Chapter X: X. Fifth ribs cut across (2)

The innominate artery lies closer behind the right sterno-clavicular junction than the left carotid or subclavian arteries lie in relation to the left sterno-clavicular articulation; and this difference of depth between the vessel of the right side and those of the left is mainly owing to the form and direction of the aortic arch from which they take origin. The aortic arch ranges, not alone transversely, but also from before backward, and to the left side of the dorsal spine; and consequently, as the innominate artery, A, Plate 9, springs from the first or fore part of the aorta, while the left carotid and subclavian arteries arise from the second and deeper part of its arch, the vessels of both sides rising into the neck perpendicularly from the root in the thorax, will still, in the cervical region, manifest a considerable difference as to antero-posterior depth. The depth of the left subclavian artery, B, Plate 10, from cervical surface, is even greater than that of the left common carotid, A, Plate 10, and this latter, at its root in the aortic arch, is deeper than the innominate artery. Both common carotids, A A, Plates 9 and 10, hold nearly the same antero-posterior depth on either side of the trachea, M, Plate 10, and D, Plate 9. Although the relative depth of the arterial vessels on both sides of the trachea is different, still they are covered by an equal number of identical structures, taking the same order of superposition.

On either side of the episternal cervical pit, which, even in the undissected body of male or female, infant or adult, is always a well-marked surgical feature, may be readily recognised the converging sternal attachments of the sterno-mastoid muscles, L G, Plate 10; and midway between these symmetrical muscular prominences in the neck, but holding a deeper level than them, is situated that part of the trachea which is generally the subject of the operation of tracheotomy. The relative anatomy of the trachea, M, Plate 10, D, Plate 9, at this situation requires therefore to be carefully considered. The trachea is said to incline rather to the right side of the median line; but perhaps this observation would be more true to nature if it were accompanied by the remark, that this seeming inclination to the right side is owing to the fact, that the innominate artery, A, Plate 9, lies obliquely over its fore part, near the sternum. However this may be, it certainly will be the safer step in the operation to regard the median position of the trachea as fixed, than to encroach upon the locality of the carotid vessels; and to make the incision longitudinally and exactly through the median line, while the neck is extended backwards, and the chin made to correspond with the line of incision. And when the operator takes into consideration the situation of the vessel A, Plate 9, and A, Plate 10, at this region of the neck, he will at once own to the necessity of opening the trachea, D, Plate 9, M, Plate 10, at a situation nearer the larynx than the point marked in the figures. The course taken by the common carotid arteries is, in respect to the trachea, divergent from below upwards; and as these vessels will consequently be found to stand wider apart at the level of K, I, Plate 10, than they do at the level of M, Plate 10, so the farther upwards from the sternum we choose the point at which to open the trachea, the less likely are we to endanger the great arterial vessels.

In addition to the fact, that the carotid arteries at an inch above the sternum lie nearer the median line than they do higher up in the neck, it should always be remembered, that the trachea itself is situated much deeper at the point M, Plate 10, D, Plate 9, than it is opposite the points F and K of the same figures. The laryngo-tracheal line is, in the lateral view of the neck, downwards and backwards, and therefore it will be found always at a considerable depth from cervical surface, as it passes behind the first bone of the sternum, midway between both sterno-mastoid muscles.

In the operation of tracheotomy, the cutting instrument divides the following named structures as they lie beneath the common integument: If the incision be made directly upon the median line, the muscles F, sterno-hyoid, and E, sterno-thyroid, Plate 9, are not necessarily divided, as these structures and their fellows hold a somewhat lateral position opposite to each other. Beneath these muscles and above them, thus encasing them, the cervical fascia, f f, Plate 10, is required to be divided, in order to expose the trachea. Beneath f f the cervical fascia, will next be felt the rounded bilobed mass of the thyroid body, lying on the forepart of the trachea; above the thyroid body, the cricoid and some tracheal cartilaginous rings will be felt; and since the thyroid body varies much as to bulk in several individuals of the same and different sexes, as also from a consideration that its substance is traversed by large arterial and venous vessels, it will be therefore preferable to open the trachea above it, than through it or below it.

