The tendon of the omohyoid muscle, or, in muscular subjects, a portion of its anterior fleshy belly, may be seen crossing the vessel from above downwards and outwards at the lower angle of the wound.

An enlarged lymphatic gland has occasionally given much trouble, by being mistaken for the vessel and cleaned, while the ligature has even been placed on a carefully isolated fasciculus of muscular fibres.

LIGATURE OF CAROTID BELOW THE OMOHYOID.--An incision in precisely the same direction as the former, but at a slightly lower level, is required, but the dissection is rather more difficult. The edge of the sterno-mastoid when exposed must be drawn outwards; the sterno-hyoid and thyroid inwards; the omohyoid upwards; the sheath opened, and the descendens noni or its branches drawn to the tracheal side. The jugular vein and vagus are both at the outer side, and must be avoided, while the inferior thyroid artery and sympathetic nerve both lie behind the vessel, and may be included in the ligature if care be not taken.

VARIETIES.--_Sedillot's Operation._--To secure the artery still lower in the neck: An incision two and a half inches long, from the inner end of the clavicle obliquely upwards and outwards in the interval between the sternal and clavicular attachments of the sterno-mastoid; this divides the superficial textures; the two portions of muscle must then be drawn apart. The internal jugular vein lies in the interval, and must be drawn to the outside before the artery can be seen at all, and it is this that makes this operation very difficult and dangerous, especially on the left side, where the vein is close to the artery, and probably even crossing it from left to right. The thoracic duct is behind.

_Malgaigne's modification of the above_ is an improvement: to expose the external attachment of the muscle, to cut it through and turn it to the outside, as in the operation for ligature of the innominate, then to divide or pull inwards sterno-hyoid and sterno-thyroid, thus exposing the sheath. The needle must be pa.s.sed from without inwards.

_Results._--Pilz has collected 600 cases, of which 43.16 per cent. died.

The united tables of Norris and Wood give 188 cases, with a mortality of sixty, or nearly one in three. These tables include cases in which the vessel was tied for wounds, and as a preparatory step in the operation of removal of tumours of the jaw, etc. Later statistics give a very much lessened mortality, due chiefly to the use of animal ligatures.

Of thirty-one cases in which it was tied for pulsating tumours of the orbit, only two died from the operation.[15] Rivington's statistics to a later date give forty-six cases on forty-four patients with six deaths.

Both carotids have been tied in the same patient twenty-five times, at intervals of less than a year; and it is a very remarkable fact that only five of these fifty ligatures proved fatal,--two in which both were tied on the same day, and three in which the operation was performed to arrest haemorrhage from malignant disease of the face and jaws--from gunshot wound,--and from syphilitic ulceration.

The external carotid, and also most of its princ.i.p.al branches, have been tied for aneurisms, wounds, goitres, enlargement of the tongue, vascular tumours on occiput and other lesions; also as a first stage in the operation of extirpation of the upper jaw, for the purpose of preventing haemorrhage. However, such operations are rare, and will probably become rarer still, and it is hardly necessary to describe the operations on each _seriatim_.

Aneurism of the external carotid or branches are rare; if idiopathic, ligature of the common carotid will be found at once easier, not more dangerous, and more effectual than ligature of the branch; if traumatic, the aneurism itself should be attacked, and the bleeding point secured by a double ligature. Wounds are common enough, but if accessible at all, the injured vessel should be tied at the bleeding point; if inaccessible (and under this head we may include wounds of the internal carotid), the common carotid must be tied.

No one would think of trying the superior thyroids for goitre, unless they were so manifestly enlarged, tortuous, and pulsating, as to render the operation so simple (from their superficial position) as to require no special directions; besides this, the cases in which it has been already done have given very little encouragement to repeat it.

As cases may occur in which any diminution of the cerebral supply is contra-indicated, and thus the more difficult ligature of the external carotid may be preferred to the more simple operation on the common trunk, and as the lingual may require ligature near its root, in consequence of obstinate haemorrhage from the tongue, short directions are given for the performance of both these operations.

