268 CLINICAL APPLIED ANATOMY. 



The deep palmar arch, on the other hand, is formed by the 

 deep branch of the ulnar anastomosing with the termination of 

 the radial in the palm of the hand, and the lowest point of its 

 convexity is placed at a level which is one finger's breadth nearer 

 the wrist than that of the superficial arch. It lies here deep, to 

 all the structures in the palm of the hand, being placed upon the 

 metacarpal bones. Hence it follows that a wound of this arterial 

 arch is very difficult to deal with. Properly applied local pressure 

 is probably the best treatment to adopt in the first instance to 

 arrest the haemorrhage, unless an aseptic exposure of the bleeding 

 point can be carried out. If, however, pressure should fail, or 

 it is not thought advisable to cut down locally, it will become 

 necessary to ligature the brachial artery. This vessel must be tied, 

 because if the radial and ulnar were secured, blood might still 

 be brought to the bleeding point through the crucial anastomosis 

 in front of the wrist, consisting of the anterior interosseous on 

 the proximal side, the anterior carpals laterally, and the recurrent 

 branches of the deep palmar arch distally. 



Arteries of the Lower Extremity. Again, injuries of these 

 vessels, like those of the upper extremity, are by no means 

 common ; they may result, however, from punctured wounds. 



Undoubtedly the best treatment is to expose the injured vessel 

 and to ligature it on the proximal and on the distal side of the 

 opening into it. This, however, may be a matter of very great 

 difficulty, on account of the effusion of blood into the muscular 

 and cellular planes, the natural anatomical relations of parts 

 being thereby greatly altered and the liability to sepsis very 

 considerably increased. 



Gangrene occurs more commonly after obliteration of the 

 femoral artery than after closure of the brachial, because the 

 distance from the heart that is, from the pump is greater, 

 and the periphery of the limb will consequently be insufficiently 

 supplied with blood. If the vein happens to be damaged at the 

 same time that the artery is wounded, the probability of gangrene 

 is still greater, the moist variety occurring on account of the 

 obstruction to the return of the flow. 



