1. That the artery is in general sound at the part in the front of
the thigh selected for operation, while it is usually unsound in the
popliteal space behind, or in the ham, where Desault operated, and
Anel recommended it to be done; that operation is now abandoned on the
continents of Europe and America, as well as in England.
2. That a ligature can readily be placed upon it at a distance from the
disease in the fore part of the thigh, and will usually be followed by
success as far as concerns the obliteration of the artery immediately
below the part on which it is applied.
3. That the artery being aneurismal, the collateral branches had begun
to enlarge, so as to be better able to carry on the circulation, after
the supply of blood to the lower part of the limb by the main trunk had
been cut off.
4. That no branches of importance are usually given off between the
ligature on the artery on the fore part of the thigh and the sac of the
aneurism in the ham.
5. That if such branches were ever given off, and brought the blood
from their collateral communications back into the main artery below
the ligature, and thence into the sac, so as to renew its pulsatory
movements, they would ultimately disappear, from the impelling force
not being sufficient to prevent a gradual coagulation taking place,
which would soon fill up the cavity of the sac, and thus prevent its
further enlargement; at which stationary point a process of removal
by absorption would begin and continue, until the diseased sac with
its contents had diminished, if not entirely disappeared, leaving only
a trace behind of its former existence, the process thus described
being frequently assisted by a commencing obliteration of the artery
immediately below the aneurism. The essential point in this theory,
which has immortalized the name of Hunter in surgery, depends on the
integrity of the aneurismal sac, which ultimately retains, as a general
rule, subject to rare exceptions, any blood which may be brought into
it, either by the collateral branches from above, or from below by what
may be called regurgitation, until it has become coagulated, when the
sac is so filled up that no more blood can pass into it to cause its
further distention, or any ulterior evil.
This theory of Mr. Hunter, then so new, so beautiful in itself, was
eagerly embraced by nearly all the civilized world; and surgeons
were not content with applying it to cases of diseased or aneurismal
arteries, to which it is especially applicable, but they extended it
indiscriminately to cases of wounded arteries, to which the practice of
the war in Spain proved it was inapplicable, and in which I have, since
1811, maintained it could only succeed as a matter of _accident_, not
of principle.
182. The essential features of the theory opposed to Mr. Hunter, with
respect to wounded arteries, and called mine, are:--
1st. That the artery at the wounded part is free from previous disease,
and may be expected to take on those healthy actions which, after the
application of a ligature, lead to the obliteration of its canal, and
the consequent suppression of hemorrhage.
2d. That the circulation of the blood by the collateral branches is
less free in a sound limb than in one which has suffered during several
weeks from the formation of an aneurism.
3d. That this freedom of circulation is less in the _lower_ than in the
_upper_ extremity, under all circumstances.
4th. That mortification of the foot and leg, and often of the whole
limb, followed by the death of the person, is a common occurrence
after a ligature has been placed high up on the artery in the thigh,
in consequence of a wound; while it is not so common an occurrence
when such operation is performed in the same place for an aneurism of
several weeks’ duration. If the vein be also wounded, mortification is
almost inevitable.
5th. That mortification of the hand and arm rarely follows the
application of a ligature to the artery of the _upper_ extremity in any
part of its course, however near the heart.
6th. That when the collateral vessels are capable of carrying on the
circulation through the lower extremity, the _lower_ end of the divided
artery bleeds _dark_ or _venous_-colored blood, while its _upper_ end
bleeds _scarlet_ or _arterial_-colored blood. In the upper extremity,
the color of the blood from the lower end of the divided artery is
little altered--a consequence of the greater freedom of anastomosis, or
of the freer collateral circulation in the upper extremity. Facts of
the greatest importance in surgery.
7th. That whenever the collateral vessels are not capable of carrying
on the circulation of a limb, mortification or death of the part
ensues; and _that whenever this collateral circulation is sufficient to
maintain the life of the limb, blood must pass into the artery below
the wound, and must, as a general rule, pass up and out through the
lower end of the divided artery, unless prevented by the application of
a ligature, or by some accidental circumstance, forming an exception to
the rule, but not the rule itself_.
8th. That the collateral branches are capable of bringing blood into
the artery above the aneurismal sac and between it and the ligature,
is admitted in the Hunterian theory, which blood the aneurismal sac
receives, and usually retains. When the artery is a wounded artery,
and the ligature is applied at a distance above the wound, blood is
often brought into it below the ligature in a similar manner; but as
there is _no aneurismal sac_ to receive and retain it, the patient
bleeds perhaps to death, unless surgery come to his assistance.
9th. The presence of an aneurismal sac in one case, and its absence in
the other, is the essential difference destructive of the Hunterian
theory for the treatment of aneurism being applicable to that of
wounded arteries.
