Subclavian artery

“ If, from some complication of injury, the axillary or other artery should give way during the treatment, the extremity is not to be amputated. The artery is to be secured by one ligature applied above the opening in it and by another below it, the surgeon always bearing in mind the fact that the proper way to get at the axillary artery is by cutting across the fibers of the pectoral muscle, and not in their direction, and that it will be better to amputate the arm than to tie the subclavian artery above the clavicle. ”

“ Amputation at the shoulder-joint is an operation of [123] little surgical importance. The fear formerly entertained of loss of blood has passed away, and every surgeon now knows that if he should happen to cut the axillary artery unintentionally, it can be held between the forefinger and thumb, without difficulty or danger, until a ligature can be placed upon it. No accomplished surgeon of the present day should give himself the least concern about compressing the subclavian artery. ”

“ Each subclavian artery gives off a brachial artery to the pectoral fin, and is then continued forwards as a lateral hypobranchial artery, which, with its fellow of the opposite side, eventually becomes continuous with the hinder end of the median hypobranchial artery. Behind the subclavian artery there is a median coeliaco-mesenteric artery, the various branches of which are distributed to the liver, stomach, and intestine. A lieno-gastric artery supplies the pancreas and spleen, and also sends branches to the stomach. ”

“ The error of placing a ligature on the subclavian artery above the clavicle, for a wound of the axillary below it, should never be committed. One person dies for one who lives after this operation, when performed under favorable circumstances, independently of the loss which may be sustained by a recurrence of bleeding from the original wound, which is always to be expected and ought to take place; when it does not happen, it is the effect of accident, which accident in all probability occurs from the state of absolute rest having been carefully observed. ”

“ The principal branches of the thoracic aorta spring from the upper part of its arch. The innominate artery, 2, is the first to arise from it; the left common carotid, 6, and the left subclavian artery, 5, spring in succession. These vessels being destined for the head and upper limbs, we find that the remaining branches of the thoracic aorta are comparatively diminutive, and of little surgical interest. The intercostal arteries occasionally, when wounded, call for the aid of the surgeon; these arteries, like all other branches of the aorta, are largest at their origin. ”

“ 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 passed round the artery from below upwards, care being taken not to injure the pleura, which lies beneath and behind the artery. ”

“ The clavicular artery (Fig. 73, No. 8) accompanies the clavicle to the shoulder-joint.
The acromial artery is given off from the sterno-clavicularis on the ligament near the shoulder-joint.
2. The thoracic artery branches from the subclavian artery (Fig. 70, No. 4) . ”

“ 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. ”

“ This method is suitable to sacculated aneurysm of the limbs, so long as they are circumscribed and free from complications. It has been successfully practised also in aneurysm of the subclavian, carotid, and external iliac arteries. It is not applicable to cases in which there is such a degree of atheroma as would interfere with the successful ligation of the artery. The continuity of the artery may be restored by grafting into the gap left after excision of the sac a segment of the great saphena vein. ”

“ The anastomosis of the intercostal arteries round the ribs is similar to the plexus, which is produced by the great sympathetic nerve in the same location. The lumbar arteries are given off farther posteriorly and along the lumbar region. The lumbar, like the dorsal branches are given off in pairs. These arterial branches pass along the thigh and the upper sacral vertebral region, and supply those parts. Ventrally they are covered by the kidneys and pass into the abdominal muscles. The posterior aorta gives off the spermatic arteries and the ovarian artery. ”

“ The coats of the external jugular vein, E, Plate 3, are said to hold connexion with some of the fibres of the platysma-myoides muscle, A A, Plate 3, and that therefore, if the vessel be divided transversely, the two orifices will remain patent for a time.
The position of the carotid artery protects the vessel, in some degree, against the suicidal act, as generally attempted. The depth of the incision necessary to reach the main blood-vessels from the fore part of the neck is so considerable that the wound seldom effects more than the opening of some part of the larynx. ”

“ When an arterio-venous sac has once formed, clinical observation shows that the general tendency is towards extension in the direction of least resistance. This direction of course varies with the situation of the aneurism, and also with the nature of the wound track.
Speaking generally the direction of least resistance in a typically pure perforation is towards the vein. Initial flow of blood from the wounded artery is naturally favoured towards the potential space afforded by a canal occupied by blood flowing at a lower degree of pressure. ”

“ It occurs with greater frequency and with greater severity in men than in women.
Atheromatous degeneration is most common in the large arterial trunks, and the changes are most marked at the arch of the aorta, opposite the flexures of joints, at the mouths of large branches, and at parts where the vessel lies in contact with bone. The presence of diseased patches in the wall of an artery diminishes its elasticity and favours aneurysmal dilatation. Such a vessel also is liable to be ruptured by external violence and so give rise to traumatic aneurysm. ”

