238 



ARTERY, PATHOLOGICAL CONDITIONS OF. 



rhages from the external aperture are more 

 frequent. If this case is treated by ligature 

 at a distance from the situation of the aneu- 

 rism, although the patient may appear relieved 

 at the moment, that relief is but delusive. The 

 blood may coagulate, but being unsupported 

 by any external resistance, it cannot make suf- 

 ficient pressure on the orifice of the bleeding 

 vessel. Fresh blood is carried round by the 

 collateral circulation, and as it constantly oozes 

 from the punctured artery, it disturbs the coagu- 

 lum in the neighbourhood, and bursts out into 

 new arid repeated haemorrhages until the sur- 

 geon is obliged to end where he ought to have 

 begun, by cutting down (if he has still the 

 opportunity) directly on the injured part of the 

 vessel, and tying it above and below the aper- 

 ture. The great difference between the trau- 

 matic aneurism and the other forms of the dis- 

 ease is, that in it the haemorrhage is external as 

 well as internal, and that the coagulum within 

 the limb being unsupported may press out- 

 wards through the wound more freely than 

 inwards upon the vessel. The coagulum, 

 therefore, is not available in the cure, and 

 the treatment must have reference to the 

 wounded artery alone. If the radial artery 

 was opened and bleeding freely from the ex- 

 ternal orifice, few surgeons would think of 

 taking up the brachial high in the arm, know- 

 ing that the inosculating branches would still 

 supply abundance of blood to the wound, 

 and although the pathology of traumatic aneu- 

 rism is somewhat different, inasmuch as a 

 portion of the blood lost still remains within 

 the limb, yet the principle of treatment is 

 unchanged. 



It may be objected that in very many in- 

 stances of traumatic aneurism success has at- 

 tended the application of a ligature on a dis- 

 tant part of the artery ; but every one of these 

 cases will require to be accurately examined 

 before the treatment here laid down can be 

 impeached. The definition of traumatic aneu- 

 rism must be borne in mind, and that it im- 

 plies not only the existence of a wound, but of 

 one through which coagulated blood may pro- 

 trude and fluid blood may trickle. The only 

 case in which such practice could succeed is, 

 where, after the ligature had been tied, a suffi- 

 cient degree of pressure ab externo could be 

 maintained to lay the opposite sides of the 

 wounded artery together, and produce sufficient 

 inflammation to procure its complete oblitera- 

 tion, in short that it shall effect that whicli 

 the resistance of the skin and fascia and 

 other superincumbent structures would have 

 accomplished in a limb less injured. Such 

 pressure as this must occasion intolerable suf- 

 fering ; and experience has proved, in nume- 

 rous instances, how little reliance can be 

 placed on it. 



Secondary haemorrhage. Hitherto the ap- 

 plication of a ligature has been noticed only 

 as a curative process, its advantages have been 

 discussed, and the manner in which it may be 

 supposed to operate explained ; but it has been 

 also stated that " the ligature is in itself not 

 infrequently a cause of great and fearful mis- 



chief," and as the consideration of the different 

 cases that mi.'Jit require the operation has been 

 just concluded, perhaps this may be a fit op- 

 portunity for examining into the nature of these 

 unfavourable cases. Secondary or consecutive 

 haemorrhage occurs, as its name implies, at 

 some period subsequent to the application of 

 the ligature, and the blood flows from the place 

 where the vessel has been tied. In many 

 instances the patient has a kind of presenti- 

 ment of that which is about to happen, and 

 becomes restless, uneasy, and agitated ; in 

 other instances there is not the slightest warn- 

 ing, and the first notification of the mischief is 

 the appearance of the dressings soaked in blood. 

 In general it has been stated that it is on the 

 separation of the ligature that this bleeding 

 takes place, but this is not the fact, for com- 

 monly it happens whilst the cord is fixed and 

 firm, and three or four days before its fall 

 ought to be expected. The longer the ligature 

 remains, provided no nerve or fascia had been 

 included with the vessel, the safer the patient is, 

 and it must be rare to meet with secondary hae- 

 morrhage after the cord has become detached and 

 been quietly withdrawn. It is remarkable that the 

 blood comes from the inferior portion of the 

 artery; it wells up abundantly from the bottom 

 of the wound, and never flows with a gush or 

 per saltum ; it is easily restrained by pressure 

 on the bleeding orifice ; and if such pressure is 

 accurately applied, and can be maintained 

 during a very few days, the cure is permanent, 

 and the patient would be safe but for a number 

 of collateral circumstances, which, however 

 important in the management of the case, form, 

 properly speaking, no portion of the pathology 

 of arteries. 



Various causes have been assigned as pro- 

 ducing secondary haemorrhage, the chief of which 

 is the too extensive detachment of the vessel 

 from its surrounding connexions during the 

 operation, an opinion that I cannot think is borne 

 out by observation. If it is supposed that this 

 dissection of an artery is injurious by depriving 

 it of its vascularity, and diminishing its supply 

 of nutrient blood, the result should be analo- 

 gous if not exactly like that whicli takes place 

 when the vessel is deprived of its cellular coat 

 from any other cause, that is, a slough should 

 form on it, on the separation of which the 

 haemorrhage should occur violently and with 

 a gush. An illustration of this is familiarly 

 observed in the phagedenic ulceration of buboes 

 in the groin, where the artery for a time appears 

 to resist the destructive process, and lies de- 

 nuded like a white cord at the bottom of the 

 sore ; but oneor more black spots form upon it, 

 which are really specks of mortification, on the 

 detachment of which the bleeding commences 

 with awful violence. Perhaps consecutive 

 haemorrhage does occasionally occur from the 

 burrowing of an abscess along the coats of an 

 artery, an example of which is on record in 

 Mott's case of ligature of the innominata, in 

 which the bleeding occurred ten days after its 

 removal, was so violent from the first as to 

 be with much difficulty restrained, and de- 

 stroyed the patient on the day but one after- 



