Manual of Surgery Volume II Part 61

#Cervical Ribs.#--Supernumerary ribs are not infrequently met with in connection with the seventh cervical vertebra, and in the majority of cases the condition is bilateral. The extra rib may be thin and pointed, and project straight out from the transverse process terminating in a free end, in which case, as it pa.s.ses above the subclavian artery and the brachial plexus, it gives rise to no trouble. In other cases it arches downwards and forwards, and is attached by dense fibrous tissue to the first thoracic rib about the level of the scalene tubercle, or to the sternum by cartilage like an ordinary rib. When it encroaches upon the posterior triangle the scalene muscles are attached to it, and the subclavian artery and the lower trunk and medial cord of the brachial plexus pa.s.s over it in a groove behind the scalenus anterior. The pleura may reach as high as the medial border of the rib.

_Clinical Features._--The condition, which is more common in women than in men, is seldom recognised before the age of twenty, and is often discovered accidentally, for example after some emaciating illness, or by a tight collar causing pain. The diagnosis is established by the X-rays.

[Ill.u.s.tration: FIG. 269.--Bilateral Cervical Ribs; the left one is the better developed.]

When symptoms arise, they may be referable either to pressure on the artery or on the nerve roots. When the subclavian artery is displaced upwards it may be recognisable as a prominent pulsatile swelling, and as the part of the vessel distal to the rib is sometimes dilated and yields a systolic bruit, it may simulate an aneurysm (Sir William Turner). The pulse beyond is weakened while the arm hangs by the side, but may be restored by raising the hand above the head. Gangrene of the tips of the fingers has been observed in rare instances, but it is probably nervous rather than vascular in origin.

Symptoms referable to pressure on the nerve roots usually affect the right arm, and may be either neuralgic or paralytic in character (Wm.

Thorburn). In the neuralgic group there is tingling pain, a feeling of numbness, and sensations of cold in the limb, most marked along the ulnar border of the forearm; the arm is weak, and susceptible to cold.

This condition may be mistaken for brachial neuritis; it is relieved, however, by holding the arm above the head, for example, during sleep.

In the paralytic group, the pressure symptoms are referred to the first dorsal, or first dorsal and eighth cervical roots. The paralysis is most marked in the muscles of the thumb, and becomes less towards the ulnar side; the affected muscles atrophy, especially those forming the thenar eminence, and the finer movements of the thumb and fingers are impaired.

When pressure symptoms are present, the extra rib should be removed through an incision which exposes the posterior triangle sufficiently to admit of the bone and its periosteum being excised, without damage being inflicted on the brachial plexus, the subclavian artery, or the pleura.

Similar clinical features to those of cervical rib may be caused by a prominent transverse process of the first thoracic vertebra and similarly got rid of by its removal.

_Branchial cysts and branchial tumours_ are described with tumours of the neck (p. 598).

WRY-NECK OR TORTICOLLIS.--The term wry-neck or torticollis is applied to a condition in which the head a.s.sumes an abnormal att.i.tude, which is usually one of combined lateral flexion and rotation.

The most important form is due to faulty action of the cervical muscles, and three varieties of muscular wry-neck are recognised--(1) the acute or transient; (2) the chronic or permanent; and (3) the spasmodic.

#Acute# or #transient wry-neck#--so-called "rheumatic torticollis"--comes on suddenly, usually after the patient has been exposed to a draught of cold air or to damp. The condition is popularly known as "stiff neck," and is probably a.s.sociated with fibrositis of the affected muscles. The sterno-mastoid, and often the trapezius, are contracted, and pull the head to one side, twisting the face slightly towards the opposite side (Fig. 270). There is tenderness on pressing over the affected muscles, and sometimes over the vertebral spines, and in the lines of the cervical nerves, and severe pain on attempting to move the head. Usually in the course of a few days the condition pa.s.ses off as suddenly as it came on, but in some cases a certain amount of wasting of the affected muscles ensues.

[Ill.u.s.tration: FIG. 270.--Transient Wry-neck, which came on suddenly after sitting in a draught, and pa.s.sed off completely in a few days.]

In the _diagnosis_ of this form of wry-neck it is necessary to exclude such conditions as cellulitis, inflammation of the cervical glands, and disease of the cervical spine, in which the head may a.s.sume an abnormal att.i.tude, the position being that which gives the patient greatest comfort.

The _treatment_ consists in ensuring free action of the bowels and kidneys, in inducing hyperaemia by means of heat, and applying gentle ma.s.sage. Salicylates and similar drugs are useful in relieving the pain.

