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LEFT   SUBCLAVIAN   ARTERY

          FOR  SUBCLAVIAN ANEURISM;
                                       /
WITH A REMARKABLE DEVIATION OF THE  VESSEjP AND CONSEQUENT CHANGE
                      OF  ITS REHATIONSgr

               BY J. MASOnMrREN, M.D.
  The great mortality attending the  ligature of the larger arterial
trunks, and of the subclavian in particular, gives interest and im-
portance to any case of operation on those vessels.  In the latter
this interest is increased by its deep situation, causing in many cases
a great difficulty of reaching it, and by the importance of the organs
in its  immediate neighborhood.  According to the valuable tables
furnished by Dr. Norris, in some former  numbers of this Journal,
out of 69 cases of ligature of the subclavian artery, 36 recovered,
and 33 died, or nearly one-half.  In operations on the iliac arteries,
out of 118 cases, 85 recovered, and 33 died.   From  38 cases of
operation on the carotid artery for aneurism, 22 recovered, and 16
died.  In every instance where  it has  been necessary to place a
ligature on the subclavian artery  on the tracheal side of the scaleni
muscles, the result has been fatal.
  The case which I propose at present to relate, offers some pecu-
liar points of interest, apart from the general one of the ligature of
the vessel.  Among the principal of these may be mentioned  the
fact of a ligature having been applied to the artery for an aneuris- 
9
mal tumor situated above the clavicle, being, so far as I am aware,
the first case of this kind that has had a successful result,  because
the recorded aneurismal tumors in that situation have required the
application of  a ligature within the  scaleni, and the termination, as
stated above, has been unfavorable.   Secondly, the anatomical pecu-
liarities in the relations of the vessel, to which may be attributed the
possibility of the  ligature  on  the outside of the scaleni.   Thirdly,
the rapidity with which the collateral circulation  was restored, the
pulse having been felt at the wrist twenty-four  hours after the ope-
ration.  Finally, the length of time  the ligature remained attached,
ninety-six days, notwithstanding all safe  means  were made use of
to detach it.
   Without  further  prelude  I  shall proceed to the  description of
the case.
   Miss A., thirty years of age, of delicate constitution, had a con-
genital  club-foot  of the worst  kind, and, in consequence,  a double
curvature of the  spine.  For the  former of these she was treated
eight or ten years since by Dr. Brown at his infirmary, and the foot,
after the section of the tendons, followed by the appropriate treat-
ment, was completely brought into its natural position, so that  she
was enabled to walk with ease, without the aid of any mechanical
support.  The curvature of the spine  was  submitted to a similar
treatment with the same successful result.
   At the request  of Dr. Brown, she consulted  me in the early part
of December,  1847, for an aneurismal tumor situated just above the
scapular  end  of  the  clavicle, about the size of a pigeon's egg, of
which she gave the following history:
   Four months previous, while in attendance on a sick brother, she
had occasion  to  draw the cork from a  bottle, and  felt at the mo-
ment a sudden crack at the point where  the present tumor is situ-
ated.  Her attention was not  attracted to it at the moment, but a
short time afterwards a small swelling, having  a decided pulsation,
was distinguished at that spot, which has gone on increasing until 
3
it has  attained  its present size.  It had a powerful pulsation, and
possessed the usual thrill characteristic of an aneurismal affection.
  After  having examined the tumor and learned its history, I en-
deavored to discover the  subclavian artery in its normal situation
beneath the clavicle, at the  point where it passes over the first rib.
To my surprise, no large vessel  or  any osseous protuberance an-
swering to the tubercle of the first rib, usually taken as the guide to
the artery in this position, could  be  found.   Different parts of the
neck were then explored, which finally led to the discovery  of a
large artery passing obliquely upwards, parallel to, and about an
inch removed  from, the external border of the trapezius  muscle.
Compression being made at this  point, the  pulsations of the tumor
ceased, as well as the pulse at the wrist.   There was no question,
therefore, in my mind, that this  was  the subclavian artery, but it
was more difficult to determine the  cause  of this remarkable  ano-
maly.
   I now sought for the first rib, and to my surprise discovered both
the first  and a  part of the second rib  passing  obliquely across the
neck above the clavicle.   The insertion of the scalenus anticus mus-
cle into the first rib, was at length distinguished ; the tubercle, how-
ever, was not  sufficiently developed to be manifest  to the touch.
The whole osseous system of the chest in this case seemed to have
undergone a partial displacement.   The  spine and ribs attached
had been, as it were, moved upwards;  while the sternum was car-
ried in an opposite direction.
   Making a strong compression  on the vessel above  the tumor, the
arm became extremely painful  with a sensation of numbness, and
on a subsequent and more  careful  examination the whole brachial
plexus of nerves could be discriminated, in immediate contact with
the artery.
   As the tumor was rapidly increasing, it was evident, that, con-
sidering its situation and  the great danger of delay, no  time was to
be lost, if any surgical operation was to be resorted to for its relief. 
4
  The patient, a  person of much fortitude and force of character,
agreed at once to the course advised.  The operation was perform-
ed, on December 24th, in the presence  of Dr. J. C. Warren, Dr.
Brown, Dr. Buckminster Brown, Dr. Bartlett, of Roxbury, Dr.
Morland and Dr. Slade.
