ARTERY, PATHOLOGICAL CONDITIONS OF. 



advanced. Hence it is, that the bleeding 

 occurs some two or three days earlier than the 

 period at which the ligature naturally separates 

 and comes from the wound. 



When the bleeding has commenced, it is a 

 case of haemorrhage from an open wound, and 

 must be managed on similar principles, that is, 

 pressure to a sufficient extent must be applied 

 directly on the orifice of the vessel. I have 

 never seen a second ligature applied on the 

 mouth of the vessel, either in consequence of 

 the difficulty of finding the artery in a wound 

 swollen and matted up with lymph and gra- 

 nulations, or from an apprehension of the ex- 

 istence of such a diseased condition of its coats 

 as would cause it again to break down under 

 the cord. But I have frequently witnessed 

 the effective operation of direct pressure, par- 

 ticularly in three cases, which occurred within 

 the last few months, two of which were 

 patients in the Meath Hospital, and all of 

 whom recovered. In the application of this 

 pressure, however, much caution is required. 

 It should not be greater than is absolutely 

 necessary to command the haemorrhage; it 

 ought to be maintained by means of some me- 

 chanical contrivance, and be independent of all 

 bandages which are liable to stretch, to loosen, 

 or to slip, and it should be removed the very 

 moment this can be done with safety. If the 

 bleeding has been perfectly restrained during 

 three or four days, it is probable it never will 

 return. The sequelae of secondary haemor- 

 rhage ought always to have been regarded as 

 more important and more perilous than the 

 bleeding itself. I have invariably found the 

 wound to become the seat of unhealthy sup- 

 puration : very frequently abscesses form in 

 different parts of the limb, and occasionally 

 gangrene supervenes. It is sometimes diffi- 

 cult to connect any of these occurrences with 

 a lesion of any structure within the limb ; but 

 too frequently the mischief can be evidently 

 traced to the pressure being directed on the 

 vein, and being either too forcible or too long 

 continued. 



Having thus, however imperfectly, sketched 

 the pathology of the arterial system in con- 

 nexion with the use of the ligature, it will be 

 necessary to revert to other forms of disease, 

 which have hitherto been postponed, in order 

 to permit the introduction of the subject of 

 secondary haemorrhage, and that the practical 

 arrangement of aneurism and its consequences, 

 both fortunate and otherwise, might be as un- 

 interrupted as possible. 



Aneurismal varix. In the year 1761, Dr. 

 William Hunter* directed the attention of the 

 profession to a disease that had not been before 

 observed, one not indeed very formidable in 

 its consequences, but exceedingly curious as to 

 its exciting cause and subsequent progress. 

 When an artery and vein lying in close con- 

 tact are transfixed by a cutting instrument in 

 such a manner that the aperture in one shall 

 exactly correspond with that of the other ; and 



* Medical Observations and Inquiries, vol. i. 

 and ii. 



VOL. i. 



241 



when subsequent inflammation has so glued 

 and fastened these apertures together, that, 

 whilst a mutual transmission of blood between 

 the vessels is freely permitted, not a drop will 

 be allowed to escape in any other direction, 

 a disease is formed, to which the discoverer 

 gave the name of aneurismal varix. All and 

 each of these several conditions are absolutely 

 indispensable, and there are so many chances 

 of their not being fulfilled in a case of 

 wounded artery, that the infrequency of the 

 disease may be easily explained. It does, 

 however, occasionally occur, and for obvious 

 reasons will most generally be found in the 

 arm as a consequence of phlebotomy. 



Soon after the infliction of the injury that 

 has been the cause of the disease, a small 

 tumefaction is observed in the vein; its ap- 

 pearance is irregular and knotted, but it is soft, 

 yielding, and disappears on pressure. On 

 laying the finger on it, a peculiar thrilling sen- 

 sation is perceptible, and on applying the ear, 

 a whizzing noise is heard, very much re- 

 sembling that occasioned by a fly inclosed in 

 a small paper bag. These phenomena dis- 

 appear on either current of blood being in- 

 terrupted by pressure on the artery above or 

 on the vein below : at the same time that the 

 tumour subsides a little, (though it soon regains 

 its original size) and the peculiar noise is no 

 longer heard. If the disease is allowed to 

 advance uninterruptedly, the calibre of the 

 artery above the point of communication be- 

 comes enlarged, but it is diminished below : the 

 vein also enlarges chiefly in the direction of 

 the current of its blood, rarely in the opposite, 

 and then but very slowly. Another interesting 

 circumstance is, that the peculiar thrill is 

 heard and felt all over the dilated portion of 

 the vein, at a distance from, as well as in the 

 immediate neighbourhood of, the point of 

 communication between the two vessels. It 

 seldom produces any inconvenience that can- 

 not be remedied by the use of a moderately 

 tight bandage, and if thus managed in time 

 never requires a severer treatment. 



From the circumstance of pressure, either 

 on the artery or vein, diminishing the size of 

 the tumour and removing the thrilling sen- 

 sation it imparted, it may be fairly inferred 

 that both these phenomena are produced by 

 the meeting of the two currents of blood, and 

 their mutual resistance to the escape of either 

 from its proper vessel. And further, it is ob- 

 vious that if the disease should by any chance 

 prove troublesome or alarming to the patient, 

 its growth might be checked and its progress 

 altogether stopped by permanently obliterating 

 the canal of either the artery above or the vein 

 below : but no operation that a surgeon would 

 be justified in undertaking can remove the 

 tumour, inasmuch as the blood still will con- 

 tinue to flow into and through the enlarged 

 vein. The dangers of secondary haemorrhage 

 after an artery is tied, or of venous inflam- 

 mation if the other vessel is tampered with, 

 ought to inculcate the greatest caution, and it 

 may be easily understood why in such cases 

 Dr. Hunter thought it advisable not to interfere. 



B 



