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

206. When the ulnar artery is wounded in the hand, which is comparatively a superficial vessel, two ligatures should be placed upon it in the manner hereafter to be directed. When the opening is small, pressure may be tried.

207. When the radial artery is wounded in the hand, in which situation it is deep seated, the case requires greater consideration. When there is a large open wound, and the bleeding end or ends of the artery can be seen, a ligature should be placed on each; but this cannot always be done without more extensive incisions than the tendinous and nervous parts will justify.

208. When search has been made by incisions through the fascia, (as extensively as the situation of the tendons and nerves in the hand will permit,) which are best effected by introducing a bent director under it, the current of blood, through either the ulnar or the radial artery at the wrist, or even through both, should be arrested in turn by pressure, which in most cases of this kind will succeed, if properly applied, and thus show the vessel injured. The bleeding point should be fully exposed, and all coagula removed, when a piece of lint, rolled tight and hard, but of a size only sufficient to cover the bleeding point, should be laid upon it. A second and larger hard piece should then be placed over it, and so on, until the compresses rise so much above the level of the wound as to allow the pressure to be continued and retained on the proper spot, without including the neighboring parts. A piece of linen, kept constantly wet and cold, should be applied over the sides of the wound, which should not be closed so as to allow of any blood being freely evacuated; and if the back of the hand be then laid on a padded splint, broader than the hand, a narrow roller may be so applied as to retain the compresses in their proper situation, without making compression on or impeding the swelling of the adjacent parts, the fingers being bent, in order to relax the palmar aponeurosis—a proceeding which should never be neglected in any operation in the palm of the hand. It has been lately proposed by M. Thierry, a French surgeon, to raise and bend the arm, as a means of impeding the circulation where the artery passes over the elbow-joint, and the proposal deserves adoption, but not to the extent he recommends, which cannot be long submitted to. Pressure made at the same time on the radial or ulnar artery, or on both, by a piece of hard wood two inches long, shaped like a flattened pencil, is much more effectual, and more to be depended upon. When from the bones being broken, or the hand so swollen, or from other circumstances, pressure, however lightly and carefully applied, cannot be borne in the manner directed, and the attempts to secure the artery at the bleeding spot have failed, and pressure on the radial or ulnar artery has been equally unsuccessful, in consequence of the swelling or other circumstances, both may be tied at the wrist in preference to placing a ligature on the brachial artery, although that even must be done as a last resource, if the bleeding should still continue. If it be asked why not do this in the first, rather than in the last instance, the answer is, that it has so often failed to prevent a renewal of the bleeding from both ends of a wounded artery in the hand, that complete dependence cannot be placed upon it, particularly if there should be a division high in the arm of the brachial into the radial and ulnar arteries. When, however, the arteries leading to the wound have been secured, either by pressure or ligature, NEAR to the part, and the bleeding returns by the collateral circulation, which in the hand is so free, the arresting the supply of blood through the main trunk may and often has suppressed the hemorrhage, at all events for a sufficient time to enable the injured parts to recover themselves, provided the forearm is bent and raised, and the person kept at rest in the most restricted manner, without which this operation will in all probability fail. It is in these cases that the instrument alluded to, page 226, will be useful, rendering the ligature on the trunk of the vessel unnecessary, more particularly if the bleeding should appear to depend on some peculiarity in the structure of the coats of the artery.

209. When the obstacle to the application of pressure arises from the injured state of the metacarpal bone or bones, one or more should be removed, with the fingers if necessary, so as to expose a clear and new surface, on which the bleeding vessels may be seen and secured. In some cases, particularly if there should be a hemorrhagic tendency in the arterial system generally, as known from previous accidents, the first compress may be wetted with the perchloride of iron, the ol. terebinth., the dilute sulphuric acid, or the tincture of matico; these remedies may be also administered internally. Some new styptics have lately been much lauded in Malta and other places, but sufficient proofs have not been given of their efficiency.

210. When the radial artery is wounded as it turns from the back to the inside of the hand, to form the deep-seated palmar arch, it meets a branch of the ulnar nerve about to terminate in the muscles of the thumb. If the treatment by pressure above recommended should not succeed, the muscles forming what is called the web, between the thumb and metacarpal bone of the forefinger, should be cut through, and the bleeding vessel exposed. They are the adductor pollicis on the inside, and the abductor indicis on back of the hand.

LECTURE XIII.

WOUNDS OF THE ARTERIES, ETC.

211. The precept so strongly insisted upon, that no operation should be done on a wounded artery unless it bleed, and at the place from which it bleeds, has been particularly opposed with reference to the neck, the opponents believing that placing a ligature on the primitive carotid is an operation not attended with much risk, and that it may therefore be done as a precautionary measure when the wounded part does not bleed; this statement is an error. Of thirty-eight cases collected by Dr. Norris in 1847, in which this vessel was tied for aneurism, twenty-six died, and twelve suffered from affection of the brain, the frequency of which occurrence has been singularly overlooked by practical surgeons; although proving, in a very marked manner, that the operation of tying the primitive carotid is not a trifling affair, and that the success, when compared with the failures, is only as one and one. A much more important objection is the difficulty of deciding, in many cases of wounds of the neck, what artery is wounded, and what trunk should be tied; whether it be the external carotid or its branches, or the internal, or the vertebral artery. Errors have been committed on all these points by men of the greatest anatomical and surgical knowledge; the trunk of a sound artery having been tied instead of that of a wounded one, inflicting thereby on the patient a second and useless wound, more dangerous, perhaps, than the original one it was intended to relieve.

When Professor of Anatomy and Surgery to the College of Surgeons in 1830, I stated that in wounds of the neck which rendered it advisable to place a ligature on some part of the carotid, on account of the supposed impracticability of laying bare the bleeding orifice, it was generally the external carotid which should be secured, rather than the primitive trunk; there not being sufficient reason for cutting off the supply of blood to the head by the internal carotid, unless the operation on the external carotid should fail. This direction should be implicitly followed.