wound, and dress. Before actually tying ligature, make sure that you have surrounded the artery, the whole artery, and nothing but the artery. Needle should be passed between the artery and its vein. Process of repair, &c.—The two inner coats are divided by the ligature and retract a little. A clot forms up to the nearest branch. Lymph is effused around the ligature. In the most favourable cases, the lymph and the clot organise; and the cut arterial coats grow together, so that when the outermost coat is ulcerated through, a new barrier has been formed against hæmorrhage. But these processes may wholly or partially fail. Then there is more or less danger of secondary hæmorrhage. Dangers.-Secondary hæmorrhage from above cause, or from suppuration. Gangrene, from non-establishment of collateral circulation, from injury to, and consequent coagulation in, the vein, or from suppuration of an aneurismal sac. Erysipelas and other accidents to which all wounds are liable. 2. Ligature of an artery open in a wound.-Be careful not to include neighbouring nerve. Reefknot. Hemp, silk, and catgut ligatures. Carbolised catgut is absorbed or organised, and scarcely, if at all, acts like a foreign body in the wound. One end of a hemp or silk ligature must be left hanging out of the wound.

AXILLARY.-Very rarely tied. Line of artery. From just internal to coracoid process, curving outwards and downwards to commencement of brachial artery. Divide skin and pectoralis major. Beware of vein and brachial plexus.

LIGATURE OF SPECIAL ARTERIES.—Abdominal Aorta.-1st method: incise the abdominal wall as in ovariotomy. Divide the peritoneum covering the aorta, and pass the ligature. 2nd method: make an incision like that for ligature of common iliac, and proceed as if for ligature of that vessel, but keep a little higher. Doubtful whether operation is ever justifiable. For details, vide larger works.

Brachial.-In middle of upper arm. Line of incision, inner edge of biceps. Avoid basilic vein and internal cutaneous nerve; open deep fascia; look out for median nerve; artery usually lies just beneath it, but may be superficial to it. Remember occasional high division of brachial.

Carotid, Common.-Position: head back, face turned away

at first. Place of selection-just above omo-hyoid (i.e., level of cricoid cartilage). Line of artery, sterno-clavicular articulation to midway between mastoid process and angle of jaw; incise skin along anterior border of sterno-mastoid three inches; platysma; deep fascia. Raise head, relax and retract. sterno-mastoid; look for omo-hyoid; carotid sheath with descendens noni. As a rule, jugular vein and vagus nerve not seen. 2. In tying artery low down, divide partially sternomastoid, sterno-hyoid, and sterno-thyroids. Fatality.-40 per cent. in ordinary cases one in three. When operation is for hæmorrhage, 56 per cent. die. When for aneurism, on Brasdor's method, only one in four. For affections of the nervous system, only one in thirty-four. Chief Dangers.—Brain symptoms and secondary hæmorrhage.

Carotid, External and Internal.-Ligature of common carotid preferred. For external carotid proceed as follows: line of incision same as for common carotid; incision from angle of jaw to thyroid cartilage; freely incise any glands which may be in the way; tie and divide cutaneous veins; look for hypoglossal nerve; tie the artery between origins of supra-thyroid and lingual arteries.

Femoral. The common femoral rarely tied; ligature of external iliac preferred. Incise in line of artery; crural branch of genito-crural nerve; open sheath; tie about one inch below Poupart's ligament; pass needle from within outwards.

Superficial Femoral tied in two places: 1. At apex of Scarpa's triangle. Position: abduction and rotation outwards; knee flexed; line of artery, from middle of Poupart's ligament to front of inner condyle; incise skin 3-4 inches at junction of upper and middle one-thirds of thigh; divide fat; avoid saphena vein; divide fascia lata well to inner side of sartorius, so as not to open sheath of that muscle; retract sartorius outwards; feel for sheath of artery; branch of ant. crural over sheath; open sheath; clean artery with point of director; pass needle from inner side. 2. In Hunter's canal. Done when operation in Scarpa's triangle fails. If done at lower end of Hunter's canal, draw sartorius to inner side; incision in the same line as when artery is tied in Scarpa's

triangle, but longer, and of course lower down thigh. steps similar to first operation. Fatality.-One in four. was successful twenty-three times in succession.

Other

Syme

Iliac, Common.-Line of artery: from half-inch to left of umbilicus to middle of Poupart's ligament. Incision, from end of last rib downwards and forwards to crista ilii, and then forwards above and parallel to crest of ilium as far as anterior superior spine; divide muscles and transversalis fascia, using finger as a director; roll up peritoneum and intestines out of way, and tie artery. Second method: incise skin first from outside internal abdominal ring, parallel to Poupart's ligament, three or four inches towards ant. sup. spine of ilium; then continue incision with a curve inwards towards umbilicus, and proceed with muscles and transversalis fascia much as in first method. Remember relation to veins, ureter, and spermatic vessels. Fatality. Very great-twenty-five in thirty-two! Chief causes exhaustion and hæmorrhage.

