Fig. 492
Carotid aneurysm successfully treated by complete extirpation. (Author’s Clinic.)
Of great interest are the blood vascular tumors of the neck, both those of spontaneous and of traumatic origin. Large angiomas, either of the arterial (cirsoid aneurysm) or of the mixed or venous type, are seen about the neck. Here more than anywhere else are found peculiar venous dilatations, especially of the smaller veins, which form cavities in a tissue that becomes thereby almost erectile. Should these tumors connect with the arteries they will pulsate. If composed of larger veins they will prove quite compressible. These tumors should be extirpated, care being taken to place a provisional or permanent ligature upon the large vessels connecting therewith before the tumor itself is attacked. Occasionally the ampullæ of these growths become sufficiently large to entitle the growths to be considered as sanguineous cysts. The neck is also frequently the site of the smaller varieties of these growths which constitute the ordinary nevi. (See chapter on [Tumors].)
Aneurysms of the cervical vessels are more frequently of spontaneous than traumatic origin. They may, however, result from contusions or penetrating injuries. While no vessel in the neck always escapes, it is the common carotid which is more frequently affected than the others. The general subject of aneurysm has been considered. Care should be taken not to confuse the vascular and pulsating goitres, or other pulsating cysts of the thyroid. It is necessary also to distinguish aneurysmal pulsation from that which is transmitted through a tumor overlying the vessels or which may be seen in some of the extensive malignant tumors of the neck. When the diagnosis of aneurysm is made the surgeon should decide what vessel is primarily affected. This, however, is not always possible, as an aneurysm of the vertebral artery projecting forward is liable to be mistaken for one of some other trunk.
Aneurysm in the neck, unless very deep, and in a very unfavorable subject, is always an indication for operation. While operation necessarily includes ligation, either on the proximal or distal side, if this can be practised the sac itself may be treated just as though it were a tumor of any other character, and extirpated. I have myself had satisfactory results by the last-mentioned procedure ([Fig. 492]). The existence of laryngeal paralysis, especially unilateral, which is not easily accounted for in other ways, should excite a suspicion of aneurysm, with consequent pressure upon the recurrent laryngeal nerve. Its possibility should be excluded as part of the diagnosis.
Wounds of the subclavian vessels give rise to serious hematomas which may be converted into spurious traumatic aneurysms of arteriovenous character. When such a tumor pulsates it is probably connected with the subclavian artery, which should be ligated. It may be possible to make this ligation above the clavicle, but a portion of the sternum should be removed as well as the inner end of the clavicle for a more complete exposure. On the right side at least the artery can only be reached above the bone after dividing the scalenus anticus, where a provisional ligature may be placed. After this the sac should be incised and the vessel ligated, on either side of it, so that the provisional ligature may be removed. On the left side it is safe to ligate the second portion of the artery at once. The clavicle should be divided to afford better exposure, and its ends reunited with silver wire ([Fig. 493]).
Fig. 493
Traumatic aneurysm of axillary artery.