The seven books of Paulus Ægineta, volume 2 (of 3)

by Aegineta Paulus

SECT. LIII.—ON HEMORRHAGE FROM VEINS AND ARTERIES.

In cases of hemorrhage from parts, the contrary position to that for sinuses will be the proper one, that is to say, the upright, but that must not be in too great a degree, for there is danger of pain being excited, and of the blood bursting forth from the vessel again; for nothing produces hemorrhage and increases inflammation more than pain. Wherefore apply your finger immediately to the part from which the blood flows, putting it gently upon the orifice of the opening in the vessel, and pressing it so as not to excite pain, for by this means you will restrain the bleeding, and block up the opening with a thrombus, and should the bleeding vessel be deep-seated you will thereby ascertain most correctly its situation and magnitude, and whether it be an artery or a vein. After this, if the vessel be small we must use some of the styptics. The best of these are the obstruents, composed of roasted rosin, of fine flour of wheat, and of gypsum, and such like, mixed up with the white of an egg and applied upon the down of a hare. When the vessel is large seize it with a hook, stretch and twist it moderately. When the bleeding is stopped, endeavour if it is a vein to restrain the blood without a ligature, by the same medicines. But if it is an artery, one of two things must be done, either apply a ligature around it, or cut the vessel asunder, by which means you will restrain the blood. Sometimes, too, we are obliged to apply a ligature to large veins, and also occasionally to cut them asunder transversely. We are sometimes driven to this necessity with regard to veins which arise from a deep-seated place, more especially when they run through a narrow passage or important parts, for thus the portions will be retracted on either side, and the wound will be blocked up and covered by the parts above it. But the safer practice is to do both these things, applying a ligature to the root of the vessel and then dividing it. Having done these things, the wound is to be incarnated as quickly as possible, before the ligature slip from the vessel. For if it is not speedily incarnated, but the emptied portion is dilated, the disease called aneurism is formed. You may know whether it is a vein or an artery that pours forth the blood, from this, that the blood of an artery is brighter and thinner, and is evacuated by pulsations, whereas that of the vein is blacker and without pulsation.

The most excellent of all the incarnative medicines which we know, is that used with safety for hemorrhages from the meninges of the brain, and which may be used in wounds of the neck, even for those of the jugular veins; for it will restrain the bleeding from them without a ligature. It contains of the fattest frankincense, p. j; and of aloes, when applied to soft bodies, p. ss; but when too hard, an equal quantity, and instead of the frankincense manna is to be substituted. These are to be mixed with the white of an egg until they become of the consistence of honey, when it is to be applied upon the soft down of a hare to the vessel and the whole wound; and a bandage is to be put on externally, the first four or five turns of which we are to make upon the bleeding vessel, and from thence extend to the root of it. Then having loosed it on the third day, if the medicine should still be properly applied to the wound, we are to put on another one all around, soaking it, as it were, and then bandaging. But if the first pledget come away of itself, the finger is to be pressed gently upon the root of the vessel, so as to prevent all discharge, and it is to be removed softly and another pledget applied. Thus it is to be treated until the vessel heal up, the upright posture being still preserved, but so as not to excite pain. Those things which form sloughs render the part more exposed than it was naturally, owing to the falling off of the sloughs; for in many cases a hemorrhage which can hardly be restrained supervenes upon the falling off of the sloughs. And yet we must have recourse to them when a great necessity compels us. A great necessity for using escharotics, or cauteries with fire, occurs when the bleeding proceeds from the vessels being corroded by mortification; and indeed, when in such affections we cut off the whole mortified part, it is safer to burn, as it were, its root, or to use escharotic medicines. This happens more especially upon the pudendum and fundament. The object of escharotics is to produce heat with astringency, as in chalcitis, misy, and copperas. Those from quicklime are stronger indeed, but owing to the want of astringency in the lime, the eschars from them fall sooner away; but it is better that they should remain longer, for thus will flesh have time to form previously at their root, and become as it were a cover to the vessels. In such cases of hemorrhage matured woad (isatis sativa) when sprinkled upon the part is excellent for restraining the bleeding, or burnt galls, but they must first be heated in the fire, and extinguished in vinegar or wine. The following Simples stop hemorrhages: Aloes, frankincense, manna, Samian earth, the rust of iron, the ashes of burnt wool finely powdered, the dung of an ass or of a horse, a small quantity of bitumen, pomegranate-rind, diphryges, galls, dried myrtle, all kinds of alum whether crude or burnt, roasted rosin, the bark or green leaves of the vine, and the down of the peels of the plane tree, more especially when the vessels throw off their crusts. In particular, hemorrhage from the nostril is to be restrained by the application of the fruit of the sharp rush, the juice of nettle leaves, chalcitis, burnt anthyllis, the down of a hare, the middle part of a ferule when burnt with vinegar, an ass’s dung dry or moist, the juice of leeks with frankincense applied upon lamp-wick. The following are compositions for restraining all kinds of hemorrhage: Having soaked a fresh sponge in liquid pitch, and smeared it with bitumen, burn it in a new pot. Mix together of the ashes of it, p. ij; of lead, p. j; of antimony, p. j.—Another: Sprinkle on the part equal quantities of the manna of frankincense, and sulphur vivum.—Another: Of chalcitis, dr. viij; of frankincense, or of its manna, dr. xvj; of roasted rosin, dr. viij; of burnt gypsum, dr. viij.—Another, an escharotic styptic: Of chalcitis, of burnt copper, of copperas, of roasted misy, equal parts. And the medicine called the Rhodian, and that called the yellow, are excellent styptics.

