Part 38

Extraction is the only means of cure. The body of the tumour is depressed and pulled outwards by the flat end of a probe slightly bent; delicate forceps are introduced gently, and passed up to the neck of the polypus, which is then firmly grasped; by combining slight twisting with gentle extractive force, it is readily removed. Or a flat scoop, with a sharp round edge, is passed along till obstructed, and by slight rotatory motion of the edge, the neck of the tumour is divided. After a day or two, a mild escharotic may be applied with the view of preventing reproduction; a bit of charpie sprinkled with the oxidum hydrargyri rubrum may be pushed up to where the tumour was attached, and the application may be repeated several times, one or two days intervening. Even after this the tumour sometimes returns, again rendering extraction necessary.

Deafness is attributable to various causes besides those already mentioned. Accumulation of cerumen in the external meatus is the most common. The cerumen is often mixed with wool, and other extraneous substances, which the patient may have been in the habit of introducing as preservatives from cold, and thus a large and firm plug is formed, completely blocking the meatus. It is removable by the assiduous injection of tepid water, the best solvent of cerumen. The whole may not be brought away at the first sitting; but the injection must be repeated again and again, till the membrane of the tympanum is free. A powerful syringe is required. By the use of a speculum, the condition of the external tube and membrane of the tympanum can be ascertained. But it is perhaps unnecessary to enlarge farther here on this subject, for such is the division of labour in these days, that a distinct profession is founded on the operation of squirting water into the external ear; it is true that other operations are talked of by these Aurists, as they style themselves, but the advantage to be derived from any of them is often very doubtful. They talk of deafness as arising from a deficient secretion of cerumen, from dryness, or from eruptions in the meatus; and heating stimulant applications are poured in—oils, ointments, mercurial salts, acetic acid, garlic, &c., all combined. They even go so far as to recommend mercurials to correct the state of the general health, to improve or rectify the functions of the chylopoietic viscera, the assistant chylopoietic, and the whole of the digestive organs, upon derangement of which, say they, many cases of deafness depend. The fools who apply to such charlatans certainly deserve to have their pockets well drained, but ought scarcely to be poisoned by them.

It has been proposed to pass probes and tubes into the eustachian tubes, to reëstablish their continuity if obliterated, or dilate them if partially closed. No doubt deafness often depends on obstruction of this outlet from the tympanum, the requisite reverberation being perhaps thereby impeded. It may be closed by swelling of the lining membrane, by inspissated mucus, by destruction of its extremity from ulceration, by the cicatrisation of ulcers in the immediate neighbourhood, by congenital deficiency, or by pressure of neighbouring swellings, or of morbid growths, producing temporary or permanent obstruction. None but the first two causes could possibly admit of the use of the probe, and even then it can scarcely be required. By removal of the cause of such turgescence at the end of the tube, or in the neighbouring parts,—which can often be detected, being local,—by counter-irritation, &c., a cure is much more likely to be effected than by the introduction of probes. Not that the operation is exceedingly difficult; for, after practice on the dead body, a probe can readily be passed into the eustachian tube of the living from the nostril. The instrument is fixed in a handle, with its point slightly bent, and on the handle there should be a mark to show the direction of the point; the distance of the termination of the tube from the nasal orifice ought also to be marked. The instrument is passed along the floor of the nostril, and then its point is directed upwards and outwards, whilst the handle is pressed towards the septum narium. It has been proposed, moreover, to force a stream of cold and condensed air into the internal ear, and to apply ætherial vapours to the cavity of the tympanum. The attempts have been made on an extensive scale in all sorts of cases, and quite indiscriminately. This plan of curing deafness has been well advertised, and unblushingly puffed in scientific and other journals. Not one case of deafness in a hundred probably depends upon any affection of the eustachian tube: vitiated mucus cannot even be displaced by injection of air or other fluid, unless the membrane of the tympanum be ruptured; this has indeed been accomplished by the operation in question, and then the mucosity could only be forced into the cavity of the tympanum, so as, if possible, to make matters worse.

