Axillary Tumors

Tumors of the axilla are almost always due to involvement of the lymph-nodes. They may be either benign and inflammatory in character, forming the ordinary axillary adenitis, or tuberculous, or they may be malignant. As they are due to disease of the lymph-nodes, the parts which the glands drain should be searched for the starting-point of the affection. Aneurism or abscess may be mistaken for a new growth and an inflamed aneurism may readily be thought to be an abscess.

The excision of axillary tumors is difficult. If the tumor is of- an inflammatory origin it may be closely adherent to the veins or arteries or nerves, and the same condition may exist in malignant cases.

The blood supply of the axilla is so free that nothing is to be gained by saving small vessels, therefore in paring a tumor off the axillary vessels the various small branches are ligated and divided and the main vessels left bare. This applies to the veins as well as the arteries.

The subscapular artery is so large that it is often allowed to remain. When working in the posterior portion of the axilla it is to be remembered that the posterior circumflex artery is opposite the surgical neck of the humerus, above the tendon of the latissimus dorsi muscle, and that the subscapular artery is on the opposite side of the axillary artery a little higher up. The large subscapular vein will bleed profusely if wounded and it should be looked for at the axillary border of the scapula below the subscapularis muscle.

Wounds of the axillary vein are particularly dangerous on account of the admission of air. The attachment of the vein to the under side of the pectoralis minor and costocoracoid membrane keeps it from collapsing; hence the danger.

Nerves Of The Axilla

The brachial plexus is above the first portion of the axillary artery. In the second portion one cord is to the inner side, one to the outer, and one behind. In the third portion the median nerve is anterior and a little to the outer side of the artery, being formed by two roots, one from the inner and the other from the outer cord of the brachial plexus.

The musculocutaneous nerve is to the outer side of the artery, leaving the outer cord to enter the coracobrachialis muscle. The ulnar, internal cutaneous (cutaneus antebrachii medialis), and lesser internal cutaneous (cutaneus brachii medians') come from the inner cord and lie to the inner side of the artery. From the posterior cord come the axillary (circumflex) and radial (musculospiral) nerves. On the inner wall of the axilla behind the long thoracic artery is the N. thoracalis longus (long thoracic, or external respiratory nerve of Bell); it is a motor nerve and supplies the serratus anterior (magnus) muscle, hence it is not to be injured in clearing out the axilla.

Still farther posteriorly, accompanying the subscapular artery, is the thoraco-dorsalis or long subscapular nerve. It also is a motor nerve supplying the latissimus dorsi muscle; therefore it is to be spared.

Crossing the axilla from the second intercostal space to anastomose with the cutaneus brachii medialis nerve is the intercostobrachial (humeral) nerve. It is a nerve of sensation and need not be spared. Sometimes another branch from the third intercostal nerve also crosses the axilla; it is also sensory and can be cut away.

As the axillary (circumflex) nerve normally winds around the surgical neck of the humerus, when luxation occurs it is stretched over the head and paralysis of the deltoid may ensue.

The various nerves of the brachial plexus are often injured by pressure resulting from the use of crutches ("crutch palsy"). It is liable to affect any or several of the nerves, the radial (musculospiral) probably the most frequently. Neuritis is common and, as in injuries, the nerves affected are recognized by the motor or sensory symptoms produced.