189. When the femoral artery is _cut across_ in the upper part of
the thigh, whether it be done by a cannon-shot, a musket-ball, or a
knife, the patient does not always bleed to death at once, although he
frequently dies after a time in consequence of the shock and the loss
of blood.
At the battle of Toulouse a large shot struck an officer and two men
immediately behind him, and nearly tore off the right thigh of each.
The artery was divided about, or less than three inches below Poupart’s
ligament. I saw the officer shortly afterward, in consequence of his
surgeon saying it was a case for amputation at the hip-joint. The
bleeding had ceased, the pulse was feeble; the countenance ghastly,
bedewed with a cold sweat, and with every indication of approaching
dissolution. The house being at an advanced point, and close to one
of the French redoubts, the fire of round shot and musketry was so
severe upon and around it as to induce me to remain, until the battery
should be taken by the troops then advancing upon our flank. In order
to occupy my time usefully, I returned to the officer, and found he
had just expired. Desirous of seeing by what means the hemorrhage had
been arrested, I cut down upon the artery, took it carefully out, and
found that its divided end was irregularly torn; a slight contraction
had taken place just above, but not sufficient to have been of the
slightest utility in suppressing the bleeding, which was in fact
prevented by an external coagulum, which filled up the ragged extremity
of the vessel, and which in a few days, if he had lived, would have
been removed with the purulent discharge, an internal one forming
in the mean time, the extremity of the artery also contracting and
retracting, so that a secondary hemorrhage might not have taken place,
indeed would not in the generality of instances.
At Salamanca I had the opportunity of examining the thigh of a French
soldier, whose femoral artery had been divided perhaps even higher up
by a cannon-shot. He lived until the next morning, when I saw him, no
operation whatever having been attempted, nor a tourniquet applied.
He died exhausted, but not from any immediate bleeding, which, when
once stopped, had not returned. The artery was in a similar state to
the preceding one, with this slight difference, that the orifice was a
little more contracted; the external coagulum filled up the ragged end
of the artery, and was slightly compressed within by the contraction,
which kept it in its place. The rest of the coagulum filled the hollow
in the surrounding parts, which the retraction of the artery had
occasioned. In this case, so unlike those I have hitherto noticed, the
first natural cause giving rise to the suppression of the bleeding was
the diminution of the power of the heart; the second, the formation of
a coagulum in the hollow of the sheath left by the retraction of the
artery. Contraction had begun, but had done nothing essential. (See
_Aph._ 413.)
In other instances in which I have examined the extremities of such
large arteries when divided, the appearances have been more or less of
a similar nature; unless where the persons had died immediately, when
the torn extremities were found quite open, with little surrounding
coagulum. I have, however, seen persons wounded in this manner live
for several days, when I have found, after death, the extremity of the
artery open, and no appearance of blood having passed into it below
Poupart’s ligament. The consent necessary between the inner coat of the
artery and the blood for the free passage of blood had been destroyed
by the injury.
190. A _small puncture_ in an artery, made with a needle, will
sometimes heal, as it generally does in dogs. I have, however, seen
several instances in which the femoral artery was wounded by a
tenaculum, during amputation, and a secondary hemorrhage followed,
requiring the application of a ligature. A _larger puncture_, or a
longitudinal slit of from one to two lines in extent, does not commonly
unite, except under pressure, although the edges of the wound may
not always separate so as to allow blood to issue in any quantity.
It sometimes only oozes out, and occasionally does not do even that,
unless some obstacle to the circulation takes place below, when blood
is propelled with a jet; and the edges of the cut having thus been
separated, blood continues to be thrown forth in considerable quantity.
In an artery of the size of the temporal, a small longitudinal slit
may sometimes heal without the canal of the artery being obliterated,
although this very rarely takes place in one of a large calibre.
In all cases of punctured wounds, when pressure can be effectually
made, and especially against a bone, it should be tried in a graduated
manner over the part injured, in the course of the artery above and
below the wound, and if in an extremity, over the whole limb generally,
the motions of which should be effectually prevented, and absolute rest
enjoined, if the artery is of any importance. This should be continued
for two, three, or more weeks, according to the nature of the injury.
A medical student, being desirous of bleeding his friend, also a
student, in the arm, opened the ulnar artery, which in this case was
very superficial. On discovering the error he had committed, he closed
the wound, and applied a firm compress and bandage, under which it
healed. On applying the ear to the part, it sounded like an aneurism,
although there was scarcely any tumor, the thrilling sound being
apparently occasioned by friction against the cut edges of the artery.
