LESIONS OF THE VESSELS
Wounds of Arteries.
Judging from the medical history of warfare, wounds of the large vessels are rare; but, on the other hand, post-mortem examination has shown that they are very frequent. Their extremely serious nature is the explanation of the rarity of cases which have been observed and subsequently published. There are new and precise data to be contributed with regard to their total as well as their relative ratio.
With the Gras and Lebel bullets, in the great majority of cases, when the projectile encountered arteries in its course, it either broke through them or bruised them. Their elasticity, their mobility, the fluid nature of their contents, hardly ever allowed them to escape from the action of the bullet. It was the same with the G bullet during the Balkan War.
The lesions seen in, arteries are-
Contusions, lateral wounds, perforations, and section.
Contusions. -They are reported less exceptionally than wounds, because overwhelming haemorrhage is not here a fatal consequence.
Three degrees of contusions may be noted
In the first degree the artery is ecchymosed on its surface, and in its interior it exhibits slight fine transverse lacerations, which look as if they had been produced by the point of a pin. These solutions of continuity correspond to the horizontal interstices in the muscular and elastic fasciculi of the middle coat of the artery. The contusion is therefore represented by a series of internal wounds.
If the middle coat is deeply and transversely fissured at points corresponding to where the bullet has passed - if it shows what is really an internal wound which is localized and irregular - then we have the second degree.
In the third degree there are deep lesions exhibiting the same characteristics; however, they are no longer localized, but extend over the whole lumen of the vessel. The outside of the artery is more ecchymosed, and the vessel is narrowed at the wounded part.
Knowledge of these facts is very important. If, strictly speaking, in the first degree the formation of an obliterating clot is not fatal (Matthew), the same thing is certain to occur in the two last, and the friction to which the arterial wall has been exposed renders it liable to gangrene. Yet in the last degree the complete rolling up of the inner coats makes the clot much firmer than in the second degree.
These contusions therefore can, especially in aseptic wounds, be of no consequence (first degree); they may cause obliteration of the artery, local ischaemia, and disappearance of the pulse of the vessel; they may be followed by the formation of a scab, especially in septic wounds; or they may be followed by consecutive terrible haemorrhages; and, lastly, they may give rise to the formation of an aneurysm.
There are no characteristic features in the troubles of sensation and of motility caused by arterial contusion; there is strong probability of gangrene occurring at a distance; the only sign of real value is derived from-
1. The close relationship the course of the bullet assumes with the artery.
2. The disappearance of the arterial pulse when there has not been any considerable primary haemorrhage, and no aneurysm has been noticed.
These signs are valuable, because they can be looked for at once. A wounded man who is suspected of suffering from a contusion of a large artery should not be moved.
He must be closely watched. His fate depends partly on asepsis, partly on a septic condition of the wound, bringing about the falling off of the scab.
It is prudent, if one has any doubt concerning the asepsis of the wound, to search for the vessel without waiting for the occurrence of haemorrhage; and if it is found to be much ecchymosed, and especially if it is narrowed, to ligature it both above and below the contused part.
Would incision into the artery, turning out the clot and suture of the vessel, be of any use? (This operation has been proposed.) After ablation of the clot, however, another one would recur in the same place through contact with the internal irregularities of the arterial wall, and, furthermore, suture of the contused wall certainly would not hold.
Lateral Wounds. - These consist of loss of substance
of a curved shape, which may involve a quarter, a third of the transverse diameter of the vessel. The indentation
is clean, sometimes it has fissures on its margins. All the arterial tunics are divided on the same level, and
the middle coat is not retracted.
Very superficial and slight scratches, but with no opening into the artery, have been described. When the wound has involved nearly the whole of the diameter of the artery, owing to movements of the injured limb, the vessel may burst; this may be regarded as a fortunate circumstance.
Complete Perforation.-Through and through perforations, as well as lateral perforations, are often described in postmortem examinations. They are circular or nearly oval, exceptionally linear with the Gras bullets and the Lebel bullet, which last is analogous to the Austrian Mannlicher and the German Mauser bullets. With pointed projectiles will linear wounds become less exceptional ? This is a matter to investigate.
The edges are clean, scarcely fimbriated; both above and below the lesion the internal tunics are not retracted.
The dimensions of the apertures are small or the contrary according to the greater or less velocity of the projectile. They are still smaller, with a pointed bullet of small diameter. As a general rule, both the walls of the artery are perforated.
