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 XI.

THE FEMORAL ARTERY, ETC.

189. When the femoral artery is cut across in the upper part of the thigh, whether it be done by a cannon-shot, a musket-ball, or a knife, the patient does not always bleed to death at once, although he frequently dies after a time in consequence of the shock and the loss of blood.

At the battle of Toulouse a large shot struck an officer and two men immediately behind him, and nearly tore off the right thigh of each. The artery was divided about, or less than three inches below Poupart’s ligament. I saw the officer shortly afterward, in consequence of his surgeon saying it was a case for amputation at the hip-joint. The bleeding had ceased, the pulse was feeble; the countenance ghastly, bedewed with a cold sweat, and with every indication of approaching dissolution. The house being at an advanced point, and close to one of the French redoubts, the fire of round shot and musketry was so severe upon and around it as to induce me to remain, until the battery should be taken by the troops then advancing upon our flank. In order to occupy my time usefully, I returned to the officer, and found he had just expired. Desirous of seeing by what means the hemorrhage had been arrested, I cut down upon the artery, took it carefully out, and found that its divided end was irregularly torn; a slight contraction had taken place just above, but not sufficient to have been of the slightest utility in suppressing the bleeding, which was in fact prevented by an external coagulum, which filled up the ragged extremity of the vessel, and which in a few days, if he had lived, would have been removed with the purulent discharge, an internal one forming in the mean time, the extremity of the artery also contracting and retracting, so that a secondary hemorrhage might not have taken place, indeed would not in the generality of instances.

At Salamanca I had the opportunity of examining the thigh of a French soldier, whose femoral artery had been divided perhaps even higher up by a cannon-shot. He lived until the next morning, when I saw him, no operation whatever having been attempted, nor a tourniquet applied. He died exhausted, but not from any immediate bleeding, which, when once stopped, had not returned. The artery was in a similar state to the preceding one, with this slight difference, that the orifice was a little more contracted; the external coagulum filled up the ragged end of the artery, and was slightly compressed within by the contraction, which kept it in its place. The rest of the coagulum filled the hollow in the surrounding parts, which the retraction of the artery had occasioned. In this case, so unlike those I have hitherto noticed, the first natural cause giving rise to the suppression of the bleeding was the diminution of the power of the heart; the second, the formation of a coagulum in the hollow of the sheath left by the retraction of the artery. Contraction had begun, but had done nothing essential. (See Aph. 413.)

In other instances in which I have examined the extremities of such large arteries when divided, the appearances have been more or less of a similar nature; unless where the persons had died immediately, when the torn extremities were found quite open, with little surrounding coagulum. I have, however, seen persons wounded in this manner live for several days, when I have found, after death, the extremity of the artery open, and no appearance of blood having passed into it below Poupart’s ligament. The consent necessary between the inner coat of the artery and the blood for the free passage of blood had been destroyed by the injury.

190. A small puncture in an artery, made with a needle, will sometimes heal, as it generally does in dogs. I have, however, seen several instances in which the femoral artery was wounded by a tenaculum, during amputation, and a secondary hemorrhage followed, requiring the application of a ligature. A larger puncture, or a longitudinal slit of from one to two lines in extent, does not commonly unite, except under pressure, although the edges of the wound may not always separate so as to allow blood to issue in any quantity. It sometimes only oozes out, and occasionally does not do even that, unless some obstacle to the circulation takes place below, when blood is propelled with a jet; and the edges of the cut having thus been separated, blood continues to be thrown forth in considerable quantity. In an artery of the size of the temporal, a small longitudinal slit may sometimes heal without the canal of the artery being obliterated, although this very rarely takes place in one of a large calibre.

In all cases of punctured wounds, when pressure can be effectually made, and especially against a bone, it should be tried in a graduated manner over the part injured, in the course of the artery above and below the wound, and if in an extremity, over the whole limb generally, the motions of which should be effectually prevented, and absolute rest enjoined, if the artery is of any importance. This should be continued for two, three, or more weeks, according to the nature of the injury.