This thrilling noise diminished, and the vessel immediately below the
wound gradually recovered its pulsation, except at the exact situation
of the injury, where none could be distinguished. It was obliterated at
that part for the length of the eighth of an inch.
The master tailor of the 40th Regiment, tempted by the approaching
prospect of plunder, was induced, on the night of the assault on
Badajos, to give up the shears, and arm himself with the halbert, and
was properly rewarded for his temerity by a wound from a pike in the
right arm, from which, he says, he bled like a pig, and became very
faint. On his arrival at the spot indicated for surgical assistance, he
fainted; but this was attributed to the unwarlike propensities of the
man, rather than to any sufficient cause. The wound was not more than
one-third of an inch long, a little below the edge of the pectoralis
major, and immediately over the artery. The arm and hand were numb and
cold; the pulse was not distinguishable at the wrist, and it appeared
to cease at the place of injury, which was harder and a little more
swollen than natural. He said that his pulse had always been felt by
the doctors in the usual place. The wound healed without any trouble.
On the 1st of May the pulsation of the artery could be felt a little
below the wound. On any exertion he had a good deal of unpleasant
numbness in the thumb and forefinger. A small cicatrix formed at the
place of the wound, which was otherwise quite natural to the touch.
This case proves that when a large artery is wounded in man by a sharp
cutting instrument, to a certain but moderate extent the process of
cure takes place through inflammation and by the obliteration of that
part of the canal of the vessel. Continental surgeons have since
sacrificed whole hecatombs of animals to prove this fact, which had
been so many years before recorded in England as having occurred in man.
It has not been satisfactorily proved in man that a large artery, such
as the femoral or even the brachial, has been opened to the extent of
one-third or a fourth of its circumference, and that the wound has
healed without the canal becoming impervious. A _smaller wound_ of a
large artery may close without obstructing the canal of the vessel, but
the part is not so firm or so solid as before, and may yield, and give
rise to an aneurism, having apparently the characters of a small true,
as opposed to the spurious diffused, or even circumscribed swelling,
which more usually follows a similar accident.
Colonel Fane was wounded by an arrow in the right side of the neck,
opposite the bifurcation of the carotid, which caused a considerable
loss of blood at the moment. The wound healed, leaving only a mark
where the point of the arrow had entered. Some time afterward he
observed a small swelling at the part, which, from its pulsation, was
declared to be an aneurism. Uneasy about it, he asked my opinion at
Badajos, after the siege. It had not increased, but it caused him some
anxiety, and I promised to place a ligature on the common carotid if
the aneurism should increase in size. He was unfortunately killed in
action a year afterward, by a shot through the head.
191. When a large artery, such as the brachial, is cut _transversely_
to a fourth of its circumference in man, it forms a circular opening as
in animals; and if the artery be large, the bleeding usually continues
until the person faints, or it is arrested by pressure. In dogs the
bleeding commonly ceases without any assistance from art, and without
the animal being exhausted; in horses and sheep the bleeding usually
continues till the animals die; while in man, even with the best aid
from compression, hemorrhage will in all probability recur, unless the
circulation be altogether arrested. If the external opening only should
be closed, a spurious, circumscribed aneurism will be the consequence
in so small an artery as the temporal, and a ligature will sometimes be
required above and below a little aneurism of this description. In a
larger artery the spurious aneurism may or may not be diffused.
When an artery of this size is _completely divided_, it is less likely
to continue to bleed than if it had been only wounded. When it is
merely cut or torn half through, but not completely divided in the
first instance, it is in the same state with regard to hemorrhage as if
it had partially given way by ulceration. It can neither retract nor
contract, and will continue to bleed until it destroys the patient,
unless pressure be accurately applied and maintained until further
assistance can be procured. The practice to be pursued is to divide the
vessel, if it be a small one, such as the temporal artery, when it will
be enabled to retract and contract; and the bleeding will in general
permanently cease under pressure, especially when it can be applied
against the bone. If the artery is of a larger class, and continues
to bleed, it should be sufficiently exposed by enlarging the wound; a
ligature should be applied above and below the opening in the vessel,
which may or may not be divided between them at the pleasure of the
surgeon.
In June, 1829, I happened to be at Windsor, on a visit to my old
friend, the late Dr. Ferguson, and was called to a young gentleman,
the upper part of whose right femoral artery had been accidentally cut
by the point of a scythe. On dilating the wound, a tourniquet being
on the limb, black blood flowed freely from it; on unscrewing the
tourniquet by degrees, arterial blood showed itself, and the upper end
of the artery was secured by ligature when the tourniquet was removed.
