A considerable number of the Boers were armed with Martini-Henry rifles, and this was particularly the case with small bodies of men, rather than with the larger commandos fighting regular engagements. The Transvaal Government, moreover, had Martini-Henry rifles made as late as 1898. The Martini-Henry bullet was responsible for some of the worst fractures that came under my notice, but it is of interest to remark that its capability to do damage did not satisfy some of the Boers, who cut them as is shown in fig. 43. I cannot say what the effect of this manoeuvre was, although it may have accounted for some of the wounds of the calf such as are mentioned below.

Some odd missiles were met with during the campaign; thus, at Ladysmith, I was told ball bicycle bearings were at one time in use amongst the Boers.

Anatomical characters of wounds of irregular type.—It will be seen from the above that in dealing with wounds of irregular type we have to consider those due to irregular impact of normal regulation bullets, to bullets deformed by contact with bone, to ricochet bullets, and lastly to bullets of the expanding type.

No further mention of those due to irregular impact is needful beyond what has already been said under the heading of wobbling, except to point out that, given a fair degree of velocity, these injuries may assume an actual explosive character, especially in the case of skull fractures. The description of extensive wounds accompanying comminuted fractures finds its most appropriate place under the heading of injuries to the bones, and will be there considered (Chapter V. p. 155).

'Explosive' exit apertures are, however, described as occasionally occurring in injuries involving the soft parts only. I saw no cases substantiating this belief, but several were described to me as having been met with in abdominal injuries, which terminated fatally at an early date.



I still, however, incline to the opinion that the bullet in these cases had come into contact with some bone, or was one of the larger varieties of projectile. A few cases of wound of the calf did, however, come under my observation which presented fairly typical 'explosive' characters without evidence of solution of continuity of the bones. I will shortly recount two of them. In the first the exit opening was very large and on the outer aspect of the limb in the upper third. The bullet had apparently passed between the bones. Secondary haemorrhage from the anterior tibial artery necessitated exploration of the wound and ligature of the vessel (Mr. Carre). When the wound was thus laid open no injury to the bones could be detected, but I do not consider that it could be actually excluded. In the second case a wound traversed the calf transversely, just above the centre; the exit aperture was large and ragged. Deep suppuration occurred, and the wound had to be laid open, when a fracture of the tibia without solution of continuity was discovered. I also saw one or two wounds of the buttock in which very large exit apertures were present with small entry openings; in these again it was impossible to exclude passing contact of the bullet with a part of the pelvic wall. Unfortunately in all these cases it is impossible to obtain the bullet responsible for the injury. In this relation I append a diagrammatic illustration of a peculiar wound shown to me by Mr. Hanwell. In this case a typical small entry wound was situated at the outer margin of the left erector spinae muscle in the loin. The bullet had taken a subcutaneous course of not more than three-quarters of an inch, while the exit opening was a long shallow wound measuring 4-1/2 in. in length by 1-1/2 in. width. (Fig. 44.)

The wound was stated to have been received at a distance of from fifty to a hundred yards. I think we can scarcely assume that impact with the margin of the erector spinae could have resulted in 'setting up' of the bullet, while an irregular tongue of skin at the point where the wound crossed the spines of the lumbar vertebrae did suggest possible bony contact. That the latter must have been of the slightest nature is evident, as no signs of concussion of the spinal cord were noted. I should rather be inclined to compare this case to one of gutter wound quoted on p. 56, and to assume that the bullet passed so closely beneath the surface as either to entirely sever the skin, or at any rate to allow it to give way on flexion of the back on movement.



On the ground of the observations made in the foregoing pages it will be gathered that the opinion I formed was against either the very free use or the great wounding power of so-called expanding bullets of small calibre. I believe that a great number of the injuries which were attributed to the employment of these missiles were produced either by ricochet regulation bullets of small calibre, or by large leaden bullets of the Martini-Henry type.

