CHAPTER XXIX

.

SURGICAL DISEASES OF THE HEART AND VASCULAR SYSTEM.

A generation ago a chapter on the surgery of the heart would have been regarded as a surgical fantasy. Today the subject is not only a live one, but experience is constantly accumulating as to the value of surgical intervention in diseases of the heart and pericardium.

MALPOSITIONS OF THE HEART.

The heart may be displaced by congenital or acquired causes. Malpositions of the former type may vary from _dextrocardia_, where the heart is placed upon the right side, and may be accompanied by a general or partial transposition of the viscera, to those cases where there are defects in the diaphragm or the chest wall, through which the heart protrudes. Dextrocardia has an interest for the surgeon, as, for example, in the following case under the writer’s observation: Disease on the left side which simulated appendicitis, in which the diagnosis was confirmed by finding the heart upon the right side, and later by operation. It was a case of complete transposition.

The acquired malpositions may be due to intrinsic or extrinsic causes. They are pressure effects, usually found in connection with intrathoracic aneurysms and other tumors or collections of fluid, or may be due to change in the shape of the spine in pronounced curvatures. Occasionally the heart is hindered in its action by pressure from beneath the diaphragm. These cardiac displacements are surgically interesting when the cause can be removed by operative measures.

WOUNDS OF THE HEART.

Wounds of the heart are mainly of the punctured or gunshot type. It was formerly considered that injuries of the heart were essentially fatal. This has been disproved by human and comparative observations. As far back as 1855, Carnochan reported a case of gunshot wound of the heart where the bullet was found in the heart substance after the patient had lived eleven days. The museums contain many illustrations of penetrating wounds of the heart or of foreign bodies in it, some of which had remained embedded for many years. Nevertheless the fact remains that the majority of wounds of the heart are fatal, either by arrest of its activity, by shock, by the outpour of blood between it and the pericardium or outside the latter, or later by processes which consume at least a few days, either infective or degenerative. Other things being equal the larger the wound the more dangerous, while an injury to the heart muscle which has not opened one of its cavities is less dangerous than one which perforates them. A punctured wound made by a small stiletto or knife-blade, or even by a needle used for homicidal purposes, may leave but small trace and not prove fatal, save through injury to one of the cardiac vessels, especially a coronary artery.[23]

[23] Illustrating the surgery of foreign bodies in the heart, Jordan has reported the case of a young woman who stated that she had received a blow on the front of the chest the previous day, and showed on examination a small projecting point in the lower part of the third left intercostal space about half an inch from the sternum, which was tender to the touch and seemed to move or pulsate with the heart. It gave to the finger the sensation of a hard substance beneath the skin without any external marking. Upon making an incision and dissecting partly through the muscle the broken end of a black steel pin came into view. After removal with forceps it proved to be a shawl pin, one and one half inches long, with its glass head broken off. The patient remembered having had such a pin in her bosom at the time of the accident. On the following day she had pericarditis. She apparently recovered, but had a relapse, and died on the twenty-fourth day, the autopsy showing pericarditis.

In practically all of these injuries there will be evidence of some external violence. It is of advantage to ascertain the nature of the accident and the character of the missile or instrument. If the depth of penetration of a knife-blade, for instance, can be ascertained more accurate conclusions can be drawn. The special indications of cardiac injury pertain to disturbance of its own function, that is, embarrassment and uncertainty of action, bellows sounds, enlarged area of dulness owing to distention of the pericardium with blood, dyspnea, and distress, and sometimes pain and syncope. These symptoms and signs do not appear instantaneously, but increase in severity.

=Treatment.=--In such an emergency everything possible should be done to relieve the embarrassment of the heart’s action--the head should be kept low, the body absolutely quiet, and nervous excitement should be allayed at once with a full dose of morphine. Heart stimulants should not be given. Ice applied over the chest will help quiet cardiac activity. If the patient be not failing too rapidly operation is advisable, and should be done in a well-equipped hospital, with trained assistants. The purpose of the operation is to expose the injured portion of the heart substance and close it with suture; at least to remove the fluid or partially coagulated blood within the pericardium.[24] As it is not always possible to expose the heart without opening the pleural cavity, there should be at hand not only the means for a tracheotomy, but an apparatus by which artificial inflation of at least one lung can be effected. _Pneumatic cabinets_ have been devised for this purpose, especially by Sauerbruch, where a difference of pressure can be maintained between the outside and the inside of the cabinet, so that the chest may be widely opened and the lung not collapsed; but such a cabinet is available in few places in the United States. The improved Fell apparatus, by which a mask is kept over the face and pressure maintained with the foot through a bellows, has been found useful. Even in the absence of such apparatus the surgeon should not abstain from the effort, though it may appear less promising.

[24] _Suture of Heart Wounds._--Stewart has tabulated 60 cases of suture of the heart reported up to May, 1904, with a remarkably high recovery rate of 38 per cent. (Amer. Jour. Med. Sci., October, 1904). Of the 60 cases 55 were stab wounds and 5 were gunshot wounds, 2 of the latter recovering. In 4 of the cases the coronary artery was injured, and only 1 of these recovered. The injury occurred through a puncture while suturing the heart, and an extra suture was necessary in order to control it. Of the 60 cases the left ventricle was wounded thirty times, with 30 recoveries. The right ventricle was wounded 21 times, with 7 recoveries. The operation has only been practised for about ten years. The results reported certainly justify its performance in all cases of this kind.

In the operative procedure one may feel inclined to utilize the already existing wound, either as a part of his incision or for exploratory purposes, or he may decide to disregard it. The operation consists in raising an osteoplastic flap on the chest wall, by which the pericardium and then the heart are exposed. The incision through the skin is extended to the bone and only enough of the soft structures separated from the ribs and cartilages to expose them sufficiently for division. Ordinarily it would be preferable to divide the third, fourth, and fifth costal cartilages at their rib terminations, and then to turn up the flap with its base at the sternum, though the procedure can be reversed to almost as good advantage. The cartilages and the ribs may be divided with the costotome and the rest of the structures with stout scissors. The flap, having been gently elevated at the edge, is separated from the underlying cellular tissue and pericardium until its sternal margin has been reached. When detached it may be sprung upward, and thus a complete window is made in the chest wall. When more room is desired bone and cartilage may be cut away with a rongeur.

[Illustration: FIG. 136

Result after thoracotomy for heart wound. (E. J. Meyer.)]

The pericardium being thus exposed may be found much distended or altered by the imbibition of blood. It should be opened to an extent sufficient to permit evacuation of its bloody contents and sufficient exposure of the heart to permit not merely inspection but suture of any wound in the heart substance. This is exceedingly difficult on account of motions of the heart, and the insertion of sutures will be as difficult as trying to hit a flying target. Nevertheless it may be done in many cases. Unless imperative, a coronary artery should not be included in the heart suture. Hemorrhage from the heart being checked the pericardium is then to be united, preferably with hardened catgut sutures, with or without drainage. In most instances the former is the better plan, and the drain may be of the cigarette type, that is, gauze wrapped in oiled silk.

Should it be found that the pericardium alone is injured and not the heart the case may be regarded in a more favorable light.

There are sufficient cases on record where procedures analogous to the above have been practised to justify the attempt in every case. Hardened animal sutures may be used in the heart substance, and the interrupted method will probably prove the better. A suture which will hold firmly for three or four days will suffice, as has been proved on animals.

RUPTURE OF THE HEART.

Rupture of the heart can scarcely be considered a surgical condition, though it has frequently been one of medicolegal interest. It may, however, afford a sudden and unexpected termination to surgical cases. The cardiac muscle may be so softened by the poisons of diphtheria and other acute infections as to be greatly weakened, even though an intubation or tracheotomy has apparently afforded security.

TUMORS OF THE HEART.

Primary malignant tumors of the heart are very rare. Secondary and metastatic manifestation are much more frequent. True primary sarcoma has been repeatedly observed, and, with the exception of endothelioma, is practically the only primary cancer that could appear in this location. Carcinoma is found only as a secondary deposit, with which, however, the heart may become so involved as to permit of terminal rupture.

THE PERICARDIUM.

This closed sac is interesting to the surgeon in cases where it becomes filled with air; with blood, as the result of injury (see above); with fluid, as in acute pericarditis, or with pus, as a later stage of the latter, with its consequent _pyopericardium_. With the introduction of the aspirating needle it is possible to draw off collections of serum or pus, and _paracentesis of the pericardium_ is now a conventional minor operation. It is managed in the same way and with the same instruments as when the pleural cavity is involved. It is ordinarily safe, and affords much relief.

The surgeon may go even farther than this and practise _cardicentesis_, as the writer did once by accident while hospital interne. After introducing the needle and withdrawing three or four ounces of pus he discovered that he had given great relief, which, however, was only temporary. The autopsy two days later revealed that he had passed the needle point through the pericardial sac into the heart wall and had tapped the abscess therein. This was in 1877, and was probably the first time that the heart wall was ever thus entered.

Now the operator goes still farther than this and practises intentional cardicentesis in cases of engorgement of the right side of the heart connected with lung disease which is threatening death from dyspnea with an overstrained heart. In such cases the needle may be introduced just above the fourth rib, from one-half to one inch to the right of the sternum, or entrance can be effected just above the fifth rib in an upward direction. From 100 to 250 Cc. of blood may be withdrawn.

