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

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.”