Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

LECTURE XII.

MORTIFICATION, ETC.

195. The gangrene, mortification, or sphacelus, consequent on a wound of the main artery of the lower extremity, is, in the first instance, local and dry, unless putrefaction be induced by heat. (See Aphorism 28.) The following case is a good example of this and of all the other points laid down as principles or facts:—

A gentleman received an injury in the upper part of the left thigh, parallel to but a little below Poupart’s ligament, from the shaft of a van. The late Messrs. Heaviside, Howship, and Chevalier were sent for immediately, and my attendance was desired next day. I called the attention of these gentlemen to the tallowy-white and mottled appearance of the foot and lower part of the leg, and assured them that the femoral artery was injured, and the femoral vein in all probability also, from the rapid appearance of the first signs of dry gangrene. In this they would not believe, until the shrinking and drying of the foot and leg became obvious, the course of the tendons on the instep and toes being marked by so many dark-red lines under the drying skin above them. The amputation I recommended below the knee they would not hear of, although they reluctantly admitted the fact of the mortification. On the eighteenth day after the accident, blood flowed from the wound in quantity, of a dark-venous color. This bleeding I pronounced to be from the lower end of the artery. My three friends, in whose hands the case was, could not understand this, and placed a ligature on the external iliac artery, which did not arrest the bleeding. They now, although too late, saw their error, and desired me to do what I pleased, and a ligature secured the lower end of the artery from which the blood flowed. The man died exhausted a few days afterward.

This is a remarkable case, deserving the most serious attention. According to the principle laid down at first as a general rule, the thigh should have been amputated at the seat of injury the morning after the accident, when the signs of mortification of the foot were obvious. But it must be borne in mind that amputations at the trochanter major or hip-joint are most formidable and not generally successful operations; in consequence of which I have recommended another course, deserving, in such cases, of the most deliberate consideration and trial. (See Aphorism 29.) The leg should have been amputated immediately below the knee, as I had ordered it to be done in the case of Turnbull, (page 202,) because that is the part in all such cases at which nature seems capable of arresting the progress of the mortification, if the constitution and powers of the sufferer are good, and equal to the calls upon them. The impairing, the destructive influence a mortified leg exerts on the whole system is removed, and an amputation substituted for it of comparatively little moment. When the hemorrhage took place, the lower end of the artery should have been tied. The upper end never bled, and the ligature on the iliac artery was useless. In this case, it is probable, as the vein was also injured, that the life of the part at and above the knee might not have been preserved, and the patient would have died.

In a case of the kind in which the artery was wounded at the lower part of the thigh instead of the upper, amputation at or just below the wound may be the proper course; this amputation, although dangerous, being much less so than one at the upper part of the thigh or hip-joint. Nevertheless, amputation should not be had recourse to unless the extension of the mortification is beyond a doubt.

196. In Aphorism 29, it is strongly recommended not to amputate a thigh when mortification has stopped just below the knee, and a line of separation has been formed between the dead and the living parts—an opinion formed on a principle laid down in opposition to those usually received by the profession at large, and which have been entertained from the fact that amputations done under these circumstances are commonly fatal.

