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muscle to expose the artery crossing the floor of the superior carotid triangle between the common carotid artery and the lobe of the thyroid gland. Avoid the lingual, facial, and superior thyroid veins. Pass the needle, directing its point toward the lobe of the thyroid gland.
LINGUAL ARTERY.—Turn the face of the subject away from the side of the operation, and draw the chin upward.
Make an incision about three inches long, following the superior border of the hyoid bone. This incision should be slightly concave superiorly, and should begin at a point one half inch external to the median line. Divide the integument, platysma, and superficial fascia. Separate the fascia from the lower part of the submaxillary gland, and hook the gland upward. The hypoglossal nerve, making a triangle with the looped tendon of the digastric muscle, is seen in the bottom of the wound. The lingual vein generally lies upon the floor of this triangle, following the hypoglossal nerve. Divide on a director the fibers of the hyoglossus muscle just above the looped tendon of the digastic muscle. The lingual artery may be encountered in the fibers of the muscle, or will be seen running horizontally beneath the muscle.
If the lingual vein should be found in company with the artery, pass the needle from the vein.
FACIAL ARTERY.—Turn the face of the subject away from the side of the operation.
Draw the skin upward over the ramus of the jaw. Make an incision two inches long, following the lower border of the bone. A point over the junction of the posterior with the middle third of the body of the bone should mark the middle of the incision. Divide the integument, platysma, and superficial fascia, being careful not to bear upon the knife as it crosses the artery. The fascia had better be divided on a di. rector. Retract the sides of the incision, when the artery can be found crossing the ramus of the jaw at the lower part of the anterior border of the masseter muscle.
Pass the needle from behind forward, to avoid the facial vein.
OCCIPITAL ARTERY.—Turn the face of the subject away from the side of the operation; shave the part.
Begin an incision posteriorly to and a little below the
apex of the mastoid process, and continue it three inches in the direction of the external occipital protuberance. Divide the integument and fascia. Divide the sterno-mastoid and splenius muscles to the extent of the wound. Retract the edges of the wound, when the tortuous artery will be seen.
TEMPORAL ARTERY.—Turn the face of the subject away from the side of the operation.
Make an incision about two inches long at a right angle to the zygoma, having its middle point just in front of the tragus, between the tragus and the root
of the zygoma.
Divide the integument and superficial fascia, when the artery can be felt surrounded by dense fascia. Divide on a director the fascia over the artery, and pass the needle from behind forward, to avoid the temporal vein and the auriculo-temporal nerve.
COMMON ILIAC ARTERY.—Place the subject on the back, inclined somewhat to the opposite side.
The surface guide to the common and external iliac arteries is a line drawn from a point a little to the left of the umbilicus to a point midway between the symphysis pubis and the anterior superior spinous process of the ilium. The upper limit of this line may also be determined by taking a point an inch to the left of the middle point of a line drawn from the highest portion of one iliac crest to that of the other. The upper two or three inches of this line correspond to the course of the vessel.
Make an incision concave internally from the cartilage of the eleventh rib to a point two inches above the middle of Poupart's ligament. Divide the integument and fascia, the external oblique aponeurosis, the internal oblique, and the transversalis muscles. Divide the transversalis fascia on a director to the full extent of the wound. With the fingers separate the peritonæum and subserous areolar tissue from the iliac fossa until the psoas muscle covered by the psoas fascia is seen. Along the inner border of this muscle, above the level of the sacro-iliac synchondrosis, the artery can be felt.
On the left side the superior hæmorrhoidal vessels and the attachment of the sigmoid mesocolon must be pushed aside, and the needle passed from within outward.
On the right side pass the needle from without inward, to avoid the iliac veins which have crossed under the artery to form the vena cava.
The ureter generally adheres to the tissues raised, but, if found crossing the lower part of the artery, it may be retracted downward.
The arteries vary in length, and may give off branches.
INTERNAL ILIAC ARTERY.—The operation is the same as that to expose the common iliac. The artery can be felt as it runs down into the pelvis over the sacro-iliac synchondrosis at the inner side of the psoas muscle. The needle should be passed nearly an inch below the origin of the artery from within outward and from behind forward. Special precautions are to be taken to avoid the external iliac vein and the ureter in front. The needle should have its curvo set at a right angle to the shaft, and should be made for right and left arteries.
The common and internal iliacs may be more conveniently ligated by performing a median laparotomy, retracting or removing from the abdominal cavity the intestines, incising the posterior wall of the peritonæum, and by passing the ligature as already described.
GLUTEAL ARTERY.—Place the subject on the belly, and rotate the hip-joint inward.
The surface guide is a line drawn from the posterior superior spinous process of the ilium to the middle of the trochanter major. At the junction of the upper and middle thirds of this line the artery emerges from the pelvis.
Begin an incision about an inch from the upper limit of this line, and extend it downward five inches, following the line. Divide the integument and fascia, separate the fibers of the gluteus maximus muscle, and divide the fascia covering its under surface. Search for the intermuscular septum between the gluteus medius and the pyriformis muscles, in which the artery and its veins will be found. By rotating the hip-joint outward, the wound can be held open more readily. Ligate the artery as near its exit from the pelvis as possible, as it soon gives off its branches.
Sciatic APTERY.—Place the subject on the belly.
The surface guide to the operation is a line drawn from the posterior superior spinous process of the ilium to the tuber ischii.
Make an incision four inches long parallel to the fibers of the gluteus maximus, having as its middle point the junction of the lower and middle thirds of this line. Divide the integument and fascia, and separate the fibers of the gluteus maximus muscle. Divide the fascia covering the under surface of the gluteus maximus muscle. The artery will be seen emerging from under the pyriformis muscle. Internally will be seen the pudic vessels, and externally situated will be seen the sciatic nerve. Pass the needle from without inward to avoid the vein.
INTERNAL Pupic ARTERY.-1. The artery may be exposed by the last operation. It is found just internal to the sciatic artery, emerging from under the pyriformis muscle, accompanied by its veins and the pudic nerve.
2. In the Perinæum.- Place the subject in the lithotomy position.
The surface guide is a line drawn from below the symphysis pubis to the inner side of the tuberosity of the ischium.
Make an incision in this line three inches long, following the ramus of the pubis and ischium, and extending nearly to the tuberosity of the ischium. Divide the integument and the thick layer of adipose tissue. Separate the tissues from the inner side of the ramus.
Avoid injuring the crus penis. The