In case 7, a musket-ball entered the right leg in such a direction as to make it evident that it must have passed close to the posterior tibial and peroneal arteries, but no immediate hemorrhage ensued-thirteen days after the accident a considerable hemorrhage suppressed by the tourniquet, but shewing a constant disposition to recur. Next morning the limb was injected with blood, florid blood issued from both openings, and on passing the finger into the outer one a sort of aneurismal tumour could be felt, on pressing which against the fibula the hemorrhage ceased, indicating that the peroneal artery was in all probability the only vessel wounded. Mr. Guthrie cut down through the calf of the leg, found the parts in all states between sphacelus and perfect health, and after being obliged to make a transverse incision in addition to the longitudinal one of seven inches in length, succeeded in securing the vessel, but not separately, with a needle. The hemorrhage never returned, kindly suppuration took place, and in three months the wound was entirely healed. The patient is now in the York Hospital at Chelsea, and walks without appearing lame, although he cannot do so for any great distance. Having given the foregoing cases, which we have materially abridged, Mr. Guthrie proceeds to criticise the opinions of Baron Dupuytren, as appended to the case of M. de Gambaud.

"In the remarks which I am going to make on the memoir and opinions of M. Dupuytren, I hope that I shall not deviate from that respect which is due to a foreigner and a gentleman of high and deserved reputation. M. Dupuytren is pleased to entitle his operation after the method of Anel, although it was not done according to the method of Anel, but after that of Hunter; neither did Anel ever do an operation in the same place, or on the same principle. If the Baron had shown himself to be thoroughly acquainted with the principles that directed Mr. Hunter in the performance of his operation, I should have thought that the omission of his name might have arisen from a jealousy of his posthumous fame, unworthy of the elevated rank which M. Dupuytren himself holds in the profession; but it clearly arises from inattention to the principles laid down by Mr. Hunter and his successors, and to the difference which really exists between these operations.

It is also very extraordinary the Baron should say, as he does, page 22, that he had consulted in vain both ancient and modern authors on this subject, when the first and seventh of the cases I have given above were published, with several others nearly similar, in Paris, nine years before his memoir appeared, by Breschet in his translation of Mr. Hodgson's work on the Diseases of Arteries and Veins. It is nevertheless very satisfactory that it should be so, because it shows that the practice which M. Dupuytren recommmends to the French surgeons in 1928 as worthy of their adoption, had been tried in the British army in 1810 and 1812, and proved to be ineffectual, and to be founded on erroneous principles; whilst, in 1815, the true method of proceeding had been demonstrated by the same surgeous, and established on safe and scientific principles." 301.

This may be an unpalatable dose for the able Baron: but it is one which the state of his case most imperatively demands. He on all occasions evinces either an extraordinary ignorance, or an overweening contempt, of English surgery and English surgeons, a trait which, however it may flatter the reputed vanity of himself and his nation, lays him open to ridicule and bares his side to criticism. What can be more absurd than the omission of the name of John Hunter, in connexion with aneurism and operations on the arteries? What can be more foolish than the attempt to pluck the laurels that time has immoveably carved upon his bust, in order to deck the brows of Mr. Anel! The attempt is alike unsuccessful and pitiful, and only redounds to the disgrace and confusion of him who makes it. M. Dupuytren would appear to be like Horace, on his mistress' mention of his rival's rosy neck :

-Væ meum

Fervens difficili bile tumet jecur!

:

It gives us pain to allude in such terms to a surgeon of eminence and merit as M. Dupuytren confessedly is, but when our country is tacitly decried, and her great nien robbed of their due, it becomes us to stand forward and maintain their rights. We would willingly believe that the spirit too frequently displayed by M. Dupuytren is not shared by the more liberal portion of his countrymen. But to revert from the man to his doctrines.

Mr. Guthrie proceeds to observe, that the last passage in M. Dupuytren's comments cannot be admitted as a correct statement of the effects of a gunshot wound on arteries.

"I have shewn in the preceding observations, pages 231 et seq. what is the real effect of a ball on the extremity of a divided artery, and that the appearances depend very much on the size and structure of the vessel. In what manner a ball can contract (froncer) the orifices of an artery has never been shewn, neither can it be easily understood; inasmuch as the act of contracting must be a vital act dependent on the powers of the artery itself. If it he a mechanical act, arising from injury, it must be a contusion; and this surely cannot be advanced as a process likely to consolidate the end of the vessel; it being now well known and admitted in England, that the first and most simple state of adhesive inflammation is the best calculated for the permanent closure of a divided artery." 203.

A torn, divided, or injured artery may suffer several different kinds of lesion; first, it may be only injured but not opened into; secondly, partly or entirely divided by a musket-ball: thirdly, it and the surrounding parts may be torn and contused by a cannon-shot. Thus, in reference to the first point the elasticity of arteries enables them to yield to an opposing force without laceration, and to suffer a considerable degree of contusion without sloughing. In the case of Captain Flack, several inches of the femoral artery were laid bare by a cannon shot, but it became covered by granulations, and maintained its functions unimpaired. If, however, the injury be considerable, a part or the whole of the circumference of the artery may ulcerate or slough.

