Surgical Experiences in South Africa, 1899-1900 / Being Mainly a Clinical Study of the Nature and Effects of Injuries Produced by Bullets of Small Calibre

by George Henry Makins

Prognosis and treatment.—No one can help being struck with the disinclination shown by the older surgeons to interference in cases of either aneurismal varix or varicose aneurism, even after the time that ligation of the vessels had become a favourite and successful operation. The objections lay in the technical difficulties of local treatment, and the danger of gangrene after proximal ligature. Modern surgery has lightened the difficulties under which our predecessors approached these operations, but none the less the experience in this campaign fully supports the objections to indiscriminate and ill-timed surgical interference, as accidents have followed both direct local and proximal ligature.

In pure varix no doubt can exist as to the advisability of non-interference in the early stage, in the absence of symptoms. This is the more evident when we bear in mind that a stage in which an aneurismal sac exists can seldom be absent. In many cases an expectant attitude may lead to the conviction that no interference is necessary, especially in certain situations where the danger of gangrene has been fully demonstrated. In connection with this subject I cannot help recalling the first case of femoral varix that ever came under my own observation. I discovered the condition accidentally in a man admitted into the hospital for other reasons. The patient remarked: 'For heaven's sake, sir, do not say anything about that. I have had it many years, and it has never given any trouble. If it is known, I shall be worried to death by people examining it.'

None the less it must be borne in mind that beyond enlargement of the vein dilatation of the artery above the seat of obstruction does occur, and gives trouble in some situations. Again the disturbance of the general circulation already adverted to shows that the existence of this condition is sometimes of importance in its influence on the cardiac action.

Under these circumstances the treatment varies with regard to the vessels affected, and the degree of disturbance the condition gives rise to.

With regard to locality, experience appears to have shown clearly that communications between the carotid arteries and jugular veins usually give rise to so little serious trouble that, in view of the grave nature of the operation and its possible after consequences on the brain, interference is as a rule better avoided. I should, however, be inclined to draw a distinction between operations on the common and internal carotid arteries in this particular, and should regard varix of the latter vessel and the internal jugular vein as especially undesirable for interference.

The vessels at the root of the neck are probably to be regarded from the same point of view, as to surgical interference.

The arteries of the upper extremity are the most suitable for operation, and the axillary may perhaps be the vessel in which interference is most likely to be useful. In this relation it may be of interest to include here a case of a man who took part in the campaign when already the subject of an aneurismal varix of the axillary artery.

(20) Twenty years previously the patient suffered a punctured wound of the left axilla from a pencil. A varix developed, but was only discovered by accident ten years later. The patient was seen by several surgeons, and treatment was discussed; the balance of opinion was, however, in favour of non-interference, and nothing was done beyond giving injunctions as to care in the use of the limb. Up to the time of discovery of the varix no inconvenience had been felt, although the patient was of athletic habits. Subsequently, the patient himself was positive that a swelling existed, but he pursued his usual work. In 1899-1900 he took part in the operations in South Africa as a combatant, and during this time was subjected to very hard manual work. During this he was seized with sudden pain in the left side of the head and neck, and in consequence invalided. No restriction in the movements of the upper extremity, and no subcutaneous ecchymosis developed, but the patient was positive as to the tumour having greatly enlarged.

Four months later the condition was little altered. A pulsating swelling 1½ inch broad existed along the line of the upper two-thirds of the axillary artery, and along the subclavian in the neck, rising some 1½ inch into the posterior triangle. Pulsation was visible; the murmur was audible when sitting beside the patient, and widely distributed over the whole chest, the neck, and upper extremity on auscultation. The pulse rate varied with the mental condition of the patient, which was excitable, between 96 and 120. There was neuralgic pain in the neck and scalp, and down the distribution of the brachial plexus. The pupils were equal, but flushing of the face and profuse sweating followed any exertion. I concluded the tumour in this case to be mainly due to dilatation of the trunk above the point of obstruction on account of its outline, the absence of any restriction of movement in the upper extremity, and the non-occurrence of subcutaneous ecchymosis at the time of the attack of severe pain. Difficulties arose as to undertaking any active form of treatment for this patient, which, to be satisfactory, needed an antecedent period of absolute rest, and he passed from my observation. I think, however, operation by ligature above and below the communication would have been possible. The case affords a good example of the course the condition may sometimes take if precaution is neglected.

The vessels of the arm or forearm may in almost all cases be interfered with, but in many instances an absence of any serious symptom renders operation unnecessary.