It is a matter of great surgical importance and interest that certain branchiogenic remnants persist in a perfectly harmless manner until advanced life is reached, after which there take place therein cancerous changes which convert them into the so-called cancers of branchiogenic origin. These are too often of hopeless character by the time they are seen by the surgeon.
Other congenital defects consist of atrophies, such, for instance, atrophy of the sternomastoid muscle, or of certain hypertrophies which may be unilateral or symmetrical.
WOUNDS AND INJURIES OF THE NECK.
The neck is everywhere exposed to incised and perforating wounds, partly as the result of pure accident, too often as the result of homicidal efforts. The most exposed parts are supplied with veins of large caliber which connect directly with the heart, and whatever danger there may be of entrance of air into the veins, under any circumstances, is in this region enhanced. This entrance of air has been regarded as a serious and often fatal accident. The writer’s experience and research have shown that it may often occur in mild degree with but little temporary disturbance. Should it occur the fact will be indicated by a slight gurgling sound, with tumultuous action of the heart, dilatation of the pupils, embarrassed breathing, and every indication of lowered blood pressure. Every competent operator will secure these large veins before dividing them, but if anything of this kind should be noted during an operation, pressure or plugging of the wound, with artificial respiration, perhaps even massage of the heart, and tracheotomy if necessary, should be practised until the patient has revived. If in the course of an exceedingly deep dissection the accident can be foreseen it may be avoided by keeping the wound filled with warm sterilized salt solution. This, however, will seriously embarrass the operative work, as it obscures vision.
The lower in the neck a serious wound be received, other things being equal, the more dangerous it becomes. Thus penetrating wounds above the larynx are of less importance than those below it. All injuries or wounds about the larynx are not only likely to dislodge its interior cartilages, but are especially likely to be followed by pressure of effused blood, or the consequences of a rapid edema of the glottis, which may prove fatal unless the trachea be opened below. It is this fact which makes fracture of the larynx so dangerous an injury.
A wound of the trachea rarely occurs by itself, as it lies deeply, and it may be especially serious if vessels in this neighborhood have been so injured that blood may be easily poured or escape into the lungs. If the trachea be completely divided its ends will be separated and gap, while the lower end will be drawn out with each deep inspiration. In this way suffocation may quickly occur. In all such cases the head should be placed lower than the body (Rose’s position), the lungs emptied completely, the wound enlarged, and the tracheal wound be sutured or else a tube be inserted. The treatment must largely depend upon the number of hours which have elapsed since its infliction, and the condition of the wound itself. In these cases it may be assumed that such a wound is infected, therefore it should not be closed without provision for drainage.
Any injury to the respiratory tract proper will be indicated by the character of the expectoration and the sounds heard on auscultation. Such injuries are likely to be complicated by a subsequent bronchitis, pneumonia, deep abscess, or various other undesirable sequences. Under the suggestive term “Schluck-pneumonie” the Germans have described a condition which we describe in the term “inhalation pneumonia.” It implies a septic type of pneumonia caused by the passage downward of foreign material, including septic wound secretions, which, not being expelled promptly, cause a type of inflammation, with consolidation, which will give most of the ordinary physical signs of pneumonia.
A rather distinct type of incised wound is that included in the term “cut-throat.” It implies a homicidal, usually suicidal, attempt on the part of the ignorant to sever the large vessels in the neck. This is but rarely accomplished, the injury being done to the larynx and the trachea and the tissues anterior to the vascular trunks. Usually inflicted with the right hand, one side of the wound may be deeper than the other. While the trachea is usually cut and often divided, the injury may be to the larynx instead. At all events, a wide gash is made and there is considerable hemorrhage, the external jugulars being nearly always severed. By the time such a wound is seen by the surgeon it is an infected wound and it should not be closed too tightly. The trachea may be sutured by itself, but it will be best to place therein a tracheal tube. Ample provision should also be made for drainage. In some instances the wound may be left open, at least for a few days, until it is granulating, and then be closed by deep sutures. Care should always be given to those of desperate suicidal intent and to the maniacal, that they do not reopen the wound in continuation of their previous efforts. This requires careful watching.
Rupture of the trachea, either due to violent coughing or straining efforts or to external violence, is known. It will call for tracheotomy, because of the emphysema which will ensue. Penetrating wounds of the large arteries and veins are always serious. When not extensive they may be followed by diffuse or circumscribed hematoma or by aneurysm. Nélaton is reported to have stated that it takes four minutes for a man to bleed to death from the carotid artery, and that two minutes should suffice for its ligation. Any injury to the vessels should be followed by their exposure, and probably by ligation or suture, in order to prevent the conditions above mentioned. If the wound be low in the neck it would be proper to remove the upper end of the sternum or to divide the sternomastoid sufficiently to expose it.
The vertebral artery is occasionally injured, mostly in the osseous canal through which it passes. At the base of the neck a wound at or near its origin is an exceedingly serious injury. The same rules apply as above.