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INAUGURAL ESSAY, 
 
 ON THE 
 
 TREATMENT OF WOUNDS OF THE 
 
 ifpemoral ©tin. 
 
 SUBMITTED TO THE EXAMINATION OF 
 
 SAMUEL BARD, M.D. L.L.D. 
 
 PRESIDENT, AND THE TRUSTEES AND PROFESSORS OE THE 
 
 COLLEGE OF PHYSICIANS AND SURGEONS OF THE UNI- 
 VERSITY OF THE STATE OF NEW-YORK : 
 
 AND PUBLICLY DEFENDED FOR THE DEGREE OE 
 
 DOCTOR OF MEDICINE, 
 
 ON THE SIXTH DAY OF THE 4TH MONTH, 1819, 
 
 By DANIEL A. ROBINSON, 
 
 Member of the Medico- Chirurgical Society of the University of the State 
 of New-York. 
 
 GENEVA, n. y. 
 
 PRINTED BY J. BOGEBT, AT HIS BOOKSTORE AND BINDERY. 
 
 1819. 
 

AN 
 
 XF we search (he records of most systematic writers 
 on surgery, it will be fuund that very little is said of wounds 
 of the veins : however, it is not our object to inquire into the 
 cause of this omission But, to show that the subject is worthy 
 of particular examination, we quote the following : First, from 
 Boyer, who observes, that " the hemorrhage from a large vein 
 may become very dangerous when the vein is the only one be- 
 longing to the limb; for then the compression or ligature ne- 
 cessary to staunch the blood, hinders its return to the heart, 
 and the member swells so prodigiously that gangrene may su- 
 pervene. For example, if the femoral vein were opened at the 
 groin, above its juncture with the saphena vein, there would 
 result, from the compression necessary to stop the bleeding, a 
 great tumefaction and its necessary consequences.'''* 
 
 Secondly. S. Cooper, in his Surgical Dictionary, a work 
 30 justly and so highly esteemed, is silent on this point. We 
 find in it, however, a reference to Dr. Hunter's second opera- 
 tion for popliteal aneurism, wherein he included in one liga- 
 ture the femoral vein with the artery. His patient died. 
 
 Thirdly. In Cooper's and Travers's Surgical Essays, a 
 work lately published, may be found several interesting cases 
 perfectly in point, from which it is thought proper to select 
 the following: 1st, John White, aged 28 years, was admitted 
 into Guy's Hospital Nov. 22, 1816, for an aneurismal tumor 
 in his left ham. During the operation of tying the femoral ar- 
 tery in the thigh with two ligatures, on Friday, Nov. 29, 1816, 
 * Vol. 1— page 124. Alexander H. Stevens' Translation. 
 
[ 4 ] 
 
 a hemorrhage took place from a small wound of the femoral 
 vein. The bleeding was at first troublesome, but was presently 
 commanded by a ligature which was applied around the opening 
 by nipping up its coats. Inflammation ensued in the vein, and 
 the man died Dec. 31, 1816. " Examination. — The limb, and 
 especially the leg and foot were oedematous ; the surface of 
 the wound was in a sloughing state, but it was filled at the 
 bottom by granulations; the extremity of the divided artery 
 presented a healthy appearance ; the femoral and profunda 
 veins were filled by adhesiev matter. When a blow pipe was 
 introduced into the upper extremity of the femoral vein, the 
 air passed by it to the wound externally. The same was at- 
 tempted to be done with the femoral artery, but it did not ap- 
 pear to have any communication with the external wound. 
 The vein was next laid open : its internal tunic was covered 
 with adhesive matter, and the sides at the lower part were ad- 
 hering. It contained nothing like recent blood. All the 
 coats were much thickened, and its capacity was gradually 
 diminished downwards to the wound, where it was completely 
 closed. There was an opening in the coats of the vein about 
 three-quarters of an inch above the obliterated part, and this 
 opening communicated with the external wound. Below the 
 obliteration the wound was in a healthy state, the coats of 
 the vessel were natural, and it contained a clot of blood. The 
 adhesive inflammation had extended from the internal surface 
 of the femoral vein to the iliac, as high as the bifurcation of 
 the cava. The cava was also inflamed, but here the inflamma- 
 tion had not produced lymph or pus. The internal surface of the 
 iliac vein presented the same appearance as the femoral ; the 
 corresponding iliac on the opposite side was not affected. The 
 artery was next examined: its internal surface was healthy; 
 the lymph plug extended some considerable distance above the 
 situation of the ligature, and its extremity was contracted and 
 closed. There was considerable serous effusion in the chest ; 
 one of the lobes of the left lung was covered with a recent 
 
t 5 'J 
 
 deposit of lymph, and llie parenchymatous substance of the 
 lungs appeared to have been inflamed. There was also a 
 slight inflammatory blush on the surface of the intestines; the 
 other viscera of the abdomen appeared in a healthy state." 
 
 Case 2nd. " John Crute, aged 30, suffered amputation of 
 his right leg above the knee, for a scrophulous disease of that 
 joint of long continuance. His health was in a considerable 
 degree affected. During the first two days succeeding the op- 
 eration, he appeared unusually low, often sighed deeply, and 
 spoke but little. On the evening of the third day it became 
 evident that he labored under more constitutional irritation 
 than is common after amputation, and he was attacked at night 
 with severe bilious vomiting, his bowels being freely open. 
 Early on the following morning, (fourth day") the dresser was 
 called to him, and finding that he had passed a very restless 
 night, and had a hard quick pulse, he drew 20 ounces of blood 
 from his arm, and administered some aperient medicine. His 
 pulse lowered and became softer, and he expressed himself re- 
 lieved by the bleeding; but the vomiting continued at inter- 
 vals. At noon the stump was opened : the lips of the wound, 
 which were generally adhering, were separated, and a copious 
 discharge of grumous blood, accompanied with purulent sanies, 
 followed. A fomentation and poultice were applied to the 
 stump : in the evening an exacerbation of the symptoms took 
 place ; slight rigors were followed by fever and delirium. On the 
 morning of the 5th day his pulse was thready and very rapid ; 
 his countenance sunken, and he had incessant low muttering: 
 he continued sinking until 3 p. m. on the following day, when 
 he died. Examination twenty hours after death. — The femor- 
 al artery in a healthy state ; a firm plug of lymph obstructing 
 the canal, which was contracted, as is usual where a ligature 
 has been applied. On the mouth of the femoral vein was a 
 ligature which the dresser, in the absence of the surgeon, had 
 applied, for the purpose of restraining a hemorrhage, after the 
 ligature of the artery, apparently proceeding from the vein : 
 
[ 6 ] 
 
 he bad done this without hesitaton, having frequently seen it 
 done with safety by the surgeon under whom he hud formerly 
 studied. From the site of the ligature, along the femoral and 
 external iliac veins, to the point at which the emulgents enter 
 the latter vessel, the interior tunic was literally coated by 
 large flakes of coagulable lymph. There were marks of dif- 
 fused inflammation terminated as described. The vein in the 
 right arm from which Crute had been blooded by a free open- 
 ing, was examined. The integuments had ciosed over the 
 wound and the vessel was uninflamed. Between the mouths 
 of the femoral vein and artery was discovered a small branch, 
 arising immediately above the ligature of the artery ; and this 
 Vessel was doubtless that from which the bleeding had pro-' 
 ceeded." 
 
