the lobes of the thyreoid. They are flattened, elliptical bodies, averaging a quarter of an inch in length and an eighth of an inch in width, of a light brown colour, smooth and glistening on the surface, and of a soft, flabby consistence (W. G. MacCallum). When tetany follows operations for goitre it is due to the removal of these glands.
#Physiological Hyperaemia.#--The thyreoid varies greatly in size even within normal limits, and may become engorged and swollen from physiological causes, particularly in the female. Before the onset of menstruation at puberty, for example, the thyreoid frequently becomes engorged, and the enlargement may recur with each period for months or even years. During pregnancy also the gland may become swollen.
#Acute Thyreoiditis# may occur in a healthy thyreoid or in one that is the seat of goitre, and may end within a few days in resolution, or go on to suppuration. It is due to infection with pyogenic bacteria, which usually gain access to the gland by the blood stream, as, for example, in typhoid fever, pyaemia, influenza, and other acute infective diseases. Direct infection sometimes occurs from an abscess, a cellulitis, or an infected wound in the neck; it has also occurred from a foreign body impacted in the oesophagus ulcerating through and perforating the gland.
One lobe is usually more involved than the other, but the condition may be diffused. When pus forms it may infiltrate the stroma of the gland, or may be collected into several small foci.
Clinical Features.--The usual signs of inflammation are present; there is severe headache of a congestive nature, and sometimes vertigo. The swelling takes the shape of the thyreoid, and although the skin may not be red, the subcutaneous veins are dilated. In severe cases there is pain and difficulty in swallowing and dyspnoea.
When suppuration ensues, all the symptoms are aggravated, and repeated rigors occur. The pus may burst into the cellular tissue of the neck, or into the air-passage or the oesophagus.
Treatment.--In the non-suppurative stage the ordinary treatment of acute inflammatory conditions is employed; if pus forms, the abscess should be opened and drained.
#Tuberculous and syphilitic affections# of the thyreoid are very rare.
PARENCHYMATOUS GOITRE OR BRONCHOCELE
The term goitre is applied clinically to any non-inflammatory enlargement of the thyreoid gland.
Etiology.--Parenchymatous goitre, sometimes called also simple, or non-toxic goitre, is endemic in certain hilly districts in England--particularly Derbyshire and Gloucestershire--and in various parts of Scotland. It is exceedingly common in certain valleys in Switzerland. It is met with less frequently in men than in women, and it occurs chiefly during the child-bearing period of life. The toxic agent that causes goitre has been traced to certain mountain springs in goitrous districts; it has been observed that a patient with goitre may, through faecal contamination apparently, infect the water supply, and that conscripts in order to avoid military service have drunk from goitrous springs with success. Children born in a goitrous district are liable to be cretins, while if goitrous parents move to a healthy district, the children are born healthy. If the water supply of a goitrous valley be changed to a healthy spring, goitre and cretinism disappear. Thorough boiling of the water rids it of its toxic properties.
Morbid Anatomy.--Both the secreting and the fibrous elements share in the hyperplasia, and the gland as a whole becomes enlarged and forms a horseshoe-shaped swelling of moderate size in the neck. This swelling is soft and smooth on the surface, and is seldom quite symmetrical. In some cases the hypertrophy involves chiefly the isthmus. In others an outlying accessory lobule of thyreoid tissue constitutes the bulk of the swelling, and this may extend a considerable distance from the position of the normal thyreoid, reaching even behind the sternum into the thorax--infra-thoracic or retro-sternal goitre.
When the secreting elements increase out of proportion to the stroma, numerous rounded or irregular spaces filled with a thick yellow colloid material are formed in the substance of the goitre--colloid goitre. The majority of these spaces are not larger than a pea, but one or more may enlarge and form cysts of considerable size--cystic goitre. These varieties, especially the cystic form, attain greater dimensions than any other form of goitre.
When the fibrous stroma is greatly in excess--fibrous goitre--the swelling is smaller, firmer, and shows a greater tendency to contract and compress the trachea. If the sclerosis is extreme and the secretory tissue undergoes atrophy, myxoedema may result.
In some cases the hyperplasia affects chiefly the blood vessels of the thyreoid--vascular goitre. The capillaries, veins, and arteries are increased in size and number; the swelling pulsates and increases in size when the patient makes any muscular effort. Haemorrhagic cysts may also develop in the substance of these goitres.
* * * * *
Effects on the Trachea.--The trachea may be displaced laterally when the enlargement of the gland affects one lobe more than the other; or it may be compressed and narrowed from side to side--the scabbard trachea--when both lobes are about equally affected and the enlargement extends posteriorly so as almost to surround the air-passage (Figs. 278, 279). The third effect is that of softening of the cartilaginous rings of the trachea so that the air-tube, instead of having a considerable degree of elastic resiliency, is soft and flaccid and readily yields to pressure. Under these conditions an alteration in the attitude of the patient, from the erect or sitting to the recumbent position, would appear to be sufficient to permit of a compression of the trachea.
Further changes in the trachea consist in catarrh and engorgement of the blood vessels of its mucous membrane, attended with an abundant secretion of mucus, which, if it accumulates behind a narrowed segment of the trachea, may still further encroach on the lumen.
Pressure on other Structures.--The recurrent nerve may be pressed upon intermittently causing spasms and choking, or continuously causing abductor paralysis and hoarseness.
The gullet is rarely compressed; if marked difficulty in swallowing develops, some additional factor should be suspected, notably carcinoma at the junction of the pharynx with the oesophagus. The carotid arteries are displaced laterally beneath the sterno-mastoids without detriment; the superficial veins--anterior and external jugular--are greatly distended in those cases in which the goitre grows downwards behind the sternum.
Clinical Features.--The symptoms vary widely in different cases, and their severity is not proportionate to the size of the goitre. The disfigurement produced by the swelling is often the only cause of complaint. In some cases the symptoms are due to the pressure of the enlarged thyreoid on surrounding structures. In others toxic effects, in the form of cardiac, nervous, muscular, and general metabolic disturbances, predominate, and are due to absorption of excessive or abnormal thyreoid secretion. This thyreoid toxaemia varies in degree; in the milder cases it merely amounts to a nervousness or excitability that may unfit the patient for occupation; it reaches its maximum in the condition of hyperthyreoidism characteristic of exophthalmic goitre or Graves' disease (p. 614).
The skin over the goitre is freely movable, and the tumour itself can be moved transversely, carrying the larynx and trachea with it, but it cannot be moved vertically. It moves up and down with the larynx on swallowing--a point of great diagnostic value. Of the mechanical symptoms dyspnoea is the most constant. It may only amount to shortness of breath on exertion, or the patient may suffer from sudden and severe dyspnoeic attacks, especially when lying on the back during sleep, and such an attack may prove fatal. This may be due to the weight of the tumour pressing on the trachea, which has been softened and distorted by the goitre, or to temporary congestion and engorgement of the mucous membrane of the air-passages. In these cases there is marked stridor both on inspiration and expiration, but no aphonia. In rare cases the goitre presses upon the recurrent nerve, causing spasmodic dyspnoea, hoarseness, and aphonia from impaired movement of the vocal cords, and these symptoms, especially if accompanied by pain, raise the suspicion of malignancy. Disturbance of the heart's action may cause palpitation and sudden attacks of syncope; and pressure on the blood vessels may give rise to a feeling of fullness in the head, and giddiness.
The occurrence of haemorrhage into the substance of the goitre or into a cyst, produces a sudden aggravation of the symptoms.
In intra-thoracic or retro-sternal goitre the tumour displaces and compresses the trachea and causes dyspnoea, and there are occasional paroxysmal attacks of breathlessness, which may be mistaken for asthma, particularly as the patient is usually the subject also of bronchitis and emphysema. In some cases the patient can, by a violent expiratory effort, such as coughing, project the goitre upwards into the neck. When the goitre is fixed in the thorax, the clinical features are those of a mediastinal tumour with lateral displacement of the trachea, and engorgement of the veins of the neck.
Treatment.--The patient should change his residence to a non-goitrous district. The evidence regarding the benefit derived from the internal administration of thyreoid extract, or of preparations of phosphorus or of iodine, is conflicting.
Operative treatment is indicated when there are symptoms referable to pressure on the air-passage, and in goitres which are steadily increasing in size. Kocher considers it advisable to operate if the patient becomes breathless on making pressure on the goitre from side to side. The suspicion of a goitre becoming malignant is also a reason for removing it by operation.
The operation--thyreoidectomy--consists in excising that portion of the thyreoid which is causing pressure symptoms, and this usually involves removal of one-half of the gland. The chief danger in operations for goitre is cardiac insufficiency, as evidenced by disturbed rhythm of the heart-beats, lowering of the blood pressure, or dilatation of the cavities of the heart (Kocher).
It is sometimes advisable to perform the operation under local anaesthesia. A general anaesthetic is, however, preferred in this country. The injection of 1/6th grain of morphin and 1/120th grain of atropin half an hour before the operation, and the administration of ether by the open method, or by intra-tracheal insufflation, is safe and satisfactory.
There is reason to believe that the absorption of thyreoid secretion squeezed from the divided surfaces gives rise to a condition known as acute thyreodism during the first few hours after operation; its symptoms are elevation of temperature, increase in the pulse-rate (150-200), rapid respiration with dyspnoea, flushing of the face, muscular twitchings, and mental excitement. The gentle handling of the tumour and the employment of a drainage tube for the first forty-eight hours diminishes this risk.
Tetany, as evidenced by the occurrence of cramp-like contractions of the thumb and fingers, may supervene within a few days of the operation if one or more of the para-thyreoids have been inadvertently removed. It may be controlled by large doses of calcium lactate. On no account may the whole of the thyreoid gland be removed, as this is followed by the development of symptoms closely resembling those of myxoedema--operative myxoedema or cachexia strumipriva.
Treatment of Sudden Dyspnoea.--When dyspnoea suddenly supervenes and threatens life, it is sometimes possible to relieve the pressure on the trachea by open division of the skin, superficial fascia, platysma and deep fascia in the middle line of the neck, so as to relax the tension on the goitre. If this is insufficient, the isthmus may be divided. Should relief not follow, tracheotomy must be performed, and a long tube or a large-sized gum-elastic catheter with a terminal aperture be passed along the trachea beyond the seat of obstruction.
#Adenoma of the Thyreoid.#--In this condition the swelling of the thyreoid is due to the growth within its substance of one or more adenomas of variable size and surrounded by a capsule. The rest of the gland may be normal, or may show some degree of hyperplasia. Some are solid, others undergo cystic degeneration, the glandular tissue being replaced by a quantity of clear or yellowish fluid, sometimes mixed with blood. The cysts thus formed may be unilocular or multilocular, and intra-cystic papillary vegetations frequently grow from their walls. The walls of the cysts may be thin, soft, and flaccid, or thick and firm, or they may even be calcified.
The thyreoid is enlarged, but instead of the uniform enlargement which characterises the parenchymatous goitre, it tends to be uneven, with hillocky projections corresponding to the individual cysts (Fig. 280), and in these fluctuation may be detected. It is to be noted that there are no toxic symptoms in cystic adenoma.
The treatment is necessarily operative; cystic tumours may be tapped and injected with iodine, but the more satisfactory procedure, both with the solid and cystic forms, is to incise freely the overlying thyreoid tissue and enucleate the tumour.
#Malignant Disease of the Thyreoid.#--This, whether in the form of carcinoma or sarcoma, usually develops in a gland that has been the seat of goitre for several years, although it may begin in a previously healthy gland.
Clinical Features.--Both sexes, above the age of fifty, are affected in about equal proportion. The characteristic features are that the tumour undergoes a progressive increase in size, that it becomes fixed to its surroundings, that its surface tends to be uneven and nodular, and its consistence densely hard. The voice often becomes hoarse from abductor paralysis due to infiltration by the growth, usually of the left recurrent nerve. The effects upon the trachea are more decided and more progressive than in parenchymatous goitre; it displaces and compresses the trachea and frequently overlaps it, so as to bury the air-passage completely. If the tumour tissue has actually penetrated the trachea, the expectoration is tinged with blood. Dysphagia is rarely a prominent symptom. The lymph glands become enlarged after the tumour bursts through the capsule; and metastases to the lungs and bones, particularly the skull, sternum, and mandible, are common. When the goitre extends behind the sternum--the malignant form of retro-sternal goitre--the pressure symptoms are due to the encroachment upon the limited accommodation of the upper opening of the thorax; the trachea especially suffers, and the pressure on the veins causes distension of the anterior and external jugulars and their tributaries. The patient is unable to lie down; there are violent paroxysms of coughing, and an abundant frothy expectoration. Death may take place suddenly from asphyxia, from heart failure, or from displacement of a thrombus from one of the veins in the neck.
Treatment.--It is only in the earliest stages that a malignant goitre can be successfully removed. In the later stages complete extirpation is not to be attempted, as it usually involves the removal of a portion of the trachea or oesophagus, and the operation is attended with grave risk to life.
Operative interference is often called for, however, for the relief of respiratory embarrassment. Tracheotomy may prove a difficult and dangerous procedure, owing to the trachea being buried under the goitre and displaced or narrowed by it, so that it is not easy to reach it or to introduce an efficient tube beyond the point of obstruction. A more certain method consists in exposing the goitre by an incision as for thyreoidectomy, rapidly removing sufficient of the growth to expose the trachea and admit of a tube being introduced. If there is a retro-sternal prolongation compressing the trachea within the thorax, a long flexible tube may have to be passed beyond the site of the compression before the dyspnoea is relieved. The benefit is immediate and decided; the accumulated secretion is coughed up, and after a few deep breaths the patient is able to lie down, and usually falls asleep. The stridor disappears. Unfortunately the relief is only temporary, and the patient soon succumbs to a broncho-pneumonia, or to secondary haemorrhage from the trachea.