“ It is argued that when a man has his internal carotid cut on the inside of his throat, by a foreign body of any kind thrust through his mouth, the artery cannot be tied by two ligatures at the wounded part through the mouth, not even if it were enlarged from ear to ear. What, then, is to be done? The artery should be secured by ligature by an incision made on the outside of the neck. ”

“ Fig. 364. Diagram of the arrangement of the arterial arches in an embryo of one of the Amniota. (From Gegenbaur; after Rathke.)
a. ventral aorta; a ́ ́. dorsal aorta; 1, 2, 3, 4, 5. arterial arches; c. carotid artery.
In the Amniota the metamorphosis of the arteries is in all cases very similar. Five arches, viz. the mandibular, hyoid, and three branchial arches are always developed (fig. 364) , but, owing to the absence of branchiæ, never function as branchial arteries. ”

“ For in several animals the arteries do not apparently differ from the veins; and in extreme parts of the body, where the arteries are minutely subdivided,15 as in the brain, the hand, &c., no one could distinguish the arteries from the veins by the dissimilar characters of their coats; the tunics of both are identical. And then, in an aneurism proceeding from a wounded or eroded artery, the pulsation is precisely the same as in the other arteries, and yet it has no proper arterial tunic. This the learned Riolanus testifies to, along with me, in his Seventh Book. ”

“ In cases of hæmorrhage for suppuration of an aneurismal sac, it might possibly be advisable, and there are certain cases of rupture of the artery, without the existence of an external wound, in which attempts have been made to save the limb by tying the vessel. [10] From the complexity of the parts, the numerous tendons, veins, and nerves crowded together in a narrow hollow, and chiefly from the great depth at which the artery lies, any attempt at ligature is very difficult. ”

“ When the bulbus arteriosus divides itself into three parts, the two lateral parts, in becoming connected with the left ventricle, will represent a double ascending systemic aorta, and having the pulmonary artery passing between them to the lungs. 12th. When of the two original superior venae cavae the right one instead of the left suffers metamorphosis, the vena cava superior will then appear on the left side of the normal aortic arch. [Footnote 2] Of these malformations, some are rather frequently met with, others very seldom, and others cannot exist compatible with life after birth. ”

“ When an artery has been tied, it is necessary that its parietes, inflamed by the action of the thread, most often cut by it, and brought into contact, should form adhesions, that the cure may be complete, and the ligature come off without danger. Now, nothing is more difficult and slower than their adhesion, from the difficulty with which the arterial texture inflames. Hence the frequency of hemorrhage after the operation for aneurism and other great operations. The blood often bursts out at the end of twenty, thirty, or forty days ”

“ Composition of clot. Condition of vessel. Changes in muscles. Causes: muscular tension, embolism. Heart clots, venous clots. Infecting debris. Symptoms: paresis or paralysis on exertion. Local suffering, tenderness, firm swollen artery, derangement of nutrition and function, atrophy. Chronic arteritis: Atheroma. Changes in serosa. Fibrous thickening, atrophy, dilatation. Strongylus. Treatment: rest, anodynes, alkalies, massage.
Inflammation of arteries has been divided into external and internal arteritis, according as it affects the fibrous sheath of the artery or its inner lining membrane. ”

“ When the peripheral arteries are palpable they are not always sclerosed. The radial artery, the one usually palpated, may lie very close to the bone in a thin person. Under these conditions the artery can be easily felt. It is better then to palpate for the brachial as it lies beneath the inner edge of the biceps muscle. ”

“ When from the bones being broken, or the hand so swollen, or from other circumstances, pressure, however lightly and carefully applied, cannot be borne in the manner directed, and the attempts to secure the artery at the bleeding spot have failed, and pressure on the radial or ulnar artery has been equally unsuccessful, in consequence of the swelling or other circumstances, both may be tied at the wrist in preference to placing a ligature on the brachial artery, although that even must be done as a last resource, if the bleeding should still continue. ”

“ The two circumflex humeri alone send down branches to inosculate with the small muscular offsets from the middle of the brachial artery. When tied in the middle of the arm between the origins of the superior and inferior profunda arteries, the collateral circulation will depend chiefly upon the anastomosis of the former vessel with the recurrent branch of the radial, and of muscular branches with each other. ”

“ The main artery of the lower limb may be exposed and tied in any part of its course from the aorta to the popliteal space. But the situation most eligible for performing such an operation depends of course upon circumstances, both anatomical and pathological. If an aneurism affect the popliteal part of the vessel, or if, from whatever cause arising, it be found expedient to tie the femoral above this part, the place best suited for the operation is that where the artery, W, first passes under cover of the sartorius muscle. ”