CHAP. I. Of the natural or spontaneous suppression of Haemorrhages from divided arteries.

WHEN agaric of the oak was first introduced in England, for sup­pressing the haemorrhage from divided arteries, I made several experiments to try in what manner it pro­duced its effects; and I was soon convinced, that it had no other property than that of ad­hering [Page 2]close to the mouth of the vessel: this circumstance, together with considering how often the smaller arteries close themselves by their own natural contraction, and that it was common for very considerable arteries to be closed in the same manner, when the impulse of the blood was abated by the swooning of the patient ^*, led me to imagine that the same thing must of course happen in the large arteries, provided the passage of the blood through them be first intercepted for a time, and that the close contraction which was ob­served in those arteries ^† to which the agaric had been applied, was intirely owing to the course of the blood being impeded by block­ing up the end of the vessel.

Every day's experience confirmed me in this opinion; for I found that the flux from very considerable arteries was easily and ef­fectually suppressed by only making a per­pendicular pressure a few minutes upon the end of the vessel.—But, in order to be more [Page 3]certain about this matter, in the latter end of the year 1755 I made the following experi­ment.

After tying a large horse down, Mr. Peale of Maidstone, then with me, took off one of his hind legs about the middle of the thigh: immediately upon the bone being divided, the horse drew the stump towards his body, at which time the tourniquet slipt off, and five arteries, the least of them about the size of a wheat-straw, some near as large as a goose­quill, and one much larger, poured out with great vehemence; but an immediate stop was put to the flux by a person pressing with both hands upon the wound; and by continuing this pressure fifteen minutes, the vessels be­came so firmly closed as not to discharge the least drop of blood. However I passed a needle and thread round one of the largest, intending to make an experiment with the ligature.

The pulsation at first was very plainly seen at their extremities; but after some time it became less perceptible, and the wound was [Page 4]covered with tow, which was kept on with very slight bandage.

The horse was kept alive forty-eight hours after the operation; and though he tumbled about and struggled much in attempting to raise himself up, yet there was not any return of the haemorrhage, nor did there appear the least pulsation.

After he was killed we dissected the thigh, and found that the bleeding was not sup­pressed by congealed blood, but by all the vessels being quite close contracted for near an inch or more from their extremity.

After this I made more experiments of the same kind upon brutes with the same success, and always found, upon dissection, the ends of the vessels close contracted for a consi­derable way: by removing my fingers from time to time, while I pressed upon the vessel, it was easy to discover this contraction taking place by a gradual decrease of the stream of blood; but in August 1757 the following case gave a further light to this matter.

Jos. Ayre of Caudwell, about twenty years of age, in being bled had the misfortune to have the humeral artery opened along with the basilic vein, and the operator with much difficulty suppressed the haemorrhage by ban­dage: however a tumor with great pulsation soon began to arise in the part wounded, which in six or seven weeks increased to the size of a pullet's egg.

The nature of the tumor was at once evi­dent, and an eschar on the upper part of it being upon the point of separation, deter­mined me to perform the operation for the aneurism.

The impulse of the blood against the liga­ture at the time of the operation was very great; and as part of the artery (whose dia­meter was considerably enlarged) was exposed, its pulsation was remarkably visible: but upon removing the dressings the third day after­wards, the pulsation could neither be seen nor felt nearer to the ligature than an inch and half; whence I was led to conclude, that the artery had collapsed and gradually closed itself [Page 6]up to the nearest lateral branches, as the re­sistance towards the ligature abated from the blood passing through those vessels.—And it appeared to me self-evident that nature always took this step to suppress the haemorrhage from divided arteries, when I reflected that the same circumstance constantly happens, when the umbilical vessels are divided at the birth of the foetus.

However, as I did not look for the lateral branches in the experiments mentioned, I cut off another horse's tail near his body, and sup­pressed the haemorrhage by pressing a few mi­nutes with my fingers; and by a careful dis­section the next day after he was killed, I found that the conclusion I had drawn was (in this subject at least) perfectly right.

Is it not owing to this cause that an hae­morrhage does not follow those mortifications, where the greatest part of the limb is de­stroyed and separates? For if the great vessels were closed no farther than where the morti­fication ends, a flux of blood must of course ensue upon the coming away of the dead [Page 7]parts. Is not this evinced in a case lately pub­lished by Mr. Antrobus ^*? where, though the mortification stopped only two inches above the ancle, yet it is probable that the large arteries closed themselves as far at least as where the femoral artery divides below the knee; because neither pulsation nor hae­morrhage appeared when the leg was taken off.

