CHAPTER XLII
.
THE NECK.
CONGENITAL ANOMALIES OF THE NECK.
These consist largely of defects due to arrest of development along the lines of the branchial clefts. Necessarily of embryonic origin, they do not reveal this until varying periods after birth, sometimes not until old age. They consist of fistulas, opening either externally or internally, or more commonly of cystic dilatations of the interior portions of the original fissures. External openings are usually seen along the sternomastoid, either in front or back of it, or between the larynx and the clavicle. Vestiges are also present in the shape of little tags of skin containing portions of cartilage or bone. They frequently occur together, the tag indicating the location of the fistula, whose opening may be found obstructed with crusts. Internally the openings are usually found in the pharynx, perhaps in the larynx or trachea, generally near the tonsil and base of the tongue. An external fistula may be tested for its completeness by injecting a colored fluid and inspecting the pharynx. The fistulous portion is usually marked by a cord-like mass which extends inward, usually toward the hyoid bone. Internal blind fistulas may gradually expand and constitute one variety of the so-called pulsion diverticula of the pharynx and upper esophagus, their dilatation being due to accumulation of food, and gradual stretching in this way.
All of these embryonic relics are of interest because from their small beginnings large growths may take place, constituting even serious surgical problems. These growths may present in almost any region of the neck and frequently extend into the mouth, where they give rise to certain forms of _ranula_. Almost every cystic tumor beneath the tongue or jaw is open to the suspicion of having an embryonic origin. Most of these vestiges are amenable to surgical treatment should they give rise to discomfort or trouble. The operations required are sometimes quite extensive, as any tumors of branchiogenic origin are especially liable to adhesions to the large vessels; moreover, they are nearly always firm and the dissection thus made difficult. A dermoid cyst may be evacuated and its wall or sac destroyed or dissected out. It may then be made to heal by packing.
=Treatment.=--In the treatment of fistulas of the neck, König has advised that a curved probe be passed through the tract to a point close to the tonsil, at which point on the inside of the mouth or pharynx the mucous membrane is incised, a silk thread is fastened to the end of the probe, pulled out with it, then made to pass to the external end of the fistulous tube, which is then invaginated and pulled back into the mouth, where it is reduced to a short stump which is fastened to the margins of the opening of the mucous membrane. The external wound is then made to heal as usual. This treatment suffices for blind internal fistulas of the cervical region.
It is a matter of great surgical importance and interest that certain branchiogenic remnants persist in a perfectly harmless manner until advanced life is reached, after which there take place therein cancerous changes which convert them into the so-called _cancers of branchiogenic origin_. These are too often of hopeless character by the time they are seen by the surgeon.
Other congenital defects consist of atrophies, such, for instance, atrophy of the sternomastoid muscle, or of certain hypertrophies which may be unilateral or symmetrical.
WOUNDS AND INJURIES OF THE NECK.
The neck is everywhere exposed to incised and perforating wounds,
## partly as the result of pure accident, too often as the result of
homicidal efforts. The most exposed parts are supplied with veins of large caliber which connect directly with the heart, and whatever danger there may be of _entrance of air into the veins_, under any circumstances, is in this region enhanced. This entrance of air has been regarded as a serious and often fatal accident. The writer’s experience and research have shown that it may often occur in mild degree with but little temporary disturbance. Should it occur the fact will be indicated by a slight gurgling sound, with tumultuous action of the heart, dilatation of the pupils, embarrassed breathing, and every indication of lowered blood pressure. Every competent operator will secure these large veins before dividing them, but if anything of this kind should be noted during an operation, pressure or plugging of the wound, with artificial respiration, perhaps even massage of the heart, and tracheotomy if necessary, should be practised until the patient has revived. If in the course of an exceedingly deep dissection the accident can be foreseen it may be avoided by keeping the wound filled with warm sterilized salt solution. This, however, will seriously embarrass the operative work, as it obscures vision.
The lower in the neck a serious wound be received, other things being equal, the more dangerous it becomes. Thus penetrating wounds above the larynx are of less importance than those below it. All injuries or wounds about the larynx are not only likely to dislodge its interior cartilages, but are especially likely to be followed by pressure of effused blood, or the consequences of a rapid _edema of the glottis_, which may prove fatal unless the trachea be opened below. It is this fact which makes fracture of the larynx so dangerous an injury.
A _wound of the trachea_ rarely occurs by itself, as it lies deeply, and it may be especially serious if vessels in this neighborhood have been so injured that blood may be easily poured or escape into the lungs. If the trachea be completely divided its ends will be separated and gap, while the lower end will be drawn out with each deep inspiration. In this way suffocation may quickly occur. In all such cases the head should be placed lower than the body (Rose’s position), the lungs emptied completely, the wound enlarged, and the tracheal wound be sutured or else a tube be inserted. The treatment must largely depend upon the number of hours which have elapsed since its infliction, and the condition of the wound itself. In these cases it may be assumed that such a wound is infected, therefore it should not be closed without provision for drainage.
Any injury to the respiratory tract proper will be indicated by the character of the expectoration and the sounds heard on auscultation. Such injuries are likely to be complicated by a subsequent bronchitis, pneumonia, deep abscess, or various other undesirable sequences. Under the suggestive term “Schluck-pneumonie” the Germans have described a condition which we describe in the term “inhalation pneumonia.” It implies a septic type of pneumonia caused by the passage downward of foreign material, including septic wound secretions, which, not being expelled promptly, cause a type of inflammation, with consolidation, which will give most of the ordinary physical signs of pneumonia.
A rather distinct type of incised wound is that included in the term “_cut-throat_.” It implies a homicidal, usually suicidal, attempt on the part of the ignorant to sever the large vessels in the neck. This is but rarely accomplished, the injury being done to the larynx and the trachea and the tissues anterior to the vascular trunks. Usually inflicted with the right hand, one side of the wound may be deeper than the other. While the trachea is usually cut and often divided, the injury may be to the larynx instead. At all events, a wide gash is made and there is considerable hemorrhage, the external jugulars being nearly always severed. By the time such a wound is seen by the surgeon it is an infected wound and it should not be closed too tightly. The trachea may be sutured by itself, but it will be best to place therein a tracheal tube. Ample provision should also be made for drainage. In some instances the wound may be left open, at least for a few days, until it is granulating, and then be closed by deep sutures. Care should always be given to those of desperate suicidal intent and to the maniacal, that they do not reopen the wound in continuation of their previous efforts. This requires careful watching.
_Rupture of the trachea_, either due to violent coughing or straining efforts or to external violence, is known. It will call for tracheotomy, because of the emphysema which will ensue. Penetrating wounds of the large arteries and veins are always serious. When not extensive they may be followed by diffuse or circumscribed hematoma or by aneurysm. Nélaton is reported to have stated that it takes four minutes for a man to bleed to death from the carotid artery, and that two minutes should suffice for its ligation. Any injury to the vessels should be followed by their exposure, and probably by ligation or suture, in order to prevent the conditions above mentioned. If the wound be low in the neck it would be proper to remove the upper end of the sternum or to divide the sternomastoid sufficiently to expose it.
The _vertebral artery_ is occasionally injured, mostly in the osseous canal through which it passes. At the base of the neck a wound at or near its origin is an exceedingly serious injury. The same rules apply as above.
_Wounds of the large veins_ are supposed to be of a more serious nature because of the possibility of inspiration of air, _i. e._, air embolism. These vessels are occasionally injured during removal of deep-seated and adherent tumors. It has been possible in some instances to make a _lateral suture of the jugular vein_ at the point of injury, providing this be not too extensive. Effort at reunion of this kind is always legitimate if the operator feel himself equal to the task. The jugular vein is also occasionally exposed and tied low down, then opened above the ligature, for the purpose of cleaning out its upper portion when filled with infective thrombi, a condition occasionally seen with mastoid abscess, etc. To open it before tying would be a surgical mistake. By this process it is practically obliterated as recovery ensues.
