operation for securing the bleeding internal carotid at the injured spot, by dividing and turning up the ramus of the lower jaw, has never been performed in the living body, and is so difficult, dangerous, and unnecessary, as not to merit description.
Ligature of Subclavian.—Note.—In consequence of the difference in the origin, and variety in the anatomical relations of the right and left subclavian arteries, in so far at least as their first stage is concerned, it is necessary to give a very brief separate account of each.
Right Subclavian.—The innominate artery divides into the right subclavian and right carotid exactly behind the sterno-clavicular articulation. The right subclavian extends from this point in an arched form across the neck, between the scalene muscles, over the apex of the pleura, till, passing under cover of the clavicle, it changes its name to axillary at the lower end of the first rib. For convenience of description, the artery is divided into three parts, which have very various anatomical relations, and differ from each other much in their amenability to surgical treatment by ligature. The anterior scalenus muscle defines the three parts, the first extending to the inner border of the muscle, the second being concealed by the muscle, and the third reaching from its outer border to the lower border of the first rib.
Branches of the Subclavian.—While the deep relations of pleura, veins, and nerves can be noticed under the head of each operation in detail, one anatomical point must never be forgotten as influencing very much the success of all surgical interference with the subclavian arteries—i.e. the branches given off. To give any chance of success in the application of a ligature to such a large vessel, so near the heart, a large portion of artery free from branches is required, that the clot may be long, firm, and undisturbed. The first part of the subclavian gives off the vertebral, thyroid axis, and internal mammary; the second, the superior intercostal; while the third part has in most cases no branch whatever. In these anatomical differences we find the reason for the almost invariable fatality resulting on any interference with the first and second parts, and the comparative safety of ligature of the third part, without requiring to account for the difference on other grounds, such as depth of part, importance of nervous relations, or nearer proximity to the heart.
The second and third parts of both arteries are so similar to each other, that a separate account is not required for the two sides.
Ligature of Right Subclavian.—First Part.—Operation.—An incision just at upper edge of sternum and right clavicle, extending from inner edge of left sterno-mastoid transversely to outer border of right sterno-mastoid through skin, platysma, and exposing sterno-mastoid, to be joined at an angle by a second incision, which, two, three, or even four inches long, must extend along inner border of right sterno-mastoid. Flap to be raised upwards and outwards. The sternal attachment of the sterno-mastoid must then be cautiously divided, as also part or the whole of its clavicular attachment, according as room is required. The sterno-hyoid and thyroid muscles will then require similar division. The internal jugular will then be seen very prominent,16 and will require to be drawn inwards or outwards, according to circumstances. The carotid and right subclavian arteries will then be felt lying close together crossed by the pneumogastric and recurrent nerves, the latter turning behind the subclavian. The nerves must be drawn inwards; the cardiac filaments of the sympathetic will then be observed, and drawn outwards. The subclavian vein lies below, concealed by the clavicle, and will probably not be seen during the operation. The needle should be passed round the artery from below upwards, care being taken not to injure the pleura, which lies beneath and behind the artery.
Results.—Twelve cases, all of which died; ten of hæmorrhage, one of pleurisy and pericarditis, and one from pyæmia. Attempted in one case by Mr. Butcher, but the artery was too much diseased to bear a ligature. The patient died on the fourth day.
Ligature of Left Subclavian.—First Part.—This operation, which has been described by some as impossible, has, I believe, been only once performed on the living body. Operation.—Incisions as for the preceding operation, except being on the opposite side. After the skin, platysma, and muscles have been divided, as already described, the deep cervical fascia requires division close to the inner edge of the scalenus anticus. The artery lies excessively deep, and great difficulty is experienced in avoiding injury to the pleura and the thoracic duct.
Results.—Once performed by Dr. Rodgers of New York; death from hæmorrhage on fifteenth day.
Anatomical Note.—The course of the left subclavian in its first stage is much straighter, as its origin is much deeper, than on the right side. The pneumogastric, phrenic, and cardiac nerves lie parallel to its course; the œsophagus and thoracic duct lie behind it, and to its inner side.
Ligature of Subclavian.—Second Part.—This very rare operation hardly requires a separate description, as the incisions necessary for ligature of the artery in its third part will, with very slight modifications, be sufficient for the purpose.
It has, however, special elements of danger in it, involved in the unavoidable division, of part at least, or probably the whole, of the scalenus anticus. The phrenic nerve, from its position on that muscle, requires special care to avoid dividing it, and in most cases the internal jugular vein is also in the way. The branches of the thyroid axis, which cross the neck, are quite in the line of the incision. The lowest cord of the brachial plexus lies immediately behind the artery, between it and the middle scalenus. The pleura lies just below it. The subclavian vein is generally quite safe, running in front of the scalenus anticus, and at a lower level.
The presence of the superior intercostal branch adds greatly to the danger of ligature of the vessel in this position, from its interfering with a proper clot.
Results.—Dupuytren17 performed it successfully for a traumatic axillary aneurism. Auchincloss18 did it for a large true aneurism, but the patient died sixty-eight and a half hours after the operation. Liston cut through the outer portion of the scalenus with success for an idiopathic aneurism. Thirteen have been collected by Wyeth with four recoveries and nine deaths.
Ligature of Subclavian.—Third Part.—For this comparatively common operation, various methods of procedure have been suggested and employed.
In the dead body, where the axilla is free from swelling, and in thin patients, the artery in this third stage is tolerably superficial, and can be secured with ease. But in very muscular men, with short necks and well curved clavicles, and specially when the axilla is filled up with an aneurism, and the shoulder cannot be depressed, the operation becomes very difficult.
Operation of Ramsden, Liston, and Syme.—Position.—The patient lying on his back with his shoulders supported by pillows, and his head lying back, and drawn to the opposite side; the shoulder of the affected side must be depressed as much as possible.
Incisions.—(Plate I. fig. 8.)—One through skin, superficial fascia, and platysma, along the upper edge of the clavicle, for at least three inches from the anterior edge of the trapezius to the posterior border of the sterno-mastoid, and in muscular subjects freely overlapping the edges of both muscles. Another two inches in length along posterior border of sterno-mastoid meets the first at an angle. On reflecting the chief flap thus made upwards and backwards, the external jugular will be seen, and, if possible, must be drawn to a side; if not, it must be divided, and both ends tied. The lower edge of the posterior belly of the omohyoid must then be sought; this leads at once to the posterior or outer margin of the scalenus anticus. The connection of the deep fascia to that muscle must then be very carefully scraped through, and by tracing the muscle to its insertion to the first rib, the artery is at once reached, lying behind the insertion. The pulsation of the vessel between the forefinger and the first rib will prove a great assistance; yet care is required, lest one of the branches of the brachial plexus be secured instead of the artery. The lowest cord lies very close to the vessel. The subclavian vein is not likely to give much trouble, from its being on a lower level, and (unless very much dilated) nearly concealed by the clavicle. The suprascapular artery is also hidden, but the transverse cervical crosses the very line