Chapter IX: Part 9

Besides these tumours a species of an anomalous character is sometimes met with, appearing to arise from an aneurismal or varicose state of the venous radicles or capillaries, and partaking somewhat also of the nature of fungus hæmatodes.[21] I shall detail shortly the more important circumstances of one case. The patient, a lad aged sixteen, was admitted into a public hospital on the 7th of November, 1819, on account of a tumour over the left scapula. It was there deemed imprudent and inadvisable to attempt operation; and, after the application of leeches, he was dismissed, at the end of eight days. He then applied to me. The tumour was very large, hard, inelastic, firmly attached to the left scapula, and extending from its spine over all its lower surface. It also stretched into the axilla to within half an inch of the nervous and vascular plexus, and a large arterial trunk could be felt along its under surface. The arm hung useless, and, from the wasting of its muscles, was hardly half the size of the other. According to his own account, the uneasiness produced by the tumour was trifling when compared to the lancinating and excruciating pains in the limb. On attempting to move the tumour independently of the scapula, crepitation was distinctly perceived, as if from fracture of osseous spicula. A tumour was first perceived about three months previous, situated immediately below the spine of the scapula, about the size of a filbert, of a flat form, and attended with distinct pulsation; it had subsequently increased with great rapidity. About ten days before his admission into the hospital, it had been punctured; nothing but blood escaped. It was evident, from the rapid growth of the tumour, and the severity of the symptoms, that the patient would soon be destroyed if no operation were attempted. There were no signs of evil in the thoracic viscera, the ribs and intercostal muscles were unaffected; though the tumour was firmly fixed to the scapula, yet that bone was moveable as the one on the opposite side, and the vessels and nerves in the axilla were quite unconnected with the swelling. The operation was commenced by making an incision from the axilla to the lower and posterior part of the tumour. The latissimus dorsi was then cut across at about two inches from its insertion, so as to expose the inner edge of the tumour, with a view to tie the subscapular artery in the first instance; in this, however, I was foiled, owing to its depth. The dissection was proceeded with to where the branches from the supra-scapular were expected to enter. In detaching the tumour from the spine of the scapula, the knife and fingers suddenly dipped into its substance. This was attended with a profuse gush of florid blood, with coagula; by a sponge thrust into the cavity, the hemorrhage was in a great degree arrested; at the same time an attempt made to compress the subclavian failed, on account of the arm being much raised to facilitate the dissection in the axilla. The patient, exhausted, made some efforts to vomit, and dropped his head from the pillow, pale, cold, and almost lifeless. Then only the nature of the case became apparent. The sponge being withdrawn, one rapid incision completely separated the upper edge of the tumour, so as to expose its cavity; and, directed by the warm gush of blood, a large vessel in the upper corner, which with open mouth was pouring its contents into the sac, was immediately secured. The coagula being removed, by dissecting under the finger, the subscapular artery was then separated, so that an aneurism needle could be passed under it at its origin from the axillary, and about an inch from the sac. After securing this and two other large vessels which supplied the cavity, the tumour was dissected from the ribs without further hemorrhage, cutting the diseased scapula and the under part of the sac. It was then found necessary to saw off the ragged and spongy part of the scapula, leaving only about a fourth part of that bone, containing the glenoid cavity, processes, and half of its spine. The edges of the wound were brought together, and the patient lifted cautiously to bed. At this time he was pale, almost insensible, and without any pulsation perceptible through the integuments in the greater arteries, though the ends of the vessels in the wound beat very forcibly. Stimuli were employed externally and internally; in the evening his pulse at the wrist was ninety, and soft.

The sac of the tumour was composed of bony matter, containing little earth, and arranged in strata of short fibres pointing to the cavity. Its outer surface was smooth, and covered by a dense membrane; whereas the inner, to which so equable a resistance was not afforded, was studded with projecting spicula. The lower part of the scapula, partially absorbed, lay in the middle of the sac, covered by the remains of its muscles and coagula. Very large vessels were perceived ramifying on the surface of the tumour.

The patient made a rapid recovery, and the wound all but healed. A fungus, however, began to appear in about six weeks, which grew rapidly. This was removed, and the bone cauterized with little good effect. The tumour was soon reproduced. It was proposed to remove the remainder of the scapula with the extremity, as the only chance, though perhaps a slight one. This was objected to, and he died about five months after the operation, worn out by hemorrhage and profuse discharge.

The diseased parts presented the following appearances. Portions of the acromion process, superior costa, and spine of the scapula, were of their natural appearance. But the coracoid process, the glenoid cavity, and the cervix, were entirely destroyed, and their situation occupied by an irregular broken-down tumour, consisting of osseous spiculæ, and cancelli, irregularly disposed, and forming cavities which were filled with blood, partly fluid and partly coagulated. The head of the humerus was extensively absorbed. The articulating cartilage was almost entirely destroyed, particularly on the inner side, where a large portion of the bony matter had also been removed. The ulcerated surfaces were of a dark, bloody colour.

[HYDATIC TUMORS.

