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)