tubes, to reëstablish their continuity if obliterated, or dilate them
if partially closed. No doubt deafness often depends on obstruction
of this outlet from the tympanum, the requisite reverberation being
perhaps thereby impeded. It may be closed by swelling of the lining
membrane, by inspissated mucus, by destruction of its extremity
from ulceration, by the cicatrisation of ulcers in the immediate
neighbourhood, by congenital deficiency, or by pressure of neighbouring
swellings, or of morbid growths, producing temporary or permanent
obstruction. None but the first two causes could possibly admit of
the use of the probe, and even then it can scarcely be required. By
removal of the cause of such turgescence at the end of the tube,
or in the neighbouring parts,—which can often be detected, being
local,—by counter-irritation, &c., a cure is much more likely to be
effected than by the introduction of probes. Not that the operation is
exceedingly difficult; for, after practice on the dead body, a probe
can readily be passed into the eustachian tube of the living from the
nostril. The instrument is fixed in a handle, with its point slightly
bent, and on the handle there should be a mark to show the direction
of the point; the distance of the termination of the tube from the
nasal orifice ought also to be marked. The instrument is passed along
the floor of the nostril, and then its point is directed upwards and
outwards, whilst the handle is pressed towards the septum narium. It
has been proposed, moreover, to force a stream of cold and condensed
air into the internal ear, and to apply ætherial vapours to the
cavity of the tympanum. The attempts have been made on an extensive
scale in all sorts of cases, and quite indiscriminately. This plan of
curing deafness has been well advertised, and unblushingly puffed in
scientific and other journals. Not one case of deafness in a hundred
probably depends upon any affection of the eustachian tube: vitiated
mucus cannot even be displaced by injection of air or other fluid,
unless the membrane of the tympanum be ruptured; this has indeed been
accomplished by the operation in question, and then the mucosity could
only be forced into the cavity of the tympanum, so as, if possible, to
make matters worse.
Nervous deafness, like functional amaurosis, may sometimes be relieved
or even removed entirely by stimulating frictions, or the application
of strychnine to a raw surface behind the auricle, and by attention to
the general health.
_Puncture of the Tympanum_ has been recommended as a remedy for
deafness arising, or supposed to arise, from obstruction of the
eustachian tube; but I believe it has not succeeded in above one out
of twenty cases. The puncture is apt to close very soon; and though
the hearing may be improved for a short time, the advantage gained
soon disappears. The means of keeping the puncture open are not
easily applicable; perhaps the most effectual is to touch the edges
occasionally with pencil-pointed lunar stone. The puncture is generally
made with a short-pointed trocar, such as is used for hydrocele. The
canula is passed down to the membrane, and placed on one side of
its centre, lest the long head of the malleus should be interfered
with. The trocar is then pushed on gently, and should penetrate but a
very short distance, for fear of injuring the important parts at the
bottom of the cavity. By some a sharp-pointed probe is used, passed
through a quill; or an instrument about the same size with the probe
is made for the purpose, with a canula to fit. But these are by much
too small; even the puncture with a trocar closes, notwithstanding
the application of nitrate of silver. I have lately used a sort of
punch, such as is employed for making holes in leather, of a pretty
large size, and neatly made, with the edge very keen, and on a small
stalk. This is introduced; and when obstructed, having reached the
bottom of the canal, an attempt is made, with a rapid turn of the
hand, to cut out a portion of the membrane. I have thus succeeded in
improving immensely the hearing of one gentleman, enabling him to
hear at four or five times the distance he could formerly. He had
repeatedly submitted to punctures before I saw him; and, previously to
the operation with the punch, I passed through the membrane a trocar,
made large, and well-pointed for the purpose; but notwithstanding this,
and the application of the nitrate of silver, I was unable to preserve
the advantage gained longer than a very few days. In suitable cases,
the operation is worthy of trial, being unattended with pain or any
dangerous consequences. M. Fabricci has contrived a very ingenious
little instrument for the purpose; by it the piece of membrane is fixed
by a small screw, before being punched out.