Venous-looking or black blood then again flowed in greater abundance
than before, evidently from a large vessel. This I restrained by
pressure made below the wound with the thumb of the left hand, while
I laid bare the lower part of the artery, from a slit in which, near
an inch in length, the black blood was seen to flow. A ligature passed
around the vessel below the wound suppressed the bleeding. The artery
was not divided, and the young gentleman perfectly recovered, and has
continued well until this day. The absolute necessity for two ligatures
was here well shown, as well as the flow of dark-colored blood from the
lower end of the artery. This gentleman is now an officer in the army,
and suffers no inconvenience from his accident.
192. When a large artery is wounded at some depth from the surface,
and the external opening is small, blood not only issues through the
opening, but is often forced into the cellular structure of the limb to
a considerable distance; the pulsation of the tumor is observable, and
the thrill or sound which accompanies a ruptured artery is distinct. If
a large quantity of blood, partly in a fluid, partly in a coagulated
state, be collected immediately over and around the wound in the
artery, the tumor may not pulsate or give forth any sound, if the
coagulated blood be in considerable quantity, although some elevation
of the tumor may be observed corresponding to the pulse.
This rising or pulsation of the swelling often depends on the impulse
given to the whole, as a mass, by the artery against which it is
lying, and not upon blood circulating through it. An impulse of this
kind is distinguishable in a bronchocele which lies immediately over
and in contact with the carotid artery. It is the same when blood is
extravasated by the rupture of several small vessels, in consequence of
the passage of a wheel over the limb, especially in the thigh, where a
swelling containing fluid blood will sometimes pulsate in a well-marked
manner, until it gradually diminishes as the blood coagulates, when
the motion becomes a mere elevation at each stroke of the heart. The
whizzing sound or thrill attendant on a ruptured artery is in these
cases wanting, being a very diagnostic mark of this accident; although
where there is true aneurism, and it has burst, forming a diffused
and spurious one, the thrill may be wanting; but the history of these
cases enables a surgeon to distinguish between them. If several ounces
of blood are thrown out, and remain fluid, they ought to be evacuated,
or suppuration will ensue. If they become coagulated, the mass will
be gradually absorbed. Fluid blood should be evacuated by a small
opening, and the part afterward treated by compress and bandage. If the
fluid or partly coagulated blood should increase in quantity, and the
swelling continue to enlarge and pulsate, the extension of the mischief
should be arrested by opening the swelling and securing the artery by
ligature. When the external opening is enlarged, and the clots which
filled it up are at all disturbed, arterial blood begins to flow, and
the finger will readily follow the track through which it passes down
to the artery, if it should not be too far distant. If the incision
be made sufficiently large to enable the operator to remove these
clots of blood with rapidity, the finger will more readily pass down
to the wound in the artery, which, if a large one, may be thus easily
discovered, if within reach and sight, provided the tourniquet be
thoroughly unscrewed, and the surgeon is not afraid. A ligature should
then be placed above and below the opening in the artery.
When an artery is wounded, and the external opening in the integument
heals so as to prevent the blood from issuing through it, a traumatic,
spurious, circumscribed, or diffused aneurism is said to form,
according to the facility which is offered by the structure of the
parts for the confinement or diffusion of the extravasated blood. A
traumatic aneurismal tumor of this nature differs essentially from
aneurism which has taken place as a consequence of disease, and not of
direct injury. If a spurious aneurism form from disease, the artery is
in general unsound for some distance above and below the tumor. In the
aneurismal tumor from a wound, the artery is perfectly sound, except as
far as concerns the seat of injury. There is, then, not only a great
and essential difference between these two kinds of aneurism as regards
their nature, but also with respect to the collateral circulation, and
the operation to be performed for their cure; and the surgeon may not
overlook these facts.
A school-boy, about fourteen years of age, let a pen-knife drop from
his hand while sitting down, and drew his knees suddenly toward each
other to catch the falling knife; the point was thus forced into the
inner and middle part of the thigh, and wounded the femoral artery.