For ordinary tapping of the pericardium the needle is inserted two inches to the left of the median line and in the fourth or fifth left interspaces, pushing it carefully until resistance is no longer felt and fluid flows through the tube. For either of these purposes the patient should be recumbent, unless the distress in this position is too great, in order that the heart may fall away from the chest wall. Aspiration can be repeated in case it gives relief. Little or no harm seems to ensue from the wound which a needle-point will make upon the heart substance. As the sac is progressively emptied the needle-point should be gradually withdrawn. When aspiration, exploratory or therapeutic, reveals the presence of pus, the well-known rule will apply, _i. e._, that pus left to itself will do more harm than will the surgeon’s knife. For pyopericardium there is but one successful treatment when aspiration fails, and that is open incision and drainage. This is not so severe a measure as exposure of the heart, as it may not even require the removal of one costal cartilage, although it would probably be better to take out at least one, since the shape of the pericardial cavity will change to such an extent after it is emptied as to raise the opening to a higher level than is given it at first. Open incision, then, with drainage, in these cases is no longer an experiment but a life-saving procedure. It will prove successful in at least half of the cases, which otherwise would certainly perish without it.

PNEUMOPERICARDIUM.

Pneumopericardium implies the presence of air in the pericardial sac, a condition of which there are now about 40 cases on record. The air nearly always enters through an ulcerative perforation from adjoining parts or through a wound, yet in 5 of these cases no opening could be found. In these it was probably due to the presence of a gas-forming bacillus, such as may also cause pneumothorax under certain circumstances. The perforation was in the esophageal wall in 7 cases, in 4 cases it was the result of softening of a lymph node, while in other instances it has followed abscess of the left lobe of the liver, pleuropneumonia and gastric ulcer perforating through the diaphragm. Of the 8 cases of penetrating wound from without, I included the small puncture made by paracentesis, while in 7 cases there had been fracture of the ribs or the sternum, with wound or laceration of the lung or the pericardium.

The most characteristic sign is a splashing, gurgling sound, synchronous with the heart beats, such as the French have called the “water-wheel bruit.” These sounds are louder than in hydropneumothorax, and are heard distinctly over the heart. The area of precordial dulness will change with position.

In unmistakable cases operation is indicated, the trap-door exposure being the best, the inner end of the fifth and sixth ribs being elevated. Irrigation and drainage will be necessary. It is encouraging to know that 11 of the 40 cases above mentioned have recovered.

CARDIOLYSIS.

Cardiolysis refers to the operative release of the heart from adhesions which have formed between it and the pericardium or the chest wall. When with every contraction the heart itself is subjected to the strain of an adhesion the work proves excessive and it will finally succumb. It has been suggested by Delorme, Peterson, and Simon to either temporarily resect the chest wall, open the pericardium and break down or divide the adhesions, or else to resect those bony portions of the chest wall, _i. e._, the sternum, cartilages, or ribs, which are so inflexible as not to yield, not removing the bands but making them harmless.[25]

[25] Those interested in the modern surgery of the heart and lungs should consult Rickett’s recent work on this subject.

THE ARTERIES.

There are few parts of the body which adhere more closely to the normal standard than do the larger arteries. Even here malformations and congenital defects are met with. In calculating the chances of a given procedure the surgeon should consider the condition of the venous and lymphatic systems before deciding to operate on a portion of the arterial system. This is particularly true when ligating the femoral artery for elephantiasis of the leg.

Thrombosis and embolism have already been considered in the chapter on the Blood. Nevertheless it may be well to remind the student at this point that thrombus means a blood clot, while thrombosis refers to the process of its formation; that embolus means something which has passed into the blood current of an artery and plugged it, the obstruction usually being a fragment of clot or tissue, though it may be a droplet of fat or a bubble of air. Emboli, like thrombi, may be sterile, and in this respect innocent, or it may be composed of material loaded with septic, tuberculous, or cancerous germs.

[Illustration: FIG. 137

Anastomosing circulation in sartorius and pectineus of dog, three months after ligature of femoral. (After Porta.)]

[Illustration: FIG. 138

Collateral venous circulation, from a woman aged forty-seven, under the care of W. W. Gull, in whom the inferior vena cava was completely obstructed from cancer. (Guy’s Hosp. Mus., Drawing 44⁴⁰.)]

[Illustration: FIG. 139

Direct anastomosing vessels of right carotid of goat, five months after ligature. (After Porta.)]

The readiness with which vessels, both arteries and veins, lend themselves to the exigencies of extra work has long been recognized, and the natural provision for collateral circulation is one of which surgeons have for centuries availed themselves. On the contrary, vessels which are no longer needed or whose function is lost will undergo atrophy almost to obliteration; thus after amputation of the thigh the corresponding iliac vessels become much reduced in size (Figs. 137, 138 and 139).

ARTERITIS; ENDARTERITIS.

That arterial walls are resistant is shown by the fact that they are usually the last tissues to yield to gangrene. Whether a primary acute arteritis often occurs is a question of less interest in this place than the fact that even arterial walls will succumb to infection and that secondary hemorrhages from ulcerative processes are by no means rare. The pathological processes which occur in the various structures of the heart are repeated in the arterial walls; thus there may be a _periarteritis_ corresponding to pericarditis, a _mesarteritis_ which in many ways resembles myocarditis, and an _endarteritis_ which corresponds more or less closely to endocarditis, and all of these in their acute or chronic forms. The acute forms which concern the surgeon are due usually to the presence of infected emboli, which have the same effect upon the arterial walls that infected thrombi have upon the venous walls, _i. e._, they lead to occlusion, infiltration, and suppuration.

Of the more chronic types those produced by syphilis are the most common. Here it is usually the outer and inner coats which suffer most. Tuberculous infection of an artery is of frequent occurrence and pertains only to those vessels which are in intimate relation with previous tuberculous lesions, while the syphilitic forms are diffuse and generalized and as likely to involve one part of the body as another. It is well known that arteritis in various degrees of intensity may be met with in most of the infectious diseases. Whether they are due to the living germs or to toxins generated during the process concerns us at this point but little. It is of importance, however, to realize that vessels so compromised may thus receive their first impetus to degeneration and subsequently form aneurysm. The degenerative types of greatest interest to the surgeon are _fatty degeneration_, which occurs in the interior rather than the exterior, and _calcification_, which is rather an involvement of peripheral vessels and which occurs mainly in the middle and the outer coats. The latter may be limited or may involve an entire vessel. When the radial arteries are involved the condition may be appreciated at the wrist. Calcification frequently follows other degenerations, especially fatty, of the intima, and then may be seen in the interior of an artery. A true ossification has been described, but is exceedingly rare.

ARTERIOSCLEROSIS.

Arteriosclerosis is a term generally applied to a combination of these degenerations, with thickening and diminution of caliber. The changes combined are comprehended in the term _atheroma_, which is seen as a localized lesion in nodules or plaques in the aorta and larger vessels and in diffuse form in the smaller. Atheroma, as a complex degeneration, constitutes an interesting study, as it leads to well-marked changes in the vessel walls, which are softened at points by fatty changes, the little mass of debris resulting being called an _atheromatous abscess_ (an unfortunate name), which may empty into the vessel, leaving a small cavity and opening known as the _atheromatous ulcer_. Around this occur usually the calcific changes above described. The disturbance and the roughening thus produced lead to the formation of fibrinous thrombi, which attach themselves firmly at these points. When to such a weakening of the vessel wall as is thus produced are added the elements of compensatory cardiac hypertrophy, and the sudden changes of blood pressure produced by certain occupations and alcoholic and other excesses, it will be seen how atheromatous patches constitute points of least resistance, where blood pressure may cause a vessel wall at least to bulge and thus to afford the beginnings of an aneurysm; while, by combination of various processes, final rupture may result.

The conditions are not so very different in the more diffuse forms, especially in patients who have not only a tendency to vascular disease but to increase it by the added toxemias of gout and syphilis, of various excesses and bad habits, in which not only do arterial coats suffer, but the heart muscle and lining as well. The relations then of systematic toxemias to arterial disease and finally to surgical conditions are not so circuitous as may at first appear.

ANEURYSM.

_An aneurysm is a tumor communicating with an artery and containing circulating or coagulated blood, or both._ It may be formed entirely from the wall of the vessel, or some portion of it may be formed by surrounding tissue. Several varieties of aneurysm are indicated by descriptive adjectives. They are divided, first, into _true_ and _false_, the former being composed of all the vascular coats and being small and infrequent; the false aneurysms imply those in which the entire arterial wall does not participate. Aneurysms inside the body cavities are called internal, and those involving the limbs external. The terms _spontaneous_ and _traumatic_ apply here as elsewhere. _Fusiform_ aneurysm implies a spindle-like dilatation of the vessel in somewhat regular form. The _sacculated_ aneurysm is essentially a pouch protruding from one side of the vessel with which it communicates. When the sac ruptures the aneurysm becomes _diffuse_. If the outer coat gives way and the inner protrudes there is a _hernial_ aneurysm. The _dissecting_ aneurysm is one formed by separation between the arterial coats, so that blood coagulates or flows between them. Such an aneurysm tends to assume a sacculate form and to rupture. A _varicose_ aneurysm is a sac through which an artery and adjoining vein communicate. A _cirsoid_ aneurysm corresponds to a varix on the venous side of the circulation, and implies dilatation of an artery and its branches. (See Figs. 140 to 145.)

[Illustration: FIG. 140

True aneurysm; the sac formed by all the coats. (Holmes.)]

[Illustration: FIG. 141

False aneurysm; the sac formed by the outer coat only. (Holmes.)]

[Illustration: FIG. 142

Traumatic aneurysm; the sac formed by the tissues around the vessel. (Holmes.)]

