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 Chapter XXXVII.

STRUMITIS.

Strumitis is a term applied to actual inflammation of an already

goitrous thyroid. It may follow such infectious diseases as typhoid, or

it may be an apparently spontaneous infection without known cause. It

may run an acute course, tending rapidly to suppuration, in which case

there will be not only pain and tenderness in the thyroid itself, but

all the local evidences of pyogenic infection, with infiltration and

rapid formation of pus, perhaps with widespread phlegmon of the neck.

This is a serious condition and may call for early and free incision

of the infected area. A hemorrhagic form of strumitis is also known.

The thyroid may also be the site of metastatic abscesses in cases of

pyemia, in which case there will be but few local indications.

THE THYMUS.

The thymus figures but rarely in surgical interest, but when seriously

affected it causes most pronounced symptoms. Its principal activity

is shown previous to birth and during the earliest months of infancy,

and it should have disappeared by the age of puberty. Instead of

atrophying, as it should, it may undergo _hypertrophy_, by which, on

account of its location, serious pressure is made upon the trachea and

the base of the neck. This may occur suddenly, so that a tumor in its

location rapidly develops and will prove fatal unless surgical relief

be afforded. This constitutes an acute hypertrophy of the thymus, which

is more than a mere surgical curiosity. In one case seen by me a long

trachea tube was with difficulty inserted just in time to prevent death

by asphyxiation. In case of such tumor the upper end of the sternum

should be removed and the tumor enucleated, or the thymus should be

sewed up to the sternum and the tumor thus raised out of its bed.

The thymus is of special interest in connection with the _status

lymphaticus_, which has been referred to in a previous chapter. Its

connection in such cases with hypertrophied lymphoid elements all over

the body, and especially of the adenoid tissues of the nasopharynx,

was therein described, and the seriousness of the condition, with the

menace which it offers to anesthesia, as well as the extreme cautions

to be observed, were fully rehearsed. The significance of laryngismus

stridulus and its relations thereto were also mentioned. All this is of

extreme importance to the surgeon, as every child with so-called thymic

asthma, and with symptoms of lymphatism, should be watched carefully

and anesthetized cautiously. (See Chapter XIV.)

_Acute inflammation of the thymus_ as well as hemorrhages within it

have been observed. It may also be the site of cystic tumors, perhaps

of hemorrhagic origin. Suppuration in these cases is possible. In

brief, the thymus, when acutely inflamed and suppurating, may be

excised, when the tumor may be removed; but when simply somewhat

involved, as in the status lymphaticus, it is best let alone, except in

the presence of urgent indications to the contrary.

CHAPTER XLIII.

THE THORAX AND ITS CONTENTS.

MALFORMATIONS OF THE THORAX.

[Illustration: FIG. 501

Congenital malformation of chest. (Sayre.)]

Congenital malformations of the thorax are not uncommon, yet but few

of them permit of surgical remedy. One or more of the ribs may be

absent or defective in formation and produce lateral distortion of

the spine. The clavicle also may be defective on one or both sides,

or absent. This is a defect which causes but little inconvenience, in

spite of its prominence. The chest as a whole may develop defectively

or irregularly, some of these conditions being expressions of

intra-uterine rickets and others being due to unknown or uncertain

causes. Thus we have the absolutely flat chest seen most often in

connection with an unduly rounded back, the flattening appearing rather

in front, while perhaps the anteroposterior diameter is actually

increased. As Hutchinson has shown, this may be a persistence of the

fetal type of chest. _Pigeon-chest_ or _keel-shaped chest_ may be

regarded as a reversion to a more primitive type, the anteroposterior

diameter being increased at the expense of the lateral. The reverse

of this deformity is the so-called _funnel-shaped chest_, where

the sternum is depressed and the lateral dimensions increased. In

addition to the defects thus noted in the ribs and sternum, absence

of a vertebra has been known, the condition not producing deformity,

but rather an appreciable shortness of the spine. Malformations are

seen frequently in the _sternum_, which may be _fissured_ in either

direction, or may present _perforations_. With these similar defects

of the ribs may also be seen, even to a degree permitting congenital

hernia of the thoracic contents.

_Supernumerary developments_ find their expression usually in an

_added rib_, either in the _cervical_ or in the _lumbar_ regions.

This condition is practically never noted at birth and may pass

unnoticed. Nevertheless a _cervical rib_ may, in adult life, produce

discomfort or actual interference with function, partly by pressure

upon the subclavian artery or the brachial plexus. When found it is

in relation with the seventh cervical vertebra, and the space between

it and the first dorsal rib is occupied by muscle developed for the

purpose. The scalenus anticus may be inserted into its anterior edge.

When sufficiently prominent to produce troublesome symptoms it may be

recognized by palpation, and cases of doubt may be made clear by a

radiograph. Should it prove troublesome it may be removed, an operation

requiring considerable caution, because of its close relation to the

pleura, which might easily be opened. It may be exposed by such an

incision as would be used for ligation of the subclavian artery.

The _thoracic muscles_ occasionally show anomalies, either in

arrangement or by their absence, the pectoralis major being

occasionally wanting in whole or in part, and furnishing the most

frequent illustration of these defects, which are usually unilateral.

(See Fig. 502.)

_Congenital luxations of either extremity of the clavicle_ are

also occasionally seen, particularly of the inner end. A peculiar

displacement and relaxation are thereby permitted, with some degree of

functional loss.

The _acquired malformations_ of the chest may be produced from a

variety of causes. Thus in connection with non-closure of the foramen

ovale and the consequent disturbance of heart action, with its

overdevelopment of the right auricle, the left side of the chest may be

pushed forward and the apex beat found far below its normal position.

