4!*vv. .y' '*%*** } i"'*-* ' ■^ -.*/*' ■' V«S. •-% "■■.•* y^ '"v ■ r " •'< m ■ ■0' <■ ''1 ' v^.*.-:^v.--> ^K';-!^*** *<^v;-r.r-•"£•.. ■.• ■.'**•; $ jr**^- VRMY MEDICAL LIBRARY WASHINGTON Founded 1886 —7 Section.//*';. "^. Number 3.S-.2..? 3- 4 Fobm 113c. W. I>.. 8. G. O. ■ ro 3—10643 (Revised June 13, 1830) .:»3E&>. ■[ ^\\\ v^rt\\V\ sv^v £) \ * -••... Discourses ON THE NATURE AND CURE OF WOUNDS. IN TWO VOLUMES. »» JOHN BELL, surgeon. FIRST AMERICAN EDITION". VOL. I. OF WOUNDS IN GENERAL. *? PROCURING ADHESION. || OF THE MEDICAL TREATMENT OF WOUNDED ARTERIES. OF WOUNDS. X>F GUN-SHOT WOUNDS. j] WALPOLE, N. H. PRINTED, FOR THOMAS 55* THOMAS is" JUSTIN HINDS, BY GEORGE W NICHOLS. 1807. TO ERASMUS DARWIN, M. D. KNOWN TO THE AUTHOR ONLY BY HIS VALUABLE WORKS, THIS BOOK. IS PRESENTED, AS AN HONEST AND INDEPENDENT TESTIMONY or RrsPEOT AND GRATITUDE. THOSE WHO, TO MEDICAL SKILL, JOIN LIBERAL AND ELEGANT STUDIES, ENNOBLE THEIR PROFESSION, AND ARE ENTITLED TO FREQUENT MARKS OF PUBLIC ESTEEM. / THE AUTHOR OF THESE DISCOURSES, INSTEAD OF COURTING PATRONAGE, THINKS HIMSELF MORE HONOURABLY EMPLOYED IN THUS ACKNOWLEDGING HIS SHARE OF THE COMMON DEBT. ADVERTISEMENT. IT is becoming in an Author to give fome reafon to die Pub- lic why a book with fo many faults is fo little improved. Thefe difcourfcs on Wounds ara too imperfect to be pinch al- tered, too good to be entirely thrown away.—The Plan was lim- ited at the firft, and the work mull remain in its original form ; for, without changing its character, it can hardly be improved. Nothing more was defigned than a (ketch of a great and intei> efting fubjett ; but that (ketch has been favourably received ; it has been found ufeful ; an Edition of Sixteen Hundred Copies. has been rapidly fold; and the approbation of *he Public forbids the Author faying much concerning thofe imperfections which an Author muft feel more fenfibly than others, yrhich, if he have a due r*fpe& for himfelf, he will be proud to acknowledge. It is fome time fince th«fe difcourfes were eompofed : The Author was, even at the firft, confcious of many imperfections, and is fenfible that he now regards them with fuch impartial and chaftened approbation as a friend might indulge : The natural progrefs of the mind, when continually employed in the purfuit of knowledge, inclines every man of fenfe and diligence to think, per- haps, too humbly of paft labours. The Author of this Elementary Book has been at pains to correct fome of the many errors of the Firft Edition, and (should be happy to make this more worthy of the approbation of the Public, or of thofe Gentlemen to whom it is infcribed. But while he is employed in another vot::, in which the gener* al principles of Surgery are more fully difplayed, he (hall feel him- felf greatly fupported if the Public conaefcend to receive, with any degree of favour, this Second Edition of the Cook on, Wounds. Efcburgh, 1800. PREFACE TQ TH£ FIRST EDITION. THE Author of thefe Difcourfes will not allow himfelf the benefit of thai; apolpgy, to which he is but too well entitled ; for the apology of want of time furely is not refpeftful towards the Public : it intimates, that with time the Author could have written a more orderly and a better Book ; an intimation which is always immodeft, and often untrue. The Author knows but too well how often, in this Book, the marks of hurry will ftrike his Reader. He mentions hk confeioufnefs of this with regret \ He feels the neceffity of requeuing that indulgence which every author needs and claims. The very plan and title of this Book is new ; and the Author has deviated from accuitemed forms in this inftance, from no oth- er motive than the hope of making thefe Leflbns both pleafant and ufeful. This method of teaching by Difcourfes is as yet un- tried : it may have its advantages, it muft have its faults ; and this increafes that kind of anxiety which is infeparable from the acT: of appearing before the Public, and which even the fenfe of duty can hardly relieve. The Author has endeavoured to bring into one eafy and com., prehenfivc view, thofe leffer operations of Surgery, which are not found under that much abufed title uf a Complete Syftem. He has endeavoured to intereft his Reader, in the manner of managing wounded Arteries and in many of the leiier points of practice. He has attempted tp refute fome favourite dodrrines, not wanton- ly, but boldly ; " not becaufe they belong to this Doctor or that Frofeifor," but becaufe they feemed to him totally incon- fiftent with true philofophy, and incompatible with found Surge- ry, in as far as it is as yet founded upon a knowledge of the pow- ers and principles of the human body. He has uied all that free- dom with great names which the caufe of truth and fcience re- quires ( he has publifhed boldly many criticifms which he would not have ventured to mention in his Lectures, or in private ; for there ciiticifm is no longer criticilm, but the foul report and priv- «.t; malic; of it works like a fecret poifon, again ft which theri is no preventative nor cure. He has criticifed the opinions of thefe chiefly, who, being at the head of the profeftion, are of courfe the beft able, and, to all appearance alfo, the molt willing to de- it,id thcmiil/L$. L vi ] But the Autlior h:is never allowed any purfuit of this kind to break in upon the order or purpofe of his Difcourfe, which he has endeavoured to keep clear of all encumbrances, and in a plain and eafy form : He has endeavoured to order it fo, that his Read- er may have firft a free and general notion of each fubjedt in the body of the Difcourfe, and he has put down more exprefs and accurate rulds at the conclufion of each : He has introduced the lighter pieces of hiftory, to give eafe and life to the fubjeft ; and to give it weight and firmnefs, he has added rules of practice. He has endeavoured to give comprehenfive and general notions, of Wounds—of Wounded Arteries—of Bruifed or Gunfhot Wounds—and of Wounds of the Breaft, Belly, Head, Throat, and limbs, and efpecially of the condition of Limbs wounded with d m^erous complications, as of lacerated Arteries and bruifed Bones. He trufts, that his manner of explaining thefe fubjetts will be plain and eafy to the young' Surgeon, to whom alone he pre- i'umes to addrefs himfelf ; and, having thus honeftly told his mo- rives and his higheft expe&ations, he hopes to find every indul- gence ; and may be permitted to fay, with Lord Halifax, That he who is refolved to play the critic with this Book on drifter terms, " muft have a degree of generous irregularity in his reaf- pning, elfe he will not be a good tiling of his kind." DISCOURSE I. ON PROCURING ADHESION. "W^H E N a modern furgeon allows himfelf to talk about th» •* mundifying, incarning, and cicatrizing of wounds, or direfts how to fill the -wound up with good and found flefh, and keep it to a fair and even level with the adjacent fein," he but pro- claims his own ignorance of the properties of the living body. Perhaps he talks this language idly, and in mere compliance with the ufual forms of fpeaking ; but if he has ferioufly any fuch idea of the bufinefs and duties of a furgeon, there is much reafon to fear, that his methods, far from incarning and cicatriz- ing wounds, will rather interfere with the regular procefs of na- ture. It is an old, but it is a becoming and modeft thought, that in our profeflion, we are but as the minifters of nature : and indeed the furgeon, (till more than the phyfician, achieves nothing by his own immediate power, but does all his fervices by obferving and managing the properties of the living body ; where the living principle is fo ftrong and active in every part that, by that ener- gy alone, it regenerates any loft fubftance, or re-unites, in a more immediate way, the more fimple wounds. Wren we can prevail upon ourfelves to renounce this parade of idle words, and to refign alfo our fupreme ofEce of afllfting nature in " mundifying, incarning, and cicatrizing wounds, of filling die wound with found flefh; and of keeping it to the right level, fo as to make an even and feemly fear," we (hall find our duties happily reduced within the narrowed bounds, viz. of fav- ing the patient from immediate bleeding, and of laying the & ON PROCURING ADHESION. Wounded parts fo cleanly, fo neatly, and fo evenly in contact With each other that they may adhere. The reft we leave to na- ture. I fear that, from my announcing a rule of conduft fo fimple as this is, you will fuppofe that I mean to fpcak only of the (lighter, and more trivial wounds ; while I do really mean to includs, under this general view, the greateft and the fmalleft wounds ; and to eftablifh but One rule for all, from the amputa- tion of a limb, or the extirpation of a tumor, to the molt trivial cut of She cheek or hand. What is amputation but a wound ? The greateft wound,-*- elean and fair,—-made carefully by the hand ©f th« furgeon,—«■ uifpofed to heal in the eafieft way i And in this great wound, (which, a fortiori, includes the dodfrine of every leflli wound,) what is there to attend to, but the procuring of adhefion, or the Hopping of the flow of blood ? What were Hie defers of the old operations, but that the furgeon knew not how to procure this adhefion ? that he had no means by which he could (top the bleeding ? The hxmorrhagy was fatal to mod of thofe who needed to fuffer this operation ; and the few, who furvived, lin- gered through all the miferies of a nine months cure, tedious and imperfect, with conical, ulcerated, and tender (tumps.— \\ hat indeed is the chief perfedion of modern furgery, or the ex- cellency of our operations ? but that in bleedings from great veflels we truft nothing to compreffion, cauteries, or aftringenta, but tie our arteries firmly ; and that we talk no longer about mundifying, incarning, or cicatrizing of wounds ; that we nevor drefs the cut furfaces as diftind wounds, but put the fides ;n-r in the enthufiaftic paffionate tone, of one pleading for his t.v. -.ii-overy, we may know that tliis does not belong to him by t V- :■) . )ken which difcovcred to Solomon which of th? two har- ■ -■ '.he mother of the living child, " for behold one of the " v.r; ■' ;:'\J■■''■'■ nay» but kt it be neither thine nor mine, but di- ON PROCURING ADHESION. U each cut furface force themfelves, and it is thus perhaps by the generation of a new intermediate fubftance, that the continuity and entirenefs of the part is fo quickly reftored. If any one point fail to adhere, there the wound muft run into fuppuration ; becaufe at that point there is a feparation of parts, which, being equivalent to a lofs of fubftance, requires the generation of new flefli. When the oppofite furfaces confent and harmonize with each other, in their mode and period of adion, then they adhere ; and fo (kin adheres to fkin, or flefh to flefh. But if one of the oppofite parts enters inftantly into a lively adion, while another has only a languid adion, and enters into that adion (lowly, and at a long interval of time ; the adion of the one has expired, before that of the other has begun. Such parts therefore do not confpire and harmonize in their adion, nor can they unite with each other ; but they may live and thrive independent of each other : and perhaps it may happen in this way, that oppofite furfaces of (kin or mufcle, may feem to be adhering firmly to the parts be- neath them ; while, perhaps, they adhere to each other only, and merely cover die cartilage or bone, without having any dired connedion with thofe parts. The bone we fee, (as in an old am- putated limb,) lives and thrives, is not limited inks new forma- tion by the adhefion of furrounding parts, but grows out into a broad knob of callus or new bone. A griftle alfo, (as in an amputated or luxated joint,) retains its pure and lubricated form. There are, no doubt, accidents both of the conftitution and of the wound, which will prevent adhefion ; for, if the patient be of a bad habit of body ; if he be lying in a foul hofpital, in die midd ©f putrid fores, and breathing a contagious air ; if he be ill of a fever, or flux, or any general difeafe ; then the properties of the body. being lefs pcrfed, his wound will not adhere : or, if the wound be foul, made with a poifoned weapon, or left with foreign bodies flicking in it, or if blood be poured out into the cavity of die wound, (for blood in this cafe is but a foreign body,*) orif ~ It is not eafy for any or.j who is not an enthufiaft in the 16 ON PROCURING ADHESION. there be a wounded lymphatic, or wounded falivary dud, a wounded interline, or a bleeding artery or vein ; any of thefe caufes will prevent the immediate adhefion of the wound : or if it beabruifed or gun-fliot wound, there is a dedrudion of parts ; the loft parts muft be regenerated, and thofe parts which remain, muft enter into a new adion for generating new parts, and fo they eannot adhere. This adhefion, then* is a property of the parts of the Hving body, which is perfed only while their ftrudure is entire ; which operates only where the oppofite parts touch each other by the fulled contad, and fympadiife with each other in their period and degree of adion; It is interrupted if any foreign body be inter- pofed ; it is lefs perfed in every unhealthy condition of the fydem __but it is a property, of which we are now fo well affured, that we look for its good effeds in the greated as well as in the fmall* eft wounds ; and the union of a hare-lip after it has been cut and pinned, reprefents the perfedion of that cure which we attempt in every greater operation, and more confidendy, in every (mailer wound ; fucceeding fometimes as perfedly after an amputation of die thigh, as after the moft trivial wound of the cheek. This property of re-union in divided parts is proved, by every day's experience, to be fo perfed, riiat where we do fail, (which, no doubt, is fometimes owing to a bad habit of body,) we have much reafon to believe, it is owing to fome negligence on our part; fome extravafated blood, fome open artery, fome portion of detached bone left in the wound, or fome awkward piece of dreffing which lies betwixt the edges, which fhould adhere ; or moft frequently to the want of that perfed and abfolute contad, which is fo effential to die perfed.adhefion, that every part of the wound which does not touch fome oppofite furface, muft fuppu- rate before it can heal. This is my chief motive for putting d.nvn carefully, in fhort diftind rules, the feveral ways in which a wound may be put together, fo as to make it adhere. "dodrine of life in the blood," to acknowledge all the very ex- traordinary conclutic ^ which have been dedu^d from it. ON PROCURING ADHESION. 17 There is no wound in which we may not try with perfed fafe- ty to procure this adhefion : for nothing furely can be more kind- ly, when applied to a wounded furface, than the oppofite furface of the fame wound ; it has been but juft feparated from the oppofite furface ; it may immediately adhere to it; though it do not ad- here, no harm is done, (till the wound will fuppurate as kindly, as freely, as if it had been roughly dreffed with dry caddis, or fome vulnerary balfam, or acrid ointment : If only a part fuppurate, while one half perhaps adheres, then half our bufinefs is done : And, in fliort, this fimple way of immediately clofing a wound is both natural and fafe. 1. A fair longitudinal cut, in the (kin only, may be] brought together merely by a good (licking plafter ; or by a piece of com- mon black court-plafter in fmaller cuts ; or by a plafter of di- achylon in large cuts. The plafter fhould be ufed in fuperficial cuts of the face, hands, feet, &c. or even over the flefhy parts, if little deeper than the (kin ; and, in naked and bony parts, as in the hairy fcalp, or on the back of the hand, comprelfes, laid upon each fide of the cut, will keep its edges in clofe contad with each other ; and will fo fupport the (licking plafter, as to fave the necefllty of making a ditch with the needle, which is furely cruel wherever it is unneceffary.* I have never found it neceffa- ry to ufe hare-lip pins in any piece of (kin which lies folid upon a bone, as that of the face or fcalp, or the back of the hand. I have never ufed any thing but pladers merely, after little opera- tions upon the forehead, face, or cheek ; unlefs there was fome lofs of fubftance.f * Sutures make knotty fears, and therefore whenever (in the face efpecially) a plader will anfwer the purpofe, we fhould avoid them. f The older authors choofe to call this manner of applying pladers by die affeded and abfurd name of Sutura Sicca, or dry future. In applying fuch a plafter, we are careful firft to let the bleeding fubfide ;—then to make an affiftant put the lips of the wound neatly together ; then we apply one end of the (ticking plafter to die (kin on one fide of the wound, and let it dry and fix there, fo that we may pull by it ;—then we pull that edge by the plafter ;—then moiften dje remaining half of the plafter ;—then VOL. i. C 18 ON PROCURING ADHESION. 2. In fome loofcr parts of the fkin, especially when moved by ftxong mufcles, we either make a ditch of the needle, or we ufe rather what is called the twilled future, or hare-lip future, which is the largeft of all. Thus the lip, for example, is fo retraded by ;dl the mufcles of the cheeks, that when cut it gapes much, and requires to be very well fecured ; therefore after cutting the edg- es of a hare-lip, or after cutting out a cancer of the lip, we put the broad edges neatly together ; transfix both lips at points ex- adly oppofite to each other with- a large pin, which is called (from this particular operation J, the hare-lip pin ; we pafs two pins through the lip, one at the very edge, or vermilion part of the lip, and one in the middle of the cut, and then twift a thread about them in the form of a figure of 8. This is named the hare-lip future. This future may be ufed in any other fuperficfal wound of the fkin. It is lefs neceffary in the fcalp, and other firm parts which lie over the bone. It is more neceffary in the loofer, and efpec- ially in the more mufcular parts,, as in the lip, or perhaps in the cheek. In accidental wounds of the lip, in boys, I have ufed the common fewing needle, which paffes with very tolerable eafe. 3. In angular wounds of the (kin, a ditch of the needle will be ufeful, to keep up the corner to the angle which it belongs to ; and this, of courfe, fupports the fides, and keeps them in contad. Then we (hall feldom find it neceffary to make more than one ft itch, and that exadly in the place of the angle ; this ditch will fupport the angle, and the fticking plafters may be laid fo as to* fupport the fides. 4-. Long wounds, down to the flefhy parts, even, though they have no angle, will need ftitches ; if the cut be acrofs the line of lay it neatly down over the oppofite edge of the wound ;—then apply fucceflive plafters till we have croffed the whole line of the wound :—Then, if any one of the flips of plafter has loft its hold by the oozing out of the blood, we take it gently off, wipe the furface, and apply a new one neatly, until we have got the whole dean and fair, all the plafters fticking foundly ; and, laftly, We fay a comprefs over the whole, which we bind down a little with a circular roller, in order to prevent internal bleeding. ON PROCURING ADHESION. 19 a mufcle, the gaping will be greater ; if it run along the courfe of die mufcle, the gaping will be lefs ; but (till fuch as to require a ditch. A long flefhy wound will require ditches, even for that gaping which arifes merely from the length of the wound, inde- pendent of the contradion of the mufcular flefh ; and the ditches mud be multiplied, according to the length of the wound ; mak- ing, for each inch of the wound, one ditch of the needle.* Erom this interruption, thefe feparate ditches have been named the Interrupted Suture. The ditches counterad the general retrac- tion, they keep the feparated parts in contad ; but to keep the whole edge of the wound neat, one (lip of black plafter muft be laid in the interftice of each ftitch. Thefe plafters keep the whole wound even ; fupport the ftitches, fo as to leave lefs (training upon thofe feparate points ; and enable you to cut your ftitches early out for a reafon which I (hall prefently-explain to you.f * Perhaps, as a general rule, the following diredions from one of our oldeft and beft authors may be followed.—" If the wound " be of two fingers breadth, make one ftitch in the middle ; if " three fingers breadth, make two ftitches ; if four fingers breadth, " three ftitches ; and fo on, making a ftitch lefs than the wound " is in number of fingers : Sometimes in declining parts we make " our ftitches at a little more diftance."—Wifeman. ^ f The older furgeons were very proud of their futures, and dill prouder of the names they gave them. They called it a Con- tinued Suture, when they fewed the wound all along like a feam ; they called it the Glover's Suture, when they palled their needles alternately from the infide to die outfide of the wound ; they alfo ufed the Shoemaker's and die Taylor's Suture. They called it the Interrupted Suture, when they doled a long wound by inter- rupted ftitches ; and Twifted Suture, when they ufed pins as in hare-lip ; they called it the Quilled Suture when they ufed the quills ; the Gaftro-raphia, when they fewed a wound of the bel- ly ; and the Intro-raphia, when they fewed a wounded gut.— They had particular needles for fewing tendons ; they had the diftindions of Sutura Sicca, and Sutura Cruenta, the moid and dry futures ; i. e. the bloody futures in which they ufed the nee- dles, and the dry Sutures in which they ufed only plafters. But the moft abfurd and dangerous of all their futures, was what they chofe to call the Reftridive Suture, (or rather they gave the general name of reftridive future to all clofe futures,) intend- ing, by the clofenefs of their futures, not only to clofe the wound, but to bind it fo firm as to prevent the bleeding from any large veifel within the wound. Their reftridive futures were as abfurd 20 ON PROCURING ADHESPON. 