A medical student, being desirous of bleeding his friend, also a student, in the arm, opened the ulnar artery, which in this case was very superficial. On discovering the error he had committed, he closed the wound, and applied a firm compress and bandage, under which it healed. On applying the ear to the part, it sounded like an aneurism, although there was scarcely any tumor, the thrilling sound being apparently occasioned by friction against the cut edges of the artery. This thrilling noise diminished, and the vessel immediately below the wound gradually recovered its pulsation, except at the exact situation of the injury, where none could be distinguished. It was obliterated at that part for the length of the eighth of an inch.

The master tailor of the 40th Regiment, tempted by the approaching prospect of plunder, was induced, on the night of the assault on Badajos, to give up the shears, and arm himself with the halbert, and was properly rewarded for his temerity by a wound from a pike in the right arm, from which, he says, he bled like a pig, and became very faint. On his arrival at the spot indicated for surgical assistance, he fainted; but this was attributed to the unwarlike propensities of the man, rather than to any sufficient cause. The wound was not more than one-third of an inch long, a little below the edge of the pectoralis major, and immediately over the artery. The arm and hand were numb and cold; the pulse was not distinguishable at the wrist, and it appeared to cease at the place of injury, which was harder and a little more swollen than natural. He said that his pulse had always been felt by the doctors in the usual place. The wound healed without any trouble. On the 1st of May the pulsation of the artery could be felt a little below the wound. On any exertion he had a good deal of unpleasant numbness in the thumb and forefinger. A small cicatrix formed at the place of the wound, which was otherwise quite natural to the touch. This case proves that when a large artery is wounded in man by a sharp cutting instrument, to a certain but moderate extent the process of cure takes place through inflammation and by the obliteration of that part of the canal of the vessel. Continental surgeons have since sacrificed whole hecatombs of animals to prove this fact, which had been so many years before recorded in England as having occurred in man.

It has not been satisfactorily proved in man that a large artery, such as the femoral or even the brachial, has been opened to the extent of one-third or a fourth of its circumference, and that the wound has healed without the canal becoming impervious. A smaller wound of a large artery may close without obstructing the canal of the vessel, but the part is not so firm or so solid as before, and may yield, and give rise to an aneurism, having apparently the characters of a small true, as opposed to the spurious diffused, or even circumscribed swelling, which more usually follows a similar accident.

Colonel Fane was wounded by an arrow in the right side of the neck, opposite the bifurcation of the carotid, which caused a considerable loss of blood at the moment. The wound healed, leaving only a mark where the point of the arrow had entered. Some time afterward he observed a small swelling at the part, which, from its pulsation, was declared to be an aneurism. Uneasy about it, he asked my opinion at Badajos, after the siege. It had not increased, but it caused him some anxiety, and I promised to place a ligature on the common carotid if the aneurism should increase in size. He was unfortunately killed in action a year afterward, by a shot through the head.

191. When a large artery, such as the brachial, is cut transversely to a fourth of its circumference in man, it forms a circular opening as in animals; and if the artery be large, the bleeding usually continues until the person faints, or it is arrested by pressure. In dogs the bleeding commonly ceases without any assistance from art, and without the animal being exhausted; in horses and sheep the bleeding usually continues till the animals die; while in man, even with the best aid from compression, hemorrhage will in all probability recur, unless the circulation be altogether arrested. If the external opening only should be closed, a spurious, circumscribed aneurism will be the consequence in so small an artery as the temporal, and a ligature will sometimes be required above and below a little aneurism of this description. In a larger artery the spurious aneurism may or may not be diffused.

When an artery of this size is completely divided, it is less likely to continue to bleed than if it had been only wounded. When it is merely cut or torn half through, but not completely divided in the first instance, it is in the same state with regard to hemorrhage as if it had partially given way by ulceration. It can neither retract nor contract, and will continue to bleed until it destroys the patient, unless pressure be accurately applied and maintained until further assistance can be procured. The practice to be pursued is to divide the vessel, if it be a small one, such as the temporal artery, when it will be enabled to retract and contract; and the bleeding will in general permanently cease under pressure, especially when it can be applied against the bone. If the artery is of a larger class, and continues to bleed, it should be sufficiently exposed by enlarging the wound; a ligature should be applied above and below the opening in the vessel, which may or may not be divided between them at the pleasure of the surgeon.

