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Show 723:: or TAPPING 'mE ABDOMEN. or TAPPING THE ABDOMEN. that point of the belly which is at an equal distance be. tween the umbilicus and centre of the spine of the ilium. But the operation having been done here, a considerable branch of the epigastric artery has been struck, and the pa tient has died of haemorrhagy. The trunk of the artery, or its principal branches, being removed from their usual place, arises from the difl‘erence in the action of the lateral muscles of the belly, and the recti muscles. The muscles expand chiefly by the separation of their fibres, because in that direction they have less power of resisting distension. The oblique and transverse muscles resist with power, because they act in the direction of their fibres ; but the recti being stretched by the lateral force, allow themselves to be expand~ ed largely over the fore part of the belly. With them, of course, the epigastric artery is extended beyond its usual limits. flflrnu/ liliiltltiilm One reason for preferring this place in the side for opera tion, is the convenience of laying the patient recumbent. But this again is necessary, on account of the sickness and faintness chiefly, and by the due compression of the belly, the patient may be placed upright when tapt; and therefore this is an insufficient reason for operating in the side : and be this as it may, London surgeons have of late operated on the fore part of the belly for the most part. But there is a circumstance attending the change of place, which is not enough adverted to. - It is the continued flowing of the water of the ascites, even days after the operation. This is very much more apt to take place when the operation is done in the linea alba, than when done in the side of the belly; and it is highly dangerous; for while the hole in the peritoneum remains open, there is danger of inflammation to the general cavity. I never have observed this consequence to follow the tap ping in the side, because then we pierce through a thickness of muscles, which swell up immediately, and close the opening. But in puncturing in the linen alba, where there is on‘ 2y firm tendons, which are incapable of the same quick swell» 233 ing or vascular action as the fleshy fibres are, this continued oozing will follow the operation: and it has even burst out suddenly when the patient has been walking in his room, with such a subsiding of the belly, that he has fainted and fallen very low. I have, I confess, a repugnance amounting to prejudice against puncturing in the umbilicus ,- besides, that it is sub- ject to the same objection with the linea alba. I have thought that a round pointed trocar would pass with sufficient ease, after a slight puncture with the lancet through the integuments, and would make less danger of wounding the epigastric artery, and by this means enable us to operate with more confidence in the old place. If there be anasarca of the integuments of the belly, it is unpleasant to perforate so great a thickness of the integuments as may be produced by the distension of the cellular substance. But by pressure this may be removed. If, with the fingers, we press around the spot where we are going to perforate, we may then pierce the belly with the same accuracy as if there were no such anasarcous swelling. The surgeon takes the common round canula and stilette, resting the round handle of the stilette in the palm of his hand, and reaching the fore-finger to near the point of the instrument, having just touched the skin with the bleedinglancet, to prevent the resistance of the tougher integuments, he pushes the instrument directly inward, the fore-finger be- ing a guard that the point do not start suddenly forward. When the resistance has ceased, and the shoulder of the ca nula has passed the peritoneum, the stilette is to be with: drawn. If the distension of the belly be very great, the slower the water is drawn off, the better; and if the patient complains of faintness, common sense teaches us to stop the flow of the water, and lay the patient with the head lower. When the water is entirely evacuated, and the trocar is withdrawn, and the orifice dried, it is simply brought close by a piece of ad» Yer. r. r; 2 _ ' now most"; r |