Another disease of the bones which ought to be introduced here is the development of hydatids, which I described twelve years ago under the name of _osteo-hydatidic_ tumours. The seat of this affection is not confined to any particular class of bones; though the long are perhaps most prone to it. Its precise nature and origin have not yet been determined; nor are its symptoms such as to enable us, in the present state of our knowledge, to distinguish it from exostosis, osteosarcoma, and other maladies. Its progress is commonly slow, the surface of the tumour is smooth and regular, the skin exhibits no unusual appearance, and the adjacent textures rarely participate in the morbid action. The hydatids, usually of a globular figure, vary greatly in size and number, and are generally filled with a thin, limpid fluid. They appear to be of the nature of acephalocysts. The prognosis unfavourable, owing to the difficulty of destroying these parasites, and their constant tendency, when interfered with, to reappear.

As soon as the true nature of this tumour is ascertained it should be laid freely open, its contents turned out, and the sac destroyed. For this purpose the sides of the cavity should be seared with the actual cautery, or touched with some of the more powerful escharotics, as the nitrate of silver, or the caustic potash. If these measures fail, and the disease involve the whole circumference of the bone, nothing short of amputation will suffice. This was successfully resorted to in one of the cases which came under the observation of Mr. Lucas of London.]

TREATMENT OF TUMOURS.

It may be observed generally, that no benefit can be derived from external applications to tumours, such as friction with liniments or ointments containing iodine, mercury, &c.; and that, therefore, it is injudicious to employ such temporising measures; for though a tumour at its commencement appear to be of a very harmless nature, yet it may soon assume a most malignant character. If an apparently simple tumour increase, and exhibit symptoms of inflammation, it will perhaps be advantageous to apply leeches, to arrest that incited action which affords the accession of new materials; this, however, cannot check the morbid activity inherent in the new formation, though it may hold the growth in check a little. If a tumour is to be removed by external applications, it is evident that these must be such as shall prevent the deposit of new matter, and allow the absorbents to remove that which already exists; for absorption is always going on in a tumour, though it leaves no evidence of its progress, on account of the deposition of new matter exceeding the removal of the old. I must say that I am unacquainted with any remedies capable of performing the above indication. The removal of a swelled gland may occasionally be accelerated by such means when stationary, or on the decline, and before cheesy tubercular unorganized matter is infiltrated into its texture; but to trifle so with a new and independent growth is altogether absurd. The knife only is to be depended on.

Many of the tumours first described have no malignant disposition originally, and only require surgical interference when they produce deformity or inconvenience from their bulk. Yet even these ought not to be allowed to attain any great size, however indolent they may appear at first, and however little pain they may produce; for there is always a danger of their assuming a malignant tendency, or forming connections with important parts, so as to render their removal either altogether impracticable, or at least attended with much difficulty. Tumours of every kind, when seated near important organs, must be early removed. Glandular tumours, however, even when of great size and long continuance, are not to be rashly interfered with, when they arise from irritation in the neighbourhood.

Those in which it is feared that malignant action has commenced cannot be trifled with; and the only means which afford a chance of the patient’s being effectually delivered from them is an operation. With a view to their complete extirpation, the external incisions ought always to be free, so as to admit of the after-dissection being easily and rapidly performed: they ought also to be made in the direction of the muscular fibres, whether these lie above or beneath the tumour. In this way the margins of the wound are easily brought into apposition, and there retained; whereas, if the fibres be divided transversely, the wound will gape, and union by the first intention be rendered absolutely impossible. If there is no reason to suppose that the tumour is malignant, little or no integument ought to be removed, unless the growth is of a large size; but, when malignity is dreaded, all the discoloured, tense, and adherent integument, all that is permeated by dilated and tortuous vessels, ought to be taken away, and the incisions made at a distance from the disease. In all cases they ought to commence at the point where the principal vessels enter; these are thus divided at the outset, can be readily secured by ligature, or by the fingers of an assistant, and the dissection is proceeded in without risk or interruption from farther hemorrhage. If the opposite course be pursued, the vessels will be divided two or more times during the operation, and thus the performance of it will either be delayed by the application of numerous ligatures, or will be attended with a considerable loss of blood. After the tumour has been exposed it ought to be principally detached in one direction, as in this way its removal will be sooner accomplished, and not first cut on one side and then on another. If malignant, great care should be taken that all the diseased mass be removed, for a minute portion remaining will form a nucleus in which similar diseased actions are certain to arise; in most instances, it will be prudent not only to remove the parts actually diseased, but those also which are in immediate connection with the tumour, though at the time they appear healthy. All important parts must be carefully avoided. After removal of the mass, and the complete cessation of bleeding, the edges of the wound must be approximated, so as to favour union by the first intention; if this fail, granulation must be promoted, and the wound dressed according to the particular circumstances of the case. All operations on malignant tumours, in their advanced stages, are unwarrantable; they are necessarily painful and severe, and cruel because unavailing; they often, indeed, expedite the dissolution of the patient. If the integuments over the tumour have ulcerated, and if the lymphatics in the neighbourhood are diseased, the disease if removed will certainly be reproduced, and the succeeding tumour will be still more malignant. The operation ought, if at all, to be performed when the disease is in its incipient state, for then only can success be expected.

