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

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.