The medical man on the spot put a plaster on the little incision in
the integuments, and the wound quickly healed. The boy complained of
uneasiness, but was supposed to be making more of it than necessary,
and was made to go into school as usual. The limb, however, began to
swell, and the boy was brought to London, supposed to be suffering from
abscess, and placed under the care of Mr. Keate, who, suspecting the
evil, carefully introduced the point of a lancet, and, after a clot
of blood had been forced out, a jet of arterial blood flew across the
room. The hemorrhage was arrested by pressure below Poupart’s ligament,
while Mr. Keate enlarged the opening in the integuments, and removed
two washhand-basinsful of coagulated blood. He then put his finger on
a large opening in the artery, under which two ligatures were passed
by means of an eye-probe, and the artery was divided between them. The
muscles had been cleanly _dissected_, and the cavity extended from the
fork internally, and trochanter externally, to the knee. There was much
less suppuration than could have been expected. The ligatures were
detached about the usual time, and the patient entirely recovered.
This admirable case should be imprinted on the mind of every surgeon.
With the hope that it will be so, I refrain from commenting on three
or four cases which have occurred within the last two years, in which,
from neglect of the precept inculcated by it, very distressing if not
fatal consequences ensued.
193. There is no precept more important than that which directs that no
operation should be done on a wounded artery unless it bleed, inasmuch
as hemorrhage once arrested may not be renewed, in which case any
operation must be unnecessary. The following case shows how firmly the
principles on which wounded arteries ought to be treated were fixed in
my mind in the year 1812; and there is no case during that eventful
period to which I look back with more satisfaction than the following:--
John Wilson, of the 23d Regiment, was wounded at the battle of
Salamanca by a musket-ball, which entered immediately behind the
trochanter major, passed downward, forward, and inward, and came out on
the inside of the anterior part of the thigh. The ball could not have
injured the femoral artery, although it might readily have divided some
branch of the profunda. Several days after the receipt of the injury, I
saw this man sitting at night on his bed, which was on the floor, with
his leg bent and out of it, another man holding a candle, and a third
catching the blood which flowed from the wound, and which had half
filled a large pewter basin. A tourniquet with a thick pad was placed
as high as possible on the upper part of the thigh, and the officer
on duty was requested to loosen it in the course of an hour; that was
done, and the bleeding did not recommence. The next day, the patient
being laid on the operating table, I removed the coagula from both
openings, and tried to bring on the bleeding by pressure and by moving
the limb; it would not, however, bleed. As there could be no other
guide to the wounded artery, which was evidently a deep-seated one, I
did not like to cut down into the thigh without it, and the man was
replaced in bed, and a loose precautionary tourniquet applied. At night
the wound bled smartly again, and the blood was evidently arterial.
It was soon arrested by pressure. The next day I placed him on the
operating table again, but the artery would not bleed. This occurred
a third time with the same result. The bleedings were, however, now
almost immediately suppressed, whenever they took place, by the orderly
who attended upon him; care having been taken to have a long, thick
pad always lying over the femoral artery, from and below Poupart’s
ligament, upon which he made pressure with his hand for a short time.
_Absolute rest_ was enjoined. The hemorrhage at last ceased without
further interference, and the man recovered.
This case was one of considerable interest at the time, and is the
model one on which the treatment of all such injuries should be
founded. If the wound had bled, I should have introduced my finger, and
enlarged it transversely, continuing the incision until the opening was
sufficiently large to see to the bottom of the wound or the bleeding
part. It is necessary in such cases to be attentive to the course of
the great vessels and nerves, but not to the safety of muscular fibers,
the division of which leads to no permanent injury. As pressure on
the main trunk led to the ultimate suppression of the hemorrhage,
it may be said that a ligature placed high up on the femoral artery
would not only have done the same, but would have relieved the man
from the anxiety necessarily dependent on the momentary fear of a
recurrence of the hemorrhage. There are two objections to this method
of proceeding: the likelihood of mortification taking place, which
in similar cases has been known to occur; and the possibility of
the hemorrhage being renewed through the anastomosing branches. The
temporary suspension of the circulation by pressure does little or no
harm, more particularly where the pad used is so thick and narrow as to
cause it to fall principally on the artery, and only in a slight degree
on the surrounding parts, which by a little attention may be readily
accomplished. It is not then good practice to cut down upon an artery
on the first occurrence of hemorrhage, unless it be so severe or so
well marked as to leave no doubt of its being from the main trunk of
the vessel itself; nor is it then advisable to do so, except the artery
continue to bleed; for many a hemorrhage, supposed to have taken place
from the main trunk of an artery, has been permanently stopped by a
moderately continued pressure exercised in the course of the vessel,
and sometimes on the bleeding part itself; particularly if the blood
be of a dark color, indicating that it comes from the lower end of the
vessel.