Nervous deafness, like functional amaurosis, may sometimes be relieved or even removed entirely by stimulating frictions, or the application of strychnine to a raw surface behind the auricle, and by attention to the general health.

Puncture of the Tympanum has been recommended as a remedy for deafness arising, or supposed to arise, from obstruction of the eustachian tube; but I believe it has not succeeded in above one out of twenty cases. The puncture is apt to close very soon; and though the hearing may be improved for a short time, the advantage gained soon disappears. The means of keeping the puncture open are not easily applicable; perhaps the most effectual is to touch the edges occasionally with pencil-pointed lunar stone. The puncture is generally made with a short-pointed trocar, such as is used for hydrocele. The canula is passed down to the membrane, and placed on one side of its centre, lest the long head of the malleus should be interfered with. The trocar is then pushed on gently, and should penetrate but a very short distance, for fear of injuring the important parts at the bottom of the cavity. By some a sharp-pointed probe is used, passed through a quill; or an instrument about the same size with the probe is made for the purpose, with a canula to fit. But these are by much too small; even the puncture with a trocar closes, notwithstanding the application of nitrate of silver. I have lately used a sort of punch, such as is employed for making holes in leather, of a pretty large size, and neatly made, with the edge very keen, and on a small stalk. This is introduced; and when obstructed, having reached the bottom of the canal, an attempt is made, with a rapid turn of the hand, to cut out a portion of the membrane. I have thus succeeded in improving immensely the hearing of one gentleman, enabling him to hear at four or five times the distance he could formerly. He had repeatedly submitted to punctures before I saw him; and, previously to the operation with the punch, I passed through the membrane a trocar, made large, and well-pointed for the purpose; but notwithstanding this, and the application of the nitrate of silver, I was unable to preserve the advantage gained longer than a very few days. In suitable cases, the operation is worthy of trial, being unattended with pain or any dangerous consequences. M. Fabricci has contrived a very ingenious little instrument for the purpose; by it the piece of membrane is fixed by a small screw, before being punched out.

Bronchocele is not rare in some districts of Great Britain, but unattended with the same peculiarities of countenance and mind as in some other countries. The majority of those affected come from mountainous districts. The disease generally commences early in life, and females are more subject to it than males; indeed almost all who present themselves are females. The tumours are of various sizes, involving either the whole gland, or only a part. One lobe is usually in a state of greater advancement than the other. The swelling is for the most part soft and yielding, the integuments are thin and moveable, and large veins shine through them. It is unattended with pain, or any great inconvenience, though sometimes it equals in size the patient’s head, or nearly so, and then it is troublesome from bulk alone. In general, there is little or no obstruction to deglutition or respiration, and the health is not impaired. The tumour is always of slow growth, at length becomes stationary, and the patient gets reconciled to the deformity. Its structure is that of the simplest form of tumour, a genuine hypertrophy, and it is seldom that its action degenerates. It is often made up also partly of cysts containing serosity, or glairy albuminous fluid.

Internal remedies have been prescribed, with the view of arresting the growth, and promoting absorption of the enlarged thyroid—burnt sponge—muriate of lime—muriate of baryta, &c. The use of iodine, externally and internally, has in many cases been attended with beneficial effects. Tumours have diminished, and even disappeared entirely, during the employment of this medicine; but in others, the diminution has been either trifling or none. The insertion of setons has been strongly recommended; and many patients are said to have been thus cured. I have tried this plan in one case only; it certainly had the effect of diminishing the swelling; but for some time great trouble was experienced from bleeding, whenever the cord was drawn, and the patient afterwards became much weakened by the profuse discharge. The proposal to tie the thyroid arteries, for the cure of bronchocele, has been put in practice, but without a favourable result.

Extirpation of such growths has been repeatedly attempted; but the patients, almost without exception, have perished from hemorrhage, under the hands of the knivesmen. The immense supply of blood afforded to the gland in the healthy state must be kept in mind, as also the enlargement of the vessels proportional to the increase of the part. Not arteries alone, but enormous veins, are to be encountered. The tumour is in the vicinity of important organs, and of the trunks of large vessels and nerves, and probably has become attached to them. In short, the operation is attended with such risks, with so absolute a certainty almost of fatal result, as not to be warranted under any circumstances, far less for removal of deformity only.

