_Secondary hæmorrhage._--In simple wounds of the soft parts by

_small-calibre bullets_ this was decidedly rare. In wounds complicated

by fractures of the bones, especially when they exhibited the so-called

'explosive' character, secondary hæmorrhage was not uncommon, and this

not necessarily in conjunction with infection and suppuration.

In the chapter on fracture some remarks will be found on the

prolongation of healing often observed in the exit portion of the wound

track, which is explained by the well-known fact that, given an aseptic

condition of the wound, sloughs of tissue separate very slowly.

Secondary hæmorrhage in these cases is due to lesions of the vessel

short of perforation, but severe enough to so lower the vitality that

local gangrene of the wall occurs. In such instances hæmorrhage most

usually occurred on the tenth to the fourteenth day, but occasionally

still later. In one instance of ligature of the anterior tibial artery

for such hæmorrhage three-quarters of the whole lumen of the vessel had

been devitalised. The resemblance of some cases of secondary hæmorrhage

of this class to those occasionally observed after amputation, and due

to accidental non-perforative injury of the artery at the time of

operation above the point of ligature, was very striking.

In other cases secondary hæmorrhage was the result of perforation of the

vessel by a sharp spicule of bone, but in the large majority sepsis and

suppuration were the cause. Naturally therefore the accident was

commoner in the more severe kinds of wound, and in those caused by

_large_ bullets or fragments of shell. The symptoms in nearly all cases

were the classical ones of repeated small hæmorrhages followed by a

sudden copious gush.

The forms of secondary hæmorrhage, however, which afforded most interest

were the interstitial and the internal, mainly on account of the scope

they allowed for diagnosis.

Characteristic examples of internal secondary hæmorrhage are furnished

by cases of chest injury accompanied by hæmothorax and fully dealt with

under that heading (Chapter X.). Cases of interstitial secondary

hæmorrhage are also described under the heading of traumatic aneurism

and abdominal injuries (No. 194, p. 445). It therefore suffices here

merely to remark on the diagnostic difficulties the condition gave rise

to. These mainly depended upon the elevation of general bodily

temperature by which the hæmorrhage was often accompanied. Further

evidence of the condition was furnished by the development of local

swellings, or physical signs indicative of the collection of fluid in a

serous cavity. These signs developed rapidly, and the rise of

temperature was sudden and decided enough to suggest commencing

suppuration. In several cases incisions were made under the supposition

that this had already occurred.

The fever accompanying blood effusions was generally a somewhat special

feature in the wounds of the campaign. At first bearing in mind that in

every case a track, even if closed, led from the surface to the effused

blood, one was disposed to suspect an infection of the clot of a

somewhat innocuous nature. The absence of subsequent suppuration,

however, was definitely opposed to this view, and suggested that the

fever resulted from absorption of some element of the blood, possibly

the fibrin ferment, or some form of albumose. A pronounced illustration

was in fact afforded of the evanescent rise of temperature usually the

accompaniment of simple fractures in the case of the limbs, and of the

more marked rise not uncommon in cases of traumatic blood effusion into

the peritoneal cavity, or when the pleuræ or joints were the seats of

the mischief. In the case of interstitial hæmorrhages I only remember to

have seen fever of such marked continued type in the subjects of

hæmophilia with recent effusions, although one is of course acquainted

with it in a less pronounced form as a result of hæmorrhage into

operation wounds.

In primary interstitial hæmorrhages a similar continued rise of

temperature was also common, and I cannot perhaps better illustrate its

character than by the brief relation of two instances.

In a patient wounded at Kamelfontein the bullet entered four inches

below the acromion, pierced the deltoid, splintered the humerus, and

crossed the axilla. A large blood extravasation developed in the axilla,

accompanied by cutaneous ecchymosis extending halfway down the arm.

There was no perceptible pulsation in either the brachial or radial

artery, but the limb was warm. There was partial paralysis of the parts

supplied by the ulnar and musculo-spiral nerves and complete loss of

power and sensation in the area of distribution of the median nerve. Six

months later the radial pulse was still absent in this patient, but

there was no sign of the development of an aneurism.

[Illustration: TEMPERATURE CHART 1.--Axillary Hæmatoma. Shows range of

temperature during process of absorption and consolidation without

suppuration]

The accompanying temperature chart is characteristic. The blood

effusion gradually gained in consistency and underwent steady diminution

in size. No suppuration occurred.

The median paralysis was found to be accompanied by the inclusion of the

nerve in a sort of foramen of callus, when the patient was explored at a

later date by Mr. Ballance.

In a patient wounded at Paardeberg, a Mauser bullet entered by the left

buttock, pierced the venter ilii, traversed the pelvis, and emerging at

the brim of the latter, crossed the back, fractured the spine of the

fourth lumbar vertebra, and escaped below the twelfth right rib. The

track suppurated where it crossed the back, but the man did well until

the twentieth day, when a swelling developed in the left iliac fossa and

the general temperature rose to 102°. An abscess was at once suspected

and the swelling incised by Major Lougheed, R.A.M.C. A large

subperitoneal hæmatoma only was discovered, and evacuated. The

temperature at once fell and the after progress was uneventful, the

wound healing by primary union.

TREATMENT OF HÆMORRHAGE

_Primary._--No deviation from the ordinary rules of surgery should be

necessary in the majority of cases, but in a certain number the

conditions are so unusual that the special considerations must be taken

into account. The natural tendency to spontaneous cessation of primary

hæmorrhage in small-calibre wounds is the first of these. Experience has

shown that often mere dressing, or at any rate slight pressure, suffices

to efficiently stanch immediate bleeding. Although, however, immediate

control is to be obtained by such means, the cases of traumatic aneurism

of every variety related in the next section show that the ultimate

result is in many such cases by no means satisfactory.

Under these circumstances it may be said that the classical rule of

ligation at the point of injury should never be disregarded. Against

this, however, certain objections may be at once raised; thus in many

cases both artery and vein need ligature, a consideration of much

importance in the case of such vessels as the carotid and femoral

arteries. Again in many of the injuries to the popliteal artery the

wound directly communicated with the knee joint, a complication which,

while it may be disregarded in civil practice, must take a much more

important place in the circumstances under which many operations in

military surgery are performed.

On the whole, it seems clear that the military surgeon must be guided by

circumstances, since it may be far better to risk the chances of

recurrent hæmorrhage, or the development of an aneurism or varix, all of

which are amenable to successful treatment later, than those of gangrene

of a limb or softening of the brain. As a general rule, therefore, on

the field or in a Field hospital, primary ligature of the great vessels

is best reserved for those cases only in which hæmorrhage persists,

while in those in which spontaneous cessation has occurred, or in which

bleeding is readily controlled by pressure, rest and an expectant

attitude are to be preferred.

A word must be added as to the objections to distant proximal ligature

for primary or recurrent hæmorrhage. In some situations this may be

unavoidable, and it is sometimes successful, but none the less it is

opposed to all rules of good surgery and a most uncertain procedure. It

leaves the patient exposed to all the risks attendant on the employment

of simple pressure. In one case which I saw, the third part of the

subclavian artery had been ligatured for axillary bleeding; secondary

hæmorrhage, as might have been expected, occurred, and that as late as

five weeks after the operation. In another case ligature of the femoral

artery for popliteal hæmorrhage was followed by the development of a

traumatic aneurism in the ham.

_Secondary._--In secondary hæmorrhage the treatment to be adopted

depends upon the nature of the case. When the wound is aseptic, and

bleeding the result of the separation of sloughs, local ligature is the

proper treatment, and this was often successfully adopted, especially in

the case of such arteries as the tibials. In septic cases, on the other

hand, it is usually far better if possible to amputate, unless the

general state of the patient and the local conditions are especially

favourable.

When neither amputation nor direct local ligature is practicable,

proximal ligature may be of use. Sometimes this may be obligatory in

consequence of the difficulties attendant on direct local treatment. I

saw a few cases successfully treated in this manner: in one the common

carotid was tied (Mr. Jameson) for hæmorrhage from an arterial hæmatoma

in connection with the internal maxillary artery. Although ligature of

the external carotid would perhaps have been preferable, the result was

excellent. When even this expedient is impracticable, local pressure is

the only resort.

Lastly, as to the treatment of secondary interstitial blood effusions, I

believe the best initial treatment is the expectant. If interference is

needed, it is much more likely to be satisfactory the more chronic the

condition has become, since the source of the bleeding may be impossible

to discover. I never saw a patient's life endangered by the amount of

such hæmorrhage, but if this should seem to be likely, local treatment

is of course unavoidable. In several cases quoted below, incision and

evacuation were followed by excellent results; in any such operation too

much care to ensure asepsis is impossible.

TRAUMATIC ANEURISMS

The experience of the campaign fully bears out that of the past as to

the steady increase of the number of aneurisms from gunshot wounds in

direct ratio to diminution in the size of the projectiles employed.

Every variety of traumatic aneurism was met with, and most frequently of

all, perhaps, aneurismal varices and varicose aneurisms. While so

experienced a military surgeon as Pirogoff could say, in 1864, that he

had never seen a case of aneurismal varix, every young surgeon lately in

South Africa has met with a series. Again, although the condition is a

well-known one, it has been rather in connection with civil life; for

the great majority of recorded cases were the result of stabs or

punctured wounds such as are liable to be received in street brawls, or

as a result of accidents with the tools of mechanics. Thus of ninety

cases collected by K. Bardeleben in 1871, only 12 or 13.33 per cent.

were the result of gunshot wound.

_False traumatic aneurism or arterial hæmatoma._--This condition was met

with comparatively frequently, and bears a very close relation to that

already described under the heading of interstitial hæmorrhages. The

latter might almost have been included here, since the difference

between the two conditions depended merely on the size of the vessels

implicated. The exact correspondence in the period of development of

some of the arterial hæmatomata, and of the occurrence of the aseptic

form of secondary hæmorrhage, also explains the pathology of the two

conditions as identical; except that in the former the effused blood is

retained in the tissues, while in the latter it escapes externally. The

history of these cases was uniform and characteristic. A wound of the

soft parts, or sometimes a fracture, was accompanied by a certain degree

of primary interstitial hæmorrhage, which might or might not have been

associated with external bleeding. A hæmatoma resulted in connection

with the wounded vessel, the general tendency in the effusion being to

coagulation at the margins and subsequent contraction. Meanwhile the

opening in the artery became more or less securely closed by the

development of thrombus, and possibly by retraction of the inner and

middle coats of the vessel. With the return of full circulatory force as

shock passed off, or with the resumption of activity and consequent

freer movement of the limb, the temporary thrombus became washed away.

The newly formed wall of soft clot bounding the effusion proved

insufficient to withstand the full force of the blood pressure, and

extension of the cavity resulted. In the more rapidly developing

hæmatomata, temporary pressure by the effused blood on the bleeding

vessels was also, no doubt, a common explanation of temporary cessation

of increase in size.

A diffuse soft fluctuating swelling, sometimes accompanied by pulsation,

but oftener without, developed, and not uncommonly diffusion was

accompanied by some discoloration of the surface and elevation of the

general temperature. Such arterial hæmatomata commonly developed from

ten days to three weeks after the original wound. A few examples will

suffice.

(1) A patient wounded at Elandslaagte was sent down to Wynberg.

The antero-posterior wound in the upper third of the arm was

healed, but a month after the injury a large fluctuating

arterial hæmatoma developed in the axilla and upper third of

the arm. This was incised (Colonel Stevenson) and a wound of

the axillary artery in its third part discovered, and the

vessel ligatured. The patient made an excellent recovery.

(2) A patient received a wound at Doornkop which traversed the

calf in an obliquely antero-posterior longitudinal direction.

Three weeks later a soft fluctuating swelling developed at the

inner margin of the tendo Achillis occupying the lower third of

the leg. Neither pulsation nor murmur was detected. There was

anæsthesia in the area of distribution of the posterior tibial

nerve. No tendency to further increase was observed, and

operation was postponed. The temperature was normal.

