Part 22

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.