314 insert them here, believing them interesting and valuable, as having been treated with a different view of the operation of the actual cautery to that generally held. I wish, also, to put forward the just claim of my esteemed and skilful master (whose early death removed him from a course of professional usefulness to the great establishment of which he was one of the surgeons, and to the students by whom he was attended, and deprived the profession of one of its most able and upright members) to the re-employment, at least in England, of, in many cases, that invaluable remedy, the actual cautery; which, like numerous other remedies of Ancient Surgery, had been thrown aside in consequence of its abuse, and of the fondness for new remedies which, in our profession, is by no means uncommon. CASES OF AFTER-BLEEDING IN WHICH THE ACTUAL CAUTERY WAS EMPLOYED, AND CASE 1.-G. G., aged twenty-eight years, a post-boy, was admitted into St. Thomas's Hospital, Jan. 24, 1815, with a compound fracture of the left leg, caused by the wheel of his carriage passing over it, he having slipped whilst getting on the bar, and fallen beneath. Both bones were broken, but did not protrude through the wound, although they evidently communicated with it. The edges were brought together with adhesive plaster, and, the limb having been placed in splints, an evaporating lotion was applied. On the 27th, as his bowels had not been relieved since his admission, and, as febrile symptoms had appeared, he was ordered a dose of infusion of senna and sulphate of magnesia immediately, and fever mixture with three drops of laudanum every six hours. Up to The result of this time the case was going on well, but the medicine produced seven or eight stools next day, and at the visit on the 29th he had passed eight or nine more. the necessary frequent movements appeared this morning in the violent inflammation with which the limb had become attacked, accompanied with gangrenous vesication. Chalk mixture, with aromatic confection, was ordered; the purging continued, however, through the night, but on the following day, Feb. 1, it was checked. He had a quick pulse, white but not furred tongue, and good appetite. The leg was now extensively inflamed, and suppuration having commenced, a poultice was applied. Early on the following day his bowels were again disturbed ten or twelve times; sloughy ulceration had occurred above the outer ankle, and on the 4th Feb. another slough upon the instep; and a piece of the shin-bone being loose, was removed. The discharge was very great and offensive. The fever mixture was continued, a grain of opium given nightly, and rhubarb bolus twice a week. The limb, which to this time had been on the side, was now placed on the heel with the knee bent, in a thigh-fracture box, and the poultice continued. This position, however, was not comfortable, and next day the limb was taken from the box, and on the day following put in a leg-fracture box, which suited well. On the 9th Feb. it was thought advisable to improve his living by giving some porter, but, as in the course of the day there was a little bleeding from the wound, it was not continued. He, however, went on well till the 15th, when a patient falling over the bed jarred his leg, and bleeding from the wound ensued to the On the 21st a sympathetic abscess in the groin was amount of six or eight ounces. opened. His constitution continued fighting with the ailment, but another piece of bone was discharged, and the lower end of the shin-bone protruded considerably through the wound. His powers at last began to fail, and amputation, which could no longer be avoided, was performed, on 9th April, above the knee, by my friend TRAVERS, whose patient he had become by the death of the surgeon under whom he had been admitted. Three ligatures were applied, and he went on exceedingly well, improving in health daily, till the evening of the 29th, when a severe arterial bleeding, to the amount of a pint and a half, occurred; the ligatures had come away on the 16th, but that on the femoral artery still remained. The bleeding continued through the following day, and although the tourniquet had been applied, he lost three pints of blood within the twentyfour hours. A solution of sulphate of copper was applied to the surface of the stump, and cold wet cloths over it, and the bowels cleared with castor oil. May 1, 1 P. M. Free bleeding to the amount of a pint took place; at half-past two, another pint, and smaller quantities continued to flow till 11 A.M., when eight ounces more escaped. Six grains of powdered digitalis were given in divided doses before Ten drops of 8 A.M., which reduced the pulse considerably, but without arresting the bleeding, though he had become very weak and covered with clammy sweat. laudanum every six hours were then ordered, but he continued in a very unsatisfactory condition, and vomited twice in the course of the morning (a). (a) Thus far is from the dresser's and my own notes, but the remainder of the case is from my master's narrative.