100 SURGERY. I 



introduced between the artery and the internal jugular vein, which 

 is upon the outer side ; great care should also be taken not to in- 

 elude the par vagum nerve, which is included in the same sheath. J 



AXILLARY ANEURISM. 



This tumour occupies the arm-pit and sometimes extends above 

 the clavicle, producing pain and numbness in the arm. The ope- 

 ration of tying the artery above the clavicle is thus performed: the 

 patient is placed upon a high table and the shoulder forcibly depress- 

 ed • an incision {b. fig. 29), is made over the clavicle, through the 

 ski'n and platysma myoides, reaching from the anterior edge ol the 

 trapezius to a little beyond the posterior edge of the mastoid ; the 

 cervical fascia is then divided, the external jugular vem pushed aside, 

 and the omo-hyoid disclosed ; in the triangle formed by this muscle 

 and the clavicle, we find the artery at the outer edge of the scalenus 

 muscle, passing over the first rib, with the nerves forming the 

 brachial plexus above it, and the subclavian somewhat in front and 

 below Great caution should be used in exposing the vessel, on 

 account of the varieties of the arterial distribution in the neck ; it 

 should also be recollected the phrenic nerve descends upon the 

 anterior face of the scalenus anticus muscle. 



The artery is tied also below the clavicle by making a semi- 

 circular incision, with the convexity upwards, from near the sternal 

 end of the clavicle towards the acromial, carefully avoiding the 

 cephalic vein and acromial thoracic artery, which pass between 

 the outer edtre of the pectoralis major muscle and the deltoid. 

 After dividing the skin, superficial fascia, and pectoralis major, 

 the pectoralis minor will be exposed, between the upper edge of 

 which and the lower edge of the subclavian muscle, the artery will 

 be found deeply imbedded in cellular tissue and fat ; the vein is in 

 front, and the axillary plexus of nerves surround the artery. 



The arteria innominata has been tied, but without much success 

 where the tumour is largre. The patient lying on his back, with 

 his shoulders raised, and head thrown back, an incision two inches 

 in lenath is made on the inner side of the sterno-cleido-mastoid, 

 reachincr to the sternum ; another incision is made just above the 

 clavicle'and through the sterno-mastoid : thus a flap can be turned 

 up- the sterno-thyroid and sterno-hyoid are then to be divided 

 on 'a director, and the deep fascia exposed ; cautiously opemng this 

 fascia, the vein is to be pushed aside, avoiding the par vagum, re- 

 current, and cardiac nerves. 



BRACHIAL ANEURISM. 



This is usually the result of violence, and is very often a false 

 aneurism ; the tumour is in the bend of the arm, and inconveniences 

 its mobility. 