Exostoses need not to be interfered with, unless they are the source of much inconvenience, either from their size and form, or from their having been detached, and lodged amongst the adjacent soft parts. If loose, they can be removed in the same way as any other extraneous body; if firm, their attachment must be divided by a saw, or by cutting pliers, close to the bone from which they spring. Sometimes, as in the scapula or other flat bone, a portion of the original bony tissue can be cut out along with the new growth, and this renders the chance of any return of disease much less likely.

Osteo-sarcomatous tumours are to be taken away, along with the part of the bone in which they are imbedded, and, if possible, before the integuments have ulcerated. The incisions must be made, and the bone sawn, at a healthy part. The removal of the entire bone in which the disease has commenced, when practicable, will afford a still better chance of immunity from farther disease.

In spina ventosa more is seldom required than to lay open the cavity, give vent to the matter, and then treat the case on the same principles as in abscess of the soft parts. The cellular tumours, partly cartilaginous, partly osseous, ought not to be permitted to remain; the operation can generally be done without much difficulty; and thus the danger of their degenerating avoided. Frequently, however, a considerable part of the bone must be removed along with the tumour, since the neighbouring tissue is generally softened, and intimately adherent to the diseased part, which it somewhat resembles in structure.

In general, regular dissection is unnecessary in the removal of encysted tumours. An incision is made, or an elliptical portion cut out; the contents escape, and the cysts, being then laid hold of by dissecting forceps, is readily separated. In some situations, as on the eyelids, under the tongue, or amongst tendons, the sac, which is thin, is not so easy of extraction; it is then inseparable, either naturally, or from previous inflammation. Caustic is used with safety to destroy those parts which cannot be detached, and for this purpose the potass is to be preferred. When, however, the tumour is large, a part of the integuments covering it must be removed, otherwise a large cavity will be left, in which pus might accumulate. In this case, the base of the tumour is to be surrounded by two elliptical incisions, and the cyst dissected out entire, leaving only integument sufficient to cover the exposed surface. In the smaller tumours, it is vain to attempt regular dissection; a portion of the cyst will be left, and the disease reproduced: whereas, by using the potass, the operation is much more speedy, and always successful. The making a minute aperture, and squeezing out the contents, is at best but a palliative measure, and is often followed by severe constitutional disturbance.

OF WOUNDS.

These vary in extent and nature. The instrument by which they are inflicted, the violence attending the injury, and the nature and importance of the parts divided, or in the neighbourhood of the wound, must all be attended to, for, from an accurate knowledge of these circumstances, the treatment of the case comes to be conducted accordingly. Wounds are divided into incised, punctured, bruised, and lacerated; that is, into such as are inflicted by a sharp-edged, sharp-pointed, or an obtuse body. In the first kind, there is greater or less effusion of blood, according to the size and number of the vessels divided. Some extend but a little way beyond the subcutaneous cellular tissue, and are consequently attended with but slight bleeding; others penetrate to a greater depth, and occasion hemorrhage from a large vessel, or other alarming symptoms, by having reached some important organ; others, though not of so great a depth as the former, may still, on account of their mere extent, be accompanied with very considerable loss of blood from a number of small branches. It is seldom that fatal effects immediately follow external wounds; but they may and do occur when bloodvessels of the first class only are cut. They are most likely to prove suddenly fatal when the arteries are only partially divided, and when the large veins accompanying them are also involved. When the artery is cut through, its extremities retract, effusion takes place into the sheath and compresses the orifice; the formation of a coagulum within the vessel is thus promoted, and the hemorrhage arrested. But, when a portion only of the circumference is divided, the blood continues to flow through the aperture and onwards, as if into a smaller ramification of itself, no retraction or contraction of the vessel can occur, coagulation is slow, and the bleeding profuse. I have seen a wound of so small a vessel as the internal mammary prove almost instantaneously fatal. Wounds of the large internal vessels for the most part prove immediately fatal; as wounds of the heart, or the large vessels passing to and from its cavities, at the root of the lungs, or at the upper part of the liver. When the heart, or the vessels within the pericardium, have been divided, it can be readily understood how life should be immediately destroyed, since the blood effused into the cavity of the pericardium by its pressure completely arrests the action of the heart. But occasionally punctured wounds, in such situations, have not been followed by instant death. In such cases, alarming symptoms occur at the time, but subside, and the patient may for some time suffer no uneasiness, but afterwards expires suddenly during muscular exertion, or perhaps in a fit of violent passion. Blood must have been effused into the pericardium at the first, causing symptoms of, or actual, syncope; but then the aperture in the vessel had become obstructed by coagulum before blood had been poured out in such quantity as to effectually prevent the actions of the heart; at a future period the coagulum gives way, and the subsequent effusion is limited only by the pericardial cavity being completely filled. In wounds, hemorrhage is the symptom which most alarms the bystanders, and which demands immediate attention; but, to operate successfully, the surgeon must divest himself of all fear, and learn to look boldly on the open and bleeding mouths of arteries. Effusion of blood ceases spontaneously, even from considerable vessels, on faintness supervening, and thus many lives are saved; but as soon as reaction commences it generally recurs, and may prove fatal, unless proper measures be resorted to.

When an artery is divided, its extremity retracts within the sheath, it also contracts, and coagulation occurs; thus the orifice is obstructed, and a temporary barrier formed to further hemorrhage. The tube, however, is permanently closed by effusion of lymph from its orifice, and consolidation of the surrounding parts.