If such a muscle as the sternomastoid be partially or completely divided muscle suture should be practised and the head and neck kept at rest for the ensuing few days.
_Injuries to the cervical nerves_ may be followed by peculiar and interesting features. That of the recurrent laryngeal will cause paralysis of the laryngeal muscles on one side, with consequent difficulty in speech; injury to the cervical sympathetic will be followed by dilatation of the pupils and protrusion of the eyeballs with flushing; of the spinal accessory, by mastoid and trapezius paralysis; of the phrenic, by paralysis of the diaphragm on one side; and of the pneumogastric, by embarrassment of respiration, with pupillary and abdominal symptoms, which are variable. Of all of these injuries that to the phrenic is probably the most serious. Some years ago I tabulated the then recorded cases of injury to the pneumogastric and was able to show that only about 50 per cent. of such cases were immediately or tardily fatal. The phrenic nerve is then the only one within the neck which can scarcely be spared. Any of these nerves when divided should be reunited by sutures, as elsewhere described.
When any portion of the _brachial plexus_ has been injured a corresponding paralysis of the arm will follow. Wounds of these nerves should be sutured at once. A distinction should be made in all cases between hysterical anesthesia, malingering, and the actual paralysis of injury. Sometimes the amount of callus thrown out after a fracture of the clavicle will include a nerve of sufficient size to produce a neurosis, usually neuralgia, or possibly a paralysis. Excessive callus, or, in effect, the bony tumor which is thus produced, may be removed by operation, and any entangled nerve should be hunted out and liberated.
Pressure of a tumor upon a nerve will cause paralysis corresponding to its degree. When this comes on gradually, even though it involve the phrenic nerve, the consequences are not so serious. Repeated irritation or pressure may cause paralysis, as in the cases of the strap of letter-carriers or those who carry burdens slung from the neck.
_Injuries occur to the cervical muscles during parturition and a hematoma_ of the sternomastoid in the newborn is described. The muscle is contracted and the head bent over. It usually disappears by resolution within a short time. This muscle is also ruptured by violence in the adult; again, hematoma is the result, with at least temporary torticollis, pain, and tenderness. When an abrupt division can be recognized, exposure of the ends and muscle suture would be indicated. At any time, in the presence of clot, it would be proper to cut down and turn it out.
_Syphilitic myositis_ is often seen in the sternomastoid, where it may affect the entire muscle, transforming it into a cord-like mass, or where it may occur as gummatous infiltration. These cases occur without pain and without known cause save the disease itself, whose possibility should be established by the history of the case. Again, these muscles are sometimes contracted because of reflex excitement from adjoining inflammatory foci. Such an affection subsides shortly after due attention to the exciting cause, unless it has been allowed to continue too long. _Inflammation_, even of the destructive type, may be propagated to the muscles by continuity from a neighboring suppurating focus.
Serious _phlegmons of the neck_ may be followed by phlebitis of the internal jugular vein, which may be recognized by the presence of a palpable cord-like clot within its lumen. Such a condition is serious because of the ease with which pyemia may ensue. It would be better to expose the vein, to tie it low down, to freely excise and turn out such a clot, than to leave it to create serious disturbance a little later.
Of the _posterior portions of the neck_ we have fewer injuries, and these less serious, excepting those by which the vertebral column or the enclosed spinal cord are injured. These injuries have been referred to in the chapter on the Spine. A high perforating injury of the cord, especially if it involve the medulla, is promptly fatal. Infanticide has been produced by a long needle driven between the occiput and the vertebræ, corresponding to the pithing of small animals in the laboratory. An injury above the origin of the phrenic, on one side, is not necessarily fatal. Injuries to the posterior portion of the high cervical cord, as well as to the membranes, may be followed by more or less atrophy of the genital organs, with corresponding impotence, Larrey claiming that this may take place even when the cord itself is not affected.
_Ruptures of muscles_ and _separations from their insertions_ or origins are occasionally noted. The scapular muscles are occasionally torn loose. A reflex spasm of the trapezius which follows some of these injuries will produce a posterior form of acute torticollis (wryneck) described in the chapter on Orthopedics (XXXIII). The resulting deformity and stiffening might be confounded with arthritis of the upper vertebral joints. It is to be overcome by traction and by suitable apparatus, save in extreme cases, when division or excision of a sufficient portion of the muscle may be practised.
[Illustration: FIG. 492
Carotid aneurysm successfully treated by complete extirpation. (Author’s Clinic.)]
Of great interest are the _blood vascular tumors_ of the neck, both those of spontaneous and of traumatic origin. Large angiomas, either of the arterial (cirsoid aneurysm) or of the mixed or venous type, are seen about the neck. Here more than anywhere else are found peculiar _venous dilatations_, especially of the smaller veins, which form cavities in a tissue that becomes thereby almost erectile. Should these tumors connect with the arteries they will pulsate. If composed of larger veins they will prove quite compressible. These tumors should be extirpated, care being taken to place a provisional or permanent ligature upon the large vessels connecting therewith before the tumor itself is attacked. Occasionally the ampullæ of these growths become sufficiently large to entitle the growths to be considered as _sanguineous cysts_. The neck is also frequently the site of the smaller varieties of these growths which constitute the ordinary nevi. (See chapter on Tumors.)
_Aneurysms of the cervical vessels_ are more frequently of spontaneous than traumatic origin. They may, however, result from contusions or penetrating injuries. While no vessel in the neck always escapes, it is the common carotid which is more frequently affected than the others. The general subject of aneurysm has been considered. Care should be taken not to confuse the vascular and pulsating goitres, or other pulsating cysts of the thyroid. It is necessary also to distinguish aneurysmal pulsation from that which is transmitted through a tumor overlying the vessels or which may be seen in some of the extensive malignant tumors of the neck. When the diagnosis of aneurysm is made the surgeon should decide what vessel is primarily affected. This, however, is not always possible, as an aneurysm of the vertebral artery projecting forward is liable to be mistaken for one of some other trunk.
Aneurysm in the neck, unless very deep, and in a very unfavorable subject, is always an indication for operation. While operation necessarily includes ligation, either on the proximal or distal side, if this can be practised the sac itself may be treated just as though it were a tumor of any other character, and extirpated. I have myself had satisfactory results by the last-mentioned procedure (Fig. 492). The existence of laryngeal paralysis, especially unilateral, which is not easily accounted for in other ways, should excite a suspicion of aneurysm, with consequent pressure upon the recurrent laryngeal nerve. Its possibility should be excluded as part of the diagnosis.
_Wounds of the subclavian vessels_ give rise to serious hematomas which may be converted into spurious traumatic aneurysms of arteriovenous character. When such a tumor pulsates it is probably connected with the subclavian artery, which should be ligated. It may be possible to make this ligation above the clavicle, but a portion of the sternum should be removed as well as the inner end of the clavicle for a more complete exposure. On the right side at least the artery can only be reached above the bone after dividing the scalenus anticus, where a provisional ligature may be placed. After this the sac should be incised and the vessel ligated, on either side of it, so that the provisional ligature may be removed. On the left side it is safe to ligate the second portion of the artery at once. The clavicle should be divided to afford better exposure, and its ends reunited with silver wire (Fig. 493).
[Illustration: FIG. 493
Traumatic aneurysm of axillary artery.]
Any open wound of the subclavian vein is a serious affair, as bleeding will be profuse, and there is also danger of air embolism. Immediate occlusion with an antiseptic dressing would probably afford better prospect than any attempt to enlarge the wound and secure the divided vessel. If the vein be thus attacked its proximal portion should be first secured in order to avoid the entrance of air. Meantime much of the hemorrhage from the distal end may be prevented if pressure be made in the axilla upon the axillary vein. If the vessel be secured both ends should be tied.
