ARTERY, PATHOLOGICAL CONDITIONS OF. 



239 



wards. But it may be observed that the phe- 

 nomena attendant on these cases are different 

 from those already described as characteristic 

 of the common forms of the accident that 

 they usually occur at a later period, even long 

 after the separation of the ligature might have 

 inspired confidence in the result, and they are 

 evidently more hopeless, for neither pressure 

 nor ligature can here be of the slightest avail. 

 Farther, to appeal to experience, the best and 

 surest foundation of every scientific principle, 

 is it not a matter of daily observation that this 

 much-dreaded insulation of the artery can have 

 but little effect on the ultimate termination 

 of the case, as operations performed in this 

 respect in the most bungling and clumsy man- 

 ner occasionally end well, whilst the utmost 

 caution in not exposing more of the artery than 

 will barely permit the passage of the ligature 

 cannot ensure the patient from secondary hae- 

 morrhage ? 



When the bleeding is occasioned by any 

 defect in the operation, such as tying the cord 

 too loosely, including adjacent structures, &c. 

 it usually appears so early as from the third to 

 the fifth day after the operation, and there is 

 another form of early consecutive haemorrhage 



/ 



that occurs in consequence of the artery itself 

 being inflamed or otherwise diseased at the 

 time of the operation. An example of this is too 

 often met, when, as a means of controlling con- 

 secutive haemorrhage, a fresh ligature has been 

 tied on the trunk somewhere higher up or 

 nearer to the heart. It has been remarked by 

 Dupuytren, that an artery under such circum- 

 stances is in a most unfavourable condition for 

 an operation ; it is surrounded by cellular tissue 

 in a state of inflammation, in which it par- 

 ticipates ; its coats are rendered so brittle that 

 they break down immediately under the liga- 

 ture, and the haemorrhage returns in a few 

 hours.* It is worthy of remark that in this 

 case also the bleeding comes from the orifice 

 of the vessel below the ligature; indeed, in all 

 cases of divided artery, whether by a cutting 

 instrument or by a cord, the remedial process 

 seems to be different in the two fragments, 

 being far more perfect in the upper. On this 

 point the statements of Mr. Guthrie are most 

 valuable because founded on extensive ob- 

 servation, and he remarks in the case of an 

 artery, the bleeding from which had ceased of 

 itself, that if it recurs it is more likely to 

 proceed from the lower than the upper portion. 

 This latter fact is the more important as it bears 

 upon another supposed cause of secondary 

 haemorrhage, namely, the state of tension in 

 which an artery inclosed in a ligature is ne- 

 cessarily placed. 



Many years ago it occurred to Mr. Aber- 

 nethy that, " as large arteries do not ulcerate 

 when they are tied upon the surface of a stump 

 after amputation, it would be right to tie them 

 in cases of aneurism as nearly as possible in 

 the same manner and under the same circum- 

 stances." It is familiarly known that he re- 

 commended for this purpose the application 



* Lesons Orales, torn. iv. p. 573. 



of two ligatures with the division of the artery 

 between them ; and he argues that the divided 

 portions would be like the large vessels on the 

 surface of the stump in possession of all their 

 surrounding connexions, whilst they are left in 

 a lax state in consequence of their division. 

 But the cases after all are not analogous, be- 

 cause in the stump there is no inferior portion 

 of vessel from which it has been seen the 

 chief cause of apprehension arises it has been 

 cut away, and only the superior remains, from 

 which it is rare to meet with haemorrhage 

 under ordinary circumstances. In Mr. Aber- 

 nethy's operation it is only the upper division 

 of the vessel that bears analogy with the artery 

 of the stump, and the insufficiency of the 

 removal of*the tension in preventing haemor- 

 rhage from the inferior is proved, first, by the 

 fact that consecutive haemorrhage occurs in 

 cases that have been thus treated proportion- 

 ally as often as in others ; and, secondly, by 

 Mr. Guthrie's observation that in the case of 

 a wound there is no tension : the artery has 

 been fairly divided, and its surrounding con- 

 nexions are undisturbed ; yet the bleeding, 

 having ceased spontaneously, or, in other words, 

 having been controlled by the power of nature 

 alone, may recur, and when it does the blood 

 ' flows from the lower orifice. 



Others have believed that the accidental 

 position of a collateral branch near to the 

 ligature might be a cause of consecutive 

 haemorrhage by interfering with the formation 

 of the internal coagulurn. I have already 

 stated that the importance attached to this 

 coagulum was greater than it deserved ; and it 

 will be only necessary here to add, that I have 

 tied the common carotid artery within an 

 eighth of an inch of its origin from the inno- 

 minata without the slightest ill consequence 

 from that circumstance. 



It has been pretty generally believed that in 

 those cases which have ended favourably, a mild, 

 healthy, and mitigated process of inflammation 

 had been established which terminated in the 

 effusion of lymph and the obliteration of the 

 vessel, whilst in the unfavourable the inflam- 

 mation was more violent and ran into ulce- 

 ration. Nothing is more familiar than to hear 

 of the ulceration of an artery in connexion 

 with and as the cause of secondary haemor- 

 rhage, yet the existence of such ulceration is 

 very questionable. Arteries are not prone to 

 ulcerate. It has been shewn that in the midst 

 of phagedenic destruction, the artery escapes 

 for a length of time, and when it is attacked, 

 it is rather by mortification : and the appear- 

 ance of arteries traversing in safety the cavities 

 of tubercular abscesses in the lungs, where 

 they have lain for weeks or months bathed in 

 purulent matter, should make us hesitate in 

 speaking so boldly of ulceration in these struc- 

 tures. The fact, as observed on dissection, 

 appears to be quite otherwise, and the haemor- 

 rhage to be occasioned not by a hyper-activity 

 of inflammation tending to ulceration, but by 

 an absence or failure of the process altogether. 



As persons, the subjects of consecutive hae- 

 morrhage, seldom die (at least in this country) 



