204 Dr. O'Bryen on dneurism of the Aorta.

can be no doubt. The only mode of explaining the rapid de- velopment of the tumour, during the patient's residence in the country, is, by taking into account the inflammatory action that was going on in the lining membrane of the aorta, which must have tended to destroy the elasticity, and of course the resisting power of tile vessel, at a moment when pure air and improved general health increased the injecting force of the heart; thus it appears to me, may be explained the rapid growth of the true aneurism, which it is remarkable, had not contracted, as "the smaller one did, any adhesions to tile neighbouring tis- sues.

The walls of the aorta, thus largely dilated, retained the thickness ofthe normal vessel. This is usually observed in parallel cases (see preparations on the table). You will ob- serve no fibrine attached to the walls of the sac, as in the false aneurism, which presents a beautiful specimen of the disease as effectually cured by its agency as by ligature.

ART. VII . - -A Case illustrative of the Means adopted by Na- ture for the spontaneous Suppression of Hcemorrhage from Lacerations of the large ~4rteries. By John HOUSTON, M.D. , M: R.I .A. , &c., Surgeon to the City of Dtlblin Hospital, Lecturer on Surgery at the School of Medicine, Park-street, &c. &c.

[Communicated to the British Association at Cork.]

SIMON WHITE, aged 33, was admitted into the City of Dublin Hospital on account of an accident by which the right upper extremity was torn from his .body at a point corresponding to the insertion of the deltoid muscle. H i s arm being caught in the revolving strap of a corn-mill, he was lifted by it from tile ground, when the arm was severed from the body, and thrown along with himself, into a heap of oats at a little distance. Helay for a short time insensible, but soon got up again and descended

from lacerated Arteries. 205

three flights of' ladders, without knowing, as he averred, that he had lost his arm,--so sudden was the injury, and so little did he suffer fi'om the act of dismemberment. He then became weak and sick, and was conveyed in about half an hour to hospital, where I saw him immediately on his arrival. His pulse was then small and irregular; he looked pale and frightened, and complained of a load at his heart, but was otherwise so little unwell that he proposed to walk up stairs to the ward without assistance. When laid in bed he was seized with a fit of trem- bling, although without any sensible diminution of the natural heat of the body. His breathing was a little hurried~ but as his friends stated at ttle time that he had a bad chest, this symptom was not much regarded.

The surface of tile stump, when stripped of the rude dress- ings that had been laid over it in the hurry, presented a coating of grumous blood and oats, the latter, firmly impacted in the flesh. It was extremely irregular. Of the nerves, some (the median in particular) hung out loose for many inches, having been pulled up by its branches from the fore-arm ; others did not appear at all, having been torn out by the roots from the brachial plexus. The lesion of the muscles and skin on the outside of the arm was straight, as if it had been made by a knife,--the result, perhaps, of the pressure of the strap on them before the yielding of the bone ; whilst, on the inside, the mus- cles, like the nerves, were irregular, and the skin torn for some distance from the side, obviously by a force of laceration. There was no discharge of blood from any part of the wound, except a little oozing from a few scattered muscular vessels. The extremity of the brachial artery was not exposed to view, being less prominent than many ot;the other textures, and con- cealed by some coagulated blood, which lay entangled among the lacerated parts; the traces, no doubt, of the gush which

must have taken place on the instant of the solution of continuity of so many vessels.

It being an object to secure the main artery against bleed- VOL. xxlv. NO. 7 I. 2 ~.

206 Dr. Houston on Suppression of Hcemorrhage

ing during the interval which it might be necessary to allow to elapse before attempting amputation of the shattered stump, a search was made for that vessel with the view of applying a liga- ture on it. When liberated from the torn sheath, to which its adhesion was so trifling as to admit of separation without the aid of a cutting instrument, the artery appeared dark coloured, smooth, and tumefied, the very extremity being the largest part. When pressed between the finger and thumb, it felt soft and elastic, as if tensely filled with half-fluid, half-coagulated blood, and was distended and jerked by pulsations synchronous with those of the heart ; but, nevertheless, not a drop of blood either issued, or could be squeezed out of, its truncated extremity. In this state it was seen and felt by several persons, who regarded its condition of security against bleeding as very remarkable. A ligature was then placed on the vessel, about an inch above its torn extremity, cold lotion applied, and a little wine admi- nistered. Amputation at the shoulder-joint was next day per- formed, and the patient in due time recovered perfectly. ~ But as I have, here, only to do with the condition of the artery by which the ha~morrhage was so effectually arrested, I shall pass by all other matters, and describe the appearances which it ex- hibited after removal from the body.