Symptoms.—I very much doubt whether the general symptoms observed as the result of wounds from bullets of small calibre differ in more than slight degree from those described when larger bullets were regularly employed. Great variation was met with, but I do not think a diminution in serious results in this direction corresponding to the comparatively limited nature of the direct injury to the organs or tissues can be affirmed. It is true that the immediate symptoms in many patients were amazingly slight, but after all, this has always been a feature of gunshot injuries on the field of battle and cannot be assigned a position of distinctive importance.

1. Psychical disturbance and shock.—Some remarkable instances of psychical disturbance were observed, and although perhaps in no way influenced by the calibre of the projectile, they seem worthy of note in this place. Thus a patient wounded over the cervical spine and who suffered later with a slight degree of spinal concussion emitted an involuntary shriek like that of a wounded hare on being struck; another (Martini wound), after receiving a wound of the chest, lost all sense of his surroundings for a considerable period, and occupied himself in attempts to write on a white stone lying near him on the veldt; then suddenly realising his position he was greatly bewildered in trying to account for his own action. A similar instance of preoccupation is probably offered by the dead man in the accompanying photograph (fig. 45), whose arms, forearms, and hands had evidently been in play until the actual moment of death. Again the influence of the psychical state on the actual occurrence of shock was often illustrated by the mental condition of the wounded after a battle; thus after the battles of Belmont and Graspan the patients came into hospital in excellent spirits, and minimised their injuries in the wish of rapidly regaining the front; while after the battle of Magersfontein the men were depressed and miserable, shock was more pronounced, and their sufferings were undoubtedly greater.

On the whole, however, shock was by no means a prominent symptom in the small-bore injuries of soft parts, and was possibly less than when larger bullets were the rule, and again it was often remarkably slight after the infliction of serious visceral injury. Still shock was observed in a considerable proportion of the patients, and its occurrence appeared to vary under very much the same conditions as obtain in civil practice. Grades of severity depended on individual idiosyncrasy, on the degree of excitement or preoccupation at the moment of injury, and to a certain degree on the range of fire at which the injury was received.



The last is the only special factor, and as far as my observation went it was one of considerable importance. When the soft parts only were affected, even high velocity did not produce much effect; but when to a flesh wound a severe bone fracture or injury to any part of the nervous system was added, shock might be severe or profound. The question of shock dependent on visceral injury will be considered in succeeding chapters, but it may be well to state here that the most severe shock appeared to follow injuries to the central nervous system especially to the spinal cord, fracture of the larger bones, and wounds of the abdominal and thoracic viscera, the latter especially when the cardiac neighbourhood was encroached upon: hence the severity depended almost solely on the importance of the part injured and the degree of damage inflicted. I never observed instances of entire absence of shock in visceral injuries, unless the range of fire had been an especially long one.

To these remarks on constitutional shock I should add a few on the 'local shock' exhibited by the actual part of the body struck. The phenomena were of a severity I was quite unacquainted with in civil practice, and apparently were attributable to the local vibration transmitted to the whole structure of a limb or part of the trunk. In many fractures, and in some wounds of the soft parts alone, without the direct implication of any large nerve trunk, the loss of functional capacity of the limb was complete, and this condition persisted for hours or even days.

2. Pain.—As an initial symptom the occurrence of pain varied greatly with the idiosyncrasy of the patient, and according to the circumstances under which the wound was received. Some individuals are remarkably insensitive, and in these the fact of a wound being a gunshot injury in no way altered their habitual insensibility, but in persons of what may be termed the normal type in this particular great differences were observed.

When a wound was received in the full excitement of battle during a rapid advance, pain was often slight, or so trifling in degree that it was almost unnoticed; many patients did not realise that they had been struck until a second wound, possibly implicating a bone or some specially sensitive structure, was superadded. In such instances the pain was often described as 'burning' in character, or even likened to a 'sting from an insect.' Occasionally the pain was referred to a distant part; thus a man struck in the head first felt pain in the great toe, and another struck in the abdomen also felt pain in his foot only. Again in some multiple injuries, pain was only felt in the more sensitive of the regions implicated; thus a patient in whom a bullet (Martini) traversed the arm and chest emerging in the neck to again enter the chin and comminute the mandible, only felt pain in the chin and first realised that he had been wounded elsewhere when he undressed. A striking instance of the entire absence of initial pain was afforded by a man shot through the buttock, the bullet then traversing the abdomen: this patient remained unaware that he had been hit until on undressing he found blood in his trousers and exclaimed: 'Why I have got this bloody dysentery!' None the less his internal injuries were sufficiently severe to lead to death during the next thirty-six hours.