It will not, I imagine, appear at all sur­prising, that the closing of the end of the vessel an inch only, or perhaps less, should be sufficient to resist the force of the circulation, when it is considered, that this impulse against the end of the artery immediately becomes less, and soon intirely ceases, from the blood upon meeting with resistance dilating and passing through the nearest lateral branches; as is fully evident from the gradual decrease, and at length the total disappearance, of pul­sation.

Nor is this contraction of the artery and the alteration in the course of the blood long in taking place, as appears from the experi­ments mentioned: and besides these, in many instances I have observed, that arteries as large as those we commonly meet with in cutting for the stone, or in taking off schir [...]ous breasts, &c. will for the most part, if they are wholly divided, be effectually closed by pressure in three or four minutes. And if in taking off a leg, we intercept the course of the blood longer than is usually done, most of the ar­teries will often be closed, if the patient is in a tolerable good habit, as I have learnt by tying the large vessels without loosening the tourniquet.

I took off a woman's leg near the middle of her thigh, and tied the large artery with­out loosening the tourniquet; upon setting it at liberty, we observed some blood draining down the muscles from one artery only, and though it had contracted itself so much as scarce to admit the passage of any blood, yet by the pulsation it appeared to be a very con­siderable [Page 9]vessel, and on this account the li­gature was used.

Several more, which did not bleed, were discovered by a strong pulsation at their ex­tremities; and therefore, instead of immedi­ately dressing the patient, we waited ten or fifteen minutes, and gave her wine to raise her spirits, so that we might see whether they would bleed or not, and thereby prevent our being alarmed with a fresh haemorrhage after she was put to bed: but during this time the pulsation gradually disappeared, and the bleed­ing was effectually stopped.

Indeed, since I have attended to this cir­cumstance I have seen it so often happen, that I am well convinced in amputations larger vessels have been trusted with lint and flour than has generally been imagined; and that when a fresh haemorrhage returns some hours after an operation, it is not from small arte­teries being dilated by an increased motion in the blood, as has generally been thought, but to the principal lateral branches which had closed themselves being again forced open.

That the large arteries are also closed in a very little time, does not only appear from the experiment made upon the horse's leg, but likewise in several of those cases where the course of the blood was intercepted, either by the application of agaric or other fungous sub­stances, especially a case related by Mr. War­ner ^*, where, ‘"in an hour after the opera­tion, the mouths of the vessels were found totally contracted, so as to resist the whole force of the circulation;"’ after which they probably, like the umbilical vessels, shrink into a perfect cord, and become impervious.— And does not nature seem to point out, that intercepting the passage of the blood for a while, is all that is required from art; as some animals by instinct, in separating their young from the placenta, lacerate the cord with their teeth, whence probably the ragged fibres stop up the end of the vessel by col­lapsing over each other?

Seeing then that nature suppresses the hae­morrhage from divided arteries by the natural [Page 11]contraction of their circular fibres, when the impediment to this contraction is removed, by intercepting the impulse of the blood, let us fairly enquire what method best answers this purpose, beginning with the ligature, on account of its having been long in general use.

CHAP. II. Of the Ligature.

THE success which has hitherto in ge­neral attended the ligature, is a full proof of its efficacy; and it is evident no­thing can more powerfully intercept the course of the blood, provided it can be properly ap­plied: and though it seems to have been a general opinion, that the vessel only unites in that part where the stricture is made, and preference has on that account been lately given to other remedies ^*; yet I imagine, from what has been said, it will readily be conceived that it is also in this case closed by its own natural contraction, and which will be found true, if the end of the artery can be discovered.

But this is often difficult, it being at first commonly covered with the swelled muscles, [Page 13]and after some time sends out (like all other parts) new flesh, and cannot be distinguished: therefore as a proof, I shall observe that the artery which was tied in the horse's leg, was net only closed below, but also at least half an inch above the ligature; so that every ad­vantage possible, in regard to stopping the blood, is obtained, provided the end of the vessel does not separate and come away with the ligature; for though no inconvenience will follow, if the stricture is made some dis­tance from the lateral branches; yet, if it happens to be very near, a fresh flux of blood must ensue, which is probably one reason why there are some few instances to be met with of the arteries bleeding again some time after they have been tied.

But, from attending several years to this particular, I find that the end of the vessel does not so often come away as is imagined, and that a separation may be generally avoided, as it only happens when the ligature is thin, and very little substance is comprised along with the vessel in the noose; whereas when we take in a proper quantity of the circum­jacent [Page 14]parts to defend it, and the ligature is of a proper size, upon digestion coming on it becomes loose and slips off, leaving the vessel firmly closed and intire.

However, that we may avoid with as much certainty as possible the separation of the end of the vessel, I would advise that the ligature should be made of long twelve-penny flax, without either being the least twisted or waxed further than just the end, to make it pass thro' the eye of the needle; and if it is rubbed over with some soft digestive, it will slip ea­sily through the flesh.