-J. F.S. At 4, P.M., his surgeon being ill, I was requested to see him. On removing the coagulum, a ligature was found and withdrawn; the blood flowed from a sinus which would admit the finger, and up this a piece of sponge was introduced, the tourniquet taken off, and the stump kept cool with GOULARD's wash. A grain of superacetate of lead was ordered at 5, P.M., and to be repeated at 6, P. M. The vomiting soon after returned, and continued during the evening; but he got a little sleep. May 2, 1, A.M. The sponge having slipped out, was replaced; but bleeding did not return, and at noon it was removed. A small quantity of sulphate of magnesia was given to produce a stool, and a drachm of powdered sarsaparilla ordered twice a day. In the course of the afternoon he had a little wandering, but it soon went off. Under this treatment he continued improving till May 23, when another profuse bleeding (the dresser says to three pints) took place. Finding the end of the stump much swollen from the pressure of the tourniquet, which had been put on to check the bleeding, I removed it, and adjusted the pad of a small truss upon the inner side of the thigh near the end of the stump, with a view to compress the sides of the artery, and at the same time permit the blood to pass through the small arteries, and allow its return by the veins, as well as that of the lymph by the absorbents. This plan succeeded, till May 26, 11, P.M., when the pad probably having slipped, another severe bleeding ensued, to the amount of two pints. The tourniquet was used, but without effect, and the bleeding could only be restrained by great pressure of the dresser's thumb, as the arterial action was very strong. An injection of strong solution of alum was thrown up, but without benefit, and gave much pain. He was much exhausted; and his pulse 120, and irritable. A grain of acetate of lead was given, with twenty drops of laudanum, at midnight, and May 27, 1, A.M., it was repeated; but the arterial action and bleeding continued. 5, A.M. I was called to him; and the means hitherto employed having failed, I determined to apply the actual cautery, by passing a hot iron up the bleeding vessel. With this view, the sinus from whence the blood flowed, together with a part of the end of the stump, were slit up; and it then appeared that the sinus was the end of the artery in a diseased state, resembling the structure of an aneurismal sac, when the whole cylinder of the vessel is enlarged. This aneurismal condition extended from the face of the stump upwards about two inches, and was large enough to admit the thumb; above this the vessel was sound. A canula was then passed up to the distance of three inches, so as to enter the healthy part of the artery, and into it a hot iron was introduced, with which the coats of the artery were burnt, in hope of producing inflammation and consequent adhesion. The cauterization gave great pain, but immediately arrested the bleeding. The canula was left in the vessel, which, shrivelling up, had become adherent to it. He began speedily to improve, and, with the exception of one slight bleeding, did well; and was discharged. Aug. 10. Perfectly well. CASE 2.-G. M., aged about twenty-five years, was admitted Feb. 11, 1819, with an affection of the left knee, of long continuance, from which his health has suffered much. A fortnight ago an abscess of considerable size had formed on the inside of the knee, and burst. He was advised at once to submit to the loss of his limb, on account of the exhausting effect of the disease on his constitution. Feb. 19. The leg was amputated above the knee in the usual manner, and three ligatures applied. Two hours after, his pulse was quick and throbbing, and slight bleeding occurred from the stump, which was then covered with cold lotion, but without advantage, as the bleeding increased; and in three hours' time had become so profuse, that it was necessary to remove the dressing, open the wound, and clear away the clot, which being done, a small artery was found and secured, and the bleeding ceased. Feb. 24. Has gone on well: part of the dressings were taken off, and replaced; there is a slight discharge, but no appearance of adhesion. On the following day the rest of the wound was dressed, and the ligature last applied came away. Feb. 28. Was requested to visit him on account of a return of the hæmorrhage, and ordered the stump to be kept cool: pulse 140, and full; he has a troublesome cough. The wound has begun to granulate. At 5, P.M. As the bleeding was still free the dressings were removed, and attempts made to secure the artery, but in vain, as it had retracted very much. The patient soon became faint, and the bleeding then ceased. March 1. He appeared weak from the loss of blood, but hæmorrhage had not recurred. His cough still remains troublesome. March 3. This