proceeds superficially over the muscles, arising from the internal condyle, instead of diving under them, in the ordinary

manner.

In general, it is best to select a vein, which rolls least under the skin. Such a vessel, though sometimes not so superficial as another, may commonly be more easily opened, than the latter. However, the operator is always to fix the vein, as much as he can, by placing the thumb of his left hand a little below the place, where he intends to introduce the lancet.

More depends on the mode of using this instrument, than on its shape. It should be pushed into the vein in an oblique direction, and, when its point is a little within the cavity of the vessel, it is not to be introduced further, but the opening is to be rendered sufficiently large by carrying the front edge of the lancet obliquely forward and upward, by which movement, it is also brought out of the part again. In cases of herniæ, it is often a great desideratum to make a free opening, in order that the sudden evacuation of blood may make the patient faint. The puncture being made, the patient is to support his arm, in a convenient position for allowing the blood to flow into a basin, by taking hold of a stick, which he may turn round and round in his hand, in order to put the muscles into action, and make the blood flow out in a freer current. Sometimes, however, it escapes so readily, that there is no occasion to move the muscles of the arm. When the patient is so circumstanced, that he cannot take hold of a stick, the surgeon is to support the arm in a convenient posture; and, if the vein should not bleed in a free manner, he is to desire the patient to take hold of any small body, and move it about in his hand, in order to put the muscles of the forearm into action.

The due quantity of blood having been taken away, the ligature is to be loosened, and removed. The current of blood now generally ceases, and always does so, when the surgeon places the thumb of his left hand just below the orifice. The arm in this state is to be washed with a sponge, and dried. The edges of the wound are to be placed in contact, and kept so by a small compress of lint, which is to be bound on the part, by applying the bleeding fillet round the arm, in the form of a figure of eight. The bandage is to meet and cross in front, exactly over the dossil of lint.

When the external jugular vein is opened, the surgeon generally makes the necessary pressure with his thumb. The orifice should be made in the direction of the fibres.of the platysma myoides muscle, and the vein is not so apt to glide out of the way, when the surgeon opens the vessel, just where it lies over some part of the sterno-cleidomastoideus.

RR 2

The temporal artery, and its branches, are the only vessels, in which surgeons now ever perform arteriotomy. When the branch seems to be superficial, it may be punctured at once; but, in other cases, it is best to make first a small incision through the integuments. After the due quantity of blood has been taken away, the bleeding may always be stopped, by means of a roller and compress. When there is much hemorrhage after the operation, some surgeons recommend cutting the vessel completely across, in orde to allow it to become retracted.

OCCASIONAL ILL CONSEQUENCES OF BLEEDING IN THE ARM.

Ecchymosis.

The most common troublesome occurrence, after bleeding, as far as my observation extends, is a swelling, which originates from blood insinuating itself, from the orifice of the vein, into the adjacent cellular substance. Sometimes, this ecchymosis, as it is technically named, forms a tumor as large as, or even larger, than a walnut. The blood is mostly absorbed, in the course of a week, or ten days; and this desirable event should be promoted by applying lotions of vinegar, sal ammoniac, &c. In some instances, the tumor suppurates, and it becomes necessary to apply poultices.

INFLAMMATION OF THE INTEGUMENTS, AND CELLULAR

SUBSTANCE.

This very often occurs, when the patient neglects to keep his arm quietly in a sling, for a day, or two, after the operation. The improper motion of the limb makes the edges of the wound rub against each other, and they necessarily inflame, and even suppurate. The inflammation and suppuration are apt to be communicated to the surrounding skin and cellular substance, for a greater, or less extent.

This case requires the same treatment, as other phlegmonous

tumors.

In persons, who lead intemperate lives, the inflammation is very often of the erysipelatous kind.

INFLAMMATION OF THE ABSORBENTS.

These vessels, we know, are susceptible of inflammation, as well as other parts. We frequently feel them extending from a part, in which there is some species of local irritation, like firm cords, of much greater thickness, than one can suppose would arise merely from the swollen coats of these delicate vessels.

The fact is, the adjoining cellular substance is also affected, and contributes to the swelling. The inflamed absorbents may sometimes be seen running from the wound, in the form of reddish streaks; and if this appearance should extend, both towards the thoracic duct, and also in a direction from it, we may conclude, that the affection is in consequence of irritation, and not of absorption. After bleeding, they are found occasionally running upward to a glandular swelling, situated about the middle of the arm, in the course of the large vessels, and to another glandular tumor, situated over the muscles of the forearm, which arise from the internal condyle. The treatment of this sort of case is entirely antiphlogistic.

INFLAMMATION OF THE VEIN.

