vessel and into the other, blood flowing into the vein, the subsequent inflammation gluing the two vessels together, and the aperture failing to close (aneurysmal varix, Fig. 45). After the infliction of the wound the two vessels may separate; the blood still flows from artery into vein, and the blood-pressure, by consolidating tissue, forms a junction (varicose aneurysm, Fig. 46). Aneurysmal varix is a far less grave disorder than varicose aneurysm.

sac of

Symptoms. In aneurysmal varix a swelling exists with the characteristic pulsation, and a loud whirring bruit is transmitted along the veins. The veins above and below the tumor are enlarged, tortuous, and pulsating. A distinct thrill is felt. Pressure over the tumor stops the thrill and greatly lessens the bruit. The extremity is apt to be swollen and the parts are usually painful. When pressure on the main artery causes the entire disappearance of the tumor,

VE IN

ARTERY

FIG. 45. Plan of an aneurysmal varix.

FIG. 46. Varicose aneurysm (Spence).

the case is one of aneurysmal varix; but if on applying this pressure the veins collapse and a distinct tumor remains which may be emptied by direct pressure, the case is one of varicose aneurysm. If light pressure on one spot stops both murmur and thrill, it is aneurysmal varix. The diagnosis between the two is often impossible.

Treatment.-Aneurysmal varix often requires only palliative measures, as it does not tend to rupture, the veins becoming thick and resistant and after a time ceasing to enlarge. Some form of support is used. If the part is painful or the vein is in danger of rupture, tie the artery above and below the opening, or excise both vessels for some little distance each side of the point of trouble. Varicose aneurysm requires the use of the plans ordinarily adopted in treating aneurysm (compression, etc.). If these fail, tie the artery above and below the opening without opening the sac, or excise the involved areas of vein, artery, and sac.

Cirsoid aneurysm, or aneurysm by anastomosis, consists in great dilatation with pouching and lengthening of

one or several arteries. The disease progresses and after a time involves the veins and capillaries. The walls of the arteries thin and the vessels tend to rupture. Cirsoid aneurysm is met with upon the forehead and scalp of young people, where it sometimes takes origin from a nevus.

Symptoms.-A pulsating mass, irregular in outline, composed of dilated, elongated, and tortuous vessels that empty into one another. The mass is soft, can be much reduced by direct pressure, and is diminished by compression of the main artery of supply. A thrill and a bruit exist. Pregnancy and puberty cause rapid growth of a cirsoid aneurysm.

Treatment. In treating a cirsoid aneurysm the ligation of the larger arteries of supply is a wretched failure. Subcutaneous ligation at many points of the diseased area has effected a cure in some cases, but it has failed in most. Direct pressure is also entirely useless. Ligation in mass has been successful. Destruction by caustic has its advocates. Electropuncture with circular compression of the arteries of supply has once or twice effected a cure. Injection of astringents has been recommended. Verneuil ligated the afferent arteries, incised the tissues around the tumor, and sunk a constricting ligature into the cut. The proper method of treatment is excision after subcutaneous ligation of every accessible tributary of supply.'

Wounds of arteries are divided into contused, incised, lacerated, punctured, and gunshot wounds, and vascular ruptures.

Contused and Incised Wounds.-A contusion may destroy vitality and be followed by sloughing and hemorrhage. A contused wound may do little damage, or it may produce gangrene from thrombus, or it may cause secondary hemorrhage. In an incised wound there is profuse hemorrhage. The artery after a time is apt to contract and retract, and thus arrest bleeding. A transverse wound causes profuse bleeding, but there is a better chance for natural arrest than in an oblique or in a longitudinal wound. In a partially divided artery, cut it entirely through and tie both ends. The clot which forms in a cut artery is known as the “internal clot;" it reaches as high as the first collateral branch, and subsequently becomes organized permanently, obliterates the vessel, and converts it into a shrunken fibrous cord. Between the vessel and its sheath, over the end of the vessel, and in the surrounding perivascular tissues is the "external clot."

1 Anderson, in Heath's Dictionary.

Lacerated wounds cause little primary hemorrhage. The internal coat curls up, the circular muscular fibers of the media contract upon it, and the external coat is so pulled out as to cap the orifice of the vessel-all of which conditions favor clotting. The vessel-wall is so damaged that secondary hemorrhage is usual.

Punctured Wounds.-In punctured wounds primary hemorrhage is slight. Secondary hemorrhage is not usual. Diffuse aneurysm and arteriovenous aneurysm are not unusual results.

Gunshot-wounds are apt to be contusions which may eventuate in sloughing and secondary hemorrhage or thrombosis and gangrene. A shell-fragment makes a lacerated wound. A modern rifle-bullet makes a clean-cut division of an artery. Secondary hemorrhage after gunshot-wounds tends to occur during the third week. Partial rupture of an artery may cause sloughing and secondary hemorrhage, thrombosis and gangrene, and aneurysm. Complete rupture is a lacerated wound, and is a condition accompanied by diffuse traumatic aneurysm.

Wounds of veins are classified as are wounds of arteries. The symptom of any vascular wound is hemorrhage.

1. HEMORRHAGE, OR LOSS OF BLOOD.

Hemorrhage may arise from wounds of arteries, veins, or capillaries, or from wounds of the three combined. In arterial hemorrhage the blood is scarlet and appears in jets from the proximal end of the vessel, which jets are synchronous with the pulse-beats; the stream, however, never intermits. The stream from the distal end is darker and is not pulsatile. Venous hemorrhage is denoted by the dark hue of the blood and by the continuous stream. In capillary hemorrhage red blood wells up like water from a sponge.

