lancet in his right band is to penetrate at once in to the vein; and before withdrawing the inftrument, an orifice fhould be made large enough for the intended evacuation. It may be proper to ob serve, that a more extensive opening ought always to be made here than is neceffary in the arm, othe wife the quantity of blood is generally procured with difficulty: and befides, there is not the fame neceflity for caution on this point here that there is in the arm; for it seldom or never hap. pens that any difficulty occurs in this fituation, in putting a flop to the blood after the preffure is removed from the veins; all that is commonly neceffary for this purpose being a flip of adhefive plafter without any bandage whatever.

268. To bring the vein more clearly into view, fo as afterwards to be able to open it with more exactn-fs, it has been recommended, that the skin, celiular fubftance, and mufcular fibres covering the vein, thould be previously divided with a fcalpel before attempting to push the lancet into it. There is not, however, any neceffity for this precaution, as it rarely happens that any difficuity is experienced in procuring a free discharge of blood by opening the vein and teguments at once in the manner directed. And it is here, as in eve. ry inftance where it is neceflary to take blood by a lancet, if it is not done at once, the patient is much disappointed, and is fure to attribute the failure entirely to a fault in the operator.

269. When blood is to be difcharged from the veins of the ankle or feet, the ligature being aɔplied a little above the ankle-joint, all the branches of the vena faphena, both in the infide and outfide of the foot, come at once into view; and as this vein lies everywhere very fuperficial, being in general covered with skin only, wherever a proper vein appears confpicuously it may with fatety be opened. To encourage the discharge of blood, it has been a conftant practice in blood-letting, in thefe veins, to dip the feet into warm water immediately on the orifice being made. But this is a very inaccurate method of proceeding, as the quantity of blood taken in this manner can never be alcertained with precision; for the blood being all mixed with the water, the operator can never be in any degree certain as to this point: and befides, there does not appear to be any neceflity for this affiftance; for when the compreflion of the fuperior part of the veins is made effectual, and the orifice is of a proper fize, there is feldom more difficulty in obtaining a full difcharge of blood from the veins of thefe parts than from any other veins of the body.

270. On removing the ligature, the difcharge is generally stopped at once; fo that a piece of adhefive plafter applied over the orifice answers all the purpose of a bandage. The arm, neck, and ankles, are the parts from whence blood is ufual ly taken by venefection; but on fome occafions, where the contiguous parts have been particularly affected, it has been thought advifable to perform venefection in other places.

271. When venefection is to be performed in the veins called ranule under the tongue, the apex of the tongue is to be elevated, and the vein on each fide opened, because the opening of one only will hardly ever difcharge blood enough. After VOL. XXI. PART II.

a fufficient quantity has been discharged, fome cold aftringent fluid taken into the mouth will generally ftop the hemorrhagy.

272. The vena dorfalis penis, which runs along the back or upper fide of this member, being generally pretty much diftended, and confpicuous in an inflammation of this part, may be opened about the middle or back part of the penis; and a fufficient quantity of blood be discharged proportionable to the urgency of the tymptoms. This being done, apply a comprefs and bandage proper for the penis. The arteries and nerves which lie on each side of the vein are to be avoided: nor ought the bandage to be too tight, otherwise the inflammation and other symptoms may turn out worfe than before.

273. When it is neceffary to difcharge blood in this manner from the penis, the veins can be eatily brought into view, by producing an accumulation of their contents in the fame manner as in other parts of the body, through the intervention of a ligature; but in the tongue, in the hæmorrhoidal veins about the anus, and other parts where compreflion cannot be applied, all that the furgeon can do, is to make an orifice of a proper fize in that part of the vein which shows itfelf moft evidently; and if a fufficient aifcharge of blood is not thus produced, as there is no other method of effecting it, immerfing the parts in warm water may in fuch circumstances be a very neceflary measure.

274. There are feveral ways of performing the operation of blood-letting in the eyes. We fhall here only relate the chic: Firft, the patient is to be feated conveniently on the bed-fide or on a chair, with his head held in a proper posture by an affiftant; which done, the furgeon makes a tranfverfe incifion with a lancet upon the turgid fmall vessels in the corners of the eye, fo as to open them or cut them quite acrofs. Some ufe a fmall pair of fciffars, inftead of a lancet, to divide the vellels; but in using either of them, the eyelids must be feparated from each other by the fingers of one hand, while the veffels are cut by inftruments held in the other. Some, again, eleyate the small turgid vellels with a crooked needle before they divide them, the eye-lids being in the mean time held afunder by an alliftant. fmall veffels being thus opened or divided, their discharge of blood should be promoted by fomentations of warm water frequently applied to the eye by means of a iponge or foft linen rags.

The

275. Among other methods that have been propofed for fcarifying the blood-vefiels of the eye, the beards of rough barley were at one period much extolled, and are ftill employed by fome individuals. By drawing them over the surface of the eye, in a direction contrary to the sharp fpicule with which they are furnished, a confiderable difcharge of blood is thereby produced: But the pain attending this operation is exquifite; and as it does not poffefs any fuperior advantage to the method with the lancet, it is now falling into general disuse.