Enlargement of the isthmus alone gives rise to more severe symptoms apparently, and may warrant an attempt at removal; but this can scarcely be accomplished altogether by incision. Such is my impression, and under this impression I proceeded very cautiously in a case of this nature with which I had to deal.—J. R., a rat-catcher, aged forty-seven, from the Highlands, was admitted into the Royal Infirmary. The isthmus of the thyroid gland was enlarged to the size of a goose’s egg. The tumour was extremely hard and irregular on its surface, but not painful when touched; it appeared to be adherent to the trachea, and did not admit of much motion. The voice was considerably impaired, and breathing much impeded, inspiration being difficult and attended with a loud wheezing noise. On making unusual exertion, even though inconsiderable, the dyspnœa was much increased; and on ascending a height, or even remaining for some time in a stooping posture, it amounted almost to suffocation. There was no pain or uneasiness in the larynx or trachea. The disease was of three years’ duration. A seton had been introduced, but effected no diminution, and rendered the tumour more dense and less moveable than formerly. I surrounded the lower part of the tumour by two semicircular incisions, and, dissecting cautiously beneath its base, detached it from its more loose connections, not interfering with the central portion and its connection to the trachea. During the progress of the dissection, the blood flowed most profusely from both arteries and veins, but was restrained by securing the former with a ligature, and compressing the latter with sponge. An armed needle was then passed through the centre of the tumour, as close to the trachea as possible, and its remaining attachment enclosed by the separate portions of the ligature firmly applied. Everything proceeded favourably. The tumour soon came away; the wound healed with a firm cicatrix, and in about a month the patient went home well. I met him by chance, in Aberdeen, twelve months afterwards, free of complaint, and breathing easily under all circumstances, his neck presenting no vestige of the tumour.

Glandular Tumours of the Neck, as formerly noticed, arise from various irritations; and some constitutions are more subject to them than others. The nature of the enlargement is dependent on the cause; it may be simple or malignant. Simple swellings often attain a large size; the lymphatic glands in both spaces of the neck, and on one or both sides, get immensely enlarged, the cellular tissue around is infiltrated with solid matter, and all matted together. Great deformity is produced; the head is turned with difficulty, and twisted to one side; often there is not much pain. After some time, the swelling becomes looser than before; its various portions separate, and gradually disappear; or the centre becomes soft, suppuration spreads extensively, and the surrounding hardness either goes off, or becomes partial.

Discussion of the swelling is to be promoted, and, if possible, the cause removed; and fomentation, friction, pressure, internal stimulants are to be employed, according to the state of the parts, along with what are called deobstruents, in the first instance. When suppuration cannot be arrested, the attention must be directed to prevent the integuments from being destroyed. With this view, the abscess should not be permitted to give way spontaneously, lest an opening be formed whose cicatrisation would cause deformity, and leave a stain on the race and generation. An artificial aperture must be made early; and in the upper and most exposed parts of the neck this should be in the direction of the folds, and small.

When many and extensive collections have formed, when the integuments have been undermined and attenuated before advice is sought, it is impossible to prevent deformity. The knife and potass are required, for reasons assigned in the preceding part of this work; and the detached glands, as well as the thinned skin, stand in need of their free application.

Deep-seated collections may originate in glandular disease, or commence in the cellular tissue; they occasionally follow transverse wounds of the neck. Great infiltration of the cellular tissue supervenes over the trachea and sternum, and also under the fasciæ; purulent matter is secreted in the cells, and the parts are extensively separated; sloughing is prevented only by free and early incision. The nature and extent of the coverings of an abscess seated deeply in the neck are to be kept in view—the platysma myoides, the superficial and deep cervical fasciæ. Collections under these interfere with the functions of the neighbouring parts, and are attended with great pain, which is somewhat relieved by resting the chin on the sternum, and so relaxing the fasciæ. The matter makes its way to the top of the sternum, and generally points on the outside of the sterno-mastoid muscles. But before the integuments become thin, the parts have been seriously injured—the cellular tissue has sloughed, the muscles have been separated from each other, with unhealthy purulent matter interposed—the trachea, the œsophagus, or the mediastinum, opened into. Such cases have been formerly alluded to.

