Manual of Surgery Volume II Part 64

It is sometimes advisable to perform the operation under local anaesthesia. A general anaesthetic is, however, preferred in this country. The injection of 1/6th grain of morphin and 1/120th grain of atropin half an hour before the operation, and the administration of ether by the open method, or by intra-tracheal insufflation, is safe and satisfactory.

There is reason to believe that the absorption of thyreoid secretion squeezed from the divided surfaces gives rise to a condition known as _acute thyreodism_ during the first few hours after operation; its symptoms are elevation of temperature, increase in the pulse-rate (150-200), rapid respiration with dyspna, flushing of the face, muscular twitchings, and mental excitement. The gentle handling of the tumour and the employment of a drainage tube for the first forty-eight hours diminishes this risk.

_Tetany_, as evidenced by the occurrence of cramp-like contractions of the thumb and fingers, may supervene within a few days of the operation if one or more of the para-thyreoids have been inadvertently removed. It may be controlled by large doses of calcium lactate. On no account may the whole of the thyreoid gland be removed, as this is followed by the development of symptoms closely resembling those of myxdema--_operative myxdema_ or _cachexia strumipriva_.

_Treatment of Sudden Dyspna._--When dyspna suddenly supervenes and threatens life, it is sometimes possible to relieve the pressure on the trachea by open division of the skin, superficial fascia, platysma and deep fascia in the middle line of the neck, so as to relax the tension on the goitre. If this is insufficient, the isthmus may be divided. Should relief not follow, tracheotomy must be performed, and a long tube or a large-sized gum-elastic catheter with a terminal aperture be pa.s.sed along the trachea beyond the seat of obstruction.

#Adenoma of the Thyreoid.#--In this condition the swelling of the thyreoid is due to the growth within its substance of one or more adenomas of variable size and surrounded by a capsule. The rest of the gland may be normal, or may show some degree of hyperplasia. Some are solid, others undergo cystic degeneration, the glandular tissue being replaced by a quant.i.ty of clear or yellowish fluid, sometimes mixed with blood. The cysts thus formed may be unilocular or multilocular, and intra-cystic papillary vegetations frequently grow from their walls. The walls of the cysts may be thin, soft, and flaccid, or thick and firm, or they may even be calcified.

The thyreoid is enlarged, but instead of the uniform enlargement which characterises the parenchymatous goitre, it tends to be uneven, with hillocky projections corresponding to the individual cysts (Fig. 280), and in these fluctuation may be detected. It is to be noted that there are no toxic symptoms in cystic adenoma.

[Ill.u.s.tration: FIG. 280.--Multiple Adenomata of Thyreoid in a woman aet. 50.

(Mr. D. M. Greig's case.)]

[Ill.u.s.tration: FIG. 281.--Cyst of Left Lobe of Thyreoid.

(Mr. D. M. Greig's case.)]

The treatment is necessarily operative; cystic tumours may be tapped and injected with iodine, but the more satisfactory procedure, both with the solid and cystic forms, is to incise freely the overlying thyreoid tissue and enucleate the tumour.

#Malignant Disease of the Thyreoid.#--This, whether in the form of _carcinoma_ or _sarcoma_, usually develops in a gland that has been the seat of goitre for several years, although it may begin in a previously healthy gland.

_Clinical Features._--Both s.e.xes, above the age of fifty, are affected in about equal proportion. The characteristic features are that the tumour undergoes a progressive increase in size, that it becomes fixed to its surroundings, that its surface tends to be uneven and nodular, and its consistence densely hard. The voice often becomes hoa.r.s.e from abductor paralysis due to infiltration by the growth, usually of the left recurrent nerve. The effects upon the trachea are more decided and more progressive than in parenchymatous goitre; it displaces and compresses the trachea and frequently overlaps it, so as to bury the air-pa.s.sage completely. If the tumour tissue has actually penetrated the trachea, the expectoration is tinged with blood. Dysphagia is rarely a prominent symptom. The lymph glands become enlarged after the tumour bursts through the capsule; and metastases to the lungs and bones, particularly the skull, sternum, and mandible, are common. When the goitre extends behind the sternum--the _malignant form of retro-sternal goitre_--the pressure symptoms are due to the encroachment upon the limited accommodation of the upper opening of the thorax; the trachea especially suffers, and the pressure on the veins causes distension of the anterior and external jugulars and their tributaries. The patient is unable to lie down; there are violent paroxysms of coughing, and an abundant frothy expectoration.

