GUC.NSHOT IN.JTt ILS OF ARTERIES.

GIIw *BrabshJatul 3i2rctnvON

(Wl IUNI OT INJ UTIRIES OF1' 'I' 1E4 IES.

DELIVERED BEFOREP THE ROYAL CLLEXiE 01- SUFiE0OoNxSOF EN(L ANN o).

By (G. IH. MAKINS, C'.B.. F.1L.C.S.,SURG!EON TO ST. THOMA.SS HIOS'PT AL, LONDO)N.

MR. VIlCE-PRESIDENT AND GENTLEMEN, I propose to dcevotothis lcctulre to the subject of glunsh1ot wounids by bUlletS Ofsm-iall calibre.

Althloughli the practice of nmilitary surgery is con-finledl toa comiparatively limnited nuniber- of sutrgeons, yet tllcclhoice of this subject seems appropriate, since theboundary which separates civil and niiilitary surgery isindefinable, anid I myself have enijoyed seine experience in

eitler field. Againi, we may not forget that iniaiiy Fellow-sof this College, only to nmention suich1 liam-les as those of theBells, Guithrlic, and MacCormac, hlave devoted their atten-tioin to thlis suibject; while our m-aster, Jolin Huniterhiiself, founded one of hiis greatest works on the observa-tions made diuring hiis period of miiilitary service.

A certain lialo of romance seeml1s to shied itself over thesubject, since the hlistory of thle suirgery of gaunschot woundsextends to very anlcienit tilimes and br-ings uts into contactwith the mi-ost famoous pioneers in suirgery, wA-hiile lno greatevent in theIhistory of the wo6rld reaianus unspohen of inits annals.At all periodls the opportunities affor(led by the field of

battle lhave exercised a strong attra'-tioni to the sutrgeon,botlh from the inistinet of patriotism-l and(I tlhe fact that inno other branclh of suirgery can experience be so rapidlygailned. One battle can afford more imaterial and that ofinore varied nature thani many years of experimental

The progress of military sni-gery hias som01e specialceharacters of its owni, tlius its pr-actice depends on oppor-

ttunities whiCh1 m11ay be few and far betAN-eeil, -while theinjulries to bC dealt withI undergo changes anid niod0ifica-tioins dependent upon the development of thlC weaponswithi which tljey are inflicted.

It is of interest to remark the varving ilnfluenice of civilupon iimilitai-y practice, and of the experience gainedt (luringwars uponi tho civil surgeon in thle hlistory of the past. Inold dlays there were reasons wlly the muilitary suirgeonshibuld stanid out pre-eminent, the field of siurgery was niotwide, wlhile thle operations practisedl in civil work were thesanie, which the military surgeon lhad vastly increased

opp ortunities of performing. Again, the actual difficultiesunidecr w-llicli military surgery lias to be carried ouit laveoffered opportunities for the observation of the powers ofNatutre, often accidental butt nonie the less of immenseimportaiice in the development of the great principle ofcoinservatism in surgery.

I mnay mnention sucih examiples as tile omllission of theIIse of boiling oil to the wound by Pare, the substitution oftlh6 ligratutre for the cauLtery in anipitations. or the eviidenceadduiced by H nliter in favour of his opinion that guInshotw6unds should not be enlarged, foulnded on the cases offoiir miien wlho escaped being subjected to this treatimienit inconsequence of being accidentally cut off fromii the army,ancd whose wotinds healed readily w%vithout any comnplica-tion. More recently the samne influenices liave hiad ani

important bearing on the application of the ordinary rulesof surgery to suchi injuries as wouniids of the arteries,fractures of the bones, and perforatinIg wounds of theabdominal cavity.Advances in the surgery of civil life nowv exercise a con-

stant influence on every bralincl of military practice,beyondl wlicil intervals of peace have been utilized by tilemililitary surgeon in experimental work bearing, upon theeffects liliely to be produced,by weapons introdticing new

ballistic problems, and varying woutinding pover.

-I WOWUNDS OF ARTERIEIS.A consideration of the progress whic h1as beenl imadle -ill

every department of military surgery is naturally too wide

rEIoCR'.-:i I 56I MF.DTC...% JOUrSAT, Ji5

a field for a siigle lecture; it- as thcrcfore seemted to momorc coniveniient to cofinc llY rellmarks to the subject ofwoullndsofolle SOricS of struictures, the arteries. This isperlaps the ml-ore fittinlg, since the last decade lhas fuLr-nislhed us witlh reiiarlkablc evidence of tlle anenability ofthe wvouindedvossel to otlher fo;-mon- of treatmiient thlan thatof its obliterationi by tlhe application of a gross ligature.

Before proceeding to tllc actuial consideration of thewounds of the ves-sels, it imiay be u-l>efnl to epitolmlize thechanges which lhave takenl pLl..ee ini the btullet 'Whiclprolduces tlheml.

C('ittmrc.s i1i B13llets.These clhanges colosist in a decrease in thel size anid

weighlt, and increased stability in formn anid struetture.Witlh tlhcse mno(liticationis in design are associated aniircrease in velocity anid accuracy of flighlt alnd consequtenitgreater striliing foi'ce.

Tllh mnost strikina modification dutring, the last decadehias been the aldoptioni by sonic powets of the pointedbullet. 'This alteration in. thc outline of tlhC bullet is dle-signield to overcomiie airial rcsistance to its progress andthus obtain a greater velocity of fliglht alnd striking power.WN'hile attaining tlhcsc advaintages,'tlhe lnecessary. slliftingbackvwards of the centre of gravity of the btillet, increasesthe difficuilty of muaintaining flighit parallel to its longa a,xis;and experimental wor-k lhas sugeste(d that this lastclharacter wouild result in ioreC scriouts wounding capa-city, since slighit inaeccIracies of imzpact siffice to result ina sudden somersault of tihe bullet and(i a consequentlygreatly increased sturface of resistance to its enitry intothe body, with attendCtanlt widening of the area of tisstuedestruiction.

Suich information as is at present to lhanid from therecent battlefields in the Balkans does niot seene to hiavestubstantiated this assumiiption. Suirgeonls, indeed, appearto agree that reversal does take place miore frequienltly,especially at loncg distances, that tllh bullet is soie--what miore frequently retained ini a reversed or trans-verse position; btit althioughi this miust restilt- in a 'widenedarea of contnsed tisstues nlo very muarkied influelnce on tthegeaneral chiaracter of thlc wounds was observedl. Oniepeculiarity miienitionied by Alajor Birrell is of practicalilinportaniec, niamely, thle tenidency of retained bullets totravel shiort distances in the tissues, such as a needle does.Most observers regard the wotiliding power of tie Inewbullet to be about equal to that of the ogival or dlolmie-tipped buillets of corresponiding, calibre. Thley describe asimilar passage of the pointad bullet in a dlirect cottrsethrough the trunkl and Iiniibs, but a peruLsal of the reportleadls one to believe that so-called colntour wounds of thelhead ' and truinli were somewlhat more conmmiioni than wasthe case witlh the ogival or dome-tipped bullets used inthe Soutlh African war, anid this occurrence is probably tobe ascribed to thc decrease in stability of flight tilopointed bullet possesses.

In tle case of injuLries to narrow struictur-es, suchl as thLeblood vessels anid periplic-al nierves, the new bullet appeal-sby reason of its slharp point and penietratinig power to cause,evelv more cleanl and lnarrow perforations than its inre-decessors. With regard to wounds of the blood vessels, itis of interest to note that one observer states that of 15cases of aneutirysm treated by him the bullet was retainedin m-iore tlaln a third of tllhe vlole number.2 I lhave onlycomlle across the description of one case3 in wlhicll theretained core of a smiiall calibre bullet closed tlhe luimeln oftlle femoral artery; this occurred in the Manclhuriali'war.

WXoundls the maini imiiportance of wlhiclh dlepends uiponithe implication of the large vascular truinks have been acommon clharacteristic of gunshot injuries for all time,and certain features of these injuries lhave undergone nonIlaterial clhange. TliLis the comparatively small tendencyto be accompaniie lby great primary liaemorrhage, tllcfrequency Witll whllich tlley are followed by secondaryhaemo'rrlage, or tlle development of haemilatolmata oraneurysms. The most stiikung feature of tlle vascularwoundls produced by bullets of s-mall calibre is the lessenedliability to afford external secondary haemorrhage andthe greatly increased frequency in which they are followedby the development of some form of aneurysm. Thischange no doubt depends in some measure upon improvedrnetli(;ds of surgicat.treatment, but in tlhe miain" is duie tothe limited nature of the wound, its narrow track, its

[2764]

DEC. ?.0, I>)TA

G7NSHOT INJURIES OF ---ATERIE..

comparative _asepticity, and the -infrequency with wlichextraneous matter is introduced with the bullet.

Jertain special characters of the older bullet wounds ofvessels, such as the temporary control of baemorrhage bythe retained bullet, the retention of the btullet within thelumen of .the vseel,:er the travelling of thc bullet-along itscourse, have become far less commoni.

Prim,tary Hacmnorrhage.Let uis now consider how far the older stirgeonls were

justified in tlhcir opinlion that primary haemorrhagc dueto gunshot injuIies of the vessels is to be regarded asless formidable than that resulting from inljunies by othierweapons.

