138 SURGICAL ANATOMY OF THE AXILLA. 



of the latissimus dorsi, teres major, and \subscapularis 

 muscles. 



Ligature of the Axillary Artery. The axillary artery 

 may be tied in the first part of its course or in the third. 



In the first part it is very deep and difficult of access, 

 but it may be reached, either by separating the fibres of 

 the pectoralis major and deltoid, or by means of a semi- 

 lunar incision through the integument, extending from 

 a little external to the sterno-clavicular joint towards the 

 coracoid process, taking care to avoid the cephalic vein ; 

 next the clavicular fibres of the pectoralis major must 

 be divided, the arm adducted, and the pectoralis minor 

 drawn down. The costo-coracoid membrane, which is 

 next seen on the stretch, must be opened, the cords of 

 the plexus drawn outwards, and the axillary vein in- 

 wards, when the ligature can be passed from within out- 

 wards. 



This operation is very difficult and dangerous, from 

 the close relation of the axillary and cephalic veins, and 

 the acromio-thoracic vessels. 



In the third part the vessel is easily reached. 



The arm is to be extended and supinated, in order to 

 throw out the fold of the coraco-brachialis muscle, the 

 inner border of which is the guide to the artery, and an 

 incision of about three inches in length is to be made 

 through the integument, rather nearer the anterior than 

 the posterior fold of the axilla, the deep fascia being 

 scratched through and the basilic or axillary vein 

 avoided ; the artery is seen lying crossed by the median 

 nerve, and having the axillary vein to its inner side, 

 and sometimes on it ; these structures must be carefully 

 isolated, and the needle passed from within outwards. 

 Occasionally the vessel divides high up into the brach- 



