Manual of Surgery Volume II Part 62

In a large proportion of suicidal attempts the patient only succeeds in inflicting one or more comparatively superficial wounds across the front of the neck. In many cases the haemorrhage from these is trifling, but if the external jugular and other large superficial veins are divided, it may be fairly profuse, although it is seldom immediately fatal, unless the blood is sucked in to the wounded air-pa.s.sage.

Occasionally, but rarely, the wound is made _above the hyoid bone_, and opens directly into the mouth. There may then be sharp haemorrhage from the base of the tongue or from the lingual and external maxillary (facial) arteries or their branches in the submaxillary region, and asphyxia may result from the base of the tongue and the epiglottis falling back and obstructing the larynx.

The _hyo-thyreoid membrane_ is frequently divided, and the pharynx thus opened. As the depressor muscles of the hyoid are divided, there is interference with deglut.i.tion and phonation, but respiration is not affected. In such cases the upper portion of the epiglottis is often cut off, and the base of the tongue, the tonsil or the soft palate may be injured. The lingual, external maxillary and superior thyreoid arteries, and the hypoglossal nerve are also liable to be divided at this level, but the main vessels of the neck usually escape. There is pain and difficulty in swallowing, and food and saliva tend to escape through the wound. Particles of food may pa.s.s into the air-pa.s.sages and cause violent fits of coughing.

In more severe cases the knife enters the _larynx_ or the _trachea_.

Sometimes the thyreoid cartilage is divided--as a rule only partly--and the vocal cords are injured; in other cases the trachea is opened, or it may be completely cut across. The bleeding is serious, as the superior thyreoid arteries are usually damaged. If the common carotid and the internal jugular vein also are wounded, the haemorrhage usually proves fatal. The fatal issue may be contributed to by blood entering the air-pa.s.sages and causing asphyxia, or by air being sucked into the open veins and causing air embolism. The laryngeal branches of the vagus may be divided and paralysis of the larynx ensue.

In all cases there is more or less dyspna and persistent coughing.

The voice is husky, and the patient can only express himself in a hoa.r.s.e whisper. There is difficulty in swallowing, and the food may enter the trachea. When the external wound is small, there may be a considerable degree of emphysema of the cellular tissue.

The _prognosis_ depends largely on the general condition of the patient. The majority of those who attempt to take their own lives are in a low state of health from alcoholic excess, mental worry, privation or other causes, and many succ.u.mb even when the wound in the neck is comparatively slight. Shock, loss of blood, asphyxia from blood entering the air-pa.s.sages, and dema of the glottis are the most frequent causes of death soon after the injury. Cellulitis, inhalation, pneumonia, and delirium tremens are later complications that may prove fatal.

_Treatment._--The first indication is to arrest haemorrhage, and this may be done by applying digital compression over the bleeding points.

The bleeding vessels are then sought for and ligated, the wound being enlarged if necessary.

If the food and air-pa.s.sages are intact, any muscles that have been divided should be sutured.

When the epiglottis is cut across in wounds opening into the pharynx, it should be united, preferably with fine silk sutures, as catgut is absorbed before healing has time to take place. The wall of the pharynx and the muscles should then be sutured layer by layer.

When the air-pa.s.sage is opened, it is usually advisable to introduce a tracheotomy tube (Fig. 273), and pack gauze round it to avoid the risk of dema of the glottis and to prevent blood entering the lungs.

The soft tissues may then be brought together layer by layer.

[Ill.u.s.tration: FIG. 273.--Recovery from Suicidal Cut-throat after low tracheotomy and gastrostomy.

(Mr. J. M. Graham's case.)]

In all cases the superficial part of the wound should be drained, and in applying the bandage the head should be flexed on the chest to take all tension off the st.i.tches. The patient must be kept under constant supervision lest he should interfere with the dressings, or make a further attempt on his life. In some cases it is necessary to feed him through a tube pa.s.sed into the stomach either through the mouth or through the nose; when this is not feasible, nourishment must be given by the r.e.c.t.u.m, or by a gastrostomy tube (Fig. 273).