10th. The processes for the natural suppression of hemorrhage are
somewhat different in the upper and lower ends of an artery, and are
less capable of resistance in the lower. This end frequently yields
to the pressure of the blood regurgitating from below, and renews a
bleeding which may have been suppressed for weeks, unless its closure
has been rendered more permanent by the application of a ligature.
11th. The absence of the aneurismal sac renders the application of two
ligatures absolutely necessary, one on each end of a divided artery, or
one above and one below the wound, if the artery should not be divided;
constituting the most essential feature of my theory, and the principal
point to be attended to in the treatment of wounded arteries.
12th. This bleeding from the lower end of the vessel, which is more
or less of a venous color, and issues in a continuous stream, may be
restrained by compression properly made on the course of the lower part
of the wounded artery; but in no instance should recourse be had to
a ligature on a distant part of the artery above the seat of injury,
until every other possible effort to arrest the hemorrhage from the
lower end of the vessel has failed.
13th. The great principles of surgery to be observed in cases of
wounded arteries, and which ought never to be absent from the mind of
the surgeon, are two in number:--
1. That no operation ought to be performed on a wounded artery unless
it bleed.
2. That no operation is to be done for a wounded artery in the first
instance but at the spot injured, unless such operation not only
appears to be, but is impracticable.
183. The means adopted by nature for the suppression of hemorrhage
have been investigated by Celsus, Rufus, Galen, Œtius, etc., down to
Dr. Jones, the most important English writer on this subject; but the
methods of inquiry they all adopted appear to have been insufficient
and unequal to the object in view. They bled an animal until he died,
and then reasoned on the manner or means by which the bleeding was
suppressed, when it was in fact arrested by death. It is obvious, then,
that it is only when nature has not been interfered with, and the
patient has not died from bleeding continued to the last moment, but
has, on the contrary, lived some time after the hemorrhage has ceased,
that the processes by which its suppression has been accomplished can
be fairly investigated. These processes essentially depend on the size
and variations of structure in an artery, which have been shown to be
dissimilar in large and small arteries, and not even quite alike in the
upper and lower ends of the same artery--facts which were elicited from
observations made on men on the field of battle during the Peninsular
war, and consequently not liable to error. It was then proved that
arteries of moderate dimensions, such as the middle part of the femoral
or the axillary, tibial or brachial, and particularly all below these
in size, are capable, by their own intrinsic powers, when completely
divided, of arresting the passage of the blood through them without any
assistance from art, or from the surrounding parts in which they are
situated. The establishment of this fact overthrew at once the theory
which relates to the importance of, and necessity for, the sheath of
the vessel, and the offices it performs in suppressing hemorrhage
in vessels of this size, and in a great measure that supposed to be
derived from the formation of an external coagulum, the _bouchon_ of
the French.
184. When the femoral artery has been fairly divided in the lower part
of the thigh, the patient has, in almost all the cases which have come
under observation, either died without assistance, or the hemorrhage
has ceased spontaneously. Having been thus arrested for twelve hours,
the efforts of nature are usually sufficient to prevent its return
from the _upper_, although not from the _lower_ end of the vessel; but
then it is of _venous_ and not of _arterial_ color--a fact I first
demonstrated, and which is now acknowledged to be of the greatest
importance. The great evil to be dreaded in such cases is not from
hemorrhage from the _upper_ end of the divided artery, but from the
_lower_, and from _mortification of the foot_.
The _upper_ end of an artery retracts on being divided, and this
retraction is accompanied by a contraction of the cut extremity of the
vessel, which assumes the shape of the neck of a French wine-bottle
or Florence oil-flask. The contraction is confined in the first
instance to its very extremity, so that the barrier opposing the flow
of blood is formed by this part alone. The contraction, however, goes
on increasing for the space of an inch; it is usually filled up with
an internal coagulum of a round, pyramidal shape, adhering firmly to
the contracted end of the artery, loose at its apex, and extending
frequently as far as the first collateral branch, but rarely under
any circumstances beyond two inches; the very orifice of the artery
on the outside being in a few days covered by a layer of a yellowish
green-colored substance or fibrin, which indicates its situation in a
remarkable manner. Some of these processes are continued even after the
external wound has healed; the artery generally goes on diminishing and
contracting as far as it is useless, so that of three or four inches,
from one to two may be impervious, the remainder being contracted,
although still permeable by a probe. An accompanying nerve, where there
is one, would do the reverse, the cut extremity would become enlarged
or bulbous, gradually diminishing as it is traced upward, until it
regains its proper size.
