THE 
COLLATERAL CIRCULATION III 
REPORT 
OF THE 
SUCCESSFUL LIGATION OF THE INNOMINATE, THE 
COMMON CAROTID, THE VERTEBRAL, AND THE 
INTERNAL MAMMARY ARTERIES, 
IN A CASE OF 
RIGHT SUBCLAVIAN ANEURISM. 
BY 
A. W. SMYTH, M. D., 
HOUSE SURGEON, CHARITY HOSPITAL, NEW 
[From the Neiv Orleans Charity Hospital Report /oM"5’7TT' 
NEW ORLEANS, LA. 
18 7 7. THE 
COLLATERAL CIRCULATION IR /NEUR1SM. 
REPORT 
OF THE 
SUCCESSFUL LIGATION OF THE INNOMINATE, THE 
COMMON CAROTID, THE VERTEBRAL, AND THE 
INTERNAL MAMMARY ARTERIES, 
IN A CASE OF 
RIGHT SUBCLAVIAN ANEURISM. 
BY 
A. W. SMYTH, M. D., 
HOUSE 8 U BO EON, CHABITY HOSPITAL, NEW ORLEANS. 
[From the New Orleans Charity Hospital Report ffrr- IWU- ] 
N E W ORLEANS, LA. 
1 8 7 7. Printed at the German Gazette Jon Office. 10H Camp Street, X. O. NEW AND SUCCESSFUL OPERATIONS 
IN RIGHT SUBCLAVIAN ANEURISM, 
WITH ORIGINAL VIEWS 
ON THE IMPORTANCE OP THE COLLATERAL CIRCULATION. 
The patient, William Banks, upon whom were performed the operations 
mentioned in this report and forming the subject of this article, was admitted 
into the Charity Hospital, New Orleans, on the 9th of May, 1864, with aneu- 
rism of the right subclavian artery. He was a native of New Orleans, aged 
thirty-two years, a mulatto, rather below the medium height and weight, 
and had been employed as steward on board of a steamship. 
The tumor had reached the size of a small orange, had existed four months, 
and was situated in the posterior inferior triangle of the neck. It pulsated 
strongly, and was very painful. The man had strained his arm severely in 
the month of February, in efforts to save himself from drowning in a collision 
at sea. This over-exertion was no doubt the cause of the aneurism. 
On the 15th of May, with the assistance of Doctors Holliday and Boyer, 
and Surgeons Bacon and Orton of the United States Army, a ligature was 
placed on the innominate artery, a quarter of an inch below its bifurcation; 
and at the suggestion of Dr. D. L. Rogers, of New York, who was present, a 
ligature was also tied on the carotid artery, an inch above its origin. 
The temperature of the arm became increased; but, except slight fever, no 
other disturbance was noticed. 
In forty-eight hours slight pulsation was discovered at the wrist. 
On the 28tli of May, the ligature came away from the carotid artery; and 
on the 29th, fourteen days after the operation, a severe hemorrhage occurred, 
causing syncope, and ceasing of itself. About sixteen ounces of blood was 
supposed to have been lost. 
Slight hemorrhage took place on the two following days: and on the 1st 
of June, I tilled the wound with fine shot, (No. 9), covered the shot with 
some lint, and, as the patient was very quiet and not disposed to move. I 
placed a small paper weight on the lint to increase the pressure. 
On the same day, after the introduction of the shot, the ligature, on 
slight pulling, came away from the innominate artery. I was desirous of 
having it away, thinking that the shot by its pressure might the sooner bring 
about occlusion of the artery. 
On the 17th of June a portion of the shot was taken out. Hemorrhage 
returned a few hours afterwards, when the shot was immediately replaced. 4 
Slight bleeding, however, occurred at intervals of two and fifteen days; 
and on the night of July 5th, a terrific hemorrhage took place, exceeding in 
quantity the first, on the 29th of May. The bleeding ceased as in the first in- 
stance, from syncope,. 
I had come to the conclusion at this time that the vertebral branch of the 
subclavian was carrying on the collateral circulation. Prof. Erichsen in his 
work, The Science and Art of Surgery, says: “I think that the presence of a 
collateral branch in close proximity to the distal side of the ligature, more 
especially if it be one that serves to carry on the anastomosing circulation, 
will be found to have a decided tendency in preventing the occlusion of the 
distal end of the artery, and will thus act in favoring the occurrence of 
secondary hemorrhage.” The peculiar character of the hemorrhage, the sud- 
den syncope and arrest of the bleeding, and its repeated occurrence in the 
fatal cases of this operation, could all be accounted for by this retrograde 
current through the vertebral,—the hemorrhage coming directly from the 
brain. 
Having satisfied myself by repeated attempts on the subject, that the 
vertebral artery could be ligated just before it enters the foramen in the trans- 
verse process of the sixth cervical vertebra, through an incision made along 
the outer edge of the sterno-mastoid muscle, and the aneurism having dimin- 
ished enough in size to permit of this operation, I determined to try it; and 
on July 8tli, with the assistance of Dr. P. C. Boyer, a ligature was placed on 
the vertebral artery. 
The circulation in the arm was very much diminished by this operation, 
all pulsation ceased, coldness and oedema supervened, and for several days 
the safety of the arm was endangered. 
On July 9th all the shot was removed from the wound with a pair of 
curved dressing forceps, and weighed two ounces and a half. The shot had 
remained in the wound thirty-eight days. 
