are either directly suspended from the main artery, or from its
principal branches, by smaller branches, destined to supply them. These
glands are more numerous in the female axilla, Plate 14, than in the
male, Plate 13, and while they seem to be, as it were, indiscriminately
scattered here and there through this region, we observe the greater
number of them to be gathered together along the axillary side of the
great pectoral muscle; at which situation, h, in the diseased condition
of the female breast, they will be felt to form hard, nodulated masses,
which frequently extend as far up through the axillary space as the root
of the neck, involving the glands of this latter region also in the
disease.
The contractile motions of the pectoral muscle, E, of the male body,
Plate 13, are during life readily distinguishable; and that boundary
which it furnishes to the axillary region is well defined; but in the
female form, Plate 14, the general contour of the muscle E, while in
motion, is concealed by the hemispherical mammary gland, F, which,
surrounded by its proper capsule, lies loosely pendent from the fore
part of the muscle, to which, in the healthy state of the organ, it is
connected only by free-moving bonds of lax cellular membrane. The
motions of the shoulder upon the trunk do not influence the position of
the female mammary gland, for the pectoral muscle acts freely beneath
it; but when a scirrhus or other malignant growth involves the mammary
organ, and this latter contracts, by the morbid mass, a close adhesion
to the muscle, then these motions are performed with pain and
difficulty.
When it is required to excise the diseased female breast, (supposing the
disease to be confined to the structure of the gland itself,) the
operation may be performed confidently and without difficulty, in so far
as the seat of operation does not involve the immediate presence of any
important nerves or bloodvessels. But when the disease has extended to
the axillary glands, the extirpation of these (as they lie in such close
proximity to the great axillary vessels and their principal branches)
requires cautious dissection. It has more than once happened to eminent
surgeons, that in searching for and dissecting out these diseased
axillary glands, H, h, Plate 14, the main artery has been wounded.
As the coracoid process points to the situation of the artery in the
axilla, so the coraco-brachialis muscle, C, marks the exact locality of
the vessel as it emerges from this region; the artery ranges along the
inner margin of both the process and the muscle, which latter, in fleshy
bodies, sometimes overhangs and conceals it. When the vessel has passed
the insertion of the coraco-brachialis, it becomes situated at the inner
side of the biceps, which also partly overlaps it, as it now lies on the
forepart of the brachialis anticus. As the general course of the
artery, from where it leaves the axilla to the bend of the elbow, is one
of winding from the inner side to the forepart of the limb, so should
compression of the vessel, when necessary, be directed in reference to
the bone accordingly--viz., in the upper or axillary region of the arm,
from within outwards, and in the lower part of the arm, from before
backwards.
All incised, lacerated, or contused wounds of the arm and shoulder,
happening by pike, bayonet, sabre, bullet, mace, or arrow, on the outer
aspect of the limb, are (provided the weapon has not broken the bones)
less likely to implicate the great arteries, veins, and nerves. These
instruments encountering the inner or axillary aspect of the member,
will of course be more likely to involve the vessels and nerves in the
wound. In severe compound fractures of the humerus occurring from force
applied at the external side of the limb, the brachial vessels and
nerves have been occasionally lacerated by the sharp jagged ends of the
broken bone,--a circumstance which calls for immediate amputation of the
member.