[Illustration: FIG. 143

Dissecting aneurysm. (Holmes.)]

[Illustration: FIG. 144

Hernial aneurysm; the sac formed by the inner coat only. (Holmes.)]

[Illustration: FIG. 145

Sacculated aneurysm of ascending aorta. Death by pressure. (Erichsen.)]

The formation of an aneurysm implies _previous disease_ of the bloodvessel _or traumatism_, by either of which its coats must have been weakened or divided. The previous disease which leads to this change is either of syphilitic or other toxic origin, and usually of the type of the endarteritis already alluded to, or its continuation into atheroma. A so-called atheromatous ulcer may lead to giving way of the intima and the passage of blood between the coats of the vessel. It is in this way that most dissecting aneurysms are formed. On the other hand, violent strain may stretch the vessels already weakened by increasing blood pressure, or those conditions which induce abnormally high blood pressure may produce it by slow processes. Lastly a vessel may be partly divided, as by a bullet or stab wound, or its adjoining supports may have been weakened by disease or by accident to such an extent that it constitutes a weakening of the arterial wall. The result of this will be expansion in the direction of least resistance and the formation of a _sacculated_ aneurysm.

As a morbid condition spontaneous aneurysm seems to be less frequent now than in the past. Certain features pertain to all cases, the most essential being a pulsating tumor, giving physical signs of its presence by pressure, which causes pain, sometimes paralysis, and nearly always absorption of surrounding tissues as the tumor expands. _Pulsation_ is characteristic and pathognomonic of aneurysm, but an aneurysmal sac may have become so filled with clots as to minimize the prominence of this symptom. The same is true of the _aneurysmal bruit_ or murmur which is heard on auscultation. This sound and pulsation, especially of the _expansile_ type, when present will rarely deceive. They may, however, be simulated by a solid tumor which overlies a large vessel and transmits its pulsation or even some of its murmur. Even in this case the significant expansile character of the pulsation will be lacking.

The _progress_ of an aneurysm may be checked by spontaneous or surgical processes, but no vessel involved in this way can return to its previous condition. As the vessel expands the tendency is to fortification of its weakened walls by coagulation of the blood around the periphery of the sac. This process may be a continuous one or may occur at intervals in such a way as to produce laminated coats of blood clot, complete or incomplete, which in certain specimens can be peeled off, one after another, much as an onion can be peeled, the innermost portion representing the most recent coagulum. In this way an aneurysm is strengthened and thickened, and rupture postponed for an indefinite period. On the other hand, as the aneurysmal tumor grows slowly but steadily it tends to make way for itself at the expense of every other tissue in the body. The hardest bone will disappear before the constant advance of such a growth, and this permits aneurysms which have had their origin in the thorax to develop into large extrathoracic tumors whose walls, lacking resistance, become thinner and finally give way, death from hemorrhage being the result. In fact, _rupture is the natural tendency_ of such lesion, the question being whether it may be averted by spontaneous or non-operative methods, or whether it should be subjected to operation (Fig. 146).

[Illustration: FIG. 146

Thoracic (aortic) aneurysm. Death from external rupture.]

Aneurysms may be minute and multiple, or single and large. The former are seen in the brain in connection with syphilis, and in the mesentery (Fig. 147). No artery in the body is necessarily exempt, though obviously the larger arterial trunks are the more frequent sufferers.

Spontaneous cure by natural methods is brought about in one of the following ways: (_a_) By consolidation of laminated clots. (_b_) A portion of the clot may become detached and plug the vessel on the distal side, effecting the same occlusion there that is produced with a ligature; in some cases the vessel may be occluded above the sac by a clot from the heart. (_c_) That which occurs naturally may be caused by accident as the result of some trifling injury. (_d_) The clot contained within the sac may have become infected, so that suppuration with necrosis of the sac contents is produced. In connection with this there is sufficient acute arteritis to occlude the vessel, and the resulting abscess within the sac may be opened and its contents cleared out. This method is extremely rare and can only terminate happily when the surgeon intervenes promptly.

In an aneurysm in which spontaneous cure has occurred there may be progressive condensation of its contents, obliteration and partial reduction in size, and a slow process of absorption.

The importance of collateral circulation, in recovery from aneurysm, cannot be overestimated, as only by taking advantage of it is it possible to furnish blood for the needs of the part affected. There is no vessel with which the surgeon can interfere where natural provisions in this direction appear insufficient (Fig. 148).

Certain conditions predispose to aneurysm of the idiopathic type, such as age, with its accompaniment of arteriosclerosis; _syphilis_, with its well-known tendency to chronic endarteritis; _occupation_ and _sex_, in that it is most frequent in those who are liable to violent exertion and dissipation, because of the well-known tendency to arterial structural changes after excesses of all kinds. Again, aneurysm may be the secondary result of embolism when an embolus leads to a local arteritis with disorganization.

[Illustration: FIG. 147

Multiple aneurysms of the mesenteric arteries. (Eppinger.)]

[Illustration: FIG. 148

Change in the trunk after ligature; with anastomosing vessel. (Erichsen.)]

=Classification.=--For surgical purposes there is no better classification than the one used by Eve:

1. _Sacculated aneurysm._ (_a_) Hernial; (_b_) Diffuse, being a form of false aneurysm.

2. _Fusiform, cylindrical, or tubular aneurysm._

3. _Dissecting aneurysm, which may become_ (_a_) Sacculated; (_b_) Diffuse and false; or (_c_) Circumscribed.

4. _Traumatic aneurysm._ (_a_) Circumscribed; (_b_) Diffuse; (_c_) Arteriovenous.

5. _Arterial varix, cirsoid or racemose aneurysm._

6. _Angioma or aneurysm by anastomosis._

1. =Sacculated Aneurysms.=--The sacculated are the most common. They assume various shapes and dimensions, and may be seen anywhere in the body. The opening between the sac and the main vessel may vary in size. These sacs are usually strengthened by plastic exudate in and around them, and condensation of surrounding tissue. In thickness they vary from 1 Cm. to the thinnest which will sustain blood pressure. In old scars may be found a stratiform or layer-like arrangement, especially where the blood stream is less active. Should spontaneous cure take place the sac may be obliterated, while later calcific or other changes in the old scar may occur. When the outer portion of such a sac has disappeared and the inner coat is pushed out so as to assume, apparently, a secondary aneurysmal arrangement, the condition is referred to as a _hernial_ aneurysm. When the ordinary sacculation gives way as the result of necrosis, of pressure from within, or loss of support from without, the opening first made is usually small and the extravasation outside the true sac will depend upon the nature and resistance of the surrounding tissues. In this way a _diffuse_ aneurysm is formed, which is one of the varieties of false aneurysm.

2. =Fusiform Aneurysms.=--Fusiform aneurysms are more or less tubular and spindle-like dilatations of arterial trunks, in whose walls may occur the changes common to all these lesions, the dilatation rarely being sufficiently large to permit of laminated coagula unless a sacculation occurs later at some particular portion (Fig. 149).

[Illustration: FIG. 149

Fusiform aneurysm of popliteal artery, due to arterial disease (man aged 59), requiring amputation of thigh on account of gangrene. (Lexer.)]

3. =Dissecting Aneurysms.=--The dissecting aneurysms are nearly always expressions of previous atheromatous changes, by which blood is forced between the arterial coats, separating them and causing them to bulge at one or more points into sacculations or distortions. In a _false aneurysm_ there is no true arterial coat; the sac is made up of surrounding tissue.

[Illustration: FIG. 150

Traumatic aneurysm of axillary artery. (Park.)]

4. =Traumatic Aneurysms.=--Traumatic aneurysms are generally sacculated by the time they come under the surgeon’s observation. They are circumscribed and diffuse. According to their age and other circumstances they may contain old and dense laminated clots as well as those which are fresh and stratified. Much will depend upon whether the artery has been extensively injured or only slightly punctured, and also upon the location and distensibility of the surrounding tissue. Such a case seen in a fresh state will show infiltration of blood and ecchymosis (Fig. 150). _Arteriovenous_ aneurysms are now seldom seen. When venesection was more frequently performed the artery and one of the veins at the bend of the elbow were often thrown into communication, as the result of the indifferent performance of this operation and the use of the old-fashioned lancet. When the communication is direct such a condition is known as an aneurysmal varix; when indirect and through the sac it is called a _varicose aneurysm_ (Figs. 151, 152 and 153.)

[Illustration: FIG. 151

Aneurysmal varix. (Bryant.)]

[Illustration: FIG. 152

Arteriovenous aneurysm at bend of elbow: _a_, brachial artery; _b_, radial artery; _c_, basilic vein; _d_, median basilic vein; _e_, aneurysmal sac; _f_, dilated vein. (Lenoir.)]

[Illustration: FIG. 153

Varicose aneurysm removed from its connections. (Erichsen.)]

[Illustration: FIG. 154

Cirsoid aneurysm. (Bruns.)]

5. =Cirsoid or Racemose Aneurysms.=--Cirsoid or racemose aneurysms constitute vascular tumors of irregular shape and outline, according to the extent of the arterial system involved.

[Illustration: FIG. 155

Cirsoid aneurysm of femoral artery and telangiectasis, with lengthening of affected limb from hypernutrition. (Parker.)]

6. =Angioma or Aneurysm by Anastomosis.=--The difference between _angiomas_ and cirsoid aneurysms is more artificial than natural. When a single vessel is involved with all its branches it constitutes an elongated tumor and partakes of the nature of a varix. When the growth is a collection of small arteries the condition is then known as an angioma. Between these there may be all varieties of vascular changes. Fig. 154 illustrates a case of this kind in the scalp, while Fig. 155, contributed by Parker, illustrates a congenital involvement of the vessels of an entire limb, with overgrowth of the same from increase of blood supply.