If again an artery be completely divided, the appearances described by Mr. Guthrie in the commencement of this article will be observed. If only a part be torn, cut into, or slough, the patient will generally bleed to death, unless assistance be obtained; the musket or other ball having no effect on the walls of the artery different from any other instrument. Where a part of the vessel remains uncut, the opening made by the sword or ball, if small, becomes round from the unequal contraction of the artery. If the vessel be merely slit up the sides of the opening will come in contact, so as not to be very perceptible if the artery be com pressed above, and no blood be allowed to pass through it. In such cases of imperfect division the only proper operation is to tie the vessel above and below.

When, in the third place, a cannon shot strikes a limb and bruises it most severely without carrying away any part, the great artery may not only be ruptured in one spot, but its internal coat may be injured in several. In one case related by Mr. Guthrie, the posterior tibial and fibular arteries were torn across, and the popliteal was closed by coagulable lymph thrown out from a rupture of the internal coat at this part. If an artery be wounded in man by a sharp cutting instrument, to the extent of one-fourth of its circumference, or even less, Mr. Guthrie believes that the process of cure always takes place through inflammation, and by oblitera tion of that part of the canal of the vessel. In proof of this he mentions a case of pike-wound in the direction of the brachial artery, after which no pulse could be felt for some time at the wrist, and the pulsation of the brachial below the wound continues imperfect.

"I consider myself then warranted in saying, first, that when an artery is injured by a ball, but not torn or bruised to such an extent as to destroy the continuity of the vessel, inflammation is the only result; secondly, that when the artery is cut or divided, the processes I have described take place; thirdly, that in some cases, particularly where the injury is inflicted by cannon shot, the internal coat may be torn in one or more places above the part where it is divided, constituting a barrier to the flow of blood from the part; but it must be recollected that this barrier is formed at a very early period. I much doubt whether blood would pass through such an artery: I am sure that it would not do so twenty-four hours after the injury. The impulse or power of the heart or circulation is as nothing when the inner coat of an artery is injured, and has inflamed so as to throw out coagulable lymph. It invariably arrests the circulation and obliterates the artery.

In all cases in which an artery is seen pulsating on the surface or other part of a wound, the obstacle to the bleeding is found to exist in the very extremity of the vessel: let only one-sixteenth part of an inch be cut off, and the blood immediately

darts forth. I bave done this fifty times at least, and it is precisely the same from whatever cause the injury is inflicted.

A divided or cut artery, in a case of wound by a musket ball, is not in a more favourable state for healing without hemorrhage than from any other wound. In regard to the other observation of M. Dupuytren, that a gun-shot wound has the remarkable property of concreting and coagulating the blood in their extremities, in a greater degree than any other wound, it is contrary to every fact I am acquainted with in regard to large arteries. The theory then which be would build on these opinions is untenable. If the wound had such an effect on the artery, why did it bleed at first? why did it continue to do so afterwards? I have shown that the lower end of the aitery is more likely to bleed than the upper, and that hemorrhage does not always depend on the impulse of the circulation. It is certainly true that if the blood can be prevented from passing into the divided vessel, there will be a greater chance of the natural processes of inflammation and granulation, which are taking place in and around it, closing it up, than if the blood be allowed to flow through it. But it is only then a chance. It is impossible to calculate the time which nature may require to bring the blood by the collateral vessels into either the upper or lower end of the vessel; it may occur immediately; it may not do so for hours or for days; and on the speculation that it may not do so, the first hope of safety depends; the second, on the further accidental circumstance, that the end of the artery may be closed in the interval. Surely this cannot be considered a scientific operation, and fit to be erected into a precept in surgery, which depends on two accidental circumstances, neither of which can in the slightest degree be calculated upon.

There are many other reasons why the operation was a bad one in this case, and always will be a bad one in all similar cases. The patient was made to undergo the chance of mortification of the extremity, which it is probable would have taken place, if the operation had not been delayed until some days after the first hæmorrhage occurred from the wound; which did not take place until the thirteenth day, during which time the inflammation in the limb had given the collateral vessels a disposition to enlarge. The wound itself was not treated as the principles of surgery require. A quantity of decomposed blood was pent up under and between the muscles of the calf of the leg, together with some of the patient's clothes, and some spiculæ of bone. Surely in a case like this, but without further fear of hemorrhage, the Baron would have enlarged the wound, cleared away the clots of blood, and have placed it in a simple state. There cannot be a doubt on the subject, and the operation of making an incision through the muscles of the calf of the leg would have enabled him to do all this, and to have secured the vessels, if there had been even four bleeding extremities, without any difficulty or danger.