Although initial pain might be slight or absent, practically all the patients complained of some of varying severity at the end of an hour after reception of the wound.

In a large proportion of the wounded, however, pain was more or less severe from the first, and this was especially the case when the men had been exposed to fire for some hours behind inadequate 'cover.' The most common descriptions under these circumstances were that they felt as if they had been struck by 'a brick,' 'a ton of lead,' or 'a sledge-hammer.'

3. Haemorrhage.—This question is fully treated under the heading of injuries to the blood-vessels. It will suffice here to say that haemorrhage was rarely of a dangerous nature so far as life was concerned, unless the large visceral vessels or those in the walls of serous cavities were concerned, when death was often rapid. From limb wounds, even when the largest trunks were implicated, the general tendency was to spontaneous cessation of the haemorrhage. Consequently, except these patients were seen on the field, one seldom had to deal with serious bleeding. None the less, the condition of the patients' clothes bore testimony to a free rush immediately after the injury, and pools of blood were occasionally found where patients had lain. In nearly all cases the rush of the bullet determined the initial flow of the blood from the exit wound, and this aperture usually furnished any haemorrhage of importance.

Diagnosis.—The only diagnostic point which it is necessary to consider in this chapter is the determination of the nature of the bullet which has caused the particular injury under observation, and this is more a matter of interest than importance.

The primary indication lies in the size of the aperture of entry, which naturally varies with the calibre of the bullet employed, and the difference, except in the case of large projectiles, is not always easily determined, unless we can be sure that the impact of the bullet was at right angles. In the latter case it is possible to distinguish even between, for instance, a Lee-Metford and a Mauser wound, if the resistance likely to be offered by the part struck is kept in mind. A ricochet bullet, on the other hand, may upset all our calculations, if size alone be taken as an indication; but here the irregularity of the wound often serves to exclude one of the larger varieties as the cause. The appearances of the exit wound are less useful in determining the nature of the bullet employed, as irregularities of outline are so much more common whatever projectile may have emerged; but examination of this wound often gives us useful information as to the existence of an injury to the bones not involving loss of continuity.



Other information beyond that furnished by the external wounds may be gleaned from the presence of fragments of lead in the wound; these, if unaccompanied by portions of casing, afford some presumptive evidence of the use of an unsheathen bullet, especially if found on the fractured surface of the bones; but it must be borne in mind that in the case of ricochet bullets the leaden core often perforates when entirely freed from its mantle. Pieces of the mantle again may give useful information both from examination of their thickness and composition. Lastly a naked core nearly always retains the marking on its base corresponding to the turning over of the mantle, this not being likely to suffer impact calculated to efface the groove. When this groove existed the employment of any of the soft-nosed bullets used in this campaign might be safely excluded (fig. 46).

Prognosis.—The question of general mortality amongst the wounded has already been considered (Chapter I. p. 11), and it has been shown, putting aside those dying at once on the field, or during the first twenty-four hours, that the mortality was a low one. Some other points specially dependent on the nature of the injury are, however, worthy of mention in this place. First, it has been shown, with a slight reservation as to when a wound can be considered definitely sound, that if suppuration did not occur, healing was rapid, and that many men with slight wounds were back with their regiments in the course of a very few days. Again, that suppuration when it did occur tended to be local in character; none the less, if it was at all extensive, it often proved very prolonged and difficult of treatment, while residual abscesses after apparent healing were not uncommon. In connection with this subject I may quote from Colonel Stevenson[12] an observation that limbs the subject of marked local shock are especially liable to furnish septic discharges. Parts the subject of local shock when infected show a lesser degree of vitality and power of resistance to the spread of infection than do normal ones, and if infected do badly. I think I convinced myself of this on many occasions, and also of the fact that cases of fracture in which this condition was marked were slow in consolidating. Again I am inclined to think that the bad results which sometimes followed the tying of the limb arteries were also consequent on lowered vitality, and possibly vaso-motor disturbance due to the effects of the exquisite vibratory force to which the nerves had been subjected. On this account I was never anxious to hurry operations in such cases, unless obviously necessary at the moment.

