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 X.

PROPER TREATMENT OF WOUNDED ARTERIES, ETC.

180. The due appreciation of the means adopted by nature and by art for the suppression of hemorrhage, as well as the proper treatment of wounded arteries, is owing to the surgery of the war in the Peninsula. They were suspected after the battles of Roliça, Vimiera, Oporto, and Talavera, but did not receive their complete development until after the battle of Albuhera. It was not until after that of Toulouse they were partially admitted; and it is only of late that they have been almost everywhere acknowledged, taught, and practiced.

Previously to the time of Mr. Hunter, the diseased or dilated state of the coats of an artery which constitutes an aneurism was, when it occurred in the ham, very often fatal. The operation of Anel, first performed in 1710, of cutting down to the artery, and placing a ligature upon it immediately above the dilated part, was not approved, and Mr. Pott, the great contemporary of Mr. Hunter, recommended in bad cases that amputation should be resorted to in the first instance; although Desault had succeeded, in 1783, in a case of popliteal aneurism, in which, after the manner of Anel, he had placed the ligature on the artery a little above the aneurismal swelling in the ham. Mr. Hunter’s contemplative mind, aided by his knowledge of anatomy and of disease, led him to believe that the ligature thus applied on the artery in the ham failed, because the vessel was unsound at that part, and was therefore incapable of taking on those healthy actions necessary for the obliteration of its canal above the ligature, which are known to take place when the artery is in a normal state. He concluded that this was sufficient to account for the failures, without especially taking into consideration the difficulty of applying the ligature in the ham immediately above the aneurismal sac, and of the probability of the sac suppurating when thus molested; an occurrence aiding materially in the necessity for the loss of the limb by amputation, performed then under circumstances of constitutional irritation, which would render it less likely to be attended with success.

From the consideration of these and other circumstances, Mr. Hunter was induced to propose, in 1785, that the ligature should not be placed on the artery near the tumor in the ham, but at a greater distance on the fore part or middle of the thigh, and Scarpa subsequently recommended it to be placed even higher—a recommendation which has been generally followed, and the spot now selected for this operation is at the lower part of the upper third of the thigh. This operation was therefore performed not only for aneurism, but improperly for a wound of the artery, not only in the ham, but even in the leg; it consequently failed in almost every instance of traumatic injury, thus rendering amputation necessary, which was generally followed by death.

181. The Hunterian theory implies:—

1. That the artery is in general sound at the part in the front of the thigh selected for operation, while it is usually unsound in the popliteal space behind, or in the ham, where Desault operated, and Anel recommended it to be done; that operation is now abandoned on the continents of Europe and America, as well as in England.

2. That a ligature can readily be placed upon it at a distance from the disease in the fore part of the thigh, and will usually be followed by success as far as concerns the obliteration of the artery immediately below the part on which it is applied.

3. That the artery being aneurismal, the collateral branches had begun to enlarge, so as to be better able to carry on the circulation, after the supply of blood to the lower part of the limb by the main trunk had been cut off.

4. That no branches of importance are usually given off between the ligature on the artery on the fore part of the thigh and the sac of the aneurism in the ham.

5. That if such branches were ever given off, and brought the blood from their collateral communications back into the main artery below the ligature, and thence into the sac, so as to renew its pulsatory movements, they would ultimately disappear, from the impelling force not being sufficient to prevent a gradual coagulation taking place, which would soon fill up the cavity of the sac, and thus prevent its further enlargement; at which stationary point a process of removal by absorption would begin and continue, until the diseased sac with its contents had diminished, if not entirely disappeared, leaving only a trace behind of its former existence, the process thus described being frequently assisted by a commencing obliteration of the artery immediately below the aneurism. The essential point in this theory, which has immortalized the name of Hunter in surgery, depends on the integrity of the aneurismal sac, which ultimately retains, as a general rule, subject to rare exceptions, any blood which may be brought into it, either by the collateral branches from above, or from below by what may be called regurgitation, until it has become coagulated, when the sac is so filled up that no more blood can pass into it to cause its further distention, or any ulterior evil.

