664

SURGERY,

forward in an oblique direction, till the orifice is of the size he in-clines to have it; taking care, during the time of pushing on thelancet, that its point he kept in as straight a direction as possible,for fear of dipping into the parts below. 'I he instrument is nowto be withdrawn ; and the surgeon, removing the thumb of hisleft-hand, is to allow the blood to run freely into the different cupspreviously provided. While the blood is discharging, the mem-ber ought to be kept in exactly the same posture it was in whenthe lancet was first introduced : otherwise the orifice in the skin isapt to slip over the opening in the vein ; a circumstance whichalways proves inconvenient, and sometimes produces much trou-ble, by the blood from the vein insinuating itself into the sur-rounding cellular substance.

V. A quantity of blood proportioned to the nature of the disor-der being discharged, the pressure upon the superior part of thevein should be immediately removed ; and if the spear-pointedlancet has been used, all farther loss of blood will in general stopimmediately. The contrary of this, however, sometimes occurs,and blood continues to flow freely even after the ligature is re-moved. When this happens, the operator ought to compress thevein both above and below the orifice, by means ot the finger andthumb of one hand, so as to prevent any farther loss ot blood. Thisbeing done, and the orifice being cleared of every particle ofblood, the sides of it should be laid as exactly together as pos-sible ; and a piece of plaster being applied so as to retain them, itwill seldom happen that any kind of bandage is necessary; butwhen the blood has issued with uncommon violence during theoperation, and has been difficult to command after the removal ofthe ligature, in such instances it will be prudent to apply a smallcompress of linen over the plaster, and to secure the whole witha linen-roller properly applied round the member. When vene-section is to be performed in the arm, the ligature for stopping thecirculation ought to be placed about an inch or an incli and a halfabove the joint of the elbow, and brought twice round: to preventthe ends of it from interfering with the lancet, the knot should bemade on the outside of the aim. In general the artery lies so lowin this place, that the median basilic vein, under which it com-monly runs, may be opened with perfect safety; and as this veinin general appears more conspicuous than any of the others, pro-bably from the continued pulsation of the artery below obstruct-ing in some measure the passage of its contents, it is in this respectmore properly calculated for this operation than any of the others.Other circumstances occur too which render the median basilicpreferable to the cephalic or median cephalic veins for blood-letting. The median basilic is less deeply covered with cellularsubstance; and by lying towards the inner part of the arm, it ismore thinly covered with the tendinous expansion of the bicepsmuscle than either of the others. From these circumstances theoperation is always attended with less pain when done in this veinthan in any of the others. In very corpulent people it sometimeshappens that all the larger veins lie so deep as not to be discoveredby the eye; but when they are sensibly felt by the fingers evenalthough they cannot be seen, they may be always opened withfreedom. In a few instances, however, they can neither be dis-tinguished by the eye nor by the finger: in such a situation, asthey may in general be met with about the wrist or on the backpart of the hand, the ligature should be removed from the upperpart of the arm ; and being applied about half-way between theelbow and the wrist, the veins below will thereby be brought intoview ; and wherever a vein can be evidently observed, there canbe no danger in having recourse to the operation. There isonly one vein of the neck, viz. the posterior external jugular,which can easily be brought so much into view as to he with pro-priety opened ;’ and even this lies deeply covered with parts, notonly with the skin and cellular substance, but with the fibres of theplatisma myoides muscle ; so that a considerable degree of pres-sure becomes necessary to raise it to any height. With a view toproduce this, the operator’s thumb is commonly advised to heplaced upon the vein, so as to compress it effectually, about aninch or an inch and a half below where the opening is to be made.This, however, seldom proves sufficient for the purpose, as theblood, on being stopped in its progress through this branch, easilyfinds a passage through the other veins ; so (hat unless the princi-pal vein on the other side of the neck is also compressed, the veinto be opened can never be fully distended. When blood is to be