The axilla becomes very frequently the seat of morbid growths, which,
when they happen to be situated beneath the dense axillary fascia, and
have attained to a large size, will press upon the vessels and nerves of
this region, and cause very great inconvenience. Adipose and other kind
of tumours occurring in the axilla beneath the fascia, and in close
contact with the main vessels, have been known to obstruct these vessels
to such a degree, as to require the collateral or anastomatic
circulation to be set up for the support; of the limb. When abscesses
take place in the axilla, beneath the fascia, it is this structure which
will prevent the matter from pointing; and it is required, therefore, to
lay this fascia freely open by a timely incision. The accompanying
Plates will indicate the proper direction in which such incision should
be made, so as to avoid the vessels A, B. When the limb is abducted from
the side, the main vessels and nerves take their position parallel with
the axis of the arm. The axillary vessels and nerves being thus liable
to pressure from the presence of large tumours happening in their
neighbourhood, will suggest to the practitioner the necessity for
fashioning of a proper form and size all apparatus, which in fracture or
dislocation of the shoulder-bones shall be required to bear forcibly
against the axillary region. While we know that the locality of the main
vessels and nerves is that very situation upon which a pad or fulcrum
presses, when placed in the axilla for securing the reduction of
fractures of the clavicle, the neck of the humerus, or scapula, so
should this member of the fracture apparatus be adapted, as well to
obviate this pressure upon these structures, as to give the needful
support to the limb in reference to the clavicle, &c. The habitual use,
for weeks or more, of a hard, resisting fulcrum in the axilla, must act
in some degree like the pad of a tourniquet, arresting the flow of a
vigorous circulation, which is so essential to the speedy union of all
lesions of bones. And it should never be lost sight of, that all
grievously coercive apparatus, which incommode the suffering patient,
under treatment, are those very instruments which impede the curative
process of Nature herself.
The anatomical mechanism of the human body, considered as a whole, or
divisible into regions, forms a study so closely bearing upon practice,
that the surgeon, if he be not also a mechanician, and fully capable of
making his anatomical knowledge suit with the common principles of
mechanics, while devising methods for furthering the efforts, of Nature
curatively, may be said to have studied anatomy to little or no purpose.
The shoulder apparatus, when studied through the principle of mechanics,
derives an interest of practical import which all the laboured
description of the schools could never supply to it, except when
illustrating this principle.
The disposal of the muscular around the osseous elements of the shoulder
apparatus, forms a study for the surgeon as well in the abnormal
condition of these parts, as in their normal arrangement; for in
practice he discovers that that very mechanical principle upon which
both orders of structures (the osseous and muscular) are grouped
together for normal articular action, becomes, when the parts are
deranged by fracture or, other accident, the chief cause whereby
rearrangement is prevented, and the process of reunion obstructed. When
a fracture happens in the shaft of the humerus, above or below the
insertions of the pectoral and latissimus dorsi muscles, these are the
very agents which when the bone possessed its integrity rendered it
functionally fitting, and which, now that the bone is severed, produce
the displacement of the lower fragment from the upper one. To counteract
this source of derangement, the surgeon becomes the mechanician, and
now, for the first time, he recognises the necessity of the study of
topographical anatomy.
When a bone is fractured, or dislocated to a false position and retained
there by the muscular force, the surgeon counteracts this force upon
mechanical principle; but while he puts this principle in operation, he
also acknowledges to the paramount necessity of ministering to the ease
of Nature as much as shall be consistent with the effectual use of the
remedial agent; and in the present state of knowledge, it is owned, that
that apparatus is most efficient which simply serves both objects, the
one no less than the other. And, assuming this to be the principle which
should always guide us in our treatment of fractures and dislocations, I
shall not hesitate to say, that the pad acting as a fulcrum in the
axilla, or the perineal band bearing as a counterextending force upon
the groin (the suffering body of the patient being, in both instances,
subjected for weeks together to the grievous pressure and irritation of
these members of the apparatus), do not serve both objects, and only one
incompletely; I say incompletely, for out of every six fractures of
either clavicle or thigh-bone, I believe that, as the result of our
treatment by the present forms of mechanical contrivances, there would
not be found three cases of coaptation of the broken ends of the bone so
complete as to do credit to the surgeon. The most pliant and portable of
all forms of apparatus which constitute the hospital armamentaria, is
the judgment; and this cannot give its approval to any plan of
instrument which takes effect only at the expense of the patient.
DESCRIPTION OF PLATES 13 & 14.
PLATE 13.
A. Axillary vein, drawn apart from the artery, to show the nerves lying
between both vessels. On the bicipital border of the vein is seen the
internal cutaneous nerve; on the tricipital border is the nerve of
Wrisberg, communicating with some of the intercosto-humeral nerves; a,
the common trunk of the venae comites, entering the axillary vein.