5. If the wound be dill deeper among the mufcular flefh, the ftitches cannot go to the bottom of the wound ; the ftitches muft be fupported, and the bottom muft be prelfed together by com- prefTes, and the uniting bandage : This bandage is made by put- ing a double headed roller round the part, paffing one head of die roller through a flit in the oppofite fide of it, and drawing both at once. 6. If the wound be pretty deep among the mufcular flefh, fo that the feveral ftitches of the interrupted future would make, (if tied by the common knots,) an awkward and painful future, likely to excite inflammation ; we then convert the interrupted fu- ture into what is called,the Quilled Suture : which is made by fplit-. ting each end of the ligature, (after die ftitches are made,) into two threads ; then, laying a quill or bougie along each fide of die wound, we tie all the ligatures of one fide round one bougie ; then draw that bougie tight down, by pulling the ligatures from die other fide ; then tie the ligatures alfo on the other fide, round the oppofite bougie ; fo that die two bougies, like two large rolls, keep the fides of the wound neat and even. The prefiure is downwards towards the bottom of the wound, at leaft, it ex* tends as deep as the ligatures ; fo there is lefs need for help- ing diis future with compreffion ; but we may (till put our ftick- ing plafters in the interftice of each ftitch.* as die expedation of the firft inventors of the flap amputation were, who fewed their large flaps of (kin, not to procure a more fpeedy cure or a flefhy ftump, but to prevent the bleeding ; for which purpofe they bound down the flap upon the face of the (lump, and kept it there with buckles and belts, and all kind of machinery. * This is not exadly what was meant by the older furgecns when they ufed this quilled future : for they fuppofed that a deep mufcular wound could not fafely be brought together ; they wifhed to bring it togedier at the bottom, but were afraid to clofe it at the mouth left that (hould confine the matter. They ufed the quilled future with this intention, as beft contrived (<■•* clofing the bottom of the wound without ftraitening its mouth. ; for the thread goes down to the bottom of the wound, but the bougies are far from the mouth, die threads in tin'-, as in every ftitch of the furgical needle, being always brought throvrb '.v fkin'an inch diftant from the lips of the wound. ° ON PROCURING ADHESION. 21 1. But there is a degree of prudence in refraining from ditches in deep mufcular wounds ; for ditches, after all, can fupport only the edges of the wound, while it is the comprefs and the unit- ing bandage that mud fupport all below. Deep mufcular wounds, then, fhould be fecured chiefly by the comprefs and uniting bandage. Stitches fhould, in fuch wounds, be ufed with referve. Thofe who have ufed ditches the mod confidendy, have been forced, as fuddenly, to cut them out again.—A point which k well illuftrated by the cafe of a foldier, who, being wounded at the corps de garde with a fabre-cut acrofs the fhoulder, through the belly of the deltoid mufcle, his furgeon fewed the wound that night, with many deep ftitches ; thefe M. Pihrac was next morning obliged to cut, on account of convulfions of the arm, which ceafed the moment that thofe cruel ftitches were undone.* —-Such deep futures may be fairly enough compared with the crofs ftitch of Paraeus, which killed the patient ; fometimes by convulfions, fometimes by high inflammations, with a total gan- grene of the dump. 8. There is alfo a degree of prudence to be obferved in ufing ftitches in unhealthy patients, where we are almoft affured, that the parts cannot adhere ; or in foul hofpitals, where all kinds of wounds are apt to fall into a foul eryfipelatous inflammation, of the low and gangrenous kind. For ftitches muft always, by exciting high inflammation, do much harm, whenever they do not do immediate good. 9. Whether the wound be broad in the form of a flap, or long and deep, or a penetrating wound, there is much danger, left the- fides of fuch a wound be not kept in clofe contad ; in fuch wounds we lay long or flat compreffes along the trad of the wound, keeping them firm with a broad and firm rolled bandage, (what long ago diey called the Expulfive Bandage,) which both prevents colledions of matter, and brings the fides of the fore in- to contad. And every furgeon, knowing the intention, muft have ingenuity enough tQ fhape his compreffes long or flat, or round * Mem. de l'Academie de Chirurgerie. 22 ON PROCURING ADHESION. or fquare, according to die form of the wound, and to draw his bandage tighter juft as the occafion requires. 10. In deep mufcular cuts, where there is bleeding, and con- fiderable veffels are wounded, we firft apply the tourniquet, then tie the arteries ; dien undo the tourniquet to fee diat the arteries be really fecured ; then fcrew the tourniquet again, that not even an oozing of blood may interrupt our next operation, viz. the clofing of the wound ; then few the wound according to its nature, or its fize, leaving the 'ligatures of the arteries hang- ing from a corner of the wound ; and, though perhaps the whole will not adhere, yet much v.ill adhere ; we always have our chance of a total adhefion ; the ligature keeps a little part open for itfelf, with a little fuppuration round it, but attended with no pain ; and it comes eafily away the fourth or fifth day *. 11. Even though the bone be wounded or cut up, this ftill makes no change in our intentions, nor in the furgery of the wound ; for the bone alfo may adhere, and perhaps the re-union *' " The way," fays Wifeman, " to (top the bleeding, as it is " common in all wounds, is by bringing the lips of the wound " clofe together by future, and by applying fuch medicaments " to them as have a drying and agglutinative faculty."—Thefe notions our older writers got from the celebrated French furgeon, Guido de Cauliaco, who fays, " Sutura reftridiva fit, quando alias future non fieri poffunt " propter magnum fanguinis impetum." —And he adds, that this, after all, is not a future to be depended upon ; for, if but one ftitch burft, the whole gives way ;—" Suf- peda tamen eft, quia rupto uno pundo, cetera relaxantur." Guy de Chauliac had in his turn copied from the Arabians in moft points, and very exprefsly in this bufmefs of futures ; fo that we find this bufinefs of the reftridive futures to have begun with the Arabians, who knew die way of ufing needles in clofing wounds, but had not learnt to ufe the needle in tying arteries, otherwile than by fewing the wound juft fo much the clofer and tighter in proportion to the bleeding ; they direded the future to be made clofe and firm, like that future which the currier makes, when he mends breaches in the tanned (kin. This is the true hiftory of one of our futures, and the reafon of its two names, viz. Reftridive and Continued Suture ; and from this hiftory it may be underftood, that even the name mould be no longer heard. As for the other ufe and reafon which furgeons have afligned for retaining tliis future, viz. diat of fewing the cm mtcibne clof.-r, tiv.it (hall alio be difcufi'ed in explaining Wound* of the Belly. b ON PROCURING ADHESION. 23 proceeds thus : We put down the bone and cover it widi the (kin in clofe contad, and the (kin adheres ; the bone itfelf moft prob- ably does not, m the (trideft fenfe, adhere ; or at leaft, its adhe- fion is different in its period, and in its manner, from that of the (kin, and yet it is like it; for the outward wound is healed, the wounded bone throws out its mucus, that mucus becomes vafcu- lar, then bone is fecreted ; then a kind of callus is formed to heal the cut bone : and all this procefs going on within ! The bone feems to have adhered at the very time of the adhefion of its foft parts. But it is very particular that, in all fradures, great as well as fmall, and of courfe, in all wounds of the bones, the bone nev- er heals, till the outward wound is firft healed, fo as to reftore the continuity of the veffels, and enable them to begin the fecre- tion of new bone. However the theory (hall (land, it is comfort- able to be thus affured of the fad ; that, if a bone be wounded or cut, fo as to be turned up, or though a piece be cut away from a bone, if that piece (till preferve its connexion widi the foft parts en- tire, it may (till adhere, live, and be reftored. And the general wound may be made to adhere as firmly with a cut bone in it, as if it were a fimple cut. How otherwife could we make the furfaces of an amputated ftump adhere, it being die largeft wound, hav- ing in it the largeft cut bone ? 12. The laft diredion which I have to give you, relates to the approach of inflammation ; for I cannot allow myfelf to call it inflammation, when the part adheres ; diis indeed were no better than to call a cure a difeafe. The adhefive inflammation (as it is called inflammation) is not attended with fever, pain, fwelling, nor rednefs, unlefs in the moft trivial degree ; indeed that gende fwelling which indicates the fulnefs, and ftrong but healthy adion of the veffels, it muft have ; but the increafed adion of thofe veffels, in re-uniting the lips of a wound, (lands on the fame footing with the healthy adion of vef- fels, in forming or in fupporting any part of the fyftem. A bone is formed and completed by the adion, fulnefs, and turgefcence of thofe arteries which are deftined to form it ; a fpoiledboneis regenerated by an increafed adion and ful*sfs of thofe veffels 2+ ON PROCURING ADHESION. the callus, which re-unites a broken bone, is formed by a full, but flow and regular adion of thofe arteries, which extend from the ends of the bone, and meet each other ; and whenever veffels, ex- tending eidier from the ends of a broken bone, or from the edges of any wound in die foft parts, meet each other, the part is entire again ; diey form a perfed fyftem of circulation ; and thus from the very firft moment of adhefion the veffels begin a healthy ac- tion, unaccompanied with inflammation or pain ; and the part is once more entire, and found. If the veffels become thus entire, from the very moment of tiieir re-union, if neither pain nor iiii flammation come on, unlefs die procefs fail, and the veffels begin to part, how can diis be called a difeafe ? or, by what fophiftry can it be comprehended under die definition of an inflamed part i To fpeak thus appears to me, to give an incorred and unfavoura- ble view ; it is to defcribe the cure, by die very name of the only difeafe which can interrupt the cure. I muft therefore confider the part as going on in a found adion while it continues to ad- here, and (hall proceed in defcribing what is to be done if the wound fhould begin to feparate and open ; or in other terms, lhould begin to inflame. Adhefion prevents inflammation ; when the parts adhere, they enter into a healthy adion, they are entire, and they do not in- flame ; whenever any part is not in contad, and does not adhere, it muft inflame ; whenever one part is left thus feparate, its in- flammation may extend to the adhering part of the wound, and fo one detached point may endanger the whole. The ftitches are themfelves a caufe of inflammation, (which again is always the caufe of the opening and burfting of the wound) ; and fo the in- flammation around the pins or ftitches, endangers the whole. If the ftitches be too tight pulled, this bracing up of the ftitches in*. flames the wound ; and fometimes the timely undoing of the ftitches, prevents this opening of the wound ; if there be blood poured out under the wounded part of the (kin, it feparates the fkin from the parts below, which is exadly equivalent to thq fepai ation of the edges of the wound itfelf :—that alfo endanger* ON PROCURING ADHESION. 25 the whole. From all which you will conclude, that die moment you obferve pain, inflammation, and fwelling of the wound, a feparation or gaping of its lips, the ditches tenfe, and the points where the ditches pafs particularly inflamed, you ought to undo your bandages, draw out your pins, or cut your ditches, and take away every thing that is like ftridure upon the wound ; thefe pru- dent meafures may abate the rifmg inflammation, and prevent the total feparation of the fkin ; while you may dill endeavour to keep the wound tolerably clofe, by the more gentle means of diet- ing pladers. But fhould the inflammation rife dill higher, and fhould you perceive diat a total feparation and turning out of the wound is inevitable ; you mud throw all loofe, put a large foft poultice round the whole, and forfake, without hefitation, all hopes of pro- curing adhefion ; for fhould you, in this critical jundure, perfid in keeping the parts togedier with futures, die inflammation would, in the form of Eryfipelas, extend itfelf over the whole Hmb, attended with a fetid and bloody fuppuration, wading die fkin, with great lofs of fubftance. Therefore, throw all loofe, ap- ply your poultice, allow the wound to feparate right as it is, and to pafs (lowly into a foft and eafy ftate of fuppuration ; and then, a fecond time, try to bring the edges up to one anotiier, not by ftitches, but by adhefive (traps, or by a gentle bandage. When the wound has fallen into a full fuppuration, then the fuppuration, granulation, and all that follows, belong (as indeed adhefion alfo does), to nature alone ; over which we have no other power than diat of fupporting the adion of the parts, i. e. keeping the fyftem in good health : and when the fuppuration goes wrong, it is, in general, by taking the form of a profufe, thin, p-leety difcharge ; and diis profufe difcharge is to be fuppreffed, and the right fuppuration reftored by bark, wine, rich diet, and good air : and this is what is ufually meant by fupporting the fuppuration, or moderating the profufe difcharge. TOL. I. D DISCOURSE II. ON WOUNDED ARTERIES. KJF all the fudden accidents which demand the afliftance of the furgeon, no one requires fuch abfolute prcfence of mind, and fuch perfed knowledge of Anatomy, as the bleeding from any great" ar- tery. I cannot conceive how a man of real feeling can, in our profeffion, pafs one compofed or eafy hour, without knowing thoroughly the courfe and value of die great arterial trunks. Without this preparation, the furgeon lies continually expofed to accidents, which may, in a fingle moment, ruin his profeffional charader, and blight all his faireft profpeds of fuccefs. Without this knowledge of the blood-veffels, a modern praditioner is much in the condition of tiiofe who lived in times before the nee- dle was invented, when the furgeon durft not cut the moft trifling tumor, or did it widi fear and trembling ; when often an operation, apparently eafy, coll the patient his life. But with a due prep- aration, even the youngeft furgeon now knows how to fpeak in confultation, and how to perform his operations ; where to be afraid, and where to venture upon a bold and refolute thing. The greater operations are eafily done, while the crofs accidents of pradice, the wounds of arteries, the confultations about aaeu- rifms, and other confultations about organic difeafes, are the only proper tefts of the furgeon's (kill. Even the few diredions which I (hall be able to give in this fliort difcourfe, will bring this appeal to bear ftrongly upon your minds, and will vindicate any thing that I might choofe to fay, either in reproof of negligence, or in praife of diligence, in re- gard to this the moft important of all ftudies, the ftudy of the ON WOUNDED ARTERIES. 27 blood-veffels ! to which Haller and Petit, the greateft mafters in anatomy and in furgery, had devoted fo much of their labour. The chief queftions, in this interefting fubjed, are thefe : 1. What is the real importance of a Great Arterial Trunk in any limb ? and what is the true value of its leffer branches, of its inofculating arteries, of thofe intricate connedions, which, in accidents of the main trunk, enable the fmaller branches to fup- ply and nourifh the limb ? 2. What is the form which a wounded artery affumes ? how is it covered ? What parts form that bag which we call an Aneu- rism, and which, both from the danger of its burfting and our fear of gangrene, is confidered as a moft dangerous difeafe i How may the operation, in dais wound of a great artery, be moft fafely performed ? 3. Or fince, even by bleedings from the Smaller Arteries, our patient fometimes dies ; how fhould we manage thefe fmaller arteries ? The needle, the comprefs, the fponge, the ftyptic waters, are all of them ufed, rather, as it fhould feem, according to the fafh- ion of the day ; or to mere accident or caprice : But are there not certain accidents, or certain parts of the body in which each of thefe will be found more or lefs ferviceable, according to fixed and fteady rules I I believe thefe to be the chief queftions ; and if, in the courfe of thefe inftrudions, I fhould try to teach you your duty accord- ing to fettled rules, they muft be rules belonging radier to the general point of wounded arteries than to the furgery of particu- lar wounds ; whatever general rules I now venture to lay down, you muft learn, by your own prudence and good fenfe, to apply according to the accidents and circumftances of each individual cafe. OF THE ANATOMY OF THE GREAT ARTERIAL TRUNKS, AND OT THE TRUE VALUE OF THEIR INOSCULATING ARTERIES. In the managing of bleeding-veffels, the furgeon is not only vexed widi the difficulties of tying the bleeding-veffels, but Ids 2S ON WOUNDED ARTERIES. mind is difcompofed with fears and doubts about his fcccefs j and furgeons who are old in pradice, and ihould know where the dan- ger is, always put tiiis aphorifm at the head of their moft intereft- ing chapter : " When the brachial or femoral artery is wounded, though the patient fhould not perifh by the hremorchagy, the limb muft foon die for want of nourifhment*." And farther, to excite the fears of the young furgeon, he is told, " That in fuch. cafe, the progrefs towards putrefadHon will be very fwift." " A wound of diis kind, very generally requires amputation ;" and of courfe, not one precious moment is to be loft in delay. If tlus were the right and legitimate cor.clufion, my dircdiona about the bleeding from dangerous wound;, (hould eiv.1 with a few fimple di red ions about tying arteries with the needle, or in difficult cafes, thruftin^ down a piece of fponge into the wound ! But I am perfuaded, that it is our duty in all fuch cafe?, to tie up even the great arteries of the thigh or arm, clofe to that very point where they come out from the body, and I hope to let up an aphorifm, at die end of this difcourfe, tl^e very reverie of diat common rule with which it begins. This important queftion refts upon two points only ; the anato- mv, and the fads : and although we might, by tracing the arter- ries-of the thigh, fatisfy ourfelves that the inofculation-; are fuffi- cient, where its great artery is wounded, to fave the limb j yet we can be allured of this only by fads. The hiftory of this piece of ftudy, viz. the inofculations of the femoral artery, is indeed very curious ; for nodiing furely can be mere furprifing than to obferve furgeons, intevefted as they are in knowing fo great an artery thoroughly, difputing every day the queftion of its incfculations, nay, what is worfe than all, in the daily pradice of cutting off limbs, fearing left thofe very in- ofculations fhould not be deficient to fupport the limb ; content- ing themfelves with talking about it merely, not knowing, by ac» tual diffedion, whedier there be two great branches of the fede- ral artery running down the thigh, or o;i:• only. * Gooch, r.. 71. PLATE I. a. The ArterialliacaGwimuni? dJ/teArteriafrofiaidas Femwis. b. TI&ArtrrialiypoyortricabithePelvis. C.77teArteria Artiai&iritlixtenia,. C. The Ferrwral Artery. f^ataMoivVeiw/viuj/bythcArtery. PLA.TE H Arteries of the Thigh. (l.Thtcommoii. b".TIu-ffj/po CC,77n>'Glutaal> d.T7ieIsehiatic eTftePudic J^TT&TJiyrcut/ y.TheEplgcvtri& A. T/ieFruwml Army i. 77u GreatAvtrria/Profunda t. Its EjctiT/ial circumflex Arteiy 2. ft! IuteiTuUtiraunJkcAr/ery 3A.!>. Tlune of 'its Perfbml?Artrri& 1:1. TJie Popliteal Artery m.mr.7ti-.Uif Articular Artrruu n.o.p.rhg tltree- Arteries- oftlteLqy. ON WOUNDED ARTERIES. 29 The anatomy of the femoral artery is fimply this : The great artery, before it emerges from the belly, and while it (till retains the name of Iliac Artery, divides into two great branches ;—■ the Internal Iliac, or Hypogaftric Artery, which defcends into the pelvis ; and the External Iliac, or Femoral Artery, which goes downwards along the tiiigh. Of the Internal Iliac or Hypogaftric Artery, the chief branches go out from the pelvis, through the fciatic notch, or through the thyriod hole ; they efcape from the pelvis, go round among the glutaei mufcles, and play about the joint of the hip, holding large communications with the uppermoft arteries of the thigh. The External Iliac or Femoral Artery, having gone down from the belly, and emerged from beneath the crural arch, de-i fcends into the thigh. Its firft bufmefs is to furnifh die diick mufcles and flefh of the thigh itfelf; about four fingers breadth, therefore, below the abdomen, it forks into two great arteries, equal in fize ; one deftined for the leg and one appropriated to the thigh. That which belongs to the thigh, plunges immedi-. ately into the thick flefli of the thigh, fending branches upwards towards the hip joint, and downwards towards the knee ; from its going thus deep it is named the Profunda Femoris ; from its fpreading itfelf among the mufcles, it was known among the older anatomifts under the name of the Muscular Artery of the Thigh. The main trunk of the artery, having given off diis pro-. funda, lies fuperficially along the thigh ; gives none but the mod trifling branches to the mufcles of the thigh ; goes down to the leg unexhaufted ; and its chief "peculiarity is, that having de« fcended into the ham, it gives off branches of the fize of a crow- quill, three in number, which play round the knee-joint, and are named from this circumftance, the Articular Arteries of the Knee. Here, then, the firft thing that ftrikes our eye is that this arte- ry, lying fo much nearer the furface, and going dow awards to- wards the bcr, fhould be named, no: Femoral, but Crural 30 ON WOUNDED ARTERIES. Artery ; while the profunda or deeper artery, fince it plunge* amon^ the mufcles tonourifti them, is the right and proper artery of the thigh. The next tiling to be obferved is diis, that die artei ia profunda, being as big as the femoral artery, fupplying the whole flefh of the thigh, running upwards towards die hip-joint, and down- wards towards the knee, muft have large inofculations ; and, if it can draw blood enough from above, will eafily tranfmit it to the lower parts : In fliort, that fo great a trunk as this muft be quite competent to the nourifliing of the thigh. But this conclufion is of too much importance, to be allowed to float thus loofe and unfettled in the furgeon's mind. It is not enough, diat he tiiinks and believes that the artery will anfwer this great purpofe ; nor that he hopes to fave the limb ; that at leaft he may try :—He muft not only think himfelf entitled to tie die artery without blame, but he muft be able to do fo confi- dently and boldly, and with great hopes of fuccefs. To acquire this (late of mind, he muft not linger in this kind of hefitation ; he (hould fee and examine the precife arteries from which he is to exped a cure. And die neceffity of fuch an examination appears more ftrongly, when we fee furgeons of the greateft experience, direding that every limb, wounded in the great artery, be cut off*. When we examine the branches of the Profunda, we find the Profunda lying a great inofculating trunk, betwixt the arteries of die pelvis and the arteries of the knee ; its firft branches turning * That thefe flight defcriptions of the arteries, and the argu- ments which proceed upon them, might be intelligible, I defired my pupil Mr. Mochler to cut up the fore part of the thigh, and (how the place where the profunda goes off; and next, to be at fome pains in diffeding out the whole line of the artery, and lay- ing it out upon a board ; from thefe two fteps of the operation, I have drawn the two plates, but (till they are to be confidered only as hafty (ketches ; fufficient for illuftrating this point, but net abfolutely corred. The one reprefenting, in the form of a drawing, the place of the thigh at which the artery forks ; the other reprefenting, ia the form of a plan, the gen ral tendency of the inofculations. ON WOUNDED ARTERIES. 