Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

LECTURE IX.

ON WOUNDS OF ARTERIES, ETC.

173. The efforts resorted to by nature for the suppression of serious hemorrhages depend on the capabilities of the arteries as resulting from their structure, into which it becomes an object of importance minutely to inquire. With this view, the old division of an artery into three coats may be continued, the difference between ancient and modern anatomy being in their subdivision into different textures or layers. The annexed diagram shows the edge of a large artery, which has been divided circularly, and magnified so as to exhibit six layers in a distinct manner; each of the three ancient coats is divided into two. The inner or old serous coat is shown to be separable into two: the epithelial, marked 1, and the fenestrated, marked 2. The middle coat is also separated into two: the inner, or muscular, marked 3, and the outer, or elastic, marked 4. The outer coat is divisible also into two layers, the inner, marked 5, and the outer, marked 6; number 5 being composed more of elastic fibers: number 6 more of areolar fibers, by which tissue, in a less condensed state, the arteries of the extremities are attached to their sheaths. Such may be considered to be the general composition of a large artery, each particular structure remaining to be examined.

No. 1.

OLD.      MIDDLE.      YOUNG.

174. If a small portion of the inner coat of an artery be gently scraped with a knife, or if the inside of the cheek be treated in a similar manner, a little white soft substance is brought away on it, called epithelium, a name given to it by Ruysch, from the delicate layer of epidermis investing the female nipple, έπι, upon, θηλή, a nipple. The epithelium of the human body is divided into three kinds by microscopists—the tesselated, pavement, or scaly; the cylindrical, or conical; and the spheroidal, or glandular. The tesselated, as it exists in arteries, is represented in diagram No. 1, in three different stages—in the young person, in middle age, and in the very old person; one stage gradually degenerating or changing into the other, at each different period of life. It is composed of a single layer of nucleated cells, of a flat, oval, round, hexagonal, or polygonal form, and about 1/1400 of an inch in diameter, the nucleus in each cell containing within itself one or more nucleoli, and even several paler granules. The epithelium has a thickness proportioned to the friction or pressure to which it is exposed, particularly when covering the skin. In the arteries of the young, and in the mammalia generally, the epithelium is strongly marked; in older persons, all traces both of cells and nuclei have disappeared. It lines not only the internal surface of the arteries and veins, but the mouth with its mucous glands; the conjunctiva of the eye; the pharynx and œsophagus; the vagina and cervix uteri; the entrance of the female urethra, and the serous membranes.

The conical or cylindrical is composed of cells closely set together, of a conical, cylindrical, or pyramidal form, about 1/1200 of an inch long, each cell inclosing a flat nucleus, with nucleoli. It lines the urethra in the female, from the entrance where the tesselated ends, and extends inward to the urinary tubules of the kidneys; the greater part of the male organs in a similar manner; the digestive canal and gland-ducts, from the cardia to the anus.

The spheroidal or glandular epithelium consists of cells, more or less circular or spherical in figure, each having a large nucleus in its center. The epithelium is met with in all glandular organs, such as the liver, kidney, lachrymal, and salivary glands, and in these cells the proper secretion of the gland is developed. The tesselated and cylindrical kinds are, on the contrary, more or less protective.

The two first kinds are sometimes ciliated, by the addition, at their free extremities, of several fine, pellucid, blunt, and pliant hairlike processes or cilia, about 1/5000 of an inch long, which are, during life, in constant motion. This kind of epithelium, known as the ciliary, lines the whole respiratory track of mucous membrane; the palpebral conjunctiva, as opposed to the tesselated on the eyeball; the ventricles of the brain; the posterior half of the uterus, and the Fallopian tubes.

The epithelium is placed upon the second layer of the internal coat, which, from certain appearances of apertures or windows, has been called the perforated or fenestrated layer. (See diagram No. 2.) It can be peeled off in small pieces only, and shows under a power of 250 diameters a series of well-marked fibers running in almost parallel lines upon a comparatively structureless membrane, resembling the inner layer of the cornea, as in the left-hand figure of the diagram, the fibers being arranged in the length of the vessel. They frequently bifurcate, and almost immediately join again, so that an oval space, resembling a hole, is perceived. This is not always a hole or perforation, as it is generally described to be, as may be seen and proved by the fact that the supposed opening is sometimes filled up by small bodies, like nuclei, as if the oval space were occupied by a cell. This fenestrated layer varies in thickness in different vessels, and is more strongly developed in the lower animals than in man; by some authorities it is not regarded as a distinct layer, but as the innermost layer of longitudinal fibers belonging to the middle coat. When this layer is very thick, the fibers which are yellow do not all run in the direction of the length of the vessel, for others crossing at right angles may sometimes be observed, as delineated in the right-hand figure of diagram No. 2. These two layers compose the ancient inner coat of an artery, and are frequently the seat of disease.