This theory of Mr. Hunter, then so new, so beautiful in itself, was eagerly embraced by nearly all the civilized world; and surgeons were not content with applying it to cases of diseased or aneurismal arteries, to which it is especially applicable, but they extended it indiscriminately to cases of wounded arteries, to which the practice of the war in Spain proved it was inapplicable, and in which I have, since 1811, maintained it could only succeed as a matter of accident, not of principle.

182. The essential features of the theory opposed to Mr. Hunter, with respect to wounded arteries, and called mine, are:—

1st. That the artery at the wounded part is free from previous disease, and may be expected to take on those healthy actions which, after the application of a ligature, lead to the obliteration of its canal, and the consequent suppression of hemorrhage.

2d. That the circulation of the blood by the collateral branches is less free in a sound limb than in one which has suffered during several weeks from the formation of an aneurism.

3d. That this freedom of circulation is less in the lower than in the upper extremity, under all circumstances.

4th. That mortification of the foot and leg, and often of the whole limb, followed by the death of the person, is a common occurrence after a ligature has been placed high up on the artery in the thigh, in consequence of a wound; while it is not so common an occurrence when such operation is performed in the same place for an aneurism of several weeks’ duration. If the vein be also wounded, mortification is almost inevitable.

5th. That mortification of the hand and arm rarely follows the application of a ligature to the artery of the upper extremity in any part of its course, however near the heart.

6th. That when the collateral vessels are capable of carrying on the circulation through the lower extremity, the lower end of the divided artery bleeds dark or venous-colored blood, while its upper end bleeds scarlet or arterial-colored blood. In the upper extremity, the color of the blood from the lower end of the divided artery is little altered—a consequence of the greater freedom of anastomosis, or of the freer collateral circulation in the upper extremity. Facts of the greatest importance in surgery.

7th. That whenever the collateral vessels are not capable of carrying on the circulation of a limb, mortification or death of the part ensues; and that whenever this collateral circulation is sufficient to maintain the life of the limb, blood must pass into the artery below the wound, and must, as a general rule, pass up and out through the lower end of the divided artery, unless prevented by the application of a ligature, or by some accidental circumstance, forming an exception to the rule, but not the rule itself.

8th. That the collateral branches are capable of bringing blood into the artery above the aneurismal sac and between it and the ligature, is admitted in the Hunterian theory, which blood the aneurismal sac receives, and usually retains. When the artery is a wounded artery, and the ligature is applied at a distance above the wound, blood is often brought into it below the ligature in a similar manner; but as there is no aneurismal sac to receive and retain it, the patient bleeds perhaps to death, unless surgery come to his assistance.

9th. The presence of an aneurismal sac in one case, and its absence in the other, is the essential difference destructive of the Hunterian theory for the treatment of aneurism being applicable to that of wounded arteries.

10th. The processes for the natural suppression of hemorrhage are somewhat different in the upper and lower ends of an artery, and are less capable of resistance in the lower. This end frequently yields to the pressure of the blood regurgitating from below, and renews a bleeding which may have been suppressed for weeks, unless its closure has been rendered more permanent by the application of a ligature.

11th. The absence of the aneurismal sac renders the application of two ligatures absolutely necessary, one on each end of a divided artery, or one above and one below the wound, if the artery should not be divided; constituting the most essential feature of my theory, and the principal point to be attended to in the treatment of wounded arteries.

12th. This bleeding from the lower end of the vessel, which is more or less of a venous color, and issues in a continuous stream, may be restrained by compression properly made on the course of the lower part of the wounded artery; but in no instance should recourse be had to a ligature on a distant part of the artery above the seat of injury, until every other possible effort to arrest the hemorrhage from the lower end of the vessel has failed.

13th. The great principles of surgery to be observed in cases of wounded arteries, and which ought never to be absent from the mind of the surgeon, are two in number:—

1. That no operation ought to be performed on a wounded artery unless it bleed.

2. That no operation is to be done for a wounded artery in the first instance but at the spot injured, unless such operation not only appears to be, but is impracticable.