This will be found sufficiently strong for the purpose for which it is wanted, without the least danger of its injuring the vessel; nor need the compressure be greater than is just necessary to intercept the passage of the blood, which will still add to the security in this re­spect, and at the same time produce other advantages, as will be observed in their proper place.

And further, if the ligature can be pro­perly applied, it is equally effectual, whether the artery be only in part or intirely divided; whether it is at liberty to retract itself, or ad­heres to an undivided muscle or the bone. And if the needle can be passed a proper depth into the adjacent parts, no accident can remove it, if they are sound, till the state of contraction and inflammation is over; when, in general, all will have been done that is necessary, the pressure of the swelled muscles most effectually assisting the closing of the vessels.

Nevertheless, along with these advantages it must be confessed, that great pain often ac­companies the use of the ligature; which, where it cannot be avoided, would make us prefer any other remedy that is equally safe and un­attended with this inconvenience. But it very fortunately happens, that where the ligature is most wanted, it may be applied with very little or no pain, if properly managed; for the large arteries are commonly surrounded with a considerable quantity of cellular mem­brane; [Page 16]and if we only take in with the vessel this nearly insensible substance, the patient seems undisturbed during the operation ^*: and upon enquiring of several at the time of tying the vessel, whether they felt much pain, I have always been answered in the negative; and though the nerve which accompanies the artery is inclosed in the noose, it makes no difference in regard to this circumstance.

Perhaps it may seem strange to those who have not considered this matter, that great pain should not arise upon a nerve, which is an organ of sensation, being compressed; but there are several instances in the practice of surgery, besides this, which lead us to ima­gine that the nerves are incapable of being irritated, till they are divested of their cover­ings, unless you penetrate through their coats down to the medullary substance ^† conse­quently, [Page 17]when they are also defended by the artery, fat, and cellular membrane, they will still be less liable to be affected.

This may be illustrated by reflecting on the situation of the nerves in the bones, tendons, membranes, and the like; where they seem to be rendered insensible and incapable of being irritated by the compactness of the parts which invest them ^*, as appears from [Page 18]the new flesh which follows their being wounded, being sensible, and again losing its sensibility, as the part acquires its natural tex­ture.

With this we may observe that numbness, the usual consequence of compressing a nerve, cannot here give any uneasiness, because the parts to which the nerves were distributed are removed.

However, when the vessels are so situated that muscular fibres must of course be in­closed, the ligature will unavoidably be at­tended with considerable pain; owing proba­bly to the nerves being divested of their cover­ings, and their medullary substance alone ex­panded over every fibre of a muscle; not, I imagine, in the form of papillae, but in the [Page 19]same manner, though much thinner, as the retina in the bottom of the eye ^*.

But this pain is only momentary, because whatever is inclosed becomes nearly insensible upon the stricture being made. If the liga­ture recommended is used, the parts will be [Page 20]less irritated; and whether the absolute secu­rity against a future haemorrhage does not fully compensate for the uneasiness the patient feels on this account, may be gathered from what follows.

But it is thought, ‘"that the ligature, by compressing the adjacent nerve, is some­times productive of convulsions."’ Now as no facts are brought to support this opinion, and as I have never yet seen any accident of this kind happen, though I have always, without regarding the nerve, freely used the needle and ligature; nor, upon strict enquiry, found one instance of its happening amongst an extensive chirurgical acquaintance, I am induced to think with Mr. Sharp ^*, that the doctrine of convulsions being caused by the tying of a nerve is merely speculative, and seems, though the theory is changed, to have taken its rise from the arguments brought against Parey, when he first introduced the practice of tying the arteries, and since to have been copied from one to another by suc­ceeding writers.

But is it not probable that in this instance, as well as many others in surgery, by quite altering the meaning of the word NERVUS we have made those symptoms follow the tying of a nerve, which should have been consi­dered only as the consequence of pricking a tendon? for long after Parey's time NERVUS was used to signify TENDON, and by ‘"ner­vosam aliquam partem, vel nervum ^†,"’ &c. there is great reason to think Parey's adver­sary meant a tendon or any tendinous part; especially as he supports his opinion by shew­ing, that for fear of the accidents described, Galen durst not stitch transverse wounds till he had first discovered the aponeurosis of the muscles.

However, we will consider this matter in the light it now stands; and for this purpose we may observe, that the ligature seems only [Page 22]capable of irritating and of totally obstructing the nerves.

