Bauhaus-Universität Weimar

Titel:
The Cyclopaedia of Anatomy and Physiology, vol. 3: Ins-Pla
Person:
Todd, Robert Bentley
PURL:
https://digitalesammlungen.uni-weimar.de/viewer/image/lit29464/592/
NECK. 
f>84 
rising in the vicinity of the sterno-clavicular 
articulation, have been mistaken for aneurisms 
of the innoxninata, 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-fiask-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 :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 seq. 
t Hodgson, Diseases of Arteries, p. 90. 
J Vide Cyclopaedia of Surgery, vol. i. p. 237. 
by venous congestion,*— and complete and 
careful stethoscopy, are all requisite to that 
study 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 flow 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 
Pattison, in his Appendix to the edition of Burns, 
(on the Surgical Anatomy of the Head and Neck,) 
from 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, adhering 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.”
        

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