The principles and practice of modern surgery

by Roswell Park

Wounds of the large veins are supposed to be of a more serious nature because of the possibility of inspiration of air, i. e., air embolism. These vessels are occasionally injured during removal of deep-seated and adherent tumors. It has been possible in some instances to make a lateral suture of the jugular vein at the point of injury, providing this be not too extensive. Effort at reunion of this kind is always legitimate if the operator feel himself equal to the task. The jugular vein is also occasionally exposed and tied low down, then opened above the ligature, for the purpose of cleaning out its upper portion when filled with infective thrombi, a condition occasionally seen with mastoid abscess, etc. To open it before tying would be a surgical mistake. By this process it is practically obliterated as recovery ensues.

If such a muscle as the sternomastoid be partially or completely divided muscle suture should be practised and the head and neck kept at rest for the ensuing few days.

Injuries to the cervical nerves may be followed by peculiar and interesting features. That of the recurrent laryngeal will cause paralysis of the laryngeal muscles on one side, with consequent difficulty in speech; injury to the cervical sympathetic will be followed by dilatation of the pupils and protrusion of the eyeballs with flushing; of the spinal accessory, by mastoid and trapezius paralysis; of the phrenic, by paralysis of the diaphragm on one side; and of the pneumogastric, by embarrassment of respiration, with pupillary and abdominal symptoms, which are variable. Of all of these injuries that to the phrenic is probably the most serious. Some years ago I tabulated the then recorded cases of injury to the pneumogastric and was able to show that only about 50 per cent. of such cases were immediately or tardily fatal. The phrenic nerve is then the only one within the neck which can scarcely be spared. Any of these nerves when divided should be reunited by sutures, as elsewhere described.

When any portion of the brachial plexus has been injured a corresponding paralysis of the arm will follow. Wounds of these nerves should be sutured at once. A distinction should be made in all cases between hysterical anesthesia, malingering, and the actual paralysis of injury. Sometimes the amount of callus thrown out after a fracture of the clavicle will include a nerve of sufficient size to produce a neurosis, usually neuralgia, or possibly a paralysis. Excessive callus, or, in effect, the bony tumor which is thus produced, may be removed by operation, and any entangled nerve should be hunted out and liberated.

Pressure of a tumor upon a nerve will cause paralysis corresponding to its degree. When this comes on gradually, even though it involve the phrenic nerve, the consequences are not so serious. Repeated irritation or pressure may cause paralysis, as in the cases of the strap of letter-carriers or those who carry burdens slung from the neck.

Injuries occur to the cervical muscles during parturition and a hematoma of the sternomastoid in the newborn is described. The muscle is contracted and the head bent over. It usually disappears by resolution within a short time. This muscle is also ruptured by violence in the adult; again, hematoma is the result, with at least temporary torticollis, pain, and tenderness. When an abrupt division can be recognized, exposure of the ends and muscle suture would be indicated. At any time, in the presence of clot, it would be proper to cut down and turn it out.

Syphilitic myositis is often seen in the sternomastoid, where it may affect the entire muscle, transforming it into a cord-like mass, or where it may occur as gummatous infiltration. These cases occur without pain and without known cause save the disease itself, whose possibility should be established by the history of the case. Again, these muscles are sometimes contracted because of reflex excitement from adjoining inflammatory foci. Such an affection subsides shortly after due attention to the exciting cause, unless it has been allowed to continue too long. Inflammation, even of the destructive type, may be propagated to the muscles by continuity from a neighboring suppurating focus.

Serious phlegmons of the neck may be followed by phlebitis of the internal jugular vein, which may be recognized by the presence of a palpable cord-like clot within its lumen. Such a condition is serious because of the ease with which pyemia may ensue. It would be better to expose the vein, to tie it low down, to freely excise and turn out such a clot, than to leave it to create serious disturbance a little later.

Of the posterior portions of the neck we have fewer injuries, and these less serious, excepting those by which the vertebral column or the enclosed spinal cord are injured. These injuries have been referred to in the chapter on the Spine. A high perforating injury of the cord, especially if it involve the medulla, is promptly fatal. Infanticide has been produced by a long needle driven between the occiput and the vertebræ, corresponding to the pithing of small animals in the laboratory. An injury above the origin of the phrenic, on one side, is not necessarily fatal. Injuries to the posterior portion of the high cervical cord, as well as to the membranes, may be followed by more or less atrophy of the genital organs, with corresponding impotence, Larrey claiming that this may take place even when the cord itself is not affected.

Ruptures of muscles and separations from their insertions or origins are occasionally noted. The scapular muscles are occasionally torn loose. A reflex spasm of the trapezius which follows some of these injuries will produce a posterior form of acute torticollis (wryneck) described in the chapter on Orthopedics (XXXIII). The resulting deformity and stiffening might be confounded with arthritis of the upper vertebral joints. It is to be overcome by traction and by suitable apparatus, save in extreme cases, when division or excision of a sufficient portion of the muscle may be practised.