On the forepart of the tracheal median line, either superficial to, or deeper than, the cervical fascia, the tracheotomist occasionally meets with a chain of lymphatic glands or a plexus of veins, which latter, when divided, will trammel the operation by the copious haemorrhage which all veins at this region of the neck are prone to supply, owing to their direct communication with the main venous trunks of the heart; and not unfrequently the inferior thyroid artery overlies the trachea at the point D, Plate 9, when this thyroid vessel arises directly from the arch of the aorta, between the roots of the innominate and left common carotid, or when it springs from the innominate itself. The inferior thyroid vein, sometimes single and sometimes double, overlies the trachea at the point D, Plate 9, when this vein opens into the left innominate venous trunk, as this latter crosses over the root of the main arteries springing from the aorta.

Laryngotomy is, anatomically considered, a far less dangerous operation than tracheotomy, for the above-named reasons; and the former should always be preferred when particular circumstances do not render the latter operation absolutely necessary. In addition to the fact, that the carotid arteries lie farther apart from each other and from the median place--viz., the crico-thyroid interval, which is the seat of laryngotomy--than they do lower down on either side of the trachea, it should also be noticed that the tracheal tube being more moveable than the larynx, is hence more liable to swerve from the cutting instrument, and implicate the vessels. Tracheotomy on the infant is a far more anxious proceeding than the same operation performed on the adult; because the trachea in the infant's body lies more closely within the embrace of the carotid arteries, is less in diameter, shorter, and more mobile than in the adult body.

The episternal or interclavicular region is a locality traversed by so many vitally important structures gathered together in a very limited space, that all operations which concern this region require more steady caution and anatomical knowledge than most surgeons are bold enough to test their possession of. The reader will (on comparing Plates 9 and 10) be enabled to take account of those structures which it is necessary to divide in the operation required for ligaturing the innominate artery, A, Plate 9, or either of those main arterial vessels (the right common carotid and subclavian) which spring from it; and he will also observe that, although the same number and kind of structures overlie the carotid and subclavian vessels, A B, of the left side, Plate 10, still, that these vessels themselves, in consequence of their separate condition, will materially influence the like operation in respect to them. An aneurism occurring in the first part of the course of the right subclavian artery, at the locality a, Plate 9, will lie so close to the origin of the right common carotid as to require a ligature to be passed around the innominate common trunk, thus cutting off the flow of blood from both vessels; whereas an aneurism implicating either the left common carotid at the point A, or the left subclavian artery at the point B, does not, of course, require that both vessels should be included in the same ligature. There seems to be, therefore, a greater probability of effectually treating an aneurism of the left brachio-cephalic vessels by ligature than attaches to those of the right side; for if space between collateral branches, and also a lesser caliber of arterial trunk, be advantages, allowing the ligature to hold more firmly, then the vessels of the left side of the root of the neck manifest these advantages more frequently than those of the right, which spring from a common trunk. Whenever, therefore, the "peculiarity" of a separate aortic origin of the right carotid and subclavian arteries occurs, it is to be regarded more as a happy advantage than otherwise.

DESCRIPTION OF PLATES 9 & 10.

PLATE 9.

A. Innominate artery, at its point of bifurcation.

B. Right internal jugular vein, joining the subclavian vein.

C. Sternal end of the right clavicle.

D. Trachea.

E. Right sterno-thyroid muscle, cut.

F. Right sterno-hyoid muscle, cut.

G. Right sterno-mastoid muscle, cut.

a. Right vagus nerve, crossing the subclavian artery.

b. Anterior jugular vein, piercing the cervical fascia to join the
subclavian vein.

Plate 9

PLATE 10.

A. Common carotid artery of left side.

B. Left subclavian artery, having b, the vagus nerve, between it and A.

C. Lower end of left internal jugular vein, joining--

D. Left subclavian vein, which lies anterior to d, the scalenus anticus
muscle.

E. Anterior jugular vein, coursing beneath sterno-mastoid muscle and
over the fascia.

F. Deep cervical fascia, enclosing in its layers f f f, the several
muscles.

G. Left sterno-mastoid muscle, cut across, and separated from g g, its
sternal and clavicular attachments.

H. Left sterno-hyoid muscle, cut.

I. Left sterno-thyroid muscle, cut.

K. Right sterno-hyoid muscle.

L. Right sterno-mastoid muscle.

M. Trachea.

N. Projection of the thyroid cartilage.

O. Place of division of common carotid.

P. Place where the subclavian artery passes beneath the clavicle.

Q. Sternal end of the left clavicle.

Plate 10

COMMENTARY ON PLATES 11 & 12.