 We wish to avoid as much as possible any unnecessary 
 multiplication of facts ; but the following case is replete with 
 pathological instruction, and for that reasou we presume it 
 will not be thought superfluous. 
 
 Case 3d. " A robust soldier, 36 years of age, was bled in 
 the arm for optha'mai, which was considerably relieved by 
 the operation ; a degree of fever, however, came on, and grad- 
 ually increased. On the seventeenth day after the bleeding, 
 his pulse was one hundred and twenty in a minute and feeble; 
 his skin w?s hot ; his tongue covered with a brown fur ; his respi- 
 ration difficult: he complained of great prostration of strength, 
 and pain in his head, back and extremities. The wound in 
 the vein had healed, but the day after the bleeding great 
 swelling and pain commenced in the arm, and gradually ex- 
 tended upwards. He was bled in the opposite arm, and vari- 
 ous medicines were administered. The symptoms continued, 
 with very little alteration, until the twenty third day, when a 
 painful swelling was observed above the clavicle ; and in a few 
 days afterwards, another soft diffused swelling was discovered 
 underneath the angle of the lower jaw. The symptoms in- 
 creased slowly ; respiration became more painful and difficult; 
 
[ 7 ] 
 
 the pulse was seldom less than one hundred and twenty ; he 
 became delirious, and died in the course of the seventh week 
 after the bleeding. 
 
 The following appearances were observed upon dissec- 
 tion : — the cephalic vein at the part where it had been punctured 
 in the first instance, resembled an artery in the thickness of its 
 coats, and retained its circular form when cut across; below 
 the punctured part it was healthy ; about an inch above the 
 puncture its cavity was obliterated, the obliteration extended 
 to the shoulder; the branches which communicated with the 
 cephalic vein, at the bend of the arm, were healthy ; the ab- 
 sorbent glands aboul (he clavicle were enlarged and hardened; 
 the internal jugular vein was much enlarged, thickened and 
 indurated ; the effects of inflammation were apparent through- 
 out its whole course; it had the external appearances of an ar- 
 tery, though larger than any artery except the aorta ; the 
 subclavian, axillary and brachial veins, to the bend of the arm, 
 exhibited similar appearances. The external jugular and sub- 
 clavian veins were filled with pus : when slit open they were 
 found to be much thickened and lined with lymph. Many of 
 the smaller veins were in a similar condition. There was so 
 much inflammation, adhesion and induration in the upper part 
 of the arm that it was extremely difficult to trace the vessels, 
 and detach them from their connections ; the vena cava superior 
 was healthy ; the diseased appearances were not gradually lost, 
 but terminated abruptly; the heart was healthy ; the lungs con- 
 tained some small abcesses. A serous fluid, with flakes of 
 lymph floating in it, was contained in the cavities of the tho- 
 rax ; the lungs adhered to the pleura costalis, partially on the 
 Jeft side, but more extensively on the right ; the structure of 
 the brain was natural, but more serum than is usual was found 
 in the ventricles; the veins of the pia mater were turgid with 
 blood ; the vena magna galeni, and sinuses were remarkably 
 loaded. 
 
 Many cases might be adduced to show that ligatures, ap- 
 
[ 8 ] 
 
 plied to large veins, are not unfrequently productive of serious, 
 if not fatal consequences ; but in a wound of a vein of the 
 magnitude of the femoral, something must be done, and that 
 too with promptitude; otherwise the patient will soon be ex- 
 hausted by hemorrhage. As has already been observed, re- 
 peated trials have proved the ligature an improper application : 
 compression, therefore, has been adopted, and under certain 
 circumstances it has been attended with success. Dr. Rodg- 
 ers, No. 14 Corliaud-street, informs me that be has seen the 
 case of a boy, who, at play with a penknife in his hand, ac- 
 cidentally plunged it into the femoral vein high up in the 
 thigh, and although the hemorrhage was very profuse, yet, by 
 the judicious application of compression, the bleeding was res- 
 trained and the boy recovered. Sometimes a ligature applied 
 to the femoral vein is not attended with any bad symptoms. 
 Dr. Hodgson has " known an instance in which it was includ- 
 ed in a ligature without any unfavorable consequences;"* but 
 cases of this kind are, however, very rare, so much so that 
 the most scientific surgeons deprecate the application of 
 them to veins upon any occasion, more especially to the femor- 
 al vein. I am very credibly informed that Astley Cooper, of 
 London, has said that he would rather have his femoral artery 
 wounded a dozen times, than to have his femoral vein injured 
 once. When, therefore, a man so prominent in science and 
 surgery as Astley Cooper is acknowledged to be, expresses him- 
 self in the above terms, it is time the sulject had a most careful 
 examination. But before entering particularly into an investi- 
 gation of the treatment of these injuries, it is thought best to 
 take a general view of the Anatomy, Physiology and Pathol- 
 ogy of the vascular systems, referring more particularly to the 
 parts about the thigh. This we think important, inasmuch 
 as it will be explanatory of our views of the proper mode of 
 treatment. 
 
 * An observation made in f he dissecting-room by Dr. Sullivan, our 
 Anatomical demonstrator, in the winter of 1817 — 18. 
 
[ 9 ] 
 
 I. Of the Arteries. 
 
 The arteries are composed of three coats : First, an ex- 
 ternal, membranous or muscular coat, which 13 very elastic: 
 Secondly, a middle, muscular one, which is composed of two 
 layers of muscular fibres. Those of the external layer extend 
 longitudinally, and are comparatively few. The fibres of the 
 internal layer are stronger and more numerous, and are ar- 
 ranged in segments of circles around the artery; but when col- 
 lectively considered, they form a complete circle. The third 
 or inner coat is composed of a transparent membrane, and 
 is remarkably thin, smooth, and dense. 
 
 II. Of the Veins. 
 
 The veins, like the arteries, are composed of three coats, 
 and are arranged in the same manner; but are remarkably thin 
 and compact. The existence of a middle muscular coat has 
 been denied by some anatomists, except in the larger trunks, 
 as the two venae cava?. The veins are furnished with valves, 
 which are very numerous in the extremities, and are general- 
 ly described as being formed by a duplicature of the internal 
 membrane. They are so arranged as to allow the blood to 
 pass on towards the heart, but prevent its reflux. 
 