_Bronchocele_ is not rare in some districts of Great Britain, but
unattended with the same peculiarities of countenance and mind as in
some other countries.[39] The majority of those affected come from
mountainous districts. The disease generally commences early in life,
and females are more subject to it than males; indeed almost all who
present themselves are females. The tumours are of various sizes,
involving either the whole gland, or only a part. One lobe is usually
in a state of greater advancement than the other. The swelling is
for the most part soft and yielding, the integuments are thin and
moveable, and large veins shine through them. It is unattended with
pain, or any great inconvenience, though sometimes it equals in size
the patient’s head, or nearly so, and then it is troublesome from bulk
alone. In general, there is little or no obstruction to deglutition
or respiration, and the health is not impaired. The tumour is always
of slow growth, at length becomes stationary, and the patient gets
reconciled to the deformity. Its structure is that of the simplest form
of tumour, a genuine hypertrophy, and it is seldom that its action
degenerates. It is often made up also partly of cysts containing
serosity, or glairy albuminous fluid.
Internal remedies have been prescribed, with the view of arresting
the growth, and promoting absorption of the enlarged thyroid—burnt
sponge—muriate of lime—muriate of baryta, &c. The use of iodine,
externally and internally, has in many cases been attended with
beneficial effects. Tumours have diminished, and even disappeared
entirely, during the employment of this medicine; but in others, the
diminution has been either trifling or none. The insertion of setons
has been strongly recommended; and many patients are said to have been
thus cured. I have tried this plan in one case only; it certainly had
the effect of diminishing the swelling; but for some time great trouble
was experienced from bleeding, whenever the cord was drawn, and the
patient afterwards became much weakened by the profuse discharge. The
proposal to tie the thyroid arteries, for the cure of bronchocele, has
been put in practice, but without a favourable result.[40]
Extirpation of such growths has been repeatedly attempted; but the
patients, almost without exception, have perished from hemorrhage,
under the hands of the knivesmen. The immense supply of blood afforded
to the gland in the healthy state must be kept in mind, as also the
enlargement of the vessels proportional to the increase of the part.
Not arteries alone, but enormous veins, are to be encountered. The
tumour is in the vicinity of important organs, and of the trunks of
large vessels and nerves, and probably has become attached to them. In
short, the operation is attended with such risks, with so absolute
a certainty almost of fatal result, as not to be warranted under any
circumstances, far less for removal of deformity only.
Enlargement of the isthmus alone gives rise to more severe symptoms
apparently, and may warrant an attempt at removal; but this can
scarcely be accomplished altogether by incision. Such is my impression,
and under this impression I proceeded very cautiously in a case of
this nature with which I had to deal.—J. R., a rat-catcher, aged
forty-seven, from the Highlands, was admitted into the Royal Infirmary.
The isthmus of the thyroid gland was enlarged to the size of a goose’s
egg. The tumour was extremely hard and irregular on its surface, but
not painful when touched; it appeared to be adherent to the trachea,
and did not admit of much motion. The voice was considerably impaired,
and breathing much impeded, inspiration being difficult and attended
with a loud wheezing noise. On making unusual exertion, even though
inconsiderable, the dyspnœa was much increased; and on ascending a
height, or even remaining for some time in a stooping posture, it
amounted almost to suffocation. There was no pain or uneasiness in
the larynx or trachea. The disease was of three years’ duration. A
seton had been introduced, but effected no diminution, and rendered
the tumour more dense and less moveable than formerly. I surrounded
the lower part of the tumour by two semicircular incisions, and,
dissecting cautiously beneath its base, detached it from its more
loose connections, not interfering with the central portion and its
connection to the trachea. During the progress of the dissection, the
blood flowed most profusely from both arteries and veins, but was
restrained by securing the former with a ligature, and compressing
the latter with sponge. An armed needle was then passed through the
centre of the tumour, as close to the trachea as possible, and its
remaining attachment enclosed by the separate portions of the ligature
firmly applied. Everything proceeded favourably. The tumour soon came
away; the wound healed with a firm cicatrix, and in about a month
the patient went home well. I met him by chance, in Aberdeen, twelve
months afterwards, free of complaint, and breathing easily under all
circumstances, his neck presenting no vestige of the tumour.