The processes adopted by nature for closing the lower end of a divided
artery of the size of the femoral at the inferior part of the thigh
are somewhat different from those employed at the upper or opposite
extremity. The retraction or contraction of the _lower_ end of a
divided artery is neither so perfect nor so permanent as at its _upper_
end, and the small internal coagulum is in many instances altogether
wanting, or very defective in its formation. The closure of the lower
orifice being less perfectly accomplished than of the upper, it is
the more likely to suffer from secondary hemorrhage, which may be
distinguished from that from the upper end of the artery at an early
period after the accident, by the _venous color of the blood, and from
its flowing or welling out in a continuous stream, as water rises from
a spring, and not with an arterial impulse_.
The retracting and contracting powers in the lower end of a divided
artery are nevertheless considerable, and are sufficient in some cases
to nearly close the lower end of the femoral artery when divided by
amputation above the knee. When the femoral artery is cut across, the
lower portion of the vessel is emptied by its last efforts, combined
with the action of the capillaries. When the collateral circulation
is powerful, blood soon regurgitates into the artery, but the force of
the regurgitation can be in no proportion to that of the propulsion at
the other or _upper_ divided end of the vessel, which will generally
be able to resist this impulse, while the _lower_ one often opens and
bleeds after the lapse of a few days. In all the cases I have had an
opportunity of examining, in which hemorrhage had taken place from the
lower end of the artery, the following appearances were observable
after the interval of from four to five days.
The same kind of yellowish-green matter marks and conceals the
situation of the lower extremity of the artery in the wound as it
does the upper. It is, however, thinner where it immediately covers
the end of the artery, which in none of these cases was contracted in
the conical manner described as taking place in the upper extremity.
On the introduction of a probe with the greatest gentleness into the
artery from below, it usually makes its appearance at a point on the
yellow space, raising a thin portion as it protrudes. On laying open
the artery, the orifice would seem to have been once closed by this
layer of fibrin, but with a less degree of contraction than the upper
end of the same artery; the layer still, however, forming an obstacle
sufficient to cover and close three-fourths of the orifice, the blood
having flowed through the remaining fourth, which had probably given
way by accident; which accident is usually some sudden or continued
motion being given to the extremity or part injured, and which motion
it is imperatively necessary to avoid, when the lower end of a wounded
artery has not been secured by ligature.
A soldier, who had his arm carried away by the bursting of a shell at
the siege of Ciudad Rodrigo, was brought to me shortly afterward. The
axillary artery, becoming brachial, was torn across, and hung down
lower than the other divided parts, pulsating to its very extremity.
Pressed and squeezed in every way between my fingers in order to make
it bleed, it still resisted every attempt, although apparently by the
narrowest possible barrier, which appeared to be at the end of the
artery, and formed by its contraction. The orifice of the canal was
marked by a small red point, to which a very slight and thin layer
of coagulum adhered, the removal of which had no influence on the
resistance offered by the very extremity of the artery to the passage
of blood through it. In this, and in another instance of a similar
nature, the end of the artery being cut off at less than an eighth of
an inch from the extremity, it bled with its usual vigor. In both, the
vessel for near that distance was contracted so as to leave little or
no canal at its orifice, which in these cases was filled by a coagulum
of the size and shape of a very small pin.
[Illustration:
1. Axillary artery.
2. Axillary vein.
3, 3. Branches of axillary plexus of nerves.
4. Curved, pointed and plugged ends of the artery and vein.
The vessels are here represented as they lay exposed in the lacerated
parts. The pointed and plugged ends of the vessels were of a dark
coagulum color, while above both artery and vein had a reddish,
vascular appearance, and were held in close relation by their sheath.
The artery bent distinctly to the very base of the coagulum.]
Mr. Deputy Inspector-General Taylor informs me that a soldier of the
44th Regiment was struck by a cannon-shot on the 21st of June, 1855, in
front of Sebastopol; it carried his left arm away from the shoulder,
leaving the artery, vein, and nerves exposed as in the accompanying
sketch. The thought, he says, crossed my mind, as I held the artery
between my finger and thumb, that it might be for the benefit of
the patient to place a ligature on the artery at the highest point,
exposed, cutting off the part below, having had a precisely similar
case at Ferozeshah, in India, in which the soldier recovered without
the artery being tied, or any hemorrhage recurring. The shot, in
carrying away his arm, struck him very severely on the chest, and
I fear has injured the lungs, but there is so much ecchymosis that
the presence or absence of sounds cannot be distinguished by the
stethoscope. Of this injury of the chest the man died some days after
its receipt. The body was buried without examination, but no hemorrhage
had taken place from the wound.
