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 ma.s.s 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 ca.n.a.l, 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 s.p.a.ce.

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 quant.i.ty, 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 haematomata._--(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 cla.s.s, 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 pa.s.s 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 pa.s.sage of ricochet bullets, when it might be very irregular, but usually not of great size.

[Ill.u.s.tration: 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 pa.s.sing bullet and then either burst or torn by the bullet and accompanying bony fragments. Fig. 47 well ill.u.s.trates this feature. A triangular tongue of skin was lifted by the pa.s.sing bullet and probably by the lower end of the upper fragment of the fractured ulna; through the resulting opening a ma.s.s 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 ma.s.s of protruded tissue was often most striking when a muscle such as the biceps in fig. 48 had been divided; but the herniae were more persistent when the ma.s.s projected in regions where tendons formed a large integral const.i.tuent, 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.

[Ill.u.s.tration: 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.

[Ill.u.s.tration: 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 haemorrhage]

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 haemorrhage, 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, pa.s.sing 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 ill.u.s.trates 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 ill.u.s.trated 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.

[Ill.u.s.tration: 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 subst.i.tution 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.]

[Ill.u.s.tration: 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.