Richard Cook, aged fifty, a mason, while sitting on a square block of stone, on the 23d of February, was struck by another, which drove the popliteal space or ham against the edge of the block on which he sat, causing him great pain, and otherwise greatly bruising the leg, although no bones were fractured, nor was the skin torn. The limb, on his admission into the Westminster Hospital half an hour afterward, was much larger than the other, and of a dark reddish-blue color, evidently from the bruise or extravasation of blood, which appeared to be still issuing from the vessel or vessels, as the limb continued to increase in size, until it became at last greatly swollen. The pulsation of neither the anterior nor the posterior tibial artery could be distinguished through the swelling the next morning. The bowels were opened, and a cold spirit lotion was applied to the calf and around the leg, and the swelling somewhat subsided, the limb becoming quite a blue-black, which, with the tenseness of the parts, distinctly indicated the effusion of a large quantity of blood. It was soon obvious that greater mischief had occurred than had been expected; and on the 2d of March, as vesications, filled with a bloody fluid, were formed on the outside of the leg, over the fibula, and the whole limb was manifestly about to pass into a state of gangrene, if it had not already done so, I prepared everything for tying the popliteal or other arteries, if found necessary, and made a long and deep incision on the outer and back part of the leg, through the integuments and muscles posterior to the fibula, and removed a considerable quantity of coagulated blood from between the muscles and from a large cavity which extended upward into the ham, without causing further hemorrhage; in no part of that cavity could an artery be felt. The patient’s countenance and body had assumed a jaundiced hue; the pulse was very quick; the tongue foul; the countenance sunken; the skin hot; the head wandering. Poultices of linseed-meal and stale beer were applied, with gentle, stimulating applications. Brandy and wine were ordered in proper quantities every hour or two, with sufficient doses of the muriate of morphia at night to allay irritation and induce sleep. The incision, together with these remedies, gave great relief, and on the 7th the man seemed to have been saved from a state of the most imminent danger. On the 8th the pulse was 112, the tongue clean, the skin of a whiter color, the bowels opened by injections; eight ounces of brandy were given in the twenty-four hours; wine, with sago, arrow-root, jelly, oranges, and anything he chose to ask for. The greatest cleanliness was observed, and the chloride of lime was used in profusion all around him. The mortification of the limb was complete; a line of separation formed about four inches below the knee in front, and extended behind toward the ham. On the 26th, the dead parts having almost entirely separated from the bones all round, those which remained were cut through where dead, the bones were sawn about five inches below the knee, and the lower part of the limb removed, leaving an irregular, and, in part, a granulating stump, with an inch of bone projecting from it. On the 24th of May this portion was found to be loose; diluted nitric acid had been applied to its surface, and on the 20th of June it separated. On the 16th of August Cook left the hospital in good health, with a very good stump, having cost the hospital £57 in extra diet. In this case, there can be little doubt of the popliteal artery having been torn; and if the incision made on the 2d had been had recourse to during the first two or three days, and the artery sought for, and secured if found bleeding, it is possible the mortification might have been prevented; although it is probable, from the pressure arising from the great extravasation and coagulation of blood, that the collateral circulation was so much impeded as not to have been able to maintain the life of the limb below even during that time. The incision made on the 2d saved the life of the patient, by taking off the tension of the part, and relieving thereby in a remarkable manner the constitutional irritation which hourly appeared likely to destroy him; indeed, no one expected anything but his dissolution. When the line of separation had formed, he was evidently unequal to undergo the operation of amputation, in order to make a good stump, without great risk, and the dead parts were therefore merely separated for the sake of cleanliness and comfort. Experience has demonstrated in too many cases of the kind that the formal operation of amputation at this time, as recommended by most modern surgeons, would in all probability have cost him his life.

The application of powdered charcoal, particularly that made from bog earth, or of areca wood, or Macdougall’s disinfecting powder, or of the disinfecting liquids now in use, such as the chlorides of lime, sodium, and zinc, removes in a great degree the intolerable odor which renders the room of the sufferer unbearable, and essentially interferes with his amendment. Incisions should be made into the dead parts to allow the evacuation of the fluids contained within them, while the parts themselves may be removed from time to time; so that when the period arrives at which an amputation is considered advisable, the bones, if of the leg, may be sawn through at or below the line of separation, and nearly the whole of the mortified soft parts removed, so as to leave little of those which are dead and offensive. This operation is done without the patient feeling it; it gives rise to no irritation, inconvenience, or danger; Nature is not interfered with in her operations; and in due time the parts which remain are separated and fall off, leaving a stump more or less good, but which will always bear the application of a wooden leg; and thus the knee-joint is saved—a saving of no small importance to the patient, and a new precept in surgery.

197. The following cases may be considered conclusive:—

A private of the 5th division of infantry received a wound at the battle of Salamanca from a musket-ball, which passed across the back part of the right leg, from above downward and inward. It entered about two inches below and behind the head of the fibula, and passed out near the inner edge of the tibia. There was little blood lost at the time, and it was considered to be a simple wound; eight days after the injury, some blood flowed with the discharge; this increased during the night, and, on examining the limb on the morning of the ninth day, it was evidently injected with blood, which flowed of a scarlet color from both orifices. It being doubtful which vessel was wounded—whether it was the trunk of the popliteal artery, or the posterior tibial or peroneal after its division into these branches—it was thought advisable to place a ligature on the femoral artery about the middle of the thigh, which suppressed the hemorrhage. The case was now shown to me, as one in proof of the incorrectness of the opinion I had a few days before stated, of the impropriety of such an operation being done. The seeming success did not long continue; hemorrhage again took place from the original wound, and the limb was then amputated. The posterior tibial artery had been injured, and had sloughed. The man died.