The lymphatic glands, situated amongst the fat and cellular tissue between the deep and superficial cervical fasciæ immediately above the sternum, may become enlarged. When the tumour is large, breathing is impeded by compression of the parts beneath, and pain and much inconvenience are endured on account of its limited situation and resisting investments.

Purulent collections in the anterior mediastinum and under the sternum are scarcely remediable. These are chronic or acute. One of the great dangers following the operations on the larger vessels at the root of the neck, in which the deep fascia is necessarily divided, is infiltration into, and acute abscess of, the anterior mediastinum. In chronic collections the parietes of the cavity on one side are fixed, on the other have constant motion; and thus the surfaces, however healthy and well disposed, are prevented from coming together and adhering. The discharge continues, and at length wears out the patient, pulmonary affection perhaps supervening. The same unfavourable causes operate in other situations, in the iliac fossa, and in chronic collections under the cranium. In chronic abscess of the mediastinum, no dependent opening can be obtained, unless by perforation of the sternum. This is perhaps warranted by œdematous swelling over some part of the bone, indicating, along with other symptoms, the existence of matter beneath. Purulent collections sometimes form in the substance of the sternum, communicate with the mediastinum, and involve the lower part of the neck.

The thymus gland is said to be liable to chronic enlargement in young subjects of weak constitution, causing serious impediment to respiration and deglutition; the tumour is confined above and anteriorly, and consequently presses backwards on the trachea and gullet. Suppuration may take place in the swelling, and the matter ultimately be diffused in the mediastinum.

An encysted tumour of the neck, to which the term HYDROCELE has been applied by some writers, is met with in both sexes and at various periods of life. Its progress is usually slow, and it generally arises without any assignable cause. Occasionally it has appeared to be congenital, but this must be considered as a rare exception. The tumour, seldom larger than a walnut, may acquire the volume of a Seville orange. When this is the case, it may impede respiration and deglutition, or even the return of the blood from the head. Its contents are of a serous or oily character, with an intermixture of flakes of lymph, and the cyst itself varies in thickness from the fourth of a line to a quarter of an inch or more. Externally it is more or less intimately connected to the cellular substance in which it is developed, while its internal surface often exhibits a rough, reticulated aspect, not unlike the false membrane of pericarditis. In cases of long standing the cyst is very firm and tough, or almost gristly, and closely adherent. The skin covering the tumour seldom undergoes any change, unless it is very large, when it is apt to become attenuated at some points and thickened at others. The subcutaneous veins may also then present a tortuous and distended appearance; but this is far from being generally the case.

The characters by which hydrocele of the neck may be distinguished from other affections are, absence of pain and tenderness on pressure, slight fluctuation, the slow progress of the tumour, years generally elapsing before it attains much development, and, above all, the history of the case. When the tumour projects outwardly over the carotid artery, it might be mistaken for aneurism, from which, however, it may, in general, be readily discriminated by the elevation of the entire swelling from the impulse of the blood, and by the want of that alternate expansion and retrocession which are present in genuine aneurism. When seated over the thyroid gland, or in its substance, it may be confounded with bronchocele. In all cases, where any doubt remains as to its true nature, an exploring needle or trocar should be introduced, which will at once determine the diagnosis.

The treatment of this affection, like that of the vaginal tunic of the testicle, may be palliative or radical. The former consists in evacuating the fluid, from time to time, with the knife or trocar; the latter, in injecting some stimulating fluid, such as wine and water, or a solution of iodine, or nitrate of silver; or, what is better, introducing a seton, and keeping it in the sac until it is obliterated by adhesive inflammation. Incision and extirpation have been practised successfully by Flaubert, Delpech, Jobert, and other surgeons.]

