the artery accompanying the vein, and, in this case, the manner in which the blood spirts out may easily deceive at the first moment, but compression above and below the wound will always determine the diagnosis.

304. Bleeding from the smaller veins usually stops of itself, if the patient be kept quiet, the edges of the wound brought together, and the circulation of the blood not disturbed. The clot which forms in the mouth of the wounded vessel prevents the escape of the blood, and, with the healing of the outer wound, that of the vein also takes place. But the bleeding is more severe, and requires the assistance of art, according to the condition of the wound, the size of the vein, and the existing obstacles to the return of the blood, such as the depending position of the wounded part, pressure upon the vein between the wound and the heart, exertion of the patient, by which either the muscles of the wounded part or those of the chest are contracted, and interruption to the return of the blood ensues; injuries of the large veins, as the internal jugular, the subclavian, the femoral, are soon fatal. 305. Compression is the usual remedy in venous bleeding; the ligature is seldom employed. The pressure must be made on the wounded part itself, and not to such extent as completely to flatten the walls of the vein, which would entirely check the return of blood, but only in a slight degree to support them. Especial attention must always be paid, at the same time, to the due freedom of respiration. The ligature must be applied, first on the lower, and then on the upper end, if the blood flow from the latter by regurgitation. It has the disadvantage of putting a complete stop to the return of the blood, and may also give rise to inflammation of the vein; it should, therefore, only be used when compression is not possible. Wounds which comprise the half or two-thirds of a vein, produce severe, and even fatal, bleeding, especially if the position of the part draw the wounded edges asunder. In this case, a better position and slight pressure often stop the bleeding; but frequently it will not cease till the vein has been completely divided. Venous bleeding, in extirpating tumours, or in amputations, usually stop when the patient ceases to scream, or by letting him frequently take a deep breath. If, however, bleeding from a large vein should continue, it is necessary to tie it; in such cases, for instance in amputations, in which I have frequently tied large veins, I have never observed any symptoms of phlebitis.

Compare DUPUYTREN (a).

[Venous bleeding in operations is sometimes very severe, especially in the removal of diseased breasts. Usually it is stopped by pressure on the divided veins, but sometimes this is insufficient, if the vessels be very large, and the cellular tissue have become brawny, so that the apertures will not come together, but remain open like holes in a sieve. A case of this kind happened to me some years ago, in which the venous bleeding was so sudden and severe, and the number of bleeding veins so great, that the woman, who was advanced in life, died under the operation. Some thought that air might have entered the veins and caused death; but I feel sure that the sudden loss of a large quantity of blood destroyed her. Should I ever meet with another case in which venous bleeding from the breast were so free, I am quite determined I would tie every vein, however tedious the operation might be rendered.

With regard to venous bleeding in amputation of the limbs, I never hesitate to tie the femoral vein, if it will not fall together and close; and I have never found inconvenience from it but in a single case. The extension of inflammation along the vein is, I think, from my own experience, scarcely to be expected. In the case of axillary aneurism mentioned at p. 307, my friend GREEN put two ligatures upon the external jugular vein, and divided it between them, to obtain more room to get at the artery, and no inflammation ensued.-J. F. S.

(a) As above.

Before dismissing the subject of bleeding from wounds, it will be neither uninteresting nor unprofitable to give a slight account

OF THE INTRODUCTION, OR RATHER RESUMPTION OF THE

LIGATURE OF VESSELS,

As now employed, into the practice of Surgery. There is no doubt that the ligature was used by the ancient surgeons; but CELSUS appears to be the first who relied much upon it. To stop the flow of blood from a wound, he recommends that it should be filled with dry lint, over which a sponge dipped in cold water is to be applied, and pressure made with the hand. These applications are to be frequently renewed; and if the lint alone be unavailing, then vinegar is to be applied, as being very efficient in suppressing hæmorrhage, on which account some pour it into the wound. And he then proceeds, "quod si illa quoque profluvio vincuntur venæ, quæ sanguinem fundunt, apprehendendæ, circaque id, quod ictum est, duobus locis deliyandæ, intercidendæque sunt, ut et in se ipsæ coëant, et nihilominus ora præclusa habeant." (lib. v. c. xxi.) And he also directs, in treating of castration, "in quibus cum multæ venæ discurrant, tenuiores quidem præcidi protinus possunt: majores vero ante longiore lino deligandæ sunt; ne periculose sanguinem fundat." (lib. vii. c. xix.)