(3) An Imperial Yeoman was struck at Zwartskopfontein at a

range of one hundred yards. The man rode four miles on his

horse after being hit, but the horse then fell and rolled over

him twice. The man was treated successively in the Van Alen,

Boshof, and Kimberley Hospitals, and from the last he was sent

to Wynberg which place he reached on the twenty-third day. When

admitted into No. 2 General Hospital the wounds of type form

and size (_entry_, in posterior fold of axilla; _exit_, 1-1/2

inch below junction of anterior fold with arm) were healed. The

whole upper arm was swollen and discoloured, while an indurated

mass extended along the line of the vessels into the axilla.

This was considered a blood effusion; it was not obviously

distensile, and pulsation was very slight. The brachial radial

and ulnar pulses were absent. A fluctuating swelling was

present along the anterior border of the deltoid. There were

some signs of nerve contusion, but no paralysis, beyond tactile

anæsthesia in the area of distribution of the median nerve.

Four days later little alteration had been noticed beyond a

tendency to variation in firmness of the different parts of the

swelling. On the thirty-first day considerable enlargement was

observed. This enlargement, together with continued rise of

temperature, aroused the suspicion of suppuration, and an

exploratory puncture with a von Graefe's knife was made by

Major Lougheed, R.A.M.C., after consultation with Professor

Chiene. Blood clot first escaped, followed by free arterial

hæmorrhage. The incision was enlarged while compression of the

third part of the subclavian was maintained; a large quantity

of clot was turned out, and an obliquely oval wound half an

inch in long diameter was found in the axillary artery.

Ligatures were applied above and below the opening between the

converging heads of the median nerve. The veins were not

damaged. The wound healed by first intention. On the twelfth

day a feeble radial pulse was perceptible, and shortly

afterwards the man left for England, diminished median tactile

sensation being the only remnant of the original symptoms.

(4) A private of the 2nd Rifle Brigade was struck while

doubling at Geluk, at a range of one hundred yards. The Mauser

bullet entered four inches above the upper border of the left

patella, internal to the mid line of the limb, and escaped in

the centre of the popliteal space. The man lay in a farmhouse

during the night and bled considerably from both wounds. He did

not fall when struck, but could not walk. He was sent to No. 2

General Hospital in Pretoria. On arrival there the external

wounds were scabbed over, and a large tumour existed beneath

the entrance wound. There was much discoloration from

ecchymosis, but no pulsation could be detected. The posterior

tibial pulse was good. At the end of ten days pulsation became

marked both in the front of the limb and in the popliteal

space. There were no symptoms of nerve injury. On the

thirteenth day an Esmarch's bandage was applied and Major

Lougheed laid the tumour open opposite the opening in the

adductor magnus. Much clot was removed, and both artery and

vein, which were found divided in the adductor canal, were

ligatured.

The foot remained very cold for the first twenty-four hours,

but otherwise progress was satisfactory, the wound healing by

first intention. No pulsation was palpable in the tibials at

the end of a month.

For the last two cases I am very much indebted to Major Lougheed. I am

glad to include them, as they illustrate one or two points of special

importance. No. 3 shows the tendency to variation in the tension and

firmness of the tumours, the tendency to primary contraction of the sac,

followed by diffusion, and the rise of temperature often accompanying

the latter occurrence. This is of great interest in relation to the

similar rise of temperature seen with the increase of hæmorrhage in

cases of hæmothorax. For purposes of comparison, the progress may well

be considered alongside of that in the case related on p. 119, in which

the wounded vessel was probably also the main trunk itself.

No. 4 differs from any of the others in depending on a complete division

of a large artery and vein. The development of the hæmatoma was

consequently more rapid and continuous. Another point of interest was

the maintenance of pulsation in the tibial vessels, in spite of complete

solution of continuity in the parent trunk. That this was independent of

the collateral circulation seems evident from its complete disappearance

and slowness of return after ligation of the wounded vessels.

_Prognosis and treatment._--The treatment in these cases is sufficiently

obvious, and consists in direct incision and ligature of the wounded

vessels. The cases related show the success with which this procedure

was attended, since uniformly good results were obtained. When possible,

an Esmarch's tourniquet should be applied in the case of the lower limb.

In the upper, compression of the subclavian is necessary during

interference with axillary hæmatomata, combined with direct pressure on

the bleeding spot after the clot has been removed. In the case of the

arm, digital compression is always to be preferred, in view of the

well-known danger of damage to the brachial nerves from the tourniquet.

Proximal ligature is always to be avoided. It is inadequate, and proved

more dangerous as far as the vitality of the limb was concerned, the

latter point probably depending on the interference with the collateral

circulation by pressure from the extravasated blood, which is unrelieved

by the operation. I know of at least two cases of gangrene which

occurred consecutively to proximal ligature of the femoral artery for

this condition.

_True traumatic aneurisms._--The cases met with differed so little from

those seen in ordinary civil practice, that but slight notice of them is

necessary. They differed from the last variety mainly in the more

localised nature of the tumour, the greater firmness of its walls, and

the more pronounced expansile pulsation. The development of this form of

aneurism was probably influenced by several circumstances, such as the

more complete rest secured for the patient, the locality in the limb as

affecting movement of the spot in the vessel actually wounded, the size

of the opening in the vessel, and the degree of support afforded by

surrounding structures. (Examples are furnished by cases 6-9.)

Under the influence of rest, all that I saw tended to contract and

become firmer, and they so far resembled spontaneous aneurisms as to be

readily cured by proximal ligature of the artery. The ideal treatment no

doubt consists in local incision and ligature on either side of the

wounded spot, with or without ablation of the sac. The choice of direct

or proximal ligature in any case depends on the position of the

aneurism, and the ease with which the former operation can be carried

out. In all these cases a very great advantage in the localisation and

diminution of the tumours was gained by postponing interference until

they became stationary. I need scarcely add that any evidence of

diffusion indicated immediate operation. The preference of direct or

proximal ligation will probably, to a certain extent, always depend on

the personal predilection of the surgeon, but while proximal ligature

has often given good immediate results during this campaign, it cannot

be with certainty decided whether the patients are definitely protected

from the dangers of recurrence.

Reference to cases 7 and 9 as illustrating the possible spontaneous cure

of traumatic aneurisms is of great interest.

I saw a number of cases successfully treated by proximal ligature; also

a number where continuous improvement followed rest, and which were sent

home for further treatment. None of these demand any special mention.

One case of a very special nature, which terminated fatally, is of great

interest:--

(5) In a man wounded at Belmont the bullet entered the second

left intercostal space and was retained in the thorax. He was

sent directly to the Base and came under the care of Mr.

Thornton at No. 1 General Hospital, Wynberg. Signs of wound of

the lung developed in the form of hæmoptysis and left

hæmothorax. The left radial pulse was almost imperceptible.

The entry wound did not close by primary union, and three weeks

later an incision was made into the chest in consequence of the

presence of fever, progressive emaciation, and weakness.

Breaking down blood clot was evacuated: general improvement

followed, and the radial pulse increased considerably in

volume.

A fortnight later sudden severe hæmorrhage occurred from the

external wound, and the man rapidly collapsed and died. At the

post-mortem a traumatic aneurism the size of an orange was

found in connection with an oval wound in the first portion of

the left subclavian artery which admitted the tip of the

forefinger.

This case is noteworthy as an illustration of the magnitude of an artery

which can be wounded without leading to rapid death from primary

hæmorrhage, even when in communication with a serous sac, and still more

as emphasising the importance of weakening of the radial pulse as a sign

in connection with a wound of the upper part of the chest on the left

side. It is somewhat surprising that this sign was not marked in two

cases (Nos. 13 and 14, p. 140) recorded below, in which the innominate

and right carotid arteries respectively were probably perforated.

(6) _Traumatic popliteal aneurism._--Wounded at Modder River.

_Entry_ (Mauser), over centre of tibia 1 inch above the

tubercle. _Exit_, about centre of popliteal space. No

hæmorrhage of any importance occurred from the wound, but there

was a typical hæmarthrosis, which subsided slowly. Twelve days

after the injury a pulsating swelling the size of a hen's egg,

to which attention was drawn on account of pain, was noted in

popliteal space. The pulsation extended upwards in the line of

the artery some 3 inches. The limb was placed on a splint and

treated by rest, and a month later the aneurism had decreased

to one half its former size, the wall having greatly increased

in firmness. Pulsation was easily controlled by pressure above

the tumour; there was no thrill present, but a high-pitched

bellows murmur. The patient was sent home on February 1.

When admitted at Netley the patient came under the care of Major Dick,

R.A.M.C., who ligatured the popliteal artery on the proximal side by an

incision in the line of the tendon of the adductor magnus. The aneurism

then consolidated.

(7) _Traumatic popliteal aneurism._--Wounded at Magersfontein.

_Entry_ (Mauser), centre of patella. _Exit_, centre of

popliteal space; the knee was bent at the time it was struck.

There was considerable primary external hæmorrhage, and so much

blood collected in the knee-joint that it was aspirated. On the

eighth day secondary hæmorrhage occurred from the exit wound

and the femoral artery was tied in Hunter's canal. No further

hæmorrhage occurred, but at the end of three weeks feeble

pulsation was palpable in the popliteal space, suggesting an

aneurism; the latter decreased and the patient was sent home

apparently well.

(8) _Traumatic axillary aneurism._--Wounded at Karree. The

bullet entered 2-1/2 inches below the acromial end of the right

clavicle and emerged over the 9th rib in the posterior axillary

line. The Mauser bullet was found in the patient's haversack.

Both apertures were of the slit form, and healed per primam.

Three weeks later at Wynberg a large arterial hæmatoma which

pulsated was noted in the axilla. Signs of injury to the

musculo-spiral nerve were also observed. The tumour altered

little, but a fortnight later Major Burton, R.A.M.C., cut down

upon it through the pectorals. The aneurism was of the third

part of the axillary artery, and a ligature was applied at the

lower margin of the pectoralis minor. The wound healed by

primary union and the aneurism rapidly shrank. The patient left

for England a month later; the musculo-spiral paralysis was

improving. I am indebted to Major Burton for the notes of this

case.

(9) _Traumatic popliteal aneurism._--Wounded in Natal. _Entry_

(Mauser), immediately above head of fibula. _Exit_, immediately

inside semi-tendinosus tendon at level of central popliteal

crease. Fulness but no pulsation was noted at end of three

weeks; seven days later pulsation was evident, and an aneurism

the size of a pigeon's egg, with firm walls, became localised

and palpable. It gave rise to no symptoms, and patient refused

operation during the three weeks he remained in hospital. The

aneurism continued to contract, and the patient was sent home.

The aneurism has since spontaneously consolidated.

_Aneurismal varix and varicose (arterio-venous)

aneurism._--Uncomplicated cases of aneurismal varix, as might be

expected, were less common than those in which the arterio-venous

communication was accompanied by the formation of a traumatic sac. The

initial lesion accountable for each condition was, however, probably

identical, and dependent on the passage of a bullet of small calibre

across the line of large parallel arteries and veins. Thus, obliquely

coursing antero-posterior wounds of the neck produced carotid and

jugular varices; vertically coursing tracks laid the subclavian vessels

in communication; antero-posterior tracks the brachial, popliteal, and

lower part of the femoral; and transverse tracks, the vessels of the

calf and forearm. Given an arterial wound, the mode of development of

the aneurismal sac in no way differs from that of the ordinary

traumatic variety; the main point of interest, therefore, is to seek an

explanation of the causes which may restrict the ultimate result to the

formation of a pure aneurismal varix. The explanation is possibly to be

found in some of the following circumstances.

_Size, position, and symmetry of the vascular wound._--It seems scarcely

necessary to insist on the calibre of the projectile, since this alone

determined the frequency of these conditions, but it must be borne in

mind that in the diameter of the bullets, classed as of small calibre

during this war, a range of from 6.5-8 mm. existed. In the case of both

the Krag-Jörgensen and Mauser, the shape of the bullet also was better

adapted to pure perforation of the vessels. I saw no case of

arterio-venous communication in which a larger bullet than one of the

four types chosen had been responsible for the primary injury, but a

difference of 1-1/2 mm. in calibre in the small projectile might well

determine the division, the pure and symmetrical perforation of the two

vessels, or the giving way of one side, so that they were deeply notched

instead of perforated.

