For the purpose of scarification the patient may occupy either the dorsal or the lateral position, and the cervix is exposed through a cylin drical, duck-bill, or valvular speculum, and steadied, if necessary, by a tenaculum. After the cervix has been carefully disinfected, a number of superficial or deep incisions are made radiating from the external os. The more extensive the incisions, the greater the hemorrhage, particularly when the angles of the os are cut. Frequently a number of large vessels are seen under the mucous membrane, and by opening one of those veins profuse hemorrhage may result. Usually, however, only the superficial vessels are thus opened and emptied.
The method of deep puncture, advocated warmly by Spiegelberg, de pends on inserting the needle to the level of the internal os, as far as the circulatory system proper of the uterus, and thus the deeper structures are depleted to the extent desired by the operator. The needle is inserted near the os, parallel to the mucous membrane of the cervix, to the depth of three-quarters to one inch, and this puncture is repeated five to srx times. In this way, within ten minutes, Spiegelberg has removed 1500 'grains of blood.
In case the introitus vaginie is very sensitive the needle may be guided along the finger.
This method, however, should only exceptionally be resorted to, since it is difficult to control the hemorrhage.
Thomas recommends, before puncture, the production of circum scribed hyperemia by means of a cylindrical hard rubber syringe. Thus more profuse hemorrhage may be obtained, and this is the rationale of the action of the artificial leech.
After scarification and puncture more profuse bleeding may be ob tained by the injection of warm water, or by baths.
The hymorrhage generally ceases of itself, and only when large vessels have been opened may it be necessary to resort to the means already out lined for checking it.
After scarification or puncture we never witness such severe symptoms as may follow on leeching; the operation may be performed without the patient's knowledge, and this is often requisite, since the knifo is feared, and when the patients are afterwards informed, having suffered no pain, they do not object to repetition of the procedure.
Puncture yields so much more blood than scarification that it is gen erally the preferable procedure, except in those instances where the aim is simply to draw blood from the mucous membrane of the cervix or to open Nabothian follicles. The great advantage of puncture, to which I almost uniformly resort, is that the control of the hemorrhage lies in the physician's hand, and that it may be repeated at short intervals.
Cupping apparatuses and the artificial leech have not become widely used.
After any profuse venesection, the patient should remain for some time in bed. Slight venesection may be practised in the office, although the effect is almost entirely neutralized by the hyperemia of the pelvic organs, which results from the patient assuming the upright position. Furthermore, for a similar reason, cold injections should not be ordered after vene3ection.