I tllink their opinion may be fully supported by a dlanceat a fe'w specimenis placed upon the table:

1. (3051) R.C. S. Museumi.-Gunshot wounid of the first part ofthe aorta; the bullet is retaijued withini the luimeni of thevessel, while the aperture cf entry is- partially closed by aplug of skin and adipose tissue; the milan- didn-ot (lie until thethird (day.

IE. (34.2) Muiiseumk' of the R.A.M.C.--A large lateral wouui(d ofthe commnon car'otid artery andl complete (livisioii of theinternal jtfunlar vein. TThis wound was followed b1 secondaryhapmorrhage on the. tlirteen-tlh (lay, anud the man di(d iiot dieuntitl after a recurring secondary haemilor-rlage onl the twelnty-foUrtlh -dxv.

rII. (3460 3Mfiscu of t7te .A.-lM.C.-A round-shot lateralwonnd-of the fermoral artery with complete div isioni of thevein.. Secondary haeniorrhage occurred all the eleventh dayantl leath upon thle twelfth.-

In eachl of the two latter specinmens the wotuni(d ill thearteLy is.partiallv closed by firmu clot. Aqnd it is. reasoniableto assume that uLder miioderin wotundl conditions the ocutir-reIee of "secoundarv haeimiorrlhage votild hlave been re)laceedby tihe fo'rmation of an anieurys;mi. Again, botlh in time caseof tlhe wounds of the carotiid anld the femnoral, the loss ofsubstan6e is niot miiore tliaii migh't be dealt witlh by miiodernimethod's at the pcriod at whliich the secondary haeworrlhagetook place.-

ANATOMICAL CII ARACTERS OF INJURIES IN.FLICTED UPONTHE BLOOD VESSELS BY THE BULLET ():

SMALL CALIBRE.It is giatural to assulme that tlle wvounds will niot

iiaterially differ in natutre from tlhose observel oi thesurface of the body. The skini and tlle vessel wyall possessmnAny chlaracters in common; botIl are elastic anid botlhoffer but slialgt resistance to the passage of the btullet, timeonily mnarked differelnce lying in, time contractility of tImeart3ry, whicil tends to close and at any rate temporaiilydiminish the size of tIme openi;g miade in its wall.We are aivare that in elastic structures like thlec blood

vessels the a-rea of tissue destructioi will be less extensivethani one corresponiding to the calibre of the buillet, al.sotlhat the revolution of the bullet and. the force it exertslaterally as a resLult of its generally coniical formiii tends todisplace the component parts of an elastic cord suchi as anerve withiotut free transverse- (Tivisionl of the fibres.The iinjuiry to a blood vessel may be citlhe of tllhe nature

of 'a contusion oir a vound, wlhile tlic extent of the lesiollvaries accordinig to the accuracy with which tllh COuIISe oftlih vessel is traversed:t With rectangular impact a notel,a 6lean- perforation,-Or comiiplete division restults; wlhen theillpalct is obliquei more extensive loss of suibstaice -follows,suchl iinjiries reaching tlheir'milost imarklied-degree whlenl thebuLllet courlses for sonie distance directly aloncg the vascularcleft. It need onily be nientio-ned' tlhat whlen t-ulc wouniid iscom)plicated by a fracture of a bone tlle injuiry to the airte'rymu ty'be produced by a spieule of baone, andI partale of then;ture of a. punctule or a miore or less comp)lete-laceration.

Coo tllSio )of t7/G Ves-sl TTtll.It, is, Ailhiult to gauge tlle imiiportanlce of this inijtury.

There-is-no ddubt tlla -tlte coiltusion IImay be sufficientlySCevere te's daage -the tissuet of thle vessel 'wll tllat illthc e-vet of infections atnd sLTppura,ttion time iiijnreJ areamiiv Xiy'w-gyiand Separating, give iYise to isecondafylaenCorrlia ' T''hat thlis ac6ident iiiay ocCuIr is" A cOldlmmooM1erlmnc§. dradging by mny own obser-vation, I thlink it isalso probablo that conltusioin thy be followeal by tledcrcl6pm:cnt--of a cicatr-ix wlilich perilniieetly marros-Altie

calibre of the vessel, and- imay possibly lead to its comlplete obliterationi.A specimen of Mr. Gtitlhrie's, preservel in the imiuseunm

of the Royal Army Mledical College, shlows the femoralvessels entirely occluded in the neighboutrlood of a sup-purating bullet track passing behind tlhem. In thisinstance, of course, the greater contuLsing power of the oidleadlen bullet mu-Lst be bolne in minid. In the case ofas ptic wouncds I doutbt if conttusions oftenl give rise to-trlublesome after-results.Some information is to liand as to the comparative fre-

qtuency and restults of the different varieties of woulnd ofthe vessel wall. Tlhus Surgeon-General Stevenson,A in hisreport on the South Africaii campaign, includes the nattureof the lesion in 16 cases of aneurysm whicll underwentoperation:

Eiglht were lateral wounids, resultinig in six arterial-and twvoarterio-venious aneurysms.

Fouir were perforations, resulting in one arterial anid threearterio-venouis aneurysms.

Fou'r ^% ere complete dlivisionls.

Saigot) inelodes- the natuLre of the lesion in 34 cases:

Of-these 21 were lateral wouinds, resulting in 13 arterial and8 arterio-venous aniesinysms.Eleven were perforations resulting in 4 arterial and 7 arterlio-venous aneuryssms.Two were comiiplete divisions.:

In a total of 50 cases we find.

29 lateral wounds ...-15 perforations ... ...

6 complete div isions ...

...58 per ceit.30 ,1

.. 12 s

It appears also tllat perforation of the vessels muorefrequienitly leads to the developmilenit of an arterio-venoul`aneurysin tlhani does a lateral inijutry.

Naturally little informiiation exists as to the results olincomplete lesiolns, but twvo observations of great iliterestm1.ay be noted. In one a graze of the femnoral arteryresLilted in the developnient of a protubehrance the size ofa lhazel nlut, accompanied by tlle signs of a traumaticaneurysmii. Ail attemnpt was made to cuere tlhe conditiouby.suturing the outer coats of the vessel over the w-ealkenedspot (Babasinoff). .Thlis proceduLre failed, the anleurysi-again developing, after wlhiclh t!ie artery- was suceessfull3ligatuired. The case is one of mnucli interest also amdemnonstratinog the necessity of the appositioni of the intiniafor a successful arterial suture.

In the second case (Stevensonl,6 Case 23) a lion-pene-tratingf inijuLry of the axillary artery was followved on thetwelftlh day by the form-ation of an arterial liaeniatom- a.On the fourteentlh day this was laid open an(d a graze 1 in.itiilengtlh, implicating the outer coats of the vessel, wasdiscovered, wlhich lhad given way in tlle centre.

Frecluccy of Various Classes of Wounds.Witlh regaud to the conmparative frequLelncy of lateral

wounid, Perforation, or coniiplete division, it is probablethat the niumbers giveni above are'not strictly accuirate,since they are fotulnded on observations imadle on -lesionisfollowed by the development of aneurysmus, anid fail totalic iito account the largeinnmber of cases in whliclhliaemorrhage eithier ceased spontaneously or led to death.One or two 'points of interest, lihowevCr, ar-iso fromi thecofisideration of this table (Table I) togctlher witlh that(Table II) slhowingo the distribtution of anetirysnms-over tlredifferent arteries.Filst of all, thle frequency witlh whicll aniy artlery is hiit

naturally corresponds directly with its calbh'c amind thelengtlh of its course.

Secondly, if we analyse 42 cases, we fiiid that the,freqLency of perfoi-ation depenids niot onily on tlie wi(tlh ofthe vessel, buit also on its comparative fixity of positioll;tlhus perforation of the feinoral anld popliteal vessels, isconimon, wlhile the axillary artery, a truniak but littlesimialler, frequently cscapes with a lateral injury.The quiestion of tlih f-einuency of, complete sce&erance of

a large artery is- mom-c diieslt to ktermiiie since It isprobable thait a cons-iderablu proportion 6f 'tfe instancesin which it -oTc!mV are followec by early death fro-haemiorrllagce, but it is significanlt that in tlle series fro1

Ti-iv.-ERman1570 BiEDcAL jou-RslL I [DEi . 20, 1913.

GIUNSHOT INJURIE', OF ARTERIES.

TABLE I.-Saiqlo )andctStevenlsonI.

Lateral Perforatioln.

C~trotid ... ...1

Subcixitn ... ... 2 1

.\Xil'ar-...... .. .. 6 1.l3rachial ... ... ... ... 10 1

Fteinordl. ... ... 7 8

Tit tal 7..3l otal .......| 27 15

Total.

2

3

7

11

15

.4

42

whlichl the above smiiall table is taken complete (livision ofthe artery was observed six times, and that i five-of theseinstances thie popliteal wvas ths vessel.iniplicat6d: in thesixtlh the femoral artery was comDpletely divided; by a bonyfragmient from the femiiuL. The liability of tlle popliteala-rtery to complete division is probably explicable oIn twogrouinds: (1) Th'at the artery is coixilonly strLucl in theconldition of ftull tension corresponding with tlhe extendedI)osition of the limb; (2) that,; except whlen tlhe- bulletenters fromii the posterior wall of the space, it lhas to per-forate resistant str.ucletutres, and lhence may be altered inform and wouonding properties.As to the anatomical eharacters of .the wounds, -we are

indebted to Bi-entano7 for tlle only aeccuate descriptionI lhave met with.