No. 2.

The middle coat, as it was termed, forms by much the greatest part of the thickness of an artery, and, generally speaking, is of a more or less yellow color. It appears fibrous to the naked eye, and can be peeled off not unfrequently in a series of circular layers; when examined microscopically, it is seen to be composed of two sets of fibers arranged in a circular direction. The inner layer is composed principally of muscular fibers, of the organic or involuntary kind. (See line marked 3 on the circular diagram.) The outer layer, marked line 4 on the same diagram, is made up chiefly of elastic fibers, with a much smaller amount of the muscular or contractile element. These conjoined layers form the muscular coat of Mr. Hunter, the fibrous or contractile coat of later anatomists, who denied its muscularity from the supposed absence of fibrin—an error fallen into from chemical science being unequal at that time to its discovery, or rather of its more elementary part, called protein, the principal constituent both of albumen and fibrin, which two are now found to differ from each other in the addition only of three per cent, of sulphur. Mülder says, in his “Animal and Vegetable Chemistry,” (Part II. p. 307:) “The combinations of sulpho-phospho protein (fibrin and albumen) and of sulpho-protein casein with acids, alkalies, and salts are especially remarkable. Protein is soluble in weak alkalies. Since, therefore, the serum of the blood is always slightly alkaline, being a proteate of soda, with sulphur and phosphorus, it keeps the sulpho-phospho protein in solution. This property is the cause of the blood remaining in a liquid state—a chief requisite for animal life.

“If a weak alkaline solution of protein be neutralized by an acid, the solubility of sulpho-phospho protein is greatly diminished. The sulphuric and phosphoric acids, by not dissolving protein, stanch bleeding. Acetic acid, by which protein is dissolved, does not, neither does the hydrochloric.

“Protein, according to Mülder—although it is doubted by Liebig—is a complex substance, consisting of several heterogeneous organic compounds united into one whole, easily acted upon by strong reagents.

“If a protein compound be brought into contact with an alkali, ammonia is immediately disengaged, and the alkaline solution can hardly be made weak enough to prevent the disengagement of ammonia. If either fibrin or coagulated albumen be dissolved in a weak potash lye, ammonia is always perceptible. Protein, therefore, is always in a state of decomposition, as serum is alkaline.”

In diagram No. 3, fig. 3, the organic or involuntary muscular fibers of the intestine are shown, consisting of more or less flattened bands, the fibers of which are soft, and marked with minute granules, sometimes exhibiting traces of nuclei. These purely muscular fibers are most abundant next to the inner coat of the artery, and diminish in number as they approach the outer layer, their place being occupied by firmer and more elastic fibers of a yellow color, seen collectively in the circular diagram, as line 4, and separately in diagram 3, fig. 4, and in diagram 4.

No. 3.

No. 4.

The involuntary muscular fibers of an artery do not always form a continuous layer; they are often smaller than those found in the intestines, bladder, and uterus, and occur as fusiform cells, detached from each other, and having a large, club-shaped nucleus, as shown at fig. 6 in diagram 3.

The voluntary muscular fibers differ from the involuntary, in having cylindrical fibers of much larger size, with transverse and longitudinal markings, unlike the flattened fibers of less size of the involuntary muscles, which have also a faintly granular appearance, instead of the more determined transverse and longitudinal lines of the voluntary muscles.

The outer or elastic layer of the ancient middle coat, represented by line 4 in the circular diagram, contains muscular fibers, but it is formed principally of strong, elastic fibers difficult of separation, and, when torn across, have curled extremities, as shown in the diagram marked 4, differing only in size from those found in the ligaments of the spine, and in the ligamentum nuchæ of quadrupeds, as shown in the separate diagram marked 4.

