334 Dr. Osborne's Observatio~zs on Local Blood-letting.

ART. XIX.--Observa~ions on Local Blood-letting, a)zd o~t

some new Methods of practising it. By JONATHAN OSBORNF, M.D., Fellow of the College of Physicians, and Physician to Sir Patrick Dun's Hospital.

FRoM the earliest period local bloodletting was a practice relied on as the most immediate means of subduing inflammation. We find leeches, scarifications, and cupping in use before the time of Galen; and in some of the writlngs attributed to Hippo- crates, bleeding is directed to be perfi)rmed on various super- ficial veins, according as those were believed by the anato- mists of the time to be connected with the affected part. Dur- ing the middle ages, and afterwards, the principles of deriva- tion and revulsion caused peculiar efficacy to be ascribed to bleeding from individual veins ; and it is well known that the controversy respecting the vein to be bled in pleurisy became so violent that the partisans of the opposite theories at length invoked the interposition of the emperor Charles the Fifth. When, however, the discovery of the circulation was esta- blished, and it was proved that all the blood-vessels formed one series of continuous pipes freely communicating with each other, file importance formerly ascribed to local blood-letting was much diminished; it was believed to be matter of indif- ference as to the part of the system from which blood was taken, and local blood-letting appears to have fallen into comparative disuse.

When afterwards improvements were gradually introduced, and clinical institutions became the sources of practical informa- tion, the value of local blood-letting could not long remain in obscurity; and at file present time it deservedly ranks as one of the most important agents in the hands of the medical practi- tioner.

Blood is drawn from an artery, a vein, or ii'om the capil- laries ; and while it is in the firstcase arterial, and in the second

Dr. Osborne's O5.s".,rvatious oa Local l~!ood-letti,~. 335

venous, it is in tile third in an intermediate state, passing from vterial into venous. This is tile state of the blood drawn by

,eeehes and scarifications. The temporal artery is the only one which is opened in mo-

dern times for the purpose of blood-letting ; and when there is much vascular excitement in tile head, as indicated by throb- bing and heat, the superiority of taking blood from it above leeching is very decided, requiring, however, in order to render tile benefit derived from it permanent, that eold applications should be immediately and unremittingly employed, for other- wise the sudden depletion is as suddenly succeeded by a return of ~ the usual inordinate aetlon. The internal carotid and its branches, which, in consequence of the exit el' blood fi'om the temporal artery, reeeive proportionately less blood than usual, eontraet, and thus continue to circulate less ; and hence is pro- dueed the benefit ; but this is merely transitory, unless the di- minished circulation is secured by the means now alluded to.

I had often observed when a vein was opened and the blood was suffered to run along lhe arm in a broad stream, and ex- posed to a strong light, that some of the red particles appeared much darker than others. Repeated inspection shewed that there was no optical illusion ; but it appeared difficult to explain how certain portions of the blood in the same vessel had been less arterialized than others. This phenomenon, however, ap- pears evidently to derive its origin from thepeeuliarity in the circulation of the hmgs, in which, as we learn by injections, the bronchial veins eommunieate with the puhnonary veins, and thus mix their venous blood with tim arterial on its passage t~om the lungs to the left cavities of the heart. Although the blood passes from thence through the arteries and capillaries into the vein, and in its course becomes venous, yet the small portion of venous blood derived from the bronchial veins being at its first mixture much deeper in eolour than the latter, the differen~:e still continues perceptible. It is, however, hardty necessary t,) remark, that when the colour of tile blood proceeding from a

~']36 Dr. Osborne's Obse,'r~ltiolts o,, Local B[ood-lellbJg.

vein is dark in consequence of obstructed respiration, this dif- ference is much reduced, and, generally, cannot be discovered.