The larger question of general nervous breakdown as the result of injuries from bullets of small calibre is at present hardly capable of an answer, and is so complicated by the co-existence of concurrent mental anxiety, exposure, &c., that a definite answer will always be difficult. I think there is already sufficient evidence, however, to suggest that the remote effects of many of these injuries may be far more serious than we expected at the moment, especially in the direction of sclerotic changes in the nervous system.

Treatment.—In view of the remarks on the treatment of special injuries contained in succeeding chapters, I shall confine myself here to the question of the treatment of wounds of the soft parts alone.

This consisted during the campaign in the primary application of the regulation first field dressing by one of the wounded man's comrades, an orderly, or less commonly an officer or a medical man. This dressing is composed of a piece of gauze, a pad of flax charpie between layers of gauze, a gauze bandage 4-1/2 yards long, a piece of mackintosh water-proof, and two safety pins, enclosed in an air-tight cover. Mr. Cheatle,[13] in insisting on the importance of an immediate antiseptic dressing in the field, recommends the following. A paste contained in a collapsible tube, made up in the following proportions: Mercury and zinc cyanide grs. 400, tragacanth in powder gr. 1, carbolic acid grs. 40, sterilised water grs. 800; sufficient bicyanide gauze and wool for the dressing of two wounds, a bandage, and four safety pins; the whole enclosed in a mackintosh bag. The paste possesses the advantage over any liquid or powder, that it can be applied in any position of the body to severe wounds, and its application in the open air is not interfered with by draughts of wind. Mr. Cheatle used a similar preparation with success during the campaign.

On arrival at the Field hospital, or in some cases at the station of the bearer company, the wounds were then commonly dressed as follows: The parts around the wound were cleansed with an antiseptic lotion, either solution of perchloride of mercury 1 in 1,000, or 2-1/2 per cent. solution of carbolic acid. The wound itself was then cleansed, and a dressing of double cyanide of mercury and zinc applied. This was covered with a pad of wool and secured with a bandage. The gauze was usually wrung out in the lotion before application as a precaution against previous contamination, and the moistening was also useful as helping to ensure the dressing from subsequent displacement. It was early recognised that the drier the dressing the better, and hence anything like a mackintosh layer was carefully avoided. In some instances, antiseptic powders were employed, but they did not find much favour, and because they tended to favour slipping of the dressing, and to prevent the adhesion of the gauze dressing to the wound, they were certainly not desirable when there was any necessity for the patient to travel. In the absence of reliable water the use of antiseptic lotions was obligatory, and such is likely to be the case in most campaigns; in the present one, filtration of the thick muddy water was impossible, without a considerable expenditure of time, which could only be obtained when the hospitals were fairly stationary. I very much preferred carbolic acid lotions.

The wound having been once cleansed, or rather the surroundings of the wound, the drier the surface was kept the better; hence a too heavy or impervious dressing was not satisfactory; in point of fact, I think some of the slighter wounds in which all the dressings slipped off, and in which there was less consequent chance of the dressing being moistened with the sweat of the patient, did as well as any.

I do not think the bicyanide gauze, absorbent wool, and common open-wove bandages, together with a good supply of nail brushes, soap, and carbolic acid for the primary disinfection of the skin and the external wound, are to be greatly bettered at the present day as materials for the first permanent dressing of cases in the field. The wound itself should be carefully shielded during the preliminary cleansing of the skin by a firmly applied antiseptic pad, and then the dressing applied as above described. The one desirable improvement is some mode of ensuring the dressing being kept in good position, and for this some form of adhesive covering for the gauze and wool should be devised. When the atmosphere is such as to allow of rapid drying, thin moistened book-muslin bandages would be preferable to the plain open-wove ones. The one period of danger is that of transport, and when that is over, the dressing in Stationary or Base hospitals should give no trouble.

