Surgical Experiences in South Africa, 1899-1900 Part 10

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 cla.s.s 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 sh.e.l.l. The symptoms in nearly all cases were the cla.s.sical ones of repeated small haemorrhages followed by a sudden copious gush.

The forms of secondary haemorrhage, however, which afforded most interest were the interst.i.tial 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 interst.i.tial 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 alb.u.mose. A p.r.o.nounced ill.u.s.tration 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 interst.i.tial 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 p.r.o.nounced form as a result of haemorrhage into operation wounds.

In primary interst.i.tial haemorrhages a similar continued rise of temperature was also common, and I cannot perhaps better ill.u.s.trate 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.

[Ill.u.s.tration: TEMPERATURE CHART 1.--Axillary Haematoma. Shows range of temperature during process of absorption and consolidation without suppuration]

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 b.u.t.tock, 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. 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 circ.u.mstances it may be said that the cla.s.sical 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 circ.u.mstances under which many operations in military surgery are performed.

On the whole, it seems clear that the military surgeon must be guided by circ.u.mstances, 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 att.i.tude 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 interst.i.tial 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 interst.i.tial 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 interst.i.tial haemorrhage, which might or might not have been a.s.sociated 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 pa.s.sed 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 ma.s.s 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 quant.i.ty 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 s.p.a.ce. 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 s.p.a.ce. 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 ca.n.a.l, 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 ill.u.s.trate 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 p.r.o.nounced expansile pulsation. The development of this form of aneurism was probably influenced by several circ.u.mstances, 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 ill.u.s.trating 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 s.p.a.ce 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 ill.u.s.tration 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.