Part 51

The characters by which hydrocele of the neck may be distinguished from other affections are, absence of pain and tenderness on pressure, slight fluctuation, the slow progress of the tumour, years generally elapsing before it attains much development, and, above all, the history of the case. When the tumour projects outwardly over the carotid artery, it might be mistaken for aneurism, from which, however, it may, in general, be readily discriminated by the elevation of the entire swelling from the impulse of the blood, and by the want of that alternate expansion and retrocession which are present in genuine aneurism. When seated over the thyroid gland, or in its substance, it may be confounded with bronchocele. In all cases, where any doubt remains as to its true nature, an exploring needle or trocar should be introduced, which will at once determine the diagnosis.

The treatment of this affection, like that of the vaginal tunic of the testicle, may be palliative or radical. The former consists in evacuating the fluid, from time to time, with the knife or trocar; the latter, in injecting some stimulating fluid, such as wine and water, or a solution of iodine, or nitrate of silver; or, what is better, introducing a seton, and keeping it in the sac until it is obliterated by adhesive inflammation. Incision and extirpation have been practised successfully by Flaubert, Delpech, Jobert, and other surgeons.]

_Distortion of the Neck_ arises from a variety of causes, and is either temporary or permanent. The head is often kept in an unnatural position for weeks by glandular swelling. Enlargement of the superficial glands, at the upper part of the neck, induces the patient to turn his head to the opposite side; swellings lower in the neck, and deep seated, require relaxation of the coverings, and the head is consequently twisted to the same side. Either rigidity, or spasmodic action, or both, of the sterno-mastoid muscles, displaces the head and twists the neck. The head is either bent forward, or turned to one side; usually, the chin is twisted over the shoulder, on the side opposite to the offending muscle. Induration of the muscle is sometimes met with, also causing distortion; it may terminate in abscess, or after a long time be discussed.

The cause of the spasmodic action in the muscle is sometimes apparent, sometimes very difficult to be detected. Sources of irritation at the extremities of neighbouring and communicating nerves are to be looked for and removed; and the spasms are to be moderated, as much as possible, by external and internal remedies. Opiate frictions, and the application of the nitrate of silver over the course of suspected nerves, are sometimes followed with benefit, and may be accompanied by the internal administration of antispasmodics, though the efficacy of these is often doubtful. When the head has been for a long period, perhaps many years, turned to one side, from any cause, the muscle on that side naturally becomes shortened, and a change takes place in the form of the bones. If the patient is still young, the deformity may, in a great measure, if not entirely, be remedied. Division of the shortened muscle was a favourite operation of old surgeons for the cure of wry-neck, and may be resorted to with advantage in some cases. One of the heads, or both, may require to be detached from the sternum and clavicle. It is only in cases where the muscle is in fault, it being shorter than usual, that benefit can be expected from this proceeding. It is a very simple operation, and can be effected by a mere puncture of the skin betwixt the two portions. By the cautious use of a blunt and flat probe or director, the cellular tissue under the origins of the muscle is separated; this is followed by a narrow and blunt-pointed knife, by which the attachments to the clavicle and sternum are cut across.

Distortion of the neck is most frequently produced by some vice in the bones, as curvature, from softening, attended with deformity of the trunk or of the limbs. In such cases, the twist is generally to the right side, the ear approaching the shoulder. No treatment can be effectual, unless the other curvatures are corrected; for the head is placed so to preserve the equilibrium of the body. The head is to be supported, and its weight removed from the vertebral column by a curved iron rod, attached to the back of stays fastened on the loins, leathern straps passing from the top of the rod under the chin and over the occiput. By the use of such apparatus for a considerable time, the vertebral column may regain its perpendicular direction, and all deformity of the neck be consequently removed. The application of such a machine is required after the division of the sterno-mastoid, so that the head may be kept straight until the muscle is reunited of a proper length, and any change in the form of the bones may be got over. In slight cases, this treatment is not required; on giving support to the trunk, and raising the shoulders to an equal level, the muscles of the back, perhaps stimulated by powerful and repeated friction, gradually bring the column into its proper form. Then the position of the head to one side is no longer required to balance the body. But a cure can be expected only when no material change has taken place in the form of the individual bones.