Remarks.—A straight incision, directly through the back of the calf of the leg, of six inches in length, and two ligatures on the wounded artery, would have saved this man’s leg and life.

Henry Vigarelie, a private in the German legion, was wounded on the 18th of June, at the battle of Waterloo, by a musket-ball, which entered the right leg immediately behind and below the inner head of the tibia, inclining downward, and under or before a part of the soleus and gastrocnemius muscles, and coming out through them, four inches and three-quarters below the head of the fibula, nearly in the middle, but toward the side of the calf of the leg. In this course it was evident that the ball must have passed close to the posterior tibial and peroneal arteries; but, as little inflammation followed, and no immediate hemorrhage, it was considered to be one of the slighter cases. On the latter days of June he occasionally lost a little blood from the wound, and on the 1st of July a considerable hemorrhage took place, which was suppressed by the tourniquet, and did not immediately recur on its removal. It bled, however, at intervals, during the night; and on the morning of the 2d it became necessary to reapply the tourniquet, and to adopt some means for his permanent relief.

The man had lost a large quantity of blood from the whole of the bleedings; his pulse was 110, the skin hot, tongue furred, with great anxiety of countenance: the limb was swollen from the application of the tourniquet from time to time, a quantity of coagulated blood had forced itself under the soleus in the course of the muscles, increasing the size of the leg, and florid blood issued from both openings on taking the compression off the femoral artery. On passing the finger into the outer opening, and pressing it against the fibula, a sort of aneurismal tumor could be felt under it, and the hemorrhage ceased, indicating that the peroneal artery was in all probability the vessel wounded.

In this case there was, in addition to the wound of the artery, a quantity of blood between the muscles, which in gunshot wounds, accompanied by inflammation, is always a dangerous occurrence, as it terminates in profuse suppuration of the containing parts, and frequently in gangrene. Its evacuation therefore became an important consideration, even if the hemorrhage had ceased spontaneously.

The leg having been condemned for amputation above the knee, the officers in charge were pleased to place the man at my disposal: and being laid on his face, with the calf of the leg uppermost, I made an incision about seven inches in length in the axis of the limb, taking the shot-hole nearly as a central point, and carried it by successive strokes through the gastrocnemius and soleus muscles down to the deep fascia, when I endeavored to discover the bleeding artery; but this was more difficult than might be supposed, after such an opening had been made. The parts were not easily separated, from the inflammation that had taken place; and those in the immediate track of the ball were in the different stages from sphacelus to a state of health, as the ball in its course had produced its effect upon them, or their powers of life were equal or unequal to the injury sustained.

The sloughing matter mixed with coagulated blood readily yielded to the back of the knife, but was not easily dissected out. The spot which the arterial blood came from was distinguished through it, but the artery could not be perceived, the swelling and the depth of the wound rendering any operation on it difficult. To obviate this inconvenience, I made a transverse incision outward, from the shot-hole to the edge of the fibula, which enabled me to turn back two little flaps, and gave greater facility in the use of the instruments employed. I could now pass a tenaculum under the spot whence the blood came, which I raised a little with it, but could not distinctly see the wounded artery in the altered state of parts, so as to secure it separately. I therefore passed a small needle, bearing two threads, a sufficient distance above the tenaculum to induce me to believe it was in sound parts, but including very little in the ligature, when the hemorrhage ceased; another was passed in the same manner below, and the tenaculum withdrawn. The coagula under the muscles were removed, the cavity washed out by a stream of warm water injected through the external opening, the wound gently drawn together by two or three straps of adhesive plaster, and the limb enveloped in cloths constantly wetted with cold water. The patient was placed on milk diet.

On the 4th, two days after the operation, the wound was dressed, and looked very well; the weather being very hot, two straps of plaster only were applied to prevent the parts separating. On the 5th a poultice was laid over the dressings, in lieu of the cold water, the stiffness becoming disagreeable. On the 6th, as the wound, although open in all its extent, did not appear likely to separate more, the plasters were omitted, and a poultice alone applied. On the 8th and 9th it suppurated kindly; and on the 10th, or eight days from the operation, the ligatures came away, the limb being free from tension, and the patient in an amended state of health, his medical treatment having been steadily attended to.

