Part 20
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.
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.