584 



NECK. 



rising in the vicinity of the sterno-clavicular 

 articulation, have been mistaken for aneurisms 

 of the mnoininala, on the one side, or of the 

 carotid or subclavian on the other, according as 

 they have, in their growth, deviated right or 

 left from the median line. Burns records a 

 case, in which an aneurism so originating from 

 the aorta, was even falsely attributed to the 

 right subclavian : it bulged first on the acromial 

 side of the sterno-mastoid muscle, " a point, 

 where no one would expect a tumour to present, 

 which had worked its way from within the 

 chest."* This is an extreme and rare instance ; 

 but not so are the misapprehensions, previously 

 alluded to : it is certain, and matter of frequent 

 experience, that aneurisms of the arch, where 

 they escape from the resisting stricture of the 

 sternum and clavicles, project so abruptly, as 

 to have the appearance of belonging to the 

 artery, over which their fundus is situated. 

 They frequently have (as in the case which 

 Burns quotes from Sir Astley Cooper) a Flo- 

 rence-rlask-hke form, the neck of which may 

 be narrow, and the fundus high in the neck. 

 In several such cases the deception has been 

 so complete, as to suggest to the surgeon the 

 propriety of tying the common carotid below 

 its supposed aneurism :f but no instance is on 

 record, as I believe, of the adoption of so 

 calamitous a proceeding. It is, indeed, true 

 and almost self-evident that an aneurismal 

 swelling, formed at the root of the carotid, 

 will commonly first be perceived in the small 

 interval between the heads of the sterno-mas- 

 toid, and, in its further growth, may displace 

 these, or cause their absorption : that one 

 connected with the arteria innominata is likely 

 to project nearer to the trachea, and on the 

 inner side of the sterno-mastoid : that one 

 originating from the subclavian will usually 

 rise on the outer side of the same muscle ; 

 and that the force of the pulse is generally 

 diminished in the branches of a trunk affected 

 with aneurism :J yet, while such facts may have 

 their weight, as excluding certain tumours from 

 the respective categories of subclavian, carotid, 

 or innominata aneurism, and as so assisting the 

 negative diagnosis of these diseases, it admits 

 of no doubt that they are insufficient to establish 

 grounds for positive recognition. The aortic 

 aneurism may imitate every circumstance of 

 position in the neck, which has been men- 

 tioned ; and can hardly fail by its abnormal 

 pressure to affect the circulation through the 

 contiguous artery, and to weaken the pulse of 

 its branches. To other criteria, than the mere 

 symptom of external prominence, the cautious 

 surgeon will look for a safe diagnosis of swell- 

 ings in the root of the neck. The minutest 

 inquiry into the history of the patient during 

 the period, which preceded any outward pro- 

 jection of the tumour, and into the actual state 

 of his thoracic organs and of their functions 

 (with notice of every pain, palpitation, or dys- 

 pnoea), an observation of any existing impe- 

 diment to the return of blood, as evidenced 



* Op. cit. p. 62 et spq. 



t Hodgson, Diseases of Arteries, p. 90. 



j Vide Cyclopedia of Surgery, vol. i. p. 237. 



by venous congestion,* and complete and 

 careful stethoscopy, are all requisite to that 

 stud i/ of the particular case, which alone can 

 justify an opinion. 



2. An important subject for mention, in re- 

 gard to the surgical anatomy of the neck, is 

 the provision for collateral circulation, when 

 the main trunks are obliterated. Mr. Burns, 

 in discussing the question of tying the arteria 

 innominata, speaks of these natural resources 

 in the spirit of confidence, which has been 

 familiar to English surgery, since the time of 

 its profound lawgiver, John Hunter : " We 

 entertained no dread of the circulation being- 

 supported in the right arm ; nay, we reduced 

 it to a demonstration. On the dead subject, I 

 tied the arteria innominata with two ligatures, 

 and cut across the vessel in the space between 

 them, without hurting any of the surrounding 

 vessels. Afterwards, even coarse injection 

 impelled into the aorta, passed freely by the 

 anastomosing vessels into the arteries of the 

 right arm, filling them and all the vessels of 

 the head completely." The fluid passed (as 

 the blood would, under similar circumstances, 

 pass in the living subject) from the carotid of 

 the left side to that of the right, through the 

 mesial inosculations of the thyroid, lingual, 

 facial, temporal, occipital, and (not least) ce- 

 rebral arteries: from the left subclavian, in like 

 manner, chiefly through the thyroid and ver- 

 tebral branches ; and thus a regurgitant stream 

 would How into the main vessels, up to the 

 very site of ligature. Partly through the con- 

 tinued trunk of the tied vessel, so reinforced 

 by its fellow, and partly by secondary commu- 

 nications (as of the occipital with the cervicalis 

 profunda, of the facial with the internal max- 

 illary, of the pharyngeal and palatine arteries; 

 the blood is distributed in its legitimate desti- 

 nation. If the subclavian alone be obliterated 

 at its commencement, the inferior thyroid and 

 vertebral (communicating with their fellows, 

 but still more largely with the carotid of the 

 same side) helped by the muscular branches 

 of the occipital, will convey the derived current. 

 If the ligature have been applied beyond the 

 scaleni, the transverse branches of the thyroid 

 axis, by their free inosculations with the articular 

 branches of the axillary, and with its subsca- 



* An interesting case is given by Professor 

 Fattison, in his Appendix to the edition of Burns, 

 (on the Surgical Anatomy of the Head and Neck,) 

 fron. which I have already quoted. A person who 

 had suffered during six months with obscure pains 

 about the lower region of the neck, which were 

 attributed to rheumatism, died comatose. It was 

 found on dissection that there arose from above the 

 arteria innominata a large tumour, which projected 

 forwards, adherini; to the sternum, which its pres- 

 sure had rendered carious ; and that " the trans- 

 verse vein, formed by the union of the left subcla- 

 vian and jugular veins, presented a very uncommon 

 appearance. It had more the character of a. liga- 

 mentous cord than of a dis'ended vessel ; and 

 when opened, it was found filled with coagulable 

 lymph, which completely obliterated its cavity. On 

 being traced downwards towards the right auricle, 

 the vein was seen to terminate at the sternal aspect 

 of the aneurismal tumour, that portion of it which 

 crossed the tumour having from pressure become 

 obliterated." 