Those gaping wounds, the spontaneous plugging of which was impossible, gave rise in former times to awful external hemorrhage; the blood poured freely from wounds with large external orifices. Now that these last contract, external bleeding is less fatal and less abundant; primary false aneurysms are more often seen, and they constitute a fortunate termination.
Complete Division.-This is more especially noticed in small arteries. In the larger vessels it seems to be caused by the action of bullets having a very high velocity. Deflected bullets and those from shrapnel very often produce it. A priori, these wounds would seem to be very grave; in reality they are not so, for the transverse tearing, the shreds and strips of the middle coat, the fraying out of the external coat at the two ends where the division has occurred, promote the formation of clots in the same way as the total narrowing of the walls is consecutive to retraction of, the two segments of the vessel. (During the Balkan War it was observed that at short distances, clear loss of substance of the artery, with hemorrhage, took place; at average distances there occurred lateral wounds, more frequently perforations, more rarely simple contusions, complete sections, the vessel being often contused and reduced to pulp, tearing of the artery when the bullet came from a cross direction; at long distances there were principally contusions.)
Wounds of arteries the results of the bursting of shells present the characteristics oflesions caused by tearing, by direct cintusin, by lateral perforation or section (sharp pointed or linear fragments). Small shell splinters might produce linear perforation. Shrapnel bullets generally give rise to contusions of arteries, and less frequently to perforation and section.
When a limb is torn off by large projectiles or their big fragments, the vessel, besides being divided, is drawn out for some distance. Thus can be explained the absence of bleeding, in spite of the gaping of the large arteries.
Arterial wounds caused by splinters thrown out by the bursting of a shell are beyond all description.
The close relations of the large arteries to the large veins are the cause of both vessels being often wounded at the same time.
SYMPTOMATOLOGY - PROGNOSIS. - Everyone knows the fundamental
signs of wounds of arteries: haemorrhage nearly always in
jets; the bright colour of the blood. This bleeding way be stopped by proximal pressure; cessation of the pulse
on the distal side of the vessel.
The concomitance of arterial and venous wounds rather mars the clearness of this description. Haemorrhage with narrow wounds often becomes haematoma, but this last brings with it a new sign - its pulsation.
External haemorrhage, in contradistinction to what one would suppose, is not always of great importance when large vessels are affected. Amongst twelve cases of lesions of large vessels Hildebrandt and Kuttner only found abundant haemorrhage six times, whilst there were five insignificant haemorrhages and one average bleeding. These are ambulance reports which really only deal with a part of the reality. Wounded men with grave haemorrhage succumb before arriving at the ambulance station if their external wounds are extensive.
A fact, the result of the experience acquired in recent wars, is that, by reason of the narrowness of the track made by the present bullets, and of the antisepsis or asepsis of the wounds, the prognosis of the lesions of the large vessels has been improved, a little, a very little, without, however, having become much less unfavourable. It is specially the prognosis of wounds of average-sized vessels that has been modified.
TREATMENT.
1. On the field of battle, at the receiving and first aid stations, indirect digital compression, followed at once by indirect mechanical compression, are the first methods to employ.
Indirect digital compression still retains its superiority for wounds of the carotid and of the subclavian.
Morel's garrot and Mayor's cravat bandage. ( a cravat with a knot which is applied to the course of the artery) (This is probably a modification of Mayor's handkerchief dressing for fractured clavicle.-Note by Translator) are the best means of applying indirect mechanical compression. They only show to disadvantage when their use is prolonged, which is quite contrary to their purpose. They should be employed almost as makeshifts, their application being only temporary.
Forced extension or flexion of the limbs is helpful and useful. In certain large wounds the surgeon may utilize aseptic plugging. This, however, is disadvantageous if left in too long, and if the wounded man is lost sight of (Russo- Japanese and Balkan Wars).
If the wounded man arrives at the ambulance station fixed up in some apparatus, or in one that it is possible to fix, he should remain in it. Whatever the future treatment decided upon, the patient must not be transported. Transport renders the clots liable to displacement, and removes the wounded man from direct supervision.
Soldiers wounded in the chest during the Transvaal War were attacked with internal haemorrhage and haemothorax in the proportion of 90 per cent. when they were transported from one locality to another, and in the proportion of 30 per cent. when they were kept at one place (Makins).
Whatever the treatment made use of, it should be employed when possible before the patient has recovered from his condition of syncope, or at any rate whilst he is recovering.
