posing a vessel, as a general rule, intervening fasciæ are divided on the director*, which is inserted through a small hole, made by pinching up the parts with the forceps, and cutting with the blade of the knife on the flat. Muscular interspaces, if large, are most conveniently separated with the forefingers, contiguous tendons with the point of the director.

To free the vessel from its sheath, a small hole must be made in the latter, as in opening a fascia; the margins of this aperture being alternately seized with the forceps, the point of the director should be insinuated between them and the coats of the vessel. This separation ought to include the whole circumference of the artery, but as little as possible of its length.

An aneurism needle, with a very large curve, will be found most convenient on the dead body; besides its obvious purpose, it may, in its passage round the vessel, separate any remaining adhesion between this and its sheath. In passing the ligature, the point of the needle is generally inserted between the vessel and any neighbouring structure there may be a risk of including in the ligature. Having withdrawn the needle and left the ligature in position, a single knot should first be formed, and the ends of the silk be grasped by the thumbs and forefingers passed down as near to the vessel as possible; the knot may now be drawn tight, and secured by a second, tied over it. It is essential to pass the fingers down to the vessel before tightening the ligature, in order to avoid disturbing its connections, and also the more accurately to appreciate the amount of force applied.

We shall describe the operations for ligature of the various arteries in the order in which they should be practised on

* Fig. 4, page 5.

the subject, and shall omit those which rarely, if ever, come under our notice on the living body.

The radial artery. The course of this vessel will be sufficiently accurately indicated, by a line drawn from midway between the condyles of the humerus to a point, half an inch internal to the styloid process of the radius at the wrist. In the upper third of its course, it lies between and is somewhat overlapped by the supinator longus on the outer side, and the pronator 'teres on the inner side; but lower down in the forearm it is found more superficially, between the tendons of the flexor carpis radialis on the inner, and the supinator longus on the outer side. In the whole of its course under consideration, this vessel is found in the outermost intermuscular space of the front of the forearm, and is covered by nothing but the integuments and deep fascia, or rather it is only necessary to divide these to expose the artery.

A ligature may be applied to this vessel in any part of its course: we propose to tie it in its lower and upper thirds.

Lower third. An incision should be made in the direction of the line above indicated, commencing three inches above the wrist, and extending downwards for two inches. This should fall between the tendons of the flexor carpi radialis and the supinator longus; immediately beneath the integuments the superficial radial vein is usually found.

Pushing this aside, divide the deep fascia on the director, and the artery will come into view, surrounded by its venæ comites and an imperfect sheath, both of which must be separated with the point of the director, and the ligature passed.

Upper third.-To tie the artery in its upper third, make an incision three inches long in the course of the vessel, commencing two inches below the bend of the elbow and

running towards the wrist, search for the most external white line in the deep fascia; this marks the intermuscular space in which lies the artery. Having opened the fascia at this spot, use the finger or the director to separate the muscles, clear the artery from its connections, and apply the ligature from without inwards, to avoid the possibility of including the radial nerve.

The ulnar artery, in the part of its course with which we are concerned, extends with a slight curve from the middle of the bend of the elbow to the radial side of the

pisiform bone. In the first part of its course it runs obliquely; here it passes beneath the muscles coming from the inner condyle, and above the flexor profundus. In the lower two thirds of the forearm, it is found on the latter muscle, and overlapped by the flexor carpi ulnaris; its nerve joins it about the middle of the arm, and continues with it on the ulnar side as far as the wrist. Practically, this artery can only be tied in the lower two thirds of its course; to expose it between the flexor sublimis and flexor profundus digitorum, in the upper part of the forearm, would necessitate a most unwarrantable division of soft parts. It must be approached through the innermost intermuscular space of the front of the forearm, that is between the flexor carpi ulnaris and flexor sublimis digi

torum.

To expose the artery in its lower third, an incision should be made in the line of the course of the vessel, commencing three inches above the wrist, immediately external to the tendon of the flexor carpi ulnaris, and extending downwards parallel to that tendon for rather more than two inches; care should be taken to avoid injuring the superficial ulnar vein. By dividing the muscular fascia, the border of the tendon of the flexor carpi ulnaris will come into view, beneath which the artery lies. The vessel being

cleared, the aneurism needle should be passed from its ulnar to its radial side, to avoid the chance of including the ulnar nerve in the ligature. The operation is much facilitated by bending the wrist directly the above-mentioned tendon comes into view, as this permits the tendon to be drawn inwards without difficulty.

Ulnar artery with middle third.— Here the artery lies more deeply, and is approached by making an incision two or three inches long, to the radial side of the inner margin of the forearm, in the direction of the vessel: beneath this spot the white line which marks the separation between the flexor carpi ulnaris and flexor sublimis must be sought, and here the muscular fascia must be divided. After separating these muscles, the ulnar nerve will probably first come into view; and to its radial side, overlapped by the flexor sublimis, will be found the artery.

The brachial artery, extending from the lower border of the tendon of the teres major to the bend of the elbow, is covered, except at the last-mentioned place, only by the integuments and deep fascia; at the elbow it has in addition a covering from the tendon of the biceps, generally termed the semilunar fascia. A line, drawn from the inner border of the coraco brachialis to the middle of the bend of the elbow, would indicate its course; or the inner border of the biceps muscle sufficiently nearly represents it. The vessel lies for some distance on the triceps, and for a short space, just above the elbow on the brachialis anticus; to its outer side in the upper third of the arm, is the coraco brachialis, and below this point the biceps. Near the commencement of the artery, the median nerve crosses it in front, and runs on its inner side to the bend of the elbow. It is worthy of remark that the basilic vein lies over the vessel in the whole of its course; it may be found either in the subcutaneous tissue, or beneath the deep fascia. We pro

pose to tie this artery at the bend of the elbow, and at two points in the upper arm.

Bend of the elbow. Here the artery is very near the surface, being covered by the skin, superficial fascia, and deep fascia, which is blended with the semilunar fascia of the biceps; the vessel lies between the tendon of the latter muscle and the median nerve. To expose it, make an oblique incision, beginning two inches above the bend of the elbow, parallel to the inner border of the biceps, and corresponding to the line of the artery; push aside the median basilic vein, and divide the fascia of the biceps on the director; the artery will be found immediately beneath. In this operation, care is required both in dividing the integuments and the semilunar fascia; for beneath the former is the basilic vein, while the latter covers the brachial artery. The aneurism needle should be passed from within outwards.

The brachial artery is reached in its middle third by an incision from two to three inches in extent, along the inner border of the biceps muscle. The skin, superficial, and deep fascia will have to be divided, and the basilic vein carefully avoided. The vessel will be found with the ulnar nerve to its inner side, the median nerve either bearing the same relation to it, or lying in front of it. The sheath of the biceps should not be opened in this operation; it is a gratuitous injury, and adds to the difficulty of exposing the vessel.

The upper third of the brachial trunk may be ligatured by making a cut three inches long, beginning beneath the anterior fold of the axilla, and running down the inner margin of the coraco brachialis and biceps. The subsequent steps of the operation are precisely the same as those described in the preceding paragraph.

The axillary artery extends from the lower border of the first rib, to the lower border of the tendon of the teres