In June, 1829, I happened to be at Windsor, on a visit to my old friend, the late Dr. Ferguson, and was called to a young gentleman, the upper part of whose right femoral artery had been accidentally cut by the point of a scythe. On dilating the wound, a tourniquet being on the limb, black blood flowed freely from it; on unscrewing the tourniquet by degrees, arterial blood showed itself, and the upper end of the artery was secured by ligature when the tourniquet was removed. Venous-looking or black blood then again flowed in greater abundance than before, evidently from a large vessel. This I restrained by pressure made below the wound with the thumb of the left hand, while I laid bare the lower part of the artery, from a slit in which, near an inch in length, the black blood was seen to flow. A ligature passed around the vessel below the wound suppressed the bleeding. The artery was not divided, and the young gentleman perfectly recovered, and has continued well until this day. The absolute necessity for two ligatures was here well shown, as well as the flow of dark-colored blood from the lower end of the artery. This gentleman is now an officer in the army, and suffers no inconvenience from his accident.

192. When a large artery is wounded at some depth from the surface, and the external opening is small, blood not only issues through the opening, but is often forced into the cellular structure of the limb to a considerable distance; the pulsation of the tumor is observable, and the thrill or sound which accompanies a ruptured artery is distinct. If a large quantity of blood, partly in a fluid, partly in a coagulated state, be collected immediately over and around the wound in the artery, the tumor may not pulsate or give forth any sound, if the coagulated blood be in considerable quantity, although some elevation of the tumor may be observed corresponding to the pulse.

This rising or pulsation of the swelling often depends on the impulse given to the whole, as a mass, by the artery against which it is lying, and not upon blood circulating through it. An impulse of this kind is distinguishable in a bronchocele which lies immediately over and in contact with the carotid artery. It is the same when blood is extravasated by the rupture of several small vessels, in consequence of the passage of a wheel over the limb, especially in the thigh, where a swelling containing fluid blood will sometimes pulsate in a well-marked manner, until it gradually diminishes as the blood coagulates, when the motion becomes a mere elevation at each stroke of the heart. The whizzing sound or thrill attendant on a ruptured artery is in these cases wanting, being a very diagnostic mark of this accident; although where there is true aneurism, and it has burst, forming a diffused and spurious one, the thrill may be wanting; but the history of these cases enables a surgeon to distinguish between them. If several ounces of blood are thrown out, and remain fluid, they ought to be evacuated, or suppuration will ensue. If they become coagulated, the mass will be gradually absorbed. Fluid blood should be evacuated by a small opening, and the part afterward treated by compress and bandage. If the fluid or partly coagulated blood should increase in quantity, and the swelling continue to enlarge and pulsate, the extension of the mischief should be arrested by opening the swelling and securing the artery by ligature. When the external opening is enlarged, and the clots which filled it up are at all disturbed, arterial blood begins to flow, and the finger will readily follow the track through which it passes down to the artery, if it should not be too far distant. If the incision be made sufficiently large to enable the operator to remove these clots of blood with rapidity, the finger will more readily pass down to the wound in the artery, which, if a large one, may be thus easily discovered, if within reach and sight, provided the tourniquet be thoroughly unscrewed, and the surgeon is not afraid. A ligature should then be placed above and below the opening in the artery.

When an artery is wounded, and the external opening in the integument heals so as to prevent the blood from issuing through it, a traumatic, spurious, circumscribed, or diffused aneurism is said to form, according to the facility which is offered by the structure of the parts for the confinement or diffusion of the extravasated blood. A traumatic aneurismal tumor of this nature differs essentially from aneurism which has taken place as a consequence of disease, and not of direct injury. If a spurious aneurism form from disease, the artery is in general unsound for some distance above and below the tumor. In the aneurismal tumor from a wound, the artery is perfectly sound, except as far as concerns the seat of injury. There is, then, not only a great and essential difference between these two kinds of aneurism as regards their nature, but also with respect to the collateral circulation, and the operation to be performed for their cure; and the surgeon may not overlook these facts.