31 up to meet the arteries of the pelvis ; its lower branches turning downwards to meet thofe of the knee ; fo that although the prop- er office of this artery is to nourifh the thigh, one accidental, but yet important office of it is, to inofculate with other arteries. Thus, by thefe conjoined offices, the economy of the limb is per- fed ; the limb is nouriflied during health ; and it is fupported by new circles of blood, when any accident touches the great trunk. The anatomy of the Profunda may now be cleared in two fhort fentences :----Firft, The two uppermoft branches of the Profun- da go off from the very root of the artery, almoft touching the great Femoral Artery ; they are very large ; they turn quick andfuddenly round the hip-joint ; they are named the Circum- flex Arteries of the hip-joint; and both thefe arteries inofcu- late upwards with the arteries of the haunch, which come from within the pelvis :-----Secondly, The Profunda has ufually three great branches running downwards, among the mufcles of the thigh ; titey go tiirough among the mufcles, and of courfe perfo- rate' from the fore to the back parts of the thigh ; thefe again are called the Peutorating Arteries : they inofculate downwardi with the articular arteries of the knee.---—Thus, in this flight (ketch is chalked out the propofition, which I mean to eftabliflt more fully, viz. That the profunda lies as a great inofculating trunk betwixt the arteries furrounding the hip joint, and the ar- ticular arteries of the knee ; that the Femoral Artery being hurt in the middle of the thigh, the profunda will, through its lower branches, nourifli the leg ; and that the External Iliac Artery be- ing wounded even at the groin, the arteries within the pelvis will prefs dicir blood upon die upper branches of the Profunda, fo that in like manner thofe upper branches of the Profunda fhall nourifli the'thigh. It is ftrange, I fay, that furgeons fhould have continued merely talking about this artery, or making experiments upon animals, more idle than even the mere conjedure and common report. The great Vefalius fcarcely knew the Profunda ; we fee it indeed in his plate, but we fee it only becaufe we know it, for though it !* marked (pfi. chi.) and though it is fccn inofculating widi the 32 CN" BOUNDED ARTERIES. arteries of the peK is, it is neither drawn truly nor well explained. But dill Vefalius obferves a very large anaftomofes witli die diy- riod art-vy, marked (omega). Vid. " Integra totbis mugnK arterisr delineatio."—Yet Vefalius's draw:;-._c:,or plan radier, is mucli wc-ri"- than that of Euftachius ; for in Luftachius's 15th Table, though we find the Profunda marked, it is not characterized widi any of thofe inofculations, which give it its chief importance in the eye of the furgeon: nor is it defcribed at all even in the explanations of the careful Albinus, who fhculd have put down T. figure 15, as the great " Arteria and Vena Profunda femoris," going down togedier into die flefli of the thigh. In Verhein, again, tins arte- ry is reprefented ; it has its true proportions to the great Arterial Trunk, but it is reprefented as one long and fimple branch, not having that importance, nor diofe wide inofcaiarirns, which con- ftitute its chief charader.-----Next comes Heifter, who blames all former authors, Verhein excepted, for having forgotten this im- portant branch, which, after all, fays Heifter, " is net fo very rare *." But it may indeed be faid, that all authors knew it, while Heifter was ignorant of it, a paradox which is eafily prov- ed ; for Vefalius, Euftachius, Verhein, Cowpcr, all marked it ve- ry diftindly, fome with more, and fome with lefs accuracy ; yet, as their drawings were intended as plans of the arterial fyftem, it is implied of courfe, fince they did draw it at all, diat tiiey un- derftood it to be a regular and conftant artery ; while Heifter knew it only as an accidental artery. Fielder began a miftake, * " Huic tanto magis miror, quod multi mngni anatomici nul- lum prorfus mentionem facerint: cum tamen non lit adeo rarus," p. 1-1-2. " Fere omnes anatomici, Verheyneo execptn, unicum tantum truncum et arteria: crura'fs et brachialis delincarur.t, ut videre eft in Euftacbii, Velalii, imo et in reception bus prxftantif- fimis anatomicis, Corp.io fcilicet," p. 149. Let any man, who knows what the Profunda fhould be, look to Cov.per's third Ta- ble in his Appendix to Lidloo, and he will ':h re raid the draw- ing of the Profundi, marked 70, nearly perfed, at lead as good and as didind as any other artery in his great plan of the aorta, and more corred than Ycrheir.'s. This n uch is allowable in fa- vour of our great Englifh iVrgcon, who ha . hern '.-rough accufed. ^ id. Gulielmus Cowper, citatus cjiam tribunate Nobihff. Am- pins', Societatis Eritaiip. ii.egr.2?. ON WOUNDED ARTERIES. S3 ■which did not end with himfelf ; and which muft have produced much confufion and apprehenfion in the furgeon's mind ; for having cured a fhoemaker, who, in dropping his paring knife, had (truck his knees together to catch it, and wounded the Femoral Artery, Heifter explains his opinion of the cafe, in the following terms : " If there be only one arterial trunk in this limb, as often happens, neither the comprefs nor ligature, nor any thing but am- putation, can fave the patient's life. The limb muft fall into ab- folute gangrene *." And fo his confultation proceeds in thefe terms.-----Firft, To try what can be done by a comprefs and bandage ; as if he had believed it poffible to heal the artery, whereas, compreftion, whenever it fuppreffes bleeding, muft do fo by obliterating the cavity of the wounded artery. Next, He advifes, if the comprefs do not fuffice, then to open up the wound, and tie the artery ; and, as if the tying of the artery obliterated die trunk more fairly than the comprefs ; he adds, " But if, having tied the artery, there (hould chance to be but one great trunk ;" " Imo, fi forte non nifi unicus arterise truncus adeffet," the leg muft be cut off; otherwife the leg will mortify, and the patient muft die. And Heifter not only explains himfelf thus upon an occafion, in which he was particularly interefted to underftand the Femoral Artery dioroughly ; but he adds to his pradical obfervation, and to his undigefted criticifms of Vefalius, Euftachius, and Cowper, '| hiftory of the Femoral Artery, worfe in all refpeds than that of any anatomift who had gone before him ; for he fays :-----« The Crural or Femoral Artery moft commonly defcends through the whole thigh, quite to the knee, in one fingle trunk, giving only very trifling branches to the great mufcles of the thigh to nourifli * Imo, fi forte non nifi unicus arteriae cruralis truncus hoc in femore adeffet; ficut faepe obfervari folet, fubinde ne ligatura qui- dem arteriae lsefse ad fanandum hoc malum fufficeret, quia tunc partes infra ligaturam polkas, ob fanguinis arteriofi hac ipfa fub- latum influxum fphacelo conipi folent, ita ut seger tunc fine ablato crure fummoque vitse difcrimine fervari non pollit. VOL. I. .'U ON WOUNDED ARTERIES. them," p. 141.—" But neverdielefs it does fometimes divide in die upper part of the thigh into two rweat arteries *." It is from notions like thefe that Heifter allows himfelf to fay, "Ifindiis cafe, (as often happens), there fhould be one great trunk only ;" when in fad, it were as difficult to find a thigh without a Profundi:, as without a Femoral Artery. But this miftake of Heifter did not end with himfelf : there is another furgeon of the prefent dav, who is guilty of calling this a lufus naturae, and of comparing it, like Heifter, with die high forking of the Humeral Artery.—Mr. Gooch miftakes this Pro- funda, calls it an accidental branch, a lufus naturae, an accident fimilar to the high forking of die Humeral Artery ; he does not indeed clench it with Ileifter's dired affirmation, " Scilicet faepe obfervari folet ;" but he writes a paper in the Philofophical tranf- adions, to inform the world of this interefting difcovery ; that he had feen three times a double artery in the thigh. The terms in which Mr. Gooch defcribes this difcovery, which he made while performing an amputation, and which he thought might turn out fo interefting in confultations about ;iraurifms of the thigh, are thefe : " In this amputation we obfcived a divifion of the Femoral Ar- tery into two trunks of equal fize running parallel. And fo near together as that we could conveniently include them in one liga- ture with the needle, avoiding the nerve, after raifing diem up with the diffeding forceps by a fniall portion of the conneding cellular membrane ; and here we found no occafion to take up a- ny other veffel." Philof. Tranf. An. 1775.—His amputation was particular only in this, that he had cut the thigh higher than uiud.—" The two great trunks lying parallel, and equal in fize to each odier," were the Femoral Artery and the Profunda, and where he tied, in one great ligature, both the Femoral Artery and * " Defcendit arteria cruralis feu femoralis unico tantum plerum- " que trance, per femur totum ufque infra genu, et utplui imurn " tantum in'noresramulos ad mufculos vicinos prcegrandes nutri- " endos fpargit." p. 111. Interea tamen fubinde in fi'prcma lemons parte, in duos mag- nos epi.ui trances fe dividit. p. 142. ON WOUNDED ARTERIES. 35 the Profunda, there was no great wonder that he found no ether bleeding arteries. Thefe are the only peculiarities that I can fee in this amputation, and I dare fay, his other amputations were very like this. When fuch an author proceeds, in the next part of his paper, to retail to us his experiments made (with the help of a famous Farrier) upon horfes and dogs, it is very allowable to fay, that fuch experiments were more idle than even the mere conjed- ure and common report. And furely, when furgeons, three years ago,* could venture to tie the Femoral Artery fupported by no better hopes than this ; we, knowing the Profunda, and all its connedions with other veffels as we do now, fhould be very bold in tying the artery very freely, not only in the thigh, but even in the groin. But the proof of this mud be wrought up to a greater degree of certainty, for it reds upon two points, the reafoning from anat- omy, and the final authority of fads ; and however drong our perfuafion might be, that the patient would recover, though the main artery of the thigh were tied ; yet, until we abfolutely fee one patient at lead recover from fuch an accident, our opinion is dill little removed from that vulgar notion which is implied in fuch expreffions as thefe ; " We refolved to try whether the limb might not be nourifhed by the inofculating arteries." This hefi- tating, timorous language is ufed even at this day, when we have the mod certain proofs of this very intereding fad ; for it has * The celebrated Profeffor Murray fays, " I never could find diis fame double artery in the thigh, which Gooch pretends to have found three times, and believes to occur very often." " Nee un- quam mihi arteriam femoralem fuperficialeni duplicam videre lic- uit, qualem celeber Gooch fe ter obfervaffe contendit," Szc. p. 44. No wonder that Murray never found any fuch thing, for Murray knew what the Profunda was, and perhaps was not fo well ac- quainted with the Englilh language, as to underftand that Mr. Gooch was calling the arteria profunda, alufus naturae, a double Fe- moral Artery, &c. and was looking out for it in horfes and dogs. That Gooch did not know the Profunda, is plain from this, that he never once mentions it in his Surgery, nor in his Royal Sociey paper. Mr Gooch's opinion, and indeed his experiments, are re- peated in that edition of his Surgery, which was publifhed in 1792. 36 ON WOUNDED ARTERIES. been tried, and it has fucceeded alfo, to a degree which our na£.. oning from anatomy could hardly have led us to expcd. The operation for aneurifm of the ham, or aneurifm in the middle of the thigh, never fails from want of a free circulation ; though, no doubt, it often does fail from another caufe, for fo great an artery is not eafily commanded ; it is not compreffion nor even ligature, thsf will always do ; and this great artery often burfts out. Many patients have died fuddenly in the night, many alfo have died of fucceffive bleedings, which the furgeon could neither prevent nor fupprefs ; while death from gangrene has been extremely rare. I think I am fafe in faying that, in all cafes where our ligatures can command the artery, our patient is fafe ; which is tantamount to faying that, wherever we can force the blood towards the in- ofculating arteries, they enlarge : and operations for popliteal and femoral aneurifms, for aneurifms in the ham and thigh, have fucceeded fo often, both in recent accidents, and in old difeafes, that on this point we need have no fear ; I need not labour to prove to you a thing fo generally known. But it is of import- ance towards giving you confidence in all accidents and difiicul-. ties, that I explain to you how poffible it is to tie the artery in the groin, and fave the limb ; an argument which I enter upon the more willingly, as it includes, a fortiori, the dodrine of all lower wounds. When we obferve the free inofculations of the Profunda, with the articular arteries of the knee, we are encouraged to tie the Femoral Artery any where below the root of the Profunda ; and feeing that it is the Profunda which faves the limb, we tie the artery in the thigh, as freely as in the ham. We are encouraged by thefe flender inofculations round the knee joint, to tie the artery any where below die giving off of the Profunda, and when we compare widi thefe the high inofculations formed by the uppci branches of the fame Profunda, afcending and encircling the moie flefhy joint of the hip, we need not want courage al!>, to tie the ar- tery in the groin. Thefe upper inofculations, belong to an order of arteries large in proportion to the limb they nourifli: i ift re the ON WOUNDED. ARTERIES. 3*F ^rteries of the knee are delicate, in proportion to the fmallnefs of the leg ; and I am perfuaded, diat in good time, the accidents of pradice, and die boldnefs of the furgeon, will make our apprehen- fions about fuccefs in this cafe appear as childifh as the notions of the older furgeons, who had their amputation inftruments in good order, whenever they ventured to operate for aneurifm in the arm. Guattani was called to attend a young man, who had an aneu- rifm of die Iliac Artery, at fird fmall and limited to the groin, lying clofe up under the ligament of the thigh, feeming indeed to come from within the pelvis. But foon after Guattani had begun to apply his compreffes, (viz. in one month after,) and while the tumor feemed yielding to the comprefllon, it burlt fuddenly during {he night, with intenfe pain, fo that they were obliged inftantly to cut the bandages and give him relief ; then immediately the blood pufhing forwards among the cellular fubftance which fur«* rounds the pfoas mufcle, produced fo fudden an enlargement of the tumor, that Guattani, at next vifit, faw that all hopes of a cure were now at an end. In a few days more the tumor filled the whole of the hypochondrium, came plainly from within the pel- vis, and going along die groin, extended quite to the middle of the thigh. With this prodigious tumor beating ftrongly, and fill-, ing the thigh and haunch botii within and without, the man lin- gered for three or four weeks, and then died. " This cafe," fays Guattani,'- excited in me a great defire of inveftigating the whole courfe of the Femoral Artery ;" and in this enquiry, we find Guattani difcovering and proving more than he himfelf knew of, and much more dian the celebrated Murray will allow ; for Mur- ray fays, *« although Guattani was able to injed tepid water, tinged with yellow from the arteries of the pelvis, round into the arteries of the leg and thigh ; yet I fufped ftrongly that the groffer fluid, the blood, would pafs through the fame channels more difficultly, nay fo fparingly as not to nourifli the limb.* * " Licet enim ex Cel. Guattani experimentis conftet, aquam colore flaveo tindam et calefadam, fi arte in Arteriam Iliacam internam pellitur, arterias femoris larga copia penetrate, hifque 38 ON WOUNDED ARTERIES. But the fad, as it dands in Guattani, is this : Firft, He found by diffeding, in going carefully along the courfe of the femoral artery, that it was draitened from the groin down to the ham, where it was almod obliterated. " I thought, indeed, fays Guat- tani, that the Popliteal Artery was abfolutely obliterated, till by examining more carefully, I found that it could jud receive one of Anell's wires*." Now, fince Anell's wire is no bigger than a brittle, may we not fay that it was obliterated, that no blood paff- ed that way, that the limb had lived from the time of the burft- ing of the aneurifm, and during the gradual obliteration of its great artery, only by the inofculations along the back part of the thigh. Secondly, Guattani found, by the injedion of tepid water tinged yellow, that the blood had gone round by the branches of the Gluteal, Sciatic, and Pudic Arteries ; that, in fliort, it had gone round by the arteries from within the pelvis furrounding the hip, into the Tibial and Fibular Arteries below the ham. This is the moft fingular fad in the whole pathology of aneu- rifms ; for the blood which had nourifhed this limb had moved not only through the common inofculations round the hip-joint, but it had gone by the moft circuitous courfe, and to finifh its cir- cle, die blood muft have paffed through three feries of inofculat- ing veffels : Thus, the blood came not from the upper inofcula- tions of the Profunda into the trunk of the Profunda, and fo round the haunch by a (hort circle, into the great artery of the thigh, but muft have proceeded firft through the Gluteal and other Arteries of the Pelvis into the Articular Arteries of the hip ; then from the Articular Arteries of the hip into the Pro- funda, which is their parent trunk ; then it had gone down from the main trunk of the Profunda along thofe lower branches of abfcifli; ex minoribu. ejusfurculis abunde dofluere ; vereor tamen ne liquor crafllor qualis fanguis eft, multo difficilius eafdem perva- detvias, vel latices hujus vitalis portio aegrius trunfmiifa iwfuffi- ci.HS prebeat membri nutrimea." - * Sed re accu^atias infpeda, cognovi, tun'um in arlcria cavi rrlidum, effe ut Auellianum fpecillum poffet ;dndttere, qu-mivu; id r.^re fieret, &c. ON WOUNDED ARTERIES. 39 the Profunda, which are named its perforating arteries ; then from thefe the lower extremities of the Profunda it had paffed into the Articular Arteries of the knee, and by this lad inofcu- lation the blood once more had accefs to the trunk, viz. to the Popliteal Artery, where it divides into arteries for the leg. In fliort, it had happened in this cafe, as mud always happen, that the fmaller arteries grew dronger in both fundions at once, i. e. that the arteries turning round the hip were both fo much in- creafed in fize as to be able to carry a fufficient quantity of blood for nourifhing the thigh ; and their inofculating extremities alfo were enlarged in like proportion, fo as to tranfmit a fufficient quantity of blood for nourifhing the leg. The blood had paffed all along by thefe veffels which lie upon the back part of the Uiigh, leaving the Proper Femoral Artery dry of blood, and almoft clefed all die way from the groin, or rather from within the pelvis, down to the ham ; and I call upon Murray, with all his knowledge of the blood-veffels, (and no other man knows fo much about them as he does,) to point out any other paffage for that blood by which the limb continued to live. Anodier thing alfo deferves notice in this very interefting cafe, viz. that in their natural and undilated condition, the arteries round the haunch will not tranfmit the blood thus freely, even through one inofculation, much lefs through three fucceeding fe- ries of inofculating arteries ; and this circulation of die yellow water ufed by Guattani was thus free, merely on account of the gradual dilatation of the arteries in this difordered limb : For Gu- attani after this made an experiment upon the arteries of a found limb,* which explains to us how vaft die difference is betwixt the * Guattani does not mark the difference betwixt his experi- ment and his diffedion ; but his experiment was this : Firft, He placed his injeding tube above die Hypogaftric Artery, then he tied the Femoral Artery in die groin, and threw in his jnjedion, and it went round eafily into the Profunda Femoris ; which he explains by faying. " More fatis copiofe perfluxit." Next, He made another ligature upon die great artery in the ham, by imi- tating the obftrudion in this cafe of aneurifm, and he forced the hije-dion round in a ilvond iacfculating circle, viz. by the Ar- 40 ON WOUNDED ARTERIES. condition of arteries in an aneurifmal limb, and in :i found one.