Part 23
The _first error_ committed in this case was in calling and believing a wounded artery to be a circumscribed, false, or diffused traumatic aneurism. Nothing can be called an aneurism, by which word a dilated vessel or a diseased shut or closed sac is understood, which has one or more holes in it, made by a ball, or by anything else, the wound or track of which remains open. It is simply a case of wound in which an artery has been divided or injured, and while this track of the ball remains open, no ingenuity of argument can make it otherwise. When the external openings made by the ball have closed, the case may then be called, if there be a collection of blood, whether fluid or coagulated, one of circumscribed, false, diffused traumatic aneurism, or anything else that philologists may please to designate it. The dissection report proved this case to be simply a small collection of blood, three ounces and a half, or seven small tablespoonfuls--communicating with two open wounds. Calling this an aneurism, or a shut sac of any kind, was then the _first_ and fundamental error, as fatal as erroneous.
The _second_ error consisted in the belief, _contrary to all experience_, that any sac or bag, or collection of blood by whatever name it may be called, having two openings leading to, or into it, and communicating with the atmosphere, could be augmented to any dangerous extent by the further pouring out of blood from an artery of any size, or from any artery at all, without some of such extravasated blood being discharged or forced out through one or both of the open external wounds in sufficient quantity to show that the opening in the vessel was not closed.
The _first two errors_, or defects of principles, gave rise to the _third_, viz.: the belief that an operation was necessary where none was required, the dissection having proved that the whole idea of the nature of the injury was a mistake: there was no large artery wounded; the small one, which had been wounded, had ceased to bleed; the quantity of blood extravasated did not exceed seven small tablespoonfuls. The third mistake could not have taken place if the first two errors had not been committed.
The _fourth_ error occurred from its being taken for granted that the femoral artery was wounded; and that ascertaining the fact by opening the small swelling which contained only three and a half ounces of blood, would be followed by a fatal hemorrhage; which supposition arose from this swelling receiving a pulsatory motion from its vicinity to the femoral artery--a mistake which should not have occurred; for it had long before been said, (page 16 of my published lectures:) “The motion or pulsation of the swelling often depends on the impulse given to the whole as a mass, by the great artery against which it is lying, and not upon blood circulating through it. When blood is extravasated by the rupture of small vessels in consequence of the passage of a wheel over the limb--especially in the thigh, where I have seen a swelling containing fluid blood pulsate in an almost alarming manner, until it gradually diminished as the blood coagulated, when the motion became a mere elevation at each stroke of the heart--the _whizzing sound or thrill_ attendant on a ruptured artery (of a size to require a ligature being understood) is in these cases wanting, constituting a very distinguishing mark of this accident.”
Surgeons fifty years ago were afraid of hemorrhage from the femoral artery, but the practice of the Peninsular war dissipated such fears. The reason given for not laying open the wound, and looking at the bleeding artery, in this case, is ingenious, but not tenable. The patient is said to have lost a large quantity of blood; and if this were even a fact, which may, however, be doubted, is there a case on record of a serious wound of the femoral artery, such as this was supposed to have been, in which that vessel has been successfully secured by ligature, without the patient having equally lost so large a quantity of blood as to be supposed to be about to die? _It has always been so_; the reason, however specious, is not valid, and cannot be admitted.
The _fifth_ error arose from imagining that the considerable loss of blood supposed to have taken place would have rendered the patient incapable of bearing more; for it is a recorded fact that those operations high up on the femoral artery, from which patients have recovered, have never been done without great losses of blood having been previously sustained; and if the patient was so weakened that his heart and arteries could not bear the abstraction from their contents of a few ounces more blood--supposing such loss to be inevitable--how could they have power to drive or force the blood through the limb by the collateral channels, in a manner sufficient to support its life, when the main trunk was cut off within the pelvis? _They could not do it_--_they have rarely done it_ under such circumstance; they could not have done it in this case; and if the patient had not died within the first forty hours of inflammation of the peritoneum, to which accident he ought not to have been exposed, he would have died of mortification within forty hours more, which had already commenced, as shown by the swelling of the limb and pain in the calf of the leg, which almost invariably attend such mortification.
The _sixth_ error consisted in the belief that if the femoral artery had been wounded, a ligature on the external iliac would have permanently arrested the bleeding. It would, in all probability, have done no such thing, beyond a day or two--perhaps even only for the moment. It is a delusion, persisted in notwithstanding the most clear and positive proofs to the contrary. The patient will die of mortification from the want of blood in the limb, if the circulation be not re-established; and if this should take place, blood must find its way into the lower end of the wounded artery, and perhaps even into the upper, and renew the hemorrhage.
If the femoral artery had been _wounded_, as was supposed in this case, but not completely _divided_, it _must_ and _would_ have continued to bleed through the external wound, until the patient died, or a ligature had been placed upon it. It has been said that, in the case as it actually occurred, the little artery, which was divided and which had not bled for some days, could not have been safely tied, if it had bled again, because it was only an inch long; but this is said in defiance of every sort of proof which has been given to the contrary.