 III. Comparative view of both sets of Vessels. 
 
 The arteries, in consequence of (he strength and thick- 
 ness of their coats, are opake, and retain their cylindrical 
 form when cut across. The veins, on the contrary, collapse, 
 and in consequence of their tenuity, are transparent. The 
 coats of an artery are distinct, and can easily be separated : 
 those of a vein are blended together, so much so as to be sep- 
 arated with the greatest difficulty. The veins, in consequence 
 of their tenuity, are very extensible, especially in the trans- 
 verse direction. The arteries have not this property. The 
 veins, as has been shown, are furnished with valves. The ar- 
 teries have no valves, except at the heart. 
 
 Of the Femoral Artery. 
 
 The femoral artery, from the point where it emerges from 
 B 
 
[ io 1 
 
 Foupart's lament, to the going off oF the profunda, will be 
 designated in this dissertation as the inguinal artery : also the 
 femoral vein, from the same point to the entrance of the saphe° 
 na major, will be known as the inguinal vein. This arrange- 
 ment will enalde us to treat the subject with more perspicuity. 
 The external side of the inguinal artery lies immediately 
 under the centre of a line drawn from the anterior superior 
 spinous process of the os ilium, to the tuberous angle of 
 the os pubis. So, if it becomes necessary to cut down upon 
 this artery, our direction is: First, find the centre of a line 
 drawn between the two points of bone above noticed; then, 
 laying the outside of the finger upon the point thus obtained, 
 directly under^'he finder will be the artery ; # taking care to 
 use the fore finger of the right hand when examining the right 
 thigh, and vice versa. The inguinal artery is from an inch 
 to an inch and a half in length : it lies upon the lower portion 
 of the psoas magnus and iliacus internus muscles, and is cov- 
 ered only by tne common integuments, some of the inguinal 
 glands and fascia of the thigh. There are several small 
 branches of arteries which proceed from it to the parts imme- 
 diahly in its vicinity, and to the external parts of generation. 
 The artery, at its lower portion, gets deeper in the thigh, and 
 opposite to the trochanter minor divides into the profunda and 
 femoral, properly so called. The arteria profunda goes to the 
 muscles of the thigh, and its branches inosculate very freely 
 
 * The outside of the fore finger is described by some anatomisti 
 to be that side which is next to the middle finger; but we think it more 
 natural, if nut more correct, to call that the outside which is, in reality, on 
 the outside ; and the inside of the finger to be on that side which is near- 
 est to a line drawn between the middle and ring fingers. This may be 
 considered to be a matter of little consequence ; but when made use of in 
 describing the local situation of the inguinal artery, it becomes a subject 
 of serious importance. Our learned and very able professor of anatomy, 
 Dr. Post, in his lectures, described the outside of the fore finger to be 
 that side which was next to the middle finder. It is hoped the impor- 
 tance of the subject may atone for a further apology. 
 
[ 11 ] 
 
 with the branches of the internal iiiac, antl also with the fe- 
 moral and popliteal artery, about the knee. In consequence 
 of its numerous and free inosculations, it is considered the most 
 important artery of the thigh. 
 
 The femoral artery, where it leaves the inguinal artery, lies 
 pretty deeply in the thigh ; Itut in its descent it soon becomes 
 more superficial and runs along the inner edge of the sartori- 
 us muscle for a short distance : it then takes somewhat of a 
 spiral direction, inclining n.ore .nwards and backwards, and 
 at the upper part of the lower third of the thigh it passes 
 through the triceps muscle, lyiug close to the bone on its pos- 
 terior surface. Continuing in this direction it passes be- 
 tween the condyles of the os femoris, where it receives the 
 name of popliteal artery. 
 
 The inguinal vein lays on the inner side of the artery, 
 and close to it. The vein is about the same length of the ar- 
 tery, and from an inch to an inch and a half below Pouparfs 
 ligament it receives : First, the saphena major : Secondly, 
 from a quarter to half an inch below this point, the pro- 
 funda vein enters. The inguinal vein then receives (he name 
 of femoral vein, which descends in company with the femo- 
 ral artery, but in its course it inclines gradually to the poste- 
 rior part of the artery, and after passing through the triceps 
 muscle, between the condyles of the os femoris and behind the 
 joint of the knee, it lays quite posterior to it. 
 
 The saphena, where it enters the inguinal vein, is conse- 
 quently pretty deeply seated, but it soon becomes quite su- 
 perficial and passes down on the inner and anterior part of the 
 thigh; on the inner side of the knee joint and os tibia; fore 
 part of the inner ancle, and so on to the foot. 
 
 We think this description is sufficient to point out the lo- 
 calities of the artery and vein under consideration, which it 
 has been our object more particularly to da. 
 
[ 12 j 
 
 PHYSIOLOGY OF THE ARTERIES AND VEINS, 
 
 I. Of Arterial Circulation. 
 
 It is taken for granted that the blood, abstractly consid« 
 ered, possesses no power of its own by which it is enabled to 
 propel itself forward : that, in this respect, it is like any other 
 fluid, and subjected to the same laws of gravity and pressure. 
 By this, however, we do not pretend to deny that it posses- 
 ses vitality; on the contrary, it is admitted. The various 
 changes which are effected in the pabulum of animal exist- 
 ence from the time the food is comminuted in the mouth, un- 
 til it becomes a constituent part of the general system, pas- 
 ses through successive degrees of animalization and conse- 
 quently corresponding degrees of vitality. Therefore, if we 
 were called upon to define the blood, we should call it that 
 substance in a fluid state which, after having passed through 
 several successive degrees of animalization and vitality, be- 
 comes fitted for the heart and arteries, and by its presence and 
 its peculiar properties, stimulates them to action, and which 
 the arteries convey to the different parts of the system for its 
 nourishment and support. 
 
 The degree of agency which the arteries exert in propel- 
 ling forward their contents, is what we are particularly desir- 
 ous to examine and elucidate ; for a knowledge of this will 
 direct us to one of the most important indications in the treat- 
 ment of wounds of the femoral vein. 
 
 The blood, after being thrown into the aorta, is prevent- 
 ed from returning to the heart by the semilunar valves, con- 
 sequently, when compressed by the contraction of the arteries, 
 it must necessarily flow in that direction in which it finds the 
 least resistance : this of course will be towards their extremi- 
 ties. That the blood is urged forward by the contraction of 
 the arteries alone, we are far from believing : the impetus giv- 
 en to it by the action of the heart, is very great. However, 
 that the arteries themselves do possess very considerable a- 
 gency in propelling forward their contents, is inculcated by 
 
[ 13 ] 
 
 some of our most enlightened physiologists. The strength 
 of their coats, their muscularity, and the fact which before was 
 not adverted to, of their muscular fibres (comparatively con- 
 sidered) increasing in the extreme branches, favor the idea 
 that the more distant the arteries are situated from the heart, 
 the more the blood is dependant on them for its motion. 
 
