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flexor longus digitorum muscle. The nerve situated behind and externally is retracted outward, and the needle passed from without inward, avoiding the venæ comites.
PERONEAL ARTERY.—Slightly flex the knee and hip joints, and rotate inward to make the limb lie with its outer surface uppermost. The course of the artery is just internal to the fibula.
In Middle of Leg.–Make an incision four inches Iong, parallel to and one half inch posterior to the fibula. Divide the integument and fascia. Cut the filular attachment of the soleus to the extent of the wound. Separate the soleus from the fascia covering the flexor longus hallucis. Extend the ankle-joint and retract the soleus inward. The artery will be found just internal to the fibula under the deep fascia. It may be found in the substance of the flexor longus hallucis. Pass the needle.
ANTERIOR TIBIAL ARTERY.—Place the subject on the back, with the limb extended.
The surface guide is a line drawn from a point on the anterior surface of the limb, one half inch in. ternal to the head of the fibula, to a point midway between the malleoli in front of the ankle-joint.
1. Middle Third of Leg.–Make an incision four inches long obliquely downward and outward, having its middle point over the course of the artery. Di. vide the integument and superficial fascia. Divide on a director the deep fascia which will require horizontal cuts to allow its retraction. Search for the outer border of the tibialis anticus muscle, which may be made more evident in the lower part of the wound, by extending the ankle and turning the foot outward. Separate the tibialis anticus from the extensor longus digitorum, down to the interosseous membrane. The artery will be found on this membrane with its veins, and with the anterior tibial nerve in front. Retract the nerve outward, and pass the needle from without inward.
2. Lower Third of Leg.–Make an incision three inches long in the line of the artery. Find the outer border of the tibialis anticus tendon. Separate the tibialis anticus from the extensor proprius hallucis, whose tendon has commenced to cross over to the inner side of the artery. The artery is found on the interosseous membrane, with the nerve situated externally. Pass the needle from without inward, avoiding the venæ comites.
DORSALIS PEDIS ARTERY. Extend the anklejoint.
The surface guide is a line drawn from a point in front of the ankle, midway between the malleoli to the first metatarsal interosseous space.
Make an incision two inches long, beginning one inch from the upper end of this line. Divide the integument and superficial fascia. Divide on a director the dense deep fascia along the outer border of the tendon of the extensor proprius hallucis, made prominent by flexing the great toe. Separate and retract outward the extensor brevis digitorum, the inner tendon of which crosses over the artery. The nerve is external. Pass the needle avoiding the venæ comites.
Tie a ligature tightly around the arm just above the elbow, and try to make the veins prominent by pressing any blood which is fluid in the forearm, up toward the elbow.
Select the median cephalic vein, which can be seen or felt. Grasp the forearm just below the elbow with the left hand, and steady the vein with the left thumb. Hold the lancet between the right thumb and index-finger, with its blade making an obtuse angle with the hand. Puncture the vein obliquely, and tilt the point of the lancet while removing it, in order to enlarge the opening.
If the external jugular is chosen for operation, the puncture must divide the fibers of the platysma myoides. Open the vein as it crosses the sterno-cleidomastoid muscle, making the length of the opening to run upward and outward. The vein is made nent for operation by placing a pad above the middle of the clavicle to make pressure on the vein.
The internal saphenous vein is cut obliquely above the inner malleolus.
Locate the anterior temporal artery. The artery is subcutaneous, and can be readily followed upward and forward from the temporal artery.
Divide the integument over the artery. Partially divide the artery by an oblique incision. When the wound is to be closed the artery must be completely divided and closed by compression, torsion, or the ligature.
One of the various methods may be practiced on the subject.
Arterial Transfusion.—(Prepare a fluid for transfusion by adding to a pint of distilled water one and a half drachm of common salt and fifteen grains of carbonate of soda. Keep the temperature of the fluid at 104° Fahr.) Expose the radial artery, and ligature it in the lowest part of the wound. Occlude the artery by means of forceps applied above the ligature, and divide the vessel between the forceps and the ligature. Separate the artery from its bed to the extent of an inch. Compress the artery above the wound. Remove the forceps, and introduce into the artery, and secure with a ligature, the end of a trocar. Place the receptacle holding the fluid six feet above the body, and attach it to the trocar by means of rubber tubing. Allow the tubing to fill with fluid to expel the air before attaching it to the trocar. Remove the pressure on the artery above the wound. Allow several ounces of the fluid slowly to enter the arterial system. When the trocar is to be removed, the artery above the end of the instrument must first be ligated.