A private of the 5th division of infantry received a wound at the
battle of Salamanca from a musket-ball, which passed across the back
part of the right leg, from above downward and inward. It entered
about two inches below and behind the head of the fibula, and passed
out near the inner edge of the tibia. There was little blood lost at
the time, and it was considered to be a simple wound; eight days after
the injury, some blood flowed with the discharge; this increased during
the night, and, on examining the limb on the morning of the ninth day,
it was evidently injected with blood, which flowed of a scarlet color
from both orifices. It being doubtful which vessel was wounded--whether
it was the trunk of the popliteal artery, or the posterior tibial
or peroneal after its division into these branches--it was thought
advisable to place a ligature on the femoral artery about the middle
of the thigh, which suppressed the hemorrhage. The case was now shown
to me, as one in proof of the incorrectness of the opinion I had a few
days before stated, of the impropriety of such an operation being done.
The seeming success did not long continue; hemorrhage again took place
from the original wound, and the limb was then amputated. The posterior
tibial artery had been injured, and had sloughed. The man died.
_Remarks._--A straight incision, directly through the back of the calf
of the leg, of six inches in length, and two ligatures on the wounded
artery, would have saved this man’s leg and life.
Henry Vigarelie, a private in the German legion, was wounded on the
18th of June, at the battle of Waterloo, by a musket-ball, which
entered the right leg immediately behind and below the inner head
of the tibia, inclining downward, and under or before a part of the
soleus and gastrocnemius muscles, and coming out through them, four
inches and three-quarters below the head of the fibula, nearly in the
middle, but toward the side of the calf of the leg. In this course
it was evident that the ball must have passed close to the posterior
tibial and peroneal arteries; but, as little inflammation followed, and
no immediate hemorrhage, it was considered to be one of the slighter
cases. On the latter days of June he occasionally lost a little blood
from the wound, and on the 1st of July a considerable hemorrhage took
place, which was suppressed by the tourniquet, and did not immediately
recur on its removal. It bled, however, at intervals, during the
night; and on the morning of the 2d it became necessary to reapply the
tourniquet, and to adopt some means for his permanent relief.
The man had lost a large quantity of blood from the whole of the
bleedings; his pulse was 110, the skin hot, tongue furred, with great
anxiety of countenance: the limb was swollen from the application of
the tourniquet from time to time, a quantity of coagulated blood had
forced itself under the soleus in the course of the muscles, increasing
the size of the leg, and florid blood issued from both openings on
taking the compression off the femoral artery. On passing the finger
into the outer opening, and pressing it against the fibula, a sort of
aneurismal tumor could be felt under it, and the hemorrhage ceased,
indicating that the peroneal artery was in all probability the vessel
wounded.
In this case there was, in addition to the wound of the artery, a
quantity of blood between the muscles, which in gunshot wounds,
accompanied by inflammation, is always a dangerous occurrence, as
it terminates in profuse suppuration of the containing parts, and
frequently in gangrene. Its evacuation therefore became an important
consideration, even if the hemorrhage had ceased spontaneously.
The leg having been condemned for amputation above the knee, the
officers in charge were pleased to place the man at my disposal: and
being laid on his face, with the calf of the leg uppermost, I made an
incision about seven inches in length in the axis of the limb, taking
the shot-hole nearly as a central point, and carried it by successive
strokes through the gastrocnemius and soleus muscles down to the deep
fascia, when I endeavored to discover the bleeding artery; but this was
more difficult than might be supposed, after such an opening had been
made. The parts were not easily separated, from the inflammation that
had taken place; and those in the immediate track of the ball were in
the different stages from sphacelus to a state of health, as the ball
in its course had produced its effect upon them, or their powers of
life were equal or unequal to the injury sustained.
The sloughing matter mixed with coagulated blood readily yielded to the
back of the knife, but was not easily dissected out. The spot which
the arterial blood came from was distinguished through it, but the
artery could not be perceived, the swelling and the depth of the wound
rendering any operation on it difficult. To obviate this inconvenience,
I made a transverse incision outward, from the shot-hole to the edge
of the fibula, which enabled me to turn back two little flaps, and
gave greater facility in the use of the instruments employed. I could
now pass a tenaculum under the spot whence the blood came, which I
raised a little with it, but could not distinctly see the wounded
artery in the altered state of parts, so as to secure it separately.
I therefore passed a small needle, bearing two threads, a sufficient
distance above the tenaculum to induce me to believe it was in sound
parts, but including very little in the ligature, when the hemorrhage
ceased; another was passed in the same manner below, and the tenaculum
withdrawn. The coagula under the muscles were removed, the cavity
washed out by a stream of warm water injected through the external
opening, the wound gently drawn together by two or three straps of
adhesive plaster, and the limb enveloped in cloths constantly wetted
with cold water. The patient was placed on milk diet.