Opening the veins of the foot is a practice still resorted 1o in cases of obstructed menstruation by practitioners who must be above the influence of vulgar prejudice on tile subject. The trials which I have made have not enabled me to arrive at a conclusion as to the question whether this practi~e possesses any advantage above general blood-letting. Bleeding fi'om the veins of the ton~le is another old practice now nearly forgotten, hav- ing been superseded by the more mmmgeable mode of taking blood by leeches. By opening the veins on the back of the bands we can usually obtain blood with great thcility when particular circumstances forbid bleeding in the arm. Bleeding from the jugular vein is not well suited for taking blood from the head, because tile external jugular, which alone is within our reach, is supplied from the superficial veins of the neck, and principally from those of the larynx, but not from the interior of the head. Great benefit, however, may be derived from opening it in sud- den attacks of croup.

The application of leeches is frequently a cause of ~eat fa- tigue to the patient, from the length of time during which stup- ing with hot water is kept up in order to promote the h~emor- rhage fi'om the leech bites; and in some cases, when this operation is continued under the bed-clothes, the damp com- municated to these produces cold, and is uncomfortable to that degree as often to prohibit their use. All this is obviated by the application of warm cloths of linen or calico applied per- feetly dry, and removed in succession according as they have be- come saturated. By these means the blood is absorbed by capillary attraction, a process which cannot take place with wet applications. When dry cloths are thus applied and renewed to cuts in the skin, or to leech bites, I have found the bleeding unitbrmly to continue as long as the application was kept up, it being required only tt~ apl~ly fi'esh portions of the dry cloth to

Dr. Osborne's Obsercations on Local Blood-letting. 337

insure tile eontinuanee of capillary attraction, and thus to pre- vent coagulation at the mouths of the vessels.

This mode of managing leeches I am thus particular in de- scribing, as it has enabled me to apply them in a ease in which if wet cloths were used, very serious danger might arise. I allude to bronchitis, both acute and chronic, in which the application of leeches to the larynx and to the trachea in the triangular space between the mastoid muscles, has appeared to me to he the most decisive and immediately successful remedy of all those which I have ever employed. In laryngitis their utility is obvious and commonly recognized, but in bronchitis it has escaped notice, that the most immediate depletory process which can be peribrmed on tile mucous membrane of the bron- chial tubes, is that of leeching tile trachea and larynx. It ap- pears to remove blood not only from the mucous membrane of that part of the bronchial tube to which the application is made, but also from the whole tract of the bronchial tubes throughout their ramifications, being nearly equally efficacious in putting an end to the cough, when the remoter tubes are aflbeted, as when the larynx is the chief seat of disease. This application is also of singular efficacy in stopping the cough of phthisis, in so much, that by resorting to it according as required in cases in the hospital, we have been enabled to secure sleep atnight, and during the day to keep the phthisical patients so free from cough that a superficial observer might readily believe that we had cured the disease.

It has been ascertained that leeches will continue to llve and to draw blood although immersed in water at a tempera- ture considerably above lO0 ~ Now, in cases of violent inflam- mation of the abdominal viscera, when local abstraction of blood and warm tbmentations are both at the same time imperatively demanded, as soon as leeches have been applied to the abdo- men the patient may immediately be placed in a hip bath with- out waiting for them to fall off. Thus we may cause the re- laxation and diminution of sensibility produced by the heat to

338 Dr. Osborne's Observatio~ts on Local Blood-letting.

eomblne with tile benefit to be derived from the topical loss of blood.

The applleation of leeches to rnueous surfaces was, I be- lieve, first described by the Surgeon-General, Mr. Crampton. Although I have not met any ease of eynanehe which required tile direct application of leeches as advised byhim, yet there can be no doubt as to the immediate benefit to be derived f~om it. I have resorted to the mode of applying leeches to other mu- cous membranes by passing a needle and thread through their tails at about one-fourth of an inch fi'om the extremity. This practice, so far from incapacitating them from action, causes them to bite with increased ardour, and, in fact, may be used to stimulate torpid leeches. The thread to be passed through the tail of the leeetl should be strong, and its extremities are to be held by the operator, while, if necessary, he may direct the mouth of the leech by a probe or channel made with card to the plate where his services are required.