* Thus, the concha fions are diefe : I. That a fine injedion of coloured water, which will not paf* through the veflels of a fonnd limb, will circulate freely in the di- lated veffels of an aaeurifmal limb. 2. That not diis yellow water only, which Murray fpeaks fo Ughtiy of, but alfo the circulating blood, will pafs freely all the tray from the arteries within the pelvis to the artery in the ham j for this leg lived a month after the burfli r.g of the aneurifm, dur- ing which time the inofculating arteries continued enlarging and the great trunk contrading, till at kill the trunk was entirely ob- literated, and the inofculatiftg branches carried all the circulating blood. 3. That we are fafe not only in tying the artery in the thigh, but in tying it in the groin ; for in this cafe the blood came down by the back part of the limb. The arteries were obliterated upon the fore part of the limb ; yet it was not by gangrene of the Kmb that this patient died. It is not from my being limited to this fingle cafe, that I here prefs the point fo drongly ; I do this only to make it clear, while I have many other cafes in referve, which will perhaps prove the point as fairly. For example, when the celebrated Heifter laid a large comprefs upon the wound of the Femoral Artery ; and laid a fuccefllon of firm compreffes all along the courfe of the artery From the wounded part, quite up to the .groin ;f when he bound ticular Arteries of the knee, where of courfe the injedion was a little retarded, but ftill flowed out indeeed " liquorcm fane effluere confpexi," but infinitely lefs eafily, "fed lon^e lentius, parci- tifque." * My friend, Mr. Harknefs, cut off die thigh of a very big and ftrong man, on account of an aneurifm of the Femoral Ar- tery complicated with a fradure of the thigh-bone ; and although die blood had been interrupted onlv for thre<; weeks, he needed to take up twelve great arteries with the needle, and dill left the ftump bleeding at every point. f This was Heifter's contrivance for fuperefling the bleeding ia the cafe of die Shoemaker. ON WOUNDED ARTERIES. 44 thefe compreffes by the tighteft roller;*, drawn with all his ftrengdi; when he continued a compreffion which fuppreffed the bleeding from a wounded Femoral Artery for three weeks ; what did he do ? Is it to be fuppofed that thefe large compreffes merely fup- preffed the flronger adion of the artery, and kept its wounded lips in contad, till they healed ? Surely not; no one who has ever feen die lips of a wounded artery will exped fuch a cure : for the lips of a wounded artery are fo callous, and fo turned away from each other, that the wound of an artery, (truck even with a keen lancet, refembles (as the celebrated Monro, the fa- tiier, obferves, in defcribing an aneurifm of the arm,) rather a round hole ftruck with a punch. When Heifter applied his com- prefs and bandages fo as to fupprefs the bleeding, furely he com- preffed the artery ! When he compreffed the artery, furely he put its fides together ! When he obliterated thus the canal of the artery, the force of the blood fell upon the inofculating branches, and they would foon enlarge to fuch a degree, as to carry freely all die circulating blood. The circulating blood would no longer feek the main trunk of the artery, which therefore would contrad by being empty ; and its walls would adhere at that point where it was particularly compreffed : Heifter's cure by compreffion, would refemble, in all effential points, the cure by ligature ; in this only it would differ, that, befides being tedious, painful, un- certain, die cure by compreffion would obliterate both trunk and branch ; for fince the Profunda lies diredly behind the Femoral Artery betwixt the comprefs and the bone, againd which the ar- tery is compreffed, the compreffes would obliterate the Profunda, as well as the Femoral Artery, leaving nothing to fupport the limb, but that feries of inofculating arteries running along the back part of the thigh ; the value of which I have jud explained. In fliort, die Profunda lying fo diredly behind die Femoral Ar- tery, as to be taken up by Gooch in the fame ligature, may very reafonably be fuppofed to be affeded by the fame broad comprefs which covers the Femoral Artery. But there is alfo another phenomenon in difeafes of the Femo- r.d Arteries, which is very interefting, and which proves tltis point K)L I. F 42 ON WOUNDED ARTERIES. completely ; for, independently of operations by ligature or com- preffion, we have evidence in the natural cures, (as fometimes, nature hcrfelf performs the cure,) that the Profunda may be cut off together with the Femoral Artery, and yet the limb be pre- ferved. We fee, for example, a great aneurifmal tumor of the groin, we fee it increafing rapidly till the fkin tiireatens to fall into gangrene, and we aiU for fome days waiting in great anxiety and fear for that lad change, in which the fkin is to burfb, and the patient to expire with one fudden gufh of blood. Then die fever begins, the beating of the tumor ceafes, the fkin becomes livid, the whole limb is cold and widiout pulfe, every thing fcems to foretel an indant gangrene. But thefe, which are fo often the mortal figns of gangrene in the whole limb, are fometimes rather the prefages of a happy cure ; for either the clotted blood has foaccumulated, or in the natural'aneurifm, (viz. that proceeding from a dllata^ tion only of the artery,) the leofer coagula have fo fallen down from the walls of the aneurifmal bag into the main channel of the artery, as to dop the circulation from the groin downwards, in both the arteries of the thigh. Such obdrudions turn afide the current of the circulation, new channels are found for the blood, and, as it begins to flow more freely in thefe, the pulfe, the heat, the feeling of the limb, are all gradually redored ; they are per- fed in a few days, the patient awakens from die low delirium which accompanied the fird alarming figns, and not only his life is fafe, but, in a little while, his limb alfo is perfedly reltori ed.* Nay, a thing dill more Angular has happened, very nearly the fame procefs has performed the cure; with this variety, drat, during this natural cure, the tumor burding, has laid the limb fo open, that the furgeon has (if we may be allowed the expref- fion) been able to look into the limb, and fee how the veffels were affeded from the groin quite down to the ham. "A young * Cafes, of this nature, may be feen in the London Medical Journal by Mr. Joart Simmons, in the Medical and Surgical Tranfadions, and in other colledions. ON WOUNDED ARTERIES. 43 man having an aneurifm of about three weeks old in the groin, it grew in a fliort time to fuch a fize, that, after giving him excru- ciating pain, it burd inwardly, upon which the tumor flattened and extended downwards towards the hip ; with relief of pain and increafe of the oedema, which had for fome time affeded the leg. The leg, now cold and motionlcfs, was in danger of prefent gangrene ; but, in forty eight hours, the limb feemed to recover, the oedema leffened, the tumor burft irregularly about the groin, and difcharged its contents, partly a thin fanies, partly clotted blood. In «ight days, the whole tumor or, in other words, the whole thigh, fell into fuch gangrenous fuppuration, that it lay en- tirely open. The Sartorius, Pedinalis, Triceps, and all the muf- cles of the thigh were naked, and as if diffeded. In the bottom of this great triangular hollow, lay the infertion of the Pfoas Magnus alfo bare.* This gangrene of'courfe penetrated quite to the Inner Trochanter of the thigh bone, and laid open all that part of the thigh, in which the nerves and great veffels lie. This triangular cavity extended from the ligament of the thigh to that part of the triceps, at which the vein and artery pafs from the fore to the back part of the tiiigh, and in all that fpace, nothing was to be feen but the mufcles clean feparated, or diffeded as it were, by the gangrene. The great nerve, vein, and artery were en- tirely gone ; nay farther, the furgeon, the celebrated Petro Javi- na, was obliged to pufh his finger up under the ligament of the thigh, and to make an incifion there, that the matter from within ihc pelvis might come down more freely. It is not wonderful that the patient, lying in this moft miferable condition, died (lowly, wafted by his difeafe. There needs no experiment of injeding yellow water, to explain 10 us what had happened in this cafe. That the patient lived one * Hinc fadum eft, mufculis, Pedineo, Iliaco, atque Pfoas parte infera, fartorio, anteriori, denique tricipitis portionc, denudatis, et a putredine vindicatis, triangularem alveum, poftremis hifce ge- minis praecipue interclufum, ab inguinis ligamento ad fedem ufque, qua decuffatim implicantur, vans, nervilque cruralibus in eodem alveo excurrentibus, a putredine penitus deftrudis, expoliatum rubentemque apparuiife.—Guattani. 4h ON WOUNDED ARTERIES. month after the burfting of his aneurifm, the thigh lying open all the while, is fufficient proof that the limb was nouriftied ; and fuch a limb having lived, fatisfies us alfo, that the thigh may Enr- vive after the Femoral Artery is interrupted, after the Profunda alfo is cut off along with the Femoral Artery, and alfo after the common Iliac Artery isburft abfolutely within die pelvis. But, in juftice to this interefting fubjed, I muft lay before you one eafe more, which I am induced to do for two reafons ; in the firft place, the cafe is perfed, the patient having lived ;—and, in the next place, I have but to prefent the cafe to you in a fair tnmfla- tion, the chief accidents of it are already explained ; and ii you reafon for yourfelves,as I have argued on the other cafes, you w/ll find it clearly proved, diat, in the following cafes cured by tire celebrated Guattani, not only the Profunda was comprclfed along with the Femoral Aitery, but that the External Iliac was fo com- preffed alfo at the paffage from under Poupart's ligament, that every artery on the fore part of the thigh was (lopped. " A goldfhaith, of the name of Mnellus, fifty-five years of .'ge, confulted Guattani about opening a tumor in the groin, which all the odier furgeons declared had come to a perfed fuppura- tion. Morellus had, during the whole winter, complained cf a fettled pain in the right groin, fometimes milder, fometimes very violent, but never abfent, accompanied during t! .' winter only with a degree oflamenefs, but now in the fpring it had begun to fwell. When this unlucky Morellus, going along with other';, on the 4th of June, to St. Peter's, to fee the pompous ceremony of the confecration of the hoft, was feized fuddenly with fuch dread- ful pain, that he was obliged to go home, and partly from liar, pardy from the violence of the pain, went to bed and lay for three months under the care cf his phyficians, their prefcriptions all ir.- effedual, his difeafe increaiing daily ; and the unfortunate Morel- lus, now almod hedic, was entirely confined t-.; bed. There w.:< great fwelling of the groin, contradicn cf the thigh, (fo that I. could not ilretch it out) and a diftind fluctuation of the grr.'a, which extended from th- Syniphifis Pubis to the fpine of the .'".:- urn, but it'll without tendon or pain ; bv, on the contrary, die. ON WOUNDED ARTERIES. 45 fluid fluduated freely, and feemed to be immediately under tha (kin. Guattani could not allow himfelf to believe *diis to be a proper fuppuration, becaufe the fluduation brought no relief; and tho' there was no pulfation, he yet fufpeded aneurifm, and explained himfelf on this head to the confulting phyfician and furgeon, A- micio and Maximinus, both profeffors in Rome. They agreed to fpend a few days longer in trying common remedies, partly that diey might make a trial of fuch remedies, but chiefly to al- low time for Guattani to make up his mind concerning the na- ture of this difeafe. After fifteen days, they found no change, except a new fuppu- ration within four fingers breadth of the great trochanter, and, therefore, refolved to do the operation, and to cut in the groin as die place the mod favourable for dopping die flux of blood, in eafe of Guattani's fears about aneurifm being well founded. But left the affiftants or friends, and more efpecially the patient himfelf, fhould be alarmed with the fight of blood, Guattani talk- ed over this fubjed with the patient, allured him that he had pro-. vided every thing for dopping the blood, explaining to him at the fame time, how eafy it would be to enlarge his. fmall incifion, in cafe of there being pus only in the tumor, and explaining alfo, that, in cafe of pure blood flowing, he would prefentiy give it a free exit, fo as at lead to empty the bag, and would let the frelh blood run dill, even after the emptying of the bag, if his drength would bear it. After which, he pledged himfelf to fecure the ar- tery by compreffion, if he could only get his comprefs fairly put down upon the artery itfelf. After all this, fays Guattani, I trud there will come on a good fuppuration, and that you will be re- dored to perfed health ; at all events this is exprel'sly what muft be done, and all diat can be done to attain that definable end." " Morellus he;rrd me," fays Guattanf, " widi a compofed mind, and we proceeded to our operation boldly ; being provided with bafons for receiving the matter, and compreffes and bandages for commanding the blood. Then the furgeon Maximinus introduc- ed his curved bidoury delicately into the highed point of die tu- 46 ON WOUNDED ARTERIES. mor, near the Crida Ilii. where the (kin was particularly thin, when indandy pure blood guflied violently out, to the great a- larm of all prefent. But encouraging the patient, I took one of the bafons, fays Guattani, in my own hand, and extraded fuch quantities of blood by this fmall opening, that I filled one bafon, took up a fecond, and dill continued my work, till the pure arte- rial blood began to flow, and the patient to faint." The blood was flopped by Maximinus clapping his thumb upon the orifice : and Guattani, by graduated compreffes one above another, with firm bandages, fo fuppreifcd the bleeding, that the patient did not faint, but, on the contrary, was prefentiy relieved from all his fever and pain ; and, being fupported with cordials from time to time, he went on without either bleeding or any other bad fymp- tom, and without their needing to touch the bandage till the 13th day, when, the dreffmgs being removed, nothing flowed from the wound but a little pus ; which (hewed that the artery was fairly clofed, and encouraged them tp go on with die cure. Although the fuppuration was not exceffive, they were forced to make a counter-opening, and accompliflied the cure in little more than two months.—Now the coagulated blood at firfl, and the frefli blood after, the patient's feeling no lownefs during the emptying of the bag, and his fainting when the pure blood began to run, prove this to have been an aneurifm, and Guattani did wifely in allowing fome of the arterial blood to efcape, that he might have a greater command of die artery, and be enabled to comprefs it. Now, it fignifies nothing to the point, whether this was or was not an aneurifm ; nor, if it were truly an aneurifm, does it fignify whether it were an aneurifm of a branch only, or of the main ar- tery of the thigh ; nor whether the aneurifm were above or below that point at which die Profunda goes off. The queftion is, whe- ther die main artery was flopped above the Profunda by the vio- lent compreffion which they needed to make ? And this is folvcd by Guattani's reflections upon the cafe, which are thefe two only. " This cafe fettles, fays Guattani, two great queftions which uiaurbed me very much ; for, in die lint place, thr preiiare was fuch as to prevent die leaft drop of blood from paff.i.g down the ON WOUNDED ARTERIES. 0 artery ; whence I was fatisfied that the limb was nouriflied by the Internal Iliac Artery alone ; and fines" this aneurifm was cur- ed by compreffion merely, I am fatisfied that compreffion will cure any aneurifm, whether from wounds or from difeafe." The ftrong conclufions of this cafe alfo the celebrated Murray tries to efcape, by faying, " Vero fimile videtur, Arteriam Femo- ralem fupra inguen jam divifam fuiffe, nam alioquin, toto truncd compreffo, vix aufa tarn fortunase ceffiffent." But far from its being likely that the Femoral Artery divided above the groin, it is impoffible for the Femoral Artery to have divided within the pelvis into two arteries deftined for the thigh. The Iliac Artery does indeed divide within the pelvis into two arteries, but they are natural ones,v/z. the Hypogaftric Artery, going from within the pelvis to fupply the hip ; and the Femoral Artery, defend- ing along the thigh. Thus you perceive that this queftion, whether to tie the Femo- ral Artery in the groin, or to cut off the thigh, is a matter of feri- ous importance ; that there are every where proofs of its fafety, if we will but feek them out ; that there are every where doubts alfo about the fafety of it in the books of the beft authors, (for a- mon'g the beft authors the celebrated Murray muft rank very high) : But upon thefe proofs and reafonings I think my con- clufion (lands firm ; that, diough our ligatures will not always hold ; though it is never eafy to command fo large an artery as the Femoral Artery at the groin ; though fucceffive inflamma- tions and die deep driving of blood will often hurt the inofcu- lations, and prevent our fuccefs, yet fome have been abfolutely cured by tying the Femoral Artery at the groin, and the bodies of diofe who have died have proved how poffible it was to have made a cure, and that in this, as in other aneurifms, the difficulty is not that nature, on her part, has failed to provide fufficient in- ofculations, but that the furgeon cannot, on his part, fecure the great artery, fo as to obliterate its canal, and make its internal furfaces adhere. The furgery of die ether gi\ at arterial trunk, viz. the artery rf the arm, (lands preeifely ia the fame eircumftances,:'. e. its in- +8 ON WOUNDED ARTERIES. ofcuh.tionS are perfed, and yet they arc not known ; for the rule of pradice, which dircds us in wounds of the Femoral Artery to cut off the thigh, concludes commonly with a more violent declaration concerning the danger from wounds of the Axillary Artery : " But if the Brachial Artery be wounded near the Axilla, or if the Ax- illary Artery itfelf be wounded, it is neceffary to take off the limb at the joint." If a man will look only fuperficially on thefe matters, or will be fatisfied with a general conclufion deduced from the accidents only of one particular cafe, then indeed he will be hurried along into this ralli pradice of cutting off arms as well as legs : Or in other words, if, to eftablifh this rule of furgery, nothing more were re- quired than an authentic cafe of a wounded Axillary Artery, follow- ed by gangrene and death, fuch proofs might be found in every common book. Thus Mr. Gooch tells us, p. 76. " That he was called by a neighbouring furgeon to attend along with him a man, who had been juft before, in a (late of exceffive intoxication, thrown from his cart, the wheels of which had paffed over the top of his arm and ilioulder, bruifing all the parts quite up to his neck, while an iron hoop projeding from the cart had cut him under die arm, tearing fairly acrofs the artery and all the great nerves which go down along the arm." " The limb was wholly deprived of fenfation and motion, they felt no pulfe at the wrift, and they concluded that the Brachial Artery was divided, although the bleeding, which was at firft pro- fufe, had (topped, partly by the retradion of the artery, and part- ly by tijeir having tied down his arm to his fide." " Had npt the drunken condition of the patient, and the violent contufion of the parts furrounding the joint, didouraged us, fays Gooch, we fhould have propofed immediate amputation at the joint. The next morning the arm appealed in different parts difcoloured, emphysematous and gangrenous; by noon it was totally dead and hifenfibb to the fingers' ends ; and on the third day towards the evening the patient expired. The day after his death, the arm was fo thoroughly putrid th..t we were unable to tiffed it, till after hjrh.g waftied it veil with v .mi vinegar and ON WOUNDED ARTERIES. 49 fpirits, we opened it, and found the bundle of the great nerves entirely cut acrofs, and the artery alfo djjfided, and its upper end retraded an inch into the Axilla."—But this, far from being a^ general proof, is an accident merely : it is explained by the gen* eral circumftances of the cafe ; the inebriation of the patient, his lofs of blood, die cutting of the whole bundle of the Axillary Nerves, are of themfelves fufficient to account for his deadi. Per- haps he died as Captain M----did, whofe cafe is related by the celebrated Mr. White, rather from his inebriation, lofs of blood, and wounded nerves, than from the neceffary confequences of his wound. Captain M-----'s arm preferved its circulation ; the natural heat had returned ; the vein fwelled upon putting a lig- ature round the arm, and he died after the arm was fafe from all danger of gangrene. 