SECT. III. Of ARTERIOTOMY.

276. WHATEVER particular advantages may in theory have been expected from arteriotomy, and howevet

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however fome of its fupporters may have recommended it, not only as being in many inftances preferable to venefection, but as an operation perfectly fafe even in veffels of confiderable fize; yet the most strenuous friends to the practice have fhrunk from any real attempt of this kind on the larger arteries, Inftances have no doubt occurred of large arteries having been opened without any danger enfuing; but these are so exceedingly rare, that no practitioner of experience will, from that confideration, be induced coolly to proceed to open any artery of importance. The smaller branches of arteries may indeed be opened with great fafety, when they are not deeply covered, and especially when they lie contiguous to bones; but in any of the larger arteries, the attempt muft be always attended with fo much hazard, and the advantages to be expected from it, in preference to venefection, are apparently so trifling, as muft in all probability prevent it from ever being carried into execution.

277. There are very few arteries, therefore, which, with any propriety, can be opened: the different branches of the temporai are the only arteries indeed from whence blood, in ordinary practice, is ever taken; for although the opening of fome other branches of arteries has by fome been propofed, yet they are fituated in fuch a manner that they either cannot be readily come at, or being in the neighbourhood of fo large nerves, the opening of them might be attended with bad confequences. In performing this opetation on any of the temporal branches, if the artery les fuperficial, it may be done with one pufh of the lancet, in the fame manner as was directed for venesection; but when the artery lies deeply covered with cellular fubftance, it is always neceffary to lay it fairly open to view, before making the orifice with the lancet: for in all the finaler arteries, when they are cut entirely across, there is little chance of being able to procure any confiderable quantity of blood from them; as, when divided in this manner, they are fure to retract confiderably within the surrounding parts, which commonly puts a ftop to all farther evacuation.

278. Some degree of nicety is alfo neceffary in making the opening into the artery of a proper oblique direction, neither quite acrefs nor directly longitudinal; for a longitudinal opening never bleeds fo freely, either in an artery or in a vein, as when its direction is fomewhat oblique. If the opening has been properly made, and if the artery is of any tolerable fize, it will at once difcharge very freely without any compreffion; but when the evacuation does not go on fo well as could be withed, the discharge may be always aflifted by compreffing the artery immediately above the orifice, between it and the corresponding veins, The quantity of blood being thus difcharged, it will commonly happen, that a very light compreffion on these finaller arteries will fuffice for putting a top to the evacuation; and whatever preffure is found neceffary, may be here applied in the fame manner as was directed in venefection. 279. It happens, however, in fome inftances, that this does not fucceed, the orifice continuing to burnt out from time to time, fo as to be productive of much diftreft and inconvenience. In

this fituation there are 3 different methods by which we may with tolerable certainty put a flop to the farther difcharge of blood. ft, If the artery is fmall, as all the branches of the temporal arteries commonly are, the cutting it entirely acrois, exactly at the orifice made with the lancet, by allowing it to retract within the furrounding parts, generally puts an immediate ftop to the discharge. 2d, When that is not consented to, we have it always in our power to fecure the bleeding veifel with a ligature, as we would do an artery acci dentally divided in any part of the body. laftly, if neither of these methods is agreed to by the patient, we can, by means of a conftant regular preflure, obliterate the cavity of the artery at the place where the operation has been perform. ed, by producing the accretion of its fides. D ferent bandages have been contrived for compre fing the temporal artery; but none of them anfwer the purpofe fo eafity and so effectually as the one figured in Plate 324, fig. 7. This method is more tedious; but to timid patients it generally proves more acceptable than either of the other two.

SECT. IV. Of TORICAL BLOODING.

And,

285. WHEN, either from the feverity of a local fixed pain, or from any other caufe, it is wifhed to evacuate blood directly from the small veffe's of the part affected, instead of opening any of the larger arteries or veins, the following are the dr ferent modes propofed for effecting it, viz. by means of leeches; by fight fearifications with, the fhoulder or edge of a lancet; and, laftly, by means of an inftrument termed a fearificator, Fig. 11. 10 which 16 or 20 lancets are commonly placed, in fuch a manner, that, when the inftrument is applied to the part affected, the whole number of jancets contained in it are, by means of a ftrorg fpring, pushed fuddenly into it, to the depth at which the inftrument has been previously regu lated. This being done, as the fmaller blood-velfels only by this operation are ever intended to be cut, and as thefe do not commonly discharge freely, fome means or other become neceffary for promoting the evacuation.

281. Various methods have been proposed for this purpofe. Glaffes fitted to the form of the affected parts, with a'fnail hole in the bottom of each, were long ago contrived; and thefe being placed upon the fearified parts, a degree of fuc. tion was produced by a perfon's mouth fufficient for nearly exhaufting the air contained in the glafs; and this accordingly was a fure enough method of increating the evacuation of blood to a certain extent. But as this was attended with a good deal of trouble, and befides did not on every occafion prove altogether effectual, an exhaufting fyringe was at laft adapted to the glafs: which did indeed answer as a very certain method of extracting the air contained in it; but the application of this instrument for any length of time is very troublefome, and it is difficult to preserve the fyringe always air-tight.