 It may be observed that the gravity of the blood has a 
 very considerable effect in facilitating, and consequently ac- 
 celerating its circulation through the arteries of the lower ex- 
 tremities when the body is in an. erect posture. However, of 
 gravity and pressure we shall have somewhat to say when 
 speaking of the treatment. 
 
 II. Of Venous CtRcuLATioN. 
 
 The veins, originating from the numerous and very ex- 
 treme arteries, receive their blood and convey it back again 
 to the heart. In this act the veins, of themselves, are passive, 
 or if they exert any power, it is very inconsiderable in effect. 
 The fluid which they contain is also passive, that is, abstract- 
 ly considered, it is so. Neither is any action excited in them 
 by the heart's contraction. The blood, however, is returned 
 by them to the heart, and some power must operate to e fleet 
 this. The veins, as has been shown, are furnished with 
 valves. These are very numerous, and exist in the greatest 
 number in the extremities. They allow the blood to pass to- 
 wards the heart, but prevent its reflux. Therefore, bearing 
 in mind their anatomical structure, we attempt a solution of 
 their function, thus : as the veins originate from the termina- 
 tion of the extreme arteries, there is the strongest probability 
 that the blood may be conveyed in them for some distance 
 by the impetus which it has received from the arteries; and 
 as two veins generally accompany one artery, and at the 
 same time lay in close contact with it, one on either side ; 
 that in this situation the pulsation of the artery affecting the 
 veins, will compress them, and then allow them to dilate. 
 Therefore, in the diastole of the artery, the veins will be com- 
 
C ™ ] 
 
 pressed, and by heing thus acted upon, the Wood which they 
 contain is set in motion, and as the valves prevent its reflux, 
 it, of course, must flow on towards the heart ; because, in that 
 direction it meets with the least resistance. Then, in the 
 systole of the artery the veins being uncompressed and com- 
 paratively empty, are allowed to fill again. Thus, by the al- 
 ternate action and reaction of the arteries compressing and 
 unloading the veins, the blood is urged forward in them to- 
 wards the heart. 
 
 It may be conceived, and the idea advanced, that this 
 theory is insufficient to elucidate venous circulation. But it 
 should be recollected that the Oiaslole of all the arteries, 
 which are very numerous, occurs at one instant of time, and 
 therefore the united area of distention which they make will 
 be very considerable : this applied to the veins, will make 
 compression on them in the same ratio ; and on the other hand, 
 the systole of all the arteries takes place at a corresponding 
 period, thereby allowing the veins to fill again. In addition 
 to the above, it may be mentioned, that the strong aponeuro- 
 sis which covers all the muscles and main mass of blood ves- 
 sels of the thigh and leg, is dense, non elastic and unyielding; 
 so, the diastole of the arteiies meeting with this resistance 
 from without, must consequently effect compression more im- 
 mediately upon the softer parts within — the veins. 
 
 In this view of the manner in which venous circulation 
 is effected, the limn or extremity has been supposed to lie in 
 an easy, natural position, peifi ctly quiet and at rest. But, if 
 the muscles are put in action, the compression which they 
 will make upon the vein* will be so considerable, that the 
 blood will be propelled towards the heart with greater force; 
 and, as muscular contraction is not incessant, but attended 
 with periods of relaxation, time is thereby allowed for the 
 veins to fill again: so, by muscular action venous circulation 
 is accelerated. 
 
 The blood is moved in the veins in a slow and progres- 
 
[ 15 ] 
 
 sive manner; and in the lower extremities in particular, it is 
 urged forward against the power of its own gravity. 
 OF PATHOLOGY. 
 
 For observations on the pathology of the blood vessels,, 
 we are more indebted to Dr. Travers than any other writer; 
 and, indeed, he is the only person who has paid any particu- 
 lar attention to it. Therelore, on the present occasion, we 
 shall make liberal use of the materials with which his talents 
 have furnished us. 
 
 Under the head of pathology will be included the natu- 
 ral process obseived in the healing of wounds of veins; the 
 effect which a ligature has upon arteries and vein9, and their 
 morbid peculiarities under high excitement; and also, the re- 
 sources instituted by nature when the principal trunk of an ar- 
 tery or vein is obliterated. 
 
 I. Of the Healing of Wounds of Veins. 
 
 " When a vein is wounded longitudinally or obliquely, 
 there is no separation of the edges of the incision, so that on- 
 ly a little, if any blood, trickles from the aperture, unless pres- 
 sure be made nearer to the heart, to obstruct the passage of 
 the blood in the vessel. If, therefore, an animal be killed im- 
 mediately after a wound of the vein from which no blood 
 has been drawn, the lips of the wound will be found in con- 
 tact ; and if permitted to live for a short time, the cicatrix 
 will form a line. 
 
 " If a vein is opene'd by a transverse section, it bleeds 
 without the addition of pressure ; and if the vein is half divi- 
 ded, the hemorrhage is, with much difficulty, suppressed — -the 
 blood escaping into the cellular sheath of the vein, and of the 
 contiguous mu.-cles in the direction of the current, and form- 
 ing a distinct coagulum between the orifice and the external 
 wound. The longitudinal or oblique wound, by which blood 
 Las issued in quantity, presents the same appearances : an 
 oval, naked coagulum forms the plug of the orifice, and a flat- 
 tened covered clot, which is an extravasation into the cellular 
 
[ 16 ] 
 
 sheath, extends to some distance around it. At the end of 
 twenty-four hours the lips of the wound are found separated, 
 forming an oval proportioned to the length of the incision; 
 the edges everted and adhering to those of the clot ; the ever- 
 sioo seeming to be the effect of distention from the extravasa- 
 tion into the sheath : there is no blush upon the edges, nor a- 
 ny appearance of organiz-tble or secreted lymph in the vein or 
 the wound. At three days the same appearances are observ- 
 ed, but the internal margin of the wound is somewhat eleva- 
 ted and rounded, and a thin and narrow membranous expan- 
 sion is perceived to be continuous with the everted edge of the 
 internal tunic; the clot itself is more compact, and upon 
 section presents concentric lamella?, the interior being of a 
 lighter color than the exterior layers. 
 