_Wounds of the thoracic duct_ have been described with affections of the lymphatics (Volume I., p. 324), and _wounds of the brachial plexus_ with injuries of individual nerves (Volume I., p. 360).

INFECTIVE CONDITIONS

#Cellulitis# may occur in any of the cellular planes in the neck, the most important form being that which occurs under the cervical fascia, for example in the course of acute infective diseases, such as scarlet fever, measles, or pyaemia. The pus tends to spread widely throughout the neck, infiltrating the connective-tissue s.p.a.ces around the blood vessels, the air-pa.s.sages, and the sophagus. The density and tension of the cervical fascia cause the pus to burrow downwards towards the mediastinal s.p.a.ces of the thorax, where it may give rise to such complications as empyema, infective pericarditis, or gangrene of the lung. The pus may also reach the axilla by spread of the infection along the subclavian vessels.

An acute phlegmonous peri-adenitis sometimes occurs in the loose cellular tissue around the submaxillary gland, and spreads with great rapidity through the cellular planes of the neck. The condition--which goes by the name of _angina Ludovici_--is usually met with in adults, and appears to originate in some infective focus in the mouth.

_Clinical Features._--In all forms the process spreads rapidly, and the neck becomes swollen, brawny, and of a dusky red colour. The head is flexed towards the affected side, and there is pain on movement and on palpating the swelling. Pus forms early, but, as it is under great tension, fluctuation can seldom be detected. Respiration may be interfered with by pressure on the air-pa.s.sages, or by the onset of dema of the glottis, and tracheotomy may be urgently called for.

Swallowing may also be affected by pressure on the pharynx and sophagus. Pressure on the important nerves traversing the neck may give rise to irritative or paralytic symptoms. The main vessels may become thrombosed or eroded--particularly when the cellulitis is a.s.sociated with scarlet fever--and in the latter case copious haemorrhage may follow incision of the abscess.

There is always marked const.i.tutional disturbance, as evidenced by rigors, high temperature, a small, rapid pulse, and delirium; and death may result within a few days from toxaemia.

_Treatment._--In the earliest stages hot fomentations or ichthyol and glycerine should be applied, but if the process does not begin to abate within twenty-four hours, and if the swelling becomes brawny in character, one or more incisions should be made through the deep fascia where the signs of inflammation are most intense, and the deeper planes of the neck opened up by dissection. Drainage is secured by tubes or strips of rubber tissue. If profuse haemorrhage occurs it may be necessary to ligate the main artery lower in the neck.

#Actinomycosis# manifests itself in the neck as a diffuse, painless swelling, which slowly infiltrates the superficial structures, becoming brawny at some places, and at others breaking down and forming sinuses from which the ray fungus escapes in the discharge.

#Boils and carbuncles# frequently occur on the back of the neck, where the skin is thick and coa.r.s.e and is rubbed by the collar.

The affections of the _cervical lymph glands_ have already been described (Volume I., p. 330).

TUMOURS

#Cystic Tumours.#--A great variety of cystic tumours is met with in the neck.

#Branchial cysts# are formed by the distension of an isolated and un.o.bliterated portion of one of the branchial clefts. They usually form in connection with the third cleft, and are met with in the region of the great cornu of the hyoid bone, to which the wall of the cyst is almost always attached. Less frequently they take origin in the second cleft, and lie below the mastoid process, in which case the cyst is adherent either to the mastoid or to the styloid process. In some cases these cysts project towards the floor of the mouth. When near the skin they are of the nature of _dermoid cysts_, being lined with squamous epithelium and filled with sebaceous material. When deeply placed, they are lined by cylindrical or ciliated epithelium and contain a glairy mucoid fluid.

Although of congenital origin, these cysts do not usually attract attention till about the age of p.u.b.erty, when they are noticed as small, soft, fluctuating tumours over which the skin moves freely.