A painter could not have had a better subject for a picture
illustrative of the miseries which follow a great battle, than some of
the hospitals at Salamanca at one time presented. Conceive this poor
man, late at night, in the midst of others, some more seriously injured
than himself, calmly watching his blood--his life flowing away without
hope of relief, one man holding a lighted candle in his hand, to look
at it, and another a pewter washhand-basin to prevent its running over
the floor, until life should be extinct. The unfortunate wretch next
him with a broken thigh, the ends lying nearly at right angles for want
of a proper splint to keep them straight, is praying for amputation or
for death. The miserable being on the other side has lost his thigh; it
has been amputated. The stump is shaking with spasms; it has shifted
itself off the wisp of straw which supported it. He is holding it with
both hands, in an agony of despair. These Commentaries are written to
prevent as far as possible such horrors; and they may be prevented by
efficient and well-appointed medical officers; but there must also be
greater attention to these points than has hitherto been given by the
government of the country.
Don Bernardino Garcia Alvarez, captain of the regiment of Laredo,
thirty years of age, was wounded at the battle of Toulouse by a
musket-ball, which passed through the thigh, a little above its middle.
The wound was not considered a dangerous one until the 30th, twenty
days after the injury, when a considerable bleeding took place; and
as the vessel from which it came seemed to be very deeply seated, the
Spanish surgeon in charge tied the common femoral artery. I saw the
gentleman in consequence of this having been done. The hemorrhage was
suppressed by the operation, and the limb soon recovered its natural
temperature, but gangrene made its appearance on the great toe on the
third day afterward. It did not seem to increase, but the limb swelled
as if nature were endeavoring to set up sufficient action to maintain
its life; and this continued until the tenth day after the operation,
when he died, completely exhausted. On the dissection of the limb, the
femoral artery was found to be perfectly sound in every part below
where the ligature had been applied. The vessel which bled could not be
discovered; but it was certainly a branch from the profunda, and not
the femoral itself. In this case the ligature of the femoral artery
destroyed the patient, and the practice pursued must be condemned.
The gunshot wound should have been largely dilated, at both orifices
if necessary, until the wounded vessel was discovered, which possibly
had not been completely divided by the ulcerative or sloughing process
which had taken place, and its division would in all probability have
suppressed the bleeding.
A young gentleman, aged twelve, accompanying his brothers shooting, in
December, 1844, was struck in the upper part of the left thigh by a
duck-shot, which entered about three inches below Poupart’s ligament,
a little to the inner side of the femoral artery. He bled until he
fainted, and was taken home. There was no return of the bleeding for
three days, during which time the limb was exceedingly painful, and
soon began to enlarge. After this occasional and considerable bleedings
took place, the limb still continuing to increase in size. Fomentations
and poultices were applied; irritative fever set in, and the pain was
intense. At the end of a fortnight the small hole made by the shot
appeared to be healed over by a thin skin of a blue color, which tint
extended for some distance. The limb was enormously swollen, with
a feeling of distention, which induced the surgeon to puncture the
most prominent part with a lancet. After some clots of blood had been
removed, an alarming arterial hemorrhage took place. The femoral artery
was now tied high up, below Poupart’s ligament. The bleeding was in
some measure restrained, but not suppressed, and after a short time
it returned at intervals with augmented violence, until death ensued,
three weeks after the accident.
_Remarks._--If an incision had been made into the thigh in the course
of the wound when the bleeding returned on the third day, and both ends
of the wounded artery had been tied, the boy would in all probability
have recovered. The ligature placed on the femoral artery above the
wound in it did restrain for a short time the flow of blood, but could
not prevent its flowing from perhaps both ends of the vessel, until
it destroyed the patient. A ligature on the external iliac would only
have caused it to be deferred for a day or two, until the collateral
branches had enlarged, or else he would have died of mortification.
This really formidable case shows most distinctly the necessity for
always observing the rule of tying the wounded artery at the part
injured, in order that the mistake may not be made of placing a
ligature on the wrong artery--the constriction of which may cost the
patient his life, while it may not prevent a return of the bleeding.
It also shows that no loss of blood from a diffused aneurism can equal
the danger which must be encountered, and the mistakes which may be
made, by not laying it open, and seeing the hole in the artery, or its
divided extremities.
