Part 24
The sloughing matter mixed with coagulated blood readily yielded to the back of the knife, but was not easily dissected out. The spot which the arterial blood came from was distinguished through it, but the artery could not be perceived, the swelling and the depth of the wound rendering any operation on it difficult. To obviate this inconvenience, I made a transverse incision outward, from the shot-hole to the edge of the fibula, which enabled me to turn back two little flaps, and gave greater facility in the use of the instruments employed. I could now pass a tenaculum under the spot whence the blood came, which I raised a little with it, but could not distinctly see the wounded artery in the altered state of parts, so as to secure it separately. I therefore passed a small needle, bearing two threads, a sufficient distance above the tenaculum to induce me to believe it was in sound parts, but including very little in the ligature, when the hemorrhage ceased; another was passed in the same manner below, and the tenaculum withdrawn. The coagula under the muscles were removed, the cavity washed out by a stream of warm water injected through the external opening, the wound gently drawn together by two or three straps of adhesive plaster, and the limb enveloped in cloths constantly wetted with cold water. The patient was placed on milk diet.
On the 4th, two days after the operation, the wound was dressed, and looked very well; the weather being very hot, two straps of plaster only were applied to prevent the parts separating. On the 5th a poultice was laid over the dressings, in lieu of the cold water, the stiffness becoming disagreeable. On the 6th, as the wound, although open in all its extent, did not appear likely to separate more, the plasters were omitted, and a poultice alone applied. On the 8th and 9th it suppurated kindly; and on the 10th, or eight days from the operation, the ligatures came away, the limb being free from tension, and the patient in an amended state of health, his medical treatment having been steadily attended to.
The man was brought to England, to the York Hospital at Chelsea, and walked about without appearing lame, although he could not do so for any great distance. He suffered no pain, except an occasional cramp in the ball of the foot, and some contraction of the toes, which took place generally when he rose in a morning, and continued for a minute or two, until he put them straight with his hand; this I did not attribute to the operation, but to some additional injury done to the nerves by the ball in its course through the leg.
This case, which has been followed by many others equally successful, even after the femoral artery had been ineffectually tied, established the practice now followed in England by all educated surgeons; and is another of those great additions to surgery for which science is indebted to the Peninsular war.
198. It may be permitted to repeat, that if an artery such as the axillary be laid bare previously to an operation for amputation at the shoulder, and the surgeon take it between his finger and thumb, he will find that the slightest possible pressure will be sufficient to stop the current of blood through it. Retaining the same degree of pressure on the vessel, he may cut it across below his finger and thumb, and not one drop of blood will flow. If the artery be fairly divided by the last incision which separates the arm from the body, without any pressure being made upon it, it will propel its blood with a force which is more apparent than real. All that is required to suppress this usually alarming gush of blood is to place the end of the forefinger directly against the orifice of the artery, and with the least possible degree of pressure consistent with keeping it steadily in one position the hemorrhage will be suppressed. It is more important to know that if the orifice of the artery, from a natural curve in the vessel, or from other accidental causes, happen at the same time to retract and to turn a little to one side, so as to be in close contact with the side or end of a muscle, the very support of contact will sometimes be sufficiently auxiliary to prevent its bleeding.
In amputation at the hip-joint, the femoral and profunda arteries are frequently divided at or just below the origin of the latter, and bleed furiously if disregarded; but the slightest compression between the finger and thumb stops both at once. They never have given me the smallest concern in these operations, or others of a similar nature; and surgeons should learn to hold all arteries that can be taken between the finger and thumb in great contempt. It is quite impossible for a man to be a good surgeon--to do his patient justice in great and difficult operations attended by hemorrhage, unless he has this feeling--unless his mind is fully satisfied of the truth of these observations. While his attention ought to be directed to other important circumstances, it is perhaps absorbed by the dread of bleeding, by the idle fear that he will not be able to compress the artery and restrain the bleeding from it--that he may have half a dozen vessels bleeding at once--that his patient will die on the table before him. Once fairly in dismay, and the patient is really in danger; but, endowed with that confidence which is only to be acquired through precept supported by experience, he surveys the scene with perfect calmness: taking the great artery between the finger and thumb of one hand, he places the points of all the other fingers, of both hands if necessary, on the next largest vessels; or he presses the flaps or sides of the wound together until his other hand can be set at liberty by an assistant, or in consequence of a ligature having been passed around the principal artery. This is a scene sufficient to try the presence of mind of any man; but he is not a good surgeon who is not equal to it--who does not delight in the recollection of it when his patient is in safety, and his recovery assured. It was in consequence of what was then considered the too great boldness of the practice that my old friend, Sir Charles Bell, whose loss to science cannot be too much regretted, represented me seated on a pack saddle on the back of a bourro, (_Anglice_, a jack-ass,) on the top of the Pyrenees, expatiating on their merits (which he did not believe) to the descendants of the Bearnois of Henri Quatre on one side, and to the children of the lieges of Ferdinand and Isabella on the other; but no one now disputes their accuracy. The surgery of the Peninsular war was many years in advance of the surgery of civil life.
