Chapter 14
WOUNDS OF THE NECK
The proportion of lesions of the neck is 1 to 3 per cent. of all the wounds treated, but the number would increase by 3 per cent. if we take into account all the immediate deaths that occur.
Two-thirds of these wounds are simple (Ferraton). Those of the larynx and the oesophagus would be exceptional. Wounds of the neck often involve the cervical part of the vertebral column. The track may be antero-posterior, transverse or vertical, direct or oblique. The antero-posterior pretty frequently involves isolated organs; on the other hand, it often includes injury to the vertebral column; deep transverse tracks lead to more complex lesions. Wounds of the supra-hyoid and of the upper supra-clavicular regions are not so serious as those of the parotido-carotid and sub-hyoid regions. Wounds of the posterior regions of the neck are the least serious.
Wounds of the Nape of the Neck. - Let us simply call attention, without dwelling upon the subject, to more or less deep cuts or stabs given by cold steel on the nape of the neck. Bullets hollow out in this region either short or extensive tracks, with or without haematomata; shell fragments leave large, deep furrows, extending as far as the vertebral column.
These wounds are benign; there is nothing particular in their treatment.
Wounds of the Antero - Lateral
Regions - Soft parts.- They comprise the supra- and
sub-hyoid regions, that contain the laryngo-tracheal and pharyngo-oesophageal passages; they also comprise the
carotido-parotid regions abounding in large vessels and nerves.
The lesions of the sterno-mastoid, and of the other cervical muscles, consist of notches, perforations, and sections.
Wounds of the carotid or of the subclavian arteries are contusions, lateral wounds, perforations
; only fragments from large projectiles give rise to sections. Haemorrhage from the
carotids is nearly always fatal. Nevertheless, arterial haematomata are sometimes seen. These haematomata, which
take on a very rapid development, cause grave compression accidents, implicating the vessels, the nerves, the laryngo-tracheal
and oesophageal passages, denoted by circulatory troubles in the head and brain, and nervous and respiratory troubles,
dyspnoea, suffocation. They diffuse as far as the axilla and the mediastinum. The blood from these arteries penetrates
sometimes into the larynx or the trachea, giving rise to bloody expectoration, causing grave or fatal haemoptysis,
asphyxia; if the blood flows into the pharyngo-oesophageal canal, it is either swallowed or vomited.
Open lesions of big veins (lateral wounds and perforations) give rise, according to the diameter of the external wounds, to very abundant haemorrhage or to venous haematomata.
Wounds of very big veins, such as the internal jugular, the subclavian, the venous brachio-cephalic trunk, are as grave as those of the accompanying arteries. Their size, the absence of valves, and the resulting emptiness of the cranial sinuses, render haemorrhage from the internal jugular particularly formidable.
Lesions of the nerves of the neck present no particular anatomo-pathological characteristics.
A bullet does not fracture the larynx or the trachea in the ordinary meaning of the word; it causes contusions, indentations, clean perforations.
These indentations and perforations bleed moderately, but they remain widely open; the result is that in cases of simultaneous lesions of the neighbouring large vessels the blood runs freely into the respiratory passages.
The thyroid is indented or perforated. A bulky fragment of a large projectile may partially abrade it, as it also might abrade the larynx or the trachea.
The pharynx and oesophagus are contused or perforated. In the case of the oesophagus it is rather difficult to recognize the lesion at first sight if the tube has not been artificially dilated.
Diagnosis.- In the narrow wounds produced by bullets the diagnosis of pharyngo-oesophageal lesions becomes very difficult; it remains uncertain in the large majority of cases. The escape of food and saliva, a pathognomonic sign, is wanting. Dysphagia, pain or difficulty in deglutition, will be about the only signs, sometimes with vomiting of blood, which is rare. In case of doubt, one should act as if the pharyngo-oesophageal lesion existed, and be ready to interfere at the slightest threatening of peri-oesophageal infection.