The first indications of the so-called definite treatment should be settled at the ambulance. They are transcribed from, and explained in, the following lines taken from my communication to the Academy, February 24, 1914:
"For a long time the practice of war surgery in cases of wounds of the large arteries has been reduced to the two following formulae:
"The opening into a large artery necessitates, as immediate treatment, compression in the interval before the application of a direct double ligature, that is to say, one that is carried both over and under the lesion. This ligature was looked upon as an operation of urgency.
"If the haemorrhage has ceased when the surgeon sees the wounded man, he can either wait, keeping the patient under close observation, or apply a direct ligature if he fears a recurrence of the haemorrhage.
"This was the rule; its carrying out had to take the risks which might be set up by the surroundings, of the case. In fact, immediate or rapid ligatures of the large vessels could be counted by units in the histories of cam- paigns, and in spite of the large number of well-known and much-talked-of extemporary compressors, first aid hardly ever arrived in time. Deaths through haemorrhage, on or close to the field of battle, reached the enormous proportions that are well known; the blood so easily escaped through the relatively large wounds made by bullets and through still larger orifices left by shells.
"The suppuration that invaded these wounds, whilst he clot, giving rise to the displacement or the softening of the clot, and, in contusions of arteries, to the separation of the scab, and, finally, to various other infections, consecutively increased the number of deaths through haemorrhage. Cases of aneurysm were very rare. I had a great deal of trouble to find, for my Treatise on Way Surgery, the number of cases of aneurysm that satisfied me. Otis, during the American Civil War, amongst several hundred thousand cases, only observed seventy-four; and Pirogoff, that veteran of Russian campaigns, tells us that he never saw an arterio- venous aneurysm the result of a projectile.
"First aid has been better understood of late years, but of more importance still are certain characteristics of the wounds brought about by modern bullets, and also, we are bound to say, the more rapid and more simple healing of the external lesions, all these have caused, in this terrible prognosis of wounds of the large vessels, a mitigation that began to be noticed by surgeons during the Transvaal War, and which continued to make an impression on medical men during the Manchurian and Balkan campaigns. The nature of the arterial and venous traumatisms was the same : contusions, indentations or lateral perforations, central perforations with a piece, as it were, punched out, that have been described by Lidell and me; but where the greatest change occurred was in the narrowness of the course the bullet made in the thickness of the soft parts - this facilitated spontaneous haemostasis.
"Speaking generally, the number of cases of profuse external haemorrhage has diminished, whilst that of arterial haematomata, of aneurysms both arterial and arterio-venous, has increased sufficiently to make it imperative for surgeons to take notice of the change and to discuss the methods of active treatment applicable to these last conditions. Surgeons wore even, to a certain extent, deluded as to their degree of frequency, this being shown by Loison's formula: in past wars haemorrhage was frequent and aneurysms were rare; in present wars it has been exactly the reverse. The aneurysms, however, remained rare. Bornhaupt, amongst 3,600 wounds seen in the ambulances at the rear, only found 8 cases; this is a great many compared with the zero of former times, but perhaps it is not enough to warrant us having an exce5sive confidence in the benefit conferred by the formation of these aneurysms, and, relying on their possible appearance, to give out as a definite rule that-
"In wounds of large vessels we must no longer put on a ligature whilst the patient is on or near the field of battle, but we must rest content with compression and with securing immobility of the limb. The wounded man, transported at once to the rear, and placed in a fixed ambulance which he reaches after an interval it is impossible to specify, can, if necessary, be treated there for his aneurysm.
"This maxim was suggested to us during the Manchurian War by a surgeon who saw the wounded in the rear - that is to say, that he only saw a part of the scene ; but Manteuffel, whose experience, on the contrary, was acquired on the field of battle and at the halting-places of the troops, had been struck by the grave nature of the haemorrhages that occurred under fire, and had seen on the line of march cases of gangrene brought on and hastened by haemostatic compression continued for too long a time, and finally haemorrhagic relapses due to the displacement of clots during the transport. Manteuffel remained an adherent of the practice of rapid ligature and of keeping the patient immobilized on the spot. 'One must not have seen,' he says, 'these blood- less corpses abandoned in large numbers at every station by the convoys of wounded in order to realize the gravity of wounds of vessels, in spite of their apparently benignant nature.'