_Asymmetry_ in the young may also be produced by several different

intrathoracic conditions, the most common being pleurisy and empyema,

with their consequent distention of the pleural cavity, and later

a tendency to cicatricial contraction. In this way marked forms of

lateral curvature are produced. In a previous chapter it was stated

that overgrowth of lymphoid tissue in the nasopharynx, ordinarily

spoken of as adenoids, with consequent embarrassment of respiration,

leads in time to stoop shoulders and poor development of the thorax.

Deformity may also be produced by such defective vision as shall compel

a peculiar or abnormal position of the head.

In _chronic emphysema_ there is noted a peculiar _barrel-shape_ of the

chest, which is also to be regarded as an acquired deformity. Paralyses

of the internal thoracic muscles will also permit of asymmetrical

growth, and projection of the lower angle of the scapula, giving it a

wing-like aspect.

[Illustration: FIG. 502

Congenital absence of the pectoralis major muscle of right side.

(Richardson.)]

The most common cause of thoracic asymmetry or deformity is _rickets_,

which may be an early or a late manifestation. By the ordinary changes

permitted in the epiphyses and along the costochondral junctions is

produced the peculiar appearance known as “rickety rosary.” In these

cases the effect of the weight of the upper part of the body upon the

soft and changeable structures of the osseous and cartilaginous ribs,

as well as the vertebræ and the sternum, are to be noted. Pronounced

types of deformity result from such changes, producing extreme cases

of _pigeon-breast_, or of hollowing in front known as _birds’ nest

deformity_, while alterations occur in the vertebræ, producing various

expressions of kyphosis and scoliosis. (See Fig. 504.)

These deformities of the back thus produced require to be

differentiated from those produced by Pott’s disease, the former being

unaccompanied by symptoms and occurring slowly, while the latter are

usually accompanied by pain and are progressive in character, as well

as more or less disabling. With a softened skeleton in a rapidly

growing child such trifling influences as the position assumed in the

nurse’s or mother’s arm, or that habitually taken in sleep, may affect

and modify symmetrical growth. Rickety deformities of the spine and

thorax, if not too far advanced, permit of being checked and much

improved by braces, along with the measures indicated in rachitis.

Without the latter, however, the former would be almost ineffectual.

[Illustration: FIG. 503

Malformation of chest following empyema. (Sayre.)]

[Illustration: FIG. 504

Deformity of the thorax, the result of rickets. (Gibney.)]

_Malformations may also be produced by injuries_ or certain

_occupations_. Extensive burns may cause cicatricial contraction;

contusions may produce paralyses, and more serious lacerations may

leave extensive scars, which will gradually warp the chest out of

shape. Burns, for instance, which may involve the axilla and the upper

arm, may be followed by such dense scars as to limit the motion of the

arm. Skin grafting should be resorted to early in the treatment of

lesions thus produced.

_Tight lacing_ is the source of a mild form of thoracic deformity, by

which the chest capacity is reduced, the respirations made peculiar in

character, the liver displaced downward, and the general welfare of the

individual materially affected. Influence of the right-hand habit is

frequently quite apparent in that the right side of the chest becomes

overdeveloped as compared with the left. This may be seen in a large

number of workmen who use heavy tools especially with the right hand.

Certain occupations, as well as sports, lead to constant assumption of

the stooping position, with the inevitable round shoulders and drooping

head so apparent in bicycle riders.

_Tattooing._--As a local expression of a bad habit, or in some

instances almost of a criminal instinct, _tattooing_ may be mentioned.

This is seen usually upon the chest and arms. It is a prevalent custom

among sailors, and is regarded by alienists and anthropologists as a

habit indulged in by criminals and the insane. La Cassagne has spoken

of tattooing as “an uninterrupted and successive transformation of an

instinct.” Among the inhabitants of the Pacific Islands it is almost a

mutual practice, and among them the tattoo marks are often found upon

the back and upon the sexual organs. The materials usually employed

are lamp-black, indigo, and India ink for the black or blue tints, and

cinnabar or carmine for the red. Practised as it is by the unschooled

and the ignorant it may be followed by all forms of local infection,

while syphilis has been thus transmitted.

For the _removal of tattoo marks_ many methods have been suggested,

but few have been found satisfactory. The minute particles of pigment

have become so deeply lodged that, like powder marks, it requires

infinite patience in their detection with the lens and individual

removal, or those portions of the skin must be destroyed which contain

them. Mechanical methods should be limited to localized stains, unless

a plastic operation is preferred, and, after removal of the affected

area, healthy skin may be transplanted by one of the plastic methods

or we may resort to skin grafting. Actual cauterization with strong

caustics or with the actual cautery will be followed by superficial

sloughing, which may remove the disfigurement. It is questionable,

however, if the resulting scar will be considered much of an

improvement upon the previous condition.

INJURIES TO THE THORAX AND ITS CONTENTS; CONCUSSION OF THE CHEST.

As a result of a severe blow made by a blunt object there may result

a form of _concussion_ or commotion, similar in its results to the

conditions which were formerly described in the cranial cavity as

concussion of the brain, but which are now known to be due to reflex

vasomotor disturbances, by which blood pressure is seriously affected

and extreme degrees, perhaps fatal, of shock or collapse produced.

It is possible for fatal injuries thus produced to leave little or

no evidence that may be discovered at the autopsy. Hence the term

_concussion of the chest_ may be retained as descriptive of what has

taken place, and implying serious symptoms produced through the agency

of the nervous system, especially through its sympathetic plexus. In

such instances the heart is seriously affected and may continue to beat

feebly for some time, as in shock from other injuries.

Severe blows upon the chest also disturb the function of respiration,

and it is possible that asphyxia, even to a fatal degree, may result

from a momentary paralysis of the entire respiratory apparatus thus

produced. In such cases artificial respiration will be required. In

many instances patients will complain of not merely distress, but

severe pain, which may require local anodyne measures as well as the

administration of an opiate.