In instances of accidental injury, or that included in the removal of large and deep tumors, the _thoracic duct_ on the left side and the _lymphatic duct_ on the right have been injured or divided. It is one of the possible dangers in performing extensive operations on the root of the neck, especially on the left side. Its occurrence would be indicated by oozing of the milk-like lymph. The accident has not been frequently reported. It would render closure of the wound without drainage impracticable, but it has been found sufficient to place a deep packing and to rely upon the natural healing process (granulation) by which such a wound would be gradually closed.
It may be said of vascular lesions that when it appears to be necessary the upper part of the sternum may be resected, as it adds little to the danger and exposes the operative field in a more desirable way. There is no better operative method for ligation of the innominate artery than that which includes removal of the upper end of this bone. Incidentally it may be added that this is also justifiable in certain penetrating wounds of the trachea and in attacking retrosternal goitres or lesions of the thymus.
PHLEGMONS OF THE NECK.
_Phlegmonous affections_ in the region of the neck are serious because of the complications which may ensue. The more deeply they lie the greater this danger. This comes not only from septic processes which may follow veins and lymphatics, but from burrowing of pus along and between the deeper muscle planes, which may carry it into one of the mediastinal spaces or within the thorax. These phlegmons may be primary, or may follow infection spreading through the open crypts of the tonsils, or the open pathways afforded by diseased teeth and by superficial ulcerations. An infection of a tonsil may cause an abscess which presents beneath the jaw, while a deep axillary abscess may be the consequence of a phlegmon beginning in the neck. Not infrequently they come about through the mechanism of infected lymph nodes, which may sometimes produce multiple or extensive single abscesses. These phlegmons occasionally follow the exanthems, especially scarlatina, and the variety of directions in which infection may spread from the middle ear is well known, since it may cause phlegmon in the neck or empyema of the mastoid antrun and even fatal disturbance within the cranium. When the resulting pus travels downward in front of the thyroid and sternum it will appear upon the thoracic wall; when behind the trachea and the oesophagus, or along the large vessels of the neck, it will be seen either within the thorax or at the root of the neck, possibly opening into the esophagus or spreading to the axillary space. _Retropharyngeal abscesses_ are often the result of caries of the vertebræ, but may occur in consequence of a deep cellulitis caused by extension from some focus within the nasopharyngeal cavity. This is an illustration of the rule that pus travels in the direction of least resistance.
=Diagnosis.=--The _diagnosis of cervical phlegmons_ is usually not difficult, especially when they are superficial. The ever-present indications of redness and edema of the surface, pitting upon pressure, tender swelling, and loss of function of the surrounding parts, often with fixation through muscle spasm, coupled with the general systemic disturbance, and, in desperate cases, the indications afforded by the blood and the urine, will enable a diagnosis to be made, usually without the use of the exploring needle. This, however, may be employed if necessary. The same is true in lesser degree of tuberculous collections of pus and pyoid, which have been earlier described as “cold abscess.” Only in the beginning of its course can any doubt arise concerning the nature of a _carbuncular process_.
A somewhat typical type of deep phlegmon is often referred to as _angina_ and _Vincent’s angina_. Semon regards these manifestations as expressions of an acute septic cellulitis which has been described as abscess of the larynx and as erysipelas of the larynx, and which other writers refer to as cynanche tonsillaris, acute peritonsillitis, etc. The disease may occur in healthy individuals, more often in the diabetic. A violent sore throat is followed by serious dysphagia, with considerable edema of the pharynx, whose surface is of a dark-blue color. Patients may become unable to swallow, while hoarseness with aphonia will result from edema of the glottis. The epiglottis will be darkly discolored, greatly tumefied, and nearly obscuring the entrance to the larynx. Dyspnea may necessitate tracheotomy. A light-colored false membrane may be seen in the throat. There is always marked lymphatic involvement. The disease may be more confined in some cases to one side. Vincent has described a particular spirillum or bacillus which he found in some of these instances. The infection here doubtless proceeds from the mouth or the tonsils, its activity being due to symbiosis of various organisms. It is to be distinguished from Ludwig’s angina, which is rather a submaxillary affection than a retropharyngeal. It infrequently leads to retropharyngeal abscess.
_Ludwig’s angina_, also called _infectious submaxillary angina_, is an infectious cellulitis of the mouth. The tongue is swollen and immovable; the mouth more or less fixed, with difficulty of swallowing, and the condition is one of extensive infiltration, with formation of pus, which is likely to burrow. In some of these cases the Micrococcus tetragenus is the organism at fault. In my experience when present it leads to a brawny infiltration which is slow to subside or disappear.
=Treatment.=--The early recognition and evacuation of pus are called for in all cervical phlegmons. The presence of pus may be assumed before it can be recognized from external evidence. Therefore when swelling begins to mask anatomical outlines, or to produce difficulty of swallowing or breathing, free external incision, with deep dissection, will prove much safer than to leave such a case to itself. Retropharyngeal abscesses, or such collections as may be recognized in the tonsil or in the pharynx, may be opened from within the mouth. That there should not be too much haste in this direction, however, was indicated to me when a well-known surgeon plunged a bistoury into what he supposed to be an abscess of the tonsil and found it to be an aneurysm, the patient dying within five minutes in his office.
Early and free incision will relieve tension, and do good by a certain amount of bloodletting, even if pus is not reached, while an easier outlet for it will be afforded when it does form. However, the surgeon will rarely fail to find it if he goes sufficiently deep or in the right direction, when the existing symptoms and signs are of serious import.
The operator should incise freely in the beginning, after which deep dissection is best effected with some blunt instrument. The exploring needle may afford valuable information, but if the deep tissues be edematous we may feel quite sure of the presence of pus in the neighborhood. Souchon has described a method of guided dilatation which requires a series of dilating instruments, and which will give good results. Search for pus can be made without them by using the blade of a dissecting knife or hemostatic forceps, or the blades of a pair of scissors to stretch a small opening. The less tissues are cut and the more they are thus separated the better.
_Perilaryngeal_ or _peritracheal abscesses_ are likely to cause dyspnea and show a tendency to extend downward along the trachea into the thorax. In these locations they produce a peculiar diffuse cellulitis, which was described by Dupuytren. Such phlegmons may extend from the ear to the clavicle or from the back of the neck to the larynx. Pus will collect in many small interspaces, and purulent infiltration will affect many of the tissues, and may produce gangrene. This condition has also been described by Gray-Coley and by Hannon. The surface not infrequently seems to be involved in erysipelas. In fact it is doubtless true that most of these affections are of the streptococcus type, where it is impossible to distinguish between erysipelas and cellulitis. Tracheotomy as well as the other free incisions may be indicated. _An early tracheotomy should be made whenever suffocation threatens from any swelling or edema._ The latter occurs so suddenly that a tracheotomy should be made early rather than wait for its necessity, especially when patients cannot be kept under constant observation. The operation may be done under cocaine, while the presence of the tube will then permit the administration of one of the ordinary anesthetics without embarrassing respiration.
All of the other phlegmons, no matter what type they assume, are to be treated on the same general principles. If seen, however, before incision and drainage appear these cases may be treated locally with the compound ichthyol-mercurial ointment, or with Credé’s silver ointment, re-inforced by hot external applications; and the mouth should be frequently rinsed with warm antiseptic solutions. Any lesion within the mouth should receive its own proper treatment.
=Carbuncles.=--Carbuncles, which appear perhaps more frequently upon the back of the neck than elsewhere, should be treated by the radical method, _i. e._, excision of all tissue which is evidently so involved that it will subsequently slough. Even an extensive carbuncle several inches in diameter, with numerous crater-like openings, and presenting large amounts of already necrotic tissue, is best treated in this same way. The more quickly the dead and dying tissues are removed the better for the patient. Such an operation requires an anesthetic and the free use of scissors and a sharp spoon, even the scalpel. After being freed of necrotic tissue the exposed surfaces should then be dressed with brewers’ yeast. In general, of all these phlegmons, it may be said that nowhere does the general rule elsewhere laid down in this work better apply, _i. e._, that pus left to itself will always do more harm than will the surgeon’s knife if judiciously used.