"Such are the sights the surgeon sees, such is the very best opinion. It is the one commonly adopted in everyday practice. It is one I have always supported, however difficult its application during a campaign, and it is the one to which we must have recourse. I reduce it to the following formula.-
In wounds of the large vessels, ligature after compression should remain an operation of urgency for cases in which the haemorrhage continues; if it stops, the patient should be immobilized on the spot and closely watched. Supervision would certainly be better carried out in the first line than in halting-places on the road or on the railway. When the surgeon considers the proper time has arrived, he will send the wounded man on to the nearest hospital.
We must not, however, carry to an exaggerated degree the number of the operations or the length of the supervision, both of which must be greatly limited by the invariably grave nature of wounds of the large arteries even when caused by small modern bullets; this was proved by the remarks of Brentano during the Manchurian campaign.
On the other hand, we must not forget that lesions of arteries by projectiles of war are nearly always gaping wounds, with no retraction of the arterial coats; for these reasons they are lesions that present very unfavourable conditions for haemostasis and spontaneous cicatrization.
Suture of the arteries has been recommended of late in bullet wounds. The large size of the vessels, their characteristics derived from loss of substance, from bruised edges, from infection, which is always to be feared, the knowledge also that suture can only be successful in absolutely aseptic wounds, all tend to militate generally against such a procedure. At most, in theory, this method, with its uncertain results in wounds by ordinary bullets seems admissible in those linear lesions (pointed bullets small shell splinters) which are brought to light durini attempts at ligature.
Suture would certainly be more worthy of trial in wound of the large veins, but bleeding from these last is very much less to be feared than that from the arteries.
Carrel's direct suture with silk, either in form of a U or continuous, is to be preferred. Haemostatics are only of use in arresting general oozing (solutions of alum, concentrated alcohol, antipyrine, adrenalin, hydrogen peroxide, horse serum, etc.).
Arterial haemorrhage gives rise to acute anaemia with which we must deal. We shall speak of this later on.
Wounds of Veins.
The walls of veins are less fragile than those of arteries, and are more extensible laterally. Experiments have demonstrated that veins escape more often than arteries from the action of projectiles that graze them. When the accompanying artery is apparently contused or shows a lateral wound, the vein appears to be intact.
The traumatisms produced by bullets are contusions, lateral wounds, complete perforations, or section.
Contusions.- Contused veins do not exhibit the lesions that are so characteristic in arteries. Whilst the external coat presents evident signs of friction, we do not see, in the dead body, any fraying or dividing of the internal coat. Circulation of blood is not interrupted in the vessel.
Lateral Wounds.-These are indentations similar to those seen in arteries.
Total Perforation.-The same remarks apply as in the case of arteries ; but already with the old bullets we find the perforations were reduced in size, often linear in shape, with insignificant contusion of the edges, and they were seen in vessels of smaller calibre.
Sections.--Caused by unequal tearing or crushing of the coats of the vessel at one point. Sometimes they are clean sections. The wounds produced by fragments of large projectiles are very similar to the arterial lesions, but ruptures at a distance are not seen.
We lay no particular stress on the well-known sign of venous haemorrhage: dribbling of black blood, which can be stopped by distal compression.
Contusion may be suspected when there is neither haemorrhage nor sanguineous suffusion, and when the track of the bullet corresponds to that of the venous trunk.
In nearly all cases the vein remains permeable; its primary thrombosis is rare. Introduction of air into veins is a very exceptional complication, and only takes place in certain regions. Arteriovenous aneurysms, formerly very rarely seen, are less exceptional at the present time.
Compression generally suffices to arrest haemorrhage of the large veins. Ligature would only be employed in cases of very severe venous bleeding with extensive external wounds, or occurring in a lesion in which we are seeking for the accompanying artery, which also has been wounded.
Complications of Wounds of the Large Vessels.
In the first rank must be placed acute anamia, going as far as apparent death.
Acute Anaemia - To the ordinary signs that form part of the symptomatology of haemorrhage the following may be added.. Tinnitus aurium, dizziness, shivering, nausea, vomiting, involuntary emission of urine, dilatation of the pupils, great acceleration, and at the same time smallness of the pulse, great fall in the temperature, discoloration, and flabbiness of the integuments, cold sweats, vertigo, syncope, or great tendency to it. The syncope is often providential.
These are the primary signs; later on they may be supplemented by more or less persistent general weakness, diarrhoea. The anaemia is all the more acute when the loss of blood has been rapid; its influence on the brain and on the medulla oblongata is immediate.
Successive losses of blood delay the healing of the wounds, increase the tendency to suppuration, and open a way to infection (Kirmisson).