_Glandular Tumours of the Neck_, as formerly noticed, arise from
various irritations; and some constitutions are more subject to them
than others. The nature of the enlargement is dependent on the cause;
it may be simple or malignant. Simple swellings often attain a large
size; the lymphatic glands in both spaces of the neck, and on one or
both sides, get immensely enlarged, the cellular tissue around is
infiltrated with solid matter, and all matted together. Great deformity
is produced; the head is turned with difficulty, and twisted to one
side; often there is not much pain. After some time, the swelling
becomes looser than before; its various portions separate, and
gradually disappear; or the centre becomes soft, suppuration spreads
extensively, and the surrounding hardness either goes off, or becomes
partial.
Discussion of the swelling is to be promoted, and, if possible,
the cause removed; and fomentation, friction, pressure, internal
stimulants are to be employed, according to the state of the parts,
along with what are called deobstruents, in the first instance. When
suppuration cannot be arrested, the attention must be directed to
prevent the integuments from being destroyed. With this view, the
abscess should not be permitted to give way spontaneously, lest an
opening be formed whose cicatrisation would cause deformity, and leave
a stain on the race and generation. An artificial aperture must be made
early; and in the upper and most exposed parts of the neck this should
be in the direction of the folds, and small.
When many and extensive collections have formed, when the integuments
have been undermined and attenuated before advice is sought, it is
impossible to prevent deformity. The knife and potass are required, for
reasons assigned in the preceding part of this work; and the detached
glands, as well as the thinned skin, stand in need of their free
application.
Deep-seated collections may originate in glandular disease, or commence
in the cellular tissue; they occasionally follow transverse wounds of
the neck. Great infiltration of the cellular tissue supervenes over
the trachea and sternum, and also under the fasciæ; purulent matter
is secreted in the cells, and the parts are extensively separated;
sloughing is prevented only by free and early incision. The nature
and extent of the coverings of an abscess seated deeply in the neck
are to be kept in view—the platysma myoides, the superficial and
deep cervical fasciæ. Collections under these interfere with the
functions of the neighbouring parts, and are attended with great pain,
which is somewhat relieved by resting the chin on the sternum, and
so relaxing the fasciæ. The matter makes its way to the top of the
sternum, and generally points on the outside of the sterno-mastoid
muscles. But before the integuments become thin, the parts have been
seriously injured—the cellular tissue has sloughed, the muscles
have been separated from each other, with unhealthy purulent matter
interposed—the trachea, the œsophagus, or the mediastinum, opened into.
Such cases have been formerly alluded to.
The lymphatic glands, situated amongst the fat and cellular tissue
between the deep and superficial cervical fasciæ immediately above
the sternum, may become enlarged. When the tumour is large, breathing
is impeded by compression of the parts beneath, and pain and much
inconvenience are endured on account of its limited situation and
resisting investments.
Purulent collections in the anterior mediastinum and under the sternum
are scarcely remediable. These are chronic or acute. One of the great
dangers following the operations on the larger vessels at the root
of the neck, in which the deep fascia is necessarily divided, is
infiltration into, and acute abscess of, the anterior mediastinum.
In chronic collections the parietes of the cavity on one side are
fixed, on the other have constant motion; and thus the surfaces,
however healthy and well disposed, are prevented from coming together
and adhering. The discharge continues, and at length wears out the
patient, pulmonary affection perhaps supervening. The same unfavourable
causes operate in other situations, in the iliac fossa, and in chronic
collections under the cranium. In chronic abscess of the mediastinum,
no dependent opening can be obtained, unless by perforation of the
sternum. This is perhaps warranted by œdematous swelling over some part
of the bone, indicating, along with other symptoms, the existence of
matter beneath. Purulent collections sometimes form in the substance of
the sternum, communicate with the mediastinum, and involve the lower
part of the neck.
The thymus gland is said to be liable to chronic enlargement in
young subjects of weak constitution, causing serious impediment
to respiration and deglutition; the tumour is confined above and
anteriorly, and consequently presses backwards on the trachea and
gullet. Suppuration may take place in the swelling, and the matter
ultimately be diffused in the mediastinum.
[HYDROCELE OF THE NECK.
An encysted tumour of the neck, to which the term HYDROCELE has been
applied by some writers, is met with in both sexes and at various
periods of life. Its progress is usually slow, and it generally
arises without any assignable cause. Occasionally it has appeared
to be congenital, but this must be considered as a rare exception.