The extremity of the outer or cellular coat of the vessel was drawn, at the point of its laceration, over the mouth of' the di- vided inner and middle coats (in the manner that a purse is closed by its string), and distended with a clot of blood, which was entangled and intimately united with tile fine meshes of the torn cellular tissue on its inner surface. The two inner coats of the artery were (if it may be so expressed) drawn within the outer one, for at least half an inch, the tube diminished in ca- libre, and thrown into transverse wrinkles, but not lacerated at any part except that where it had been actually torn through, and the canal occupied by a eoagulum. Outside the mouth of these

* Dublin Medical Press, vol. v. p. 211.

fi'om lacerated Arteries. '207

tunics there lay a small piece of pure coagulated blood like that in their cavity;* but the remainder of the projection in front consisted of the textures above described, viz. a mixture of blood and cellular tissue, which offered a complete barrier to further haemorrhage. This grumous materiel was even traceable for a short way up between the tunics, assisting by its pressure there, from without, to diminish the calibre of the vessel, and coutri- b~lting also to that increase of its bulk observed in the fi,'st in- stance, before the parts had been interfered with by dissectio,.

The other extremity of tile artery--that in the part of tile limb torn off--was found retracted, empty, and open-mouthed. Tile veins were also irregularly torn and empty.

The annexed wood-cut, exhibiting the lacerated artery, of the natural size, in a vertical section, demonstrates all these cir- cumstances very satisfactorily. 1. The brachial artery. 2. The ligature of security, placed

on the artery about one hour after the accident.

3. The longitudinal slit made in tl,e artery after amputation, to show the disposition of its tunics at the torn extremity.

4, 4. The internal and middle coats, presenting a straight edge, in- feriorly, at the torn part.

5, 5. The external coat, projecting nearly half an inch beyond the internal and middle coats ; closed over at the extremity, and dis- tended with grumous blood en- tangled in the cellular tissue of its inner surface.

* The blood in the interior of this part of the artery and outside its mouths

although coagulated whet) thus examined, was, I have no doubt, fluid, up to the

time of the application of the ligature of security on the vessel.

208 Dr. H6uston on Suppression of Hcemorrhage

6, 6. A small'space, corresponding to the open mouth formed by the inner coats, containing a plug of coagulum.

OBSERVATIONS.

The results of experiments on the blood-vessels of lower animals, undertaken to determine the phenomena which occur in the reparation of wounded arteries, cannot fully be relied upon as indicating those which take place in similar lesions in tile human body. There are differences in the organization of the vessels, in the degrees of coagulability of the blood, and in the reparative powers, in animals, as compared with man, which break the analogies and mar the conclusions we might oflmrwise be justified in drawing from such experiments. Investigations on the former may give us a knowledge of the general principles which regulate the actions ofreparatlon in all, but, nevertheless, this constitutes only an approximation to a knowledge of what actually occurs in man. The real facts, those on which we can rely in practice, can only be come at by ocular inspection of them as they take place in the latter.

It is to be presumed, that almost all that can he done, on this head, by experiments on living animals has been accomplished ; and we must now, therefore, look to the opportunities which may arise out of the frailties and casualties to which man himself may become the victim, for extension of our knowledge on this inte- resting branch of surgery.

That our information on this subject is still vague and un- certain every one must feel ; and, as expressive fiflly of this fact, and also, as giving the only advice which can be followed at pre- sent, regarding the matter, I shall quote from one of the latest and best writers on the subject--M. Sanson, who says, that as none of the hypotheses hitherto published, account satisfactorily for the facts connected with the spontaneous stoppage of h~emor- rhage from wounded vessels, we must be content, for the pre- sent, with registering the cases as they occur, and awaiting far- ther and more complete observations.

from lacerated ./lrteries. 209

The case before us affords a satisfactory instance of the ar- rest of the h~emorrhage in a lacerated artery, by the agency of the external tunic alone. Such, it is conjectured, is what occurs in arteries which do not bleed when torn across, but I am not acquainted with any description, much less any specimen from the life in man, placing the matter clearly beyond a doubt, like

that which I have here described. When stretched beyond its power of resistance, the artery

gave way. The inelastic, internal, and middle coats first yielded by a simple transverse fissure. There was no irregular breakage here, such as some suppose to attend on such an injury, and to be capable, by its roughness, of attracting the blood, and in- ducing it to coagulate in tile artery : on the contrary, the lesion was single. The external cellular coat, in virtue of its extensi- bility, yielded so as to allow itself to be stretched, nearly, per- haps, to the extent of an inch, thereby permitting itself to be drawn into a tube, narrowing like an hour-glass in the centre, in a manner that might, at the moment of its giving way, be ima- gined to have resembled a double cone, like an hour-glass, with the apices touching each other, and the bases at the remote la- cerated extremities of the deeper coats. In the actual rupture, the stretched and torn filaments of tile fine cellular tunic, drawn to a point and matted together, fell over the mouth of the ves- sel, smoothly and continuously, and without any aperture for the escape of the blood. The gush which would, otherwise, on the insta ,' have taken place, was thereby arrested, filling the hoode(~ oag in front, and producing that soft, bluish enlarge- ment of the end of the vessel, so strikingly remarkable when first seen. This bag, by its softness, was then known to contain blood in a fluid state, and by its swelling out and pulsating with every stroke of the heart, gave evidence of being still in direct communication with the interior of the artery.