199. The principles laid down for the treatment of wounded arteries in the _lower_ extremity are equally to be observed with respect to those of the _upper_. There is, however, little or no fear of mortification taking place in the upper extremity, the collateral circulation being more direct and free; while there is greater danger from this cause of hemorrhage from the lower end of the artery, if a ligature should not have been placed upon it, or if it should not be retained a sufficient length of time.
200. The error of placing a ligature on the subclavian artery above the clavicle, for a wound of the axillary below it, should never be committed. One person dies for one who lives after this operation, when performed under favorable circumstances, independently of the loss which may be sustained by a recurrence of bleeding from the original wound, which is always to be expected and ought to take place; when it does not happen, it is the effect of accident, which accident in all probability occurs from the state of _absolute rest_ having been carefully observed.
201. The necessity for an aneurismal sac below the clavicle, and for its remaining and continuing to remain intact, until the cure is completed, when the subclavian artery has been tied above, is rendered unmistakable by the following case:--
Ambrose C. was admitted into the Charing Cross Hospital, in August, 1848, in consequence of a bruise from a sack of beans; there was axillary aneurism, extending under the pectoral muscle up to the clavicle. A ligature was applied in the usual situation on the outside of the scalenus muscle, and came away on the twenty-second day. The aneurismal sac suppurated, and burst three days afterward, when a quantity of pus and blood, partly fluid, partly coagulated, but very offensive, was discharged. The opening was enlarged, and everything appeared to be going on well, at which time I saw him. On the nineteenth day after the ligature came away, I visited him again with Mr. Hancock, and merely observed that he must keep himself very quiet, and I thought he would do well. In the evening he died from hemorrhage, while eating some gruel. On examination after death, the artery was found to be sound, except where it communicated with the sac by an opening three-quarters of an inch in length. The ligature had been applied midway between the thyroid axis and the first of the thoracic branches. There was a small coagulum, of half an inch in length, both internal and external to the ligature, _but not extending to the branch above or below it_. The artery was of its natural size as far as the remains of the sac, but beyond it the axillary artery was diminished; the remains of the sac were void of coagulum, except where it communicated with the artery, to which opening a small coagulum had adhered, but had given way at its lower part, and thus caused his death. _Between the opening and the ligature_, five large branches entered into or were given off by the artery, and through some of these blood was brought round by the collateral branches in an almost direct manner, so that the man’s life depended on the resistance offered by the small coagulum after the sac had given way; proving in an exemplary manner the value of the sac remaining entire.
If this case will not convince the incredulous, it would be useless to bring even the sufferers in such cases from their graves, to affirm the fact of the inapplicability of the theory of aneurism to the treatment of a wounded artery--of the impropriety of placing a ligature on the subclavian artery above the clavicle, for a wound of the artery below it.
Corporal W. Robinson, 48th Regiment, was wounded at the battle of Toulouse, by a piece of shell, which rendered amputation of the right leg immediately necessary, and so injured the right arm as to cause its loss close to the shoulder-joint eighteen days afterward. At the end of a month the ligatures had separated, and the wound was nearly healed, although a small abscess had formed on the inside, near where the upper part of the tendon of the pectoralis major had been separated from the bone. Sent to Plymouth, this little abscess formed again, and was opened on the 2d of August, three months after the amputation. The next day blood flowed so impetuously from it as to induce the surgeon to make an incision, and seek for the bleeding vessel, which could not be found. The late Staff-Surgeon Dease, warned by the case of Sergeant Lillie, (page 198,) strongly objected to the subclavian artery being tied above the clavicle, and, true to the principle inculcated at Toulouse, advised the application of a ligature below the clavicle on a sound part of the artery, but as near as possible to that which was diseased. The operation was done by the senior officer, Mr. Dowling, who carried an incision from the clavicle downward through the integuments and great pectoral muscle, until the pectoralis minor was exposed. This was then divided, and a ligature placed beneath it on the artery where it was sound, at a short distance from the face of the stump, where it was diseased. The man recovered without further inconvenience.