_Contusion of the chest_ leaves more visible and lasting effects upon

the tissues of the chest wall. Thus extensive hemorrhages may result

and hematomas form, or ribs may be broken, with or without injury to

the pleura, or internal hemorrhages may occur, as from a ruptured

intercostal or internal mammary artery, the consequences of such

injuries not necessarily appearing at the time, but developing later.

Along with these injuries to the chest there may occur other injuries

to the abdominal viscera or to other portions of the body. Something

will depend upon the distention or relative emptiness of the lungs at

the time of injury, and whether there may have been at the same time

a sudden closure of the glottis, in which case, by an external blow,

something resembling an explosive effect may be produced within the

air passages. The degree of stomach distention may also have its own

effect. _Laceration of lung_ tissue will usually be shown by appearance

of bloody froth at the mouth, as well as by more or less dyspnea.

Rapidly developing symptoms of pressure upon the lung would indicate

the accumulation of blood within one pleural cavity and cause the

ordinary physical evidences of the presence of fluid. The _diaphragm

may be ruptured_, and the proper viscera of one cavity be displaced

into the other. When emphysema of the tissues of the chest occurs it is

usually safe to assume that a rib has been fractured, even though the

injury cannot be located or even otherwise recognized.

A series of later lesions may result from such contusions, which may

be of serious character. Thus there has been described a so-called

_contusion pneumonia_, whose symptoms are similar to but milder than

those of the genuine disease. It is a result of inflammatory and

hemorrhagic infiltration. It may lead to a pleuropneumonia, with

subsequent hydrothorax or pyothorax, or these may take place more

directly and without its occurrence. The products of this disease

afford foci in which, later, tuberculous expressions are commonly met.

It has been shown experimentally that the blood serum of animals

subjected to severe injuries of the chest and abdomen has well-marked

toxic properties. Thus the appearance of sugar or albumin in the urine

or of other toxemic indications may be perhaps explained.

=Treatment.=--The _treatment of these injuries_ should include the

relief of pain; the performance of artificial respiration, along with

the inhalation of oxygen; the customary treatment for shock, with the

use of adrenalin, when needed, for raising blood pressure; absolute

rest, and especially the enforcement of local physiological rest by

bandaging or the application of broad strips of adhesive plaster about

the thorax. In addition to these general measures special indications

should be met when they arise. The occurrence of phenomena indicating

the development of pneumonia or collection of fluid should be noted, as

the latter may call for removal, with perhaps ligation of a vessel, if

it be bloody, or later evacuation, should it be serum or pus. External

extravasation will usually disappear under soothing, warm, and moist

applications. No hesitation need be felt in opening a hematoma which

does not show a disposition to prompt resolution. Other non-perforating

injuries include, for example, severe burns or scalds, which may need

the same treatment as when occurring in other parts of the body. Fluid

may accumulate within the chest when there has been any such serious

external disturbance.

PENETRATING WOUNDS OF THE CHEST.

Penetrating wounds of the chest are generally inflicted by stab

or gunshot injury. Two serious elements of danger accompany these

injuries: the first immediate, that of _hemorrhage_ from division of

some vessel of importance concealed from sight; the other that of

_infection_, for either by the penetrating object itself or by air or

clothing which may follow it, infection may ensue, which may result

in septic pneumonia, pyothorax, or some deep phlegmonous process,

with always dangerous and sometimes fatal results. _Gunshot wounds_

vary, and according to the character of the missiles and the weapons

from which they are discharged. Those occurring during warfare and

made by bullets of the Krag or Mauser type are usually driven with

such velocity that they produce a minimum of laceration, even though

they pass through the chest. Such injuries have in the late wars in

different parts of the world been frequently observed, and have shown a

surprisingly low mortality rate, providing only that the heart itself,

the pericardium, the large vessels, and the spine be not injured.

Stories of the battle-field afford abundant illustration of men shot

through the chest being scarcely affected by the injury, but continuing

in action, at least for some time, and finally recovering. On the other

hand, the ordinary revolver or pistol, with which most affrays in civil

life are terminated, does not drive its bullet with nearly the same

velocity, and is more likely to inflict a serious or even fatal wound.

(See Plate XLVIII.)

A bullet or a stab wound almost invariably so opens the thorax as

to permit the immediate entrance of air. In theory this should be

followed by prompt collapse of the lung; in fact, however, this is only

partial, and often surprisingly so. If such a bullet wound be occluded

the air thus admitted is more or less absorbed, disappearing into the

bloodvessels, and the lung once more expands to its natural dimensions.

Much will depend, therefore, on the size and character of the wound

as to whether occlusion may occur spontaneously, or may be practised

through the first-aid dressing or its equivalent.

The entrance of air may be recognized by a certain degree of

embarrassment of respiration, by alteration in the percussion note, and

often by its passage to and fro through the opening.

The principal indications of possible injuries, in addition to those

just noted, will be the occurrence of _paroxysmal coughing_, with

inspiration of blood, and the added physical signs of the presence of

blood in the pleural cavity. Thus dulness on percussion, with the line

of dulness altering with position, will indicate the presence of fluid,

and should this occur soon after the injury it can only be regarded as

an evidence of hemorrhage into the pleural cavity. A combination of

abnormal tympanitic condition, as above, with the physical signs of

fluid beneath, will indicate a condition of pneumohemothorax. These

signs will change from hour to hour or from day to day in accordance

with altering internal conditions. If they become rapidly more

pronounced they indicate a condition which will probably call at least

for free incision, evacuation of blood, and very likely determination

of the source of its escape and proper attention thereto.

[Illustration: PLATE XLVIII

Radiograph of Chest, showing Mauser Bullet.