A school-boy, about fourteen years of age, let a pen-knife drop from his hand while sitting down, and drew his knees suddenly toward each other to catch the falling knife; the point was thus forced into the inner and middle part of the thigh, and wounded the femoral artery. The medical man on the spot put a plaster on the little incision in the integuments, and the wound quickly healed. The boy complained of uneasiness, but was supposed to be making more of it than necessary, and was made to go into school as usual. The limb, however, began to swell, and the boy was brought to London, supposed to be suffering from abscess, and placed under the care of Mr. Keate, who, suspecting the evil, carefully introduced the point of a lancet, and, after a clot of blood had been forced out, a jet of arterial blood flew across the room. The hemorrhage was arrested by pressure below Poupart’s ligament, while Mr. Keate enlarged the opening in the integuments, and removed two washhand-basinsful of coagulated blood. He then put his finger on a large opening in the artery, under which two ligatures were passed by means of an eye-probe, and the artery was divided between them. The muscles had been cleanly dissected, and the cavity extended from the fork internally, and trochanter externally, to the knee. There was much less suppuration than could have been expected. The ligatures were detached about the usual time, and the patient entirely recovered.

This admirable case should be imprinted on the mind of every surgeon. With the hope that it will be so, I refrain from commenting on three or four cases which have occurred within the last two years, in which, from neglect of the precept inculcated by it, very distressing if not fatal consequences ensued.

193. There is no precept more important than that which directs that no operation should be done on a wounded artery unless it bleed, inasmuch as hemorrhage once arrested may not be renewed, in which case any operation must be unnecessary. The following case shows how firmly the principles on which wounded arteries ought to be treated were fixed in my mind in the year 1812; and there is no case during that eventful period to which I look back with more satisfaction than the following:—

John Wilson, of the 23d Regiment, was wounded at the battle of Salamanca by a musket-ball, which entered immediately behind the trochanter major, passed downward, forward, and inward, and came out on the inside of the anterior part of the thigh. The ball could not have injured the femoral artery, although it might readily have divided some branch of the profunda. Several days after the receipt of the injury, I saw this man sitting at night on his bed, which was on the floor, with his leg bent and out of it, another man holding a candle, and a third catching the blood which flowed from the wound, and which had half filled a large pewter basin. A tourniquet with a thick pad was placed as high as possible on the upper part of the thigh, and the officer on duty was requested to loosen it in the course of an hour; that was done, and the bleeding did not recommence. The next day, the patient being laid on the operating table, I removed the coagula from both openings, and tried to bring on the bleeding by pressure and by moving the limb; it would not, however, bleed. As there could be no other guide to the wounded artery, which was evidently a deep-seated one, I did not like to cut down into the thigh without it, and the man was replaced in bed, and a loose precautionary tourniquet applied. At night the wound bled smartly again, and the blood was evidently arterial. It was soon arrested by pressure. The next day I placed him on the operating table again, but the artery would not bleed. This occurred a third time with the same result. The bleedings were, however, now almost immediately suppressed, whenever they took place, by the orderly who attended upon him; care having been taken to have a long, thick pad always lying over the femoral artery, from and below Poupart’s ligament, upon which he made pressure with his hand for a short time. Absolute rest was enjoined. The hemorrhage at last ceased without further interference, and the man recovered.

This case was one of considerable interest at the time, and is the model one on which the treatment of all such injuries should be founded. If the wound had bled, I should have introduced my finger, and enlarged it transversely, continuing the incision until the opening was sufficiently large to see to the bottom of the wound or the bleeding part. It is necessary in such cases to be attentive to the course of the great vessels and nerves, but not to the safety of muscular fibers, the division of which leads to no permanent injury. As pressure on the main trunk led to the ultimate suppression of the hemorrhage, it may be said that a ligature placed high up on the femoral artery would not only have done the same, but would have relieved the man from the anxiety necessarily dependent on the momentary fear of a recurrence of the hemorrhage. There are two objections to this method of proceeding: the likelihood of mortification taking place, which in similar cases has been known to occur; and the possibility of the hemorrhage being renewed through the anastomosing branches. The temporary suspension of the circulation by pressure does little or no harm, more particularly where the pad used is so thick and narrow as to cause it to fall principally on the artery, and only in a slight degree on the surrounding parts, which by a little attention may be readily accomplished. It is not then good practice to cut down upon an artery on the first occurrence of hemorrhage, unless it be so severe or so well marked as to leave no doubt of its being from the main trunk of the vessel itself; nor is it then advisable to do so, except the artery continue to bleed; for many a hemorrhage, supposed to have taken place from the main trunk of an artery, has been permanently stopped by a moderately continued pressure exercised in the course of the vessel, and sometimes on the bleeding part itself; particularly if the blood be of a dark color, indicating that it comes from the lower end of the vessel.

