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.