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

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.