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Mr. Guthrie has had many cases of injury of the femoral artery from smaller projectiles under his care. When the artery has been completely cut across in the middle or lower part of the thigh, the patient has either died without assistance, or the hæmorrhage has ceased spontaneously. He has not met with an instance in which it has been necessary to tie the femoral artery after it had been divided and the hæmorrhage had ceased for the space of twelve hours, the efforts of nature being efficient to prevent its return. Mr. Guthrie has met with a considerable number of cases of gangrene of the extremity, or hæmorrhage from the lower end of the vessel requiring amputation, after wound of the femoral artery. Ten or cleven cases of this kind are detailed by Mr. G., but as many, if not most of them, have already been published in the 4th vol. of the Medical and Physical Journal, and as on several occasions we have drawn the attention of our readers to this point, we shall pass them over without any further comment.

"An artery of the size of the femoral at the middle or lower part of the thigh, retracts on being divided within its sheath; this retraction is also accompanied by a contraction of the orifice or extremity, which gradually assumes the shape of a Florence oil flask, or French claret bottle, in a similar manner to the contraction of the axillary artery, described page 224. I have not met with an instance so perfectly clear and decided of the femoral artery hanging out of a wound as in this case of the axillary artery, so as to demonstrate that the whole process is carried on in a similar manner. I have however seen the femoral artery at the lower part of a thigh, which had been struck by a cannon ball, so little supported by coagulum, and yet so much closed, as to lead to the belief, that in some instances the extre mity of it may be closed by similar means, a conclusion which analogy would lead us to, if observation were wanting. In all successful cases, the retraction of the artery leaves a space occupied by a coagulum, which also in an artery of this size fills up the contracting opening, which is in a circular direction, just within the ragged edges, which when they exist do not themselves contract, because the continuity of fibre is wanting. The continued contraction of the artery expels the external coagulum, and this operation is assisted by the lymph effused from the cut edges and from the coats of the vessel; so that in a few days the whole of the coagulum is removed with the purulent discharge from the part; and the place it would occupy, the orifice of the artery, and the surrounding parts for at least an inch in extent, are filled up and covered by a yellowish green-coloured matter, very distinct in appearance from the neighbouring parts. On the examination of a wound after death or amputation, in which it was known that a great artery had been divided, I have always from this appearance pointed out the situation of the extremity of the artery.

The contraction of the divided end of the artery is confined in the first instance to its very extremity, so that the barrier opposing the flow of blood is formed by this part alone, as I proved by cutting it off in the case mentioned, page 224. This contraction goes on however increasing for the space of an inch, and the inside of this contracted inch of the vessel is filled up with an internal coagulum, which takes the shape of and adheres to the inside of the artery, rarely extending as far as a collateral branch, or under almost any circumstances beyond a couple of inches. Towards the extremity of the artery it adheres firmly, so as to form a real substantial obstacle to the flow of blood through it. The very orifice of the artery on the outside of this is covered by the yellowish green-coloured matter or lymph, which ultimately becomes organized. These processes are continued long after the wound is healed. The artery generally goes on diminishing and contracting up to its first large branch, so that of four or five inches, two or three will be impervious, the remaining part very much contracted, although perhaps still permeable by a probe. The accompanying nerve, where there is one, has just done the reverse, the cut extremity having become enlarged or bulbous, and gradually diminishing as it is traced upwards, until it becomes of its proper size." 248.

Mr. Guthrie observes, that it is a very curious and interesting fact, that the lower end of a divided artery is more prone to secondary hæmorrhage than the upper; so much so indeed, that when it occurs after having been arrested for a period of four hours, it takes place in all probability from the lower end. This may always be known by the darker colour of the blood, and by its welling out in a

continuous stream without any arterial impulse. Mr. G. paid particular attention to this point during the war, and he is confident he cannot be mistaken as to the fact.

"The same kind of yellowish green matter marks and covers the situation of the lower extremity of the artery, as it does the upper; it is, however, thinner where it immediately covers the end of the artery, which in none of these cases was contracted in the conical manner I have described as occurring in the upper extremity of the vessel. On the introduction of a probe into the artery with the greatest gentleness from below, it made its appearance at a point on the yellow space, raising a thin portion of it as it protruded. On laying open the artery, the orifice seemed to have been once closed by this layer of fibrine or lymph, but without a degree of contraction corresponding to that observable in the upper end of the same artery; the layer still forming an obstacle, sufficient to cover and close three-fourths of the orifice, the blood having flowed through the remaining fourth." 250.

