Operation. The patient sits on a chair "with the arm. abducted, extended, and inclined outward" (Barker). The parts are asepticized and a tape is tied around the arm just above the elbow. The surgeon stands to the right of the arm, holds the elbow with his left hand, and puts his thumb

too deep, as nothing but the bicipital fascia separates it from the brachial artery. The median cephalic may be selected (we thus avoid endangering the brachial artery); under this vein lies the external cutaneous nerve (Fig. 54). Steady the vein with the thumb and open it by transfixion, making an oblique cut which divides two-thirds of it. Remove the thumb and allow bleeding to go on, instructing the patient to work his fingers. When faintness begins remove the fillet, put an antiseptic pad over the puncture, apply a spiral reverse bandage of the hand and arm and a figure-of-8 bandage of the elbow, and place the arm in a sling for several days.

Transfusion of Blood.-This operation has been a recognized procedure since 1824, though it has certainly been known since 1492, when transfusion in the case of Pope Innocent VIII. was made. Its chief use was in severe hemorrhage, especially post-partum, in which it served to replace the blood lost and supplied something for the heart to contract upon until new blood formed. Senn insists that the operation has proved an absolute failure. It does not prevent death from hemorrhage, and the transferred blood-elements do not retain vitality. Von Bergmann showed us that after severe hemorrhage we do not need to inject nutritive elements, but do need to restore the greatly diminished intracardiac and intravascular pressure. At the present day a saline fluid is transfused rather than blood. In fact, the ope

ration of transfusion has become all but extinct. It exposes the patient to the danger of embolism and infection, its employment requires material often hard to obtain, and it has no single element of value beyond that secured by the use of salt solution.

Transfusion of saline fluid is used after severe hemorrhage, in shock, in diabetic coma, in post-operative suppression of urine, and occasionally in sepsis. After a hemorrhage its beneficial effects are often prompt and obvious. This saline fluid increases the arterial tension, gives the heart enough matter to contract upon, and so restores the activity of the circulation. We may use a simple apparatus consisting of a rubber tube, a funnel, and an aspirating-needle. Some employ an Aveling syringe, and others Collin's apparatus

FIG. 56.-Intravenous injection of saline fluid.

(Fig. 56). The last-named instrument can be used without any danger of air entering with the fluids. Normal salt solution is the fluid usually employed, salt solution of a strength of 0.7 per cent. (about a teaspoonful of common salt to a pint of boiled water). Some surgeons employ an artificial serum. which contains 50 grains of chlorid of sodium, 3 grains of chlorid of potassium, 25 grains of sulphate and 25 grains of carbonate of sodium, 2 grains of phosphate of sodium in a pint of boiled water.' Szumann's solution consists of 6 parts of common salt, I part of sodium carbonate, and 1000 parts of water. The following solution is used by Locke and Hare: calcium chlorid, 25 gm.; potassium chlorid, 1 gm.; sodium. chlorid, 9 gm.; sterile water sufficient to make I liter. One 1 A. Pearce Gould, in Treves' System of Surgery.

bottle of the commercial fluid when diluted to 1 liter gives a solution of the above composition. Whatever fluid is used, it should be at a temperature of 100° F. From pint to 2 pints or even more are slowly injected, the condition of the patient determining the amount given. In one case of violent hemorrhage the author used 2 quarts. In order to transfuse this fluid tie a fillet well above the elbow, and expose by dissection the median basilic vein, or the basilic vein in the portion of its course where it is superficial to the deep fascia. Tie the vein. Incise it above the ligature, insert a fine cannula, and hold the cannula firmly in the lumen by tightening a second ligature (Fig. 56). Slowly and gradually introduce the fluid, carefully watching the pulse. When the tension of the pulse returns withdraw the cannula, tie the second ligature tightly, sew up the wound, and dress it aseptically. In very severe operations an assistant can do transfusion while the surgeon is operating. It may be necessary to repeat the transfusion if the circulation fails again.

Arterial Transfusion.-Hueter preferred the arterial method of transfusion, in order to send the blood more gradually to the heart, and thus prevent sudden disturbance of the circulation. A little air in an artery will do no harm, and the danger of venous embolism is avoided. Saline fluid can be thrown into an artery. The radial artery is exposed and surrounded by three ligatures, and the thread toward the heart is at once tied. The distal ligature is slightly tightened to cut off anastomotic blood-supply. The artery is cut transversely half through; the syringe is inserted, pointed toward the periphery, and fastened by the third ligature; the second ligature is loosened and the blood is injected. On finishing, the peripheral thread is tied tightly and that portion of the artery which held the cannula is excised.

