Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

When any of the branches of the external carotid has been wounded, it ought to be tied by a similar operation at both ends, at the part wounded. If the surgeon cannot do this, and the hemorrhage demand it, the trunk of the external carotid is the vessel on which the ligature should be placed, not that of the common carotid.

232. The internal carotid artery, when wounded near the bifurcation of the common carotid, is to be secured by two ligatures, and the steps in the operation are the same as those for exposing the external carotid, the surgeon recollecting that the internal carotid is more deeply seated and to the outside of the external. A ligature may be placed on the internal or external carotid, close to the bifurcation, with safety; but if the wound of either vessel should encroach on the bifurcation, one ligature should be applied on the common trunk and another above the part wounded; but as neither of these would control the collateral circulation through the uninjured vessel, whichever of the two it might be, a third ligature should be placed on it above the bifurcation.

When the internal carotid is wounded through the mouth, at the upper part of the neck, it should be secured by the operation described on page 248, Aph. 216.

233. The arteria innominata arises from the upper part of the arch of the aorta, generally on a line nearly parallel with the upper edge of the cartilage of the second rib, ascends obliquely toward the right side, and usually divides opposite the sterno-clavicular articulation into the right subclavian and the right carotid arteries; the last of which appears to be its continuation, although the smaller in size. The arteria innominata is about two inches in length, rarely exceeding two inches and a half, although it is very variable both in length and situation, so much so as sometimes to render the operation of placing a ligature upon it during life impracticable. It is covered by the right vena innominata, which receives the left at a right angle, near the origin of the artery. Exterior to the vena innominata are the sterno-thyroideus and sterno-hyoideus muscles, some strong fascia covering the vein at its upper part, and the first bone of the sternum. The arteria innominata may ascend higher in the neck before it divides, in which case its pulsation will be perceptible in front of the trachea, and the subclavian artery will cross higher in the neck, which is one reason for not continuing the external incision down to the sterno-clavicular articulation in the operation on the right carotid. The subclavian artery, given off behind or a little above the articulation, proceeds outwardly for the space of one inch before it reaches the inner edge of the scalenus anticus muscle, which is about half an inch in width; so that the subclavian artery, when it clears the outer edge of the scalenus anticus muscle in a tall man, is not more than one inch and a half or three-quarters from its origin, even to the spot at which a ligature is usually placed upon it. The first branch given off is the vertebral on the upper and back part of the artery, distant half an inch from the carotid at the bifurcation. The thyroid axis is given off at the anterior and upper part of the artery, a quarter of an inch more outwardly, and the internal mammary often arises directly opposite from the anterior and inferior part of the artery, descending into the chest behind the junction of the first and second ribs with their cartilages. The inner edge of the scalenus anticus muscle is close to these two last vessels. The phrenic nerve, crossing this muscle obliquely, lies on the outside of the thyroid axis, and on the inside of the internal mammary artery; having crossed the subclavian artery at this part, it descends between it and the junction of the internal jugular and subclavian veins to the chest. Internal to this, some small branches of the great sympathetic nerve, which lies behind, pass over the artery; and still more internal, but distant about a quarter of an inch from the carotid artery, the par vagum crosses likewise. The only point at which the subclavian artery can be tied internal to the edge of the scalenus anticus muscle is at this point, on the inside of the par vagum, in a space scarcely more than one-quarter of an inch in width, to which the carotid will be the best guide. It would appear that a ligature may be as readily applied around the innominata, immediately below the bifurcation, as around the subclavian, although little or no reliance can be placed on success attending either operation.