Now as the nerves upon the muscular fibres are very easily irritated, a theory plausible enough may be invented to shew, that in cer­tain habits convulsions will come on upon their being tied; but then this would most probably happen at the very time they were irritated ^*: so far from this, no one that I know of has even pretended to say, that he has seen any patient fall into convulsions at the time the stricture was made. It is true there are instances where convulsions have instantly been brought on by irritation ^†; but they seem not to have any analogy with the case in hand: for the parts were diseased, and in all probability had a more acute feel­ing than ever happens to the nerves in their natural state, and consequently different effects would arise.—May not the pain in this case, as it is smart and of short duration only, somewhat in the manner of volatiles applied [Page 23]to the nose, rather enliven the spirits than bring on convulsions?

On the other hand, if convulsions arose in consequence of the nerve being obstructed, instead of being a symptom that but very rarely happens, they would either in a greater or less degree appear almost every time a large one was tied; for if these are, as is generally believed, distinct cords from their origin, the obstruction and its effects would be always nearly the same. But so far from this, con­vulsions of any kind are not more frequent where the large nerves are inclosed in the li­gature, than in slight injuries where it is not used.

Lately Le Dran ^* seems to have biassed the minds of people ^† in favour of this doctrine; but unfortunately his practice immediately contradicts his theory: for speaking of those who, in performing the operation for the aneurism, inclose the adjacent flesh within [Page 24]the ligature, he says ^{{horizontal ‡}}, ‘"though by this me­thod they tie the nerve together with the artery, yet it is very seldom any ill conse­quences ensue from thence, as the quantity of flesh included by the ligature prevents the nerve from being much compressed."’ And does not the same reasoning hold good, as is already shewn in amputations, where as great a quantity of the neighbouring parts is com­monly inclosed? Besides, when he tells us, ‘"that tying the nerve along with the vessel, sometimes brings on convulsions some days after the ligature is made."’ He also in­forms us, ‘"that there will not be any danger of this happening, if we apply a button of vitriol when the dressings are first re­moved;"’ which, he says, ‘"gradually forms an eschar that includes the ligature, and renders it useless."’

Now in a few days the ligature becomes loose spontaneously, and is no longer capable of doing injury. The parts being now in­flamed and more sensible, vitriol will act with [Page 25]great violence upon the nerves; so that if no ill effects arose from this complicated treat­ment, much less could they arise from the li­gature alone.

If the convulsions then were not the con­sequence of the dying state of the patient ^*, is it not probable they were owing to the nerves being irritated, either with acrid mat­ter or some other cause? for it is well known after the inflammation comes on the nerves become tense, and acquire a more acute feel­ing, and sometimes, where the fluids are very acrid, in few days are rendered so extremely sensible, as to bring on convulsions upon the slightest touch: and this seems to hold equally good in regard to the locked jaw, which within these few years has been said, ‘"sometimes to come on in consequence of the stricture made upon the arteries and their neigh­bouring parts by ligatures;"’ for in all the cases of this kind which have come to my knowledge, it appears not to have happened till the injured part has been inflamed and painful. In wounds it has often come on, [Page 26]when there has been the greatest reason to believe that the habit was become bad ^*, and the parts extremely sensible from a long con­tinued flux of acrid matter falling upon them. But it seems most frequently to have occurred in wounds of the joints and other mem­branes ^†, where the nerves being put more upon the stretch are more liable to produce this terrible symptom, which seems only to differ from other convulsions in its degree of vio­lence, and affects those, probably, where the whole nervous system is in a most extreme degree of irritability, as appears by the large and repeated doses of opium necessary to quiet the spasms.

From the whole then of what has been said, there is reason to acquit the ligature of [Page 27]being productive of those convulsions which sometimes have happened to attend a wound wherein it has been used.

Another kind of spasms, that are partial and attended with pain, are said constantly to attend the use of the needle and ligature; and it must be confessed, that while the needle is piercing a muscle a spasm is often produced: but it may with equal truth be observed, that it immediately ceases when the parts inclosed are numbed with the ligature. And it seems more likely that those spasms, which conti­nue more or less for some time after the ope­ration, arise from the nerves being irritated by the knife, by the air, and by the dress­ings; for whoever attends to this circum­stance will find, that the spasms which fol­low, for instance, an amputation of the leg, immediately seize the muscles upon their be­ing divided before any needle can be used. And we know by experience they will con­tinue some time after the irritating cause is removed, in proportion as the nerves were more or less affected ^*. That a similar effect [Page 28]will be produced by the other causes assigned, there is reason to conclude from observing, that even the muscles of animals, immedi­ately after death, are thrown into spasms by being exposed to the cold air; and spasms are also often brought on by touching naked wounds with dry lint.

