the posterior surface of the muscle, and not allow it to include any of the deeper structures.

Division of the tendon of the tibialis anticus. The spot which is usually selected for division of this tendon for club foot, is just in front of the ankle joint where the tendon is most prominent. Here it lies on the tibia, in the innermost of the sheaths in front of the ankle, having the anterior tibial artery to its outer side but separated from it by the extensor proprius pollicis.

The foot being abducted and extended by an assistant, the operator, standing on the opposite side of the leg to that of the tendon which he wishes to divide, and facing the patient for the muscle of the right side *, should feel for the prominence of the tendon with the forefinger of the left hand; keeping his finger on this spot, he should make an incision with the sharp-pointed knife, straight down to the inner side of the tendon, the blade of the scalpel being parallel to the latter; let him now introduce the bluntpointed knife, and having passed it on the flat beneath the tendon, let him turn its edge and divide the tendon at a right angle, while the assistant puts the parts on the stretch. The usual precautions must be adopted for guarding the integuments from injury.

The body being turned on its face, the remainder of the operations enumerated at the commencement of this chapter can be performed.

Section of the hamstring tendons.-The biceps may be divided where it lies in the outer fold of the popliteal space, external to and overlapping the peroneal nerve. The operator should stand on the same side of the limb as the tendon which he is about to divide, and with his back

* His back being towards the body in operating on the muscle of the opposite side.

turned towards the subject in operating on the right leg. Placing the forefinger of the left hand on the prominence of the outer hamstring, an incision should be made immediately over and down to the tendon; through this the bluntpointed knife should be introduced on the flat, so as to glide along the inner side of the tendon, between it and the peroneal nerve. The edge of the knife being turned, and the leg extended, the operation may be completed in the usual way.

The semimembranosus and semitendinosus can be divided in the popliteal space exactly opposite to the spot selected for section of the biceps, i. e. opposite the condyles of the femur. These tendons, lying in the inner fold of the space, are not in close relation with any important part; of the two, the semitendinosus is to the outer side, and communicates a more cord-like sensation to the touch. The operator should stand on the same side of the limb as the tendons on which he operates, and should face the subject in dividing those of the right lower limb. In operating on either tendon an incision should be made immediately on its outer * side, and the blunt-pointed knife being introduced, the operation may be completed as in the section of other tendons.

Division of the tendo Achillis. — The foot being put in a position of extension over the edge of the table, the operator should take up his position outside the limb, and in operating on the right leg, with his back turned towards the body: he should pierce the skin with a pointed tenotomy knife about an inch and a half above the calcis, and on the opposite side of the tendon to that on which he stands, and passing it beneath the tendon, should divide the latter, while the end of the thumb is placed on the skin over the

* "Outer" as regards the median line of the body.

parts; the assistant in the meantime putting the foot in a position of flexion to stretch the tendon.

It is customary with some operators to introduce the scalpel on the dorsal surface of this tendon, and this is best effected by pinching up the skin on the back of the heel, while the parts are relaxed, and subsequently cutting from the superficial towards the deeper aspect of the limb.

Division of the tibialis posticus. - The tendon of this muscle is found behind the inner ankle, in a groove on the tibia, and nearer to the inner malleolus than the other tendons; it is separated from the posterior tibial artery and nerve, which lie behind it, or nearer to the os calcis, by the flexor longus digitorum. The point usually selected for its division is at a spot about an inch and a half above the inner malleolus, immediately behind which point of bone the tendon is found. The foot being flexed and placed in a position of forced abduction, the line of the tendon should be felt for, and having been determined, the forefinger of the left hand should be placed on the spot, and retained there during the operation. The operator, standing on the opposite side of the leg to that of the tendon, should introduce the sharp-pointed tenotomy knife to its inner side, and thrust it quite down to the bone; having substituted a blunt-pointed knife, the tendon may be divided from within outwards, taking care not to pass over it, as it lies in its groove on the bone.

CHAP. IV.

LIGATURE OF ARTERIES.

General Rules for the Ligature of Arteries.-Instruments required and their respective use.-Ligature of Arteries of Upper Extremity and Head and Neck radial, ulnar, brachial, axillary, subclavian, innominate, common carotid, external carotid, internal carotid, lingual, facial, temporal.— Arteries of Abdomen and Lower Extremity: common iliac, internal iliac, external iliac, femoral, anterior tibial, posterior tibial, peroneal, popliteal.

To expose the large vessels of the body with certainty, it is necessary not only to know their relational anatomy as regards the parts with which they are in immediate contact; but accurately to ascertain their position, and the direction of their course with respect to the external conformation and outline of the parts of the body in which they are found. With this object it is usual to take as guides and landmarks to the position of subjacent vessels, either the outline of some muscle, or imaginary lines drawn from one point to another. In all cases where the external conformation of the limb admits of it, we have chosen prominent points of bone as landmarks; as these are more constant in their relative positions, and more easily discovered than the outlines of muscles, which latter are too liable to be obscured by fat, or rendered indistinct from other causes.

The subject being placed on its back on a narrow table, the operator may prepare to perform the ligature of all the principal arteries of the body. He will require a scalpel,

a pair of dissecting forceps, a grooved steel director, and an aneurism needle. The scalpel should be from two to three inches in length in the blade. The groove in the director should run quite to its extremity, and leave no cul de sac in which the point of the knife can catch.

As there are certain general rules which must be followed in attempting the ligature of all arteries, we propose to notice them here, to avoid subsequent repetition.

The knife is for cutting, and for this alone, it should not be used for scraping or scratching at the sheath of a vessel; it had best be laid aside so soon as the artery comes into view. When the direction and length of incision have been determined, the integuments should be slightly stretched by the middle finger and thumb of the left hand, placed on either side of the line of incision. The scalpel should be held as a pen in writing (fig. 1, page 4), and on its first contact with the skin should be held at the same inclination to the surface as a pen; as the integuments are divided, its position should gradually become vertical, so that on the completion of the incision it may be perpendicular to the surface. When practicable the first incision is always made immediately over and parallel to the course of the vessel to be tied; it should not divide more than the integuments. Each successive cut ought to be of precisely the same extent as the preceding.

The use of the forceps is obvious, but it may be well to remark that they are not to be applied directly to the artery itself, or to any large nerve or vessel that may be exposed during the operation.

The steel director is used for dividing fascia upon, for separating muscular interspaces, and for detaching the artery from its sheath; it is of great service in all those cases in which a silver knife is used by many operators. In ex