460 



SURGERY. 



squeezing the blood along (In- vein onwards to 

 the orifice, or by inserting a lancet, and such tear- 

 ing steps \ve have known to be employed even by 

 a regular practitioner, three times in twenty-four 

 hours. In cases where a second bleeding is 

 required, in the course of ten or twelve hours, 

 and where there are no inflammatory appear- 

 ances of the arm present, this method may be 

 adopted with impunity; but in other circumstances, 

 even at the termination of eighteen hours, it is ex- 

 tremely liable to produce inflammation of the vein, 

 as the adhesive process takes place very quickly 

 between the lips of a vein and a small wound in the 

 skin, especially when a clean sharp lancet has been 

 employed. It is therefore preferable to open a 

 vein in the other arm. It is also a very improper 

 practice, although sometimes followed, to open the 

 same vein close to within half an inch of the fresh 

 wound, in the space of one day ; neither of these 

 practices should be adopted, more particularly in 

 thoracic inflammations, as the veins are very liable 

 to take on an inflammatory action. 



The symptoms of an inflamed vein are tumefaction 

 of the arm, pain in the wound darting to the 

 axilla or shoulder joint, and even to the chest, ac- 

 companied with difficult respiration and inflamma- 

 tory fever, which, if not speedily checked, assumes 

 the typhoid type. The vein to the touch feels 

 hard, is very tender, and sometimes inflamed both 

 upwards and downwards, the sides of the wound 

 are inverted or turned outwards, much swollen, and 

 occasionally pus or serum, mixed with blood, can be 

 pressed out of it, or escape without any pressure. 

 An oedematous baggy feeling is frequently felt in 

 some parts of the arm, and the integuments partake 

 more or less of inflammatory discolouration. The 

 vein becomes so thickened in its coats, that in dis- 

 section it exhibits the appearance of a nerve; when 

 the cavity is not obliterated, coagulable lymph and 

 pus are deposited in its cavity, sometimes plugging 

 it up while the internal coat exhibits a reddish pur- 

 ple claret colour, and the contiguous cellular tissue 

 and intercostal muscles are infiltrated with pus 

 and an effusion of purulent matter. The thoracic 

 viscera afford the most incontestible proof of the 

 ravages of inflammation, as the consequence of the 

 veins circulating their contents onwards to the 

 heart, and imparting their inflammatory action to 

 that viscus and its immediate associates, with an 

 alarming celerity. 



In such a case, it must be evident that the most 

 prompt and decided measures should be taken, simi- 

 lar to those recommended in the treatment of a 

 wounded nerve; and in addition to the bleeding 

 from the jugular vein, tobacco clysters, cathartics, 

 the warm bath, opiate poultices and fomentations, 

 a profusion of leeches ought to be applied, and the 

 wounds kept bleeding by warm fomentations ; or 

 where leeches are not to be procured, numerous scar- 

 ifications and warm fomentations. If these means 

 fail, blisters should be applied to the chest, and the 

 most rigid cooling regimen adopted. J. Hunter 

 recommended, in addition to other means, pressure 

 on the vein, both above and below the wound ; but 

 further experience induced the late J. Abernethy 

 to recommend the division of the vein, a practice 

 now adopted. 



When early and judicious means have been 

 resorted to, and the patient has recovered, it should 

 always be.observed, in any future bleedings that may 

 be required, that the same vein be never twice 

 opened, ae there arc some constitutions peculiarly 



liable to this disease on the most trifling existing 

 cause. 



The lymphatics, when inflamed in consequence of 

 blood-letting, evince their inflammatory state by the 

 wound appearing fretful, inflamed and suppunitive, 

 by a cord or cords being felt sometimes above, and at 

 other times below the wound, but not precisely in 

 the course of the vessel. These cords arc exceed' 

 ingly tender to the touch, and assume a delicate rosy 

 red colour, having frequently one or more tumefied 

 points on the inner or ulner margin of the biceps 

 muscle, (see Anatomy, plate of Muscles,") in the 

 course of the brachial vessels or vessels of the arm. 

 Similar tumours are also seen on the fore arm. 

 between the elbow and the wrist joints. The glands 

 of the axilla or armpit become greatly affected, 

 and there is general tumefaction of the arm, with 

 acute pain in the wound in these corded lines, and 

 tumours accompanied with considerable symptom- 

 atic fever. In this inflammatory action, the con- 

 tiguous cellular substance becomes very early in- 

 volved, either before or after the inflammation of 

 the lymphatics, frequently producing extensive in- 

 flammation of both, which proceeds to the axillary 

 glands, and is always attended with more or less 

 oedematous feeling. 



The treatment of this affection is similar to the 

 last, and especially the early application of leeches 

 for some inches below the wound, and extending 

 up to the armpit; indeed the whole arm should be 

 covered with these useful reptiles. The strictest 

 antiphlogistic regimen should be observed, and the 

 general treatment the same as in a case of inflam- 

 matory fever. The compiler of this article once 

 suffered severely from inflammation of the lym- 

 phatics of the arm, from diseased matter, from a 

 bad conditioned sore on the leg of a patient whom he 

 was dressing, inoculating itself into a slight wound 

 on one of his fingers. This is a frequent case, and 

 the greatest care should be taken, by those dress- 

 ing sores or ulcers, to protect any wound or even 

 slight scratch, that the diseased matter might touch ; 

 and the numerous accidents from the introduction 

 of morbid matter during the dissection of dead 

 bodies, afford striking examples. The fascia of 

 the arm is likewise subject to inflammation, from 

 blood-letting. 



The/ascfa is an expansion of a muscle, inclosing 

 others like a band, and is derived from the term 

 fascis, a bundle. This accident takes place when 

 the operator has carelessly transfixed the vein, and 

 wounded this membrane. This, however, may 

 occur in the most skilful hands ; for occasionally 

 the most prominent vein at the bend of the arm, 

 and the one any surgeon would select, runs beneath 

 or connected to the fascia of the biceps. The symp- 

 toms of this affection are acute pain in the arm, 

 extending to the shoulder, whenever the fore-arm 

 is moved, which latter is in some degree bent on 

 the arm, with the fingers also bent and contracted. 

 There is great tension, some degree of tumefaction, 

 in consequence of an anasarca or effusion of fluid, 

 and slight erysipelatous inflammation, and general 

 sympathetic spasms are felt over the whole system. 



Thickening of the fascia, and suppuration or heal- 

 ing quickly supervenes, and consequent contraction 

 of the elbow joint and fingers; the treatment 

 should be extremely prompt, the same means beiig 

 used as for inflammation of the vein, which we 

 need not repeat. Contraction frequently results, 

 and in that case an operation is required, which 

 must call into action a surgeon of skill and dexter- 