Witlh regard to lateral wounds, h-te -points--out bltat theiuiargins are tattered irregularly, givina tlhe inpression oflhaving beeni gnawed ouit. Again, tlhat a lateral woundinvolving morle than lhalf thle circumfefrenee of tie -arterygapes wridely longitudinally, acquiritng a greatly increasedsize in consequence of the elastic nature of the vessel wall.The artery lhence becomlies incapable of coniducting theb)lood, anld the injury is comparztble to a complete division.PerforatinD grwouinds do not separate so widely in conse-qtience of the continuiity of their miarlgins; the loss ofstubstanice is also less, tlhe size of the openling not equiallingthe calibrc of the bullet. Perforations caise somye obstrutc-tion to the circulation, due to thln escape of blood, aiid theeffect upon the vessel is to produce soelle proxinmal and alcsser distal dilatation of the lumneni.

Iflimnediate Results of Jiujirics.Ini proceeding to a consideration of tlle reicults of tlhese

inljuries it is of interest to premilise tllat we ar lhere metw\,itli olne of the Imlost str-ilkin-g aniomalies of miiilitaryl)ractiCe, sinice we are abouLt to detal with a series of coent-plications not onie of whielh wouild be miet withl did lnot theexigencies of the work in the fiedl render it imipracticableto abide by a futndanmental ruile of surgery--that is, that a

bleeding vessel shlould be secuired at the first possiblei-onenlt after its injtury.

Prik1ary/ Il1c(norr-htage.The quiestioni as to the proportion of vascular in1jurties

wlhich leadl to carly deatlh upon tlhe field of battle soermisone almost iiicapable of au anIswer. Tllhcr can be nodouLbt that it is a large one, and in support of this it isonly lnecessary to mnention the fact thlat lhaemorrliagefroml, or aneurysmns developinig in connexion witlh, thelarge arteries of the trunkli practically receive lno menitionin the large series of cases reported from recent campaians.Operatiolns upon the great vessels of the neck and tllelimbs arc frequent, but, e-.ecept for an occasional ligatureof the external annd still niore rarely of the commiion iliacvessels, we find iio mcntioii of the vessel of the trunlk. Itseem-is, therefore, reasonable to assume that wotunds oftlhese vessels lead, witlh feyv exceptions, to.rapid deatlh.'rlTe same resuilt probably follows a certain proportioil ofthte -wounds Cf the large vessels in tlle limbs also.

Voiantconeus Healing of Arterial Woun ds.It connIexion witil this subiect woe nay conveniiently

consider the quiestion of spontanoous healing of the largerVessels. I tl1ink th1ere is every reason to conclude thatth1is, as cithier ani inmmuediate or remote sequence, takesplace withI a certaini degree of frequency, on the followinggroun1ids: In tile first place. clinical observation of wounds

traversing thle course-of large vessels, as the suibelaviani orthe femoral, las demonstrated thie presence of localmurmnirs, pointing to local constriction of the vessel, alsodiminislied puilsation in the periphleral circulationi. Again,sulch dinminished ptilsation mlay be temporary. It mav, ofcourse, be suggested that in these instances ithe vesselsliave suffered contusion only, and thlat the sign.s are(lependent on temporarv thirombosis of the vessel or onpressure exercised by cicatricial tissue in the wound trackon the artery. Hence tle importance of dlefinite evidleicederived from observatioln of the conditionis found incertain varieties of 'aneuryssm.-First; as to- tlhc primary occlusion of the vessel -by a

provisional tlhrolnibtus. Tihis lhas been obkerved ini sevevalcases where the injury lhas been followed by gangaene ofthe limb (Manteuffel, Stibbotich, etc.). The gangrenc insuclh cases is comTiparable to that whichl soumetimesfollows primary proximal occluision of the vessel byligature..lThen as to imlnmedliate cicatrization of the wound. III

Surgeon-General Stevenson's repor-t (Case No. 96, iuderthe care of Dr. Archibald Young) the followving conditioniswere found in a patient who died pf enteric fever fifteciidays after receiviug- a wotund wliicli perforated the stuper-ficial femi-oral artery anid vein antero-posteriorly at thlcapex of Sicarpa's triangle. Tlih wound of entry into theartery was closed by a small, firm clot embedded in theposterior aspect of the sartorius; the smuall circular exitwouind was attaclhed to a similar opening in thle opposedsuirface of the vein; wlhile the woundc of exit -in the veillwas 'nnearly cicatrized." No extravasated blood was&Ircsent either around or betwieen the vessels.A mnore astonishing obscrvation was made bv Brentano

in the case of a wouind traversinig the aWdomininal aortajust above the origin of the renal arteries, and tlenip,assing- tlhroLughl the liver. The patient died utpoln theseventietlh day from a ssubplhrenic abscess in connexionwitlh the wound of the liver. Tlle following condition wasfound in thle aorta: The entry wound visible on tlle outeraspect of tile vessel was circular, and looked like theproximiial ext.renmity of a smiiall branch wlhiclh lhad been ctitoff. The exit wound was slit-likie in c-haracter. Whethe vessel was fir.st opetned thie wotunds were scarcelyvisible on its inner aspect. lBotlh were firmly closed, whilethe exterior of the vessel was coated witlh a. layer ofplastic lyxiplh, quite separate fromii the suppurating bloodclot wlhich lay arounlld. Thiis case recalls to m-y m-ind thatof a patient I saw (lie suddelnly w-itll signs of an abdominallhaciorrllhagetwo days after the receipt of a perforating-wound in Soutlh Africa.8As to the condition discovered durlillOr operatioins, ini five

of eleven petrforationis in Saigo's series of extir-pations ofaneurysmn, onie of the two ar terial wounds lhad cicattizedat the en(d of six imiontlhs, four anld a lhalf mohtlhs, thirty-nine, thirty-seven, and twventy-five days respectively. Inone of these cases the scar btulged, and in the second asm1all consolidated anceulrysmlial sac was present at the siteof the wounid.A second metlhod of occlusion i3 by tlle adlhesion of the

surrotin(dingc vessels and nerves; Such cases were observedby Sir W. MacCormac and Sir W'illiamii Stokes. A striliingiustance observed by Major Holt is reported in Spencer'sG(i ns7tot }Wounds (p. 68): 1 In dissecting otut the uipper endlof the divi(ledlulnar nerve in the uipper arnm I canrc acrossthe divided braclhial artery tied up in a scarlike tissue.Astonislhm-lent and cu1riosity led miie to free the proximalend, and it at once bled as a normal braehial artery would.I tied it, and, to confirm matters, eventuially fotund thelower end also in the scar."

Brentano, wlho draws special attentioln to this mode oflhealing, mentions a simnilar observation. It is notewvortlhvthat in all four instances the brachial was the arter'ycoiieerned.

Secondly, spontaneous curte may be the terminal resultin arterial hlaem-lat(m Wta wlich conttact to form circunt-scribed traumatic an ;rysms and eventtually consolidate.Of thlis sequence o± events I lave seen several instances,andtthey lhave been observecd by many sur ons. I thinkwe mllay conclude that the opening in the artery graduiallycontracts, the flow of blood into the aneuirysmis lessened,and consolidation of ihle sac follows, as a restult of thecleposition of laminated clot.A ease of great initerest is Melated by Saigo, in whlielh

tlle femoral arterv was completely severe(r by a spietle of

I)-]','C'- -20, 1913-1 I Tity, PRITISHL M-t--DICALTovu-,;&L I 5 I

7cGUNSHOT INJURIE'S OF ARTEII E.[D. 0T3.

r.TABLE II.-Distribution of .Anlury)sms an lAneurysmal Varices.(Uouth Africa, 98; MaUnchuria, 121; Balkanis, 61.)

Traumiiiatic Anetrysis. ArLterio-venotus Anieurysmsis. Aneurysiiial Variecs.

tSteven *Sai Subbo-° It nson. 1tic-.

(aroti.l - 1 1 4

External c trotid 1 -_ 1 2 -

Initeirnial caro'id - _ 1 1 -

Stbe;iaviall 2 - 2 -

'Fralnsx-ersalis colli - -- -

Axillary .11 4 4 19 2

lbl)-scal)lar ... 1 1 2 -

I1nachial ... ... 6 6 2 14 2

iladial.,.. . 1 1 2

I-I,iar ... ... ... 3 - 2 5

Supfl-volae ... ... 1 - -

lhte'rosseons fore- - - 1 1arii.

EIxternalI iliac .. 1 - 1 -

1

26

3

1

1

2472

88

21

1

132

171

5

I

Suibbo- 'StevenSaigo. tich.°Total son. Saigo.

-I -j - - -

2 - 1 - 4

1 1 43

2 2 29

__.__ __ ____

.. Snl)bo- Total!tich.

1

1

1

2

1

2

1

2

1

1

2

1

6

1

'TotalKik ranid Percen~tagoITtl iuzi. CTn'tal. Occuir-

A , ~ rence.

7

3

14

23

2

21

2

5

11

42

77

5

28

8

2

1

1

14 198

1

2

736

10

54

1

1

26

163

85

8

5

1

11

3

29

2

31

7

91

1

5

3

103

5

44

1121.

1

283

2.81.7

0.75

3.630.5

10.2

0.7

10.92.4

3.13

0.35

0.3r1.71.0

_';6.3

1.7'15.5

3.83

0.7

0.330.35

bone. The injury -was followed by tllo development of-two smiall aneurysimal sacs, onie on eitlher side of thjeproximal end of the vessel, wlile the distil eild wasconllpletely occluded.

