Part 21

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.

LECTURE XI.

THE FEMORAL ARTERY, ETC.

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.