lower third it is superficial, between the tendons of the flexor carpi ulnaris on the inside and the flexor sublimis digitorum on the outside, the vessel being a little overlapped by the flexor carpi ulnaris. This vessel rests first upon the brachialis anticus muscle, next upon the flexor profundus, to which it is bound by a distinct process of fascia, and next upon the annular ligament, which structure it crosses to become the superficial palmar arch. Two venæ comites attend the vessel. In the upper third the nerve is well internal, but in the lower two-thirds the nerve lies near the artery and to its ulnar side. The guide is the outer edge of the flexor carpi ulnaris.

Operations (Pl. 2, Fig. 6).—Ligation of the Lower Third. -The position in this operation is the same as for the radial artery. Make a two-inch incision to the radial side of the tendon of the flexor carpi ulnaris, which incision is not taken lower than a point one inch above the pisiform bone. Avoid the superficial ulnar vein in the subcutaneous tissue. Open the deep fascia, find the tendon of the flexor carpi ulnaris, flex the wrist and draw the tendon inward, open a second layer of fascia, clear the vessel, separate the veins, and pass the ligature from within outward to avoid the nerve. the artery is the palmar cutaneous branch of the ulnar nerve, and this branch must not be included in the ligature.

On

Ligation of the Middle Third (Pl. 2, Fig. 6).—In this operation the position is the same as in the preceding one, the incision being three inches long. Avoid the anterior ulnar vein and the branches of the internal cutaneous nerve in the superficial fascia. Open the deep fascia a little external to the superficial cut (Treves). Find the space between the flexor carpi ulnaris and the superficial flexor, feeling with the index finger, and when the space is discovered flex the wrist, retract the flexor carpi ulnaris inward and the flexor sublimis digitorum outward, open the fascia, find the ulnar nerve, look external to it for the artery, clear the vessel, separate the venæ comites, and pass the needle from within outward. The ulnar artery should not be ligated in continuity in the upper one-third of its course.

Brachial Artery.-The line of the brachial artery is from the junction of the anterior and middle thirds of the outlet of the axilla, the arm being abducted and the forearm supinated, to the middle of the front of the elbow-joint.

Anatomy (Pl. 2, Fig. 1).-The brachial artery is the prolongation of the axillary, and extends from the lower edge of the teres major muscle to half an inch below the bend of the

1, Anatomy, 2, Ligation, of the Brachial Artery. 3, Anatomy of the Axilla. 4, Ligation of the Third Part of the Axillary Artery. 5, Anatomy, 6, Ligation, of the Radial and Ulnar Arteries. (From Bernard.)

elbow, where it divides into the radial and ulnar. It lies first to the inner side of the arm, but passes to the front of the elbow. It is crossed by no muscle, and is in fact superficial, barring its being somewhat overlaid in part of its course by the edge of the biceps muscle. The median nerve is outside above, crosses over it about the middle of the arm, and reaches the inside. The coracobrachialis and biceps muscles are external, and both often overlap the vessel. The ulnar nerve is internal above, and the median nerve below, the middle. The basilic vein is internal to the artery, being outside the deep fascia to near the middle of the arm, at which point it pierces it. The artery above is separated from the long head of the triceps by the musculospiral nerve and superior profunda artery and vein; it rests from above down on the inner head of the triceps, the coracobrachialis, and the brachialis anticus. The artery is covered by skin and by superficial and deep fascia. The internal cutaneous nerve lies in front of the artery, upon the deep fascia, until it pierces the fascia along with the basilic vein. The artery has venæ comites, and in its upper half has also the basilic vein to its inner side. The guide to the brachial is the inner edge of the biceps muscle. Just in front of the elbow-joint the artery lies in a triangle, the base of which is formed by an imaginary transverse line above the condyles, the apex by the junction of the pronator radii teres and the supinator longus. The outer line is the supinator longus, the inner line is the pronator radii teres, and the floor is formed by the brachialis anticus and the supinator brevis. From within outward the triangle contains the median nerve, brachial artery, tendon of the biceps, anastomosis of the superior profunda and radial recurrent arteries, and the musculospiral

nerve.

Operations.-Ligation at the Bend of the Elbow. In this operation (Pl. 2, Fig. 2) the patient is supine, the arm is moderately abducted and extended, and is allowed to lie upon its posterior aspect. The forearm is supinated. The surgeon stands upon the side operated upon, and cuts from above downward on the right side and from below upward on the left side. Accurately locate the tendon of the biceps and the median basilic vein. An incision is made parallel with the inner edge of the biceps tendon and two inches in length, the center of this cut being in the crease of the elbow. On exposing the median basilic vein, retract it downward and inward, open the bicipital fascia, clear the artery of fat, separate the venæ comites, and pass the ligature from within outward

to avoid the median nerve. The above operation is not frequently performed.

Ligation in the Middle of the Arm.-In this operation the patient is placed supine and abduction of the arm and supination of the forearm are brought about. An assistant holds the forearm, but the arm should not rest upon the table, because, if it be allowed to do so, the inner head of the triceps will be forced forward and may overlie the artery, and thus complicate the operation. Locate the inner edge of the biceps, which is the guide. Make an incision three inches long in the line of the artery. Incise the skin and fascia, flex the elbow slightly, retract the biceps outward, feel for the artery, open its sheath, separate its venæ comites, and, having located the median nerve, pass the ligature from it. In the middle of the arm the nerve is in front of the vessel, above the middle it is external, and below the middle internal. High up the arm the inner edge of the coracobrachialis is the guide, rather than the biceps. Above the middle of the arm the basilic vein is beneath the deep fascia and runs along to the inner side of the artery; hence, high up, the artery has three companion veins, the venæ comites and the basilic vein, and there is seen the ulnar nerve to the inside of the artery.

Axillary Artery.-To determine the line of the axillary artery place the arm at right angles to the body, with the patient supine, and lay down a line from the middle of the clavicle to the humerus near the inner border of the coracobrachialis. The line of the third portion can be approximated by projecting the line of the brachial upward.

Anatomy (Pl. 2, Fig. 3; Pl. 3, Fig. 1).—The axillary artery is the continuation of the subclavian, and runs from the lower margin of the first rib to the inferior border of the teres major muscle. It is divided into three portions by the pectoralis minor muscle. The first portion is above, the second portion is behind, and the third portion is below, the pectoralis minor. The position of the artery varies with the position of the limb. When the arm is parallel with the body the artery is far from the surface and forms a curve whose convexity is upward and outward. When the arm is at right angles to the body the vessel is nearer the surface and straight. When the arm is raised above a right angle the artery comes near the surface and forms a curve with the convexity downward.

The first portion of the axillary artery is occasionally ligated. It lies upon the first intercostal muscle and the