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BLEEDING FROM THE EXTERNAL JUGULAR may be done by the fingers and

VEIN.

The occasions for this operation are, when it is necessary to abstract a large quantity of blood more spaedily than it can be drawn from a vein in the arm; or, when it is desirable, in addition to the effect of a general bloodletting, to diminish more immediately the fulness of the vessels of the head; sometimes, also, it is called for in the diseases of children, when general bloodletting is required, and yet the veins of the arm may be so small or so deeply imbedded in fat, as to render bleeding from the arm difficult or impracticable.

The surgical anatomy of the neck, particularly of the superficial and lateral parts, should be carefully studied before, this operation is performed by the student on the living body; for though the operation is extremely simple in skilful hands, yet fatal accidents have been known to result from the performance of it. The point usually suggested for opening the jugular vein, is where that vessel crosses over the sterno mastoid muscle, and is covered only by the integuments, and the platisma myoides. This thin muscle, which must be perforated before the vein can be reached, affords a somewhat greater resistance than is felt in bleeding at the bend of the arm. The same precautions of placing the thumb so as to keep the vein steady, and using the fingers not employed in holding the lancet as a rest to afford steadiness to the hand, are as essential as in bleeding from the arm. The operation is performed by compressing the external jugular vein of each side at its lower part, and this

thumb of the operator's left hand as readily as by a bandage. The point of the lancet is entered obliquely to the direction of the vein, and carried through the integuments and platisma myoides till it opens the vein, but not deep enough to transfix it, when the point of the lancet is raised so as to make the aperture through the integuments come directly over that of the vein. Care is taken so to arrange the position, that it should not be changed during the performance of the operation, for a slight motion of the neck is apt to change the relation of the parts, so as to render the opening valvular, and thus prevent a sufficient quantity of blood being obtained.

I should particularly suggest an attentive watching of the countenance and pulse of the patient during the abstraction of blood from this large vein, as the effect produced is comparatively more sudden than in ordinary bleeding, and in children. this becomes imperatively necessary. I should further recommend the abstraction to be suspended, if not before, at least as soon as the countenance and pulse indicate the approach of syncope, by which I believe every remedial indication may be fulfilled without danger; whilst, in carrying the depletion so far as to produce perfect deliquium, a state of danger is induced, from which no one can with certainty say the patient is sure to recover. A sufficient quantity having been abstracted, and the pressure below removed, the orifice must be cleaned, and neatly and accurately closed, and its sides be retained in contact, either by a strip

or strips of plaster, or by compress and bandage. In this, as in other parts of surgery, there are lesser precautions, which are not unworthy of our attention. In performing this operation upon children, it may be well to ascertain that the steadiness of the nurse or assistant can be depended upon. That intensity of parental feeling, which every one must honour, is sometimes too powerful to be under the control of sound judgment, and therefore renders mothers doubtful assistants on such occasions. I have been informed of a case in which, during the performance of this operation, the child, supported on its mother's knee, fainted. The pallid death-like countenance of her infant might well alarm a mother, who had never seen a person faint before; in her alarm she raised the child upright, grasping and pressing it to her bosom, and apparently insensible to the entreaties made to place the child in a horizontal position instantly; the effect of the upright position was equivalent to a larger loss of blood, convulsions supervened, and the unfortunate sufferer expired.

Secondary hemorrhage, in proportion to the largeness of the vessel, is more to be feared than from the arm. Several years ago, an unfortunate instance of secondary hæmorrhage from the external jugular, after bleeding, came under my cognizance, which forcibly illustrated the necessity which I have previously dwelt upon, of giving directions respecting any probable occurrence which should be avoided, and of adapting the mode of communication to the intellect of the patient or attendants. The operation had been performed, and considerable relief experienced; the orifice was closed by compress and a bandage, and was supposed to be secure. The patient was a child, and, as too often happens in humble life, when the alternate exercise of indiscreet indulgence and hasty chastisement super

sede more rational means of moulding the character, was habitually fretful and obstinate. The mother had unguardedly left the child without any attendant, and when she returned found the child, as it were, deluged in blood, and expiring or dead. The gentleman who had performed the operation was known to be liberally educated, and humane and attentive in the exercise of his profession, yet, strange as it may seem, I found an altercation had aken place, scarcely to be expected, recently after so lamentable an occurrence; the unfortunate mother accused the practitioner of having killed the child, and he retorting that she had caused its death by leaving it for the purpose of going out to get drunk; perhaps some cause of blame might attach to each. The orifice had certainly been made 'arger than I should, under ordinary circumstances, have deemed necessary, and the poor mother was no free from indications of intoxication. Notwithstanding the large orifice, as the bleeding had been restrained in the first instance, it might have been commanded subsequently, and even supposing the child by its restlessness to have misplaced the bandage and compress, yet had the probability of such an occurrence been pointed out, and constant watching insisted upon and adopted in consequence, even had the bleeding recurred, a finger placed upon the orifice would have restrained the further loss of blood, till the parts might have been more effectually secured by the professional attendant, and thus the fatal event have been prevented.