=Diagnosis.=--All aneurysm so constituted as to be easily palpated can scarcely be mistaken for a tumor of any other kind. It can be recognized by its circumscribed nature; its pulsation, which is always of the expansile type; its bruit, which is synchronous with systole. It can be emptied by pressure, fills somewhat slowly if pressure is made above it, but more rapidly if pressure is made below it, being in this respect the counterpart of a venous angioma. Its size and rapidity of pulsation are influenced by position, and its location is usually that of one of the large arterial trunks. The murmur, heard through the stethoscope, is sometimes more than a mere bruit, and may be of a tumultuous, almost roaring character, the sounds being modified by the smoothness or roughness of the interior blood channel as well as by the thickness of the parts outside. Naturally the sounds can be altered by pressure. The overlying integument is at first unchanged, but if an aneurysm is working its way toward the surface and threatening rupture the skin will be stretched and discolored and may finally ulcerate. Blood pressure as measured by the sphygmomanometer is not altered in a limb which is affected by aneurysm.

Signs and symptoms which are not local are also produced in most cases, their variety being great and depending upon the location of the primary disturbing cause; for example, there is generally edema with venous congestion of parts situated distally, these features being so extreme in some cases as not only to threaten but even to occasion gangrene. By pressure upon nerves both pain and paralysis are produced and important functions impaired.

The tendency in all aneurysms is to increase in size and cause atrophy or disappearance of the tissues upon which they exercise their present influence.

[Illustration: FIG. 156

Varices of saphenous and branches (phlebectasis). (Lexer.) Compare with Fig. 153.]

=Regional Indications. Innominate Aneurysms.=--Innominate aneurysms usually appear behind the right sternoclavicular joint. As they increase in size they cause pain and edema of the right arm and the right side of the face, cough, dyspnea, and dysphagia. As the swelling increases it rises above the rib and sternum, pushing forward the sternomastoid and the clavicle. After being displaced the bones and cartilages in front begin to disappear by erosion, and the growth makes its way to the surface, where pulsation can be easily seen as well as felt and heard. In proportion to their increase other significant pressure symptoms, with venous turgescence, will occur. Innominate aneurysms can sometimes be differentiated from aortic by the sign, described by Porter, of _tracheal tugging_. This is elicited by causing the patient to sit up and bend the head forward, after which the cricoid is grasped and drawn forcibly upward, thus stretching the trachea. If with each cardiac impulse a well-marked tugging sensation be felt it may be attributed to the pulsation of an aortic aneurysm.

=Subclavian Aneurysms.=--Subclavian aneurysms of the first part of the vessel present similar features, only that the bruit is propagated down the axillary artery rather than up the carotid, and is not influenced by carotid pressure, while the pressure symptoms are limited mostly to the arm. In _axillary_ aneurysm the radial pulse is more delayed.

=Carotid Aneurysms.=--Carotid aneurysms are not always easy of early diagnosis, as at the root of the neck solid tumors often transmit a deceiving pulsation and convey an exaggerated vascular sound. They may also give rise to the same pressure symptoms as do subclavian aneurysms. Non-vascular tumors do not have an expansile pulsation, nor is the arterial sound conveyed upward along the carotid as in true aneurysm. In aneurysms of the _external carotid_ there may be paralysis of the tongue as well as difficulties in speech and deglutition. Aneurysms of the _internal carotid_ tend to extend inward rather than outward. _Intracranial aneurysms_ are difficult of diagnosis, but they usually give the symptoms of brain tumor, with possibly a bruit that may be heard and described by the patient himself, especially in certain positions of the head.

Wardrop used to formulate the diagnostic features of certain aneurysms at the base of the neck, as follows: Innominate aneurysms generally monopolize the episternal notch or rather its right side, taking up this whole space, even though not rising high. They first present to the inner side of the right sternomastoid, while carotid aneurysms appear in the interval between the sternal and clavicular heads, and subclavian aneurysm to the outer side of this muscle.

In the _abdomen_ the _aorta_ is most frequently involved, and sometimes its larger branches. An aneurysm of the renal or mesenteric arteries can easily be mistaken for an aortic aneurysm. The aorta proper terminates at the level of the umbilicus. A pulsating tumor below this level should belong to one of the _iliacs_. Recognition will depend largely upon the thinness of the abdominal wall and the absence of fat. In many cases expansile pulsation can be detected even here, while the pain is radiated along the well-known branches of the sympathetic, and the location to which it is referred may be of aid in deciding the part of the aorta most involved. Aortic pulsation is communicated by growths overlying it, and the surgeon is liable to be deceived by a certain abnormality of the natural pulsation through this trunk, as it is often exaggerated and appears pathological when it is not. _Abnormal pulsation of the abdominal aorta was first described_ by Cooper, and has served as a topic for surgical essays ever since. Schede’s test may be applied here to advantage: if firm pressure be made simultaneously upon both femoral trunks the extra blood pressure thus caused inside the tumor will give rise to pain, whereas in the absence of aneurysm it produces no such effect.

_Iliac_ and _femoral_ aneurysms may be made difficult of recognition by obesity, but the bruit can almost always be heard, and this, with such extra aid as the rectal or vaginal examination may afford, coupled with pressure symptoms confined to one limb, will usually facilitate diagnosis. Fig. 157 illustrates what features a tumor of this kind may present when located in the upper part of the thigh.

[Illustration: FIG. 157

Sacculated aneurysm of femoral artery. (Parmenter.)]

=Treatment.=--The general purpose of the treatment of aneurysms is to favor _coagulation_ and to effect a cure in this way. In the pre-antiseptic era it is not strange that men resorted to the method of starvation, by which the coagulability of the blood was much increased, or to the rest treatment, with the use of cardiac sedatives, by which the heart’s activity and power were greatly reduced. Nor was it strange that non-operative, yet mechanical, methods were used, in order to minimize the danger attending operative procedures. With the confidence, however, which Lister and his followers have given, it is generally conceded that with an aneurysm which can be made accessible by an operation radical methods are more satisfactory. To the surgeon belong all aneurysms except, perhaps, those of the aorta and the innominate, and even these have not been exempt from surgical methods. The following operative measures are worthy of discussion in these cases: (1) _Ligature._ (2) _Open operation._ (3) _Extirpation._ (4) _Opening and suture._ (5) _Introduction of wire, with or without electrolysis._

1. Ligation includes the application of a ligature in one of the following situations: (_a_) Proximal ligation (Anel’s) at a convenient point shortly above the sac; (_b_) proximal ligation (Hunter’s) at a distance from the sac; (_c_) distal ligation, either of the main trunk just below the sac (Brasdor’s) or of the highest main branch given off below the sac (Wardrop’s). Thus proximal ligation could be practised in case of aneurysm, either of the external or internal carotid, by tying the main trunk, or in the case of popliteal aneurysm (Hunter’s suggestion), by tying the femoral in Hunter’s so-called canal. Brasdor’s distal ligation may be illustrated by ligature, in Hunter’s canal, of the femoral for aneurysm in the groin, while Wardrop’s modification would consist in tying one of the tibials for popliteal aneurysm, or one of the lesser carotids for aneurysm of the common trunk. Should _ligation_ be determined upon, circumstances will dictate where the ligature should be applied, and the surgeon will decide the character of the suture material. The methods of attack upon the large vascular trunks will be considered later. Inasmuch as it takes time to establish collateral circulation, attention should be given to physiological rest, as well as to all other general measures calculated to make any operation successful.

[Illustration: FIG. 158

Anel’s operation.

Hunter’s operation.

Distal operation.

(Erichsen.)]

[Illustration: FIG. 159

Brachiocephalic aneurysm; ligature of the subclavian only.

Brachiocephalic aneurysm; ligature of the carotid only.

Brachiocephalic aneurysm; ligature of the subclavian and carotid.

Different schemes for application of the ligature according to the necessities of the case. (Erichsen.)]

2. _Open division_ was first suggested in the fourth century by Antyllus. It soon fell into disuse and was taken up during the middle of the past century by Syme, to whom the operation has been frequently credited, although it was really the revival of an antique method; but Syme gave it so much of his anatomical exactness and brilliancy of operative skill that he almost made it his own. The method was essentially one by long and free incision, through which the interior of the sac was fully exposed, its contained clots turned out, its vascular openings plugged, while a ligature was applied above and below in order to prevent further arterial communication. Performed before the days of anesthesia or of antisepsis it was an exceedingly bold procedure, yet in Syme’s hands it gave brilliant results.

3. The _open division_ has been replaced by the more perfect procedure of _extirpation of the sac_, based upon the general principle that an aneurysm is a _tumor_ and should be extirpated, the parts being sutured and expected to heal promptly. It constitutes in many cases the ideal method of treatment. There could be but one improvement on it, namely, that suggested by Matas, of _arteriorrhaphy_, as one of the radical methods which is often applicable to aneurysms of the extremities, or to those where rupture has occurred or is imminent. The part should be made bloodless, as in this way perfect control can be secured; should this be impracticable, the vessel should be ligated above the aneurysm before proceeding to its excision. This done, and the vessels secured above and below, the wound may be closed as after any other operation, and in this way radical cure achieved within a few days.

Fig. 160 illustrates a recent case of this kind in the author’s hands, where an aneurysm of the common carotid, of about the size of a lemon, was treated in this way, the patient leaving the hospital in eight days, and having no unpleasant complications.