Excurvation of the cervical vertebræ,—bending of the head forwards, and perhaps a little to one side, generally to the right,—takes place as a consequence of disorganisation of the ligaments and connecting fibro-cartilages of the vertebræ, with subsequent ulceration of the bones. The disease generally occurs in the superior vertebræ; in the articulation of the atlas with the occiput, or with the vertebræ dentata, or in the articulation of the latter with the one below. The articulations on the left side are usually affected first. There is stiffness, pain, and swelling of the soft parts covering the affected bones, attributed perhaps to exposure to cold, as when sitting in a draught, and supposed to be merely crick of the neck. The posterior cervical muscles are weakened, and the head is bent forwards. The patient is unable to support his head by the usual muscular action, and when in the erect position places his hands on the temples, to prevent it from dropping, and to keep it steady. Difficulty of swallowing is a prominent symptom from the first, as can readily be imagined when the close application of the constrictors of the pharynx to the forepart of the affected bones is kept in remembrance. The position of the head also renders deglutition awkward. The disease is attended with great suffering, evinced by marked anxiety of the countenance; and the pain is most violent during the night. The complaint is too frequently trifled with at the commencement, being not understood, nor its danger appreciated. The swelling increases, with pain, and the chin falls down on the sternum. The patient grows emaciated, and perhaps becomes weak in the lower limbs, and even in the upper; the feces and urine are imperfectly retained. Occasionally, abscess forms behind the upper part of the pharynx, increasing the pain and the difficulty of deglutition. On making an examination through the openings by which the abscess has emptied itself spontaneously, the bone is felt bare; and portions, even large, of the vertebræ, or vertebra, are, after some time, discharged, so as to expose the theca of the spinal cord. Even in such circumstances patients have lingered on, and that for so long a period as to allow of some unprincipled fool advertising a perfect recovery.

The termination of caries of the cervical vertebræ, often without any appearance of abscess, is in general fatal and sudden. The head, slipping from its support, falls forwards or to a side, causing immediate and complete paralysis of the whole body; dissolution soon follows. On examination, the articulating surfaces of the vertebræ are found displaced, and the shreds of ligaments which connected them ruptured. The atlas is separated from the occiput; or the processus dentatus, escaping from its situation, in consequence of destruction of its confining ligaments, is found compressing the medulla oblongata. This process is very often destroyed almost entirely, or it is so far detached by ulceration at its root as to be easily broken off. The disease in general seems to commence in the articulations, whereas in the vertebræ with larger bodies, abscess and ulceration have their foundation and origin more frequently in the deposit of tubercular matter in the cancellated texture of the bones. In other instances, the termination may be more slow and gradual; the patient is worn out by long suffering and continued purulent discharge; change of structure takes place in the theca vertebralis, or in the medulla itself; serous effusion occurs at the base of the brain; the patient’s sensations are blunted, and he loses the use of his limbs gradually; his intellects fail, and coma supervenes, followed by death.

Active and early interference can alone arrest, subdue, or prevent the dreadful consequences of the disease above described; it is quite intractable in its later stages. Confinement to the recumbent posture, and strict rest of the affected parts must be enjoined; and blood is to be abstracted locally, once and again, according to circumstances; afterwards counter-irritation is to be employed, and repetition of moxas or of caustic issues is the most efficacious. When the painful feelings have subsided, and some impression has been made on the disease, the patient appearing to convalesce, the head must be supported by a proper machine for a long time. He will thus be enabled to use his limbs, to move about, and repair his general health, the weight of the head being taken from the weakened column.