 "On the fifth day these appearances are more confirmed; 
 the membranous appearance extends over the surface of the 
 clot, if the wound is not exceeding a quarter of an inch in 
 length; and in larger wounds the coagulum, which is reduc- 
 ed in size, has a membranous surface. On the eighth day the 
 new membrane is complete ; the interior margin of the Avound 
 is raised and tumid, and the coagulum of a common bleeding 
 wound is nearly absorbed. From the twelfth to the sixteenth 
 day, numerous vasa vasorum may be seen by the aid of a 
 glass, passing from the internal tunic over the new-formed 
 membrane, and anastomosing upon it. At the latter period 
 the edges are less raised, so as to be more upon a level with 
 the new membrane, and have a slight red blush. The coagu- 
 lum is entirely absorbed. On the twentieth day it is only 
 possible to distinguish the recent from former wounds by the 
 tenuity, smoothness and transparency of the new membrane 
 compared with the o'd, which is dense, tough and wrinkled. 
 
 " This description applies to wounds of the size usually 
 made in bleeding : the process is, of course, longer in comple- 
 tion, though not otherwise d'fferent in those which are more 
 extensive. The coagulum which forms the plug, is exactly 
 
E 17 ] 
 
 proportioned to the size of the wound. The site and extent 
 of the wound are ever afterwards marked by the membrane 
 which occupies it, which is thinner, more transparent, and 
 more extensile than the proper parietes of the rein. It forms, 
 when the vein is filled, a pouch or bag; and the jugular veins 
 of horses present many of these contiguous to each other. 
 Farriers avoid bleeding in these pouches, because they find it 
 difficult to staunch the blood. I at first supposed that this 
 was a condensed cellular membrane, formed by the sheath of the 
 vein; but I am satisfied that it is continuous with the everted 
 edges of the internal tunic, and organized by its vessels. If it 
 were consistent with what we know of reproduction, I should 
 be disposed to couclude, that the new membrane was formed 
 out of the coagulum of the blood, although I found that the 
 coagulum could, with care, be detached from the membrane, 
 which was continuous with the everted edge of the internal 
 tunic. The new membrane is, however, evidently denser 
 than the valves, iu structure, which are said to be prolonga- 
 tions or even duplicatures of the proper tunic."* 
 
 II. The Effect which a Ligature has upon Arte- 
 ries and Veins ; and their Morbid Peculiarities 
 under high Excitement. 
 
 1st. When a ligature is drawn tightly around an artery, 
 it causes a separation of its internal and middle coats. In- 
 flammation at the place of stricture, and tor a short distance a- 
 round it, ensues; coagulating lymph is then thrown out and 
 an union of the sides pf the artery is soon effected. The part 
 immediately around which the ligature is passed ulcerates, 
 and iu a short time a division of the artery takes place, and 
 the ligature is then discharged. No extension or diffusion of 
 the inflammation takes place; no constitutional affection is 
 thereby induced ; the injury is merely a local one, and produc- 
 tive of no evil effect. 
 
 * Cooper's and T ravers' Surgical Essays, part first. 
 G 
 
i is ] 
 
 It then may be said of arteries, they inflame readily, heal 
 quicHy, and no constitutional affection is thereby induced. 
 
 2d. When a ligature is put around a vein and drawn 
 tightly, it does not cause a division of its internal and middle 
 coats, but the vein fails in longitudinal folds. That part next 
 the heart collapses, the other end is distended with blood, 
 which soon coagulates. There is no redness or other signs of 
 inflammation on the internal tunic ; consequently, no adhesion 
 takes place, and no agglutination of the contiguous folds, but 
 the cellular sheath is thickened by a deposit of lymph in the 
 vicinity of the ligature, which, after a little time becomes so 
 considerable as to encompass the ligature : ulceration ensues, 
 and about the fifteenth or twentieth day the ligature is cast off: 
 no thickening of the proper coats ensues, nor appearances of 
 inflammatory action within the canal, neither of the upper nor 
 lower portion of the vein. But when inflammation of the 
 vein does ensue, it extends along the vein towards the heart, 
 sometimes from the point of irritation as far as the right auri- 
 cle. Lymph is effused, which coats the inner tunic of " the 
 vein like a fringe; and though the quantity effused is some- 
 times sufficient to obstruct the tube, the inflammation is not 
 bounded by the obstruction." Pus is sometimes effused, " and 
 the inflammation is often mixed, presenting both terminations 
 alternately, viz. in lymph and pus.' ,# 
 
 Although the inflammation generally extends from the 
 point of irritation towards the heart, or from branch to trunk, 
 yet, " in some instances the inflammation has extended down- 
 wards as weil as upwards in the course of the vein. The same 
 symptoms have taken place when the inflammation has been 
 excited by the application of a ligature."! 
 
 In a summary view of the pathology of the veins, it may 
 be said they are not very susceptible of inflammation, and 
 
 * Cooper's and Travera' Surgical Essays, page 242, vol. 1. 
 
 t Hodgson, on Diseases of Arteries and Veins, page 515. 
 
[ 19 J 
 
 when it does ensue, it spreads very extensively, producing 
 great constitulioual irritation wilb all ils dreadful consequences. 
 
 It therefore becomes very important to know when in- 
 flammation of the vein does ensue while compressed by a liga- 
 ture. We may reply, " the fatal catalogue of tied veins" 
 has induced surgeons to proscribe its application to them. We 
 are aware that there are many cases on record wherein no 
 unfavorable symptoms have followed the application of a liga- 
 ture ; but it may be observed, that these successful cases are 
 more particularly confined to the ligation of veins about the 
 neck, thereby assisting to confirm the fact, that wounds of 
 the upper part of the body heal quicker, and with less injury 
 to the constitution, than those of the same extent and nature 
 of the inferior extremities. 
 
 III. Op Collateral. Circulation. 
 
 1st. Of arterial collateral circulation. — It is a fact well 
 established in surgery, that the circulation will he carried on 
 in a limb sufficient for its support, even though its principal 
 artery be obliterated. This fact has been repeatedly proven 
 by the many successful operations on the external iliac artery, 
 (and there might be added the subclavian artery, and even the 
 arteria innominata*) and accordingly, at the present day this 
 artery is ligated, without hesitation, as often as circumstances 
 render it necessary. 
 
 2d. Of venous collateral circulation.— rThe principal vein 
 of a limb is not obliterated with the same freedom or confi- 
 dence of success. However, there are on record some very 
 singular cases of obliterated veins, which are worthy of being 
 noticed. Dr. Balie mentions an instance in which the vena 
 cava inferior, of a female subject, was obliterated from the en- 
 trance of the emulgents to the right auricle of the heart. " In 
 this remarkable case, the vena cava inferior was obliterated 
 where the venae cavas bepaticee open into it, so that not only 
 
 * The Medical and Surgical Register of Cases in the New-York Hos- 
 pital, 18iS. 
 