evening a fresh bleeding having come on, ASTLEY COOPER endeavoured to secure the vessel with a needle and ligature, but as the bleeding ceased before this could be effected he did not persist. March 5. Again very profuse bleeding, which was stopped by the application of some styptic. March 9. As fresh hæmorrhage had taken place the bleeding vessel was sought for, found near the sciatic nerve, and the actual cautery then applied by CLINE, which immediately stopped the flow of blood. In its application he did not complain of any pain. Since that time he had no repetition of the bleeding, continued to improve in health, and during the course of the month was able to sit up, and ultimately recovered. Clinical Observations. In order that my intention in applying the actual cautery, in the cases just mentioned, may be understood, I shall make some remarks on after-hæmorrhage, commonly so called, and on the use of the actual cautery in cases of hæmorrhage after operations or other injuries. By after-hæmorrhage is meant a bleeding that takes place when the wound has been closed up and dressed, and the patient put to bed; and it may happen at various periods after the operation. Such occurrence is particularly painful and alarming to the patient, as parts require to be disturbed which are in a state of inflammation, and if the bleeding be some hours after the operation, the inflammation is considerable, and the pain greater than when the parts are uninflamed. These cases are also very anxious and harassing to the surgeon; for, as he is unaware of the time of the occurrence of the hæmorrhage, the patient may die in his absence. I do not purpose entering into all cases of after-hæmorrhage, nor into those which, coming on two or three hours after the operation, are generally stopped by removing the coagulum and all extraneous and irritating matter except the ligatures, and exposing the face of the stump to the air, applying cooling lotions, and paying attention to the state of the bowels, but only to those cases which occur during the healing process, are obstinate, and very much reduce the patient. Eight or nine years since, this subject passing through my mind, and reflecting upon it, it seemed to me that those bleedings arose in consequence of the want of adhesive inflammation; that instead of an effusion of coagulable lymph, an ulcerative process commenced, and perhaps I might say that the ulcerative inflammation succeeded the application of the ligature instead of the adhesive. Now, from what one observes to follow the application of a high temperature to living animal bodies, it seemed to me that the actual cautery would be most likely to bring on quickly the adhesive inflammation, just as in a scald or burn, though serum is thrown out so as to resemble a bladder of water, yet flakes of coagulable lymph are seen floating about in it. I therefore at that time applied the actual cautery to the carotid artery of a dog. As regards the case of J. G., it may be asked what effect could sarsaparilla have in checking hæmorrhage? to which I reply, I gave it from having observed that it has considerable power in tranquillizing the arterial system; and hence conclude that if it relieve the thrilling and throbbing of the pulse, the irritability of the arteries, and produce in their extremities a healthy action, independent of its improving the general health, we may consider it an auxiliary in stopping the hæmorrhage. But I do not mean to say that when taken into the circulation it has any chemical operation in producing this effect. When I saw the patient on the 27th of May, I found the dressers alternately relieving each other in compressing the artery, and with which they had been occupied during the whole night, as nothing could be done with the tourniquet. I thought it extraordinary that the tourniquet would not stop the bleeding, and therefore myself put it on, carefully placing the pad upon the artery, and then screwed it up, using as much force as I thought safe, taking care to avoid such as would crush the muscles, which might be easily done with so powerful an instrument, but the bleeding continued, and I therefore determined to use the actual cautery. Having first cauterized the aneurismal part, as I have called it, of the artery, which caused no pain, I then passed the canula up into the sound part of the vessel, and as soon as the red heat had to the eye subsided, the cautery iron was run up the canula, which caused extreme pain, along the artery and its accompanying nerve, as much it seemed as the circular incision in amputation. The object of using the canula was to conduct the hot iron up to the spot to be cauterized; otherwise, as soon as it touches the vessel it is stuck fast, and you cannot pass it further up. Besides, if this did not happen, few have so good an eye and so accurate a hand as not to miss so small an orifice as that of the artery; which, however, does not occur if the canula