Such positive evidence as was afforded by operation as to the exact

condition of the vessels in two cases of femoral arterio-venous aneurism

was, that in either case a clean perforation existed.

It is improbable that notching of the two vessels can primarily produce

a pure varix, although it may result in the formation of an

arterio-venous aneurism, especially if the bullet should have passed

between the two vessels in such a way as to notch the contiguous sides.

It is impossible to say, in any given case, what the result of secondary

contraction of a sac produced in this manner may be in the determination

of the ultimate relation of the vessels. In many of the cases clinically

designated pure varix, the remains of such a sac may still actually

persist. In the case also of pure perforation of the vessels, it is

difficult to believe that a localised blood cavity has not originally

existed. Given complete division of the vessels, as far as my experience

went, arterial hæmatoma was the uniform result.

Under these circumstances I am inclined to believe that a symmetrical

perforation of both vessels is the most common precursor of either

condition; that the pure varix is the rarer and less likely result, and

that its formation is dependent mainly on certain anatomical conditions.

The most important of these conditions are the proximity and degree of

cohesion of the two vessels, the comparative spaciousness or the

opposite of the vascular cleft, and the degree of support afforded by

surrounding structures.

Thus, the close proximity of the popliteal artery and vein, together

with the particularly firm adhesion which exists between the vessels,

probably favours the formation of a varix; again, a varix more readily

forms if the femoral artery and vein are wounded in Hunter's canal than

if the injury is situated high in Scarpa's triangle, where the vessels

lie in a large areolar space. The passage of a bullet between an artery

and vein may perhaps produce either condition, but wide separation of

the two vessels, as for instance of the subclavian artery and vein,

renders an aneurismal sac almost a certainty. These suggestions seem

borne out by the cases recounted below, since the pure varices are one

femoral, one popliteal, and one axillary. I cannot include the calf and

forearm cases, as the existence of a small sac could not be disproved.

To these anatomical factors certain others must be added. In most cases

a false sac exists at first, which tends to undergo contraction and

spontaneous cure, as is observed in some of the ordinary traumatic sacs.

This history of development is moreover supported by the observation

that proximal ligature of the artery usually converts an arterio-venous

aneurism into an aneurismal varix. The process is no doubt favoured by

cleanness and small size of the perforation, moderation in the amount of

primary hæmorrhage, the tone and resistance of the surrounding tissues,

special points in the circulatory force and condition of the blood, and

the possibility of maintaining the part at rest after the injury.

Aneurismal varix, when pure, was evidenced by the presence of purring

thrill and machinery murmur alone. In none of the cases I saw was pain

or swelling of the limb present. In one popliteal varix, slight

varicosity of the superficial veins of the leg was present, but it was

not certain that the development of this was not antecedent to the

injury, as the patient did not notice it until his attention was drawn

to its existence. In none of the cases under observation in South Africa

had enough time elapsed for sufficient dilatation of the artery above

the point of communication to give rise to any confusion from this cause

as to the presence of a sac.

When an arterio-venous sac has once formed, clinical observation shows

that the general tendency is towards extension in the direction of least

resistance. This direction of course varies with the situation of the

aneurism, and also with the nature of the wound track.

Speaking generally the direction of least resistance in a typically pure

perforation is towards the vein. Initial flow of blood from the wounded

artery is naturally favoured towards the potential space afforded by a

canal occupied by blood flowing at a lower degree of pressure. The

partial collapse of the vein dependent on the wound in its wall also

probably helps in determining the initial flow in its direction.

Examples are afforded by the carotid aneurisms (cases 10, 11, and 14),

and here it must be borne in mind that the outer limits of the cervical

vascular cleft are those least likely to offer resistance to extension

of the sac. In each the aneurisms mainly occupied the exit segment of

the track; this is the general rule, as in the case of external

hæmorrhage, and is determined by the same cause.

The latter rule however finds exceptions when the entry segment is so

situated as to cross a region of lesser resistance, and case 12

illustrates this point with regard to the cervical vascular cleft.

Examples of the tendency to spread in the anatomical direction of least

resistance are also offered by the cases of aneurism at the root of the

neck, where extension was into the posterior triangle.

The further clinical history and signs are as follows. A local swelling

is found, usually at first diffuse, often commencing to develop with

cessation of the external hæmorrhage. It increases, for the first few

days maintaining its diffuse character. If near the surface, it may be

superficially ecchymosed. At the end of this time a tendency to

localisation, as evidenced by increasing firmness and more definite

margination, takes place, and this is followed by general contraction

and rounding off of the tumour. The latter process may be continuous,

and eventually the sac may become small and stationary or ultimately

disappear and a pure varix be the result. The latter is only likely to

be the case under the most satisfactory of the conditions enumerated

above. Occasionally an opposite course may be followed, and fresh

extension take place, as evidenced by enlargement of the tumour,

disappearance of sharp definition, softening, and pain. The natural

termination of such cases in the absence of interference would no doubt

be rupture, and possibly death in some positions, loss of the limb in

others. The former I never saw.

_Purring thrill._--This, the pathognomonic sign of either condition, was

always present in the fully developed stage, and is probably present

from the first unless a temporary thrombosis obstructs the vascular

openings. It was noted as early as the third day in case 13. In many of

the other patients it was palpable only with the subsidence of the

primary swelling attendant on the injury. In some of the forearm and

calf aneurisms, and in some of the popliteal, it was only discovered by

accident some weeks even after the injury, but this often because no

serious vascular lesion had been suspected. The thrill was widely

conducted, often apparently superficial on palpation, and much more

pronounced with light than with forcible digital pressure.

In case 10 the _visible_ vibration in consonance with the thrill when

the vein was exposed during the operation of ligature of the carotid was

a novel experience to me.

_Murmur._--The typical 'bee in the bag,' or 'machinery' murmur was

present in every case, and was often very widely distributed, especially

over the thorax. (Cases 13, 14, and 20.)

In all three carotid cases the murmur was troublesome, being audible to

the patient at night when the head was rested on the side corresponding

to the aneurism.

_Expansile pulsation._--Pulsation in combination with the existence of a

tumour is the main feature in the diagnosis between the conditions of

pure varix and varicose aneurism. It was not always existent or

prominent in the earliest stages, probably from temporary blocking of

the artery, or from the diffuse and irregular nature of the cavity

offering conditions unsuitable to the satisfactory transmission of the

wave. When localisation had occurred it was always present.

EFFECTS OF ANEURISMAL VARIX OR VARICOSE ANEURISM ON THE CIRCULATION

(_a_) _General._--The most striking feature in these injuries is the

remarkable effect of the disturbance to the even flow of the circulation

on the heart. This first struck me in two of the cases of carotid

arterio-venous aneurism recorded below (Nos. 10 and 11). In these I was

inclined at first to attribute the rapid and irritable character of the

pulse solely to injury to the vagus, as in each laryngeal paralysis

pointed to concussion or contusion of the nerve. The pulse reached a

rate of 120-140 to the minute. This disturbance was not of a transitory

nature, for in the two cases referred to the rapid pulse persists, in

spite of entire recovery of the laryngeal muscles, and the fact that in

one case the aneurismal sac has been absolutely cured, and in the second

only a small sac remains, in each as a result of proximal ligature of

the carotid artery. In the former a varix still exists, and at the end

of seven months the pulse is still over 100. In the latter, in which a

sac is still present, the pulse rate varies from 110 to 130. In each

case the condition has now existed twelve months. My attention once

directed to this point, I noted a similar acceleration of the pulse in

the case of these aneurisms elsewhere; thus in a femoral aneurism the

rate was 120, and in an axillary varix of twenty years' standing which

came under my observation the pulse rate varied from 110 to 120,

according to the position of the patient. Unfortunately I had not

directed my attention to this point in the early series of cases which

came under observation.

It will be remarked in cases 13 and 14 that at the expiration of a year

the pulse rate was still high, but these again are cervical aneurisms

each in contact with or near the vagus.

In a case of aneurismal varix of the femoral artery of three years'

standing, which was under the charge of Mr. Mackellar, the pulse rate

was normal. In this instance great dilatation of the vessels had

occurred.

These observations raise the interesting question whether the irritable

circulation which has been classically considered one of the

predisposing causes of spontaneous aneurism should not rather be

regarded as a result of the condition.

(_b_) _Local._--In none of the cases of varix was the period of

observation long enough to allow me to determine the development of

dilatation of the arterial trunk above the point of obstruction. This,

however, is the common sequence, and no doubt will occur in those

patients who resume active occupation without operation.

The effects of either condition on the distal circulation were

remarkably slight. The distal pulses were little, if at all, modified in

strength or volume, and signs of venous obstruction, if present at

first, disappeared with much rapidity. In one case (No. 15) of a large

arterio-venous popliteal aneurism there was considerable swelling of the

leg, but in this case the sac was large and situated at the apex of the

space, and no doubt exercised external pressure on the vein.

In the case of the carotid aneurisms, especially that probably on the

internal carotid, transient faintness was a symptom in the early stages

of the case. All three of the cases recorded here, however, had been the

subjects of very free hæmorrhage, either primary or recurrent.

(10) _Carotid arterio-venous aneurism._--Wounded at Paardeberg.

_Entry_ (Mauser) to the right side of the Pomum Adami, _exit_

at anterior margin of left trapezius, two inches below the

angle of the jaw. There was some hæmorrhage at the time from

the exit wound, but no hæmoptysis; about four hours later,

however, in the Field hospital bleeding was so free that an

incision was made with the object of tying the common carotid.

During the preliminary stages of the operation bleeding ceased

and the wound was closed without exposing the vessel. The

patient remained a week in the Field hospital, and then made a

three day and night's journey in a bullock waggon to Modder

River (40 miles), and fourteen days later he was transferred to

the Base hospital at Wynberg, when the condition was as

follows. Operation and bullet wounds healed. Considerable

extravasation of blood in the posterior triangle. Beneath the

sterno-mastoid in the course of the bullet track, swelling,

thrill and pulsation over an area 1-1/2 inch wide in diameter.

Loud machinery murmur audible to the patient when the left side

of the head is placed on the pillow, and widely distributed on

auscultation. The left eye appears prominent, but the pupils

are normal and equal in size. Voice weak and husky, and there

is cough. Laryngoscopic examination showed the cords to be

untouched, but some swelling still persisted. No headache, but

giddiness is troublesome at times. Pulse 100, regular but

somewhat irritable.

The patient was kept quiet in the supine position for a month,

and during this time the condition in many ways improved. The

voice improved in strength, the pulse steadied, falling to 80,

the prominence of the left eye disappeared, and all the blood

effusion in the posterior triangle became absorbed. Meanwhile

the aneurism contracted at first, until it became oval in

outline, with a long axis of 2 inches by 1-1/2 broad extending

in the line of the wound track, but mainly situated in the exit

half. During the last fortnight, however, it remained quite

stationary in size, and as it showed no further signs of

diminution in spite of the favourable conditions under which

the patient had been placed, it was considered best to try to

ensure its consolidation by a proximal ligature. Thrill had

become slightly less pronounced, and was less evident to the

patient himself, but was otherwise unchanged. The probabilities

in this case seemed rather in favour of wound of the internal

carotid artery, and it was decided to bare the upper part of

the common carotid, follow up the main trunk, and if possible

apply the ligature to the internal branch. On April 12, 61 days

after the injury, the classical incision for securing the

common carotid was made, and the sterno-mastoid slightly

retracted. It was found that the sac of the aneurism extended

over the bifurcation of the artery, reaching to the wall of the

larynx. The omo-hyoid muscle was therefore divided, and the

artery ligatured beneath, in order to ensure against any

interference with the sac. Some difficulty was met with, for on

opening the vascular cleft the vein was exposed and found to

completely overlie the artery: although it was on the left side

of the neck, the position of the vein was so completely

superficial that there seemed no doubt that it had been

displaced by the development of the aneurismal sac. A striking

appearance was noted on exposure of the vein, the coats of

which vibrated visibly, quivering in exact consonance with the

palpable thrill. On tightening the silk ligature all pulsation

ceased in the aneurism, and the vibratory thrill in the vein

became much lessened.