183. The means adopted by nature for the suppression of hemorrhage have been investigated by Celsus, Rufus, Galen, Œtius, etc., down to Dr. Jones, the most important English writer on this subject; but the methods of inquiry they all adopted appear to have been insufficient and unequal to the object in view. They bled an animal until he died, and then reasoned on the manner or means by which the bleeding was suppressed, when it was in fact arrested by death. It is obvious, then, that it is only when nature has not been interfered with, and the patient has not died from bleeding continued to the last moment, but has, on the contrary, lived some time after the hemorrhage has ceased, that the processes by which its suppression has been accomplished can be fairly investigated. These processes essentially depend on the size and variations of structure in an artery, which have been shown to be dissimilar in large and small arteries, and not even quite alike in the upper and lower ends of the same artery—facts which were elicited from observations made on men on the field of battle during the Peninsular war, and consequently not liable to error. It was then proved that arteries of moderate dimensions, such as the middle part of the femoral or the axillary, tibial or brachial, and particularly all below these in size, are capable, by their own intrinsic powers, when completely divided, of arresting the passage of the blood through them without any assistance from art, or from the surrounding parts in which they are situated. The establishment of this fact overthrew at once the theory which relates to the importance of, and necessity for, the sheath of the vessel, and the offices it performs in suppressing hemorrhage in vessels of this size, and in a great measure that supposed to be derived from the formation of an external coagulum, the bouchon of the French.

184. When the femoral artery has been fairly divided in the lower part of the thigh, the patient has, in almost all the cases which have come under observation, either died without assistance, or the hemorrhage has ceased spontaneously. Having been thus arrested for twelve hours, the efforts of nature are usually sufficient to prevent its return from the upper, although not from the lower end of the vessel; but then it is of venous and not of arterial color—a fact I first demonstrated, and which is now acknowledged to be of the greatest importance. The great evil to be dreaded in such cases is not from hemorrhage from the upper end of the divided artery, but from the lower, and from mortification of the foot.

The upper end of an artery retracts on being divided, and this retraction is accompanied by a contraction of the cut extremity of the vessel, which assumes the shape of the neck of a French wine-bottle or Florence oil-flask. The contraction is confined in the first instance to its very extremity, so that the barrier opposing the flow of blood is formed by this part alone. The contraction, however, goes on increasing for the space of an inch; it is usually filled up with an internal coagulum of a round, pyramidal shape, adhering firmly to the contracted end of the artery, loose at its apex, and extending frequently as far as the first collateral branch, but rarely under any circumstances beyond two inches; the very orifice of the artery on the outside being in a few days covered by a layer of a yellowish green-colored substance or fibrin, which indicates its situation in a remarkable manner. Some of these processes are continued even after the external wound has healed; the artery generally goes on diminishing and contracting as far as it is useless, so that of three or four inches, from one to two may be impervious, the remainder being contracted, although still permeable by a probe. An accompanying nerve, where there is one, would do the reverse, the cut extremity would become enlarged or bulbous, gradually diminishing as it is traced upward, until it regains its proper size.

The processes adopted by nature for closing the lower end of a divided artery of the size of the femoral at the inferior part of the thigh are somewhat different from those employed at the upper or opposite extremity. The retraction or contraction of the lower end of a divided artery is neither so perfect nor so permanent as at its upper end, and the small internal coagulum is in many instances altogether wanting, or very defective in its formation. The closure of the lower orifice being less perfectly accomplished than of the upper, it is the more likely to suffer from secondary hemorrhage, which may be distinguished from that from the upper end of the artery at an early period after the accident, by the venous color of the blood, and from its flowing or welling out in a continuous stream, as water rises from a spring, and not with an arterial impulse.

The retracting and contracting powers in the lower end of a divided artery are nevertheless considerable, and are sufficient in some cases to nearly close the lower end of the femoral artery when divided by amputation above the knee. When the femoral artery is cut across, the lower portion of the vessel is emptied by its last efforts, combined with the action of the capillaries. When the collateral circulation is powerful, blood soon regurgitates into the artery, but the force of the regurgitation can be in no proportion to that of the propulsion at the other or upper divided end of the vessel, which will generally be able to resist this impulse, while the lower one often opens and bleeds after the lapse of a few days. In all the cases I have had an opportunity of examining, in which hemorrhage had taken place from the lower end of the artery, the following appearances were observable after the interval of from four to five days.

