584 
rising in the vicinity of the sterno-clavicular 
articulation, have been mistaken for aneurisms 
of the innominata, 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 expecta 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-tlask-like 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 :{ 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- 
pneea),—an observation of any existing impe- 
diment to the return of blood, as evidenced 
* Op. cit. p. 62 et seq. 
+ Hodgson, Diseases of Arteries, p. 90. 
¢ Vide Cyclopedia of Surgery, vol. i. p. 237. 
NECK. 
by venous congestion,*— and complete and — 
careful stethoscopy, are all requisite to that 
study of the particular case, which alone can — 
justify an opinion. ee 
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 arte 
innominata, speaks of these natural resow 
in the spirit of confidence, which has been 
familiar to English surgery, since the time 
its profound lawgiver, John Hunter: “ y 
entertained no dread of the circulation bei 
supported in the right arm; nay we reducec 
it to a demonstration. On the dead subject, IT 
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 a oe the 
anastomosing vessels into the arteries 
right arm, filling them and all the vessels « 
the head completely.” The fluid passed (as 
the blood would, under similar circumstance 
pass in the living subject) from the carotid 6 
the left side to that of the right, through 
mesial inosculations of the thyroid, ling 
facial, temporal, occipital, and (not least 
rebral arteries: from the left subclavian, in lik 
manner, chiefly through the thyroid and vel 
tebral branches; and thus a regurgitant stred 
would flow into the main vessels, up to th 
very site of ligature. Partly through the e 
tinued trunk of the tied vessel, so reinfore 
by its fellow, and partly by secondary comm 
nications (as of the occipital with the ce 
rofunda, of the facial with the internal 
illary, of the pharyngeal and palatine arterie 
the blood is distributed in its legitimate dt 
nation. If the subclavian alone be obliter 
at its commencement, the inferior thyroid 
vertebral (communicating with their felle 
but still more largely with the carotid of 
same side) helped by the muscular bran 
of the occipital, will convey the derived curt 
If the ligature have been applied beyond 
scaleni, the transverse branches of the thyt 
axis, by their free inosculations with the arti¢ 
branches of the axillary, and with its s 
a 
. 
“"y 
pa e 
’ 
ae 
ste 
a 
* An interesting case is given by F 
Pattison, in his Appendix to the edition of — 
(on the Surgical Anatomy of the Head ‘N 
from. which L have already quoted. A perso 
had suffered during six months with ob 
about the lower region of the neck, wi 
attributed to rheumatism, died comatose. — 
found on dissection that there arose from abo 
arteria innominata a large tumour, which pr 
forwards, adhering to the sternum, which its 
sure had rendered carious; and that ** the 1 
verse vein, formed by the union of the | 
vian and jugular veins, presented a very unco! 
appearance. It had more the character of « 
mentous cord than of a distended ves: 
when opened, it was found filled with coagu 
lymph, which completely obliterated its cavity 
being traced downwards towards the right aa 
the vein was seen to terminate at the sternal a 
of the aneurismal tumour, that portion of it w 
crossed the tumour having from pressure 
obliterated.” " 