On the 4th, two days after the operation, the wound was dressed, and
looked very well; the weather being very hot, two straps of plaster
only were applied to prevent the parts separating. On the 5th a
poultice was laid over the dressings, in lieu of the cold water, the
stiffness becoming disagreeable. On the 6th, as the wound, although
open in all its extent, did not appear likely to separate more, the
plasters were omitted, and a poultice alone applied. On the 8th and
9th it suppurated kindly; and on the 10th, or eight days from the
operation, the ligatures came away, the limb being free from tension,
and the patient in an amended state of health, his medical treatment
having been steadily attended to.
The man was brought to England, to the York Hospital at Chelsea, and
walked about without appearing lame, although he could not do so for
any great distance. He suffered no pain, except an occasional cramp
in the ball of the foot, and some contraction of the toes, which took
place generally when he rose in a morning, and continued for a minute
or two, until he put them straight with his hand; this I did not
attribute to the operation, but to some additional injury done to the
nerves by the ball in its course through the leg.
This case, which has been followed by many others equally successful,
even after the femoral artery had been ineffectually tied, established
the practice now followed in England by all educated surgeons; and
is another of those great additions to surgery for which science is
indebted to the Peninsular war.
198. It may be permitted to repeat, that if an artery such as the
axillary be laid bare previously to an operation for amputation at the
shoulder, and the surgeon take it between his finger and thumb, he will
find that the slightest possible pressure will be sufficient to stop
the current of blood through it. Retaining the same degree of pressure
on the vessel, he may cut it across below his finger and thumb, and
not one drop of blood will flow. If the artery be fairly divided by
the last incision which separates the arm from the body, without any
pressure being made upon it, it will propel its blood with a force
which is more apparent than real. All that is required to suppress this
usually alarming gush of blood is to place the end of the forefinger
directly against the orifice of the artery, and with the least possible
degree of pressure consistent with keeping it steadily in one position
the hemorrhage will be suppressed. It is more important to know that if
the orifice of the artery, from a natural curve in the vessel, or from
other accidental causes, happen at the same time to retract and to turn
a little to one side, so as to be in close contact with the side or end
of a muscle, the very support of contact will sometimes be sufficiently
auxiliary to prevent its bleeding.
In amputation at the hip-joint, the femoral and profunda arteries
are frequently divided at or just below the origin of the latter,
and bleed furiously if disregarded; but the slightest compression
between the finger and thumb stops both at once. They never have given
me the smallest concern in these operations, or others of a similar
nature; and surgeons should learn to hold all arteries that can be
taken between the finger and thumb in great contempt. It is quite
impossible for a man to be a good surgeon--to do his patient justice
in great and difficult operations attended by hemorrhage, unless he
has this feeling--unless his mind is fully satisfied of the truth
of these observations. While his attention ought to be directed to
other important circumstances, it is perhaps absorbed by the dread
of bleeding, by the idle fear that he will not be able to compress
the artery and restrain the bleeding from it--that he may have half
a dozen vessels bleeding at once--that his patient will die on the
table before him. Once fairly in dismay, and the patient is really
in danger; but, endowed with that confidence which is only to be
acquired through precept supported by experience, he surveys the scene
with perfect calmness: taking the great artery between the finger and
thumb of one hand, he places the points of all the other fingers, of
both hands if necessary, on the next largest vessels; or he presses
the flaps or sides of the wound together until his other hand can be
set at liberty by an assistant, or in consequence of a ligature having
been passed around the principal artery. This is a scene sufficient
to try the presence of mind of any man; but he is not a good surgeon
who is not equal to it--who does not delight in the recollection of
it when his patient is in safety, and his recovery assured. It was in
consequence of what was then considered the too great boldness of the
practice that my old friend, Sir Charles Bell, whose loss to science
cannot be too much regretted, represented me seated on a pack saddle
on the back of a bourro, (_Anglice_, a jack-ass,) on the top of the
Pyrenees, expatiating on their merits (which he did not believe) to the
descendants of the Bearnois of Henri Quatre on one side, and to the
children of the lieges of Ferdinand and Isabella on the other; but no
one now disputes their accuracy. The surgery of the Peninsular war was
many years in advance of the surgery of civil life.
199. The principles laid down for the treatment of wounded arteries in
the _lower_ extremity are equally to be observed with respect to those
of the _upper_. There is, however, little or no fear of mortification
taking place in the upper extremity, the collateral circulation being
more direct and free; while there is greater danger from this cause of
hemorrhage from the lower end of the artery, if a ligature should not
have been placed upon it, or if it should not be retained a sufficient
length of time.
200. The error of placing a ligature on the subclavian artery above
the clavicle, for a wound of the axillary below it, should never be
committed. One person dies for one who lives after this operation, when
performed under favorable circumstances, independently of the loss
which may be sustained by a recurrence of bleeding from the original
wound, which is always to be expected and ought to take place; when
it does not happen, it is the effect of accident, which accident in
all probability occurs from the state of _absolute rest_ having been
carefully observed.