[ 20 ] 
 
 the blood from {he lower extremities, but also that from the 
 liver must have passed through collateral channels to the 
 heart.* 
 
 Dr. Hodgson et has seen two instances in which the com- 
 mon iliac vein was obliterated," In one of them, " the exter- 
 nal and internal iliac veins on the left side were obliterated 
 by the pressure of an aneurism of the abdominal aorta; the 
 vena azygos was as large as the little finger, and extended on 
 the left side info the loins, where it received two considerable 
 branches which communicated with the lumbar veins, and 
 with branches which came from the pelvis." " In both these 
 cases there were no symptoms which indicated obstruction in 
 the venous circulation during the life of the patients." 
 
 The two preceding cases have been selected more par- 
 ticularly on account of the fact which was contained in the 
 last clause, viz. that "there were no symptoms which indi- 
 cated obstruction in the venous circulation during the life of 
 the patients." This is what could not, a priori, be looked for: 
 however, it leads us more strongly to conclude, that the oblit- 
 eration must have taken place in a very gradual manner, thus 
 allowing the collateral veins to enlarge by slow degrees; for 
 if even the external iliac vein was obliterated suddenly, and at 
 the same time the principal artery of the thigh perform its 
 function, there is the strongest probability that the tumefac- 
 tion of the limb would be so great that gangrene, and ulti- 
 mately death, would ensue. 
 
 Having thus completed our original design, of giving a 
 view of the importance of the subject under consideration ; 
 and also^the anatomy, physiology and pathology of the blood- 
 vessels, more particularly of the thigh, we are now prepared 
 to enter into a particular investigation of the treatment, com- 
 mencing — 
 
 Firstly. With wouuds of the Inguinal vein. 
 
 Secondly. With those of the proper Femoral vein. 
 
 * Hodgson, on the Diseases of Arteries and Veins, page 526. 
 
[ 21 ] 
 
 Wounds of either vein will be divided according to the 
 nature of the injury: 1st. Incised wounds, or those caused 
 by cutting instruments. 2d. Lncerated or contused, as those 
 caused by musket balls, blunted instruments, &c. 3d. Ulce- 
 rated or sloughing wounds, as those produced by a corroding 
 ulcer, or sloughing bubo or ulcer, &c. 
 
 Incised wounds will be subdivided into, First, Longitu- 
 dinal. Secondly, Transverse. 
 
 Of Longitudinal Incised Wounds of the Inguinal 
 Vein. 
 
 A surgeon, when called to a person bleeding profusely 
 from a wound of the inguinal vein, (and the same applies to 
 blood-vessels in general,) will have his attention directed im- 
 mediately to the hemorrhage, and accordingly his indications, 
 which are naturally suggested, are, 1st, to restrain the bleed- 
 ing. 2d, To devise the best means for speedily healing the 
 wound. 
 
 Means of accomplishing the first indication: — Compres- 
 sion in wounds of veins is generally resorted to, and in most 
 cases it is the best means that can be adopted : accordingly, 
 in longitudinal incised wounds of the inguinal vein, it would 
 be entirely entrusted to; but an elevated position of the foot 
 we think an important auxiliary, not only in this particular 
 case, but in wounds of the blood-vessels of the thigh and leg 
 generally. Therefore, our uotions respecting this particular 
 position will be given in full, before proceeding any further 
 with a detail of treatment. 
 
 An elevated position of the foot is, we believe, not men- 
 tioned by any systematic writer on surgery, as being worthy 
 of notice in the treatment of wounds of the blood-vessels. 
 Therefore it is deemed expedient to be more particular in an 
 investigation of the subject. 
 
 In our physiological remarks it was observed, that the 
 blood, abstractly considered, possessed no power of its own 
 by which it was enabled to propel itself forward ; that, in this 
 
[ 22 ] 
 
 respect, it was like any other fluid, and subject to the same 
 laws of gravity and pressure. 
 
 Of fluids it is commonly said, ' they press equally on all 
 sides at the same height.' But to make the subject, as we think, 
 a little more explicit, we say that fluids, in consequence of 
 their gravity, have a tendency to disperse and flow in that 
 direction in which they find the least resistance, and the force 
 of their dispersing power, or gravity, is in proportion to the 
 height of their column. Therefore, when the hody is in an 
 erect posture, the arterial blood of the lower extremities flows 
 with freedom and ease, because it is then assisted by its own 
 gravity, which has the pressure of the column of blood from 
 the top of the head to assist in urging through the branches 
 of the lower extremities. It is presumed the truth of this as- 
 sertion will not. be questioned by any who know that fluids 
 press equally on all sides at the ssme height, whether contain- 
 ed in a straight tube or one having as many branches and con- 
 volutions as (he numerous arteries of our frame. 
 
 Now, if the posture of the body he changed, and the foot 
 be elevated, (which, when a person is lying on his back, may 
 be raised to an angle of 45° and even 55° without occasioning 
 any pain from tension of the muscles on the posterior part of 
 the thigh,) then the gravity of the blood will operate so as to 
 retard arterial circulation in the limb; and if our patient be a 
 person of ordinary height, or five feet and ten inches, bis 
 whole leg and foot will be two feet and eleven inches long ; 
 taking for granted the thigh, leg and foot to be half the length 
 of the whole frame, which, as a general principle, is correct. 
 —Then his foot raised to an angle of 45° will be two feet from 
 an horizontal plane, or if at 55° it will be two feet and a half; 
 therefore, the effect which an elevMted position has, will be e- 
 qual to the gravity of a column of blood two feet, or two feet 
 and a half high, which, doubtless, from what has already been 
 said, will now be perceived to have very considerable effect 
 to retard the circulation. But the flow of arterial blood into 
 
[ 23 ] 
 
 the limb when the foot is elevated, may be shown to be les- 
 sened on a different |>rincij>le than that of gravity alone. Thus 
 the blood, by its pressure and its peculiar properties, stimulates 
 the heart and arteries to action, and the strength and force of 
 their contraction is dependant very much upon the quantity of 
 blood present in them. If, for instance, the quantity be very 
 small, there is, of course, less stimulus applied, consequently, 
 there will be less action produced: the alteration of the pulse, 
 so universally effected from the common operation of blood-let- 
 ting, is sufficient to illustrate this fact. Therefore, when the 
 foot is elevated, and part of the blood abstracted from the 
 limb by its gravity, this, operating as blood-letting, lessens the 
 contractile power of the arteries, which disenables them to 
 urge forward their remaining contents with the same degree of 
 energy as formerly. Moreover, it must appear evident to all, 
 that the great distance at which (he extreme arteries of the 
 foot and leg are situated from (he heart, allows an elevated po- 
 sition of the loot to command a vast influence over arterial 
 circulation, to retard it. 
 