[Illustration: FIG. 160

Aneurysm of the common carotid successfully treated by complete extirpation. (Park.)]

4. _Open division with arteriorrhaphy_ has been proposed by Matas and Murphy and in their hands has been successful. Its greatest usefulness is found in traumatic aneurysms of long standing where the arterial opening is usually small and the vessel wall healthy, so that after excision of the sac a sufficient amount of aneurysmal wall or stump may be retained in order to afford a firm surface for union. The circulation being controlled the sac is exposed, opened, and dissected down to a location near the arterial opening. Here the arterial walls are trimmed and freshened, turned in or rolled in, and a row of sutures applied, one line apart, through the outer and middle coats. Matas suggests that after the suture is complete the size of the vessel should be less than its normal, in order that pressure may be reduced at this point and more perfect union follow. The method may also be resorted to in certain fusiform aneurysms, where the arterial wall is still sufficiently healthy to sustain sutures. Here an elliptical piece can be excised, or it may be possible to infold the coats of the sac and apply sutures through a series of folds, on the same principle that they are applied in cases of dilatation of the stomach. Arterial suture as practised in these cases is similar to the Lembert suture used in intestinal surgery. It is necessary to support the tissues around the sutured artery by other buried sutures in such a manner as to fortify them against yielding of the arterial coats.

For these radical methods, either by excision or this combined with suture, the arteriovenous aneurysms afford an inviting class of cases. The parts having been made bloodless and the vessels separated, sutures may be applied, if there be sufficient room for them without too much occlusion of the vessels, which would afford but little advantage over ligatures.

In spite of what has been said about the rarity of these lesions, which is true in civil life, it has been shown, during recent wars, that bullets of small caliber having high velocity have produced instances of this character.

5. For cases so situated as to make any of the above methods inexpedient there is still the more or less promising method of treatment by the _introduction of wire, coupled perhaps with the use of the electric current, and the injection of gelatin solutions_. While ligation of the abdominal aorta has been practised with temporary success it has not yet proved so encouraging as to justify its performance, save in exceptional cases, but into any intrathoracic or intra-abdominal aneurysm, which appears to be otherwise inoperable, a number of feet of fine steel wire may be introduced, in the attempt to coil it up irregularly within the sac and thus to afford a sort of skeleton framework, upon which coagula will more readily form and by which they may be retained. In some cases the end of this wire has been attached to the negative pole of a galvanic battery, the other pole being affixed to an external electrode, and a weak galvanic current has been passed for a period of say from five to thirty minutes, the time varying in accordance with the strength of the current. By this procedure coagulation is much encouraged. In cases of intra-abdominal aneurysm the abdomen may be opened and the sac more or less completely exposed, after which this insertion may be more minutely performed.

Occasionally surgeons have exposed an aortic aneurysm and endeavored to externalize or exclude it by producing adhesions around it, while some portion of the sac is exposed to the outer world. After adhesions have formed such methods of treatment can be repeated as may be desired. They may also be combined with the subcutaneous use of 2 per cent. sterile gelatin solution, or this may be thrown into the sac in small amounts. It is true, however, that cases of this character are desperate, and while life has been in perhaps half of the operated cases more or less prolonged, but few instances of final recovery have been recorded.

The after-treatment consists of physiological rest of the part operated upon, and rest and abstention from violent exertions of any kind. During this time elimination should not be neglected, emotional excitement should be avoided, and, in the presence of syphilitic disease or a well-founded suspicion of it, conventional antispecifics should be administered in sufficient amounts. When the aneurysm is of traumatic origin and there is no general vascular or cardiac disease, there will be a quick restoration of the integrity of parts as well as of their usefulness. Massage and an elastic bandage will be useful, in order to atone for the results of a disturbed circulation.

SUTURE OF BLOODVESSELS.

This is almost a new topic in surgery, especially suture of the arteries. Surgeons have learned that the walls of the arteries and of the veins, when not too much diseased, will tolerate sutures and unite easily. The larger the vessel the easier it is to apply a suture, as its walls are thicker and the method easier. The greater, too, will be the need of suture when the vessel is an important one. Small vessels are relatively so unimportant as not to demand so formal a procedure. The vessels to which the method is most applicable are the common carotid, the subclavian, axillary, brachial and femoral, with their accompanying veins, including the common jugular. It is applicable when it is an injury to the vessel which has necessitated an operation, or when, during its performance, some trunk has been torn out or torn open, as in separating adhesions. It is serviceable, also, when both artery and vein have been involved, as in the groin, where the danger of gangrene of the limb would be enhanced if both the outflow and the inflow of the blood were shut off.

[Illustration: FIG. 161

End-to-end suture of a divided artery, permitting a certain degree of invagination. (After Murphy.)]

_Lateral suture of injured bloodvessels_ may be regarded as a standard procedure, as it is nearly always possible to temporarily control the circulation on both sides of the field of operation, either by elastic constriction or temporary ligation or clamping. For this purpose fine silk makes the best suture material. It should be threaded into round needles and the sutures should include only the two outer coats. After completing the suture the distal provisional closure of the vessel should be first removed. As the blood backs up in the artery it will test the efficacy of the sutures. Should there be no leakage the proximal clamp may be removed, and then if the condition appear satisfactory the arterial sheath should be carefully closed, and over this the other tissues, with buried sutures.

_End-to-end suture_ of bloodvessels is a recent measure, for which we are indebted to Murphy. It is applicable to vessels which have been divided circularly and completely or almost completely. In the event of the adoption of this method the ends should be divided squarely and then reunited by sutures threaded upon the needles, passing through all the coats, about 1 Mm. from the margin of division, as well as about the same distance apart. If the upper end can be drawn into the lower one, and gently held there by a series of U-shaped stitches, it may be considered the best method.[26] (See Fig. 161.)

[26] There are now before the profession three methods of repairing arteries--by _invagination_, by _suture of the two outer coats_, by the _through-and-through method_--each of which has its advantages and disadvantages. The presence of sutures in the interior of the vessel does not seem to produce coagulation, even though the intima of the vessel is injured by the passage of the same. Nevertheless sutures must be kept out of the blood stream. Liability to secondary hemorrhage is reduced if a double line of sutures can be used.

LIGATION OF ARTERIES.

Arteries are exposed and ligated in their continuity for the purpose of controlling hemorrhage, either for temporary or permanent purposes. The results of permanent ligature have been described in the chapter on Wounds. The application of a ligature should be so made as to thoroughly break up the intima without serious injury to the other coats of the vessel. Coagulation and organization of the thrombus soon produce a permanent occlusion and obliteration. It is a mistake to endeavor to tie the ligature too tightly. Hardened catgut or freshly boiled silk make the best ligature material. It is seldom a difficult matter to find the desired artery upon the normal individual or upon a cadaver. In some cases in practise the tissues through which search must be made will be found infiltrated with blood or otherwise altered, and the discovery of and attack upon the vessel may be thus made very trying. The vessel when exposed in its continuity will be recognized by the sense of touch rather than that of sight, and almost the entire maneuver may be made, by touch alone, by one whose tactile sensibility has been well trained and without any clear view of the vessel. The arteries which are thus exposed have their own sheaths, especially the larger ones, which should be opened with care, not alone to avoid injury to the vessel itself, but in order that the amount of separation may be as slight as possible, as the sheath is necessary for support and for nutrition. Having exposed the vessel and divided the sheath the ligature is introduced with a blunt, curved needle attached to a handle, and known as an _aneurysm_ or _artery needle_. It is made to carry the ligature, or it is so insinuated and brought out from behind the vessel that the ligature may be threaded into its eye. Caution should be exercised that nothing but the artery itself is included; this is especially necessary in the neck, where the relations between the large vessels and the nerves are very intimate. As a general rule the needle should not be threaded until after it has been passed. The knot should be tied in the depths of the wound, and the vessel should not be disturbed by efforts to secure the knot. If the operation have been done as it should it will not be necessary to drain such a wound, but it may be closed by buried and superficial sutures. When one of the limbs has been involved in this operation it should be kept absolutely at rest, in a somewhat elevated position, and warm applications made, in order that the warmth previously maintained by the free circulation of arterial blood may not be allowed to drop too low.

=Innominate Artery.=--The innominate had been tied between thirty-five and forty times, up to 1905. A number of patients have survived the operation, and died within a few weeks of cardiac and arterial disease. Some have progressed a number of weeks, with rapid recovery from the operation and temporary improvement sufficient to justify this operation in apparently favorable cases. This vessel and the carotid also should be tied, in order that the resulting clot may be more perfect and that there should be no return pressure made upon the aneurysmal sac. The incision is made along the anterior border of the sternomastoid down to the clavicle and then along the inner third of this bone, thus forming a flap whose free edges are 10 Cm. in length. The sternal and clavicular heads of the sternomastoid are divided, while the sternohyoid and sternomastoid are separated from the sternum, care being taken especially of the anterior jugular vein, which may be double ligated, if necessary, and, in the deeper dissection, of the pneumogastric and the recurrent laryngeal nerves, which wind around the innominate, and the phrenic, which is in close relation with it. In view of the great engorgement which the aneurysm may produce in the veins of the neck it would be a great help in this operation to follow Crile’s suggestion for removal of goitres, placing the patient in the semi-upright position and having him wear the pneumatic suit, in order that, by suitable pressure from without, the blood pressure may be kept at the proper degree, while, at the same time, the veins of the neck are emptied by gravity. The carotid, having been found, is traced downward and will lead to the innominate and the sac. When the ligature is ready to be drawn tight the table should be lowered and the pneumatic pressure in the suit reduced.