1. LIGATURE OF EXTERNAL CAROTID.--Head in same position as for the common carotid. A straight incision parallel with the anterior edge of sterno-mastoid, but about half an inch in front of it, must begin almost at angle of jaw, and extend downwards nearly to the level of the thyroid cartilage. Cautiously divide skin, platysma, and fascia; the lower end of the parotid must be pulled upwards, and the veins, which are numerous, cautiously separated. The anterior border of the sterno-mastoid must be pulled backwards, and the digastric and stylo-hyoid forwards and inwards. The superior laryngeal nerve which lies behind the vessel must be avoided.

2. LIGATURE OF LINGUAL.--To secure this vessel either before it becomes concealed by the hyo-glossus, or after it is under the muscle, a curved incision is necessary, following the line of the hyoid bone, and especially of its greater cornu, but a line or two above its upper border. After the skin and platysma are divided, the posterior belly of the digastric must be recognised, which again will guide to the posterior edge of the hyo-glossus. The edge of the sub-maxillary gland may very probably require to be raised out of the way. The artery can then be secured, either before it dips under the hyo-glossus muscle, or after it has done so, by the division of a few of its fibres on a director. Care is needed to avoid injury of the hypo-glossal nerve, which lies above the muscle.

The internal carotid artery occasionally, but very rarely, is the subject of aneurism. It may, like any other artery, be wounded, especially from the fauces. The treatment of either of these lesions is ligature of the common carotid itself, in preference to ligature of the internal carotid. Guthrie's operation for securing the bleeding internal carotid at the injured spot, by dividing and turning up the ramus of the lower jaw, has never been performed in the living body, and is so difficult, dangerous, and unnecessary, as not to merit description.

LIGATURE OF SUBCLAVIAN.--_Note._--In consequence of the difference in the origin, and variety in the anatomical relations of the right and left subclavian arteries, in so far at least as their first stage is concerned, it is necessary to give a very brief separate account of each.

_Right Subclavian._--The innominate artery divides into the right subclavian and right carotid exactly behind the sterno-clavicular articulation. The right subclavian extends from this point in an arched form across the neck, between the scalene muscles, over the apex of the pleura, till, pa.s.sing under cover of the clavicle, it changes its name to axillary at the lower end of the first rib. For convenience of description, the artery is divided into three parts, which have very various anatomical relations, and differ from each other much in their amenability to surgical treatment by ligature. The anterior scalenus muscle defines the three parts, the first extending to the inner border of the muscle, the second being concealed by the muscle, and the third reaching from its outer border to the lower border of the first rib.

_Branches of the Subclavian._--While the deep relations of pleura, veins, and nerves can be noticed under the head of each operation in detail, one anatomical point must never be forgotten as influencing very much the success of all surgical interference with the subclavian arteries--_i.e._ the branches given off. To give any chance of success in the application of a ligature to such a large vessel, so near the heart, a large portion of artery free from branches is required, that the clot may be long, firm, and undisturbed. The first part of the subclavian gives off the vertebral, thyroid axis, and internal mammary; the second, the superior intercostal; while the third part has in most cases no branch whatever. In these anatomical differences we find the reason for the almost invariable fatality resulting on any interference with the first and second parts, and the comparative safety of ligature of the third part, without requiring to account for the difference on other grounds, such as depth of part, importance of nervous relations, or nearer proximity to the heart.

The second and third parts of both arteries are so similar to each other, that a separate account is not required for the two sides.

LIGATURE OF RIGHT SUBCLAVIAN.--_First Part._--_Operation._--An incision just at upper edge of sternum and right clavicle, extending from inner edge of _left_ sterno-mastoid transversely to outer border of right sterno-mastoid through skin, platysma, and exposing sterno-mastoid, to be joined at an angle by a second incision, which, two, three, or even four inches long, must extend along inner border of right sterno-mastoid. Flap to be raised upwards and outwards. The sternal attachment of the sterno-mastoid must then be cautiously divided, as also part or the whole of its clavicular attachment, according as room is required. The sterno-hyoid and thyroid muscles will then require similar division. The internal jugular will then be seen very prominent,[16] and will require to be drawn inwards or outwards, according to circ.u.mstances. The carotid and right subclavian arteries will then be felt lying close together crossed by the pneumogastric and recurrent nerves, the latter turning behind the subclavian. The nerves must be drawn inwards; the cardiac filaments of the sympathetic will then be observed, and drawn outwards. The subclavian vein lies below, concealed by the clavicle, and will probably not be seen during the operation. The needle should be pa.s.sed round the artery from below upwards, care being taken not to injure the pleura, which lies beneath and behind the artery.