Private J. Barnes, 29th Regiment, on the 16th of May, 1811, at the
battle of Albuhera, received a musket-ball in the right thigh, behind
and above the knee, inclining downward and inward, close to the
condyles of the femur, and in the direction of the femoral artery
becoming popliteal; it bled violently at the moment, and so continued
for a few minutes, during which time he conceives he lost two quarts of
blood. It then ceased, and he was dressed in the usual slight manner,
and remained two days upon the field of battle, until removed to
Valverde, nine miles, on a bad road, on men’s shoulders, in a blanket
converted into a bearer. He was considered as one of the slighter
cases, until the gentleman in immediate charge of him requested me to
see him, on account of his toes being in a state of mortification.
On the evening of the 3d of June, eighteen days after the accident,
the man was placed on a bullock car, to be removed with the rest of
the wounded to Elvas, the mortification of the foot having ceased to
increase, and a line of separation having been formed. Shortly after
the cars moved, I was informed that he was bleeding from the wound: it
evidently appeared to flow from the popliteal artery; and as it issued
slowly, I supposed from the lower divided end. The foot being partly
lost, I determined on amputation above the knee, which was performed
at Olivença. The amputated limb was sent after me to Elvas, that it
might be examined at leisure. I carefully traced the course of the
wound, and found in it a little coagulated blood, but could not see the
mouth of the vessel. A probe passed into the upper end of the artery
was obstructed before it reached the ulcerated surface by nearly an
inch; and on passing it up the lower one, it was stopped exactly in the
middle of the track of the ball, by a veil or substance drawn across
the mouth of the vessel, which, on careful examination, showed the
point of the probe at one part of the circle, although too small to let
it through; from this part I conceive the hemorrhage came. The divided
ends were one inch apart. The _upper_, or femoral portion, for nearly
an inch, contained a firm coagulum, filling up that part of the artery,
which had contracted like the neck of a claret bottle. The _lower_ or
popliteal portion of the artery had a very peculiar appearance; the
substance drawn across appeared to have closed it completely at one
time, and to have given way from the rough motion of the car at the
point now open, which was very small even when the sides of the artery
were approximated. A very little soft coagulum was behind it; and if
the man had not been removed, the vessel might have remained secure.
This case shows very distinctly the means adopted by nature for the
suppression of hemorrhage from both ends of a divided artery.
Corporal Carter, of the pioneers of the 29th Regiment, was wounded
at the battle of Roliça, in August, 1809, by a musket-ball, which
passed through the anterior and upper part of the forearm, fracturing
the ulna. Shortly afterward a profuse hemorrhage took place, and the
staff-surgeon in charge tied the brachial artery. In the night the
hemorrhage recurred, and the man nearly bled to death. The arm was then
amputated, when the ulnar artery was found in an open and sloughing
state.
_Remarks._--A simple incision to expose the wounded artery, and placing
two ligatures upon it, would have saved this man his arm and his life.
At the battle of Vimiera, which followed a few days afterward, a
soldier received a somewhat similar wound, save that the brachial
artery bled forthwith, the hemorrhage being stopped by the tourniquet.
Warned by the preceding case, I cut down on the artery, carefully
avoiding the nerve, which had been tied in the former instance, and
found the artery more than half divided. It was secured by a ligature
above and below the wound: the bleeding did not afterward return, and
the man recovered.
185. Thomas Carryan, of the 3d Regiment, was wounded at Albuhera, on
the 16th of May, 1811, on the inside of the calf of the right leg,
the ball passing out on the fore and outside of the tibia: it bled
considerably for some minutes, when it ceased, and the hemorrhage
did not return until the 15th of June, on which day a little blood
followed the dressings, and increased on the patient making any
exertion; so that on the 4th, the gentleman under whose care he was
tied the femoral artery on the outside of the sartorius muscle, which
suppressed the hemorrhage for that day, the limb continuing with little
or no interruption of the same temperature to the hand as the other. On
the 5th, the original wound had a bad appearance, and some coagulated
blood was readily pressed out of it; on the 6th, a greater quantity
came away; and on the 7th, the exertion of using the bed-pan was
followed by a stream of arterial blood, which ceased on tightening the
precautionary tourniquet.
The limb was amputated above the ligature on the artery. Its dissection
showed the anterior tibial artery to have been destroyed for some
distance, and the muscles on the back part of the leg nearly in a
gangrenous state. The patient died a few days afterward.
_Remarks._--If an incision had been made in the leg so as to expose the
artery, and ligatures had been placed on it above and below the wound,
the man, in all probability, would not have died.
Sergeant William Lillie, of the 62d Regiment, aged thirty-two, was
wounded in the right thigh, on the 10th of April, at the battle of
Toulouse, by a musket-ball, which passed through, in an oblique
direction downward and inward, close to the bone, describing a track of
seven inches. The ball was extracted behind on the field. He said he
had bled a good deal on the receipt of the injury, which he had stopped
by binding his sash round the limb. The discharge from the wound was
considerable; it appeared, however, to be going on well until the
20th of the month, when, on making a sudden turn in bed, dark-colored
blood flowed from both orifices of the wound in considerable quantity.