The same kind of yellowish-green matter marks and conceals the situation of the lower extremity of the artery in the wound as it does the upper. It is, however, thinner where it immediately covers the end of the artery, which in none of these cases was contracted in the conical manner described as taking place in the upper extremity. On the introduction of a probe with the greatest gentleness into the artery from below, it usually makes its appearance at a point on the yellow space, raising a thin portion as it protrudes. On laying open the artery, the orifice would seem to have been once closed by this layer of fibrin, but with a less degree of contraction than the upper end of the same artery; the layer still, however, forming an obstacle sufficient to cover and close three-fourths of the orifice, the blood having flowed through the remaining fourth, which had probably given way by accident; which accident is usually some sudden or continued motion being given to the extremity or part injured, and which motion it is imperatively necessary to avoid, when the lower end of a wounded artery has not been secured by ligature.

A soldier, who had his arm carried away by the bursting of a shell at the siege of Ciudad Rodrigo, was brought to me shortly afterward. The axillary artery, becoming brachial, was torn across, and hung down lower than the other divided parts, pulsating to its very extremity. Pressed and squeezed in every way between my fingers in order to make it bleed, it still resisted every attempt, although apparently by the narrowest possible barrier, which appeared to be at the end of the artery, and formed by its contraction. The orifice of the canal was marked by a small red point, to which a very slight and thin layer of coagulum adhered, the removal of which had no influence on the resistance offered by the very extremity of the artery to the passage of blood through it. In this, and in another instance of a similar nature, the end of the artery being cut off at less than an eighth of an inch from the extremity, it bled with its usual vigor. In both, the vessel for near that distance was contracted so as to leave little or no canal at its orifice, which in these cases was filled by a coagulum of the size and shape of a very small pin.

1. Axillary artery.
2. Axillary vein.
3, 3. Branches of axillary plexus of nerves.
4. Curved, pointed and plugged ends of the artery and vein.

The vessels are here represented as they lay exposed in the lacerated parts. The pointed and plugged ends of the vessels were of a dark coagulum color, while above both artery and vein had a reddish, vascular appearance, and were held in close relation by their sheath. The artery bent distinctly to the very base of the coagulum.

Mr. Deputy Inspector-General Taylor informs me that a soldier of the 44th Regiment was struck by a cannon-shot on the 21st of June, 1855, in front of Sebastopol; it carried his left arm away from the shoulder, leaving the artery, vein, and nerves exposed as in the accompanying sketch. The thought, he says, crossed my mind, as I held the artery between my finger and thumb, that it might be for the benefit of the patient to place a ligature on the artery at the highest point, exposed, cutting off the part below, having had a precisely similar case at Ferozeshah, in India, in which the soldier recovered without the artery being tied, or any hemorrhage recurring. The shot, in carrying away his arm, struck him very severely on the chest, and I fear has injured the lungs, but there is so much ecchymosis that the presence or absence of sounds cannot be distinguished by the stethoscope. Of this injury of the chest the man died some days after its receipt. The body was buried without examination, but no hemorrhage had taken place from the wound.

Private J. Barnes, 29th Regiment, on the 16th of May, 1811, at the battle of Albuhera, received a musket-ball in the right thigh, behind and above the knee, inclining downward and inward, close to the condyles of the femur, and in the direction of the femoral artery becoming popliteal; it bled violently at the moment, and so continued for a few minutes, during which time he conceives he lost two quarts of blood. It then ceased, and he was dressed in the usual slight manner, and remained two days upon the field of battle, until removed to Valverde, nine miles, on a bad road, on men’s shoulders, in a blanket converted into a bearer. He was considered as one of the slighter cases, until the gentleman in immediate charge of him requested me to see him, on account of his toes being in a state of mortification.