#Toxic Goitre#--#Exophthalmic Goitre#--#Graves'# or #Basedow's Disease#.--These terms are applied to a variety of goitre in which the symptoms due to absorption of thyreoid secretion--thyreotoxicosis--predominate. The name "exophthalmic goitre" is misleading, as in some cases the enlargement of the thyreoid, and in others the eye symptoms, are scarcely appreciable, while the general symptoms are well marked. The term toxic goitre or hyperthyreoidism, suggested by C. H. Mayo, is preferable, as the manifestations of the disease depend upon excessive or abnormal action of the thyreoid tissue.
The condition is chiefly met with in young adult women, and may develop suddenly after a shock to the nervous system. The intoxication affects the higher cerebral functions and causes nervousness, irritability, and tremor; the cardiac and vaso-motor centres, causing tachycardia and pallor of the skin; the sympathetic fibres to the eye, causing protrusion of the eyeballs, staring of the eyes without winking, narrowing of the palpebral fissure, dilatation of the pupil, and lagging behind of the upper lid, and sometimes also of the lower lid--von Graefe's symptom. There may be diarrhoea and vomiting, loss of weight, and in the worst cases there is delirium at night. In course of time there develops cardiac insufficiency with fibroid degeneration of the myocardium. Coagulation of the blood is retarded, and there is a marked diminution in the number of leucocytes, especially the neutrophils, and an increase in the lymphocytes (Kocher).
In the early stages the thyreoid is enlarged and pulsatile, and bruits may be heard over it; later, these vascular symptoms disappear, and only a firm, diffuse, uniform swelling implicating all parts of the gland remains.
Prognosis.--The tenure of life is uncertain as the patient offers little resistance to intercurrent affections such as influenza and pneumonia. If the average course of the disease is represented by a curve, the greatest height is reached during the second half of the first year and then descends. For the next two to four years it fluctuates with occasional exacerbations of symptoms due to fright or worry.
Treatment.--Medical measures, along with the external application of radium, the strict observance of rest in bed with the exclusion of all forms of excitement and worry, the administration of bromides, heroin or other sedatives, and of digitalis or other cardiac tonics, are to be prescribed in the first instance, and in any case, as a desirable preparation for operation.
Operative measures consist in the ligation of the vessels and nerves at one or other pole of the gland--usually the superior on one side--followed by, if necessary, a partial thyreoidectomy.
Crile of Cleveland has organised his clinic in the direction of arranging that the operation shall be performed without the patient knowing that it is to take place--what he calls "stealing the goitre"--the thorough preparation of the patient for the operation, the minimising the risk from the anaesthetic by the combination of novocain locally and of nitrous oxide and oxygen; and of diminishing the risk of absorption of thyreoid secretion by packing the (open) wound with gauze wrung out of a solution of flavin.
Operations on the cervical sympathetic cord have been abandoned.
The presence of toxic goitre may influence the question of operation in the treatment of other surgical conditions, and may determine the selection of one or other form of anaesthesia.
XXVIII. THE OESOPHAGUS
Surgical Anatomy--Methods of examination--Wounds--Rupture--Swallowing of caustics--Impaction of foreign bodies--Infective conditions: Oesophagitis; Peri-oesophagitis; Tuberculosis; Syphilis--Varix--Conditions causing difficulty in swallowing: Impaction of foreign bodies; Compression of the gullet from without; Spasm of the muscular coat; Cardiospasm; Paralysis of the gullet; Diverticula or pouches of the gullet; Innocent stricture; Malignant stricture, including cancer at the junction of pharynx and gullet and cancer at the lower end of the gullet.
#Surgical Anatomy.#--The oesophagus extends from the level of the cricoid cartilage to about the level of the lower end of the sternum. The distance from the upper incisor teeth to the commencement of the oesophagus is about 5 or 6 inches, and the oesophagus measures from 9 to 10 inches. The whole distance, therefore, from the teeth to the stomach is from 14 to 16 inches.
The cervical portion of the oesophagus, extending from the cricoid cartilage to the upper edge of the sternum, measures about 2 inches. It lies behind and to the left of the trachea, and in the groove between them on each side runs the recurrent nerve. The thoracic portion is about 7 inches long, and traverses the posterior mediastinum lying slightly to the left of the middle line. It is crossed by the left bronchus, and below this level has the pericardium immediately in front of it. The left pleura is closely related to the anterior surface of the oesophagus throughout, while the right pleura passes behind it in its lower part. This accounts for the frequency with which growths in the oesophagus invade the pleura. The oesophagus passes through the diaphragm about an inch above the cardiac opening of the stomach.
There are three points at which the oesophagus shows narrowing of the lumen: (1) at the lower border of the cricoid--the "mouth of the oesophagus"; (2) where it is crossed by the left bronchus; and (3) where it passes through the diaphragm. It is at these points that foreign bodies tend to become impacted. The mucous membrane of the oesophagus is insensitive to tactile and painful stimuli, but is sensitive to heat and cold and to exaggerated peristaltic contractions.
#Methods of Examination.#--It is sometimes possible to detect an impacted foreign body, a distended diverticulum, or a new growth in the cervical portion of the oesophagus by palpation.
Auscultation while the patient is drinking sometimes aids in the diagnosis of stricture; the stethoscope is placed at various points along the left side of the dorsal spine, and abnormal sounds may be heard as the fluid impinges against the stricture or trickles through it.
Introduction of Bougies.--Oesophageal bougies or probangs are used for diagnostic purposes in cases of suspected stricture, and to aid in the detection of foreign bodies. Various forms are employed, of which the most generally useful are the round-pointed gum-elastic or silk-web bougie, and the olive-headed metal bougie, consisting of a flexible whalebone stem, to which one of a graduated series of aluminium or steel bulbs is screwed. For some purposes, such as pushing onward an impacted bolus of food, the sponge probang--which consists of a small round sponge fixed on a whalebone stem--is to be preferred.
Before passing bougies, it is necessary to make certain that the symptoms are not due to the pressure of an aneurysm on the oesophagus, as cases have been recorded in which a thin-walled aneurysm has been perforated by a bougie. The existence of ulceration or of an abscess pressing on the gullet also contra-indicates the use of bougies.
For the passage of a bougie the patient should be seated on a chair with the head thrown back and supported from behind by an assistant, and he is directed to take full deep breaths rapidly. The bougie, lubricated with butter or glycerine, and held like a pen, is guided with the left forefinger. As soon as the instrument engages in the opening of the oesophagus, the chin is brought down towards the chest, and if the patient is now directed to swallow, the instrument may be carried down the oesophagus, or can be passed on by gentle pressure. Great gentleness must be exercised, and no attempt should be made to force the instrument past any obstruction. The instrument may catch against the hyoid bone, and this may be mistaken for an obstruction.
It is to be borne in mind that in some cases the passage of a bougie may be attended with a considerable degree of shock, and cases are on record in which this has proved fatal without any gross lesion being found after death.
Intubation, or the passage of a cannula through a stricture, is referred to later.
Oesophagoscopy.--The oesophagoscope--a form of speculum which enables the oesophagus to be illuminated by an electric lamp--is employed for the detection and removal of foreign bodies, for the examination of ulcers, diverticula, and strictures of the tube, and with its aid it is possible to remove a portion of a growth for microscopic examination. The mouth, pharynx, and entrance to the oesophagus having been cleansed and cocainised, the patient is placed in the recumbent or sitting posture, and the tube introduced. For prolonged examinations a general anaesthetic is preferred.
The mouth of the oesophagus is closed by the sphincter-like action of the lower fibres of the inferior constrictor muscle, and the cervical part of the tube appears as a transverse slit, due to the backward pressure of the trachea. The thoracic portion is more open and may contain air, so that it is possible to see down to the lower end, the closed cardiac orifice appearing as an oblique cleft surrounded by a rosette-like cushion of mucous membrane. The pulsation of the aorta can be seen just above the prominence formed by the left bronchus.
Radiography.--Opaque foreign bodies can be detected by the screen or in a radiogram; and the position of a stricture by making the patient swallow capsules containing bismuth and examining with the screen. To determine the position and size of a diverticulum, a radiogram is taken after the patient has swallowed some food, such as porridge mixed with bismuth.
#Wounds# of the oesophagus inflicted from without, for example stabs, cut-throat or gun-shot injuries, are rare, and are almost invariably accompanied by lesions of other important structures in the neck, which may rapidly prove fatal. It is more common to meet with wounds inflicted from within, for example by the swallowing of rough and irregularly shaped foreign bodies, or by unskilful attempts to remove such bodies or to pass bougies along the oesophagus. The severity of the lesion varies from a scratch of the mucous membrane to a perforation of the tube. The less severe injuries are attended with pain on swallowing and a sensation as if something had lodged in the oesophagus. In more severe cases there is bleeding, followed by attacks of coughing and expectoration of blood-stained mucus. When the oesophagus is perforated, diffuse cellulitis of the neck or of the posterior mediastinum may ensue. In the treatment of these injuries the chief point is to give the oesophagus rest by feeding the patient entirely by the rectum or through an opening made in the stomach--gastrostomy.
#Rupture# of the oesophagus has occurred during violent vomiting, and during lavage. The tear is longitudinal and is usually near the cardiac orifice. It is probably due to increased pressure within the gullet. The accident has usually been met with in alcoholics, and has proved fatal by setting up left-sided empyema or cellulitis.
#Swallowing of Corrosive Substances.#--The oesophagus is damaged by the swallowing of strong chemicals, such as sulphuric acid, nitric acid, carbolic acid, or caustic potash. These substances produce their worst effects at the two ends of the oesophagus, but in some cases the whole length of the tube suffers. The mucous membrane alone may be destroyed, or the muscular and even the fibrous coats may also be implicated. The damaged tissue undergoes necrosis, and when the sloughs separate, raw surfaces are left, and are very slow to heal.
If not rapidly fatal from shock and oedema of the glottis, these injuries are usually attended with intense pain, severe thirst, and vomiting, the vomit containing shreds of mucous membrane and blood. Complications, such as cellulitis, perforation of the oesophagus, or peri-oesophageal abscess, may follow. Later, cicatricial contraction takes place at the injured portions, producing the most intractable form of fibrous stricture.
The treatment consists in administering solutions of carbonate of potash, of soda, or of magnesia when an acid has been swallowed, or vinegar diluted with water in the case of an alkali. When carbolic acid has been swallowed, a large quantity of olive oil should be administered. The stomach should be washed out with water, the tube being passed with the greatest gentleness to avoid perforating the softened oesophageal wall. Subsequently the patient should be fed by the rectum, but, in the majority of cases, gastrostomy is called for to enable the patient to take nourishment and put the gullet at rest.
As soon as the oesophagus has healed, say in three or four weeks, bougies should be passed every three or four days to prevent cicatricial contraction. As the calibre of the tube is restored, the instruments may be passed less frequently, but for some years--it may be for the rest of the patient's life--a full-sized bougie should be passed at least once a month.
#Impaction of Foreign Bodies in the Pharynx and Oesophagus.#--It is an interesting fact that foreign bodies, even as large as a dinner fork, when intentionally swallowed, can pass through the pharynx and oesophagus and enter the stomach without apparent difficulty. When the body is accidentally swallowed impaction is more liable to take place, probably on account of the spasm induced by fright and by inco-ordinated attempts to eject it. For obvious reasons the accident is most liable to occur in children, in epileptics, and in those who are under the influence of alcohol. It happens also during anaesthesia for the extraction of teeth or if the patient vomits solid substances. The clinical aspects vary according as the object is impacted in the pharynx or in the oesophagus.
In the Pharynx.--If a large bolus of unmasticated food becomes impacted in the pharynx, it blocks the openings of both the oesophagus and the larynx, and the patient may, without manifesting the usual signs of suffocation, suddenly fall back dead, and if he happens to be alone at the time of the accident, the cause of death is liable to be overlooked unless the pharynx is examined at the post-mortem examination. Most surgical museums contain specimens illustrating the impaction of a bolus of meat in the pharynx; this fatal accident has occurred especially in men in a condition of alcoholic intoxication.
An object of irregular shape, for example a large denture, also, is most likely to lodge in the pharynx, obstructing the openings of both the oesophagus and the larynx, and causing suffocation. The face immediately becomes blue and engorged, the patient is speechless, and violent efforts are made to eject the object by retching and coughing. It may be seen from the mouth and touched with the finger.
In the case of small sharp bodies, such as fish, game, and mutton bones, there is not the same urgency, and a methodical search for the foreign body is carried out. Even after the foreign body has been got rid of, the patient may have the sensation that it is still present. This may be due to a scratch of the mucous membrane, or to spasm, in which case the swallowing of a few drops of cocain solution will cause the sensation to disappear.
Treatment.--In the presence of impending suffocation, the mouth must be forced open by an extemporised gag, the finger passed into the back of the throat, and the body hooked out. If this is impossible, and if suitable forceps are not at hand, it may be necessary at once to perform laryngotomy, followed by artificial respiration, because, although the patient may appear lifeless, the heart continues to beat after breathing has ceased. The foreign body should then be removed with forceps. Sub-hyoid pharyngotomy, which consists in opening the pharynx by a mesial vertical incision carried through the hyo-thyreoid membrane, may be called for, as in the case of a denture, the hooks of which have penetrated the wall of the pharynx.
In the Oesophagus.--Smaller bodies, such as coins, bones, or pins, usually enter the oesophagus, and the great majority become impacted above the level of the manubrium sterni. Those that pass farther down are liable to stick where the tube is narrowed at the crossing of the bronchus, or at the opening through the diaphragm. In children, coins predominate and are nearly always arrested at the level of the upper end of the sternum; in adults, dentures are the commonest foreign bodies, and may be impacted anywhere.