 When, therefore, it is established that an elevated posi- 
 tion of the loot does retard the flow of arterial blood into the 
 limb, it is clear there cannot be so much to be returned by the 
 veins; consequently, the hemorrhage cannot be so dangerous. 
 But (his is not the only advantage which position affords; for 
 when the foot is elevated it favors, in the highest possible de- 
 gree, the ready circulation of venous blood. The valves, in 
 this position, are of no use; because the blood, as soon as it 
 gets into the veins, flows towards the heart by the power of 
 its own gravity. But if the limb be in a horizontal posture, 
 er more particularly if the foot be a little depressed, the blood 
 is urged on towards the heart by a vis atergo; consequently, 
 all the veins of the limb will be full, and even distended with 
 blood. It is, therefore, evident, that under these circumstan- 
 ces hemorrhage will be more profuse, and far more difficult to 
 restrain than when the foot is elevated. Besides, when the 
 
[ 24 ] 
 
 column of venous blood is considerably lessened, and what re- 
 mains is placed under the most favorable circumstances for 
 its circulation, it is evident there cannot be any accumula- 
 tion of blood in the veins to make lateral pressure ; but on the 
 contrary, the veins being half empty, and verging towards a 
 collapsed state, not only will favor very much the coaptation 
 of the sides of a longitudinal wound, but will, to a very great 
 degree, lessen the hemorrhage. Therefore, in longitudinal in- 
 cised wounds of the inguiual vein our practice would be, 
 First, an elevated position of the foot. Secondly, lateral com- 
 presses to be placed on either side of the wound. Thirdly, 
 a circular bandage applied so as to secure the compresses. 
 This, we presume, is all that will be necessary. Care, how- 
 ever, should be taken not to draw the circular bandage too 
 tight; for it cannot be necessary, and if pressure be made so 
 as to retard the flow of blood through the vein, it certainly 
 would do injury. 
 
 Of Transverse Incised Wounds of the Inguinal 
 Vein. 
 
 The degree of danger attending wounds of this descrip- 
 tion will depend upon the extent and depth of the incision ; 
 but all transverse wounds, more especially of the inguinal vein, 
 are infinitely more dangerous than longitudinal ones : the rea- 
 son of this is very obvious: the longitudinal contraction of 
 the vein separates the edges of the wound, and thereby pro- 
 duces a circular hale in the vein, which will admit a more 
 ready exit for the blood : this hole will be larger or smaller in 
 proportion as the wound of the vein is more or less extensive. 
 
 If the incision be a small one, and the hemorrhage not 
 very considerable, the treatment recommended in the prece- 
 ding case wUl be applicable in this, viz. an elevated position 
 of the foot, and compression. 
 
 Id all transverse wounds there will be more or less re- 
 traction of the common integuments, as well as the coats of 
 the vein. Consequently, this will afford a freer exit for the 
 
[ 25 ] 
 
 blood. This circumstance might Induce the surgeon to make 
 use of a stitch to bring the sides of the wound in contact : if 
 the needle be directed no deeper than merely through the 
 skin, or ou!j r a little disfance below it. it may then be admis- 
 sible, and even proper ; but beware of " nipping up the coats" 
 of the vein for the purpose of applying a ligature around 
 them : — this practice, experience has shown, is fraught with 
 danger, and should be deprecated. There is the greatest 
 probability that the closure of the wound externally by a 
 stitch, with moderate and judicious compression, the hemorr- 
 hage will be restrained ; observing, at the same time, an ele- 
 vated position of the foot as important, in a high degree. But 
 when the vein is nearly or quite divided, the danger from he- 
 morrhage becomes exceedingly great : in short, it is one of 
 the most alarming and difficult cases surgeons have to contend 
 with. If we are fortunately called in at the moment, and 
 compression be promptly applied, the bleeding may be res- 
 trained; but if it be continued long "the member swells so 
 prodigiously that gangrene may supervene." Therefore, on 
 an occasion like the present, we stand in need of all the infor- 
 mation which the science of surgery can afford. 
 
 When recounting the condition of our patient and laying 
 our plans for his cure, it is not sufficient, it is not right to 
 look no further than the bleeding orifice, and there confine all 
 our endeavors for his relief. It is well known that the veins 
 receive their blood from the extreme branches of arteries, and 
 consequently, when a vein is divided, it bleeds from the lower 
 portion of the orifice ; however, it may be supposed to pro- 
 ceed also from the superior portion of the vein ; but for the 
 most part it will be found that the perfection of the valves is 
 a security against any danger from this source. Though we 
 have not been able to examine a variety of subjects, yet, hav- 
 ing an opportunity a few days ago in our dissecting room of 
 closely inspecting one, it was found in this subject that the 
 valves were perfect immediately under Poupart's ligament : so, 
 
 D 
 
[ 20 ] 
 
 even (hough the inguinal vein should be completely divided, 
 there would be no reflux of blood from the external iliac. 
 Whether a valve is invariably found at the above place, we 
 are unable to say; but, as the epigastric vein and circumflex 
 vein of the os ilium enter the externa! iliac almost directly un- 
 der Pouparfs ligament; are pretty large in size, and from the 
 fact that valves are most generally found where large veins 
 are entering, it may be fairly conjectured that, as a general 
 rule, there is a valve situated under Poupart's ligament. If 
 this be the case, the retrograde course of the blood will be 
 stopped, and hemorrhage proceed from the lower portion of 
 the divided vein only. 
 
 Now, if there be a valve in the upper portion of the 
 vein, the blood above it, taking a retrograde course, is stopped 
 by the valve, which will thereby not only keep the vein dis- 
 tended, but, by its pressure upon the valve, will render it in 
 some degree tense; and the venous blood from below, meeting 
 with this resistance, and at the same time finding an open pas- 
 sage externally, will, of course, all pass in that direction. 
 Now, to restrain the bleeding, it will be necessary to complete- 
 ly obliterate the calibre of the vein by compression. To ef- 
 fect this, very considerable force must be used, and all the 
 small anastomosing veins on the posterior part of the thigh be 
 compressed : the direful consequences of which have already 
 been explained. All this we think may be avoided by tying 
 up the inguinal artery; for then the blood will be prevented 
 from flowing through it, and all its numerous branches will im- 
 mediately cease to pulsate ; consequently, the veins are not 
 only debarred their source of blood, but even the quantity which 
 they already contain is prevented from circulating by the re- 
 moval of the visa tergo given to them by the pulsative motion 
 of the arteries. Therefore, very slight compression will be 
 required to restrain the blood. 
 
