Ligature of Axillary in its third stage.—This is an operation very much more common, more easy of accomplishment, and safer in its results than either of the preceding; the artery in this stage being more superficial, in fact almost subcutaneous.
Operation.—The arm being extended and supinated, an incision ([Plate I.] fig. 10) two and a half or three inches long, must be made in the base of the axilla over the artery, involving at first skin and superficial fascia only; the deep fascia is then exposed and must be carefully scraped through, avoiding injury of the basilic vein, if (as sometimes occurs) it has not yet dipped through the fascia. The vessel can now be felt; the median nerve which lies over the artery, or slightly to its outer side, must be drawn outwards, and the axillary vein, which lies at the thoracic side, but often overlaps the vessel, must be carefully drawn inwards. The ligature must then be passed from within outwards.
When the patient is very fat or muscular, the coraco-brachialis muscle may be required as a guide to the vessel; but in general its superficial position renders any guide quite unnecessary, even in the dead body.
Anatomical Note.—While in each stage the axillary artery gives off branches, those arising from the third stage are by far the most important, especially the subscapular, which leaves it at the edge of the muscle of the same name. To avoid these the ligature should be applied as low down on the vessel as possible, and, in point of fact, the operation called ligature of the third stage of the axillary is, anatomically speaking, really ligature of the brachial high up, and where there is room at all, there will be the less chance of secondary hæmorrhage, the greater the distance is between the ligature and the great subscapular branch.
Mr. Syme's Operation for Axillary Aneurism.—Description of the operation in his own words:—
"Chloroform being administered, I made an incision along the outer edge of the sterno-mastoid muscle, through the platysma myoides and fascia of the neck, so as to allow a finger to be pushed down to the situation where the subclavian artery issues from under the scalenus anticus and lies upon the first rib. I then opened the tumour, when a tremendous gush of blood showed that the artery was not effectually compressed; but while I plugged the aperture with my hand, Mr. Lister, who assisted me, by a slight movement of his finger, which had been thrust deeply under the upper edge of the tumour, and through the clots contained in it, at length succeeded in getting command of the vessel. I then laid the cavity freely open, and with both hands scooped out nearly seven pounds of coagulated blood, as was ascertained by measurement. The axillary artery appeared to have been torn across, and as the lower orifice still bled freely, I tied it in the first instance. I next cut through the lessor pectoral muscle close up to the clavicle, and holding the upper end of the vessel between my finger and thumb, passed an aneurism-needle, so as to apply a ligature about half an inch above the orifice."[19]
In a similar operation lately performed by the author for traumatic aneurism, the result of a stab, very little blood was lost, though no incision was made above the clavicle. The patient made a good recovery.[20]
Ligature of Brachial.—To arrest hæmorrhage from a wound of the artery itself, no special directions are required, except to enlarge the wound, and secure the vessel above and below the bleeding point. There are, however, rare cases in which for bleeding in the palm (after all other means have failed), or for aneurism lower down the arm, a ligature may be necessary.
Operation.—The biceps muscle, at its inner edge, is the best guide to the position of the incision, or if it be obscured by fat or œdema, a line extending from the axilla, just over the head of the humerus to the middle of the bend of the elbow will define its course. An incision ([Plate I.], fig. 11) three inches in length, about the middle of the arm (when you have the choice of position), through skin and superficial fascia, will expose the deep fascia, and probably the basilic vein. Drawing the latter aside, cautiously divide the deep fascia. The artery is then exposed, but in close relation to various nerves; of these the ones most likely to come in the way are—1. The median, which lies in front of, but a little to the outside of the artery, though in some rare cases it lies behind it; 2. The internal cutaneous; 3. The ulnar, both of which ought to be rather to the inside of the artery. Two brachial veins accompany and wind round the vessel, occasionally interlacing. Pulsation will, in the living body, usually suffice to distinguish the artery from the other textures, and the ligature may be passed from whichever side is most convenient.
Note.—The relation of the median nerve to the vessel varies according to the part of the arm—thus, as low as the insertion of the coraco-brachialis it is to the outer side, as has been described, it then crosses the vessel obliquely, and two inches above the elbow it is on the inner side of the artery. Again, the operator must never forget the possibility of there being a high division of the artery. This occurs, Mr. Quain has shown, perhaps once in every ten or eleven cases, and may necessitate ligature of both trunks.