The Surgical Form Of The Male And Female Axillae Compared

Sources: Surgical Anatomy

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

divers ty, 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 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.