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

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.

LECTURE XII.

MORTIFICATION, ETC.