SURGERY. 



455 



becomes conspicuous, and bleeds, freely, which it 

 would not do were the ligature not to be applied. 

 Hence, according to the situation of that part of 

 the body where the vein is to be opened with 

 regard to the heart, the ligature must be applied 

 either above or below the puncture. In the arm 

 and ankle , where the blood flows upwards to the 

 heart, the ligature must be applied above the 

 intended place of the puncture ; but in the jugular 

 vein, or any vein in the head where the blood 

 ascends, it must be tied below it. All the apparatus 

 necessary for blood-letting are a bandage or fillet of 

 cotton tape or silk, about a yard and a half in 

 length and near two inches broad, a common ribbon 

 or garter being frequently made use of; a compress, 

 which is easily made from four or five folds of 

 linen rag about two inches square; it is best to 

 have two such compresses ready ; and in addition 

 to these, a vessel to hold the blood ; and a very 

 clean, sharp, spear-pointed lancet. An instrument 

 of this form (see plate LXXXVII, fig. 5.), readily 

 penetrates the skin and vein with very little pain 

 to the patient ; the wound in both is made very 

 nearly alike in size ; and the blood is easily stopped, ! 

 neither of which is the case when abroad shouldered | 

 lancet is employed. 



In blood-letting, it is necessary to attend to the 

 posture in which the patient must be kept during 

 the operation ; and this will be different according 

 to the different intentions with which the blood is 

 taken away. If the design is merely to empty the 

 vessels a little, where there is plethora, or too 

 great fullness of the vessels, we ought to be careful 

 to prevent fainting. This object is best attained 

 by bleeding the patient in a recumbent posture, or 

 lying on a bed or sofa, which ought always to be 

 chosen when great fear exists, or an aptness to faint 

 on the loss of a small quantity of blood. But when 

 the person is strong and vigorous, there is little 

 occasion for this precaution, and a sitting posture 

 is to be preferred. In some cases, however, parti- 

 cularly in strangulated hernia, or rupture, or in 

 luxations of the larger joints, it is necessary to 

 induce fainting, that by the sudden and general 

 collapse of the system, the parts affected may be 

 more easily reduced. In this case the patient is to be 

 bled in an erect posture, and the wound made large, 

 that the blood may flow with the greater velocity. 



The first step in the operation of blood-letting, 

 as already observed, is to apply the ligature, which, 

 in the arm, must be tied a little above the elbow. 

 (See plate LXXXVI, fig. 1.) It is to be made so 

 tight that the passages of the blood through all the 

 superficial veins may be interrupted ; but we must 

 by no means tighten it to such a degree as to com- 

 press the artery, because this would effectually 

 prevent the veins from rising at all, by depriving 

 them of the blood which ought to make them swell. 

 When the ligature is properly applied, the veins 

 in the arm will be compressed and swell, and by 

 consulting the above plate, fig. 1, the operator will 

 easily distinguish which is most convenient to open. 



In the jugular vein we cannot so conveniently 

 apply the ligature, because there is danger of 

 stopping the patient's breath. When any of the 

 jugxilar veins are to be opened, the operator should 

 make choice of one of the veins previous to at- 

 tempting the operation ; then to put a compress of 

 linen upon the vein of the opposite side, tying it 

 tight with a ligature under the arm pit ; that is, if 

 the operator makes choice of the right jugular vein, 

 he must put a compress on the left one, and tie it 



under the right arm. Thus the reflux of blood 

 through these veins will be checked, and they will 

 swell as much as is necessary without any of that 

 disagreeable strangulation occasioned by a ligature 

 round the neck. In operating on the jugular vein, 

 the patient's head is to be laid on one side, and 

 properly supported ; then the operator is to press 

 upon the vein with the thumb of the left hand, in 

 order to make it swell, and when it becomes turgid, 

 place the fore and middle fingers of the same hand 

 above and below the point to be wounded. (See 

 Plate LXXXVI, fig. 5.) Then with the lancet in 

 the right hand an incision is to be made obliquely 

 across the integuments, from above downwards, 

 using the lancet as a knife or scalpel; and when the 

 vein is distinctly to be seen it is be cut upwards, or 

 rather in the angle shown in the plate, fig. 5, 

 as at the bend of the arm. Some good practical 

 surgeons prefer pushing the lancet through the 

 integuments and skin into the vein, till the blood 

 begins to appear as in the arm, because it is neces- 

 sary to go much deeper than in the arm, as the 

 veins are very deeply seated, and there is not here 

 any reason to fear the wounding of either artery or 

 tendons; neither by the perpendicular descent of 

 the blood through the veins, is there commonly any 

 difficulty in stopping the flux after the pressure ia 

 removed. Whenever the blood has begun to flow, 

 the middle fingers of the left hand are to be re- 

 moved, but the thumb is to remain until the quan- 

 tity required has been abstracted, and the wound 

 neatly brought together and kept close with adhesive 

 plaster, and this should be done as quickly and ef- 

 fectually as possible, as air may enter in by the 

 wound of the vein, and there are cases on record 

 where such an event has proved fatal. No compress 

 or bandage other than the shirt neck is to be used, 

 as it would check the circulation in veins of the 

 skin of the head, an occurrence which would be 

 dangerous. 



In operating on the arm after the ligature has 

 been properly applied, as already directed (see fig. 1), 

 the next thing is the choice of the vein, which is 

 attended with more difficulty in the arm than any 

 where else, the danger arising from the vicinity of 

 a nerve, tendon or artery, the wounding of any one 

 of which has often been attended with very serious 

 consequences. At the part of the arm where 

 blood is commonly drawn, there are four veins, 

 which are accurately delineated in the figure, viz. 

 the cephalic, on the outside, the basilic on the 

 inside, and the median basilic and median cephalic 

 between them, the two last being sent off from a 

 trunk called mediana major. This trunk runs up 

 the fore-arm between the cephalic and basilic, 

 dividing into two large branches, one of which runs 

 into each of the others, from which they take their 

 names of median basilic and median cephalic. Of 

 these, the median cephalic is the safest, and next 

 to it the median basilic. The basilic is dangerous, 

 on account of its lying directly above the artery, 

 (which may be felt by its pulsation") and tendons 

 of the biceps muscle. The cephalic is surrounded 

 by the branches o: the cutaneous nerve. In general, 

 we are to make choice of that vein which rolls least 

 under the skin, and by reason of its firmness, to 

 have some connection with the subjacent parts. 

 Though lying at a considerable depth, veins of this 

 kind are more easily opened than those which roll 

 much, by reason of their having no connection with 

 the cellular texture. The difficulty attendant on 

 the opening of loose veins may in a great measure 