The man was brought to England, to the York Hospital at Chelsea, and walked about without appearing lame, although he could not do so for any great distance. He suffered no pain, except an occasional cramp in the ball of the foot, and some contraction of the toes, which took place generally when he rose in a morning, and continued for a minute or two, until he put them straight with his hand; this I did not attribute to the operation, but to some additional injury done to the nerves by the ball in its course through the leg.

This case, which has been followed by many others equally successful, even after the femoral artery had been ineffectually tied, established the practice now followed in England by all educated surgeons; and is another of those great additions to surgery for which science is indebted to the Peninsular war.

198. It may be permitted to repeat, that if an artery such as the axillary be laid bare previously to an operation for amputation at the shoulder, and the surgeon take it between his finger and thumb, he will find that the slightest possible pressure will be sufficient to stop the current of blood through it. Retaining the same degree of pressure on the vessel, he may cut it across below his finger and thumb, and not one drop of blood will flow. If the artery be fairly divided by the last incision which separates the arm from the body, without any pressure being made upon it, it will propel its blood with a force which is more apparent than real. All that is required to suppress this usually alarming gush of blood is to place the end of the forefinger directly against the orifice of the artery, and with the least possible degree of pressure consistent with keeping it steadily in one position the hemorrhage will be suppressed. It is more important to know that if the orifice of the artery, from a natural curve in the vessel, or from other accidental causes, happen at the same time to retract and to turn a little to one side, so as to be in close contact with the side or end of a muscle, the very support of contact will sometimes be sufficiently auxiliary to prevent its bleeding.

In amputation at the hip-joint, the femoral and profunda arteries are frequently divided at or just below the origin of the latter, and bleed furiously if disregarded; but the slightest compression between the finger and thumb stops both at once. They never have given me the smallest concern in these operations, or others of a similar nature; and surgeons should learn to hold all arteries that can be taken between the finger and thumb in great contempt. It is quite impossible for a man to be a good surgeon—to do his patient justice in great and difficult operations attended by hemorrhage, unless he has this feeling—unless his mind is fully satisfied of the truth of these observations. While his attention ought to be directed to other important circumstances, it is perhaps absorbed by the dread of bleeding, by the idle fear that he will not be able to compress the artery and restrain the bleeding from it—that he may have half a dozen vessels bleeding at once—that his patient will die on the table before him. Once fairly in dismay, and the patient is really in danger; but, endowed with that confidence which is only to be acquired through precept supported by experience, he surveys the scene with perfect calmness: taking the great artery between the finger and thumb of one hand, he places the points of all the other fingers, of both hands if necessary, on the next largest vessels; or he presses the flaps or sides of the wound together until his other hand can be set at liberty by an assistant, or in consequence of a ligature having been passed around the principal artery. This is a scene sufficient to try the presence of mind of any man; but he is not a good surgeon who is not equal to it—who does not delight in the recollection of it when his patient is in safety, and his recovery assured. It was in consequence of what was then considered the too great boldness of the practice that my old friend, Sir Charles Bell, whose loss to science cannot be too much regretted, represented me seated on a pack saddle on the back of a bourro, (Anglice, a jack-ass,) on the top of the Pyrenees, expatiating on their merits (which he did not believe) to the descendants of the Bearnois of Henri Quatre on one side, and to the children of the lieges of Ferdinand and Isabella on the other; but no one now disputes their accuracy. The surgery of the Peninsular war was many years in advance of the surgery of civil life.

199. The principles laid down for the treatment of wounded arteries in the lower extremity are equally to be observed with respect to those of the upper. There is, however, little or no fear of mortification taking place in the upper extremity, the collateral circulation being more direct and free; while there is greater danger from this cause of hemorrhage from the lower end of the artery, if a ligature should not have been placed upon it, or if it should not be retained a sufficient length of time.

200. The error of placing a ligature on the subclavian artery above the clavicle, for a wound of the axillary below it, should never be committed. One person dies for one who lives after this operation, when performed under favorable circumstances, independently of the loss which may be sustained by a recurrence of bleeding from the original wound, which is always to be expected and ought to take place; when it does not happen, it is the effect of accident, which accident in all probability occurs from the state of absolute rest having been carefully observed.