The patient made a good recovery, only disturbed by a slight

attack of vomiting, and at the end of a week the wound had

healed, and pulsation in the aneurism had completely ceased.

The thrill persisted as before.

Six months later, a small sac still exists beneath the sterno-mastoid.

The pulse still reaches 110-120 in pace. The purring thrill is very

slight. The condition gives rise to little or no trouble. Pulsation is

strong in the external carotid artery, there is little in the common

carotid. The voice is strong and good. This aneurism is either at the

bifurcation of the common carotid, or on the immediate commencement of

the internal carotid. Ligature of the external carotid will probably

cure it.

(11) _Arterio-venous aneurism, probably affecting both

carotids._ Wounded at Paardeberg. _Entry_ (Mauser), at dimple

of chin immediately below mandibular symphysis. _Exit_, at

margin of right trapezius, the track crossing the carotids

about the level of normal bifurcation. The patient was lying on

his back with the head down when struck. Some hæmorrhage from

the exit wound occurred at the time, and later on the way to

Jacobsdal this was so profuse as to be nearly fatal. A

considerable hæmorrhage also occurred on the tenth day. The

patient made the journey to Modder River safely, and was then

under the charge of Mr. Cheatle. A large diffuse pulsating

swelling developed on the right side of the neck, with

well-marked thrill and machinery murmur. During the next three

weeks the swelling steadily contracted, and the patient was

sent down to the Base one month after receiving the wound, when

the condition was as follows. There is no evidence of any

fracture of the jaw. On the right side of the neck a large

aneurism fills the carotid triangle, extending from the

mid-line backwards to the margin of the trapezius, and from the

level of the top of the larynx upwards to the margin of the

mandible. The wall is fairly firm, pulsation is both visible

and palpable, and a well-marked thrill and machinery murmur are

present. The latter annoys him by its buzzing when the head

rests on the right side. The pupils are equal. Pulse somewhat

irritable, about 100. The voice is weak and husky, and there is

difficulty in swallowing solids. The actual swelling is

somewhat remarkable in outline, on the one hand following up

the course of the external carotid and facial arteries, and on

the other extending backwards in the line of the wound track

towards the exit. The patient was kept on his back with

sandbags around the head during the next fortnight. For the

first eight days such change as occurred was in the direction

of localisation and contraction, but during the last six,

evident extension occurred both backwards and downwards; this

extension was accompanied by severe pain in the cutaneous

cervical nerve area of the neck. The larynx became pushed over

3/4 of an inch to the left of the median line, and the

extension beneath the sterno-mastoid downwards raised a doubt

as to whether the common carotid could be exposed without

encroaching on the walls of the sac. Owing to indisposition I

had not been able to see the patient for some days, but now,

after consultation with Major Simpson and Mr. Watson, it was

decided that the best plan would be to expose and tie the

common carotid as high as could be safely done. The operation

was performed six weeks after the injury, and somewhat to our

surprise offered little difficulty. The carotid was exposed at

the upper border of the omo-hyoid, only a small amount of

infiltration having occurred in the vascular cleft. No

dilatation of the jugular was noticeable, and when a silk

ligature was applied to the artery all pulsation was

controlled, and the thrill in the vein disappeared completely.

The after progress was satisfactory, but four days later the

wound was dressed, as the patient's temperature had risen above

100°. The tumour was consolidated: no pulsation could be felt,

but there was little apparent diminution in its size. A loud

blowing murmur was audible, especially at the posterior part of

the swelling.

On the morning of the fifth day the patient mentioned that he

again heard the whirr during the night. There had been no sign

of any cerebral disturbance and the pupils had remained equal

throughout.

A week after the operation the stitches were removed, there was

evidence of some blood clot in the lower part of the wound, and

this later liquefied and was let out on the eleventh day. At

that time a slight bubbling thrill could be felt at the upper

part of the tumour, also slight pulsation in the line of the

external carotid and at the most posterior part of the sac. The

latter was much contracted, diminished in size and apparently

solid, so that it was hoped that such pulsation as existed was

communicated. Ten months later, no trace of the aneurismal sac

exists. Neck normal, except for purring thrill. Voice strong

and good. Pulse 100. Following his usual work.

(12) _Carotid arterio-venous aneurism_.--Wounded at Paardeberg.

Aperture of _entry_ (Mauser), at the posterior border of the

left sterno-mastoid, 1 inch above the clavicle; _exit_, near

the posterior border of the right sterno-mastoid, 2 inches from

the sterno-clavicular joint. The injury was followed by very

free hæmorrhage, mainly from the wound of entry, some 'quarts'

of blood escaping; at any rate his clothes were saturated. The

voice was hoarse and weak, and there was much difficulty in

swallowing; for the first twenty-four hours he could swallow

nothing, but gradual improvement took place. The patient was

carried two miles to the Field hospital, and three days later

travelled 36-40 miles in a bullock waggon to Modder River.

Thence he travelled to Orange River 55 miles by train on the

next day. A swelling was first noted when the wound was dressed

some seven days after the injury. No evidence was ever existent

of gross damage to either trachea or oesophagus beyond the

initial dysphagia. The hoarseness of voice due to left

laryngeal paralysis slowly improved, and was probably the

effect of concussion or contusion of the left recurrent

laryngeal nerve. During the patient's stay at Orange River a

large pulsating swelling with a strong thrill developed. This

was at first diffuse, but under the influence of rest it

steadily contracted and localised. During this period the

patient was seen several times by Mr. Cheatle, who noted

considerable temporary enlargement of the thyroid gland.

At the end of eight weeks he had been allowed up some days, and

travelled 570 miles to Wynberg. The aneurism was about 1-1/2

inch in diameter, smooth and rounded, extending just beneath

the left clavicle and nearly the whole width of the

sterno-mastoid, but well defined in all directions. There was

well-marked expansile pulsation, purring thrill along the

jugular vein and over the tumour, and loud machinery murmur

widely diffused along the whole neck and into the thorax. The

voice was still weak and husky, but there was no dysphagia or

dyspnoea. The left pupil was larger than the right.

The patient acquired enteric fever at Wynberg and when

convalescent was sent to Netley, whence he returned home. The

aneurism caused little discomfort. It may possibly have been of

the inferior thyroid artery.

(13) _Innominate arterio-venous varix_.--Wounded at Modder

River. _Entry_ (Mauser) posterior margin of left

sterno-mastoid, close above the clavicle. _Exit_ in anterior

axillary line one inch below the right anterior axillary fold.

Soon after the injury a considerable amount of blood was

coughed up, and occasional hæmoptysis persisted for the next

four days. The patient was moved from the Field hospital by

train to Orange River, a journey of 55 miles and some four

hours' duration, on the fourth day. When examined there was

slight fulness over an area roughly circular and about 2-1/2

inches in extent, of which the sterno-clavicular joint lay just

within the centre. Over this area there was faint pulsation

with a strongly marked thrill and loud systolic bruit. The

radial pulses were even, the right pupil larger than the left.

No pain, and no dyspnoea. The right eye was partially closed,

but could be opened by the levator palpebræ superioris. The

patient was shortly afterwards sent to the Base, and when seen

there twenty-five days after the injury, there was little

change in the condition except that the fulness had

disappeared, the thrill was more marked, and a typical

machinery murmur transmitted along both carotid and subclavian

arteries had developed. There was no headache and the man

himself did not notice the bruit. Evidence of mediastinal

hæmorrhage existed in the presence of subcutaneous

discoloration of the abdominal wall, below the ensiform

cartilage and extending slightly over the costal margin of the

thorax. In the absence of an aneurismal swelling, or of the

development of any further symptoms, the patient was sent home

to Netley in January.

I saw this patient in Glasgow a year later. He was employed as a

lamplighter, and was able to do his work well, only complaining of

attacks of shortness of breath on exertion. He said these were apt to

come on each evening about 6 P.M. The pulse was 100 when the erect

position was maintained, and 84 to 88 in the sitting posture. The right

pupil was still dilated, reacting for accommodation but little to light.

The palpebral fissure was normal in size and there was little, if any,

diminution in strength of the right radial pulse.

On inspection no pulsation was visible; in fact, the pulsation of the

normal left subclavian was more apparent in the posterior triangle of

that side. The sterno-mastoid was prominent, also the sternal third of

the clavicle. On firm pressure some pulsation was palpable beneath the

sterno-mastoid, but no definite evidence of the presence of a sac could

be detected. Purring thrill and machinery murmur were still present, but

the former was slight, and palpable only with the lightest pressure. The

machinery murmur had ceased to be audible to himself, and was by no

means loud or very widely distributed.

The condition had, in fact, steadily improved, and become far less

obvious. The prominence of the sterno-mastoid and clavicle still present

was difficult of explanation, except on the theory of an injury to the

bone, or that an aneurismal sac had consolidated spontaneously.

(14) _Arterio-venous aneurism, root of right carotid._--Wounded

at Magersfontein. _Entry_ (Mauser), centre of right

infra-spinous fossa. _Exit_, 3/4 of an inch above clavicle,

through point of junction of the heads of the right

sterno-mastoid muscle. Range 200-300 yards. When wounded the

man ran two hundred yards to seek cover. There was no serious

external hæmorrhage, but the injury was followed by some

difficulty in swallowing, and hæmoptysis, which lasted for the

first two days. The right radial pulse was noted to be smaller

than the left, and weakness in flexion of the fingers, with

hyperæsthesia in the ulnar nerve distribution, was observed.

The right pupil was also noted to be larger than the left.

The patient was sent down to the Base, and on the twenty-fourth

day the condition was as follows. A pulsating swelling existed

extending 1-1/4 inch upwards beneath the right sterno-mastoid,

from the mid line of the neck backwards to the centre of the

posterior triangle, and downwards over 2 inches of the first

intercostal space, which latter was dull on percussion. There

was some evidence of a bounding wall, but it was thin and the

tumour was soft and yielding. A loud machinery murmur was

audible over the tumour, over nearly the whole extent of the

thorax, and in the distal vessels as far as the temporal

upwards, and the brachial as far down as the bend of the elbow.

The murmur was audible to the patient with his ears closed.

Over the swelling a strong thrill was palpable; this extended

some little distance into the distal vessels and felt

remarkably superficial. It was particularly evident in the line

and course of the anterior jugular vein, and appeared to be

extinguished by local pressure. Although readily felt in the

posterior triangle, it was impalpable on deep pressure in the

suprasternal notch, a fact which seemed in favour of localising

the aneurismal varix to the subclavian artery and vein. The

right pulse was good, although smaller than the left, and was

said to have improved in volume. The right pupil was slightly

larger than the left, but reacted normally. There was no pain

or difficulty in swallowing. Weakness in power of flexion of

the fingers persisted, and there was some impairment of

sensation in the area of distribution of the ulnar nerve.

Three weeks later no material change had occurred, except that

the swelling was perhaps softer and the thrill more

superficial, and at the end of two months the patient was sent

to England.

I saw this patient a year later in Glasgow, when the condition was as

follows. He was living at home, and out of employment. He complained of

shortness of breath on exertion, and said that when he mounted stairs he

felt 'as if his heart were going to leave him.' The heart's apex beat in

the sixth interspace in the nipple line, and the precordial dulness was

somewhat increased. The pulse numbered 80 to 84. The muscles supplied by

the ulnar nerve were very weak, but not much wasted, and ulnar sensation

was imperfect.

The aneurism had considerably altered in form and outline; its walls

were dense and firm; it extended 2-1/2 inches upwards in the line of the

carotid artery, beneath the sterno-mastoid, but projected beyond the

posterior border of that muscle. The larynx was displaced 1/2 an inch to

the left of the median line; the voice was still husky, although much

stronger than it was; the anterior jugular vein was dilated. The purring

thrill was very superficial, and chiefly palpable over the subclavian

vessels. The machinery murmur was still loud, but much less widely

distributed than before; it was still audible to the patient when he lay

on his right side.

This case was of much interest from the diagnostic point of view. When I

first saw the patient I considered the injury to have implicated the

innominate vessels. Later, from the facts that the thrill was

imperceptible in the episternal notch, and that the main part of the

tumour was situated in the posterior triangle, that the wound was of the

root of the right subclavian vessels.