No further hemorrhage took place. The ligature came away from the 
vertebral artery on the tenth day, and on the loth of September the wounds 
had healed, and the patient was considered cured. Some paralysis of the ex- 
tensor muscles of the fingers of the right hand remained, the consequence of 
pressure from the weight of the arm on the musculo-spiral nerve during the 
long confinement to bed. 
After the patient left the Hospital he resumed his employment of steam- 
boating, and for this reason came only occasionally under observation. 
He was exhibited at a meeting of the American Medical Association in 
New Orleans, on the 6th of May, 1869, and then no vestige of the aneurism 
remained. Naturally enough, no great interest was manifested in the case. 
There was nothing to be seen but the scars left from the operations. The use 
of shot to prevent hemorrhage and the ligation of the vertebral artery were 
original procedures in surgery. The conclusion to which the members came, 
that the operations never had been performed at all, was perhaps not to be 
wondered at. The operator was unknown. I stated in the meeting that the 
ligation of the vertebral artery, to arrest collateral secondary hemorrhage from 
the distal end of the ligated innominate artery, was a procedure entirely new 
in surgery; but this only made the matter worse to those who had had no 
experience upon the point, and had bestowed no attention upon it, and there- 5 
fore could not possibly know anything about it. It was only the more incom- 
prehensible to them. The surgeons of New Orleans believed it, for the 
character of the gentlemen present at the operation was known to them. The 
late Prof. Valentine Mott received a minute account of the operation from his 
friend Doctor Rogers, and gave full credit to it. Prof. Erichsen noticed the 
case in his work on surgery; and I received a letter from Sir William Fergus- 
son, acknowledging it. The tying of the vertebral artery was to these gentle- 
men a satisfactory explanation of the success of the operation. 
Shortly after this time, Banks took up his residence in Galveston, Texas, 
and was lost sight of for some years. He wrote me in June, 1874, that the 
tumor had returned to his neck and was causing him some pain. I requested 
him to come to New Orleans at once, but he did not come until September, 
when I was surprised to find that the aneurism was considerably larger than 
at the time of the original operation. It did not pain him much, no doubt 
from its slow growth. He said that he had noticed that the tumor had been 
returning for about a year. Pulsation was perceptible, but not strong. The 
fingers applied over the tumor were seen to be elevated with each arterial 
pulsation. The tumor was tense, globular in shape, with distinct boundary. 
It occupied the original site, filling the posterior inferior triangle of the neck. 
Repeated careful examinations principally directed to the cardiac side of 
the tumor failed to reveal any pulsating artery communicating with it; and 
believing that a single branch of the subclavian was carrying on the collateral 
circulation, and that this branch was on the cardiac side, I considered the 
internal mammary the one most likely to be carrying the retrograde current, 
from its free anastomosis with the deep epigastric. It might possibly have 
been the superior intercostal, but this I could not reach. I therefore deter- 
mined to ligate the internal mammary artery, and on October 5th the patient 
was again admitted into the Hospital, and the same day, with the assistance 
of Drs. Boyer and Souchon, a ligature was tied on the artery in the third 
intercostal space. 
The artery was small, and when exposed with the ligature around it, no 
pulsation could be detected in either direction. 
The patient recovered quickly from this operation, and left the Hospital 
on the 10th of November. He complained a good deal of pain, caused by 
cutting the intercostal muscles, and said the operation was the most painful 
he had undergone. Some improvement was thought to have taken place in 
the tumor. This, I think, was entirely owing to rest. A small abscess formed 
under the clavicle; this was punctured with a trocar, and the contents were 
drawn off twice; an incision was made into it, and a tent put in, which 
caused it to disappear. 
He now insisted on returning to Galveston, declaring that he was easier 
and believed he would get well. He did not come back until March 29th, 
1875, and then it was the return of the abscess that induced him to do so. He 
would not let it be opened in Galveston, and it had become quite large and 
prominent under the clavicle. No change seemingly had taken place in the 
aneurism. I drew off the contents of the abscess with a fine trocar. The pus 
was mixed with blood of a dark color. He promised to return the next day, 
but did not do so. The day after, I was informed he was much w orse, and I 
ordered him to be brought back to the Hospital. On his admission I found 6 
that the aneurism had ruptured into the cavity of the abscess, and had be- 
come diffused. 
On the following day the arm was swollen and painful, with great ten- 
sion about the shoulder, extending below the clavicle. I determined on one 
more effort; and with the approval and assistance of Prof. T. G. Richardson 
of the University of Louisiana, the patient having been placed under chloro- 
form, I laid open the sac of the aneurism by a free and deep incision; scooped 
out the clots of blood as quickly as possible, hoping to be able to reach the 
mouth of the vessel supplying the sac; but not knowing the direction of the 
current, and the hemorrhage being very great, I was compelled to give up the 
search, and to arrest the bleeding by stuffing the sac with lint. The patient 
became pulseless for a time, but reacted. Some hemorrhage, not to any great 
extent, took place two days afterwards; but lie rapidly failed in strength and 
spirits, and soon betraying utter discouragement and prostration, finally died 
on tlie ot April, 1875, within thirty-three days of eleven years after his 
original entrance into the Hospital. 