In subcutaneous hemorrhage from vascular rupture (diffuse aneurysm) there are great swelling, cutaneous discoloration, and systemic signs of hemorrhage. If a main artery ruptures in an extremity, there is no pulse below the rupture, and the limb becomes cold and swollen. At the seat of rupture a large fluctuating swelling forms, and sometimes there is bruit and pulsation. If a vein ruptures in an extremity, intense edema occurs. Profuse hemorrhage induces constitutional symptoms, and death may occur in a few seconds. Loss of half of the blood will usually cause death (from four to six pounds), though women can stand the loss of a greater rela

tive proportion of blood than men. Generally, after the bleeding has gone on for a time syncope occurs, which is Nature's effort to arrest hemorrhage, for during this state the feeble circulation and the increased coagulability of blood give time for the formation of an external clot. When reaction occurs the clot may hold and be reinforced by an internal clot, or it may be washed away with a renewal of bleeding and syncope. These episodes may be repeated until death supervenes. Nausea and vertigo are present, black specks float before the eyes (muscæ volitantes), tinnitus aurium exists. The patient is restless and tosses to and fro, and great thirst is complained of Delirium is not unusual, and convulsions often occur. After a profuse hemorrhage an individual is intensely pale and his skin has a greenish tinge; the eyes are fixed in a glassy stare and the pupils are widely dilated; the respirations are shallow and sighing; the skin is covered with a cold sweat; the legs and arms are extremely cold; the pulse is soft, small, compressible, fluttering, or often cannot be detected; the heart is very weak and fluttering; there is muscular tremor; the patient tosses about, and asks often for water. orrhage the hemoglobin is greatly diminished in amount. When such a dangerous condition is due to a visible hemorrhage, temporarily arrest bleeding by digital pressure in the wound, or the application of an Esmarch band above the wound (if the bleeding is arterial). In some cases forced flexion is used. Lower the head, and have compression made upon the femorals and subclavians, so as to divert more blood to the brain. Apply artificial heat. Inject by hypodermoclysis the normal salt solution (10 to 16 ounces) into the cellular tissue of the buttock, or transfuse the salt solution into a vein, inject ether hypodermatically, then brandy, and then strychnin in doses of gr. 2. Atropin, digitalis, and morphin are recommended. Give enemata of hot coffee and brandy. Apply mustard over the heart and spine. Lay a hot-water bag over the heart. As soon as reaction is established, arrest the bleeding permanently by the ligature.

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A severe hemorrhage is apt to be followed by fever-hemorrhagic fever due to the absorption of fibrin ferment from extravasated blood and its action upon a profoundly debilitated system. In this form of fever there are most intense thirst, violent headache, dimness of vision, great restlessness, often mental wandering, with a very frequent, weak, and fluttering heart. After a severe hemorrhage leukocytes are increased, not only relatively but absolutely. Red corpuscles are diminished both relatively and absolutely. Hemoglobin

diminishes; many of the corpuscles become irregular and microcytes are noticed.

In treating a patient who has reacted after a severe hemorrhage, apply cold to the head to prevent serous effusion into the brain. Aconite, morphin, and neutral mixture are given by the mouth. Fluids and ice are grateful. Frequently sponge the skin with alcohol and water (S. W. Gross). Milk punch, koumiss, and beef-peptonoids are given at frequent intervals. If the hemorrhage is from a spot inaccessible to ligation, such as the lung, give the patient 3 grains of gallic acid, I grain of powdered digitalis, I grain of ergotin, andgrain of powdered opium every three or four hours.

Hemostatic agents comprise (1) the ligature; (2) torsion; (3) acupressure; (4) elevation; (5) compression; (6) styptics; (7) the actual cautery; and (8) forced flexion of limbs.

The ligature may be made of silk, floss-silk, or catgut, but it must be aseptic. The ligatures should be about ten inches long. The vessel is drawn out with forceps and separated from surrounding tissues. The forceps are better than the tenaculum in most cases, because the tenaculum makes a hole through which blood may subsequently exude. When the artery lies in hard tissues or is retracted deeply in muscle or fascia, the tenaculum is best. Tie with a reef-knot. The tightening of the first knot cuts the internal and middle coats. The second knot must not be tied too tightly, or it will cut the ligature. Do not jerk the ligature in tying, and cut off closely. Both ends of the vessel are tied. If an artery is incompletely divided, tie on each side of the cut and entirely sever the vessel between the ligatures. If a large vein is slightly torn, try pinching up the vein-walls around the rent and apply a ligature (lateral ligature) (Fig. 48). If a vein is longitudinally torn, sew up with a Lembert suture of silk (Ricard and Niebergall have done this successfully). In extensive tears tie both ends of the vein; cut the vein between the ligatures. If the bleeding comes from an artery very close to its point of origin, tie the main trunk as well as the bleeding branch, otherwise the clot formed will be too short and secondary hemorrhage will be inevitable. When the parts about an artery are so thickened that the artery cannot be drawn out, arm a Hagedorn needle (Fig. 47) with catgut and so pass the latter around the vessel that the catgut will include the vessel with some of the surrounding tissue, and tie the ligature. This method is pursued in necrosis, atheroma, scar-tissue, sloughing, etc. Never include a nerve. If this mode of ligation fails, try acupressure. Murphy of Chicago has recently shown that longitudinal