Chapter IV: Injuries to the Blood Vessels (2)

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.