Besides, spasms follow those amputations just in the same manner, where the vessels are not tied ^*; nor can the absence of this symptom with justice be ascribed to the omis­sion of the ligature in amputations of the breasts ^†, because in this case the muscles, which are the seat of spasms, are seldom touched with the needle; the cellular and adipose membrane only being taken in with the vessel, and which, from their small de­gree of sensibility, give but little uneasiness: and out of many instances I do not remember any patient attended with troublesome spasms after this operation, though the needle and ligature were always used.

Another objection to the ligature is, ‘"that it increases the symptomatic fever, because its application gives violent pain:"’ but though it often gives smart pain for an in­stant, it does not follow that it aggravates the symptomatic fever, for the pain is only mo­mentary, and whatever is included in the li­gature immediately becomes so insensible, as to give no future disturbance. It is true, an inflammation will take place above the stric­ture; but as an inflammation of equal degree would probably have occurred, though the ligature was not used, very little difference of pain can arise from this cause, as is evinced by the symptoms following an operation be­ing much the same, whether we use many ligatures or few.

But the symptomatic fever seems not to arise from the pain which accompanies or im­mediately follows any part of the operation, but to the distension which is caused by the obstruction and inflammation that comes on some time after in consequence of the division of the parts; for that pain which arises from the nerves being irritated and disordered in [Page 30]the operation, presently goes off, the irritating cause being instantly removed. And does not the symptomatic fever gradually come on, a few hours after the operation, as the parts about the wound begin to swell, and again decline as the distension abates, from the lymphatic vessels freely transmitting their con­tents?

Besides, from the account given us of the symptomatic fever following an amputation of the leg, where the ligature was omitted, we see ^* it came on about the usual time, and seems to have been nearly the same as when it is used. And though the symptomatic fe­ver has been slight in amputations of the breasts ^†, where the vessels were not tied, yet it does not appear to be a proof that it is increased by the use of the ligature, because in this operation the symptomatic fever is for the most part, if not always, slight; for the fat in the cellular membrane easily melts down, and the reticular or membranous part [Page 31]sends out new flesh without giving much dis­turbance, and in this case these, with the skin, are the only parts wounded; for even when a schirrus adheres, it is separated from the pectoral muscle without doing much in­jury, as this operation, I imagine, is never practised when the adhesion is otherwise than slight.

With this we should remember, that the symptomatic fever is always slight where the solids are relaxed and weak, in consequence of the small degree of force with which the blood is carried against the obstructed vessels. And is it not therefore more likely owing to this cause than to the omission of the liga­ture, that a slight fever only followed in those whose legs were amputated by Mr. Warner ^*, as all these patients were much reduced pre­vious to the operation? And is not, in such habits, the symptomatic fever constantly slight, though the ligature is used.

It is also said that abscesses are the conse­quence of using the ligature, and that it some­times [Page 32]remains fixed to the last, so as to retard the healing of the wound; but these incon­veniencies only happen when the needle is passed very deep, and may therefore be avoid­ed by a contrary practice: nor is passing the needle deep at all necessary (if the parts are sound) as a small quantity of flesh or cellular membrane below the stricture will sufficiently prevent the ligature being pushed off by the impulse of the blood. However I would cau­tion against extremes; for with passing the needle but a very little way the vessel some­times may not be tied, and cause unnecessary trouble; if we therefore pass the needle only a moderate depth, the ligature will always come away in due time without inconveni­ence, or at least it may be taken away long before the wound is healed, without any dan­ger of bringing on a fresh haemorrhage: for as soon as digestion is complete, and the new flesh begins to rise, the ligature makes not any pressure upon the vessel; and though new flesh may have covered the noose, yet if we take the advice long since given by Monro ^*, [Page 33]it may be removed without any hazard of cutting the artery.

This is the light in which I have been led to consider the use and abuse of the needle and ligature in tying the blood vessels, and shall now proceed to enquire into the method of suppressing the haemorrhage by fungous substances; which, like the ligature, will ap­pear to have their advantage and inconve­nience.

CHAP. III. Of suppressing the haemorrhage by the applica­tion of fungous substances, by coagulated blood, by astringents, and by perpendicular pressure.

THE late success which has attended the application of fungous substances is a full proof that an haemorrhage from large ar­teries may often be effectually suppressed by their use; and it at the same time points out the truth of the doctrine advanced, and what little assistance in this case is wanting.

But the manner of applying funguses makes a material difference in regard to success; for if they are pressed close against the end of the vessel, they intercept the passage of the blood; and the artery closes itself up in the manner described: whereas, when this circumstance is not observed, and they are only laid near to the orifice, in the manner Cheselden ^* used [Page 35]spunge, they suppress the haemorrhage by choaking up the mouth of the vessel with coagulated blood, which hinders its being closed; and though it stops the bleeding at present, yet it may be the source of a future haemorrhage.