These appearances seem to indicate a different process to that adopted for the closure of the upper end of the vessel, and their frequency to demonstrate that the process is a natural one. Two cases are detailed in illustration of the foregoing statements, and we shall briefly glance at the first.

Serjeant Lillie, æt. 32, was wounded in the thigh by a musket-ball, which described a track of seven inches, and was extracted behind on the field. He bled a good deal at the time, but restrained the hæmorrhage with his sash, and, for 19 days, the wound appeared to be going ou extremely well, when, on making a sudden turn in bed, dark-coloured blood flowed from both orifices of the wound in considerable quantity. Mr. Dease, in the absence of Mr. Guthrie, performed the operation for aneurism at the lower part of the upper third of the thigh; in 8 days the hæmorrhage returned, the limb was amputated, and the patient died. On examination, the artery was found to have been divided, where it passes between the tendinous expansion of the triceps and the bone; the upper portion, divided by the shot, was closed; a probe introduced into it from above would not come out at the face of the wound, although the impulse given to the part on moving it was observable in the middle of a large yellowish green spot, where the vessel presented a claret-shaped contraction for about an inch, and an internal but small coagulum for nearly the same extent. The lower or bleeding end of the artery was marked by a nearly similar spot; but, on passing a probe upwards from the popliteal space, it came out at a very small hole in the extremity of the artery in the centre of the spot. The canal of the vessel was not contracted or diminished, but only apparently closed by a layer of the yellowish green lymph laid over it, and adhering to its circumference.

When an artery is merely cut or torn, without being completely divided, it is just as if it had given way by ulceration. It can neither retract nor contract, but, if pressure be not accurately applied and maintained, it will bleed until the patient is destroyed. If the vessel is a small one, as the temporal artery, it must be cut across; if of larger dimensions, a ligature should be placed on it above and below the wound, between which it may or may not be divided, at the pleasure of the surgeon. This rule is so important that every tyro should learn it by heart. We now arrive at the section entitled

On the METHODS OF PERFORMING OPERATIONS ON WOUNDED Arteries. Our author sets out with the just and important principle, that however applicable may be the Hunterian operation to cases of aneurism, and however brilliant its success in the treatment of that disease, it is totally inapplicable to wounded arteries. Surgeons for some time imagined that the same operation must answer in the one which had been followed by such splendid consequences in the other, and dazzled by the glory that surrounded the genius of Hunter, they misconstrued his views and perverted his principles. The error is now perceived and abandoned, but although the necessity of securing an artery of any size above and below the wound in its coats is now generally acknowledged, Mr. Guthrie contends that the modus operandi has been absurdly and unnecessarily retained. The examples of this mis

take singled out by Mr. Guthrie are, the operation for wound of the posterior tibiał artery, of the axillary, and ulnar at its origin from the brachial. In operations for aneurism, the surgeon, in some measure, chooses his situation, and proceeds in a straight-forward manner, according to certain definite rules. In casual wounds of course it must be otherwise, but Mr. Guthrie contends that rules are still inflicted to clog and bewilder the younger surgeon. "The principal error," says our author, "in this method of proceeding, as adapted to wounded arteries, arises from a strange and unaccountable fear of cutting muscular fibres, which seems to have pervaded the minds of all the surgeons of the present day who have treated on these subjects.” Suppose, for instance, that the posterior tibial artery is wounded, and the surgeon determines to tie the vessel, he will be obliged, according to the usual mode of operating, to raise the inner edge of the gastrocnemius muscle, to detach the inner head of the soleus from the tibia, to divide the deep-seated fascia on a director, and then to secure the vessel in a deep cavity, taking care to avoid the posterior tibiał nerve. After noticing, in a very forcible manner, the acknowledged difficulties of this awkward operation, Mr. Guthrie proceeds to propose his own method of operating :

"An incision is to be made six or seven inches in length, by successive and rapid incisions, through the integuments and muscles of the calf of the leg down to the fascia. The centre of the incision is to be on a line with the shot holes, or if they are diagonal to each other, between them; and it may be either directly in the middle of the calf, or a little to the side of, or directly over, the artery supposed to be wounded; it is not material which. The smoothness of the fascia points it out, and the loose cellular membrane connecting the divided muscles to it, allows of the edges of the long incision being easily separated, and to such a distance as to admit of the exposure of the great nerve, the arteries, and veins, in as distinct a manner as any other arteries, veins, and nerves, can be exposed in the human body. The tourniquet is now to be unscrewed, and the bleeding, if the wound did not bleed before, leads to the spot where the artery is injured. The knife may be applied perpendicularly to the fascia, and the artery laid bare for three or four inches in extent, by as common a piece of dissection as any ever practised, and nothing can interrupt the application of the ligature. The nerve and the fascia cease to be surgical bugbears, and the operation is as simple as any in surgery. No surgeon or anatomist will dispute this statement: he may however, say, that the muscles have been divided, and that surgeons have not been in the habit of cutting through them by a fair incision in their length; that they have hitherto only done it by insinuating a director under the head of the soleus, and separating it from its attachment to the bone; as if the separation of a muscle from its bony attachment was not much more likely to lead to weakness and defect in the action of that muscle, than a mere interstitial incision in a longitudinal direction. There is no anatomist who will deny that it is so." 261.