Captain Seton, a short man, fat of his age, was wounded in a duel, in
1845, in the upper part of the right thigh, a little above and in front
of the great trochanter, the wound being continued across the thigh,
its internal opening being about the middle of the fold of the left or
opposite groin. He lost a great deal of blood at the time, the issue of
which ceased on his fainting. Ten days after the duel his countenance
was blanched, his pulse rather quick and feeble. On examining the
wounds, that on the right hip (the opening of entrance) was circular,
filled with a dry, depressed slough, and there was a narrow, faint
blush of redness round its margin. In the left groin the opening of
exit was marked by a jagged slit, already partly closed by a thin
cicatrix. There was extensive mottled purple discoloration (ecchymosis)
of the skin in both groins, and over the pubes, scrotum, and upper part
of the right thigh. In the right groin was found a large, oval, visibly
pulsating tumor, its long diameter extending transversely from about
an inch and a half on the inner side of the anterior superior spinous
process of the ilium to about opposite the linea alba, and its lower
margin projecting slightly over Poupart’s ligament into the upper and
inner part of the thigh. On handling this tumor, it appeared elastic
but firm, very slightly tender, and not capable of any perceptible
diminution in bulk by gradual and continued pressure. The pulsation was
distinct in all parts of the swelling, and was equally evident whether
the fingers were pressed directly backward, or whether they were placed
at its upper and lower margins, and pressed toward the base of the
tumor, in a direction transversely to its long axis, the parts being
for the time relaxed. The femoral artery was slightly covered by the
swelling, and the pulsations of that vessel were with some difficulty
distinguished in the upper third of the thigh, below the margin of the
tumor. This appeared to depend partly on the natural obesity of the
patient, and partly on a considerable degree of general swelling of
the thigh. Pressure on the femoral artery or over the abdominal aorta
did not arrest the pulsation in the tumor, and in the former situation
was attended with severe pain. Under these circumstances it was deemed
advisable to apply a ligature on the external iliac artery, and give
the patient a chance of the occurrence of coagulation in the tumor,
and closure of the wounded vessel, before the free re-establishment
of the circulation through the femoral artery. In the present case it
was supposed that mortification of the limb was all the less likely
to occur from the circumstance that the greater part of the effusion
appeared in front of the abdominal parietes, and therefore exercised
less pressure on the femoral vein than if further extension into the
thigh had taken place. The danger of peritonitis was by this proposal
made a new element in the calculation; but it was estimated that the
chances of this and of mortification of the limb, taken together,
were less unfavorable than the chances of immediate and secondary
hemorrhage attaching to the operation of tying the artery at the spot
injured. The operation being completed, the right foot, leg, and thigh
were enveloped in lamb’s-wool and flannel, and the limb elevated on
an inclined plane of pillows, so as to favor the return of blood as
much as possible, and prevent venous congestion. The day on which the
operation was performed was passed in considerable pain, the patient
being restless, and complaining of a sense of burning in the limb.
An anodyne, however, secured him a tolerably good night’s rest. The
day after the limb was found altogether diminished in bulk, and its
temperature equal to that of the healthy limb; no return of pulsation
had taken place in the tumor. The same evening some tenderness and
tension of the abdomen came on, though the bowels had been kept in a
regular state by occasional small doses of castor-oil. In the morning
of the second day, pain in the belly, with increased tension, hurried
breathing, short, dry cough, and tenderness over the lower part of the
abdomen, were observed. Pulse quicker and small. Leeches were applied,
and three-grain doses of calomel, with a little Dover’s powder, ordered
every three hours. The symptoms, however, became rapidly worse; the
patient complained of severe pain in the right leg, and a sensation of
great heat over the whole body, although the actual temperature was
rapidly falling below the natural standard. The right leg also became
cold sooner than the left. At seven P.M. he became more easy, and
expressed an opinion that he should “do well;” but in little more than
half an hour he expired.