It now appears that, at any rate, the root of the right carotid is the

artery implicated.

In spite of the continued existence of a large aneurism, the

localisation of the sac, which had taken place, was very striking,

considering that the man had been walking about freely, and living an

ordinary life, except that he had undertaken no work.

(15) _Popliteal arterio-venous aneurism_.--Wounded at

Paardeberg. _Entry_ (Mauser), at lower margin of patella.

_Exit_, at centre of back of thigh. Perforation of lower end of

femur. The patient was lying down with crossed knees when the

injury was received. Much oedema of the foot and leg followed

the injury, and on the third day a thrill was discovered. Three

weeks later there was still some swelling of the calf, the

posterior tibial pulse was imperceptible, the anterior very

small. An aneurism was palpable at the inner part of the top of

the popliteal space, about the size of a pigeon's egg; a strong

thrill was to be felt, especially when the knee was flexed, and

with this expansile pulsation and a loud machinery murmur. The

entry wound was firmly healed; the exit still furnished

blood-stained serous discharge. The synovial cavity of the knee

was distended and doughy on palpation. During the next three

weeks the aneurism contracted considerably and the patient was

sent home.

When admitted to the Herbert Hospital the patient complained

chiefly of pains in the foot and leg. The aneurism was cured by

ligation of the vein above and below the communication and

proximal ligature of the popliteal artery.[15]

(16) '_Femoral arterio-venous aneurism._--A private of the West

Yorkshire Regiment was hit on February 11, 1900, at Monte

Christo by a bullet which passed through the inner border of

his right thigh above its middle. On arrival at Woolwich the

patient was found to have a varicose aneurism at the upper end

of Hunter's canal. On May 31 the femoral artery was ligatured

just above its communication with the vein, and as this stopped

all pulsation in the vein, it was decided to postpone ligature

of the latter to a subsequent occasion, if it should ever be

necessary; such a procedure would, it was thought, interfere

less with the circulation of the limb, and would therefore be

less likely to be followed by gangrene, which is so frequent a

result of high ligature of the femoral. But a few days after

the operation the foot became cold and mummified, and there

was no alternative but to amputate the limb through the

condyles of the femur. From this operation the patient made a

good recovery, and when discharged there was no sign of an

aneurism of the vein.'

Case 16 is quoted from a paper in the _Lancet_ by Lieut.-Colonel Lewtas,

I.M.S. It illustrates a result with which I became acquainted in three

other instances not under my own observation.

ANEURISMAL VARICES

(17) _Axillary._--Wounded at Modder River. _Entry_ (Mauser), at

inner margin of front of left arm, just below level of junction

of axillary fold. _Exit_, at about centre of hollow of axilla.

A month later when the wound was healed a typical thrill and

machinery murmur were noticed. The latter was audible down to

the elbow and upwards into the neck. The radial pulse appeared

normal. No swelling or pulsation existed. At the end of three

months the condition was unaltered; the patient said he noticed

nothing abnormal in his arm, except that it was sometimes 'sort

of numb' at night.

(18) _Popliteal._--Wounded at Magersfontein. _Entry_ (Mauser),

in centre of popliteal space. _Exit_, about centre of patella,

which latter was cleanly perforated. Three weeks later the

typical thickening of the knee-joint following hæmarthrosis was

present, also a well-marked thrill and machinery murmur in the

popliteal vessels with no evidence of a tumour. The leg was

normal except for slight enlargement of the internal saphenous

vein and its branches, probably independent of the arterial

lesion.

(19) _Femoral._--Wounded at Magersfontein. _Entry_ (Mauser), 7

inches below left anterior superior iliac spine. _Exit_, at

inner aspect of thigh. One month later slight fulness without

pulsation was discovered on the inner side of the femoral

vessels just above the level of the wound track. Some

blood-staining still remained in the fold between the scrotum

and thigh. Machinery murmur and a well-marked thrill, most

palpable to the inner side of the superficial femoral artery,

were noted. No further symptoms developed and the patient was

sent home.

_Prognosis and treatment._--No one can help being struck with the

disinclination shown by the older surgeons to interference in cases of

either aneurismal varix or varicose aneurism, even after the time that

ligation of the vessels had become a favourite and successful operation.

The objections lay in the technical difficulties of local treatment, and

the danger of gangrene after proximal ligature. Modern surgery has

lightened the difficulties under which our predecessors approached these

operations, but none the less the experience in this campaign fully

supports the objections to indiscriminate and ill-timed surgical

interference, as accidents have followed both direct local and proximal

ligature.

In _pure varix_ no doubt can exist as to the advisability of

non-interference in the early stage, in the absence of symptoms. This is

the more evident when we bear in mind that a stage in which an

aneurismal sac exists can seldom be absent. In many cases an expectant

attitude may lead to the conviction that no interference is necessary,

especially in certain situations where the danger of gangrene has been

fully demonstrated. In connection with this subject I cannot help

recalling the first case of femoral varix that ever came under my own

observation. I discovered the condition accidentally in a man admitted

into the hospital for other reasons. The patient remarked: 'For heaven's

sake, sir, do not say anything about that. I have had it many years, and

it has never given any trouble. If it is known, I shall be worried to

death by people examining it.'

None the less it must be borne in mind that beyond enlargement of the

vein dilatation of the artery above the seat of obstruction does occur,

and gives trouble in some situations. Again the disturbance of the

general circulation already adverted to shows that the existence of this

condition is sometimes of importance in its influence on the cardiac

action.

Under these circumstances the treatment varies with regard to the

vessels affected, and the degree of disturbance the condition gives rise

to.

With regard to locality, experience appears to have shown clearly that

communications between the carotid arteries and jugular veins usually

give rise to so little serious trouble that, in view of the grave nature

of the operation and its possible after consequences on the brain,

interference is as a rule better avoided. I should, however, be

inclined to draw a distinction between operations on the common and

internal carotid arteries in this particular, and should regard varix of

the latter vessel and the internal jugular vein as especially

undesirable for interference.

The vessels at the root of the neck are probably to be regarded from the

same point of view, as to surgical interference.

The arteries of the upper extremity are the most suitable for operation,

and the axillary may perhaps be the vessel in which interference is most

likely to be useful. In this relation it may be of interest to include

here a case of a man who took part in the campaign when already the

subject of an aneurismal varix of the axillary artery.

(20) Twenty years previously the patient suffered a punctured

wound of the left axilla from a pencil. A varix developed, but

was only discovered by accident ten years later. The patient

was seen by several surgeons, and treatment was discussed; the

balance of opinion was, however, in favour of non-interference,

and nothing was done beyond giving injunctions as to care in

the use of the limb. Up to the time of discovery of the varix

no inconvenience had been felt, although the patient was of

athletic habits. Subsequently, the patient himself was positive

that a swelling existed, but he pursued his usual work. In

1899-1900 he took part in the operations in South Africa as a

combatant, and during this time was subjected to very hard

manual work. During this he was seized with sudden pain in the

left side of the head and neck, and in consequence invalided.

No restriction in the movements of the upper extremity, and no

subcutaneous ecchymosis developed, but the patient was positive

as to the tumour having greatly enlarged.

Four months later the condition was little altered. A pulsating

swelling 1-1/2 inch broad existed along the line of the upper

two-thirds of the axillary artery, and along the subclavian in

the neck, rising some 1-1/2 inch into the posterior triangle.

Pulsation was visible; the murmur was audible when sitting

beside the patient, and widely distributed over the whole

chest, the neck, and upper extremity on auscultation. The pulse

rate varied with the mental condition of the patient, which was

excitable, between 96 and 120. There was neuralgic pain in the

neck and scalp, and down the distribution of the brachial

plexus. The pupils were equal, but flushing of the face and

profuse sweating followed any exertion. I concluded the tumour

in this case to be mainly due to dilatation of the trunk above

the point of obstruction on account of its outline, the absence

of any restriction of movement in the upper extremity, and the

non-occurrence of subcutaneous ecchymosis at the time of the

attack of severe pain. Difficulties arose as to undertaking any

active form of treatment for this patient, which, to be

satisfactory, needed an antecedent period of absolute rest, and

he passed from my observation. I think, however, operation by

ligature above and below the communication would have been

possible. The case affords a good example of the course the

condition may sometimes take if precaution is neglected.

The vessels of the arm or forearm may in almost all cases be interfered

with, but in many instances an absence of any serious symptom renders

operation unnecessary.

With regard to the femoral varices, I would refer to the remarks below,

and those on the treatment of varicose aneurism as indicating that a

certain amount of caution should be exercised in interfering with them.

The same remarks in a lesser degree apply to the popliteal vessels. In

the leg the tibials may readily and safely be attacked, but it may be

mentioned that the widespread and diffused nature of the thrill may in

some cases give rise to considerable difficulty in sharp localisation of

the varix to either of the vessels, or to any particular spot in their

course. In one case in my experience the posterior tibial was cut down

upon, when the varix was probably peroneal in situation.

The operation most in favour consists in ligation of the artery above

and below the varix, the vein remaining untouched. Even this operation,

however, in two cases of femoral varix failed to effect more than a

temporary cessation of the symptoms, although the ligatures were placed

but a short distance from the communication. Failure is due to the

presence of collateral branches, which are not easy of detection. Even

when the vessels lie exposed, the even distribution of the thrill

renders determination of the exact point of communication difficult, and

the difficulty is augmented by the temporary arrest of the thrill

following the application of a proximal ligature to the artery. A

successful case is reported by Deputy Inspector-General H. T. Cox, R.N.,

in which the ligatures were placed 1/2 an inch from the point of

communication.[16] Single ligation, or proximal ligature, is useless.

If the vein cannot be spared, excision of a limited part of both vessels

may be preferable, particularly in those of the upper extremity.

Proximal ligation of the artery combined with double ligature of the

vein, as adopted in case 15 by Colonel Lewtas for a varicose aneurism,

might offer advantages in some situations.

Given suitable surroundings and certain diagnosis, the ideal treatment

of this condition, as of the next, is preventive--_i.e._ primary

ligation of the wounded artery. Many difficulties, however, lie in the

way of this beyond mere unsatisfactory surroundings. It suffices to

mention the two chief: uncertainty as to the vessel wounded, and the

necessity of always ligaturing the vein as well as the artery in a limb

often more or less dissected up by extravasated blood, to show that this

will never be resorted to as routine treatment.

_Arterio-venous aneurism._--Many of the remarks in the last section find

equal application here, but in the presence of an aneurismal sac

non-intervention is rarely possible or advisable. In the early stages

the proper treatment in any case consists in placing the patient in as

complete a condition of rest as possible, and affording local support to

the limb by a splint, preferably a removable plaster-of-Paris case.

Should no further extension, or, what is more likely, should contraction

and diminution occur, it will be well to continue this treatment for

some weeks at least.

When the aneurism has reached a quiescent stage the question of further

treatment arises, and whether this should consist in local interference

or proximal ligature. The answer to this mainly depends on the size and

situation of the vessels concerned. To take of the cases above described

the five instances in which the cervical vessels were the seat of the

aneurism. In No. 13 the symptoms appeared fairly conclusive of the

injury being to the innominate artery and vein, or possibly innominate

artery and jugular vein. Fortunately the aneurismal sac in this case was

small and showed a tendency to decrease, but in any case no interference

would have been justifiable. I think a similar opinion was unavoidable

in No. 14, probably affecting the root of the right carotid. Here under

any circumstances interference would have been most hazardous. The

position of large aneurism made the route of approach to the wounded

spot necessarily through the sac, exposing the patient to the double

danger of immediate hæmorrhage and of entrance of air into the great

veins. Nos. 10, 11, and 12 fall into the same category, except that in

No. 11 the immediate indication for interference was extension. In each,

ligature of the artery above and below the point of communication would

have necessitated so near an approach to the sac which must remain in

communication with the vein as to have entailed injury to the latter,

when both artery and vein must have been ligatured, probably risking

serious cerebral trouble. In No. 11 I believe both the external and

internal carotids were implicated; in No. 10 I believe the internal

alone, close to its origin. The operation of proximal ligature ensured

primary consolidation of the sac in both cases 10 and 11, but left the

thrill unaltered, except in so far as it was temporarily weakened. It,

in fact, converted these cases from arterio-venous aneurisms into pure

aneurismal varices. In No. 10 a sac subsequently redeveloped. No. 12

stood on a different basis. No operation was done for him in South

Africa, but the first portion of the carotid might have been ligatured

in the episternal notch, or by aid of removal of a part of the sternum,

and a second ligature placed above the sac. Here a ligature above and

below the communication would have been comparatively easy.

