inflicted, the violence attending the injury, and the nature and
importance of the parts divided, or in the neighbourhood of the
wound, must all be attended to, for, from an accurate knowledge of
these circumstances, the treatment of the case comes to be conducted
accordingly. Wounds are divided into incised, punctured, bruised,
and lacerated; that is, into such as are inflicted by a sharp-edged,
sharp-pointed, or an obtuse body. In the first kind, there is greater
or less effusion of blood, according to the size and number of the
vessels divided. Some extend but a little way beyond the subcutaneous
cellular tissue, and are consequently attended with but slight
bleeding; others penetrate to a greater depth, and occasion hemorrhage
from a large vessel, or other alarming symptoms, by having reached
some important organ; others, though not of so great a depth as the
former, may still, on account of their mere extent, be accompanied with
very considerable loss of blood from a number of small branches. It
is seldom that fatal effects immediately follow external wounds; but
they may and do occur when bloodvessels of the first class only are
cut. They are most likely to prove suddenly fatal when the arteries
are only partially divided, and when the large veins accompanying them
are also involved. When the artery is cut through, its extremities
retract, effusion takes place into the sheath and compresses the
orifice; the formation of a coagulum within the vessel is thus
promoted, and the hemorrhage arrested. But, when a portion only of
the circumference is divided, the blood continues to flow through the
aperture and onwards, as if into a smaller ramification of itself, no
retraction or contraction of the vessel can occur, coagulation is slow,
and the bleeding profuse. I have seen a wound of so small a vessel
as the internal mammary prove almost instantaneously fatal. Wounds
of the large internal vessels for the most part prove immediately
fatal; as wounds of the heart, or the large vessels passing to and
from its cavities, at the root of the lungs, or at the upper part of
the liver. When the heart, or the vessels within the pericardium,
have been divided, it can be readily understood how life should be
immediately destroyed, since the blood effused into the cavity of the
pericardium by its pressure completely arrests the action of the heart.
But occasionally punctured wounds, in such situations, have not been
followed by instant death. In such cases, alarming symptoms occur at
the time, but subside, and the patient may for some time suffer no
uneasiness, but afterwards expires suddenly during muscular exertion,
or perhaps in a fit of violent passion. Blood must have been effused
into the pericardium at the first, causing symptoms of, or actual,
syncope; but then the aperture in the vessel had become obstructed
by coagulum before blood had been poured out in such quantity as to
effectually prevent the actions of the heart; at a future period the
coagulum gives way, and the subsequent effusion is limited only by
the pericardial cavity being completely filled. In wounds, hemorrhage
is the symptom which most alarms the bystanders, and which demands
immediate attention; but, to operate successfully, the surgeon must
divest himself of all fear, and learn to look boldly on the open and
bleeding mouths of arteries. Effusion of blood ceases spontaneously,
even from considerable vessels, on faintness supervening, and thus many
lives are saved; but as soon as reaction commences it generally recurs,
and may prove fatal, unless proper measures be resorted to.
When an artery is divided, its extremity retracts within the sheath, it
also contracts, and coagulation occurs; thus the orifice is obstructed,
and a temporary barrier formed to further hemorrhage. The tube,
however, is permanently closed by effusion of lymph from its orifice,
and consolidation of the surrounding parts.
The circumstances which follow division of an artery are these:—The
immediate effect is retraction of its ends within the investing sheath,
and a simultaneous contraction of the coats, so as to diminish the
calibre. From the superior orifice there is necessarily a profuse flow
of blood, which is discharged through the sheath that formerly enclosed
that part of the vessel which has retracted. After considerable
effusion of blood, the flow becomes slower and less profuse; particles
of blood adhere to those filaments which previously connected the
artery to the sheath, but which were lacerated by the sudden retraction
of the divided extremity; these particles coagulate, and lessen the
canal through which the blood is discharged, whilst they present an
irregular surface, on which the blood continues to be deposited and to
coagulate; and thus the aperture in the sheath is ultimately closed.