The various fixations of the neck by muscle spasm or muscle infiltration due to these phlegmons, _i. e._, the temporary forms of wryneck, will nearly always subside as infiltration disappears. Some degree of permanent contracture may follow neglected cases and may call for massage, stretching, and the use of a suitable brace.
AFFECTIONS OF THE CERVICAL LYMPH NODES.
The cervical lymphatics are abundant in number, as they need to be to serve their purpose, considering the variety and extent of the possible sources of infection, both from within and without. They become enlarged even in a trifling case of tonsillitis, while in more serious infections they participate with the surrounding tissues, but sometimes suppurate independently of them. They are involved in nearly every case of constitutional _syphilis_, and serve as an index of the saturation of the system with the specific poison. Treatment for the same should never be discontinued so long as they are perceptibly enlarged. They
## participate, then, in both the local and the constitutional infections.
In no respect is this more true than in local tuberculous infections, or in others which have become tuberculous through the process of mixed or secondary infection.
_Tuberculosis of the cervical lymphatics_ is then one of the results of previous mild or severe infections. They constitute the so-called “scrofulous glands” or swellings of writers of the past generation. There may be seen repeated within these structures those processes which in the lungs cause at one point softening, at another caseation, and at another sclerosis. An acute suppurative process may also be going on, or there may be found, in broken-down cavities, that pyoid material which is often seen in cold abscesses, and to which elsewhere in this work is given the name archepyon, indicating that it was originally of a truly purulent type, which it has lost in course of time.
[Illustration: FIG. 494
Cluster of tuberculous lymph nodes removed by dissection, and showing the usual and various changes. (Lexer.)]
Tuberculosis of the cervical lymph nodes may be a limited and almost single expression of disease, or one involving both sides of the neck, and to a degree that may produce large and disfiguring swellings. It is nearly always a secondary infection, the original lesion being found upon the surface of the skin, more frequently in the middle ear, the pharynx, the tonsils, the nose, the teeth, or other parts within the mouth. The first measure in every instance should be to trace this source of the infection, since to leave it uncared for is to invite a continuance of the disease. The course of events often is an acute exanthem, a chronic tonsillitis, a mildly septic involvement of the lymph nodes, followed later by tuberculous invasion through a port of entry opened by the previous process (Fig. 494).
Most of the acute septic infections of these lymphatics will be followed by local abscess and by one of the extensive phlegmonous manifestations described above. This usually means an acute abscess formation, which should lead to early incision and speedy recovery. It is the more chronic and less suppurative types which cause serious trouble. They occur more frequently in the young. There is a distinct form, however, occurring in the aged, which is called _senile tuberculosis_. Its pathology nowise differs from that of the type occurring in the young, although it has a different clinical expression.
When the lymph nodes are but recently involved they are simply so encapsulated as to be easily shelled out from their beds; but when degenerating and slowly suppurating they become so firmly embedded in the surrounding tissues by dense infiltration that their extirpation is exceedingly difficult. This condition has been spoken of as peri-adenitis, a bad term, because nowhere in this work are lymph nodes spoken of as “glands.” Not infrequently the operator will find large masses affixed to the carotid sheath, or surrounding the vessel and nerve trunks, so that it is almost impossible to separate them. During the dissection the internal jugular may be torn, or one of its branches severed at its base, while an important nerve trunk may be so lost in the mass that it is almost impossible to distinguish it, and it may not escape injury.
=Treatment.=--Search should be first made for the source of the infection, since to attack the consequences of the disease and to leave the cause untouched would be a mistake. If it be a chronic nasopharyngeal catarrh it will require considerable local treatment. If an enlarged tonsil this should be removed. If due to dental caries, or ulceration in connection with faulty dentition, or to pyorrhea alveolaris, the patient should be sent to the dentist; if the trouble be in the middle ear, to the aurist; if the infection come from the skin, as in various ulcerating skin diseases, again appropriate external measures should be adopted. When the patient is otherwise in good condition and freed from liability of further infection, then the question of surgical intervention is to be decided. Decision will rest somewhat upon the general condition of the patient and the extent of the lesions. A consumptive patient, for instance, is not a good subject for surgery, and it may be held that the lymphatics will be benefited by such change of climate as is indicated for his tuberculous lungs. A puny or anemic subject is not a favorable one for an extensive surgical operation, such as the removal of a large mass of those nodes often necessitates. It may be deemed advisable to delay while the patient is temporarily sent to the mountains, or is placed upon treatment, including arsenic as an alterative, and the best restorative tonics. Some cases not favorable for operation are benefited by x-ray treatment. This should be judiciously administered, in such manner as not to produce a dermatitis nor increase the infiltration in the tissues of the neck. It is to be advised rather in cases considered inoperable than in those favorable for operation.
Excision is the measure usually resorted to because of the promptness of its effect, as well as the extent. Excision, however, necessitates an exceedingly careful and tedious dissection. When the whole side of the neck is involved I would advise an S-shaped incision, by which a double flap, with much better exposure, is afforded. There may perhaps be found two quite different sets of involved nodes, the superficial lying rather to the outside and to the front of the sternomastoid, which will be adherent to the carotid sheath, and a deeper set lying back of the sternomastoid whose removal will usually take one down to the transverse processes of the cervical vertebræ. In an average case there may be found all possible combinations of degeneration, with softening and cold abscess on one hand, and caseation and calcification on the other. Proceeding more deeply masses will be found whose existence had not been appreciated from the surface. Nevertheless, such cases usually do well and often recover. Thus a wound extending from the mastoid to the clavicle may be entirely healed within a week if the wound has not been infected by fresh pus. Such extensive wounds should be treated with at least one drainage provision, a drain being brought out through the wound or a special opening made for it, at a point where the resulting cavity will empty itself with the patient lying upon his back in bed.
For all these operations the patient should be prepared in the best possible manner. It will be of advantage to send patients to the woods, while, under any circumstances, they should be kept under those surroundings most favorable to tuberculous individuals, where hypernutrition, lively elimination, and oxygen fulfil the general requirements. They may also take such alteratives as arsenic, and such drugs as creosote or its derivatives, which are supposed to have more or less specific effect.
A distinct type of involvement of the cervical lymphatics is seen in connection with the spread of _malignant disease_ from adjoining structures. Nowhere is this more marked than in epithelioma of the lip, but it may be seen in cancer spreading upward from below, as in connection with cancer of the breast. When the cervical lymph nodes are involved in a case of cancer of the breast a hopeless aspect is thereby put upon it. Although operation may be justified for temporary relief it should be so understood.
TUMORS OF THE NECK.
_Aeroceles_ of the neck are sacs formed by air distention of an adventitious pouch, and constitute a species of local emphysema, due to weakening and yielding of some portion of the respiratory tract, produced by such strains as cough, labor, etc. A congenital dilatation of a laryngeal ventricle may produce the same effect. It may also follow a distinct wound of the trachea, or the expansion of a cavity in one of the mucous glands produced by its ulceration or breaking down. They may also result from abscess cavities opening into the respiratory tract. According to their location they may be referred to as _laryngoceles_, _tracheoceles_, etc. The term _pneumatocele_ implies a protrusion of the pleura and the lung into the region above the clavicle. It will give distinct signs here on percussion, will disappear under pressure, and quickly recur as the result of forced expiration, coughing, etc. It may even follow the respiratory movements. This latter form is scarcely amenable to treatment unless tissues can be brought together over it and the opening closed. The other aeroceles are more or less amenable, according to their location and exciting cause. It is rare that there is any contra-indication to their exposure and extirpation.