As a general rule proximal ligature is to be reserved for those cases

alone in which double ligature is either impracticable or inadvisable,

and it can only be expected to convert a varicose aneurism into the less

dangerous condition of aneurismal varix.

In the case of arterio-venous aneurisms in the limbs the possibilities

of treatment are enlarged, and here the alternatives of (_a_) local

interference with the sac and direct ligature of the wounded point,

(_b_) simple ligature above and below the sac, (_c_) proximal ligature

(Hunterian operation), come into consideration.

Direct incision of the sac is suitable, and the best method of treatment

for aneurisms in the calf, forearm, and probably arm. Several cases in

the two former situations were successfully treated by this method. On

the other hand, the only case I saw in which a proximal ligature had

been applied for an arterio-venous aneurism of the leg resulted most

unsatisfactorily. The sac in the calf suppurated at a later date, and

for many weeks the escape of small quantities of blood from the

remaining sinus kept up the fear of a severe attack of secondary

hæmorrhage until the sinus closed.

In the case of femoral and popliteal aneurisms the method of Antyllus is

often unsuitable. A case of arterio-venous aneurism of the femoral

artery quoted in the _Lancet_[17] will illustrate the difficulty which

may be met with in determining the actual bleeding point in the

irregular cavity laid open. In any case the necessary ligature of both

artery and vein is a serious objection to the direct method either in

the thigh or ham, and more particularly if adopted before the damage

dependent on the dissection of the limb by extravasated blood has been

repaired.

Proximal ligature (Hunterian) even, offers dangers under these

circumstances. In one case with which I became acquainted, it was

followed by gangrene, necessitating amputation. The lesion in this

instance was a perforating one of the femoral artery and vein.

For either femoral or popliteal arterio-venous aneurisms ligature of the

artery above and below the aneurism is the best and safest treatment. In

view of the healthy state of the vascular wall in most of these cases,

the advantage of placing the ligatures as near to the wounded spot as

can be managed without interference with the sac is afforded. A number

of popliteal cases treated in this way did perfectly. In the femoral

cases a considerable period of rest to allow of consolidation of the

sac, and readjustment of the circulation, should always be allowed to

elapse.

In the case of popliteal arterio-venous aneurisms a number were

successfully treated by proximal (Hunterian) ligature, and by single

ligature immediately above the sac. In a considerable proportion of the

latter both artery and vein were tied. This was apparently the result of

the difficulty of isolating the vessels in the tangled mass of clot and

cicatricial tissue surrounding them, and is a strong argument against

too early interference. The late Sir William Stokes expressed himself as

in favour of ligature of the artery in Hunter's canal, combined with

that of the great anastomotic branch, and quoted some successful cases

to me. I have grave doubts, however, whether the varix can often be

permanently cured by this operation.

I can give no useful statistics on this subject, but with regard to the

popliteal aneurisms I may state that in three instances gangrene of the

leg followed early operative interference in the popliteal space.

My own opinion on this subject is strong, and to the effect that none of

these operations should be undertaken before a period of from two to

three months after the injury, unless there is evidence of progressive

enlargement. In every case which came under my own observation

progressive contraction and consolidation took place up to a certain

point under the influence of rest. When this process has become

stationary, and the surrounding tissues have regained to a great extent

their normal condition, the operations are far easier, and beyond this

more likely to be followed by success.

It appears to me that one argument only can be raised against the above

opinion, viz. the possibility of healing of the recent wound in the

vessels when the force of the circulation is lowered by proximal

ligature. Such experience as that quoted from Sir W. Stokes and two of

Mr. Ker's cases, mentioned below, support this possibility, but in all

the reported results were recent. Against them I can only advance my

knowledge of several mishaps following early operation.

In concluding these observations on injuries to the arteries and

aneurisms, a few general remarks as to the occurrence of gangrene after

operation must be added. This was not uncommon, and in the main was no

doubt attributable--(1) to the lowering of the vitality of the

surrounding tissues by creeping blood extravasation, and sometimes to

actual pressure by the extravasation on the vessels necessary for the

establishment of the collateral circulation. (2) To the frequency with

which both artery and vein required to be ligatured.

Beyond these common causes, however, others must be advanced, dependent

on the general and local condition of the nervous system in these cases.

In general mental state many of the patients were much shaken, and in

others the condition spoken of as local shock in a former chapter had

been marked. In a third series obvious individual nerve lesions were

co-existent with those to the vessels. Beyond this a fourth nervous

element of unknown quantity, the effect of the form of injury on the

vaso-motor nerves accompanying the great vessels, must be taken into

consideration.

I believe all these factors were of importance, since it appeared to me

that gangrene occurred more often than I should have expected. In one

case which I have heard of, gangrene followed a very slight injury to

the foot in a patient who had apparently made an excellent recovery

after ligature of the femoral artery.

The nervous factor seems another element in favour of reasonable delay

in active interference with traumatic aneurisms of the above varieties

in the absence of threatening symptoms.

It is worthy of remark that no case of gangrene due to aneurism came

under my notice, except subsequently to operation.

Since the above chapter was written, my friend, Mr. J. E. Ker, has sent

me his experience in the treatment of four aneurisms, which is of such

interest that I insert it as an addendum.

_Arterial hæmatomata._--(1) Popliteal, treated by local incision. Both

artery and vein completely divided. Ligature of the four ends. Cure.

(2) Traumatic aneurism of upper third of forearm. Treated by rest and

pressure by bandage. On the eighth day pulsation and bruit ceased

spontaneously, and the remains of the sac steadily consolidated until

the man's discharge on the twenty-sixth day.

_Arterio-venous aneurisms._--(1) At junction of brachial and axillary

arteries. Proximal ligature. Cure. (2) Arterio-venous aneurism at the

bend of the elbow. Ligature of the brachial at the junction of the

middle and lower thirds of the arm. Cure.

FOOTNOTES:

[14] The murmur is still present at the expiration of one year, but no

other change.

[15] Lieut.-Colonel Lewtas, I.M.S. See _Lancet_, 1900, vol. ii. p. 1073.

[16] _Lancet_, 1900, vol. ii. p. 1074.

[17] Sir W. MacCormac, _Lancet_, vol. i. 1900, p. 876.

CHAPTER V

INJURIES TO THE BONES OF THE LIMBS

Injuries to the bones of the limbs formed a very large proportion of the

accidents we were called upon to treat, and afforded as much interest as

any class, since they possessed many special features. I shall hope to

show, however, as in some of the other injuries, that these features

differed only in degree from those exhibited by injuries from the old

leaden bullets of larger calibre, although with few exceptions they were

of a distinctly more favourable character.

It is of considerable interest to note that, taking the fractures as a

whole, there was a somewhat striking change in their nature during the

earlier and later portions of the campaign. In the earlier stages I

think there is no doubt that punctured fractures were proportionately

more common than in the later, when comminuted fractures were much more

often seen. There was, I believe, a source of error in this opinion, as

far as I myself was concerned, in that the first cases I saw were at

Capetown and had come from Natal. There is no doubt that the punctured

fractures were earlier fit to travel, and hence a larger number of them

found their way to the Base hospitals at a period when the comminuted

fractures were still in the Field or Stationary hospitals. I do not,

however, rely on the cases seen at Capetown alone for my opinion, as

while at the front I saw the same large proportion of clean punctures in

the early engagements of the Kimberley relief force.

I am inclined to attribute the change to two reasons: first, I believe

that the use of regulation weapons was more universal in the earlier

part of the war, while later, as more men were engaged, the

Martini-Henry came more into evidence, and the Boers took more freely

to the use of sporting rifles and ammunition. Another element also in

the less clean punctures of the short and cancellous bones was probably

the less accurate and hard shooting of the Mauser rifles as they became

worn; the bullets seemed to evidence this by the comparative shallowness

of their rifle grooves, which, I take it, would mean less velocity and

accuracy in flight. This would be of importance, since the clean

puncture of cancellous bone was no doubt favoured by a high rate of

velocity.

The special features of the fractures caused by the small-calibre

bullets were: (1) The nature of the exit wound, which in a certain

proportion of the cases exhibited the so-called 'explosive' character.

(2) The presence, in a marked degree in the severe cases, of the

condition spoken of in Chapter III. as 'local shock.' (3) The striking

contrast of clean perforation and extreme comminution in different

cases. (4) The occasional occurrence of fractures of a very high degree

of longitudinal obliquity. (5) The rarity of any that could be termed

transverse fractures. (6) The general tendency of longitudinal fissuring

when it occurred to stop short of the articular extremities of the

bones.

It will perhaps be most convenient to consider first the explanation of

the development of the so-called explosive apertures, and then to pass

on to a general consideration of the types of fracture commonly met

with, before proceeding to the description of the injuries to the

separate bones.

_Explosive wounds in connection with fractures._--The aperture of entry

in these injuries presented little or no deviation from the normal,

unless it was due to the passage of ricochet bullets, when it might be

very irregular, but usually not of great size.

[Illustration: FIG. 47--(21) 'Explosive' Exit Wound of Forearm over

margin of ulna. Note creased tongue of skin originally covering whole

wound. The entry wound was a small typical circular one]

The aperture of exit offered special features beyond simple increase in

size. First of all, as in the small type wounds, the actual extent of

destruction of the skin was small, this having been projected outwards

by the passing bullet and then either burst or torn by the bullet and

accompanying bony fragments. Fig. 47 well illustrates this feature. A

triangular tongue of skin was lifted by the passing bullet and probably

by the lower end of the upper fragment of the fractured ulna; through

the resulting opening a mass of soft tissues and bone fragments, bound

together by an infiltration of coagulated blood, was extruded,

separating the lateral lips of the aperture, while the original tongue

has shortened and retracted up to the top of the wound.

The small extent of skin actually destroyed is an important element in

the rapid contraction often seen in these wounds when they progress

favourably. Thus the large wound portrayed in fig. 48 contracted to

one-fourth its original size ten days after the diagram and measurements

were made. The large mass of protruded tissue was often most striking

when a muscle such as the biceps in fig. 48 had been divided; but the

herniæ were more persistent when the mass projected in regions where

tendons formed a large integral constituent, as at the wrist or lower

third of the forearm. The protruding tissues naturally consisted of many

varieties, according to what lay in the track of any particular wound.

It should be added that for 'explosive' features to reach their

strongest development, it is necessary that the bone affected should lie

near the surface of the body; hence the most characteristic explosive

wounds were met with in the forearm or leg, over the metacarpus or

metatarsus, or in the arm. In the thigh, on the other hand, where the

femur in a great part of its course not only lies deeply, but is also

protected by particularly strong and resistent skin and fascia, another

type of wound was met with. The explosive exit aperture, although large,

was still only moderate in extent, sometimes, as in the front of the

lower third, exposing a somewhat angular large track walled by the

divided quadriceps extensor cruris. In other cases, on introducing the

finger through a moderate exit opening on the inner aspect of the thigh,

a large cavity, sometimes 4 or 5 inches in diameter, was discovered,

full of clot and shreds of destroyed tissue and lined by a layer of

similar material. In either of these latter cases the fractured bone

ends were situated too deeply to take part in the actual laceration of

the skin, while the force transmitted to the bone fragments, although

sufficient to cause them to widely destroy the first soft tissues met

with, did not suffice to cause them to burst or lacerate the skin

widely.

[Illustration: FIG. 48.--(22) 'Explosive' Exit Wound of front of Arm.

Wound actual size eight days after its infliction. The prominences in

the upper and lower parts correspond with the lacerated biceps. The dark

crater led down to the fracture. In another week the wound had

contracted to half the size. The entry aperture was a normal circular

one. The arm a year later was used in the patient's employment as a

hammer-man.]