Distortion of the Neck arises from a variety of causes, and is either temporary or permanent. The head is often kept in an unnatural position for weeks by glandular swelling. Enlargement of the superficial glands, at the upper part of the neck, induces the patient to turn his head to the opposite side; swellings lower in the neck, and deep seated, require relaxation of the coverings, and the head is consequently twisted to the same side. Either rigidity, or spasmodic action, or both, of the sterno-mastoid muscles, displaces the head and twists the neck. The head is either bent forward, or turned to one side; usually, the chin is twisted over the shoulder, on the side opposite to the offending muscle. Induration of the muscle is sometimes met with, also causing distortion; it may terminate in abscess, or after a long time be discussed.

The cause of the spasmodic action in the muscle is sometimes apparent, sometimes very difficult to be detected. Sources of irritation at the extremities of neighbouring and communicating nerves are to be looked for and removed; and the spasms are to be moderated, as much as possible, by external and internal remedies. Opiate frictions, and the application of the nitrate of silver over the course of suspected nerves, are sometimes followed with benefit, and may be accompanied by the internal administration of antispasmodics, though the efficacy of these is often doubtful. When the head has been for a long period, perhaps many years, turned to one side, from any cause, the muscle on that side naturally becomes shortened, and a change takes place in the form of the bones. If the patient is still young, the deformity may, in a great measure, if not entirely, be remedied. Division of the shortened muscle was a favourite operation of old surgeons for the cure of wry-neck, and may be resorted to with advantage in some cases. One of the heads, or both, may require to be detached from the sternum and clavicle. It is only in cases where the muscle is in fault, it being shorter than usual, that benefit can be expected from this proceeding. It is a very simple operation, and can be effected by a mere puncture of the skin betwixt the two portions. By the cautious use of a blunt and flat probe or director, the cellular tissue under the origins of the muscle is separated; this is followed by a narrow and blunt-pointed knife, by which the attachments to the clavicle and sternum are cut across.

Distortion of the neck is most frequently produced by some vice in the bones, as curvature, from softening, attended with deformity of the trunk or of the limbs. In such cases, the twist is generally to the right side, the ear approaching the shoulder. No treatment can be effectual, unless the other curvatures are corrected; for the head is placed so to preserve the equilibrium of the body. The head is to be supported, and its weight removed from the vertebral column by a curved iron rod, attached to the back of stays fastened on the loins, leathern straps passing from the top of the rod under the chin and over the occiput. By the use of such apparatus for a considerable time, the vertebral column may regain its perpendicular direction, and all deformity of the neck be consequently removed. The application of such a machine is required after the division of the sterno-mastoid, so that the head may be kept straight until the muscle is reunited of a proper length, and any change in the form of the bones may be got over. In slight cases, this treatment is not required; on giving support to the trunk, and raising the shoulders to an equal level, the muscles of the back, perhaps stimulated by powerful and repeated friction, gradually bring the column into its proper form. Then the position of the head to one side is no longer required to balance the body. But a cure can be expected only when no material change has taken place in the form of the individual bones.