201. The necessity for an aneurismal sac below the clavicle, and for its remaining and continuing to remain intact, until the cure is completed, when the subclavian artery has been tied above, is rendered unmistakable by the following case:—

Ambrose C. was admitted into the Charing Cross Hospital, in August, 1848, in consequence of a bruise from a sack of beans; there was axillary aneurism, extending under the pectoral muscle up to the clavicle. A ligature was applied in the usual situation on the outside of the scalenus muscle, and came away on the twenty-second day. The aneurismal sac suppurated, and burst three days afterward, when a quantity of pus and blood, partly fluid, partly coagulated, but very offensive, was discharged. The opening was enlarged, and everything appeared to be going on well, at which time I saw him. On the nineteenth day after the ligature came away, I visited him again with Mr. Hancock, and merely observed that he must keep himself very quiet, and I thought he would do well. In the evening he died from hemorrhage, while eating some gruel. On examination after death, the artery was found to be sound, except where it communicated with the sac by an opening three-quarters of an inch in length. The ligature had been applied midway between the thyroid axis and the first of the thoracic branches. There was a small coagulum, of half an inch in length, both internal and external to the ligature, but not extending to the branch above or below it. The artery was of its natural size as far as the remains of the sac, but beyond it the axillary artery was diminished; the remains of the sac were void of coagulum, except where it communicated with the artery, to which opening a small coagulum had adhered, but had given way at its lower part, and thus caused his death. Between the opening and the ligature, five large branches entered into or were given off by the artery, and through some of these blood was brought round by the collateral branches in an almost direct manner, so that the man’s life depended on the resistance offered by the small coagulum after the sac had given way; proving in an exemplary manner the value of the sac remaining entire.

If this case will not convince the incredulous, it would be useless to bring even the sufferers in such cases from their graves, to affirm the fact of the inapplicability of the theory of aneurism to the treatment of a wounded artery—of the impropriety of placing a ligature on the subclavian artery above the clavicle, for a wound of the artery below it.

Corporal W. Robinson, 48th Regiment, was wounded at the battle of Toulouse, by a piece of shell, which rendered amputation of the right leg immediately necessary, and so injured the right arm as to cause its loss close to the shoulder-joint eighteen days afterward. At the end of a month the ligatures had separated, and the wound was nearly healed, although a small abscess had formed on the inside, near where the upper part of the tendon of the pectoralis major had been separated from the bone. Sent to Plymouth, this little abscess formed again, and was opened on the 2d of August, three months after the amputation. The next day blood flowed so impetuously from it as to induce the surgeon to make an incision, and seek for the bleeding vessel, which could not be found. The late Staff-Surgeon Dease, warned by the case of Sergeant Lillie, (page 198,) strongly objected to the subclavian artery being tied above the clavicle, and, true to the principle inculcated at Toulouse, advised the application of a ligature below the clavicle on a sound part of the artery, but as near as possible to that which was diseased. The operation was done by the senior officer, Mr. Dowling, who carried an incision from the clavicle downward through the integuments and great pectoral muscle, until the pectoralis minor was exposed. This was then divided, and a ligature placed beneath it on the artery where it was sound, at a short distance from the face of the stump, where it was diseased. The man recovered without further inconvenience.

202. In all those cases in which it has been supposed necessary to place a ligature on the artery above the clavicle, after a failure in the attempt to find the artery below it, the failure has occurred from the error committed in not dividing the integuments and great pectoral muscle directly across from the lower edge of the clavicle downward. It is quite useless dividing these parts in the course of the fibers of the muscle, and the case of Robinson is the model on which all such operations should be done. If this operation had not succeeded, the ligature of the artery above the clavicle was a further resource; but as the artery was sound below, with the exception of the end engaged in the face of the stump, the operation was successful; no doubt should be entertained in such cases of the propriety of an operation which is attended with little risk, compared with that which destroys one man for every one it saves.

203. Punctured wounds of the arteries of the arm and forearm ought to be treated by pressure applied especially to the part injured, and to the limb generally; but when the bleeding cannot be restrained in this manner, in consequence of the extent of the external wound, the bleeding artery is to be exposed, and a ligature applied above, and another below the part injured, whether the artery be radial, ulnar, or interosseal.

204. When the external wound closes under pressure, and blood is extravasated in such quantity under the fascia and between the muscular structures as is not likely to be removed by absorption under general pressure, the wounded artery should be laid bare by incision and secured in a similar manner, even at the expense of any muscular fiber which may intervene.

205. When an aneurismal tumor forms some time after such an accident, in the upper part of the forearm in particular, the application of a ligature on the brachial artery is admissible, on the Hunterian principle.