A few hours after death about half a gallon of solution of chloride of zinc 
was injected into the right femoral artery; and on the following day, the lint 
having been removed from the sac of the aneurism, the opening was carefully 
stitched up, and a compress of lint secured by a bandage placed over it. A 
quantity of melted cacao butter, colored with carmine, was now injected into 
the same artery, enough to well distend the whole arterial system. Two days 
afterwards the body was given to Dr. Edmond Souehon, Demonstrator of An- 
atomy, University of Louisiana, who kindly undertook the dissection, and 
furnished me with the following account of the autopsy : 
“ The body, not at all emaciated, was in a good state of preservation, with 
rather too much adipose tissue for a clean dissection ; and the arteries were 
all apparently well distended by the injected material. No perceptible dis- 
proportion existed between the lateral halves of the bodv. The ri'-ht arm 
was as rftuscular as the left. 
“ lTpon exposing and clearing the parts at the root of the neck, and open- 
ing the thorax, the arch of the aorta, well injected, was found to be perfectly 
normal. The innominate artery was injected to the point of ligation, less 
than an inch from its origin, where it suddenly became reduced to a bundle 
ot tough fibrous tissue, in which could be traced the origin of the common 
carotid and subclavian arteries. The carotid arising from this fibrous tissue 
was occluded, and continued so up to the bifurcation, growing larger as it 
approached this point. It was cut into, and no evidence of channel could be 
found. The fork of the carotid was well distended with the injection. The 
external carotid and all its branches were also well tilled, and so was the in- 
ternal carotid. 
“ The subclavian was impervious from its origin to within a fourth of an 
inch ot the thyroid axis. The thyroid axis and its branches were all pervious 
and seemed not above the ordinary size. They were not well distended by 
the injected material. The subclavian from the thyroid axis to the aneu- 
risinal sac, into which it opened, was rather under the ordinary size. 
rhe vertebral artery originated from the subclavian as a white fibrous 
cord ot small size, which became reduced at the point of ligation to a mem- 
branous tissue; from this point up, it increased in size and became pervious 
at the fourth cervical vertebra. It continued of small size into the cavity of 
the skull, where it was smaller than its fellow of the opposite side by at least 
one-tlnrd. 1 he basilar artery was ot ordinary size. The posterior communi- 
cating arte lies were larger than usual, and the anterior cerebrals were freely 
connected by three short and large anterior communicating arteries. 
“ The arteries in the brain were all well injected. 7 
“ The internal mammary artery was slightly distended from its origin 
down to the first intercostal space. From this point it became impervious to 
some distance beyond the point of ligation, where it again became pervious, 
but of small size. The right epigastric was not any larger than the left. 
“ The superior intercostal was well distended Avith the injection, and 
seemed to be somewhat above the ordinary size ; no anastomosing branches 
from it could be found communicating with the princeps cervicis behind. The 
princeps cerricis itself presented nothing noticeable. 
“On continuing the dissection to the distal side of the sac, the first artery 
that attracted attention was the subscapular, with its branches to the great 
dorsal and great serrate muscles. 
“ These branches were numerous, were well distended by the injection, 
were as large as crow quills, and very tortuous in their course downwards. 
Seven of these branches communicated directly with a similar number of per- 
forating branches from the aortic intercostals. These branches ran into each 
other, of full size, without the interposition of any plexus. The dorsalis 
scapulas and the other branches of the subscapular and axillary arteries were 
not A ery Avell distended. They were traced far enough to show that there 
were no anastomoses of any consequence* either with the posterior or superior 
scapular arteries. The trunk of the subscapular was not well distended, and 
seemed not to be above the natural size. The axillary artery below the origin 
of the subscapular Avas better distended, and ran as usual into the humeral, 
which was well injected. This artery divided, about the junction of the 
upper Avith the middle third of the arm, into two branches Avliich ran down 
along and under the median nerve to the elbow, one forming the radial and 
the other the ulnar artery. The profunda Avas exposed and presented nothing 
remarkable. 
“ The upper portion of the axillary, extending from the origin of the 
snbscapular to the aneurismal sac, Avas not well distended, and seemed to be 
rather under than over the ordinary calibre. It Avas thoroughly pervious, 
as shown by passing a probe into it from the sac. It opened into the bottom 
of the sac by an oval round-edged opening, apparently not quite as large as 
the size of the artery. The distance between this opening in the sac and that 
of the subclavian on the cardiac side Avas about an inch. The ruptured and 
everted artery, with its internal coat quite distinct, extended along this dis- 
tance on the bottom of the sac, recognized by its yellowish color and smooth 
surface. It was firmly attached to the deep parts. This internal coat of the 
artery did not extend upwards on the inner surface of the sac. The sub- 
clavian artery opened into the sac about a quarter of an inch from the origin 
of the superior intercostal artery. 
“The base of the aneurism occupied the whole of the posterior triangle 
of the neck, encroaching upon the surrounding l’egions, pressing against the 
trapezius muscle behind and the sternomastoid on the inner side. In front 
the tumor had caused absorption of the greater portion of the clavicle— 
bending this bone outwards. The roof or superficial covering of the sac had 
been opened during life. 