Of the many true _cysts_ of the neck a large proportion are due to _incomplete closure of some portion of one or more branchial clefts_. These have already been mentioned in the chapter on Tumors. The lesions vary from trifling submaxillary dermoid tumors to extensive hydroceles of the neck, such as those illustrated in Figs. 495 and 496. Not every congenital tumor, however, is of branchial origin. There is a possibility of the development of others along the thyroglossal duct, along the great vessels, and in the neighborhood of the pharynx and larynx. _True bursal cysts_, as well as true _atheromatous cysts_, also develop at various ages. The former will be found filled with serous fluid. They occur on the anterolateral aspect of the neck and generally on the left side. _Dermoid cysts_ also abound here. They have an epithelial lining, which always indicates their congenital origin. They frequently do not develop until puberty. They may contain various epithelial products, which may escape by suppuration or perforation. These growths sometimes extend into the mediastinum. A form of _median thyrohyoid cyst_ of this character often grows rapidly after confinement. Such a cyst if incompletely treated will be followed by persistent fistula. All of these growths should be thoroughly extirpated if attacked at all, or widely opened and packed, and then made to heal by granulation. Fig. 497 illustrates another type of cystic growth of the neck connecting freely with the lymph spaces and vessels and regarded as a congenital lymphangioma.
[Illustration: FIG. 495
Congenital multilocular serous cysts (hydrocele) of neck. (Lannelongue.)]
[Illustration: FIG. 496
Branchial cyst. (Case of Dr. Parmenter.)]
Still another type of cystic growth is connected with the anterior jugular vein. It contains sanguineous fluid, and sometimes true venous blood. Connection with the vein may be determined by making pressure. A growth easily emptied and rapidly refilling will be distinctive. It should not be mistaken for an aneurysm, as it does not pulsate. It is known as a _sanguineous cyst_.
[Illustration: FIG. 497
Branchial cyst or hydrocele of neck. Baby six weeks old. (Case of Dr. Parmenter.)]
The difficulty of distinguishing between dermoid cyst and dermoid tumor has been mentioned in the chapter on Tumors. The distinction is one of small importance, for no matter what its character such a growth calls for extirpation. A similar dermoid in the course of the thyrolaryngeal duct is represented in Fig. 498.
[Illustration: FIG. 498
Dermoid (ad-hyoid) cyst at base of tongue. (Marchant.)]
[Illustration: FIG. 499
Diffuse symmetrical lipoma, multiple. (Lexer.)]
In the neck, more often than in any other part of the body, may be seen well-marked cases of diffuse lipoma. These are painless overgrowths of fatty tissue, unencapsulated and consequently liable to spread to an unlimited extent (Fig. 499). They form disfiguring clinical pictures, but cause no unpleasant symptoms. They are scarcely to be attacked surgically, as they have no anatomical limit. They are rarely operated. More circumscribed growths can be more or less easily removed.
Of the true tumors of this region little need be said here. There is a form of fibrochondroma, springing from a branchial cleft, which occupies the external orifice of a congenital fistula a little above the clavicular joint. This makes it of interest, and, at the same time, distinctive in character.
Any of these growths may give rise to serious pressure symptoms and may be so located as to make tracheotomy difficult. They often extend downward behind the sternum, in which case the upper part of that bone should be removed in order that they may be safely followed. Such a tumor, if it so extends and is a true cyst, should be treated by free incision and packing; but when solid, no other resource than extirpation is left. On their posterior aspect the greatest caution should be exercised, and it may be well to leave a part of their posterior walls to avoid the danger of injuring the large veins.
The majority of tumors that present on the floor of the mouth which are not of malignant type, nor adenomas of the salivary glands, are embryonic relics, a type alluded to above. A small vestige of this kind may long remain dormant and then suddenly assume a rapid growth.
Of the _malignant tumors_ there are many expressions in the neck of endothelioma, of sarcoma, and of carcinoma, the latter only arising from epithelial structures like those of the skin, the glands, or the mucous membrane. They may extend in all directions. Many cancers of the neck are metastatic, the primary growth not necessarily being in the immediate neighborhood. A distinct form of cancerous degeneration of embryonic vestiges is known under the name of _branchiogenic carcinoma_. It is seen usually in elderly people and along the line of the branchial clefts. If possible it constitutes a more hopeless variety than others, because of its origin and depth. Certain sarcomas of the neck are prone to assume the type of fungus hematodes. Any tumor of this character should be attacked with spoon and cautery, for the vessels which bleed so easily are only those of the growth itself, those which lead up to it and around its margin not being enlarged.
THE CAROTID BODY.
The carotid body seems to have been first described by Haller, in 1743, although his description has attracted but little attention. In 1833 Mayer recognized that, aside from the well-known cervical ganglia, there was met at the bifurcation of the common carotid a small, so-called glandular structure, about the size of a grain of rice, red, firm, and vascular, much resembling the superior cervical ganglion, which receives sympathetic filaments as well as branches from the vagus. Luschka, in 1862, spoke of it as a glandlike appendage of the sympathetic system in the neck. It is usually wrapped in a sheath from the adventitia of the carotid and perhaps by more or less fat, the former having to be divided before the gland becomes visible. It seems to be a common meeting-place for fibers from the superior laryngeal, the glossopharyngeal, the sympathetic, and certain ganglion nerve fibers. It is not always present and may vary in position, lying either below the division of the artery or considerably above it upon the external carotid. In any case it is enclosed by a sort of capsule.
Its principal surgical interest obtains in that it is the occasional site of tumors, which as they grow will have intimate and perplexing arrangements to the surrounding tissues, which may necessitate most painstaking dissection, or may call for sacrifice of the large vessels. In one case reported by Scudder the tumor became larger and more tender whenever the patient caught cold. Such a tumor will not of itself pulsate, but will transmit pulsation from the carotid in a perplexing manner. They move sidewise, but not vertically. When vascular they may diminish upon pressure, or they may pass in between the other tissues in a way to simulate collapse on pressure. They lie in front of the sternomastoid, above the level of the thyroid cartilage, are usually of slow growth, and are sometimes accompanied by such vasomotor disturbance as flushing of the face and irregularity of the pupil. They are likely to be mistaken for tuberculous lymph nodes, or for common tumors of the neck. While views concerning their absolute malignancy differ, one may be certain that at least they rest upon the border line, and should in all cases be removed. Instances are reported, however, where the tumor has shown an extremely malignant tendency.
THE THYROID AND THE PARATHYROIDS.
By virtue both of its complex functions and complicated affections the thyroid is an object of surgical interest. Between it and some of the most important body changes there is intimate relation, and its effects on disposition, mentality, voice, general appearance and behavior, sexual function and the development of the sexual organs are matters of common knowledge. The latter features are abundantly illustrated by the effect upon these parts of removal of the thyroid. Embryologically it develops from the floor of the pharynx, between the upper branchial arches. Within it there forms a duct, known as the _thyroglossal duct_, whose glossal portion opens upon the base of the tongue, where it is of great surgical importance, because of growths of embryonic origin occurring along its path, and because downward growth of cancer of the posterior portion of the tongue usually takes the same course. In the early days of its existence it contains no iodine, at least in mankind, this lack of iodine being supplied from the mother’s milk, the babe thus receiving from its mother that which its own thyroid at first fails to supply.[49]
[49] This may afford an explanation of the unsatisfactory character of artificial foods, as well as of cows’ milk, since, unlike the babe, the calf is born with a functionating thyroid. Cows’ milk does not contain in this respect that which is found in human milk, all of which may afford a reason for adding minute amounts of thyroid extract for a short time to artificial foods for children.
That the thyroid normally produces substances of vital import in the human economy is shown both by the bad effects of their overproduction, as in tetany and certain spasmodic affections, with final clonic rigidity, and in thyroidism or the hyperthyroidism of Graves’ disease or exophthalmic goitre, with its tachycardia, mental depression, and numerous other symptoms, and by those of its underactivity, as in myxedema, cretinism, cachexia strumipriva, and certain of the toxemic neuroses.