3. LIGATION OF ARTERIES IN CONTINUITY.

The instruments used in this operation are two scalpels

FIG. 57.-Aneurysm-needle of Saviard.

(one small, one medium), two dissecting-forceps, several hemostatic forceps, toothed forceps, blunt hooks or broad

metal retractors, an Allis dissector, an aneurysm-needle, for superficial arteries the instrument of Saviard (Fig. 57), for deep vessels the needle of Dupuy

tren (Fig. 58), ligatures of catgut, of chromicized gut, or of silk, curved needles and needle-holder, and silkworm-gut, and the reflector or electric forehead-lamp for deep vessels.

The position varies according to the vessel, though the body is supine except when ligation is to be performed on the gluteal, sciatic, or popliteal. The operator, as a rule, stands upon the affected side, cutting from above downward on the right side and from below upward on the left side.

FIG. 58.-Dupuytren's aneurysmneedles.

Operation.-Accurately determine the line of the artery, and make an incision at a slight angle to this line, avoiding subcutaneous veins, and holding the scalpel like a fiddlebow or a dinner-knife while cutting the superficial parts, and like a pen while incising the deeper parts. On reaching the deep fascia make out the required muscular gap by the eye and finger, so moving the extremity as to bring individual muscles into action. Treves cautions us not to depend upon the yellow line of fat, which often cannot be seen in emaciated people or when an Esmarch bandage is employed; nor upon the white line due to attachment to the fascia of an intermuscular septum. In opening the deep portion of the wound relax the bounding muscles by altering the posture. Open a muscular interspace with a sharp knife, not with a dissector. Make the depths of the wound as long as the superficial incision. Do not tear structures apart with a grooved director; cut them. Arrest hemorrhage as it occurs. Try to find the situation of the artery with the finger. Pulsation is present, but it may be very feeble and hard to detect. The artery feels like a very thin rubber tube; it is compressible, though not so easily as a vein, and when compressed feels like a flat band which is thinner in the center than at the edges (Treves). A nerve feels like a hard round cord. The veins are soft, larger than their related arteries, and so very compressible that they can scarcely be felt when pressed upon, compression causing distal distention. If the wound can be seen well into, it will

be noted, as Treves asserts, that "the nerves stand out as clear, rounded, white cords; that the veins are of a purple color and of somewhat uneven and wavy contour; that the artery is regular in outline and of a pale-pink or pinkishyellow tint, the large vessels being of lighter color than the small." All the arteries of the upper extremity and all the arteries below the knee are accompanied by two veins, known as "venæ comites." The arteries of the head and neck have each a single attending vein, except the lingual, which has venæ comites. Most of the smaller arteries of the trunk (pudic, internal mammary, etc.) have venæ comites. These companion veins may lie on each side of the artery or in front and back of it, and they communicate with one another by transverse branches crossing the artery. On reaching the sheath pick up this structure with toothed forceps so as to make a transverse fold, and thus avoid catching the artery or vein; lift the fold to see that it is free, and open the sheath by cutting toward the edge of the forceps with a scalpel held obliquely with its back toward the vessel, thus making a small longitudinal incision (Pl. 1, Figs. 1, 2). Hold the edge of the incised sheath with the forceps; pass an Allis dissector under the vessel and from the forceps; this clears one-half of the vessel. Grasp the other edge of the sheath and pass the blunt dissector all the way around the vessel. Pass an aneurysm-needle under the cleared vessel away from the forceps holding the sheath. Thread the needle and withdraw it always from its most dangerous neighbor. If venæ comites are in the way, try to separate them; but if this proves difficult, include them in the ligature. In small vessels always include them if they are in the way, as this saves trouble. If, in passing the needle, a large vein is severely wounded (such as the femoral), Jacobson advises the employment of digital pressure in the lower portion of the wound while the artery is being tied on a level above or below that of the vein-injury, and after ligation the maintenance of pressure on the wound for a couple of days. A slight puncture in a vein merely requires a lateral ligature. A small longitudinal cut can be closed with Lembert sutures of fine silk. After getting a ligature under an artery press for a moment upon the artery over the ligature, which is held taut; this pressure will arrest pulsation below if the ligature is around the main artery and there is not a double vessel. Tie the thread at right angles to the vessel with a reef-knot (Fig. 59), rupturing the internal and middle coats. As the ligature is tightened place the extended index fingers