(From Plate X, “Use of Röntgen Ray by the Medical Department of U. S.

Army in the War with Spain, 1898.”)]

An intercostal artery is of itself a small vessel, but when cut across

by the edge of a knife or torn by the passage of a bullet it may pour

sufficient blood into a pleural cavity to cause serious dyspnea and

perhaps fatal result. To discover at the coroner’s inquest that a

patient has been allowed to die because no one had the judgment to

enlarge the wound and assure himself whether such a hemorrhage was not

occurring is not at all creditable to those in charge of the case.

The combined dangers of infection and of collapse of the lung are not

so great as those of possibly fatal hemorrhage, or intrinsic disaster

through septic infection from neglect of this kind.

Aside from the injuries thus produced to the respiratory apparatus

there are those especially involving _the heart_. It has been supposed

that gunshot wound of the heart was necessarily fatal. There is now

reason to think that this is not invariably true, even in individuals

not promptly operated upon, while the resources of modern surgery have

enabled the surgeon to save a number of cases of absolute gunshot

injury to the pericardial sac and even to the heart itself. (This

subject has already been considered in the chapter on Surgery of the

Heart and Great Vessels.) Every case which is not promptly fatal is

worth attempting to save, if suitable help be at hand, by a resection

of the chest wall, exposure of the pericardium, and of the heart

itself, with the introduction of sutures or the use of the ligature

wherever these may appear to be needed.

The occurrence of more special forms of traumatic lesion may be

indicated by particular features. Thus if the _esophagus_ has been

wounded the patient may expectorate or vomit blood, whose presence in

the stomach could not be explained by other features of the case. On

the other hand blood which comes into the mouth from the _lungs_ may be

swallowed and its appearance in the ejected materials thus accounted

for. A violent disturbance of cardiac regularity or evident paralysis

of the diaphragm may be accounted for by injury to the _pneumogastric_

or _phrenic nerves_.

=Treatment.=--In regard to the general _treatment_ of these injuries

the use of the _probe_ should not be encouraged, at least in the way in

which it was formerly used. It is a serious matter to stir up clot or

to open up a wound with a probe, thus inviting free entrance of air.

Nearly all the information desired may be more accurately obtained by

careful physical examination and study of symptoms. It should never be

used except with aseptic precautions. It affords little information

as to the course, and practically none as to the location of a bullet

which has penetrated the chest wall. It may possibly be of service

in searching for a bullet in the muscles of the back, but the only

information it is capable of furnishing is afforded by a skiagram.

Miscellaneous probing should be condemned, and in these injuries is

rarely justifiable.

The first measure to adopt in cases of gunshot wound of the chest

is to determine that the heart has not been disturbed; the next to

estimate what injury may have occurred to large vessels, then a

general determination of the other surgical features of the case. The

patient who shows no depressing symptoms nor develops them during the

ensuing few hours may be left with only a temporary occlusive dressing

placed over the wound; but increasing embarrassment of respiration,

or weakening and increasing rapidity of pulse, should be carefully

watched to guard against internal hemorrhage. If it be learned that

there is such internal bleeding prompt action should be taken for

its control. This means anesthesia and perhaps _thoracotomy_, with

resection of one or two ribs, in order to afford space through which

to practise deep suture or ligation. So long as one side of the chest

alone is involved--_i. e._, one lung thus exposed--the surgeon may

widely open the chest and meet every surgical indication without the

necessity for artificial respiration or the use of the Fell apparatus.

It is, however, advisable to have this at hand for such work, while

cases demanding such extreme measures can scarcely be made worse by the

performance of a tracheotomy and resort to some means for forced and

artificial respiration.

To simply enlarge a small bullet opening or punctured wound, in order

to be sure that an intercostal artery has not been injured adds but

little to the danger and much to the security of such a case. _In case

of doubt give the patient the benefit of that doubt and operate_ to any

necessary extent. When hemorrhage is slight and not alarming it may be

sufficient to make the occlusive dressing include a tamponing of the

opening between the ribs, gauze being packed in the opening in such a

way as to prevent hemorrhage.

A study of the escaping blood will permit of differentiation between

arterial and venous hemorrhage, that which escapes from the lung being

ordinarily of the latter type. Richter has suggested an ingenious

method of deciding whether hemorrhage comes from an intercostal artery

or lung tissue, by introducing a sterilized piece of pasteboard,

similar to a visiting card, rolled up in the form of a circular tube

and flattened with a crease; should blood flow out along the groove it

shows that it is an intercostal artery which is bleeding; but if it

flows out of the wound through the tube the source of the bleeding is

the pulmonary tissue itself. (Dennis.)

The question of the _presence of a foreign body_, bullet or otherwise,

is important. This is less so when it is a question of the bullet

itself than of driving in some fragment of rib or of foreign body

introduced from without. A bullet, a broken knife-blade, or anything of

such character will be revealed by an _x_-ray picture. The probe will

rarely give this information. Clothing, objects carried in the pocket,

or various other foreign material may escape detection.

The first measure of importance is the determination of the occurrence

of serious _internal hemorrhage_, the second is the emergency

_treatment of the injury itself_, which should include primary aseptic

occlusion, to be followed later by other measures. A withdrawal of

fluid is also indicated. Escaped blood may be contaminated and produce

later a pyothorax. As the result of a traumatic pleurisy serum may

collect within the ensuing few days, and it too should be removed. It

should be first found with the exploring needle. If seen to be free

from pus it may be withdrawn by the aspirator; but if it be destined to

become pus, then the sooner it is evacuated by incision the better.