A painter could not have had a better subject for a picture illustrative of the miseries which follow a great battle, than some of the hospitals at Salamanca at one time presented. Conceive this poor man, late at night, in the midst of others, some more seriously injured than himself, calmly watching his blood—his life flowing away without hope of relief, one man holding a lighted candle in his hand, to look at it, and another a pewter washhand-basin to prevent its running over the floor, until life should be extinct. The unfortunate wretch next him with a broken thigh, the ends lying nearly at right angles for want of a proper splint to keep them straight, is praying for amputation or for death. The miserable being on the other side has lost his thigh; it has been amputated. The stump is shaking with spasms; it has shifted itself off the wisp of straw which supported it. He is holding it with both hands, in an agony of despair. These Commentaries are written to prevent as far as possible such horrors; and they may be prevented by efficient and well-appointed medical officers; but there must also be greater attention to these points than has hitherto been given by the government of the country.

Don Bernardino Garcia Alvarez, captain of the regiment of Laredo, thirty years of age, was wounded at the battle of Toulouse by a musket-ball, which passed through the thigh, a little above its middle. The wound was not considered a dangerous one until the 30th, twenty days after the injury, when a considerable bleeding took place; and as the vessel from which it came seemed to be very deeply seated, the Spanish surgeon in charge tied the common femoral artery. I saw the gentleman in consequence of this having been done. The hemorrhage was suppressed by the operation, and the limb soon recovered its natural temperature, but gangrene made its appearance on the great toe on the third day afterward. It did not seem to increase, but the limb swelled as if nature were endeavoring to set up sufficient action to maintain its life; and this continued until the tenth day after the operation, when he died, completely exhausted. On the dissection of the limb, the femoral artery was found to be perfectly sound in every part below where the ligature had been applied. The vessel which bled could not be discovered; but it was certainly a branch from the profunda, and not the femoral itself. In this case the ligature of the femoral artery destroyed the patient, and the practice pursued must be condemned. The gunshot wound should have been largely dilated, at both orifices if necessary, until the wounded vessel was discovered, which possibly had not been completely divided by the ulcerative or sloughing process which had taken place, and its division would in all probability have suppressed the bleeding.

A young gentleman, aged twelve, accompanying his brothers shooting, in December, 1844, was struck in the upper part of the left thigh by a duck-shot, which entered about three inches below Poupart’s ligament, a little to the inner side of the femoral artery. He bled until he fainted, and was taken home. There was no return of the bleeding for three days, during which time the limb was exceedingly painful, and soon began to enlarge. After this occasional and considerable bleedings took place, the limb still continuing to increase in size. Fomentations and poultices were applied; irritative fever set in, and the pain was intense. At the end of a fortnight the small hole made by the shot appeared to be healed over by a thin skin of a blue color, which tint extended for some distance. The limb was enormously swollen, with a feeling of distention, which induced the surgeon to puncture the most prominent part with a lancet. After some clots of blood had been removed, an alarming arterial hemorrhage took place. The femoral artery was now tied high up, below Poupart’s ligament. The bleeding was in some measure restrained, but not suppressed, and after a short time it returned at intervals with augmented violence, until death ensued, three weeks after the accident.

Remarks.—If an incision had been made into the thigh in the course of the wound when the bleeding returned on the third day, and both ends of the wounded artery had been tied, the boy would in all probability have recovered. The ligature placed on the femoral artery above the wound in it did restrain for a short time the flow of blood, but could not prevent its flowing from perhaps both ends of the vessel, until it destroyed the patient. A ligature on the external iliac would only have caused it to be deferred for a day or two, until the collateral branches had enlarged, or else he would have died of mortification.

This really formidable case shows most distinctly the necessity for always observing the rule of tying the wounded artery at the part injured, in order that the mistake may not be made of placing a ligature on the wrong artery—the constriction of which may cost the patient his life, while it may not prevent a return of the bleeding. It also shows that no loss of blood from a diffused aneurism can equal the danger which must be encountered, and the mistakes which may be made, by not laying it open, and seeing the hole in the artery, or its divided extremities.