As far back as 1815 I said: “There was no foundation for the theory which declared that a ligature when placed on an artery such as the femoral would fail, if in the immediate vicinity of a collateral branch, in consequence of the flow of blood through this vessel preventing the obstruction and consolidation of the main branch for a distance sufficient to enable it to resist the impulse of the blood behind.” This was said from pure practical facts, free from all kinds of theory; and the preparation before alluded to, in the museum of the College of Surgeons, in which I tied the common iliac artery, will show the mark of a simple thread around it, and a single line of adhesion resisting the whole power of the heart, the canal above the spot not being obliterated.
The _seventh_ error committed in this case was in contravening the great surgical precept, formed on no inconsiderable experience during the early part of the war in the Peninsula, “_not to perform an operation on an artery until it bleed_.”
194. When a wound occurs in the thigh, implicating the femoral artery or its branches, and the bleeding cannot be _restrained_ by a moderate but regulated compression on the trunk of the vessel, and perhaps on the injured part, recourse should be had to an operation, by which both ends of the wounded artery may be secured by ligature; and the _impracticability_ of doing this should be ascertained only by the failure of the attempt. If the lower end of the artery cannot be found at the time, the upper only having bled, a gentle compression maintained upon the track of the lower may prevent mischief; but if dark-colored blood should flow from the wound, which may be expected to come from the lower end of the artery, and compression does not suffice to suppress the hemorrhage, the bleeding end of the vessel must be exposed, and secured near to its extremity.
The instruments which have been invented for the cure of aneurism, by compressing the main trunk of the artery, will be found eminently useful, if applied with care, in many cases of hemorrhage in which it may be doubtful what vessel is actually injured, as in the case of Wilson, page 215, and in cases also of wounds of the hand or foot in which bleeding occurs through the medium of collateral branches. These instruments, although they cannot conveniently be placed in the capital cases of instruments, should be in store, whether with divisional or general hospitals.
LECTURE XII.
MORTIFICATION, ETC.
195. The gangrene, mortification, or sphacelus, consequent on a wound of the main artery of the lower extremity, is, in the first instance, _local_ and _dry_, unless putrefaction be induced by heat. (See _Aphorism_ 28.) The following case is a good example of this and of all the other points laid down as principles or facts:--
A gentleman received an injury in the upper part of the left thigh, parallel to but a little below Poupart’s ligament, from the shaft of a van. The late Messrs. Heaviside, Howship, and Chevalier were sent for immediately, and my attendance was desired next day. I called the attention of these gentlemen to the _tallowy-white_ and _mottled_ appearance of the foot and lower part of the leg, and assured them that the femoral artery was injured, and the femoral vein in all probability also, from the rapid appearance of the first signs of dry gangrene. In this they would not believe, until the shrinking and drying of the foot and leg became obvious, the course of the tendons on the instep and toes being marked by so many dark-red lines under the drying skin above them. The amputation I recommended below the knee they would not hear of, although they reluctantly admitted the fact of the mortification. On the eighteenth day after the accident, blood flowed from the wound in quantity, of a dark-venous color. This bleeding I pronounced to be from the lower end of the artery. My three friends, in whose hands the case was, could not understand this, and placed a ligature on the external iliac artery, which did not arrest the bleeding. They now, although too late, saw their error, and desired me to do what I pleased, and a ligature secured the lower end of the artery from which the blood flowed. The man died exhausted a few days afterward.
This is a remarkable case, deserving the most serious attention. According to the principle laid down at first as a general rule, the thigh should have been amputated at the seat of injury the morning after the accident, when the signs of mortification of the foot were obvious. But it must be borne in mind that amputations at the trochanter major or hip-joint are most formidable and not generally successful operations; in consequence of which I have recommended another course, deserving, in such cases, of the most deliberate consideration and trial. (See _Aphorism_ 29.) The leg should have been amputated immediately below the knee, as I had ordered it to be done in the case of Turnbull, (page 202,) because that is the part in all such cases at which nature seems capable of arresting the progress of the mortification, if the constitution and powers of the sufferer are good, and equal to the calls upon them. The impairing, the destructive influence a mortified leg exerts on the whole system is removed, and an amputation substituted for it of comparatively little moment. When the hemorrhage took place, the lower end of the artery should have been tied. The upper end never bled, and the ligature on the iliac artery was useless. In this case, it is probable, as the vein was also injured, that the life of the part at and above the knee might not have been preserved, and the patient would have died.
In a case of the kind in which the artery was wounded at the _lower_ part of the thigh instead of the _upper_, amputation at or just below the wound may be the proper course; this amputation, although dangerous, being much less so than one at the upper part of the thigh or hip-joint. Nevertheless, amputation should not be had recourse to unless the extension of the mortification is beyond a doubt.