Thiirdly, I thlinik tlle development of a pure aneurysimnalvarix can only be regarded as an instance of the perlmanentarrest of lhaelmorrlhage by a spontaneous proCess of lhcalinl.ln miiany such cases the primuary absence of aniy trace ofextravasated blood in the slheath of the vessels, excentsuch an amiiounit as miiay have ensured tlhe firum lateraladhesions of tlle twvo vessels, points to a proce%-s resemblingthat following the ligature of a vessel. Trhie op 3ning is atfirst occluLded by clot, formed on the margins of tlle wotnidin the vessel, which temporarily arrests the passage of theblood into the veini; this clot persists until, in the processof hiealing, the intima of the artery has becomei continuouswith that of tlle vein. The provisional clot is thenabsorbed or washed -away, as is the temporary throlmbusdeveloped after ligature, and we get the development ofthe characteristic -thrill and murmur, with the establish-ment of tthe arterio-venous communication.T he period occupied by this process corresponds with

the interval of days or weeks commonly noticed betweenthe reception of the wound and the.development of tllepurring thrill aud murmur. Lastly, an aiieuirysmiial varixmay heal spontaneously muany months after its develop-miient. In muy book on the wounds of the Soutlh African-war two instances of spontaneous cure of this nature incarotid arterio-venous aneuLrysms are described, tlle tlhrilland all symptoms disappearing some months after tlheapplication of a proxinmal ligature to the artery. A case ofspolntancouis cure where the communication was.supposedto be between the innominate vessels is also related tlhere,asnd many otlher instances of this sequence of events havebeen observed.An instance of a still more remote closure of the opening

in an anenrysmal varix ig recorded by Sir WV. Osler.9 Thiepatient was seen by me in 1900 with the classical signs of

an ysmal varix of the axillary artery of twenty-twoyears' standing. Wlhen he died in 1909 no trace of anycommtunicating opening could be discoverod between thevessels, although both were dilated and the walls were

mauch tlhickened. Tlle drawinig in the Lantcet sllows tllevessels in intimate relation at tlle point of greatestdilatation.These cases appear to afford definite evidence of the curo

of a wounded artery eitlher by an imnmediate or a reimAetoprocess.

Seconda ry Mac;no rrliaye.The dncrease in fre(lquency of externial secondary lhaemoir-

rlhage inl gulnshot woulns oinly brings tlhenm into line witlthe injuries of civil life., the decre tse bearing a direct pro.

portion to tIle decroase of infection and suppurationi.Whien the small nullb3r of c -ses ieedina treatment byamlputation or ligaturao mi qntioned in the reports of recentwars is contrasted vitli tlhe forinidable list recorded inthe report of tile older canmpaigns th3 clhange is strikingindeed.

It cainnot, however, be too strongly urged that altlhouLalhinfection is less common, yet tile second cause of secondaryhaemorrliage, disturbance of tlle wound incident on tlletransport of tlle patient, exists in an equal or exaggerateddegree, and is unaffected either by the anatomical natureof the wound or the muethod of treatmlent adopted.External llaemorrlhage is replaced by bleeding into the

tissues, tlle extension of localizing arterial hiaematoml-a, or

increase of blood collections in the pleurae, peritonealcavitv, or tlle joints. Thlese accidents are sufficientlyconmtmion to render absolute the rale that no subject of a

wounded vessel should ba suLbmitted to the dangers oftransport excepJ in the case of actual necessity, and thenonly witlh the watiunded part as far as possible immnobilized.

The Development of Aneurysms.Thie frequency with which wounds of arteries are fol-

lowed by the formation of the different kinds of aneurysmnis not possible to accurately determine, since so large a

proportion of vascular wounds in war escape record.Tlle accompanyina table (II), showever,so%vs tile gener al

distribution of the lesions in 283 cases collected frolnreports of the South African (98), Manclihirian (121), andrecent Balkan (64) campaigns.

Gluntcal .,, .,.

Femioral ... ...

Proftunda ... ...

Popliteal .., ...

Posterior tibial ..

Anterior tibial ...

PIelronieal .. ...

iiternial plantar ...__ __~~~~~~~~~~~~~~~~~I- 1

3

1

182

13

7

I _;~~~ ,_- ---I

I `2 'TitE IPniTll.;Tl

31LIDIC-ILL JOUR\Ar. I [DEC. 20, 19I3-

I_-1-!1

I 1-

T1EC. 2o, 19r3.] GUNSHOT INJU1RIES OF ARTERIES. LLDICALJoFRAsL 1573

The next table gives in addition a rough estimate of theproportion in whicll the various forms of aneurvsm occurredin 162 instances.

TABLE III.-P-ro0)0ortion of Var14iouS F'rm)13 of Aneuirysm inl16C? Cases.

Dlh Mancliuria Balkans TotalAfrica (Saigo). I(Suibbotich). Total. cent--~~~~ (Stevenson). Iage.

Arterial (liffuise 31 21 43 95 58.6or localize(I

Arterio - venous 33 10 * 16aneturyzi-n 3361 41.3

A neurys -in a 1 67 41.3varix I

Totals ... 64 36 62

It imiust be borne in mind, however, that these tablesmerely record the survival of the fittest, since tlley arebased on cases treated in the base hospitals, and that aconsiderable nuimber of small traumatic aneurysms, and astill larger number of pure varices, escape not only thesurgreon but also any record whatever.

TREATMENT OF WOUNDED ARTERIES.Tlle question, At what moment tlle treatmuent of a

wounded artery should be undertaken in miiilitary prac-tice, is one fraught witlh tlle greatest difficulty. Reasonshave already been given for believing deatlh fromn primaryhaesnorrhage, when the great arteries of the trunk areim-plicated, to be the commlion result, and to that point inofurtlher reference need be miiade, but in the case of wouindsof vessels in the neck and limbs we know tbat a nutimberm-iiglht be saved wlho die from secondary haemorrlhage organgrene, and that a large nLumber develop aneurysmswhich need operations of some severity before tlley arecutredl.

It is clear that primary ligature of the vess;el wouldenlsure tlle life and avoid tlhe dangers attendant upon theaneurysm to this latter class did not tlhe exigencies ofmilitary practice forbid the adoption of the commoui ruleof surgery in the great niajoritv of instances. If thepatient is bleeding seriously, manifestly tlle ordinary- rulemust be followed, but if ihaemorrhage is sliglht or hasceased spontaneously, pressure and a first dreSSing will beapplied and the patient sent to the rear. He now passesthirough the hands of the medical officers of tlle bearercompany, the field hospital, the stationary hospital, andpossibly of-the ambulance train before lie reaclies tllelhaven of the base hospital, at which alone extensiveoperations can be performed under the best conditions.Once entered uponl, until this transitory period is ended,n1ot only are the general conditions and surroundings

unsatisfactory as far as the operating surgeou is con-cerned, btut experience lias also abundantly proved tllelocal condition of tlhe wound to be eminently unquitablefor direct treatment. The wound cavity contains a largeamount of clot and its walls are stiffened by extravasatedblood and reactionary effusion. Tlhese conditions rendertlle employment of drainage a necessity, a provisionrendering, tlle wound readily liable to the dangers ofinfection during transport.These difficulties existing with regard to the compara-

tively simple operation of ligature acquire still miioresignificance in considering the far more delicate operationof suture, requiring not only greater skill, but also moresatisfactory surroundings, even puttina on one side the(question whetlier the recent gunsliot iijutry of the arteryis in itself a class of wound suitable to primary suture asto its fitness for direct union, or as to tle risks of coIn^sequent gross tlhrombosis of the vessel.

Little actual experienice of the primiiarysuttLre lhas beengained, but suclh as exists is not of a nature to encouragethe lhope ofanly great future for thisinetlhod of treatingc,wounded arteries in military surgery. I thinkl it indubit-al)le that in tlhe preselnt state of suLrgery direct ligationi,hllen niecessary, is likely to remain tlle only operationsuitable for application to the prinmary injury, and thiisrule is still more applicable to tlhe treatmlent of exterlnalrec urrent or secondarylhaemorrlhage.

In military surgery it is, tlhen, chiefly in the treatmentof the secondary consequences of wounds of the arteriesthat time quiestion of the relative applicability of ligatureor suture of thle vessel comiies into consideration, in spiteof the fact that a few isolated primary operations forsuture liave been uudertakenl witlh somewhat doubtfulresults.This brinigs us to the question of dealing with artceial

lhaematomata, traumiiatic aneurysmis, arterio - veaous,aneurysms, and aneurysmal varices.Both the recognition of aneurysm-n as a condition

amenable to operative treatment alone, and every methodof treatment now in use can be traced to the most ancienttimes. Arterio-venous aneurysmn -was described by Rutfusof Eplhesus in the first century, while Galen in the seconidcentury speaks of it as a well-known condition. Commonduring tlle long period that bleeding from time bend of theelbow was a routine practice, its frequency diminished a,its source of origini became limited to occasional stabwounds and injuries from shot guns, only to beconme againenormously increased in connexion with the employmetitof the bullet of small calibre.The simple employment of the ligature was supplementeJI

between the first and fourlth centuries by tlhe addition ofincision combined with proximzal and distal ligature ofthe artery by Antylltus, while Plhilagritus introduced tilefurtller procedure of extirpation of the aneuirysmal sac.After an interval of more than twelve itundred vears tlOcmetimod of Philagrius was reintroduced by M. G. PuLrnmanin 1669, wlho successfully treated thlree cases of bracimialarterio-venous aneurysm by proximnal and distal ligatureof tlle artery combined with extirpation of the sac.10From that period methods of treatment lhave variecd, butno really new procedure had been employed until theapplication of time nmetlhod of suture to wounded bloodvessels opened up a new avenue.The history of tlle application of a methiod of suiture

to an artery commnenced witlh tlle closure of a wound oftlhe bracllial artery by " twisted sutures" on a pin byHallowell in 1759, while lateral sutture of a vein wasfirst performed by Schlede in 1882. Tlie first lateralsuture of tlhe femoral artery was made by Postempski in1886, and the first successfuLl coniplete circular suture onthe human subject was performed bv J. B. Murplhy in 1896,of the femoral artery by hiis invauination me;thod, thisoperation being followed by a similar one upon timeaxillary artery.