“From the large size of the anastomotic branches of the subscapular and 
the perforating branches of the aortic intercostals, it is evident that the 
blood had circulated in this Avay,—from the aortic intercostals up through 
the subscapular into the upper portion of the axillary, and into the aneurism, 
—supplying it by a retrograde current: and from the absence of anastomotic 
communications with the branches of the subclavian on the cardiac side of 
the aneurism, and from their comparatively small size, these arteries evidently 
carried on the retrograde circulation from the aneurism through the subcla- 
vian artery.” * 
* In illustration of important points , in this case. Dr. J. J. Castellanos, Lecturer on Piin- 
ciples of Surgery in the Charity Hospital School of Medicine, very kindly made drawings of 
the arteries in the haso of the brain, and in the neck, with the anastomosing arteries com- 
municating with the aneurism. The change in the direction of the right vertebral artery is 
prominent among these. I should like to have published the drawings with this report, but 
could scarcely do it satisfactorily here in New Orleans. 
The anatomical preparation preserved from the case remains in the care of Dr. Sonchon. 8 
This report of Dr. Souchon’s was written two years ago, and might have 
been published at that time. I made some delay, which may have appeared 
longer than was absolutely necessary, in order to enable me to give such ex- 
planations as might occur from a full and careful consideration and study of 
the case. 
If I am correct, however, in the conclusions at which I have arrived, and 
which I am now prepared to state, the time taken will not, I think, be pro- 
nounced wholly lost. 
The subject of aneurism is very different to me now from what it had 
been. The rationale of the cure of the disease, and the action of the various 
methods adopted to bring about a cure, are more comprehensible to me. In 
fact, although I had cured many aneurisms, I never knew exactly until now 
how they were effected. I have learned more from failure than from success, 
and better understand much that I had read and seen in the past. Before 
entering upon this subject, however, I think it of importance to give some 
particulars of the case not yet stated, or not as fully stated, as the reader 
may desire. 
The exact time of the return of the aneurism is uncertain. Banks stated 
on his coming to New Orleans in September, 1874, that the tumor had com- 
menced returning about a year previous to that time. Some swelling and 
pulsation had existed, however, even before this returning was acknowledged; 
for Prof. Paul F. Eve, of Nashville, Tenn., called my attention to a notice of 
an examination of Banks previously made in Galveston by a Surgeon of the 
United States Army, and mentioned in a report to the Surgeon-General. I 
cannot now turn to this report, but it was of much earlier date tliau the time 
given by Banks as that of the returning of the aneurism. The writer stated 
that slight pulsation existed in the sac of the aneurism, which, however, lie 
did not then consider of any immediate import. 
It may appear strange to the reader that the supply of blood to the 
aneurism through the subscapular artery was not discovered during life; but 
there is an explanation for this. The patient, during the time of his recovery 
from ligation of the internal mammary artery, was examined by many pro- 
fessional gentlemen,—by all the leading surgeons of New Orleans, and by 
other visitors, among whom I may mention Dr. Robert McDonnell, of Dublin, 
then present in our city. I consider that the frequent examinations during 
these visits caused the abscess that indirectly led to his death. Yet none of 
those who examined him suspected the source of supply. 
From the time the vertebral artery was tied on July 8th, 18(>4, no pulsa- 
tion ever reappeared in either the axillary or the brachial artery. They 
seemed to be occluded; and yet slight pulsation existed at the wrist, in the 
continuations of these arteries. Compressing them to arrest the pulsation at 
the wrist was never tried; and the total absence of pulsation in the lower 
end of the axillary and in the brachial arteries, created a very strong im- 
pression that the supply of blood did not come in this distal direction. I 
think it probable that preconceived correct opinions on the course of the 
circulation were sometimes changed after an examination. 
The circulation of blood to the arm was very peculiar. The subscapular, 
from the direction of its origin, ran up in a nearly straight course to the 
aneurism; and the retrograde current through it, during the heart’s contrac- 9 
tion, went into the sac. Immediately afterwards, a direct current from tlie 
aneurism returned through the axillary and brachial, supplying the arm, but 
without any perceptible pulsation in these arteries. The supply, however, 
was abundant; for the right arm was as strong and muscular as the left. 
That portion of the axillary artery extending from the origin of the subscap- 
ular to the aneurism was carrying a double current, that is, a to and fro 
current. It may be better understood by saying that a systolic retrograde 
current to the aneurism, and a diastolic direct current to the arm, circulated 
through it. 
I noticed during the dissection, that the elevation of the arm to a right 
angle with the body changed the direction of the trunk of the subscapular 
artery and would have reversed this circulation. With the arm elevated, the 
retrograde current from the subscapular would have gone directly to the arm, 
and a return retrograde current would have supplied the aneurism. This 
simple experiment would not only have revealed the source of the circulation ; 
but would also have shown an easy way to lessen the circulation in the 
aneurism. 
It is stated in Dr. Souchon’s report that several arteries were not well 
distended by the injected material; and it is w ell, in order to prevent any 
wrong conjectures being made from this condition of the arteries, to explain 
that the injection was forced out by the compress and bandage applied over 
the opening in the sac. The arteries w ere wrell distended at the time of the 
injection, but ihe pressure of the bandage afterwards, while the material 
remained fluid, pressed some of it out. This w ill make it clear w hy the con- 
tinuations of some arteries were well injected and their trunks not. 
The autopsy shows nothing very remarkable except the peculiar circula- 
tion which reproduced the aneurism as mentioned in the report. 
The aneurism w as reformed on a retrograde current, circulating towards 
the heart; and I know of no previous case in which an aneurism was ever 
reproduced in this way. 