be used. During the progress of the case I was asked why I did not slit up the sinus, and tie the artery again. But if it did not heal when one ligature was applied, it was highly probable it would not if a second were put on. I was also asked, whether I would not tie it as in tying the artery above for aneurism. But then we should have still been in the neighbourhood of the diseased part: the same accident would have recurred, and probably the vessel would have bled again by anastomosis. To prevent this bleeding it was that I cauterized the aneurismal structure, for the purpose of producing a change in the action of the vessels. This case presented to me a new view of the subject, hæmorrhage. It appeared the cause of the bleeding originated in a new structure being built up, whilst the artery was enlarged by absorption, so that a sort of aneurism was found at its extremity. I do not mean that sort of aneurism in which one side only of the vessel becomes diseased, but where a general circular dilatation takes place. This explains my reason for not applying a ligature upon the vessel, for had it been put on it would have given way: just as would an aneurism, if a ligature could be passed around it. The enlargement of the extremity of the artery is similar to what occasionally happens after bleeding from the temporal artery; you puncture the vessel, take as much blood as you wish: but, expecting to require more in a day or two, you do not divide it, but apply a compress. A spurious aneurism soon follows, and is occasionally accompanied with a sinus, from which repeated and obstinate hæmorrhages occur. Four or five years ago I saw a man in Guy's Hospital bleeding from a sinus, with which the dressers had been harassed night and day making pressure with the thumb on the vessel, which seemed to be the commencement of such a case as I have described. It appears to me, therefore, that the advantage of using the actual cautery consists in changing the action of the part, and rapidly inducing the adhesive inflammation. After the employment of the actual cautery in after-hemorrhage, pressure should be made on the artery with a tourniquet, with the finger, or with the pad of a truss, which is better than a tourniquet, as it touches only two points and does not prevent the blood circulating to the stump for its support; and this pressure should be continued till there has been sufficient time for the effusion of lymph. In the second case the patient did not feel pain when the hot iron was applied to the artery, which was a remarkable circumstance. But although it should give pain, yet it ought not on that account to be disused. It is a case of life and death. The pain is supportable, and soon goes off. It is remarkable in cases of hæmorrhage, that when something efficient is done, before there is time for any change to take place, the system becomes tranquil, there seems to be a sympathy between the arterial system and the diseased extremity of the vessel; and so long is the patient in a state of uneasiness as this something efficient remains undone. This is what Mr. HUNTER called a "consciousness of wrong," the body being unable to be at rest, wanting to do a something which nature is incapable of accomplishing. In the two cases above mentioned, I feel certain that the hæmorrhage ceased from the use of the actual cautery. I am not an advocate for using this remedy instead of ligatures; it is not so convenient nor so certain as ligatures, in recent cases. It is only when you can do nothing else that I recommend its use. It must be applied up the canal of the artery, or else the end only is shrivelled and no union produced. I find that the mere burning or searing the extremity of an artery is not to be depended on even in quadrupeds; the vessel will still bleed: I am certain, therefore, it would not do in the human subject. And I conceive that by the old method of applying the actual cautery, the bleeding was stopped by burning all the parts which constringed and pressed upon the vessels. I have ascertained that this method is sufficient in the dead subject to prevent injection being forced out; but, by simply cauterizing the arteries in the old way, without touching the surrounding parts, this cannot be effected. The instruments required for this operation are a straight wire of corresponding size to the vessel to be cauterized, fitted with a canula, closed at its extremity to prevent the blood flowing into it and cooling the hot iron. The artery having been slit up, as already mentioned, the canula is to be passed up into its sound part, having been first smeared with grease, which renders its introduction and removal easier, and also when heated burns the vessel with the hot grease, and assists in exciting the inflammation. The cautery iron having been heated, is then to be introduced into the canula at a black heat. The object is not to destroy the parts, nor to bring on sloughing, but only to