46 Anatomy Applied to Medicine and Surgery. 



to be dealt with shortly, so that the third part is the por- 

 tion elected for the purpose of ligation. The ligature 

 has occasionally been applied to the first part in the fol- 

 lowing manner: an incision starting from a point one- 

 half inch external to the sterno-clavicular articulation is 

 carried in a semi-lunar direction, with concavity upwards, 

 to a point half an inch from the beak of the coracoid pro- 

 cess dividing skin, superficial fascia, root of platysma, 

 superficial pectoral fascia, pectoralis major and deep pec- 

 toral fascia. Before incising the pectoralis major avoid 

 the cephalic vein which crosses the outer angle of the line 

 of incision. The sides of the wound are now retracted 

 and the pectoralis minor and the costo-coracoid membrane 

 exposed. The point where the cephalic vein pierces this 

 membrane to enter the axillary vein is the guide to the 

 artery. It is impossible to incise the costo-coracoid mem- 

 brane however, at this point, since the vein lies in front 

 of the artery and is adherent to the axillary sheath, and 

 the axillary sheath is adherent to the costo-coracoid 

 membrane. Should an attempt be made to open the 

 fascia here, the incision into the membrane would likely 

 open up the vein, and we would have a severe hemor- 

 hage occurring from the bottom of a deep funnel-shaped 

 wound, a wound in which there would be great 

 difficulty in compressing the opened vein. Besides, the 

 wound in the vein would be kept patulous, since its 

 union to the rigid costo-coracoid membrane would pre- 

 vent any retraction or occlusion of the vessel, and fur- 

 ther, there would be grave danger of the entrance of air 

 into the circulation on account of the "suction" action of 

 respiration on a vessel which is in close proximity to the 

 thorax arid in which there is an open wound. Hence 

 the opening in the membrane should be made at some 

 distance from the vein, preferably nearer the coracoid 