On the evening of the 3d of June, eighteen days after the accident, the man was placed on a bullock car, to be removed with the rest of the wounded to Elvas, the mortification of the foot having ceased to increase, and a line of separation having been formed. Shortly after the cars moved, I was informed that he was bleeding from the wound: it evidently appeared to flow from the popliteal artery; and as it issued slowly, I supposed from the lower divided end. The foot being partly lost, I determined on amputation above the knee, which was performed at Olivença. The amputated limb was sent after me to Elvas, that it might be examined at leisure. I carefully traced the course of the wound, and found in it a little coagulated blood, but could not see the mouth of the vessel. A probe passed into the upper end of the artery was obstructed before it reached the ulcerated surface by nearly an inch; and on passing it up the lower one, it was stopped exactly in the middle of the track of the ball, by a veil or substance drawn across the mouth of the vessel, which, on careful examination, showed the point of the probe at one part of the circle, although too small to let it through; from this part I conceive the hemorrhage came. The divided ends were one inch apart. The upper, or femoral portion, for nearly an inch, contained a firm coagulum, filling up that part of the artery, which had contracted like the neck of a claret bottle. The lower or popliteal portion of the artery had a very peculiar appearance; the substance drawn across appeared to have closed it completely at one time, and to have given way from the rough motion of the car at the point now open, which was very small even when the sides of the artery were approximated. A very little soft coagulum was behind it; and if the man had not been removed, the vessel might have remained secure. This case shows very distinctly the means adopted by nature for the suppression of hemorrhage from both ends of a divided artery.

Corporal Carter, of the pioneers of the 29th Regiment, was wounded at the battle of Roliça, in August, 1809, by a musket-ball, which passed through the anterior and upper part of the forearm, fracturing the ulna. Shortly afterward a profuse hemorrhage took place, and the staff-surgeon in charge tied the brachial artery. In the night the hemorrhage recurred, and the man nearly bled to death. The arm was then amputated, when the ulnar artery was found in an open and sloughing state.

Remarks.—A simple incision to expose the wounded artery, and placing two ligatures upon it, would have saved this man his arm and his life.

At the battle of Vimiera, which followed a few days afterward, a soldier received a somewhat similar wound, save that the brachial artery bled forthwith, the hemorrhage being stopped by the tourniquet. Warned by the preceding case, I cut down on the artery, carefully avoiding the nerve, which had been tied in the former instance, and found the artery more than half divided. It was secured by a ligature above and below the wound: the bleeding did not afterward return, and the man recovered.

185. Thomas Carryan, of the 3d Regiment, was wounded at Albuhera, on the 16th of May, 1811, on the inside of the calf of the right leg, the ball passing out on the fore and outside of the tibia: it bled considerably for some minutes, when it ceased, and the hemorrhage did not return until the 15th of June, on which day a little blood followed the dressings, and increased on the patient making any exertion; so that on the 4th, the gentleman under whose care he was tied the femoral artery on the outside of the sartorius muscle, which suppressed the hemorrhage for that day, the limb continuing with little or no interruption of the same temperature to the hand as the other. On the 5th, the original wound had a bad appearance, and some coagulated blood was readily pressed out of it; on the 6th, a greater quantity came away; and on the 7th, the exertion of using the bed-pan was followed by a stream of arterial blood, which ceased on tightening the precautionary tourniquet.

The limb was amputated above the ligature on the artery. Its dissection showed the anterior tibial artery to have been destroyed for some distance, and the muscles on the back part of the leg nearly in a gangrenous state. The patient died a few days afterward.

Remarks.—If an incision had been made in the leg so as to expose the artery, and ligatures had been placed on it above and below the wound, the man, in all probability, would not have died.

Sergeant William Lillie, of the 62d Regiment, aged thirty-two, was wounded in the right thigh, on the 10th of April, at the battle of Toulouse, by a musket-ball, which passed through, in an oblique direction downward and inward, close to the bone, describing a track of seven inches. The ball was extracted behind on the field. He said he had bled a good deal on the receipt of the injury, which he had stopped by binding his sash round the limb. The discharge from the wound was considerable; it appeared, however, to be going on well until the 20th of the month, when, on making a sudden turn in bed, dark-colored blood flowed from both orifices of the wound in considerable quantity. I had given an order, as the Deputy Inspector-General in charge of all the wounded, that no operation should be performed on a wounded artery without a report being sent to me, and an hour at least granted for a reply, unless the case were of too urgent a nature to admit of it. It appeared to be so in this instance, and before I arrived Mr. Dease had performed the operation for aneurism at the lower part of the upper third of the thigh. I could only express my regret that it had been done, and point out the probability of the recurrence of the hemorrhage from the lower end of the artery, which took place on the 7th of May, when the limb was amputated, and the man subsequently died. On examination the artery was found to have been divided exactly where it passes between the tendon of the triceps and the bone. The upper portion of the artery thus cut across was closed. A probe introduced into it from above would not come out at the face of the wound, although the impulse given to this part on moving it was observable in the middle of a large, yellowish-green spot, which I had previously declared to be the situation of the extremity of the artery which had contracted behind this, in the shape of a claret bottle, for about an inch, having within it a small coagulum. The lower end of the artery from which the hemorrhage had taken place was marked by a spot of a similar character; but on passing a probe upward from the popliteal space, it came out at a very small hole in the extremity of the artery, in the center of the yellow spot, the canal of the artery not being contracted and diminished, but only apparently closed by a layer of the yellowish-green matter laid over it, and adhering to its circumference.