As a rule the wounds themselves need no interference, but in some instances either the exit or entrance wounds may be in undesirable positions for purposes of asepsis, when a large opening may seem safer closed and actually sealed. I saw this method tried in a few cases, but without much success. It is one which might be of much use in Base hospitals if the patients were brought directly into them, but in the Field hospitals, in face of the rush with which the first dressings have to be done, I think it is seldom applicable, and consider the interference with the wound as rather likely to increase the danger of infection than to decrease it.

Dressings should not be too frequent; two should suffice for simple wounds with type forms of entry and exit; there is little discharge and usually no bleeding: hence the more the dry scab form of healing can be simulated the better. When a dressing needs changing from fouling of its outer parts, it is preferable to cut round the adherent part of the deep layers and apply some fresh gauze over the central scab rather than to remove it. One point should be kept in mind: the first dressing in the Field hospital seals the fate of the wound as to the chances of primary union, and hence too much care is impossible with it.

Operations in the Field hospitals were proportionately not numerous, and they should be kept down in number, as far as possible. At the same time such operations as are necessary are mostly of capital importance, such as the treatment of fractures of the skull, abdominal section, the ligature of arteries, and amputations. Of these only the first and last classes occur with any degree of frequency. In order to be prepared for these a stock of filtered water which has been boiled, and some special sterilised sponges, should be at hand if possible, also some small towels which can be wrung out in antiseptic lotion. If sterilised sponges are not to be had, wool pads wrung out in carbolic lotion must be substituted.

Primary amputations bore transport badly. I saw few sent down from the front within a few days of their performance in which the flaps did not slough, or worse consequences ensue. On the other hand, if the first fortnight could be tided over at the front, they did well enough. The head cases on the other hand bore movement fairly well, provided only that asepsis was ensured.

Retained bullets are rarely suitable for removal in the rush of the first work of a Field hospital after an engagement. A short delay is of no importance, and ensures their being removed safely if necessary. With regard to the broad question of the advisability of removing them at all, it may be laid down that they should not be interfered with unless some obvious reason exists. Those most commonly calling for removal are as follows: 1. Bullets lying immediately beneath the skin or quite superficially in any region, or those which, although they have produced an exit opening, yet lie within the body. 2. Those which lie at the bottom of an infected track, or cause secondary suppuration. 3. Those causing pressure on important structures, particularly nerves. 4. Those which interfere with the movements of joints when lodged in the bones or soft tissues in close proximity, or those which lie within the articular cavity itself. Bullets sunk in the great body cavities or in positions difficult of access should never be interfered with. Retained bullets sometimes give rise to unexpected surprises; thus in a man with a retained bullet in the pelvis no steps for its removal were taken. During the man's voyage home on a transport he had an attack of retention of urine. As a catheter would not pass, he was placed in a warm bath, and shortly after passed a Mauser bullet per urethram, and thus saved himself a cystotomy.

One word may be added as to the treatment of shock when severe. Quiet in the supine position, and the administration of a small amount of stimulant, was usually all that was required. Hypodermic injections of strychnine sulph. grs. 1/30 to 1/10 were useful, and in some severe cases, especially where operations were needed, saline infusions with a small amount of stimulant were made into the veins, either at the elbow, or in amputation cases into one of the large veins exposed.

The treatment of haemorrhage is dealt with in Chapter IV.

The after treatment of simple wounds needs little comment, but bearing in mind what has been said as to the definite healing of the internal portion of the tracks, it will be obvious that in parts such as the thigh or calf, care was needed as to not commencing active work at too early a date. On the other hand, a too long period of absolute rest is also to be deprecated. The best results were obtained by careful movement and massage, commenced after the first week or ten days, according to the appearance presented by the external wound, followed by a gradual resumption of active movement. It was a striking fact that some of the patients suffering from such wounds took longer to become apparently well than many of those who had suffered visceral injuries.

