(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 haemoptysis 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 palpebrae 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 haemorrhage 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 haemorrhage, but the injury was followed by some difficulty in swallowing, and haemoptysis, 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 hyperaesthesia 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 s.p.a.ce, 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 inters.p.a.ce 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 s.p.a.ce, 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. .h.i.t on February 11, 1900, at Monte Chris...o...b.. a bullet which pa.s.sed 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 ca.n.a.l. 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 ill.u.s.trates 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 s.p.a.ce. _Exit_, about centre of patella, which latter was cleanly perforated. Three weeks later the typical thickening of the knee-joint following haemarthrosis 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 s.c.r.o.t.u.m 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 att.i.tude 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 circ.u.mstances 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 pa.s.sed 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. c.o.x, 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 circ.u.mstances 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 haemorrhage 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 quant.i.ties of blood from the remaining sinus kept up the fear of a severe attack of secondary haemorrhage 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 ill.u.s.trate 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 circ.u.mstances. 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.