THE AEM. 1447 



being only slightly abducted, so as not to stretch the axillary fascia. The central group 

 (Leaf), imbedded in the fat immediately beneath the axillary fascia, become inflamed in 

 poisoned wounds of the upper extremity. The same group, along with the pectoral group 

 (related to the medial wall of the axilla, at the inferior border of the pectoralis minor), are 

 usually the first to become diseased in malignant affections of the breast. When the 

 disease is more advanced the posterior (subscapular) and the apical (subclavicular) groups 

 are generally affected as well ; and Rotter has shown that in a considerable porportion of 

 cases diseased glands are to be found in the retro-pectoral fascia, i.e. between the pectoralis 

 major and minor and, above the latter muscle, on the first intercostal space in relation to 

 the supreme thoracic artery. In operating for malignant disease of the breast, the 

 surgeon removes, in addition to the whole breast and the greater part of the skin over it, 

 both pectoral muscles (with the exception of the clavicular fibres of the pectoralis major), 



Brachial artery Clavicle 



Biceps tendon Anterior axillary fold 



Brachio-radial 



Coraco-brachialis Deltoid 



Biceps 



Flexor muscles 



Lacertus fibrosus 



Medial epicondyle 



Brachialis 



Ulnar nerve 

 Medial iritermuscular septum 



Median nerve 

 Medial head of triceps 



Long head of trice 

 Lower border of teres majo 



Posterior axillary fold 



FIG. 1112. AXILLA, MEDIAL ASPECT OF ARM AND ELBOW. 



all the axillary lymph glands, and, as far as possible, all the fat and fascia, including the 

 sheath of the axillary vein. It must be remembered that the distal part of the axillary 

 vein lies immediately underneath the deep fascia of the lateral wall of the axilla ; in clean- 

 ing the medial wall the long thoracic nerve must not be injured; and in removing the 

 posterior group of lymph glands the thoraco - dorsal nerve, which accompanies the 

 subscapular vessels, must be avoided, as it is doubly important to retain the action of the 

 latissimus dorsi after removing the pectorals. The writer has so frequently met with 

 disease in these retro-pectoral glands, that he is convinced of the necessity of removing 

 the pectoral muscles. 



THE ARM. 



The anterior and posterior borders of the deltoid may be traced from the 

 shoulder girdle to the insertion of that muscle. The surface relations of the anterior 

 border have already been referred to ; the posterior border forms a well-marked 

 and important landmark as it crosses the angle between the axillary margin of the 

 scapula and the proximal part of the body of the humerus. By making an incision 

 along this part of the posterior border of the deltoid, and retracting the edge of the 

 muscle^ .upwards and laterally, we expose the surgical neck of the humerus, and the 

 Quadrilateral opening in the posterior wall of the axilla, transmitting the posterior 

 circumflex artery of the humerus and the axillary nerve ; a little more distally is the 

 radial nerve. The coraco-brachialis, the guide to the proximal half of the brachial 

 artery, forms a prominence occupying the proximal half of the medial licipilal 

 furrow. Traced distally the medial bicipital furrow widens out into an elongated 

 triangle. This triangle, which may be termed the medial supracondylar triangle, 

 becomes continuous, distally, with the medial part of the triangle in front of the bend 

 of the elbow, and is limited posteriorly by the medial intermuscular septum, which 

 may be felt as a cord-like band extending proximally from the medial epicondyle ; 

 the floor of the space is formed by the medial part of the brachialis. Within the 

 triangle are the following important structures, enumerated from the lateral to the 

 medial side, viz. : the brachial artery, the median nerve, the distal part of the basilic 



