SECTION 3. SUMMARY OP THE SURGICAL HISTORY OF THE INTERN'AL AND (Part 4)

in Fig. 4.) The profunda cervicis was a branch of the superior intercostal in 35 of 52 cases ; in 15 it came direct from the subclavian, and in 2 of 52 it was a branch of the thyroid axis. This vessel is usually very small. I am led to believe that its importance as a collateral chan- nel after ligature of the common carotid or first portion of the suh- clavian has been overrated. On the right side, when this branch was not common with the superior intercostal, its origin from the main trunk was to the outer side of the intercostal branch. (See Fig. 3.) On the left side, under above circumstances, this branch was nearer the inner edge of the scalenus anticus. T\Q posterior scapular, one of the most'important branches of the subclavian in a surgical view, since it must be in dangerous prox- imity to a ligature applied (as is most often done) in the 3d surgi- cal division (not given in many standard text-books, except as an occasional branch of this artery*)^ was present in 36 of 52 dissections, or 69 per cent. It was present in 19 of 26 on the right side; and in 17 of 26 on the left. In 23 of the 36 cases in which it was present, it was derived from the 3d division; in the remaining 13, from the 2d division close to its outer limit. In Fig. 4 the range of varia- tion is shown in the lines radiating from P S. On the right side 74 per cent, came from the subclavian within \ of an inch to the outer and inner side of the external border of the scalenus muscle; 26 per cent, external to this. On the left side 82 per cent, were within \ of an inch to the outer and inner side of the line dividing the middle and external thirds of the main trunk ; 18 per cent, were to the outer side of this. The tendency of this important branch is to originate near the scalenus, i. e. within one-fourth of an inch of its outer edge. When this ves- sel is present the transversalis colli is small, and when absent the de- scending branch of the transversalis takes its distribution. Passing outward behind the most superficial cords of the brachial plexus, it turns sharply downward, along the posterior border of the scapula, to anastomose with the subscapular branch of the axillary. Small anomalous branches were observed in only 9 instances — 1 from the 2d division of the left side, 4 from the 3d portion, and 2 from the 1st portion. On the right side only 2 small branches were observed, both from * Wilson, Gray, Morton, Monro, Winslow, Cloquet, Paxtou, Richardson, Leidj. INNOMINATE AND SUBCLAVIAN ARTERIES. 155 the neighborhood of the internal mammary. (One of these was the comes nervi phrenici, the other a pericardiac branch.) None of these had any surgical significance, being so small that they would not, if present, contraindicate the application of the ligature. OPERATIVE SURGERY. From the foregoing dissections I would advise the following methods of procedure in ligature of the great vessels at the base of the neck. Ligation of the Innominate, From the centre of the interclavicular notch, make an incision about three inches long along the clavicle. A second incision, commencing at the inner border of the sterno-mastoideus about two inches above the clavicle, is made to unite with the first incision at the middle of the interclavicular notch. Dissect the flap upwards, until the sterno-mastoid muscle is exposed, which should be divided over the sternum and clavicle upon a grooved director carefully in- troduced. Superficial to the muscle some small veins will be found, and underneath its clavicular portion is the junction of the subcla- vian and jugular, in dangerous proximity. (It is best to leave some of the outer fibres of this muscle attached to prevent its retraction after the operation.) The anterior jugular veins will be seen imme- diately beneath this muscle, and should be tied and divided. Dis- secting carefully, with the handle of the scalpel, the connective and areolar tissue in which these veins are imbedded, the origins of the ster7io-hyoid and sterno-ihyroid muscles will be reached, and, when these are divided carefully upon the director, the arteria innominata will be seen pulsating just behind the sterno clavicular articulation. Being exposed with the scalpel handle, or any dissector not likely to wound the vessel, the aneurism needle should be passed from right