In order to prove that a muscle may be cut across, whenever it may be desirable to do so in order to place a ligature upon au artery, and that little or no inconve nience is the consequence, Mr. Guthrie relates the case of Lieutenant Colonel Wildman, in whom the deltoid was completely divided by a sabre-cut. By raising the arm to a right angle with the body, and bringing the sides of the wound together with compress and bandage, granulations sprung up, and the officer's recovery was so perfect, that he is now unconscious of any defect in strength and motion. In a French soldier, also, the lower and fore-edge of the pectoralis major was completely cut across, and yet merely a little weakness, of no consequence was left. In accordance with these facts and the principles already brought forward, Mr. Guthrie criticises sharply the operation, as laid down in Harrison, of tying the axillary below the clavicle, for wound of the artery through the pectoralis muscle. He also animadverts on a case related in Mr. C. Bell's Commentary on John Bell's Surgery, in which this operation was performed unsuccessfully for secondary hæmorrhage from the axillary, after the arm had been torn off by machinery. The artery, when

For an account of this operation, see Harrison en the Arteries.

wounded, should always be secured at the spot, and, if necessary, the pectoralis major muscle should be divided, taking the hole or cut as the centre of the incision. Mr. Guthrie next passes on to the manner of securing the ulnar artery when wounded a little below its origin, and whilst covered by the pronator teres, &c. In Mr. Harrison's work it is stated that, at this point, a ligature of the artery "would be impracticable," but Mr. Guthrie tauntingly remarks, that it would only be so because it is so considered. The surgeon should make a clean incision down to the artery through all the muscular fibres that cover it, avoiding the median nerve as it runs between the two origins of the pronator teres, and then he should place a ligature above and another below the wound in the artery," when there would be nothing more to do." Mr. Guthrie has seen these parts divided, and he has divided them himself, and the patient has recovered without any sensible defect. In a case at the battle of Vimiera, in which the ulnar artery was wounded, Mr. Gut down upon the vessel, which he found more than half divided, and tied it above and below the wound. The patient was cured. Before continuing the thread of our analysis, we may observe that Mr. Guthrie has proved, that the mere division of muscular fibres is far from being an insuperable objection to an operation. The only question appears to be, the facility in all cases of performing it. Suppose, for instance, a wound of the ulnar artery near its origin, with great extravasation of blood into the neighbouring parts; in such a case, it would be difficult to find and secure the bleeding vessel, buried, as it is, under layers of muscle and a mass of blood. The same may be said of wound of the posterior tibial artery; but, as Mr. Guthrie has had a practical experience in these operations which others have not, his opinion is entitled to more weight than theirs. We would not be understood as quarrelling with the principle inculcated, of tying both ends of a wounded vessel in every practicable case; on the contrary, it is one to which we yield our undivided assent, and to which we would most earnestly direct the attention of our readers.

Connected with this subject our author adverts to, and keenly animadverts on, a memoir published by M. Dupuytren, in the Repertoire General d'Anatomie et de Physiologie, &c. tome v. 1828, entitled-" Sur les Anévrysmes qui compliquent les Fractures et les Plaies d'Armes-à-Feu, et sur leur Traitement par la Ligature, pratiquée suivant la Methode d'Anel."

After alluding to some cases by Petit, Pelletan, M. Delpech and himself, M. Dupuytren proceeds to relate, at some length, the case of M. de Gambaud, a captain of cavalry, who received a wound from a horse-pistol bullet, which entered the upper part of the right leg, from the front backwards and from the outside inwards, passing between the tibia and the fibula, which latter it slightly injured. Violent bleeding immediately ensued, which was stopped by compress and bandage, although the limb became swollen and very painful. An aneurismal tumour formed, the pulsations of which were at first arrested by the pressure of a tourniquet and pad on the femoral artery, but they soon returned, and, on the thirteenth day, hæmorrhage took place from the wound. The bleeding returned from day to day, and M. Dupuytren was called into consultation with Messrs. Aumont and Dessien. The foot and leg were of a violet colour, swollen, cold and numb, and uncertain whether the anterior or posterior tibial artery, or the peroneal or popliteal, or several of them at the same time, were divided, M. Dupuytren tied the femoral artery. Inflammation was moderate; on the twentieth day the ligature on the femoral artery came away, and, in six weeks, all the wounds were completely healed.