From this view of the parts it will be evident that the operation may be done in the following manner: Raise the shoulders of the patient, and allow the head to fall backward, by which the artery will be drawn a little from within the chest. Let an incision be made over and down to the sterno-cleido-mastoideus muscle, the sternal origin of which, and nearly the whole of the clavicular origin, should be divided on a director, carefully introduced below it, avoiding some small veins which run below and parallel with its origin. An incision is now or previously to be made, two inches in length, through the integuments, along the inner edge of the muscle, which will admit of its being raised and turned upward and outward. Some cellular texture being torn through, the sterno-hyoideus muscle is brought into view, and should be divided on a director. The sterno-thyroideus is then to be cut through in a similar manner. A strong fascia and some cellular texture here cover the artery, having the nerves above mentioned running beneath it, the carotid being to the inside, the internal jugular vein to the outside. By following the carotid downward, the finger will rest on the innominata and on the origin of the subclavian, and a ligature may be placed on either. If on the innominata, the aneurismal needle (and several kinds should be at hand) should be passed from without inward, immediately below the bifurcation, close to the vessel. If on the subclavian, the surgeon must recollect that there is only about a quarter of an inch of this artery on which the ligature can be applied; this small space being bounded internally by the carotid artery, and externally by the par vagum above, and the vertebral artery below. The ligature should be applied close to the vertebral artery, the needle being passed from below upward, the greatest care being taken to avoid the recurrent nerve, which separates from the par vagum at this part, and winds under the subclavian and carotid arteries, to be continued upward to the larynx. If the ligature be placed on the arteria innominata, the same care must be taken to draw the par vagum outward, and to avoid the recurrent nerve. The edges of the wound should be brought together and dressed in the usual manner, the head being bent forward on the trunk, and maintained in that position, in order to relax the parts, and admit of their being kept in apposition.

This operation ought only to be performed in cases of aneurism of the subclavian artery, in which it is presumed that the disease extends as far as the external edge of the scalenus anticus muscle, but not more inwardly. The arteria innominata has certainly been tied five, if not six times in vain, and in two or three other instances the attempt failed, the operator not succeeding in his object. In Dr. Mott’s case the ligature came away on the fourteenth day, but the patient died from hemorrhage, in consequence of ulceration of the artery, on the twenty-sixth day after the operation. Dr. Graëfe’s patient also died from hemorrhage on the sixty-seventh day. It is evident, from these cases, that a man may live so long after the operation as to show that he does not die from its immediate effects, or from any that must necessarily take place. It is therefore possible that if the operation be often repeated it may eventually be successful.

234. The left subclavian artery rises perpendicularly out of the chest like the innominata, but on a plane much posterior to it, so that at the part where the vertebral artery is given off, which is about an inch and a half from the origin of the artery, it lies nearly an inch deeper from the surface than the vessel on the opposite side. It is covered by, or is more directly connected with, the important parts which are also in the vicinity of the right subclavian. The pleura adheres to it, and can scarcely avoid being torn in putting a ligature around it. The par vagum is parallel with and anterior to it. The internal jugular vein and the left vena innominata lie over it. The thoracic duct and œsophagus are connected with it; and the carotid artery is in front. So that with the most careful dissection it is not a very easy matter to place a ligature upon the ascending portion of the left subclavian artery, without doing more mischief than is compatible with the life of the patient.

Aneurisms of the arch of the aorta have been sometimes known to appear so far beyond the outer edge of the scalenus anticus muscle as to impress the surgeon with the idea that they arose from the subclavian artery, and that an operation on that vessel might be attended with success. This error is not likely, however, to occur in the present day, for the stethoscope will always point out the existence of such an aneurism within the chest, and will therefore demonstrate the impropriety of the operation. Aneurisms of this nature are usually attended by some circumstances indicating their more internal origin, independently of the information derived from the stethoscope. An operation should only be attempted when the case is free from doubt.

Whenever an aneurismal tumor in the neck is accompanied by any alteration of the sterno-clavicular articulation, the case is clearly one totally unfitted for any operation. The same may be said of any case of aneurismal swelling, either internal or external to it, in which the stethoscope applied on the sternum in the course of the arteria innominata, or of the arch of the aorta, indicates disease. A swelling at the root of the carotid is more likely to be an aneurism of the arch of the aorta, or of the arteria innominata, than of the carotid itself. The stethoscope will remove all doubt.

235. The subclavian artery has been frequently tied above the clavicle, external to the scalenus anticus muscle. It should be done in the following manner: The patient being placed horizontally on the table, in such a situation that the light may be directed into the hollow in the bottom of which the artery is to be tied, the shoulder is to be depressed, and an incision made along the edge of the clavicle, commencing one inch nearer the sternum than the clavicular edge of the sterno-cleido-mastoideus muscle, and carried outward to the extent of three inches and a half or four inches. The platysma myoides and the superficial fascia are to be divided, taking care not to injure the external jugular vein, which should be drawn to the outer side of the wound. By this incision the edges of the trapezius and sterno-cleido-mastoideus muscles will be exposed.