This external coagulum is found to commence at the extremity of the
artery, where it is of a cylindrical form, and shuts up the mouth of
the vessel; it then extends along the canal in the sheath, frequently
assuming a conical form; and, if a free discharge has been allowed for
the blood, it will terminate at the cut margin of the sheath, otherwise
it will be found continuous with the coagulum blocking up the external
wound. Also, when hemorrhage has been resisted by the shutting of the
external wound, blood is infiltrated into the cellular tissue around
the bleeding point, and there coagulates; but this circumstance can
be productive of little or no pressure on the parietes of the vessel,
so as to assist those other natural means which obstruct it. The flow
of blood through the divided vessel being prevented, the circulating
fluid necessarily passes through the nearest collateral branches,
leaving the blood in the extremity of the larger trunk in a state of
comparative rest; consequently, coagulation occurs in this situation.
The internal coagulum, however, is small, and not sufficient to occupy
completely the cavity of the vessel; it is of a conical form, its apex
being towards the heart, and opposite to the first collateral branch,
and its base resting on the external coagulum, and there adhering to
the internal surface of the artery. But, whilst this latter process
is advancing, the capillary vessels supplying the cut margins of
the artery have begun to act; they throw out coagulating lymph, and
continue to do so until their secretion has completely filled the
vessel immediately opposite to its divided margins; thus a third and
more effectual coagulum is formed,—one of plastic matter, situated
between the external and internal coagula of blood, and in general
closely adherent to them. Lymph is also effused externally to the
artery and its sheath, forming a dense stratum, which separates the
extremity of the vessel from the external wound; it becomes organised,
forms granulations, and thus the parts are consolidated, and the wound
cicatrised. When the artery is permanently obstructed by the adhesion
of its cut margins, the external coagulum can be dispensed with, and
is gradually absorbed. Afterwards all the newly formed parts are
condensed, and diminish in size; the artery contracts, its internal
surface finally embraces the coagulated blood which lay loose in its
canal; its coats appear to be thickened, and it is firm and hard.
Ultimately, in consequence of the continuance of absorption, it becomes
much more attenuated, so as scarcely to differ from the surrounding
cellular tissue. Similar changes occur in the lower extremity of the
divided artery; in general it retracts farther, its orifice is more
contracted, and, the flow of blood being much less profuse than in
the superior, the natural means for its temporary closure are sooner
accomplished. When an artery has been divided close to the origin of
a collateral branch, no bloody coagulum can form internally, for the
blood in that situation is necessarily in a state of constant motion.
If the hemorrhage is suppressed artificially, either by ligature, or by
otherwise well-applied pressure, no external coagulum is formed; there
appears only the internal bloody coagulum, the lymphatic effusion,
and consolidation of the compressed part. The natural contraction and
retraction cannot occur in vessels partially divided; hemorrhage,
therefore, is more violent and dangerous from a partial than from a
complete section. Again, transverse wounds are more dangerous than
longitudinal; in the latter, the edges of the wound are spontaneously
approximated on account of the structure of the vessels, whilst, from
the same cause, the margins of the latter continue separate, and, in
fact, the aperture is a complete circle; the lips of an oblique wound
will be more or less apart, in proportion as it approaches to the
transverse direction. When an artery has been punctured, the wound in
the sheath perhaps does not correspond with that in the vessel; blood,
therefore, accumulates between the vessel and its sheath, and there
coagulates. The wound is thus compressed, its edges kept in contact,
and the farther escape of blood prevented; the lips of the incision are
then agglutinated by effused lymph, and cicatrisation occurs. This,
however, cannot be expected to take place unless methodical pressure
has been applied from the first. Even from small punctures blood is
effused under the sheath and into the neighbouring cellular tissue,
rapidly, and in such quantity as to prevent adhesion. The effusion
continues, and a false aneurism is formed. If a considerable part of
the circumference has been divided, the lymph may be, and generally
is, superabundant, and often to such an extent as to close up the
canal of the artery at that point; but, if the aperture is minute and
in a longitudinal direction, lymph will seldom be effused in greater
quantity than is sufficient for the cicatrisation; and, though it
should be superabundant, it is afterwards removed by the absorbents.