#Permanent# or #true wry-neck# is due to an organic shortening of the sterno-mastoid muscle. The trapezius, the splenius, the scaleni, and the levator scapulae muscle may also undergo shortening, along with their investing sheaths derived from the cervical fascia.

The sternal head of the sterno-mastoid is always markedly shortened, and stands out as a tight cord; sometimes the clavicular head is also prominent.

There is evidence that in the majority of cases the deformity results from some interference with the development of the muscles during intra-uterine life. This is probably the effect of undue pressure on the ftus diminishing the arterial supply to the central part of the muscle, with the result that the muscle fibres undergo degeneration with subsequent sclerosis and contraction. It may result also from cicatricial contraction of the muscle following rupture of its fibres during delivery. In such cases there is a history that the birth was a difficult one, the presentation having been abnormal; and that a swelling was observed in the sterno-mastoid shortly after birth. This swelling--_a haematoma of the sterno-mastoid_--is at first soft, later becomes smaller, and eventually disappears. In course of time, sometimes months, sometimes years after the disappearance of the swelling, shortening of the muscle takes place, and the deformity is established.

_Clinical Features._--Although the condition is usually described as "congenital," it is the common experience in practice that the child has reached the age of from seven to ten years before advice is sought. The appearance of the patient is characteristic (Fig. 271).

The shortening of the sterno-mastoid pulls the head towards the affected side, usually the right, so that the ear is approximated to the shoulder. At the same time the head is rotated towards the opposite side and slightly tilted backwards, with the result that the chin is directed towards the opposite side, and is somewhat raised.

The shortened sterno-mastoid stands out prominently, and, on any attempt to straighten the head, can be felt as a firm, fibrous band.

The skin of the affected side of the neck may be thrown into transverse folds. The patient is unable to correct the deformity, but it is usually possible to diminish it by manipulation.

[Ill.u.s.tration: FIG. 271.--Congenital Wry-neck in a boy aet. 14.]

If the condition is not corrected, all the structures on the affected side of the neck undergo organic shortening, with the result that the deformity becomes accentuated. In advanced cases a lateral curvature, with the convexity towards the normal side, occurs in the cervical region, the vertebrae becoming wedge-shaped from side to side, and a compensatory curve may develop in the thoracic region (Fig. 272).

[Ill.u.s.tration: FIG. 272.--Congenital Wry-neck seen from behind to show scoliosis.]

There is also asymmetry of the head and face, the affected side being the smaller. The eye on this side lies on a lower level, and is more oblique than its neighbour, the cheek is flattened, and the mouth asymmetrical. Instead of the eyebrows and the lips forming parallel lines, their axes converge towards the side of the contracted muscles and fasciae.

_Treatment._--While it may be possible when the condition is recognised during infancy to counteract the tendency to contraction and deformity by manipulations, ma.s.sage, and exercises alone, it is usually necessary to divide the shortened structures as a preliminary to orthopaedic measures.

Subcutaneous tenotomy--at one time the favourite method of treatment--has been entirely replaced by the _open operation_, which admits of all the structures at fault, including the cervical fascia, being thoroughly divided, without risk of injuring other structures in the neck. The result of division of the shortened tissues is seen at once in a marked increase in the interval between the sterno-clavicular joint and the mastoid process. As in other deformities, the operation is only a preliminary, although an essential one, to the treatment by ma.s.sage, movement, and exercises which must be persevered with for months, and it may be for years.

When the torticollis att.i.tude has been corrected in childhood, the asymmetry of the skull disappears.

#Spasmodic wry-neck# is the term applied to a condition in which clonic contractions of certain muscles produce jerkings of the head.

The muscles most frequently at fault are the sterno-mastoid and trapezius of one side, and the posterior rotators of the opposite side. By these muscles the head is pulled into the wry-neck position, and is at the same time retracted, and there is more or less constant nodding or jerking of the head.

The condition is usually met with in adults of a neurotic disposition who are in a depressed state of health, and is due to some lesion, as yet undiscovered, in the nerve mechanism of the affected muscles--most probably in their cortical centres. It would appear that in some cases the spasmodic jerkings are originated by certain movements habitually made by the patient in the course of his work. In others, as a result of astigmatism and other errors of refraction, the patient has acquired the habit of repeatedly tilting his head to enable him to see clearly, and these movements have become continuous and uncontrollable.

The affection tends to become progressively worse until the patient is incapacitated for work or enjoyment. Sleep even may be interfered with.

_Treatment._--In well-marked cases the use of drugs, electricity, or restraining apparatus is never curative, but these measures combined with ma.s.sage have been temporarily beneficial in milder cases.