The tumour, seldom larger than a walnut, may acquire the volume of
a Seville orange. When this is the case, it may impede respiration
and deglutition, or even the return of the blood from the head. Its
contents are of a serous or oily character, with an intermixture of
flakes of lymph, and the cyst itself varies in thickness from the
fourth of a line to a quarter of an inch or more. Externally it is
more or less intimately connected to the cellular substance in which
it is developed, while its internal surface often exhibits a rough,
reticulated aspect, not unlike the false membrane of pericarditis.
In cases of long standing the cyst is very firm and tough, or almost
gristly, and closely adherent. The skin covering the tumour seldom
undergoes any change, unless it is very large, when it is apt to become
attenuated at some points and thickened at others. The subcutaneous
veins may also then present a tortuous and distended appearance; but
this is far from being generally the case.
The characters by which hydrocele of the neck may be distinguished
from other affections are, absence of pain and tenderness on pressure,
slight fluctuation, the slow progress of the tumour, years generally
elapsing before it attains much development, and, above all, the
history of the case. When the tumour projects outwardly over the
carotid artery, it might be mistaken for aneurism, from which, however,
it may, in general, be readily discriminated by the elevation of the
entire swelling from the impulse of the blood, and by the want of that
alternate expansion and retrocession which are present in genuine
aneurism. When seated over the thyroid gland, or in its substance,
it may be confounded with bronchocele. In all cases, where any doubt
remains as to its true nature, an exploring needle or trocar should be
introduced, which will at once determine the diagnosis.
The treatment of this affection, like that of the vaginal tunic of
the testicle, may be palliative or radical. The former consists in
evacuating the fluid, from time to time, with the knife or trocar; the
latter, in injecting some stimulating fluid, such as wine and water,
or a solution of iodine, or nitrate of silver; or, what is better,
introducing a seton, and keeping it in the sac until it is obliterated
by adhesive inflammation. Incision and extirpation have been practised
successfully by Flaubert, Delpech, Jobert, and other surgeons.]
_Distortion of the Neck_ arises from a variety of causes, and is either
temporary or permanent. The head is often kept in an unnatural position
for weeks by glandular swelling. Enlargement of the superficial glands,
at the upper part of the neck, induces the patient to turn his head
to the opposite side; swellings lower in the neck, and deep seated,
require relaxation of the coverings, and the head is consequently
twisted to the same side. Either rigidity, or spasmodic action, or
both, of the sterno-mastoid muscles, displaces the head and twists the
neck. The head is either bent forward, or turned to one side; usually,
the chin is twisted over the shoulder, on the side opposite to the
offending muscle. Induration of the muscle is sometimes met with, also
causing distortion; it may terminate in abscess, or after a long time
be discussed.
The cause of the spasmodic action in the muscle is sometimes apparent,
sometimes very difficult to be detected. Sources of irritation at
the extremities of neighbouring and communicating nerves are to be
looked for and removed; and the spasms are to be moderated, as much
as possible, by external and internal remedies. Opiate frictions, and
the application of the nitrate of silver over the course of suspected
nerves, are sometimes followed with benefit, and may be accompanied
by the internal administration of antispasmodics, though the efficacy
of these is often doubtful. When the head has been for a long period,
perhaps many years, turned to one side, from any cause, the muscle on
that side naturally becomes shortened, and a change takes place in
the form of the bones. If the patient is still young, the deformity
may, in a great measure, if not entirely, be remedied. Division of the
shortened muscle was a favourite operation of old surgeons for the cure
of wry-neck, and may be resorted to with advantage in some cases. One
of the heads, or both, may require to be detached from the sternum and
clavicle. It is only in cases where the muscle is in fault, it being
shorter than usual, that benefit can be expected from this proceeding.
It is a very simple operation, and can be effected by a mere puncture
of the skin betwixt the two portions. By the cautious use of a blunt
and flat probe or director, the cellular tissue under the origins of
the muscle is separated; this is followed by a narrow and blunt-pointed
knife, by which the attachments to the clavicle and sternum are cut
across.
