A treatise on operative surgery : comprising a description of the various processes of the art, including all the new operations : exhibiting the state of surgical science in its present advanced condition / by Joseph Pancoast.
- Joseph Pancoast
- Date:
- 1844
Licence: Public Domain Mark
Credit: A treatise on operative surgery : comprising a description of the various processes of the art, including all the new operations : exhibiting the state of surgical science in its present advanced condition / by Joseph Pancoast. Source: Wellcome Collection.
Provider: This material has been provided by the National Library of Medicine (U.S.), through the Medical Heritage Library. The original may be consulted at the National Library of Medicine (U.S.)
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![vide, the position of the outer border of the scalenus, which is an uiL'h and 6ve-eighthfl out from the sternal end of the clavicle; as tins is in the line of direction of the axillary artery. ].!(.' ITURE OF THE BRACHIAL ARTERY. (PL. XI.) Surgical anatomy.—This artery, which is a continuation of the axillary, descends in a straight line in the muscular groove found between the inner edges of the coraco-brachialis and bi- ceps in front, and the triceps extensor cubiti behind. About an inch and a half above the elbow joint, it bends slightly outwards along the interior edge of the biceps, and crosses the face of the brachialis amicus so as to reach the middle of the bend of the arm. At this point, it is covered by the aponeurotic expansion sent oil' inwards and downwards from the tendon of the biceps, and divides there into the radial and ulnar arteries, just at the insertion of the muscle on the tuberosity of the radius. The brachial artery, in a subject moderately muscular, is found about half an inch below the surface. It is covered by the integument, a superficial fascia consisting of two thin layers, and a deep- seated muscular or brachial aponeurosis. Just above the elbow johit, it is slightly overlapped by the internal edge of the belly of the biceps. On its inner side, and in close connection, is found the trunk of the brachial vein; but where there are two satellite veins, the artery is placed between them. The median nerve lias important relations with the artery, and serves as a guide for its discovery in ligature of the vessel. At the superior and middle third of the arm, the nerve is found at the external and front margin of the artery. About two inches and a half above the elbow joint, it crosses obliquely in front of the artery so as to get completely to its inner side. The ulnar nerve passes down the arm at some little distance within and behind the artery, in the direction of the back part of the internal condyle. The 'in- ternal cutaneous is found at the inner surface and somewhat in front of the vessel. In their descent along the arm, the vessels are surrounded by loose cellular tissue rather than a distinct sheath. The artery, in a healthy state of the parts, can be felt pulsating through the skin, and may be tied in any portion of its course. Anomalies.—Nothing is more common than anomalies in the distribution of this vessel. It may divide, as before observed into us radial and ulnar branches as high as the armpit, or at any part of its course down the arm. The frequency of this irre-ular distribution, should be well understood. Fortunately, it may usually be detected by careful external examination; otherwise the surgeon might become embarrassed in attempting to check a haemorrhage or cure an aneurism, in finding that he had exposed a vessel which was not the subject of disease. He may, before begmnmg the incision, by alternately compressing the respective branches, be able to discover which is the proper subject of operation. It may be necessary even to tie both branches, as they arc sometimes found to have direct communication with each other at the elbow; and this double operation could be at- tended wnh no greater danger than the single ligature of the undivided trunk. In cases of division high up, the branches are usually found running down near together, (the radial being the more superficial and external,) to the neighbourhood of the elbow joint where they diverge. Anaslomosis.-The anastomosing branches by which the cir- culation is carried on after obliteration of the brachial trunk, are the profunda major, profunda minor, and the anastomotica on the part of this artery. The profunda major is usually given off near the armpit, the principal branch of which, the musculo- spiral, winding round the bone with the nerve of that name, forms a continuous trunk with the recurrens radialis in front of the external condyle, and is connected also by a branch with the interosseal recurrent at the back part of the joint. The profunda minor, passing down behind the brachial artery as far as the middle of the arm, sends a branch of considerable size down with the ulnar nerve behind the inner condyle, where it inoscu- lates with and forms a continuous tube with the recurrens ulnaris. The anastomotica. coming off an inch or two above the elbow joint, winds across the brachialis anticus, and divides into two branches, one of which, passing in front of the outer condyle, unites with the radial recurrent, and the other dips down between the capsule and olecranon process to anastomose with the inter- osseal recurrent. Remarks.—The brachial artery, in consequence of its prox- imity to the bone, may be readily compressed in any part of its course with the extremities of the fingers or a compress and bandage. If the latter means be used, the compress should be of moderate size, so as to admit of being pressed under the edge of the biceps. It is well to avoid making compression at the point where the artery passes over the insertion of the coraco-bra- chialis muscle, as here the median nerve is so placed in relation to it as to be painfully affected by the force applied. From the mobility and exposed position of the arm, and the frequency of venesection at the elbow, it is of all the larger arteries most exposed to traumatic injury. If there be lesion of the vessel above the elbow, we may tie it either at the place in- jured, or, if there is such infiltration of blood as to mask the parts, cut down upon it in any point above. In case of puncture of the artery in venesection at the elbow, the course to be pursued va- ries according to circumstances. Pressure made with graduated compresses, covered with a piece of coin or other metal, or with a special apparatus for the purpose, may, particularly if the wound be longitudinal, so diminish the calibre of the vessel as to allow the wound both in the artery and vein to heal. But to succeed, it must be immediately applied, and is even then an uncertain measure. If it fail, or the case be altogether neglected in its first stage, even though the wound on the two surfaces of the vein should heal, we may have a false aneurism developed in its sheath or the surrounding cellular tissue, constituting a resisting pulsating tumour below the bicipital aponeurosis, limiting the extension of the arm, and as it grows in size bulging up just above the upper margin of this membrane, where the fascia is less resisting; or there may be instead direct communication be- tween the artery and superficial vein. The posterior wound in the vein and that of the artery not healing by first intention, and being brought into close contact by the compression necessary to stop the haemorrhage, the blood of the latter vessel leaving its route to the hand, and turning in a direction in which it meets less resistance, forms an oblong prominent pulsating tumour in the superficial veins at the elbow, constituting what is called a varicose or arterio-venous aneurism. The communication may be made directly, as has been observed, between the artery and](https://iiif.wellcomecollection.org/image/b21145398_0094.jp2/full/800%2C/0/default.jpg)