"Ought we to attribute'" 'says M. Dupuytren, "the success of this operation to the accidental concurrence of fortunate circumstances? or ought we look upon it as the natural and necessary consequence of the principle acted upon, in placing a ligature on the femoral artery? and should such a method of proceeding he established as a precept in surgery? To answer these questions, allow me again to mention, that this method of treating simple aneurisms always stops the pulsation of the tumour; and even when employed against aneurism complicated with fracture has been very successful; and, finally, that this method, which M. Delpech and myself first practised nearly at the same time, in cases of hemorrhage following amputation, has invariably been attended with success. From these results I think it evident, that the success of the present operation was not dependent upon any fortuitous occurrence; but on the contrary was the natural consequence of the

practice pursued. The ligature, in suspending the course of the blood in a divided vessel, the solution of continuity of which had caused an external and internal bleeding, gave time and means to the inflammation to cicatrize the wound in the vessel, and to render the cut extremities impermeable to the blood which the anastomosing branches might bring to them.

To judge by analogy, this obliteration ought to be more easy and more certain after gunshot wounds than any other.

One of their most remarkable effects being to contract (froncer) the orifices of the vessel, to concrete or coagulate the blood contained in their extremities, and to render them impervious.

Without therefore wishing to elevate this single fact into a principle, I do not hesitate to consider the success obtained in this case of M. de Gambaud as the forerunner of other similar fortunate results.

Many other reflections occur to me, but I hasten to a conclusion, drawing attention to the two principal points of the memoir. First, the rupture of the principal artery of a limb, occasioned by a fracture, and followed by an extravasation of arterial blood round the broken bone. Secondly, the rupture of the principal artery of a limb caused by a musket ball, followed by an extravasation of arterial blood, baving in both cases the character of an aneurismal tumour. This complication of injuries, either of which alone would be serious, had never till now been cured but by amputation.

The ligature of the principal artery of the limb, made at some distance from the wound, and between it and the heart, will I believe prevent the necessity of this cruel mutilation.'" 282.

Previous to making any comments on the preceding case and observations, Mr. Guthrie details the particulars of seven cases of wounded artery. We shall give a skeleton account of them. In the 1st the anterior tibial artery was wounded by a ball on the 16th of May. On the 15th of June secondary hemorrhage, for which the femoral artery was tied. Hemorrhage again took place on the 5th, 6th, and 27th of July-the limb was amputated, and the patient died. The muscles on the back of the leg were nearly gangrenous.

In the second case the wound was in the calf-secondary hemorrhage eight days afterwards with injection of the limb-femoral artery tied-hemorrhage again— amputation-death. The posterior tibial had been injured and sloughed.

In case 3, musket-ball passed through the thigh-aneurismal swelling-usual operation-matter collected in the thigh and a counter opening was made from which there was hemorrhage, which was arrested by pressure, returned, and amputation was performed. Patient died. The artery had not been wounded in the first instance, but become involved in the disease of the neighbouring parts.

In case 4, musket-ball entered a little in front of the left trochanter major, between the rectus and vastus externus, struck and flattened the os femoris, passed underneath the anterior edge of the glutei and along the ilium for three inches, and lodged in the posterior part of the belly of the gluteus maximus, from whence it was cut out next day. Much blood was lost at the time-on the 15th day violent hemorrhage from the posterior wound, which on the employment of pressure, continued going on internally, and produced an aneurismal swelling-on the 18th day another profuse hemorrhage-incisions made to enlarge the wound, blood sponged out, two large branches of the gluteal artery tied at each extremity by the needle, and a large vessel close upon the bone which had furnished the bleedings treated in the same manner. The patient nearly sunk from exhaustion during the operation, and died the next day. No adhesion of the parts had taken place.

Jo case 5, a musket-ball broke both bones of the left leg-incisions were necessary-erysipelas and hospital gangrene followed-about a month after the injury hemorrhage from a spot two inches and a half above the ankle-joint. The anterior tibial was tied an inch and a half above the bleeding part, and all did well.

In case 6, a musket-ball wounded the left femoral artery a little below Poupart's ligament-on the 11th day slough separated from the wound with frightful hemorrhage. The external iliac was immediately tied with two ligatures and divided between them. Rigors, pain in the chest, and subsequently typhoid symptoms succeeded, but no return of bleeding; six days after the operation he died.

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