_The External Jugular_ vein may require to be opened for the abstraction of blood in affections of the head; or when venesection cannot be readily performed at the bend of the arm, from the small and indistinct condition of the veins in children, or in people loaded with fat. The vein is made to rise by pressure with the finger or thumb, as seen in the accompanying cut, above the clavicle. The lancet is passed though the integuments and platysma myoides into the vessel, midway between the jaw and clavicle. After a sufficient quantity of blood has been withdrawn, the pressure below is removed, and the edges of the wound are put together with a bit of court plaster, or by means of a compress and bandage lightly applied.[41]

_Ligature of the common Carotid_ may be required for the cure of aneurism at the angle of the jaw; or on account of hemorrhage from deep wounds in the same situation, when, from any circumstances, the divided extremities of the vessels cannot be secured. A deep incision of the angle of the jaw, towards the base of the cranium, not only divides important branches of the carotid, but may also wound the vertebral arteries where they project in a tortuous fashion, betwixt the dentata and atlas, or betwixt the latter bone and the occiput.

Ligature of the common carotid has been had recourse to, in order to stop bleeding from the mouth, nostrils, and other parts connected with the face,—for the cure of large or deep-seated aneurism by anastomosis,—and as a preliminary step to the removal of large and firmly attached morbid growths of the face or neck. This last proceeding, as already remarked, does not in any way enhance the patient’s safety, whilst it adds much to his suffering.

The carotid has also been tied for the cure of aneurism at the root of the neck, when it was impossible to place a ligature betwixt the tumour and the heart. My opinion regarding this practice I have given formerly, when treating of aneurism in general.

For aneurism at the angle of the jaw, the point of deligation must in a great measure depend on the size of the tumour. The artery is most conveniently reached where it is crossed by the omo-hyoideus; and, when deligation at this point is both practicable and eligible, the vessel is exposed at the upper edge of the muscle. But circumstances may require the ligature to be placed much lower.

The patient is placed, either sitting or lying, with the head thrown back, and turned slightly to the side opposite the tumour. An incision is made in the upper triangular space of the neck, and in the course of the vessel, midway betwixt the sterno-mastoid muscle and the muscles covering the forepart of the larynx. Its extent depends on the thickness of the neck—on the muscular development and quantity of fatty matter, whether the neck be long or short. From two to three inches will in general afford sufficient space. The first sweep of the scalpel penetrates the skin, platysma-myoides, and cellular tissue. The cervical fascia is then divided carefully, with the hand unsupported. During the incision, the parts should be a little relaxed by attention to the position of the head. The sheath of the vessels is exposed by cautious division of the cellular tissue which occupies the space betwixt it and the cervical fascia. Thin copper spatulæ, bent to suit the purpose, are used to keep the edges of the wound apart. In general there is very little bleeding; but, that the operator may be sure of what he cuts, it is necessary frequently to clear the cavity with a bit of soft sponge. Each step of the operation should be slowly and surely accomplished; the least hurry is culpable. When the slight oozing has ceased, the common sheath,—which is distinctly seen, with the descendens noni lying on its forepart,—is to be opened to a slight extent with the point of the knife—the hand steady and unsupported, and no director used. The descendens noni is left to the inner side. The internal jugular vein, swelling up on account of the struggles and hurried respiration of the patient, has in some cases been found troublesome at this period of the operation, rendering the opening of the sheath and the use of the needle difficult. I have not met with any such obstacle in the cases in which I have been concerned. The aneurism needle should be slightly curved, with a perforation near the point; and the point should neither be bulbous, nor at all sharp, but all of the same thickness, and well blunted at the extremity and edges. It is introduced, carrying a firm round ligature of flax or silk, well waxed through the opening in the sheath, betwixt the par vagum and the artery, and from the outer side. The point is moved very slightly from side to side, and carried under the artery; no force being used, as it is unnecessary, and apt to be injurious. The instrument is thus gently insinuated, not thrust, through the cellular tissue, and made to appear on the opposite side of the vessel, with its point towards the trachea. It ought to be passed close to the arterial coats, and care must be taken to avoid including within its track part of the common sheath, or the descending branch of the ninth. Unless the surgeon be indeed very rash, there is little risk of the vein or par vagum being injured; to include them along with the artery would argue no small degree of most deplorable ignorance. The loop of the ligature is laid hold of either with the fingers, with forceps, or with a small blunt hook, and drawn towards the surface of the wound. It is then divided, and one-half retained, whilst the other is withdrawn along with the needle. The vessel must not be raised up from its situation, or detached from its cellular and vascular connexions, more than is merely sufficient for transmission of the needle. A single knot is cast upon the remaining half of the ligature, passed down, and tied firmly on the vessel, by the forefingers of the operator. This is secured by the finger of an assistant, whilst the ends are again passed through, so as to complete the reef-knot, and run down tight as before, the assistant slowly withdrawing his finger to make way for the ligature. A third knot may be made to insure security; but is seldom, if ever, necessary. As already observed, everything must be done with deliberation and caution, and the operation may be thus safely concluded in a very few minutes. One end of the ligature may be cut away close to the knot, or both brought out of the wound. The edges of the wound are put together, after all oozing has ceased, by one or two stitches, and the intermediate application of isinglass plaster; bandaging is unnecessary, and might be hurtful. The patient is placed in bed, with the head elevated considerably, so as to relax the neck. The wound will probably heal by the first intention, excepting in the immediate neighbourhood of the ligature; and the separation of this may be looked for from the tenth to the twentieth day. Then all risk of danger may be considered as past.