to left behind the artery, care being taken to avoid wounding the right vena innominata and the pneumogastric nerve, or punctur- ing the pleura, which the artery rests upon and is partly imbedded in, and (if the ligature is applied low down upon the vessel) the left innominate vein which crosses in front. When the aorta is situ- ated low in the thorax, it may be necessary to remove the sternal end of the clavicle and a segment of the sternum, as was done by Cooper, of San Francisco, in two instances. (See History.) From the remarkable results after torsion of large vessels (Bryant's 156 PRIZE ESSAY. Surgery), and in consideration of the frightful mortality which has heretofore accompanied this operation, I would advise that the in- nominate^ carotid, and subclavian be simultaneously ligatured near the junction of these three trunks, divided between the ligatures, and each well tioisted. Torsion of the innominate would increase the area of resistance to the heart's action, would cause apposition and adhesion of the walls of the artery close to the aorta, and avoid the great risk of the ligature cutting through, as a result of the constant pulsation and pressure brought against it. Torsion of the subclavian "would occlude the vertebral, internal mammary, and the thyroid axis, which would obviate the necessity of their being tied (which should always be done when torsion is not practised), since a study of the causes of death in the ligature of these large vessels has shown that these branches are among the most important factors of death when left open.^ Torsion of the carotid is not so essential, but should be performed. Ligature of the Right Subclavian in its 1st Surgical Division, or of the Bight Common Carotid at the Moot of the Neck, Operation the same as for the Innominate, The subclavian vein will be found from J to | of an inch below and in front of the artery. The internal jugular vein crosses the artery in front of the thyroid axis at the inner border of the scalenus. Between this and the common carotid is the vertebral vein, and the pneumogastric nerve in front, while its recurrent branch is looped underneath and passes up behind the vessel. The internal jugular vein should be drawn to the side most convenient, the outer side being safest on account of the right lymphatic duct being at its junction with the subclavian vein. The phrenic nerve should not be forgotten, as it crosses the subclavian in front of the last portion of the 1st division, being in front of the scalenus anticus muscle and behind the transversalis colli and suprascapular arteries. (In one instance I noticed a communicating filament from the brachial plexus join the phrenic in front of the artery.) The vertebral, internal mammary, and thyroid axis or its branches^ may be secured by the same operation as for the ligature of the 1st surgical division on the right side. The vertebral will be found J of an inch to the inner side of the inner border of the scalenus anticus muscle in the vast majority of * See R6sume of Surgical History. INNOMINATE AND SUBCLAVIAN ARTERIES. 157 cases. It is the only vessel coming from the posterior inferior aspect of the main trunk in its 1st surgical division (excepting the superior intercostal occasionally seen on the right side, oftener on the left, but in all cases much smaller than the vertebrals). The thyroid axis and its branches are in contact with the inner border of the salenus anticus. The internal mammary will be found just beneath and opposite to the axis. It can be secured in either of the 6 upper intercostal spaces by making an oblique incision, the centre of which will be between \ and | of an inch distant from the margin of the sternum. Care should be taken not to wound the pleura in passing the aneu- rism needle around the vessel. Ligature of the Suhdnvian Arteries in their 2d and %d Surgical Divisions, ^\iQ scalenus anticus muscle on both sides of the neck is the guide in these operations, and it can be found as follows: From the mid- dle of the interclavicular notch, measure along the clavicle to the acromion process. One-fourth of this distance from the median line will be opposite the centre of the scalenus anticus. Drawing the skin well down upon the clavicle, make an incision through it upon this bone, the incision extending one inch toward the median line, and two inches toward the acromion