Haemorrhage having been arrested, we should deal with. the syncope by making the patient lie down, with the head low, by frictions, flagellation, artificial respiration, inhalations of ether, etc., elevation of the limbs. If necessary, we can make use of subcutaneous injections of sulphuric ether (the contents of one, two, or three Pravaz syringes), of injections of camphorated oil, of caffeine, of injections of normal salt solution (sea-salt 7 per1000). Subcutaneous injections of normal saline are employed in the least serious complications, and intravenous injections in the most serious. These injections take the place of transfusion, which, moreover, it would be almost impossible to make use of in war surgery, even were it more efficacious and absolutely free from danger.
Apparent Death.-Although syncope going as far as apparent death can be produced by pain, violent moral impressions, cold, extreme fatigue, or hunger, it is most often caused by severe haemorrhage.
When syncope is prolonged - and this frequently happens - it might give rise on the field of battle to mistakes, did we not make a point at the time of interment of seeking for the positive signs of death. When there is the slightest doubt, the wounded man should be left on the spot where he has been found.
The following examples should always be borne in mind by the military surgeon.
L--, corporal in a line regiment, received a bullet in the face,
and was left for dead on the Medole plain. It was only on the following day when burying the dead was being carried out that signs of life were discovered. L-- is now living on his pension (Chenu).
I experienced, says Nusbaum, an awful shock after the Battle of Orleans, October 10 and 11, 1870, when, during a gloomy, cold and dark night, I found there were a very large number of cases of lethargy. Many times we returned with four or five stretcher-bearers to wounded men who had been left for dead, although the beating of their heart could still be felt. After we had brought them in, made them warm, given them food, we succeeded in bringing them back to life. Loss of blood, exhaustion, hunger, cold, fright, seemed to me to have been the causes of the lethargy. It is dreadful to think that these poor brave young men could have remained lying in a moribund condition in the ditches at the sides of the road whilst the ambulance men went to and fro without noticing them. There is not the slightest doubt but that lethargy can change into absolute death when several hours elapse before the wounded are attended to or afforded warmth (Nusbaum).
Traumatic Aneurysms-Arterial Aneurysms.-Traumatic aneurysms of the arteries are seen under different aspects. Sometimes we see a diffuse, tense haematoma with a souffle; sometimes a more or less extensive haematoma which a sudden haemorrhage, when compression is taken off, has increased; at other times it is a more or less extensive infiltration having no
souffle, the peripheric pulse being weakened, but still perceptible (Laurent). It can be easily understood that these last aneurysms are not recognized at the beginning of a campaign; this has been pointed out by Professor Laurent of Brussels. Sometimes the haematoma is tense, very painful, and infected. It might be taken for a vast phlegmonous exudation, which one might be tempted to incise. It is well known that such errors have been committed by the greatest surgeons.
After several weeks or months of waiting, during which time the cellular tissue of the limb which has been compressed by the blood has had time to become organized, to thicken, to form a genuine sac, we have to deal more often with a localized, well circumscribed, small, hard tumour which has a souffle; this constitutes the arterial or arterio- venous aneurysm ripe for operation.
In all cases the treatment-that is to say, the operation-should be in the hands of a skilled surgeon, for it is difficult and requires nerve.
This operation in primary diffuse arterial haematoma consists, after preliminary compression at some distance of the principal artery, in the free laying open of the sac, search after the wounded vessel, ligature below, and above the lateral perforation, or the through-and-through perforation, and cross- section of all that remains of the divided vessel.
When the operation, instead of being performed at once, has been delayed for a week or two, the changes that have taken place in the sac, in its contents, or in the neighbouring parts, render the search after the artery more difficult, but the method of closing it is the same.
In a completely circumscribed aneurysm recourse must be had to one of the following plans, which at the present time are both classical:
(1) Dissecting out.the aneurysm like a tumour and removing it, after having ligatured the artery both above and below ;
(2) opening the. sac, and search for the artery in its lowest part. The vessel is then tied with a double ligature, and the sac excised either partially or completely.
Extirpation, which nowadays is the operation of choice, gives favourable results in these cases. After the Manchurian War, Bornhaupt mentioned fourteen cases of traumatic aneurysm treated by this method about four weeks after the wound had been received; a cure was obtained in all the fourteen. Saigo, after the same campaign, reported fourteen cases of cure among fifteen extirpations of arterial aneurysms. The results obtained by Professor Laurent of Brussels are quite as conclusive.