Of the operative procedures, resection of portions of the accessory nerve on one side, and of the posterior primary divisions of the first five cervical nerves on the opposite side, seems to offer the best prospect of recovery. Simple division of these nerves or resection of the accessory alone has not proved permanently curative. Open division of the offending muscles without interfering with the nerves has given good results, and is a much simpler operation (Kocher).

Spasmodic wry-neck must be distinguished from the #hysterical# variety, which after lasting for weeks, or even months, may pa.s.s off completely, but, like other hysterical affections, is liable to recur.

Deviations of the neck simulating torticollis may occur in cervical caries, and in unilateral dislocation of the spine.

The #cicatricial contraction# of the integument of the neck that results from extensive burns, abscesses, or ulcers, may cause unsightly deformity and fixation of the head in an abnormal att.i.tude, and call for surgical treatment. The contraction which follows the disappearance of a gumma of the sterno-mastoid may also produce a deformity resembling wry-neck.

INJURIES

#Contusion# of the neck may result from a blow or crush, as, for example, the pa.s.sage of a wheel over the neck, or from throttling, strangling, or hanging. In medico-legal cases the distribution of the discoloration should be carefully noted. When due to throttling, the marks of the fingers may be recognisable, and nail-prints may be present. In cases of strangling, the mark of the cord pa.s.ses straight round the neck, while in suicidal hanging it is more or less oblique and is higher behind than in front. When due to a direct blow, for example by a fist, the discoloration is limited, while it is usually diffused over the neck when due to the pa.s.sage of a wheel over the part.

The clinical importance of these injuries depends on the complications that may ensue; for example, extravasation of blood under the cervical fascia may press upon the air-pa.s.sage and sophagus to such an extent as to cause interference with breathing and swallowing; the larynx or the trachea may be so grossly damaged that death results immediately from suffocation, or later from gradually increasing dema causing obstruction of the glottis. If the mucous membrane of the air-pa.s.sage or the apex of the lung and its investing pleura is torn, emphysema of the connective tissue may develop and spread widely over the body. In contusions of the lower part of the neck the cords of the brachial plexus may be injured.

#Fractures of the Hyoid, Larynx, and Trachea.#--The _hyoid bone_, on account of its mobility and the protection it receives from the body of the mandible, is seldom fractured, except in old people in whom the great cornu has become ossified to the body of the bone. It is usually broken either by a direct blow, or by transverse pressure as in garrotting. The fracture is almost always at the junction of the great cornu with the body, and there is marked displacement of the fragments, which may injure the pharyngeal mucous membrane.

The _thyreoid and cricoid cartilages_ are also liable to be fractured in run-over accidents, particularly in old people after calcification or ossification has taken place.

The _trachea_ may be lacerated, or even completely torn from the larynx, by the same forms of injury as produce fracture of the laryngeal cartilages.

The _clinical features_ common to all these injuries are swelling and discoloration; and if the mucous membrane is torn, air may escape into the tissues and produce emphysema. There is always more or less difficulty in breathing, which may amount to actual suffocation, and this may come on immediately, or in the course of a few hours from dema of the glottis. Blood may pa.s.s into the lungs and be coughed up.

Swallowing is usually difficult and painful, especially in fracture of the hyoid bone. There is also pain on speaking, the voice is husky and indistinct, and spasmodic coughing is common. When blood has entered the air-pa.s.sages there is considerable risk of septic pneumonia.

_Treatment._--As the immediate risk to life is from suffocation, it is usually necessary to perform tracheotomy at once. In fracture of the hyoid the fragments may be replaced by manipulation through the mouth, after which the head and neck are immobilised by a poroplastic collar.

#Wounds--Cut-throat.#--The most important variety of wound of the neck met with in civil practice is that known as "cut-throat"--an injury usually inflicted with suicidal, less frequently with homicidal intent.

Suicidal wounds are usually directed from left to right (if the patient is right-handed), and they run more or less obliquely from below upwards across the neck; the wound being deepest towards its left end, that is where the weapon enters, and gradually tailing off towards the right. In most cases the would-be suicide throws his head so far back at the moment of inflicting the wound, that the main vessels are carried backward under cover of the tense sterno-mastoid muscles, and so escape injury. The knife may even reach the vertebral column without damaging the contents of the carotid sheath.

Homicidal wounds are usually more directly transverse, and are of equal depth throughout. The main vessels are generally divided, the sophagus and trachea opened into, and in some cases the vertebral ca.n.a.l is opened and the cord and its membranes injured.

_Clinical Features._--The clinical features vary with the level of the wound and with its depth. In all cases the contraction of the platysma causes the wound to gape widely, and its edges tend to be turned in.