The stoppage of the h~emorrhage was here perfectly mecha- nical. I have little doubt that it was instantaneous also, being one of the consequences of the act of lesion in the vessel itself,

210 Dr. Houston on Suppression of H~morrha~'e

independently altogether of its sheath or other surrounding tex- tures, all of which admitted of being removed t'rem about it without diminishing the disposition and capacity of the vessel to prevent the escape of the blood, as even when so disembar- rassed from them, it admitted of being squeezed, and pulled, and turned in every direction, without giving issue to a single drop of that fluid. The only difficulty towards a belief in the instantaneous arrest of the h~emorrhage (and it is one urged ge- nerally against this theory), is that conveyed in the question,-- where did the blood lost by the man come from ? If the artery was hermetically sealed on the instant, why any h~emorrhage at all? I think that in this case, at least, there was no bleeding from the vessel. The emptying of the veins and arteries of the lower part of the limb, together with some blood, which must have flowed from the veins and smaller vessels of the stump, was sufficient to account fqr the quantity spilt; and I think that the vigorous state of the man, which enabled him, almost imme- diately after the accident, to walk down three ladders unassisted, the strength of his pulse, the heat of his body, and the charac- ter of the tremor which he laboured under being more that of fright than of loss of blood, also show that the quantity lost must have been so inconsiderable, that the main artery of the limb can scarcely have been concerned in its production.

Cases, like that of Samuel Wood* and others, ma);, how- ever, be adduced in evidence, that serious h~emorrhage can fol- low the tearing away of a member, notwithstandingi as may be supposed, that a state of the principal artery, like that just de- scribed, has been induced; but all cases of the same accident need not be alike as regards this lesion. For example, if the laceration occurred at a point where a large artery was given off, the act of stopping the open mouth by a process of this nature might be but imperfectly accomplished. Or, if the vessel were firmly bound to any neighbouring resisting object, the same un-

* Philosophical Transactions, vol. xl.

from lacerated .4rteries. 21 l

favourable result might equally be expected. The state of health

or of disease of the vessel would also influence the result very materially. Different arteries, even, are differently circum- stanced as to structure, in a manner seriously to affect the con- sequences of such accidents. The external coat is more fully cellular or reticulated on the outside in some, than in others, and I think there is, in the axillary and brachial arteries in particu-

lar, a laxity in tissue of ihe surface of the outer coat, a freedom from intimate connexion to any closely adhering fibrous sheath, which disposes them more than most other vessels of equal mag- nitude to have their mouths sealed up in this manner, when torn across by violence. A comparison, in this respect, between the ~xillary, or brachial arteries, and the iliac or femoral, both as regards their anatomical bearings and the effects of such injuries on them, will fully bear out this observation. Tile former, which, from the nature of their cellular envelopes, roll about easily and safely in their beds, afford many instances of sponta- neous cures after laceration : whilst the latter, being compara- tively fixed and rigid, and enveloped closely by dense fibrous sheaths, to which they are connected by a short, fine, cellular tis- sue, have, when lacerated, so little means of reparation from this source, as almost necessarily to remain open, and to offer such facility for fatal hmmorrhage, as to leave but few instances of recovery for record in the annals of medicine. Every second

case must here, as in diseases generally, have something, new. The laws regarding them may be fixed, but the varieties are innumerable. Some may bleed much ; others only a little; and others again, under the same kind of lesion, not at all: but in all such, the same laws must, more or less, be in operation in

remedying similar lesions. It may be added, that this theory of the spontaneous cessa-

tion of h~emorrhage from lacerated arteries, is both rational and intelligible ; for, when we take into account the very moderate amount of resistance which is capable of stopping the flow of blood from a divided artery, as ascertained by Mr. Guthrie and

212 Dr. Churchill on the Swellings on the

others, we may readily conceive that even a trifling mechanical obstruction of the nature produced in this accident, and applied so directly over the mouth of the vessel, would be quite sufficient for the purpose.

The case which I have here detailed may, I think, be regarded as proving, what has been hitherto more a conjecture than a mat- ter of certainty, at least as regards the human body, namely, that the external tunic is capable of itself, without contraction of the whole artery, and without even a coagulation of the blood in its mouth (phenomena usually considered essential to the success of the process), of arresting, on the instant, and both effectually and permanently, the escape of blood from an artery divided by laceration. ~

ART. VIII . - -On the Swellings on the Head of New-born In- fants. By FLE~TWOOO CnvaCmLL, M. D., M. R. ]. A., &c.

{'Read before the Obstetrical Society, Thursday, March 3, 1842.]

I vaovos~ occupying the attention of the Society for a short time this evening, with the consideration of the tumours which are formed on the head of the new-born infant, either during its passage through the pelvis or very shortly afterwards. At first sight the subject may appear insignificant, yet it is nevertheless of some importance, for these tumours are of great practical value in the diagnosis of the presentation and position of the

t

child, and occasionally require special treatment. They have also been almost overlooked by English writers, and the foreign works in which they are described may not be accessible to all the members of the Obstetrical Society.

The only reference to these turnouts that I ha,r met with in British writers, previous to the commencement of the present century, is in Mr. Moss's treatise on the Diseases of Children,

The preparation from which the above wood-cut was taken may be seen in the Museum of the Royal College of Surgeons in Ireland, marked B. c. 228.