With regard to the theories of the production of these phenomena, that

of the transmission of a part of the force of the bullet to the

comminuted fragments, which thus themselves acquire the characters of

secondary projectiles, seems quite adequate.[18] Examination of any of

the skiagrams in which considerable comminution has taken place, shows

that the fragments are carried forward and perforate the tissues distal

to the fracture.

[Illustration: FIG. 49.--'Explosive' Wounds of Legs. Large irregular

entry (1 × 3/4 in.). First exit (2 in.) roughly circular. Second entry

wound, produced by bone fragments driven out of left leg, very large and

irregular (5 × 3-1/2 in.). The measurements were taken eight days after

infliction of the wounds. The right limb was amputated later for

secondary hæmorrhage]

Fig. 49, although a poor delineation of the actual condition, shows well

the possible action of projected fragments, even after they have been

driven from the wound. In this case either a large or a ricochet bullet

entered on the outer aspect of the upper third of the left tibia; it

produced a severe comminuted fracture, the fragments from which,

together with the deformed bullet, then struck and perforated the upper

third of the right tibia. A large irregular entry wound 5 inches in

transverse diameter was produced in the second limb together with a

comminuted fracture of the bone. The right limb had eventually to be

amputated for secondary hæmorrhage, but I am unacquainted with the later

history of the patient.

The mode of displacement of the lateral fragments when a wide shaft such

as that of the femur is struck, throws some light on that of the

displacement of soft tissues such as the component parts of a perforated

nerve or artery. The bullet, passing through, expends the chief part of

its energy in driving before it the fragments produced in its direct

course, while a minor part of the energy is expended on displacing the

lateral fragments, which are pushed to either side without becoming

separated from their periosteal attachment. The appearance, in fact,

somewhat suggests what might be expected were a small charge of dynamite

introduced into the centre of a small tunnel made across the shaft of

the bone. Examination of some of the skiagrams also illustrates another

point of interest, viz. that a certain degree of recoil on the part of

the bone results from the blow, since in many of them portions of the

mantle of the bullet and bone fragments are seen in that portion of the

track proximal to the fractured bone.

The importance of 'setting up' of the bullet is at once evident in

relation to the production of wounds of an explosive type in connection

with fractures of the bones. There can be no doubt that a considerable

number of the most severe injuries we saw were produced by the various

soft-nosed or expanding forms of bullet, also that others of an equally

serious nature were produced by Martini-Henry or large leaden sporting

bullets. Allowing for this, however, I think a considerable proportion

were the result of deformation from bony impact, or ricochet deformities

external to the body acquired by regulation Mauser bullets, and I think

these bullets can be quite as formidable as any of the sporting

varieties met with. The soft-nose varieties of small calibre may not set

up enough to cause severe injury, while the large leaden bullets often

flatten out so completely as to lose all penetrating power. As far as

my impressions went, the small soft-nosed bullets needed to be

travelling at a very considerable rate of velocity to be dangerous. In

the form of soft-nose Mauser employed, the soft-nose was too short to

allow of as successful a mushrooming of the bullet as often occurred

with the regulation projectile, because, as already explained, the

mantle acquires increased stability from its closed base.

FRACTURES OF THE SHAFTS OF THE LONG BONES

_Types of fracture._--The common types of fracture of shafts of the long

bones are illustrated diagrammatically in fig. 50. Of the whole series

comminuted fractures were by far the most frequently met with, while the

various wedge-shaped forms were the most strongly characteristic of the

special form of injury in which we are interested.

[Illustration: FIG. 50.--Five Types of Fracture: A. Primary lines of

stellate fracture; wedges driven out laterally and pointed extremities

left to main fragments. B. Development of same lines by a bullet

travelling at a low degree of velocity; suppression of two left-hand

limbs and substitution of a transverse line of fracture; a spurious form

of perforation. See plate XXIII. C. Typical complete wedge. See plate

VII. D. Incomplete wedge; impact of bullet, lateral or oblique, and two

left-hand lines seen in A are suppressed. E. Oblique single line, one

right and one left hand line seen in A, suppressed. The influence of

leverage from weight of the body probably acts here. Compare plates XVI.

and XXI.]

[Illustration: PLATE III.

Skiagram by H. CATLING

Engraved and Printed by Bale and Danielsson Ltd.

(23) SPURIOUS PERFORATION OF CLAVICLE

Range unknown, probably either mean or long.

The bullet entered from the front, grooved the under surface of the

acromial end of the clavicle with increasing depth, and eventually

perforated the posterior margin of the bone, raising the compact tissue

in an angular manner.

The commencement of an incomplete groove extending from the anterior

margin is seen, resembling the groove of the humerus, fig. 58.]

1. _Stellate comminuted fractures._--A shows the primary nature of the

lesion in all comminuted fractures of compact bone, consisting in the

production of a number of radiating fissures, which assume a stellate

form of which the point of impact corresponds to the centre. B shows an

incomplete development of this form, the fragments being simply

displaced laterally with slight loss of substance, so as to simulate a

real punctured fracture. An illustration of this fracture produced by a

bullet travelling at a low degree of velocity is seen in plate XXIII.,

which also shows the unaltered bullet lying in close proximity to the

injured fibula.

The degree of comminution in these fractures depends first on the range

of fire and consequent striking force retained by the bullet, a high

degree of velocity producing extreme comminution of compact bone. The

severity of the latter again may be influenced by the measure of

resistance dependent on the density and brittleness of any individual

bone, or on the possession of the same characters as a special property

by the tissues of the man struck. Thus plate IV. shows a fracture of the

humerus produced by a bullet shot from a short range, and the fragments

are comparatively large and of even dimensions, while plate XIV. shows

extreme comminution of the portion of the femur exposed to direct

impact, with elongated large fragments at the sides of the track. Plate

XIX. shows less extreme comminution and less separation of the

fragments, and was probably produced by a bullet from a longer range of

fire.

The separation of elongated lateral fragments is a special feature, and

best marked when the portion of bone struck is considerably wider than

the bullet, as in the case of the shaft of the femur. These fragments

correspond in the method of their production to those seen in the wedge

fractures described below, while their separation leaves a pointed

extremity to either segment of the shaft. This fracture in its purest

type is, I believe, spoken of as the 'butterfly fracture.'

With regard to the spread of the fissures in the long axis of the bone

into neighbouring articulations I think fractures produced by bullets of

small calibre differ considerably from those produced by larger

projectiles, in that their general tendency is not to extend beyond the

commencement of the cancellous bone forming the joint end. This is

perhaps capable of explanation on several grounds: first, the smaller

area of impact results in the assumption of a strongly marked stellate

figure, the radiating fissures of which rapidly reach the lateral limits

of the shaft, producing a solution of continuity in the bone which

interrupts the continuance of the action of the wedge represented by the

bullet. Secondly, the small size of the wedge itself is opposed to the

wide separation of the parts directly implicated, which is necessary for

the continued progress of the process of fissuring, and again the

rapidity of passage minimises the period during which the force is

exerted. It is in these points that I believe the chief differences

between the modern and old gunshot fractures find their explanation,

since with the larger bullets fractures extending from some distance

into the joints were a somewhat special feature. In addition it is

probable that the alteration in structure at the junction of the shafts

with the cancellous ends also tends to check the regular extension of

the fissures, as a similar limitation is illustrated even in some

fractures by Snider bullets. Fig. 51 of the lower end of the femur

illustrates a not uncommon lower limit to a comminuted injury in this

region.

[Illustration: FIG. 51.--Lower end of Femur. From Case needing

amputation. It shows the usual tendency of the fissures to stop short of

the articular ends of the long bones]

The degree and nature of the comminution also vary with the directness

of impact on the part of the bullet. The more nearly this approaches at

a right angle, the more severe is the local comminution, but probably a

lesser area of the shaft is implicated. Plate V. shows an example of

this: all trace of continuity is lost, a wide gap separates the bone

ends, while the fragments themselves have been for the most part driven

altogether out of the wound. Oblique impact, on the other hand, may

widen the comminuted area at the point of impact, while, if the bullet

retains sufficient force and regularity of outline, it may then travel

'cutting its way' through the remainder of the bone in an oblique

direction. It will be of course recognised that the exact impact of the

bullet depends not alone on the direction of the projectile, but also

on the nature of the slope offered by the surface of bone struck.

2. _Wedge fractures._--This form (C and D, fig. 50) is equally

characteristic of gunshot injury with pure perforation; it is met with

in two varieties. C illustrates the more strongly marked type; in it the

bullet makes passing lateral impact with the shaft, and from the point

struck radiating fissures extend to the opposite margin, so that a

wedge-shaped piece of bone often secondarily comminuted is separated

from the remainder of the shaft; see plate X. of the radius.

The second variety, D, is an incomplete development of the stellate

fracture in which the fissures pass to one margin of the bone only. The

explanation of this variation is probably to be sought in the direction

of impact on the part of the bullet, since the main fissure is often

accompanied by secondary lines which run a somewhat parallel course to

the main one, and suggest the dispersion of the force in the form of

concentric waves. Such fractures were most strongly marked in the tibia,

the breadth of the surfaces of this bone presenting especially

favourable conditions for their production.

3. _Notched fractures._--These may be a slight degree of the form of

wedge fracture last described; such a one is depicted in plate XXII.

where a portion of the spine of the tibia has been carried away by a

passing bullet. Other notched fractures approximate themselves more

nearly to perforations, the notch being a groove secondary to the

opening up of such a track as is shown in the illustration of a

perforation of the lower third of the shaft of the tibia (fig. 57 on p.

219). Notching or grooving is naturally much more common in the

cancellous portions of bones.

4. _Oblique fractures._--These also occur in two varieties: the first

has been already alluded to; in it the bullet actually cuts an oblique

track in the bone; the main line of fracture is often considerably

comminuted, usually at the proximal end of the track (see plates XV. and

XIX.).

The second variety (E, fig. 50) is less common; in it two of the main

limbs of the simple stellate figure are suppressed, while the remaining

two form a continuous line from one margin of the shaft to the other,

the point of impact lying approximately in the centre of the line of

fracture. Such a fracture is illustrated by the skiagram of a femur in

plate XVI. in which the bullet traversed the soft parts transversely at

the level of the centre of the fracture, which was 9 inches in length.

In another case the line of fracture occupied the lower third of the

femur, passing from the inner border of the shaft, the lower end of the

upper fragment was formed by the compact tissue forming the outer wall

of the external condyle. This latter perforated the vastus externus and

lay beneath the skin; as it could not be disentangled, an incision was

made over it, and the fragments when reduced were screwed together by

Mr. S. W. F. Richardson. In neither fracture was there any comminution.

Such fractures most nearly resemble the oblique or spiral ones met with

in civil practice as the results of falls. In all the instances I

observed the patients were supported on the lower extremities at the

time of the accident, and one can only assume that a twist of the trunk

consequent on the fall of the body diverts the most forcible vibrations

resulting from the impact of the bullet into one line, and thus produces

a solution of continuity of a simple oblique nature. In both the cases

mentioned above the bullet was probably travelling at a low degree of

velocity; in the first it was a ricochet and was retained. I never saw

one of these fractures in the upper extremity.

Plate XXI. affords an excellent example of this mechanism. The patient

was standing when struck, and then fell backwards. An incomplete fissure

7 inches in length is seen to extend from an otherwise pure perforation

of the shaft of the tibia.

5. _Transverse fractures._--Throughout these were of very rare

occurrence. Plate XX. illustrates a pure transverse fracture produced by

passing contact of a bullet probably fired at a distance not exceeding

400 yards, and which subsequently struck the fibula plumb and produced

considerable comminution. No fissure extended into the ankle-joint.

Comminutions such as that illustrated by plate V. more or less simulated

transverse fractures, but I saw no examples of transverse tracks

comparable to the oblique ones described above 'cut through' the shaft

of a bone.

6. _Perforations._--Although these were common in cancellous bone, they

were comparatively rare in the compact shafts. I saw, however, complete

pure perforations of the shafts of the tibia, femur, clavicle, and other

bones. These perforations were, I believe, always the result of low

degrees of velocity, and they took the place of simple transverse

fractures of the 'cut' variety. The apertures of entry and exit in the

bones resembled in character those seen in the soft parts, or in the

bones of the skull in low-velocity injuries (see figs. 71 and 72, p.