The circumstances which follow division of an artery are these:—The immediate effect is retraction of its ends within the investing sheath, and a simultaneous contraction of the coats, so as to diminish the calibre. From the superior orifice there is necessarily a profuse flow of blood, which is discharged through the sheath that formerly enclosed that part of the vessel which has retracted. After considerable effusion of blood, the flow becomes slower and less profuse; particles of blood adhere to those filaments which previously connected the artery to the sheath, but which were lacerated by the sudden retraction of the divided extremity; these particles coagulate, and lessen the canal through which the blood is discharged, whilst they present an irregular surface, on which the blood continues to be deposited and to coagulate; and thus the aperture in the sheath is ultimately closed. This external coagulum is found to commence at the extremity of the artery, where it is of a cylindrical form, and shuts up the mouth of the vessel; it then extends along the canal in the sheath, frequently assuming a conical form; and, if a free discharge has been allowed for the blood, it will terminate at the cut margin of the sheath, otherwise it will be found continuous with the coagulum blocking up the external wound. Also, when hemorrhage has been resisted by the shutting of the external wound, blood is infiltrated into the cellular tissue around the bleeding point, and there coagulates; but this circumstance can be productive of little or no pressure on the parietes of the vessel, so as to assist those other natural means which obstruct it. The flow of blood through the divided vessel being prevented, the circulating fluid necessarily passes through the nearest collateral branches, leaving the blood in the extremity of the larger trunk in a state of comparative rest; consequently, coagulation occurs in this situation. The internal coagulum, however, is small, and not sufficient to occupy completely the cavity of the vessel; it is of a conical form, its apex being towards the heart, and opposite to the first collateral branch, and its base resting on the external coagulum, and there adhering to the internal surface of the artery. But, whilst this latter process is advancing, the capillary vessels supplying the cut margins of the artery have begun to act; they throw out coagulating lymph, and continue to do so until their secretion has completely filled the vessel immediately opposite to its divided margins; thus a third and more effectual coagulum is formed,—one of plastic matter, situated between the external and internal coagula of blood, and in general closely adherent to them. Lymph is also effused externally to the artery and its sheath, forming a dense stratum, which separates the extremity of the vessel from the external wound; it becomes organised, forms granulations, and thus the parts are consolidated, and the wound cicatrised. When the artery is permanently obstructed by the adhesion of its cut margins, the external coagulum can be dispensed with, and is gradually absorbed. Afterwards all the newly formed parts are condensed, and diminish in size; the artery contracts, its internal surface finally embraces the coagulated blood which lay loose in its canal; its coats appear to be thickened, and it is firm and hard. Ultimately, in consequence of the continuance of absorption, it becomes much more attenuated, so as scarcely to differ from the surrounding cellular tissue. Similar changes occur in the lower extremity of the divided artery; in general it retracts farther, its orifice is more contracted, and, the flow of blood being much less profuse than in the superior, the natural means for its temporary closure are sooner accomplished. When an artery has been divided close to the origin of a collateral branch, no bloody coagulum can form internally, for the blood in that situation is necessarily in a state of constant motion.

If the hemorrhage is suppressed artificially, either by ligature, or by otherwise well-applied pressure, no external coagulum is formed; there appears only the internal bloody coagulum, the lymphatic effusion, and consolidation of the compressed part. The natural contraction and retraction cannot occur in vessels partially divided; hemorrhage, therefore, is more violent and dangerous from a partial than from a complete section. Again, transverse wounds are more dangerous than longitudinal; in the latter, the edges of the wound are spontaneously approximated on account of the structure of the vessels, whilst, from the same cause, the margins of the latter continue separate, and, in fact, the aperture is a complete circle; the lips of an oblique wound will be more or less apart, in proportion as it approaches to the transverse direction. When an artery has been punctured, the wound in the sheath perhaps does not correspond with that in the vessel; blood, therefore, accumulates between the vessel and its sheath, and there coagulates. The wound is thus compressed, its edges kept in contact, and the farther escape of blood prevented; the lips of the incision are then agglutinated by effused lymph, and cicatrisation occurs. This, however, cannot be expected to take place unless methodical pressure has been applied from the first. Even from small punctures blood is effused under the sheath and into the neighbouring cellular tissue, rapidly, and in such quantity as to prevent adhesion. The effusion continues, and a false aneurism is formed. If a considerable part of the circumference has been divided, the lymph may be, and generally is, superabundant, and often to such an extent as to close up the canal of the artery at that point; but, if the aperture is minute and in a longitudinal direction, lymph will seldom be effused in greater quantity than is sufficient for the cicatrisation; and, though it should be superabundant, it is afterwards removed by the absorbents. In all cases, the cellular tissue round the wounded point is much thickened and condensed by the deposition of lymph, but this gradually disappears after cicatrisation has been completed. Sometimes, and generally when the wound has been transverse and large, the process of adhesion is disturbed, and suppuration occurs; in this case the wound in the vessel communicates with the fistulous track in the externally effused lymph, and may be the source of troublesome hemorrhage. In other instances of extensive transverse wounds, the undivided slip ulcerates, and the artery becomes obliterated, by means of the same natural processes that occur in complete division. In cases of laceration of an artery, when its coats have been forcibly torn rather than divided, little or no bleeding takes place. The vessel retracts; the lacerated margins of its inner coat become puckered up, so as to contract greatly the orifice of the vessel; the lacerated sheath is pulled out to a point, and closed at a little distance from the divided inner coats. If a large artery is torn asunder in the dead body, this stretching out and contraction of the sheath will prevent injection passing; in short, the immediate effects of the injury are such as to favour the instant formation of coagula, by which the hemorrhage is arrested until the orifices of the vessel be permanently closed by the adhesive process. Thus, in instances where the whole of an extremity has been torn off, the patients have generally lost but a very small quantity of blood.