202. In all those cases in which it has been supposed necessary to place a ligature on the artery above the clavicle, after a _failure_ in the attempt to find the artery below it, the failure has occurred from _the error committed_ in not dividing the integuments and great pectoral muscle _directly across_ from the lower edge of the clavicle downward. It is quite useless dividing these parts in the course of the fibers of the muscle, and the case of Robinson is the model on which all such operations should be done. If this operation had not succeeded, the ligature of the artery above the clavicle was a further resource; but as the artery was sound below, with the exception of the end engaged in the face of the stump, the operation was successful; no doubt should be entertained in such cases of the propriety of an operation which is attended with little risk, compared with that which destroys one man for every one it saves.
203. Punctured wounds of the arteries of the arm and forearm ought to be treated by pressure applied especially to the part injured, and to the limb generally; but when the bleeding cannot be restrained in this manner, in consequence of the extent of the external wound, the bleeding artery is to be exposed, and a ligature applied above, and another below the part injured, whether the artery be radial, ulnar, or interosseal.
204. When the external wound closes under pressure, and blood is extravasated in such quantity under the fascia and between the muscular structures as is not likely to be removed by absorption under general pressure, the wounded artery should be laid bare by incision and secured in a similar manner, even at the expense of any muscular fiber which may intervene.
205. When an aneurismal tumor forms _some time_ after such an accident, in the upper part of the forearm in particular, the application of a ligature on the brachial artery is admissible, on the Hunterian principle.
206. When the ulnar artery is wounded in the hand, which is comparatively a superficial vessel, two ligatures should be placed upon it in the manner hereafter to be directed. When the opening is small, pressure may be tried.
207. When the radial artery is wounded in the hand, in which situation it is deep seated, the case requires greater consideration. When there is a large open wound, and the bleeding end or ends of the artery can be seen, a ligature should be placed on each; but this cannot always be done without more extensive incisions than the tendinous and nervous parts will justify.
208. When search has been made by incisions through the fascia, (as extensively as the situation of the tendons and nerves in the hand will permit,) which are best effected by introducing a bent director under it, the current of blood, through either the ulnar or the radial artery at the wrist, or even through both, should be arrested in turn by pressure, which in most cases of this kind will succeed, if properly applied, and thus show the vessel injured. The bleeding point should be fully exposed, and all coagula removed, when a piece of lint, rolled tight and hard, but of a size only sufficient to cover the bleeding point, should be laid upon it. A second and larger hard piece should then be placed over it, and so on, until the compresses rise so much above the level of the wound as to allow the pressure to be continued and retained on the proper spot, without including the neighboring parts. A piece of linen, kept constantly wet and cold, should be applied over the sides of the wound, which should not be closed so as to allow of any blood being freely evacuated; and if the back of the hand be then laid on a padded splint, broader than the hand, a narrow roller may be so applied as to retain the compresses in their proper situation, without making compression on or impeding the swelling of the adjacent parts, the fingers being bent, in order to relax the palmar aponeurosis--a proceeding which should never be neglected in any operation in the palm of the hand. It has been lately proposed by M. Thierry, a French surgeon, to raise and bend the arm, as a means of impeding the circulation where the artery passes over the elbow-joint, and the proposal deserves adoption, but not to the extent he recommends, which cannot be long submitted to. Pressure made at the same time on the radial or ulnar artery, or on both, by a piece of hard wood two inches long, shaped like a flattened pencil, is much more effectual, and more to be depended upon. When from the bones being broken, or the hand so swollen, or from other circumstances, pressure, however lightly and carefully applied, cannot be borne in the manner directed, and the attempts to secure the artery at the bleeding spot have failed, and pressure on the radial or ulnar artery has been equally unsuccessful, in consequence of the swelling or other circumstances, both may be tied at the wrist in preference to placing a ligature on the brachial artery, although that even must be done as a last resource, if the bleeding should still continue. If it be asked why not do this in the first, rather than in the last instance, the answer is, that it has so often failed to prevent a renewal of the bleeding from both ends of a wounded artery in the hand, that complete dependence cannot be placed upon it, particularly if there should be a division high in the arm of the brachial into the radial and ulnar arteries. When, however, the arteries leading to the wound have been secured, either by pressure or ligature, NEAR to the part, and the bleeding returns by the collateral circulation, which in the hand is so free, the arresting the supply of blood through the main trunk may and often has suppressed the hemorrhage, at all events for a sufficient time to enable the injured parts to recover themselves, provided the forearm is bent and raised, and the person kept at _rest_ in the most restricted manner, without which this operation will in all probability fail. It is in these cases that the instrument alluded to, page 226, will be useful, rendering the ligature on the trunk of the vessel unnecessary, more particularly if the bleeding should appear to depend on some peculiarity in the structure of the coats of the artery.
