199. The principles laid down for the treatment of wounded arteries in the lower extremity are equally to be observed with respect to those of the upper. There is, however, little or no fear of mortification taking place in the upper extremity, the collateral circulation being more direct and free; while there is greater danger from this cause of hemorrhage from the lower end of the artery, if a ligature should not have been placed upon it, or if it should not be retained a sufficient length of time.
200. The error of placing a ligature on the subclavian artery above the clavicle, for a wound of the axillary below it, should never be committed. One person dies for one who lives after this operation, when performed under favorable circumstances, independently of the loss which may be sustained by a recurrence of bleeding from the original wound, which is always to be expected and ought to take place; when it does not happen, it is the effect of accident, which accident in all probability occurs from the state of absolute rest having been carefully observed.
201. The necessity for an aneurismal sac below the clavicle, and for its remaining and continuing to remain intact, until the cure is completed, when the subclavian artery has been tied above, is rendered unmistakable by the following case:—
Ambrose C. was admitted into the Charing Cross Hospital, in August, 1848, in consequence of a bruise from a sack of beans; there was axillary aneurism, extending under the pectoral muscle up to the clavicle. A ligature was applied in the usual situation on the outside of the scalenus muscle, and came away on the twenty-second day. The aneurismal sac suppurated, and burst three days afterward, when a quantity of pus and blood, partly fluid, partly coagulated, but very offensive, was discharged. The opening was enlarged, and everything appeared to be going on well, at which time I saw him. On the nineteenth day after the ligature came away, I visited him again with Mr. Hancock, and merely observed that he must keep himself very quiet, and I thought he would do well. In the evening he died from hemorrhage, while eating some gruel. On examination after death, the artery was found to be sound, except where it communicated with the sac by an opening three-quarters of an inch in length. The ligature had been applied midway between the thyroid axis and the first of the thoracic branches. There was a small coagulum, of half an inch in length, both internal and external to the ligature, but not extending to the branch above or below it. The artery was of its natural size as far as the remains of the sac, but beyond it the axillary artery was diminished; the remains of the sac were void of coagulum, except where it communicated with the artery, to which opening a small coagulum had adhered, but had given way at its lower part, and thus caused his death. Between the opening and the ligature, five large branches entered into or were given off by the artery, and through some of these blood was brought round by the collateral branches in an almost direct manner, so that the man’s life depended on the resistance offered by the small coagulum after the sac had given way; proving in an exemplary manner the value of the sac remaining entire.
If this case will not convince the incredulous, it would be useless to bring even the sufferers in such cases from their graves, to affirm the fact of the inapplicability of the theory of aneurism to the treatment of a wounded artery—of the impropriety of placing a ligature on the subclavian artery above the clavicle, for a wound of the artery below it.
Corporal W. Robinson, 48th Regiment, was wounded at the battle of Toulouse, by a piece of shell, which rendered amputation of the right leg immediately necessary, and so injured the right arm as to cause its loss close to the shoulder-joint eighteen days afterward. At the end of a month the ligatures had separated, and the wound was nearly healed, although a small abscess had formed on the inside, near where the upper part of the tendon of the pectoralis major had been separated from the bone. Sent to Plymouth, this little abscess formed again, and was opened on the 2d of August, three months after the amputation. The next day blood flowed so impetuously from it as to induce the surgeon to make an incision, and seek for the bleeding vessel, which could not be found. The late Staff-Surgeon Dease, warned by the case of Sergeant Lillie, (page 198,) strongly objected to the subclavian artery being tied above the clavicle, and, true to the principle inculcated at Toulouse, advised the application of a ligature below the clavicle on a sound part of the artery, but as near as possible to that which was diseased. The operation was done by the senior officer, Mr. Dowling, who carried an incision from the clavicle downward through the integuments and great pectoral muscle, until the pectoralis minor was exposed. This was then divided, and a ligature placed beneath it on the artery where it was sound, at a short distance from the face of the stump, where it was diseased. The man recovered without further inconvenience.
202. In all those cases in which it has been supposed necessary to place a ligature on the artery above the clavicle, after a failure in the attempt to find the artery below it, the failure has occurred from the error committed in not dividing the integuments and great pectoral muscle directly across from the lower edge of the clavicle downward. It is quite useless dividing these parts in the course of the fibers of the muscle, and the case of Robinson is the model on which all such operations should be done. If this operation had not succeeded, the ligature of the artery above the clavicle was a further resource; but as the artery was sound below, with the exception of the end engaged in the face of the stump, the operation was successful; no doubt should be entertained in such cases of the propriety of an operation which is attended with little risk, compared with that which destroys one man for every one it saves.
203. Punctured wounds of the arteries of the arm and forearm ought to be treated by pressure applied especially to the part injured, and to the limb generally; but when the bleeding cannot be restrained in this manner, in consequence of the extent of the external wound, the bleeding artery is to be exposed, and a ligature applied above, and another below the part injured, whether the artery be radial, ulnar, or interosseal.
204. When the external wound closes under pressure, and blood is extravasated in such quantity under the fascia and between the muscular structures as is not likely to be removed by absorption under general pressure, the wounded artery should be laid bare by incision and secured in a similar manner, even at the expense of any muscular fiber which may intervene.
205. When an aneurismal tumor forms some time after such an accident, in the upper part of the forearm in particular, the application of a ligature on the brachial artery is admissible, on the Hunterian principle.