process, from the middle of the scalenus. Make a second incision at right angles to this, about 1 J inch in length in the axis of the scalenus, terminating in the first incision at tlie point indicated above as the centre of this muscle. The outer fibres of the clavicular origin of the mastoid muscle are then divided upon a carefully inserted director (the large subclavian vein is almost in contact with this muscle here). The internal jugular vein seen in the anterior portion of the wound will be care- fully drawn to tlie inner side, the operator keeping well above the junction of this with the subclavian and thus avoiding the lymphatic duct, A prominent plexus or group of veins, viz., the external jugular^ transversalis colli^ and suprascapular, will be seen traversing the wound coming from their respective origins, toward the subclavian near the jugular. These should be secured and divided. Dissecting carefully, the suprascapular and transversalis colli arteries will be observed running in general in the direction of the first incision. The posterior belly of the omo-hyoid may be found in the upper margin of the wound, crossing the scalenus at about a right angle. 158 PRIZE ESSAT. The transversals colli and the suprascapular may be secured or held to one side, the finger passed along the scalenus until the rib is felt, when the artery will be found just behind the muscle. If it shall have been determined to tie the artery in its second portion, the scalenus anticus muscle will be cut upon a director, the operator being careful to avoid the phrenic nerve which crosses the muscle in front, coming from above downwards and inwards. (It is between the layers of the sheath of this muscle.) The ligature is next passed around the artery from before backwards, care being taken not to wound the pleura. In all cases of ligature in this division, the posterior scapular (if present and within one inch of the ligature), the branches of the thyroid axis, the vertebral, and the superior intercostal should be tied, in order to remove the too constant cause of secon- dary hemorrhage which the rSsume of the surgical history of this operation will show to be one of the prime factors of death. If the third division of the artery is to be secured, the part of the above operation relating to the division of the scalenus and ligature of the branches will be omitted. 1l\q posterior scapular artery alone will require the ligature, with the common trunk. In this last operation the nearest cord of the brachial plexus must be carefully excluded, posteriorly to the artery; the subclavian vein in front and below. Depression of the shoulder and clavicle and extension of the head backward and slightly to the opposite side will facilitate ligature in the first and third divisions and in ligature of the innominata. Ligature of the 2d and Sd divisions of the left subclavian is accom- plished by the same procedure as for the opposite side. The operation for ligature of the 1st portion of the left subclavian is more difficult and dangerous, since the vessel is more deeply situated and has the thoracic duct in dangerous proximity. Find the anterior scalenus muscle by the rule heretofore given. One inch external to this point, commence an incision (the integu- ment having been pulled down as before) which is carried along the clavicle to the sterno-chvicular articulation. Divide the sterno- mastoid, and after this the sterno-hyoid and sterno-thyroid muscles. The subclavian artery will be seen ascending almost vertically just behind the sterno-clavicular junction. The internal jugular vein will be drawn outward, and, passing the finger along the inner border of the scalenus muscle, the artery will be felt to pulsate. The thoracic duct usually is to the right of and a little behind the artery oppo- site the upper border of the sternum. On a level with the insertion INNOMINATE AND SUBCLAVIAN ARTERIES. 