580 



NECK. 



self accordingly. It must have been through 

 these means of fallacy that I have seen a 

 most cautious and experienced operator de- 

 ceived : he compressed the supposed ar- 

 tery, raised on the aneurism-needle, with 

 his finger; the pulsation ceased, the ligature 

 was tightened, and the severe pain occa- 

 sioned by this step at once declared the error 

 (which was in the course of a few moments 

 remedied, and the operation ultimately and 

 entirely successful); the convexity of the nee- 

 dle was doubtlessly resting on the artery, and 

 compressed it upon the surface of the rib. 



The application of a ligature to the sub- 

 clavian artery on the tracheal side of the sca- 

 leni presents, perhaps, fewer merely mecha- 

 nical difficulties than that just described, but 

 involves a disturbance of more important or- 

 gans, and requires perfect acquaintance with 

 their anatomy. A separation of the slerno- 

 cleido-rnastoideus from its inferior attachment, 

 and a division of the sterno-hyoid and sterno- 

 thyroid muscles and of their sheaths (includ- 

 ing that deep layer which lies beneath the 

 sterno - thyroideus and immediately covers 

 the vessel) will expose the artery.* The ju- 

 gular vein is seen crossing it, close to the 

 scalenus, at the outer part of the wound, be- 

 hind which lies the phrenic nerve; at the inner 

 part of the wound the bifurcation of the arteria 

 innominata is brought into view, and the sub- 

 clavian is seen diverging from the carotid. 

 Between this point and the border of the ju- 

 gular vein, from half an inch to an inch of 

 artery intervenes, about midway on which the 

 nervus vagus crosses at a right angle. If 

 the nerve require to be drawn aside, this ma- 

 noeuvre must be executed with the extremest 

 delicacy and gentleness ;f and the operator 



* The description in the text is confined to the 

 mode of tying the right subclavian artery, on which 

 alone, as yet, the operation has been performed. As 

 regards the left, the course of the vagus and phrenic 

 nerves (which run parallel to the vessel), and of 

 the thoracic duct (which almost surrounds it) 

 would enormously multiply the risks of the opera- 

 tion ; and the increasing depth and oblique descent 

 of the artery, as traced from the scalenus inwardly, 

 would, it is believed, defeat every endeavour to 

 effect its adequate exposure. Should it be desi- 

 rable to secure the vessel internally to its passage 

 over the rib, the most available method would pro- 

 bably be that of tying it in the scalene space. 

 This operation was performed in a single instance 

 by Dupuytren in 1819 with success. The section of 

 the scalenus anticus, if it were carefully executed, 

 would be less perilous than on the right side, and 

 might, under favourable circumstances, afford a 

 sufficient space, between the branches of the artery 

 and the aneurismal sac, to admit the safe appli- 

 cation of a ligature. A complete division of the 

 clavicular origin of the sterno-cleido-mastoideus 

 would be required ; and it would be necessary to 

 obtain a distinct view of the phrenic neive, before 

 cutting the scalenus: the internal mammary artery 

 might, as M. Malgai^ne remarks, be injured even 

 more readily than the nerve, if this incision were 

 carelessly extended toward the median line. 



t It is difficult, in reading the record, or in wit- 

 nessing the progress of unsuccessful cases of ope- 

 ration at this part of the neck, to avoid believing 

 that a neglect of cautious tenderness in managing 

 the pneumogastric nerve, has tended to compromise 

 the safety of the patient. No surgeon, who con- 

 siders its viml importance to the functions and 



should not fail to remember his dangerous prox- 

 imity to the pleura. The view of these parts 

 is obscured by considerable venous haemor- 

 rhage, which is here especially inconvenient, 

 from the imperative necessity which exists for 

 clearly seeing the artery and ascertaining the 

 position of its branches before making any 

 attempt to pass the needle. It is considered 

 desirable to apply the ligature on the inner 

 side of the vertebral branch, and as near to it 

 as possible : yet, even under the most favour 

 able circumstances, the adhesive actions at the 

 seat of ligature must be seriously disturbed, 

 both by the near direct stream of the carotid, 

 and by the recurrent tides of the vertebral, 

 mammary, and thyroid arteries. The single in- 

 tance, in which I have seen this rare operation 

 performed, was by my friend, Mr. Partridge, 

 who brought to bear on its execution a per- 

 fect familiarity with every actual relation, and 

 with every possible contingency ; nor could it 

 have been confidently undertaken, or safely 

 conducted, by one of inferior resources. The 

 case was in so far favourable, that the tumour 

 was small, the position of parts unaltered, the 

 arteries regular and free from disease, and the 

 venous haemorrhage not so troublesome as in 

 many cases it certainly would be ; the parts 

 were clearly seen, and the artery secured with- 

 out the least unnecessary disturbance of con- 

 tiguous parts. Yet, I confess the impression, 

 which I derived from this single instance of 

 operation, and from frequent consideration of 

 the parts in a great variety of subjects, to have 

 been, that ligature of the arteria innominata 

 would in all cases be as easy, and, in many, 

 far easier to perform, would (by involving 

 organs of less delicacy and importance, than 

 those interested in the tracheal ligature of the 

 subclavian) render haemorrhage a less embar- 

 rassing obstacle, and would afford a better 

 prospect of undisturbed adhesion in the artery. 

 Tli e steps, necessary for exposing the one, re- 

 quire so little modification, to become equally 

 adapted for the other, that the surgeon might 

 even be determined in his choice of either, 

 by considerations developing themselves during 

 the operation, by greater or smaller branchless 

 extent of the subclavian artery, by tlie verte- 

 bral vein obscuring a large portion of this, or 

 by other circumstances of the kind. 



Although the arteria innominata cannot in 

 anatomical strictness be considered as belong- 

 ing to the neck, yet, in regard both of disease 

 and of surgical operation, its affinity to that 

 region is so close as to warrant its mention in 

 this place. It rises from the convexity of the 

 arch of the aorta, just as that main vessel, 

 having terminated its ascent, inclines leftward. 

 This point is in young subjects the highest 

 level to which the aortaattains ; but, as Cruveil- 

 hier notices, in old age the extreme part of the 

 arch, which corresponds to the origin of the 

 left subclavian artery, is higher. In early life, 

 too, from incomplete development of the ster- 

 num, the convexity of the arch more nearly 



nutrition of the lung, can avoid viewing any un- 

 necessary disturbance or rude traction of it as 

 eminently perilous. 