FOOTNOTES:

[9] Loc. cit. p. 31.

[10] Loc. cit. p. 100.

[11] Loc. cit. pp. 54, 55.

[12] Wounds in War, p. 83. Longmans & Co. 1897.

[13] A First Field Dressing, Brit. Med. Jour. 1900, vol. ii. p. 668.



CHAPTER IV

INJURIES TO THE BLOOD VESSELS

The small calibre of the modern bullet, and its tendency to take a direct course, naturally favour the occurrence of more or less uncomplicated wounds of the large vascular trunks, and both the nature of these wounds and the results which follow them are in some respects most characteristic.

NATURE OF THE LESIONS

1. Contusion or laceration without perforation.—(a)The vessel may be struck laterally, the injured portion then forming a part of the bounding wall of the wound track, or (b) one or more layers of the vessel wall may be destroyed over a limited area. Given primary union, these conditions are only of importance in so far as subsequent contraction of the lumen of the vessel may result from implication in the neighbouring cicatrix. One of the most striking features of the wounds as a whole was seen in the hair-breadth escapes of the large limb vessels with no subsequent ill effects, and such injuries were seen in every situation.

In a certain proportion of wounds in close proximity to large vessels, however, a diminution of the normal calibre of the arteries was observed, either shortly after the injury or later in the advanced stages of cicatrisation. As an example of early obstruction, the following may be related. A Mauser bullet passed from the inner side of the thigh across the neck and great trochanter of the femur beneath the femoral vessels, and probably struck and grooved the bone, since the aperture of exit was large and irregular, some 3/4 of an inch in diameter. One week later no pulse was palpable in either anterior or posterior tibial arteries at the ankle, and pulsation which was strong in the common femoral artery was very weak in the superficial femoral. Slight fulness existed in the hollow of Scarpa's triangle, but not sufficient to make any serious difference in the contour of the two limbs. No thrill or abnormal murmur was discoverable. There was no oedema of the limb, which was also normal in temperature. The patient was kept at rest in the supine position for three weeks, during which time the tibial pulses gradually returned. Three weeks later he was invalided home, the pulses, however, still remaining considerably smaller than normal.

In the advanced stages of cicatrisation narrowing of the lumen of the trunk vessels was far from uncommon, especially in cases of wounds of the arm crossing the course of the brachial artery; in many of these the radial pulse was diminished almost to imperceptibility. How far this condition may prove permanent there has been little opportunity of judging; nor as to the possible ultimate weakening of the vessel wall and the development of a secondary aneurism has time allowed the acquisition of experience. In the light of the observation of so many cases in which large vessels were wounded without the occurrence of severe haemorrhage, either primary or secondary, it is impossible to be certain whether some of the cases of arterial obstruction were not secondary to perforating lesions of the vessels.

Pressure on, or minor lesion of the vessel was sometimes evidenced by the development of a murmur, as in the following case. A Mauser bullet entered immediately within and below the left coracoid process, and emerged at the back of the arm at its inner margin, 2-1/2 inches above the junction of the right posterior axillary fold. During the first week dysphagia and some pain and soreness in the episternal notch, with pain and difficulty of respiration, were noticed. Eight weeks later no trouble with the pharynx or oesophagus remained, but a short sharp systolic murmur was audible over the first part of the left axillary artery, which could be extinguished by pressure on the subclavian; the radial pulse was normal.[14]

When primary union failed or was prevented by infection and suppuration, lesions, although incomplete, of the vessel coat naturally frequently gave rise to secondary haemorrhage.

2. Perforation of the vessels.—(a) This may be oblique or transverse to the long axis of a trunk; when the vessel is impinged upon laterally, an oval or circular notch, as the case may be, is produced; or (b) the bullet may strike more or less in the centre of the vessel, perforating both in front and behind, while lateral continuity is maintained; (c) beyond these degrees a vessel may, of course, be completely divided. Cases of notching of the vessel will be referred to under the heading of traumatic aneurism; those of perforation under that of aneurismal varix and varicose aneurism, the perforations in these cases affecting a parallel artery and vein.