 It may be asked, why not direct an elevated position of 
 the foot in this case, as well as any other ? We reply : the re- 
 
[ -? J 
 
 iraclion of the ends of the divided vein will be so considera- 
 ble, and the external opening so free, that it will be necessa- 
 r3' to completely obliterate the calibre of the vein before the 
 hemorrhage can be restrained. Consequently, when the vein 
 fills with blood (as it will do if the artery be not tied or other- 
 wise compressed) there will be a column of blood as high as 
 the elevation of the foot to be supported by the compresses and 
 bandages. This, therefore, would not only be very difficult 
 to accomplish, but, even though it should be effected, the com- 
 pression which would thereby unavoidably be made upon the 
 niimerous, though small anastomosing branches of veins on 
 the posterior part of the thigh would, as we have already ob- 
 served, completely obstruct all circulation through them. But 
 where is the objection to tying up the 1 inguinal artery ? Surely, 
 the numerous and generally successful cases of tied arteries, 
 is sufficient to do away all objection ; and when we recount 
 the advantages thus obtained, they will be found by no means 
 inconsiderable. Our patient can then have his wound dressed 
 easily. If necessary, a stitch or two may be used to bring 
 the retracted integuments in close coaptation. Lint, com- 
 presses, and short adhesive straps will be sufficient to restrain 
 the bleeding: then, by laying him in bed on his well side, his 
 lame leg may be placed in an easy, natural position, and sup- 
 ported by pillows, cushions, &c. thus allowing the numerous, 
 though small anastomosing arteries and veins of the internal 
 iliac and profunda, the most perfect liberty to enlarge and sup- 
 port the limb by a free circulation of blood. 
 
 Of Lacerated or Contused Wounds of the In- 
 guinal Vein. 
 
 Wounds of this description are more difficult to heal, 
 more insidiou?, and consequently more dangerous than incis- 
 ed ones of the same extent. The contusion so diminishes and 
 sometimes even destroys the vitality of the part, that exten- 
 sive s'oughing is very liable to take place, and consequently, 
 
[ M ] 
 
 secondary hemorrhage is to be looked for, and particularly to 
 be dreaded. 
 
 Treatment. — A detail of treatment is deemed quite un- 
 necessary. The principles promulgated in the preceding in- 
 stances, are applicable in the present. 
 
 Of Ulcerated Wounds of the Inguinal Vein ; or, 
 Wounds caused by a Sloughing Ulcer at the 
 Groin. 
 
 These varieties have been named merely because we 
 think the same principles of treatment applicable to them. 
 The only difference would be in the local remedies, and the 
 nature of the affection must dictate them ; but as wounds of 
 this description, and also those which are lacerated or con- 
 tused, take a long time to heal, and are particularly danger- 
 ous on account of their liability to hemorrhage, it becomes 
 more imperiously necessary to take up the inguinal artery. 
 
 Of Wounds of the Proper Femoral Vein. 
 
 We have nothing in particular to offer on this subject : 
 however, it may, perhaps, be proper to observe, that in 
 wounds of this vein, whether inei3ed, lacerated or ulcerated, 
 we think it never will be necessary to take up the inguinal ar- 
 tery, but that an elevated position of the foot, with compres- 
 sion applied directfy over the wounded vein, is all that frill 
 be necessary. 
 
 It should be recollected that the saphena vein is sufficient 
 io carry en the circulation even though the proper femoral 
 vein be obliterated ; therefore, in making compression on the 
 proper femoral, pressure on the saphena should be avoided as 
 much as possible. Our views of the proper method of apply- 
 ing compression are the following :— have three long and wide 
 splints; arrange them longitudinally around the thigh so as to 
 leave a space on the inner and anterior part of the thigh, or 
 along the course of the saphena vein, about two inches wide. 
 Apply a roller over the splints just firm enough to keep them 
 steady. Then one inch distant from the wound, on the low 
 
[ 29 ] 
 
 er portion of the vein, or that portion next the foot, place the 
 tourniquet. Have, then, some graduated compresses, formed 
 in a conical shape ; place the apex of the cone over the 
 wounded vein — the other end of the compress, or its base, 
 under the strap of the tourniquet, then turn the screw of the 
 tourniquet, and compression will be made more directlj upon 
 the wounded vein. 
 
 It is thought best to apply the compression a little below 
 the oriSce of the wound, for then the wound may be dressed 
 without disturbing the splints, compresses, &c. and not only 
 that, but it is presumed the wound would heal quicker. But 
 compression applied in this manner never will be necessary 
 except when the vein is divided, or nearly so. 
 
 When the wound of the vein is small, an elevated posi- 
 tion of the foot will so much lessen the volume of blood in 
 the vein and facilitate the circulation of that which remains, 
 that the veins, in a great measure, will be kept empty; con- 
 sequently, there will not be lateral pressure enough to force 
 the blood out of the wound. Lint, lateral compresses, and 
 adhesive straps to secure them, we presume, is all that will be 
 necessary. 
 
 Of the period of time an elevated position of the foot should 
 be persisted in : — Our knowledge of the healing process will be 
 our guide in this respect. If, therefore, the wound be a longitu- 
 dinal one, and small in extent, an elevated position may not be 
 observed longer than forty-eight hours; for by that time we 
 may fairly conclude the lips of the wound have united, When, 
 however, the wound is more extensive, the process of healing 
 will be slower; consequently, an elevated position of the foot 
 must be continued longer : also, as venous hemorrhage is very 
 liable to recur; all exertion should be proscribed until the 
 wound be fairly healed. 
 
 It may be proper in this place to observe, that the lint 
 which was applied immediately to the orifice of the wound, 
 should not be removed until it is loosened by the process of ul- 
 
[ 30 ] 
 
 ceralion ; for it is not improbable that within the space of 
 twenty-four hours (he circulation may be so far restored ia 
 the limb as to produce, if ihe lint and close dressings be for- 
 cibly detached, a dangerous hemorrhage; and not only that, a 
 premature removal of the dressings and lint may disturb the 
 healing process, and thereby cause the inflammation to rage 
 violently, which, eventually, may be either very difficult to 
 suppress, or fatal to the patient. 
 
 If the elevated position of the foot should, after a time, 
 produce numbness and coldness of the leg and foot, reason 
 \vould dictate to us the propriety, and even necessity of low- 
 ering the limb. 
 
 THE END. 
 
 errata; 
 
 Page 4— 10th line, for " adhesiev" read " adhesive." 
 " 6— 50th line, for " oplhaliaai" read " oplhalmia." 
 m g — The note being misplaced, the reader is requested to omit it 
 
 altogether. 
 " 23— 3d line, for "pressure" read "presence." 
 
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 $ttltQL 
 
 VALENTINE MOTT, M. D. 
 
 Professor of Surgery. 
 
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