Since tlhat period tlhe technique of suture lias beenw%videly developed botlh in, experimental work and insurgical practice, wlhile the late war in tile Balkans lia:;allowed a fairly extensive trial of its suitability to thetreatment of gunslhot wounds.

Proxim.al Ligataric.The main outcomie of time experience in time treatment

of vascular injutries gained in the Soutth African warwas to emphasize the dangers of Hunterian ligatuteat tlhe seat of election, especially in the vessels of thelower extremity, and to suggest various methods of dealingwith arterio-venous aneurysms and vartces. Of tlleselatter, ligature of tlle artery above and below the cons-munication, leaving tlhe vein uintouchled, received tileimpress of official recognition, wlhile double ligatture ofbotli vessels, proximal ligatuLre of the artery withi ligatureof tlhe veini above and below the opening (Lewtas) wereperLforled successfully, and a number of cases of simpleproxinlal ligature (Anel), especially in the neck and upperextremity, gave good results.

In tlle Manclhurian catnpAign tlhe chlief clhange consistedin tlle greater freqtuency witlh whiich ligature of tlle vesselswas accompanied by excision of the portion of the vesselsinvolved toaetlher witlh tle sac itsAf, and Sym&'s modifi-cation of tlle metlhod of Antyllus, in which the sac isopaned prior to the application of the ligatures to tilewounded vessel, called by Kikuzi "intrasaccular directligation."A series of results published by Saigo will suffice to

illustrate the suLccess with wisich extirpation was attendedin skilled hands (Table IV). In Saigo's practice operatiouon the aneurysm was preceded by some days' or -weeks'digital colmnpression of the artery withi a viewv to eneouragingthe developulent of the collateral circulation.

I

GUNSHOT INJURIES Ok1 ARTERIES.

Gan- Died.|Complications.

14

1

19 2

Feinoral.

Brachial gangrenie,amputatiou

Gluteal.

A rterio- Venouis A neurysm.

No. Cured Complications.

Extirpation ... ... ... ...

Ligature of artery abovebelow; eiln untouched

Antyllus ... ... ... ...

and

...

11

2

2

11

1 1 femioral gangrene,amiiputation.

1 1 haemiiorrhage;secondary ligationi.

In the recent war in the Balkans tIme metlhod of sutureof the vessels lhas been somewlhat widely employed in tliotreatment of the secondary consequences of woundedarteries. The results of tlis metlod of treatment in theBelgrade State Hospital have been collated by Dr. V.Subbotich, and were communicated to time Section of Navaland Military Surgery at the recent seventeenth meetingof the International Congress of Medicine. I am muclhindebted to Dr. Subbotich for some supplementary reportsregarding some of the cases, of whiclh the result wasunknown at the time his paper vas written.We may now proceed to compare the various metlhods

of treatmlent employed duiring the last decade.First, as to the timne-honoured measure of ligature in its

various applications. I[ tlhink the entire concourse ofsurgical opinion is opposed to the operation of ligation atthe seat of election. The tragic history of its employmentin the treatment of secondary haemorrhaae in the oldercampaigns lhas been followed in the more recent ones byan only qualified improvement in its application to thetreatment of traumatic aneurysms.

TABLE V.-Cases of Ligat(re (South Afrieat, 1'Var).

Secondary haemor-rhage

Secondary haemor-rhage

Arterial haematoma

Direct ligation

Proximal ligation

Direct ligation

No.

8

11

27

IGan-Igrene. Died.

6 2 25.0%

7 4 36.3%

27 -

Arterial haematoma Proximal ligation 16 16

Circumscribed trau- Direct ligation 4 4

iimatic aneurysmlCircumscribed trau- Proximal ligation 14 13 1

muatic aneurysm

Arterio-venous Proximal ligation' *14 6 3

57.1 % gangrene; 25 %6of these died after ampuitation.>Recoveries 11; amptutationis 6.

%,

In tlle smiall number of cascs notedlin the SouthiAfricaniwar we find tllat 36.3 per cent. of the cases of secondaryhaemorrhage treated by proximal ligature died. The resultin 30 cases of arterial aneurysn wvas better, no instancesof gangrene being reported and only one death, 3.3 percent., but in a number of these the proximal ligature wasof the nature of an Anel's operation.The worst results were those followinaproximal ligature

for arterio-venous aneurysms. Here, of 17 patients died,and in 8 the operation was followed by gangrene. If3 operations on the carotids are subtracted, we find 14 casesof ligature of arteries of the extremities, witli 2 cases of

gangrene in the upper and 6 in the lower limb. Tlhus a

percentage of 57.1 of gangrene and 21.4 of deatlh.A distinction must, hiowever, be certainly drawn be-

tween the operation of Hunter and that of Anel. I myselfsaw 3 cases of proximal ligature of the carotid followed byimmediate cure of the aneurysm and remote spontaneous

cure of the arterio-vcnous communication of two, wvlikthe same result was observed in some cases of brachiia!arterio-venous aneurysms where a proximal ligatturc wasplaced close above thc sac.These results of proximal ligature hiave beeu fullj

confirmed in the Manclhurian campaigu.

Simple Dir ect Ligatture.The operation of simple direct ligature m-iay,oi the otlhet

lhand, be regarded as higlhly successful; of 31 cases ofarterial aneuiry'sm so treated and recorded in Stevenson'sreport all were cured.

In the 'Manchurian campaign Kikuzi, Alexandrow,Koratkoff, and otlhers employed Syme's modlification o'ftlhe operation of Antyllus with mnuchl success. Kikuzi,!'wlho calls the m-letlhod ' intrasaccular direct ligature,"claims the following advantages for it:

1. Ease of application.2. The slhort time required for its performiiance.3. The practicability of performing the operation under

local anaesthesia.4. The limilited extent of the vessels excluded.5. Few collateral branches are injured, and tlhus CirlCt-

latory distuirbance and danger of gangrene is diminished.Kikuzi employs an Esmarchl's bandage in operating oni

the extremities, or follows Syme's netlhodI of introducing,a finger into a small opening made in the sac, whlere thleelastic tourniquiet is inapplicable. He records two suc-cessful cases-one of the carotid and one of the externialiliac arteries-where Syme's method was employed.

In the Manchuirian campaign extirpation of the aneury.Cintogetlher witlh the portion of the vessels from wlichl i1sprung after ligattire above and below the aneurysn, wasalso employed. Saigo'5 reports the results of 26 aneurysinstreated by tllis metlhod with one deatlh (itnDm:ediatelyfollowing the operation)-3.8 per cent.Of the 26 aneurysims, 15 vere arterial and 11 arterio-

venous. The series was practically unaccoimpanied byserious gaugrene, since only gangrene of the tulltmb ina case of axillary anenrysm and of tlhe toes in a femoralaneurysmn, 7.6 per cent., occurred (Table V).A series of 5 cases of arterial and 9 of arterio-venous

aneur ysm tlhus treated are also recorded by L. Bornliaupt'in whichl no single accident occurred.The procedure of extirpation, lhowever, is a serious one,

needing considerable time for its performance, and, inspite of this excellent series of results, I tlhink the casessuitable for its employmeut need careful discrimuination.Let us now proceed to consider more fully tile latest

addition to metlhods of treatment.Suture, whether lateral or circular, mnay well be con-

sidered the ideal procedure, since by it alonie can thenormal circulation be re-establislhed and maintained, andsufficient evidence lhas now accumulated to allow a pro-visional judgement being given as to its advantages.

1. The method of suture obviates the niecessity of aniydependence on the establishment of a collateral route forthe circulation. Tlhis, even in the lhcaltlhy young mencommonly the subjects of military surgery, must bereg,arded as an imlportanit feature, the more so that in theearly stages of arterial lhaematomata blood extravasationnmay initerfere witlh the comnpensatory enlargement of quitonornmal collateral svstems.

2. By the nmethod of sututre no loss of lengttlh of theartery is suffered and the least clhance of destroying aimvcollateral branclhes is attained, the latter poinit being ofsone weighlt slhould the suture be followed by localtlhrombosis.

3. By this miietlhod not only is the imumlediate vitalityof the limb less endangered, but the clhanices of per-manent deficient nultrition consequent on an imperfect anclinsufficienit blood suipply are lessened or abolislied.

There seemils nio questioni that the first two of thesepropositions must be conceded; the tlhird needs furtlherexamination.