The external coat of an artery, divided also into two layers, is shown on the circular diagram by lines 5 and 6. These two layers are composed of the yellow elastic fibers last noticed, and another set of fibers, white in color and inelastic in structure, arranged in various directions; the inner layer predominating in yellow elastic, the outer layer in white inelastic fibers, constituting a firm investment to all the other layers of which the artery is composed. The white inelastic fibers are shown in diagram No. 3, fig. 5, with a yellow elastic fiber curling round them. The constant crossing and recrossing of these two sets of fibers form certain spaces, which, when not in a compact form, become real spaces, meshes, or areolæ, constituting what is now called areolar tissue, rather than the cellular of the older anatomists, from the circumstance that the areolæ communicate, and that perfect cells in any tissue do not. These elements of areolar tissue can be readily distinguished by the action of acetic acid, under which reagent the white fibers will almost disappear, leaving only a slight trace of fibers containing oval nuclei, as seen and marked in diagram 3, fig. 5. It is seen when unraveled in b, diagram 5.

No. 5.

a. Yellow elastic fibers.
b. White inelastic fibers.
c. Nuclei.
d. Fiber, with nucleus.

The inner layer of the middle coat, or muscular coat, as it may be justly termed, forms, it will be seen, the greatest part of the thickness of the wall of certain arteries, and in some instances, as in the anterior tibial artery, constitutes nearly the entire thickness of the vessel. The internal coat in all is frequently seen puckered in a longitudinal direction.

175. The arteries are supplied with blood by vessels of small size, which do not come off immediately from the part of the artery they are destined to supply, but principally from neighboring vessels. They are called vasa vasorum. They are arranged precisely in the same manner as those of the areolar tissue. A few of these vessels penetrate as far as the middle or muscular coat, but do not reach the inner, which has no vessels, proximity to the circulating fluid being apparently sufficient for its nutrition.

Arteries are supplied with nervous influence by branches from the sympathetic system running in their walls, and through their connection by ganglions with the organs they supply with blood.

176. The cells, nuclei, and nucleoli alluded to are supposed to be thus produced. In a shapeless, consistent, sometimes almost gelatinous mass, to which the name of cyto-blastema or formative substance has been given, containing the materials requisite for the production of cells, small, round grains or nucleoli are perceived in the act of formation. Around these grains a layer of granular matter is deposited, which continually increases in thickness, and constitutes the kernel or nucleus. This is oval shaped or round, almost always opaque, has a granular surface, and is considered to be a vesicle, a little cell itself. From the surface of this kernel a small, very thin transparent vesicle is raised, appearing as a segment of a sphere, which soon expands, and becomes so large, when full grown, that the kernel lies as a minute corpuscle upon its interior wall; the material for its formation being supplied by the cyto-blastema, it is converted into a vesicle by the kernel which is first formed, its embryo existing in the formative substance.

The first trace of organization is the production of a small, perceptible body, or nucleolus, which deposits on the surface a granular substance from the cyto-blastema, to give rise to a little producing organ, the kernel or nucleus. This further transforms the surrounding cyto-blastema into a granular surface, from which the vesicle is formed, raised, expanded, and filled with a liquid, in which vesicle thus enlarged the kernel remains inclosed and adhering to a certain spot of its wall.

If two nucleoli lie close to one another, they coalesce and become one solid mass, capable of producing one cell only, containing one kernel and two nucleoli. This view is that of Schleiden and Schwann, supported by Mülder, but not entirely approved by Henle; inasmuch as no kernel can be perceived in the cells of many cellular systems while in the act of formation. In the elementary parts of animals which have long since lost their cellular form, the remnants of kernels are frequently found, as has been demonstrated in the preceding diagrams. The manner, however, in which the elementary first-seen granules are formed in the cyto-blastema, science has not yet been able to discover. The chemists have proved that all elementary organic substances consist of carbon, hydrogen, oxygen, and nitrogen, susceptible of endless modifications of their respective forces, under which an organic molecule or ovum is produced, and after that, under certain circumstances, an animal such as man.

177. When the current of blood through the main trunk of the arteries of an extremity is cut off, the circulation is carried on by the collateral branches. This collateral circulation is more perfect, more active in young persons during the increase or growth of the body, than it is either at maturity or in the decline of life. The important point is not, however, alone referable to the time of life at which the continuity and permeability of the main trunk cease to exist, but to the nature of the disease or injury which has given rise to it.