This is evident from the experiments made by La Foss ^*, where the coagulated blood, which filled the end of the artery, was formed into a cone with its apex towards the heart; consequently, if the plug happens to extend to the next collateral branch, a fresh flux of blood must ensue upon its coming away; for it does not unite with the vessel, as some have imagined.

I know there are instances, where an ori­fice made in an artery has been stopped with a clot of solid blood, which adhering firmly to the cicatrix of the integuments, produced a considerable callosity, and which seems to have given rise to this opinion. But it must be observed in these cases, the wound was [Page 34] [...] [Page 35] [...] [Page 36]without coming to suppuration; whereas when the air has free access, we well know a putrefaction of the coagulated blood, as well as digestion, is always the consequence; and I make no doubt but the separation of coa­gulated blood is one cause why a fresh bleed­ing has sometimes come on after the inflam­mation was abated, and matter began to be freely discharged. In a very late instance, where the bleeding from a divided artery had been suppressed by coagulated blood, I saw it renewed again next day by taking this blood away; the artery bleeding in the same manner as when it was first opened; but upon pressing it betwixt my fingers it was soon effectually closed. Hence we may observe, that the prac­tice of laying allum, or any thing else, at the end of the artery to coagulate the blood, is very improper, as every impediment to the contraction of the vessel should on the con­trary be removed.

This leads me to take notice of Petit's opi­nion, who imagined that the haemorrhage from divided arteries was always suppressed by plugs of blood within the vessel; because [Page] [Page] [Page] [Page 37]he found in some of them, after the death of the patient, coagulated blood, which extended itself upwards a considerable way.

But notwithstanding this, it is very proba­ble that the haemorrhage was stopped by the natural contraction of the vessel; for we find in the two waggoners mentioned by Mons. Fagot ^* where, after death, coagulated blood was found in the same manner, ‘"their ex­tremities were contracted and straitened, as if they had been tied."’ And in the many experiments I have made on this occasion, I never found coagulated blood but once; and then the extremity of the artery was close contracted ^†.

Pouteau ^† opened several arteries, and ne­ver found any coagulum; nor is there any [Page 38]coagulum found in the umbilical vessels of children after death: from all which may we not conclude, that this circumstance is merely accidental, and no step taken by nature, who is always uniform, if no impediment, is in the way? Indeed, I think with some other writers, ^† that it is of the same kind, and produced in the same manner as the fibrous blood we often find in the great arteries near the heart: that which I saw had exactly the same appearance; nor did it seem sufficient to have blocked up the vessel. What is al­ready said about coagulated blood preventing the contraction of the vessel, here also takes place; and was it extended to the extremity of the artery, putrefaction and its consequences must of course ensue, from its being in con­tact with the air.

It follows then, that whatever fungus is used, it should be pressed close to the end of the vessel; and that kind which adheres clo­sest should be chosen. Mr. White says ^† that spunge is on this account preferable; and if [Page 39]his directions, in regard to the choice, pre­paration, and manner of applying it, be ob­served, I believe he says true; but even this sticks the fastest when it is least wanted; for though after a while it adheres so firm, that it is removed with difficulty, yet, till the parts begin to swell and become moist, the adhe­sion is very slight.

Bandage therefore must be carefully applied to preserve it in its proper situation; and if this circumstance had been duly attended to, instead of relying upon a specific property in agaric, better success would probably have at­tended it when in vogue; for where agaric itself proved ineffectual, tight bandage and common dressings suppressed the haemorrhage. And we might produce innumerable instances which prove, that whatever is kept firm upon the end of the vessel is sufficient for the pur­pose. —However, if what is said about tying the great arteries be true, most surgeons, I imagine, will still secure them with the liga­ture; for no sort of bandage can with safety in amputations be so applied, but the fungus may sometimes be displaced by spasms, cough­ing, [Page 40]vomiting, or the like: and should an hae­morrhage return from these vessels, we know death may ensue from the loss of no very large quantity of blood. Mr. Sharp's ^† pa­tient, in whom the vessels burst open three hours and half after he had applied agaric, died in about twenty minutes with the loss of less than thirty ounces of blood, including what was lost in the operation: nor could as­sistance be speedy enough to prevent this ca­tastrophe, though it was upon the spot when the haemorrhage returned; and how much more likely is this to be the case in private practice, especially in the country, where the person obliged to be intrusted with our pa­tient is often an intire stranger to chirurgical operations?