I had given an order, as the Deputy Inspector-General in charge of
all the wounded, that no operation should be performed on a wounded
artery without a report being sent to me, and an hour at least granted
for a reply, unless the case were of too urgent a nature to admit of
it. It appeared to be so in this instance, and before I arrived Mr.
Dease had performed the operation for aneurism at the lower part of
the upper third of the thigh. I could only express my regret that it
had been done, and point out the probability of the recurrence of the
hemorrhage from the lower end of the artery, which took place on the
7th of May, when the limb was amputated, and the man subsequently died.
On examination the artery was found to have been divided exactly where
it passes between the tendon of the triceps and the bone. The upper
portion of the artery thus cut across was closed. A probe introduced
into it from above would not come out at the face of the wound,
although the impulse given to this part on moving it was observable in
the middle of a large, yellowish-green spot, which I had previously
declared to be the situation of the extremity of the artery which had
contracted behind this, in the shape of a claret bottle, for about an
inch, having within it a small coagulum. The lower end of the artery
from which the hemorrhage had taken place was marked by a spot of a
similar character; but on passing a probe upward from the popliteal
space, it came out at a very small hole in the extremity of the artery,
in the center of the yellow spot, the canal of the artery not being
contracted and diminished, but only apparently closed by a layer of the
yellowish-green matter laid over it, and adhering to its circumference.
Sergeant Baptiste Pontheit, of the French 64th Regiment, was wounded
by a musket-ball at the battle of Albuhera, on the upper and fore part
of the thigh; it passed out behind, in the direction of the femoral
artery. He lost a great quantity of blood before the hemorrhage ceased,
but the wound went on well until the 26th, ten days after the battle,
when he felt something give way in his thigh, and found himself
bleeding from the wound, which, however, soon ceased on pressing his
hand upon it. In the afternoon, on again moving, he lost about half
a pint of florid blood, which induced the surgeon on duty to place a
tourniquet on the limb. When at leisure (in the course of two hours) I
removed the tourniquet, and as no hemorrhage occurred, and there was
no swelling in the vicinity of the wound, I replaced the dressing with
a precautionary screw tourniquet, explaining to him its use, and the
probable nature of his wound, together with the operation requisite to
be performed in case of further bleeding.
On turning in bed at night he lost a little more blood, which ceased
on his tightening the tourniquet, which was shortly after loosened. In
the morning, everything being removed, there appeared some swelling
about the wound, the opening of which was filled up by a coagulum:
gentle pressure being made, it readily turned out, and was followed
by a stream of arterial blood, leaving little doubt of the femoral
artery being wounded. Compression being effected in the groin, I
made an incision three inches and a half in length, taking the wound
as a central point, and exposed the femoral artery and vein: both
were wounded, the former being half destroyed in its circumference,
surrounded with coagulated blood, and appearing as if it had sloughed
from being touched by the ball, the course of which was directly
past it, and would have carried it away if it had not been for the
elasticity of the artery. A ligature placed above, and another below
the wound, secured both artery and vein; the incised wound was brought
together by adhesive plaster, and the limb placed in a relaxed
position. The operation was of short duration; he lost little or no
blood, but, the circulation was very languid, and the man exceedingly
low. The warmth of the leg and foot was soon below the standard of the
other; warm flannels were applied, and some brandy was given to him.
In the evening the heat was more natural, and the man returned thanks
for the humanity and kindness shown to him, congratulating himself and
me upon the success of an operation which he had supposed would be
infinitely more severe. The next morning he ate a tolerable breakfast,
but felt a pricking sensation in the calf of the leg, which was as
warm to the hand as the other, but the foot was cold. The second day
the swelling of the limb, its appearance, and discoloration on the
under part, indicated approaching mortification, which on the third was
evident, and on the fourth, at mid-day, he died, the limb up to the
wound being nearly all in a gangrenous state. No adhesion had taken
place in the wound, or in the artery, which showed the inner coat cut,
the ligatures being firm, and no coagulum behind them.