First, as to the immediate vitality of the liiib.It is stated that a review of publishied cases shows thiai

gangrene follows the operations of ligature in from 6 tc12 per cent. of all cases. This is probably niot an ex-cessive estiimiate if bothi traumatic and spontaneousaneurysms are taken into account; but I thiink if tinftraumatic aneurysmis are considered separately, and.further, if the nmiirelv arterial aneurysms are considered

574 NuzAD an

TABLE IV.-Trauimatic mAeu

No.

ExtirpAtion ... ... ... 15

Central ligature incision and 3sil sequent extirpation

Antsllus ... .. 1

Central ligaturoand inicision 1

Incision and plugginig. . 1

Total . . 21

~~--. ~~i j- l~-1 I 1..

-1.. -

2

.- -

[DEC. 20, 1 c) 1 3 -

DEC. 20, 19I3.] GUN'SHOT IN-JURIES OF ARTERIES. TimE BnIrT,s I575LMZDICAL JOURN-AL

apart from those in wlich an arte-io-venouis commnunica-tion is present, that the ligature of a hlealthly artery is notto be regarded as so dangerous a proceeding.

Ini the case of 31 direct ligations of large arteries for.arterial liaematomia and circumscribe-d aneurysm in theSouithi African war, gangrene did not occur in a singleinstance; and in 30 cases of proximal ligature for thesamne codition only 1 case of gangrene (following ligattureof the femnoral) occurred (1.6 per cent.); and 1 patienitdi d (1.6 per cent.) from septicaemia one montlh after theopcration, the aneurysmI itself being cured.The bad resuilts followed tlhe operat on of proximal

ligature for artetio-venots aneurysms-an operation wliclh,except in some special instanices, slhouldl lnever beperforimied.

Again, if the 26 extirpatiolns com--binied with ligatureby Saigo are considered, gangrenie occurred in only twoinistances, and lhere was minilllial. in (legree, resutlting inthe loss of a tllum-b after ligature of tlle axillary arteryand of the toes in 1 case of ligatuire of the fem--oralartery.To com-lpare with these resuLlts, we miiay take first

31 cases of suture performned in civil practice, collectedby Tsclherniachowslii,'4 including 15 isolated stltures of theartery, 7 isolated sutures of the vein, 9 suttures of arteryand vein. Of the aneuLrysms treated, 11 were arterial,20 arterio-velnous.Amongst these cases ganigrene also occurred twice-once

in a reiiiarkable instance in wvhiclh repeated secondarylacnmorrlrages followed stuture, resututre, ligature, andamputation, and in tlle second as the result of an infectioncausing gaseous celltulitis. In the miiatter of gangrenethese statistics show a sliglit advantage.In 22 cases of arterial sutture collated by Subboticl

during the Balkan war gangrene occurred once afterlateral stutture of the popliteal artery and vein, and onceafter circular suiture of the external iliac artery conibinedwith ligature of tlle vein. In a case of incipient gangrenefollowing a wound of tlhe popliteal artery lateral stuturefailed to arrest tIme process. If tlle 2 cases only arecounted tllere is a percentage occurrence of 9 per cent.

"It is obvious that these numbers are far too smyiall foranly definite deduction to be drawn, andcl also thjat theyprobably represent only a sm.all proportion of the cases

operated tupon; btut they at any rate go to prove thatunider existingr conditions the employment of sututre lhasniot abolislhed tlhe occutrrence of gaunrene.

Permanent Lowverinlg of the Nut-rition of Limib.As to the question of permanent lowering of the nltutrition

of thle limb. In civil piractice, givecn fair condition of theblood vessels, this sequela lhas not been onie wlich in thepast hias attracted serious attention oni the part of thesurgeon. In fact I tlhink suLrgeons hiave looked upon theligatture of a large artery as a satisfactory operation inregard to its permanent results. In military practice, inniyy owni experience, I hatve seen bad results; tlhuis a con-dition. not appreciably clifferiiig from that of Volkmann'scontractutre of tlle leg in two instances after ligatureof the popliteal artery for arterial lmaematoma; and again,gangrene of tlhe leg followiing a sliglht inijury some monthssubsequently to ligature of the stperficial fermoral artery.In these cases, lhowever, I tllink somle w-eight mtIst begiven to the widlespread nature of the blood extravasationand dissection of the limb, the unsatisfactory conditionsunider wvhichl thle cases were treated (botlh tlle popliteal casescainie from field hospitals), and perlhaps to the nieuirastlhenicstate of tlho patients themselves.

Friscb,',; on the examination of 10 cases in wlliclharteries hiad been tied at periods of from one to eiglhtyears, found only four sound limbs; in thle rem-1aining sixtrophic clhanges were present.

Again, Koratkoff estimated the peripheral blood pres-s;ure in 17 patients in wlhom arteries lhad been tied, andfound it to be-

Peripleral Blood Prsc.sure.Ini 7 cases less thain half that of sounld limb.In 4 ,, about half ,. .In 4 ,, miiore than half ,, .,

In 2 ,, equal to that of soundc limb.

In one of the two cases the estimation was ma(le onlY sisweelks after the operation.

These numlubers speak for themselves, but it still remainsto be seen whether a series of suttires will show betterresults.

Thromrlbosis.Intimately connected wnitlh te occtierence of gaiigarello

is the question of lhoxv frequenitly tlhrombosis follo'ws tllhoperation of sLtttre. We know from the resuLlts of expevi-mental work thiat thrombosis does occtur in a certainnuimber of instances, fuirtlher that its occurrence is deter-nined by eveln si-iall errors in ani exactingc teclhniquie.Again, the clinical observation'18 of a firmii tlirombus

11 cm. in length on the sixtlh day, extending from tlhesite of a lateral woound in the femoral artery and givinarise to gangrene of the leg- is suggestive of tlle riskl ofa wound inaccurately closed. A case of spontaneoustlhrombosis of tlhe femoral artery after complete divisioniaccom--paniedI by no local blood extravasation is alsorecorded by Suibboticli. In thlis incipient gangrenoe wvacnoted.A precise deteriniiation as to the sequenice of thrombosi-:

to suture of the artery in suirgical practice is lhardly pos-sible, since even does the artery tliromiibose thle patient iF:in no worse plighit than if a ligature hias been applied.The only usedful indication is to be soughit in tle peripheralblood pressure, but-of this in most cases we liave only therouah estimlate wlhicll can be obtained by feeling the pulsa-tion in a distal artery. In Tschierniachowski's table of 16lateral sutures, amiong 14 case3 wlichl survived the peri-pheral puLlsation is noted as weaker in 2 cases, while in 2weak pulsation noted before tile operation became normalafter the artery liad been sutiured. Amona 9 cases ofcicutilar suture of the artery, in 2 instances no return ofpulsation in the posterior tibial or dorsalis pedis followedsuiture of the popliteal artery, whiile in 1 the renewed'pulsation was observed to become weaker. In 1 case ofsu'ture of the axillary and 1 of the femoral arterv pulsationreturned when none lhad existed prior to the operation.In 4 ftirtlieL cases wlhere bothi artery and vein were joinedby circular suttire, in 1 case (Lexer) the peripheral pulsewas noted to be weaker at the end of eight months, pos-sibly as the result of cicatricial contraction at the site ofuinion. In 2 out of 24 cases in Subboticlh's paper thedevelopnenit of gangreno points to the occutrrence ofthromnbosis of thle artery.

Othtcr Accidentts.Lastly, we have to consider holv far the practice of

suture is exempt from the other accidents which somze-timles follow upon operations on the arteries. Un-fortunatelv, not very muhell information is to liand oni thissubject. Thlie mere failure to be able to apply the methodcitlher from tle discovery of a defect too extensive toallow of renair, or from teclinical difficulties dependentuipon the positioln of the wound, is of little inoment sincethe exploratory operation may equally well be followedby ligation of thle vessel.The more serious question of failuire in competenicy of

the suture itself either froin primnary insufficiency of tlhestitchl or from secondary inifection is niore important.Amyioncg the cases collated by Tschieriiiachlowski no suclhaccidents are recorded, but eveni liere tihe fallacy dependingon the fact that.unsuccessful ol)erations are not freelypublished mllust be given due weiglht. Z. voni Manteuffclrecords a case in whlichi a lateral sutture applied to thefemoral artery onl thle sixtlh day lealked, and liad to besupplemented by a double ligatuLre, anid hlere one muayemphiasize tlhe fact thiat voln Manteuffel 1himself hasquestioned the suitability of recent wvounnds to primarvsuture by reason of their coutused nature. AgainSubbotich, while lhe records the fact that secondaryliaemorrliage followed none of thle 22 operations performedin the Belgrade Hospital, adds, in spealiing of arterialhiaeniatorna: " The haeniatorna mnusi be removed, thebleeding vessels dealt with, and the cavity drained aftercomplete closuire by suture of the incision wound byothier openings specially mnade for the purpose. In thesecases secondary lhaebnorrhage may occir after several daysand be very serious."

(omparative Resumlts inl 41 Cases of Liqature and 21 Citse., ofSuiturie in the Belgrade State liospital.

Ligature .. . ... 41 cases.Gangrene ... ... 6 cases, 14.6 %',Deatls ... ... ... ... 4 cases. = 9.75 %0

7(6 l1JORr GUNSHOT INJURIES OF ARTEHIES.. IEIA ORA

Oine deatlh due to softening of the brain and pneumionia afterligatulre of the carotid; 1 from secondary haemorrlhage; 1 fromsepsis; 1 from anaemia and exhaustioni.