261). The entry was more or less cleanly cut, while at the exit a plate

of bone was raised, and either separated or turned back on a hinge by

the bullet (fig. 52), (plate XVII.) Such a projecting hinged fragment

was sometimes a source of some trouble; thus in a case of

postero-anterior perforation of the lower third of the shaft of the

femur, the long exit fragment projected into the substance of the

quadriceps extensor muscle, and interfered with flexion of the

knee-joint. Fig. 57 of a superficial tunnel of the lower third of the

tibia is especially interesting as bringing such injuries of the long

bones into line with fractures of the flat bones of the skull, such as

are illustrated in fig. 68, p. 259.

Plate XXI. affords an excellent example of perforation of the shaft of

the tibia, although complicated by the secondary fissure.

Plates XXIII., VIII., and III., of the fibula, humerus, and clavicle,

exhibit examples of what may be called spurious perforations of the

shafts of bones, since comminution or loss of continuity accompanies all

three.

Subsequently to writing the above paragraphs, I took the opportunity of

re-examining the magnificent series of gunshot fractures collected

during the Franco-German campaign by Sir William MacCormac, and

afterwards presented by him to the museum of St. Thomas's Hospital.

The close approximation in type between the main features in these and

those in the fractures produced by the modern bullet is very striking.

In the case of the shafts of the long bones, the same stellate, oblique,

wedge-shaped, and even perforating injuries are illustrated on a coarser

scale. In a specimen of a patella, a perforation of the lower half,

implicating also the tendon of the quadriceps muscle is, though large,

almost as pure as a Mauser perforation.

The difference in the nature of the lesions of the bones is seen to be,

firstly, one of pure magnitude, corresponding to the size of the large

Snider bullet by which they were produced. Thus the fragments generally

are larger, and occupy a wider area of the shafts, the first character

depending on the lesser degree of velocity of the bullet, the latter on

its volume and weight. Fine comminution, however, the most striking

feature of the modern injury, is throughout absent.

The effect of the larger size of the wedge provided by the bullet in

increasing the length of secondary longitudinal fissures is well marked,

and for the same reason the perforations are usually accompanied by

fissures of considerable extent. It is interesting to note, however,

that even in the case of the large bullets, and the special tendency

shown by them to cause the extension of fissures into the joints, one or

two specimens still show that these fissures incline to stop short when

the point of junction between the portion of the shaft occupied by the

medullary canal and that built on a foundation of cancellous tissue is

reached.

LESIONS OF THE SHORT AND FLAT BONES

The above types of fracture are those common to the shafts of the long

bones, but the difference in structure of the articular ends and the

short and flat bones endows lesions of these with somewhat different

characters, the nature of which varies between grooving, perforation,

and great comminution.

The most typical injury consists in the production of a clean

perforation of the cancellous bone; this was common both in the

articular ends and in the short bones. The tunnel differed little in

character from those already described, a tendency always existing to

the lifting of a lid of compact tissue at the exit end of the track.

For the production of the cleanest forms of injury I believe high rates

of velocity were distinctly favourable, although I am unable to maintain

this statement by proof in the case of injuries received at the shortest

ranges of fire. When the velocity was lower, yet with force still

sufficient to produce a perforating injury, the separation of an

extensive scale of bone at the exit aperture was a marked feature not

seen in perforations produced by higher degrees of velocity. Fig. 52, of

a perforation of the lower end of the femur, well exhibits this feature;

but it must be borne in mind in this case that the illustration is not a

pure one, both shaft and epiphysis taking part in the walls of the

track, and the exit opening is in the former, where a thicker layer of

compact bone exists than would cover any epiphysis, and hence the

fragment is larger. I use the example, however, because it so forcibly

illustrates the effect of increased resistance on the part of the bone

struck in widening the area of the lesion. When the track was entirely

limited to the articular ends the small amount of damage at either

aperture was shown by clinical evidence in the rarity of subsequent

limitation of joint movements due to bony deformity.

[Illustration: FIG. 52.--Oblique perforation, implicating both epiphysis

and diaphysis. Large fragment detached at exit aperture. Caused by a

bullet travelling at a low rate of velocity. Compare with figs. 71 and

72 of a skull fracture. The dotted lines indicate the course of the

track]

Again, it was rare for fissuring to extend from these tunnels to the

articular surfaces; thus many instances could be given of perforation of

the head of the humerus, the olecranon, or the femoral condyles, in

which no evidence of joint fissure was discoverable. The slight amount

of resistance offered by the cancellous ends was also clinically

illustrated by the absence of severe synovial effusions when they were

struck. When the joint cavity was not crossed, slight effusion only

resulted, while in the case of fractures of the femoral shaft great

effusion into the knee-joint, resulting from the forcible vibration

transmitted to the limb, was a common feature, even when the point

fractured was situated above the centre of the bone. Again, when the

joint cavity was crossed a moderate degree only of hæmarthrosis was the

most common result.

With regard to the implication of joints, either primary or secondary,

in connection with fractures of the articular ends, I am inclined to

place the lesions of the upper end of the tibia in a more important

position than those of any other bone. Evidence of this implication was

in my experience more frequent here than in any other situation. This

may in part be attributable to the complexity of structure of this

epiphysis, and perhaps more correctly to the influence of its irregular

outline in favouring lateral forms of impact on the part of the bullet

and consequent increase in the area of damage.

Next to tunnelling, grooving was the most common form of injury to the

short bones. In the case of superficial tracks the compact tissue might

be considerably comminuted, but not, as a rule, over a width greatly

exceeding the calibre of the bullet.

Comminution and crushing of a single or several bones were rare in

proportion to the occurrence of similar injuries produced by

Martini-Henry or large leaden bullets. When the condition was produced

by bullets of small calibre, I believe it was in the majority of cases

the result of irregular impact on the part of the projectile. In support

of this view it may be added that such injuries were most common in the

bones of the tarsus, bones especially liable to be struck by ricochet

bullets.

It was generally believed that bullets travelling at a very high degree

of velocity were liable to cause severe comminution of the short bones,

but I never saw any cases supporting this opinion; in point of fact, all

the short-range lesions of this nature that I saw were of the clean

perforating variety. I believe that this is capable of satisfactory

explanation on the ground of the thin character of the layer of compact

tissue which for the most part ensheaths the short bones; this decreases

the resistance offered to the bullet and so tends to localise the

lesion. This statement may be supported by two observations with regard

to the long and flat bones. First, if the shaft of a long bone be hit

above the junction of diaphysis and epiphysis, the cancellous tissue in

and extending from the medullary cavity is pulverised, and examination

of fragments from such fractures gives the impression of the inner

aspect having been scraped clean. Secondly, I saw one fracture of the

ilium produced by a bullet taking a course between its compact layers

for 3 inches from the notch between the anterior superior and anterior

inferior spines; the bone to the extent of 2-1/2 square inches was

pulverised, the cancellous tissue blown away as dust, and the compact

tissue only represented by scales still adhering by their periosteum to

the muscles attached to the two surfaces of the bone. This injury was

produced from a rifle fired at five yards distance, and was an extreme

example; but, on the other hand, it illustrates only what we are

thoroughly well acquainted with in the case of flat bones, such as those

of the cranium, where the compact element is abundant in comparison with

the cancellous, and the resistance offered to the bullet is consequently

great.

Some remarks on transverse fractures of the patella will be found under

the heading devoted to that bone.

Lesions of the flat bones are considered at some length in Chapter VII.,

which deals with injuries to the head, and their special features are

there described; some further remarks on these injuries will be found

under the headings of the individual bones.

_Special characters of the symptoms observed, and of the course of

healing of the fractures._--Peculiarities in the initial signs may be

rapidly passed over. The first depended on the large number of lesions

of the bone which were unaccompanied by loss of continuity. In the case

of perforations attention to the course of the track, external

palpation, and possibly the detection of bone dust in the aperture of

exit, were usually sufficient to indicate injury to the bones. When

these did not suffice the introduction of a probe would usually set the

question at rest; but this is always to be avoided if possible, as

adding a fresh item of risk to the wound. The X rays were not always to

hand, and are not always capable of giving reliable information in the

matter of perforations, although very useful in detecting grooves or

notching. The latter injuries are those in which information as to the

condition of the bones is often of most interest in view of the

characters of the external wounds.

Fractures with solution of continuity were, as a rule, easy of

detection, but the relative prominence of the classical signs varied

somewhat from what we are accustomed to see in civil practice.

The first striking peculiarity noted in comminuted fractures of the long

bones was the degree of local shock; the limbs were often quite

powerless, the muscles flaccid, and common sensation lowered. This was

of importance in two ways; firstly, shortening of the limb was often

absent as a sign, and, secondly, pain was sometimes not at all

pronounced even when the patient was moved. The primary absence of

shortening, even persisting for the first two or three days, was a

phenomenon always important to bear in mind, as it affected the degree

of extension needed in the treatment of the fracture, which, if

sufficient at the moment, often proved quite inadequate with the return

of tone in the muscles. Secondly, abnormal mobility was usually strongly

marked, and this sometimes without very definite crepitus, as a result

of the fine nature of the comminution and the displacement of the small

fragments.

During the course of healing some other peculiarities are worthy of

mention. First of all, union was tardy and often not strong. On the

other hand, an abundance of provisional callus was common, which formed

large swellings apt to implicate neighbouring nerves, and sometimes to

interfere with the movements of joints. The slowness of healing was

particularly noticeable in those cases where the degree of local shock

had been marked, and was probably to some extent dependent on

disturbance of the general nutrition of the tissues of the affected

limb. Beyond this, however, it was in many cases a direct result of the

degree of comminution and displacement of the fragments, which

necessitated the formation of a large amount of provisional callus, and

time for the proper consolidation and contraction of the same. In many

cases a large ball-like mass of callus surrounding the fragments was

developed, into which the actual ends of the broken bone only dipped,

and hence union was weak and insecure. As to those cases in which the

wounds closed by primary union, we must bear in mind in this relation

the tardy union often observed in civil practice, when the irritation of

suppuration and consequent inflammation are absent.

Another peculiarity of a similar nature was the occasional late necrosis

of fragments; the wounds apparently healed well, only to break down

weeks or months later for the discharge of a sequestrum. Such cases were

quite distinct from those in which primary suppuration had occurred. I

saw one or two instances in fractures of the humerus, the trouble

arising with commencing use of the limb, and I suppose that fragments

which suffered death at the time of the injury had been enclosed, and

only caused irritation as foreign bodies when the muscles again came

into action. In the absence both of evident necrosis and suppuration,

however, in some cases the exit portion of the track in the soft parts

was extremely slow in healing. Although no discharge beyond a small

quantity of blood-tinged serum escaped, the wounds remained open for

many weeks, even when the fracture consolidated well. I ascribed this to

slow separation of aseptic sloughs, a point which has already been

mentioned under the heading of wounds in general.

Superabundance of callus, as far as I had an opportunity of judging,

comparatively seldom gave rise to permanent mechanical trouble. This was

no doubt due to the infrequency of extension of the comminuted fractures

beyond the junction of diaphysis and epiphysis.

Lastly, with regard to suppuration, only a small proportion of the

fractures, accompanied by the presence of large wounds, escaped

infection. When infection did occur, the results offered some special

features dependent on the small relative amount of damage to the soft

tissues, compared with that suffered by the bone. In an ordinary

compound fracture, such as we meet with in civil practice, whether the

result of direct or indirect violence, a considerable amount of

contusion or laceration, as the case may be, accompanies the injury to

the bone. The result of this is a widespread effusion of blood into the

limb, which tears and strips up the various layers of soft parts, and

opens up the way to the spread of infection, often into the whole

length of the segment of the limb affected. In fractures produced by

bullets of small calibre, even when the exit portion of the track is

large, the injury to the soft parts is far more localised, except in

extreme cases, while the bone itself is the tissue which has suffered

the most severe violence and contusion. When infection occurred, its

spread corresponded with this anatomical feature of the lesion, and the

bone itself and its immediate neighbourhood suffered the most severely.