discharged from the veins of the ancle or feet, the ligature beingapplied a little above the ankle-joint, all the branches of the venasaphena, both in the inside and outside of the fool, come at onceinto view ; and as this vein lies every where very superficial, beingin general covered with skin only, wherever a proper vein appearsconspicuously it may with safely be opened. When venesectionis to be performed in the veins called ranulse under the tongue,the apex of the tongue is to he elevated, and the vein on eachside opened, because the opening of one only will hardly everdischarge blood enough. After a sufficient quantity has been dis-charged, some cold astringent fluid taken into the mouth will gene-rally stop the hemorrhagy. Whatever particular advantages mayin theory have been expected from artcriolomy, and howeversome of its supporters may have recommended it, not only asbeing in many instances preferable to venesection, but as an opera-tion perfectly safe even in vessels of considerable size; yet themost strenuous friends to the practice have shrunk from any realattempt of this kind on the larger arteries. Instances have nodoubt occurred of large arteries having been opened without anydanger ensuing ; but these are so exceedingly rare, that no prac-titioner of experience will, from that consideration, be inducedcoolly to proceed to open any artery of importance. Differentbandages have been contrived for compressing the temporal ar-tery ; but none of tlidm answer the purpose so easily and so effec-tually as the one figured in Plate CLX1V. fig. 10. When, eitherfrom the severity of a local fixed pain, or from any oilier cause, it iswished (o evacuate blood directly from the small vessels of thepart affected, instead of opening any of the larger arteries or veins,the following are the different modes proposed for effecting it, viz.by means ol leeches ; by slight scarifications with the shoulder oredge of a lancet; and, lastly, by means of an instrument termed ascarificator, fig. 11, in which sixteen or twenty lancets are com-monly placed, in such a manner, that, when the instrument is ap-plied to the part afffidted, the whole number of lancets containedin it are, by means of a strong spring, pushed suddenly into it, tothe depth at which the instrument has been previously regulated.This being done, as the smaller blood-vessels only by this opera-tion are ever intended to be cut, and as these do not commonlydischarge freely, some means or other become necessary for pro-moting the evacuation. Various methods have been proposed forthis purpose. Glasses fitted to the form of the affected parts,with a small hole in the bottom of each, were long ago contrived ;and these being placed upon the scarified parts, a degree of suc-tion was produced by a person’s mouth sufficient for nearly ex-hausting the air contained in the glass: and this accordingly was asure enough method of increasing the evacuation of blood to acertain extent. But as this was attended with a good deal of trou-ble, and besides did not on every occasion prove altogether effec-tual, an exhausting syringe was at last adapted to the glass: whiclidid indeed answer as a very certain method of extracting the aircontained in it; but the application of this instrument for anylength of time is very troublesome, and it is difficult to preservethe syringe always air-tight. The application of heat to the cup-ping glasses (fig 12) has been found to rarefy the air contained inlitem to a degree sufficient for producing a very considerable suc-tion. And as the instrument in this simple form answers the pur-pose in view with very little trouble to the operator, and as it is atall times easily obtained, the use of the syringe has therefore beenlaid aside. 'I here are different methods adopted for thus applyingheat to the cavity of the glass. By supporting the mouth of it fora few seconds above the flame of a taper, the air may be suffi*ciently rarefied: but if the (lame is not kept exactly in the middle,but is allowed to touch either the sides or bottom of the glass, itis very apt to make it crack. A more certain, as well as an easier,method of applying the heat, is to dip a piece of soft bibulouspaper in spirit of wine ; and having set it on fire, to put it intothe bottom of the glass, and, on its being nearly extinguished, toapply the mouth of the instrument directly upon the scarifiedpart. This degree of heat, which may be always regulated bythe size of the piece of paper, and whicli it is evident ought to bealways in proportion to the size of the glass, if long enough ap'plied, proves always sufficient for rarefying the air very effectually*and at the same time, if done with any manner of caution, neverinjures the glass in the least. The glass having been thus supplied*if the scarifications have been properly made, they instantly begin