Increasing embarrassment of the heart’s action, which is not caused by

the collection of blood, may be due to _pyopericardium_. So soon as

the physical signs indicate gradual enlargement of the cardiac area

the exploring needle should be used. A _traumatic pericarditis_ may

simply require aspiration of the pericardium, whereas the presence of

pus in the pericardial cavity will not only necessitate aspiration, but

occasionally open _incision_, with or without drainage. The appropriate

manner of affecting these procedures will be found more fully discussed

in the section on the Heart.

INJURIES TO THE THORACIC VISCERA.

In general, and without regard to the nature of the accident,

_injuries_ to the _thoracic viscera_ include wounds of the _pleura_,

the _lung_, the _diaphragm_, the various large and small _vessels_, the

_pericardium_, the _heart_, the _thoracic duct_, and the _nerves_.

=Wounds of the Pleura.=--Injuries to the _pleura_, including rupture,

are produced by severe blows which do not inflict fractures, although

these are rare in the absence of such injuries. They are usually

not accompanied by external markings, but are indicated rather by

dyspnea and cough, with involuntary limitation of respiratory motions

and by the physical signs of escape of blood (hemothorax) or air

(pneumothorax), or by some crepitation at the site of fracture, which

may be recognized with the stethoscope. In many instances lacerations

of the pleura are accompanied by more or less injury to the lung,

perhaps with perforation of air cells or small bronchi and the

inevitable pneumohemothorax. With a wound situated near the twelfth

rib the lung, which extends normally only to the tenth, may escape

injury. A small wound of the pleura is of little consequence. By itself

it is of serious import only as it is accompanied by more serious

disturbances of the lung which it envelops, or the heart which it

contains.

When air passes freely to and fro through the opening in the chest

wall, without expectoration of froth or bloody mucus, it may be assumed

that the lung itself has not been injured. To this condition the name

_traumapnea_ has been given.

Uncomplicated cases of _pneumothorax_ usually take care of themselves,

the air being gradually absorbed by the bloodvessels. In certain cases

this air may be withdrawn by the aspirator. A small amount of _blood_

within the pleural cavity is usually absorbed. An amount sufficient to

embarrass respiration should be withdrawn either with the aspirator

or by incision. For the latter purpose the wound may be utilized when

properly situated.

=Wounds of the Lung.=--Wounds of the lung are made immediately

dangerous by injury to its bloodvessels or are given a serious aspect

by the possibilities of various forms of infection, including septic

pneumonia. In serious cases this may proceed to _abscess_ formation

or _gangrene_. Should either of these be sufficiently localized no

surgical procedure directed to evacuation or to excision or removal of

the gangrenous tissue can be more dangerous than the condition left to

itself. The surgeon may, therefore, be impelled to perform a pneumotomy

or a pneumectomy.

When the lung tends to protrude or prolapse through an external

injury the condition is referred to as _pneumocele_, or sometimes as

_hernia_ or _prolapse of the lung_. This is rare, and occurs usually

in connection with punctures or stab wounds placed anteriorly and

generally low. The lung may be entangled, after having been forced

out by violent coughing, and the external portion has been known to

be strangulated in such a way as to slough off. Should this occur

the mass may be permitted to slough, or it may be removed by cautery

or by ligature, the wound being left to heal by granulation. In rare

instances the pneumocele has been covered by the parietal pleura, as is

abdominal hernia by parietal peritoneum.

Another form of pneumocele is the later consequence of injury, the

soft, crackling, or crepitating tumor presenting beneath the skin and

returning the usual breathing sounds when auscultated. It may increase

and diminish in size with the respiratory movement. Such a hernia may

occur beneath a scar or through ruptured intercostal muscles. It is of

small surgical consequence, and, if troublesome, may be retained by a

suitable pad.

The lung is occasionally _ruptured_ by a violent concussion of the

chest, as is also the heart. Its consequences will be emphysema,

pneumohemothorax, with vomiting of blood, and later infection.

The later consequences of hemothorax, simple or uncomplicated, may

be troublesome pleuritic adhesions, by which freedom of respiration

is impaired, and, it may be, chest motions interfered with and chest

development limited. The pleural surfaces are usually gradually drawn

toward each other by the development of granulation tissue and its

subsequent contraction and condensation.

=Wounds of the Diaphragm.=--The diaphragm may also be lacerated by

the compressing effects of violent blows, either upon the chest or

abdomen. In consequence there may be passage of viscera (_hernia_)

from either cavity into the other. Accurate recognition of these

cases will scarcely be possible, but the development of distinct

abdominal symptoms or noticeable displacement of the heart or of the

abdominal viscera may lead to exploratory section, which shall reveal

the location of the rent and possibly permit of appropriate repair or

suture.

=Injuries to the Thoracic Duct.=--The thoracic duct is occasionally

injured by penetrating wounds, while, at the base of the neck, it has

been known to be divided in the course of the removal of deep and

adherent tumors. In the latter case the escape for a short time of

the milk-like _chyle_, which it carries, will give evidence of the

injury. Several cases on record show the comparatively innocent nature

of the injury and its tendency toward spontaneous recovery without the

necessity for further intervention. The very low pressure of the fluid

in the duct is a contributing cause to this exemption from serious

harm. Should the duct become obliterated near its upper end doubtless

collateral circulation will enable the right and smaller duct to take

up its work and continue it.

=Injuries to the Upper Nerve Trunks.=--In regard to injuries of the

upper nerve trunks in the chest it is necessary to add but little to

statements made regarding injuries to the same nerves in the neck.