The relations between the thyroid and the genital organs, especially in the female, are in many instances pronounced. Menstrual suppression and pregnancy are often followed by thyroidal enlargement, and nearly every woman having a goitre notes its temporary enlargement with each menstrual epoch, and its permanent enlargement with each succeeding pregnancy. The most specific constituent of the thyroglobulin, which is supposed to be the substance formed within the thyroid, is iodine, which is present in variable amounts.
In general it may be said of the thyroid: (1) That it secretes some material requisite for normal nutrition; (2) that it has much to do with the assimilation of oxygen by the tissues as well as with phosphorus metabolism; (3) that its peculiar secretion has a marked effect in lowering blood pressure and quickening the pulse, in the former respect being the direct antagonist of adrenalin.
The _parathyroids_ have only recently assumed importance either in surgery or pathology. Their existence as separate structures with an identity of their own was first demonstrated by Sanström in 1860. Up to his time they had been assumed to be small accessory thyroids. In 1884 they were described by Horsley. Since that time they have been an object of the greatest interest to experimenters. They are of different character from the thyroid proper. Nevertheless the two are not absolutely independent of each other, for removal of either one causes changes in the other; the symptoms caused by removal of the parathyroids, especially, including tremors and various nervous symptoms, of which tachycardia and sometimes exophthalmos are the most prominent. Experimental animals will usually survive removal of the thyroid alone, but to take away all four of the parathyroids is almost invariably fatal. Anatomically they consist of two pairs of small bodies, with an average diameter of ¹⁄₂₅ inch, having color and texture much like the thyroid in gross appearance, but containing epithelioid cells, lying in man in close relation to the lateral lobes of the thyroid, behind them and to their inner sides. In minute structure they resemble that of the pituitary body. Their relatively trifling size and deep position in man have caused them to be neglected in pathology, and to be seldom recognized during operations or except by a careful dissection made for the purpose. The present trend of opinion, especially among the experimenters, ascribes to them an important role in the production of exophthalmic goitre, it being made to appear that by some neglect of duty their function of indirectly regulating the heart and controlling the sympathetic system is not properly performed.
CONGENITAL AFFECTIONS OF THE THYROID.
Congenital affections of the thyroid may assume the type either of defect or of absence of the organ, or an hypertrophy which may involve one side or both. Presumably when the thyroid is lacking its function is to some extent assumed by the thymus and perhaps by other portions of the body.
Anatomical alterations are met in the so-called _supernumerary or accessory thyroids_, which may be due to separate development of one of the original lobules, or they may arise independently. These vary in size, location, and importance. They may be seen as high as the base of the tongue or as low as the upper end of the sternum or behind it. Tissue of this kind has been seen in the body of the hyoid bone. These accessory masses are subject to the same type of affections as those which involve the principal thyroid, and thus tumors may develop in the anterior region of the neck, which may cause some perplexity.
An extraordinary feature of thyroidal tissue is that when affected it may infrequently produce _metastases_, even to distant parts of the body. Thus cases are on record of benign goitre, with universal metastases, and, on the other hand, of numerous metastases without any noticeable thyroidal enlargement. They occur frequently in the osseous system, and in the lungs, and when the thyroid is the site of a colloid type of goitre. The same is equally true of the malignant growths of the same tissue.
The immediate results of a total removal of the thyroid, as by operation, are _myxedema_, or _cachexia strumipriva_, conditions which require a few weeks for development and which may be preceded by an acute mania. These conditions are indicated by anemia with weakness, defective circulation, swelling of the extremities, usually first in the fingers, the swelling being of a hard, inelastic type, and not pitting on pressure, appearing later in the face so that the features become altered. Later appear also muscular tremors, with tetanoid convulsive attacks. These results of thyroidectomy may be combated by feeding thyroid extract, or by transplantation of thyroid tissue from a sheep into the tissue of the body or into the abdominal cavity. While Horsley and others have been successful with the surgical procedure, it is usually now sufficient to resort to continuous administration of thyroid extract, this being indicated only in cases where thyroid
## activity is defective and being contra-indicated in instances of
overactivity, such as exophthalmic goitre.
THYROIDITIS.
Thyroiditis as a more or less acute affection is occasionally noted, being due to one of the infectious fevers, or occasionally following dermatitis, local infections, etc. It may assume a hemorrhagic type and be followed by production of hematoma. It may also assume a suppurative type and lead to the formation of abscess. This, if impending, is always of a serious nature, as it is sure to be followed by local cellulitis, perhaps with serious pressure symptoms, and escape of pus along the deeper fascial planes into the thorax.
_An acute idiopathic hypertrophy_ in children has been noted by the writer in one instance, in which the enlargement was rapid, occupying but a few days, and had already caused such compression of the trachea when the case was first seen that even a tracheotomy promptly performed did not serve to save the patient’s life.
_Intra-uterine hypertrophy_ of the thyroid is also known. There are at least five cases on record of this condition following the administration of potassium chlorate to the mother during pregnancy. In one case reported the tumor attained a size sufficient to constitute a serious complication in delivery of the child.
Among the special symptoms produced by these acute affections are: difficulty of swallowing, which may lead to great thirst; head symptoms due to obstruction to the return circulation, with congestion of the face and epistaxis; while pressure upon the pneumogastric may cause nausea or vomiting. The treatment of such a case when seen early should consist of wet and ice-cold applications for several hours; but when seen later, especially if suppuration be already threatening, pus formation and its localization may be encouraged by hot applications, followed by free incision, thus relieving tension and evacuating pus.
Thyroiditis occurring in goitrous thyroids is usually referred to as strumitis, as the enlargement itself was formerly known as struma; it follows the exanthems and fevers, and may cause sudden and distressing complications.
TUMORS OF THE THYROID.
Aside from those thyroidal enlargements to be considered under the heading of goitre may be met tumors of congenital origin, especially the simple or complicated cysts, which may grow slowly or rapidly, or may not appear at all until puberty or adult life. An apparently innocent cyst may suddenly increase in size and produce serious symptoms, or hemorrhage may occur into it, or it may rupture, in either of which instances severe pressure symptoms will ensue. All cystic tumors of the thyroid should be enucleated, an operation usually easy of performance unless the collection be multilocular and extensive. If an entire thyroidal lobe be occupied by growths of this character it may be assumed that its function has been so much impaired that it should be completely removed.
The thyroid body is occasionally the site of teratomas, _i. e._, tumors containing tissue of each blastodermic layer. No two such tumors are alike. They may assume various sizes and shapes, growing in various directions, and will hardly define themselves until removal.
The benign solid tumors consist mainly of the various types of goitre.
Of the _malignant tumors_, _sarcoma_ is perhaps the most frequent, and is met here in all its varieties. _Endothelioma_ occurs here also, while true carcinoma can hardly be primary in the thyroidal tissue, but may frequently extend to it and invade it, thus seriously complicating a case already made desperate by its presence in the neck. Metastatic forms of true cancer may also occur here as elsewhere. For a growth of this kind there is but one resort, _i. e._, extirpation, but this will be difficult and usually inexpedient.
GOITRE; STRUMA; BRONCHOCELE.
The enlargement or hypertrophy of a part or the whole of the thyroid, now known universally as goitre, has been known also as bronchocele and trachelocele. The condition is one of unilateral or symmetrical affection, met with much oftener in women than in men, and particularly in certain regions. It is most prevalent in Switzerland and in Upper India. It is occasionally known to assume an endemic or epidemic form, the affection disappearing from the region of the country concerned after a period of some years. Practically nothing is known of its cause. Many theories have been advanced, that which finds perhaps widest acceptance referring to the character of the water supply.
