Licence: Public Domain Mark
Credit: Surgical operations / by Sir William MacCormac. Source: Wellcome Collection.
Provider: This material has been provided by the Royal College of Physicians of Edinburgh. The original may be consulted at the Royal College of Physicians of Edinburgh.
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![of the external wound. The upper border of the minor pectoral will then be visible in the lower part of the wound, and should be drawn downwards with a broad retractor. The costo-coracoid membrane must now be divided, when the cellular sheath of the vessel will be exposed. Care must be taken not to wound the acromial thoracic artery and vein, as they pass through the membrane. The veih lies internal and anterior to the artery, and will probably be first seen ; the brachial plexus is above and external, as well as behind. Pass the needle from within upwards and outwards, to avoid injuring the vein, which is often very large, overlaps the artery, and may become suddenly distended in consequence of respiratory obstruction. Guthrie recommended a straight incision to be made, in the line of the vessel from the centre of the clavicle downwards and outwards, to the middle of the axillary fold. After the pectoralis major muscle is divided, the steps of the operation are the same as in the former procedure. The artery may also be secured through the wound below the pectoralis minor, or, if need be, the second stage may be exposed by dividing this muscle. The axillary artery is difficult to secure in all parts of its course. Many vessels in the wound will require ligature. The operation in the first and second stages is not desirable, on account of the depth and extent of the wound, which in the first stage entails division of a very large muscle, namely, the pectoralis major, and in the second the pectoralis minor in addition. In the second stage the operation should not be attempted, save, perhaps, to search for a wound of the artery. Collateral Circulation. Axillary, in 3rd Part (between the origins of subscapular and circumflex arteries). (Figs. 52, 60.) Supra-scapular \ w'th [ ^^^'^^^^'ifl^^ {upon acromion and in Acromio-thoracic ] ^ ( shoulder-joint). Ill the first part the collateral circulation will be the same as when the third stage of the subclavian is tied (Fig. 60). In the third part, when the ligature is applied beneath the origin of the subscapular, it will be the same as when the brachial is hgatured above the superior profunda artery (Fig. 52).](https://iiif.wellcomecollection.org/image/b21979431_0073.jp2/full/800%2C/0/default.jpg)