When an aneurismal limb has been injected, on which an operation has not been performed, the collateral vessels have all been found larger and more fully shown than on the opposite side, although not to the same extent as in cases of a similar nature in which the operation has been done.

It is necessary that this enlargement of the collateral branches should lake place at an early period, because in many cases of aneurism the artery beyond or below the tumor is obliterated long before any operation is performed. The main supply of blood has been already cut off from the extremity, and the operation adds very little to the derangement of the circulation which has for some time taken place below the tumor.

When an operation has been successfully performed for aneurism, and the patient has died some time afterward, dissection has shown various arteries enlarged, both above and below the part where the trunk was obliterated by the ligature; and not only an enlargement of arteries, which, from their regularity have received names, but others have been developed not usually known to exist, or not of a size to be conveniently traced. These through their frequent anastomoses bring the blood at last into several large trunks, by which it is again conveyed to the original vessel below all and every obstruction which may have taken place; thus compensating by a circuitous route for the loss of the direct supply. The principal object of inquiry is, do these vessels always exist, or at what period of time do they begin to enlarge, so as to enable them to carry on the circulation, in the manner in which it is presumed to be done?—for few will assert that the enlargement of these particular collateral vessels was an accidental play of nature, and existed previously to the commencement of the disease or injury for which the operation was performed. On this point, the theory of the operation for aneurism and its applicability to wounded arteries appears to hinge; and, what is of more importance, on which the practice resulting from it depends.

Two distinct kinds of collateral circulation are at present acknowledged: one by direct large communicating arteries; the other through the direct medium of the capillary vessels inosculating with each other. Where direct communicating arteries exist, little subsequent change beyond enlargement takes place in them. It is otherwise with the indirect capillary vessels. When the radial or ulnar artery has been divided in the hand, the blood will not only flow readily from each end of the divided vessel, but equally red and arterial from both, the communication being through direct arterial branches from one vessel to the other. It will also be red and arterial if the division take place at the wrist, and may be so in the brachial; but if the femoral in the lower part of the thigh be wounded, the color of the blood issuing from the lower end of the artery, if any issue at all, will be dark or venous. It is so, because it has been obtained from the capillary arteries, which in this case being empty received blood by regurgitation from the veins, the valves of which when present do not prevent its reflux course. If a limb be injected and carefully dissected four or five days after a ligature has been placed during life high up on the principal trunk, the capillary vessels will be seen to be well injected; but few or none will be found large enough to admit of their inosculation being traced throughout. If another limb be injected and dissected, some sixty days after the ligature has been applied, a difference will be distinctly observed between the two preparations. In the latter, the capillaries will not appear to be so fully injected, but several larger and more tortuous vessels will be found in situations where they were not expected to exist; and the anastomoses of these one with another, generally by arches, may be traced to their communication with the principal trunk, both above and below the obliterated part. If an incision were made in the nearest pervious portion of the lower part of an artery in the thigh of a person who had undergone this operation, arterial blood would issue from it. The communication would have become direct by communicating branches, and the capillaries would have returned to their accustomed duties.

178. During the first twenty-four hours after the division of an artery such as the femoral, or the application of a ligature, the temperature of the limb is commonly diminished; after that period, and as the action of increase takes place, the temperature is usually from three to five degrees higher than in the opposite healthy limb. At the end of from eighteen to twenty-eight days, in a successful case, it is found to be equal in both.

It is asserted by some sanguine supporters of the all-powerful influence of the collateral circulation, that it is sufficient at all times, and under all natural circumstances, to maintain the life of the extremity. The practice of the Peninsular war proved the fallacy of this opinion in too many instances to admit of any doubt of its inadequacy to do so in the lower extremity after the division of the femoral artery, under ordinary circumstances. The fact of enlargement or of a new development of vessels having taken place after the commencement of disease or the reception of an injury, has been demonstrated by dissection, and it is through them the life of the limb is to be preserved; but time is required for their development. When a limb is lost through mortification, as the consequence of a division or obstruction of the principal artery, it usually takes place after the infliction of a sudden injury, in consequence of these collateral branches not having had time to enlarge.

179. The collateral circulation is therefore not the same, and is not in the same stage of preparation, in a limb suffering from a divided or wounded artery, as in one in which an aneurism has for some time existed; this is the reason why mortification is more common after wounded arteries than after operations for aneurism.