At the moment of impaction there is pain, which assumes the character of cramp due to spasm of the muscular coat, and which is increased on attempting to swallow, and violent retching and coughing are set up; in many cases, as when bodies are impacted in the pharynx, respiratory distress is again the predominant feature. If the passage is completely obstructed, food and saliva--sometimes blood-stained--are regurgitated with retching soon after being swallowed. When the obstruction is incomplete, fluids may pass into the stomach while solids are regurgitated.
If the mucous membrane is injured, there is severe stabbing pain and choking attacks, both due to spasm, sometimes even after the body has passed on, and the pain is not always referred to the seat of the injury.
The diagnosis is made by the history, and by the use of the fluorescent screen, or X-ray photographs (Figs. 283, 284). The oesophagoscope is also of great value, both for diagnostic purposes and as an aid in the removal of the impacted body. Bougies are to be employed with great care, as there is a danger of pushing the foreign body farther down, or of wedging it more firmly in the oesophagus, and the information obtained is often misleading.
It should be borne in mind that drunkards may suffer from a form of spasm of the oesophagus, which simulates the impaction of a foreign body; hospital records also show that the patient may only have dreamt that he has swallowed a foreign body, usually a denture. These possibilities should be always excluded before further procedures are undertaken.
Treatment.--There being no urgency, a careful examination is carried out, not only to confirm the impaction of a foreign body, but its site and its relation to the wall of the gullet. In skilled hands, the safest and most certain means of removing impacted foreign bodies is with the aid of the oesophagoscope. If this apparatus is not available, other measures must be adopted varying with the nature of the body, its site, and the manner of its impaction.
A bolus of food, for example, or a small smooth object that is likely to pass safely along the alimentary canal, if it cannot be extracted with forceps, may be pushed on into the stomach by the aid of a bulbous-headed or sponge probang. This must be done gently, especially if the body has been impacted for any time, as the inflammatory softening of the oesophageal wall may predispose to rupture.
Small, sharp, or irregular objects, such as fish bones, tacks, or pins, may be dislodged by the "umbrella probang"--an instrument which, after being passed beyond the foreign body, is expanded into the form of a circular brush which, on withdrawal, carries the foreign body out among its bristles.
Coins usually lodge edgewise in the oesophagus, and are best removed by means of an instrument known as a "coin-catcher", which is passed beyond the coin, and on being withdrawn catches it in a hinged flange. In emergencies a loop of stout silver wire bent so as to form a hook makes an excellent substitute for a coin-catcher.
In difficult cases the removal of solid objects is facilitated by carrying out the manipulations in the dark room with the aid of the X-rays and the fluorescent screen.
Irregular bodies with projecting edges or hooks, such as tooth-plates, tend to catch in the mucous membrane, and attempts to withdraw them by forceps or other instruments are liable to cause laceration of the wall. When situated in the cervical part of the oesophagus, these should be removed by the operation of oesophagostomy (Operative Surgery, p. 195).
If the foreign body is lodged near the lower end of the gullet, it may be necessary to perform gastrostomy (Operative Surgery, p. 291), making an opening in the anterior wall of the stomach large enough to admit suitable forceps, or, if necessary, the whole hand, in order that the body may be extracted by this route; experience shows that an impacted body is more easily extracted from below, that is, from the stomach, than from above.
When the surgeon fails to remove the body by either of these routes, gastrostomy must be performed both to feed the patient and to place the gullet at rest. Smooth bodies may lie latent for long periods, but those with points or hooks damage the mucous membrane, cause ulceration and perforation with the risk of erosion of vessels and secondary haemorrhage or of cellulitis of the neck or mediastinum and empyema.
Other complications include septic broncho-pneumonia from damage to the air-passage, and suppurative thyreoiditis.
#Infective conditions# due to pyogenic infection (oesophagitis and peri-oesophagitis) are rare.
A chronic form of oesophagitis is occasionally met with in alcoholic subjects, giving rise to symptoms that simulate those of impacted foreign body, or of stricture.
In tuberculous lesions the symptoms are pain, dysphagia, and regurgitation of food mixed with blood, and the condition is liable to be mistaken for gastric ulcer or for cancer of the oesophagus.
Syphilitic affections of the oesophagus are rare.
#Varix# at the lower end of the oesophagus may give rise to haematemesis, and be mistaken for gastric ulcer. Bleeding from the dilated veins may follow the use of bougies or of the oesophagoscope.
CONDITIONS CAUSING DIFFICULTY IN SWALLOWING
Difficulty in swallowing may arise from a wide variety of causes which it is convenient to consider together.
#Impaction of Foreign Bodies# has already been discussed, and attention has been drawn to the importance of the history given by the patient and to the various sources of fallacy or deception--in children it may be artful reticence or misrepresentation, in adults, the possibility of nightmare and of dreams.
#Compression of the Gullet from without.#--Any one of the numerous structures in relation to the gullet may, when enlarged as a result of disease, give rise to narrowing of its lumen, for example a lymph-sarcoma at the root of the lung, or any enlargement of the thyreoid or of the mediastinal lymph glands. The possibility of aneurysm must always be kept in mind because of the risk attending the passage of instruments for diagnostic purposes.
#Spasm of the Muscular Coat.#--As in other tubular structures containing circular muscular fibres, sudden contraction or spasm may occur in the oesophagus and cause narrowing of the lumen, attended with difficulty in swallowing. This spasmodic dysphagia includes such widely varying conditions as the "globus hystericus" of neurasthenic women, the spasm of chronic alcoholics, and the affection known as cardiospasm or "hiatal oesophagismus."
In contrast with other affections causing difficulty in swallowing, spasmodic dysphagia usually has a sudden and unexplained onset, the progress of symptoms is irregular and erratic, while the remission of symptoms common to all affections of the oesophagus, and the influence of mental impressions, such as excitement, hurry in the presence of strangers, are exaggerated.
In testing the calibre of the gullet it is found that on one occasion a full-sized bougie may pass easily and be completely arrested at another.
Apart from the treatment of the neurosis underlying the dysphagia, reliance is placed upon dilatation of the portion of gullet affected.
#Cardiospasm# is the name given to "a recurrent interference with deglutition by spasmodic contraction of the lower end of the oesophagus." As there is no muscular or nervous mechanism at the cardiac end of the oesophagus forming a true sphincter, the term "oesophagospasm" would be more accurate (D. M. Greig).
According to H. S. Plummer, who has had an experience of 130 cases, there are three stages in the development of this condition. In the initial stage, the first attack occurs suddenly and unexpectedly; a choking sensation is felt at some point in the gullet, usually at its lower end. Attacks of choking with difficulty in swallowing occur chiefly at meals, but they have also been known to occur apart from the taking of food. In this stage the peristalsis of the gullet is sufficient to force the food through the cardia.
In the second stage, the peristalsis of the gullet above being no longer able to overcome the contraction, there is regurgitation of food, which at first is returned to the mouth immediately after being swallowed, but, as the gullet becomes dilated, is retained for longer periods.
In the third stage, the gullet becomes more and more dilated, and the food collects in it and is regurgitated at irregular intervals. The patient complains of a sensation of weight and discomfort in the lower part of the chest, and sometimes of regurgitation of food into the nasal passages during sleep.
Cardiospasm should be suspected as the cause of difficulty in swallowing if a rubber tube cannot be passed into the stomach while a solid one can. When it is impossible to pass a solid instrument in the ordinary way it can always be passed on a silk thread as a guide. The patient is directed to swallow 6 yards of silk thread, half in the afternoon and the remainder on the following morning. The first portion forms a snarl in the gullet or stomach which passes out into the intestine during the night; the proximal end is fixed to the cheek by a strip of plaster. The olive heads of the bougies are drilled for threading from the tip to one side of the base.
The treatment consists in dilating the contracted segments by a bougie. The results are immediate and are most striking, the patients being almost invariably able to take any kind of food at the following meal, and the gain in weight and strength is rapid. In a small proportion of cases, dilatation fails to give relief, and recourse has been had to anastomosing the lower end of the dilated and pouched oesophagus with the stomach.
#Paralysis of the Gullet.#--As the passage of the food along the gullet is entirely dependent upon muscular peristalsis, when the muscular coat is paralysed, as it may be after diphtheria, for example, the patient is unable to swallow and the food materials are regurgitated, with consequent loss of flesh and strength. The difficulty may be tided over for a time by feeding through a rubber tube, but it is to be remembered that, in children, struggling in resisting the passage of the tube may seriously strain a heart that is already threatened by the toxins of diphtheria.
#Diverticula or Pouches of the Gullet.#--A diverticulum consists in the protrusion of the mucous and submucous coats through a defect or weak part in the muscular tunic; it is therefore of the nature of a hernia and not a localised dilatation of the tube as a whole. Anatomically, there is such a weak spot in the posterior wall opposite the cricoid cartilage, known as the pharyngeal dimple, between the circular and oblique fibres of the crico-pharyngeus muscle. As the pouch increases in size by pressure from within, it usually extends downwards and to the left. This pouch is described as a pressure or pulsion diverticulum because the hernial protrusion is ascribed to increased pressure within the pharynx, not only the normal increase caused by the act of swallowing, but an abnormal pressure from the too rapid swallowing or bolting of imperfectly masticated food materials.
The clinical features are not so characteristic of difficulty in swallowing as might be expected. The patient, usually a man over forty years of age, complains of dryness in the throat and of a sensation as of a foreign body; later there is regurgitation of saliva and of food with occasional choking. In about one-third of the cases, there is a fullness, or a palpable tumour in the neck, about three times more often on the left than on the right side, which may increase in size after a meal, and pressure on which may cause a gurgling sound and, it may be, regurgitation of food.
It is suggestive of a pouch, if the patient regurgitates food materials which can be identified as having been swallowed several days before, currants perhaps being those most easily recognised and remembered.
Diverticula are also met with at a lower level, springing from the gullet at or below the upper opening of the thorax; the distension of the pouch with food materials presses upon the gullet with more serious effect, even to the extent of complete obstruction and consequent rapid emaciation. In men over fifty, the resemblance to carcinoma may be very close.
In this, as in all cases of difficulty in swallowing, chief stress should be laid on the X-ray appearances after the administration of an opaque meal; a pouch shows as a uniform, spherical shadow of from one to two inches in circumference.
Treatment is influenced by the manner in which the patient may have learned to overcome the difficulty of getting food into his stomach--Lord Jeffrey, who was the possessor of the pharyngeal pouch shown in Fig. 286, was in the habit of emptying it, after a meal, by means of a long silver spoon. Some patients learn to feed themselves through a soft rubber tube.
If an operation is decided upon, and for this it is essential that the pouch should be accessible from the neck, the general condition is improved by feeding through a stomach tube and by rectal and subcutaneous salines. The operation consists in exposing and isolating the pouch by a dissection on the left side of the neck, and either excising it as if it were a tumour or cyst, or if the risk of infection of the deeper planes of cellular tissue is regarded with apprehension, the pouch may be infolded into the lumen of the gullet, or the excision be carried out in two stages. At the first stage, the pouch is isolated and rotated on its pedicle, in which condition it is fixed by sutures; after an interval of from ten to fourteen days it is excised.
Should the diverticulum be inaccessible from the neck, and the difficulty of swallowing be attended with progressive emaciation, gastrostomy may be required to avert death by starvation.
Traction diverticula are due to the contraction of scar tissue outside the gullet, as for example that resulting from tuberculous glands in the posterior mediastinum; they are rarely attended with symptoms, and are rather of pathological than surgical interest.
#Innocent Stricture or Cicatricial Stenosis of the Gullet.#--The innocent or fibrous stricture follows upon the swallowing of corrosive substances, usually by inadvertence, sometimes with suicidal intent. Having recovered from the initial effects of the corrosive agent, the patient suffers from gradually increasing difficulty in swallowing, first with solids and later with fluids. There is the usual variation or intermittence of symptoms that attend upon all conditions causing difficulty of swallowing, the exacerbations being due to superadded spasm of the muscular coat and congestion of all the coats. As the gullet dilates above the stricture, there is an increasing accumulation of what has been swallowed, and this the patient regurgitates at intervals; this is usually described as "vomiting," but the material ejected shows no signs of gastric digestion. There is pain referred to the epigastrium or between the shoulder-blades, the patient suffers from hunger and thirst, and may present an extreme degree of emaciation.
The diagnosis is suggested by the history, and is confirmed by the oesophagoscope or by the X-rays after an opaque meal. The use of bougies has taken a secondary place since the introduction of these methods of examination, but, when other means are not available, the passage of bougies having a whalebone shaft and a series of metal heads shaped like an olive, may give useful information regarding the site, number, and size of the strictures that require to be dealt with.
Treatment.--If the patient is in a critical state from starvation, gastrostomy must be performed to enable him to be fed; otherwise he is prepared for treatment of the stricture by rest in bed, sedatives, and suitable liquid or some solid foods to improve his general condition and eliminate the muscular spasm and congestion already referred to. If the passage of bougies with the object of dilating the stricture is difficult or impossible, it may be made easier or possible by getting a silk thread through the stricture. The patient swallows several yards of a reliable silk thread a day or two before the proposed dilatation is carried out; the thread is expected to pass through the stricture of the stomach, and to enter for some distance into the small intestine; the metal head of the bougie, which is canalised in its long axis, is "threaded" on the silk, and the latter acting as a guide, the bougie is passed safely and confidently through the stricture. Larger olive-shaped heads are passed at intervals until the normal calibre of the gullet is exceeded, after which it is usually easy to pass an ordinary full-sized instrument at intervals of a month or so.
In the event of failure, recourse must be had to gastrostomy, and through the stomach it may be possible to dilate the stricture by the "retrograde" route. In aggravated cases, the gastrostomy opening must be retained in order to prevent death from starvation.