206. When the ulnar artery is wounded in the hand, which is comparatively a superficial vessel, two ligatures should be placed upon it in the manner hereafter to be directed. When the opening is small, pressure may be tried.

207. When the radial artery is wounded in the hand, in which situation it is deep seated, the case requires greater consideration. When there is a large open wound, and the bleeding end or ends of the artery can be seen, a ligature should be placed on each; but this cannot always be done without more extensive incisions than the tendinous and nervous parts will justify.

208. When search has been made by incisions through the fascia, (as extensively as the situation of the tendons and nerves in the hand will permit,) which are best effected by introducing a bent director under it, the current of blood, through either the ulnar or the radial artery at the wrist, or even through both, should be arrested in turn by pressure, which in most cases of this kind will succeed, if properly applied, and thus show the vessel injured. The bleeding point should be fully exposed, and all coagula removed, when a piece of lint, rolled tight and hard, but of a size only sufficient to cover the bleeding point, should be laid upon it. A second and larger hard piece should then be placed over it, and so on, until the compresses rise so much above the level of the wound as to allow the pressure to be continued and retained on the proper spot, without including the neighboring parts. A piece of linen, kept constantly wet and cold, should be applied over the sides of the wound, which should not be closed so as to allow of any blood being freely evacuated; and if the back of the hand be then laid on a padded splint, broader than the hand, a narrow roller may be so applied as to retain the compresses in their proper situation, without making compression on or impeding the swelling of the adjacent parts, the fingers being bent, in order to relax the palmar aponeurosis—a proceeding which should never be neglected in any operation in the palm of the hand. It has been lately proposed by M. Thierry, a French surgeon, to raise and bend the arm, as a means of impeding the circulation where the artery passes over the elbow-joint, and the proposal deserves adoption, but not to the extent he recommends, which cannot be long submitted to. Pressure made at the same time on the radial or ulnar artery, or on both, by a piece of hard wood two inches long, shaped like a flattened pencil, is much more effectual, and more to be depended upon. When from the bones being broken, or the hand so swollen, or from other circumstances, pressure, however lightly and carefully applied, cannot be borne in the manner directed, and the attempts to secure the artery at the bleeding spot have failed, and pressure on the radial or ulnar artery has been equally unsuccessful, in consequence of the swelling or other circumstances, both may be tied at the wrist in preference to placing a ligature on the brachial artery, although that even must be done as a last resource, if the bleeding should still continue. If it be asked why not do this in the first, rather than in the last instance, the answer is, that it has so often failed to prevent a renewal of the bleeding from both ends of a wounded artery in the hand, that complete dependence cannot be placed upon it, particularly if there should be a division high in the arm of the brachial into the radial and ulnar arteries. When, however, the arteries leading to the wound have been secured, either by pressure or ligature, NEAR to the part, and the bleeding returns by the collateral circulation, which in the hand is so free, the arresting the supply of blood through the main trunk may and often has suppressed the hemorrhage, at all events for a sufficient time to enable the injured parts to recover themselves, provided the forearm is bent and raised, and the person kept at rest in the most restricted manner, without which this operation will in all probability fail. It is in these cases that the instrument alluded to, page 226, will be useful, rendering the ligature on the trunk of the vessel unnecessary, more particularly if the bleeding should appear to depend on some peculiarity in the structure of the coats of the artery.

209. When the obstacle to the application of pressure arises from the injured state of the metacarpal bone or bones, one or more should be removed, with the fingers if necessary, so as to expose a clear and new surface, on which the bleeding vessels may be seen and secured. In some cases, particularly if there should be a hemorrhagic tendency in the arterial system generally, as known from previous accidents, the first compress may be wetted with the perchloride of iron, the ol. terebinth., the dilute sulphuric acid, or the tincture of matico; these remedies may be also administered internally. Some new styptics have lately been much lauded in Malta and other places, but sufficient proofs have not been given of their efficiency.

210. When the radial artery is wounded as it turns from the back to the inside of the hand, to form the deep-seated palmar arch, it meets a branch of the ulnar nerve about to terminate in the muscles of the thumb. If the treatment by pressure above recommended should not succeed, the muscles forming what is called the web, between the thumb and metacarpal bone of the forefinger, should be cut through, and the bleeding vessel exposed. They are the adductor pollicis on the inside, and the abductor indicis on back of the hand.