B. Axillary artery, crossed by one root of the median nerve; b, basilic
vein, forming, with a, the axillary vein, A.
C. Coraco-brachialis muscle.
D. Coracoid head of the biceps muscle.
E. Pectoralis major muscle.
F. Pectoralis minor muscle.
G. Serratus magnus muscle, covered by g, the axillary fascia, and
perforated, at regular intervals, by the nervous branches called
intercosto-humeral.
H. Conglobate gland, crossed by the nerve called "external respiratory"
of Bell, distributed to the serratus magnus muscle. This nerve descends
from the cervical plexus.
I. Subscapular artery.
K. Tendon of latissimus dorsi muscle.
L. Teres major muscle.
[Illustration: Arm and chest, showing blood vessels, muscles and other
internal organs.]
Plate 13
PLATE 14.
A. Axillary vein.
B. Axillary artery.
C. Coraco-brachialis muscle.
D. Short head of the biceps muscle.
E. Pectoralis major muscle.
F. Mammary gland, seen in section.
G. Serratus magnus muscle.
H. Lymphatic gland; h h, other glands of the lymphatic class.
I. Subscapular artery, crossed by the intercosto-humeral nerves and
descending parallel to the external respiratory nerve. Beneath the
artery is seen a subscapular branch of the brachial plexus, given
to the latissimus dorsi muscle.
K. Locality of the subclavian artery.
L. Locality of the brachial artery at the bend of the elbow.
[Illustration: Arm and chest, showing blood vessels, muscles and other
internal organs.]
Plate 14
COMMENTARY ON PLATES 15 & 16.
THE SURGICAL DISSECTION OF THE BEND OF THE ELBOW
AND THE FOREARM, SHOWING THE RELATIVE POSITION
OF THE ARTERIES, VEINS, NERVES, &c.
The farther the surgical region happens to be removed from the centre of
the body, the less likely is it that all accidents or operations which
involve such regions will concern the life immediately. The limbs
undergo all kinds of mutilation, both by accident and intention, and yet
the patient survives; but when the like happens at any region of the
trunk of the body, the life will be directly and seriously threatened.
It seems, therefore, that in the same degree as the living principle
diverges from the body's centre into the outstanding members, in that
degree is the life weakened in intensity; and just as, according to
physical laws, the ray of light becomes less and less intense by the
square of the distance from the central source, so the vital ray, or
vis, loses momentum in the same ratio as it diverges from the common
central line to the periphery.
The relative anatomy of every surgical region becomes a study of more or
less interest to the surgeon, according to the degree of importance
attaching to the organs contained, or according to the frequency of such
accidents as are liable to occur in each. The bend of the elbow is a
region of anatomical importance, owing to the fact of its giving passage
to C, Plate 15, the main artery of the limb, and also because in it are
located the veins D, B, E, F, which are frequently the subject of
operation. The anatomy of this region becomes, therefore, important;
forasmuch as the operation which is intended to concern the veins alone,
may also, by accident, include the main arterial vessel which they
overlie. The nerves, which are seen to accompany the veins
superficially, as well as that which accompanies the more
deeply-situated artery, are, for the same reason, required to be known.
The course of the brachial artery along the inner border of the biceps
muscle is comparatively superficial, from the point where it leaves the
axilla to the bend of the elbow. In the whole of this course it is
covered by the fascia of the arm, which serves to isolate it from the
superficial basilic vein, B, and the internal cutaneous nerve, both of
which nevertheless overlie the artery. The median nerve, d, Plate 15,
accompanies the artery in its proper sheath, which is a duplication of
the common fascia; and in this sheath are also situated the venae
comites, making frequent loops around the artery. The median nerve
itself, D, Plate 16, takes a direct course down the arm; and the
different relative positions which this nerve holds in reference to the
artery, C, at the upper end, the middle, and the lower end of the arm,
occur mainly in consequence of the undulating character of the vessel
itself.
When it is required to ligature the artery in the middle of the arm, the
median nerve will be found, in general, at its outer side, between it
and the biceps; but as the course of the artery is from the inner side
of the biceps to the middle of the bend of the elbow, so we find it
passing under the nerve to gain this locality, C, Plate 16, where the
median nerve, D, then becomes situated at the inner side of the vessel.