_Examination after death._--Swelling and ecchymosis of the right
thigh, particularly at the upper part, and in the right iliac region;
also swelling and ecchymosis of the scrotum, chiefly in the right
side, with general tumefaction of the abdominal parietes below the
umbilicus. A wound into which the little finger could be passed was
on the upper and outer aspect of the right thigh, about three inches
below the crest of the ilium and about an inch nearer the mesial
line than the great trochanter, and on the left side another smaller
wound, situated about the external aperture of the left spermatic
canal. The first-mentioned wound was open; the lips of the latter
were partially adherent. The course of the wound was traced from the
outside through a dense layer of fat about two inches in thickness,
(on an average.) It had divided one of the superficial branches of the
femoral artery, about half an inch below Poupart’s ligament, and about
an inch from the main body of the femoral artery; this had caused a
false aneurism. The sac contained about three ounces of blood. Blood
was also effused into the cellular structure of the scrotum, and
downward beneath the sartorius muscle. The wound passed through the
cellular tissue, across the pubes, and emerged about the situation of
the left external spermatic ring, without having divided the cord on
either side, and was quite superficial to the bladder. No other artery
appeared to have been wounded. When the parietes of the abdomen were
reflected, a considerable quantity of sero-purulent fluid was found in
the abdominal cavity; and on different parts of the large and small
intestines patches of acute inflammation were observed, particularly
on the ascending arch of the colon. The peritoneum adjoining the wound
of the operation was inflamed, and approaching to gangrene: it had not
been injured by the knife during the operation. The intestines were
unusually large, and distended with flatus. The other abdominal viscera
were healthy, but loaded to an extraordinary degree with fat. The
ligature had been properly applied to the iliac artery; the vein was
not injured; the surface of the wound and the cellular tissue in the
neighborhood of the artery were sloughy. There was some enlargement of
the right limb, but apparently no mortification. The femoral artery was
pervious; the course of the wound was through a bed of fat, fourteen
inches in length, and three inches in depth, over the pubes, and no
muscular substance was injured; the blood found in the aneurismal sac
was firmly coagulated, and there was no mark of recent oozing from the
injured artery.
_Remarks._--If this gentleman had been wounded at the foot of the
breach in the wall of Ciudad Rodrigo, in January, he might, to his
great dissatisfaction, have been one of eleven officers whom I saw
lying dead, and as naked as they were born, on the face of the breach
of Badajos, in April. He would have been saved by _one_ doctor, or an
old woman, and a little cold water, in 1812, and did die of _seven_ in
1845, after an operation most brilliantly performed, but done in the
wrong place, even if any operation had been necessary, which it was
not. The case is an _experimentum crucis_ of principles.
The _first error_ committed in this case was in calling and believing
a wounded artery to be a circumscribed, false, or diffused traumatic
aneurism. Nothing can be called an aneurism, by which word a dilated
vessel or a diseased shut or closed sac is understood, which has one
or more holes in it, made by a ball, or by anything else, the wound or
track of which remains open. It is simply a case of wound in which an
artery has been divided or injured, and while this track of the ball
remains open, no ingenuity of argument can make it otherwise. When the
external openings made by the ball have closed, the case may then be
called, if there be a collection of blood, whether fluid or coagulated,
one of circumscribed, false, diffused traumatic aneurism, or anything
else that philologists may please to designate it. The dissection
report proved this case to be simply a small collection of blood, three
ounces and a half, or seven small tablespoonfuls--communicating with
two open wounds. Calling this an aneurism, or a shut sac of any kind,
was then the _first_ and fundamental error, as fatal as erroneous.
The _second_ error consisted in the belief, _contrary to all
experience_, that any sac or bag, or collection of blood by whatever
name it may be called, having two openings leading to, or into it, and
communicating with the atmosphere, could be augmented to any dangerous
extent by the further pouring out of blood from an artery of any size,
or from any artery at all, without some of such extravasated blood
being discharged or forced out through one or both of the open external
wounds in sufficient quantity to show that the opening in the vessel
was not closed.
The _first two errors_, or defects of principles, gave rise to the
_third_, viz.: the belief that an operation was necessary where
none was required, the dissection having proved that the whole
idea of the nature of the injury was a mistake: there was no large
artery wounded; the small one, which had been wounded, had ceased to
bleed; the quantity of blood extravasated did not exceed seven small
tablespoonfuls. The third mistake could not have taken place if the
first two errors had not been committed.
The _fourth_ error occurred from its being taken for granted that the
femoral artery was wounded; and that ascertaining the fact by opening
the small swelling which contained only three and a half ounces of
blood, would be followed by a fatal hemorrhage; which supposition arose
from this swelling receiving a pulsatory motion from its vicinity to
the femoral artery--a mistake which should not have occurred; for it
had long before been said, (page 16 of my published lectures:) “The
motion or pulsation of the swelling often depends on the impulse given
to the whole as a mass, by the great artery against which it is lying,
and not upon blood circulating through it. When blood is extravasated
by the rupture of small vessels in consequence of the passage of a
wheel over the limb--especially in the thigh, where I have seen a
swelling containing fluid blood pulsate in an almost alarming manner,
until it gradually diminished as the blood coagulated, when the motion
became a mere elevation at each stroke of the heart--the _whizzing
sound or thrill_ attendant on a ruptured artery (of a size to require
a ligature being understood) is in these cases wanting, constituting a
very distinguishing mark of this accident.”