produce a higher degree of inflammation, so that an effusion of lymph may soon take place and seal up the vessel; and for this purpose the black heat is sufficient. After the cauterization is effected, the canula may be with drawn; but if it will not come away, it is not of consequence, and may be left, as in the first case, to come away of itself; for the process of closing the vessel goes on without inconvenience. The following are some experiments which I made in reference to this subject :Exp. 1, which was performed with a view to the treatment of those aneurisms in which a ligature cannot be applied upon that part of the artery next the heart, shows that a wooden plug may be passed into a vessel, and the natural processes as regards its closure be accomplished. I divided the carotid artery of a dog, thrust a wooden plug an inch down that portion of the vessel next the heart, and tied it in. No hæmorrhage ensued, and the artery healed. Exp. 2. On 6th Jan., 1818, two ligatures were put upon the carotid artery of a sheep, and the vessel divided between them. A hot iron was applied to the end next the heart, till about half-an-inch of it from the ligature towards that organ shrivelled and turned white. At noon of the following day the sheep was killed. A portion of the artery immediately below that which had been cauterized was one-sixteenth of an inch less than the corresponding vessel on the other side of the neck, and contained a coagulum an inch long; but in the uncauterized part the coagulum measured three-eighths of an inch. In other respects the two portions were similar. Exp. 3. On the 12th Jan., 4 P.M., two ligatures were applied on the carotid of a sheep, which was divided between them. The ligature on that part of the vessel next the head was then untied, and the actual cautery passed up it; after which the ligature was retied to prevent hæmorrhage. Twenty-one hours after, the sheep was killed, and there was found in the cauterized end a very firm coagulum, two and a half inches long, completely filling the cylinder of the artery, to the extent of one inch from the ligature. The uncauterized end contained a slender filament of coagulum, one inch long. Exp. 4. On the 19th Jan., 3 P.M., I cauterized the lower end of a sheep's carotid by passing in a tube closed at one end, and introducing the hot iron into it. The ends of the artery were tied as before. At noon of the following day the animal was killed; the ligatures were covered in with lymph, so that the cavity containing them and the ends of the artery was excluded from the air. The lower portion of the carotid contained a very firm coagulum, an inch and a quarter long, adhering strongly to the internal coat of the vessel. The coats of the artery and the surrounding cellular membrane were much inflamed, and a mass of matter having the appearance of coagulated blood, but which had probably been effused by the inflammation, surrounded the artery about half an inch from the ligature. Exp. 5, made on Jan. 25th, was the reverse of the former. The lower portion of the vessel contained a clot of blood three-quarters of an inch long, and as thick as a probe. The upper portion had nearly the same appearance as the lower in the last experiment, except that the coagulum was about an inch longer, and that there was less coagulum around the outside of the artery. In both experiments the iron was passed only once, and as the red heat went off. (2) Although in CLINE'S experiment a wooden plug was introduced into the carotid artery of a dog, and the vessel, having been tied upon it, did well, it does not render any support to the plan proposed by CHELIUS for treating bleeding ossified arteries. In the former case the vessel was healthy, in the latter diseased, and not very likely to adhere. I should certainly prefer amputation with the hope of finding the artery healthy above; but if that were not done, I think it would be better to trust either simply to pressure, or to use the actual cautery for the purpose of shrivelling the vessel up, and inducing the formation of a clot, to form a natural plug, and rely upon the accompanying increased inflammation to do the best for the patient. Such cases, however, must always be considered very doubtful as to their successful termination.-J.F.S.] 303. Bleeding from wounded veins, although less thought of, may produce dangerous consequences. It is characterized by the above-described symptoms (par. 276); differences may, however, occur, which, for the moment, render the diagnosis difficult. If there be no prevention to the return of the blood, it flows in an unbroken current; but, if there be any obstacle, the blood spirts in a stream, or even in jets, as if from a wounded artery. This latter circumstance depends either on contraction of the muscles surrounding the vein, and is in direct proportion to the strength and frequency of the contractions; or it is consequent on the motion propagated from |