Obviously the deeper the surgeon dissects the more difficulties he will encounter. The innominate artery is crossed by the left innominate vein, which may be in the way, while all the other vessels may be so much disturbed as to alter their relations and make their recognition difficult. The gradual progress of the aneurysm may have caused the tissues to become matted to each other and thus lose their identity. The innominate having been found is traced downward behind the sternum and a suitable base is sought for the ligature. This search may be aided by changing the position of the patient’s head, and with the assistance of artificial light. In the depths of the wound the veins, the vagus, and the pleura can only be avoided by care in keeping the point of the artery needle in contact with the artery. If necessary gentle traction on the carotid trunk may aid by lifting the sac and making its isolation more easy.

As suggested by Bardenheuer the upper end of the sternum may be removed with sufficient of the inner end of the clavicle to facilitate approach. This has been done in this country by Burrell. The aneurysm needle is passed from without inward and from below upward, in order to avoid injury to the pleura. An artery needle made with a flexible tip, which may be bent to suit the exigencies of the case, will make the most difficult part of the work more easy. The ligature should not be tied too tightly, and for this purpose silk is the preferable material. Strips of ox aorta and other animal materials have been used, but if the knot is not too tight no harm will be done to the artery wall.[27]

[27] Sheen (Annals of Surgery, July, 1905) reports a successful case, his method being as follows: Median incision from the cricoid to one inch below the sternal notch, exposure of the carotid and innominate, then a silk ligature carried around the innominate distally and tied with Balance’s stay-knot; pulsation ceased, to later reappear. A second similar operation also failed. A third operation was performed through a five-inch transverse incision above the clavicle, the artery being twice ligated proximally. Sheen advises that ligature should always be of silk, that the incision should be central, with horizontal and vertical division of the manubrium; that the carotid should also be tied; that two ligatures be placed; that drainage is inadvisable, and that next to sepsis as a cause of death stand cerebral lesions. Statistics are thirty-six cases of ligature, with a mortality of 78 per cent.

As stated above, the common carotid should also be tied at the conclusion of the other ligation. These cases should be drained with a few strands of catgut. Absolute rest is an essential of the after-treatment.

=The Common Carotid.=--The common carotid may be tied above or below the omohyoid. The carotid divides at the level of the thyroid prominence, and it is more easily exposed above the omohyoid than below. It may be reached by an incision, 10 Cm. in length, along the anterior border of the sternomastoid, whose centre should be at the level of the intended ligature. The sternomastoid, after exposure, is drawn outward and the other muscles inward; bleeding veins are secured; the artery recognized by its pulsation; its sheath opened, preferably on the inner side, and the needle passed from within outward, the operator taking pains to avoid the descendens noni. The internal jugular is more likely to be in the way and to need retraction on the left side than on the right. In this operation when the omohyoid is exposed it is retracted upward.

Through this exposure _temporary occlusion_, either by provisional ligation or the employment of Crile’s clamps, may be practised.

Ligature above the omohyoid is performed in the same way, the veins being divided and secured. The omohyoid is now drawn downward and the other muscles separated as above. The so-called carotid tubercle is the anterior projection of the transverse process of the sixth vertebra, and the ligature is usually applied at the point where the vessel can be felt pulsating upon this prominence. The same care should be exercised in avoiding the descendens noni. Nélaton is reported to have said that it would take a man four minutes to bleed to death after opening the carotid artery, but it should take only two minutes to tie it.

=The External Carotid.=--The incision now is placed higher, from the angle of the jaw to the level of the cricoid cartilage, still along the anterior border of the sternomastoid, which is to be retracted outward. The posterior belly of the digastric will now appear, with the hypoglossal nerve below it, both being carefully avoided. The great cornu of the hyoid being sought and found, the artery is found opposite its tip, and ligated between the superior thyroid and the lingual branches, or perhaps below the latter. The superior laryngeal nerve which passes behind the vessel is to be scrupulously excluded.

_Excision of the external carotid_ has been recommended, especially by Dawbarn, for the purpose of cutting off the blood supply from certain inoperable cancers of the tongue, face, and jaws. He regards mere ligature as insufficient and insists that, since anastomosis is perfected too soon after the other procedures, it is necessary to completely excise a portion of the vessel. He does this first on the side most affected, and then, say a few weeks later, attacks the other side. He advises to ligate the external carotid just beyond its origin, to divide it, to seize the upper end in forceps, and then, controlling the vessel, to isolate it up to a point where it disappears in the substance of the carotid, tying each branch as it is exposed. He would again tie it just below the origin of the internal maxillary and temporal branches.

=The Internal Carotid.=--The internal carotid is very rarely attacked in this way. It lies at first to the outside and back of the external carotid, and here it may be sufficiently exposed to admit of ligation. The incision does not differ essentially from that for the external carotid. After the vessels are exposed the external branch should be drawn inward, the digastric upward, or divided, if necessary, and the needle passed from without inward, avoiding the jugular and the vagus (Fig. 162).

[Illustration: FIG. 162

Aneurysm of the right internal carotid. (Peacock.)]

=The Lingual Artery.=--The lingual artery may be conveniently tied before some of the radical operations on the tongue, and it is also tied in cases of cancer in order to shut off nutrition. Incision is made 2 Cm. above the hyoid, parallel with it, from the middle line nearly to the angle of the jaw. Through this the submaxillary gland will be exposed and should be retracted upward and out of the way. The fascia is then divided, and the posterior border of the mylohyoid identified. The digastric tendon is then drawn upward from the hyoglossus, upon which it rests. The hypoglossal nerve is now seen, the artery lying behind it. It is, therefore, necessary to divide the hyoglossus by a short incision in order to reach the vessel. The most important precaution is to avoid injury to the nerve (Figs. 163 and 164).

[Illustration: FIG. 163

FIG. 164

Surgical anatomy of the neck; ligation of the carotid, lingual, and facial arteries. (Bernard and Huette.)]

=Other Arteries of the Face and Head.=--The _facial_ may be tied through an incision nearly identical with that for the external carotid, or at the margin of the lower jaw 1 to 2 Cm. in front of the angle. The _temporal_ may be attacked through a vertical incision over its course between the tragus and the condyle. Branches of the facial nerve cross the artery at right angles to it; these should be avoided. The _occipital_ may be tied close to its origin, through the same incision as that for the external carotid, or behind the mastoid, through an incision commencing at its tip, carried backward and upward. It will be necessary here to divide the posterior fibers of the sternomastoid, of the splenius, and perhaps of the trachelomastoid. The vessel is then recognized by its pulsation between the mastoid and the transverse portion of the atlas.

=The Vertebral Artery.=--The vertebral artery is tied through an incision commencing at the clavicle, extending along the outer border of the sternomastoid, some of whose clavicular fibers must be divided. This muscle and the anterior jugular veins being drawn to the inner side, the transverse processes of the sixth and seventh vertebræ should be found in the space between the scalenus anticus and the longus colli. The artery should be found below the seventh cervical vertebra as it enters the foramen intended for it. The vein lies in front of it, the pleura close to it, and on the left side the thoracic duct is not far away.

=The Inferior Thyroid Artery.=--The inferior thyroid artery may be tied through an incision along the inner border of the sternomastoid, which is retracted outward, the carotid being found and also retracted outward. The artery lies a little below the level of the sixth vertebra, whose transverse process may be easily found. It passes inward and to the rear of the carotid, close to whose main trunk the ligature should be applied, in order to avoid the recurrent laryngeal.

[Illustration: FIG. 165

FIG. 166

Surgical anatomy and ligation of the axillary and subclavian arteries. (Bernard and Huette.)]

=The Subclavian Artery.=--This is best tied by making an incision 2 Cm. above the clavicle, beginning nearly at its sternal joint, and extending outward to the anterior border of the trapezius. In exposing it the cervical branches of the superficial nerves should also be divided. The external jugular lies here, near the posterior border of the sternomastoid, and winds around it to empty into the internal. Unless it can be avoided it should be carefully double ligated. The omohyoid should appear at the inner angle of the wound and may be drawn out of the way in either direction. The suprascapular artery and perhaps one or two other vessels may cross the wound and require retraction. It is usually necessary to remove considerable adipose tissue in which these vessels lie. The brachial plexus, of course, will be encountered. The scalenus anticus, which should be followed down to its tubercle of attachment on the first rib is of special importance. To its inner side is the internal jugular, with a somewhat bulbous enlargement. In front is the subclavian vein and behind the muscle is the artery. The phrenic nerve passes down upon the anterior surface of the scalenus anticus, and the thoracic duct ascends close to it, opening into the angle between the subclavian and internal jugular veins. While it is not impossible nor even impracticable to apply a ligature to the subclavian on the inner side of the scalenus anticus it is rarely necessary, and the ligation is almost invariably performed to its outer side, in the free part of its trunk. There must be sufficient space in which to work with safety, and, when necessary, adjoining muscles, _i. e._, sternomastoid and trapezius, may be divided to any necessary extent. The patient should always be placed in such a position that the shoulder is pulled well down, with the arm passed behind the back, while the neck is stretched by extending the head to the opposite side. The artery needle should be passed from above downward and from behind forward, the vein being carefully held out of its way. The patient should wear the Crile pneumatic suit, in the semi-elevated position, in order that the veins in the neck may be less engorged (Figs. 165 and 166).