  An incision, about two inches long, was made, extending from
near the outer and upper edge of the sterno-mastoid muscle down-
wards, in the direction of the scapuloclavicular articulation, and an
inch from the edge of the trapezius muscle, the pulsations of the
vessel being the principal guide, as the other anatomical marks  were
wanting.  This incision divided the skin and superficial fascia; a
second cut opened one of the branches of an artery given off  from
the thyroid axis, which  was  tied.   A nervous band  of some  size
was now encountered, and at its side and directly over the artery
a large vein, apparently the external  jugular.   The vein was car-
ried to the  upper part of the wound  with a silver hook, and the
nerve to the lower ; the dragging upon the latter  caused a disagree-
able and somewhat painful sensation in the arm.
  The sheath of the vessel was next opened, the cellular membrane
around it cleared away, and the  aneurism needle, unarmed, passed
from below upwards, on account of the  difficulty of  introducing it
in the contrary direction from the interference of the scalenus  anti-
cus, which  had its  insertion just below.  The needle  at once en-
countered and raised the lower nerve of the brachial plexus, which
was in the most intimate  contact  with the artery.  By depressing
the handle and urging the point forwards, with careful manipulation
the eye of the needle  was without difficulty brought out between
these two organs.  The instrument was now threaded with the liga-
ture and withdrawn.  Careful exploration was  made  to ascertain
if any nerve was  included in the ligature, the painful sensations in
the arm caused by drawing the ligature downwards at first leading to
the supposition that this might be the case.  But' when the  same
traction was made  directly upwards, no pain was felt; the former 
5
sensations being produced by the dragging on the  cervical portion
of the brachial plexus, owing to their connection with the vessel.
  The ligature was now tied, and the wound dressed.  The  pulsa-
tions in the aneurismal sac, as well as those of the radial artery at
the wrist, at once ceased, and all appearance of tumor vanished.
The patient's arm and  hand were a little cold  directly after the
operation, but being rolled in flannel they soon regained their natu-
ral temperature.
  25th.—Found  her quite  comfortable.   She had passed a quiet
night.
  26th.—Patient states that the pulse at the left wrist returned for
a time last evening, it then disappeared, but returned again, though
faintly,  this morning.   I could not discover it at the time of my
visit.
  27th.—She has been somewhat troubled by occasional  pains in
the arm.  The pulse was felt yesterday once or twice by Dr.  Buck-
minster Brown, being  intermittent.  The wound has healed  by the
first intention.  She has suffered occasionally from  palpitation of
the heart.
  29th.—The pulse was perceived, though feebly, at the wrist, but
could not be  detected  in the axilla.  The spot formerly occupied
by the aneurismal tumor, now presents an obvious depression.
  Jan. 2d, 1848.—The pulse is constant at the wrist.
  I4lh.—The ligature  still remains on the artery,  notwithstanding
the traction daily made by the patient in accordance with my direc-
tions.   A number of large vessels, taking their origin from the  sub-
clavian, exist  in  different parts  of the neck.   One of these,  appa-
rently the supra-scapular, passes directly over the sac, and pulsates
so strongly as at first to convey the impression of a return of pulsa-
tion in the aneurismal tumor.
  March  30th.—Once  or twice  in  the  course of the last two or
three weeks, finding that the ligature on the vessel was not  disposed
to become  detached, I have seized it with the forceps, and, holding 
6
the artery  forcibly  down on  the rib, have twisted the thread with
considerable force.   This was done for the third  time yesterday,
and immediately afterwards  the  ligature separated, ninety-six days
after the operation.
  The wound almost at once closed.
  I saw this patient  on  September  14th for the last time.  At that
period she was quite well, had recovered the use of her  arm, and
was in no way incommoded by the operation to which she had sub-
mitted.  The aneurismal tumor had in a great measure disappeared ;
but it still conveys the  impression of containing a  fluid.  Directly
on its surface, and  incorporated with it,  is a  very large arterial
trunk, supposed, as above stated, to  be the supra-scapular.   This
vessel pulsates powerfully, and at first gives an appearance of pul-
sation to the tumor ;  but by  careful  manipulation can be separated
from it.  The  pulse at the wrist still remained a little less strong
than in the  corresponding artery of the other side.
  Boston,  Nov. 1848.
  To those persons who may have noticed a case of ligature of both
carotids, in the April number of this Journal  for 1846, an account
of the state of this patient, after  the  lapse of three years, may not
be without interest.
  The object of this operation, it may be remembered, was to allow
of the excision of a fungous tumor occupying nearly the whole of
the lower lip, and based on an  erectile tissue pervading the tongue,
face, neck and chest.  This tissue was rapidly increasing, and it
was hoped that its growth might be arrested by thus cutting off the
direct supply of blood to it.
  The arteries were tied in the latter part of the year 1845, and the
tumor of the lip was then  excised without the occurrence of any
alarming hemorrhage. 
i
  This  patient I have had an opportunity of seeing within a few
months, and of making some observations on the slate of the circu-
lation in those parts about the face and neck supplied by the caro-
tids.
  The situation of the temporal arteries being explored, no appear-
ance of pulsation could be discovered  in  those vessels.   The same
was found to be the case in regard to the labial arteries.   The an-
gular arteries, where they inosculate with the nasal branch of the
ophthalmic, gave the faintest pulsatory motion.
  In the region of the  neck were  a number of large vessels having
their  origin from the  subclavian,  among which the  supra-scapular
was chiefly to be distinguished.
   The lip was rather more  full  in appearance than when the report
of  the case was made, but free from ulceration.
   The functions of the brain had not in any way been disturbed.