Iliac, External.-Line of artery same as common iliac. Incise skin half an inch above Poupart's ligament from just external to internal abdominal ring outwards in a curve three inches long, and parallel to the ligament; divide muscles and transversalis fascia carefully; push up peritoneum; separate artery from vein; pass needle from within outwards; the higher up the artery is to be tied, the farther must the outer end of the incision be extended upwards and inwards, the incision thus becoming like that for the common iliac. Beware of seven dangers: 1, wound of epigastric artery; 2, wound of spermatic cord; 3, laceration of peritoneum; 4, puncture of external iliac vein; 5, of circumflexa ilii vein; 6, ligature of genito-crural; 7, too free disturbance of sub-peritoneal cellular tissue. Fatality. One in three. Chief causes: gangrene,

hæmorrhage, and peritonitis.

Iliac, Internal.-Steps of operation as for common iliac. Trace internal iliac from bifurcation of common iliac; scratch artery clean with finger-nail and director; pass ligature threequarters of an inch from origin. Beware of ureter, vein, and peritoneum. Fatality.-One in two.

Innominate. Incision, along anterior border and sternal

end of sterno-mastoid; divide as much of sterno mastoid as may be necessary to expose carotid, and trace carotid downwards to innominate. Fatality.-Only one case has recovered. In it the carotid and vertebral were also ligatured (Smyth's case).

Lingual.-Line of artery: just above greater cornu of hyoid bone; incision horizontal, with centre opposite end of greater cornu of hyoid bone; look for hypoglossal nerve; artery crosses beneath it; divide hyo-glossus muscle from hyoid bone artery is thus exposed. Object.-Usually to check hæmorrhage from cancer of tongue.

Radial.-Line of artery: from inner side of biceps tendon at bend of elbow to half an inch internal to styloid process of radius. Ligature in upper third incision in line of artery. Separate supinator longus from pronator teres, and tie. Lower third divide skin and deep fascia to outer side of flexor carpi radialis.

Subclavian.-Tied only in third part of its course. Raise patient on a pillow, head back, face turned away, arm pulled down; incise along clavicle, pulling skin down over it; divide border of sterno-mastoid if necessary; deep fascia; retract external jugular; separate vessels and cellular tissue beneath deep fascia without using knife-blade; feel for scalene tubercle and scalenus anticus. Subclavian lies behind them; brachial plexus and subclavian vein; pass needle from below upwards. Fatality. Nearly one in two. Chief causes: hæmorrhage, gangrene, intra thoracic inflammation, sloughing or suppuration of aneurism.'

Tibial, Anterior.-Line of artery: from head of fibula to midway between two malleoli. Upper or middle third: divide skin in line of vessel; look for a white line in deep fascia, marking outer border of tibialis anticus; divide the line and separate tibialis anticus from ext. long. dig. above, and from extensor prop. poll. below; nerve superficial; patient should put tibialis anticus into action before anesthesia. Lower third: artery nearly superficial.

Tibial, Posterior.-Upper half: two methods-1 (Guthrie's), perpendicular incision, six inches long, through middle of gastrocnemius, soleus and deep (submuscular) fascia; artery lies on

tibialis posticus; nerve crossing superficially and obliquely from within outwards. 2nd method incision, three quarters of an inch behind and parallel to posterior border of tibia, down to tibial origin of soleus. Separate soleus from bone, divide submuscular fascia, and find artery immediately beneath it.

Near Ankle.-Artery lies beneath thick deep fascia, rather nearer malleolus than heel. Incise over it.

Ulnar.-Line: from middle of bend of elbow, curving inwards slightly, to outer side of pisiform bone. Upper half: incise obliquely over course of vessel and well to inner side of arm; find outer border of flex. carpi ulnaris; divide it from flex. sublimis, and find artery between superficial and deep flexors; inner border of flexor sublimis may be found in thin people by putting that muscle in action.

Above Wrist.-Divide skin and deep fascia just outside tendon of flex. carpi ulnaris. Nerve on the inner side.

Asphyxia.-Causes.-1, Compression of chest; 2, compression of lungs by air in pleura; 3, traumatic compression of trachea, as in garrotting; 4, foreign body in air-passages; 5, immersion in some fluid, including (a) water (drowning), (b) some inert gas, (c) some poisonous gas; 6, disease, including (a) pressure by aneurism, oedema glottidis, accumulation of mucus, &c., (b) paralysis of respiratory muscles. Hanging may be classed with cause 3. Appearances.-Lividity, swelling of face, perhaps bleeding from nose or mouth. Post mortem : engorgement of right side of heart, emptiness of left side of heart; arteries contain venous blood; abdominal viscera engorged; lungs not peculiar when there has only been mechanical obstruction; but in drowning they are filled with frothy water, doughy and heavy, and the air-tubes are choked with frothy and bloody water and mucus. Brain sometimes hyperæmic, especially after hanging or suffocation. Prognosis. Almost hopeless after five minutes' submersion. Remember, a person may be immersed some time without being submerged. Recovery has taken place after three-quarters of an hour of asphyxia (Weeks). Prognosis much worse if water has got into the lungs.

Treatment. In drowning, hold the patient's head downwards for a few seconds to begin with. In hanging or choking, bleed

D