Death may take place suddenly from asphyxia, from heart failure, or from displacement of a thrombus from one of the veins in the neck.

_Treatment._--It is only in the earliest stages that a malignant goitre can be successfully removed. In the later stages complete extirpation is not to be attempted, as it usually involves the removal of a portion of the trachea or sophagus, and the operation is attended with grave risk to life.

Operative interference is often called for, however, for the relief of respiratory embarra.s.sment. _Tracheotomy_ may prove a difficult and dangerous procedure, owing to the trachea being buried under the goitre and displaced or narrowed by it, so that it is not easy to reach it or to introduce an efficient tube beyond the point of obstruction. A more certain method consists in exposing the goitre by an incision as for thyreoidectomy, rapidly removing sufficient of the growth to expose the trachea and admit of a tube being introduced. If there is a retro-sternal prolongation compressing the trachea within the thorax, a long flexible tube may have to be pa.s.sed beyond the site of the compression before the dyspna is relieved. The benefit is immediate and decided; the acc.u.mulated secretion is coughed up, and after a few deep breaths the patient is able to lie down, and usually falls asleep. The stridor disappears. Unfortunately the relief is only temporary, and the patient soon succ.u.mbs to a broncho-pneumonia, or to secondary haemorrhage from the trachea.

#Toxic Goitre#--#Exophthalmic Goitre#--#Graves'# or #Basedow's Disease#.--These terms are applied to a variety of goitre in which the symptoms due to absorption of thyreoid secretion--_thyreotoxicosis_--predominate. The name "exophthalmic goitre" is misleading, as in some cases the enlargement of the thyreoid, and in others the eye symptoms, are scarcely appreciable, while the general symptoms are well marked. The term toxic goitre or _hyperthyreoidism_, suggested by C. H. Mayo, is preferable, as the manifestations of the disease depend upon excessive or abnormal action of the thyreoid tissue.

[Ill.u.s.tration: FIG. 282.--Exophthalmic Goitre.]

The condition is chiefly met with in young adult women, and may develop suddenly after a shock to the nervous system. The intoxication affects the higher cerebral functions and causes nervousness, irritability, and tremor; the cardiac and vaso-motor centres, causing tachycardia and pallor of the skin; the sympathetic fibres to the eye, causing protrusion of the eyeb.a.l.l.s, staring of the eyes without winking, narrowing of the palpebral fissure, dilatation of the pupil, and lagging behind of the upper lid, and sometimes also of the lower lid--von Graefe's symptom. There may be diarrha and vomiting, loss of weight, and in the worst cases there is delirium at night. In course of time there develops cardiac insufficiency with fibroid degeneration of the myocardium. Coagulation of the blood is r.e.t.a.r.ded, and there is a marked diminution in the number of leucocytes, especially the neutrophils, and an increase in the lymphocytes (Kocher).

In the early stages the thyreoid is enlarged and pulsatile, and bruits may be heard over it; later, these vascular symptoms disappear, and only a firm, diffuse, uniform swelling implicating all parts of the gland remains.

_Prognosis._--The tenure of life is uncertain as the patient offers little resistance to intercurrent affections such as influenza and pneumonia. If the average course of the disease is represented by a curve, the greatest height is reached during the second half of the first year and then descends. For the next two to four years it fluctuates with occasional exacerbations of symptoms due to fright or worry.

_Treatment._--Medical measures, along with the external application of radium, the strict observance of rest in bed with the exclusion of all forms of excitement and worry, the administration of bromides, heroin or other sedatives, and of digitalis or other cardiac tonics, are to be prescribed in the first instance, and in any case, as a desirable preparation for operation.

_Operative measures_ consist in the _ligation_ of the vessels and nerves at one or other pole of the gland--usually the superior on one side--followed by, if necessary, a partial _thyreoidectomy_.