Commentary. See Celsus (v, 26); Galen (Meth. Med. v, et alibi); Oribasius (Med. Collect. x, 22; Morb. Curat. iii, 36; Synops. vii, 20); Aëtius (xiv, 51); Actuarius (Meth. Med. vi, 4); Palladius (Comment. in Hippocr. Epidem. ed Dietz, ii, 189); Albucasis (Chirurg. i, 58); Avicenna (iv, 4, 2,16); Averrhoes (in Avicennæ Cantic. ii, 2, and Collig. vii, 23); Serapion (v, 16); Haly Abbas (Pract. iv, 21); Rhases (Divis. i, 139; Contin. xxviii.)

Contrary to what is often stated in modern works on surgery, the ancients appear to have been very well acquainted with the proper treatment of hemorrhage. Celsus directs us when a dangerous hemorrhage is apprehended from a wound, to fill it up with dry pledgets, then to apply a sponge squeezed out of cold water, and to make pressure with the hand. If the bleeding does not stop, he directs us to change the pledgets often, and if dry ones do not answer to soak them in vinegar. For fear of inflammation he recommends us not to use caustics and escharotics except in urgent cases. When all other means fail, he directs us to seize upon the vessels (venæ) which pour forth the blood, and having tied them in two places about the wound, to cut them asunder, so that they may contract and still have their mouths shut up. If circumstances prevent this from being done, they are to be burnt with a red-hot iron. He also speaks of stopping bleeding by revulsion, as for example, by applying a cupping-instrument to the hindhead for bleeding in the forehead.

Galen has treated of this subject at great length in the Fifth Book of the ‘Meth. Med.’ When blood is discharged from a wounded artery, he directs us to apply a finger to the orifice of the vessel firmly, yet so as not to occasion pain, and thus a thrombus will be formed that will stop the flow of blood. When the vessel is deep-seated he advises us to examine accurately into its situation and size, and to ascertain whether it be an artery or vein; after which it is to be seized with a hook and twisted moderately. If the flow of blood is not stopped thereby, he recommends us, if the vessel is a vein, to endeavour to restrain it without a ligature by means of styptics, or things of an obstruent nature, such as roasted rosin, the fine down of wheaten flour, gypsum, and the like. But if the vessel is an artery, he says, one of two things must be done,—either a ligature must be applied to it, or it must be cut across. He adds, we are even obliged sometimes to apply a ligature to large veins and cut them across. From this extract of Galen’s practice, it will be readily perceived how much our author is indebted to him. He makes mention of the ligature in many other parts of his works. He also recommends the actual cautery.

To stop bleeding, Oribasius directs, in the first place, cooling and astringent applications to be used, and if these do not succeed, caustics, such as misy, chalcitis, copperas, or the actual cautery. Upon the whole, his account of hemorrhage is nearly the same as our author’s, only he says nothing of the ligature.

Aëtius treats of this subject in the same terms as Galen, recommending the ligature under the circumstances mentioned by him. Some of his styptics are powerful escharotics and astringents, such as copperas, chalcitis, alum, galls, quicklime, rosin, and frankincense. He informs us that Ammonius, the famous Alexandrian lithomist, used a composition of arsenic, sandarach, chalcitis, and quicklime.

Actuarius recommends a composition containing burnt copper, chalcitis, galls, frankincense, &c.

Palladius, in his Commentary on the ‘Epidemics’ of Hippocrates, treating of hemorrhage says, we often stop the bleeding by applying a ligature to the divided vessel.

Albucasis mentions four methods of stopping the discharge of blood from an artery: 1, by the cautery; 2, by dividing the artery across; 3, by using the ligature; 4, by styptics applied upon a bolster or compress, and tightly bandaged.

Averrhoes recommends to stop bleeding by styptics, the cautery, or the ligature. He says distinctly, that when the bleeding cannot be stopped, the artery or vein is to be secured with a thread.

Avicenna treats of all the modes of stopping hemorrhage with singular accuracy, but at so great length that we can only afford room for a few remarks. He recommends stupefying things, cold water, exposure to cold, escharotics, and the actual cautery. He also directs in extreme cases the vessel to be cut across, or a ligature to be applied, namely, a flaxen thread. His description of the process of taking up and tying an artery has quite a modern complexion. He also recommends the application of a compress with tight bandaging when the ligature cannot be applied.

Rhases makes mention of the cautery, of the application of snow, of the ligature, of styptics, and of cutting the vessel across. He mentions that Galen in certain cases approved of two ligatures, as it sometimes happens that the inferior portion will pour forth blood. He further speaks of his having occasionally used two or three ligatures for the sake of greater security. He also mentions torsion of the artery.

Haly Abbas gives an interesting account of hemorrhage, and makes mention of bandages and the ligature. He and Serapion agree in recommending strongly as a styptic a mixture of one part of frankincense, with a half part of aloes, applied upon the down of a hare. This is the application called the plaster of Galen, and is much recommended by Zacutus Lusitanus (Pract. Admin. i, 85), by Scultet (Arsinal de Chirurg. Tab. 33), by Brunus (Chirurg. Maj. i, 12), and Lanfrancus (Chir. parva. 5.)

The early modern writers on surgery make mention of all the ancient methods of stopping hemorrhage. Guy of Cauliac recommends the ligature upon the authority of Galen and Avicenna (iii, 1, 3.) It is also recommended by Brunus (i, 12), Theodoricus (i, 13), Rolandus (ii, 1), and Lanfrancus (iii, 1, 9.) It appears, therefore, that the use of the ligature for stopping hemorrhages was well understood by the ancients, and had never been lost sight of even in the darkest ages.