THE SURGICAL DISSECTION OF THE AXILLARY AND BRACHIAL REGIONS, DISPLAYING THE RELATIVE ORDER OF THEIR CONTAINED PARTS.

All surgical regions have only artificial boundaries; and these, as might be expected, do not express the same meaning while viewed from more points than one. These very boundaries themselves, being moveable parts, must accordingly influence the relative position of the structures which they bound, and thus either include within or exclude from the particular region those structures wholly or in part which are said to be proper to it. Of this kind of conventional surgical boundary the moveable clavicle is an example; and the bloodvessels which it overarches manifest consequently neither termination nor origin except artificially from the fixed position which the bone, R, assumes, as in Plate 11, or c*, Plate 12. In this position of the arm in relation to the trunk, the subclavian artery, B, terminates at the point where, properly speaking, it first takes its name; and from this point to the posterior fold of the axilla formed by the latissimus dorsi muscle, O, Plate 11, N, Plate 12, and the anterior fold formed by the great pectoral muscle, K, Plate 11, I, Plate 12, the continuation of the subclavian artery is named axillary. From the posterior fold of the axilla, O P, Plate 11, to the bend of the elbow, the same main vessels take the name of brachial.

When the axillary space is cut into from the forepart through the great pectoral muscle, H K, Plate 11, and beneath this through the lesser pectoral muscle, L I, together with the fascial processes which invest these muscles anteriorly and posteriorly, the main bloodvessels and nerves which traverse this space are displayed, holding in general that relative position which they exhibit in Plate 11. These vessels, with their accompanying nerves, will be seen continued from those of the neck; and thus may be attained in one view a comparative estimate of the cervical and axillary regions, together with their line of union beneath the clavicle, c*, Plate 12, R, Plate 11, which serves to divide them surgically.

In the neck, the subclavian artery, B, Plate 11, is seen to be separated from the subclavian vein, A, by the breadth of the anterior scalenus muscle, D, as the vessels arch over the first rib, F. In this region of the course of the vessels, the brachial plexus of nerves, C, ranges along the outer border of the artery, B, and is separated by the artery from the vein, A, as all three structures pass beneath the clavicle, R, and the subclavius muscle, E. From this latter point the vessels and nerves take the name axillary, and in this axillary region the relative position of the nerves and vessels to each other and to the adjacent organs is somewhat changed. For now in the axillary region the vein, a, is in direct contact with the artery, b, on the forepart and somewhat to the inner side of which the vein lies; while the nerves, D, d, Plate 12, embrace the artery in a mesh or plexus of chords, from which it is often difficult to extricate it, for the purpose of ligaturing, in the dead subject, much less the living. The axillary plexus of nerves well merits the name, for I have not found it in any two bodies assuming a similar order or arrangement. Perhaps the order in which branches spring from the brachial plexus that is most constantly met with is the one represented at D, Plate 12, where we find, on the outer border of B, the axillary artery, a nervous chord, d, giving off a thoracic branch to pass behind H, the lesser pectoral muscle, while the main chord itself, d, soon divides into two branches, one the musculo-cutaneous, e, which pierces G, the coraco-brachialis muscle, and the other which forms one of the roots of the median nerve, h. Following that order of the nerves as they are shown in Plate 12, they may be enumerated from without inwards as follows:--the external or musculo-cutaneous, e; the two roots of the median, h; the ulnar, f; the musculo-spiral, g; the circumflex, i; close to which are seen the origins of the internal cutaneous, the nerve of Wrisberg, some thoracic branches, and posteriorly the subscapular nerve not seen in this view of the parts.

The branches which come off from the axillary artery are very variable both as to number and place of origin, but in general will be found certain branches which answer to the names thoracic, subscapular, and circumflex. These vessels, together with numerous smaller arteries, appear to be confined to no fixed point of origin, and on this account the place of election for passing a ligature around the main axillary artery sufficiently removed from collateral branches must be always doubtful. The subscapular artery, Q, Plate 12, is perhaps of all the other branches that one which manifests the most permanent character; its point of origin being in general opposite the interval between the latissimus and sub-scapular muscles, but I have seen it arise from all parts of the axillary main trunk. If it be required to give, in a history of the arteries, a full account of all the deviations from the so-called normal type to which these lesser branches here and elsewhere are subject, such account can scarcely be said to be called for in this place.