Sergeant Baptiste Pontheit, of the French 64th Regiment, was wounded by a musket-ball at the battle of Albuhera, on the upper and fore part of the thigh; it passed out behind, in the direction of the femoral artery. He lost a great quantity of blood before the hemorrhage ceased, but the wound went on well until the 26th, ten days after the battle, when he felt something give way in his thigh, and found himself bleeding from the wound, which, however, soon ceased on pressing his hand upon it. In the afternoon, on again moving, he lost about half a pint of florid blood, which induced the surgeon on duty to place a tourniquet on the limb. When at leisure (in the course of two hours) I removed the tourniquet, and as no hemorrhage occurred, and there was no swelling in the vicinity of the wound, I replaced the dressing with a precautionary screw tourniquet, explaining to him its use, and the probable nature of his wound, together with the operation requisite to be performed in case of further bleeding.

On turning in bed at night he lost a little more blood, which ceased on his tightening the tourniquet, which was shortly after loosened. In the morning, everything being removed, there appeared some swelling about the wound, the opening of which was filled up by a coagulum: gentle pressure being made, it readily turned out, and was followed by a stream of arterial blood, leaving little doubt of the femoral artery being wounded. Compression being effected in the groin, I made an incision three inches and a half in length, taking the wound as a central point, and exposed the femoral artery and vein: both were wounded, the former being half destroyed in its circumference, surrounded with coagulated blood, and appearing as if it had sloughed from being touched by the ball, the course of which was directly past it, and would have carried it away if it had not been for the elasticity of the artery. A ligature placed above, and another below the wound, secured both artery and vein; the incised wound was brought together by adhesive plaster, and the limb placed in a relaxed position. The operation was of short duration; he lost little or no blood, but, the circulation was very languid, and the man exceedingly low. The warmth of the leg and foot was soon below the standard of the other; warm flannels were applied, and some brandy was given to him. In the evening the heat was more natural, and the man returned thanks for the humanity and kindness shown to him, congratulating himself and me upon the success of an operation which he had supposed would be infinitely more severe. The next morning he ate a tolerable breakfast, but felt a pricking sensation in the calf of the leg, which was as warm to the hand as the other, but the foot was cold. The second day the swelling of the limb, its appearance, and discoloration on the under part, indicated approaching mortification, which on the third was evident, and on the fourth, at mid-day, he died, the limb up to the wound being nearly all in a gangrenous state. No adhesion had taken place in the wound, or in the artery, which showed the inner coat cut, the ligatures being firm, and no coagulum behind them.

Captain St. Pol, of the 7th or Royal Fusiliers, was wounded in the ham from behind, while in the ditch at the foot of the great breach at Badajos. He fell instantly, and lost, as he thinks, a considerable quantity of blood. On recovering he was raised from the ground, and walked a few paces prior to his being carried to his tent, where I saw him in the afternoon of the next day, the 7th. The leg had ceased to bleed before his arrival in camp. A substance could be felt on the inner side of the patella, which, by the sensation communicated to the finger on moving, appeared to be the ball, which was extracted. Some dark-colored blood issued from the cavity; the ball was lying loose and unconnected; the finger, on being passed into the joint, which was swollen, discovered no splinters of bone, and the entrance of the ball behind would not admit the finger. His having walked some distance on the leg, and the absence of any splinters between the articulating extremities of the bones, induced Dr. Armstrong, the surgeon of his regiment, and myself to think that the ball had entered with little injury to the bone; and after stating to the patient the little hope we had of ultimately saving the limb, independently of the great danger to which he was exposed, compared to the certainty of the operation of amputation at the moment, we recommended its being done, but he would not consent. The next day he was removed to Badajos on a litter, the heat of the tent being unsupportable.

