Obliterated Brachial Jlrtery, with Compound Fracture of the Hume-
rus.—When a limb has suffered compound fracture of a severe des-
cription, the question of amputation will be materially influenced by the
amount of injury which the large vessels have sustained; and it has in
general been found an excellent rule to remove the limb when an
important artery is wounded, and the other circumstances of the case
do not contra-indicate such an operation. But it may happen that a
compound fracture may be accompanied by an injury to the principal
artery of the limb, which, without wounding the same, may suspend the
circulation through it; in such case the rule is not so clear, and the sur-
geon must evidently be guided by various considerations before he
determines on a decided course. The more or less likelihood of the
circulation being re-established by the collateral vessels must of. course
have considerable weight in the question. A case of this description
came lately under the care of Mr. Hawkins, and we consider that it
will be extremely useful to report it with full details, as such instances
are calculated to serve as guides in cases of a similar nature. We are
indebted for the particulars to Mr. Francis Day, one of Mr. Hawkins’s
dressers.
The patient is a market gardener, twenty-eight years of age, who
was admitted into St. George’s hospital, under the care of Mr. Haw-
kins, June 4th, 1850. He is tall and healthy in appearance, but of
very drunken habits, and when received into the hospital, at three
o’clock in the morning, he was in a state of intoxication and more or
less collapse. An hour before, he had suffered a severe compound
fracture of the right arm, caused by falling off the shafts of a wagon,
the wheel of which passed over the arm. On examination, three
wounds were seen near the seat of the fracture, the latter being situated
about the upper part of the middle third of the humerus. One of the
wounds was situated on the outer side of the arm; it was about two
inches long, and bone was easily detected at the bottom of it, the soft
parts within this solution of continuity being greatly destroyed. Two
other wounds were noticed on the inner and the posterior part of the
arm ; muscle protruded through them, and blood likewise exuded, but
to a small amount. The patient was reported not to have lost any
more blood than was seen on the sleeve, which was saturated to some
extent, but not alarmingly. The hand was perfectly cold, but as the
whole surface of the body presented a very low temperature, the cold-
ness of the hand was attributed partly to the state of collapse, and partly
to the loss of blood.
The limb was placed on an angular splint, the edges of the wound
brought together by a plaster, and three splints applied, one to the inner,
a second to the outer, and the third to the anterior surface of the arm;
the latter being raised on a cushion. The collapse having passed off
in a few hours, the hand and forearm were found to be still cold ; and
sensation seemed to be more or less lost on the outer side of the thumb,
and index finger, and at the back of the hand. Pulsation could be felt
in the brachial artery, above the seat of the fracture, but none could be
detected at the bend of the elbow, or at the radial or ulnar arteries.
The hand had, however, retained its natural color, the face was flushed,
and the patient seemed to be in great pain. A consultation was held in
the middle of the day, when it was decided not to amputate the arm at
once, but to wait and see whether collateral circulation would be esta-
blished, reserving the removal of the limb till gangrene had commenced.
The patient, though he took an opiate, suffered great pain during the
night, and the next day the forearm and hand were still cold, nor had
any appreciable sensation returned to these parts. Ammonia, in saline
draughts, and an opiate, were prescribed; but on the third day the skin
at the end of the elbow was found in a state of gangrene, and vesicated ;
and as the wounds looked rather tense, a few incisions were made into
them with great relief. Patient was ordered good diet and porter, but
on the fourth day the gangrene began to spread on the outside of the
arm, and severe symptomatic fever set in, with great pain in the side
and abdomen. On the fifth day, the gangrene involved the deeper
structures, and Mr. Hawkins then resolved, after consultation, to ampu-
tate immediately.
The patient was placed under the influence of chloroform, and Mr.
Hawkins, taking his stand to the inside of the arm, so as to steady the
comminuted parts during the process of sawing, removed the limb by
the circular incision about an inch and a half from the shoulder-joint,
the subclavian artery being compressed by Mr. Prescott Hewett above
the clavicle.
The patient proceeded very favorably after the operation; nothing of
importance happened during the next two months, at the expiration of
which the stump was quite healed, and the patient discharged in good
condition.
A careful dissection of the amputated arm showed that superficial
gangrene had occurred in several places, affecting large patches of skin,
both in the arm and forearm; in the latter, however, it was only in an
incipient stage. Lymph and serum were effused in the subcutaneous
tissues throughout the limb, but especially in the arm; in the latter
region there were also large cavities containing ill-formed pus, both in
the subcutaneous and deeper textures. The muscles at the middle
part of the arm were much torn, and the bone, broken at its centre, was
comminuted and bathed in pus. Both the superficial and deep veins
were extensively clogged up by coagula, especially the vense comites
of the brachial artery. The latter was also found blocked up by a firm
coagulum adhering to its internal coat, measuring about one inch in
length. This coagulum was situated at about three inches above the
elbow joint; the other portions of the artery were pervious, and quite
sound, and the nerves were not found injured.
It would appear that the violence of the injury, when it reached the
brachial artery, principally affected the inner and perhaps the middle
coat, in the manner of the ligature, producing, like the latter, a complete
obliteration of the vessel. It can hardly be wondered at that the colla-
teral circulation did not become established, for that beautiful provision
of nature may sometimes be tardy even in a perfectly sound limb, and
partial gangrene take place, so that there was but a small chance of the
collateral branches acting powerfully in this instance, as the whole
limb had suffered so great a shock. Thus amputation was the only
means of saving life, and the healing of the stump required no small
amount of care, as the patient had undermined his health by habits of
intemperance.—London Lancet.