From wounds of veins the blood flows, not in a sub-saltatory but in a uniform stream: its colour is dark, and the flow is easily suppressed. The common opinion is, that to place a ligature on a vein is dangerous, and to be scrupulously avoided. The process of reparation, besides, in a wounded vein, is different from that in an artery. Veins are less disposed to the secreting action by which adhesion is perfected; and, when inflamed, the inflammation is extremely apt to extend along the coats of the vessel; which latter circumstance has been ascribed to the great proportion of cellular tissue in their coats. When punctured longitudinally, the lips of the wound remain in contact, and cicatrisation, by means of effused lymph, is soon effected; in fact, the wound heals by the first intention. But if opened obliquely or transversely, not to a great extent, the immediate result is discharge of blood, and, when this has ceased, a coagulum forms in the wound, the margins of which remain separate; and this coagulum generally communicates with blood effused into the sheath of the vessel. After some time, the lips of the wound, encircling the coagulum which occupies the aperture, and which has temporarily averted the hemorrhage, become somewhat turgid, and increased in vascularity; they then appear to assume a secreting action, by which a membranous substance, of extreme delicacy, is produced; and the extent of this membrane is increased until it form an expansion, investing the outer surface of the clot; it then becomes thickened, by addition of matter, similar to itself, from the recent vessels which ramify in it. At the same time it forms adhesions to the surrounding cellular tissue, and resembles the original tunics of the vein. After being consolidated, so as to prevent the flow of blood through that part, the coagulum, formed to arrest the hemorrhage until a more complete barrier should be furnished, is gradually absorbed. But the membrane long remains smooth, thin, and diaphanous, and can be thereby readily distinguished from the original coats. This reparative process is much longer in being finished than the corresponding one in arteries; and, from what has been stated, it is evident that the two actions differ in other respects than the time requisite to complete them. When a vein has been completely divided, the extremities are closed by means similar to those which have been already detailed in regard to arteries.

In many, nay in most, instances of hemorrhage from a wounded artery, the surgeon cannot wait for the natural processes by which the flow of blood is arrested, but must have recourse to immediate and certain means. In division of the smaller arteries, or in minute wounds of the larger, pressure, well applied, will often be sufficient. In both cases it immediately stops the flow: in the former, it prevents the blood from penetrating into that portion of the sheath which has been vacated by the retracted artery; and it being thereby confined, and kept in a state of rest, coagulation soon takes place. At the same time, the compression brings the divided margins of the vessel into close apposition, and thereby permanent closure, by adhesion, is quickly accomplished. In the latter, the mere circumstance of the escape of blood being prevented, naturally hastens the closure of the minute aperture by the natural process; and, if the compression be accurate and very firm, the opposite surfaces of the vessel, being brought in contact, may adhere, and the canal be obliterated at the wounded point. It is obvious that, in this latter class, pressure can only be of advantage immediately after the infliction of the wound, and not when blood is extravasated to a great extent.

Pressure may be used along with styptics, or along with escharotics, actual or potential. They may be often employed when pressure ought not; styptics promote the contraction and retraction of the divided extremities, and thereby expedite the formation of a coagulum. Escharotics form a slough, which, adhering to the extremity of the vessel, stops the flow of blood, and the cut margins of the vessel, being stimulated by the application, soon cohere. Active stimulating applications merely cause effusion quickly of coagulated lymph, and thus often arrest hemorrhage from very vascular surfaces better than the so-called styptics. Not unfrequently, after the separation of the slough, it is found that union has not taken place, and hemorrhage is renewed; from this circumstance, the remedy cannot be trusted to, except when the divided vessels or vessel are of small size. It may be stated, generally, that these means are of little avail without methodical pressure. In oozing from small vessels, pressure may be applied by means of agaric, sponge, or lint. In bleeding from small vessels, where there is general oozing from the surface, and pressure cannot readily be made, applications tending to produce effusion of lymph—stimulants, such as turpentine or creosote, are often remarkably efficacious, and very speedily so; but in wounds of the larger vessels, the most efficient mean is a graduated compress of lint placed immediately on the external wound, and supported by a firmly-applied bandage. The bandage ought to encircle not only the wounded part, but every part of the limb with a uniform tightness, not so great as to arrest the general circulation; the parts are thereby supported, and engorgement prevented. This method, when employed previously to the effusion of much blood into the cellular tissue, has proved effectual in wounds even of the brachial, femoral, and carotid arteries. When blood has been extensively injected into the limb, when the aperture in the vessel has remained pervious, and when a large diffused aneurism exists, bandaging is worse than useless. By its application in such a case the limb becomes discoloured and swells extensively; there is a risk of mortification from impeded circulation. If a small quantity only of blood has escaped, its diffusion and increase may be prevented by the bandage: but a cyst will nevertheless be formed in the cellular tissue; its parietes will communicate with the margins of the aperture in the artery, its cavity with the canal of the vessel; an aneurism of the false kind will be established, and will run the course of one arising spontaneously.