In the application of a ligature for the cure of aneurism, we always en- 
deavor, if possible, to throw the collateral circulation beyond the tumor; and 
if successful in this a cure almost always results. It did not result in a cure, 
however, in the present case; and to understand fully the reasons for this 
exception, it becomes necessary to take into consideration the action of the 
collateral circulation in the cure of aneurism. This has never yet been done; 
but I am satisfied it is a most important agent, not alone in carrying on the 
circulation after the aneurism is cured, but in actually bringing the cure 
about. 
It will aid us very much in this undertaking to begin by considering 
what a collateral circulation is,—how it is carried on,—and the conditions 
which must accompany its establishment. 
A collateral circulation is a circulation around an obstruction to the 
direct current of blood through an artery. More accurately defined, it is a 
retrograde circulation through a .branch, from its anastomotic communica- 
tions, into an artery, beyond an obstruction to the direct current through 
that artery. 
The collateral circulation is always carried on through a single branch 
into an artery beyond an obstruction to the direct current through it; and 10 
but a single branch carries on the retrograde circulation into an artery on 
the distal side of an aneurism after it is cured. It was my belief in this fact 
that induced me to tie the internal mammary artery; and the post mortem 
shows that I was right in theory, but that I should have ligated the subscap- 
ular instead of the internal mammary. 
When a collateral circulation takes place in consequence of an obstruc- 
tion to the direct circulation in an artery, the direct current must cease at the 
point of obstruction, the instant the collateral circulation becomes established. 
The direct circulation impinges on the obstruction on the proximal side, and 
the collateral circulation impinges on it from the distal side. 
To those who have hitherto believed that a collateral circulation could 
take place into the distal end of a ligated artery, through a number of branches, 
that a collateral circulation could become gradually established during 
the increase of an aneurism, and that a direct and a collateral circulation 
could circulate together in an artery, the assertions just made, with regard 
to the collateral circulation, will certainly be new, if not startling. It is only 
necessary, however, to take a plan or sketch of the arteries and trace upon it 
the collateral circulation coming in from different branches, with the direct 
circulation at the same time going on in the same artery, to see the utter im- 
possibility of any such circulation as that generally believed in ever taking- 
place. Opposing currents cannot circulate in the same artery without inter- 
fering with each other: one must arrest the other. 
The action of the collateral circulation in bringing about a cure of an- 
eurism may be well illustrated by reference to cases of occasional sponta- 
neous cure. 
From obvious physical laws, the circulation of blood is obstructed in an 
artery dilated into the form of an aneurism. The obstruction is greater from 
a large aneurism than from a smaller one, and a weak current is more ob- 
structed by the aneurism than a stronger one. When the obstruction, either 
from increase in the size of the aneurism or from diminution in the force of 
the current, or from both causes combined, reduces the force of the circula- 
tion in the attery and its branches, on the distal side of the aneurism, to a 
certain extent or degree below the force of the general circulation, a retrograde 
collateral circulation becomes established, through one of the branches on the 
distal side of the aneurism. The establishment of the collateral circulation 
on the distal side has the effect of arresting the obstructed direct circulation 
through the aneurism, and the cure of the aneurism commences from this 
point. 
Pulsation may go on in the tumor for some time after the circulation 
through it ceases. It may even be quite strong, owing to the combined direct 
force of the circulation on the cardiac side, with the indirect force on the 
distal side. We know that pulsation in an aneurism, for a time, is not 
evidence of circulation through it: any more than pulsation up to the point of 
ligation on a continuous artery is evidence of circulation through this artery; 
and we are acquainted with the pulsation -produced by the collateral circula- 
tion. It is frequently noticed coming on shortly after ligation on the cardiac 
side of an aneurism and continuing for two or three days longer. 
The arrest of the circulation in an aneurism by the establishment of a 
collateral circulation on its distal side, when the arrest of circulation is not 11 
otherwise produced, either by total obstruction to the circulation in the 
aneurism, or by the application of the ligature either on the cardiac or on the 
distal side, close to the aneurism, will readily explain to us the way in which 
compression brings about a cure. Compression lessens the force ot the circula- 
tion in the artery to the aneurism—reducing the circulation in the artery on 
the distal side of the aneurism to the condition required, as already stated, for 
tin' establishment of a collateral circulation. 
Compression made on the aneurism or on the artery on its distal side, it 
effective, must act in the same way as when made on the artery on the cardiac 
side of the aneurism. • . 
It is manifest that compression is a very efficient means of establishing a 
collateral circulation ; and that the lessening of the force ot the general cir- 
culation is not; for the collateral circulation must derive its force from the 
general circulation, and the stronger the force of the collateral current, the 
more readily can it become established, and the stronger direct current is it 
capable of arresting. 
The cure of aneurism by the use of the ligature brings us to the consid- 
eration of our present case. When a ligature is applied close to the cardiac 
side of an aneurism, arresting all circulation through it, the process of cure is 
of the simplest kind. A collateral circulation is then established on the dis- 
tal side with no direct current to oppose it. But when a ligature is applied 
at a distance from the cardiac side of the aneurism, with branches interve- 
ning between it and the aneurism, this proeess of cure becomes complicated. 
The collateral circulation is then sometimes established on the cardiac side ot 
the aneurism. This was the case in Banks, after the first operation ot liga- 
ting the innominate and common carotid arteries. I'he collateral circulation 
was established through the vertebral artery. 