The Baron Dupuytren applied Mr. Hunter's theory of the operation for aneurism to the treatment of a wounded artery, and succeeded by chance; others have done the same long before him; but nothing which is dependent on chance or accident can ever become a principle in surgery.' 310.

The theory, observes Mr. G. is not always applicable even when the wounded artery forms an aneurism, because the whole limb is not in the same state as one which has gradually become aneurismal from disease. A man, aged 24, was wounded in the thigh on the 18th of June, and lost much blood. The wound healed, but an aneurism formed and extended to within an inch of Poupart's ligament. On the 28th of August staff-surgeon Collier tied the external iliac artery, in the manner recommended by Sir Astley Cooper. The temperature of the limb shewed a great disposition so sink, discoloured patches appeared upon its surface, and pain in the abdomen with inflammation of the wound succeeded. The patient was bled at three times to 36 ounces, the limb turned livid and vesicated, and on the 1st of September the patient died. On dissection there was slight peritoneal inflammation, and the whole limb was in a state of gangrene. The operator, says Mr. Guthrie, should either have cut into the sac and performed the old operation, or he should have tied the artery immediately above it. More anastomotic branches would thus have been saved, and mortification probably averted.

When a deep seated branch of an artery is wounded and continues to bleed, considerable difficulty often arises as to the best method of proceeding; because it is possibly an uncertain branch, and the facility of anastomosis must be taken into

account. It is not good practice to cut down upon an artery on the first hæmorrhage, unless the main trunk be wounded; for many a bleeding supposed to come from the great vessel, has been permanently stopped by a moderately continued pressure in the course of the vessel sometimes combined with pressure on the bleeding part itself. If, however, this be insuficient, Mr. G. would introduce his finger into the wound, and enlage it until he could see to the bottom or the bleeding part, when he would tie the two extremities of the vessel.

Hæmorrhage may take place from an artery which cannot be tied at the part where it is wounded, as in the throat; and the question of placing a ligature on the main trunk comes under consideration. Mr. Guthrie details a case, in which both carotid arteries were wounded by pins, purposely introduced on a cork, which stuck in, and produced ulceration of the œsophagus. He also relates a case which occurred to staff-surgeon Collier, in which a spear wound at the angle of the jaw, was followed by secondary hæmorrhage, and the common carotid artery on the same side was tied with success. He then adverts to the cases of Mr. Luke and Mr. Mayo, in which the same operation was successfully performed, for hæmorrhage in consequence of ulceration of the throat. Our author was summoned to see a gentleman who had cut his throat very deeply, having laid bare the left carotid artery, and wounded the left internal jugular vein. The opening in the latter was distinct, and Mr. Guthrie ripped up the edges and included them in a knot, without destroying the continuity of the vessel. The carotid appeared to be wounded as deeply as its inner coat, but no deeper. On the eighth day secondary hæmorrhage took place from the artery, and Mr. Guthrie tied it below, and the external carotid above the wound; the bleeding ceased, but the patient died next day. The internal jugular was found pervious, and the internal carotid had a soft coagulum of blood for about a quarter of an inch. In a similar case Mr. Guthrie, warned by this, would place a ligature above and below the injury to the outer coat of the vessel.

In all cases of hæmorrhage from the throat, which cannot be suppressed without tying the carotid artery, Mr G. would tie the external, as being nearer the bleeding branch. If this fails, he would tie the internal or common carotid also.

In bleeding wounds of the hand or foot, dilate the wound and tie the vessel, or if this is impracticable or unsuccessful, compress the principal trunks and the wound itself. The alnar artery in the palm should always be tied when wounded, for the deeper seated radial, compression should be tried. If this be not allowed by the swelling of the hand, first tie the radial, then the ulnar, and if these operations fail, a clean and decided incision is to be made in the line of the wound, from the annular ligament to the finger (avoiding the flexor tendons), and down to the metacarpal bone, which bone, and the finger is, if necessary, to be removed; by which space will be obtained to see the bleeding vessels. The hand or foot should only be amputated as the very last resource. Such are the rules laid down by Mr. Guthrie in cases of wounds of the hand or foot. Some very good remarks are offered on wound of the brachial artery in bleeding, and then the precepts already inculcated in different parts of this article are summed up together, in the form of 24 aphorisms or 66 conclusions." We wish we had space for their insertion. A chapter on aneurism by anastomosis, and one on the mode of performing the various operations on the arteries, conclude this valuable work.

Here we must end, not for want of matter, but deficiency of room. After the copious account we have given of a portion of Mr. Guthrie's book, it would be a work of supererogation to say that we think it deserving of very attentive perusal. Surgeons will derive much information and correct principles from studying its contents, which we recommend all to do. In our next Number we shall analyze that portion which treats of the diseases of arteries.

* We have given a full account of these and other cases in the Periscope of the present Number, p. 260, et seq.

Periscope;

OR,

CIRCUMSPECTIVE REVIEW.

"Ore trahit quodcunque potest, atque addit acervo."