But suppose our assistant should be so lucky as to compress the tourniquet time enough to save the patient's life, yet it is probable a quantity of blood will often be lost, that may be injurious to him; for though the loss of some blood from this accident may be ser­viceable, when the patient is not much re­duced [Page 41]by the disease ^†; on the other hand, the loss of a few ounces, when he is become weak, will be very improper, and very likely retard the recovery of his health: and we may observe, even in strong habits, that the discharge of blood ought not to be commit­ted to chance, but intirely directed by the judgment of the surgeon. And though it should happen that very little blood is lost, the patient may not only undergo great pain from the compressure, till the surgeon can be called, perhaps from a considerable distance, but the parts may be much injured by the fluids being so long in a state of stagnation.

But this inconvenience will for the most part attend the use of this remedy in ampu­tation of the limbs; for all agree that it is necessary to keep the limb compressed a con­siderable time with the tourniquet, and which will also in all probability overbalance the pain caused in using the needle and ligature. Nor can we help thinking but some mistake hap­pened [Page 42]in describing those cases, where we are told, though the tourniquet was kept compressed for half an hour, that the pa­tient was remarkably easy during that time. Mr. Sharp's ^* patient, when he used agaric, complained grievously of pain arising from the tourniquet; and my patients tell me, it is the worst part of the operation: besides, I have observed when a piece of fungus ad­heres close, it gives very considerable pain in being removed; so that upon the whole, this method of securing the great vessels is attended with more pain and less safety, than the liga­ture when properly applied.

This reasoning also holds good in regard to the lesser arteries, when they are surrounded with the cellular or adipose membrane only; though it cannot be extended to the tying of those which are situated amongst the muscles, because, as is already observed, the ligature is here attended with considerable pain; nor is the tourniquet in this case wanted; and I make no doubt, but these vessels may in ge­neral [Page 43]be trusted with spunge, or any thing else that adheres close to their extremities: but the spunge should be removed the first or second dressing, otherwise the new flesh grow­ing into its pores will cause an increase of pain in the removal.

On the other hand, if the bleeding should happen to return, though on account of the size of the vessels it might not be dangerous, yet even here more blood might be discharged than it would be prudent to lose; a fresh hae­morrhage is always alarming to the patient; and as momentary pain seems to be the only inconvenience, perhaps many surgeons will think it best to leave their patients in perfect security: and we may just observe, that in many operations the ligature must of course be used upon all the vessels, as it will be ne­cessary to stop the bleeding as we go on.

Nevertheless, when the flesh is become ten­der, and gives way to the ligature, spunge seems to be the best remedy; for though the large vessels might be pulled out, and tied in [Page 44]the manner Dionis ^* describes, yet, being un­defended, the end would commonly separate; and unless the ligature was placed near its ex­tremity, sometimes bring on a fresh haemor­rhage in the manner already observed. And this was most probably the reason why Parey had more certain success, when he took in, along with the vessel, some of the adjacent parts, than when he inclosed it alone in the ligature.

Where the vessels are so deeply situated as not to be come at with the needle, the same kind of application must have preference, if it can be laid close to the mouth of the ar­tery; and it succeeds better in this case, as the sides of the wound assist in keeping it in its proper situation: but before it is applied, it seems necessary to examine whether the ar­tery is wholly divided; for without this cau­tion we may sometimes be disappointed in our expectation, and ascribe insufficiency to [Page 45]this method, as was done to the agaric ^†, when the want of success was owing to the vessel being in part divided, whence it was incapable of intercepting the passage of the blood. Nor should we forget, that in wounds which admit of cure by an immediate union of their divided parts, fungous substances are unnecessary, as the common method of dress­ing effectually suppresses the bleeding, though it is from considerable arteries.

However, if the artery is large, and any difficulty occurs, if the part will admit of the practice of dilating the wound, perhaps it may seem more proper by that means to use the ligature, especially if it adheres to an un­divided muscle or the bone, and bandage can­not be conveniently applied; and where the principal trunk of a large artery is wounded in a longitudinal direction, Mr. Lambert's ^† method of sewing it up should, I think, be tried.

When an haemorrhage arises from a thin state of the blood, and the discharge is from the whole surface of the wound, puff ball seems preferable to spunge, or the like, as the blood would probably escape through its pores. In this case, with tight bandage it has an­swered my purpose, till internal medicines had their proper effect: and if upon trial it should prove successful under the like circum­stances, will it not be more proper than styp­tics or astringents, &c. as these harden the fi­bres, and prevent digestion, from which in­convenience this remedy is free? Nor do I apprehend the bandage will be so unartfully applied, as to bring on a flux of blood by compressing the veins, as I imagine in general this obvious cause of an haemorrhage is well understood, being pointed out by several wri­ters on surgery, and clearly demonstrated by Monro ^*.