In all cases, the cellular tissue round the wounded point is much
thickened and condensed by the deposition of lymph, but this gradually
disappears after cicatrisation has been completed. Sometimes, and
generally when the wound has been transverse and large, the process of
adhesion is disturbed, and suppuration occurs; in this case the wound
in the vessel communicates with the fistulous track in the externally
effused lymph, and may be the source of troublesome hemorrhage.
In other instances of extensive transverse wounds, the undivided
slip ulcerates, and the artery becomes obliterated, by means of the
same natural processes that occur in complete division. In cases of
laceration of an artery, when its coats have been forcibly torn rather
than divided, little or no bleeding takes place. The vessel retracts;
the lacerated margins of its inner coat become puckered up, so as to
contract greatly the orifice of the vessel; the lacerated sheath is
pulled out to a point, and closed at a little distance from the divided
inner coats. If a large artery is torn asunder in the dead body, this
stretching out and contraction of the sheath will prevent injection
passing; in short, the immediate effects of the injury are such as to
favour the instant formation of coagula, by which the hemorrhage is
arrested until the orifices of the vessel be permanently closed by the
adhesive process. Thus, in instances where the whole of an extremity
has been torn off, the patients have generally lost but a very small
quantity of blood.
From wounds of veins the blood flows, not in a sub-saltatory but in a
uniform stream: its colour is dark, and the flow is easily suppressed.
The common opinion is, that to place a ligature on a vein is dangerous,
and to be scrupulously avoided. The process of reparation, besides,
in a wounded vein, is different from that in an artery. Veins are
less disposed to the secreting action by which adhesion is perfected;
and, when inflamed, the inflammation is extremely apt to extend along
the coats of the vessel; which latter circumstance has been ascribed
to the great proportion of cellular tissue in their coats. When
punctured longitudinally, the lips of the wound remain in contact,
and cicatrisation, by means of effused lymph, is soon effected; in
fact, the wound heals by the first intention. But if opened obliquely
or transversely, not to a great extent, the immediate result is
discharge of blood, and, when this has ceased, a coagulum forms in
the wound, the margins of which remain separate; and this coagulum
generally communicates with blood effused into the sheath of the
vessel. After some time, the lips of the wound, encircling the coagulum
which occupies the aperture, and which has temporarily averted the
hemorrhage, become somewhat turgid, and increased in vascularity;
they then appear to assume a secreting action, by which a membranous
substance, of extreme delicacy, is produced; and the extent of this
membrane is increased until it form an expansion, investing the outer
surface of the clot; it then becomes thickened, by addition of matter,
similar to itself, from the recent vessels which ramify in it. At the
same time it forms adhesions to the surrounding cellular tissue, and
resembles the original tunics of the vein. After being consolidated,
so as to prevent the flow of blood through that part, the coagulum,
formed to arrest the hemorrhage until a more complete barrier should
be furnished, is gradually absorbed. But the membrane long remains
smooth, thin, and diaphanous, and can be thereby readily distinguished
from the original coats. This reparative process is much longer in
being finished than the corresponding one in arteries; and, from what
has been stated, it is evident that the two actions differ in other
respects than the time requisite to complete them. When a vein has been
completely divided, the extremities are closed by means similar to
those which have been already detailed in regard to arteries.
In many, nay in most, instances of hemorrhage from a wounded artery,
the surgeon cannot wait for the natural processes by which the flow
of blood is arrested, but must have recourse to immediate and certain
means. In division of the smaller arteries, or in minute wounds of the
larger, pressure, well applied, will often be sufficient. In both cases
it immediately stops the flow: in the former, it prevents the blood
from penetrating into that portion of the sheath which has been vacated
by the retracted artery; and it being thereby confined, and kept in
a state of rest, coagulation soon takes place. At the same time,
the compression brings the divided margins of the vessel into close
apposition, and thereby permanent closure, by adhesion, is quickly
accomplished. In the latter, the mere circumstance of the escape of
blood being prevented, naturally hastens the closure of the minute
aperture by the natural process; and, if the compression be accurate
and very firm, the opposite surfaces of the vessel, being brought in
contact, may adhere, and the canal be obliterated at the wounded point.
