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 anæsthetic 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 anæsthesia.

CHAPTER XXVIII
THE ŒSOPHAGUS

Surgical Anatomy.—The œsophagus 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 œsophagus is about 5 or 6 inches, and the œsophagus 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 œsophagus, 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 œsophagus throughout, while the right pleura passes behind it in its lower part. This accounts for the frequency with which growths in the œsophagus invade the pleura. The œsophagus passes through the diaphragm about an inch above the cardiac opening of the stomach.

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