Elements of Surgery

by Robert Liston

When many and extensive collections have formed, when the integuments have been undermined and attenuated before advice is sought, it is impossible to prevent deformity. The knife and potass are required, for reasons assigned in the preceding part of this work; and the detached glands, as well as the thinned skin, stand in need of their free application.

Deep-seated collections may originate in glandular disease, or commence in the cellular tissue; they occasionally follow transverse wounds of the neck. Great infiltration of the cellular tissue supervenes over the trachea and sternum, and also under the fasciæ; purulent matter is secreted in the cells, and the parts are extensively separated; sloughing is prevented only by free and early incision. The nature and extent of the coverings of an abscess seated deeply in the neck are to be kept in view—the platysma myoides, the superficial and deep cervical fasciæ. Collections under these interfere with the functions of the neighbouring parts, and are attended with great pain, which is somewhat relieved by resting the chin on the sternum, and so relaxing the fasciæ. The matter makes its way to the top of the sternum, and generally points on the outside of the sterno-mastoid muscles. But before the integuments become thin, the parts have been seriously injured—the cellular tissue has sloughed, the muscles have been separated from each other, with unhealthy purulent matter interposed—the trachea, the œsophagus, or the mediastinum, opened into. Such cases have been formerly alluded to.

The lymphatic glands, situated amongst the fat and cellular tissue between the deep and superficial cervical fasciæ immediately above the sternum, may become enlarged. When the tumour is large, breathing is impeded by compression of the parts beneath, and pain and much inconvenience are endured on account of its limited situation and resisting investments.

Purulent collections in the anterior mediastinum and under the sternum are scarcely remediable. These are chronic or acute. One of the great dangers following the operations on the larger vessels at the root of the neck, in which the deep fascia is necessarily divided, is infiltration into, and acute abscess of, the anterior mediastinum. In chronic collections the parietes of the cavity on one side are fixed, on the other have constant motion; and thus the surfaces, however healthy and well disposed, are prevented from coming together and adhering. The discharge continues, and at length wears out the patient, pulmonary affection perhaps supervening. The same unfavourable causes operate in other situations, in the iliac fossa, and in chronic collections under the cranium. In chronic abscess of the mediastinum, no dependent opening can be obtained, unless by perforation of the sternum. This is perhaps warranted by œdematous swelling over some part of the bone, indicating, along with other symptoms, the existence of matter beneath. Purulent collections sometimes form in the substance of the sternum, communicate with the mediastinum, and involve the lower part of the neck.

The thymus gland is said to be liable to chronic enlargement in young subjects of weak constitution, causing serious impediment to respiration and deglutition; the tumour is confined above and anteriorly, and consequently presses backwards on the trachea and gullet. Suppuration may take place in the swelling, and the matter ultimately be diffused in the mediastinum.

[HYDROCELE OF THE NECK.

An encysted tumour of the neck, to which the term HYDROCELE has been applied by some writers, is met with in both sexes and at various periods of life. Its progress is usually slow, and it generally arises without any assignable cause. Occasionally it has appeared to be congenital, but this must be considered as a rare exception. The tumour, seldom larger than a walnut, may acquire the volume of a Seville orange. When this is the case, it may impede respiration and deglutition, or even the return of the blood from the head. Its contents are of a serous or oily character, with an intermixture of flakes of lymph, and the cyst itself varies in thickness from the fourth of a line to a quarter of an inch or more. Externally it is more or less intimately connected to the cellular substance in which it is developed, while its internal surface often exhibits a rough, reticulated aspect, not unlike the false membrane of pericarditis. In cases of long standing the cyst is very firm and tough, or almost gristly, and closely adherent. The skin covering the tumour seldom undergoes any change, unless it is very large, when it is apt to become attenuated at some points and thickened at others. The subcutaneous veins may also then present a tortuous and distended appearance; but this is far from being generally the case.

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.