250 



APPLIED ANATOMY. 



circumflex, a small ascending branch of the anterior circumflex which runs in the 

 bicipital groove, and the humeral branch of the acromial thoracic which accompanies 

 the cephalic vein. 



A glaring and common mistake in the performance of shoulder amputations is 

 the making of the flaps entirely too short, especially when a Larrey operation is 

 attempted. 



The avoidance of serious hemorrhage is usually accomplished by clamping the 

 small vessels as the operation proceeds, and before the final division of the axillary 

 vessels slipping the fingers behind the bone and compressing them. 



Esmarch's tube has been used by encircling the shoulder as close to the trunk 

 as possible, the tube being kept from slipping by a bandage passed beneath it and 

 fastened to the opposite side. Wyeth's pins have been used for the same purpose. 

 One is inserted through the lower edge of the anterior axillary fold a little internal 

 to its middle and brought out above in front of the acromion process, the other is 

 entered at a corresponding point of the posterior fold and brought out above just 

 behind the angle of the spine of the scapula or acromion process. 



Interscapulothoracic Amputation. For malignant growths of the axilla, 

 shoulder, or scapula, and, rarely, for injury, the whole upper extremity with the 



Cords of brachial plexus 



Subclavian artery 



Superficial cervical artery 

 Trapezius 



, Posterior scapular artery coming 

 Omohyoid muscle-_:^^^ / * m the subclavian 



^?^/^H R^^ CB^^^fe^. Costocoracoid ligament 

 Scalenus anterior ^L/ - S3^ fer^. / Deltoid 



muscle 



Transverse cervical 

 artery 



Internal jugular 

 Phrenic nerve 

 Suprascapular artery 

 Thoracic duct 



Innominate \ 

 vein 



Subclavius muscle 



Subclavian vein 



Acromial thoracic artery 



FIG. 264. Structures exposed bv excising the inner portion of the clavicle. 



scapula and part or whole of the clavicle have been removed. Anteroposterior 

 flaps are made. 



The greatest danger is death from shock and hemorrhage. In order to obtain 

 some idea of the topography and vessels involved, see Fig. 264. 



Excision of the Clavicle. Excision of the clavicle in the living body, like 

 tracheotomy, is much more difficult than when practiced on the dead body; this 

 is due to the condition of the parts for which operation is undertaken. It has been 

 often excised for malignant growths. On the upper anterior surface are attached the 

 clavicular origin of the sternomastoid, the deep cervical fascia, and the trapezius 

 muscle. Crossing the clavicle near its middle is the jugulocephalic vein which some- 

 times connects the cephalic with the external jugular. It is likewise crossed by the 

 superficial descending branches of the cervical plexus. The external jugular vein, 

 about 2.5 cm. (i in.) above the middle of the clavicle, pierces the deep fascia and 

 turns inward to empty into the internal jugular just behind the outer edge of the 

 sternomastoid muscle; just below it empties the thoracic duct at the junction of the 

 internal jugular and subclavian veins. The Subclavian vein is directly behind the 

 clavicle and the left innominate vein crosses behind the left sternoclavicular joint and 

 passes across the posterior surface of the sternum just below or on a level with its 



