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.



CHAPTER 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.



CHAPTER 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.