580 
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 ~ 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 themee- 
dle was doubtlessly resting on the artery, and 
compressed it upon the surface of the rib. 
€ application of a ligature to the sub- 
clavian artery on the tracheal side of the sca- 
Jeni 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 sterno- 
cleido-mastoideus 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 
art 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- 
neuvre must be executed with the extremest 
delicacy and gentleness;+ 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 itin the scalene space. 
This operation was performed in a single instance 
by Dupaytren 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 arter 
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 nerve, before 
cutting the scalenus: the internal mammary artery 
might, as M. Malgaigne remarks, be injured even 
more readily than the nerve, if this incision were 
carelessly extended toward the median line. 
+ 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 vital importance to the functions and 
NECK. 
should not fail to remember his dangerous 
imity to the pleura. The view of these 
is obscured by considerable venous 
rhage, which is here especially incon 
from the imperative necessity which exists for 
clearly seeing the artery and ascertaining the — 
position of its branches before maki n 
attempt to pass the needle. It is considered 
desirable to apply the ligature on the inner 
side of the vertebral branch, and as near toi e 
as possible: yet, even under the most favou 
able circumstances, the adhesive actions at the © 
seat of ligature must be seriously ¢ d, 
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 operatic 
performed, was by my friend, Mr. Partridge, 
who brought to bear on its execution a Ff = 
fect familiarity with every actual relation, ane 
with every possible contingency; nor could i 
have been confidently undertaken, or \ 
conducted, by one of inferior resources. 
case was in so far favourable, that the tumou 
was small, the position of parts unal the 
arteries regular and free from disease, 
venous hemorrhage not so troublesome as it 
many cases it certainly would be; the part 
were clearly seen, and the artery secured wi 
out the least unnecessary disturbance of 
tiguous parts. Yet, I confess the impressior 
which I derived from this single instance 
Operation, and from frequent consideration ¢ 
the parts in a great variety of subjects, to ha 
been, that ligature of the arteria innomir a 
would in all cases be as easy, and, in mai 
far easier to perform, would (by inve 
organs of less delicacy and oe th 
those interested in the tracheal ligature of | 
subclavian) render hemorrhage a less emb 
rassing obstacle, and would afford a be 
poet of —— adhesion in Aes a 
le steps, neces ‘or exposing one, 
quire ai little modification, +6 Sa 
adapted for the other, that the surgeon m 
even be determined in his choice of 
by considerations developing themselves du 
the operation, by greater or smaller branel 
extent of the subclavian artery, by the ¥ 
bral vein obscuring a large portion of th 
by other circumstances of the kind. 
Although the arteria innominata cann 
anatomical strictness be considered as b 
ing to the neck, yet, in regard both of d 
and of surgical operation, its affinity to 
region is so close as to warrant its 2 
this place. It rises from the convexity 
arch of the aorta, just as that main 
having terminated its ascent, inclines le! 
This point is in young subjects the 
level to which the aorta attains ; but, as € 
hier notices, in old age the extreme part ¢ 
arch, which corresponds to the origin 
left subclavian artery, is higher. In earl, 
too, from incomplete development of the: 
num, the convexity of the arch more D 
‘f 
ny 
y. 
< 
aa 
nutrition of the lung, can avoid viewing an 
naeeerney disturbance or rude traction of © 
eminently perilous. 