The establishment of the collateral circulation on the cardiac side of the 
aneurism follows ligation of the external iliac artery for aneurism below the 
profunda, and may occur from the application of the ligature at some distance 
from any aneurism, provided a branch or branches of some size intervene. 
When a cure takes place after the establishment of the collateral circulation 
on the cardiac side of the aneurism, it takes place more slowly than when the 
collateral circulation is established on the distal side, and the cure is brought 
about by a change of the collateral circulation from the cardiac to the distal 
side of the aneurism. 
Occasionally the collateral circulation on the cardiac side of an aneurism 
reproduces it. In a ease of femoral aneurism treated in this Hospital a few 
years ago, the collateral circulation, from occlusion of the iliac by digital 
compression, continued to increase the aneurism more rapidly than the direct 
current. I attributed this at the time to absence of resilience in the tumor 
during the heart’s diastole. This, I considered, left no opportunity for circu- 
lation within the boundaries of the sac. 
When a collateral circulation becomes established on the cardiac side of 
an aneurism, after ligation on the cardiac side, the ligature may be said to 
act in the same way as compression. It does not cut off all the circulation. 
It lessens it by substituting a collateral current in place of the direct one ; 
and in the event of a cure following, a collateral circulation becomes estab- 12 
listed on the distal side, opposing and arresting the collateral circulation on 
the cardiac side. 
In some instances, this transfer of the collateral circulation from the car- 
diac to the distal side must be interfered with by pressure of the tumor. 
In Banks, the collateral circulation established through the vertebral 
artery on the cardiac side of the aneurism was changed to the distal side by 
ligation of this artery; and as other branches besides the vertebral existed 
between the ligature on the cardiac side and the aneurism, the collateral cir- 
culation on the distal side established a current through the aneurism to 
these branches. 
If secondary hemorrhage had not occurred, necessitating the tying of the 
vertebral artery, and it the collateral circulation had changed from the car- 
diac to the distal side of the aneurism, with the vertebral open, the collateral 
circulation on the distal side could not have passed to the branches on the 
cardiac side of the aneurism ; for the current from the vertebral would have 
supplied these branches and opposed the retrograde current through the 
aneurism. 
If the innominate artery had been successfully ligated without the verte- 
bral having been tied, it is legitimate to suppose that the retrograde current 
from the vertebral might have supplied the other branches of the subclavian 
on the cardiac side of the aneurism, and that a retrograde current- through 
the subscapular would have supplied the axillary and its other branches be- 
yond the aneurism. This would have been an instance of two branches car- 
rying a retrograde current into the distal end of a ligated artery. It will be 
perceived, however, that there existed two obstructions to the direct circula- 
tion to account for this. 
The circulation in Banks was indeed very peculiar. It was produced by 
two operations :—first, by the ligation of the main artery going to an aneu- 
rism ; and secondly, by the ligation some time afterwards, of a branch carry- 
ing on the collateral circulation on the cardiac side of the aneurism. If this 
branch had been the only one intervening between the ligature on the main 
artery and the aneurism, a total arrest of circulation through the aneurism 
would have been effected ; but three other branches, the internal mammary, 
the thyroid axis, and the superior intercostal, also intervened ; and the col- 
lateral circulation established on the distal side of the aneurism, by the liga- 
tion of the branch carrying on the collateral circulation on the cardiac side, 
passed through the aneurism to the branches on its cardiac side. 
It is probably safe to say that no such circulation ever existed before, 
and it could have been produced in no other way than by the two operations 
mentioned. 
We have seen that a collateral circulation can be established on the distal 
side of an obstruction in an artery, opposing a collateral circulation on its 
proximal side. Now, if we understand the circulation as it existed in Banks, 
we can see that the collateral circulation, established on the. distal side of the 
aneurism, could have been arrested only by the establishment of a collateral 
circulation on its cardiac side; and the important question arises, can such a 
collateral circulation be established f Can a collateral circulation be set up 
on the cardiac side of an obstruction to the circulation in an artery, after a collateral circulation has been established on its distal side ? In reply to this 
question. I answer “No! ” 
For years, a weak, indirect, collateral current circulated through an an- 
eurism, to branches on its cardiac side. These branches,—the internal mam- 
mary, the thyroid axis, and the superior intercostal,—were, from their anas- 
tomotic communications, as capable of carrying on a retrograde circulation, 
as the branch that supplied them from the distal side of the aneurism; and it 
is evident that the force of a collateral circulation through an aneurism can- 
not equal the force of a collateral circulation without the obstruction of the 
aneurism; so that the distal collateral circulation did not, by its force of 
current, oppose the establishment of a collateral circulation on the cardiac 
side. The conditions, as far as we can see, were all favorable for the estab- 
lishment of a collateral circulation on the cardiac side of the aneurism,— 
necessary to bring about its cure. It did not, however, take place. Such an 
event would have been contrary to the law that the collateral circulation is 
established on the distal side of an obstruction to the direct circulation. 
I have been frequently asked why I did not ligate the axillary artery 
above the subscapular; and Dr. Souchon originally closed his report by say- 
ing that this ought to have been done. I have omitted the suggestion, first, 
because it was too late, and secondly, because it was made without the reflec- 
tion, that this operation would certainly have been followed by secondary 
hemorrhage. It is precisely the operation to which Prof. Erichsen’s remarks 
already quoted apply. The only safe ligation would have been that of the 
subscapular artery,—a very different operation from the other. This 
might have thrown the collateral circulation again on the cardiac side of the 
aneurism ; but if my present reasoning is correct, the aneurism could have 
been cured only by a return of the collateral circulation again to the distal 
side. With the subscapular tied, this might have been impossible ; and I now 
see that it was not so easy a matter as some suppose, to have cured the recur- 
rent aneurism in Banks, by the ligation of any artery. 