A ligature, well applied, is the only means that can be relied on. The immediate effect of a tightly-drawn ligature is to avert the flow of blood, to divide the internal and middle coats at the deligated point, the cellular coat remaining entire, and to narrow the canal for some extent above the point at which it is applied. Coagulation then occurs within the vessel above the ligature, provided there is no collateral branch in the immediate vicinity. The ruptured margins of the internal coat effuse lymph and cohere; lymph is effused also in the cellular tissue, exterior to the artery and to the ligature; by the compression of the ligature, ulceration occurs in those parts which it envelopes, and the foreign body is discharged; but before this occurs the canal of the vessel has been obliterated by an internal coagulum, and by the effused lymph. Afterwards, the same absorption and consolidation occur as in a divided artery, the orifice of which has closed permanently and spontaneously.

When from a punctured wound profuse hemorrhage ensues, there is reason to suspect that an important vessel has been hurt, and the bleeding point must be sought for. After the artery giving out the blood has been discovered, the external wound must be enlarged, so as to expose the vessel, and admit of the convenient application of a ligature. It will not be sufficient to include the vessel above the wounded point, for the lower part will, after some time, be supplied with blood by the collateral branches almost as freely as by the large trunk, and, consequently, bleeding will be renewed. Two ligatures are to be employed, one above, the other below, the wound. The wounded vessel must be exposed, as already stated, but not detached more than is sufficient for the application of the ligature; and at the same time the ligatures ought to enclose nothing but the vessel. Neither ought the ligatures to be placed at any considerable distance, but as close to the wounded point as possible; otherwise circulation in the included part may be restored. The ligature, round, narrow, and firm, ought to be tightly applied. Cases of hemorrhage have occurred in which the tying of the vessel immediately above the wound has been successful; but these are few, and by no means afford any authority for the general adoption of such a measure. If the vessel is merely punctured, it is necessary to apply the ligature by means of a blunt pointed needle, and the parts are to be disturbed as little as possible. If, however, the artery is completely divided, its cut extremities are to be drawn out of their sheath by a hook or forceps, and the ligatures applied close to the connections of the vessel; the vasa vasorum, in the immediate vicinity of the deligated point, being left to carry on those processes by which obliteration is accomplished. In punctured or partial wounds of arteries, it deserves consideration whether the hemorrhage may not be restrained by the application of slight pressure, so regulated as to prevent the flow of blood laterally through the wound, but not so forcibly applied as to stop the onward current of the blood along the vessel, from the part of the tube above to that below the puncture. Some experiments made by Dr. Davy seem favourable to this view; as bleeding from the carotid arteries, partially divided transversely, in dogs was easily arrested by the means above-mentioned, the wound of the vessel readily healing, so as to preserve its tube entire; whereas, when the pressure was increased, the hemorrhage became violent. The subject is mentioned as one worthy of a further experimental investigation. The instrument which will generally be found most useful for laying hold of the vessel is the common dissecting forceps, but a tenaculum will, in certain circumstances, be more convenient. By far the most convenient machine is that here represented.

When no assistant is at hand, and in cases of emergency, the surgeon provided with this little instrument can tie vessels without the least difficulty; and in operation, when many vessels spring, several of these forceps can be applied; there is besides this great advantage in their employment, that a clumsy assistant can scarcely include the point of the instrument with the vessel. Hemorrhage from the smaller vessels soon ceases; and, before reaction occurs, their orifices have generally become so obstructed as to resist the effusion of blood.

The effects of ligature on a vein are somewhat different from those on an artery. The inner coat of the former is more dense and elastic, and remains entire, whilst the external and middle are divided. It is puckered by the ligature, and its opposite surfaces are placed in immediate contact; but there is no breach of surface, and adhesion does not occur till the tunic has been divided by ulceration; then the opposite margins cohere, the vessel is obliterated, and undergoes changes resembling those in an artery similarly circumstanced. The coagulum between the ligature and extremity is of considerable extent, dense, and completely filling the canal of the vein, and consequently, of a cylindrical form.

The edges of the wound, in the soft parts, ought not to be approximated till the bleeding has entirely ceased, and the surface become glazed, for the interposition of the slightest quantity of blood prevents union by the first intention. When bleeding has ceased, the divided edges are to be brought together as accurately as possible, and adhesion promoted. The minute vessels assume an action greater than in the healthy state, though not equal to inflammatory action; they effuse coagulating lymph, by which the opposed surfaces are agglutinated, though the union is at first feeble and easily broken up. Soon the lymph is firmly attached, by newly-formed vessels, to the surface from which it was secreted; in effect, it becomes organised, and rendered capable of undergoing, through its inherent powers, the changes necessary for its perfection and stability. Similar processes go on in it as in any sound part of the body; new matter is deposited, and the superfluous is absorbed. The process of nutrition, however, is not the same in all parts of its substance, that is, the new matter deposited is not exactly similar at all points; but, according as the new secreting vessels proceed from the different tissues of which the margins of the recent wound are composed, so, in various parts of the new formation, these vessels assume peculiar modes of action, one set forming muscular, another cellular tissue, and a third a substitute for skin, formations corresponding to the primary tissues from which the secreting vessels proceed.