On the morning of the 9th I saw him early, when the want of circulation in the foot was evident from its having lost its natural color and warmth; the knee was swollen, but not painful, and I had no doubt that the artery had been divided by the ball. The marbled appearance and tallow-white color soon indicated the loss of the leg above the calf; and vesications had formed on the foot, already of a green color.

On the 12th, the extent of the gangrene was defined on the back of the knee up to the original wound at its lower edge, gradually receding as it advanced to the fore part of the leg, which for three inches below the knee was apparently sound; the uneasiness of the knee being moderate, and the incised wound looking perfectly healthy, although the latter had not united.

On the 16th, the separation of the dead from the living parts having taken place behind, and being well marked and commencing on the fore part, the limb was amputated as low down as possible. Sixteen vessels were tied; the parts were gently brought together, without any hope of union. According to subsequent experience, this operation should not have been performed. The dead parts only should have been removed, and the stump left to nature until the health was perfectly restored.

On the 24th he died.

On examining the amputated limb, the popliteal nerve was found untouched, the ball having passed on the inside; the popliteal vein was also entire, having a small tumor adhering to its under part between it and the artery, the divided end of which was closed by a yellowish-green firm substance readily distinguishing it from the surrounding parts. On clearing the whole from the bone, and making a small circular opening into the tumor, which was elastic and covered with brown fibrous layers, it proved to be an aneurismal sac, smooth on the inside, containing florid arterial blood and some little coagula. The artery, on being carefully opened to the closed end, appeared to have been injured above the part divided by the ball, and communicated with the sac by a small fissure or rupture. The end of the artery was then slit up, so as to show the very little thickness of the closing substance and the great original contraction of the diameter of the vessel. There was no internal coagulum, neither was there any laid over the external part of the artery; between it and the bone there was a coagulum about the size of a small phial cork. The other end of the artery could not be found, from the gangrenous state of the parts.

Private P. Turnbull, of the grenadiers of the 74th Regiment, of good stature, was wounded on the 10th of April, 1814, at Toulouse, by a musket-ball passing from the inside to the outside of the middle of the thigh; he says it bled considerably at first, but the bleeding soon ceased; the wound was not painful, and he thinks he observed the leg and foot to be colder than the rest of his body for the first two or three days, but did not much attend to it, further than conceiving the numbness, coldness, and impeded power of motion as natural to the wound.

On the 18th of April, the gentleman in charge of this patient pointed him out to me as an extraordinary case of gangrene coming on without, as he supposed, any sufficient cause. The wound on the outside of the thigh, or the exit of the ball, was nearly healed, and that on the inside was without inflammation or tumefaction, and with merely a little hardness to be felt on pressure. The pulsation of the artery could be distinctly felt to the edge of the wound, but not below it; the leg was warm, the gangrene confined to the toes. The artery of the other thigh could be distinctly traced down to the tendon of the triceps. As he was at a small hospital, about two miles from town, on the field of battle, I did not see him again until the 20th, and afterward on the 23d, when, although the gangrenous portion included all the toes, it had the appearance of having ceased. Satisfied that it would again extend, I left directions with the assistant-surgeon that the limb should be amputated below the knee.

The surgeon, whom I had not seen, and who did not understand the subject, disobeyed the order, conceiving that there must be some mistake. On visiting the hospital, a little after daylight on the 25th, I was greatly annoyed at finding that the operation had not been done, and that the mortification had begun to spread the evening before. It was then too late. On the 26th it was above the ankle, with considerable swelling up to the knee. At night the man died; and the next morning, at six o’clock, I removed the femoral artery from Poupart’s ligament to its passage through the triceps, which part was affected by the mortification.

The ball had passed between the artery and vein in the spot where the vein is nearly situated behind it and adherent only by cellular membrane, through which the ball made its passage, the coats of the vein being little injured, and those of the artery not destroyed in substance, although bruised; it was at this spot much contracted in size, and filled above and below by coagula, which prevented the transmission of blood, and the vein above and below the wound was filled by a coagulum and was also impassable. This preparation is unique; it is perhaps the only one in existence proving the elasticity which vessels possess, and their capability of avoiding to a certain extent an injury about to be inflicted upon them. It is in the museum at Chatham.

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.