This operations has been frequently performed for aneurism and wounds of the axillary artery. Mr. Ramsden first tied the artery in the year 1809; since then it has been frequently the subject of successful operation. Dr. Post of New York first performed this operation with success in 1817, and Mr. Liston afterwards, in the year 1820: finding the artery diseased at the commencement of its third stage, Mr. Liston cut across the external half of the scalenus anticus muscle, and in this situation included the artery in a ligature.‡ In this city the operation in the third stage has been performed by Professor Colles, Professor Porter, Dr. Hutton, Mr. Ellis, and others.

The following method is recommended in order to expose this vessel: the patient should be placed lying on a table of convenient height, with the shoulders elevated, so that the light may fall directly on the parts exposed. The first incision should commence at the external margin of the sterno-mastoid muscle, immediately above the clavicle, and be continued transversely outwards for the extent of about three inches. The platysma myoides and fascia may now be divided on a director to the same extent. Some operators prefer dividing these three layers at once by cutting down on the clavicle after having previously pushed the shoulder upwards; such an incision will of course be above the clavicle when the shoulder is again depressed in order to continue the operations. In many cases, however, of large aneurism, these motions of the shoulder would be impossible. The lips of the wound should now be separated by retractors, and any fibres of the trapezius muscle which advance beyond its outer angle should be carefully divided on a director. The external jugular vein which now presents itself should be drawn to the sternal extremity of the wound: if, however, it should happen to lie more towards the acromial side, it should be drawn outwards; lastly, if it cross the centre of the incision, or if there be a second external jugular in this situation, it may be necessary to include it in two fine ligatures and divide the vessel between them. A plexus of veins, which usually next presents itself, should be separated with the handle of the scalpel, but injured as little as possible, as the further steps of the operation will be considerably obscured by the blood which these vessels throw out. The omo-hyoid muscle may be observed a little above the clavicle, from which point it ascends obliquely upwards and inwards. In a case operated on by the late Professor Todd, this muscle lay below the clavicle, and it became necessary to draw it up and divide it before the artery could be exposed. Connecting the margin of this muscle to the adjacent margin of the scalenus anticus, a strong fascia will be found, through which the operator should cautiously tear with his nail. The finger may now be passed behind the outer margin of the scalenus anticus muscle, in order to search for the subclavian artery. It should be borne in mind that the transversalis humeri artery lies nearly in front of the subclavian, passing horizontally either behind or immediately above the clavicle; the circumstances of its smaller size, and its crossing in front of the scalenus anticus muscle, may assist in distinguishing it. The difficulty of at once finding the subclavian has, however, occasionally been found greater than would have been expected a priori: the artery when exposed frequently contracts and its pulsation ceases; the margin of the scalenus anticus is rendered indistinct by its connection with fascia, and the welling of blood, the depth of the artery and alteration of the relative position of the part caused by the aneurismal tumor pushing up the clavicle, together with an enlargement of one or two lymphatic glands, present difficulties that require the greatest presence of mind, judgment, and knowledge of anatomy on the part of the surgeon. It has been suggested by Professor Hargrave, under these circumstances, as well as for the purpose of allowing the artery to be gently relaxed after having been secured, to saw through the clavicle.* Cruveilheir has also advocated a similar practice. Dupuytren recommends that some of the outer fibres of the scalenus anticus muscle should be divided if necessary, and this may be easily effected without injuring the phrenic nerve. We have seen that Mr. Liston was obliged to divide the fibres of this muscle.

* Lecons Orales, vol. iv. p. 530.

† See Edin. Med. and Surg. Jour., vol. xlv.

‡ Edin. Med. and Surg. Jour., No. 61.

The subclavian artery has been tied for aneurism of the arteria innominata in conformity with the recommendation of Mr. Wardrop. We have seen that the carotid artery has also been tied upon the same principle. A few words of explanation as to the rationale of this operations, called the application of the " distal ligature" may be useful at the present stage of the subject. It will be remembered that the Hunterian operation for the cure of aneurism consisted in the application of a ligature upon the artery between the heart and the aneurismal sac; the object held in view in this operation was the prevention of the direct flow of blood through the main channel into the tumor; this was followed by the coagulation of its contents, and ultimately by its entire absorption. The mode of operating for aneurism, known by the name of the distal ligature, was originally suggested by Brasdor, and was recommended by him in cases where no branch would intervene between the ligature and the sac, and where the surgeon could not well tie the artery between the tumor and the heart. It was supposed that, if no branch originated from the aneurism, or from the artery either above or below the aneurism, the blood would coagulate in the tumor, and that a cure would be accomplished by the absorption of the coagulum and the subsequent contraction and absorption of the sac. The principle upon which a cure is expected to follow this mode of operating is the same as that upon which varicose veins of the leg are treated, by making pressure upon the superior part of the saphena vein : the blood becomes obstructed in the vessel, a coagulum is formed, and an obliteration of the venous channel is accomplished. Mr. Wardrop reports the successful termination of the case in which he performed the operation already mentioned. He was, moreover, induced, from various considerations, to apply the principle suggested by Brasdor to the cure of aneurismal tumors of certain arteries, by applying a ligature, not upon the artery itself, but upon one of the branches of the diseased trunk: he imagined that this would be sufficient to diminish the momentum of the circulation through the aneurism, and so produce a consolidation of the tumor and subsequent cure of the disease. In 1827 he was consulted by a patient, a female, who had an aneurism of the arteria innominata: the tumor had advanced into the neck, and made such pressure upon the carotid artery as to prevent the circulation of the blood through it. He was of opinion that a ligature placed now upon the subclavian artery alone would effect a consolidation of the aneurismal tumor; accordingly, in the month of July of that year, he tied this artery in its third stage. There was no secondary hemorrhage: the operation was unattended by any unfavorable results. On the twenty-second day the ligature came away and the wound healed. The pulsation in the common carotid artery, however, returned upon the ninth day. Some months after the operation, two newly formed swellings, which were engrafted upon the old one, had made their appearance, and the aneurism continued to enlarge. Symptoms of bronchial inflammation made their appearance, diarrhoea set in, general anasarca took place, and she died twenty-three months after the performance of the operation.

* Hargrave's Operative Surgery, p. 44, and Dublin Quarterly Journal for February, 1849, p. 53.