lead to secondary haemorrhage, and the interesting observation was often made, that when the collateral circulation was well established, the leakage occurred on the distal side of the ligature.  While it may happen that the initial haemorrhage is rapidly fatal, as for example when the external carotid or one of its branches suddenly gives way, it is quite common to have one, two or more warning haemorrhages before the leakage on a large scale, which is rapidly fatal.

The appearances of the wound in cases complicated by secondary haemorrhage are only characteristic in so far that while obviously infected, there is an absence of all reaction; instead of frankly suppurating, there is little or no discharge and the surrounding cellular tissue and the limb beyond are oedematous and pit on pressure.

The general symptoms of septic poisoning in cases of secondary haemorrhage vary widely in severity:  they may be so slight that the general health is scarcely affected and the convalescence from an operation, for example, may be apparently normal except that the wound does not heal satisfactorily.  For example, a patient may be recovering from an operation such as the removal of an epithelioma of the mouth, pharynx or larynx and the associated lymph glands in the neck, and be able to be up and going about his room, when, suddenly, without warning and without obvious cause, a rush of blood occurs from the mouth or the incompletely healed wound in the neck, causing death within a few minutes.

On the other hand, the toxaemia may be of a profound type associated with marked pallor and progressive failure of strength, which, of itself, even when the danger from haemorrhage has been overcome, may have a fatal termination.  The prognosis therefore in cases of secondary haemorrhage can never be other than uncertain and unfavourable; the danger from loss of blood per se is less when the artery concerned is amenable to control by surgical measures.

Treatment.—­The treatment of secondary haemorrhage includes the use of local measures to arrest the bleeding, the employment of general measures to counteract the accompanying toxaemia, and when the loss of blood has been considerable, the treatment of the bloodless state.

Local Measures to arrest the Haemorrhage.—­The occurrence of even slight haemorrhages from a septic wound in the vicinity of a large blood vessel is to be taken seriously; it is usually necessary to open up the wound, clear out the clots and infected tissues with a sharp spoon, disinfect the walls of the cavity with eusol or hydrogen peroxide, and pack it carefully but not too tightly with gauze impregnated with some antiseptic, such as “bipp,” so that, if the bleeding does not recur, it may be left undisturbed for several days.  The packing should if possible be brought into actual contact with the leaking point in the vessel, and so arranged as to make pressure on the artery above the erosion.  The dressings and bandage are then applied, with the limb in the attitude that will diminish the force of the stream through the main artery, for example, flexion at the elbow in haemorrhage from the deep palmar arch.  Other measures for combating the local sepsis, such as the irrigation method of Carrel, may be considered.