After some time, but when is uncertain, the use of the ligature gave way to the practice of searing the wound with a hot iron, or of applying various caustic remedies, and no more is heard of it till THOMAS GALE, Maister in Chirurgerie, again brings it forward in describing the various kinds of stitches required in the treatment of wounds (a), as follows:"The fourth maner of stiching is when as a vayne or arterie is cut, and we use to stay the flux of blood, especially when as vene iugulares is cut. Then we thurst the needle through that vaine or arterye and then knit the same with the thried, then draw out the needle and let a portion of the threed hange out so longe untyll it falleth awaye." (p. 3.) Subsequently, also, in speaking specially" of woundes in vaynes and arteries,” he says:-"If they be the smalle vaynes it shall suffyce to stiche the wound and use the pouder desiccatiue mencioned in the chapter goyng before, with twoe and the whighte of an egge. But if any of the great vaines be wounded, then the cure aforesaid is not sufficient. Wherefore you may attempt to stay the fluxe of blood with bending the contrary side to the place wounded; or with letting of blood in another place, whereby there is made diuersion of the fluxe. Also wyth frictions and rubbing the contrary parts. Yf these suffice not, then you must applye causticke pouders as arsenicum sublimatum, vitriall burnt, unsleked lime, or such like; or ells make cauterization with an yron, or stiche the ende of the vaine. And lay some desiccatiue pouder on it, and so dresse the wounde, lettyng it so remayne foure daies. And if there be any asker, (escar,) you must apply to it the whight of an egge and oile of roses well beaten together. And the cure that is heare spoken of vaines, is also to be understand of arteries; and the way to know whether a vaine or arterie is wounded: is by the yssuing oute of the blood. For in an arterie cut, the blood commeth leping and springing out with sume staye, accordinge to the dilatation and compressyon of the arterye." (p. 4.)

From the notes which MALGAIGNE has added to his recent edition of PARE's works, it appears that when PARE published his Surgery, in 1552, he still employed the actual cautery, and made no mention of tying vessels till the following edition in 1564, published at Paris, and bearing the title Dix livres de Chirurgie avec Le Magasin des Instrumens necessaires a icelle, in the seventh book of which, speaking of the treatment of gangrene and mortification which requires amputation, he first recommends tying the vessels to suppress bleeding after that operation in the following terms:

membre.

"Des moiens pour arrester le flux de sang quand le membre est coupé. "Lorsque l'amputation du membre est faitte: il est necessaire que quelque quantité du Il est necessaire sang s'escoule, à fin qu'à la partie deschargee y suruiennent moins d'accialler laisser fluer dents, et ce selon la plenitude et force du malade. * * * Le sang du sang apres escoulé en quantité suffisante (prenans tousiours indication des forces l'amputation du du malade) il faut promtement lier les grosses veines et arteres si ferme qu'elles ne fluent plus. Ce qui se fera en prenant lesditz vaisseaux auec vn tel instrument nommé bec de corbin. De cest instrument faut pinser lesdits vaisseaux, les tirant et amenant hors de la chair, dans laquelle se sont retirez Il n'y a danger de lier quelque et cachez soudain apres l'extirpation du membre, ainsi que font toutes portion de chair autres parties tousiours vers leur origine. Ce faisant il ne te faut estre auec les dits vais trop curieux de ne pinser seulement que lesdits vaisseaux: pourcequ'il n'y a danger de prendre auec eux quelque portion de la chair des muscles (a) An Enchiridion of Chirurgerie, conteyning the exacte and perfect Cure of wounds, fractures, and dislocations; newly compiled and published. London, 1553.

seaux.

ou autres parties. Car de ce ne peut aduenir aucun accident. Ains avec ce l'union des vaisseaux se fera mieux et plus seurement que s'il n'y auoit seulement que le corps des ditz vaisseaux compris en la ligature. Ainsi tires, on les doit bien lier auec bon fil qui soit en double." (ch. 13.)

seaux.

