" Thomas Duffy, aged 39 years, a man of robust frame, and twenty years employed as helper in a stable, was admitted into Jervis Street Hospital, April 15, 1836, under the care of Mr. O'Reilly, for aneurism of the right subclavian artery. He has lived a life of continued intemperance, always drinking, but never incapable of attending to his duty. The aneu-rismal tumor was distinctly circumscribed, of a somewhat oval shape, and measuring in transverse diameter two inches and a half, and in the vertical direction two inches. The pulsation could be distinctly felt in all parts of the tumor, and pressure on the subclavian artery not only commanded the pulsation of the sac, but even diminished its contents to the degree of rendering it flaccid ; finally, the bruit de soufllet was distinctly audible over all its surface. The first time he observed this tumor was in February last, and since that time he thinks it has made little progress. The symptoms he complained of on admission were, numbness of his fingers and uneasy sensations in his arm and forearm, with occasional cramps, since last Christmas. For the last eight or nine weeks he has been obliged to remain almost constantly in bed, with his arm extended from his body, as he suffered considerable pain whenever he walked about for any time, or approached his arm to his side; in bed, however, with his arm extended, he is quite free from pain. His general health did not seem impaired, and his heart and lungs were sound, judging from careful physical examination. On the whole he appeared to be a favorable subject for the operations which was decided on at a consultation held with the hospital surgeons: the patient, being informed of the nature and urgency of his symptoms, expressed his willingness to submit to any operation which would give him relief. Accordingly, at two o'clock the following day (September 16), Mr. O'Reilly proceeded, with the assistance of his colleagues, to perform the operation.

* Lancet, 1837.


The patient being placed in Heurteloup's bed, with his head slightly depressed and turned to the left side, so that the light from the sky-light might fall into the deep space in which the artery was imbedded, Mr. O'Reilly commenced the operations in the following manner, standing by the patient's right side. He first drew down the integuments of the lower part of the neck over the clavicle with his left hand, and then cut freely on the bone, beginning his incision about the centre of the clavicular origin of the right sterno-mastoid muscle and terminating it over the trachea, opposite the centre of the sternal origin of the left sterno-mastoid muscle; this incision was about four inches in length. The next incision was made through the integuments along the internal margin of the right sterno-mastoid, and terminating inferiorly in the centre of the preceding incision; in the same line the superficial fascia and platysma were divided successively on a director. The sternal origin and internal half of the clavicular origin of the right sterno-mastoid muscle were divided transversely close to the bone, and detached. On introducing the finger, the line of the carotid artery could be distinguished, and its pulsation felt. The deep fascia was next divided, and a little of the internal margins of the sterno-hyoid and sterno-thyroid muscles, so as to expose the carotid artery, the sheath of which was cautiously opened by pinching a small portion of it with a forceps, and dividing the raised portion of it horizontally. A blunt silver instrument the size of a small scalpel, with a round point, was used in the subsequent steps of the operation. The carotid artery being taken as a guide, the subclavian artery was easily exposed lying at the bottom of a very deep cavity. The jugular vein was drawn outwards by means of a curved spatula, and the pneumogastric nerve inwards by a similar instrument. Mr. L'Estrange's needle, armed with a three-threaded ligature, was passed round the artery from below upwards with facility, and without disturbing the artery in its situation. The ligature being tightened round the vessel, the edges of the wound were brought into contact, and retained so by two strips of adhesive plaster; the operation occupied only twenty-five minutes, and not more than a teaspoonful of blood was lost. Three hours after the operation he felt comfortable and well in every respect, and heat and sensation were the same as in the opposite arm.

Subsequently the patient had repeated hemorrhages, and died upon the twenty-third day.

Post Mortem Examination

The divided extremities of the subclavian artery were patulous and separated nearly two inches by coagula: their edges were jagged and irregular, and there seemed not to have been the slightest attempt at the reparative process. The distal end of the artery was of the natural size. External to the scalenus anticus there was a sudden enlargement of the artery or aneurismal swelling, which extended four inches to the commencement of the axillary artery. On its upper and outer surface were stretched the brachial nerves. About an inch from the commencement of the tumor the clavicle passed over it, and made a depression in it. The arteria innominata was healthy and the heart natural: the trachea red externally, and pale internally, was filled with a frothy mucus. A small portion of the upper part of the lung was hepatized. Bronchitis of the right lung; left lung healthy; no effusion into the thorax. A second aneurism about an inch in diameter was found on the axillary artery in the first stage of its course. The account of this case is abridged from the notes of Mr. Banon, one of the surgeons of the Hospital.

Mode Of Performing The Operation

The patient should be placed in the same position as in that recommended for tying the arteria innominata. The first incision should commence immediately above the sternum, at the internal margin of the sterno-mastoid muscle, and be continued horizontally outward along the anterior and upper portion of the clavicle for the extent of about three inches : the second incision, about two inches long, should descend along the internal margin of the same muscle, so as to terminate inferiorly in the internal extremity of the preceding incision. The flap of integument thus formed is to be dissected up, and the lower part of the sterno-mastoid exposed. Behind this muscle a director should be now introduced, on which its sternal and part of its clavicular origin should be divided. In a similar way the origin of the sternohyoid, and then that of the sterno-thyroid, should be cautiously divided. By scraping through some areolar tissue we may now get a view of the carotid artery, and bypassing the finger between this vessel and the jugular vein, which is situated more externally, the subclavian artery may be felt. It is crossed near its origin by the pneumogastric and recurrent nerves, which must be drawn inwards, and the needle is to be carried round it from below upwards and inwards, on the inside of its vertebral branch. The cardiac filaments of the sympathetic nerve should be avoided, and the operator should bear in mind the vicinity of the top of the pleura, as it may be wounded in performing this operations.