For present purposes goitre may be understood to include the following forms:
Simple hypertrophy, the so-called parenchymatous form;
Thyroid adenoma;
Cystic goitre;
Exophthalmic goitre (Graves’ or Basedow’s disease).
The _parenchymatous_ form consists essentially of an overgrowth of the ordinary thyroid tissue. It is diffuse and unencapsulated, all the thyroidal tissues participating in its structure. Sometimes whole families suffer from this form of goitre, and occasionally an apparently hereditary influence may be traced. The tumor thus produced may attain great size. According as it involves one side or both will it be symmetrical or otherwise. It is elastic, smooth, rounded, sometimes apparently subdivided by furrows which mark the original lobar arrangement. It displaces the structures around it, and may attain a large size without producing serious pressure effects. When these occur they assume the type of dyspnea, dysphagia, and laryngeal paralysis. The growth is insidious, usually increases markedly with each pregnancy, and may spontaneously recede. Within it changes may occur which lead either to cystic softening and formation of cysts, or fibrous trabeculæ may appear and thus make it more firm and dense. The denser the growth the earlier the pressure symptoms appear. Occasionally the isthmus alone will appear involved, in which case there will be a central growth.
The so-called _thyroid adenoma_ (the term adenoma being used on the supposition that thyroidal tissue is true gland tissue) is often of cystic type. It consists of more or less isolated tumors of general thyroid character, but circumscribed, often encapsulated, perhaps undergoing cystic degeneration, occurring frequently in multiple form, and producing cysts of all sizes. Such a growth will displace the other thyroidal tissue and may give a decidedly irregular aspect to the resulting tumor. The cysts often contain cholesterin. In recent cases the capsule is thin; in old tumors it may be calcified, and so may be the tissue within the capsule. These growths are seen in successive generations of the same family. They have their beginnings usually in the earlier years of life.
Similar growths may also arise from the outlying portions of the thyroid, or from _accessory thyroids_, so that they may be found back of the sternum, or lying deeply in the neck or near the base of the tongue. If near the surface and cystic they give a sense of fluctuation which the harder forms do not afford.
=Endotracheal Goitre.=--A recent study of Enderlen has shown that small, goitrous growths make their appearance within the trachea more commonly in females than in males, and in patients of middle age. The known duration of growth has varied from a few weeks to fifteen years. He believes the majority of the cases begin to grow at the age of puberty. These growths have been found on the posterior wall of the larynx or in the trachea itself. They have usually rounded bases and broad implantation, with smooth surfaces, covered with intact mucosa. In most instances the thyroid itself is also enlarged. The only recorded symptom is dyspnea, proportionate to the degree of obstruction. They are probably to be explained by the inclusion theory, some thyroidal rest being disintegrated and so entangled as to grow in this direction. The only satisfactory treatment is ablation of the tumor, after tracheotomy, as endolaryngeal operations are more dangerous.
These constitute the ordinary types of goitre. _Diagnosis_ is not difficult, as the resulting tumors are more or less prominent, involve the region of the thyroid, and rise and fall with each act of swallowing. When the entire organ is involved the tumor may have a horseshoe shape. Large veins appear upon the surface, while pressure symptoms will correspond with its size and location. They pursue an irregularly slow course. Many patients attain old age and a considerable size of growth without such discomfort as to require operation. Any goitrous enlargement in which considerable softening occurs, with formation of colloid material, is entitled to the term in frequent use, “_colloid goitre_.” By accident of location any growth of this kind behind the sternum may cause serious pressure effects before attaining large size. In symmetrical enlargement of both lobes the trachea may be so compressed as to be narrowed and to entitle it to the term _scabbard trachea_.
Iodine has been used externally and sometimes with benefit. The favored method in India is to use an ointment containing one grain of red iodide of mercury to the ounce. This is daily rubbed over the goitre and then the parts exposed to the bright sunlight for an hour or more. Iodine has also been used by parenchymatous injection. It is mainly used, however, by those who object to operation or do not dare perform it. The iodine treatment, whether externally or internally used, is usually disappointing. So also is that by the Röntgen rays, and, for that matter, all other non-operative measures. Operative relief alone is complete and final. It is described below.
EXOPHTHALMIC GOITRE.
As a clinically distinct type of disease this was first described by Graves, of Dublin, in 1835, and five years later by Basedow, of Magdeburg; hence it is frequently called by their names. Although the thyroid participates in the clinical picture it cannot be stated that it is primarily at fault. Three marked objective features characterize pronounced cases--_thyroidal enlargement_, more or less pronounced _tachycardia_, and _exophthalmos_.
So far as known there is an essentially toxemic feature behind these lesions, which is mysterious, nor is the nature of the toxemia certain. No constant lesions have been found in the nervous system, although the sympathetic nerves are always involved when the heart and the eyes are affected. The three cardinal symptoms or signs above mentioned are nearly always associated; but with pronounced rapidity of the heart’s action there may be but little involvement of the thyroid or slight protrusion of the eyes. Whatever the original toxemia, or its source, a prominent feature of the condition is _hyperthyroidism_--_i. e._, hypersecretion of the substance which regulates nutrition--whose overproduction materially disturbs the heart and vasomotor nerves. It stands in strong contrast to myxedema and cachexia strumipriva, which are considered to be due to hypothyroidism or diminished secretion. Consequently it is not to be treated by feeding thyroid extract. A recent view which has much to support it is that at the basis of this condition the parathyroids are so concerned that any operation which includes their extirpation would be a serious menace. At present it may be held that the parathyroids are intermediate factors between the primary toxemia and the hyperthyroidism.
Aside from mere thyroidal enlargement, which is influenced by pressure and shows an increased pulsation, always palpable, sometimes visible, there occur increased heart activity, with a rapid and easily influenced pulse; widening of the palpebral fissures, the upper lid not following the motions of the globe, with defective convergence; rhythmic muscular tremors; increase of general sensibility; insomnia, with disturbed sleep; psychical disturbance, sometimes amounting to melancholia or mania; digestive disturbances, including diarrhea, vomiting, and thirst; cough, with frequent and shallow respiration; loss of hair and nails; sweating, flushing of surface and sometimes leukoderma or pigmentation of the skin. Terminal symptoms consist of all those mentioned above, with acute mania, high temperature, vomiting, profuse sweating, dermatitis, jaundice, and final convulsions with exhaustion, all these resembling those of death in experimental animals after the removal of the parathyroids.
A sign recently described by Teillas, which he considers pathognomonic, consists of deep-brown pigmentation of the outer surface of the eyelids, the color being evenly diffused, bounded above by the eyebrow, below by the margin of the orbit, the conjunctiva being not affected. Its effect is to apparently increase the degree of exophthalmos and to intensify the fixity of gaze observed in these subjects.
=Treatment.=--This is not the place in which to consider in detail either the pathology or the drug treatment of this affection. By many surgeons it is regarded as a surgical disease, _i. e._, one to be treated by one of two operative methods, either thyroidectomy or excision of the cervical sympathetic. When such measures as electricity, Röntgen rays, and hydrotherapeutic treatment, and such drugs as belladonna, sodium phosphate, arsenic, iodine, phosphoric acid, etc., have failed, and when the antithyroidal serums or preparations, such as thyroidectin and antithyroidin have proved insufficient, then surgery remains a last resort. Unfortunately this is too long delayed. To remove the thyroid so soon as it is shown to be producing an injurious amount of oversecretion is neither a difficult nor a dangerous procedure, but to wait until the heart beats 150 times a minute and the patient is nearly maniacal is to wait until he is almost moribund and until it is too late. Nowhere does the remark, “The resources of surgery are seldom successful when practised on the dying,” apply more forcibly than to such cases as these.