Suiture ...e('a thsrelieDeatbs ...

.. 24 cases.

... 3 cases, 12.5 I)%... ... .......2cases, -- 8.3°'0

These figures, wlhile exhibiting nlo very striking supe-

riority for the new inctlhod in imml-lediate resuilts, at leasttljoroughly justify its employment, and this jtustificationmiiay be strengtlhened in the future if it can be shlown thatthe permanent resuilt is better in regard to the conditionof the limib. On this latter point I can only (qiote againSuibbotichl:

Oni seeilng some monitlhs later cases that have )eenl operated1up)01, we Iiild both in cases of ligationi and of suture greater orless iiiterference witlh the functions, suell as mluscular w-eak-ness, nleturasthenia, oedema, etc. OIn the other hand, we tiudsome quite ideal cases.

CONCLUSION-S.Wliat colulcisionas are we to draw froni these results?9Operations for wounds of the arteries may lhave to be

undertaken during three dlistinct periods, whliclh miiay beclassedt as primary, intermediate, and seconidary.

Primiary Haem?iorrhage.Tlle operatioln of clhoice for primary haemorlhaae from

a guinslhot wound in the field is direct ligature. In stip-port of this opinion may be advanced the comuparativesiimplicity of the operation and its applicability evenunder adverse conditions. Primary ligation slhouild beconfined to cases in 'which lhaemorrllage is obviouslycendangerinig life.The objections to the methodl of suture are twofold:

First, the local conditiolns are not favouirable ill conse-

quence of the col'tused and tattered inarginis of tlheopeninig in the artery commonly liiet -with. The ania-toinical character of tllh wotund, in fact, is unifavouirablebotlh to the safe closure of tlle wvound, and to the avoidanceof subsequent throlmibosis in consequence of the impractic-ability of ensuiring an accurate apposition of the intim-aa.One has only to consider the fact that thie comiiparativelyslight damage attendant upon the use of tootlhed forceps tofacilitate the introduction of the suiture is genierally con-sidered enough to risk subsequent obliterationi of tle vesselby tlhromiibosis, to conic to the coiiclusion that the raggedcoiitused miarginis of a gunshot wound are ill suited tosuture. Secondly, althouglh these difficulties are to beavoided in certain cases by excisioln of tlhe damnageld por-tion of tlhe vessel and circular ssuture of tlle proximiial and(listal ends, yet this unidertaking needs so muchl time,skill, and perfection in the general suirroun1dings that itcannot be regarded as a practical procedure.

In this stage there is no dcoubt that a lilne miiust bedrawn between thle wounds of civil priactice in wlhichlsuture miiay be advisable alnd the -wounds produced bybullets of small calibre.Wlhen priiimary operationis are necessary anxdthlewounded

artelrv is dealt witlh duLring tlle first tlhree dlays tlhe difficultyof evacuating the clot niiay not be great, wlhilc the pro-

cedure saves muclh time, and the general nutritioni of tilelimb suffers less than if a secondary operation is waitedfor. Furtlher, where incipient gangrene tllreatens, thelimnlib miay be rescued by elieving the collateral circulationfroim the pressure exerted by tlhe lhaemiiatolmia. The latterf.act is especially to be borne inmind in the case of popliteallhaculatolmsata (Z. vonl Manteuffel).

In ter-mi1ediatC Operat ions.It hias already been pointed out that tlle wouin(ds are

ill suited to any form of treatm-ient except the simiiplest.The evacuation of clot is difficult, thje stiff oedemiia of tlhearterial wall itself, aswell as that of the bounidaries of thecavity (Brentano), and the probability of the necessity ofproviding drainage, negative the chances of a successfulsiuture, and render the prognosis even of a siliiple directsuiture doubtful.

The1 experience of all recent campaignis h1as been tosl!ow tlhat, in the absence of secondary liaemuorrliage or

rapid extensioil of the lhaematoma, tlle general tendencyis towards contraction and localization of the extravasatedblood and to diminution in the size of tlle arterial woulld,wliile the conditions imnprove for th-eC successful applicationof treatm-ient,

Thie uLnsuitable clharacter of these inijuries at this stagefor the enmployment of proximnal ligation at the seat ofelectionl has already been dwelt upon. It is unsafe, notonly from the risk of fturtlher secondary htaclorrlhage, batalso becauise, beingc donie at a period. wheni Ithe coniiditionsfor the establislhmenit of an efficienit collateral circulationare bad, gangrene is fequeint. Tlhis lIas beeni a comiorestult in the limbs, and no miiore strliking exam-Xple couLld begivenl than that of a suirgeon in tlhe Manchurian camnpaign,who saw cerebral softening follow tlree times conisectu-tively after ligatuiring tlhe commron carotid in healthyYOUDng soldiers.

Secondary OpeCra(tiongs.These may le undertaken at an average period of about

four weels, anid practically resolve themiiselves iulto opera-tions for aneuirysm-iis of tlhree varieties.

Eaclh of tlhe five mnethods of treatmlent mzay offeradvantages uinder certain conditions whliclh mnay be shlortlystated:

(a) Si)miple Ligqat-are.-Simple proximal ligature as neartlle aneurysmal sac as practicable h1as shiown itself asatisfactory mietlhodl of treatment for traumriatic arterialaneurysms. Unnder certain circumllsstances it is likely to bestill employed, eitlher in (lealing withl simall aneuirysmls, orin situtations where direct treatment mnay noecessitate aprolongsed alnd seriouLs operation, as in the case of tliocarotid artery, especially when the conclitions nuder whlichthe op)eration hias to be performed are lot good.

(b) Proximnal anid Distal Ligature, citther of thle Arteryalone o, of both Artcrya.nd -rei7i.-Trhis method issuitable to the treatment of citlher arterial or arterio-venous aneurysms. Ligature of the artery alone isinilsuitable to arterio-venouis aneurysms or varices wiherethlere is aniy likelilhood of tlho sac being in part fed by a.collateral branch. If suelh a branclh does exist, the tlhrillof tlle varix will conitinue, anid tlhis, thouighl not a seriouisaccident, is yet unidesirable. The ad(ition of doubleligature of the vein lhas niot proved disadvantaglous.

(c) Symne's 31odlification of Antylyluts's Operation.- Theintrasaccular direct ligature of Kilikuzi. Tiri-,J imethlod isapplicable especially to large arterial hiaematomiiata, butalso to recent arterio-venous anciurysts in somne instances.The slhort length of the artery iiiclt(le(d between the liga-tures, tlhe limited amzolllit of dissection needed to exposethe vessel, and tlhe fact that in the linibs) tlhe operattionmiiay often be performed whlile tlle circutlationl is conitrolledIby an Esmarchl touirniquiet are maniifest advantages.Moreover, the (lancger of overlook1inga thle presenice of smallbranclhes feedina the saC is avoided, ancd inere evacuatioilof tlIe clot is substituted for tlle tronblesotme di.ssectionreqluired if tlhe sac is to be extirpated. This m-letlhod lhaslnuileli to recommiienid it as an operatioln in military surgery.

(d) Exztirpation of tlhe Sac with limtited Excision ofthexVessels in commnutnication wivith it.---This metliod is applic-able to the case of all aneulysnis of wllatever variety,where the occltusion of the vessel is not of appreciableimportanice to tlhe aelneral nuitritioni of tlhe limb, plracti-cally, therefore, to aniy vessels below tlhc braclial in the,upper and the popliteal in the lower extremiity. It lia,rproved itself a highlly suecessfuil procedLire elsewhere, ontit necessitates ani often prolonged and difficuLlt (issection,and offersno material advantage over the last operationi.

(e) Suturite of t(le W7otunded IVclssel, ivith or wi/heot.Extipa(ion of the Sac.- The relative advantages to beobtained by this metlhod lhave been already discussed. Ifsutccessful the result is ideal; it lhas not been shlowi t-o beattended by any accident to wlicil otlier procedures areniot liable, wlhile even if tlhronmbosis occurs andC robs theoperation of its crutcial advantage, tlhe patient isnot worseoff than if ligatuire lhad been performaed. Theoretically itsapplicability to the treatmiient of alny of tlle forlms ofanieurysmii is limited olnlyby a lesion thio situation or tIhecextent of whiclh prevents accurate ancd secuire apposition,and eveni this difficuLlty is to be overcomce by the insertionof an autoplastic graft from a neighboutrinig vein. Againi,in certain sittuation's, stlch as the neck, it obviates a ri!ik ofirrecoverable damage to the brain. Practically, liowever,the necessity of an aseptic field of operation, the existelleeof perfect operative surroundilgs. and a really hihlstandard of Iiianiipulative skill on the part of the surgeon,must at present considerably linmit its adoptioni in tlioroUtine ofnmilitary surgery.