#Malignant Stricture--Carcinoma of the Gullet.#--This is met with in two forms which present widely different pathological and clinical features.
Cancer of the cervical portion affects the gullet at its junction with the pharynx, and for some unexplained reason is much more common in women, and at the comparatively early age of between thirty and fifty. Cancer of the thoracic portion affects the extreme lower end of the gullet, and is met with almost exclusively in men over fifty.
#Cancer of the Cervical Portion.#--Difficulty of swallowing may arise suddenly; more often it is slow and progressive over a period of months and, in some cases, even of years. Pain on swallowing is not a constant or prominent feature; it may be referred to the site of the lesion or to one or both ears. In a considerable number of cases, the complaints of the patient are referred to the larynx; coughing, with abundant mucous expectoration disturbing the night's rest, hoarseness, or even loss of voice, which symptoms are due either to direct invasion of the larynx or to implication of one or other recurrent nerve; for the same cause, difficulty of breathing may supervene, sometimes of such a nature as to render tracheotomy imperative. A gurgling noise on swallowing, and regurgitation of food are occasionally observed.
Palpation of the neck, and particularly of the larynx and trachea, should be carried out in all cases presenting the symptoms described; and as bearing on the question of operation, enlargement of the cervical lymph glands and of the thyreoid should be looked for; cancer of the thyreoid is sometimes secondary to disease at the pharyngo-oesophageal junction.
Direct and indirect laryngoscopic examination is then made; if the laryngeal mirror fails to reveal anything abnormal, suspension laryngoscopy, which gives a more extensive view of that part of the pharynx lying behind the larynx, may be employed, or the oesophagoscope may be preferred. A portion of the growth may be removed for microscopical examination.
The use of the oesophageal bougie as a diagnostic agent must be deprecated; it gives no satisfactory explanation of the cause of the obstruction, and its employment when malignant ulceration is present, is not free from serious risk to the patient (Logan Turner).
Treatment.--The surgeon is dependent on the help of the laryngologist not only for the diagnosis of the disease at the earliest stage possible, but also for information as to its extent, especially with regard to involvement of the larynx.
Oesophagectomy, or resection of the cancerous segment of the gullet, in suitable cases, even if it does not yield a permanent cure, not only prolongs life but relieves the patient of her most distressing symptoms. It is rarely possible to secure an end-to-end anastomosis, but the feeding by means of a tube introduced into the open end of the gullet is more satisfactory and the laryngeal symptoms are more efficiently relieved, than by either of the purely palliative operations. In the majority of cases, however, only the palliative measures of oesophagostomy or gastrostomy can be adopted. Oesophagostomy presents the advantage, that by exposing the cervical portion of the gullet, the operator is enabled to investigate the extent of the disease and to revise his opinion on the feasability of its removal if necessary. In advanced cases, when the disease has spread widely in the neck and involved, it may be, the thyreoid and the larynx, it may only be possible to relieve the urgent distress of the patient by gastrostomy. Tracheotomy may also become necessary because of the spread of the cancer to the interior of the larynx.
#Cancer of the Lower End of the Gullet.#--The remarkable preference of this location of oesophageal cancer for the male sex has already been referred to; it affects the same type of male patients as are subject to squamous epithelioma in other parts of the body. So far as we have observed, its association with chronic irritation of the mucous membrane in which it takes origin, or with any pre-cancerous condition, has not been demonstrated.
The clinical features resemble those of cicatricial stricture; the difficulty of swallowing is usually of gradual onset, it concerns solids in the first instance, then semi-solids like porridge or bread and milk, and finally fluids. As in other forms of oesophageal obstruction, the difficulty of swallowing varies quite remarkably from time to time, presumably from variations in the degree of congestion of the mucous membrane and of spasm of the muscular coat, but also from mere nervousness, the patient having greater difficulty when in a hurry, as in a railway refreshment room, or embarrassed by the presence of strangers.
As the lumen of the gullet becomes narrower, the food materials accumulate above the obstruction, and the consequent dilatation of the gullet above the stricture accounts for the large amount that may be regurgitated and for the patient describing it as vomiting. Along with food materials there is abundant saliva, and, if the cancer has ulcerated, of pus and blood. Contrary to what might be expected, there is little or no complaint of hunger, in spite of the progressive starvation and emaciation which inevitably supervene.
Death takes place within a year or so of the onset of symptoms, usually from starvation, but the fatal issue may be precipitated by ulceration and perforation of the gullet into a large blood vessel or into the left pleural sac; in the latter event, there follows a basal empyema which may contain gas and food materials.
Diagnosis.--In the majority of cases the history is so characteristic that there is little doubt regarding the diagnosis; the most reliable corroboration, with least risk and distress to the patient, is obtained by radiographic examination after an opaque meal; the appearance of the dilated gullet is that of an elongated sausage, parallel with the vertebral column, and terminating abruptly at the site of stricture (Fig. 285). A filiform, tortuous shadow of the bismuth may be continued downwards and show up the lumen of the stricture. The use of the oesophagoscope and of bougies is to be deprecated as not free from risk.
Treatment.--The lower end of the gullet is one of the most inaccessible portions of the body, and although it has been removed by operation the prospects of success are so small that it is not at present regarded as justifiable.
Among palliative measures, may be mentioned intubation of the stricture with a view to increasing the amount of food that can be swallowed; a funnel-shaped tube like that of Symonds or of Hill is introduced into the lumen of the stricture by means of a bougie or with the help of the oesophagoscope. The tube is anchored to a denture, or by means of a silk thread to the cheek by sticking-plaster. Our experience of intubation is that it merely serves to tide the patient over a critical period of starvation, so that he may regain some strength for any other procedure that may be indicated.
The value of making a fistula in the stomach--gastrostomy--in order to feed the patient, is a question about which widely different opinions are held both by patients and by surgeons. Many patients allege that they would prefer to die rather than prolong a precarious existence by being fed through a tube; some surgeons look upon the operation with disfavour because they doubt whether it even prolongs life, and it is often followed by a pneumonia which rapidly proves fatal. Variation in the results of gastrostomy observed by different surgeons is partly due to differences in the stage of the disease at which the operation is performed, and probably to a greater extent to the confusion between cases of slowly growing squamous epithelioma of the lower end of the gullet and cases of glandular carcinoma of the cardiac end of the stomach, these being grouped together under the clinical heading of "malignant stricture of the lower end of the gullet." In our experience cases of epithelioma of the gullet (in the strict sense of the term) benefit greatly if subjected to gastrostomy as soon as the condition is recognised. In a case operated upon by Thomas Annandale the patient survived the operation for three years and some months.
Radiation.--The introduction of a tube of radium into the stricture and its retention there, the silk thread attached to the tube being secured to the cheek by a strip of plaster, is described by Hill and Finzi as the most valuable palliative measure that has so far been employed in cancer of the gullet; the capacity of swallowing may be regained to a considerable extent. The employment of radium is rendered easier and more efficient if it is preceded by gastrostomy.
The Roux-operation.--This consists in making a new gullet to replace that which is obstructed; the abdomen is opened and a loop of jejunum is isolated; its lower end is anastomosed--end to side--to the stomach; the intestine is brought upwards through a tunnel made for it between the skin and the sternum, and the upper end is brought out and fixed to the skin, in the supra-sternal notch. It has scarcely passed beyond the experimental stage.
XXIX. THE LARYNX, TRACHEA, AND BRONCHI[7]
Examination of the larynx--CARDINAL SYMPTOMS OF LARYNGEAL AFFECTIONS: (1) Interference with the voice: Hoarseness; Aphonia--(2) Dysphagia--(3) Interference with respiration: Diphtheritic laryngitis; Acute oedema of the larynx; Intubation of the larynx; Tracheotomy; Bilateral abductor paralysis; Syphilitic affections; Tuberculosis--Tumours: Papilloma; Epithelioma; Sarcoma--Foreign bodies in the air-passages: In the pharynx, larynx, trachea, bronchi.
[7] Revised by Dr. Logan Turner.
#Examination of the Larynx.#--For this purpose the examiner requires a laryngeal reflector with forehead attachment, one or two sizes of laryngeal mirror, a tongue cloth, and the means of obtaining good illumination. The source of light should be by preference placed opposite to and on the same horizontal plane as the patient's left ear. The forehead reflector is placed over the observer's right eye so that he may look through the central aperture, while at the same time he throws a good circle of light into the patient's mouth. The patient should be seated with the head thrown slightly back; the tongue is protruded and covered with the cloth, and held lightly but firmly between the finger and thumb of the left hand. A full-sized mirror, warmed so as to prevent the condensation of the breath upon it, is inserted with the reflecting surface turned downwards, and pressed gently against the soft palate so as to push that structure upwards. The handle of the instrument is carried towards the left angle of the mouth, and by slightly altering the plane of the reflecting surface of the mirror the different parts of the larynx are in turn brought into view. The movements of the vocal cords should be observed during both respiration and phonation, and for the latter purpose the patient should be directed to phonate the vowel sound "eh."
In the upper part of the mirror the epiglottis usually comes first into view: it is of a pinkish yellow colour, and presents a thin, sharply defined free margin. In front of the epiglottis are the median and lateral glosso-epiglottic folds passing forwards to the base of the tongue, and enclosing the two valleculae. Extending backwards and downwards from the lateral margins of the epiglottis are the two ary-epiglottic folds which reach the arytenoid cartilages posteriorly. Between the two layers of mucous membrane of which the ary-epiglottic folds are composed are the cartilages of Wrisberg and Santorini. In the interval between the two arytenoid cartilages is the inter-arytenoid fold of mucous membrane, which forms the upper margin of the posterior wall of the larynx. The upper aperture of the larynx is bounded by the epiglottis in front, the ary-epiglottic folds laterally, and the inter-arytenoid fold behind. In the interior of the larynx the vocal folds (true vocal cords) form the most prominent features, being conspicuous as two flat white bands, which form the boundary of the rima glottidis or glottic chink. Above each true cord, and parallel with it, the ventricular fold or false cord is evident as a pink fold of mucous membrane. Between the ventricular fold and the vocal fold on each side is a linear interval, which indicates the entrance to the ventricle of the larynx.
Direct Laryngoscopy.--The larynx may also be examined by the direct method by means of Jackson's or Killian's spatulae. After cocainisation of the base of the tongue, the soft palate, and the posterior surface of the epiglottis, the patient is seated upon a low stool and his head supported by an assistant. The light is obtained from a small lamp in the handle of the instrument or reflected from a forehead mirror. The spatula is warmed and introduced under the guidance of the eye, its end being passed over the epiglottis, and pressure exerted so as to draw the latter structure forward. In children a general anaesthetic is required, and the examination is made with the head hanging over the end of the table. Killian's "suspension laryngoscopy" affords the best method of examining the larynx in young children.
Tracheoscopy and Bronchoscopy.--Direct examination of the trachea and larger bronchi may be carried out in a similar way, by passing through the mouth and larynx metal tubes, after the method devised by Killian. This procedure is described as direct upper tracheoscopy and bronchoscopy. The examination may also be made through a tracheotomy wound--direct lower tracheoscopy. These procedures have proved of great service in the recognition of foreign bodies in the lower air-passages, and in their extraction; in the diagnosis of stenosis of the trachea, and of aneurysm pressing on the trachea.
CARDINAL SYMPTOMS OF LARYNGEAL AFFECTIONS
The cardinal symptoms of laryngeal affections are interference with the voice and with respiration, and pain on swallowing. Laryngeal cough of a croupy or barking character may be present, and is usually associated with a lesion of the posterior wall or inter-arytenoid fold. Haemoptysis is seldom of laryngeal origin, and unless the bleeding spot is visible in the mirror, the source of the bleeding is much more likely to be in the bronchi or lungs.
#Interference with the Voice.#--Hoarseness results from some affection of the vocal cords: it may be simple laryngitis, some specific cause such as tuberculosis or syphilis, or some condition which prevents the proper approximation of the cords, as in tumours and certain forms of paralysis. Huskiness of voice occurring in a middle-aged person, lasting for a considerable period, and unattended by any other local or constitutional symptom, should always arouse suspicion of malignant disease, and calls for an examination of the larynx. Should this reveal a congested condition of one vocal cord, associated with some infiltration, and should the mobility of the cord be impaired, suspicion of the malignant character of the affection is still further increased. The hoarseness in these cases is sometimes greater than the local appearances would seem to account for.
Aphonia, or loss of voice, sudden in origin, and sometimes transient, occurs more often in women, and is usually functional or hysterical in nature. Although the patient is unable to speak, she is quite able to cough. In these cases there is a bilateral paralysis of the adductor muscles, so that the cords do not approximate on attempted phonation; or the internal tensors may be paretic, leaving an elliptical space between the cords on attempted phonation. If the arytenoideus muscle alone is paralysed, a triangular interval is left between the cords posteriorly. There is no inflammation or other evidence of local disease.
The treatment of functional aphonia should be general and local; tonics such as strychnin, iron, and arsenic should be administered; the intra-laryngeal application of electricity usually effects a sudden cure. In obstinate cases the use of the shower-bath and cold douching, the administration of chloroform, and even hypnotism may be tried.
An examination of the lungs should be made in all cases of adductor paralysis, as this functional condition may be met with in early pulmonary tuberculosis.
#Dysphagia.#--Pain on swallowing, due to causes originating in the larynx, is usually associated with ulceration of the mucous membrane covering the epiglottis, ary-epiglottic folds, or arytenoid cartilages, that is, in connection with those parts with which the food is brought into direct contact.
The most frequent causes of such ulceration are tuberculosis, syphilis, and malignant disease. The differential diagnosis is often difficult from local inspection alone. The Wasserman test, the previous history, the state of the lungs and sputum, and the results of anti-syphilitic treatment may clear it up.