Surgeons fifty years ago were afraid of hemorrhage from the femoral
artery, but the practice of the Peninsular war dissipated such fears.
The reason given for not laying open the wound, and looking at the
bleeding artery, in this case, is ingenious, but not tenable. The
patient is said to have lost a large quantity of blood; and if this
were even a fact, which may, however, be doubted, is there a case on
record of a serious wound of the femoral artery, such as this was
supposed to have been, in which that vessel has been successfully
secured by ligature, without the patient having equally lost so large a
quantity of blood as to be supposed to be about to die? _It has always
been so_; the reason, however specious, is not valid, and cannot be
admitted.
The _fifth_ error arose from imagining that the considerable loss of
blood supposed to have taken place would have rendered the patient
incapable of bearing more; for it is a recorded fact that those
operations high up on the femoral artery, from which patients have
recovered, have never been done without great losses of blood having
been previously sustained; and if the patient was so weakened that his
heart and arteries could not bear the abstraction from their contents
of a few ounces more blood--supposing such loss to be inevitable--how
could they have power to drive or force the blood through the limb by
the collateral channels, in a manner sufficient to support its life,
when the main trunk was cut off within the pelvis? _They could not do
it_--_they have rarely done it_ under such circumstance; they could not
have done it in this case; and if the patient had not died within the
first forty hours of inflammation of the peritoneum, to which accident
he ought not to have been exposed, he would have died of mortification
within forty hours more, which had already commenced, as shown by the
swelling of the limb and pain in the calf of the leg, which almost
invariably attend such mortification.
The _sixth_ error consisted in the belief that if the femoral artery
had been wounded, a ligature on the external iliac would have
permanently arrested the bleeding. It would, in all probability,
have done no such thing, beyond a day or two--perhaps even only for
the moment. It is a delusion, persisted in notwithstanding the most
clear and positive proofs to the contrary. The patient will die of
mortification from the want of blood in the limb, if the circulation be
not re-established; and if this should take place, blood must find its
way into the lower end of the wounded artery, and perhaps even into the
upper, and renew the hemorrhage.
If the femoral artery had been _wounded_, as was supposed in this case,
but not completely _divided_, it _must_ and _would_ have continued to
bleed through the external wound, until the patient died, or a ligature
had been placed upon it. It has been said that, in the case as it
actually occurred, the little artery, which was divided and which had
not bled for some days, could not have been safely tied, if it had bled
again, because it was only an inch long; but this is said in defiance
of every sort of proof which has been given to the contrary.
As far back as 1815 I said: “There was no foundation for the theory
which declared that a ligature when placed on an artery such as the
femoral would fail, if in the immediate vicinity of a collateral
branch, in consequence of the flow of blood through this vessel
preventing the obstruction and consolidation of the main branch for a
distance sufficient to enable it to resist the impulse of the blood
behind.” This was said from pure practical facts, free from all kinds
of theory; and the preparation before alluded to, in the museum of the
College of Surgeons, in which I tied the common iliac artery, will show
the mark of a simple thread around it, and a single line of adhesion
resisting the whole power of the heart, the canal above the spot not
being obliterated.
The _seventh_ error committed in this case was in contravening the
great surgical precept, formed on no inconsiderable experience during
the early part of the war in the Peninsula, “_not to perform an
operation on an artery until it bleed_.”
194. When a wound occurs in the thigh, implicating the femoral artery
or its branches, and the bleeding cannot be _restrained_ by a moderate
but regulated compression on the trunk of the vessel, and perhaps on
the injured part, recourse should be had to an operation, by which
both ends of the wounded artery may be secured by ligature; and the
_impracticability_ of doing this should be ascertained only by the
failure of the attempt. If the lower end of the artery cannot be
found at the time, the upper only having bled, a gentle compression
maintained upon the track of the lower may prevent mischief; but if
dark-colored blood should flow from the wound, which may be expected to
come from the lower end of the artery, and compression does not suffice
to suppress the hemorrhage, the bleeding end of the vessel must be
exposed, and secured near to its extremity.
The instruments which have been invented for the cure of aneurism,
by compressing the main trunk of the artery, will be found eminently
useful, if applied with care, in many cases of hemorrhage in which it
may be doubtful what vessel is actually injured, as in the case of
Wilson, page 215, and in cases also of wounds of the hand or foot in
which bleeding occurs through the medium of collateral branches. These
instruments, although they cannot conveniently be placed in the capital
cases of instruments, should be in store, whether with divisional or
general hospitals.