Distortion of the neck is most frequently produced by some vice in
the bones, as curvature, from softening, attended with deformity of
the trunk or of the limbs. In such cases, the twist is generally to
the right side, the ear approaching the shoulder. No treatment can be
effectual, unless the other curvatures are corrected; for the head
is placed so to preserve the equilibrium of the body. The head is to
be supported, and its weight removed from the vertebral column by a
curved iron rod, attached to the back of stays fastened on the loins,
leathern straps passing from the top of the rod under the chin and over
the occiput. By the use of such apparatus for a considerable time,
the vertebral column may regain its perpendicular direction, and all
deformity of the neck be consequently removed. The application of such
a machine is required after the division of the sterno-mastoid, so that
the head may be kept straight until the muscle is reunited of a proper
length, and any change in the form of the bones may be got over. In
slight cases, this treatment is not required; on giving support to the
trunk, and raising the shoulders to an equal level, the muscles of the
back, perhaps stimulated by powerful and repeated friction, gradually
bring the column into its proper form. Then the position of the head to
one side is no longer required to balance the body. But a cure can be
expected only when no material change has taken place in the form of
the individual bones.
Excurvation of the cervical vertebræ,—bending of the head forwards,
and perhaps a little to one side, generally to the right,—takes place
as a consequence of disorganisation of the ligaments and connecting
fibro-cartilages of the vertebræ, with subsequent ulceration of the
bones. The disease generally occurs in the superior vertebræ; in the
articulation of the atlas with the occiput, or with the vertebræ
dentata, or in the articulation of the latter with the one below. The
articulations on the left side are usually affected first. There is
stiffness, pain, and swelling of the soft parts covering the affected
bones, attributed perhaps to exposure to cold, as when sitting in a
draught, and supposed to be merely crick of the neck. The posterior
cervical muscles are weakened, and the head is bent forwards. The
patient is unable to support his head by the usual muscular action, and
when in the erect position places his hands on the temples, to prevent
it from dropping, and to keep it steady. Difficulty of swallowing is a
prominent symptom from the first, as can readily be imagined when the
close application of the constrictors of the pharynx to the forepart
of the affected bones is kept in remembrance. The position of the head
also renders deglutition awkward. The disease is attended with great
suffering, evinced by marked anxiety of the countenance; and the pain
is most violent during the night. The complaint is too frequently
trifled with at the commencement, being not understood, nor its danger
appreciated. The swelling increases, with pain, and the chin falls down
on the sternum. The patient grows emaciated, and perhaps becomes weak
in the lower limbs, and even in the upper; the feces and urine are
imperfectly retained. Occasionally, abscess forms behind the upper part
of the pharynx, increasing the pain and the difficulty of deglutition.
On making an examination through the openings by which the abscess has
emptied itself spontaneously, the bone is felt bare; and portions,
even large, of the vertebræ, or vertebra, are, after some time,
discharged, so as to expose the theca of the spinal cord. Even in such
circumstances patients have lingered on, and that for so long a period
as to allow of some unprincipled fool advertising a perfect recovery.
The termination of caries of the cervical vertebræ, often without
any appearance of abscess, is in general fatal and sudden. The head,
slipping from its support, falls forwards or to a side, causing
immediate and complete paralysis of the whole body; dissolution soon
follows. On examination, the articulating surfaces of the vertebræ
are found displaced, and the shreds of ligaments which connected them
ruptured. The atlas is separated from the occiput; or the processus
dentatus, escaping from its situation, in consequence of destruction of
its confining ligaments, is found compressing the medulla oblongata.
This process is very often destroyed almost entirely, or it is so far
detached by ulceration at its root as to be easily broken off. The
disease in general seems to commence in the articulations, whereas in
the vertebræ with larger bodies, abscess and ulceration have their
foundation and origin more frequently in the deposit of tubercular
matter in the cancellated texture of the bones. In other instances, the
termination may be more slow and gradual; the patient is worn out by
long suffering and continued purulent discharge; change of structure
takes place in the theca vertebralis, or in the medulla itself; serous
effusion occurs at the base of the brain; the patient’s sensations are
blunted, and he loses the use of his limbs gradually; his intellects
fail, and coma supervenes, followed by death.