Crile of Cleveland has organised his clinic in the direction of arranging that the operation shall be performed without the patient knowing that it is to take place--what he calls "stealing the goitre"--the thorough preparation of the patient for the operation, the minimising the risk from the anaesthetic by the combination of novocain locally and of nitrous oxide and oxygen; and of diminishing the risk of absorption of thyreoid secretion by packing the (open) wound with gauze wrung out of a solution of flavin.

Operations on the cervical sympathetic cord have been abandoned.

The presence of toxic goitre may influence the question of operation in the treatment of other surgical conditions, and may determine the selection of one or other form of anaesthesia.

CHAPTER XXVIII

THE SOPHAGUS

Surgical Anatomy--Methods of examination--Wounds--Rupture--Swallowing of caustics--Impaction of foreign bodies--Infective conditions: _sophagitis_; _Peri-sophagitis_; _Tuberculosis_; _Syphilis_--Varix--Conditions causing difficulty in swallowing: _Impaction of foreign bodies_; _Compression of the gullet from without_; _Spasm of the muscular coat_; _Cardiospasm_; _Paralysis of the gullet_; _Diverticula_ or _pouches of the gullet_; _Innocent stricture_; _Malignant stricture, including cancer at the junction of pharynx and gullet and cancer at the lower end of the gullet_.

#Surgical Anatomy.#--The sophagus extends from the level of the cricoid cartilage to about the level of the lower end of the sternum.

The distance from the upper incisor teeth to the commencement of the sophagus is about 5 or 6 inches, and the sophagus measures from 9 to 10 inches. The whole distance, therefore, from the teeth to the stomach is from 14 to 16 inches.

The cervical portion of the sophagus, extending from the cricoid cartilage to the upper edge of the sternum, measures about 2 inches.

It lies behind and to the left of the trachea, and in the groove between them on each side runs the recurrent nerve. The thoracic portion is about 7 inches long, and traverses the posterior mediastinum lying slightly to the left of the middle line. It is crossed by the left bronchus, and below this level has the pericardium immediately in front of it. The left pleura is closely related to the anterior surface of the sophagus throughout, while the right pleura pa.s.ses behind it in its lower part. This accounts for the frequency with which growths in the sophagus invade the pleura. The sophagus pa.s.ses through the diaphragm about an inch above the cardiac opening of the stomach.

There are three points at which the sophagus shows narrowing of the lumen: (1) at the lower border of the cricoid--the "mouth of the sophagus"; (2) where it is crossed by the left bronchus; and (3) where it pa.s.ses through the diaphragm. It is at these points that foreign bodies tend to become impacted. The mucous membrane of the sophagus is insensitive to tactile and painful stimuli, but is sensitive to heat and cold and to exaggerated peristaltic contractions.

#Methods of Examination.#--It is sometimes possible to detect an impacted foreign body, a distended diverticulum, or a new growth in the cervical portion of the sophagus by _palpation_.

_Auscultation_ while the patient is drinking sometimes aids in the diagnosis of stricture; the stethoscope is placed at various points along the left side of the dorsal spine, and abnormal sounds may be heard as the fluid impinges against the stricture or trickles through it.

_Introduction of Bougies._--sophageal bougies or probangs are used for diagnostic purposes in cases of suspected stricture, and to aid in the detection of foreign bodies. Various forms are employed, of which the most generally useful are the round-pointed gum-elastic or silk-web bougie, and the olive-headed metal bougie, consisting of a flexible whalebone stem, to which one of a graduated series of aluminium or steel bulbs is screwed. For some purposes, such as pushing onward an impacted bolus of food, the sponge probang--which consists of a small round sponge fixed on a whalebone stem--is to be preferred.

Before pa.s.sing bougies, it is necessary to make certain that the symptoms are not due to the pressure of an aneurysm on the sophagus, as cases have been recorded in which a thin-walled aneurysm has been perforated by a bougie. The existence of ulceration or of an abscess pressing on the gullet also contra-indicates the use of bougies.