The treatment of dysphagia, apart from that of the disease associated with it, resolves itself into the use of local sedative applications, such as a weak cocain or eucain spray before meals, insufflations of acetate of morphin and boracic acid, and the use of a menthol spray. One of the best anaesthetic applications is orthoform powder, introduced by means of the ordinary laryngeal insufflator. Its action is more prolonged than that of any of the others, often lasting for from twenty-four to forty-eight hours.
Injection of the superior laryngeal nerve with a 60 per cent. solution of alcohol has been found satisfactory where other means have failed.
#Interference with Respiration.#--It is only necessary here to refer to such causes of interference with respiration as may call for surgical treatment.
The chief forms of laryngitis to be considered in connection with the production of dyspnoea, are membranous or diphtheritic laryngitis and acute inflammatory oedema.
#Diphtheria of the larynx# is described on p. 110, Volume I.
#Acute Oedema of the Larynx.#--Oedema of the larynx may be inflammatory or non-inflammatory in origin. The former is the more common, and may arise in connection with disease of the larynx, such as tuberculosis or syphilis, or it may be secondary to acute infective conditions at the base of the tongue, or in the fauces or pharynx; more rarely it results from infective conditions of the cellular tissue or glands of the neck. The non-inflammatory form may be a local dropsy in renal or cardiac disease, may be induced by pressure on the large cervical veins, and in some cases it appears to follow the administration of potassium iodide in the treatment of laryngeal affections.
The oedema consists of an exudation into the loose submucous areolar tissue, which may be of a simple serous character or may become sero-purulent. The situations mainly involved are the glosso-epiglottic fossae between the base of the tongue and the epiglottis, the ary-epiglottic folds (Fig. 287), and the false cords. If the infective process commences in front of the epiglottis this structure becomes swollen and rigid, and often livid in colour--points which are readily discerned on examination with the mirror, or even without its aid in some cases. The patient complains of great pain on swallowing, and has the sensation of a foreign body in the throat. Should the oedema spread to the ary-epiglottic folds, either from the interior of the larynx or from the fauces and pharynx, dyspnoea becomes a prominent and grave symptom. The patient may rapidly become cyanosed, the inspirations assume a noisy, stridulous character, and great distress and imminent suffocation supervene. If laryngoscopic examination is possible, the ary-epiglottic folds may be found greatly swollen and the upper aperture of the larynx partly occluded. Digital examination may reveal the swollen condition of the parts. The urine should be examined for albumin and tube casts.
Treatment.--In the milder forms, the sucking of ice, the inhalation of medicated steam, or spraying with a solution of adrenalin, and the application of poultices to the neck, may suffice to relieve the condition. Scarification of the epiglottis and ary-epiglottic folds with a knife, followed by free bleeding, may give complete relief. Diaphoretic and purgative treatment should not be neglected. If suffocation is imminent, tracheotomy or intubation is called for.
In performing #tracheotomy#, a roller pillow is placed beneath the neck to put the parts on the stretch, and an incision is carried from the lower margin of the cricoid cartilage downwards for about 2 inches. The sterno-hyoids and sterno-thyreoids are separated; the cross branch between the anterior jugular veins, and any other veins met with, secured with forceps before being divided; and the trachea exposed by dividing transversely the layer of deep fascia which passes from the cricoid to the isthmus of the thyreoid. If the isthmus cannot be pulled downwards sufficiently, it may be divided in the middle line. All active bleeding having been arrested, the larynx is steadied by inserting a sharp hook into the lower edge of the cricoid cartilage, and the trachea is opened by thrusting a short, broad-bladed knife through the exposed rings. The back of the knife should be directed downwards, and the opening in the trachea enlarged upwards sufficiently to admit the tracheotomy tube. In children it is sometimes found necessary to divide the cricoid for this purpose (laryngo-tracheotomy). The slit in the trachea is then opened up with a tracheal dilator, and the outer tube inserted and fixed in position with tapes. The inner tube is not fixed, so that it may be coughed out if it becomes blocked, and that it may be frequently removed and cleaned by the nurse. The tube should be discarded as soon as the patient is able to breathe by the natural channel.
Intubation of the Larynx.--This procedure is employed as a substitute for tracheotomy, especially in children suffering from membranous and oedematous forms of laryngitis. As experience is required to carry out the manipulations successfully, and as its use is attended with certain risks which necessitate that the surgeon should be constantly within call, the operation is more adapted to hospital than to private practice. O'Dwyer's apparatus is that most generally employed. The operation consists in introducing through the glottis, by means of a specially constructed guide, a small metal or vulcanite tube furnished with a shoulder which rests against the false vocal cords. The part of the tube which passes beyond the true vocal cords is bulged to prevent it being coughed out.
In an emergency a gum-elastic catheter with a terminal aperture may be passed, as recommended by Macewen and Annandale.
#Bilateral Abductor Paralysis.#--Both recurrent nerves may be interfered with by such conditions as enlargement of the thyreoid, tumour of the oesophagus, or intra-thoracic tumour, or by injury in the course of operations for goitre. A gradually increasing inspiratory dyspnoea is developed, which at first is only noticed on exertion, when the desire for air is increased; later it becomes permanent, and even during sleep the stridor may be marked. Suffocation may become imminent. When the larynx is examined with the mirror, the vocal cords are seen to lie near each other, and on inspiration their approximation is still greater.
The treatment is directed to removing the cause of pressure on the nerves. In the majority of cases tracheotomy is called for and the tube must be worn permanently.
#Syphilitic Affections of the Larynx.#--Secondary syphilitic manifestations in the form of congestion of the mucous membrane, mucous patches, or condylomata, are occasionally met with, and give rise to a huskiness of the voice. These conditions usually disappear rapidly under anti-syphilitic treatment.
In tertiary syphilis, whether inherited or acquired, the most common lesion is a diffuse gummatous infiltration, which tends to go on to ulceration and to lead to widespread destruction of tissue. It usually attacks the epiglottis, the arytenoids, and the ary-epiglottic folds, but may spread and implicate all the structures of the larynx. Syphilitic ulcers are usually single, deep, and crateriform; the base is covered with a dirty white secretion, and the surrounding mucosa presents an angry red appearance. When the perichondrium becomes invaded, necrosis of cartilage is liable to occur.
Hoarseness, dyspnoea, and, when the epiglottis is involved, dysphagia, are the most prominent symptoms.
Cicatricial contraction leading to stenosis may ensue, and cause persistent dyspnoea.
The usual treatment for tertiary syphilis is employed, but on account of the tendency of potassium iodide to increase the oedema of the larynx, this drug must at first be used with caution. Intubation or tracheotomy may be called for on account of sudden urgent dyspnoea or of increasing stenosis. The stenosis is afterwards treated by gradual dilatation with bougies, which, if a tracheotomy has been performed, may conveniently be passed from below upwards. An annular stricture causing occlusion may be excised, and the ends of the trachea sutured.
#Tuberculosis.#--The larynx is seldom the primary seat of tubercle. In the majority of cases the patient suffers from pulmonary phthisis, and the laryngeal mucous membrane is infected from the sputum. The disease may take the form of isolated nodules in the vicinity of the arytenoid cartilages, of superficial ulceration of the vocal cords and adjacent parts, or of a diffuse tuberculous infiltration of all the structures bounding the upper aperture of the larynx. The mucous membrane becomes oedematous and semi-translucent. The nodules coalesce and break down, leading to the formation of multiple superficial ulcers. The parts adjacent to the ulcers are pale in colour. Perichondritis may occur and be followed by necrosis of cartilage and the formation of abscesses in the submucous tissue of the larynx or in the cellular tissue of the neck.
The voice becomes hoarse or may be lost, there is persistent and intractable cough, and in some cases dyspnoea supervenes. When the epiglottis is involved there is pain and difficulty in swallowing.
In the presence of advanced pulmonary phthisis the treatment is chiefly palliative, but if the disease in the lungs is amenable to treatment, and the laryngeal lesion limited, the electric cautery may be used. Tracheotomy may be called for on account of urgent dyspnoea.
#Tumours.#--The commonest form of simple tumour met with in the larynx is the papilloma. It may occur at any age, and is comparatively common in children. It most frequently springs from the vocal cords and adjacent parts, forming a soft, pedunculated, cauliflower-like mass of a pink or red colour, which may form a fringe hanging from the edge of the cord (Fig. 288), or may spread until it nearly fills the larynx. In children, the growths are frequently multiple and show a marked tendency to recur after removal. They sometimes disappear spontaneously about puberty.
The most prominent symptoms are hoarseness, aphonia, and dyspnoea, which in children may be paroxysmal.
The treatment consists in removing the growth by means of laryngeal forceps or the snare, under cocain and adrenalin anaesthesia. For the removal of multiple papillomata, the removal of the growths through Killian's tubes or by suspension laryngoscopy has now taken the place of the external operation in children. In a certain number of cases it has been found that the tumour disappears after the larynx has been put at rest by the operation of tracheotomy.
#Cancer.#--Epithelioma of the larynx is almost always primary, and usually occurs in males between the ages of forty and seventy. It is important to distinguish between those cases in which the growth first appears in the interior of the larynx--on the vocal cords, the ventricular bands, or in the sub-glottic cavity (intrinsic cancer)--and those in which it attacks the epiglottis, the ary-epiglottic folds, or the posterior surface of the cricoid cartilage (extrinsic cancer).
Clinical Features.--In the great majority of cases of intrinsic cancer the first and for many months the only symptom is huskiness of the voice, which may go on to complete aphonia before any other symptoms manifest themselves. When the larynx is examined in an early stage, the presence of a small warty growth on the posterior part of one vocal cord, or a papillary fringe extended along the free edge of the cord, should raise the suspicion of malignancy, especially if the affected cord is congested and moves less freely than its fellow. Early diagnosis is essential in intrinsic cancer, and the absence of enlargement of lymph glands, or of foetor and cachexia, must in no way influence the surgeon against making a diagnosis of malignancy. The impaired mobility of the affected cord is an important point in determining the malignant nature of the growth.
Intrinsic cancer may spread over the upper boundaries of the larynx and become extrinsic, or the disease may be extrinsic from the outset.
In cases of extrinsic cancer the early symptoms are much more marked, pain and difficulty in swallowing, and the secretion of frothy, blood-stained mucus being among the earliest manifestations. The cervical glands are infected early, sometimes even before there are any symptoms of laryngeal disease. Difficulty of breathing is also an early symptom on account of the growth obstructing the entrance of air. Tracheotomy may therefore be called for. In other respects the course and terminations are similar to those of intrinsic cancer.
When the growth spreads into the tissues of the neck the patient's sufferings are greatly increased. The oesophagus may be invaded with resulting dysphagia; the nerve-trunks may be pressed upon, causing intense neuralgic pains; the lymph glands become infected and break down, and the growth fungates through the skin. The general health deteriorates and death results, usually from septic pneumonia set up by the passage of food particles into the air-passages, from absorption of toxins, or from haemorrhage. The duration of this form of the disease varies from one to three years.
The treatment consists in removing the growth. In early and limited forms of intrinsic cancer laryngo-fissure (thyreotomy) gives good results; in more advanced cases the entire larynx must be removed--complete laryngectomy--and at the same time, or after an interval, the associated lymph glands are removed from the anterior triangle of the neck on both sides.
In cases in which excision is impracticable, the sufferings of the patient may be alleviated by performing low tracheotomy, and by feeding with the stomach tube or by nutrient enemata. In some cases the difficulty of feeding the patient may make it necessary to perform gastrostomy.
#Sarcoma# of the larynx gives rise to the same symptoms as cancer, and can seldom be diagnosed from it before operation.
#Foreign Bodies in the Air-Passages.#--Foreign bodies impacted in the pharynx usually consist of unmasticated pieces of meat or large tooth-plates, and they occlude both the food and the air-passages, frequently causing sudden death. They are considered with affections of the pharynx.
The bodies most frequently impacted in the larynx are small tooth-plates in the case of adults, and buttons, beads, sweets, coins, and portions of toys in children. These are drawn from the mouth into the air-passage during a sudden inspiratory effort, for example while laughing or sneezing. If the glottis is completely blocked, rapidly fatal asphyxia ensues. If the obstruction is incomplete, the patient experiences severe pain, difficulty of breathing, and a terrifying sensation of being choked. The irritation of the foreign body causes spasmodic coughing and retching, and may induce spasm of the glottis, with threatening suffocation.
Small round bodies may lodge in the upper aperture or in one of the ventricles, and give rise to hoarseness and repeated attacks of dyspnoea and spasmodic cough. Wherever the body is situated, the symptoms may suddenly become urgent from its displacement into the glottis, or from the onset of oedema. The position of the body may often be ascertained by the use of the X-rays.
Treatment.--If the symptoms are urgent, laryngotomy, which consists in opening the larynx below the glottis by dividing the crico-thyreoid membrane, or tracheotomy must be performed at once, and an attempt made to remove the foreign body thereafter. In less severe cases in adults, the throat should be sprayed with cocain, and the larynx examined with the mirror; in children, the direct method must be employed. In both instances an attempt should be made to extract the body by the direct method. As these manipulations are liable to induce sudden spasm of the glottis, the means of performing tracheotomy must be at hand. If it is found impossible to remove the body through the mouth, laryngotomy or tracheotomy should be performed, and the body extracted through the wound, or pushed up into the pharynx and removed by this route. In the case of small bodies, a strand of gauze pushed up from the tracheotomy wound, through the larynx and out of the mouth, catches the foreign body and carries it out (Walker Downie).
The foreign bodies that are most likely to become impacted in the trachea are tooth-plates with projecting hooks, and small coins. The position of the foreign body may be ascertained by the use of Killian's tracheoscope, or by means of the X-rays. If the body remains movable in the trachea, it is apt to be displaced when the patient moves or coughs, and it may be driven up and become impacted in the glottis, setting up violent attacks of coughing and spasmodic dyspnoea.