_Results._--Twelve cases, all of which died; ten of haemorrhage, one of pleurisy and pericarditis, and one from pyaemia. Attempted in one case by Mr. Butcher, but the artery was too much diseased to bear a ligature.

The patient died on the fourth day.

LIGATURE OF LEFT SUBCLAVIAN.--_First Part._--This operation, which has been described by some as impossible, has, I believe, been only once performed on the living body. _Operation._--Incisions as for the preceding operation, except being on the opposite side. After the skin, platysma, and muscles have been divided, as already described, the deep cervical fascia requires division close to the inner edge of the scalenus anticus. The artery lies excessively deep, and great difficulty is experienced in avoiding injury to the pleura and the thoracic duct.

_Results._--Once performed by Dr. Rodgers of New York; death from haemorrhage on fifteenth day.

_Anatomical Note._--The course of the left subclavian in its first stage is much straighter, as its origin is much deeper, than on the right side. The pneumogastric, phrenic, and cardiac nerves lie parallel to its course; the oesophagus and thoracic duct lie behind it, and to its inner side.

LIGATURE OF SUBCLAVIAN.--_Second Part._--This very rare operation hardly requires a separate description, as the incisions necessary for ligature of the artery in its third part will, with very slight modifications, be sufficient for the purpose.

It has, however, special elements of danger in it, involved in the unavoidable division, of part at least, or probably the whole, of the scalenus anticus. The phrenic nerve, from its position on that muscle, requires special care to avoid dividing it, and in most cases the internal jugular vein is also in the way. The branches of the thyroid axis, which cross the neck, are quite in the line of the incision. The lowest cord of the brachial plexus lies immediately behind the artery, between it and the middle scalenus. The pleura lies just below it. The subclavian vein is generally quite safe, running in front of the scalenus anticus, and at a lower level.

The presence of the superior intercostal branch adds greatly to the danger of ligature of the vessel in this position, from its interfering with a proper clot.

_Results._--Dupuytren[17] performed it successfully for a traumatic axillary aneurism. Auchincloss[18] did it for a large true aneurism, but the patient died sixty-eight and a half hours after the operation.

Liston cut through the outer portion of the scalenus with success for an idiopathic aneurism. Thirteen have been collected by Wyeth with four recoveries and nine deaths.

LIGATURE OF SUBCLAVIAN.--_Third Part._--For this comparatively common operation, various methods of procedure have been suggested and employed.

In the dead body, where the axilla is free from swelling, and in thin patients, the artery in this third stage is tolerably superficial, and can be secured with ease. But in very muscular men, with short necks and well curved clavicles, and specially when the axilla is filled up with an aneurism, and the shoulder cannot be depressed, the operation becomes very difficult.

_Operation of Ramsden, Liston, and Syme._--_Position._--The patient lying on his back with his shoulders supported by pillows, and his head lying back, and drawn to the opposite side; the shoulder of the affected side must be depressed as much as possible.

