In such cases it will be found far more advantageous to arrest the hemorrhage by pres sure on the brachial artery, at the same time allaying the local inflammation by due attention to the position of the arm, and the usual antiphlogistic remedies, a plan which I have seen adopted with great success by Mr. Tyrrell, at St. Thomas's Hospital.* There are some eases, however, which im peratively require the application of ligat9res, as for instance, when either of these vessels is opened by sloughing of the tissues from phleg M0110US inflammation, or from aneurism in the fore-arm or hand. In the first of these cases, patients have frequently been lost from the temporary suspension of the hemorrhage by the use of cold applications or accidental circumstance, and its occurring again suddenly during the absence of the surgeon.
In the performance of the operation of tying the radial artery the supinator radii longus muscle affords an unerring guide throughout the fore-arm, but the surgeon must remember that the inner edge of this muscle is not on the outer side of the fore-arm, but as nearly in the centre as possible. The needle must be passed from without inwards, in order to avoid wound ing the nerve.
The ulnar artery cannot be secured in the upper third of the arm, it lies so completely covered by most of the flexors arising from the inner condyle ; as soon as the vessel has gained its position between the flexor carpi ulnaris and the flexor digitorum communis, it may be easily reached, the former muscle overlapping it, and therefore forming an excellent guide. The needle in this operation must be passed from within outwards, as the nerve lies to the ulnar side of the artery.
The bones of the fore-arm are not unfre quently fractured, either singly or together, but the radius, from its external position and strong connection with the bones of the hand, is more frequently fractured than the ulna. The injury generally takes place a little above the middle of the bone.
When both bones are fractured, the accident is frequently occasioned by the passage of a heavy weight over the limb, the violence acting immediately on the injured portions. In child hood these bones are sometimes bent instead of being broken, and as the deformity is slight, though the effect altogether very serious, the nature of the accident is not very readily de tected.
" When these bones are fractured near their inferior extremities," says M. Boyer,* " the in flammatory swelling might render the diagnosis difficult, and cause the fracture to be mistaken for a luxation of the hand. But the two cases
may be distinguished by simply moving the hand ; by the motion, if there be luxation with out fracture, the styloid processes of the radius and ulna will not change their situation ; but if a fracture do exist, these processes will follow the motion of the hand." If the radius be fractured a little below the head and above the tubercle, that is, through the neck, and the annular ligament remain en tire, the deformity is so slight that there is great difficulty in detecting the nature of the injury, especially if there be much swelling and effu sion. Unless the surgeon can distinctly feel the head of the radius, so that he can clearly ascertain on rotating the lower portion with the hand, that the upper does follow but remains perfectly unmoved, he has no equivocal guide as to the real nature of the injury.
If the ulna is fractured separately from the radius, which seldom occurs, the injury gene rally happens to the lower third of the bone, which is much smaller and more exposed than the upper ; the accident is easily detected by running the finger down the posterior edge of the bone. When the radius is fractured near its centre, the pronator quadratus muscle ob tains entire power over the bone, and drawing the lower portion across towards the ulna, causes a considerable projection in the anterior interosseous space. If this be not corrected by the use of a pad, as recommendeda little fur ther on, the two bones will unite, and all mo tion of pronation and supination be entirely lost.
In all these cases of fracture of the bones of the fore-arm, nearly the same plan of treatment is required, namely, 1st, two pads, increasing in thickness from the elbow to the wrist, and not wider in any place than the arm itself, suffi ciently soft to be pushed well into the interos seal spaces, applied anteriorly and posteriorly ; a long linen roller enveloping the baud and the whole of the fore-arm, and pressing the pads between the two bones, so as to counteract the action of the two pronator muscles which have a tendency to bring them together. Splints ex tending from the elbow to the hand.
When the radius alone is fractured, it is ad visable not to support the hand, but to allow it to hang down, and by this plan the hand acting as a weight, will draw the lower fractured por tion, which has a tendency to overlap the upper, downwards, and thus bring them into apposition.
(Samuel Sally.)