The form of the axillary space is conical, while the arm is abducted from the side, and while the osseous and muscular structures remain entire. The apex of the cone is formed at the root of the neck beneath the clavicle, R, Plate 11, and the subclavious muscle, E, and between the coracoid process, L*, of the scapula and the serratus magnus muscle, as this lies upon the thoracic side; at this apex the subclavian vessels, A B, enter the axillary space. The base of the cone is below, looking towards the arm, and is formed in front by the pectoralis major, K H, and behind by the latissimus dorsi, O, and teres muscles, P, together with a dense thick fascia; at this base the axillary vessels, a b, pass out to the arm, and become the brachial vessels, a*b*. The anterior side of the cone is formed by the great pectoral muscle, H K, Plate 11, and the lesser pectoral, L I. The inner side is formed by the serratus magnus muscle, M, Plate 12, on the side of the thorax; the external side is formed by the scapular and humeral insertion of the subscapular muscle, the humerus and coraco-brachialis muscle; and the posterior side is formed by the latissimus dorsi, the teres and body of the subscapular muscle.

In this axillary region is contained a complicated mass of bloodvessels, nerves, and lymphatic glands, surrounded by a large quantity of loose cellular membrane and adipose tissue. All the arterial branches here found are given off from the axillary artery; and the numerous veins which accompany these branches enter the axillary vein. Nerves from other sources besides those of the axillary plexus traverse the axillary space; such nerves, for example, as those named intercosto-humeral, seen lying on the latissimus tendon, O, Plate 11. The vein named cephalic, S, enters the axillary space at that cellular interval occurring between the clavicular origin of the deltoid muscle, G, and the humeral attachment of the pectoralis major, H, which interval marks the place of incision for tying the axillary artery.

The general course of the main vessels through the axillary space would be indicated with sufficient accuracy by a line drawn from the middle of the clavicle, R R, Plate 11, to the inner border of the biceps muscle, N. In this direction of the axillary vessels, the coracoid process, L*, from which arises the tendon of the pectoralis minor muscle, L, is to be taken as a sure guide to the place of the artery, b, which passes, in general, close to the inner side of this bony process. Even in the undissected body the coracoid process may be felt as a fixed resisting point at that cellular interval between the clavicular attachments of the deltoid and great pectoral muscles. Whatever necessity shall require a ligature to be placed around the axillary in preference to the subclavian artery, must, of course, be determined by the particular case; but certain it is that the main artery, at the place B, a little above the clavicle, will always be found freer and more isolated from its accompanying nerves and vein, and also more easily reached, owing to its comparatively superficial situation, than when this vessel has become axillary. The incision required to be made, in order to reach the axillary artery, b, from the forepart, through the skin, both pectoral muscles, and different layers of fasciae, must be very deep, especially in muscular, well-conditioned bodies; and even when the level of the vessel is gained, it will be found much complicated by its own branches, some of which overlie it, as also by the plexus of nerves, D, Plate 12, which embraces it on all sides, while the large axillary vein, a, Plate 11, nearly conceals it in front. This vein in Plate 11 is drawn somewhat apart from the artery.

Sometimes the axillary artery is double, in consequence of its high division into brachial branches. But as this peculiarity of premature division never takes place so high up as where the vessel, B, Plate 11, overarches the first rib, F, this circumstance should also have some weight with the operator.

When we view the relative position of the subclavian vessels, A B, Plate 11, to the clavicle, R, we can readily understand why a fracture of the middle of this bone through that arch which it forms over the vessels, should interfere with the free circulation of the blood which these vessels supply to the arm. When the clavicle is severed at its middle, the natural arch which the bone forms over the vessels and nerves is lost, and the free moving broken ends of the bone will be acted on in opposing directions by the various muscles attached to its sternal and scapular extremities. The outer fragment follows more freely than the inner piece the action of the muscles; but, most of all, the weight of the unsupported shoulder and arm causes the displacement to which the outer fragment is liable. The subclavius muscle, E, like the pronator quadratus muscle of the forearm, serves rather to further the displacement of the broken ends of the bone than to hold them in situ.

If the head of the humerus be dislocated forwards beneath L, Plate 11, the coracoid attachment of the pectoralis minor muscle, it must press out of their proper place and put tensely upon the stretch the axillary vessels and plexus of nerves. So large and resistent a body as the head of the humerus displaced forwards, and taking the natural position of these vessels and nerves, will accordingly be attended with other symptoms--such as obstructed circulation and pain or partial paralysis, besides those physical signs by which we distinguish the presence of it as a new body in its abnormal situation.

