238 The Upper Extremity 



intervenes between these vessels, the artery is well protected from 

 injury by the lancet. Branches of the internal cutaneous nerve cross in 

 front of the vein. 



Before using the lancet the surgeon should make out the exact 

 situation of the brachial artery, and should satisfy himself that that 

 irregularity does not exist in which the ulnar artery descends into the 

 forearm superficial to the group of muscles arising from the internal 

 condyle. 



For the operation of venesection a tape should be tied round 

 the arm above the elbow, just tight enough to prevent the venous 

 return, but not to compress the artery, as I have known to happen. 

 The patient should hold something in his hand on which he can keep 

 exercising the flexors of his fingers, so as to hurry on the venous 

 return. The staff which was formerly used for this purpose has been 

 left in the keeping of the surgeon's old associate, the barber, who, 

 having now no other use for it, has decorated it in spirals of clean 

 and blood-stained tapes, and has fixed it over his shop-door as the 

 sign of his present craft. 



If during phlebotomy the lancet traverse the vein and wound the 

 subjacent artery, and the lips of the adjacent wounds become glued 

 together, blood is pumped with each ventricular contraction into the 

 vein. Thus, not only the median basilic and the neighbouring veins 

 become distended and varicose, but they pulsate after the manner of 

 an aneurysm. The condition is called aneurysmal varix it is a varix 

 with an aneurysmal pulsation. 



But when the edges of the wound in the vein do not become glued 

 to those in the artery, and the blood collects in the intervening con- 

 nective tissue before entering the vein, a pulsating tumour (aneurysm) 

 exists in addition to the aneurysmal varix, the condition being called 

 varicose aneurysm. 



Both these lesions may be treated by forcible flexion of the limb, 

 or, if that fail, by ligature of the artery above and below the wound. 



The basilic vein is formed by the confluence of the median-basilic 

 and common ulnar, and, lying along the inner side of the biceps, super- 

 ficial to, but in a line with, the brachial artery, it pierces the deep fascia 

 below the middle of the arm. It then lies alongside of the brachial 

 artery, and joins its venae comites at the lower border of the tendon of 

 the teres major to form the axillary vein. 



The median-cephalic vein ascends obliquely over the hollow between 

 the biceps and supinator longus, the musculo-cutaneous nerve lying 

 beneath it, but over the deep fascia. This vein when opened in 

 'bleeding' is said to be less easily compressed than the median-basilic 

 because of its lying over the intermuscular hollow. 



The cephalic vein ascends superficially on the outer side of the 

 biceps, lying afterwards in the groove between the pectoralis major and 

 deltoid. It pierces the deep fascia just below the clavicle, and then, 