Wounds of the laryngo-tracheal passage by projectiles hardly ever are recognized by the noisy entrance or escape of air through the cervical wound, a pathognomonic sign. The diagnosis may, perhaps, be rendered less difficult by the rapid apparition of an extensive and deep emphysema. Cough coming on in fits, asphyxiant dyspnoea, bloody expectoration, aphonia, which occurs in subglottic wounds, finally, the relations of the track with the respiratory passages will furnish the rudiments of the diagnosis. The most characteristic symptom of penetrating wounds of the laryngo-tracheal passage is dyspnoea, with threatening asphyxia.
In cases of simultaneous lesion of the respiratory and oesophageal passages, ingested fluid will pass into the trachea, and may be expelled by cough or through the cervical wound; but we must not rely on this symptom, for it is rather by the whole of the preceding signs that these wounds are recognized.
To establish the origin of alarming haemorrhage is usually very difficult, because of the number and the close relationship of the large jugulo-carotid vessels.
The disappearance of temporal or radial peripheral pulse is not always an indication of a carotid or subclavian section (collateral circulation, compression by a haematoma).
Nearly always the diagnosis of nervous lesions will not be made until at a period more or less remote from the date of the traumatism (Ferraton). At first their symptomatology is masked by that of the neighbouring lesions, the extreme gravity of which occupies all our whole attention.
Wounds of the thyroid body are diagnosed by the relations of the external lesions, by haemorrhage (which generally is moderately abundant), and by the appearance of a haematoma.
Prognosis.- The evolution of the injuries of the neck by projectiles is frequently aseptic when the soft tissues are the only ones involved. On the other hand, lesion of the laryngo-tracheal and pharyngo-oesophageal passages, the presence of foreign bodies, wide-spreading haematomata, promote or favour the development of circumscribed or diffuse abscesses in different strata of the region. These abscesses, sometimes enormous, are of a decidedly inflammatory type, sometimes ultraseptic, ligneous, with emphysematous gangrene.
Limited or extensive emphysema is an immediate compliCHAPTER `cation of these wounds, likewise asphyxia by laryngo- tracheal compression due to effusion of blood or to extensive emphysema; broncho-pneumonia is a later complication.
The prognosis is favourable in simple wounds. It is very bad in those that involve the large vessels. It is grave in lesions of the larynx, the trachea, the laryngo-tracheal passage. The narrow wounds of the laryngo-tracheal passage are perhaps more grave than the large lesions.
Instant or very rapid death occurs frequently; when delayed, the fatal ending is due to haemorrhage or to the complications stated above, especially to broncho-pneumonia.
During the Hispano-American War, out of 119 wounded in the neck, 24 died on the battlefield, and 22 subsequently.
Treatment.-The immediate and prolonged treatment of simple wounds presents no special indications; however, it is well to mention, with Professor Ferraton, that the dressing must obtain support from the forehead or in the axilla, to avoid all chance of displacement. Immobilization of the head is absolutely necessary.
To combat severe haemorrhages, digital compression should be applied to the wound, followed by mechanical compression localized on the wound, exerted either through the integument or on the vessel itself, after it has been relieved from all constriction. By giving solid support from the head and from the axilla on the same side, and by making the dressing very thick, we can exert strong lateral compression, which at first sight would seem to be hardly bearable. We have noticed this again and again. Ferraton advises covering the dressing with a wooden or zinc splint kept in place by the spica bandage of the neck.
Ligature of both ends is the ideal treatment, but in its application it necessitates coolness and all the ability of a skilful surgeon.
Wounds of the veins require the same treatment as those of the arteries.
Tracheotomy should be performed on men wounded in the larynx and trachea. This must be done at once; it must be expeditious and preventive - that is to say, it should be utilized in cases in which asphyxia is not threatening, and on the first signs of emphysema.
When a pharyngo-oesophageal wound is suspected, food must no longer be introduced into the mouth; we must have recourse to watery or nutrient enemata, or to sub- cutaneous injections of normal saline; thirst is to be treated by frequent rinsing of the mouth.
Abscesses should be opened, the line of incision for ligatures being followed, this being along the anterior border
of the sterno-mastoid; rarely along the posterior border or in the supra-clavicular space.