159 of the scalenus it arches to the left, crosses in front of the subclavian, in front of the scalenus, behind the internal jugular^ and curves downward to empty into the subclavian at its junction with the jugular to form the left innominate vein. On account of the intimate relations of the thoracic duct to the left subclavian artery as this ves- sel goes behind the scalenus, the ligature should not be attempted close to this muscle, nor should the dissection be carried fully to the scalenus. The artery should be tied as low down as possible, the duct being less likely to be injured here, since in passing behind the aorta it is deeper than the artery. It will be found behind and to the right, the pneumogastric in front and to the right, the left vena innominata crossing in front, while the pleura is directly be- hind. (I consider this operation the most formidable in the domain of operative surgery. It has been undertaken only once (by J. K. Eodgers, of New York^); the case terminated fatally.) Ligature of the thyroid axis and internal mammary artery near their points of origin on the left side is not justifiable, on account of the proximity of the thoracic duct, which by virtue of its difiicult recognition renders operative procedures in this quarter exceed- ingly dangerous. In very rare instances an anomalous origin of the right subclavian artery, with absence of the innominate, may occur. As seen in Fig. 5, the order of origin is : first, right and left carotid (usually from a common origin), then the left subclavian, and lastly, and from the third portion of the aorta, the right sub- clavian. From this origin the subclavian passes behind the oeso- phagus and trachea to the right, and assumes its normal position "behind the scalenus anticus. In still rarer instances the aorta is reversed, and with it the order of origin of its branches. 1 See History of Ligature of Subclavian in 1st Surgical Division. SURGICAL HISTORY OF THE INNOMINATE AND SUBCLAVIAN ARTERIES. 11 PRIZE ESSAY. Ligature of tht , . w Turk Mad. Bs- ^orri. Conlrlbnllotu; lol-rsetlDiiieuriierTi Qnj'8 Hoap. Kaporis, INNOMINATK AND 8DB0LAVIAN AR Arteria Innominata. <b.d<iUr<d ■Ed nftar 2.M dsT. imllfnl wm » fat Iniproorl [hul hg vtlkad KloH ibaal tlus boapital nardi ; ■i.M, btuorthiRs from viiuQd, aad oD 34Ih. Kllk. and 2eih oan. llDued, and ho dlnd ok SCib ilar lilsTd. "'Intop';: Jano^uCi) >ai cigisd on central >1d«sr LIf. th'Mmil'^« o"( lit Te.»rinS tha pli'Dca, nor of [ha tordUl fuai ot tl,« .on.. (Jathenb. aboa7& liVlf"ch JKDi Iha In. PBIZB GSSAT. Ligature of the (eU.): Horrii Contrib. ';X.7d."T.' JCS.- t HBlI.Kftlllmoia, INNOMINATE AND SUBCLAVIAN ARTERIES. 165 eria Innominata — continued. ate of eration. V »* - - O 9 « «> rf ® O « 1^ s 0« BB8ULT. Recovery. Condition. Cause of death, dnte after op. REMARKS trch 15, 1822. 1824. eo. 24, 1827. After few weekn, and on 66aud 67 days, 60 h'rs. None. ept. 7, 1830. Oc- curred. During opera- tion, and im- medi- ately after. 14 67th day. Hem. 60 hours. Hem. 8th day. Exhaus- tion. (Pyamia?) i Hemorrhage. ffth day. Exhaus- tion from hemor- rhage, venesection (possibly pyaemia), and pericarditis. ,0n March 15, 1822, the operation was made, intending to tie the subclavian in Its Jlrst portiov^ but as in the catte of Mott, this vessol was so involved in the disease that the innominate was tied one inch from the aortic arch. Theanfurinmhad exiKtrd about one year, immediately after operation, tumor dimin- ished in size, and patient did well for first tew weeks. Hem- orrhage occurred later and was repeated until death ensued on the 67th Any. Autopsy showed that the central end of the liga- tured vessel was closed per- fectly. The hemorrhage was from distal side. (Am unable to obtain details of this case. — Author.) One year before operation patient had been struck on shoulder, which dwelled immediately, but subsided on application of cold. 6 weeks before operation tumor had reappeared and increased rapidly in Hire. Dec. 2-1 th, lb27, innominate tied. Inafewhour^ difficult breathing, pain, right arm blue ; bled patient 2() oz. He continued to grow weaker on 25th, 26th, 27th, and 28th of Dec. 5 days after operation, pus in wound, which increased in quantity. Patient died 8 dayx after operation, from exhaus- tion. Autop<iy: Cellnlar tissue in region of wound infiltrated with pus. Innominate closed, ligature not being separated. Circumscribed pneumonia of right lung. (Pyemia. ?) No details of tniii case. Operation Sept. 7, 1810; innomi- nate diseased and dilated ; after ligature hero, from wound con- trolled by compression with sponges ; Ist and 2d day doing well; was bled 15 ounces; 3d day, patient walked agood deal, and went into the yard ; 4thdt<y, sudden change for worse, and died 5th day after the operation. Autopsy: Pericarditis; aorta enlarged; innominate, carotid, subclavian,