756 
SURGERY. 
begin an incision on the inner edge of the gastrocnemius; 
continue it obliquely for three inches in the direction of that 
muscle, so as to separate it from those beneath; elevate it 
with the upper part of the tendo Achillis, and on the first 
division of the muscle beneath, you find the artery with the 
nerve rather behind and to its outer side, and an accom¬ 
panying vein on each side. 
Peroneal.—Let the incision be three inches long, 
parallel with the fibula, but behind its outer edge; a few 
muscular fibres will require to be divided; the artery may 
then be felt by passing the finger across the bone to its pos¬ 
terior and inner border, where it is situated; as it is small 
and deeply seated, there will be some difficulty in passing 
the ligature. 
The anterior tibial.—Begin an incision rather below the 
middle of the tibia on its outer edge; continue it upwards 
and outwards, for three inches, in the direction of the inter¬ 
space of the tibialis anticus, and extensor longus digitorum 
muscles; cut through the fascia to the same extent, then 
separate the muscles, between which, on the interosseus 
ligament, you find the artery, having before it a branch 
of the peroneal nerve, and an accompanying vein on 
each side. These arteries, like the smaller of the upper 
extremity, require, when wounded, to be secured by two 
ligatures. 
Of the Upper Extremity. 
The arteries of the upper extremity require to be tied for 
aneurisms, in operations, or for great wounds. To tie the 
arteria innominata, make an incision from the middle of the 
upper edge of the first bone of the sternum obliquely up¬ 
wards, along the inner margin of the sferno-cleido-mastoi- 
deus muscle, about three inches; the muscular fibres of the 
sterno-hyoid and sterno-thyroideus being now divided, the 
finger may be passed under the sternum to where the artery 
may be felt lying on the fore-part and right side of the 
trachea.—There is great difficulty in passing the ligature 
round the vessel. 
The subclavian above the clavicle.—Mr. Hodgson has 
given the following rules for performing this operation:— 
“ The patient being seated in a chair, or placed upon a 
table, in a horizontal position, with the shoulder of the dis¬ 
eased side drawn dowmwards as much as possible, the ope¬ 
rator divides the skin immediately above the clavicle, from 
the external margin of the clavicular portion of the mastoid 
muscle, to the margin of the clavicular insertion of the tra¬ 
pezius. The edges of this incision being separated, the 
platysma myoides will be exposed, and its fibres are to be 
cut through, so as to avoid wounding the external jugular 
vein, which will be found immediately under them, near to 
the middle of the incision. When this vein is discovered, it 
is to be detached from the surrounding parts, and drawn 
towards the shoulder with a blunt hook. The operator then 
divides with his knife, or separates with his finger, the cel¬ 
lular membrane in the middle of the wound, until he arrives 
at the acromial margin of the anterior scalenus muscle. He 
passes his finger down the margin of this muscle, until he 
reaches the part where it arises from the first rib, and in the 
angle formed by the origin of the muscle from the rib he will 
feel the artery. The ligature is now to be passed underneath 
the artery, either with a common aneurism-needle, or that 
recommended by Desault.” 
The subclavian below the clavicle.—Put the pectoral mus¬ 
cle on the stretch by raising the arm and extending it back¬ 
wards; then observe the depression formed by the junction 
of its clavicular with its sternal portion, the direction of 
which must be the course of the incision. Begin it half an 
inch from the sternal extremity of the clavicle, and continue 
it through the integuments for three inches in the above 
direction; separate the two portions of muscle from each 
other exactly in the course of its fibres, then bring the arm 
to the side, which, by allowing of a wider separation, ex¬ 
poses more readily the parts beneath; at exactly one third of 
the length of the clavicle from its sternal extremity, you find 
the vein which is situated directly anterior to the artery, 
often concealed by fat and cellular membrane. To avoid 
wounding the vein, the greatest care is requisite. 
The axillary artery.—The part being shaved, or the hairs 
cut closely off with a pair of scissars, place the patient on his 
side, and let the arm be raised up by an assistant; then feel 
in the axilla for the head of the bone, which is thus lowered 
by the position of the arm; over it make an incision, in the 
direction of the limb, three inches long, the middle part of 
which should be exactly over the head of the bone; this will 
expose a part of the axillary plexus, behind the largest nerve 
of which, the median, the artery will be found: the vein 
passes rather below the artery at this part. 
The brachial.—Make an incision through the integuments 
two inches long on the inner edge of the biceps muscle: 
this first exposes the median nerve, which has the artery on 
its inner side between its two accompanying veins; the in¬ 
ternal cutaneous nerve is situated on the inner side of the 
artery, diverging from if, as it descends in the arm. 
. The radial near the elbow joint.—In the axis of the angle 
formed by the two condyles of the os humeri, and the ex¬ 
tensors and flexors of the hand, an incision is to be made 
through the integuments, commenced a little below the joint, 
and continued downwards for three inches. This exposes 
the fascia of the forearm, which is to be divided to the same 
extent; when the artery will be laid bare. 
The radial.—Feel for the styloid process of the radius, at 
which point begin your incision; continue it through the 
integuments for two inches, in the direction of a line which, 
if continued, would pass between the condyles of the os 
humeri; the artery will be found superficially situated, 
having the tendon of the supinator radii longus muscle on 
its outer side. 
The ulnar.—Feel for the pisiform bone, half an inch above 
which, and on the outer side of the flexor carpi ulnaris 
muscle, make a straight incision of two inches in extent 
through the integuments; cut through the fascia, an assistant 
drawing the internal edge of the wound to the inner side; 
dissect carefully by the side of the tendon, and you find the 
artery situated on the outer side of the nerve. 
Of fractures and dislocations of the upper extremity.. 
—The exposed situation, and natural slenderness of the 
clavicle, render it very liable to be broken, either at its 
middle, its sternal, or its scapular extremity. Its middle 
part, however, where its curvature is greatest, most frequently 
suffers. 
Fractures of the clavicle, besides being oblique, or trans¬ 
verse, may be divided into two different kinds, according as 
they happen to be situated at some point between the 
coracoid process of the scapula and the sternal extremity 
of the clavicle; or more towards the scapular end of the 
bone. 
The first case is most frequently the consequence of a fall 
upon the outer part of the shoulder, or upon the palm of the 
hand; for, anatomy teaches us, that the clavicle receives 
the impulse of every force, which is applied to the whole 
upper extremity. The second kind of fracture is generally 
produced by a blow directly on the part, and is attended 
with but a very trivial displacement of the fragments. On 
the contrary, in the former case, the displacement is very 
conspicuous; being caused by the weight of the arm, and 
the action of the pectoralis major and latissimus dorsi. 
Hence, the shoulder is depressed nearer to the trunk; the 
arm falls downwards and inwards; the inner end of the 
fracture is made to project partly by the action of the sterno- 
cleido-mastoideus, but chiefly by the external portion of the 
bone descending below it, the latter being displaced in the 
direction downwards, inwards, and forwards. In general, 
the fragments are still in contact, but, in such a manner, that 
the extremity of the outer piece touches only the lower side 
of the sternal portion. 
The symptoms of a fracture of the clavicle are, pain at 
the injured part; all motion of the arm difficult, but not 
very painful; impossibility of raising the hand to the head; 
the arm hangs close to the side, and is rotated inwards; the 
shoulder 