Captain Seton, a short man, fat of his age, was wounded in a duel, in 1845, in the upper part of the right thigh, a little above and in front of the great trochanter, the wound being continued across the thigh, its internal opening being about the middle of the fold of the left or opposite groin. He lost a great deal of blood at the time, the issue of which ceased on his fainting. Ten days after the duel his countenance was blanched, his pulse rather quick and feeble. On examining the wounds, that on the right hip (the opening of entrance) was circular, filled with a dry, depressed slough, and there was a narrow, faint blush of redness round its margin. In the left groin the opening of exit was marked by a jagged slit, already partly closed by a thin cicatrix. There was extensive mottled purple discoloration (ecchymosis) of the skin in both groins, and over the pubes, scrotum, and upper part of the right thigh. In the right groin was found a large, oval, visibly pulsating tumor, its long diameter extending transversely from about an inch and a half on the inner side of the anterior superior spinous process of the ilium to about opposite the linea alba, and its lower margin projecting slightly over Poupart’s ligament into the upper and inner part of the thigh. On handling this tumor, it appeared elastic but firm, very slightly tender, and not capable of any perceptible diminution in bulk by gradual and continued pressure. The pulsation was distinct in all parts of the swelling, and was equally evident whether the fingers were pressed directly backward, or whether they were placed at its upper and lower margins, and pressed toward the base of the tumor, in a direction transversely to its long axis, the parts being for the time relaxed. The femoral artery was slightly covered by the swelling, and the pulsations of that vessel were with some difficulty distinguished in the upper third of the thigh, below the margin of the tumor. This appeared to depend partly on the natural obesity of the patient, and partly on a considerable degree of general swelling of the thigh. Pressure on the femoral artery or over the abdominal aorta did not arrest the pulsation in the tumor, and in the former situation was attended with severe pain. Under these circumstances it was deemed advisable to apply a ligature on the external iliac artery, and give the patient a chance of the occurrence of coagulation in the tumor, and closure of the wounded vessel, before the free re-establishment of the circulation through the femoral artery. In the present case it was supposed that mortification of the limb was all the less likely to occur from the circumstance that the greater part of the effusion appeared in front of the abdominal parietes, and therefore exercised less pressure on the femoral vein than if further extension into the thigh had taken place. The danger of peritonitis was by this proposal made a new element in the calculation; but it was estimated that the chances of this and of mortification of the limb, taken together, were less unfavorable than the chances of immediate and secondary hemorrhage attaching to the operation of tying the artery at the spot injured. The operation being completed, the right foot, leg, and thigh were enveloped in lamb’s-wool and flannel, and the limb elevated on an inclined plane of pillows, so as to favor the return of blood as much as possible, and prevent venous congestion. The day on which the operation was performed was passed in considerable pain, the patient being restless, and complaining of a sense of burning in the limb. An anodyne, however, secured him a tolerably good night’s rest. The day after the limb was found altogether diminished in bulk, and its temperature equal to that of the healthy limb; no return of pulsation had taken place in the tumor. The same evening some tenderness and tension of the abdomen came on, though the bowels had been kept in a regular state by occasional small doses of castor-oil. In the morning of the second day, pain in the belly, with increased tension, hurried breathing, short, dry cough, and tenderness over the lower part of the abdomen, were observed. Pulse quicker and small. Leeches were applied, and three-grain doses of calomel, with a little Dover’s powder, ordered every three hours. The symptoms, however, became rapidly worse; the patient complained of severe pain in the right leg, and a sensation of great heat over the whole body, although the actual temperature was rapidly falling below the natural standard. The right leg also became cold sooner than the left. At seven P.M. he became more easy, and expressed an opinion that he should “do well;” but in little more than half an hour he expired.