13ut this cafe, related by Mr. Gooch, was complicated with other accidents; for we are told that they were deterred from amputation, by the bruifed condition of the parts furrounding the joint. The wheel had paffed along the arm and fhoulder quite up to the neck ; thefe parts were black, and, I dare fay, little better than gangrenous : It is no wonder, then, that an arm fo mangled, upon a body fo hurt and difordered, fell into immedi- ate gangrene. Hence we fee the folly of deducing any general conclufion from an individual cafe, and we are thus farther reminded of this good rule in philofophy, that one pofitive evidence muft outweigh any number of negative proofs. If we can find one fingle ex- ample of an Axillary Artery wounded, and the arm faved ; it is then a fettled point, that in favourable circumftances the inofcu- lating arteries round the fhoulder will fave the arm ; and the con- clufion (lands fo firm, that, though there fhould be produced againft that fingle recovery a whole hoft of negative proofs, it evidently becomes our duty, whenever we are prefented with fuch a cafe feeming to contradid diis pofitive proof, to fearch into the circumftances and accidents which have made that one cafe fail, while anodier has been followed by fuch perfed fuccefs. As die VOL. I. G 50 ON WOUNDED ARTERIES. pureft cafe, the leaft complicated, and the moft unequivocal ex- ample of diis fuccefs, 1 put down the following : " About fixty years ago, Mr. Hall was called to a man in Cheftiire, who had received a very confiderable wound, juft below the Axilla, by a fcythe which had divided the Brachial Artery. The man foon fainted away with the lofs of blood, which pre- ferved his life, as nobody was near him. Mr. Hall, being only accidentally in the neighbourhood, had no needles with him ; but, as foon as he arrived, he eafily laid hold of die artery with his finger and thumb, till he could procure fome thread, which he immediately tied round the veffel, and effectually fecured iC- The man recovered the vfe of his arm ; though he had ever after a weak and trembling pulfe*." It was the broadnefs and opennefs of this wound, that enabled the furgeon to fee the bleeding artery, to take it up fo fairly, as to fave at once, both the life and die limb of the patient; for in many other cafes, it has only been by confenting to lofe the limb, that the patient has faved his life ; or, where the limb has been faved from amputation, it has in general hung lifelefs, and like a piece of mummy by his fide. If it were worth while, I fhould be careful to explain the chief accidents of this kind, fo as to prove the following pofitions : That the wound of the Axillary is lefs dangerous ftill, than wounds of die Femoral Artery : That, when gangrene has feemed to proceed from a wound of the Axillary Artery, it has been owing rather to the complications-and accidents of the cafe : That when, together with a wound of die artery, the bones are fradured, or the foft. parts braifed, as with a waggon wheel, the cure will be almoft impoffible, and the parts muft fall into gangrene : That where, by the force of the artery driving the blood inwards, the Cellular Subftance and the interftices of the mufcles are filled, or, as I may fay, rather injeded with blood, drere we (hall have a flow and tedious cure j that, if the inofculating arteries be torn by a lacerated wound, or their circulation difordered and interrupted * Vid. White's cafe of Captain Mounfey. ON WOUNDED ARTERIES. 51 by a high inflammation and fwelling of the parts, this alfo will make a very doubtful cafe, in thefe circumftances alfo, it muft be dangerous to attempt the cure. But all thefe do not belong to the general queftion ; they are merely the peculiarities of the cafe; they are the very points to be debated in any great confulta* tion ; but they are not arguments for a general rule. Let, there- fore, the furgeon do as he fees prudent in cafes of wounded ar- teries, with lacerated wounds, broken bones, a difordered fyftem, a weakly habit of body ; but, on account of a fimple wound of the great artery, he fhould not allow himfelf even to talk of the amputation of die limb. Although I am fatisfied that I have explained to you the true grounds of this rule of pradice, yet I (hould feel as if there were fomething imperfed in the proof, unlefs I faid alfo here, as I did in fpeaking of the lower extremity, a few words about the inofcu- lating arteries. The arteries which go round the joint of the fhoulder, may be very properly compared widi thofe which belong to die hip joint; the one fet of arteries goes round the Scapula, as the odier goes round the haunch bone, and the one is as well able as the other, by free inofculations, to fupply the limb below. Firft, one great artery comes from within the cheft, paffes tranfverfely acrofs the root of the neck, croffes over the fhoulder, and going down over the Scapula, fhould be named the Supra-Scapular Artery, and is one upon which we may chiefly rely.* Secondly, other branches come off from the artery without the cheft, from the deepeft part of the Axillary Artery, where it lies high up in the axilla. Thefe, as they turn over the lower part of the Scapu- * This artery is regular, as far as relates to the Scapula, but in its origin it is quite inegular. This great artery, going over the Scapula, named Supra-Scapular artery, or Arteria Dorfalis Sca- pula;, moil commonly comes from within the cheft, being the firft great branch of the Thyroid Artery ; fometimes it pro- ceeds from the Cervicalis, or artery of the neck ; fometimes it comes off upon die outfide of the cheft ; it makes large inofcu- lations and is the branch particularly to be depended upon ; but all the Cervical Arteries affift with their leffer inofculations, and all of them, or any one of them, may be fo enlarged as to per- form this office. ol ON WOUNDED ARTERIES. la, (hoidd be named the Subscapular Arteries, and they nave free inofculations with thofe above. The third great artery coming off from the general trunk of the humeral artery, is a great muf- cular branch, which runs down along die back part of the arm ; belongs chiefly to die mufcles and (like the mufcular artery of the thigh,) this alfo is named Protunda. And whether the great artery be wounded juft where it comes from under the clavicle, i. e. betwixt that great branch which goes over the Scapula, and that which goes round the Scapula from below ; or whether it be wounded betwixt the lower Scapular Artery and the Profunda, (till die limb is fafe ; we are affured of it by cafes ; we forefee the fuccefs of all fuch operations by the fuccefs of our injedions ; I have often found that when, even in the oldeft fubjeds, I have pufh- el injedion (of the coarfeft kind,) from the arch of the aorta, try- ing to fave the arteries of the arm for a fecond injedion, by tying both arteries in the axilla very fecurely, I have notwithftanding had an injedion of the arteries of the arm ; fometimes in both arms, more frequently only in one ; but even one experiment of the kind, and one arm injeded, were a fufficient proof. And you will be inclined to remark this proof as a very ftrong one, when I inform you that our coarfeft injedion goes dius freely round the inofculations of the fhoulder, (where \vc are fo much afraid of performing an operation,) while even tepid water will not pafs, or will fcarcely pafs round the inofculations of the elbow, where in our operations for the common aneurifm, we are fo fure of fuccefs. As for the inofculations in all the lower parts of the arm, no doubts about their fufficiency trouble us now, although this alfo is a degree of confidence and boldnefs in furgery which we have attained very (lowly. I have already mentioned that, whenever a furgeon ventured to perform the operation for aneurifm at the bend of the arm, he was careful to have his amputation inftruments ready, and wc find the celebrated Ruilh fpeaking of this operation in fuch terms : ,; This is an operation v.hEh furgeons chyle rather to do:crib?, ON WOUNDED ARTERIES. 33 than to perform, I have good reafon to fay fo, fince, for more than 20 years, in all this great city to which fo many under all kinds of ailments crowd for affiftance, no furgeon, as far as I have heard, has ventured to tie fo great an artery*." Heifter believed, that wherever we cured the aneurifm of the arm by tying the artery, the arm was faved, by a high forking of the artery, and it was only latterly he began to fufped that the fmaller branches might fometimes be fo far enlarged as to car- ry the blood freely ; becaufe he oqcafionally obferved, that af- ter the operation for aneurifm there was no pulfe in the wrift during three days, after which it began to be perceived, and foon returned to its natural ftrength.f " If the Axillary Artery be wounded," fays Mr. Gooch, " it is neceffary to take die limb off at the joint ; yet as there are in, (lances of the Brachial Artery dividing into two, foon after it leaves the axilla, which lufus naturae I have obferved at different diftances in the arm, it will be rational pradice, when we feel a pulfation at the wrift, to treat fuch cafe as an aneurifm, by tying the artery," &c. p. 72. In (hort, there were two accidents with which the older fur- geons encouraged one another to this operation, viz. that the ar- tery often forked very high in the Axilla ; or, fecondly, that in common an artery touched with the lancet in bleeding was prick- * It is commonly faid, that Ruifh was adually the firft who had performed this operation in Holland : whereas, the parhige (lands thus : " Operationem fane ab authoribus majus comr.ien- " datam et laudatam quam inftitutam ; quod dicere non gravor, " quia viginti abhinc annis, et quod excurrit in hac vafta civitate, " ad quam fine numero confluunt afflidi, banc operationem in " arteria adeo ingenti nullus (quantum noverim) chirurgorum " inftituit." Ruifh, Vol. I. Obferv. 2. f " Poffe vero ramulas minores fe ita fcnfim dilatare, ut " #XXXVII1. diximus, Clar. Du. Praefes inde fufpicatur, quia " cum aliquando truncum arteriae brachiaiis internum, graviter " vulncratum, praedida ratione fupra vulnus ope fili circumdidi " ligaffet, intra triduum nullum in arteria juxta carpum pofita, " qua: a medicisexplorari folet, pulfum fentireaut percipcre;potu- " it; pofthaec vero hanc arteriam, primo leviffime micarc, fenfini " vero fenilmquo pcnitus pulfare fenfit." 54 ON WOUNDED ARTERIES. ed not in its trunk, but only in one of the two branches int« which it divides at the elbow. Thus Cheffelden fays, " I had always thought this wound was in the inferior Cubital (». e. in the Ulnar) Artery, and thus the fudden reflux of the blood was accounted for, by the communication of the two Cubital Ar- teries in the palm of die hand, and thus fatisfied, I enquired no farther ; though Mr. Sharp, even fo long ago as when he wai my apprentice, told me that the wound was in the trunk, in the Humeral Artery itfelf, as indeed it is." p. 457. And yet the celebrated Dr. William Hunter, notwithftanding this affirmation of Cheffelden, lays it down in the moft formal, pofitive manner, in the (hape of a pradical rule or inference, we know not what to call it, marked xv. " That though the Brachial Artery in moft people divides into its two branches a little below the part where we commonly bleed ; yet perhaps it will be found, that the aneu- rifm happens oftener to one of the branches, than to the trunk of that artery, becaufe thefe often lie nearer the fkin, and are thereby more expofed to injury." p. 353. This has nothing in it of the ufual corrednefs of Dr. Hunter ; for in point of fad It is wrong ; the branches do not lie nearer to the fkin, they are buried deep under the bellies of the pronators and flexors of the arm, and any one may know this, whoever in his life has tied up an arm for bleeding, where he muft have obferved the ftrong beating of the artery only where it was entire, running in one trunk under the Median Bafilic Vein. And his reafoning is farther wrong than his affertion ; for if in moft peo-. pie the artery divides a little below the place where we bleed, it matters litde whether below that point the two branches be fu- perficial or deep, the aneurifm cannot happen " oftener to one of the branches than to die trunk." I feel myfelf entitled to fet up, at the conclufion of this difcourfe, a rule, the very reverfe of that with which it began, and to fay diat, after thefe proofs, the queftions about inofculations may be r/otted out altogether; that wounds of th'j Axillary Artery, :'k2 wounds of the Femoral Artery, are often dangerous from ON WOUNDED ARTERIES. 55 bleeding, but never fatal from the want of inofculations ; that we (hould tie the greateft arteries confidently wherever they are wounded without the trunk of the body, and that we (hould tie the arteries as boldly at the groin or in the axilla as in the leffer branches going down the thigh or arm. Accidents undoubtedly (as we are in all our operations at the mercy of accident) may pre- vent our achieving a cure; a limb bruifed with a waggon wheel, or wounded with a great ball, cannot be fo eafily faved, as when the artery alone is wounded by the (lab of a knife orfword : Yet, al- though the accidents and dangers of gangrene were multiplied tenfold, this common way of cutting off the thigh, or amputat- ing the arm at the fhoulder joint, is bad dodrine, and cruel prac- tice. DISCOURSE III. OF THE CONDITION OF A WOUNDED ARTERY } OF THE NATURE OF THE TUMOR WHICH RISES OVER THE WOUND OF A GREAT ARTERY } AND OF THE WAV OF OPERATING IN THOSE RECENT ANEURISMS. J. am now to explain to you the condition of a wounded artery ; not where it is touched in a wide and open wound, for there the artery bleeds profufely, and either it is prefentiy tied, or the pa- tient dies. But I am to explain to you the (late of a greater ar- tery, wounded deep among the mufcular fleih, ftruck perhaps widi the point of a fword or knife, or cut acrofs by a ball, for then the blood efcapes difficultly through the narrow wound ; there is little outward bleeding ; the artery bleeds chiefly within, and by that inward bleeding forms a fudden tumor of the mod dangerous kind, requiring a fudden operation almoft as if the ar- tery were (till open pouring out its blood : The artery, indeed, is (till open, is dill pouring out its blood, and nothing refids it but the fkin ; if that flender barrier give way, the patient dies with one gufh of blood. When a man is wounded in any great artery, the blood flows in fo full a dream, that in a moment he faints, falls down, and it is then only that the by danders can command the blood, by gathering up any cloths that are at hand, and cramming them into the wound in a confufed and ineffedual way, till at lad the furgeon comes and dops the blood. Now the furgeon at the fird fight of fuch a wound is himfelf alarmed, he fears that it is the great artery of the limb ; he is unwilling to cut up the arm or ON WOUNDED ARTERIES. 57 tiiigh, and to undertake the tying up of the great artery without fome farther help and advice ; he throws off the loofe cloths or bandages ; lays a fair and very firm comprefs upon the wound ; rolls it with a deady bandage, and, leaving a tourniquet about the limb, informs the friends of all his fears, and of all the expeded difficulties and dangers of fuch a cafe, and defires that fome con- fulting furgeons may be called. The confultation proceeds at fird upon thefe points, the place of the limb that is wounded, the fhape ef the weapon, the deepnefs of the wound ; but the furgeons do not in general unbind the wound, at lead, if it be a deep and pundured wound, till the fkin has adhered, till the aneurifmal tu- mor is formed, and then being able to undo the dreffings without any danger of farther bleeding, they have all die cafe before them. The tumor rifes higher and higher every day ; at every vifit they fee a change. The tumor is large, hard, circumfcribed,and beating very drongly ; the fkin over it begins to inflame, the wound of the knife threatens to open again, the whole limb is feeble and cold ; the furface of the tumor is livid, and in a few days the beating, from fuch an artery as the Femoral Artery, is mod a- larming, and to the patient very awful ; he fpreads his hand broad over the tumor, feels its beating, like the heart in its drong- cd palpitations ; beating againd the fide. He is laid with tour- niquets round the limb ; he fees by thefe precautions, and he feels, as it were, that, if die tumor burd during the night, he mud lofe his life with one gufh of blood. Lying in this anxious condition, he is watched from hour to hour, till the time appointed for the operation arrives : and it is then only, (however great the fur- geon's fears about this operation), that the patient is in any de- gree fafe. It is not always that the furgeon has his mind fo fettled con- cerning the tying of thefe great arteries, as to do his operation on the very moment of the wound ; and yet he may as well do fo ; for, whether he determine by his reafoning that it is fafe, c- dan- gerous, to tie the great artery of the limb, dill the circumftances of the wound are the fame ; and the artery, whether it be die vol. i. H 5o ON WOUNDED ARTERIES. great artery, or fome fecondary branch, whether pundured 01 fairly cut acrofs, is lod to that limb ; and fince die wound itfelf of a great artery cannot hed, its cavity mud be clofed. This a- lone (hould determine us how to move in this critical moment ; and I am clear that the furgeon, when he is called in good time to fuch a wound, fhould clap the point of his finger upon the wounded artery, cr make his affiftant hold the artery ; cut the wound fo far open, as to fee the artery ihirly ; draw it out if it be Gut acrofs, and have lhrunk among the fleih ; or tie it like the artery of the arm in aneurifm, by palling ligatures under it, ir diis greater artery be pundured only with the knife or fword, as that of die arm often is with the lancet. But in nine often cafes, die furgeon wants courage to do this, as he diinks, hopelefs operation, upon the fpot. The cafe falls to be determined by (low and heiitaring confultations, the lurgeons debate whether it be the trunk of the artery diat is wounded ; whether, if it be the trunk, it fhould be tied ; doubting, perhaps, whether the limb fhould not rather be cut off. Thus the outward wound is allowed to heal, the inward bleeding goes on, and the regular aneurifmal bag is formed. There are certain circum- ftances, in which it is even our duty to bring the cafe into this fhape ; for example, if there be a wound of the great arteries in the back of the hip, in the groin, in the armpit, we cannot com- mand the blood eafily ; we are not fure of clapping our finger down upon the artery, at the very point where it is wounded ; we are afraid left the patient fhould die, (even after we have come to him), with one fingle gufh of blood ; we therefore clofe the nar- row wound, put its lips together, fettle it with a very fteady com- prefs and bandage, and try to make the lips adhere, and '.hen we have a fair aneurifm, which we can look upon compofedly ; we can refled upon the courfe of the wound, and calculate which ar- tery is moft pr bably wounded ; for befides the main trunk there are other arteries in the armpit and the thigh, as the arteries of the fcapula or the Arteria Profunda, which being wounded, will make aneurifms as large, though not fo dangerous as thofe of ON WOUNDED ARTERIES. 50 the Axillary or Femoral Arteries, and to be diftinguifaed from diem chiefly by the pulfations in the wrift or ancle, continuing ftrong *. The arterial trunks and all their greater branches in every part of the body lie under the fafcia ; and feem to owe no lefs to the fupport of thefe fafciae, than the mufcles themfelves. Over all the body the fafcia is almoft equally ftrong ; the fkin and fafcia, where the wound is fecured with compreffes, are preff- ed together and adhere ; the blood, by this accident, is al- ways driven hard under the fafcia, and is never diffufed under the fkin ; the fkin merely covers the aneurifmal tumor, while it is the tenfe fafcia that gives form to the aneurifm. The fafcia, thus confining the blood, limits the fize of the tumor, gives it a fair and circular form, is itfelf tenfe and firm, livid alfo by the colour of the contained blood ; fliining and refplendent like the inner furface of the gizzard of a fowl, and the fkin and fafcia may be cut diftindly from each other, as freely as we cut the fkin over a difeafed bread without touching the hardened gland, or rather, (for a more clofe refemblance), as we draw our knife clean along the furface of a hernia, without touching the fac ; or as we cut the fcrotum over the hydrocele without touching the vaginal coat. Nor is the furface of an aneurifmal bag very irregular, even upon its back part, for each mufcle is involved in its own fafcia, fo that the fafcia is alfo of tolerable ftrength within ; the internal proceffes of the fafcia, and the condenfation of the cellular fub- ftance, (as it is driven clofer by the blood), fet alfo fome bounds to its extenfion within, fo that the blood is no more diffufed among the flefh, than under the (kin ; but the circumftances of the tu- mor will vaiy infinitely according to the nature of the wound. I have feen the Femoral Artery cut fairly acrofs with the knife ; there the wound, paffing deeper than the artery, will allow of a greater bag, and the artery will pour out its blood behind, as well as before it. I have feen the Femoral Artery juft touched * The pulfation may fometimes continue in the lower part of a limb, notwithftanding a wound of its main trunk, from the obli- uahy of the outward wound, as (hall be explained prefentiy. GO ON WOUNDED ARTERIES. widi the point of a penknife and not transfixed, the wound not paffing through the artery, no blood behind, but the aneurifmal bao- formed immediately beneath the fafcia and (kin, and the ar- tery keeping its place among the mufcles of the thigh ; nothing of the artery but the wounded (lit in it appearing, the mufcles ad- hering firmly to the artery, and with a degree of inflammation, and thickening ; the flat furface of the artery nitched in among the inflamed mufcles, and die flat furfaces of the mufcles them- felves forming the back part of the tumor : and I have alfo feen the artery entirely cut acrofs by the fradured ends of the thigh bone, fo that the oppofite ends of the artery hung together by a fingle tag, and the aneurifmal bag, indead of being formed be- twixt the fafcia and the great mufcles of the thigh, was formed betwixt the great mufcles and the bone, fo that the broad belly of the mufcle named Vadus luternus, formed the chief furface of thefac. But, whatever be the form of the bag or the condition of the artery, let the furgeon be prepared to encounter difficulties, by trying to calculate how die parts may probably be conneded with each other, whether under the fafciae only, or under the muf- cles, whether prelfed together by inflammation, or thickened by the driving and compreffion ef the blood. Thus the advantages from an aneurifmal bag being formed be- fore we are called, or by our own compreffes healing die wound, are thefe ; that we are not hurried all at once into the midd cf a bloody operation y that we arc fomewhat eafy about our patient's immediate fafety, there being no danger of fatal bleeding, at leaft for a few days ; that we ha\ e warning of every dangerous change by the alteration in die furface ; that we have time to confult ; to calculate which artery is wounded, and to fettle all the (teps as in any other operation, putting our tourniquets round the leg or thigh, or fettling the compreffes of the clavicle or groin, if the ar- tery be wounded very high. But it is equally plaia, that though a recent aneurifm is thus managed with more eafe to the furgeon, and lefs lofs of blood to the patient, than a large;■:.d open wound ; yet an old aneurifm, ON WOUNDED ARTERIES. 