282. The application of heat to the CUPPING. GLASSES, Fig. 12. has been found to rarefy the air contained in them to a degree fufficient fr producing a very confiderabie fuction. And a

the

tion of thefe fubftances cannot be of any ufe. This future is accordingly now very rarely practifed, and it is probable that it will be foon laid entirely afide.

300. By the term TWISTED SUTURE, is meant that species of ligature by which parts, either naturally or artificially separated, are united together, by means of ftrong threads properly twifted round pins or needles puthed through the edges of the divided parts. This future is commonly employed for the purpose of uniting the parts in cafes of hare-iip; and this indeed is al moft the only ufe to which it has been hitherto applied: But it may with great advantage be put in practice in a variety of other cafes, particularly in ail artificial or accidental divifions either of the lips or cheeks; and in every wound in other parts that does not run deep, and in which futures are neceffary, this future is preferable to the interrupted or any other. The pins made ufe of for twitting the threads upon ought to be made of a flat form, fo as not to cut the parts through which they pafs fo readily as the ligatures employ. ed in the interrupted future. And thus one great objection to the latter is very effectually obviated: for every practitioner must be fenfible of this being the most faulty part of the interrupted future, that when mufcular parts are divided fo as to produce much retraction, the ligatures employed for retaining them almoft conftantly cut them through before a reunion is accomplished; whereas the flatnes of the pins used in the twifted future, and upon which the whole preffure produced by the ligatures is made to reft, proves in general a very effectual preventative againft ali fuch

Occurrences.

301. The pins used in this operation are reprefented in Plate 324, fig. 15. They are commonly made of gold or filver; and in order to make them pafs with greater eafe, fteel points are added to them. They are fometimes ufed, however, of gold or filver alone.

302. The manner of performing this operation is as follows. The divided parts intended to be reunited, muft, by the hands of an affisant, be brought nearly into contact; leaving just as much fpace between the edges of the fore as to allow the furgeon to fee that the pins are carried to a proper depth. One of the pins muft then be introduced through both fides of the wound, by entering it on one fide externaily, pushing it forwards and inwards to within a little of the bottom of the wound, and afterwards carrying it outwardly through the oppofite fide, to the fame distance from the edge of the fore that it was made to enter at on the other.

303. The diftance at which the needle ought to enter from the edge of the fore must be determined by the depth of the wound, and by the degree of retraction produced in the divided parts. In general, however, it is a proper regulation, in deep wounds, to carry the pins nearly to the fame diftance from the fide of the fort as they are made to penetrate in depth: And whatever the deepness of the wound may be, the pins ought to pafs within a very little of its bottom: other wife the parts which lie deep will run a risk

of not being united; a circumftance which mute always give rife to troublefome collections of matter.

304. The first pin being paffed in this manner very near to one end of the fore, and the parts being full fupported by an affiftant, the furgeon, by means of a firm waxed ligature, paffed three or four times round and across the pin, fu s nearly to defcribe the figure of 8, is to draw the parts through which it has paffed into immediate and clofe contact: and the thread being now fe cured with a loofe knot, another pin must be introfuced in the same manner at a proper distance from the former; and the thread with which the other was fixed being loofed, and in the fame manner carried round this pin, others must be introduced at proper diftanées along the whole courfe of the wound; and the fame ligature ought to be of a fufficient length for fecating the whole.

305. The number of pins to be used must he de termined entirely by the extent of the wound. Whenever this future is practifed, a pin ought to be introduced very near each end of the wound, otherwife the extremities of the fore are apt to feparate fo as not to be afterwards cafity reunited. in large wounds, if the pins are introduced at the distance of three quarters of an inch from one another, it wil in general be found fufficient; but in cuts of faller extent a greater number of pins become neceflary in proportion to the dimensions of the fores. Thus in a wound of an inch and half in length, three pins are abfolutely requifite; one near to each end, and another in the middle of the fore: whereas five pins will always be found fully fufficient for a wound of three inches and a half in extent, allowing one to be within a quarter of an inch of each extremity of the wound, and the others to be placed along the courfe of the fore, at the diftance of three quarters of an inch from one another.

306. The pins being all introduced and fecured. in the manner directed, nothing remains to be done, but to apply a piece of lint wet with mucilage all along the courfe of the wound, with a view to exclude, as effectually as pofüible, every accefs to the external air. When the pins remain long, they generally do harm, by the unneceffary irritation and confequent retraction of parts with which they are always attended; and if they are not continued for a fufficient length of time, that degree of adhetion is not produced between the divided parts, which is neceffary for their future retention; fo that the effect of the operation comes to be in a great meafure, if not entirely, loft.

397. In wounds of no great depth, for instance of three quarters of an inch or fo, a fufficient degree of adhesion always takes place in the space of five days; and fix, or at most feven days, wilt generally be found fufficient for wounds of the greatest depth. But with refpect to this circumstance, it must always be understood, that the patient's ftate of health must have a confiderable influence on the time neceffary for producing adhefion between divided parts. When the pis are withdrawa, the uning bandage may be ap

ped