Consulting brevity, as far as consistent with clearness, I will state, in 
the form of propositions, the conclusions to which, from consideration of the 
present case, I have been led, concerning the cure of aneurism, and the action 
of the collateral circulation in bringing it about. Conditions, applying only to 
the exceptional case of Banks, are enclosed in brackets :— 
1. 
The complete cure of aneurism, that is, solidification and absorption of the 
tumor, with the occlusion of that portion of the artery involved in the aneurism, 
always results from the total arrest of the circulation of blood in the aneurism. 
2. 
When a cure of aneurism follows from 'procedures lessening the force of the 
direct circulation to the aneurism, or from increasing the obstruction to the circula- 
tion in the aneurism, or from obstructing the circulation in the artery or arteries on 
the distal side, the total arrest of the circulation in the aneurism, required to effect 
a cure, is caused by the establishment of a collateral circulation on the distal side of 
the aneurism. 3. 
A collateral circulation is established on the distal side of an aneurism, when 
the force of the circulation in the distal continuation of the artery involved in the 
aneurism becomes reduced to a certain degree below the force of the circulation in its 
anastomosing arteries. 
4. 
The collateral circulation on the distal side of an aneurism opposes the direct 
circulation through the aneurism. The retrograde collateral current must arrest the 
obstructed direct current. [The collateral circulation under extraordinary circum- 
stances may establish a retrograde current through the aneurism to the artery and 
its branches on the cardiac side, if this artery is occluded on the cardiac side of the 
branches. ] 
5. 
The collateral circulation is always carried into the distal continuation of an 
obstructed or occluded artery, through a single branch. A careful consideration of 
the currents in the circulation ivill show a necessity for one branch alone carrying 
the retrograde current, and a necessity for some action controlling this and regula- 
ting the circulation in the communicating or anastomosing branches between arteries. 
Aneurisms are not the only accidents to the circulation requiring the establishment 
of a collateral circulation. It is reasonable to suppose that during health temporary 
obstruction to the circulation in an artery gives rise to a collateral circulation,— 
ceasing on removal of the obstruction and restoration of the direct current. 
6. 
The collateral circulation consequent upon obstruction to the direct circulation 
in an aneurism, and upon obstruction to the circulation in the artery or arteries on 
the distal side, is always established on this side. In the use of compression or liga- 
tion on the cardiac side, at some distance from the aneurism, causing a greater ob- 
struction to the direct circulation than that arising from the aneurism, the collateral 
circulation is occasionally established through a branch on the cardiac side of the 
aneurism, but on the distal side of the greater obstruction. In the event of a com- 
plete cure following the establishment of this proximal collateral circulation, the 
cure is brought about by the subsequent establishment of a distal collateral circula- 
tion which arrests the proximal collateral current through the aneurism. 
7. 
In all aneurisms, except sacculated aneurisms, involving a portion of the wall 
of an artery, or aneurisms through which the circulation is totally arrested by the 
use of the ligature, or by complete obstruction in the sac of the aneurism, the cure is 
owing to the establishment of a collateral circulation on the distal side of the aneu- 
rism, which arrests the direct circulation in the aneurism. 
8. 
When the collateral circulation becomes permanently established on the distal 
side of an aneurism, its cure is certain to folloiv, unless hemorrhage, rupture, or sup- 
puration of the sac, should ensue, [ora retrograde current through the aneurism 
from the collateral circulation to the artery and its branches on the cardiac side 
should be established. ] 15 
The consideration of the collateral circulation is necessary to enable us 
to comprehend many of the well-known facts connected with the cure of 
aneurism. Indeed, many of the phenomena connected with the cure are in- 
comprehensible without a knowledge of its action. Pulsation may go on for 
days after the circulation has ceased, arising from the indirect collateral cur- 
rent alone; and often the direct and indirect currents both combine in pro- 
ducing it. Spontaneous cure sometimes takes place, and compression of vari- 
able degree and duration of time effects a cure. Frequently, some time after 
the compression has been withdrawn, a spontaneous cure follows. 
The theories advanced to explain the cure of aneurism without taking 
into consideration the action of the collateral circulation are not well found- 
ed. It is held that a weak current of blood circulating through an aneurism 
forms a coaguhim,—a deposit of fibrin in the sac, of a different kind from that 
left by a more active or stronger current,—and that the deposit from the 
weaker current is capable of totally arresting the circulation of blood through 
the aneurism ; of solidifying and of becoming absorbed; leaving the artery 
permanently occluded. Our present case has proved all these theories unten- 
able ; and the post mortem shows that no arteries were permanently occluded 
except those in which the circulation was totally arrested. The aneurism was 
absorbed, and was reproduced by a weak current; and for ten years a weak 
current circulated through it, and still the aneurism was not completely 
cured. 