_Incisions._--(Plate I. fig. 8.)--One through skin, superficial fascia, and platysma, along the upper edge of the clavicle, for at least three inches from the anterior edge of the trapezius to the posterior border of the sterno-mastoid, and in muscular subjects freely overlapping the edges of both muscles. Another two inches in length along posterior border of sterno-mastoid meets the first at an angle. On reflecting the chief flap thus made upwards and backwards, the external jugular will be seen, and, if possible, must be drawn to a side; if not, it must be divided, and both ends tied. The lower edge of the posterior belly of the omohyoid must then be sought; this leads at once to the posterior or outer margin of the scalenus anticus. The connection of the deep fascia to that muscle must then be very carefully sc.r.a.ped through, and by tracing the muscle to its insertion to the first rib, the artery is at once reached, lying behind the insertion. The pulsation of the vessel between the forefinger and the first rib will prove a great a.s.sistance; yet care is required, lest one of the branches of the brachial plexus be secured instead of the artery. The lowest cord lies very close to the vessel. The subclavian vein is not likely to give much trouble, from its being on a lower level, and (unless very much dilated) nearly concealed by the clavicle. The suprascapular artery is also hidden, but the transverse cervical crosses the very line of incision, and may give trouble, being occasionally much enlarged, so much so as even for a time to have been mistaken for the subclavian itself. If possible, both these branches should be saved, as being important means of carrying on the anastomosis for the future support of the limb.

An absorbent gland is occasionally in the way, and has even been mistaken for the vessel and carefully cleaned. Such may be removed without scruple.

Care must be taken not to injure the pleura, which lies immediately behind and below the vessel at the seat of ligature. Various instrumental devices have been invented for pa.s.sing the ligature. The simplest seems still to be best, a common aneurism-needle with a considerable curve.

_Other methods of operating._--A single curved incision above the clavicle, with its concavity upwards, of about three or four inches long, with its inner end rather higher than the outer (Green, Fergusson).

A linear transverse incision in the same situation (Velpeau).

A single linear incision perpendicular to the clavicle (Roux).

An arched incision (Plate IV. fig. 2) with its convexity outwards, and its base on the posterior edge of the sterno-mastoid, from three inches above the clavicle to the clavicular attachment of the muscle (Skey).

_Results._--Dr. Wyeth's Tables in 1877 give 251 cases with 134 or 53 per cent. of deaths.

The late Mr. Furner of Brighton reported a most interesting case, in which he tied both subclavian arteries at an interval of two years in the same patient, for axillary aneurisms, with success.

LIGATURE OF AXILLARY.--_Anatomical Note._--This vessel, the next stage in the continuation of the subclavian downwards, may be defined surgically as extending from the clavicle to the lower border of the teres major. From the depth of the vessel at its upper part, the numerous nerves, and the close proximity of the vein, the surgeon has carefully to study the anatomical relations. It, like the subclavian, is commonly divided into three stages, and, also like the subclavian, these stages are defined by the relations of the artery to a muscle, the pectoralis minor. Surgically we may draw a very close parallel between the two vessels, for we find that in the axillary, as in the subclavian, the first stage is very deep, and very rarely amenable to ligature; the second, still deeper and more rarely attempted, as in both the operation involves division of a deep muscle; while the third stage in each is the one most frequently chosen by the surgeon.

_First Stage._--Between the lower edge of the first rib and upper border of the pectoralis minor the vessel is deeply seated, contained in that process of deep fascia called the costo-coracoid membrane, and covered above by skin, platysma, and the clavicular portion of the pectoralis major. It lies on the first intercostal muscle and the upper digitation of the serratus magnus, while the cords of the brachial plexus are on its acromial side, and the axillary vein in close contact with it on its thoracic side, and frequently overlapping the artery.

_Operation._--The great desideratum is free access. An incision (Plate I. fig. 9), semilunar in shape, with its convexity downwards, must extend from half an inch outside of the sterno-clavicular articulation to very near the coracoid process, stopping just before it arrives at the edge of the deltoid, in order to avoid injury of the cephalic vein.

It must include skin, fascia, and platysma, and the flap must be thrown upwards. The clavicular portion of the pectoralis major must then be divided right across its fibres, which will retract. The arm must then be brought close to the side to relax the pectoralis minor, which must be drawn aside. The artery will then be felt pulsating, but hidden by the costo-coracoid membrane, which acts as its sheath. This must be carefully scratched through, the nerves pulled outwards, the vein avoided and pulled downwards and inwards, and the thread pa.s.sed round from within outwards. (Manec, Hodgson, and, with slight modification in the incision through the skin, Chamberlaine.)

Ligature has been performed in this position by separating the pectoralis and deltoid muscles, without dividing the muscular fibres (Roux, Desault).