The considerations of the functions, size, and situation of the innominata,as well as its relations not only to the heart and aorta but also to the surrounding parts,at all times rendered the study of this vessel a subject of interest and impor tance in the eyes of the operative surgeon; but it is comparatively of later years since Mr. Allan Burns tirst directed the attention of the profession to the fact that circulation through this vessel might be suddenly arrested without the functions of the brain, and power of the superior extremity being of necessity de stroyed, that surgeons have been found bold enough to attempt placing a ligature upon it.
There are three eases upon record in which a ligature has been placed upon the trunk of the innominata itself. The first operation was per formed by Professor Mott, of New York, on the 1 lth of May, 1818. The patient died on the 26th day after the operation from repeated hemorrhage resulting from ulceration and yield ing of the vessel.
The second was by Professor Graeff on the 5th of March, 1829. The patient died on the sixty-seventh day after the operation from re peated hemorrhage.
The third was by Mr. Lizars at the Edin burgh Royal Infirmary, on the 31st of May, 183?. The patient died on the twenty-first day after the operation, likewise from hemorrhage. This artery was likewise tied by Mr. Bland on the 25th March, 1832. The patient died on the 13th of April, three weeks after the operation. The following are the steps of the operation. The patient being placed in the horizontal po sition with the shoulders raised and the head thrown back, make an incision of about two inches upwards along the anterior margin of the sterno-eleido-mastoid muscle of the right side, commencing at the upper edge of the sternum : from the inferior extremity of this carry another of similar extent outwards upon the right clavicle; these should divide the skin and subcutaneous tissue : next dissect this flap from below upwards and reflect it, exposing the platisma muscle; cut through this muscle and the superficial fascia beneath it, and then care fully detach the sternal insertion of the sterno mastoid muscle and anterior layer of deep fascia, and should there not be sufficient space a portion of the clavicular fibres of the muscle. Having proceeded thus far, cut through the second layer of deep fascia, avoiding the vein already described as crossing this space, and subsequently divide the sterno-hyoid and thy roid muscles upon a director; this will expose the third layer of deep fascia covering the vessel ; a portion of this should be pinched up by forceps and an opening cautiously made in it, after which, with the handle of a scalpel, clear the artery of its surrounding cel lular tissue, draw the thyroid veins to the left side, the right plieuino-gastric nerve and in ternal jugular vein to the right, and pressing the left braelno-cephalic vein downwards, Barry the ligature obliquely upwards and inwards, or from the right to the left side, keeping it close to the vessel to avoid implicating the cardiac nerves.
Other plans of operation have been recom mended, but the above appears to me to be the best, as it gives the surgeon room and oppor tunity to see the state of parts through which he cuts, and enables him, if necessary, to tie either the subclavian or carotid, or both, with out further trouble or inconvenience.
It has been recornmended to remove a por tion of the first bone of the sternum ; but the idea will scarcely be entertained by any sur geon possessing a proper knowledge of the parts, or who is competent to perform the operation.
In the year 1827 Mr. Wardrop introduced a new method for treating aneurisms of the innominata in imitation of Brasdor's plan of tying the vessel beyond the aneurismal tumour. He tied the subclavian artery, having found that the circulation through the carotid was very weak if not quite obliterated.
The patient was a Mrs. Denmark. The results of this case have been recorded as fa vourable, but erroneously so. Mrs. Denmark died in the year 1829 of the same malady on account of which she underwent the operation.
Altogether his example has been followed in six cases, with various results.
In the first, Mr. Evans, of Belper in Derby shire, in the year 1828, tied the carotid for aneurism of the innominata and commence ment of the carotid. The patient recovered.
In the second, M. Dupuytren, on the 12th of June, 1829, tied the subclavian for aneu rism of the innominata. The patient died nine days afterwards.
In the third, Professor Mott tied the carotid for aneurism of the innominata on the 26th of September, 1829. The patient recovered.