When the main vessels and nerves pass from the axillary space to the inner side of the arm, they become comparatively superficial in this latter situation. The inner border of the biceps muscle is taken as a guide to the place of the brachial artery for the whole extent of its course in the arm. In plate 11, the artery, b*, is seen in company with the median nerve, which lies on its fore part, and with the veins called comites winding round it and passing with it and the nerve beneath the fascia which encases in a fold of itself all three structures in a common sheath. Though the axillary vein is in close contact with the axillary artery and nerves, yet the basilic vein, d*, the most considerable of those vessels which form the axillary vein, is separated from the brachial artery by the fascia. The basilic vein, however, overlies the brachial artery to its inner side, and is most commonly attended by the internal cutaneous nerve, seen lying upon it in Plate 11, as also by that other cutaneous branch of the brachial plexus, named the nerve of Wrisberg. If a longitudinal incision in the course of the brachial artery be made (avoiding the basilic vein) through the integument down to the fascia of the arm, and the latter structure be slit open on the director, the artery will be exposed, having the median nerve lying on its outer side in the upper third of the arm, and passing to its inner side towards the bend of the elbow, as at b*, Plate 12. The superior and inferior profunda arteries, seen springing above and below the point b, Plate 12, are those vessels of most importance which are given off from the brachial artery, but the situation of their origin is very various. The ulnar nerve, f, lies close to the inner side of the main arterial trunk, as this latter leaves the axilla, but from this place to the inner condyle, Q, behind which the ulnar nerve passes into the forearm, the nerve and artery become gradually more and more separated from each other in their descent. The musculo-spiral nerve, g, winds under the brachial artery at the middle of the arm, but as this nerve passes deep between the short and long heads of the triceps muscle, P, and behind the humerus to gain the outer aspect of the limb, a little care will suffice for avoiding the inclusion of it in the ligature.

The brachial artery may be so effectually compressed by the fingers on the tourniquet, against the humerus in any part of its course through the arm, as to stop pulsation at the wrist.

The tourniquet is a less manageable and not more certain compressor of the arterial trunk than is the hand of an intelligent assistant. At every region of the course of an artery where the tourniquet is applicable, a sufficient compression by the hand is also attainable with greater ease to the patient; and the hand may compress the vessel at certain regions where the tourniquet would be of little or no use, or attended with inconvenience, as in the locality of the subclavian artery, passing over the first rib, or the femoral artery, passing over the pubic bone, or the carotid vessels in the neighbourhood of the trachea, as they lie on the fore part of the cervical spinal column.

DESCRIPTION OF PLATES 11 & 12.

PLATE 11.

A. Subclavian vein, crossed by a branch of the brachial plexus given to
the subclavius muscle; a, the axillary vein; a *, the basilic vein,
having the internal cutaneous nerve lying on it.

B. Subclavian artery, lying on F, the first rib; b, the axillary artery;
b *, the brachial artery, accompanied by the median nerve and venae
comites.

C. Brachial plexus of nerves; c*, the median nerve.

D. Anterior scalenus muscle.

E. Subclavius muscle.

F F. First rib.

G. Clavicular attachment of the deltoid muscle.

H. Humeral attachment of the great pectoral muscle.

I. A layer of fascia, encasing the lesser pectoral muscle.

K. Thoracic half of the great pectoral muscle.

L. Coracoid attachment of the lesser pectoral muscle.

L*. Coracoid process of the scapula.

M. Coraco-brachialis muscle.

N. Biceps muscle.

O. Tendon of the latissimus dorsi muscle, crossed by the
intercosto-humeral nerves.

P. Teres major muscle, on which and O is seen lying Wrisberg's nerve.

Q. Brachial fascia, investing the triceps muscle. .

R R. Scapular and sternal ends of the clavicle.

S. Cephalic vein, coursing between the deltoid and pectoral muscles, to
enter at their cellular interval into the axillary vein beneath E, the
subclavius muscle.

Plate 11

PLATE 12.

A. Axillary vein, cut and tied; a, the basilic vein, cut.

B. Axillary artery; b, brachial artery, in the upper part of its course,
having h, the median nerve, lying rather to its outer side; b*, the
artery in the lower part of its course, with the median nerve to its
inner side.