Should there be great difficulty in restraining the hæmorrhage after bleeding from the neck, a circumstance which I have never experienced, although I have had frequently occasion to bleed from the external jugular in cases of hooping cough, croup, &c., where the impulse given to the blood during a fit of coughing was extremely liable to disturb the

parts, yet care being taken that the orifice has been no larger than required, I have found the flow of blood to cease immediately on removing the pressure below the opening; so that I have generally found a strip of plaster, after the orific had been carefully closed, a sufficient security; but if there has been the slightest probability of return of bleeding, I have adopted the precaution of using graduated compresses and bandage, in addition to careful superintendence. Although from the extensive motion of the neck there may be some difficulty in retaining the bandage in its proper situation, yet, when we come to consider the use and application of bandages, I shall have occasion to demonstrate that the simple roller, or bandage, may be so applied as to make efficient pressure upon any part of the body.

The mode which nature adopts to restrain hæmorrhage is, first by fainting, by which the blood, ceasing to flow, coagulates at the point from which it issued; and secondly, by extravasation into the surrounding cellular membrane, there coagulat ing and mechanically diminishing or closing the aperture from which the blood had flowed. This is often observed after the application of leeches, the livid colour thus produced by extravasation of blood having sometimes been mistaken as an indication of mortification.

Should any case occur in which there appeared sufficient reason to apprehend the occurrence of secondary hæmorrhage, although I consider it the duty of every surgeon to avoid the unnecessary infliction of pain upon those confided to his care, yet I should employ the twisted suture, as affording perfect security against secondary hæmorrhage, in preference to the risk of loss of life, which I have shown you may result; but means of treatment must vary with circumstances; with attentive nurses, and the practitioner within a

short distance, danger may be prevented; whilst in the country, and at a great distance from the patient, should the attendants be wanting in presence of mind, death might ensue

fore the practitioner could arrive. I would again exhort you to reflect on the rational indications of the treatment of disease drawn from the consideration of the previous history and symptoms, and to see your way clearly, that you may not use dangerous and severe remedies when the patient's safety may be effected by mild and safe measures. Thus in apoplexy, and some other diseases, when a vital organ, such as the brain, may be undergoing a dangerous injury by the bursting of one of its blood-vessels, it is our imperative duty, if called in time, to adopt instantaneously those energetic resources of the healing art which are capable of immediately arresting the further progress of injury, and you will find, in such cases, the abstraction of blood from the jugular vein, or from the temporal artery, in such quantity as to act as a general bloodletting, amongst the most efficacious means with which we are acquainted.

Having shown you that the taking of blood from the external jugular vein may be performed with safety and advantage, under judicious treatment, when the circumstances of any case require it, yet you must be aware that the attempt to perform it often fails in the hands of those who have not been at the pains to learn, with sufficient precision, the various circumstances of situation, depth, and relative position of the parts concerned in the operation. The instances I have adduced will be sufficient to put you on your guard that the operation is not always free from danger; hence I need not enlarge on the unprincipled folly of performing a dangerous operation when the recovery of the patient may be equally promoted by safe and simple means. If patients sometimes attach undue importance to

ing is so conducted as not to give a start
to the blood or produce general perspira-
tion.
therefore it is useless-nay worse than
In just this proportion of cases
useless; it induces fatigue, and not vig-

operations which may have been needlessly performed, such consideration ought not, for one instant, to bias your judgment in the choice of means, which ought to be guid solely by the welfare of the patientur, and persons tell us they don't see confiding in or committed to your care and integrity.

Taking this view of the duties of your profession, you cannot be made too sensible, that the ordinary duties of surgery, are much more frequently demanded than those exertions of talent rarely required, which some. times stamp the character of a daring operator; and as you advance in life you will become convinced, that precision in the use of ordinary means is of higher value, as subservient to the relief of your suffering fellow-creatures, than any degree of skill in extraordinary operations.

Mr. Alcock's Lecture.

ON RUNNING.