=The Axillary Artery.=--The axillary artery is practically tied in its third portion, beyond the lesser pectoral. The incision is made through the middle of the axilla, over the course of the vessel, the deep fascia exposed and divided, the coracobrachialis and musculocutaneous nerve retracted outward, and the artery recognized with the finger-tip. It should be so cleared, especially from the median nerve, as to be easily raised upon the blunt hook. The accompanying veins should not be enclosed in the ligature (Figs. 167 and 168).

[Illustration: FIG. 167

FIG. 168

Surgical anatomy of the axilla and ligation of the axillary artery. (Bernard and Huette.)]

=The Brachial Artery.=--The brachial artery is easily found in the middle of the arm, near the inner edge of the biceps, whose inner border is identified. The median and other nerves should not be brought into view. The parts will be relaxed by flexing the forearm. The venæ comites should be carefully excluded from the ligature (Figs. 169 and 170).

[Illustration: FIG. 169

FIG. 170

Surgical anatomy and ligation of the brachial artery. (Bernard and Huette.)]

=The Radial Artery.=--The radial artery is the direct extension of the brachial and passes underneath a nearly straight line to the neighborhood of the scaphoid bone. High up in the forearm it may be exposed between the supinator longus and pronator teres, being found beneath the former. In the middle portion of the forearm it may be exposed along the ulnar border of the supinator longus, and lying upon the pronator radii teres. At the wrist it may be exposed with perfect ease, where it is usually outlined when feeling the pulse (Figs. 171 and 172).

=The Ulnar Artery.=--The ulnar artery is the larger of the two main trunks, and is rarely tied in the upper part of the arm, lying too deep for easy exposure. Should it be divided by a wound of this region the opening may be enlarged sufficiently for its detection and double ligation (Figs. 171 and 172).

Of the large vessels of the trunk the _abdominal aorta_ has been tied, although it is questionable whether this would ever be a justifiable operation, as all recorded cases have succumbed from one cause or another.

=The Common Iliac Artery.=--The common iliac artery is best tied by an incision commenced parallel with Poupart’s ligament and curved upward and outward. The abdominal muscles and fascia having been divided, with the least possible injury to their fibers, the peritoneum is detached from the iliac fascia, the patient being turned upon the side in such a way that gravity may assist in the exposure of the vessel behind the peritoneum. A needle of medium length, and strong, with oblique lateral curve, should be passed from within outward, the vein lying behind the artery on the right side, near to its inner side, and behind on the left side. In the fossa thus formed, and lying upon the psoas, will be found not only the common trunk but the external cutaneous nerve, running downward and outward, and also the iliac branch of the iliolumbar artery.

The operator may decide, for some reason, to open the abdomen directly, and to go through from front to rear, drawing aside the intestinal loops, with the patient in the Trendelenburg position, exposing the main trunk by a small incision through the posterior peritoneum and applying the ligature there. By this same _transperitoneal_ method the _internal iliac_ may be attacked. Its course inward and downward, rather than outward, makes it more easy of attack in this way. The ureter, which lies in front of the artery, should be raised, along with the peritoneum, in order that it may be avoided. This vessel has thus been tied for hypertrophy of the prostate, for inoperable cancer of the uterus, during excision of the rectum, and even for the cure of vascular tumors or aneurysms affecting its terminal arteries.

[Illustration: FIG. 171

FIG. 172

Surgical anatomy and ligation of the radial and ulnar vessels. (Bernard and Huette.)]

=The External Iliac Artery.=--The external iliac artery is exposed without great difficulty by a 10 Cm. incision about Poupart’s ligament, beginning near the pubic spine, extending outward and slightly upward. It will probably be necessary to double ligate and divide the superficial epigastric artery, after which the outer border of the conjoined tendon is to be recognized at the lower and inner end of the incision. The lower fibers of the internal oblique are then to be divided, the transversalis exposed and transversely divided, after which the deep epigastric artery will probably come into view. The pulsations of the external iliac will now identify it. The subperitoneal tissue should be carefully detached and the peritoneum gradually separated from the vessels and properly retracted. Beneath it the areolar tissue which helps form the sheath of the vessel must be avoided, after which the artery needle may be passed from within outward. In closing the wound the deep layers should be brought together, each by itself, in order to avoid the possibility of ventral hernia. Through this same incision both the _deep epigastric_ and the _deep circumflex arteries_ may be exposed (Figs. 173, 174 and 175).

[Illustration: FIG. 173

FIG. 174

FIG. 175

Surgical anatomy and ligation of the femoral, external iliac, and epigastric arteries. (Bernard and Huette.)]

[Illustration: FIG. 176

FIG. 177

Surgical anatomy and ligation of the femoral artery. (Bernard and Huette.)]

=The Femoral Artery.=--The femoral artery is usually tied either at the base of Scarpa’s triangle, just below Poupart’s ligament, or in Hunter’s canal. In the first location its pulsation can be easily felt before dividing the skin, and will serve as the best guide. It requires an incision made downward over the course of the vessel, from the middle of Poupart’s ligament. In approaching it here a number of lymph nodes may be encountered, some of which may be considerably enlarged. They should be disturbed as little as possible, unless involved in cancerous or serious septic disease. The anterior crural nerve lies to the outer side of the vessel and the vein to its inner side. Between these it may easily be found and tied (Figs. 176 and 177).

In Hunter’s canal the femoral artery may be found nearly beneath the long saphenous vein, and near the outer edge of the sartorius. If the leg be abducted, and the adductor magnus thus stretched, the position of the canal, between the latter and the vastus internus, is easily recognized. The canal itself is partly formed by fascia which should be divided, while the artery will be found within.

[Illustration: FIG. 178

FIG. 179

Surgical anatomy and ligation of the posterior tibial artery. (Bernard and Huette).]

The lower part of the femoral artery, or practically the _popliteal_ artery, may be found, if necessary, by an incision in the middle of the popliteal space, the operator gradually working down by blunt dissection to the location of the vessel, which is easily recognized by its pulsation.

=The Posterior Tibial Artery.=--The posterior tibial artery nearly underlies a line from the centre of the popliteal space to a point between the inner malleolus and the heel. To expose it easily the limb, somewhat flexed, should lie upon its outer side, the patient lying nearly on his face, and incision made in the calf of the leg, beginning at the head of the fibula, after which one may expose the junction of the two heads of the gastrocnemius. Through this the tendon of the plantaris is to be sought, after which it may be necessary to divide a portion of the soleus. Here the vessel should be sought by the sense of touch, the operator seeking for its pulsation. Lower down, and in the lower part of the leg, it may be found by incision along the imaginary line which it underlies, lying on the flexor longus digitorum, with its accompanying nerve on its outer side. Still lower, at the ankle, it may be easily found, just behind the malleolus. (See Figs. 178 and 179.)

[Illustration: FIG. 180

FIG. 181

Surgical anatomy and ligation of the anterior tibial and peroneal arteries. (Bernard and Huette.)]

=The Anterior Tibial Artery.=--The anterior tibial artery underlies a line drawn from a point between the head of the fibula and the outer tuberosity of the tibia, to the front and centre of the ankle-joint. At almost any point along this line it can be exposed between the tibialis anticus and the common extensor of the toes, the latter being held downward and outward and the former upward. Here in the depths it may be recognized upon the interosseous membrane. In the lower part of the leg the extensor pollicis lies to its outer side. Here the accompanying veins should be avoided. Quite low in the leg and in front of the ankle the vessel will be found between the tendons of the tibialis anticus and extensor pollicis (Figs. 180 and 181).

THE VEINS.

The veins are of interest to the surgeon particularly because of the role they play in the pathology of sepsis, especially of pyemia, and because of their various dilatations and even new formations which admit of none but surgical remedy; that is, varices, under their various names--for example, hemorrhoids, varicocele, and nevi.

The veins have an endothelial lining, between which and circulating, or more especially stagnant, blood there exist peculiar susceptibilities and relations which cannot be well described. The pathologist appreciates what disturbances of the endothelium will provoke coagulation of the blood in contact with it, but is not yet in a position to explain the relationship. Veins, moreover, are provided with valves to a more perfect degree than are the lymphatics, but the valves often become inadequate for their purpose, and then we have such conditions as varicosities; the fact that they are usually seen about the rectum and the lower extremities illustrating the _disadvantages accruing from the upright position_ into which, by the process of evolution, man has erected himself from the quadrupedal. Even the myriads of years that have elapsed since this change took place have not sufficed to afford sufficient protection against the added weight of the column of blood inseparable from it.

Of pathological changes which interest the surgeon there may be _atrophy_ as the result of pressure from without or prolonged distention from within, even to such an extent as to permit of rupture and serious or fatal hemorrhage. _Fatty degeneration_ occurs in the serious intoxications and infections. _Calcification_ occurs only in limited areas and is secondary to other changes or to thrombophlebitis. True osseous patches have been found in the walls of veins, but are great rarities. Calcification occurs in the portal and also in the femoral veins and their branches. In other directions vein walls become _hypertrophied_, all coats partaking in the change, enlargement or distention being especially likely to occur where there is most tendency to stagnation. The changes which lead to the varicose condition include not only absolute thickening, but increase in every dimension, the venous tubes becoming _elongated_ as well as distended and thickened, to such an extent that they take a spiral or curved course, sometimes almost doubling on themselves.

PHLEBITIS.

In all forms of phlebitis, whether acute or chronic, the three venous coats are practically involved in the same manner. With enlarged knowledge of the lymphatics it is difficult to separate an acute phlebitis from a lymphangitis of the venous wall. Only in this way can descending phlebitis be accounted for, the infection travelling apparently against the blood stream. This accounts for the discoloration along the subcutaneous veins when they become involved, the same red lines appearing in the skin as when the lymphatics are involved. The relations between the intima and the blood have been mentioned above. In cases of acute phlebitis in which the intima is involved there is coagulation of the contained blood, the clot and the vein wall undergoing changes which simulate a _thrombophlebitis_.