_Ligature of the Arteria Innominata_ has been practised in very few cases. It may possibly be required for aneurism of the subclavian, or of the root of the carotid; or for large axillary aneurism, greatly raising the shoulder, and involving the parts at the root of the neck.

The patient should be placed recumbent, with the head well thrown back. An incision from two inches and a half to three inches in extent is made in the course of the carotid, terminating over the sterno-clavicular articulation. If the incision is made more towards the inner border of the left mastoid muscle, greater space is gained. From that point, another is carried along the upper margin of the clavicle, to the extent of an inch and a half. The sternal attachment of the sterno-mastoid muscle is separated, the cervical fascia divided, the cellular tissue betwixt the sterno-hyoid muscles separated, and the vessel exposed. During the dissection, the internal jugular vein, the par vagum, and the recurrent branch, the inferior thyroid artery, and the arterial distributions from the thyroid axis, must be carefully avoided. The operator should, by free external incisions, make a dissection sufficiently spacious to admit of his seeing the bottom of the wound distinctly as he proceeds. It is necessary that he not only feel but see what he is about to cut; groping in this situation, and amongst such important parts, is unsafe, to say the least of it. Caution in passing the needle is here required equally as in ligature of the carotid. In such deep wounds the aneurism needles of Weiss, Bremner, Mott, or Gibson, may perhaps be found useful; but in general the common one is sufficient, and has always answered my purpose perfectly. During the dissection, it must be borne in mind that the pleura is not far from the edge of the knife. In one case of aneurism above the clavicle, and close to the outer border of the sterno-cleido mastoid muscle, and of the anterior scalenus, I exposed the arteria innominata by a cautious dissection; but, instead of surrounding that vessel, applied ligatures to the root of the subclavian and of the carotid. This latter was closed with the view of insuring the formation of a clot in the arteria anonyma. The patient suffered under abscess of the mediastinum, inflammation of the heart and pericardium, and ultimately he had repeated hemorrhage from the wound. The arteria innominata and the root of the two vessels were obstructed by firm coagulum. The blood had come from the distal end of the subclavian, and had been furnished by the regurgitation through the vertebral, thyroid, mammary, &c.

_Ligature of the Subclavian Artery_ is required for the cure of axillary aneurism. That portion of the vessel within the scalenus and outside of the pneumogastric nerve is unfavourable for operation, in consequence of many branches being given off in an exceedingly short space. Besides, important veins and nerves are in the immediate vicinity. And though these were avoided, and the vessel reached and tied, still there would be no likelihood of a favourable result; obliteration of the vessel would not be expected to take place at the deligated point, one or more collateral branches arising close to the ligature. On the outside of the scalenus there is no such objection. But the vessel is deep, even in the healthy state, and much more so when aneurism has appeared in the axilla, and has attained but even a small size. But again, when the tumour is large, the shoulder is much elevated, and firmly fixed in its exalted level, so as greatly to increase the depth of the vessel.