The writer has collected over fifty cases of destructive injury to

the pneumogastric, in over one-half of which recovery followed. It

has been shown that unilateral resection of the vagus is almost

devoid of danger, though when it is required the nerve is rarely in a

normal condition. Unless the nerve be attacked or involved below the

branch which forms the recurrent laryngeal, laryngeal symptoms may be

certainly expected. Irritation to the cervical _sympathetic_ is usually

followed by dilatation of the pupil, widening of the palpebral fissure,

some degree of protrusion of the bulb, and paresis of that side of the

face, while absolute sympathetic paralysis, such as follows division,

will produce dilatation of the pupil, ptosis, and increased flushing of

that side of the face. The sympathetic nerve may have to be extirpated

in certain cases of excision of malignant tumors. Again, it has been

deliberately resected, as recommended by Jonnesco and others, for the

cure of epilepsy, of exophthalmic goitre, and of glaucoma. This will

demonstrate the fact that injury to it is not necessarily of itself a

severe accident.

In certain injuries to the chest branches of the _brachial plexus_

will be divided or compromised, or displaced by fragments of bone or

otherwise. When nerve pressure can be recognized the compressing cause

should be removed. If a nerve be divided every attempt should be made

to suture it.

Partial or complete division of the large _vascular trunks_ is usually

too promptly fatal to justify much consideration here. On the other

hand, injuries to the _intercostal_ and _internal mammary_ vessels

are not uncommon and should not be fatal if only they can be properly

recognized and treated. It is stated that even an intercostal artery

may pour four pounds of blood into the pleural cavity in case of

gunshot or stab wound. The presumption would be that one of these

vessels, if injured, is wounded at the site of the evident puncture.

While this is usually true it is possible that a bullet penetrating

may have divided an intercostal on the opposite side. If a ligature is

to be applied it should be done on each side of the wound, whereas a

tampon used to check hemorrhage may be packed in such a direction as to

completely meet the indication. While many methods have been suggested

for arresting bleeding, the surgeon will enlarge the puncture, seek

out the source of the hemorrhage, and then resort to ligature or to

tamponing, as the case may indicate. When the tampon is used it is well

to push ahead of it a piece of gauze like a glove finger and fill this

with the tampon, in order to ensure complete removal of the whole mass

at the proper time.

This is true also of injuries to the _internal mammary_. Dennis

mentions five cases, quoted to him by Langenbeck, of perforation of

the chest with a sword-blade, as the result of duels among university

students of Göttingen, of which number two died. The latter also stated

that up to 1876 there never had been a successful ligation of this

artery. The vessel, leaving the subclavian between the two heads of

the sternomastoid muscle, lies in its course just to the inner side of

the sternum, with the vein on its inner aspect. Near the clavicle it

lies on the pleural sac, where if injured the pleura will not escape.

Lower down the pleura is not necessarily opened, although it rarely

escapes. As Dennis shows, the inference from this is that tamponing

the wound in the two upper intercostal spaces is impracticable, while

below these it might succeed, as the triangularis sterni lies between

the pleura and the artery. The mortality of the injury has been stated

to have been nearly 70 per cent. Diagnosis is not difficult so long

as the blood escapes externally. With a wound properly situated and

rapid accumulation of blood within the chest, and increasing collapse,

assumption of the injury or provisional diagnosis will scarcely prove

fallacious.

The _internal mammary_ when injured should be secured. The operator

need never hesitate to resect a portion of the sternum, or the rib ends

or cartilage, in order to expose it, since no danger can be so great

as that of not finding it. Incision may be made along or between the

ribs, parallel to them, or over the known course of the artery. After

retracting the tissues down to the bone a sufficient amount of the

bone should be removed to afford space for the examination. The pleura

should be first separated, care being taken not to inflict upon it more

than a minimum of injury. A T-shaped incision will afford more room

when the case is complicated. The ends of the vessel having been found

and secured, it becomes then a question of emptying the chest of the

blood already accumulated. This is preferably done by incision placed

laterally and sufficiently low, with the introduction of a drainage

tube. Should the blood be already coagulated the incision should be

made sufficiently wide to permit of breaking up the clot and completely

removing it.

=Treatment.=--In general, with regard to the treatment of all these

injuries, it should be said that, in addition to whatever local

measures may be indicated, general rest of the parts should be secured

by as complete immobilization of one or both sides as can be effected.

This should be made a part of the treatment of all fractures, simple or

compound, as well as of all perforating injuries. Anodynes, hypnotics,

and the like need to be used both to restrain motion and to allay

cough, either of direct or reflex origin, by which harm is always done.

THE THORACIC WALLS.

The complex structure of the thoracic walls is not exempt from

the infections and other diseases which may involve skin, muscle,

cartilage, and bone. Thus upon its surface all sorts of phlegmonous

lesions may occur, assuming carbuncular or localized type, or

occasionally ending in widespread gangrene, usually of that particular

type which is due to the morbid activity of the gas-forming bacilli,

whose first expression is a _gangrenous emphysema_. These infections

occur not only in consequence of some external irritation, but are

seen after the infectious fevers, as well as in connection with

syphilis, tuberculosis, scurvy, actinomycosis, and other forms of

infection. Tuberculous disease beginning on the exterior of the

chest wall may spread to the interior and even deeper, and, _vice

versa_, tuberculous lesions beginning within the chest spread to the

adjoining bone, producing caries, and then to the exterior surface, the

resulting sinuses being irregular and sometimes opening at a point at

considerable distance from the origin of the trouble.

All the infectious processes, whether slow or rapid, need radical

attack, including free incision, curetting, removal of diseased bone,

cauterization of the affected area, and suitable dressing and packing.

_Carious ribs or portions of the sternum_ may be removed without fear,

it being necessary in certain advanced cases to remove nearly the

entire sternum. Any concealed focus of disease is sure to spread and do

more harm than will a well-directed attempt to eradicate it. Infection

originating within the bone may spread in either direction, and may

give rise to pleurisy, with adhesions, and possibly even subsequent

abscess of the lung. The same is true of the diaphragm, while products

of infection travelling in the proper direction may cause the beginning

of an extensive subphrenic or hepatic abscess.

[Illustration: FIG. 505

Erosion of sternum, the result of pressure of an aneurysm. Wood Museum.