RESULTS OF INJURY TO THE VESSELS

1. Haemorrhage.—The fact that haemorrhage was not a prominent feature in the wounds received during this campaign can scarcely be regarded as an experience confined to injuries caused by bullets of small calibre. The same observation was often made in the case of larger bullets in old days, and the absence of severe haemorrhage has previously been regarded as a special characteristic of gunshot wounds. None the less, as high a proportion as 50 per cent. of deaths occurring on the field in earlier days has been ascribed to this cause.

Unfortunately no new facts can be furnished on this point, although a few cases of rapid death from primary haemorrhage will be found recounted under the heading of visceral injuries. Beyond these the general evidence offered by observations on men brought in from the field with vascular injuries, was opposed to the frequent occurrence of death from haemorrhage, at any rate of an external nature. This subject will be dealt with under the classical three headings of primary, recurrent, and secondary haemorrhage.

Primary haemorrhage.—A marked distinction needs to be drawn between external and internal haemorrhage. External haemorrhage from the great vessels of the limbs, or even of the neck, proved responsible for a remarkably small proportion of the deaths on the battlefield. This statement may be made with confidence, since it is not only my own experience, but coincides with what I was able to glean from many medical officers with the Field bearer companies. It is, moreover, supported by the facts that cases in which primary ligature had been resorted to were extremely rare at the Base hospitals, while, on the other hand, traumatic aneurisms and aneurismal varices of any one of the great trunks of the neck and limbs were comparatively common. Again, primary amputation for small-calibre bullet wounds, except when complicated by severe injury to the bones, was so rare as to render more than doubtful the frequent occurrence of severe primary haemorrhage on the field. Only one case of rapid death due to bleeding from a limb artery was recounted to me. In this a wound of the first part of the axillary artery proved fatal in the twenty minutes occupied by the removal of the patient to the dressing station. The amount of haemorrhage in many instances was no doubt checked by the application of pressure at the time of the first field dressing; but it can scarcely be argued that such dressings as were applied were of sufficient firmness to control bleeding from such trunks as the brachial, femoral, or carotid arteries.

The spontaneous cessation of haemorrhage is rather to be ascribed to the special method of production and the consequent nature of the wound. The lesions were the result of immense force strictly localised in its application, which might well induce very complete and rapid contraction of the vessel wall; while the track in the soft parts was not only narrow, but also lined by a thin layer of tissue possibly so devitalised superficially as to specially favour rapid coagulation of the blood. Beyond this the tracks were often sinuous when the position of the limb at the time of reception of the injury was replaced by one of rest. The influence of mere narrowness of the track is illustrated by classical experience in the development of aneurismal varices after stabs by knives or bayonets; and in the injuries under consideration the frequent development of large interstitial haemorrhages into the tissues of the limbs indicated that blood does not readily travel along the wound track. It was noteworthy that when haemorrhage did occur it was most free from, or often limited to, the wound of exit. This is due to the direction of the active current set up by the rush of the bullet through the tissues. The mechanical factor is, no doubt, the most important.

Control of primary haemorrhage from a wounded vessel by the impaction of a foreign body was of much less frequent occurrence than appears to have been the case with the older bullets. I saw a case in which, on removal of a fragment of shell (Mr. S. W. F. Richardson), very free haemorrhage occurred from a wound of one of the circumflex arteries of the thigh, but not a single one in which a similar result followed the extraction of a bullet of small calibre. The comparative infrequency of retention of modern bullets is probably one of the main elements in this relation. A very curious instance of provisional plugging of a wound in the upper part of the brachial artery by an inserted loop of the musculo-spiral nerve was related to me by Mr. Clinton Dent. This instance must, I think, be regarded as an accident definitely dependent on the size and outline of the bullet and on the nature of the force transmitted by it to neighbouring structures.