Captain St. Pol, of the 7th or Royal Fusiliers, was wounded in the
ham from behind, while in the ditch at the foot of the great breach
at Badajos. He fell instantly, and lost, as he thinks, a considerable
quantity of blood. On recovering he was raised from the ground, and
walked a few paces prior to his being carried to his tent, where I
saw him in the afternoon of the next day, the 7th. The leg had ceased
to bleed before his arrival in camp. A substance could be felt on the
inner side of the patella, which, by the sensation communicated to the
finger on moving, appeared to be the ball, which was extracted. Some
dark-colored blood issued from the cavity; the ball was lying loose
and unconnected; the finger, on being passed into the joint, which was
swollen, discovered no splinters of bone, and the entrance of the ball
behind would not admit the finger. His having walked some distance on
the leg, and the absence of any splinters between the articulating
extremities of the bones, induced Dr. Armstrong, the surgeon of his
regiment, and myself to think that the ball had entered with little
injury to the bone; and after stating to the patient the little hope we
had of ultimately saving the limb, independently of the great danger
to which he was exposed, compared to the certainty of the operation of
amputation at the moment, we recommended its being done, but he would
not consent. The next day he was removed to Badajos on a litter, the
heat of the tent being unsupportable.
On the morning of the 9th I saw him early, when the want of circulation
in the foot was evident from its having lost its natural color and
warmth; the knee was swollen, but not painful, and I had no doubt that
the artery had been divided by the ball. The marbled appearance and
tallow-white color soon indicated the loss of the leg above the calf;
and vesications had formed on the foot, already of a green color.
On the 12th, the extent of the gangrene was defined on the back of the
knee up to the original wound at its lower edge, gradually receding
as it advanced to the fore part of the leg, which for three inches
below the knee was apparently sound; the uneasiness of the knee being
moderate, and the incised wound looking perfectly healthy, although the
latter had not united.
On the 16th, the separation of the dead from the living parts having
taken place behind, and being well marked and commencing on the fore
part, the limb was amputated as low down as possible. Sixteen vessels
were tied; the parts were gently brought together, without any hope of
union. According to subsequent experience, this operation should not
have been performed. The dead parts only should have been removed, and
the stump left to nature until the health was perfectly restored.
On the 24th he died.
On examining the amputated limb, the popliteal nerve was found
untouched, the ball having passed on the inside; the popliteal vein
was also entire, having a small tumor adhering to its under part
between it and the artery, the divided end of which was closed by a
yellowish-green firm substance readily distinguishing it from the
surrounding parts. On clearing the whole from the bone, and making a
small circular opening into the tumor, which was elastic and covered
with brown fibrous layers, it proved to be an aneurismal sac, smooth on
the inside, containing florid arterial blood and some little coagula.
The artery, on being carefully opened to the closed end, appeared to
have been injured above the part divided by the ball, and communicated
with the sac by a small fissure or rupture. The end of the artery was
then slit up, so as to show the very little thickness of the closing
substance and the great original contraction of the diameter of the
vessel. There was no internal coagulum, neither was there any laid over
the external part of the artery; between it and the bone there was a
coagulum about the size of a small phial cork. The other end of the
artery could not be found, from the gangrenous state of the parts.
Private P. Turnbull, of the grenadiers of the 74th Regiment, of good
stature, was wounded on the 10th of April, 1814, at Toulouse, by a
musket-ball passing from the inside to the outside of the middle of the
thigh; he says it bled considerably at first, but the bleeding soon
ceased; the wound was not painful, and he thinks he observed the leg
and foot to be colder than the rest of his body for the first two or
three days, but did not much attend to it, further than conceiving the
numbness, coldness, and impeded power of motion as natural to the wound.
On the 18th of April, the gentleman in charge of this patient pointed
him out to me as an extraordinary case of gangrene coming on without,
as he supposed, any sufficient cause. The wound on the outside of the
thigh, or the exit of the ball, was nearly healed, and that on the
inside was without inflammation or tumefaction, and with merely a
little hardness to be felt on pressure. The pulsation of the artery
could be distinctly felt to the edge of the wound, but not below it;
the leg was warm, the gangrene confined to the toes. The artery of
the other thigh could be distinctly traced down to the tendon of the
triceps. As he was at a small hospital, about two miles from town,
on the field of battle, I did not see him again until the 20th, and
afterward on the 23d, when, although the gangrenous portion included
all the toes, it had the appearance of having ceased. Satisfied that it
would again extend, I left directions with the assistant-surgeon that
the limb should be amputated _below the knee_.
The surgeon, whom I had not seen, and who did not understand the
subject, disobeyed the order, conceiving that there must be some
mistake. On visiting the hospital, a little after daylight on the
25th, I was greatly annoyed at finding that the operation had not
been done, and that the mortification had begun to spread the evening
before. It was then too late. On the 26th it was above the ankle,
with considerable swelling up to the knee. At night the man died; and
the next morning, at six o’clock, I removed the femoral artery from
Poupart’s ligament to its passage through the triceps, which part was
affected by the mortification.