It is commonly asserted that the collateral circulation is becoming estab- 
lished during the increase of an aneurism. I believe that during the increase 
of an aneurism the collateral circulation frequently arrests for short periods 
of time the direct circulation through the aneurism. The two circulations 
may be said to alternate with each other. The deposit of fibrin on the inner 
walls of an aneurism, taking place in separate and distinct layers, indicates 
the occurrence of an intermittent action in the direct current. The obstruc- 
tion to the circulation in the aneurism is diminished in consequence of the 
deposit of a coagulum in the sac of the aneurism, which lessens the quantity 
of fluid blood contained in it, during the arrest of the direct circulation ; and 
this enables the direct current to become again re-established—the collateral 
current ceasing. From the action of the collateral circulation in this way 
only can it be said to become gradually established. Increase in the size of 
an aneurism increases the obstruction to the circulation of blood through it, 
tending to set up a collateral circulation. When the collateral circulation 
becomes permanently established, it may, by increase in the number and size 
of the communicating or anastomosing branches to the single branch carry- 
ing it into the artery on the distal side of the aneurism, keep increasing in 
force and volume for an indefinite period of time. 
The short communicating arteries frequently laid down in surgical 
works, as uniting the two ends of a ligated artery, and illustrating the man- 
ner in which the circulation is then carried on, are wholly imaginary. They 
can have no existence. 
In conclusion, it may be asked, What have we learned from these opera- 
tions, and, how can the knowledge obtained be applied in directing our ef- 
forts to greater success in the future ? We have learned that the innominate artery has been successfully liga- 
ted in a case of subclavian aneurism ; and from the relation or affinity exist- 
ing between like things, this extraordinary operation has been followed by 
an event perhaps quite unprecedented. After an interval of ten years, the 
one followed as a consequence of the other. An aneurism was reproduced by 
a retrograde collateral current of blood, circulating through it from the distal, 
to branches on its cardiac side. We have learned that in this strangely re- 
versed circulation, arising from the interruption of a collateral current to the 
distal side of a ligated artery, the usual law governing the establishment of 
the collateral circulation could no longer operate towards the effecting of a 
cure. It has been proved that the innominate, the common carotid, the verte- 
bral, and the internal mammary arteries could all be successfully ligated on the 
same patient, without curing a subclavian aneurism on their distal side. It 
may he claimed, however, that a mire was effected for ten years; for during 
that period the patient enjoyed the best health of his life. He gained twenty 
pounds in weight and possessed the full and complete use of all his physical 
and mental faculties. We have learned that ligation of the innominate and 
common carotid arteries, with the ligation of the vertebral to arrest secondary 
hemorrhage from the distal side of the ligated innominate artery, is a suc- 
cessful operation for the cure of subclavian aneurism, compared with the 
operations of the past. We have learned, I think, the reason why it is ob- 
jectionable under some circumstances, when it can be avoided, to ligate a 
collateral branch carrying the retrograde current of blood to the distal side of 
a ligated artery, to arrest secondary hemorrhage from it. And we have learned 
something about the collateral circulation and its action in bringing about 
a cure of aneurism. Surely all this knowledge, derived from the successful li- 
gation of the innominate artery, should be enough to disprove the stereotyped 
denunciations of this is an ‘‘unjustifiable” operation. 
We have also learned from the present case that ligation of the innomi- 
nate and common carotid arteries alone, without that of the vertebral, would 
in all probability effect a complete cure of subclavian aneurism. It seems to 
me the course to be adopted in the future is quite plain. We must endeavor 
to ligate the innominate and common carotid arteries, in some way that will 
prevent the occurrence ofsecondary hemorrhage, which alone has proved fatal 
to the vast majority of the patients hitherto operated upon. In this attempt, 
recourse to the ligation of the vertebral artery, if secondary hemorrhage 
should come on, makes it safe to adopt any procedure that promises a chance 
of success. 
The discovery of a means of arresting the secondary hemorrhage from the 
distal side of the ligature on the innominate artery, and effecting a cure of 
aneurism for a period of ten years, is a long step forward from the past. 
Patients will not be allowed to bleed to death from this hemorrhage as they 
have been heretofore. The abundance of loose cellular tissue in the root of 
the neck makes it an unfavorable locality for trying the antiseptic ligature ; 
still it may be worth the attempt I have thought for some time that should 
another case of right subclavian aneurism present itself to me, I would tie the 
innominate and common carotid arteries, and, making a longitudinal incision 
opposite the origin of the subclavian, would, through the incision, insert into 
this artery a round ball of lead or some lighter substance which we know to 17 
become readily encysted, and await the result. Several sizes of shot attached 
to the ends of curved wires would determine the proper size to introduce, and 
the plug should be forced some distance into the artery. I would try this 
operation on the left side by tying the subclavian, making a longitudinal in- 
cision on the distal side of the ligature. I should not dread any danger from 
a single hemorrhage from the vertebral; and on its occurrence I would ligate 
this artery as I did in Banks. 
I would not amputate at the shoulder joint, for several reasons. First, it 
is an operation to which patients do not readily consent; secondly, even it 
successful it cannot be more so in my opinion than that performed in the 
present case; and, thirdly, it is an operation from which nothing valuable 
can be learned, and nothing creditable ever obtained. After the experience 
and knowledge derived from the operations here recorded, I could not but con- 
sider it a most objectionable procedure. I prefer to take my place upon the page 
of surgical history among the ligators of the innominate, and with them, in 
our common effort, share the credit of endeavoring to accomplish a result 
more beneficial to our race, and more honorable to our profession.