Examination after death.—Swelling and ecchymosis of the right thigh, particularly at the upper part, and in the right iliac region; also swelling and ecchymosis of the scrotum, chiefly in the right side, with general tumefaction of the abdominal parietes below the umbilicus. A wound into which the little finger could be passed was on the upper and outer aspect of the right thigh, about three inches below the crest of the ilium and about an inch nearer the mesial line than the great trochanter, and on the left side another smaller wound, situated about the external aperture of the left spermatic canal. The first-mentioned wound was open; the lips of the latter were partially adherent. The course of the wound was traced from the outside through a dense layer of fat about two inches in thickness, (on an average.) It had divided one of the superficial branches of the femoral artery, about half an inch below Poupart’s ligament, and about an inch from the main body of the femoral artery; this had caused a false aneurism. The sac contained about three ounces of blood. Blood was also effused into the cellular structure of the scrotum, and downward beneath the sartorius muscle. The wound passed through the cellular tissue, across the pubes, and emerged about the situation of the left external spermatic ring, without having divided the cord on either side, and was quite superficial to the bladder. No other artery appeared to have been wounded. When the parietes of the abdomen were reflected, a considerable quantity of sero-purulent fluid was found in the abdominal cavity; and on different parts of the large and small intestines patches of acute inflammation were observed, particularly on the ascending arch of the colon. The peritoneum adjoining the wound of the operation was inflamed, and approaching to gangrene: it had not been injured by the knife during the operation. The intestines were unusually large, and distended with flatus. The other abdominal viscera were healthy, but loaded to an extraordinary degree with fat. The ligature had been properly applied to the iliac artery; the vein was not injured; the surface of the wound and the cellular tissue in the neighborhood of the artery were sloughy. There was some enlargement of the right limb, but apparently no mortification. The femoral artery was pervious; the course of the wound was through a bed of fat, fourteen inches in length, and three inches in depth, over the pubes, and no muscular substance was injured; the blood found in the aneurismal sac was firmly coagulated, and there was no mark of recent oozing from the injured artery.

Remarks.—If this gentleman had been wounded at the foot of the breach in the wall of Ciudad Rodrigo, in January, he might, to his great dissatisfaction, have been one of eleven officers whom I saw lying dead, and as naked as they were born, on the face of the breach of Badajos, in April. He would have been saved by one doctor, or an old woman, and a little cold water, in 1812, and did die of seven in 1845, after an operation most brilliantly performed, but done in the wrong place, even if any operation had been necessary, which it was not. The case is an experimentum crucis of principles.

The first error committed in this case was in calling and believing a wounded artery to be a circumscribed, false, or diffused traumatic aneurism. Nothing can be called an aneurism, by which word a dilated vessel or a diseased shut or closed sac is understood, which has one or more holes in it, made by a ball, or by anything else, the wound or track of which remains open. It is simply a case of wound in which an artery has been divided or injured, and while this track of the ball remains open, no ingenuity of argument can make it otherwise. When the external openings made by the ball have closed, the case may then be called, if there be a collection of blood, whether fluid or coagulated, one of circumscribed, false, diffused traumatic aneurism, or anything else that philologists may please to designate it. The dissection report proved this case to be simply a small collection of blood, three ounces and a half, or seven small tablespoonfuls—communicating with two open wounds. Calling this an aneurism, or a shut sac of any kind, was then the first and fundamental error, as fatal as erroneous.

The second error consisted in the belief, contrary to all experience, that any sac or bag, or collection of blood by whatever name it may be called, having two openings leading to, or into it, and communicating with the atmosphere, could be augmented to any dangerous extent by the further pouring out of blood from an artery of any size, or from any artery at all, without some of such extravasated blood being discharged or forced out through one or both of the open external wounds in sufficient quantity to show that the opening in the vessel was not closed.

The first two errors, or defects of principles, gave rise to the third, viz.: the belief that an operation was necessary where none was required, the dissection having proved that the whole idea of the nature of the injury was a mistake: there was no large artery wounded; the small one, which had been wounded, had ceased to bleed; the quantity of blood extravasated did not exceed seven small tablespoonfuls. The third mistake could not have taken place if the first two errors had not been committed.

The fourth error occurred from its being taken for granted that the femoral artery was wounded; and that ascertaining the fact by opening the small swelling which contained only three and a half ounces of blood, would be followed by a fatal hemorrhage; which supposition arose from this swelling receiving a pulsatory motion from its vicinity to the femoral artery—a mistake which should not have occurred; for it had long before been said, (page 16 of my published lectures:) “The motion or pulsation of the swelling often depends on the impulse given to the whole as a mass, by the great artery against which it is lying, and not upon blood circulating through it. When blood is extravasated by the rupture of small vessels in consequence of the passage of a wheel over the limb—especially in the thigh, where I have seen a swelling containing fluid blood pulsate in an almost alarming manner, until it gradually diminished as the blood coagulated, when the motion became a mere elevation at each stroke of the heart—the whizzing sound or thrill attendant on a ruptured artery (of a size to require a ligature being understood) is in these cases wanting, constituting a very distinguishing mark of this accident.”