Excurvation of the cervical vertebræ,—bending of the head forwards, and perhaps a little to one side, generally to the right,—takes place as a consequence of disorganisation of the ligaments and connecting fibro-cartilages of the vertebræ, with subsequent ulceration of the bones. The disease generally occurs in the superior vertebræ; in the articulation of the atlas with the occiput, or with the vertebræ dentata, or in the articulation of the latter with the one below. The articulations on the left side are usually affected first. There is stiffness, pain, and swelling of the soft parts covering the affected bones, attributed perhaps to exposure to cold, as when sitting in a draught, and supposed to be merely crick of the neck. The posterior cervical muscles are weakened, and the head is bent forwards. The patient is unable to support his head by the usual muscular action, and when in the erect position places his hands on the temples, to prevent it from dropping, and to keep it steady. Difficulty of swallowing is a prominent symptom from the first, as can readily be imagined when the close application of the constrictors of the pharynx to the forepart of the affected bones is kept in remembrance. The position of the head also renders deglutition awkward. The disease is attended with great suffering, evinced by marked anxiety of the countenance; and the pain is most violent during the night. The complaint is too frequently trifled with at the commencement, being not understood, nor its danger appreciated. The swelling increases, with pain, and the chin falls down on the sternum. The patient grows emaciated, and perhaps becomes weak in the lower limbs, and even in the upper; the feces and urine are imperfectly retained. Occasionally, abscess forms behind the upper part of the pharynx, increasing the pain and the difficulty of deglutition. On making an examination through the openings by which the abscess has emptied itself spontaneously, the bone is felt bare; and portions, even large, of the vertebræ, or vertebra, are, after some time, discharged, so as to expose the theca of the spinal cord. Even in such circumstances patients have lingered on, and that for so long a period as to allow of some unprincipled fool advertising a perfect recovery.

The termination of caries of the cervical vertebræ, often without any appearance of abscess, is in general fatal and sudden. The head, slipping from its support, falls forwards or to a side, causing immediate and complete paralysis of the whole body; dissolution soon follows. On examination, the articulating surfaces of the vertebræ are found displaced, and the shreds of ligaments which connected them ruptured. The atlas is separated from the occiput; or the processus dentatus, escaping from its situation, in consequence of destruction of its confining ligaments, is found compressing the medulla oblongata. This process is very often destroyed almost entirely, or it is so far detached by ulceration at its root as to be easily broken off. The disease in general seems to commence in the articulations, whereas in the vertebræ with larger bodies, abscess and ulceration have their foundation and origin more frequently in the deposit of tubercular matter in the cancellated texture of the bones. In other instances, the termination may be more slow and gradual; the patient is worn out by long suffering and continued purulent discharge; change of structure takes place in the theca vertebralis, or in the medulla itself; serous effusion occurs at the base of the brain; the patient’s sensations are blunted, and he loses the use of his limbs gradually; his intellects fail, and coma supervenes, followed by death.

Active and early interference can alone arrest, subdue, or prevent the dreadful consequences of the disease above described; it is quite intractable in its later stages. Confinement to the recumbent posture, and strict rest of the affected parts must be enjoined; and blood is to be abstracted locally, once and again, according to circumstances; afterwards counter-irritation is to be employed, and repetition of moxas or of caustic issues is the most efficacious. When the painful feelings have subsided, and some impression has been made on the disease, the patient appearing to convalesce, the head must be supported by a proper machine for a long time. He will thus be enabled to use his limbs, to move about, and repair his general health, the weight of the head being taken from the weakened column.

The External Jugular vein may require to be opened for the abstraction of blood in affections of the head; or when venesection cannot be readily performed at the bend of the arm, from the small and indistinct condition of the veins in children, or in people loaded with fat. The vein is made to rise by pressure with the finger or thumb, as seen in the accompanying cut, above the clavicle. The lancet is passed though the integuments and platysma myoides into the vessel, midway between the jaw and clavicle. After a sufficient quantity of blood has been withdrawn, the pressure below is removed, and the edges of the wound are put together with a bit of court plaster, or by means of a compress and bandage lightly applied.

Ligature of the common Carotid may be required for the cure of aneurism at the angle of the jaw; or on account of hemorrhage from deep wounds in the same situation, when, from any circumstances, the divided extremities of the vessels cannot be secured. A deep incision of the angle of the jaw, towards the base of the cranium, not only divides important branches of the carotid, but may also wound the vertebral arteries where they project in a tortuous fashion, betwixt the dentata and atlas, or betwixt the latter bone and the occiput.

Ligature of the common carotid has been had recourse to, in order to stop bleeding from the mouth, nostrils, and other parts connected with the face,—for the cure of large or deep-seated aneurism by anastomosis,—and as a preliminary step to the removal of large and firmly attached morbid growths of the face or neck. This last proceeding, as already remarked, does not in any way enhance the patient’s safety, whilst it adds much to his suffering.