239
ARTERY, PATHOLOGICAL CONDITIONS OF.
wards. But it may be observed that the phe¬
nomena attendant on these cases are different
from those already described as characteristic
of the common forms of the accident—that
they usually occur at a later period, even long
after the separation of the ligature might have
inspired confidence in the result, and they are
evidently more hopeless, for neither pressure
nor ligature can here be of the slightest avail.
Farther, to appeal to experience, the best and
surest foundation of every scientific principle,
is it not a matter of daily observation that this
much-dreaded insulation of the artery can have
but little effect on the ultimate termination
of the case, as operations performed in this
respect in the most bungling and clumsy man¬
ner occasionally end well, whilst the utmost
caution in not exposing more of the artery than
will barely permit the passage of the ligature
cannot ensure the patient from secondary hæ-
morrhage ?
When the bleeding is occasioned by any
defect in the operation, such as tying the cord
too loosely, including adjacent structures, &c.
it usually appears so early as from the third to
the fifth day after the operation, and there is
another form of early consecutive haemorrhage
that occurs in consequence of the artery itself
being inflamed or otherwise diseased at the
time of the operation. An example of this is too
often met, when, as a means of controlling con¬
secutive haemorrhage, a fresh ligature has been
tied on the trunk somewhere higher up or
nearer to the heart. It has been remarked by
Dupuytren, that an artery under such circum¬
stances is in a most unfavourable condition for
an operation ; it is surrounded by cellular tissue
in a state of inflammation, in which it par¬
ticipates ; its coats are rendered so brittle that
they break down immediately under the liga¬
ture, and the haemorrhage returns in a few
hours.* It is worthy of remark that in this
case also the bleeding comes from the orifice
of the vessel below the ligature ; indeed, in all
cases of divided artery, whether by a cutting
instrument or by a cord, the remedial process
seems to be different in the two fragments,
being far more perfect in the upper. On this
point the statements of Mr. Guthrie are most
valuable because founded on extensive ob¬
servation, and he remarks in the case of an
artery, the bleeding from which had ceased of
itself, that if it recurs it is more likely to
proceed from the lower than the upper portion.
This latter fact is the more important as it bears
upon another supposed cause of secondary
haemorrhage, namely, the state of tension in
which an artery inclosed in a ligature is ne¬
cessarily placed.
Many years ago it occurred to Mr. Aber-
nethy that, “ as large arteries do not ulcerate
when they are tied upon the surface of a stump
after amputation, it would be right to tie them
in cases of aneurism as nearly as possible in
the same manner and under the same circum¬
stances.” It is familiarly known that he re¬
commended for this purpose the application
* Leçons Orales, tom. iv. p. 573.
of two ligatures with the division of the artery
between them ; and he argues that the divided
portions would be like the large vessels on the
surface of the stump in possession of all their
surrounding connexions, whilst they are left in
a lax state in consequence of their division.
But the cases after all are not analogous, be¬
cause in the stump there is no inferior portion
of vessel from which it has been seen the
chief cause of apprehension arises—it has been
cut away, and only the superior remains, from
which it is rare to meet with hæmorrhage
under ordinary circumstances. In Mr. Aber-
nethy’s operation it is only the upper division
of the vessel that bears analogy with the artery
of the stump, and the insufficiency of the
removal of the tension in preventing hæmor¬
rhage from the inferior is proved, first, by the
fact that consecutive hæmorrhage occurs in
cases that have been thus treated proportion¬
ally as often as in others ; and, secondly, by
Mr. Guthrie’s observation that in the case of
a wound there is no tension : the artery has
been fairly divided, and its surrounding con¬
nexions are undisturbed ; yet the bleeding,
having ceased spontaneously, or, in other words,
having been controlled by the power of nature
alone, may recur, and when it does the blood
flows from the lower orifice.
Others have believed that the accidental
position of a collateral branch near to the
ligature might be a cause of consecutive
hæmorrhage by interfering with the formation
of the internal coagulum. I have already
stated that the importance attached to this
coagulum was greater than it deserved ; and it
will be only necessary here to add, that I have
tied the common carotid artery within an
eighth of an inch of its origin from the inno-
minata without the slightest ill consequence
from that circumstance.
It has been pretty generally believed that in
those cases which have ended favourably,a mild,
healthy, and mitigated process of inflammation
had been established which terminated in the
effusion of lymph and the obliteration of the
vessel, whilst in the unfavourable the inflam¬
mation was more violent and ran into ulce¬
ration. Nothing is more familiar than to hear
of the ulceration of an artery in connexion
with and as the cause of secondary hæmor¬
rhage, yet the existence of such ulceration is
very questionable. Arteries are not prone to
ulcerate. It has been shewn that in the midst
of phagedenic destruction, the artery escapes
for a length of time, and when it is attacked,
it is rather by mortification: and the appear¬
ance of arteries traversing in safety the cavities
of tubercular abscesses in the lungs, where
they have lain for weeks or months bathed in
purulent matter, should make us hesitate in
speaking so boldly of ulceration in these struc¬
tures. The fact, as observed on dissection,
appears to be quite otherwise, and the hæmor¬
rhage to be occasioned not by a hyper-activity
of inflammation tending to ulceration, but by
an absence or failure of the process altogether.
As persons, the subjects of consecutive hæ¬
morrhage, seldom die (at least in this country)