Symptomatology, diagnosis, and surgical treatment of cervical ribs / by W.W. Keen.

  • Keen, William W. (William Williams), 1837-1932.
Date:
1907
Catalogue details

Licence: In copyright

Credit: Symptomatology, diagnosis, and surgical treatment of cervical ribs / by W.W. Keen. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    ing rib almost always has been followed by sinking downward of the plexus and relief of the nervous symptoms. 7. Again, the lower cords of the plexus are much more frecjuently involved than the upper. This is consonant with the theory that it is the upward pressure of the cervical rib lifting the lower, rather than the more distant upper cords which produces the lesion. Naturally, the upper cords would be the most likely to escape. The artery would not show this so well, since its walls are elastic and its contents fluid. Angulation. The subclavian artery, arising either on the left side, directly from the aorta, or on the right side, from the innomi- nate as it passes outward in a gentle curve to the axilla, rises normally into the neck a little above the upper border of the clavicle. In Fig. 21 the dotted line shows its normal course. In cases of cervical rib the artery usually rises in the neck from 3.5 to 5 cm. or more above the level of the clavicle and must bend acutely downward and outward to reach the axilla, as shown in Fig. 21. This shows the difference between the normal course of the subclavian artery and by contrast its course when it runs over a cervical rib. It shows also the necessary sharp bend or angulation in the artery when a cervical rib is present. See also Figs. 9,12,13,14. and 15. In almost every case it is noted that the pulsation of the subclavian artery was felt or seen, or both, far above the level of the clavicle, instead of being just behind that bone or barely above its level. This sharp bend or angulation of the artery, in addition to tension or pressure, I believe to be of considerable influence in producing the vascular symptoms. How can we Account for the late Appearance of the Symptoms The age at which symptoms have been noticed in the 42 cases operated on was as follows: Under fifteen, 6, that is, at seven, nine, ten, twelve, thirteen, and fourteen years; fifteen to twenty, 15; twenty- one to thirty, 8; thirty-one to forty, 11; sixty-two, 1; not stated, 1. It will be seen that in a large majority of the cases the symptoms do not arise until after fifteen years of age, and in some compara- tively late in life. Murphy is disposed to ascribe the outbreak at puberty or later to the growth of the rib occurring chiefly between the cartilage of the anterior end and the bone. Naturally, with growth in size from childhood to adult life, all the bones grow in length, and a cervical rib would be no exception. It seems to me that in the cases in which the symptoms appear late in life, as in my own case at sixty-two years of age, and Rutkowski’s at fifty- nine, and others not in my table about the same age, this is not due to any one but to a number of factors. For example, arterio- sclerosis would have some influence as the arteries begin to lose their elasticity, and if they are subject to any unusual pressure between a cervical rib and the scalenus anticus or by the repeated lifting action of the rib, changes in the wall of the vessel would be likely