(Dennis.)]

[Illustration: FIG. 506

Erosion of vertebræ, the result of pressure of an aneurysm. Wood

Museum. (Dennis.)]

The pressure of advancing tumors will sometimes cause surprising

changes, not so much the result of ulceration as of mere absorption

in the path of the advancing mass. Thus _aneurysms_ will gradually

erode the sternum or the ribs, and in time form bulging projections

from within the chest, which may ultimately rupture and thus terminate

the case. Even upon the vertebral column the effects of such pressure

are pronounced. Figs. 505 and 506 illustrate what may happen under

circumstances just detailed.

Remarkable expressions of subcutaneous _emphysema_ may be seen in

certain cases of fracture of ribs, with perforation of the lung, air

escaping into the tissues and puffing up the whole upper part of the

body and neck, giving it an appearance and shape very different from

the original. For this condition there is no particular treatment,

save immobilization, by which respiratory efforts shall be limited.

Ordinarily the tissue distention quickly subsides. Should, however,

putrefactive organisms enter with the air there may arise emphysema,

terminating in gangrene, with fatal septicemia.

Painful affections of the thoracic walls are associated with lesions,

either of the intercostal nerves or the ganglia or special nerves

with which they are connected, which produce _intercostal neuralgia_

of various types, including that with its peculiar eruption known

as _herpes zoster_, or as the laity call it, “shingles” (being a

corruption of the Latin _cingulum_, meaning a girdle). Neuralgia may

also be caused by inclusion of nerve branches in callus which is

formed around a badly united fracture of the ribs. The diseases of the

vertebræ which lead to softening and changes of shape will also permit

of pressure upon nerve centres and trunks, which cause more or less

pain, referred more often to the distribution of the nerves involved

than to their origin. Thus the referred pains of spondylitis (Pott’s

disease) are to be thus explained and are sometimes very pronounced.

We give the term “neuralgia” to those painful affections for which

there is no satisfactory explanation, and thus we are told that in

intercostal neuralgia there are three points of tenderness, known as

those of Valleix, whose determination confirms the diagnosis--the first

being at the point of exit of the spinal nerve from the vertebral

canal, the second in the axillary line, and the third close to the

costosternal articulation. Abrams has shown that if a freezing spray be

applied over the first spot the neuralgia will at once subside if it

be of peripheral, but not if of central origin. Again, if one pole of

the galvanic current be placed on the affected side and the other upon

any one of the above spots the pain, if neuralgic, will disappear. If

the current employed be the Faradic, and the pain subside, its cause is

located in the muscles, as the induced current does not influence the

pain of a genuine neuralgia. (Dennis.) So far as the treatment of these

painful affections is concerned it is rarely surgical; although it was

the relief afforded by the accidental stretching of an intercostal

nerve which first suggested to Nussbaum the utility of nerve

stretching as a more general procedure, and it was thus introduced to

the profession. The treatment of _herpes_, _i. e._, of that form of

neuralgic affection which is characterized by the appearance of papules

which soon become vesicular, which collect in clusters and appear along

the course of certain intercostal nerves, is rarely surgical. It is

not difficult to distinguish this from ordinary eczema, which does not

follow the nerve distribution and is not accompanied by the severe pain

of herpes.

THE MEDIASTINUM.

MEDIASTINITIS.

The principal interest attaching to diseases in either mediastinum

pertains to the consequences of spreading infection, which will be

practically always of the phlegmonous type, and which will produce

clinical expressions varying much with its location and the direction

of its course. These are included under the general head of acute or

chronic _mediastinitis_, which might be the result of an extension

from above, as from cervical abscesses, spondylitis of the cervical

vertebræ, deep cervical phlegmons, and the like; or the result of

perforation, or of foreign bodies impacted in the esophagus or

elsewhere; or may again come from the osseous structures of the chest

proper, spine, ribs, and sternum. Doubtless certain cases of subphrenic

abscess are the result of suppuration begun in the mediastinum.

Instances are also occasionally seen after typhoid and the other

infectious and contagious fevers.

The _indications of mediastinitis_ consist of intrathoracic soreness

and pain, increased upon coughing and deep inspiration, difficulty

of deglutition, disturbances of respiration and of heart action.

Any irregularity of the pupils is evidence of irritation along the

sympathetic nerves. Displacement of the heart means accumulation in its

neighborhood and pressure disturbance. The lesion which will produce

this will probably give dulness on percussion, and alterations of the

ordinary chest sounds. With trouble high in the thorax the recurrent

laryngeal may be involved, with the inevitable change in the voice. If

the pneumogastric be compressed there will be rapid and irregular heart

action. If the esophagus thus suffer dysphagia will result. Should the

presence of pus be suspected a differential blood count may do much

to clear up the diagnosis. Should pus come near the surface it will

probably give the ordinary surface indications which one should be

quick to appreciate and to relieve. Collections of pus within the chest

tend always to migrate and pus may burrow to a considerable distance.

=Treatment.=--The treatment of phlegmonous mediastinitis mainly depends

upon recognition of the lesion and its degree of accessibility. Certain

deep forms are hopeless, since they tend to kill before even pus can be

located and evacuated. So soon as there be found any surface indication

surgical attention should be promptly given. Any of these cases may

be complicated by septic conditions within the lung or accumulations

within the pleural cavity. The latter at least may be recognized and

relieved. The proper use of the exploring needle may afford much

information, and, in the presence of suitable indications, the sternum

should be trephined and exploration made behind it. The main thing in

all these cases is to distinguish between pressure effects produced by

phlegmon and those due to aneurysm or tumor. Only rarely, and then only

by surgeons of wide experience, should radical measures be attempted

for the latter. Chronic processes, of tuberculous character and leading

to formation of cold abscesses, will usually produce symptoms much less

urgent, while the nature of the relief to be afforded will scarcely be

left in doubt.