The ball had passed between the artery and vein in the spot where
the vein is nearly situated behind it and adherent only by cellular
membrane, through which the ball made its passage, the coats of the
vein being little injured, and those of the artery not destroyed in
substance, although bruised; it was at this spot much contracted in
size, and filled above and below by coagula, which prevented the
transmission of blood, and the vein above and below the wound was
filled by a coagulum and was also impassable. This preparation is
unique; it is perhaps the only one in existence proving the elasticity
which vessels possess, and their capability of avoiding to a certain
extent an injury about to be inflicted upon them. It is in the museum
at Chatham.
186. When a round and small ligature is properly applied to an artery
of a large size, such as the femoral, the sides of the vessel are
brought together in a folded, plaited, or wrinkled manner; the ancient
inner and middle coats of the artery, including the modern four, are
divided, while the outer one remains entire and apparently unhurt. If
the ligature be removed, an impression or indentation made by it on the
outer coat will remain as a mark; and if the artery be slit open in a
careful manner, the division of the inner coats will be obvious. These
changes were known to Desault, and are mentioned by Deschamps in his
work on the Ligature of Arteries. They were more satisfactorily proved
to occur by Dr. Jones, and have been clearly stated by Mr. Hodgson and
others. The remaining part of the process differs from the account they
have given, and, according to observations I have had opportunities
of making on the living and on the dead, is as follows: the inner and
middle coats, formed by four distinct layers or structures, are not
only divided, but the inner ones particularly appear to be curled
inward on themselves, so that the cut edge of one half or side is not
applied to its fellow in the usual way of two surfaces, but by curling
inward meets its opponent on every point of a circle, and in this
way forms a barrier inside that of the external coat, which is tied
around it by the ligature; so that, in fact, when a small ligature is
firmly tied, its direct pressure is not applied to the inner coats,
which have been divided and have curled away from it, but to the two
layers of the outer coat, which are in consequence of that pressure
made to ulcerate or slough--processes which could scarcely fail to
take place also in the other coats if they were subjected to pressure
in a similar manner. The cut edges of the four inner layers being from
this provision of nature perfectly free, are capable of taking on the
process of inflammation, which stops at the adhesive stage. This they
do by the effusion of lymph or fibrin both within and without, to a
greater or less extent as the case may require. The outer coat of the
artery must either yield by ulceration or sloughing, or the ligature
must remain until it is decomposed and destroyed. It usually yields by
sloughing, in consequence of its being deprived of life by the pressure
of the ligature, which is left at liberty by the ulceration which takes
place in the sound part of the artery immediately above and below the
part strangulated, which part is frequently brought away in the noose.
The artery does not always yield by sloughing, particularly if it be a
large one and the ligature thick and soft. In this case, a part of the
outer coat, and particularly the white, inelastic substance, from its
folding or plaiting under the ligature, seems to escape that degree of
pressure necessary to destroy it; and when the remaining part yields,
it continues entire, and is only removed by a subsequent process of
ulceration occasioned by its irritation as an extraneous body.
In such cases, the layers of the external coat could not close around
the inner ones, which are thus shown to be capable of forming an
effectual barrier without it, although it materially assists in giving
greater strength to the cicatrix, by the effusion of fibrin which takes
place within, without, and around.
While this process is going on without, and at the very extremity of
the artery, the vessel is gradually contracted above it, and its coats
become more or less inflamed, soft, and vascular. The inner layers
are seen to be wrinkled transversely, and a small coagulum of blood
is formed within them. This sometimes completely fills the artery,
but it is more common for a small, tapering coagulum to be formed,
adhering by its base to the extremity of the vessel; the white color
of which renders it distinctly observable, when contrasted either
with the coagulum or the inner coat of the artery, which latter is
usually of a red or scarlet color while the inflammatory action is
going on. A coagulum, contrary to the usually received opinion, is not
absolutely necessary to the permanent closure of the artery, although
it certainly assists in maintaining it. An artery is also supposed to
contract gradually up to its first collateral branch; but this is not
always the case, and depends entirely on the use for which the branch
is required. After amputation at the middle of the arm, the artery will
go on diminishing in size up to the subscapular branch, the circumflex
arteries diminishing in proportion, in consequence of their being so
much less necessary than before the operation. In several instances the
principal artery has remained pervious below the collateral branch, the
next immediately above the part where the ligature has been applied.
Neither will the presence of a collateral branch immediately above
where the ligature has been placed upon the artery always, although
it sometimes may, interfere with the consolidation of the wound, and
the closure of the canal of the vessel. It may impede the process,
and render it for a time less safe, and in some instances it may
prevent it altogether, but I have so often seen large arteries, heal
after division close to the giving off of a considerable branch,
that I consider them to be always capable of doing so, provided they
are naturally sound. If they are not sound, it is very doubtful what
process may take place; but it will be less likely to be a healthy one,
if interfered with by the immediate proximity of a collateral branch.
