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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    ing again took place to the amount of three pounds from the first wound made in the groin, from which it flowed, not by jerks, but in a continued uniform stream, although of a red colour, and was restrained by pressure made below on the side of the aneurism, showing that it came from the lower end of the vessel. Pressure by graduated compress was made upon this part, and steadily kept upon it by bandage; the bleeding did not return, and the patient ultimately recovered. Remarks.— Dr. Murray acknowledges that the first bleeding came on, in all probability, from the same place as the second, and that the ligature on the external iliac artery was unnecessary, although he strongly recommends that the external iliac should be tied in such a case in the first instance, and being one of aneurism of twelve months’ standing, after a blow which might cause disease in the artery to some distance, he is certainly right in his recom- mendation. If, instead of being a case of aneurism from a blow, it had been one of a wounded artery, or of a diffused aneurism communicating with a wounded artery and an open wound externally, tying the external iliac would have been of no use. Compression could not have been so readily made, an 1 an operation for securing the vessel at the part injured must have been done. Would any surgeon with an open wound in his own femoral artery an inch and a half below Poupart’s ligament feel satisfied with having his external iliac artery tied, trusting to pressure on the wound to prevent hemor- rhage ? He would fear that both ends of his femoral artery might bleed through the hole in the side of the vessel, and that a ligature would be ultimately necessary above and below it, proving that he had run the risk of the ligature on the external iliac artery for nothing. Case 102.—T. Berger, aged forty-five, struck his groin with the end of a plank, and two months afterwards discovered a tumour the size of a hazel- nut, about two inches below the crural arch. A year afterwards, having made a violent exertion, the swelling increased to the size of a hen’s egg, and soon after became larger. Compression was employed in vain, and on the 16th of October Baron Dupuytren tied the external iliac artery. On the eighth day afterwards, the circulation was esta- blished in the limb, and pulsation was felt and seen in the tumour. On the ninth the swelling was diminishing in size, but the pulsations were more dis- tinct. On the twentieth day they were quite sensible to both touch and sight, and on the same day hemor- rhage occurred from the wound. It was repeated on the second day, was arterial, and apparently from the lower end of the wound. The iliac artery was tied again higher up, and the pulsation in the tumour ceased for six days. It then returned, and it was plain that the blood which flowed did not come from the end of the artery which had been tied, but from vessels placed between the ligature and the ventral aorta ; and what vessels, the Baron asks, could it be, unless it were the internal iliac and the internal mammary. By what trunk was it that the blood was conveyed to the aneurismal sac ? The femoral artery presented no pulsation below the tumour, and compression appeared to in- crease rather than diminish it. Was it by the pro- funda ? The position of this artery behind the tumour rendered it difficult to say. Was it, in fine, by the epigastric artery ? The double communica- tion of this vessel with the substernal and obtura- trix is well known ; nor is it a rare thing for a very considerable arterial branch to extend from one to the other of these arteries. This idea induced him, he says, to examine carefully the course of the epigastric artery, and it was with no small surprise that he felt strong pulsations along its course, even through the thickness of the abdominal parietes, and especially in the vicinity of the tumor. It seemed probable, therefore, that the epigastric artery was the prineipal agent in restoring the pulsations to the tumor, and that in this case, as it happens sometimes after tying the primitive carotid, the very facility of communication, so far from favour- ing the cure, was the cause of the reproduction of t he disease. In the present instance, that facility had the additional inconvenience of giving rise to hemorrhage that might prove fatal. Baron Dupuytren made compression above and below the wound; the former allowed blood to flow, the latter stopped it. The blood, therefore, he says, came from the lower and not the upper end of the artery. Graduated compresses and bandages were applied, five hemorrhages took place, and were sup- pressed between this and the thirty-sixth day, when the tumour, having apparently suppurated, was opened, and a quantity of sanious matter and thick pus was discharged. After this Berger went on well, and in two months was cured. Remarks.—The collateral circulation restored the pulsation in the aneurismal sac on the sixth day. If there had been an open wound, Berger would have bled to death. If there had been a diffused aneurism with a hole or two in it, he would equally have bled to death. If the eircula- tion had not been so restored as to enable the pa- tient in such a case to bleed to death, he would have died of gangrene. Nothing can more clearly show the impropriety of placing a ligature on the external iliac artery for a wound of the femoral. This case was published in 1833, three years after the publication of my work, in wl^ich I have pro- nounced this operation to be inapplicable to a wounded artery, without a shut aneurismal-sac. Case ] 03.—Sir C. Bell, in alecture delivered at the Middlesex Hospital on the 20th December, 1834, made the following statement:—A man was wounded in the artery of the groin, and stopped the bleeding by holding the cut parts together until the surgeon arrived. He opened the wound, the man lost a quantity of blood, and fainted. The surgeon tied the artery, and went away. Hemorrhage re- curred, and the man died. The surgeon was not aware, says Sir C. Bell, that the circulation is so free that the blood must flow by regurgitation where there is an open wound. A ligature must be ap-