In certain headaehs confined to the frontal sinus, which, al- though originally derived from derangements of the digestive organs, yet do not cease when those derangements have been removed, a prompt relief is obtained from applying leeches in this manner to the interior o[" the nostrils ; and in those ease.s no benefit is usually derived from leeches externally applied. The bleeding is usually rather more copious than if" the appli- cation had been made on the skin; if, however, it should be deficient, the patient may encourage it l)y breathing over the vapour of hot water.

In inflammations of the eonjunetiva, a leech thus applied t() tile Sebueiderian membraue of the adjacent nostril evidently un- loads the vessels of the eye. This application I have found of great use after the previous application of leeches to tile tar- sal eonjunctiva. It appeared to render the improvement de- rived fi'om the latter permanent, and prevented the necessity of repeating it.

In inflammations of the ear, this mode of alq)l)iag a leech inside the meatus is eminently u~efi~l ; aud next to it in import-

Dr. Osborne's Observations on Local Blood-letting. 339

ance is the application of them behind the ear as uear as may be to the meatus. It may be objected, that such applications are not well suited to inflammations of the internal parts of the ear, inasmuch as those are supplied by a diflbrent set of vessels f~on, the external. But the effect of leeches is independent of vascular connexion. For example, in inflammations of the sto-

mach or intestinal canal the benefit derived from leeches applied to tile corresponding region of the abdomen is acknowledged by all ; but the vascular connexion between those parts is as remote as that between distant regions of the body, tile one being sup- plied from the arteries arising from the abdominal aorta, and the other from the eplgastric and mammary arteries ; and that there can be no anastamosis of vessels is evident from the interposition of the peritonemn, which insulates the viscera completel~ from the an- terior parietes of the abdomen. The same observation applies

"with the same force to the thoracic viscera and to the brain. In all those cases, however, the effect of local bleeding is proved so repeatedly in our daily experience, that the inability of satis- factorily explaining the way in which the effect is produced must not be allowed for one moment to press against the evidence of

facts. In inflammations of the mucous membranes of the bowels,

especially of the rectum, the French practitioners apply leeches to the margin of the anus. If the leeches take externally, no benefit is derived, and to apply them internalby is often ditfieult, on account of the violent contractions of the sphincter. Those contractions also prevent any considerable quantity of blood from being obtained from the bites. I have employed a me- thod of taking blood from the rectum which obviates these in- conveniences.

A metal rod, shaped thus, (see Fig. 1.), has one ormore shallow grooves cut in its extremity, in which the threads at- tached to the tails of leeches, as above described, are Interred. The operator, holding the ends of the threads, introduces the instrument into the rectum, and pushes it up so as to cause it to

340 Dr. Osborne's Obserration.~ u, Local Blood-letti,~.

draw up tile leeches along with it into lhe rectum. When lhev have thus been conveyed u 1) beyond tile sl~lfiucter , the instrument is withdrawn, and the leeches arc suflbl'ed to remain till gorged with blood and loosened from their hold, when they are drawn out by means of the threads which the operator retains outside the anus.

I have never used more than four leeches at once, in this way. fearing lest too great a ha~morrhage might be produced 1)y a greater number. From those the discharge was moderate, and was productive of that immediate benefit which was to be expected from the direct abstraction of blood i)'om lhe inflamed surfi~cc. I have never witnessed any injurious eftL'cts from the leech bilcs, and entertain the hope that this mode ot' taking blood from the

system of the vena portce may be of use in many hepatic and in- testinal diseases connected with a congested state of that system.