Thus the vasa vasorum, ramifying on the divided ends of the minute vessels, secrete a substance which is transformed into a set of minute capillaries, and these also, assuming a secretive action, produce an arterial or venous tube, similar to that nourished by the original vasa vasorum. By this process the lymph becomes well supplied with bloodvessels, those from the opposite surfaces meeting, and freely inosculating with each other. These bloodvessels, as already stated, have been produced from arteries possessing different powers, and hence the newly-formed assume actions similar to those of the primary, and thereby interstitial matter is deposited of its proper kind and in its proper place, a cuticular membrane superficially, then cellular tissue, afterwards muscular, and so on according to the primary tissues which had been divided; these parts do not at first resemble exactly the corresponding natural tissues, but, by the continued action of the new vessels and capillaries, they are moulded and prepared for the due performance of their respective functions. If the degree of action necessary for the accomplishment of these processes increase to inflammation, adhesion is interrupted till the action be lowered to its previous standard.

From this view it is evident, that, besides a certain excitement of the bloodvessels, it is necessary that the raw margins be in close apposition, and carefully retained so, for, by ever so slight movement of the parts, the recent and delicate bond of union will be ruptured; and, if this motion be allowed to continue, adhesion may be at divers times begun, but can never be perfected. Whereas, if the necessary precautions are adopted, union is often completed in thirty or forty hours, sometimes sooner, seldom later. From a knowledge of the astonishing powers of nature in repairing injuries, many and important improvements have of late years been made in the practice of surgery. In the majority of instances it is also requisite that the parts be brought in contact soon after division, otherwise granulation will have commenced in the different parts of the wound, and the surfaces then approximated will not so readily adhere: pus is formed, and, having lodged between the surfaces, acts as an extraneous substance, keeping them apart, and separating them still farther by its accumulation. All foreign bodies in the wound must be removed before adhesion can occur; and, on the same principle, care ought to be taken that no effused blood be interposed. In many cases the margins of the wound can be accurately adjusted by careful attention to the position of the part, or by the application of a few strips of adhesive plaster; but the latter, from indiscriminate use, often prove the source of much irritation, and totally frustrate the end for which they are designed. When employed, they ought to be narrow and few. If such means be considered insufficient, recourse must be had to a few points of interrupted suture, and these are not productive of bad consequences which have been by some attributed to them. When neatly applied, they can produce but little irritation, more especially if removed as soon as their presence is unnecessary, that is, as soon as adhesion has fairly commenced, and the natural bond of union is of such strength as to need no artificial assistance. By these the edges of the wound are more neatly and suitably placed than by any other means; they meet easily, without the puckering or overlapping of each other; and, from the circumstance of sutures obtaining a more just coaptation, they can be sooner discontinued. In most wounds no other dressing is required; but in some a combination of sutures, adhesive plaster, and compress, is necessary.

Of late, I have greatly dispensed with stitches and the common adhesive plaster, using, instead of the latter, slips of glazed riband smeared with a saturated solution of isinglass in brandy, which is much less irritating and more tenacious than the common adhesive compost. The parts are fixed temporarily with a single stitch, or two at most, and cloths dipped in cold water are placed over the wound; the ribands are not applied till the adhesive substance has partly congealed, and the oozing of blood ceased. The divided margins being approximated by the fingers of an assistant, the ribands are laid gently over, and held for a few seconds. Soon after a sufficient number have been applied the stitches are withdrawn, being no longer necessary. No other dressing is required unless suppuration occur; the ribands will adhere firmly till the completion of the cure, and thus the pain and irritation caused by frequent dressing is avoided. Even the largest wounds, as after amputation, are treated in this manner with the most satisfactory results. Of late years a plaster, made by coating oiled silk with a solution of isinglass, has been used instead; the glazed surface of the slips is moistened, and applied as here directed.

If at any part adhesion fail, suppuration and granulation must follow. The adhesion may be prevented by any of the circumstances already mentioned, or by an unfavourable state of the constitution, the nature of the wound, exposure to bad air, the occurrence of fever, or of a flux natural or not. The wound may contain foreign matter; blood or the contents of canals may be effused into it, and many other obstacles may exist to retard, or prevent adhesion. Notwithstanding, in all cases, though the chance of union be but small, the parts should be approximated. A great point is gained if certain parts only are brought to adhere, for by their natural attachments the opposite surfaces are preserved in more direct contact than they could otherwise be, and thereby but little space remains to be filled up with granulations. If, on the contrary, the surfaces are not approximated, the flap is diminished in size, and when afterwards placed in contact with the surface from which it was detached, it is found not to correspond, leaving considerable deficiency to be repaired by the comparatively slow process of granulation. Whereas, if it had been early replaced, partial attachments would probably have been formed by adhesion, the flap thereby retained in situ, and prevented from shrinking, so that but little new matter would be required.