Surgeons fifty years ago were afraid of hemorrhage from the femoral artery, but the practice of the Peninsular war dissipated such fears. The reason given for not laying open the wound, and looking at the bleeding artery, in this case, is ingenious, but not tenable. The patient is said to have lost a large quantity of blood; and if this were even a fact, which may, however, be doubted, is there a case on record of a serious wound of the femoral artery, such as this was supposed to have been, in which that vessel has been successfully secured by ligature, without the patient having equally lost so large a quantity of blood as to be supposed to be about to die? It has always been so; the reason, however specious, is not valid, and cannot be admitted.

The fifth error arose from imagining that the considerable loss of blood supposed to have taken place would have rendered the patient incapable of bearing more; for it is a recorded fact that those operations high up on the femoral artery, from which patients have recovered, have never been done without great losses of blood having been previously sustained; and if the patient was so weakened that his heart and arteries could not bear the abstraction from their contents of a few ounces more blood—supposing such loss to be inevitable—how could they have power to drive or force the blood through the limb by the collateral channels, in a manner sufficient to support its life, when the main trunk was cut off within the pelvis? They could not do it—they have rarely done it under such circumstance; they could not have done it in this case; and if the patient had not died within the first forty hours of inflammation of the peritoneum, to which accident he ought not to have been exposed, he would have died of mortification within forty hours more, which had already commenced, as shown by the swelling of the limb and pain in the calf of the leg, which almost invariably attend such mortification.

The sixth error consisted in the belief that if the femoral artery had been wounded, a ligature on the external iliac would have permanently arrested the bleeding. It would, in all probability, have done no such thing, beyond a day or two—perhaps even only for the moment. It is a delusion, persisted in notwithstanding the most clear and positive proofs to the contrary. The patient will die of mortification from the want of blood in the limb, if the circulation be not re-established; and if this should take place, blood must find its way into the lower end of the wounded artery, and perhaps even into the upper, and renew the hemorrhage.

If the femoral artery had been wounded, as was supposed in this case, but not completely divided, it must and would have continued to bleed through the external wound, until the patient died, or a ligature had been placed upon it. It has been said that, in the case as it actually occurred, the little artery, which was divided and which had not bled for some days, could not have been safely tied, if it had bled again, because it was only an inch long; but this is said in defiance of every sort of proof which has been given to the contrary.

As far back as 1815 I said: “There was no foundation for the theory which declared that a ligature when placed on an artery such as the femoral would fail, if in the immediate vicinity of a collateral branch, in consequence of the flow of blood through this vessel preventing the obstruction and consolidation of the main branch for a distance sufficient to enable it to resist the impulse of the blood behind.” This was said from pure practical facts, free from all kinds of theory; and the preparation before alluded to, in the museum of the College of Surgeons, in which I tied the common iliac artery, will show the mark of a simple thread around it, and a single line of adhesion resisting the whole power of the heart, the canal above the spot not being obliterated.

The seventh error committed in this case was in contravening the great surgical precept, formed on no inconsiderable experience during the early part of the war in the Peninsula, “not to perform an operation on an artery until it bleed.”

194. When a wound occurs in the thigh, implicating the femoral artery or its branches, and the bleeding cannot be restrained by a moderate but regulated compression on the trunk of the vessel, and perhaps on the injured part, recourse should be had to an operation, by which both ends of the wounded artery may be secured by ligature; and the impracticability of doing this should be ascertained only by the failure of the attempt. If the lower end of the artery cannot be found at the time, the upper only having bled, a gentle compression maintained upon the track of the lower may prevent mischief; but if dark-colored blood should flow from the wound, which may be expected to come from the lower end of the artery, and compression does not suffice to suppress the hemorrhage, the bleeding end of the vessel must be exposed, and secured near to its extremity.

The instruments which have been invented for the cure of aneurism, by compressing the main trunk of the artery, will be found eminently useful, if applied with care, in many cases of hemorrhage in which it may be doubtful what vessel is actually injured, as in the case of Wilson, page 215, and in cases also of wounds of the hand or foot in which bleeding occurs through the medium of collateral branches. These instruments, although they cannot conveniently be placed in the capital cases of instruments, should be in store, whether with divisional or general hospitals.