Tracheotomy should be performed at once, and the edges of the tracheal wound held widely open with retractors, the patient being inverted, or coughing induced by tickling the mucous membrane with a feather. The foreign body is usually expelled, but it may be inhaled into one of the bronchi. One of Killian's tracheal tubes may be introduced through the tracheotomy wound and the body extracted by means of suitable forceps.
Foreign Bodies in the Bronchi.--Rounded objects, which pass through the larynx, usually drop into one or other of the bronchi, usually the right, which is the more vertical and slightly the larger. The body may act as a ball-valve, permitting the escape of air with expiration, but preventing its entrance on inspiration, with the result that the portion of lung supplied by the bronchus becomes collapsed. The physical signs of collapse of a portion or of the whole lung may be recognised on examination of the chest. In some cases the body is dislodged and driven up into the larynx, causing severe dyspnoeic attacks and spasms of coughing. The irritation caused by the foreign body in the bronchus may set up bronchitis or pneumonia, and abscess of the lung may supervene. This has frequently followed the entrance of an extracted tooth into the air-passage, and it may be a considerable time before pulmonary symptoms arise. Sometimes the tooth is ultimately coughed up and the symptoms disappear. In some cases the physical signs closely simulate those of pulmonary phthisis.
The treatment consists in removing the body by the aid of Killian's or Jackson's tube passed through the mouth. If this is not successful, low tracheotomy is performed and the tube is passed through the tracheotomy opening.
INDEX
Abducens nerve, 400
Abductor paralysis, 404, 639 splint, 221
Abscess. See Individual Organs and Regions
Accessory nasal sinuses. See Individual Sinuses nerve, 404
Acetabulum, fracture of, 125 tuberculous disease of, 210 wandering, 210, 227
Achillo-bursitis, 294
Acoustic nerve, 579
Acromion process, fracture of, 69
Actinomycosis. See Individual Organs and Regions
Adenoids, 578
Alveolar abscess, 507 process, fracture of, 519 tumours of, 513
Ambulant splint for ankle, 189 treatment of hip disease, 222
Amputation in compound fracture, 26
Anatomy. See Surgical Anatomy
Angina Ludovici, 548, 597
Ankle, deformities of, 273 diseases of, 238, 240 dislocations of, 194 fractures in region of, 186, 187 injuries in region of, 185 surgical anatomy of, 185 tuberculous disease of, 238
Ankylosis of joints. See Individual Joints
Anosmia, 399, 578
Anterior poliomyelitis, 242
Aphasia, 335
Aphonia, 636
Arm, upper, injuries of, 44
Arthritis. See also Individual Joints
Arthritis, septic, 34
Arthrodesis, 246
Astragalus. See Talus
Athetosis, 247
Atlo-axoid disease, 440 joint, fracture-dislocation of, 430
Auditory nerve, 403
Aural polypi, 558 vertigo, 555
Auricular appendages, 560
Avulsion of scalp, 322
Balkan frame splint, 150
Basedow's disease, 614
Bell's paralysis, 401
Bennett's fracture, 116
Bezold's mastoiditis, 566
Bier's constricting bandage, 12, 26
Black eye, 370, 484
Blepharospasm, 403
Bones, atrophy of, 2 contusion of, 1 fracture of, 1 gun-shot injuries of, 27 injuries of, 1 repair of, 8 wounds of, 1
Bow-knee, 271 -leg, 271
Box splint, 182
Brachial plexus, lesions of, 597
Brachio-thoracic triangle, 470
Bradford frame, 438
Brain, abscess of, 360, 374, 376, 378, 382 localisation of, 380 adhesions, 358 cerebral irritation, 342, 346 compression of, 347 differential diagnosis of, 350 concussion of, 341, 344 contusion of, 342 cyst of, haemorrhagic, 344 decompression operations on, 396 diseases of, 373 pyogenic, 373 foreign bodies in, 350 functions of, 331 haemorrhage into, 352 hernia of, 397 injuries of, 341 mechanism of, 343 repair of, 344 irritation of, 342, 346 laceration of, 342 lesions of, 341 localisation of centres in, 336 membranes of, 328 diseases of, 372 motor area of, 330 sclerosis of, 358 sensory mechanism of, 332 softening of, 342 surgical anatomy of, 328 syphilitic gumma, 395 traumatic oedema of, 343, 352 tuberculosis of, 395 tumours of, 393 localisation of, 394 wounds of, 357
Branchial carcinoma, 601 cysts, 598 fistulae, 585
Broken back, 427
Bronchi, foreign bodies in, 644
Bronchocele. See Goitre, 605
Bronchoscopy, 635
Bryant's triangle, 129
Bunion, 296
Cachexia strumipriva, 610
Calcaneus, fracture of, 193 separation of, tuberosity of, 193 spurs on, 294
Callipers, ice-tong, 165
Callus, absorption of, 10 excess of, 9 tumours of, 10 varieties of, 8
Cancrum oris, 497
Capitate bone, dislocation of, 114
Carcinoma. See Cancer
Cardiospasm, 624
Carotid artery, internal, injuries of, 356 gland, tumours of, 603
Carpal bones, dislocation of, 113 fracture of, 110
Carpo-metacarpal dislocations, 115
Cauda equina, injuries of, 419
Caudal appendage, 458, 459
Cavernous sinus, phlebitis of, 386
Cellulitis. See Individual Regions
Cephal-hydrocele, 321 traumatic, 390
Cephaloceles, 387
Cerebello-pontine angle, tumours of, 394
Cerebellum, abscess of, 381 tumours of, 394
Cerebral abscess, 360 apoplexy, 351 centres, 334 embolism, 351 hyperpyrexia, 348 irritation, 342, 346 localisation, 336 oedema, 352 palsies of childhood, 247 shock, 341, 344 softening, 358 tumours, 393 vomiting, 377
Cerebro-spinal fluid, 329, 339 meningitis, 378
Cerebrum. See Brain
Cerumen in ear, 561
Cervical auricles, 583 caries, 440 fascia, 583 ribs, 585 sympathetic, 405, 615
Charcot's disease of hip, 228
Chauffeur's fracture, 106
Cheilotomy, 228
Chiene's test, 129
Cilio-spinal reflex, 405
Cirsoid aneurysm of scalp, 326
Clavicle, absence of, 303 dislocations of, 49 fracture of, 45
Cleft palate, 475, 477
Club-foot, 273
Club-hand, 311, 312
Coccydynia, 127, 450
Coccyx, fracture of, 127
Cock-up splint, 77
Coin-catcher, 622
Colles' fracture, 102 reversed, 106 unreduced, 106
Compound dislocation, 40
Compression of brain, 347
Compression fracture of spine, 426
Concussion of brain, 344 of spinal cord, 413
Congenital deformities, 241. See Individual Regions dislocation, 43. See Individual Joints
Conus medullaris, injuries of, 419
Coracoid process, fracture of, 69 separation of epiphysis of, 70
Coronoid process, fracture of, 87
Coxa valga, 256, 261 vara, 136, 256, 257
Cranial nerves, affections of, 398. See Individual Nerves
Cranium. See Skull
Crepitus in fracture, 15, 30
Cricoid cartilage, fracture of, 593
Crossed-leg deformity, 224, 257
Cruciate ligaments, rupture of, 171
Cubitus valgus, 84, 308 varus, 84, 310
Cut-throat, 593
Deafness, varieties of, 553
Decompression of brain, 396
Deep sensibility, 332
Deformities of extremities, 241. See Individual Regions
Dental caries, 507 ulcer of tongue, 529
Dentigerous cysts, 517
Diplacusis, 554
Dislocation. See also Individual Joints and Bones compound, 40 congenital, 43 by elongation, 96 with fracture, 40 habitual, 43, 65 old-standing, 40, 65 pathological, 43 recurrent, 43 traumatic, 36 varieties of, 37
Displacement of semilunar menisci, 168
Dorsal abscess, 444
Drop-finger, 318 wrist, 76, 311
Dugas' symptom in dislocation of shoulder, 54, 55
Dupuytren's contraction, 314 fracture, 187, 188, 196 splint, 190
Dysphagia, 623, 636
Ear, 553. See also Tympanic membrane
Ear, aspergillus in, 562 boils, 562 cardinal symptoms of disease of, 554 deafness, 553, 554 deformities of, 560 discharge from, 555 earache, 554 eczema of, 562 foreign bodies in, 563 furunculosis of, 562 hearing tests, 555 inspection of, 556 middle, acute infection of, 564 chronic suppuration in, 565 inflation of, 558 noises in, 554 otorrhoea, 555 outstanding, 560 pain in, 554 physiology of, 553 polypi, 558 rupture of membrane of, 563 syringing of, 561 surgical anatomy of, 553 tumours of, 560 vertigo, 555 wax in, 561
Earache, 554
Ectropion, 483
Elbow, ankylosis of, 208 arthritis deformans of, 208 diseases of, 205 dislocations, congenital, 308 paralytic, 308 traumatic, 88, 92 examination of, 80 injuries in region of, 79 neuro-arthropathies of, 208 pyogenic diseases of, 208 sprain of, 96 surgical anatomy of, 79 tennis player's, 97 tuberculous disease of, 206
Empyema of knee, 232
Encephalitis, 376, 377
Encephalocele, 388, 389
Epicritic sensibility, 332
Epilepsy, 397 Jacksonian, 359 traumatic, 358
Epiphyses, separation of. See Individual Bones
Epistaxis, 575
Epulis, 513
Ethmoidal cells, suppuration in, 577, 578
Eustachian catheter, 558
Extension by Hodgen's splint, 151, 159 by ice-tong callipers, 150, 158 by perineal band, 152 by Steinmann's apparatus, 150 vertical, 154 by weight and pulley, 220
Extra-dural abscess, 374
Eyeball, injuries of, 486
Eyelids, wounds of, 484
Face, cicatricial contraction of, 483 congenital malformations of, 474, 481 development of, 474 diseases of, 483 epithelioma of, 484 frog-, 581 injuries of, 482 rodent cancer of, 484 tumours of, 484
Facial cleft, 481 nerve, 400 paralysis, 400 spasm, 403
Facio-hypoglossal anastomosis, 403
False joint, 12
Fat embolism in fractures, 19
Femur, fracture of, in children, 135, 154 of condyles of, 162 of greater trochanter of, 139 of head of, 129 just below lesser trochanter of, 139 of lower end of, 157 of neck of, 130 of shaft of, 148 of upper end of, 129 incurvation of neck of, 257 separation of epiphyses of, 129, 139, 161
Fibula, absence of, 272 dislocation of, total, 167 fracture of, 165, 178, 183
Fingers, congenital contraction of, 313 deficiencies, 317 deformities of, 313 dislocation of, 121 drop-, 121, 318 Dupuytren's contraction of, 314 fractures of, 115 hypertrophy of, 317 injuries of, 115 mallet, 121, 318 supernumerary, 316 trigger, 318 webbed, 317
Flat-foot, 285 adolescent, 287 degrees of, 291 exercises for, 291 paralytic, 292 spasmodic, 292 static, 287 traumatic, 293 varieties of, 287, 294
Foerster's operation, 247
Foot, club-, 273 deformities of, 273 flat-, 285 hollow claw-, 284 injuries of, 185 movements of, 185 splay-, 285 surgical anatomy of, 185
Foot and mouth disease, 530
Footballer's knee, 172
Forearm, deformities of, 310 fracture of both bones of, 97 injuries of, 79 intra-uterine amputation of, 311
Fracture, 1. See also Individual Bones amputation in, 26 badly united, 10 Bennett's, 116 during birth, 3 chauffeur's, 106 clinical varieties of, 4 Colles', 102 comminuted, 6 complications of, 18 compound, 5, 24 crepitus in, 15 deformity in, 15 delayed union, 11 depressed, 5, 7 with dislocation, 40 displacement of fragments in, 7 Dupuytren's, 196 extension in, 26 fat embolism in, 19 fever in, 18 fibrous union of, 12 fissured, 5 greenstick, 5, 98 gun-shot, 27 indentation, 5 intra-uterine, 3 Jones', 194 longitudinal, 6 mal-union of, 10, 99, 183 massage in, 21 mechanism of, 14 multiple, 6 non-union, 9, 12 oblique, 6 old-standing, 87 open, 5 operation in, 24 pain in, 17 passive hyperaemia in, 12 pathological, 1 prognosis in, 19, 25 radiography in, 16 reduction of, 20 repair of, 8 retention of, 21 setting of, 20 shock in, 18 simple, 4, 8, 14, 19, 24 Smith's, 106 spiral, 6 splints in, 22 sprain-, 35 subcutaneous, 4 sub-periosteal, 6 transverse, 6 traumatic, 3 treatment of, 20, 25 un-united, 12, 78, 100, 101, 183 varieties of, 4 violence, forms of, causing, 3 X-rays in, 16
Frog-face, 581
Frontal sinus, suppuration in, 577
Gampsodactyly, 302
Genu recurvatum, 263 valgum, 264, 265 varum, 264, 271
Gingivitis, 508
Girdle-pain, 419
Glands, lymph. See Lymph Glands
Globus hystericus, 624
Glomus carotica, tumours of, 603
Glossitis, 530, 533
Glosso-pharyngeal nerve, 403
