On wounds and injuries of the arteries of the human body; with the treatment and operations required for their cure. Illustrated by 130 cases ... with critical remarks / [G.J. Guthrie].

  • Guthrie, G. J. (George James), 1785-1856
Date:
1846
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Licence: Public Domain Mark

Credit: On wounds and injuries of the arteries of the human body; with the treatment and operations required for their cure. Illustrated by 130 cases ... with critical remarks / [G.J. Guthrie]. Source: Wellcome Collection.

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    usually sufficient to prevent its return from the upper, although not from the lower end of the vessel; but then it is of venous and not of arterial colour—a fact now acknowledged to be of the greatest importance. The great evil to be dreaded in such cases, is not from hemorrhage from the upper end of the divided artery, but from the lower, and from mortification of the foot, which circum- stance I shall notice in its proper place. The upper endof an artery retracts on being divided, and this retraction is accompanied by a contraction of the cut extremity of the vessel, which assumes the shape of the neck of a French wine-bottle or Florence oil-flask. The contraction is confined in the first in- stance to its very extremity, so that the barrier opposing the flow of blood is formed by this part alone. The contraction goes on, however, increas- ing for the space of an inch, which is usually filled up with an internal coagulum, of a round pyramidal shape, adhering firmly to the contracted end of the artery, loose at its apex, and e.xtending frequently as far as the first collateral branch, but rarely under any circumstances beyond two inches; the very orifice of the artery on the outside being in a few days covered by the yellowish green-coloured matter I have already alluded to. Some of these processes are continued even after the external wound has healed; the artery goes on diminishing and con- tracting as far as it is useless, so that of four or five inches, from one to two may be impervious, the remainder being contracted although still perme- able by a probe. An accompanying nerve where there is one would do the reverse, the cut extremity would be enlarged or bulbous, gradually diminish- ing as it is traced upwards, until it becomes of its proper size. The processes adopted by nature for closing the end of the lower extremity of an artery of the size of the femoral at the inferior part of the thigh, are difierent from those employed at the upper or oppo- site extremity. The retraction or contraction of the lower end of a divided artery is neither so perfect nor so permanent as at its upper end, and the small internal coagulum is in many instances altogether wanting or very defective in its formation. The closure of the lower orifice being less perfectly ac- complished than the upper, it is the most likely to suffer from secondary hemorrhage, which may be distinguished from that from the upper end of the artery at an early period after the accident, by the venous colour of the blood, and from its flowing or welling out in a continuous stream, as water rises from a spring, and not with an arterial impulse. Ihe retracting and contracting powers in the lower endof a divided artery are, nevertheless, con- siderable, and are sufficient ui some cases to nearly close the lower end of the femoral artery when divided by amputation above the knee. When the femoral artery is cut across, the lower portion of tlie vessel is emptied by its last efforts, combined i with the action of the cajiillai ies. When tlic col- lateral circulation is powerful, blood soon regurgi- I tates into the artery, but llic force of t],c rcgurgiia- ' tion can be in no proportion to that of the propulsion at the other or upper divided endof the vessel, whicli will generally be able to resist this impulse ; whilst the lower one often opens and bleeds after the lapse of a few days. In all the cases I have had an opportunity of examining, in w'hich hemorrhage had taken place from the lower end of the artery, the following appearances were observable after the interval of four to five days :— The same kind of yellowish-green matter marks and conceals the situation of the lower extremity of the artery as it docs the upper. It is however thinner where it immediately covers the end of the artery, which in none of these cases is contracted in the conical manner described as taking place in the upper extremity. On the introduction of a probe with thegreatestgentlcness into the artery from below, it usually makes its appearance at a point on the yellow space, raising a thin portion as it pro- trudes. On laying open the artery, the orifice would seem to have been once closed by this layer of fibrin, but with a less degree of contraction than the upper end of the same artery; the layer still however forming an obstacle sufficient to cover and close three-fourths of the orifice, the blood having flowed through the remaining fourth, which had probably given way by accident. The following case is illustrative of the several points alluded to. Case 9.—Serjeant William Lillie, of the 62nd regiment, aged thirty-two, was wounded in the right thigh, on the lUth of April, at the battle of Toulouse, by a musket-ball, which passed through, in an oblique direction downwards and inwards, close to the bone, describing a track of seven inches. The ball was extracted behind on the field. He said he had bled a good deal on the receipt of the injury, which he had stopped by binding his sash around the limb. The discharge from the wound was considerable; it appeared, however, to be going on well until the 2Uth of the month, when, on making a sudden turn in bed, dark coloured blood flowed from both orifices of the wound in con- siderable quantity. I had given an order as chief of the medical staff in Toulouse, that no operation should be performed on a wounded at tery without a report being sent to me, and an hoiu- at least granted for a reply, unless the case were of too urgent a nature to admit of it. It appeared to be so in this instance, and before I arrived Mr. Lease had performed the operation for aneurism at the lower part of the upper third of the thigh. I could only express my regret that it had been done, and point out the probability of the re- currence of the hemorrhage from the lower end of the artery, which took place on the 7 th of May, when the limb was amputated, and the man died. On examination the artery was found to have been divided exactly where it passes between the tendinous expansion of the triceps and the bone. The upper portion of the artery thus cut across was closed. A probe introduced into it from above would not come out at the face of the wound, although the impulse given to tliis part on moving