There are few general directions given by physicians which are so commonly misunderstood, and imperfectly followed, as the injunction to take free exercise-to walk out daily, and to allow no state of the weather to interrupt the regularity of this exercise. It is not the mere circumstance of walking which can give any vigour to the frame or strength to the digestive functions. Walking is the means of effecting a certain object, and this last it is that promises the general benefits of exercise. It is by this means we wish to quicken and invigorate the circulation, and give action to the functions of the skin to give a start to the blood and produce a general perspiration. These two purposes effected, the digestion is improved, the bowels kept in order, the equilibrium of the circulation preserved, the mind invigorated, and all the powers of the system strengthened ;-general health therefore is the consequence, and without those effects of walking the general health

will decline.

Now in ninety-nine cases in an hundred-we speak far within bounds-walk

nat exercise does them any good." Why, they don't take any exercise. They draw one leg after another it is true, and this they do perhaps for half an hour, or until they can scarce darw it any longer. But this is not what physicians mean by walking. It is a technical term when employed in a prescription, and must be understood before it can be followed. By walking, we mean a quick active exercise of the locomotive organs, continued for some time, performed in open air, and so conducted as to induce a general glow and moisture upon the surface. If persons would remember this, they would see how powerful an instrument is walking in the preservation as well as the restoration of health.

We often see men, looking pale and sickly, carefully guarded from the air, creeping along our streets with a weak and tardy step, and we always pity such men. They are undoubtedly following, as they think, the prescription of their physician, who has recommended walking. But they have misunderstood his meaning, and although they get by their walk the benefit of the air, they return languid and fatigued. Let such step as quickly as they can, let them make an exertion to walk as fast as their strength will allow, and if very weak let them walk six rods instead of creeping half a mile, and they will feel refreshed. Perspiration is more readily induced in proportion to debility, and therefore all its benefits may be gained with comparative ease by the enfeebled.

ing slow is injurious, inasmuch as it de-
As a general custom, loitering or walk-
prives individuals of the privilege of that
preventive of disease which ought to be
neglected by no one.
tom in Europe for
through the streets.

gentlemen to run It is a general cusThis is an admira

ble custom, and most sincerely do we wish it could be adopted this side the Atlantic. It has a thousand advantages. It quickens and invigorates the circulation. It enlivens the mind, promotes healthful perspiration, and gratifies the impatience which arises from the mental activity it produces. Not that we would have men always running through the streets, but let every man, several times in the day, particularly when in haste, run instead of walk, and he will be better able, in body and mind, to attend to his business, live longer, and enjoy life

better.

TETANUS.

In this complaint, no remedies are now so generally in use as opium and the warm bath. A German physician has recently written on the subject, and condemns the use of these means, He has met with great success by first bleeding the patient freely, and next applying bladders of ice to the head and along the spine. After four hours the jaw falls; an emetic of antimony is then given, followed by an enema of flax-seed tea, and half an ounce of spirit of turpentine, and a tea-spoon or two of laudanum. By these means, he says, the proper connexion between the muscular and nervous system is restored, and the patient is in no danger of a relapse. The use of the ice should be persevered in till spasm be subdued.

THE TEETH.

We have often said that teeth require great care. First let them be well set in order, by removing the tartar, &c. with a proper instrument, and using frequently a large and as stiff a brush as can be procured. It should be used dry two or three times a week, for this will harden the gums, and prevent the collection of extraneous matter, and give a fine polish to the teeth. A simple brush, however hard, can never injure the enamel, and a soft brush is worse than useless. The best brushes seldom admit of use more than a month or two, when they become

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AN ORATION ON PROFESSIONAL REPUTATION, BY JOHN D. GODMAN. This performance contains a great deal of good advice which is calculated to be particularly useful to the younger members of the profession. The author evidently has elevated views of the dignity of medicine, and has made some very sensible observations on the subject, and laid down many excellent rules for attaining a solid professional reputation. His style is not sufficiently simple to please our taste, but on this we do not much insist, having much greater confidence in the healing powers of time and experience, for the cure of this malady, than in any sour criticisms of our own. We respect the author's independence in vindicating the utility of classical learning against the perverse and superficial objections which wrong-headed and shallow thinkers are busy in urging against one of the most important branches of human learning.

MECHANICAL TREATMENT OF POISONS.

The mechanical treatment of poisons is a subject of considerable importance; but there is a period to which its usefulness is limited, namely, whilst the poison remains in the stomach; for it is in vain to expect relief from the extraction of the remainder, after a sufficient quantity to detroy life may have passed the pylorus, or have been carried into the circulation.

There is another circumstance of which we should be aware, that whilst the stomach retains its irritability, the poison may be as effectually and as speedily evacuated by vomiting, as by the use of a pump; and if such emetics as the sulphate of zinc, which in sufficient dose acts almost instantaneously, be timely ad

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