The median nerve, thus found to be differently situated in reference to
the brachial artery, at the upper, the middle, and the lower part of the
arm, is (with these facts always held in memory) taken as the guide to
that vessel. An incision made of sufficient length (an inch and a half,
more or less) over the course of the artery, and to the outer side of
the basilic vein, B, Plate 16, will divide the skin, subcutaneous
adipose membrane, which varies much in thickness in several individuals,
and will next expose the common fascial envelope of the arm. When this
fascia is opened, by dividing it on the director, the artery becomes
exposed; the median nerve is then to be separated from the side of the
vessel by the probe or director, and, with the precaution of not
including the venal comites, the ligature may now be passed around the
vessel. In the lower third of the arm it is not likely that the operator
will encounter the ulnar nerve, and mistake it for the median, since the
former, d, Plate 16, is considerably removed from the vessel. If the
incision be made precisely in the usual course of the brachial artery,
the ulnar nerve will not show itself. It will be well, however, to bear
in mind the possible occurrence of some of those anomalies to that
normal relative position of the artery, the median, and the ulnar nerve,
which the accompanying Plates represent.
The median nerve, D, Plate 16, is sometimes found to lie beneath the
artery in the middle and lower third of the arm. At other times it is
found far removed to the inner side of the usual position of the vessel,
and lying in close contact with the ulnar nerve, d. Or the brachial
artery may take this latter position, while the median nerve stands
alone at the position of D, Plate 16. Or both the main artery and the
median nerve may course much to the inner side of the biceps muscle, A,
Plate 16, while in the usual situation of the nerve and vessel there is
only to be found a small arterial branch (the radial), which springs
from the brachial, high up in the arm. Or the nerve and vessel may be
lying concealed beneath a slip of the brachialis anticus muscle, E,
Plate 16, in which case no appearance of them will be at all manifested
through the usual place of incision made for the ligature of the
brachial vessel. Or, lastly, there may be found more arteries than the
single main brachial appearing at this place in the arm, and such
condition of a plurality of vessels occurs in consequence of a high
division of the brachial artery. Each of these variations from the
normal type is more or less frequent; and though it certainly is of
practical import to bear them in mind, still, as we never can foretell
their occurrence by a superficial examination of the limb, or pronounce
them to be present till we actually encounter them in operation, it is
only when we find them that we commence to reason upon the facts; but
even at this crisis the knowledge of their anatomy may prevent a
confusion of ideas.
That generalization of the facts of such anomalies as are liable to
occur to the normal character of the brachial artery, represented in
Plates 15 and 16, which appears to me as being most inclusive of all
their various conditions, is this--viz., that the point of division into
radial, ulnar, and interosseous, which F, Plate 16, usually marks, may
take place at any part of the member between the bend of the elbow and
the coracoid process in the axillary space.
At the bend of the elbow, the brachial artery usually occupies the
middle point between e, the inner condyle of the humerus and the
external margin of the supinator radii longus muscle, G. The structures
which overlie the arterial vessel, C, Plate 16, at this locality,
numbering them from its own depth to the cutaneous surface, are these--
viz., some adipose cellular membrane envelopes the vessel, as it lies on
E, the brachialis anticus muscle, and between the two accompanying
veins; at the inner side of the artery, but separated from it by a small
interval occupied by one of the veins, is situated the median nerve d,
Plate 15. Above all three structures is stretched that dense fibrous
band of the fascia, H, Plate 16, which becomes incorporated with the
common fascial covering of the forearm. Over this fascial process lies
the median basilic vein, F B, Plate 15, accompanying which are seen some
branches of the internal cutaneous nerve. The subcutaneous adipose
tissue and common integument cover these latter. If it be required to
ligature the artery at this locality, an incision two inches and a half
in length, made along the course of the vessel, and avoiding the
superficial veins, will expose the fascia; and this being next divided
on the director, the artery will be exposed resting on the brachialis
anticus, and between the biceps tendon and pronator teres muscle. As
this latter muscle differs in width in several individuals, sometimes
lying in close contact with the artery, and at other times leaving a
considerable interval between the vessel and itself, its outer margin is
not, therefore, to be taken as a sure guide to the artery. The inner
border of the biceps indicates much more generally the situation of the
vessel.