61 fuffered to grow for weeks or months, is attended with great danger ; for, if die artery be very great, as in the hip or thigh, the bag enlarges very rapidly ; all die parts are compreffed and hurt, the blood is driven deeper and deeper among the mufcular flefh, and at the fame time that the foft parts are difordered, even the bone may be fpoiled, which muft render the operation ineffedual in faving the limb. The accumulation makes it more difficult to find the artery, preffes it deeper every moment, and farther out of the reach of the furgeon ; the bag comes, in a few weeks, to hold fix orfeven pounds of blood, and this extenfion 6T furface, caufes i greater fuppuration, which (wherever the matter is, as in this cafe, contaminated with blood), is never kindly nor well difpofed to heal. Wherever we have it in our power to apply the tourniquet, and command the blood ; or, in other terms, wherever we have to deal only with a wound, or fmaller aneurifm of the arm or ham, or the lower part of the thigh, the operation is eafy. But in the greater aneurifms of the armpit, haunch or groin, we muft truft nothing to compreffion, and muft do our operation with particular boldnefs and (kill, otherwiie we (hall hardly fave our patient, for in a very moment he is either faved or dead. The rules belonging to diis cafe of an aneurifmal bag, holding fome great artery, are chiefly diefe : 1. You are -not to truft entirely to the compreffion which your affiftant tries to make upon the groin, or below the clavicle ; for it is one matter to fupprefs the pulfe in the lower part of a limb, and another to (lop altogether the current cf the blood ; but you are to look upon this as an open artery, and exped that the mo- ment you cut the tumor, die blood will rwfti upon y ou with a terrifying violence : nor fhould you ever exped to clean the great cavity with fponges or clodrs, for the artery will fill the cavity with blood, falter than you can throw it out, till the patient breathes his lad. Indead of this, you draw your knife deliber- ately and fairly over the tumor, fo as to lay it open. The (kin being thus divided, the great livid bag of the aactaifm furroaad- 62 ON WOUNDED ARTERIES. ed with its ftrong fafcia, rifes into view. Next pufii your lancet into the bag, and then do all that remains in your operation with great boldnefs ; run your bidoury upwards and downwards fo as to flit up the tumor quickly ; plunge your hand fuddenly down towards the bottom ; turn out die great clots of blood with your hand and fingers, till having reached the bottom entirely, you begin to feel the warm jet of blood, and direded by diat, clap your finger upon the wounded point of the artery, as it has but a point, your finger will cover it fairly, and your feeling the beating of the artery affures you diat all is now fafe. Now the bleeding, confufion, and fainting are over in a mo- ment ; the operator breathes, and the affidants are compofed ; and all the operation goes on eafily and fafely. The artery is effedually commanded by this preffure with the finger ; but the firfl movement in fuch an operation, viz. die ad of dopping the blood is dl boldnefs, and nothing of caution ; no danger is to be apprehended, but that of fuffering your patient to lofe blood. e2. Being now compofed, you take time to arrange every thing for die next dep of your operation, you feel the beating of the ar- tery with the point of your finger, perhaps you lift the point of your finger for a moment, to difcover whether the preffure of your affiftants, at the groin or clavicle, commands the artery : If fo, you lift your finger, and examine round the artery ; if not, you keep your finger Heady, make die affiftants clean the bag round the artery ; then, if the artery lies fair and free in the bottom of ehe cavity, you proceed to tie it; but if not, you muft diffed round die artery, until you fet it free from other parts, and have it fo infulated as that you may put your ligature eafily under it ; wnlefs indeed the recolledion of fome great trunk beiiiP- near the wounded artery (as of the Profunda, when yam are tying the fe- moral artery) fhould (top you ; but yet the nearnefs of aiv great artery or nerve, is an argument as ftrong againft y our diving with the needle to catch the wounded artery, as a^ainit your diffedhw *"ith the k:-i:e. Since therefore the diffedion is done with your ry»s open, and you can fee and feel before the point of your knife ; ON WOUNDED ARTERIES. 63 rather diffed, or fometimes tear the artery naked with the point uf your fingers, tying its open mouth, if cut acrofs, as fairly asia an amputated ftump ; or,if it be touched only with the point of a knife or (word, put two ligatures round it, one above and one be- low the wound, and put them neatly and fairly round the artery, as in tying for aneurifm of the arm, and cut it acrofs betwixt the two ligatures. 3. In regard to the fize and form of your ligatures, do not al- low in yourfelf the flavifh and abfurd fear of cutting arteries acrofs with them. It makes furgeons ufe ligatures in amputation, fuch as are often ineffedual ; and in aneurifms of the thigh or fhould- er, they ufe fuch tapes as it would be impoffible to draw tight even round the aorta, though that could become the fubjed of their operation ; the circle of the knot made by fuch a ligature is often wider than the diameter of the arterial trunk. Surgeons have complained diat they could not draw their tapes tight enough round the femoral artery, even with the whole (trength of their kands. Let your ligature, dien, be made of three or four threads well waxed, tied not with die furgeon's knot, but with one fingle knot moderately drawn, fecured with a fecond fingle knot, the threads left hanging from one corner of the wound. _ , 4. It can hardly be neceffary to advife that, after fuch opera- tions upon the Humeral or Femoral artery, tourniquets be dill kept round the limb, to guard againd thofe accidents, which have fo often happened, and will we fear continue to happen, in the hands of the mod famous furgeon. But if it chance that the parts are fo maffed with inflammation, fo difordered by the driving of the blood in old aneurifms ; or perhaps the parts fo hurt, as to be almod in a date of gangrene ; if the furgeon cannot by any means get a fair view of the artery, and that his patient be lofing blood, pouring from fome great trunk, then mud he drike his needle at random, in order to come at his objed the neared way ; and the only fatisfadion that he can have, or the only proof of his having tied the artery at all, 64 ON WOUNDED ARTERIES. will be only the fudden dopping of the blood, when he draws his ligature. In circumdances like thefe, the greated furgeons, (even Mr. Pott himfelf), have been accufed of having miffed the arte- ry ; b".t at all events fince it is irregularly tied, or perhaps not at all, the attendants, that are appointed, mud be (kilful, and mud be intereded ; both friends and furgeons (hould watch over the patient's life mod faithfully ; for fucceflive bleedings will hap- pen, often from fome fudden turn, or unwary motion in his bed during the night ; and he is lod or faved in a moment of time *. One thing I am chiefly afraid of, that this defeription may feem overcharged ; that I may appear to have exaggerated the diffi- culties of an operation like this ; that it may be thought that an accident requiring all thefe precautions, and diis plunging down of the hand, can hardly occur. Therefore I date to you the fol- lowing cafe, and I dare fay, after having confidered it, you will perceive that it needs no apology ; but that,as it is new and inter- cding, it deferves its place. A poor man, who was by trade a leech-catcher, fell as he was ftepping out of a boat, and the long and pointed fciffars which are ufed in his bufinefs being in his pocket, pierced his hip exadly over the place of die fciatic notch, where the great Iliac Artery * Mr. Hume ftiys, in reporting one of Mr. Pott's obfervatiom, that the depth of the incifion made it very difficult for any one but die operator, and thofe immediately around him, to fee what was included in the ligature ; and at the time the Popliteal Artery was fuppofed to be fecurcd by it. The infmuation is as dired, as good manners will allow ; but it is more than an infmuation ; for, in an account of the fame cafe, publifhed fome years fince, Mr. Hume fays, " No doubt was made at the time, of its being any thing but the artery that he had tied." Next, Mr. Hume proceeds to reafon upon it in fuch a form, as to imply a dired af- firmation, that the artery was not tied. Whether the aneurifm was in a branch, or whether it was in the trank of the artery, the pulfation fhould not have been felt in the tumor, if the Popliteal Artery was rendered impervious : But however we fhall choofe to explain it, the fad is, that, by the fecond day after the opera- tion, the artery was again throwing its blood into thevaneurifmal bag, fo diat a ftrong pulfation was felt; and the tumor (welled fj rapidly, that Mr. Pott cut off the limb. ON WOUNDED ARTERIES. 65 comes out from the pelvis. The artery was (truck with the point of the fciffars, it bled furioufly, the patient fainted : and in fo narrow and deep a wound, the furgeon, when he came, found little difficulty in (topping it up, and lefs difficulty (till in making it heal. The outward wound was cured ; the great tumor foon formed ; and die man travelled up from the North Country where the accident had befallen him, and in fix weeks after arriv- ed in our hofpital here with a prodigious tumor of the hip, his thigh rigidly contraded, the ham bended, die whole leg fhrunk, cold and ufelefs, as if it had been an aneurifm rather of the arte- tery on the fore part of the thigh. The tumor was of a prodigious fi/.e, and by that very circum- ftance of its being one of the greateft aneurifms, it loft all the charaderiftics of aneurifm, efpecially there was no pulfation, no retroceffion of the blood when the tumor was preffed upon ; there was nothing peculiar except this, that the great and fudden dif- tention was the caufe of great pain ; and from the continual pain, lamenefs, and his hopes of a cure, he was ready to fubmit to any thing, befeeching us to operate. There was little doubt of its being a great aneurifm, but there was a poffibility of its being a vaft abfeefs ; and it was refolved, in confultation, that he fhould be carried into the operation room ; that a fmall incifion fhould be made ; that the fkin being cu£, the bag itfelf fhould be juft touched with the point of a lan- cet ; and if found to contain matter, fhould be fully opened ; but if blood, that it was then to be confidered as an aneurifm of fo particular a kind, as to entide us to call for a full confulta- tion. I made an incifion two inches and a half in lengdi ; the great fafcia in the hip, blue, and very ftrong, formed the coat of die tumor, and under that were feen the big fibres of the great Glutxus Mufcle. The knife was (truck into it, and large clots of very firm black blood rolled out by the tenfenefs of the tu- mor, which began 10 emit the clots in this way die moment that it was opened at one point. There was one thing farther defira- voi- i. I 66 ON WOUNDED ARTERlS. ble before we put the patient to bed, that we (hould undeiftand the cafe fo far as to be able to report to the confultation, whether the artery was abfolutely open, and whether it was die great ar- tery of die hip. 1 continued therefore (knowing that the open- ing I had made could be covered with the point of the thumb) to pull out a few more clots of blood, till the warm and florid blood began to flow ; I then pulhed in a tent-like comprefs into the fmall wound of the tumor, (.-viz. of die fafcia,) laid a broad comprefs over the outward wound, and put die patient to bed with one of the pupils holding his hand upon the hip. This was done at one (/clock, and at four the confultation met, and the operation was performed. And in my notes, I find two (leps of the operation chiefly marked : Firft, That upon our opening the tumor fully with an incifion of eight inches long, and turning out the great clots, die blood was thrown out with a whilhing noife, and with fuch impetus, that die affiftants were covered with it, and in a moment twenty hands were about die tumor, and the bag was filled with fponges, and cloths of all kinds, which had no better effed than the cloths, which, in any accident, the friends in great confufion wrap round a wounded arm ; for though the blood was not thrown in a full dream, nor in jets, it was feen rifing above the edges of the incifion ; it float- ed by the fides of die cloths, which were preffed down by the hands of the affidants. But we knew by a more alarming lign that the artery was throwing out blood ; for the man who was at fird lying not flat, but fupporting himfelf on his elbows, fell down, his arms fell lifelefs, and without pulfe, over the fide of the table, his head hung down and was livid, he uttered two or three heavy groans, and we believed him dead. Secondly, Seeing in this critical moment that, if he was to be faved, it could be only by a fudden ftroke, I ran the biftoury upwards and downwards, and at once made my incifion two feet in length : I thruft my hand down to the bottom of the tu- mor, turned out the great fponge which was Over the artery, felt the warm jet of blood, and placed the poot of my finger upon die ON WOUNDED ARTERIES. 67 mouth of the artery; then I felt diftindly its pulfe, and dien only was I affured diat die man was dill alive. The affidants laid afide the edges of this prodigious bag, and fought out the feveral fmaller fponges which had been thrud in, and the bag being de- liberately cleaned, and its edges held afide, I kept the fore finger of my left hand deady upon the artery, paffed one of the larged needles round under my fore finger, fo as to furround the artery : one of my friends tied the ligature, and then upon lifting the point pf my finger, it was didindly feen, that it was the Poderior Iliac Artery,—that the artery had been cut fairly acrofs, and had bled with open mouth—that it was cut and tied exadly where it turns over the bone : and although the extremities were cold, the face of a leaden colour, and die man had ceafed to groan, and lay as dead ; though the faint pulfation could not be felt through the fkin, in any part of the body ; we faw the artery beating fo drongly, whenever I lifted my finger, that we were affured of out- patient's fafety ; however, he was fo low that, after laying down the fides of the fac, and putting bandages round his body to keep all firm, we were obliged to have a bed brought in, and having given him fome cordials we left him to deep in the great opera- tion room, attended by the pupils and by nurfes. He was cured of this great wound in lefs than feven months, although his cure was protraded by the foul fuppuration of fuch a bag, and by the exfoliation of the Ilium and Sacrum, which fpoiled, not fo much from their having been laid bare by the lad fudden droke of the knife, as by the aneurifmal blood having lain upon them ; the exfoliations were very large, and the Sacrum efpecially continued exfoliating to the very day on which die wound clofed. I do not know whether this man be recovered entirely, for he left die houfe lame, from tire contradions of the hip and ham, and walking by the help of a dick ; but however, lie drought himfelf fit to undertake his profefiion, and went to England with that defign.* * Dr. Farquharfon, who fucceeded me in the charge of the 6S ON WOUNDED ARTERIES. Tihs cafe will imprefs the diredions already given upon yia.'> mind, and is lingular and well worthy of a place, fince this was one of the largeft aneurifms ever heard of, containing not lefs than eight pounds of blood. It is an inftance of one of the leaft prob- able of all wounds, viz. a fmall fharp point touching one of tire deepeft arteries, and one of die largeft ; and wounding it at die very point, where it comes out from the trunk of die body ; and where it cannot be compreffed ; for though my friend Dodcr Farquharfon tried to make fome impreffion upon the defcending aorta, by preffing down his fid into the belly, fo as almoft to touch die fpine, dill there was a deluge of blood upon cutting up the tumor, and the artery beat drongly under my finger. But there is a thing more didrefling to the furgeon, tiian all the difficulties of die operation, viz. That the artery, after it feems to be fecured, often gives way ; fo that, as I have obferved already, fuch cafes are dangerous, not fo much by nature failing in her bu- finefs of fupporting the circulation through the anadomofing ar- teries, as by die furgeon's not being able on his part to fecure the greater arterial trunks ; hardly any have died of gangrene ; very many have died from the lofs of blood : It was from fre- quent disappointments that Mr. Hunter was induced to change his operation ; he tied die Popliteal Aneurifm, not in the ham, but in the thigh ; thinking to find trie artery lefs difeafed at that higher point. It was under the fmart of frequent difappoint- ments, that he thought of this new operation, and I fear, his dis- appointments were not fewer after this change ; for in glancing our eye over the lid of cafes, we find, that it is by hoemorrhagy that patients have generally died, fome after the common opera- tion, fome after the operation in Hunter's way, fome have died Hofpital, has jud informed me, of this man having called upon khn after his return from England, walking doutly, and in good healdi. ON WOUNDED ARTERIES. 69 early, fome late, fome even have died of bleeding, fo late as the twentieth day. In one of Mr. Hunter's operations, the artery gave way, even fo late as die 26th day ; for this fatal bleeding began fird upon the 14th day; returned, and was fuppreffed by compreffes upon the 10th day ; burd out upon the 20th day; and burding out upon die 20th day a fecond time, Mr. Hunter was forced to cut up the thigh on its fore part, and tie the artery anew : But dill the artery was not fecured, on the 23d day it was dill bleeding, and on the 26th day it bled violently, till the man fell low, fainted, became delirious and expired. Mr. Birche's patient died on the 14th day ; he went in the evening to fee him, but he had jud expired, " the limb was dill warm, he lifted the dreffings, and he found a fmall dream of frefh arterial blood iffuing from the wound:" Heifter, and Hunter, and Pott, and the celebrated Sabbatier, and Mr. Dufchamps, and Mr. Deffault, all of them have loft patients by the burfting of the artery, and after death injedions, thrown into the Iliac Ar- tery, have run freely out by the wound in the thigh. All thefe patients have died of bleeding, and all of them have lived long enough to prove that the limb was fife—From thefe accidents, we are now certain, that there is either fomething peculiar in the nature of a great artery, fo that it cannot eafily be fubdued ; or that there is fomething wrong in our manner of operating, or that die confufion of thefe operations is fuch, that even the beft fur- geons are accufed of having failed : Mr. Pott himfelf, was only fuppofed to have tied the artery of the thigh. Such accidents hap- pening thus in the hands of the moft famous furgeons, fhould be remembered in vindication of thofe to whom in future the like misfortunes may happen : (hould they not alfo be a ftrong motive for our driving to find out by future obfervations what may be the caufe ? We are not yet arrived at fuch a degree of knowledge, of the drudure, and fundions of arteries, as to underdand fully the caufe of this infecurity : but we cannot be without a defire to under- so ON WOUNDED ARTERIE'. (land it. I (hould put down here fome notions on this fubjed more freely, if I thought diem in any degree proved ; but, how- ever, the few that I (hall now propofe, leads us to precautions which have this advantage at lead, that they do no ill. The mod obvious reafons dien, of this infecurity, arc diefc, which they will bed underdand who are mod employed in di flec- tion.----We obferve, towards the decline of life, a change on the conditions of the whole arterial fyftem plainly unfavourable to our operations. We find the arteries lefs pliant, fometimes contraded, fometimes enlarged, fometimes offified, their coats al- ways thick, and feparating from each other upon the flighted touch. They are brittle and fragile, and have a crifped feeling, they have lod all their drengtii, our injedions burd them, and our ligatures cut them acrofs ; in fhort, our anatomical injections go well or furely, only in the fmalled arteries, or in the limber and pliant arteries of a younger fubjed : In fubjeds beyond the prime of life, they often fail. The anatomid knows by the firft touch Of the artery, when it is hard, that he needs not fix his tube there ; and the furgeon often forefees alfo, by the firft touch of his finger in performing his operations, diofe terrible haemorrhages, and burftings of the arteries, which occafion fo much anxiety and diftrefs. In fubjeds beyond the age of forty, we have more reaf- on to be apprelienfive, though we often fee thefe changes in the arterial fyftem, this tendency to diffolution, or at leaft to difeafe, very early in life *. Thus, by the age of the fubjed, the arteries may want a difpo* fition to inflame ; or by the thicknefs of the arterial coats they are not pliant, fo that they cannot be put in contad ; and, whcdi- * Petit cut off the thigh of a gentleman, on account of a com- pound fradure, by which he had been confined eighteen mondis to bed, he found the Femoral artery fo offified, that his tourni- quet had no effed upon it; his ligatures did not draw its fides together, there was no likelihood that caultics or cauteries, or any diing but continued compreffion could have any effed, and he was obliged to invent a machine having two plates, which, by die w.wking oi a fcrew, preffed continually upon the broad face of the * j rap. ON WOUNDED ARTERIES. 