[DEC. 20, I913-

OEC. 20, I9I3.] TYPHOID-PARATYPHOID -VACCINATION WITH- MIXED VACCINES. [ M TuE BRiTIs I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~EDC ,O2A ..5 ./

If aloptedl, tlle operative teelhniquie devised by Carrelappears to offer tlhe best echanee of success. In old-stand-ilng cases of trauinmatic arterlio-venous aneuirysms, oraneurysmal varices MIatas's arteriorrhaphy or tlle Matas-Bickllam operation mlay be adopted.A consideration of the wounds of arteries by bullets of

smiiall calibre and their treatmllent Uhowvs thlat progress inthis branecll of military surgory has taken the direction ofin-erased conservatismn and expectancy. In this it is nioexception to that observed in every other clhapter of thesubject. Non-interference in fractures lhas become alinostthe genieral rule, operations on joints h-ave decreased inn1um1iber almost to a vanishingicy point, injuLries to the nervesarc scldom the subjects of prinmary treatm-ienit, and we lhaveseen that tllose of the vessels come into the samie category.Still more striking- is tlhe expectant atitude- mainitainedby tle surgeon in the case of woniids traversing the greatbody cavities, in all of wlhiclh primary operations hiavebecome progressively fewer.

REFERENCES.IMiihsani, Centralbl. f. Chvir,., 1913, No. 28 Beilage, p. 104; 45 tholracic,

13 conitour; 22 skull, majority contour. 2Frisch, Cenlt-ralbl. f. Chir.,1913, No. 28. Beil. 107. 3Kikuzi, B *itr. z. M/in. hitr., Bd. I, p. 21.4Repori on tho Surgical Cases noted in the Souith African War, 1899-]902, 1905. 15 cuttselte Zeitsehr. f. Chir., Band 85,1906. p. 577. 6 Loc. cit.7Blentano. Arch. f k1in. Chliir. vol. lxxx. 1906, p. 395. 8Surrl. E.rp. in S.Afrita, p. 117. 9Lairct. vol. ii, 1913, p. 1248. ;°A. Kohler, Arc/. f. k/in.Chlir., Vol. 1, 1). 333, 1906. ]Beitr-ige znr M/in. Clii-., Bd. 1, 196. p. 1.12Saigo, Deuttsclc Zeitschr-. f. Chlii-., vol. 85, 1906, p. 577. 1'3AArc. f.k/in. Clii..Bd. 77, ). 590,1905. 1'Dceutschle Zeitsehr. f. Chiir-., ]3d. 123,191', p. 1 1- A)(-ch.f. k/1in. Chir-., BI. 79, p. 515. '5Von Mantenffel, Aic/if. klin. Chir., Bd. 81, p. 1.

TYPIIOID-PARATYPHOID V'ACCINATION WIThIMIXED VACCINES.

BY ALDO CASTELLANI, M.D.,DIRE1C'TOR, GOVERNMENT CLINIC FOR TROPICAL DISEASESS, COLOMBO,

CEYLON.

CC)NSIDERIN-CT the fairly frequent occurrence of para-typlhoid A and parmtyplhoid B in tropical regions, at leastin Ceylon and India, I lhave for several years advocatedtlle use of a miiixed vaccine, naamelv, typhoid + para-typlhoid A + paratyphoid B, instead of tlle usual simpletyplhoid vaccine.'My belief in the possibility of producing an efficient

mixed vaccine was based on tlle experiments f carried outin Bonn, working under Professor Kruse during 1901 and1902. I demonstrated then2 that by inoculating an animalwitlh twvo different bacteria at the same time, the bloodproduced aaglutinins and immune bodies for botlh, andltllat provided a sufficient minimmni quantity h1ad beeninoculated, tlle amount of agglutinins anid immune bodiesfor each -germ- was about thle same as in the animnalsinoculated with one germ only. I demonstrated that eveninoculating a rabbit with three different micro-organisms(B. typh7osts + B. pse2udo-dysentericuts, No. 1 (Kruse)+ strain of B. coli comm7n7n?'is), the amount of agglutininsand protective bodies elaborated for each germ was nearlytlle samue as in animals respectively inoculated with onegerm only. DuLring the course of these experinments I wasable to confirm the fact tllat when the im-imunization isobtained by a single inoculation, provided the iuiinimuimdose sufficient to obtain the maximum immlunization begiven, the amount of agglutinins and imnmune bodies elabo-rated by the inoculated animals is not in proportion to theamount of cultures injected. A series of rabbits inoculatedwvitli 2 c.cm. of typhoid cultures will give the same averageagglutination linmit and the sam-ie amount of immune bodiesas a series of rabbits inoculated witlh 4 c.cm.

Since 1905 I have experimented witlh several nmixedlvaccines in mani, of whiclh tlle principal are (1) atyplhoid + paratyphoid A + paratyphoid B vaccine, and(2) a typlioid + dysentery (Kruse - Shiga) + dysentery(Flexner) vaccine. I will limiit my rem-larkis to (1), butI may be allowed to note tllat anyone wisllin to experi-nment with mixed dysentery vaccines slhould be carefulalways to use peptone-water cuLltuires, as brotlh cultu'resof dysentery give rise to an extremely painfull infiltrationat the point of inoculation.

MIcthod of Prelr-alton of the Alixed Typ.)hoid-Paratyp7hoid Vaccaic.

Tlle miixed vaccines as prepared by me are either deadvaccines, the cultures being killed in the usual way by

heating at 53° C., or live attenuated vaccines got by lheatinigthe etltures at 50`('C., for an lhour. Duiri'ng r,ecent yearsI have used ratlher extensively botlh the dead mlixedvaccine and the live attenuated one.At first I uised to prepare the vacciine in the following

manner: Several tubes containiing 10 cernu. of brotlh eaclhwere inoculatcd witlh two loopfuls of an agar cult-ure oftyplhoid forty-eight honrs old, othier-tUTes witlh two toop-fuls of paratyplhoid B, and othlers -with. tw%o loopfuls-ofparatyphoid A. All the strains I uised -were non-Virulfntbtut rich in antigell, as slhown by animal experiments.Tlhe inoculated tubes were kept for twentv-four lhoursin the incubator at 350 C. These cultures weie thenlheated in a -water bath at 553 C. (dead vaccine)or- 50' C. (live attentuated vaccine) for an lour;tlley were thenl mixed together in certailn pro-portions in sterile Petri dishes-two tubes (20 c.cim.)of typhoid, one tube (10 c.cm.) of paratyphoid B, and onetube (10 c.cn.n) of paratyplioid A. The mixed vaccine con-sistecl, tlleni, of two parts typhoid, one part paratvplhoid A,ancd one part paratvplhoid B. I used to givo- 10 niinims oftlhe mixed vaccine at thle first inoculation, and 20 or moreat tlhe second and 1lh1rd. At the present time the vaccineis stanidardized by conlting the germs before mixing. Thiem-iixed vaccine I use at the present timiie contains per cubiccentimetre 500 mriillion typhoid, 250 nmillion paratyplhoid B,and 250 miiillion- paratyplhoid A, and is prepared either frombroth cultures or emulsions in physiological salt solution.A little lysol (0.2 per cent.) is added.

Dose and1ethod of Vaccination.As already stated, the mixed vaccine I now uise-eitlher

thle dead one obtained by heating cultures at 530 C. or. theattenuated live one prepared by heating cultures at 50 '.for anl lhour-contains per cuibic centimetre 500 miilliontyphoid, 250 million paratyphioid A, alnd 250 million para-typlhoid B. I give 0.6 c.cm. the first timie, and double tlhodose a week later, and, whenever possible, a third dosetwo weeks from the first. In some cases, however,.1 giveonly T c.cm. tlle first time, and 1 c.cmn. the second. Verytllin, delicate individuals and young women receive a littleless. Clhildren between 8 anid 15 get a quartcr to half tleadult dose. The inoculation of the miiixed vaccille isfollowed by a local and general reaction which, as a rule,is not distinctly severer than after- the inoculation ofsimple typlhoid vaccine. Three or four hlours after inocula-tion the region on tlle arlm where thle injection has beenmade becomes painful and red, and fever may supervene,,which does not last longer, as a rule, than twenty.four tothirty-six hours, and does not in most eases incapacitateone for workI.As I do not believe that the immunization given by

bacterial inoculation lasts in man very long, I generallyadvise people to be vaccinated once every-two years, oreven once a year.

Inn7o0culity of the Mixed Typhtoid-Paratyp7hoidVaccine.

Thle miiixed vaccine, either the dead one or the attenuiatedlive oIne, is innoctious, as proved by several thousandinoculations done to date in Ceylon. Professor Browning,the Director of the Ceylon Government Clhemical Institute,lhas to date received 35 inoculations of mixed live vaccineat one or two weeks' intervals, in addition to 29 inocula-tions of simple typhoid live vaccine. He lhas alwaysremained in very good health.

Rec1t,iks on the Lninnanization, Obtained in Man, by theMixed- Vaccine.

Lack of time prevented my studying the aml-ount of allprotective substances produced in inoculated individuals;tlle investigation, therefore, has been limiited to studyingcomparatively the amou'nt of agglutinins produced in somcindivwnuals inoculated witlh mixed and simple vaccines.Tw natives, D. and F., were inoculated with miixed (dead)vaccine, 0.6 c.cm. the first time; 1.2 c.cm. after a week.One native, P., was inoculated with simple typhoid vaccine(dead), 0.6 c.cm. the first time; 1.2 c.cm. after a week.One native, S., was inoculated with simple paratvplioid Av+accine (dead , 0.6 c.cm. the first time;* 1.2 cer. after a veek.Onle nativ-e, A., was inloculated Withl simple paraty-phoidl Bvaccine (dead), 0.6 c.cm. the first time;* 1.2 c.cm:. after a wveek.T:wo nlatives, A. E. de St. and D. G., were inoculated withs0.6 ceni.-mixed tire (attenulated) vaccinle, anld with 1.2 C.CIl.after a w-eek.