They grow slowly, but may attain great dimensions. The only treatment that yields satisfactory results is complete excision.

The _cystic lymphangioma_, _hygroma_, or _hydrocele of the neck_ (Fig.

274), has been described with affections of lymphatics (Volume I., p.

327); and _thyreo-glossal cysts in the neck_ at p. 583.

[Ill.u.s.tration: FIG. 274.--Hygroma of Neck.

(Photograph lent by Mr. J. W. Dowden.)]

_Blood Cysts._--These may originate in a diverticulum of a vein that has become isolated, or in a cavernous angioma; or they may be due to haemorrhage taking place into a branchial or thyreo-glossal cyst. The diagnosis is often only possible by exploratory puncture; and the treatment consists in complete excision.

_Cystic Bursae._--Cystic degeneration may occur in the supra-hyoid and thyreo-hyoid bursae, and give rise to a rounded swelling which moves with the thyreoid on swallowing, and is only troublesome from the disfigurement it causes. It is treated by excision.

#Solid Tumours#, apart from the common enlargements of lymph glands, and the various forms of goitre, are not often met with in the neck.

The _circ.u.mscribed lipoma_ usually occurs over the nape of the neck or in the supra-clavicular region. It may attain considerable size, and from its weight become pedunculated and hang down over the back or shoulder.

_Diffuse lipomatosis_ usually begins over the nape and spreads more or less symmetrically till it completely surrounds the neck. As the new-formed fat is not encapsulated, extirpation of the ma.s.s is difficult and is seldom called for.

[Ill.u.s.tration: FIG. 275.--Lympho-sarcoma of Neck.

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

_Fibroma_ originating in the ligamentum nuchae, or the periosteum of the vertebral processes, is of slow growth, but it may attain considerable size, and on account of its deep attachments the operation for its removal may be difficult.

_Mixed tumours_ like that described as occurring in the vicinity of the parotid, and taking origin from branchial rests, are sometimes met with in the upper part of the anterior triangle.

_Osseous_ and _cartilaginous tumours_ occasionally grow in connection with the transverse processes of the lower cervical vertebrae.

_Sarcoma_ and _fibro-sarcoma_ of the slowly growing type may develop from any of the fascial structures in the neck, or from the connective tissue surrounding the blood vessels. In those taking origin beneath the sterno-mastoid, there is difficulty in removing them completely on account of their deep attachments, and when they are found to infiltrate the surrounding tissues the attempt should be abandoned.

This rule may be relaxed in view of the aid that may be afforded by the insertion of a tube of radium, which is capable of rendering inert such portions of the growth as are not capable of being removed.

Sacrifice of the common carotid artery is attended with the risk of hemiplegia and cerebral softening, especially in persons over fifty; resection of a portion of the vagus is less dangerous to life than stimulation by irritation of its fibres; resection of the internal jugular vein and of the cervical sympathetic cord are factors which add to the shock of the operation but do not carry with them any special risk.

_Carcinoma._--The commonest form of primary cancer is the _branchial carcinoma_, a squamous epithelioma which originates in connection with the second visceral cleft (Fig. 276). It appears as a rule under the sterno-mastoid at the level of the hyoid bone, and extends towards the submaxillary region, infiltrating the muscles and the sheath of the vessels.

[Ill.u.s.tration: FIG. 276.--Branchial Carcinoma--subsequently removed by operation.]

It is more common in men than in women, and there is often a history of a small swelling having been present for many years, or even since birth. About middle life more active growth begins, the swelling becomes more fixed and is painful, and once it begins to grow, it increases rapidly and within a month or two may reach the size of a child's head. In spite of its size, however, it seldom causes interference with breathing or swallowing, and it has comparatively little effect on the general health. Clinically, the induration and fixation of the tumour suggest its epitheliomatous character, but the absence of a primary growth in the mouth or pharynx excludes its being a metastasis in the lymph glands.