Excision is the measure usually resorted to because of the promptness of its effect, as well as the extent. Excision, however, necessitates an exceedingly careful and tedious dissection. When the whole side of the neck is involved I would advise an S-shaped incision, by which a double flap, with much better exposure, is afforded. There may perhaps be found two quite different sets of involved nodes, the superficial lying rather to the outside and to the front of the sternomastoid, which will be adherent to the carotid sheath, and a deeper set lying back of the sternomastoid whose removal will usually take one down to the transverse processes of the cervical vertebræ. In an average case there may be found all possible combinations of degeneration, with softening and cold abscess on one hand, and caseation and calcification on the other. Proceeding more deeply masses will be found whose existence had not been appreciated from the surface. Nevertheless, such cases usually do well and often recover. Thus a wound extending from the mastoid to the clavicle may be entirely healed within a week if the wound has not been infected by fresh pus. Such extensive wounds should be treated with at least one drainage provision, a drain being brought out through the wound or a special opening made for it, at a point where the resulting cavity will empty itself with the patient lying upon his back in bed.
For all these operations the patient should be prepared in the best possible manner. It will be of advantage to send patients to the woods, while, under any circumstances, they should be kept under those surroundings most favorable to tuberculous individuals, where hypernutrition, lively elimination, and oxygen fulfil the general requirements. They may also take such alteratives as arsenic, and such drugs as creosote or its derivatives, which are supposed to have more or less specific effect.
A distinct type of involvement of the cervical lymphatics is seen in connection with the spread of malignant disease from adjoining structures. Nowhere is this more marked than in epithelioma of the lip, but it may be seen in cancer spreading upward from below, as in connection with cancer of the breast. When the cervical lymph nodes are involved in a case of cancer of the breast a hopeless aspect is thereby put upon it. Although operation may be justified for temporary relief it should be so understood.
TUMORS OF THE NECK.
Aeroceles of the neck are sacs formed by air distention of an adventitious pouch, and constitute a species of local emphysema, due to weakening and yielding of some portion of the respiratory tract, produced by such strains as cough, labor, etc. A congenital dilatation of a laryngeal ventricle may produce the same effect. It may also follow a distinct wound of the trachea, or the expansion of a cavity in one of the mucous glands produced by its ulceration or breaking down. They may also result from abscess cavities opening into the respiratory tract. According to their location they may be referred to as laryngoceles, tracheoceles, etc. The term pneumatocele implies a protrusion of the pleura and the lung into the region above the clavicle. It will give distinct signs here on percussion, will disappear under pressure, and quickly recur as the result of forced expiration, coughing, etc. It may even follow the respiratory movements. This latter form is scarcely amenable to treatment unless tissues can be brought together over it and the opening closed. The other aeroceles are more or less amenable, according to their location and exciting cause. It is rare that there is any contra-indication to their exposure and extirpation.
Of the many true cysts of the neck a large proportion are due to incomplete closure of some portion of one or more branchial clefts. These have already been mentioned in the chapter on Tumors. The lesions vary from trifling submaxillary dermoid tumors to extensive hydroceles of the neck, such as those illustrated in [Figs. 495] and [496]. Not every congenital tumor, however, is of branchial origin. There is a possibility of the development of others along the thyroglossal duct, along the great vessels, and in the neighborhood of the pharynx and larynx. True bursal cysts, as well as true atheromatous cysts, also develop at various ages. The former will be found filled with serous fluid. They occur on the anterolateral aspect of the neck and generally on the left side. Dermoid cysts also abound here. They have an epithelial lining, which always indicates their congenital origin. They frequently do not develop until puberty. They may contain various epithelial products, which may escape by suppuration or perforation. These growths sometimes extend into the mediastinum. A form of median thyrohyoid cyst of this character often grows rapidly after confinement. Such a cyst if incompletely treated will be followed by persistent fistula. All of these growths should be thoroughly extirpated if attacked at all, or widely opened and packed, and then made to heal by granulation. [Fig. 497] illustrates another type of cystic growth of the neck connecting freely with the lymph spaces and vessels and regarded as a congenital lymphangioma.
Fig. 495
Congenital multilocular serous cysts (hydrocele) of neck. (Lannelongue.)
Fig. 496