The bend of the elbow being that locality where the operation of
phlebotomy is generally performed, it is therefore required to take
exact account of the structures which occupy this region, and more
especially the relation which the superficial veins hold to the deeper
seated artery. In Plate 15, the artery, C, is shown in its situation
beneath the fascial aponeurosis, which comes off from the tendon of the
biceps, a portion of which has been cut away; and the venous vessel, F
B, which usually occupies the track of the artery, is pushed a little to
the inner side. While opening any part of the vessel, F B, which
overlies the artery, it is necessary to proceed with caution, as well
because of the fact that between the artery, C, and the vein, F B, the
fascia alone intervenes, as also because the ulnar artery is given off
rather frequently from the main vessel at this situation, and passes
superficial to the fascia and flexors of the forearm, to gain its usual
position at K, Plate 15. I have met with a well marked example of this
occurrence in the living subject.
The cephalic vein, D, is accompanied by the external cutaneous nerve,
which branches over the fascia on the outer border of the forearm. The
basilic vein, B, is accompanied by the internal cutaneous nerve, which
branches in a similar way over the fascia of the inner and fore part of
the forearm. The numerous branches of both these nerves interlace with
the superficial veins, and are liable to be cut when these veins are
being punctured. Though the median basilic, F, and the basilic vein, B,
are those generally chosen in the performance of the operation of
bleeding, it will be seen, in Plate 15, that their contiguity to the
artery necessarily demands more care and precision in that operation
executed upon them, than if D, the cephalic vein, far removed as it is
from the course of the artery, were the seat of phlebotomy.
As it is required, in order to distend the superficial veins, D, B, F,
that a band should be passed around the limb at some locality between
them and the heart, so that they may yield a free flow of blood on
puncture, a moderate pressure will be all that is needful for that end.
It is a fact worthy of notice, that the excessive pressure of the
ligaturing band around the limb at A B, Plate 15, will produce the same
effect upon the veins near F, as if the pressure were defective, for in
the former case the ligature will obstruct the flow of blood through the
artery; and the vein, F, will hence be undistended by the recurrent
blood, just as when, in the latter case, the ligature, making too feeble
a pressure on the vein, B, will not obstruct its current in that degree
necessary to distend the vessel, F.
Whichever be the vein chosen for phlebotomy at the bend of the elbow, it
will be seen, from an examination of Plates 15 and 16, that the opening
may be made with most advantage according to the longitudinal axis of
the vessel; for the vessel while being cut open in this direction, is
less likely to swerve from the point of the lancet than if it were to be
incised across, which latter mode is also far more liable to implicate
the artery. Besides, as the nerves course along the veins from above
downwards--making, with each other, and with the vessels, but very acute
angles--all incisions made longitudinally in these vessels, will not be
so likely to divide any of these nerves as when the instrument is
directed to cut crossways.
The brachial artery usually divides, at the bend of the elbow, into the
radial, the ulnar, and the interosseous branches. The point F, Plate 16,
is the common place of division, and this will be seen in the Plate to
be somewhat below the level of the inner condyle, e. From that place,
where the radial and ulnar arteries spring, these vessels traverse the
forearm, in general under cover of the muscles and fascia, but
occasionally superficial to both these structures. The radial artery, F
N, Plate 16, takes a comparatively superficial course along the radial
border of the forearm, and is accompanied, for the upper two-thirds of
its length, by the radial branch of the musculo-spiral nerve, seen in
Plate 16, at the outer side of the vessel. The supinator radii longus
muscle in general overlaps, with its inner border, both the radial
artery and nerve. At the situation of the radial pulse, I, Plate 15, the
artery is not accompanied by the nerve, for this latter will be seen, in
plate 16, to pass outward, under the tendon of the supinator muscle, to
the integuments.