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SURGICAL REGISTRAR, WESTMINSTER HOSPITALT. H., male, aged 45 years, lorry driver, admitted December 18, 1936. HISTORY.-h I914 a small soft swelling was first noticed on the right side of the head, and this had gradually increased in size since that time. The lump was quite painless until ten days ago when, in attempting to stand upright, he struck his head against an iron girder in the roof of his lorry. Following this, the swelling was painful for five or six days and began to grow more rapidly. He had never suffered from headaches or felt any throbbing in the head. There was never any discoloration of the skin noticed, or bleeding from the lump. When aspirated by his doctor after the recent injury, however, bright blood was withdrawn. He had had no treatment, his eyesight was normal, and there were no other symptoms.PHYSICAL EXAMINATION.-GrOWth of hair on the scalp was thinner in the part involved by the tumour. After shaving, an irregular lump, roughly triangular in shape, was to be seen occupying the right temporal and frontal regions. The border of the tumour correspondmg to the base of the triangle was 2 in. long and just transgressed the midline. The apex was directed laterally and forwards, and became continuous with the tortuous and very prominent superficial temporal artery (Fig. 625). In its longest transverse diameter the lump measured 29 in. Its surface was raised about $in. above the general level of the scalp, but just behind the middle of the tumour it projected I in. above the general level, and again near the apex its surface was elevated nearly I in. The postero-lateral border of the tumour followed roughly the line of the fronto-parietal suture, and about its middle was a small prolongation of the tumour along the posterior auricular vessels.Close scrutiny of the shaven scalp failed to reveal any sign of recent or old trauma, and the colour of the skin overlying the tumour was normal. The whole swelling was seen and felt to pulsate synchronously with the pulsation in the superficial temporal artery. On palpation the lump was extremely soft and easily compressible, but on releasing the pressure it immediately returned in a symmetrical fashion to its original size; lowering the head and straining seemed slightly to increase its prominence. The peculiar softness of the tumour gave an impression to the examining fingers similar to that of a depressed fracture.Four groups of vessels were seen running into the tumour. The right superficial temporal artery was principally involved. Its course was plainly outlined and appeared to be a very tortuous one. As can be seen from the drawing, the artery approached the tumour by a very circuitous pathway. The wall of the vessel was soft, and when its lumen was obliterated by digital pressure, pulsation in the tumour promptly ceased, it diminished slightly in size, and refilled only very slowly when emptied. Other vessels to assist in supplying the lump were the right posterior auricular, the right supra-orbital, and the left superficial temporal arteries, ...

THE object of the present communication is to report three cases of aneurysm of the innominate trunk, all treated by surgical methods. In one case the innominate, common carotid, and subclavian trunks were tied simultaneously close up to the aneurysmal sac. This is the first clear record of such an operation being carried out with success. In the second case the three trunks were ligatured and the sac excised. Extirpation of an aneurysm of the innominate trunk has been reported on only one occasion previously. In the third case, in which a fatal termination eventually ensued, the aneurysm had been treated by lesser measures than ligation of the three trunks in the first instance, and it is of particular interest as illustrating the probability of recurrence of pulsation in the aneurysm under these circumstances.Aneurysm of the innominate artery is not common, comprising, as it does, only about 3 per cent of the total cases. It is, however, a site of peculiar interest to the surgeon, especially when the dilatation affects the termination of the vessel. Under such circumstances it presents a problem more difficult than does ordinary peripheral aneurysm, and is certainly without the hopelessness of aneurysm of the aorta. The possibility of the sac being adherent to the manubrium sterni and other structures, the risk of attempting its exposure, the problem of cerebral and brachial complications following ligature, all call for careful consideration, and contribute to making each individual case a fascinating study.That the treatment of innominate aneurysm is within the province of surgery is shown by the successful results gained in seven of the last ten cases reported. The striking fact is that the terrain now apparently so secure was won by the surgeon only after continued effort in the face of the most disheartening experiences throughout the nineteenth century and in the early days of the present one. A table is given below summarizing the records of aneurysms of the innominate trunk in which surgical treatment has been adopted. Although the innominate artery has been ligatured on over seventy occasions, it is evident that in the great majority of cases the operation was done for conditions other than aneurysm of that vessel itself. Failure to appreciate this distinction has resulted in great confusion in the literature, both in regard to the frequency of innominate aneurysm and also the efficacy of the various forms of treatment. Indeed, in a recent publication it is assumed that all ligations of the innominate trunk were performed for the treatment of innominate aneurysms, and the mortality of the condition was estimated on this basis. Though the number of cases is small, the table is helpful in indicating the comparative benefits conferred by the different surgical procedures.

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