826 



SUBCLAVIAN ARTERIES. 



daman artery, but a small opening was found 

 in the carotid from which the haemorrhage 

 had proceeded." 



In this instance the innominata was healthy ; 

 but, a little to the left of the origin of that 

 vessel, the aneurismal tumour, which was of 

 a pyriform shape, sprung from the arch of the 

 aorta, and thence passed upwards into the 

 neck, in front of, and overlapping the arteria 

 innominata. It is an extremely interesting 

 circumstance connected with this case, " that 

 the tumour was filled with a firm coagulum." 



This is the only instance, as far as the writer 

 knows, in which a ligature placed on the sub- 

 clavian artery, in its first stage, became detached 

 without the supervention of secondary hcemor- 

 rhage. In none of the cases where this artery 

 alone was secured did this circumstance occur, 

 much less in any of these instances did " per- 

 fect union," the result of adhesive inflamma- 

 tion, follow the application of the ligature. * 



Until very recently it was thought that the 

 ligature of the subclavian artery internal to 

 the scaleni was feasible on the right side only, 

 and this opinion of British surgeons originated 

 perhaps in Mr. Colics' statement, that " this 

 operation, difficult on the right, must be 

 deemed impracticable on the left subclavian 

 artery." Dr. Rodgers, of New York, has, 

 however, lately succeeded in securing the left 

 subclavian artery in its first stage. The result 

 of this case does not verify the opinion of 

 Velpeau, that *' the operation would be much 

 less dangerous on the left side than on the 

 right," as the patient died of secondary hae- 

 morrhage on the fifteenth day. 



British anatomists will be little disposed to 

 agree with Velpeau in such a prediction, and 

 still less will they concur with him in thinking 

 that it would be easier to tie the left sub- 

 clavian artery than the right ; on the contrary, 

 the great depth of the left subclavian trunk 

 from the surface, the short distance to which 

 it rises out of the thorax, and the close con- 

 nection of the veins and nerves with its anterior 

 surface, must entitle this operation to the 

 distinction of being one of the most difficult, 

 whilst the peculiar and unseen risk of wound- 

 ing the thoracic duct must ever render it one 

 of the most dangerous, in surgery. 



Second stage. The subclavian artery has 

 been tied between the scaleni muscles in a 

 few instances. This operation was first per- 

 formed by Dupuytren, in 1819, in a case of 

 traumatic axillary aneurism ; the result was 

 successful ; yet there is nothing in this opera- 

 tion to recommend it, provided there be the 

 option of tying the artery in the supra-clavi- 

 cular space. Dupuytren did not (as some 

 have supposed) intend it to supersede the 

 latter operation ; he advised it in those cases 

 only, where the depth of the vessel in its 



* The full details of this interesting case, which 

 occurred in the practice of Dr. Hobart, of Cork, will 

 be found in the forthcoming edition of " Fkod's Sur- 

 gical Anatomy of the Arteries," edited by Dr. Power, 

 one of the lecturers at the Richmond Hospital 

 School, to whom the writer is indebted for the facts 

 already quoted. 



third stage is unusually great, in consequence 

 of some peculiarity of development, or the 

 unnatural elevation of the clavicle produced 

 by an aneurismal tumour. 



The anatomical objections to this innovation, 

 which is sanctioned by the authority of Dupuy- 

 tren, are the following, and they are suffi- 

 ciently important to justify the conclusion 

 that, where a choice exists, the third stage of 

 the artery should always be selected for the 

 application of a ligature. 



1st That in order to expose the subclavian 

 artery in its second stage, the division of two 

 muscles is required, viz., the clavicular portion 

 of the sterno-mastoid, and the scalenus anticus. 



2d. That considerable risk of injuring the 

 phrenic nerve is incurred. 



3d. That the ligature must be in close 

 proximity to the branches usually furnished 

 by the subclavian artery between the scaleni, 

 viz., the cervicalis profunda, and superior 

 intercostal; and, 



4th. That from its close connection with 

 the artery, the cone of the pleura is en- 

 dangered. 



These theoretical objections to the ligature 

 of the subclavian between the scaleni, are 

 not the less deserving of notice because they 

 were originally passed over in silence, and 

 they go far to disprove the "innocmte" of the 

 operation, an advantage which has been 

 claimed for it by Dupuytren.* 



The objections which have just been enu- 

 merated, are not however of sufficient weight 

 to forbid a repetition of the operation in any 

 case where insuperable difficulties are en- 

 countered in attempting to tie the artery in 

 its third stage ; under such circumstances, the 

 surgeon would evince both skill and dexterity 

 by dividing, as far as necessary, the scalenus 

 anticus muscle, and thus accomplishing the 

 object of the operation; and in so doing he 

 would follow the example of the late Mr. 

 Liston, who, in a parallel case, thus succeeded 

 in securing the arterj' between the scaleni. 



Where the outer edge of the muscle alone 

 is divided, and where proper caution is used, 

 the safety of the phrenic nerve is not neces- 

 sarily compromised ; but without very great 

 caution in passing the needle, the pleura 

 will suffer injury, as it is placed in close con- 

 tact with the back of the artery. It should 

 also be borne in mind, that the phrenic nerve 

 has in a few instances been seen to pass down 

 beneath the clavicle, lying on the outer edge of 

 the scalenus anticus muscle ; should such an 

 anomaly occur in a person subjected to Du- 

 puytren's operation, the nerve could scarcely 

 escape from injury. This irregularity in the 

 cervical stage of the phrenic nerve, has usually 

 been seen in connection with a variety of 

 origin of the axis thyroideus, which has been 

 already adverted to.-f 



* Vide " LeQons Oracles," torn. iv. ; and M. Marx 

 account of the operation in the " Repertoire Generale 

 d' Anatomic," No. 2. 



f It may be presumed that the phrenic nerve was 

 thus unusually placed in a case which occurred in 

 the practice of Mr. Bransby Cooper, and which he 



