chap, vii.] CERVICAL FISTULA. 175 



Paget 1 in 1878. Lastly, the whole evidence as to cervical fistulse 

 and the structures associated with them has been fully collected 

 up to 1889 and tabulated by Kostanecki and Mielecki 2 . who 

 also discuss in detail the relations of these abnormalities to the 

 facts of development. The following account is taken from these 

 sources. For figures the reader is referred to the original memoirs. 



.43. Cervical fistulse are generally known as orifices placed in the region 

 of the neck, leading into a sinus of greater or less extent, varying in 

 size from a mere pit to a duct some inches in length. In the greater 

 number of cases the sinus ends blindly, but in about a third of recorded 

 cases (K. and M.) it passes inwards to open into the pharynx, forming 

 thus a communication between the pharyngeal cavity and the exterior. 

 Such passages are spoken of as complete cervical fistula?, those which 

 have an external but no internal opening being external incomplete 

 fistula?. Besides these there are cases of diverticula from the pharynx 

 or oesophagus which do not reach the exterior, and these are known as 

 internal incomplete fistula?. 



Cervical fistula? are more commonly present on one side only, but 

 in a good many cases they have occurred on both sides. According to 

 Fischer they are more common on the right side than on the left. 

 The following statistics are given by him. 65 persons had 79 fistula? : 

 51 unilateral, 14 bilateral: 20 complete, 53 without an opening to the 

 pharynx : of the unilateral cases 33 were on the right and 13 on the 

 left : 34 in males, 30 in females. There was evidence of heredity in 

 21 cases. 



The external opening is very small and may either be on the 

 surface of the skin or elevated on a minute papilla. Sometimes it is 

 covered by a small flap of skin as with a valve, in other cases it is 

 placed as a fissure between two lips. The positions in which the ex- 

 ternal openings of cervical fistula? are found are very variable, but in 

 the great majority of cases the opening is close to the middle line 

 in the neighbourhood of the sterno-clavicular articulation, generally 

 from a few lines to an inch above it, on either the inner or the outer 

 border of the sterno-cleido-mastoid muscle. In rarer cases the external 

 opening is placed at the level of the middle of the cricoid cartilage, and 

 is sometimes just behind the angle of the jaw. These positions are not 

 however at all precisely maintained, but vary a good deal in different 

 cases. When the external opening is in the higher situation and the 

 fistula is complete, a sound may then be passed into the pharynx, but 

 when the external opening is low, the duct when present passes 

 upwards covered by skin only, in a straight line so far as the upper 

 limit of the larynx, at which point it turns at a sharp angle upwards 

 and inwards. For this reason it is not possible in such cases to follow 

 the course to the pharynx by means of a sound, but in some of them 

 the presence of an internal opening has been proved by the injection of 

 fluids having colour or taste. The position of the internal openings is 

 also variable, and from the nature of the case has been accurately 



1 Paget, Sir J., Tram. Med. Chir. Soc, lxi., 1878. 



2 Von Kostanecki unci Von Mielecki, Arch. f. path. Anat. u. Plujs., cxx. 

 and cxxi. 