201. The necessity for an aneurismal sac below the clavicle, and
for its remaining and continuing to remain intact, until the cure is
completed, when the subclavian artery has been tied above, is rendered
unmistakable by the following case:--
Ambrose C. was admitted into the Charing Cross Hospital, in August,
1848, in consequence of a bruise from a sack of beans; there was
axillary aneurism, extending under the pectoral muscle up to the
clavicle. A ligature was applied in the usual situation on the
outside of the scalenus muscle, and came away on the twenty-second
day. The aneurismal sac suppurated, and burst three days afterward,
when a quantity of pus and blood, partly fluid, partly coagulated,
but very offensive, was discharged. The opening was enlarged, and
everything appeared to be going on well, at which time I saw him. On
the nineteenth day after the ligature came away, I visited him again
with Mr. Hancock, and merely observed that he must keep himself very
quiet, and I thought he would do well. In the evening he died from
hemorrhage, while eating some gruel. On examination after death, the
artery was found to be sound, except where it communicated with the
sac by an opening three-quarters of an inch in length. The ligature
had been applied midway between the thyroid axis and the first of the
thoracic branches. There was a small coagulum, of half an inch in
length, both internal and external to the ligature, _but not extending
to the branch above or below it_. The artery was of its natural size as
far as the remains of the sac, but beyond it the axillary artery was
diminished; the remains of the sac were void of coagulum, except where
it communicated with the artery, to which opening a small coagulum
had adhered, but had given way at its lower part, and thus caused his
death. _Between the opening and the ligature_, five large branches
entered into or were given off by the artery, and through some of these
blood was brought round by the collateral branches in an almost direct
manner, so that the man’s life depended on the resistance offered by
the small coagulum after the sac had given way; proving in an exemplary
manner the value of the sac remaining entire.
If this case will not convince the incredulous, it would be useless to
bring even the sufferers in such cases from their graves, to affirm the
fact of the inapplicability of the theory of aneurism to the treatment
of a wounded artery--of the impropriety of placing a ligature on the
subclavian artery above the clavicle, for a wound of the artery below
it.
Corporal W. Robinson, 48th Regiment, was wounded at the battle of
Toulouse, by a piece of shell, which rendered amputation of the right
leg immediately necessary, and so injured the right arm as to cause
its loss close to the shoulder-joint eighteen days afterward. At the
end of a month the ligatures had separated, and the wound was nearly
healed, although a small abscess had formed on the inside, near where
the upper part of the tendon of the pectoralis major had been separated
from the bone. Sent to Plymouth, this little abscess formed again, and
was opened on the 2d of August, three months after the amputation.
The next day blood flowed so impetuously from it as to induce the
surgeon to make an incision, and seek for the bleeding vessel, which
could not be found. The late Staff-Surgeon Dease, warned by the case
of Sergeant Lillie, (page 198,) strongly objected to the subclavian
artery being tied above the clavicle, and, true to the principle
inculcated at Toulouse, advised the application of a ligature below
the clavicle on a sound part of the artery, but as near as possible to
that which was diseased. The operation was done by the senior officer,
Mr. Dowling, who carried an incision from the clavicle downward through
the integuments and great pectoral muscle, until the pectoralis minor
was exposed. This was then divided, and a ligature placed beneath it
on the artery where it was sound, at a short distance from the face of
the stump, where it was diseased. The man recovered without further
inconvenience.
202. In all those cases in which it has been supposed necessary to
place a ligature on the artery above the clavicle, after a _failure_
in the attempt to find the artery below it, the failure has occurred
from _the error committed_ in not dividing the integuments and great
pectoral muscle _directly across_ from the lower edge of the clavicle
downward. It is quite useless dividing these parts in the course of
the fibers of the muscle, and the case of Robinson is the model on
which all such operations should be done. If this operation had not
succeeded, the ligature of the artery above the clavicle was a further
resource; but as the artery was sound below, with the exception of the
end engaged in the face of the stump, the operation was successful;
no doubt should be entertained in such cases of the propriety of an
operation which is attended with little risk, compared with that which
destroys one man for every one it saves.
203. Punctured wounds of the arteries of the arm and forearm ought to
be treated by pressure applied especially to the part injured, and
to the limb generally; but when the bleeding cannot be restrained in
this manner, in consequence of the extent of the external wound, the
bleeding artery is to be exposed, and a ligature applied above, and
another below the part injured, whether the artery be radial, ulnar, or
interosseal.
204. When the external wound closes under pressure, and blood is
extravasated in such quantity under the fascia and between the muscular
structures as is not likely to be removed by absorption under general
pressure, the wounded artery should be laid bare by incision and
secured in a similar manner, even at the expense of any muscular fiber
which may intervene.