Perhaps some will think that styptics and astringents will forward the contraction of the vessels: but we may learn how little they [Page 47]are wanted, from the artery in the young fel­low's arm, which was evidently relaxed and weak, closing itself without any assistance; and I am persuaded, from some experiments I have made, that these applications, instead of assisting, would, if they were not hindered by mixing with the blood in wounds, rather prevent the collapsing of the vessel by hard­ing its fibres. And however contrary this doc­trine may be to the generally received opi­nion, experience is certainly in its favour; for though by coagulating the blood, they might succeed upon very small arteries, yet, being applied to those which were large, they were always found insufficient to suppress the bleeding, unless tight bandage was at the same time used, and to which I think it is clear the success was owing: for many of these com­positions, which were thought to be astrin­gents, had certainly no other property as blood-staunchers than that of choaking up the mouths of the vessels ^*.

It is obvious that the fungus, when used, must be kept in its proper situation by ban­dage differently applied, according to the part wounded; and in this matter every surgeon's own judgment will best direct him. How­ever we may just observe, that in amputations good slicking plaister, as advised by Mr. White ^*, and keeping the hand pressed harder against the part for a few hours, may often be suffcient; though the machine recom­mended by Mr. Gooch ^† will, probably, be more certain; and when this is not at hand, a circular piece of leather may be made to answer nearly the same purpose.

This piece of leather must be large enough to cover the end of the stump, and near its edge must be cut four slits in opposite direc­tions, that will admit each a fillet.—Supposing a leg taken off below the knee, two fillets be­ing passed through these slits crossways, and under a roller or a piece of cloth that goes round the thigh, above the knee, must be [Page 49]brought back again, and tied upon the end of the stump, by which means the dressings will be fixed, and any degree of pressure may be made: and this bandage, if it is kept from slipping down, by being fastened with filleting to a roller round the waist, serves equally well when we amputate above the knee. Nor do I recommend this method without experience; for having amputated a leg, where the blood was extremely poor, and the flesh very tender, the ligatures were forced off the vessels a few hours after the operation, by a fit of cough­ing and vomiting; I immediately applied the bandage above-mentioned, with bolsters of dry lint, which effectually answered the pur­pose: for, though the patient vomited and coughed several times afterwards, the haemor­rhage did not return.

Indeed bandage seems hitherto to have proved less serviceable than it might have been, merely from imagining it would be useless, unless the sides of the vessels were brought together in close contact; whereas, had the pressure been made only upon the end of the vessel, and just sufficient to resist; the im­pulse [Page 50]of the blood, it might much oftener have been used without inconvenience, and with better success, as there is reason to think from many instances.

We have only further to add on this head, that where the wounded artery cannot be come at, pressure is still the only remedy; and where things are so circumstanced that we are obliged to choak up the mouths of the vessels with coagulated blood, it seems neces­sary, for reasons already given, to make a pressure, if it can be done, against the end of the artery, that the contraction beyond the plug may more certainly take place.

CHAP. IV. Of suppressing haemorrhages by cauteries, cau­stics &c.

BESIDES the methods above-mentioned, Mr. Warner ^* has shewn, that when an artery is opened in the roof of the mouth, the actual cautery is sometimes necessary to stop the bleeding: and many years ago, after ex­tirpating a tumor from this part, I was obliged, for the same reasons, to have recourse to the same remedy; but the iron was no hotter than just sufficient to form the neighbouring parts into an eschar upon the end of the artery; by which means the course of the blood was in­tercepted, and the vessel left at liberty to close itself up; whereas when the cautery is very hot, it not only burns the end of the artery a considerable way, but hardening its fibres beyond the eschar, renders it incapable of col­lapsing; so that it is no wonder an haemor­rhage [Page 52]should so often ensue upon the sepira­tion of the dead parts.

However, the cautery is at all times a cruel application, and should be avoided, if possi­ble: nor do I now call to mind any other part where its use can be wanted. But if this is cruel, the potential cautery is more so, as it spreads itself further into the neighbouring parts; and yet it is not very uncommon for surgeons in performing operations to apply lint soaked in scalding oil of turpentine, where the artery, though not very large, cannot be readily come at: and this piece of cruelty is still aggravated, when we consider that a few minutes pressure would, in all probability, have alone [...]en suffcient for the purpose.

Caustics, &c. are, I believe, in general, laid aside in supperssing haemorrhages; and therefore we need only observe, that, though they do not, by hardening the sides of the a [...]ery, render it incapable of collapsing above the part destroyed, yet, by causing its end to [...] thei [...] [...] is [...] [...]rary to right [...] advise ill, [Page 53]who give up every advantage gained by the ligature, in afterwards applying a piece of vitriol.

But all these errors in the choice of reme­dies, or their application, have arose from the true principles of supperssing haemorrhages not being previously investigated; it will therefore give great pleasure to the author of this little essay, if it appears that he has set in its proper light this important, though common operation.