Another occasional ill-consequence of venesection is an inflammation of the vein. This affection may differ in degree and extent, as well as in its progress. One degree of inflammation may only occasion a slight thickening of the venal tube, and an adhesion of its sides; a more violent degree may produce abscesses, the matter of which may sometimes become blended with the circulating fluids, and produce dangerous consequences; or it may be circumscribed by the thickening and adhesion of the surrounding parts, and, like a common abscess, make its way to the surface. A good deal of sympathetic fever is likely to attend an extensive inflammation of the vein; and this affection, it is thought, may possibly become continued along the cuticular coat of the vessel to the heart.

If, however, an adhesion of the sides of the vein to each other should be occasioned, a little way from the wound, the expansion of the inflammation will be stopped at the place, where the vessel has been rendered impervious. In one instance, Mr. Hunter employed compression, and he imagined, that he thus limited the extent of the inflammation, by producing an adhesion of the above kind. The affection sometimes spreads in the direction from the heart.

The treatment should consist in attempting to diminish the inflammation by the usual antiphlogistic means, and, in applying a compress at some distance from the puncture, in order to produce an adhesion of the sides of the vein, and thus remove the danger, which would result from the spreading of the inflammation, along the lining of the vessel, towards the heart.

* Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge, vol. 1, p. 29.

INFLAMMATION OF THE FASCIA Of the forEARM.

This is an event, which sometimes follows venesection. The arm cannot be moved, without pain and difficulty. The whole forearm is tender, wnen compressed, though the integuments are scarcely at all affected. There is generally a great deal of uneasiness in the axilla, and the affection is attended with sympathetic fever. After suppuration has occurred, the matter does not readily point. The treatment should be antiphlogistic, in every sense of the word. Leeches should be applied; the patient purged, the arm covered with the saturnine lotion; and kept at rest in a sling. When matter is known to have collected, an early depending opening ought to be made, and the arm should be gently compressed with a roller.

Mr. Abernethy, in his ingenious essay on this subject, seems to be of opinion, that the contracted state of the forearm, sometimes following inflammation of the fascia, might be cured by dividing the portion of fascia, sent off, at the bend of the elbow, from the tendon of the biceps muscle.

ILL CONSEQUENCES OF A WOUND OF A NERVE.

The above gentleman informs us, that Mr. Pott, in his lectures, used to mention cases, in which patients had suffered distracting pain, followed by convulsions, and other symptoms, which could only be ascribed to nervous irritation. Mr. Abernethy has treated this subject with much discrimination; he explains, what nerves are exposed to injury; what are the effects likely to be produced by such an accident; and what means are most likely to afford relief.

The two cutaneous nerves are most in the way of the lancet. Most frequently, all their branches pass beneath the veins at the bend of the arm; but, sometimes, many small filaments are detached from these branches, and proceed over the vessels. The above eminent surgeon remarks, that when a nerve is irritated at any part, between its origin and termination, a sensation is felt, as if some injury were done to the parts, which it supplies. Hence, when the cutaneous nerves are injured, the integuments of the forearm will seem to suffer pain.

It seems highly probable, that some symptoms, consequent to vencsection, in certain instances, have been unfoundedly imputed to the irritation of a nerve, arising from its partial division. As Mr. Abernethy observes, in the many operations, which are performed, and in wounds of daily occurrence, it would be strange, if a partial division of a nerve should not happen; yet, no peculiar symptoms usually ensue,

The practice of completing the division of the nerve, supposed to be injured, is very questionable, in regard to the utility which it presents. However, if the surgeon should think the plan justifiable, a transverse incision may be made above the orifice of the vein. This wound, as Mr. Abernethy remarks, need not be extensive, for the injured nerve must lie within the limits of the original orifice, and there is no occasion for the cut to descend more deeply than the fascia, as all the filaments of the cutaneous nerves lie above this part.

I cannot do better, in concluding this subject, than refer the reader to Mr. Abernethy's instructive essay.*

The consideration of the several ill consequences, occasionally resulting from phlebotomy, is closely connected with the subject of all other wounds, which are followed by extraordinary symptoms.

CHAP. LXXV.

PARTICULAR FRACTURES.

FRACTURE OF THE OSSA NASI.

THE lower portion of these bones is most subject to be broken by external violence. The two ossa nasi are not always broken together; sometimes one is fractured all across, while the other, without having suffered any solution of continuity, is either elevated or depressed. These cases are often attended with a fracture of the perpendicular lamella of the os ethmoides, which process, in this circumstance, always becomes distorted to one side, and may be easily moved with the little finger, ora probe. Such accidents are commonly accompanied by inflammation of the pituitary membrane, swelling of the whole nose and face, ophthalmy, a great deal of hemorrhage from the nostrils, obstructed respiration, nay, the blow, which has broken the ossa nasi, may also have produced a concussion of the brain; an extravasation of blood within the cranium; or pressure on the brain, from the crista galli being actually driven inward.

* See his Surgical Works, vol. 2, p. 133, &c.