71 er they have or have not the difpofition to inflame, they have not an opportunity of adhering—or by the greater caliber of fuch an artery, its circle being wide in its natural condition, is puckered and unequal when it is tied ; fo that by this alfo it cannot fo well adhere ; and I am fure that the tapes, which have been ufed for tying fo great an artery, have often, when tied with the furgeon's knot, been larger in their diameters than the arterial trunk itfelf j and Mr. Dufchamps adually tells us of a furgeon, who could not draw his ligature fo as to flop the'artery, and was obliged on that account alone to cut off the limb. Perhaps it is from natural and unavoidable eaufes like thefe, without feeking for any more curious explanations, that we are to explajn the frequent burftings of great arteries, as in the thigh or ham. We do not know all the caufes, but thofe which we do know, are fuch as fhould make us anxious and watchful in no common degree, with a continual and minute attention to every circumftance in the tying of the artery. Ulceration of the artery is the great, and almoft the fole caufe of its burfting ; for always the artery muft be regarded as a part of die living body, fubjed to the fame affedion with the other foft parts. To enumerate a few of the caufes of this ulceration of the artery, will fuggeft precautions very different from thofe which have hitherto been pradifed ; and will, perhaps, induce furgeons to revive the oldeft method of all, viz. that of tying the artery with two ligatures, and cutting acrofs in the fpace betwixt them. 1. When a ligature is ufed too large for the occafion, the liga- ture being ftiff, firmly waxed, and unpliable, hardly compreffes the artery even at die firft, and no fooner do the foft parts begin to die under the ligature, dian die loop of it is found flack, the ar- tery is not dedroyed, nor its canal obliterated ; the blood runs along, and iffues, as at fird, from the wound of the artery. 2. The ligature, in place of being laid under the artery, after a fair and clean diffedion cf it, is puftied through among the muf- cles and cellular fubftance, with a large and (harp needle ; in or- 72 ON WOUNDED ARTERIES. derto avoid the main artery itfelf, the needle is paffed at fome dif- tance from it ; die ligature is drawn firm, and the artery for the time compreffed ; but, in a few days, die foft parts under the ligature fade, and it lofes all command of die artery. 3. When, in diis rude way, the great nerve is included along with the artery, the danger is not of that kind, which furgeon* have ufually apprehended ; we need not be afraid of convulfion? and locked jaws ; the tying of any artery is fafe in diis refped ; but the danger is quite of anodier kind ; it relates not to the nerve itfelf, but to the artery which is included along with it in the fame ligature ; for the nerve is an indedrudible part ; its firm coats defend it from the ligature ; it is not compreffed like the artery ; it is ndt killed and mortified by the dridure ; it never gives way to the ligature, and the ligature keeping its hold fo long, is fure to produce difmal confequences ; for this is the nat- ural progrefs of the artery tied with a ligature ; that it is dran- rded by the ligature ; the part thus drangled, is foon to be cut off; but while the part of the artery, betwixt the two ligatures, is thus cut off, the part round which the ligature is diredly ap- plied, is only inflamed ; the fides of the arterial canal adhere ; the canal of the artery is clofed, before the ligature falls off. But when the nerve alfo is included in the ligature, the ligature holds its place ; it keeps linn, even after the artery is cut acrofs ; and, by keeping its hold too long upon die artery, the procefs of inflammation is continued ; the ulceration mounts upwards along the artery ; and when it arrives at that point, where the channel of the artery is dill open, and when the ulceration weak- ens the coats of the artery, it burds ; and it fometimes burds from the progrefs of the ulceration, after the ligature has been drawn awayr. *. On this, as on many occafions, the furgeon forgetting that he io operating upon the living—forgetting that it is not the firm. nefsofhis ligature (which mud foon be pulled away) that fu- tures the artery, but that procefs of adhefien of the fides of the ar.erul Lube winch obliterates its canal—Tie fr.rge \ ■'. »•* ON WOUNDED ARTERIES. 79 to you all that remains of this mod intereding fubjed. For, whether I confider the fuddennefs with which thefe embarraffing accidents overtake the young furgeon ; or the frequency of the accidents themfelves ; or the prefent or the remote confequences of fuch a wound ; or the drange things that we read every day, of wounded arteries managed in a trifling, undecided way ; of patients dying, or lofing dieir limbs, even from wounds of the Radial Artery at the wrid ; of furgeons unprepared, uncertain what they fhould do, fometimes diving clumfily with their needle among the flefh, fometimes thrufting a fponge into the wound, fometimes laying clumfy compreffes upon the artery, with litde better (kill, and no better fuccefs than the friends could do ; and worfe than all, of furgeons expofing themfelves, by holding con- fultations, to determine what next to do, or whether to cut off the limb ;—I cannot but think this fubjed very important : And as it is important, I believe it will be well to explain to you firfl of all, the only thing which dands to this fubjed in the relation of a general dodrine, viz. the opinions of authors, concerning the va- rious ways in which bleeding arteries are clofed, (whether by the formation .of a clot, or whether by the retradion of their epen mouths, fhrinking among the flefh) ; for upon this hidory of opinions there follows, in mod natural order, a fhort hiftory of the means that have been ufed for fecuring arteries, as ftyptics, compreffion, fponges, and the needle : But yet on this, as on many occafions, it is really the pradice that fuggefts the dodrine, which then affumes a moft impofing appearance, and feems to be itfelf the root of all the improvements in pradice *. * The juftly celebrated Mr. White relates the confequences of bleeding from the Radial Artery, in the following terms. " The arteries of die wrift, having been cut, had been twice taken up by Mr.------, a furgeon well accultomed to the operation ; and Bo villa and many other things had been tried. After each of thefe methods, the hsemorrhagy (lopped for a few hours, and then frequently burft out again ; efpecially upon the acceffion of a hot fit, to which he was now very liable. On the 7th day, I was call- ed in confultation with Mr. Allan, to take off the arm : we found Lis hand and arm fwelled to three times its natural fize, from the frequent ufe of the tourniquet; which had been under a nectfhtr 80 ON WOUNDED ARTERIES. Mr. Petit was die firft who called die public attention to a point of pradice, which was of particular importance, at a time when the pradice of tying arteries was not fully eftablifhed, when fur- geons ftill had their fears, and were ftill talking about convulfions, and the yielding of the ligature, debating hotly die danger of this operation. Mr. Petit believed, that every bleeding artery was (lopped, on- ly by the formation of a clot ; aftringents made clots, by coagu- lating the blood ; fponges, bovifta, charpie, made clots by ab- forbing die moifture ; compreffes made furcr clots, by (hutting the mouths of the arteries, and by allowing time for the coagula* tion of the blood ; and even the tying of arteries was ufeful chief- ly by forming a clot, but lefs fecure, fince, whenever the ligature came off from the artery, die clot was loofened, when often there was a flighter bleeding, from blood paffing by the fide of the clot, and fometimes there was a full haemorrhagy, from the clot being driven forwards, and at laft expelled by the blood. In a tied ar» tery, fays Petit, we have a conical clot; in an artery which has been compreffed, (fince the artery is flattened like the reed of a hautboy), we have a flattened clot: In arteries flopped by char- pie or aftringents, we have a clot formed, pardy by the contrac- tion of the mouth of the artery, pardy by the effed of the dreff- ing, fo that fuch an artery is (lopped by a fort of double clot, of which there is one part fmall and conical, which, like a plug or cork, fills the canal of the artery, and another adhering to the dreffings, of a flattened form, lying like a lid or cover over the mouth of the artery, but fo conneded with the other, that the rude or early removal of the dreffings, pulls out this cork-like clot. The chief of Mr. Petit's obfervations, for proving the autiienti- of being moved to different parts of die arm, on account of the excoriations it had occafioned. For the laft 2-1 ho rs, it had been applied almoil without intermiffion, from a dread of his bleeding to death, as he had loft a prodigious quantity of blooJ. After the dreffings and clotted blood were removed, we could diftindly fee the mouth of the veffel, throwing, per faltus, what 1 can fcarce- ly call blood, as its colour could hardly be diftinguiflred from lir.- en."—White'i Cas.'.s. ON WOUNDED ARTERIES. 81 cit y of this dodrine, was this, diat, in diffeding the thigh of a man who had died five days after amputation, he found in the great Femoral Artery a large and folid clot. This he prefented to the Royal Academy of Sciences in great pomp : But I believe it were no difficult matter to prove, that this great academy of the preat King of France, Louis Quatorze, was very eafily fatisfied with prefents of this nature ; but, rather than fpeak this kind of language, I fhould choofe to fay, that fuch a proof does not prove his very dangerous dodrine. It is a fad, which every one would do well to admit eafily, whether he do or do not like the dcdrine : for it is not likely that the mouth of an artery fhall be (topped up after amputation, without the blood being coagulated behind the ligature ; nor is it likely that the arteries fhould all lie dead for fome days in a gangrened limb, without the blood alfo lying ftag- nant in thefe motionlefs arteries, and coagulating of courfe. We are not therefore furprifed to find many proofs of coagula being formed in every artery of a gangrened limb, or in the chief arte- ries of an amputated ftump, or in die artery which has been tied for aneurifm ; nor are we furprifed, on the other hand, if in many diffedions no fuch clots are found. It is an accident plainly ; no furgeon depends entirely upon a matter of fuch chance as this ; no furgeon facrifices a gangrened limb, without having fome thoughts about its great arteries, nor is there any furgeon almoft, who has not feen very dangerous bleedings, from imprudent fcar- ifications of fuch a gangrene. Why then fhould Mr. Pouteau* be at fo much pains in denying accidents like thefe, feeing that fuch clots are both fo likely to happen, and are really fo well proved by Hunter, and others ; and feeing diat the formation of fuch clots has fo little to do with that dodrine which Petit want- ed to eftablifh, and which Mr. Pouteau wifhed fo earneftly to re- fute. The proving that clots are formed in arteries, is no proof that it is the clot only that clofes fuch arteries ; but rather, that it is the clofing of the artery that forms the clot. The next proof that Mr. Petit gives of his dodrine, is really very ludicrous ; for * Vid. Pouteau, page 306. T©L. i. E 82 ON WOUNDED ARTERIES. he next proceeds to fetde the value of the various abforbents, by a long fuite of experiments, which he conduded in the following manner :— " Aftringents raid furir fubftanccs, as ufually are em- ployed for (launching the blood of wounds, furely muft do fo, fays Mr. Petit, chiefly, by abfoibing drat humidity, which lies be- tween the veffels and the fleih*." Petit made all his aftringents abforbents, chiefly that dicy might drink up the thinner parts of the blood, and fo help to form for him good, ftiff, folid clots : he puts lumps of mutton into tea cups, v.idi a reafonable proportion of the following aftringents : irril of common bole, then of terra figillata, which is a finer earth or bole, then of Paris plafter, then of flacked lime, then of various gums, then of grnr-arabic, then of vitriol, dien of fait, then of fugar, and laft of all, of fpider's webs ; and obferves, with moft curi> us precifion, the exad degree in which each of thefe ufelefs, foolifh things contraded, or hard- ened the la raps of mutton ; which experiments are ftill extant in excellent French, in the Ads of the Academy of Sciences, for the year 1732 ; a perfed builefque upon fuch experiments, and fuch fubjeds : And towards the end <1" this moft philofophi- cal paper, Mr. Petit inferts this wife caution, which completes die joke. " But all thefe aftringents muft of courfe abforb more humidity, and ad in a more lively and perfed manner in the liv- ing body ; whofe parts are always warm, and always ready to put themfelves in motion, by the force of the animal fpirits, which are continually flowing."f But I fhould want all apology for this long account of Petit, and of his dodrine, if it were not that it is a dangerous dodrine, and had abfolutely led Petit himfelf in- to great miftakes ; he perfuaded himfelf that the ligature was hardly more fecure than any common means of fupprefling bleed- ing ; that it was only fo far ufeful, as itenfuved a firm and coni- cal clot ; that if the ligature fell eff before diis clot was fully * Vid. Acadcra. des Sciences, Ann. 1 Y;'>2, page 321. f Tous ces aitriagents doivent abforber plus d'humiditc et agir plus efficacement, fur les parties d'un corps vivant, qui font chaud^s, et toujours pretes a fe mettre en contradion par les ef- prits u.-hai.uu qui y coulcnX iaceffamment. ON WOUNDED ARTERIES. 8.; formed, and perfed in its office, the artery would bleed. lie therefore preferred the ufe of a comprefs, to that of a ligature, even in fecuring the arteries of a great dump : And we find him boading that, though this method, viz. of compreffion, is the old- cd of all, he will give to it all the effeds of novelty ; and fince it is the mod natural way, and the very means which fhould have prefented itfelf, fird of all, to the imagination of the furgeon, I will redore it, fays Petit, and fet it up above all other means ; as cauteries, adringents, fpongcs, or even the ligature itfelf**" There is not one of all thefe, fays Petit, that is fufficient of itfelf ; we mud ufe the comprefs, to affid even the ligature. We have here a mod curious example of a man's genius and his good fenfe at variance with each other. His theory feduced him, his good fenfe would have kept him right; we find him forcing himfelf, as it were, to fay, " I will ufe the comprefs in preference to the adringents, dyptics, caudics, or even the liga- ture itfelf; wherever it is poffible for me to do fof ;" which is plainly acknowledging, that he would ufe that kind o£ uncer- tain operation, to which his theory inclined him, wherever he was not forced, by the immediate danger of the cafe, to return to fome furer means of redraining the blood. And in one particular cafe where, after amputation of the thigh, the great Femoral Artery had, by a fudden motion of the patient, given way, we find Mr. Petit fo averfe to the ufe of die needle, that he would not tie this artery a fecond time, he kept his patient for many days in a very unhappy and very dangerous condition; attended by four young furgeons, who relieved each other every hour, continually preffing with the point of the finger upon the moutii of the artery ; till, at lad, he got a machine made, a fort of clumfy, complicated tourniquet, which, by die help of two broad plates, kept up a firm compreffion upon the whole face (f die dump. ■■ Vid. Podhumous Works, page 16*, Vol. III. f Soitpar rapport a l'ufage exclufuque je lui donne, en rejet- r.mt celui des aftringens, des ftiptiques, des cauftiques, et de la lig-iture meme, autani qu'il est possible. 64 ON WOUNDED ARTERIES. If thefe pradices, and the invention of fuch machines, are to h • die beft fruits of fuch dodrines, we fhould be careful Ivuv we re- ceive the other dodrines which have followed this in a i apid fuc- ceffion. Next comes Mr. Mor .ad, who adds his little bit of a dodrine to Mr. Petit's, which, whether true or falfe, was framed upon a grander fcale. " No doubt," fays Mr. Morand, " Petit h.as ex- plained vaftly well how the clots ftop bleeding,* but thefe clot" cannot be the worfe for fome help from the artery." I think I (hall be able to give you a tolerable idea of what his confufed no- tion was, in one fingle word: for, it was neidier that contradion of the diameter of the artery, which has been fince then {o dif- tindly made ©ut by Kirkland, White, and many of our bed En- glifli furgeons ; nor that-retradion cf the artery among tire fur- rounding flelh, which has been fo much infilled upon by Pouteau and other good authors ; but an equivocal generation betwixt diefe two ideas floating confufedly in the man's mind. You have his notion all at once, when I tell you, that the word, by which he always expreffes it, is the crifping up of the artery, " par hi crifpation du tuyau :" And he can tell no more about it, than that this cabaging of the artery affifts the clot. Next came Mr. Pouteau, whofe experiment; and reafoning ap- proached indeed nearer the truth; but always a man lc.doni firft, and makes his experiments alter ; and this is plainly the light in which his diffedions are to be viewed. " I have diffeded a Femoral Artery, fays Mr. Pouteau, three weeks after it had been tied in amputation ; but in it I found nodiing of Mr. Petit's clot ; nothing to clod; or comprefs the ar- tery, except merely the thickening of die furrounding cellular fubftance ; for the ligature was loofe about the artery. The can- al of the artery was conical, for it grew narrow neaier to the lig- ature. Immediately under the ligature it was not obliterated but was much ftraitened : It was only below the ligature that it was entirely ftraitened, ending in a blind fac." This itraitcning * Memoirs dela Soclete Rovr.le des Science, A;:. 17SC, p?g' Z2\. ON WOUNDED ARTERIES. 85 ri the arterial tube was accompanied, or rather, according to Mr. Pouteau, was caufed by a thickening of the furrounding flefh: for the flefh which furrounded the ftraitened part of the arte- ry, was a good deal gorged and fwelled ; that, which lay im- mediately under the ligature, was in a (late of gangrene ; the flefti again, which adhered about the mouth of the artery, where it ended in the blind fixe, was of a cartilaginous hardnefs and much fwelled. Of courfe, it was Mr. Pouteau's opinion, that it was the fwelling of the furrounding cellular fubftance that compreff- ed the artery and (topped the blood. This, then, being the dodrine of Mr. Pouteau, his pradice fol- lows his dodrine reafonably enough : for, fays Mr. Pouteau, " Let it be once proved that it is the fwelling merely of the parts furrounding the artery that prevents the blood, it follows, of courfe, that the greater the bundle of flefh that is accumulated round the artery ; the more of the parts you include in your ligature, the greater the fwelling muft be, and the refiftance t& the irruption of the blood muft be proportionably great*. Mr. Pouteau is cunning enough to (how us only an arterial trunk tied coarfely with die needle, with much cellular fubftance furrounding the artery above the ligature, and fome below ; and thus he takes his opportunity of infmuating his dodrine, by fay- ing, " there was much cellular fubftance thickened above the lig- ature, and diere was a like thickening of the cellular fubftance below ; and die artery was not obliterated at the point where the ligature-was, but only its mouth was clofed." But what is to be faid of thofe cafes, where there is little cel- lular fubftance furrounding the artery above, and none below ; where die artery is drawn out with the tenaculum, and tied clean of all the furrounding flefh, and what would happen in this cafe, if the artery were net obliterated at the point, where the ligature compreffed its coats ? This dodrine of Mr. Pouteau fcems at * Mais s'il eft une fois avCic que le gonflement des parties au deffous de la ligature, fair le principal obltacle a l'irruption du fane art»r il, il fera naturel de conchire, que plus ce gonflement fera conliderablc, et plus il oppofcra de reliitance a l'impetuohtc du fang arteiiid. 8(5 ON WOUNDED ARTERIES. leaft to be harmlefs ; it feems to inculcate the tying of arteries with die needle in die fureft way. But, here alfo there is a villany infeparable from all falfe dodrines, which lead us unawares into very dangerous and very extravagant pradices, fuch as, in our cooler moments, we cannot remember but with regret. Mr. Pou- teau infilled upon including all die parts ; he had no fcruple, under this ample tide of all die parts, to include the nerves ; he confidered the tying in alfo of the nerve, as a fecurity to the tied artery, or, I fear radier, he conceived that it would be a fe- curity to his dodrine ; and fo he proceeds to reprefent the tying of the Radial Nerve in an aneurifm, as nearly harmlefs, and die tying the extremity of die nerve in amputation as quite fo ; till at laft, hardened by bad pradices, and blinded by dodrine, fome furgeons of die very higheft charader came, as it were, to play with our judgment, and to fport with their patient's feelings, fay- ing ; " May not the pain upon tying a nerve, as it is fmart and of fliort duration only, fomewhat in the manner of volatiles appli- ed to the nofe, radier enliven the fpirits, than bring on convul- fions*." This is enough to cure any fenfible man of any inclina- tion he may have indulged, to hearken to thofe who blend theory and fads in this ftrange fafhion, who compare die fmart pain, or rather, as I would term it, the (hock and terrible violence of tying a nerve, with fo flight a matter, as the fnuffing hartfhorn up the nofe. Let any man, who will talk to me on this point, firft dem- onftrate that the tying in of the nerve will do good, before 1 clofe with him upon the fecondary queftion, whether it may not do harm. I have conftandy obferved, that die tying of a nerve gives immediate pain ; fo that the patient has always cried with the anguifh of it ; and, to fay the leaft of it, there is vw r a flow feparation of the ligature, fo that it is not to be got away, till it be cut out. How elfe indeed fhovtid any ligature hold its place, upon an amputated ftump for three weeks, as this of Mr. Pouteau did, uniefs it were tied round the nerve ? I have feen * Kirhland, p. 22. ON WOUNDED ARTERIES. 