It is obvious that, in this latter class, pressure can only be of
advantage immediately after the infliction of the wound, and not when
blood is extravasated to a great extent.
Pressure may be used along with styptics, or along with escharotics,
actual or potential. They may be often employed when pressure ought
not; styptics promote the contraction and retraction of the divided
extremities, and thereby expedite the formation of a coagulum.
Escharotics form a slough, which, adhering to the extremity of the
vessel, stops the flow of blood, and the cut margins of the vessel,
being stimulated by the application, soon cohere. Active stimulating
applications merely cause effusion quickly of coagulated lymph, and
thus often arrest hemorrhage from very vascular surfaces better than
the so-called styptics. Not unfrequently, after the separation of the
slough, it is found that union has not taken place, and hemorrhage
is renewed; from this circumstance, the remedy cannot be trusted to,
except when the divided vessels or vessel are of small size. It may
be stated, generally, that these means are of little avail without
methodical pressure. In oozing from small vessels, pressure may be
applied by means of agaric, sponge, or lint. In bleeding from small
vessels, where there is general oozing from the surface, and pressure
cannot readily be made, applications tending to produce effusion of
lymph—stimulants, such as turpentine or creosote, are often remarkably
efficacious, and very speedily so; but in wounds of the larger vessels,
the most efficient mean is a graduated compress of lint placed
immediately on the external wound, and supported by a firmly-applied
bandage. The bandage ought to encircle not only the wounded part, but
every part of the limb with a uniform tightness, not so great as to
arrest the general circulation; the parts are thereby supported, and
engorgement prevented. This method, when employed previously to the
effusion of much blood into the cellular tissue, has proved effectual
in wounds even of the brachial, femoral, and carotid arteries. When
blood has been extensively injected into the limb, when the aperture in
the vessel has remained pervious, and when a large diffused aneurism
exists, bandaging is worse than useless. By its application in such a
case the limb becomes discoloured and swells extensively; there is a
risk of mortification from impeded circulation. If a small quantity
only of blood has escaped, its diffusion and increase may be prevented
by the bandage: but a cyst will nevertheless be formed in the cellular
tissue; its parietes will communicate with the margins of the aperture
in the artery, its cavity with the canal of the vessel; an aneurism
of the false kind will be established, and will run the course of one
arising spontaneously.
A ligature, well applied, is the only means that can be relied on. The
immediate effect of a tightly-drawn ligature is to avert the flow of
blood, to divide the internal and middle coats at the deligated point,
the cellular coat remaining entire, and to narrow the canal for some
extent above the point at which it is applied. Coagulation then occurs
within the vessel above the ligature, provided there is no collateral
branch in the immediate vicinity. The ruptured margins of the internal
coat effuse lymph and cohere; lymph is effused also in the cellular
tissue, exterior to the artery and to the ligature; by the compression
of the ligature, ulceration occurs in those parts which it envelopes,
and the foreign body is discharged; but before this occurs the canal
of the vessel has been obliterated by an internal coagulum, and by the
effused lymph. Afterwards, the same absorption and consolidation occur
as in a divided artery, the orifice of which has closed permanently and
spontaneously.