Arterio -Venous Aneurysms. - Surgeons have been struck by the relative frequency of arterio-venous aneurysms in recent wars. Whilst during the 1870-71 war only 1 case in 2,000 wounded was noticed, Hildebrandt has seen 4 cases in 100 wounds of the vessels. In the Morocco campaign many wounded were treated in our base hospitals for these aneurysms (Rouvillois). During the present war we should make a point of computing the number of these cases, and of elucidating some points in their history that are still obscure.
Arterio-venous aneurysms occur after complete arterio- venous perforation, after an indentation of both the artery and the vein by a projectile that had insinuated itself between them, or, finally, after a double arterio-venous contusion, or after a contusion of a vessel in close proximity to a traumatic indentation in another.
These aneurysms present themselves under two principal. clinical aspects: Sometimes we see a haematoma which has occurred at once that is diffuse, progressive, becoming rapidly of an enormous size, threatening the whole limb with rupture and gangrene, very painful, easily recognizable by its intense souffle, whose thrill is carried for a considerable distance. Sometimes we see a progressive circumscribed tumefaction of moderate size, which seems to indicate expectant measures as much as the first points to immediate ligature or amputation. Occasionally we see a tumour that appears at a late moment without any notable haemorrhage; in reality it is an aneurysmal varix.
These different characteristics partly depend on the kind of lesion. Two indentations tend to give rise to aneurysmal varix; arterio-venous contusion to the late tumour; extensive perforation and indentations to rapid tumefaction.
The sac of an organized aneurysm is either on the side of the vessel or completely surrounding it.
As a general rule these aneurysms should be treated at the rear by a skilled surgeon, as is done with arterial aneurysms whose condition is not threatening ; but when they develop very rapidly, they necessitate immediate ligature or a more simple operation - namely, amputation. It really seems that on this point there ought to be no further discussion. Vital interests are here concerned, and as, at the beginning, any medical man may be left in charge of the case, he must not hesitate to amputate.
Under other conditions we may employ conservative methods. Ligature at a distance has been condemned; it is insufficient. Extirpation entails injurious damage to a limb, the vitality of which is already much impaired. We must have recourse to incision of the sac followed by ligature in the sac of the artery and the vein above and below the lesion.
Suture can only be successful in cases of fissure or very small indentation of the artery or of the vein. If necessary it may be combined with ligature of the second vessel.
Late and Secondary Haemorrhage.- Late haemorrhage generally comes on at the end of twenty-four or forty-eight hours after either spontaneous or surgically produced haemostasis.
Cessation of syncope, untimely movements on the part of the wounded man, or those caused during the application of the dressings, or during the carrying out of exploration whilst searching for splinters of bone, movements caused by transport, all tend to displace the obturating clots.
Late haemorrhage is much more rarely seen after wounds of veins than after wounds of arteries.
Secondary Hamorrhage.- It is specially connected with a septic condition of the wound. It was very frequent in former times, but has become rare in modern days; but it still is seen (septicaemia, scurvy, etc.).
The fall of the scab that had formed on a contused artery, ulceration of a vessel by a splinter, by a metallic foreign body, more often disaggregation of a clot through suppuration, premature falling of a septic or even of an aseptic ligature, may all be causes of secondary haemorrhage.
We speak of haemorrhage occurring from the eighth to the fifteenth day as precocious, and of haemorrhage appearing from the thirtieth to the fortieth day as late.
Very often, and especially when it is connected with the failing of scabs, the haemorrhage is indicated by premonitory symptoms which the surgeon must not fail to notice: rigors, vague pains, slight oozing of blood, renewed and increasing in quantity in proportion as the scab becomes more separated, and staining the dressings a roseate hue (Roux).
Direct or indirect compression are the first methods to employ until it is possible without further delay to ligature the two divided ends of the vessel. Such is the treatment for choice. Putting a ligature on at a distance would he a deplorable mistake.
Hot water, solutions of alum, of adrenalin, of gelatine (5 to 10 grammes of gelatine absolutely sterilized in a litre of normal saline), of antipyrin, of antidiphtheritic serum, are all useful; they should be employed alone or with direct compression and in conjunction with ergotine in hypodermic injections (fluid extract of the codex - the French Pharmacopoeia - 0.50 in one dose, and 2.50 grammes in the twenty-four hours), white gelatine in hypodermic injections (1/50th), chloride of calcium (4 grammes every day for four or five days), horse serum as a topic or in hypodermic injections, quinine in large doses.
Chapter 5 - Wounds of the Nerves
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