Note 42 — PART SECOND. OF PARTICULAR SURGICAL SUBJECTS. (continued 6)

[I am induced to subjoin the following example of axillary aneurism for which the subclavian artery was tied, in the belief that, from the unique manner of its termination, it will be interesting and instructive to the reader. The particulars of it, together with an analysis of twenty-six other cases reported by different surgeons, will be found in the Western Journal of Medicine and Surgery for June, 1841.

Daniel Monday, a married negro, thirty-six years of age, of a stout muscular frame, and a brickmaker by occupation, consulted me, in February, 1841, for a circumscribed, pulsating tumour, produced by the recoil of the butt-end of a yager, and situated beneath the right pectoral muscle, extending from the clavicle down towards the cartilage of the fourth rib. It was of an irregular, conical shape, and about the volume of a large fist, measuring fully four inches at its base in one direction, by three and a half in the other. In its feel it was tense, as well as inelastic; the blood rushed into it with a whizzing noise, and the pulsation was so distinct that it could be seen at the distance of some feet from the patient. The clavicle was thrown above its natural level; the whole limb, from the top of the shoulder to the ends of the fingers, was benumbed, painful, and almost deprived of power; the pectoral muscle was much stretched; and the patient constantly inclined his head towards the affected side, keeping the elbow nearly at a right angle, and supporting it carefully with the opposite hand, to prevent tension of the tumour. The swelling of the limb, however, was slight; the temperature was also good, and the pulse at the wrist was nearly as distinct as in the natural state. For the last four weeks the pain was almost incessant; it was particularly severe at the chest and shoulder, and had become so agonizing of late as to deprive him of sleep, and even prevent him from lying down. The appetite was also much impaired, and the countenance expressive of the deepest distress. The tumour had grown with great rapidity during the last two months; and, as there was danger of its bursting, an operation was at once decided upon.

The patient was placed upon a narrow table of moderate height, the head and chest being elevated with pillows, and the face turned slightly towards the opposite side, while an assistant pulled at the wrist, to depress the affected shoulder. The integuments over the clavicle being stretched upon the chest, I made my first incision along the centre of that bone, beginning near the sternal origin of the mastoid muscle, and passing out towards the acromion process of the scapula for about three inches and a half; thus dividing at one stroke the skin, cellular substance, and fibres of the platysma-hyoid. The parts being allowed to retract, left the lower margin of the cut parallel, and on a level with the superior border of the clavicle. A second incision, about two inches in length, was carried along the posterior edge of the sterno-mastoid muscle, at a right angle with the preceding. The triangular flap thus formed was then dissected up and held away, care being taken not to interfere with the external jugular vein, or any of the smaller arteries of the neck. Having advanced thus far, the cervical aponeurosis was detached from the clavicle by cautious strokes of the handle of the scalpel, which laid bare the brachial plexus of nerves and the omo-hyoid muscle. At this stage of the operation a small vein, a branch of the subclavian, was divided, and, although it bled very little, it was immediately secured by a temporary ligature. Taking the omo-hyoid for my guide, I divided the loose cellular substance in the triangular space bounded above by the muscle just mentioned, by the clavicle below, and by the anterior scaleni muscle internally, and thus approached the artery as it passed over the first rib. The vessel here lay at some distance from the inferior branch of the brachial plexus of nerves, rather deeply behind the collar-bone; and with a common aneurism needle, armed with a double ligature of saddler’s silk, no difficulty was experienced in securing it, the instrument being carried from before backwards and from below upwards. The ligature was then drawn very firmly with the fingers, and tied with a double knot within a few lines of the anterior scaleni muscle: as soon as this was accomplished, all pulsation in the sac, as well as at the wrist, ceased. One end of the ligature being cut off, the other was left protruding at the inner angle of the wound, the edges of which were closed by three sutures and adhesive strips. Not half an ounce of blood was lost during the operation, which lasted twenty minutes.

The patient being put to bed, the limb was laid in an easy position, and wrapped in cotton wadding. In less than an hour the temperature, which had been considerably depressed, was thoroughly restored; the pain and numbness had greatly abated; and the poor fellow expressed himself more comfortable than he had been for a month. In less than twenty hours the tumour was quite solid; the ligature came away on the morning of the thirteenth day; and the patient was in all respects convalescent, the swelling having diminished fully one-half in size. No untoward symptoms of any kind occurred until the morning of the twenty-seventh day, when the patient was suddenly seized with intense pain in the right side of the chest, attended with short, hurried, and laborious respiration, quick and tense pulse, great anxiety of countenance, prostration of the vital powers, and entire subsidence of the aneurismal tumour. Being absent from town, he was kindly visited by my friends, Dr. T. L. Caldwell and Dr. S. B. Richardson, until he expired, early on the thirty-first day after the operation.

The body, carefully examined after death, was somewhat emaciated; the wound had completely cicatrised, and the pectoral muscles were a good deal wasted, though in other respects unchanged. The subclavian artery terminated abruptly at the outer margin of the scaleni muscle, where the ligature had been applied, its calibre being closed by a mass of solid fibrin, about one-third of an inch in length, which adhered firmly to the lining membrane, and thus presented an effectual barrier to the passage of the blood. Between this and the thyroid axis the vessel was occupied by a dark coagulum, which, as it was loose, was probably formed only a short time before death. Beyond the seat of the ligature the artery had a rough, ragged appearance, and was sufficiently pervious to admit of the ready passage of a small probe into the aneurismal sac. Superiorly the tumour was overlapped by the brachial plexus, while in front, at its lower part, was the subclavian vein, which, besides being thrown out of its natural course, was considerably diminished in size. No pus was anywhere perceptible, the structures involved in the operation being consolidated by plastic lymph. The aneurismal tumour, placed immediately below the clavicle, was of a conical form, and about the volume of a moderate-sized orange, being two inches and a quarter in diameter at its base. Its walls varied in thickness at different points, from half a line to the eighth of an inch; and its interior communicated, by means of an oval aperture, one inch and three-quarters in length by an inch and a half in width, with the pleuritic cavity: it was situated between the first and second ribs, nearly equi-distant between the sternum and the spine, and was the result obviously of ulcerative absorption induced by the pressure of the tumour. Both ribs were denuded of their periosteum immediately around the opening, and the serous membrane had a shreddy, ragged aspect. The aneurismal sac contained a few reddish clots arranged in a laminated manner, and closely adherent to its inner surface, especially at the part corresponding with the apex of the tumour.

The right thoracic cavity contained nearly three quarts of bloody-looking serum, intermixed with flakes of lymph and laminated clots; the latter of which were of a reddish-brown colour, and had evidently escaped from the aneurismal sac. The pleura exhibited signs of extensive inflammation; and the right lung was greatly reduced in volume, from the compression of the effused fluid. The left lung was considerably engorged, and at one or two points almost hepatized. The heart and pericardium were sound, as were also the abdominal viscera, and the larger arterial trunks.

From the description of this operation in the text, it will be seen that Mr. Liston recommends two incisions, as performed in the above case. Were I to be again called upon to tie the subclavian artery above the clavicle, I should certainly omit the vertical incision, from a conviction that it is altogether unnecessary: it does not expedite the operation, nor does it facilitate the application of the ligature.—ED.]