Goitre, 605 adenomatous, 610 colloid, 607 cystic, 607 exophthalmic, 614 fibrous, 607 intra-thoracic, 607, 609, 613 malignant, 612 non-toxic, 605 parenchymatous, 605 retro-sternal, 607, 609, 613 sudden dyspnoea in, 608-610 thyreoidectomy for, 610 toxic, 614 vascular, 607
Gooch's splinting, 22
Graefe's symptom, 614
Graves' disease, 614
Gravitation paraplegia, 414
Greenstick fracture, 5
Gumboil, 507
Gums, affections of, 508
Gun-shot injuries. See Individual Structures
Habitual dislocation, 43
Haemarthrosis, 33
Haematoma auris, 560 of periosteum, 1
Haematomyelia, 414
Haematorrachis, 414
Hallux dolorosus, 298 flexus, 298 rigidus, 298 valgus, 296 varus, 298
Hammer nose, 570 toe, 300
Hanche a ressort, 254
Hand, club-, 311, 312 deformities of, 310 injuries of, 102 surgical anatomy of, 102
Hare-lip, 475
Head injuries, 340 after-effects of, 358
Hearing, impairment of, 554 tests of, 555
Heel, painful affections of, 294
Hemianopia, 335
Hemi-glossitis, 530
Hernia cerebri, 397
Hiatal oesophagismus, 624
Hip, ankylosis of, 256 arthritis deformans of, 226 Charcot's disease of, 228 contractures of, 256 contusion of, 147 disease, 209 dislocations, congenital, 248 old-standing, 147 varieties of, 126, 142 examination of, 128, 211 hysterical, 229 injuries in region of, 127 loose bodies in, 229 neuro-arthropathies of, 228 osteo-chondritis deformans juvenilis, 228 paralytic deformities of, 255 Perthes' disease of, 228 pyogenic diseases of, 224 snapping, 254 sprain of, 147 surgical anatomy of, 128 Thomas' splint for, 222 tuberculous disease of, 210 abscess formation in, 217 bilateral, 224 deformities following, 223 diagnosis of, 218 dislocation in, 218 stages of, 211 treatment of, 220
Histrionic spasm, 403
Hoarseness, 635
Hodgen's splint, 151
Hollow claw-foot, 284
Homonymous hemianopia, 335
Hospital throat, 500
Humerus, fracture, of anatomical neck, 74 of condyles, 80 with dislocation of shoulder, 63 of head, 70 of lower end, 84 of shaft, 75 of surgical neck, 70 of tuberosities, 74 un-united, 78 separation of lower epiphysis of, 82, 84 of upper epiphysis of, 73
Hunch-back, 440, 444
Hydrencephalocele, 388, 389
Hydrocele of neck, 599
Hydrocephalus, 391 acute, 386, 391 chronic, 391
Hygroma of neck, 599 sacral, 459
Hyoid bone, fracture of, 593
Hyperaesthesia acustica, 554
Hyperpituitarism, 396
Hyper-thyreoidism, 609, 614
Hypoglossal nerve, 404
Hypophysis cerebri, tumours of, 396
Hypopituitarism, 396
Hysterical aphonia, 636 spine, 448 wry-neck, 592
Ice-tong callipers, 150
Iliac abscess, 445, 446
Ilium, fracture of, 126
Infantile paralysis, 242
Injuries. See Individual Regions
Internal derangements of knee-joint, 168
Inter-phalangeal dislocation, 200
Intra-cranial haemorrhage, 352 in newly born, 356 syphilis, 387, 395 tuberculosis, 386 venous sinuses, injuries of, 356
Intra-uterine amputation, 311
Intubation of larynx, 639 of oesophagus, 632
Ischaemic contracture of muscles, 85, 98, 310
Ischium, fracture of, 127
Jacksonian epilepsy, 359, 394
Jaw, lower. See Mandible upper. See Maxilla See also Temporo-mandibular Joint
Joints. See also Individual Joints Charcot's disease of, 228, 238 contusions of, 33 dislocations of, 36 false, 12 gun-shot injuries of, 34 injuries of, 32 sources of strength of, 32 sprains of, 35 wounds of, 34
Jones' fracture of fifth metatarsal, 194
Kernig's sign, 386
Klapp's four-footed exercises for scoliosis, 472
Knee, ankylosis of, 264 arthritis deformans of, 237 bow-, 271 Charcot's disease of, 238 cold abscess of, 234 contracture of, 264 deformities of, 236, 264 diseases of, 229 pyogenic, 237 tuberculous, 231 dislocations of, 165 congenital, 262 empyema of, 232 footballer's, 172 genu-recurvatum, 263 valgum, 265 varum, 271 hydrops of, 172 hysterical diseases of, 238 injuries in region of, 155 injuries of semilunar menisci, 167 internal derangement of, 168 knock-, 265 loose bodies in, 238 rugby, 165 rupture of cruciate ligaments of, 171 sprains of, 171 surgical anatomy of, 155 tuberculous disease of, 231 clinical types of, 231 deformities following, 236 extra-articular abscess in, 234 white swelling of, 233
Knock-knee, 265
Kocher's method of reducing dislocation of shoulder, 58
Kyphosis, 461, 462
Laryngitis, 637
Laryngoscopy, 635
Larynx, cancer of, 641 cardinal symptoms of affections of, 635 diphtheria of, 637 examination of, 634 foreign bodies in, 642 fracture of, 593 inflammation of, 637 intubation of, 639 oedema of, 637 paralysis of, 639 surgical anatomy of, 634 syphilis of, 639 tuberculosis of, 640 tumours of, 640 wounds of, 594
Laryngo-tracheotomy, 638
Lateral curvature of spine, 463 sinus. See Transverse Sinus ventricles, bursting of abscess into, 381 haemorrhage into, 342
Leg, bow-, 271 fracture of bones of, 178 congenital deficiencies of, 272 injuries of, 155 rickety deformities of, 271
Lepto-meningitis, 376
Leucokeratosis, 530
Leucoplakia, 530
Ligaments, cruciate, rupture of, 171
Lingual dermoids, 537
Lip, chancre of, 491 chronic induration of, 491 cracks of, 491 cysts of, 493 double-lip, 491 epithelioma of, 493 fistulae of, 482 hare-lip, 475 herpes of, 490 lymphangioma of, 492 macrocheilia, 492 mucous cysts of, 493 strumous, 491 syphilis of, 491 tuberculosis of, 491 tumours of, 492 ulcers of, 491
Lipoma nasi, 570
Liston's long splint, 152
Little's disease, 247, 357
Longitudinal sinus, phlebitis of, 385
Lordosis, 461
Ludwig's angina, 548, 597
Lumbar abscess, 445 puncture, 338
Lunate bone, dislocation of, 114 fracture of, 110
Luxation. See Dislocation
Lymphangiomatous macroglossia, 540
Macrocheilia, 492
Macroglossia, 540
Macrostoma, 481
Madelung's deformity of wrist, 313
Malar bone. See Zygomatic Bone
Malformations. See Individual Regions
Mallet finger, 318
Mandible, actinomycosis of, 512 cleft of, 481 dentigerous cyst of, 517 dislocation of, 523 old-standing, 524 fixation of, 526 tumours of, 517
Manus valga, 109, 313 vara, 313
Massage in fractures, 21
Mastoid, suppuration in, 566
Maxilla, affections of, 510 fracture of, 519 tumours of, 514
Maxillary sinus, suppuration in, 577
Meninges, surgical anatomy of, 328
Meningitis, 360, 374 basal, 377 cerebro-spinal, 378 serous, 377 spinal, acute, 453 chronic, 452 tuberculous, 433 syphilitic, 387 tuberculous, 386
Meningocele, 388 spinal, 454
Meningo-encephalitis, 376
Meningo-myelocele, 454
Mercurial gingivitis, 508 glossitis, 530
Metacarpals, fracture of, 115, 116
Metatarsals, diseases of, 240 fracture of, 194
Metatarsalgia, 295
Micrencephaly, 393
Microstoma, 481
Middeldorpf's splint, 72
Middle-ear disease, cerebral abscess due to, 378
Middle meningeal haemorrhage, 352
Mid-tarsal dislocation, 199
Miller's method of reducing dislocation of shoulder, 60
Mobile semilunar meniscus, 168
Morbus coxae, 210
Morton's disease, 295
Motor areas, 330 tracts, 331
Mouth, affections of, 496 floor of, 499 roof of, 498
Mumps, 546
Musculo-spiral nerve. See Radial Nerve
Myelitis, compression, 453 haemorrhagic, 453 spinal, 453 syphilitic, 453 tuberculous, 433
Myelocele, 455
Myxoedema, post-operative, 610
Nasal affections. See Nose bones, fracture of, 567 ducts, injuries of, 567
Naso-pharynx, affections of, 567 tumours of, 580
Navicular bone, dislocation of, 115 fracture of, 110, 194
Neck, actinomycosis of, 598 boils of, 598 branchial carcinoma, 160 bursal swellings in, 599 carbuncles of, 598 cellulitis of, 597 cervical auricles, 583 fascia, 583 ribs, 585 cicatricial contraction of, 592 contusion of, 592 cystic lymphangioma of, 599 cysts of, 598 blood, 599 branchial, 598 bursal, 599 dermoid, 598 fistulae of, 584, 585 hydrocele of, 599 hygroma of, 599 injuries of, 592 malformations of, 583 paraffin epithelioma of, 602 potato-like tumour of, 603 stiff, 587 surgical anatomy of, 582 thyreo-glossal cysts in, 538 tumours of, 598, 599 wounds of, 593 wry-, 587
Nelaton's line, 129
Nerve anastomosis, 246
Nerve roots, injuries of, 420
Neuralgia, trigeminal, 400
Neuro-arthropathies. See Individual Joints
Neurone lesions, 334
Node, traumatic, 1
Nose, adenoids, 578 anomalies of smell, 578 artificial, 570 asthma, reflex, 578 bleeding from, 575 carcinoma of, 573 cardinal symptoms of nasal affections, 571 concretions in, 575 deformities of, 568 discharge from, 574 displacement of cartilages of, 567 emphysema of, 568 erectile swelling of, 572 examination of, 570 foreign bodies in, 574, 576 fracture of, 567 hammer, 570 lipoma nasi, 570 obstruction of, 572 ozaena, 575 polypi of, 573 potato, 570 reflex symptoms, 578 rhinitis, 575 rhinoliths, 575 rhinophyma, 570 saddle, 567, 568 sarcoma of, 580 septum of, deviations, 573 haematoma, 573 ridges, 573 spines, 573 sunken-bridge, 568 suppuration in accessory sinuses, 576 swelling of turbinated bones, 572 traumatic saddle, 567
Nystagmus, labyrinthine, 555
Oculo-motor nerve, 399
Odontoid process, fracture of, 430
Odontoma, 517
Oedema glottidis, 637
Oesophagismus, hiatal, 624
Oesophagitis, 623
Oesophagoscopy, 617
Oesophagospasm, 624
Oesophagus, carcinoma of, 629, 631 cicatricial contraction of, 628 compression of, 624 dilatation of, 625 diverticula of, 625 examination of, 616 foreign bodies in, 619, 621, 623 inflammation of, 623 intubation of, 632 paralysis of, 625 rupture of, 618 spasm of, 624 stricture of, cicatricial, 628 malignant, 629 spasmodic, 624 surgical anatomy of, 616 swallowing of corrosive substances, 618 syphilis of, 623 tuberculosis of, 623 tumours of, 629 varix of, 623 wounds of, 618 X-ray examination of, 617
Old-standing dislocations, 40. See also Individual Joints
Olecranon, fracture of, 85 separation of epiphysis of, 87
Olfactory nerve, 399
Ophthalmia, sympathetic, 487
Ophthalmoplegia externa, 400
Optic nerve, 399
Orbit, aneurysms of, 490 cellulitis of, 487 contusions of, 484 emphysema of, 486 eyeball, injuries of, 486 foreign bodies in, 485 fractures of, 485 injuries of, 484 tumours of, 487 wounds of, 485
Os magnum. See Capitate Bone
Osteo-chondritis deformans juvenilis, 228
Os trigonum tarsi, 193
Otitis media, 564
Otorrhoea, 555
Ozaena, 575
Pachymeningitis, 374, 433
Palate, affections of, 498 cleft, 477
Palmar fascia, Dupuytren's contraction of, 314
Panophthalmitis, 487
Paracusis of Willis, 554
Paralysis, abductor, 404, 639 Bell's, 401 conjugate, 335 crossed, 334 facial, 400 infantile, 242 spastic, 247 of sterno-mastoid, 404 of tongue, 542 of trapezius, 404
Paraplegia dolorosa, 448 gravitation, 414 spastic, 451
Para-thyreoid glands, 604
Parosmia, 578
Parotid, carcinoma of, 552 duct, affections of, 544 fistula, 544 inflammation of, 545 injuries of, 543 mixed tumours of, 549 recurrent enlargement of, 547 sarcoma of, 552 surgical anatomy of, 543 tuberculosis of, 549 tumours of, 549
Parotitis, 545, 547
Patella, absence of, 262 dislocation of, 177 congenital, 262 floating, 171, 229 fracture of, 173 injuries of, 173
Patheticus nerve, 400
Pathological dislocation, 43 fracture, 1
Pelvis, fractures of, 122 injuries of, 122
Periodontitis, 507
Peri-oesophagitis, 623
Periosteum, haematoma of, 1
Peri-tonsillitis, 501
Perthes' disease, 228
Pes arcuatus, 273, 284 calcaneo-valgus, 273, 282, 284 calcaneo-varus, 273, 282, 284 calcaneus, 273, 282 cavus, 273, 282, 283, 284 equinus, 273, 280 excavatus, 284 planus, 285, 287 transverso-planus, 294 valgus, 273, 285, 287 varus, 280
Phalanges of fingers, injuries of, 119, 121 of toes, injuries of, 194, 200
Pharyngeal dimple, 626
Pharyngitis, varieties of, 500
Pharynx, affections of, 500, 619 foreign bodies in, 619, 642 tumours of, 504
Phlebitis. See Individual Vessels
