M tlie dilli it are great, and ita state in the wound will not allow of a ligature being applied to it there. Sanaon, again (Dea Hannorrnagiea Trauma tiq tics), con ligature applied to the two ends of,t a n Hut we do not think, after the example of the English surgeons, that it should be put in force in all Anel's operation is undoubtedly the best in one class of cases dwelt upon by Dupuytren, in which rises from the tearing of an artery in a simple fracture. The ligature of the main vessel commonly succeeds in these cases, while to find the bleeding vessel is most difficult, and to expose the seat of fracture to the air is a risk greater than should be encountered.
There are, unquestionably, some situations where it is impossible to get at the wounded vessel, especially when the bleeding has taken place at a late date. The deep branches of the carotid afford, perhaps, the most patent example. In a case of this sort, in which the deep temporal and internal maxillary were wounded, in a Russian admitted into the general hospital after the assault in September, Mr. Maunder tied the carotid to arrest the bleeding, which had recurred several times, notwithstanding pressure. The ligature of the main vessel commanded the haemorrhage, although the patient subsequently died of exhaustion. Secondary haemorrhage may appear at a very late date from ulceration, set up by the pressure of a fragcases, and whatever be the situation of the artery, from the risk of causing great destruction, violent inflammations, and long suppurations.
We often meet with wounds attended with haomorrhage, or false primitive aneurisms, in which it is difficult or impossible to determine which is the divided vesseL In other cases we recognise the source of the bleeding, but it is situated too deeply for us, without causing grave injury, to find and tie the artery above and below the wound. We are thus compelled to ligature this artery, or at least the trunk from which it proceeds, between the heart and the wound, but at a considerable distance from the latter. It is true that traumatic haemorrhages are much less favourable than aneurisms, properly so called, to the success of Anel's method. But it is a necessity in a way, and besides we can, if the method of Anel fails, have recourse at a later period to the ligature of the two ends in those cases in which it is possible." "T WOUNDS. i of bone pressing upon the vessel.
The ulcerative process in tli very slow. Tintoll.. cas is conveys much.due of the different places in which to apply the ligature. A Russian l>y whn tlu> eighth day i'mm the ligature of the main vessel luemorrhauv recurred, In.ih in-iu the original wound and the incision of ligatii: -sure was airain tried in vain.
Tinsn tennn-al was OB th'- tenth day i'mm the dcliiration oplitcal. Four days ai'terwards the Mecding rctur. i preaeure ilien secnscd to The ligature separated from the femoral on the twelfth day after its lieim; applied, and the third day day frnld (iuthrie not have saved lliis man's limit, and In wounds of regions whvascular communications, Main r consccr. n lc ol TIIK (' KIM KAN WAR. use, as it is seldom possible to be sure that the haemorrhage proceeds from the main vessel, nor yet can we by such an operation cut off the collateral circulation.
If the. source of the haemorrhage could be certainly ascertained, and if pressure could be applied to the lower portion of the divided vessel at the same time, then we might reasonably hope to arrest the bleeding by tying the main artery; but the mere placing of a ligature on the distal side can give no security against the continuance of tne bleeding. If the sloughing preceding, and accompanying the bleeding, be extensive, and situated in a muscular and vascular part like the calf of the leg, and if the haemorrhage has continued notwithstanding the employment of means applied locally, I should never hesitate between stant recourse to the former, as being the only reliable and satisfactory proceeding.* The following may be taken as a good example of a class of cases frequently occurring.
M'Gartland, a soldier of the 38th regiment, an unhealthy man, who was still suffering from the effects of scurvy and fever, was shot from the outside and behind, forwards * 1 may note the following figures, in passing, as a small contribution to the statistics of this question. The French, in one hospital at Constantinople, ligatured the femoral at a distance from the wound for secondary haemorrhage seven times, and all failed. The subclavian was ligatured under like circumstances once, and it succeeded. I have found the detailed report of only four cases in which the main vessel was tied in India. The ligature was applied twice to the femoral, once to the brachial, and once to the radial. It succeeded in arresting the haemorrhage in three cases; one femoral failed.