205. When an aneurismal tumor forms _some time_ after such an accident,
in the upper part of the forearm in particular, the application of
a ligature on the brachial artery is admissible, on the Hunterian
principle.
206. When the ulnar artery is wounded in the hand, which is
comparatively a superficial vessel, two ligatures should be placed upon
it in the manner hereafter to be directed. When the opening is small,
pressure may be tried.
207. When the radial artery is wounded in the hand, in which situation
it is deep seated, the case requires greater consideration. When there
is a large open wound, and the bleeding end or ends of the artery can
be seen, a ligature should be placed on each; but this cannot always be
done without more extensive incisions than the tendinous and nervous
parts will justify.
208. When search has been made by incisions through the fascia, (as
extensively as the situation of the tendons and nerves in the hand
will permit,) which are best effected by introducing a bent director
under it, the current of blood, through either the ulnar or the
radial artery at the wrist, or even through both, should be arrested
in turn by pressure, which in most cases of this kind will succeed,
if properly applied, and thus show the vessel injured. The bleeding
point should be fully exposed, and all coagula removed, when a piece
of lint, rolled tight and hard, but of a size only sufficient to cover
the bleeding point, should be laid upon it. A second and larger hard
piece should then be placed over it, and so on, until the compresses
rise so much above the level of the wound as to allow the pressure to
be continued and retained on the proper spot, without including the
neighboring parts. A piece of linen, kept constantly wet and cold,
should be applied over the sides of the wound, which should not be
closed so as to allow of any blood being freely evacuated; and if the
back of the hand be then laid on a padded splint, broader than the
hand, a narrow roller may be so applied as to retain the compresses
in their proper situation, without making compression on or impeding
the swelling of the adjacent parts, the fingers being bent, in order
to relax the palmar aponeurosis--a proceeding which should never be
neglected in any operation in the palm of the hand. It has been lately
proposed by M. Thierry, a French surgeon, to raise and bend the arm,
as a means of impeding the circulation where the artery passes over
the elbow-joint, and the proposal deserves adoption, but not to the
extent he recommends, which cannot be long submitted to. Pressure made
at the same time on the radial or ulnar artery, or on both, by a piece
of hard wood two inches long, shaped like a flattened pencil, is much
more effectual, and more to be depended upon. When from the bones
being broken, or the hand so swollen, or from other circumstances,
pressure, however lightly and carefully applied, cannot be borne in
the manner directed, and the attempts to secure the artery at the
bleeding spot have failed, and pressure on the radial or ulnar artery
has been equally unsuccessful, in consequence of the swelling or other
circumstances, both may be tied at the wrist in preference to placing
a ligature on the brachial artery, although that even must be done as
a last resource, if the bleeding should still continue. If it be asked
why not do this in the first, rather than in the last instance, the
answer is, that it has so often failed to prevent a renewal of the
bleeding from both ends of a wounded artery in the hand, that complete
dependence cannot be placed upon it, particularly if there should be
a division high in the arm of the brachial into the radial and ulnar
arteries. When, however, the arteries leading to the wound have been
secured, either by pressure or ligature, NEAR to the part, and the
bleeding returns by the collateral circulation, which in the hand is so
free, the arresting the supply of blood through the main trunk may and
often has suppressed the hemorrhage, at all events for a sufficient
time to enable the injured parts to recover themselves, provided the
forearm is bent and raised, and the person kept at _rest_ in the most
restricted manner, without which this operation will in all probability
fail. It is in these cases that the instrument alluded to, page 226,
will be useful, rendering the ligature on the trunk of the vessel
unnecessary, more particularly if the bleeding should appear to depend
on some peculiarity in the structure of the coats of the artery.
209. When the obstacle to the application of pressure arises from the
injured state of the metacarpal bone or bones, one or more should be
removed, with the fingers if necessary, so as to expose a clear and
new surface, on which the bleeding vessels may be seen and secured.
In some cases, particularly if there should be a hemorrhagic tendency
in the arterial system generally, as known from previous accidents,
the first compress may be wetted with the perchloride of iron, the
ol. terebinth., the dilute sulphuric acid, or the tincture of matico;
these remedies may be also administered internally. Some new styptics
have lately been much lauded in Malta and other places, but sufficient
proofs have not been given of their efficiency.
210. When the radial artery is wounded as it turns from the back to
the inside of the hand, to form the deep-seated palmar arch, it meets
a branch of the ulnar nerve about to terminate in the muscles of the
thumb. If the treatment by pressure above recommended should not
succeed, the muscles forming what is called the web, between the thumb
and metacarpal bone of the forefinger, should be cut through, and the
bleeding vessel exposed. They are the adductor pollicis on the inside,
and the abductor indicis on back of the hand.