In a subsequent chapter, (15th,) which he heads with: Ce qu'il faut faire s'il suruenoit flux de sang à cause d'vn des susditz vaisseau deslie, he describes another mode of proceeding, first advising, as more easy and less painful than the reapplication of a light bandage round the limb, as used in his time preparatory to amputation, "qu'vn ministre prene le membre à deux mains pressant fort de ses doigtz sur l'endroit du chemin desditz vaisseaux: Car en ce faisant il empeschera le flux de sang. Ce pendant tu prendras vne aiguelle longue de quatre pouces ou enuiron, quarree et bien tranchante, enfilee de bon fil en trois on quatre doubles, de laquelle tu relieras les vaisseaux en la façon qui s'ensuit: car alors le bec de corbin ne te pourroit seruir. Tu passeras laditte aiguille par le dehors de la playe, à demy doigt ou plus, à costé dudit vaisseau, iusques au trauers de la playe, pres l'orifice du vaisseau: puis la repasseras sous ledit vaisseau, le comprenant de ton fil et feras sortir ton aiguille en laditte partie exterieure de l'autre costé dudit vaisseau, laissant entre les deux chemins de laditte aiguille seulement l'espace d'vn doigt: puis tu lieras ton fil assez serré sur vne petite compresse de linge en deux on en trois doubles de la grosseur d'vn doigt, qui en gardera que le neud n'entre dedans le chair et l'arresteras seurement. Laditte ligature retire entierement dedans la bouche et l'orifice de la veine ou artere auec lesquelles aussi cachees et couuertes des L'on ne se doit parties charneuses adiacentes, se reprend aisement ledit orifice. Je te beaucoup sorcier puis asseurer que iamais apres telle operation on ne voit sortir vne goutte du sang sortant de sang des vaisseaux ainsi liez. Et ne se faut trauailler d'user des susdes petits vais- dits moyens d'arrester le sang aux petits vaisseaux: pource que aisement il sera supprimé par les astringents que nous te ordonnerons cy apres." I have made these long extracts from GALE and PARE, as both were celebrated Surgeons of the same period, the former having been with HENRY VIII.'s army at Montreuil in 1544, and with that of PHILIP OF SPAIN, our QUEEN MARY'S husband, at the siege of St. Quintin in 1557; and the latter surgeon to CHARLES IX. and HENRY IV. of France. GALE in 1563 speaks of stitching the wounded vein or artery, and leaving one end of the thread to hang out until it falls away as a common practice with him; but does not advert to either of the methods proposed by PARE for tying the vessels after amputation, trusting to the potential cautery in preference to "actual cateriseng yrons, which sore feared the people with the orrror of cauterization, or burning as we call it, that many of them rather would dye wyth the member on, then to abyd the tirreble fyre, by means whereof manye people peryshed." (p. 56.) PARE uses the actual cautery in 1552, but in 1564 strongly recommends ligatures, but in a very different and preferable manner than as proposed by GALE. And among the reasons he assigns for such recommendation, he says:-" On ne vit oncques de six ainsi cruellement traittez, eschapper deux, encore estoient ils long temps malades, et mal-aisement estoient les playes ainsi bruslees, menees à consolidation, pource que vne telle vstion faisoit des douleurs si vehementes que les malades tomboient en fieure, en spasme et autres mortelles accidents auec ce que le plus souuent l'escare cheut suruenoit nouueau flux de sang qu'il falloit encor estancher auec les cauteres actuels et potentiels, lesquels repetez consumoient vne grande quantité de chairs et autres parties nerueuses. Pour laquelle deperdition les os demeuroient puis apres nuds et decouuers. Ce qui a rendu à plusieurs la cicatrisation impossible, aiants tout le reste de leur vie gardé vn ulcere au lieu du membre couppé, qui leur ostoit le moyen de se pouuoir seruir d'vn membre fait artificiellement." (chap. xvii. p. 115.) From a comparison of these accounts it must be admitted that, although to PARE must be assigned the just praise of having reintroduced the employment of the ligature as now used, (for it is of little consequence whether he was aware of CELSUS having recommended it or not, he has made it so completely his own,) yet GALE's practice of tying vessels, though in a different manner, was earlier given to the world than PARE's, and his horror of the actual cautery not less great, although less picturesquely described.

The ligature of arteries, as recommended by PARE, was very slowly received by Surgeons, and even so late as 1761 it appears in the fourth edition of SHARP'S Critical Enquiry into the present state of Surgery, that the forceps were not used, but PARE'S second method with the needle employed, and in many parts of Europe not even that, whilst in France some of the Surgeons at least thought it not applicable in all cases, and sometimes used it, and at other only lotions of vitriol or of alum.

The tenaculum, now in common use by some practitioners in preference to the forceps, was invented by BROMFIELD, Surgeon of Guy's Hospital.—J. F. S.]

VOL. I.

Y

306. The removal of foreign bodies from the wound, is, next to stanching the blood, the circumstance which requires the greatest attention; because, if they remain, the healing of the wound is disturbed, and severe inflammation, suppuration, gangrene, nervous symptoms, and the like, may be produced. Foreign bodies may be either sand, pieces of clothing, bullets, broken pieces of the wounding instrument, fragments of bone, and the like. The presence and position of such bodies are to be ascertained by examination of the wound, which, in incised wounds, is attended with no difficulty; but, in stabs and gun-shot wounds, the difficulty is often very great. They are to be drawn out either with dressing-forceps or with bullet-forceps, of which those invented by PERCY are the most convenient, inasmuch as they serve at once for spoon, forceps, and ball-screw. If a foreign body lie near the skin, on the side opposite to where it entered, it must be removed by an incision at that place. If the form of the wound prevent the drawing out of the foreign body, it must be dilated in the proper direction. If a foreign body, a bullet, for instance, have penetrated into a bone, its removal is generally difficult. If superficial, it may often be removed with a spatula or an elevator. If it lie deeper, or be wedged in between two bones, the bullet-screw must be used. If it cannot be reached by these means, it must be left alone, in the hope it may become loosened during suppuration; at least, this seems better than to remove the foreign body with mallet and chisel, or with the trepan; an exception, however, is to be made if the body be lodged in the skull. When a bone is splintered, care must be taken to remove only those pieces which are entirely loose; such as are still attached should be pressed into their place, in hope that they may unite or be discharged during suppuration.

