Unsuccessful Application of a Ligature on the Femoral Artery for a
Wound, of the Anterior Tibial, followed by Amputation. By VV. S.
Davis, Esq., M.R.C.S. &c., Heytesbury.—A case which occurred in
my practice during the last summer bears so much on a point of surge-
ry mooted in the lectures of that high authority, Mr. Guthrie, and
commented on in your journal lately, by Dr. Massey, of Nottingham,
that, though I am but a young country practitioner, I am tempted to
publish it, begging you to consider it as taken from a kind of general
note book for my own private use, and consequently deficient in detail.
Aug. 4th, 1848.—William P-------, aged twenty-eight, robust and
temperate, a farm-labourer, whilst engaged in reaping, allowed his
very sharp hook to dangle carelessly between his thumb and finger ;
whilst hitting at a few stray wheat straws the point was driven deeply
into the anterior part, of the leg.
I was summoned to him, and being from home did not see him (two
miles from my house) till about two hours after the accident. I found
him seated at his cottage, with the wounded leg in a chair, before a
good fire, and very 'faint from loss of blood. I learnt that tobacco had
been applied to the wound, which was tightly bound with handker-
chiefs in the field, by a bystander, which effectually stayed the haem-
orrhage. All that I could ascertain in addition was, that “ he had
lost some pints of blood, which came from him as from a stuck pig.”
I presumed that an artery had been Wounded, however, from his de-
pressed state. I merely saw him removed to bed, did not interfere
with the bandages, and applied a tourniquet loosely over the upper
third of femoral artery, giving directions as to tightening, should bleed-
ing return, ordering him to be kept cool, &c. I visited him again
some four hours after, found him rallied; no return of hasmorrhage.
August. 5th.—No oozing of blood. To be kept very quiet, and
carefully watched.
6th & 7th.—No uneasiness about the wound, which was not inter-
fered with. No oozing of blood.
8th.—Complained much of stiffness of bandages, pain, &c. from tight-
ness. Removed bandages, dressed wound, &c.
9th.—Wound looking pretty well; no return of haemorrhage. Or-
dered him to be kept low, and in the same position as before.
10th.—I was summoned in great haste at four a. m. Found the pa-
tient nearly sunk from loss of blood, which had flowed in a considera-
ble stream. His wife had tightened the tourniquet, and after some
flurry had succeeded in stopping it; it had escaped in sufficient quanti-
ties to have almost saturated the sheets.
Satisfied that an artery was wounded, and that the tourniquet com-
manded the flow of blood, I made up my mind to tie the femoral, and
rode after a valued friend, an experienced surgeon of twenty years’ ex-
tensive practice, who kindly came and assisted me in the operation,
which was performed at six a. m., the patient being under the influ-
ence of chloroform. The limb was afterwards wrapped in flannel, &c.
Saw him twice again on the same day, and found him comfortable. On
the two succeeding days he went on well.
13th —Was summoned to my patient about six p. m., and found con-
siderable arterial bleeding from the accidental wound. In consultation
with my friend I applied tannin, Ruspini’s styptic, bandage, &c.
14th.—No fresh haemorrhage. Applications seemed to have effect.
15th.—Was summoned about nine p. m., and, in consultation with
my friend, finding he was much reduced from an additional loss of
blood, and darkness coming on, I re-plugged the wound, and left it till
morning.
16th.—An experienced surgeon of many years’standing met us early
in consultation, when we agreed to remove plugs and enlarge wound,
endeavoring to find ends of bleeding vessel or vessels; and if we failed,
to amputate the leg below the knee, as a last resource. There had
been no escape of blood since the previous night, but on removing
plugs, &c., hsemorrhage burst forth with increasing violence. I pro-
ceeded as we agreed, but found the difficulty consequent on state of
parts; we could not command the flow of blood sufficiently to
justify delay, and I performed the circular amputation as quickly as I
could, the patient being under the influence of chloroform. A large
quantity of blood was lost. I remained within a few yards of him during
day and night, but no hemorrhage followed this last operation. From
this time everything proceeded satisfactorily ; there was a slight exfo-
liation at the edge of the divided tibia, yet the stump healed kindly,
and he is now earning a good living as a “ pike-keeper.”
Remarks.—1 have had the opinion of two or three hospital surgeons,
of very high standing, that the treatment pursued was proper. I give
the words of one :—141 am not prepared to say that it could have been
better managed. In nine cases out of ten your first operation of liga-
turing the superficial femoral artery would have sufficed to control all
haemorrhage, but the tenth case (such I consider yours) has induced
surgeons of authority to lay down the rule, that an artery when wound-
ed, should be cut down upon, and both ends secured; of course there
are exceptions to every general rule, and your case might fairly be
considered one.”
I have not the presumption to give an opinion on the practice with
such high authorities, but I can only say, from the disappointment the
first operation occasioned me, that I should, in a similar case, follow
the principle laid down by Mr.Guthrie. It is some consolation tome to
know that an hospital surgeon now in practice, and whom three-fourths
of the profession would, I believe, place at the very top of the tree,
failed to find and secure bleeding vessels in the same situation !
Some may think I might have tied the popliteal, others, that the fe-
moral should have been secured above, the profunda. The reasons for
not choosing the former operation are well explained by Dr. Massey in
his paper. In the latter case, I acknowledge, my patient might have
escaped with his limb; but I would ask any surgeon—Had I not a
right to expect I had secured him by tying the superficial femoral?
With regard to the wounded vessel or vessels, I am induced to be-
lieve that more than one was injured, as the principal vessels of the
leg are so close to each other, and which rendered my second opera-
tion far more difficult. Many, perhaps, will say that it could have been
easily ascertained in the amputated limb. I would, with all deference, ask
those who know the inconvenience of surgical operations, dissections,
&c., in a confined country cottage,—where you have not only innu-
merable disadvantages to put up with, but the prejudices of relatives
against your removing the limb from their sight, or making one more
incision than perfectly necessary, though a dead member, believing in
their ignorance, curiosity to be your motive, if it is to be wondered at
that I did not ascertain it ? I did make a quick dissection of the limb
in an adjoining room, but, from the hurried and rough way in which
I was obliged to proceed, I will not advisedly assert that I avoided
wounding another branch, besides anterior tibia, during the process !
Should any gentleman favour me with a notice of the case in your
valuable journal, 1 shall be pleased to supply any additional particulars
he may require to this imperfect statement !
In Dr. Massey’s case the patient is described as suffering for many
years from large ill-conditioned ulcers on his extremeties. My patient,
a large framed, robust, and healthy fellow, had never suffered frompa/-
pitation or other ailments. Could the condition of the two have caused
so marked a difference in freedom of anastomosis!—Lancet.