As between _sympathectomy_, already described, and _thyroidectomy_ (see below) it may be difficult to choose. By the time such a case comes to operation each will present its distinct difficulties. The question is mainly one of choice. A large tumor will obscure access to the sympathetic trunk in the neck, while, on the other hand, the neurectomy itself is probably a less dangerous procedure. The decision should be based on the predominance of the features due to vasomotor disturbances. Thus when the eyes are prominent, the pupils dilated, the palpebral fissure widely open and difficult of closure, there is reason for attacking the middle and upper cervical ganglia, which are not so difficult of access. Again when the heart is affected there would be a special indication for extirpating the inferior cervical ganglion, as well as the first dorsal; but the former will always be difficult in the presence of a thyroidal tumor, and the latter wellnigh impossible. When, however, thyroidal symptoms are pronounced, with difficulty in respiration or other purely pressure effects, thyroidectomy is indicated. This should be performed as described below. An effort should be made to preserve the capsule, at least on the inner and posterior aspect of the thyroid, in order that the parathyroids which lie in close relation to it may not be disturbed. Operations upon the vessels for the purpose of controlling the circulation are rarely practised, and the question in these cases is as between partial and complete extirpation.
Curtis has recently collected from the statistics of two German and two American operators 136 cases of exophthalmic goitre treated by thyroidectomy, with 17 deaths, chiefly from acute thyroidism. The most marked improvement realized was disappearance of tremor, nervousness, and insomnia, and of a feeling of anxiety, so common to the disease. To these may be added the more extensive experiences of Charles Mayo, which present extirpation as an almost ideal method of treatment.
As remarked above, all attempts at feeding with thyroid extract should be avoided, the case being one already suffering from hyperthyroidism. It should be noted that in few instances the thyroid seems to suffer from its own overactivity, and passes into a stage of physiological atrophy, with more or less subsidence in volume. In such a case the symptoms of Graves’ disease would gradually change into those of myxedema.
The thyroid itself is extremely vascular under all circumstances,
## particularly under these, to such an extent that pulsation becomes a
prominent feature. This, however, should not be mistaken for that form of ordinary goitre in which the vessels undergo increase in dimensions and in which sometimes a loud _bruit_ may be heard.
_Malignant goitre_ implies a generalized involvement of the thyroid in one of the malignant forms of neoplasm. (See below.) It is of rapid growth, with more or less infiltration of surrounding tissues, which is evidently not of inflammatory character but more distinctive.
THYROIDECTOMY.
This may be partial or total. It is important to leave a portion of the thyroid in order that the patient may not suffer from the consequences of _athyroidism_, _i. e._, _cachexia strumipriva_. It is generally understood that if one-sixth or one-seventh of the total mass can be left _in situ_, with sufficient blood supply, it will suffice. Thus it may be possible to leave the isthmus, after removing both lateral lobes, or a portion least affected of one of the latter may be left in place.
The character of the incision will depend on the size and position of the enlargement. For complete thyroidectomy a horseshoe-shaped incision, convexity downward, should be made, extending along the anterior border of the sternomastoids and then across the neck. This should be carried through the platysma and superficial fasciæ, the anterior jugular veins being secured when cut. The flap thus made is then raised, after which a large part of the subsequent procedure is made by blunt dissection, and separation of the surrounding muscles, which are held aside with retractors. When the tumor is so shaped and placed as to make it possible it is well to approach it laterally and secure the upper and lower thyroidal vessels on one side or both, dividing between double ligatures. If this be done the mass can be drawn forward in such a way as to avoid injury to the nerves and vessels, the operator keeping in close contact with the capsule, or, for reasons specified above, perhaps dividing and shelling out the mass from within it. Although the tumor may be occupied by large vessels, those which lead up to it--_i. e._, the thyroids--are rarely much enlarged. Nevertheless it is wise to secure them first. While the anterior muscles may, in many instances, be separated and the tumor mass exposed between them, there are cases which will require transverse division of the sternohyoid and sternothyroid, in which case they should be subsequently sutured.
One of the complications is to find the tumor mass extending down behind the sternum or the clavicle. From these locations it should be separated by cautious blunt dissection, else the pleura or one of the deep veins might be wounded. The former accident would be instantly denoted by the passage of air and its entrance into the thorax, the latter by severe hemorrhage.
In exophthalmic cases it may be held to be especially desirable to enucleate the thyroid from within its capsule. This makes the performance easier in some respects and more difficult in others.
Extreme caution should be taken in two particular respects: First, that the trachea be not compressed, nor its caliber interfered with, by the traction efforts used in removing the mass. The second caution necessary in exophthalmic cases is to _make the least possible amount of pressure upon the thyroid during the operative procedure_, since, as mentioned above, its secretion is depressing to the heart, and it would complicate matters to force more of this material into the circulation at a time when everything conspires to reduce blood pressure and the reliability of the heart’s action. A certain amount of manipulation is unavoidable, but this should be made as gentle and as slight as possible. Moreover, these cases are to be drained to permit of free escape of thyroidal secretion. (Mayo.)
In performing thyroidectomy for Graves’ disease advantage should be taken of the pneumatic suit devised by Crile, and the patient placed in the semi-upright position. These are advisable precautions to take in every such operation. The position allows more natural emptying of the veins at the base of the neck and the suit permits of the blood pressure being maintained by mechanical means. In order to use the suit to best advantage the blood pressure should be noted throughout the course of the operation.
The enucleation or extirpation concluded, hemostasis should be observed, as with returning cardiac vigor secondary hemorrhage is by no means an impossible event. Every vessel which can be recognized should be carefully tied, and tissues which ooze should be caught up with suture and tied _en masse_. All the deeper portions of the wound should be brought together by buried sutures in such a way as to leave no dead spaces. Cases where a retrosternal pit has been left, by removal of a low-lying growth, should be drained to avoid the accumulation of blood. Where doubt exists as to security from secondary hemorrhage it is the writer’s custom to place secondary sutures, and to pack the cavity with gauze dipped in balsam of Peru, leaving this packing in place for two days, then removing it and closing the wound by utilization of the sutures.
Shock after these operations may be extreme, and is to be combated by transfusion or infusion of salt solution, with small amounts of adrenalin.
Should the surgeon attack a so-called malignant goitre he must be prepared to meet with greater difficulties and perhaps to abandon the operation before its completion. Death on the table is not unusual in such cases.
Operation under cocaine local anesthesia is often most advantageous, and is the rule in such clinics as that of Kocher, in Berne. The patient should be well narcotized with morphine, after which a weak cocaine solution is injected along the proposed line of incision. The pain produced by the balance of the work is not beyond endurance, while the dangers are certainly minimized, especially in cases where there is compression of the trachea or excessive heart action, the latter being
## particularly true in Graves’ disease. There is less fulness of veins,
and there is neither coughing nor vomiting. The operative features are the same as those described. As the anterior thyroid artery is approached all possibility of including the recurrent laryngeal nerve in the ligature is avoided by having the patient talk, injury to the nerve producing instant hoarseness. If the growth extend low and into a pit behind the sternum it may be possible to extirpate it from above downward, and finally to lift it from its bed, securing its base or pedicle with an elastic ligature.
[Illustration: FIG. 500
Patient placed in semivertical position, and enclosed in Crile’s pneumatic suit, as recommended for many cases of goitre, brain tumor, or other serious operations about the head and neck. (Crile.)]
A danger common to all thyroidectomies is that of injury to the trachea. This is avoided when there are no abnormal adhesions, but when the growth surrounds the trachea, or is firmly fastened to it, such an accident may happen in spite of the greatest care. According to its size and location the surgeon may endeavor to close the opening with sutures, or he may insert a tracheotomy tube or leave the wound open sufficiently to pack it snugly, preventing entrance of fluid into the trachea, at the same time expecting the wound to be subsequently closed by granulation tissue.
Sympathectomy as a measure directed toward the treatment of exophthalmic goitre, as well as of glaucoma and certain forms of epilepsy, has been described in