While, however, deaths from external primary haemorrhage were rare, a considerable number resulted from primary internal haemorrhage. In some of these, injury to the largest trunks in the thorax or abdomen led to an immediately fatal issue; in others wounds of the large visceral arteries, as of the lungs, liver, or mesentery, were scarcely less rapid in their results. In such cases the potential space offered by the peritoneal or pleural cavities favours the ready escape of blood from the wounded vessel, while the tendency of the blood effused into serous cavities to rapid coagulation is notably slight. Beyond this the comparative deficiency in direct support afforded by surrounding structures to vessels running in the large body cavities is also an important element in their behaviour when wounded.

These remarks receive support from the observation that few, if any, patients survived an injury to the external iliac vessels within the abdomen, while the remarkable instances of escape from fatal haemorrhage from large vessels recorded below (cases 1-19) indicate that the mere size of a wounded vessel is not to be regarded as the sole factor in prognosis.

Recurrent haemorrhage was occasionally met with both in the case of the limb and trunk vessels. In the limbs it often necessitated ligature of the artery. I saw several cases in the lower extremity where recurrent haemorrhage on the second or third day was treated by ligature of the femoral or popliteal artery, and it also occurred during the course of development of one of the carotid aneurisms recounted below. On two occasions I saw rapid death follow recurrent abdominal haemorrhage; in one I was standing in a tent when a man who had been wounded the day before suddenly exclaimed: 'Why, I am going to die after all.' The appearance of the man was ghastly, and on examining the abdomen it was found greatly distended, and with dulness in the flanks; the patient expired a few minutes later. Another example of recurrent abdominal haemorrhage is related in case 169, p. 432.

Secondary haemorrhage.—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 haemorrhage 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 haemorrhage 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 haemorrhage 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 haemorrhage three-quarters of the whole lumen of the vessel had been devitalised. The resemblance of some cases of secondary haemorrhage 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 haemorrhage 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 haemorrhages followed by a sudden copious gush.

The forms of secondary haemorrhage, 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 haemorrhage are furnished by cases of chest injury accompanied by haemothorax and fully dealt with under that heading (Chapter X.). Cases of interstitial secondary haemorrhage 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 haemorrhage 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 pleurae or joints were the seats of the mischief. In the case of interstitial haemorrhages I only remember to have seen fever of such marked continued type in the subjects of haemophilia with recent effusions, although one is of course acquainted with it in a less pronounced form as a result of haemorrhage into operation wounds.

In primary interstitial haemorrhages 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.



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 deg.. An abscess was at once suspected and the swelling incised by Major Lougheed, R.A.M.C. A large subperitoneal haematoma only was discovered, and evacuated. The temperature at once fell and the after progress was uneventful, the wound healing by primary union.

TREATMENT OF HAEMORRHAGE

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 haemorrhage 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 haemorrhage, 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 haemorrhage 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 haemorrhage. 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 haemorrhage, 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 haemorrhage was followed by the development of a traumatic aneurism in the ham.

Secondary.—In secondary haemorrhage 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 haemorrhage from an arterial haematoma 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 haemorrhage, 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 haematoma.—This condition was met with comparatively frequently, and bears a very close relation to that already described under the heading of interstitial haemorrhages. 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 haematomata, and of the occurrence of the aseptic form of secondary haemorrhage, 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 haemorrhage, which might or might not have been associated with external bleeding. A haematoma 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 haematomata, 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 haematomata 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 haematoma 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 anaesthesia 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 anaesthesia 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 haemorrhage. 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 haemorrhage in cases of haemothorax. 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 haematoma 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 haematomata, 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 haemoptysis and left haemothorax. 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 haemorrhage 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 haemorrhage, 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 haemorrhage of any importance occurred from the wound, but there was a typical haemarthrosis, 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 haemorrhage, and so much blood collected in the knee-joint that it was aspirated. On the eighth day secondary haemorrhage occurred from the exit wound and the femoral artery was tied in Hunter's canal. No further haemorrhage 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 haematoma 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-Joergensen 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 haematoma 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 haemorrhage, 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 haemorrhage, 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 haemorrhage. 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 haemorrhage, 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 haemorrhage at the time from the exit wound, but no haemoptysis; 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 haemorrhage 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 haemorrhage 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 deg.. 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 haemorrhage, 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 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 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.