Sometimes union does occur, and that speedily, after the flap has remained separate for a considerable time; and in such cases it may be doubted, whether union is accomplished by adhesion, strictly so called. Most probably it is by this process that the rapid union occurs in such circumstances: the divided parts have assumed an excited action, and effused lymph; during their state of separation, the lymph will become organised when it is connected with the original parts, just as well as if the surfaces had been in contact; and when they are at length so placed, they will be agglutinated to each other by the outer part of the effused lymph, which still continues soft and unorganised. If motion be then prevented, organisation, which has already commenced in the connecting medium, will proceed undisturbed, converting the agglutination of soft unorganised lymph into firm and permanent union by means of organised tissue. In these circumstances, it is not to be wondered at if adhesion should be completed in a shorter time than when the surfaces are brought together immediately after their division; in each instance the process is the same, only in the one it has to proceed from its very commencement, whilst in the other it is previously all but perfected, and after the parts have been put together, the last stage only requires completion. It is only in a particular stage of a granulating surface, that adhesion will take place speedily, when the discharge is diminished, but healthy, and the granulations florid and firm.

When a wound is to heal by granulation, the exposed surface at first is dry, painful, and slightly swelled, and afterwards a thin discharge of bloody serum is poured out, with relief to the painful sensations; the surface is at this time covered by a thin layer of coagulated lymph, and the parts, if approximated, are in the most favourable state for adhesion. Soon, however, the vessels assume a different mode of action, and secrete a fluid which becomes purulent; the effused lymph has been organised, forms a living part of the surface from which it was deposited, and is covered and protected, in its yet delicate condition, by the purulent fluid. This new matter is disposed in numerous small conical projections of a florid colour; and these, by their own power, form others similar to themselves, at the same time discharging purulent matter; so that, in a healthy constitution, the cavity is soon filled by the granulations, which come to the same level as the surrounding integument. Sometimes they are exuberant, soft, and spongy, and in this state possessed of little sensibility, and but ill supplied with bloodvessels. At others, they are slow in approaching the surface, and then often morbidly sensible. In all cases, the new matter is very apt to be absorbed, either from the state of the patient’s health, or from the nature of the applications; and foreign substances, in a state of solution or minute division, are more readily taken into the system from the raw surface than from the sound skin. When, then, the granulations approach the skin, the sore contracts, the newly formed parts being modelled into a more firm and dense condition by the action of the absorbents. Sometimes, in superficial sores, the skin is seen spreading from several parts near the centre; but at these points portions of the original skin must have remained uninjured, though the others were destroyed, and have formed cutaneous matter as soon as they were on the same level with the surrounding granulations; for these insulated portions of skin are not a product of granulations, as some suppose, but of a substance similar to themselves. Skin is formed from skin. Thus, where a part of the integuments has been completely removed by operation, or destroyed by accident, no islands of skin are observed during the cure, but the sore is uniformly covered by skin proceeding from its margins. The margins of a healing sore are of a white colour, and adherent to the subjacent parts; but in an unhealthy one the margins are often unsupported, the subjacent granulations are absorbed, and their place is occupied by thin purulent matter; the new skin is unable to maintain its independent existence, continues of a dark colour, perhaps for a long period, then wastes away or sloughs. The recent cutaneous matter covering a sore contracts, and the neighbouring old skin is extended; the new surface is thus diminished; it assumes a slightly puckered appearance, and is termed cicatrix. This is at first pretty vascular, the vessels running straight; after a time they contract and become invisible, and scarcely admit fine injections. Frequently the scar is so far absorbed after some time, as to leave only a firm line, whiter and more dense than the surrounding integument.

If union by the first intention does not take place, then all the application to procure it must be abandoned, all sutures, plasters, compresses, &c., must be dismissed, for they now can do no good, and may be productive of harm; the attention, on the contrary, must be directed to effecting union by granulation; with this view, other means are to be chosen, so that to continue those which were formerly used to promote adhesion would be absurd, when adhesion can no longer be expected. The stitches must then be taken out, when inflammation has gone off, and œdema remains, the parts are to be supported; and by attention to position, and gentle bandaging, the size of the wound will be diminished. Inflammation must be subdued by the usual means, and suppuration encouraged by fomentation and poulticing, or warm water dressing. After inflammation has subsided, tension disappeared, purulent discharge occurred, and granulations formed, the edges of the wound are to be gently brought together, so as to render the quantity of new matter requisite for filling up the cavity as small as possible. Nature will then accomplish the union in her own way, and we can only assist and minister to her; for who thinks now of healing wounds by pure force of surgery? The dressings ought to be light, the ointment, if any is used, scanty; in some cases the application may be dry; but in many cases various lotions will be found of much advantage. These latter are used of different qualities, according to the nature of the sore; and these can be of little avail unless evaporation be prevented, by a piece of oil-silk laid on the outer surface of the dressing. In most granulating wounds, they require to be of a mildly stimulating nature, and the one which I have most frequently employed is a weak solution of the sulphate of zinc. The integuments round the wound may be occasionally washed, to prevent excoriation, but no good can accrue from washing the sore; its natural discharge is its best protection, and if superabundant, it can be removed by means of dry lint or tow from the surrounding parts.