Phosphorus necrosis of jaw, 510
Pigeon-toe, 298
Pituitary body, tumours of, 396
Plaster-of-Paris splints, 23
Pneumatocele capitis, 326
Pneumogastric nerve, 403
Poliomyelitis, anterior, 242
Politzer's inflation of middle ear, 558
Polydactylism, 303, 316
Polypi. See Individual Organs
Poroplastic felt, 23
Post-anal dimple, 459
Posterior nerve roots, resection of, 247
Post-nasal obstruction, 578
Pott's disease of spine, 431 fracture, 186 with inversion, 191 puffy tumour, 375, 406
Premaxillary bone, 474
Protopathic sensibility, 332
Pseudarthrosis, 12
Psoas abscess, 445
Pubes, fracture of, 123
Pulpitis, 507
Pyorrhoea alveolaris, 509
Quinsy, 501
Radial nerve, implicated in fracture of humerus, 76
Radio-carpal joint, dislocation of, 112
Radio-ulnar joint, inferior, dislocation of, 112 superior, synostosis of, 310
Radius, absence of, 310 avulsion of tubercle of, 88 dislocation of, 94 fracture of lower end, 102 of shaft, 100 of tubercle, 88 of upper end, 88 separation of epiphyses, 88, 109, 110 subluxation of, 96
Railway spine, 422
Ranula, 549
Recurrent dislocation, 43
Reduction of dislocations. See Individual Joints
Retro-pharyngeal abscess, 441, 442, 505
Rhinitis, 575
Rhinoliths, 575
Rhinophyma, 570
Rhinoscopy, 570, 571
Rib hump, 466
Ribs, cervical, 585
Round shoulders, 462
Rugby knee, 165
Sacral hygroma, 459
Sacro-coccygeal fistulae, 459 sinuses, 459 tumours, 459
Sacro-iliac joint, tuberculosis of, 446
Sacrum, fracture of, 127
Saddle nose, 567, 568
Salivary calculi, 545 fistulae, 544 glands. See Parotid, Submaxillary, Sublingual Mikulicz's disease of, 547 recurrent enlargement of, 547 surgical anatomy of, 543 tuberculosis of, 548 tumours of, 549
Scalp, abscess of, 323 air-containing swellings of, 326 aneurysms of, 326 avulsion of, 322 cellulitis of, 322, 406 cirsoid aneurysm of, 326 contusion of, 320 cysts of, 323 dangerous area of, 321 diseases of, 323 emphysema of, 326 erysipelas of, 323 haematoma of, 320, 366 infective conditions of, 323 injuries of, 320 lupus of, 323 pneumatocele of, 326 surgical anatomy of, 319 tumours of, 324 wounds of, 321 complications of, 322
Scaphoid. See Navicular
Scapula, congenital elevation of, 303 displacements of, 303, 306 fracture of, 67 separation of epiphyses of, 69, 70 winged, 306
Schlatter's disease, 165
Scissors-leg deformity, 224, 257
Scoliosis, of adolescents, 465 congenital, 465 exercises for, 472 habitual, 465 paralytic, 464 postural, 465 rickety, 464 static, 463
Sculler's sprain, 97
Semilunar menisci of knee, injuries of, 167
Sensation, varieties of, 332
Separation of bony processes, 6 of epiphyses. See Individual Bones
Shock, cerebral, 341, 344
Shoulder, ankylosis of, 204 arthritis deformans of, 203 contusion of, 66 diseases of, 201 deformities of, paralytic, 308 dislocation of, with fracture of humerus, 63 dislocation of, 52 congenital, 306 old-standing, 65 paralytic, 308 recurrent or habitual, 65 varieties, 53 examination of, 44 injuries of, 44 loose bodies in, 204 neuro-arthropathies of, 203 pyogenic diseases of, 203 sprain of, 66 Sprengel's, 303 surgical anatomy of, 44 tuberculosis of, 201
Sigmoid sinus, phlebitis of, 384
Sinus phlebitis, 383 thrombosis, 360
Skull, contusion of, 361 diseases of, 406 fracture of, 361 base, 367 anterior fossa, 369 middle fossa, 370 posterior fossa, 371 comminuted, 364 compound infected, 382 by contre-coup, 362 depressed, 364 fissured, 363 gutter, 364 indentation, 364 pond, 364 punctured, 364 vault, 361 injuries of, 360 necrosis of, 406, 407 osteomyelitis of, 406 periostitis of, 406 surgical anatomy of, 328 syphilis of, 407 tuberculosis of, 407 tumours of, 407
Smell, anomalies of, 399, 578
Smith's fracture of radius, 106
Smoker's patch on tongue, 532
Snapping hip, 254
Sore throat, varieties of, 500
Spastic paralysis, 247 paraplegia, 451
Speech centres, 335
Sphenoidal cells, suppuration in, 578
Spina bifida, 453 occulta, 457
Spinal accessory nerve, 404
Spinal cord, concussion of, 413 diseases of, 431 functions of, 331, 412 haemorrhage into, 413 injuries of, 413 at different levels, 416 localisation of, lesions in, 410, 412 membranes of, 412 partial lesions of, 420 in Pott's disease, 433 reflex centres in, 412 segments of, 412 surgical anatomy of, 411 total transverse lesions of, 415 tuberculosis of, 433 tumours of, 450 haemorrhage, 413
Spine, railway, 422
Splay-foot, 285
Splints, 22 abduction; for hip, 221 frame, for arm, 72 ambulant, for ankle, 189 Balkan frame, 150 box, 182 Bradford frame, 438 "cock-up," 77 for Colles' fracture, 106 Dupuytren's, 190 Hodgen's, 151 Liston's long, 152 Middeldorpf's, 72 Syme's stirrup, 190 Taylor's, for hip, 222 Thomas', arm, 72 double, 439 hip, 222 knee, 149, 159, 235 wheel-barrow, 439
Spondylitis, traumatic, 427
Sprains of joints, 35 fracture, 35, 171 sculler's, 97
Sprengel's shoulder, 303
Status lymphaticus, 602
Steinmann's apparatus, 150
Stenson's duct, 543
Sterno-mastoid, haematoma of, 588
Stomatitis, varieties of, 496
Subclavicular dislocation of shoulder, 62
Sub-conjunctival ecchymosis, 369
Sub-coracoid dislocation of shoulder, 54
Subdural abscess, 376
Sub-glenoid dislocation of shoulder, 62
Subgluteal abscess, 446
Sublingual gland, inflammation of, 548 ranula of, 549 surgical anatomy of, 543 tumours of, 552
Submaxillary gland, calculi of, 545 inflammation of, 548 peri-adenitis of, 548 recurrent enlargement of, 547 surgical anatomy of, 543 tuberculosis of, 549 tumours of, 552
Subspinous dislocation of shoulder, 62
Sub-taloid dislocation, 198
Superior sagittal sinus, phlebitis of, 385
Supernumerary fingers, 316 toes, 303
Surgical anatomy, of ankle, 185 of brain, 328 of ear, 553 of elbow, 79 of forearm, 79 of foot, 185 of hip, 128 of knee, 155 of meninges, 328 of neck, 582 of oesophagus, 616 of parotid gland, 543 of salivary glands, 543 of scalp, 319, 328 of shoulder, 44 of sublingual gland, 543 of submaxillary gland, 543 of thymus gland, 582 of thyreoid gland, 604 of tongue, 528 of tympanic membrane, 557 of vertebral column, 411 of wrist, 102
Swallowing, difficulty in, 623, 636 pain in, 623, 636
Syme's stirrup splint, 190
Symonds' tube, 632
Symphysis pubis, separation of, 122
Syndactylism, 303, 317
Synovitis, septic, 34
Syphilis. See Individual Organs
Syringo-myelocele, 455
Tail-like appendage, 458, 459
Talipes equino-varus. See also Pes acquired, 279 congenital, 274
Talus, dislocation of, 196 fracture of, 192
Tarso-metatarsal dislocation, 200
Tarsus, diseases of, 240 dislocations of, 196 fractures of, 192 tuberculosis of, 240
Taste, anomalies of, 578
Taylor's splint for hip, 222
Temporal abscess, 380
Temporo-mandibular joint, arthritis of, 525 arthritis deformans of, 525 dislocation of, 523 fixation of, 525 internal derangements of, 524 suppuration in, 525 tuberculosis of, 525
Tendons, lengthening of, 248 transplantation of, 245
Tennis elbow, 97
Tetany, 610
Thomas' flexion test for hip disease, 215 splints, 72, 149, 159, 222, 235, 439
Thoracic duct, 597
Throat, hospital, 500
Thrush, 496
Thumb, dislocation of, 119 fracture of, 116 stave of, 116
Thymic asthma, 603
Thymus death, 603 gland, affections of, 602 surgical anatomy of, 582 stenosis, 602
Thyreo-glossal cysts, 538, 583, 599 fistulae, 538, 583 tumours, 538
Thyreoid cartilage, fracture of, 593 gland. See also Goitre accessory, 604 adenoma of, 610 carcinoma of, 281 goitre, 605. See also Goitre inflammation of, 605 malignant, 612 physiological hyperaemia of, 604 sarcoma of, 281 surgical anatomy of, 604 syphilis of, 605 tuberculosis of, 605
Thyreoidectomy, 610
Thyreoidism, acute, 610
Thyreoiditis, 605
Thyreotoxicosis, 614
Tibia, absence of, 272 fracture of, 183 upper end of, 162 head of, 162 separation of lower epiphysis of, 192 upper epiphysis of, 165 tuberosity, avulsion of, 165 and fibula, fracture of, 178
Tibio-fibular articulation, inferior, dislocation of, 196 superior, dislocation of, 167
Tinnitus aurium, 554
Toes, clawing of, 280 deformities of, 296 dislocation of, 200 fracture of phalanges of, 194 hammer-, 300 hypertrophy of, 302 pigeon-, 298 supernumerary, 303 webbing of, 303
Tongue, absence of, 540 atrophy of, 540 bifid, 540 cancer of, 534 inoperable, 537 cysts, 537 dental ulcer of, 529 foot and mouth disease, 530 foreign bodies in, 529 glossitis, 530 gumma of, 533 hemi-glossitis, 530 inflammatory affections of, 530 leucokeratosis, 530 leucoplakia, 530 macroglossia, 540 malformations of, 540 mucous patches on, 533 nervous affections of, 540 neuralgia of, 540 paralysis of, 542 sarcoma of, 536 sclerosing glossitis, 533 smoker's parch, 532 spasm of, 542 surgical anatomy of, 528 syphilis of, 533 -tie, 540 tuberculosis of, 532 tumours of, 534, 537 ulcers of, 532, 536 wounds of, 529
Tonsil, calculi of, 503 hypertrophy of, 502 infective conditions of, 500 inflammation of, 500 Luschka's, 579 naso-pharyngeal, 579 quinsy, 501 syphilis of, 503 tuberculosis of, 503 tumours of, 504
Tonsillitis, varieties of, 500
Tooth, wisdom, impaction of, 508
Torn semilunar meniscus, 170
Torticollis, 587. See Wry-neck
Trachea, foreign bodies in, 643 fracture of, 593 scabbard, 608 thymus stenosis of, 602 wounds of, 595
Tracheoscopy, 635
Tracheotomy, 638
Transplantation of tendons, 245
Transverse sinus, phlebitis of, 384 tarsal dislocation, 199
Trapezius, paralysis of, 404
Traumatic apoplexy, 355 cephal-hydrocele, 321, 390 epilepsy, 358 insanity, 360 neurasthenia, 345, 358 node, 1 oedema of brain, 352 spondylitis, 427
Trendelenburg's test, 252
Trigeminal nerve, 400 neuralgia, 400
Trigger finger, 318
Trochlear nerve, 400
Tuberculosis. See Individual Organs
Tumours. See Individual Organs
Tympanic antrum, suppuration in, 566 membrane, lesions of, 557 perforation of, 557 rupture of, 557, 563 surgical anatomy of, 557
Typhoid spine, 448
Ulna, deficiency of, 311 dislocation of, 94 fracture of upper end, 85 lower end, 110 shaft, 100 separation of epiphysis of, 87, 110
Uvula, bifid, 477 elongation of, 499
Vagus nerve, 403
Valsalva's method of inflating ear, 558
Venous sinuses, intra-cranial injuries of, 356
Ventricles, lateral, bursting of abscess into, 381 haemorrhage into, 342
Vertebral column, actinomycosis of, 448 arthritis deformans of, 449 blastomycosis of, 448 compression fracture of, 426 congenital deformities of, 458 deviations of, 461 diseases of, 431 dislocations of, 424, 427, 428 fracture-dislocation of, 427 fractures of, 425, 426, 427 hydatid cysts of, 448 hysterical affections of, 448 injuries of, 423 kyphosis, 461, 462 lateral curvature of, 463 lordosis, 461 malignant disease of, 447 osteomyelitis of, 431, 448 Pott's disease of, 431 scoliosis, 463 sprains of, 423 surgical anatomy of, 411 syphilis of, 447 tuberculous disease of, 431 tumours of, 447 twists of, 423 typhoid, 448 wounds of, 430
Vertigo, 555
Visual centres, 335
Volkmann's ischaemic contracture, 85, 98, 310 supra-malleolar deformity, 273
Wandering acetabulum, 210, 227
Wax in ear, 561
Webbed fingers, 317 toes, 303
Wens, 324
White swelling of knee, 233
Winged scapula, 306
Wisdom tooth, impaction of, 508
Wounds. See Individual Regions and Organs
Wrist, diseases of, 208 dislocation of, 111, 112 congenital, 313 drop-, 311 injuries of, 102 Madelung's deformity of, 313 sprain of, 115 surgical anatomy of, 102 tuberculous disease of, 208, 209
Wry-neck, 587 acute, 587 hysterical, 592 permanent, 588 rheumatic, 587 spasmodic, 591 transient, 587
Xerostomia, 547
X-rays in fracture, 16
Zygomatic bone, fracture of, 519
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