209. When the obstacle to the application of pressure arises from the injured state of the metacarpal bone or bones, one or more should be removed, with the fingers if necessary, so as to expose a clear and new surface, on which the bleeding vessels may be seen and secured. In some cases, particularly if there should be a hemorrhagic tendency in the arterial system generally, as known from previous accidents, the first compress may be wetted with the perchloride of iron, the ol. terebinth., the dilute sulphuric acid, or the tincture of matico; these remedies may be also administered internally. Some new styptics have lately been much lauded in Malta and other places, but sufficient proofs have not been given of their efficiency.
210. When the radial artery is wounded as it turns from the back to the inside of the hand, to form the deep-seated palmar arch, it meets a branch of the ulnar nerve about to terminate in the muscles of the thumb. If the treatment by pressure above recommended should not succeed, the muscles forming what is called the web, between the thumb and metacarpal bone of the forefinger, should be cut through, and the bleeding vessel exposed. They are the adductor pollicis on the inside, and the abductor indicis on back of the hand.
LECTURE XIII.
WOUNDS OF THE ARTERIES, ETC.
211. The precept so strongly insisted upon, that no operation should be done on a wounded artery unless it bleed, and at the place from which it bleeds, has been particularly opposed with reference to the neck, the opponents believing that placing a ligature on the primitive carotid is an operation not attended with much risk, and that it may therefore be done as a precautionary measure when the wounded part does not bleed; this statement is an error. Of thirty-eight cases collected by Dr. Norris in 1847, in which this vessel was tied for aneurism, twenty-six died, and twelve suffered from affection of the brain, the frequency of which occurrence has been singularly overlooked by practical surgeons; although proving, in a very marked manner, that the operation of tying the primitive carotid is not a trifling affair, and that the success, when compared with the failures, is only as one and one. A much more important objection is the difficulty of deciding, in many cases of wounds of the neck, what artery is wounded, and what trunk should be tied; whether it be the external carotid or its branches, or the internal, or the vertebral artery. Errors have been committed on all these points by men of the greatest anatomical and surgical knowledge; the trunk of a sound artery having been tied instead of that of a wounded one, inflicting thereby on the patient a second and useless wound, more dangerous, perhaps, than the original one it was intended to relieve.
When Professor of Anatomy and Surgery to the College of Surgeons in 1830, I stated that in wounds of the neck which rendered it advisable to place a ligature on some part of the carotid, on account of the supposed impracticability of laying bare the bleeding orifice, it was generally the _external_ carotid which should be secured, rather than the primitive trunk; there not being sufficient reason for cutting off the supply of blood to the head by the internal carotid, unless the operation on the external carotid should fail. This direction should be implicitly followed.
212. A man was wounded by a ball in the side of the neck, and suffered severely from secondary hemorrhage. Some days after being brought into the hospital, M. Breschet, unable to arrest the bleeding, was about to apply a ligature to the common carotid, when the man died in time to prevent it. On examination after death, the vertebral was found to be the artery wounded, between the second and third vertebræ. The ligature of the carotid, had he lived a little longer, would have been a useless addition to his misery.
Professor Chiari, of Naples, tied the trunk of the left common carotid on the 18th of July, 1829, on account of a false aneurism below the mastoid process, consecutive to a wound made by a sharp-pointed instrument under the angle of the jaw. The man died on the ninth day, and the wounded artery was found to be the vertebral, between the transverse processes of the first and second vertebræ. M. Ramaglia says, a man, thirty-nine years of age, was wounded by a sharp-cutting, penetrating instrument, below the left ear, from which an aneurismal swelling resulted. The common carotid was tied, but as this did not arrest the pulsations of the aneurism, the ligature was removed, and the patient, after suffering from various accidents, died, when the vertebral was found to be the artery wounded.