When from a punctured wound profuse hemorrhage ensues, there is reason
to suspect that an important vessel has been hurt, and the bleeding
point must be sought for. After the artery giving out the blood has
been discovered, the external wound must be enlarged, so as to expose
the vessel, and admit of the convenient application of a ligature. It
will not be sufficient to include the vessel above the wounded point,
for the lower part will, after some time, be supplied with blood
by the collateral branches almost as freely as by the large trunk,
and, consequently, bleeding will be renewed. Two ligatures are to be
employed, one above, the other below, the wound. The wounded vessel
must be exposed, as already stated, but not detached more than is
sufficient for the application of the ligature; and at the same time
the ligatures ought to enclose nothing but the vessel. Neither ought
the ligatures to be placed at any considerable distance, but as close
to the wounded point as possible; otherwise circulation in the included
part may be restored. The ligature, round, narrow, and firm, ought to
be tightly applied. Cases of hemorrhage have occurred in which the
tying of the vessel immediately above the wound has been successful;
but these are few, and by no means afford any authority for the general
adoption of such a measure. If the vessel is merely punctured, it is
necessary to apply the ligature by means of a blunt pointed needle, and
the parts are to be disturbed as little as possible. If, however, the
artery is completely divided, its cut extremities are to be drawn out
of their sheath by a hook or forceps, and the ligatures applied close
to the connections of the vessel; the vasa vasorum, in the immediate
vicinity of the deligated point, being left to carry on those processes
by which obliteration is accomplished. In punctured or partial wounds
of arteries, it deserves consideration whether the hemorrhage may not
be restrained by the application of slight pressure, so regulated as
to prevent the flow of blood laterally through the wound, but not so
forcibly applied as to stop the onward current of the blood along the
vessel, from the part of the tube above to that below the puncture.
Some experiments made by Dr. Davy seem favourable to this view; as
bleeding from the carotid arteries, partially divided transversely, in
dogs was easily arrested by the means above-mentioned, the wound of the
vessel readily healing, so as to preserve its tube entire; whereas,
when the pressure was increased, the hemorrhage became violent.
The subject is mentioned as one worthy of a further experimental
investigation. The instrument which will generally be found most useful
for laying hold of the vessel is the common dissecting forceps, but a
tenaculum will, in certain circumstances, be more convenient. By far
the most convenient machine is that here represented.
[Illustration]
When no assistant is at hand, and in cases of emergency, the surgeon
provided with this little instrument can tie vessels without the least
difficulty; and in operation, when many vessels spring, several of
these forceps can be applied; there is besides this great advantage
in their employment, that a clumsy assistant can scarcely include the
point of the instrument with the vessel. Hemorrhage from the smaller
vessels soon ceases; and, before reaction occurs, their orifices have
generally become so obstructed as to resist the effusion of blood.
The effects of ligature on a vein are somewhat different from those
on an artery. The inner coat of the former is more dense and elastic,
and remains entire, whilst the external and middle are divided. It
is puckered by the ligature, and its opposite surfaces are placed in
immediate contact; but there is no breach of surface, and adhesion
does not occur till the tunic has been divided by ulceration; then
the opposite margins cohere, the vessel is obliterated, and undergoes
changes resembling those in an artery similarly circumstanced. The
coagulum between the ligature and extremity is of considerable extent,
dense, and completely filling the canal of the vein, and consequently,
of a cylindrical form.
The edges of the wound, in the soft parts, ought not to be approximated
till the bleeding has entirely ceased, and the surface become glazed,
for the interposition of the slightest quantity of blood prevents union
by the first intention. When bleeding has ceased, the divided edges
are to be brought together as accurately as possible, and adhesion
promoted. The minute vessels assume an action greater than in the
healthy state, though not equal to inflammatory action; they effuse
coagulating lymph, by which the opposed surfaces are agglutinated,
though the union is at first feeble and easily broken up. Soon the
lymph is firmly attached, by newly-formed vessels, to the surface from
which it was secreted; in effect, it becomes organised, and rendered
capable of undergoing, through its inherent powers, the changes
necessary for its perfection and stability. Similar processes go on
in it as in any sound part of the body; new matter is deposited, and
the superfluous is absorbed. The process of nutrition, however, is
not the same in all parts of its substance, that is, the new matter
deposited is not exactly similar at all points; but, according as the
new secreting vessels proceed from the different tissues of which the
margins of the recent wound are composed, so, in various parts of the
new formation, these vessels assume peculiar modes of action, one set
forming muscular, another cellular tissue, and a third a substitute for
skin, formations corresponding to the primary tissues from which the
secreting vessels proceed.