This operations has been performed in about ten cases; in nine upon the first stage of the right subclavian, and in one upon the first stage of the left: all these cases were attended with fatal results.

A Lancinating Character

This recurred at intervals till August, after which it remained permanently, being, however, attended with increased severity at intervals.

"August 22, 1835. She was seen by Dr. Ireland, Messrs. Wilmot, O'Beirne, and Hayden, for the first time.

" Sept. 7. The patient was admitted into the Anglesey Hospital. On examination, a large pulsating tumor was observed, situated internally to the axilla, parallel to the upper edge of the pectoralis minor, and extending above the clavicle: it is circumscribed, and has pulsation referrible to its inferior part. There is considerable tension on the upper portion of the tumor, the size of which can be diminished by pressure. Comparing the clavicle of this side with the opposite one, the former appears somewhat displaced, being pushed upwards. The arm, forearm, and hand were much swollen and cedematous some days since, and 'bruit de soufflet' was audible over the tumor.

" The results of stethoscopic examination were not unfavorable in reference to the operations for this disease, which is declared to be aneurism of the subclavian artery extending to the scalenus. She now describes the pain as darting through the tumor to the back of the shoulder, and down to the elbow. She also complains of an almost insupportable sense of weight and numbness in the whole extremity, although the swelling of it is inconsiderable".

Operation

On September 15, 1835, Mr. Hayden proceeded to perform the operations in the following manner :

"The patient was placed on the back upon a large table, furnished with mattress and bolsters; head slightly depressed, and turned to the left side. First incision, commenced nearly at the left sterno-clavicular articulation, traversed the upper margin of the sternum and clavicle, and terminated beyond the posterior or acromial margin of the sterno-mastoid muscle, having divided the integuments and platysma, including subjacent adipose tissue of about a quarter of an inch in depth. Second incision, commenced about four inches above the sternum, a little to the left of the mesial line of the neck, so as to terminate by falling at right angles on the commencement of the first incision, dividing the parts to the same depth: two sides of a triangle were thus formed, the apex at the sternum. The flap, consisting of integument, platysma, and adipose layer, was raised from the apex upwards and outwards: the outline of the sterno-cleido-mastoid was now very distinct, but still covered by the superficial fascia; the latter was carefully divided immediately above the sternum, corresponding to the anterior edge and lower extremity of the sternal portion of the sterno-cleido-mastoid. A director was next introduced beneath this muscle, the fibres of which were divided at about a quarter of an inch from the sternum and clavicle, and precisely parallel to its origin. The muscle was now raised upwards and outwards with the handle of a scalpel: a small vein was here tied. In the next stage of the operations, the sternohyoid and sterno-thyroid were divided upon a director. Hemorrhage from a small artery and vein so inundated the part, that it was found necessary to secure them before the operation was proceeded with. After the displacement of some cellular structure with a director, the innominata, carotid, and subclavian were felt; compression of the last-mentioned vessel suspended pulsation at the wrist and tumor. The first part of the subclavian was found not involved in the disease, and, consequently, it was decided that this vessel should be tied in preference to the innominata, which had been clearly exposed, and which, from its direction, and being uninterfered with by the clavicle, seemed to offer much less obstacle to the passage of the ligature; this was, at first, attempted with an aneurism-needle, made of silver, in order that it might be bent so as to present a degree of concavity to the clavicle, to be determined by the displacement of this bone, and the depth of the artery. The eyed part of the needle, for about an inch, was made to slide off and on, like the canula of a trocar, so that when the extremity of the needle was brought around the artery, the eyed portion, with the ligature, might be withdrawn. But when the handle of the instrument was depressed, the upper part slipped from the lower before the latter had passed under the artery. The vessel was subsequently secured with Mr. L'Estrange's needle.

" On the 25th, though positively forbidden, she got out of bed, and walked about the room. " Subsequently, at two o'clock p.m., she would not suffer the nurse to pass the bed-pan under her, but got out of bed; while in the act of doing so, and rising upon her right hand placed upon the bed, considerable hemorrhage suddenly set in.

" The patient died on the 27th, twelve days after the operations. The artery at the side of the ligature was gaping irregularly for three-fourths of its calibre; the remaining fourth was sound, and retained the ligature."*