For the pa.s.sage of a bougie the patient should be seated on a chair with the head thrown back and supported from behind by an a.s.sistant, and he is directed to take full deep breaths rapidly. The bougie, lubricated with b.u.t.ter or glycerine, and held like a pen, is guided with the left forefinger. As soon as the instrument engages in the opening of the sophagus, the chin is brought down towards the chest, and if the patient is now directed to swallow, the instrument may be carried down the sophagus, or can be pa.s.sed on by gentle pressure.

Great gentleness must be exercised, and no attempt should be made to force the instrument past any obstruction. The instrument may catch against the hyoid bone, and this may be mistaken for an obstruction.

It is to be borne in mind that in some cases the pa.s.sage of a bougie may be attended with a considerable degree of shock, and cases are on record in which this has proved fatal without any gross lesion being found after death.

_Intubation_, or the pa.s.sage of a cannula through a stricture, is referred to later.

_sophagoscopy._--The _sophagoscope_--a form of speculum which enables the sophagus to be illuminated by an electric lamp--is employed for the detection and removal of foreign bodies, for the examination of ulcers, diverticula, and strictures of the tube, and with its aid it is possible to remove a portion of a growth for microscopic examination. The mouth, pharynx, and entrance to the sophagus having been cleansed and cocainised, the patient is placed in the rec.u.mbent or sitting posture, and the tube introduced. For prolonged examinations a general anaesthetic is preferred.

The mouth of the sophagus is closed by the sphincter-like action of the lower fibres of the inferior constrictor muscle, and the cervical part of the tube appears as a transverse slit, due to the backward pressure of the trachea. The thoracic portion is more open and may contain air, so that it is possible to see down to the lower end, the closed cardiac orifice appearing as an oblique cleft surrounded by a rosette-like cushion of mucous membrane. The pulsation of the aorta can be seen just above the prominence formed by the left bronchus.

_Radiography._--Opaque foreign bodies can be detected by the screen or in a radiogram; and the position of a stricture by making the patient swallow capsules containing bis.m.u.th and examining with the screen. To determine the position and size of a diverticulum, a radiogram is taken after the patient has swallowed some food, such as porridge mixed with bis.m.u.th.

#Wounds# of the sophagus inflicted from without, for example stabs, cut-throat or gun-shot injuries, are rare, and are almost invariably accompanied by lesions of other important structures in the neck, which may rapidly prove fatal. It is more common to meet with wounds inflicted from within, for example by the swallowing of rough and irregularly shaped foreign bodies, or by unskilful attempts to remove such bodies or to pa.s.s bougies along the sophagus. The severity of the lesion varies from a scratch of the mucous membrane to a perforation of the tube. The less severe injuries are attended with pain on swallowing and a sensation as if something had lodged in the sophagus. In more severe cases there is bleeding, followed by attacks of coughing and expectoration of blood-stained mucus. When the sophagus is perforated, diffuse cellulitis of the neck or of the posterior mediastinum may ensue. In the treatment of these injuries the chief point is to give the sophagus rest by feeding the patient entirely by the r.e.c.t.u.m or through an opening made in the stomach--gastrostomy.

#Rupture# of the sophagus has occurred during violent vomiting, and during lavage. The tear is longitudinal and is usually near the cardiac orifice. It is probably due to increased pressure within the gullet. The accident has usually been met with in alcoholics, and has proved fatal by setting up left-sided empyema or cellulitis.

#Swallowing of Corrosive Substances.#--The sophagus is damaged by the swallowing of strong chemicals, such as sulphuric acid, nitric acid, carbolic acid, or caustic potash. These substances produce their worst effects at the two ends of the sophagus, but in some cases the whole length of the tube suffers. The mucous membrane alone may be destroyed, or the muscular and even the fibrous coats may also be implicated. The damaged tissue undergoes necrosis, and when the sloughs separate, raw surfaces are left, and are very slow to heal.

If not rapidly fatal from shock and dema of the glottis, these injuries are usually attended with intense pain, severe thirst, and vomiting, the vomit containing shreds of mucous membrane and blood.

Complications, such as cellulitis, perforation of the sophagus, or peri-sophageal abscess, may follow. Later, cicatricial contraction takes place at the injured portions, producing the most intractable form of fibrous stricture.