[Illustration: PLATE XLIX

Neurofibroma of Skin.]

TUMORS OF THE THORAX.

_Primary tumors of the chest wall_ constitute less than 1 per cent.

of those occurring in general practice; this, of course, not having

reference to secondary developments from cancer in the breast, which

are somewhat frequent. Of the benign tumors those which most frequently

appear upon the surface are the _lipomas_, which are seen either in

circumscribed or diffuse form, as illustrated in Figs. 507 and 508.

[Illustration: FIG. 507

Circumscribed lipoma of back. (Dennis.)]

[Illustration: FIG. 508

Congenital diffuse lipoma of back. (Mixter.)]

They are sometimes multiple and perfectly innocent, save as they

may attain large size or ulcerate from surface irritation. The

_granulomas_, especially those of syphilis and tuberculosis, are

common, appearing either as superficial tumors which ulcerate, or as

deeper ones which may break down in the course of months or years,

after perhaps involving the ribs or a considerable portion of the chest

wall. _Actinomycosis_ is perhaps as often seen in this region of the

body as anywhere.

The _fibromas_ are seen more commonly in the axilla and beneath

the thoracic musculature. The chest is a frequent site for those

pedunculated fibromas which have been described under the term keloid.

A most striking case of neurofibroma of the skin is portrayed in Plate

XLIX.

_Chondromas_ of the chest are slow-growing, usually painless, may

involve a considerable area, both of bone and cartilage, are not

infrequently the seat of cystic changes, and often undergo a final

sarcomatous degeneration. All this is true in lesser degree of the

_osteomas_, which are of the cancellous type.

The malignant tumors of the thorax proper are mostly _sarcomas_ which

assume various types, according to their cellular characters, the

round-cell sarcomas growing rapidly, becoming extremely hemorrhagic

and fungous, and tending to kill early, while the larger and more

spindle-cell and the giant-cell forms grow relatively more slowly, and

may even be successfully removed (Figs. 509 and 510.)

[Illustration: FIG. 509

Sarcoma of rib and pleura, result of injury by a base-ball. (Dennis.)]

_Carcinoma_ of the chest wall is generally the result of extension from

cancer of the breast or of some other epithelial structure. Advancing

carcinoma spares nothing, and may not only perforate the chest but

involve the lung beneath, with or without later ulceration, and the

occurrence of pneumothorax.

[Illustration: FIG. 510

Skiagram of a large sarcoma of the thorax and humerus, whose

bloodvessels were injected previous to taking the _x_-ray picture.

(Lexer.)]

While these are the more common forms of tumor of this region there are

no known growths which may not occasionally be met here.

=Treatment.=--The treatment for all these tumors is _extirpation_. With

benign growths outside of the ribs proper this is usually a simple

matter. When the whole or nearly the whole thickness of the chest wall

is involved it becomes then a serious problem how far to proceed in the

effort to extirpate. This is true alike whether sternum or ribs are

involved. The entire sternum may be separated from its surroundings and

lifted out of place, and this would be justifiable when dealing with

an osseous or cartilaginous growth. If, however, it were distinctly

sarcomatous it would be hardly worth while. If in such an operation

the pleura be spared and air not admitted to the pleural cavity

almost anything is allowable. If, however, it appear that it will be

necessary to open the pleural cavity caution should be observed. Of

late years, however, less hesitation has been felt in this regard,

and Parham and others, including myself, have shown that extensive

portions of the thoracic wall may be resected without the necessity

for employment of the elaborate operative methods suggested by some

recent experimenters. For instance, Sauerbruch has devised a “pneumatic

cabinet,” the patient’s head resting outside when the anesthetizer

administers the anesthetic. The balance of the body rests within the

cabinet, which is sufficiently large to accommodate the operator and

two or three assistants, and which, being closed, is subjected to a

lowering of atmospheric pressure equivalent to 10 Mm. of mercurial

column, or to a difference in atmospheric level of 1000 to 1200 feet.

The patient breathing air at external pressure does not suffer the

collapse of the lung, thus exposed, which would otherwise take place.

The operation being completed within the cabinet, the dressings are

applied and hermetically sealed, and the door then opened and pressure

equalized. Subsequent dressings can be made in the same way. Thus has

been afforded a scientific method of doing that which the experience of

many American surgeons has shown to be only theoretically indicated.

Sauerbruch’s device is ingenious in theory and complicated in operation.

A simpler method is to apply the Fell-O’Dwyer apparatus over the face

and thus keep up artificial respiration. It is not, in theory, so ideal

as to open the trachea and practise this procedure as is done in the

experimental laboratory, but is much simpler and will usually suffice,

should anything of the kind be required.

A malignant tumor of the chest wall whose overlying skin is seriously

involved, and whose removal would leave a defect which it would not be

possible to cover with integument, should not be disturbed. It might be

possible in certain cases to partially transplant the breast in such

a manner as to permit closure of a defect thus made. Nevertheless it

is questionable if any cancer advanced to the extent of requiring this

procedure is to be considered operable.

Nor should any malignant tumor of the chest wall be operated if, in

addition to its own presence, there be indication of the involvement of

the lymphatics or other structures within the chest, such indications

including, for instance, cough, loss of voice, dyspnea, dysphagia,

disturbance of pneumogastric control of the heart, displacement of the

latter, or great accumulation of fluid in any of the chest cavities.

The only exception to this statement is possibly when the lung has

attached itself to its interior surface, but yet not so extensively but

that removal of a small amount of lung tissue will not interfere with

extirpation of the growth. Cases of recurring carcinoma where the chest

wall is completely involved rarely justify operation.

TUMORS OF THE LUNG.