C. Subclavius muscle.

C*. Clavicle.

D. Axillary plexus of nerves, of which d is a branch on the coracoid
border of the axillary artery; e, the musculo-cutaneous nerve, piercing
the coraco-brachialis muscle; f, the ulnar nerve; g, musculo-spiral
nerve; h, the median nerve; i, the circumflex nerve.

E. Humeral part of the great pectoral muscle.

F. Biceps muscle.

G. Coraco-brachialis muscle.

H. Thoracic half of the lesser pectoral muscle.

I. Thoracic half of the greater pectoral muscle.

K. Coracoid attachment of the lesser pectoral muscle.

K*. Coracoid process of the scapula.

L. Lymphatic glands.

M. Serratus magnus muscle.

N. Latissimus dorsi muscle.

O. Teres major muscle.

P. Long head of triceps muscle.

Q. Inner condyle of humerus.

Plate 12

COMMENTARY ON PLATES 13 & 14. THE SURGICAL FORM OF THE MALE AND FEMALE AXILLAE COMPARED.

Certain characteristic features mark those differences which are to be found in all corresponding regions of both sexes. Though the male and female bodies, in all their regions, are anatomically homologous or similar at basis, yet the constituent and corresponding organs of each are gently diversified by the plus or minus condition, the more or the less, which the development of certain organs exhibits; and this diversity, viewed in the aggregate, constitutes the sexual difference. That diversity which defines the sexual character of beings of the same species, is but a link in that extended chain of differential gradation which marks its progress through the whole animal kingdom. The female breast is a plus glandular organ, situated, pendent, in that very position where, in a male body, the unevolved mamma is still rudimentarily manifested.

The male and female axillae contain the same number and species of organs; and the difference by which the external configuration of both are marked mainly arises from the presence of the enlarged mammary gland, which, in the female, Plate 14, masks the natural outline of the pectoral muscle, E, whose axillary border is overhung by the gland; and thus this region derives its peculiarity of form, contrasted with that of the male subject.

When the dissected axilla is viewed from below, the arm being raised, and extended from the side, its contained parts, laid deeply in their conical recess, are sufficiently exposed, at the same time that the proper boundaries of the axillary cavity are maintained. In this point of view from which the axillary vessels are now seen, their relative position, in respect to the thorax and the arm, are best displayed. The thickness of that fleshy anterior boundary formed by both pectoral muscles, E F, Plate 13, will be marked as considerable; and the depth at which these muscles conceal the vessels, A B, in the front aspect of the thoracico-humeral interval, will prepare the surgeon for the difficulties he is to encounter when proceeding to ligature the axillary artery at the incision made through the anterior or pectoral wall of this axillary space.

The bloodvessels of the axilla follow the motions of the arm; and according to the position assumed by the arm, these vessels describe various curves, and lie more or less removed from the side of the thorax. While the arm hangs close to the side, the axillary space does not (properly speaking) exist; and in this position, the axillary vessels and nerves make a general curve from the clavicle at the point K, Plate 14, to the inner side of the arm, the concavity of the curve being turned towards the thoracic side. But when the arm is abducted from the side, and elevated, the vessels which are destined to supply the limb follow it, and in this position they take, in reality, a serpentine course; the first curve of which is described, in reference to the thorax, from the point K to the head of the humerus; and the next is that bend which the head of the humerus, projecting into the axilla in the elevated position of the member, forces them to make around itself in their passage to the inner side of the arm. The vessels may be readily compressed against the upper third of the humerus by the finger, passed into the axilla, and still more effectually if the arm be raised, as this motion will rotate the tuberous head of the humerus downwards against them.

The vessels and nerves of the axilla are bound together by a fibrous sheath derived from the membrane called costo-coracoid; and the base or humeral outlet of this axillary space, described by the muscles C, K, E, G, Plate 13, is closed by a part of the fascial membrane, g, extended across from the pectoral muscle, E, to the latissimus dorsi tendon, K. In the natural position of the vessels at that region of their course represented in the Plates, the vein A overlies the artery B, and also conceals most of the principal nerves. In order to show some of these nerves, in contact with the artery itself, the axillary vein is drawn a little apart from them.

The axillary space gives lodgment to numerous lymphatic glands, which 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.

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.

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.