I am now to introduce to the reader a new instrument, de- signed to supersede the scarifieator, and which, in order to avoid circumlocution, it is proposed to desi~,mate by the name polytome. In the scarificator a number of lancets are, by means of a spring, forcibly projected into the patient's body to a depth

of nearly one-third of an inch. Now this depth is useless, be- cause fi~e cellular tissue under the spine is not vascular; and this latter is not on the average deeper than one-eighth of an inch, and the cellular and adipose substance rising up through the wound in the subsequent process of cupping choke the ori- fices of the vessels, and soon put a stop to their bleeding. This circumstance has not escaped the observation of Baron Larrey and others, who have in cupping abandoned the use ot' the scari- ficator, and make their incisions by means of the knife or lancet. The object of the instrument to be described, is, to improve ou this practice by making a number of incisions at one stroke, of the proper depth, and no deeper, and at the same to avoid the

pain and shock of the spring scarificator, which alone often for- bids its use.

This instrument consists of two or more (in the present instance

l)r. Osborne's Obserrations o~ Local Blood.letting. 34 [

six) lancets, with elreularedges, fixed parallel in a frame, to whicll a eonvenient handle is attached (Fig,. 2.) They are fixed on the framo in such a manner that they can be easily taken out for the purpose of being cleaned or whetted, and a suflieient sp~e is left between them for wiping after ordinary use. The mode of using is to draw it rapidly along the skin, so as to make a row of continu- ous incisions of about one-sixteenth or one-eighth of an inch in depth, and an inch in length (Fig. 3.) This is attended with little or no pain, and in the ease of children can be performed without their cogni~lmoe or consent by keeping the frame under the fore and two adjoining fingers, and then drawing it along in the~ place required. When cupping glasses are applied over those incisions, the quantity of blood which may be drawn appears to me almost without limit. That it should be l~ar greater than that yielded by the ordinary scarificator is obvious, both on account of the ori- fices not being choked by the rising up of fat or cellular tissue, as already mentioned, and from the t~ar ~eater number of cu- taneous capillaries which are opened in those continuous super- ficial streaks than in file deep but short wounds inflicted by the

searificator. Mr. Thompson, of Henry-street, in this city, has made this

instrument ill a very superior manner. To some he has added a guard regulated by a screw, to define the precise depth to wlxich the blades should penotrate, In others, as in the figure,

the circles at the ends of the frame serve the purpgse of aguard. On using the instrument the guard will be found unnecessary, or rather disadvantageous, when it is to be applied to the hol- low below the oceiput, or other similar parts, and the finger is a sufficient security even when using it with the greatest rapidity. On applying it to patients who had previous experience of the scarificator, they at once acknowledged the comparative im- munity from pain enjoyed under its use.

One word on cupping glasses. Those which have broad spreading edges are far im%rior, both in convenience of appli- cation and in power of preserving a vacuum to those with per-

VOL. m. No. 9. 2 v

342 Dr. O'Beirne on the E.ristence of k'alves in the Rectum.

pendleular edges. In using glasses it frequently happens that the rarefaction of the air is carried too far, and the suction be- comes so great as to stop the circulation of blood through the

part and prevent the bleeding. This especially happens in cupping the abdomen and other soft parts.

There ~hould always be an assortment of eupping glasses, with oval and other shaped months, in order to be applied as oeeaslon may require. By attention to those partieulars, cup. ping may be rendered of much more general application than heretofore, and in public institutions, where eeonomy is an ob- ject, a ~eat saving in the artiele of leeches may be effeeted.

ART. XX.--DR. O'BEIRNg in reply to Dr. Houston on the E~xi~tence of Valves in the Rectum.

TO THE EDITOR OF THE DUBLIN JOURNAL OF MEDICAL AND

CHEMICAL SOIENGE.

North Cumberland-street, Dublin, ,May 28th, 1833.

Sm,--The paper sent herewith was read at a late meeting of the Surgical Society of Ireland. I am perfectly satisfied with the opinions which it has elicited. But as my able and re- spected opponent has informed me of his intention to rep//y to me as soon as he eonvenimtly can, and as the subject is impor- tant, and treated in rather a novel manner, I trust that you will see the propriety of giving the paper insertion in your Journal. With the exception of two or three verbal alterations, it is in the state in which it was read to the Society.

I have the honour to be, Sir,

Your obedient S~rvant,

JAMES O'BEIRNE.