The power which suppresses hemorrhage in a bleeding artery resides, it
must be borne in mind, in the very extremity of the vessel itself. It
is, however, advisable to take care that a ligature shall be applied
above rather than immediately below a branch given off from a trunk,
more particularly when it may be doubted whether the trunk is free from
disease.
In 1834 I placed a ligature of strong dentists’ silk on the right
common iliac artery of a lady of middle age for a swelling in the
hip, supposed to be a gluteal aneurism, which, after commencing the
operation, was found to occupy a considerable part of the iliac region.
The lady died a year afterward, and it was then found that the ligature
had been applied at the distance of five-eighths of an inch from the
bifurcation of the aorta, and three-eighths of an inch above the origin
of the internal iliac, independently of the line of separation between
the parts of the iliac divided by the ligature, which did not seem to
be wider than the ligature itself. The separated ends were united at
the point of separation by new matter, the orifice or end of each being
closed by a very narrow barrier, the inner coat of the artery being
redder than natural, somewhat irregular and contracted, and containing
hardly any coagulum. _The fact was thus proved in the largest artery
in the body save one, that a coagulum is not necessary for the safety
of the union, while the immediate vicinity of so large a vessel as the
internal iliac, to say nothing of the aorta itself, also proves that
the danger hitherto expected from the neighborhood of a collateral
branch is more imaginary than real_--two great facts the practice of
the Peninsular war led me to declare, and which ought no longer to be
doubted.
The preparation exemplifying these points is in the museum of the Royal
College of Surgeons, together with the ligature still carrying in its
noose the portion of the artery it strangulated and brought away with
it.
187. A ligature should always be round and small, provided it be
sufficiently strong. The strength of a ligature is variously estimated;
some surgeons trying it by the strength of their own fingers, others
by what they conceive to be the resisting power of the coats of the
artery, in which perhaps they may err. The only way in which a surgeon
can hope to acquire correct information on this point is by trying on
the dead body what force of fingers is required to cut the inner coats
of arteries of various sizes; and then taking the least force required
for this purpose, to ascertain whether he can easily pull the ligature
over or off the divided end of the artery. If a surgeon will take the
trouble to do this, he will find that he has estimated the necessary
force much too highly, and that he is in more danger of breaking his
ligature than of failing to secure the artery. Hemorrhage has, however,
been known to occur from the ligature having slipped off the end of an
artery, which had been divided in the operation for aneurism, although
I have never seen it happen after amputation, where the vessels were
tied with a small, firm ligature. It constitutes a valid objection to
the division of the artery between the ligatures, when two are applied.
A ligature composed of one strong thread of dentists’ silk, well waxed,
is sufficiently firm for the largest artery. It does not, however, much
signify what may be the shape, size, form, or substance of ligatures,
when they are applied to arteries in a sound state, provided they are
not too large, are fairly and separately tied, and with a sufficient
degree of force to retain the ligature in its situation until separated
by the usual processes of nature, which generally take from fourteen to
thirty days for their completion.
188. When arteries are unhealthy, the selection and proper application
of a ligature are points of great importance. A larger although yet a
small, round ligature should be fairly, evenly, and firmly, although
not so forcibly applied as on a sound artery; without the intervention
of any substance whatever between it and the cellular covering of the
vessel. The secondary hemorrhages which are recorded by different
writers as prone to occur, and which did take place, happened, I am
disposed to believe, more from the application of improper ligatures
than from any other cause; for the inner coat of an artery is so prone
to take on the adhesive state of inflammation that if a strong, small
ligature be applied in the manner directed, it is more than probable
that the closure of the artery will be effected. Ulceration will,
however, sometimes take place on the inner coat of the vessel, and
slowly extend outward, undoing in its progress any steps which may have
been begun for the consolidation of the extremity of the artery. When
a secondary hemorrhage does occur from this or from any other cause,
it is usually from the beginning of the second to the fourth week; but
there is no security for the patient until after the ligature has come
away, unless it is retained an inordinate length of time, from having
included some substances which do not readily yield under irritation,
such as the extremity of a nerve, or a slip of ligament which is not
sufficiently compressed in the noose of the ligature.
Secondary hemorrhage may also take place from the extension of
ulceration or sloughing to the artery from the surrounding parts, and
perhaps as frequently as from any other cause; but when mortification
occurs, there is no secondary hemorrhage, unless in that species
which is called hospital gangrene. The advantages to be derived from
the application of a strong, small ligature, from the least possible
disturbance of the surrounding parts, and from absolute quietude, while
the healing processes are going on, must be so obvious as to require
no further observation. An undue interference with the ligature, by
pulling at it, cannot be too earnestly deprecated at an early period;
although, at a subsequent time, some force is occasionally required for
its removal after amputation.