196. In Aphorism 29, it is strongly recommended not to amputate a thigh when mortification has stopped just below the knee, and a line of separation has been formed between the dead and the living parts--an opinion formed on a principle laid down in opposition to those usually received by the profession at large, and which have been entertained from the fact that amputations done under these circumstances are commonly fatal.
Richard Cook, aged fifty, a mason, while sitting on a square block of stone, on the 23d of February, was struck by another, which drove the popliteal space or ham against the edge of the block on which he sat, causing him great pain, and otherwise greatly bruising the leg, although no bones were fractured, nor was the skin torn. The limb, on his admission into the Westminster Hospital half an hour afterward, was much larger than the other, and of a dark reddish-blue color, evidently from the bruise or extravasation of blood, which appeared to be still issuing from the vessel or vessels, as the limb continued to increase in size, until it became at last greatly swollen. The pulsation of neither the anterior nor the posterior tibial artery could be distinguished through the swelling the next morning. The bowels were opened, and a cold spirit lotion was applied to the calf and around the leg, and the swelling somewhat subsided, the limb becoming quite a blue-black, which, with the tenseness of the parts, distinctly indicated the effusion of a large quantity of blood. It was soon obvious that greater mischief had occurred than had been expected; and on the 2d of March, as vesications, filled with a bloody fluid, were formed on the outside of the leg, over the fibula, and the whole limb was manifestly about to pass into a state of gangrene, if it had not already done so, I prepared everything for tying the popliteal or other arteries, if found necessary, and made a long and deep incision on the outer and back part of the leg, through the integuments and muscles posterior to the fibula, and removed a considerable quantity of coagulated blood from between the muscles and from a large cavity which extended upward into the ham, without causing further hemorrhage; in no part of that cavity could an artery be felt. The patient’s countenance and body had assumed a jaundiced hue; the pulse was very quick; the tongue foul; the countenance sunken; the skin hot; the head wandering. Poultices of linseed-meal and stale beer were applied, with gentle, stimulating applications. Brandy and wine were ordered in proper quantities every hour or two, with sufficient doses of the muriate of morphia at night to allay irritation and induce sleep. The incision, together with these remedies, gave great relief, and on the 7th the man seemed to have been saved from a state of the most imminent danger. On the 8th the pulse was 112, the tongue clean, the skin of a whiter color, the bowels opened by injections; eight ounces of brandy were given in the twenty-four hours; wine, with sago, arrow-root, jelly, oranges, and anything he chose to ask for. The greatest cleanliness was observed, and the chloride of lime was used in profusion all around him. The mortification of the limb was complete; a line of separation formed about four inches below the knee in front, and extended behind toward the ham. On the 26th, the dead parts having almost entirely separated from the bones all round, those which remained were cut through where dead, the bones were sawn about five inches below the knee, and the lower part of the limb removed, leaving an irregular, and, in part, a granulating stump, with an inch of bone projecting from it. On the 24th of May this portion was found to be loose; diluted nitric acid had been applied to its surface, and on the 20th of June it separated. On the 16th of August Cook left the hospital in good health, with a very good stump, having cost the hospital £57 in extra diet. In this case, there can be little doubt of the popliteal artery having been torn; and if the incision made on the 2d had been had recourse to during the first two or three days, and the artery sought for, and secured if found bleeding, it is possible the mortification might have been prevented; although it is probable, from the pressure arising from the great extravasation and coagulation of blood, that the collateral circulation was so much impeded as not to have been able to maintain the life of the limb below even during that time. The incision made on the 2d saved the life of the patient, by taking off the tension of the part, and relieving thereby in a remarkable manner the constitutional irritation which hourly appeared likely to destroy him; indeed, no one expected anything but his dissolution. When the line of separation had formed, he was evidently unequal to undergo the operation of amputation, in order to make a good stump, without great risk, and the dead parts were therefore merely separated for the sake of cleanliness and comfort. Experience has demonstrated in too many cases of the kind that the formal operation of amputation at this time, as recommended by most modern surgeons, would in all probability have cost him his life.
The application of powdered charcoal, particularly that made from bog earth, or of areca wood, or Macdougall’s disinfecting powder, or of the disinfecting liquids now in use, such as the chlorides of lime, sodium, and zinc, removes in a great degree the intolerable odor which renders the room of the sufferer unbearable, and essentially interferes with his amendment. Incisions should be made into the dead parts to allow the evacuation of the fluids contained within them, while the parts themselves may be removed from time to time; so that when the period arrives at which an amputation is considered advisable, the bones, if of the leg, may be sawn through at or below the line of separation, and nearly the whole of the mortified soft parts removed, so as to leave little of those which are dead and offensive. This operation is done without the patient feeling it; it gives rise to no irritation, inconvenience, or danger; Nature is not interfered with in her operations; and in due time the parts which remain are separated and fall off, leaving a stump more or less good, but which will always bear the application of a wooden leg; and thus the knee-joint is saved--a saving of no small importance to the patient, and a new precept in surgery.
197. The following cases may be considered conclusive:--
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.