It now appears that, at any rate, the root of the right carotid is the artery implicated.
In spite of the continued existence of a large aneurism, the localisation of the sac, which had taken place, was very striking, considering that the man had been walking about freely, and living an ordinary life, except that he had undertaken no work.
(15) Popliteal arterio-venous aneurism.—Wounded at Paardeberg. Entry (Mauser), at lower margin of patella. Exit, at centre of back of thigh. Perforation of lower end of femur. The patient was lying down with crossed knees when the injury was received. Much œdema of the foot and leg followed the injury, and on the third day a thrill was discovered. Three weeks later there was still some swelling of the calf, the posterior tibial pulse was imperceptible, the anterior very small. An aneurism was palpable at the inner part of the top of the popliteal space, about the size of a pigeon's egg; a strong thrill was to be felt, especially when the knee was flexed, and with this expansile pulsation and a loud machinery murmur. The entry wound was firmly healed; the exit still furnished blood-stained serous discharge. The synovial cavity of the knee was distended and doughy on palpation. During the next three weeks the aneurism contracted considerably and the patient was sent home.
When admitted to the Herbert Hospital the patient complained chiefly of pains in the foot and leg. The aneurism was cured by ligation of the vein above and below the communication and proximal ligature of the popliteal artery.[15]
(16) 'Femoral arterio-venous aneurism.—A private of the West Yorkshire Regiment was hit on February 11, 1900, at Monte Christo by a bullet which passed through the inner border of his right thigh above its middle. On arrival at Woolwich the patient was found to have a varicose aneurism at the upper end of Hunter's canal. On May 31 the femoral artery was ligatured just above its communication with the vein, and as this stopped all pulsation in the vein, it was decided to postpone ligature of the latter to a subsequent occasion, if it should ever be necessary; such a procedure would, it was thought, interfere less with the circulation of the limb, and would therefore be less likely to be followed by gangrene, which is so frequent a result of high ligature of the femoral. But a few days after the operation the foot became cold and mummified, and there was no alternative but to amputate the limb through the condyles of the femur. From this operation the patient made a good recovery, and when discharged there was no sign of an aneurism of the vein.'
Case 16 is quoted from a paper in the Lancet by Lieut.-Colonel Lewtas, I.M.S. It illustrates a result with which I became acquainted in three other instances not under my own observation.
Aneurismal Varices
(17) Axillary.—Wounded at Modder River. Entry (Mauser), at inner margin of front of left arm, just below level of junction of axillary fold. Exit, at about centre of hollow of axilla. A month later when the wound was healed a typical thrill and machinery murmur were noticed. The latter was audible down to the elbow and upwards into the neck. The radial pulse appeared normal. No swelling or pulsation existed. At the end of three months the condition was unaltered; the patient said he noticed nothing abnormal in his arm, except that it was sometimes 'sort of numb' at night.
(18) Popliteal.—Wounded at Magersfontein. Entry (Mauser), in centre of popliteal space. Exit, about centre of patella, which latter was cleanly perforated. Three weeks later the typical thickening of the knee-joint following hæmarthrosis was present, also a well-marked thrill and machinery murmur in the popliteal vessels with no evidence of a tumour. The leg was normal except for slight enlargement of the internal saphenous vein and its branches, probably independent of the arterial lesion.
(19) Femoral.—Wounded at Magersfontein. Entry (Mauser), 7 inches below left anterior superior iliac spine. Exit, at inner aspect of thigh. One month later slight fulness without pulsation was discovered on the inner side of the femoral vessels just above the level of the wound track. Some blood-staining still remained in the fold between the scrotum and thigh. Machinery murmur and a well-marked thrill, most palpable to the inner side of the superficial femoral artery, were noted. No further symptoms developed and the patient was sent home.