87 fuch confequences arifing from tying the nerve in aneurifm, as I am not at prefent entitled to explain ; but which make it a duty with me to advife you againft this pradice, which is at leaft fu- perfluous, if not hurtful. Amidft all this confufion of opinions, there was engendered here, in England, a new dodrine, about the contradion of arteries ; bearing no other mark of authenticity, nor any thing elfe to com- mand one moment's attention ; but that it has been embraced by fome of our moft able furgeons, efpecially by Mr. Kirkland, and by the celebrated Mr. White ; " For I am now convinced, fays Mr. White, in oppofition to the dodrine of Mr. Pouteau, which once feemed more probable, that, according to the fuppofition of Mr. Gooch, fince confirmed by my ingenious friend Mr. Kirk- land, the arteries by their Natural Contraction, coalefceas far as their fird ramifications*."-----Mr. Kirkland fays, in perfed harmony with Mr. White, " that nature fuppreffes the haemorrh- ages from divided arteries, by the natural contradion of thei mufcular fibres," p. lOf. But if it really were fo, this conclu- * Page 171. f Mr. Aitkin Warrington is alfo of the fame opinion, as may be feen in his pamphlet, p. 173, where he fays, *' That the ob- literation of the fac, in the extremity of die artery, is caufed by its natural contraction." They have been at great pains to found this dodrine on principles and fads. The only fads are the docking of horfes' tails, and the cutting off their legs. Thefe are to be found in Mr. Kirkland's Treatife ; and the only principle, that is to fay, the only general fad, which I have ever yet been able to difcover, is, that an artery clofes, not only immediately under the ligature ; but for a confiderable way above, that is, up to the nearelt inofculating branch. The clofing under the ligature is plainly the work of the ligature ; the obliteration of the canal, higher than the ligature, is fuppofed to arife from this contradion of the artery. The explanation that I fhould choofe to give of the appearance, is this; That the contradion under the ligature could not be permanent ; that the artery would open the very moment the ligature was wididrawn, if its fides had not adhered. The clofing under die ligature, therefore, I confider as the adhe- fion, which follows the ftridure. The obliteration above, I con- fider as a thickening, or continued adhefion, by the iufaaimade«! going a little forward along the arterial coats. 88 ON WOUNDED ART 1.HIES. fion fliould follow, more dangerous tlian the rafli conclufions of Mr. Petit, diat the comprefs or die flighted aftringent would be more effedual dian die needle ; and diat keeping die point of the finder for a few minutes tfpon the point of any (mailer artery, until it had time to contrad, would be quite fufficient to (lop die blood. This contradion of the artery, an accident which cannot or need not be denied, does more harm than good ; if it ever fup- prefs bleeding, it muft be only in arteries of die fmalleft order. the bleeding from which (tops thus fpontaneoufly, and needs ne particular care. But the contradion of a larger artery often (lops the bleeding for a time ; its retradion among the cellular fub- ftance hides from the furgeon d*e arterial moudi from which the blood had flowed ; and thus it bleeds again unexpcdcdly, endan- gering the patient's conftitution, or even his life ; if the (kin heal over it, it forms aneurifms under the (kin ; or, where the (kin has not healed over it, I have feen it form a fort of aneurifm among the foft granulating flefh. From all that we have feen, we have reafon to be jealous of any dodrine, which tends to laxity of pradice, in rcfpcd of tying even the fmaller arteries ; or which holds out any fuch apology, as die contradion of arteries, or the formation of clots. No mod- ern furgeon, I believe, would think his bufinefs fecurely done, while he conceived any great artery to be fecured merely by a clot; nor will any fenfible or cautious man be eafy, when he has miffed a bleeding artery, or while he is waiting till it contrad : Nor will any man who has that degree of dexterity and boldnefs, vhich the management of bleeding arteries requires, be fatisfied, un- til he has tied every artery fairly, unlefs it be in fome very diffi- cult or dangerous place ; for it is only to the adhesion and total obliteration of an artery, that we can truft with fafety : How this is beft to be procured, may, I think, be made very plain. We find an artery as capable of influrr.rnation, as any ether part of the body. We find an artery defcribed by Mr. Hume us infiar.i.d, not only at the point, where it was tied for a Feme- ON WOUNDED ARTERIES. 53 ral Aneurifm, but alfo onwards from that point quite up to the heart.—If an artery, infenfible as it is, be thus fufceptible of in- flammation, we know, a priori, that the tying it fo hard as almoft to cut through its coats, will always, or almoft always, make it inflame. We have it proved by Pouteau, Kirkland, and others, who intended to prove nothing more than the contradion merely, —that its coats are thickened, and that its canal is obliterated under the ligature, and contraded above it, to a degree which their dodrines of natural contradion or retradion of the artery will never explain : All this is proved by furgeons, who contin- ued talking about the contradion and the retradion of the artery, after they faw evidently, that the internal furfaces of die artery had adhered*. And finally, the procefs, as it goes on in nature, is plainly declared by the effeds of our common operation of aneurifm of the arm ; for there we apply two ligatures, which include the length of two inches of the Arterial Trunk ; they are drawn tight upon the artery, one above the point wounded by the lancet, and one below ; and bodi thefe ligatures come away eafily (and without our cutting the ring of the ligature) upon the third or fourth day. How is it that they come away fo eafily ? How is it thus poffi- ble to remove them, without cutting open that ring of each liga- ture, by which the artery was encircled ? What becomes of the interrupted part of the artery itfelf ?—Surely it happens here, as in all other cafes, in which we apply a ligature, that die part * " Another woman, fays Mr. White, having died three weeks after the amputation of her leg ; I was defirous of feeing in what ftate the arteries were, after the ufe of the fponge ; and, for this purpofe laying bare the Humeral Artery, I cut it open to die place where it divides into die radial, and ulnar branches : I then introduced a common filver probe into each branch, which paff- ed very eafily to a certain point, which feemed about an inch from the extremity of the ftump ; but could go no fardier. I next laid open the arteries to their extremities, and found them entire- ly clofed, near an inch from the end of die ftump ; but from that point upwards, their capacities were not at all diminifhed, nor was there any coagulum or clot of blood in the veffels, or any where near them." N id. White's Cases. TOL. !. M L-i) ON WOUNDED ARTERIES. intercepted by the ligatures is killed ! Firft, The pulfe ceafes up- on drawing the knot of each ligature, which proves that the fides of the artery are compreffed. Next the intermediate piece of the artery is fairly killed, rots like a polypus tied in a noofc ; and, as a polypus fades on die fecond, and drops away on the third*or fourth day ; in like manner, this artery decays, mixes with the pus, leaves the ligature (lack on the fecond, and allows them to be withdrawn eafily by the fourth or fifth day. And moreover, it is very obvious, if the artery be thus cut acrofs by our ligatures? as fairly as the older furgeons cut it acrofs with dicir knife, that its two ends muft each have adhered ; otherwife, upon drawing away the ligatures,' a haemorrhagy muft enfue. Mr. Petit warns us that even the ligature is infecure; for if the lig- ature, fays he, falls offbefore the clot within die artery be ftrong in its oflice of (topping the artery, the artery will bleed : But diis premature falling off of the ligature, which he apprehended, can- not happen until the ligature has done its bufinefs effedually ; or, in other words, one part of the artery will not rot, or give way, before the parts of the artery above and below the ligatures have adhered. Perhaps die whole procefs may be reprefented in few words. The ligatures operate, by making the feveral points of the arterial canal pafs through" the feveral ftages of inflammation, from adhe- fion in one point, to gangrene in another. The fpace included betwixt the ligature falls into gangrene ; the fpace immediately under the (tridure of each ligature adheres, (the ligature and the adhefion preventing the gangrene from paffing higher along the canal) ; and by this inflammation extending upwards and down- wards along the artery, its walls are thickened, and its canal ob- literated a little beyond the draitened point*. The adhefion of * We find the following account of this procefs in Kirkland, p. 5. " An aneurifm of the arm, being in great danger of burding, obliged me to perform the operation : The impulfe of the blood againd the ligature, at the time of the operation, was very great; and'as a part of the artery (whofe diameter was confiderably en- larged) was expofed, its pulfations were vifible ; but, upon re- moving die dreffings the third day afterwards, the pulfation could neither be feen, nor felt nearer to the ligature than an inch ON WOUNDED ARTERIES. 91 the artery and obliteration of its canal, are, in aneurifm as in am- putation, or in other wounds, the only fecurity againd bleeding ; and the ligature or comprefs is the only way in which fuch adhe- fion can be enfured ; and there needs no more than two fhort rules on this fubjed, the tendency of which is very plain. 1. If we are to try it with comprefs, let it be chiefly in thofe accidents, and in thofe parts of the body, where we have a good refiflance, as in the temple, the wrid, the tarfus or fore part of the foot, where we can feel the artery lying naked upon the bone. Let the comprefs be a firm and hard one, deadily applied, well preffed with a roller, fo fixed as not to permit one drop of blood to pafs along the canal of the artery, nor to efcape from the wound ; for that would defeat the intention. Let there be a tourniquet round the limb, and attendants appointed ; for fome have died du- ring the night *. Let this compreffion be continued thus deady and a half ; whence I was led to conclude, that the artery had collapfed and gradually clofed itfelf up to the neared lateral branch- es." I have obferved, after I had performed the operation for aneur- ifm, that, on the third day, no pulfe was to be felt at all in the wound ; but I never confidered this as in the lead wonderful, feeing how very probable it is, that by that time, the ligature muft have cut acrofs the artery, the artery mud have flirunk, and its canal mud have been obliterated confiderably beyond the place to which it has flirunk. But there is alfo another thing particular that Mr. Kirkland, and Mr. White infinuate upon all occafions, that the artery is obliterated juft up to the firft inofculating branch, and always up to it. Mr. White fays,—" In the arm I have by me, on which the operation for aneurifm had been per- formed, it is plain to a demonftration by the injedion, that the ar- tery was clofed, bodi above and below the ligature, to the next lateral branch." His preparation was, at that time, the only one in exiftence ; " but I have now by me," the preparation from the a: ei of a man who had formerly had the operation for aneurifm performed upon him, and it is fo particularly like Mr. White's, diat, if I were to give a drawing of it, it would be thought to be a mere plagiarifm ; but in this very curious point it differs, that the in- jedion, though coarfely done, and in great hurry, has paffed the great inofctilation, (for in my preparation, there is but one great inofculadon to fupport the limb), it paffes it a full inch and a half, terminating in a blind fac. ': We find, in the following tranfeript from Murray, two very 9> ON WOUNDED ARTERIES. till the fourdi or fifth day, for that is the term which we find ne- ceffary for obliterating die artery and enlarging the inofculaticn in aneurkms of the arm ; and it is fufficient : for we find die di- lated artery of the thigh itfelf, obliterated by compreffion on the Angular things : In the firft place, we find two p.itieni . allowed to die of bleeding, during the night, after fome awkward attempt at curing the aneurifm of the arm, in which, according to die oldeft falhion, they had tried compreffion not above the (kin, with the hopes of faving their patients from the pains and horror of a bloody operation ; but had firft cut up the aneurifmal tumor, and then, inftead of tying the artery widi a ligature, had applied a comprefs, and applied it fo infecurely, diat both the patients, from fome unwary motion in deep, had bled to death during the night. This is his fad ; and his opinion, as it is plainly implied in the following words, is very curious. " If your compreffion be too powerful, in place of faving the artery, you will abfolutely oblite^ rate the artery ; but if you comprefs lighdy with defign of faving the artery, you are never out of danger of an alarming, or even fatal haemorrhagy." This language very clearly implies, that Murray, like mod others, expeds from compreffion not an oblite-. ration of the artery, but thinks, as Heider did long ago, and Mr. Morrand more lately (Vid. Acad, des Sciences, Vol. V. p. 172. odavo), that the comprefs, by fuppreffing the quick motion of the artery, heals the wound, " Murray fpeaks thus : Frudra itaque, fi firmam compreoffi- ncm indituinru ;, confervationcm arteriae expedamus, in leviore au- tem, qualis ad fcopum obtinendum requiritur, hacmorrhagiae re- pctitar quae chirurgi animum quam maxime follicitant : atque eti- am rrrrum ad ultimam fixpe metam detrudunt, vi\ evitari poffuit, leviori fub fomno, motu brachii, quo compreffio aliquantum fuit perturbata, binos aegros Montifpeffulani vigelimo poll operation- em die, haemorrhagia exitiali correptos fuilfe, narravit eel. Praffes. (viz. Murray.")—Vid. Arvidfon Murray, p. 20. All authors have believed that, when they cured aneurifm by com predion, or by fponges, they healed the wound of the artery. Mr. Morrand, of die French Academy, fays, in the following paf- fage, that he cured an artery wounded with the lancet, in a man- ner very different from that in which we ufe the ligature. " I need not, fays Mr. Morrand, mention the feveral precautions which I took after applying Mr. Broffard's agaric to die artery." I lhall only obferve, that the pulfe, which was interrupted for twen- ty hours, returned at th.e end of drat time, and that 1 cicatrized the wound in a month." " Je dirai feulement que lc poulx inter- cept l* a la main pendant environ vingt heures, fe manifeda an bout de ce temps la," che. p. 16s. I dare fay my reader has a tolerable notion what this interruption of die pulfe means ; and what Mr. Morrand was doing widi his puff-ball. # ON WOUNDED ARTERIES. v'j fourth or fifth day. Be bold enough alfo, if it be the great arte- rial trunk of the limb, to draw your rollers till the limb be abfo- lutely without pulfe, and cold : for this operation with die com- prefs, though apparently mUder, is quite the fame with tying the artery with the needle. 2. If it be your defign to obliterate the artery by ligature, your bufinefs is more eafily and furely, and rather more quickly dcr.e. You mud fee your bleeding artery fairly, tie it clean and clear of all furrounding parts ; tie your arteries with ligatures well pro- portioned to their dze, not clumfy and rigid, but rather final], pcr- fedly flexible, and moiflened with oil, that they may glide eafdy ; draw them pretty tight, fo at lead as to lay the fides of the artery in contad, and till you fee a pulfe above your ligatures, and none below ; but never draw diem fo as to run the rifle of cutting the artery". Hence, I think, the general conclufion is, that if you under- ftand the principle of your operation, and do it with the proper precautions, you will be fure to make good your point, whether you tie, or whedier you comprefs the artery ; and this eafy adhe- fion of an artery I take to be die chief reafon why every man hitherto has been pleafed with his own litde difcoverie-, and every furgeon is ftill pleafed with his own mediods, whether they be 01 be not perfedly regular and corred. But, in this great fubjed, there is yet more to do ; for there- are many accidents in which we cannot operate with the comprefs or with the needle, in which we muft ufe the dyptics, puff-ball, or fponge : And, of courfe, it may be right to give you a fhort ac-. count of thefe means of fuppreffing bleeding, for difputes about the caufes by which bleeding arteries are dopped are ufeiefs, and to thofe who delight in thern, endlefs ; unlefs there were found fome one Catholic authority", by v. lich the points might be feu tied at once : But we ought to be chiefly def.rous of knowing the means by which diis end is acccmpliihed. Though there ate four 9* ON WOUNDED ARTERIES. chief methods of fuppreffing hccmorrhagy, viz. cauteries, aftring- ents, fungi, and the ligature, there is one only, viz. the ligature, that is abfolutely fecure. 1. Burning Irons were ufed by the ancients, merely becaufe they knew of no odier means of fuppreffing the bleeding ; and we cannot wonder that die ancients were fo curious in the degree of heat : or in the way in which it was to be applied ; or in the (hapes of their irons, which were conical, that they might touch nothing but the point of the bleeding aitery ; nor in the choice of their metals, preferring fuch as were fufceptible of only a moder- ate degree of heat: for if they heated their irons too little, they did nothing ; there was no efchar formed, and the bleeding was not flopped ; if they burnt too much, the flough, though fully formed, fell off almod as foon as the iron was withdrawn. But let diem burn ever {o cautioufly, the (loughs were to fall offfoon- er or later, and it made little difference whether they fell off on the firft or on the fecond dreffing, on the fourth or on the eighth day ; and, as they were in continual fear of this, they never undid the wound, without having a tourniquet round the limb. At every dreffing the patient was tormented with the irons, and at every fucceeding dreffing he lod more blood, fo that the lad con- dition of that man was wrorfethan the fird. It was in thofe times that the invention of a new cautery, or a new fhape for the iron, was thought meritorious. It was then, alfo, that Fabricius ab Aquapendente, publifhed his new method, as he calls it, of cutting out a cancerous bread : " For if it be a moveable cancer, I cut it away," fays Aquapendente, " with a red hot knife, which fears or burns as it cuts ; but if it be a cancer adhering firmly to the thorax, I cut it, without either bleeding or pain, with a wooden or horn knife foaked in aquafortis, with which, having cut through the fkin, I then do the red by dig- ging out the gland with my fingers *." Thefe are methods real- * Ego autem, etfi nil tale fa cere molitus fum, fi effem fadurus, W dob .-rem primo vitarem, ct fanici profufionem, fi cancer lit r:c-b:!i-s ; dim .'bre;pe hoc apprehend) datim cidtre, uno eodenieu- ON WOUNDED ARTERIES. 95 ly deferving of the encomium which Mr. Dionis put in the au- thor's name. " They have chiefly the merit, fays Dionis, of kill- ing two birds with one done." " On ferait d'une pierre deux coups *." But it mud not be forgotten that there are cafes where even this horrid method may yet need to be ufed, as in bleedings from the gums, cheeks, palate, or tondls, or other parts within the mouth. 2. The Styptic Solutions, powders and doffils of various kinds, came next into ufe ; for furgeons, pradifmg chiefly the ac- tual cautery or hot iron, were naturally led next to think of the various fubflances, which are ufually called Potential Cauteries, and which are chiefly metallic or earthy falts, as filver caudic, vitriols, corrofive fublimate, alum, or the mineral or vegeta- ble acids ; which are, when diluted, gentle dimulants, or, as they are called, adringents ; exciting contradion of the veffels, and forming coagula upon the bleeding furface. Before furgeons came to ufe the needle freely, they often truded to cauftics^ but, in ufing buttons of vitriol, or little bags of it in powder, applied to the end of each artery, they found that, by this method alfo, the end of die artery was dedroyed, as by the burning irons, and floughed off, and required the application of the tourniquet, every time that the dreffings were undone, and, at each dreffing, the ap- plication alfo of new vitriols. Even after they came to ufe the needle freely, it feemed to be a harfh method. Surgeons were (lill hoping to find fome lefs painful one; which eafy and credul- ous temper, in men of our profeffion, has given the tone to thofe tempore candente et incidente opus peragerem, ut forcipe valide condringente fenfus partes hebetetur, cultro incidente amputetur cancer, et eodem candente fanguis fupprimatur. Quod fi cancer maniillx adherens et firmus fit, neque dringi poffit, excedendus omnino ed, atque ad vitandum et dolorem et profufionem, exce- dercm cum ligno aut cornu, aciem habente intindo tamen fubinde in aqua ilia, qua aurifices ab argenteo aurum feparant, quam for- tem vulgus nominat, quotota cutis in circuita mammillae inciden- da ed, podca digitis potiffimumet unguibus mammillae glandulo- fa fubflantia a fubjeda parte feparanda. * Dionis, page ?>