The greatest care must be taken in the removal of foreign bodies. It is only very rarely that they remain without inconvenience, by becoming enveloped in a cellular capsule. Often, at a subsequent period, they sink deeper in various directions, produce pressure, inflammation, suppuration, and so on. Only when the removal of the foreign body would cause greater mischief than letting it remain, or when the wound is already much swollen, or the extraction of the foreign body is impossible without great violence, or when it closes large blood-vessels, is its removal contra-indicated.

307. When the bleeding is stanched, the foreign bodies removed, and the wound cleaned, its condition must decide whether the further treatment is to be effected by quick union, or by suppuration and granulation. The former kind of treatment is always preferable, because the healing is quickest, is least interfered with by untoward accidents, and leaves the least trace of the injury behind it.

308. The cleaner the solution of continuity is, the more is it disposed to quick union. When the divided parts have suffered much stretching, tearing, and bruising, before giving way, the inflammation which follows is not such as will bring about the healing of the wound by quick union; but suppuration necessarily ensues. Various, however, are the degrees, from simple division of a part by a cut, to wounds with destruction of parts by bruising. Slight bruises require union, and severe bruises do not contraindicate it and, even although the condition of the part give but little hope that it will be effected, yet much is gained if the edges of the wound hold together only at some few points, because its extent is thereby diminished, and the suppuration much lessened. Only in wounds where the greatest degree of bruising and tearing has occurred, can no union or approximation of the edges of the wound be undertaken.

Simultaneous injury of bone does not contra-indicate union. Union may

even take place of completely separated pieces of bone hanging in the flaps of the soft parts. The proper adjustment of the bony fragment is, however, very difficult in these cases, especially if the flaps of the wound be swollen. Hence the advice given by many, that the pieces of bone should be cut out from the flaps, and the latter properly arranged.

The form and extent of the wound give no definite contra-indication to its union. If the bleeding be slight, an accurate approximation of the edges of the wound will stanch it; but, if the bleeding be considerable, it must first be stanched, and upon the mode in which this is effected depends whether union will take place.

The presence of foreign bodies in the wound, which merely act mechanically, contra-indicates union only so long as they remain there. The existence of deleterious matter in the wound contra-indicates it altogether. When the secretion of a fluid takes place from the bottom of a wound, the retention of which would excite dangerous symptoms, union is contraindicated, unless such retention may be made use of as a means towards effecting a cure.

309. A wound to be united must be properly cleansed, the blood-clot removed from it, and then such apposition of the wounded edges made as shall bring similar structures into contact. The means to be employed for this purpose are, the proper position of parts, uniting bandages, sticking plaster, and sutures. In most cases, union is effected by several of these methods.

["It is with a view to this principle of union (by the first intention)" says JOHN HUNTER, "that it has been recommended to bring the sides (or lips) of wounds together; but as the natural elasticity of the parts makes them recede, it has been found necessary to employ art for that purpose. This necessity first suggested the practice of sewing wounds, and afterwards gave rise to various inventions in order to answer this end, such as bandages, sticking plasters, and ligatures. Among these, the bandage, commonly called the uniting bandage, is preferable to all the rest where it can be employed; but its application is very confined, from being only adapted to parts where roller can be used." (p. 209.)]

310. The position of the wounded parts should always be such that the edges of the wound may be relaxed, and their retraction diminished. This is specially to be observed in transverse wounds of muscular parts. Such wounds on the extensile side of a limb require the straight, and, on the flexile side, the bent position. Longitudinal wounds usually need no particular position, because in them retraction of the edges cannot be very great; in general, therefore, that position is chosen in which the parts are stretched. The position of the wounded part is only the preparation and aid to union.

311. Uniting Bandages, (Fascia unientes, Lat.; Vereinigende Binden, Germ.; Moyens unissans, Fr.,) so called in opposition to those which merely serve to keep dressings together, are such as produce and maintain the immediate apposition of the edges of wounds. Their application is very different according to the form, direction, and locality of the wound. In transverse wounds of the extremities, two long strips of linen, of corresponding breadth with the wound, are required. One of these is to be divided to its middle into as many heads as its breadth contains inches; the other piece is to have a corresponding number of slits made in its middle. These two pieces are to be placed on the limb above and below the wound, and fastened with the spiral bandage. The heads of one strip are next to be passed through the corresponding number of slits in the other, drawn in