=Acute Phlebitis.=--Acute phlebitis is of infectious origin. It may be seen in connection with injury, erysipelas, childbirth, and the superficial and deep infections, as from a hypodermic injection, a pin-prick, etc. It is also seen in typhoid, pneumonia, diphtheria, and gonorrhea. In most of these instances it is difficult to trace the path of infection. I have seen death from pyemia following gonorrhea, where the earliest recognizable disturbance occurred in the peri-urethral and prostatic veins. I believe it to have been my report on these cases, in 1885, which first called attention to the fact that gonorrhea might terminate fatally by the pyemic process.

When the venous system has become involved in a septic process of this kind neither its fate nor that of the patient can be regarded as secure. Occlusion, with serious circulatory disturbance, may permanently impair function, while there may be speedy death from pyemia. This is nowhere more true than in those portions of the venous system having rigid walls without valves, to which is given the name “sinuses” (cranial), in which exactly similar processes may occur, which by virtue of their location will always give rise to the gravest anxiety. To phlebitis occurring in these channels there has been given the somewhat distinctive name _sinus phlebitis_. It nowise differs from the same condition elsewhere, save that it is of almost invariably extravascular origin. It takes but a small venous branch, lying in the midst of an infected area, to commence the process that may extend from the basal sinus to the vena cava.

In most of the surgical infections acute phlebitis has an extravascular origin, the lymphatics of the outer wall communicating the infection to the inner coats, and so distributing it that coagulation occurs, after which the path of infection from the containing veins to the contained clot is direct. The thrombi thus formed may completely or only

## partially occlude the vessel. As a continuation of the lesion we have

infiltration and separation of the coats of the vein from each other, and finally their necrosis. Thus in the terms of the pathologist an acute phlebitis may lead to a phlebitis desicans, and this to phlebitis gangrænosa. In every case where the patient survives such conditions as these the veins lose their identity and become obliterated by the very violence of the process in which they have participated.

A somewhat different type of acute or subacute phlebitis is produced by intravascular irritants, namely, toxins or bacteria circulating in the blood, or to some chemical or thermic agency which may produce thrombosis, such as extremes of heat and cold. These, too, may lead to partial or complete occlusion, and the latter may be followed by calcification or the formation of _phleboliths_. The destructive character of the entire process will, therefore, depend upon the nature and virulence of the exciting cause. As between fatal septic infection, local gangrene of a part as the result of involvement of the majority of its veins, or comparatively slight and temporary disturbance, such as edema, there may be degrees of activity, with results varying between fatality and evanescent discomfort.

=Chronic Phlebitis.=--This is of the proliferative type and is followed by more or less organization. _Phlebitis obliterans_ is sometimes seen in connection with syphilis and other chronic intoxications, and with various operations upon the veins.

=Symptoms.=--Phlebitis may occur without known cause or may follow as an expected result from deep or surface lesions. The deeper the involved veins the more obscure the case. Involvement of superficial veins, especially in acute cases, is easily made known by the dark-bluish or dusky red cord which occupies the place of the previously healthy vein. As its contained clot becomes firmer the clot becomes harder. This is accompanied by more or less fever, with extreme tenderness, often pain. If a single vein only be involved the disturbance will be quite local; if thrombosis be general there will be edema of the parts to which the vein is distributed. Involvement of certain veins implies the establishment of a collateral circulation through others. If there be no others available then danger from venous insufficiency threatens, and it may not be possible to avert gangrene. “_Milk leg_,” or so-called _phlegmasia alba dolens_ (“painful white swelling”), is an expression of portal, pelvic, and femoral thrombophlebitis. In many instances in which it does not kill it may cripple the individual for life. Phlebitis of the deep veins can be inferred rather than detected. Phlebitis of the _hemorrhoidal veins_ frequently follows inflammation and suppuration of piles, while that of the pelvic veins, especially the perivesical, frequently follows gonorrhea and prostatitis. _Mesenteric phlebitis_ and _pylephlebitis_ frequently follow the ulcerative infections of the intestines, while in the _newborn a phlebitis of the umbilical vein_ plays an important

## part in the mortality of infants. The _cranial sinuses_ are likely

to be affected in connection with middle-ear disease, while in acute osteomyelitis there are distinctive pictures of the lesion in the veins of the bone and the marrow. No matter where the lesions may centre they are of the most serious character. The role of the veins in the production of metastatic foci has been described in the chapter on Pyemia. The danger attending the liquefaction of a thrombus and the escape of its fluid debris into the general circulation stamps an acutely infected clot with a dangerous character. This fact justifies such measures as are now pursued in connection with the cranial sinuses and mastoid disease, where there is not only a sinus exposed by removal of a portion of the temporal bone but the jugular opened low in the neck and the entire intervening channel freed from its putrefying contents by the probe and the irrigating stream. In other words, a recognition of the pathology of thrombosis and sepsis may lead to the performance of difficult operations.

=Treatment.=--It is difficult to separate the treatment of phlebitis from that of lymphangitis, which generally accompanies it. The first essential is physiological rest for the part involved, such as confinement in bed, and the least possible disturbance of the inflamed area, which should be placed in the most restful position and handled as little as possible. Local soothing and evaporating lotions may be used, or, as seems to the writer preferable in most cases, applications of a 10 per cent. ichthyol-mercurial ointment, or of the Credé silver ointment, neither of which should be rubbed in, but spread upon the skin and covered with an impermeable material. These will, after a few days, prove irritating, and a substitution of something milder may be required; but in the acute stage they will render greater service than anything else. _A phlebitis which has been provoked and is perpetuated by the presence of septic material cannot be successfully treated so long as its provoking cause remain._ Puerperal sepsis which results in pelvic phlebitis calls for thorough curetting of the uterus, while an abscess in the jaw or about the mouth, resulting from diseased teeth, necessitates the extirpation of the latter, providing the jaws can be separated sufficiently to permit of it. What may be needed in cases of thrombophlebitis of the cranial sinuses has just been mentioned.

In any part of the body a vein which is filled with a breaking-down clot can be promptly and judiciously treated by exposure and removal of the involved part, or by free and open incision, with suitable after-treatment.

A chronic phlebitis that produces such lesions as varices will be dealt with under its proper head.

INJURIES OF VEINS.

=Rupture of Veins.=--Rupture of small veins is the inevitable consequence of every injury sufficiently serious to be in any sense disabling, its visible expression taking the form at least of ecchymosis, sometimes of distinct hematoma. Again, after long-continued pressure by which return of venous blood is prevented, certain degenerations take place in the vein walls which lead to their yielding on apparently trivial provocation; thus veins situated distally to large aneurysms sometimes give way, while the frequency with which they rupture in large varices of the limbs and in hemorrhoids is everywhere recognized. In the days when venesection was so frequently practised, usually at the bend of the elbow, a traumatic communication between the artery and the vein was frequently produced, with consequent anastomosis. When this was direct, the vessels being in contact with each other, it was an _aneurysmal varix_. When there was more or less of an intervening sac, through which the blood flowed from one to the other, it was spoken of as a _varicose aneurysm_. Save in rare cases produced by puncture or gunshot wounds such lesions are curiosities. Should operation be required the sac, if there be one, may be extirpated, or the vein may be ligated above and below the communication. (See above.)

=Air Embolism.=--Air embolism may follow injury to the large venous trunks, especially about the head and neck. This term implies the entrance, by aspiration, of air into the veins, its bubbles being carried along to the right side of the heart, where they are supposed to more or less interfere with its action. Sometimes at the instant of the accident a sucking or gasping sound may be heard. Formerly the condition was considered alarming, but now it is almost a bugbear. It is probable that minor degrees of the accident often occur without perceptible alteration in heart action. Serious disturbance, however, is possible, especially if the longitudinal sinus or the common jugular be extensively opened, and the patient’s head is above the level of the body at the time. Such an accident might call for artificial respiration, and it has been suggested to aspirate the right side of the heart. When its danger can be foreseen precautions should be taken by pressure on the proximal side of the injury. Air embolism is said also to have followed parturition, and even exposure of veins in the stomach by the ulcerative process. (See p. 38.)

=Treatment.=--Most injured veins can be tied _in situ_ and their function left to the collateral circulation. Fear is sometimes felt about the axillary and the femoral veins, and serious discussions have arisen as to whether amputation might be called for should these large channels be so injured as to be made useless. Experience has shown that either of them may be ligated, with nothing worse than temporary edema of the limb beyond. Should there then occur, by accident or during an operation, an opening of these venous trunks one may apply the ligature, if necessary. Before resorting to this, however, one may consider the advisability of the application of a fine _suture_ to the margins of the wound in the vein, which has become a standard procedure, or, if the opening be small, and it can be seized with a hemostat, it may be left _in situ_ for two or three days, closing the wound around it, and so supporting and protecting the part with dressings that it shall not be disturbed. A small forceps or its equivalent may thus be left upon a cranial sinus, a jugular, subclavian, axillary, femoral, or other vein without jeopardizing the result.

VARICES AND PHLEBECTASES.

The term _phlebectasia_ implies an extensive affection of a portion of the venous system, characterized by more or less uniform enlargement of all its veins. A similar involvement of isolated veins is usually spoken of as _varix_. These conditions may be congenital or acquired. Fig. 182 illustrates a congenital varicose condition occurring in a lad aged sixteen years. Such a lesion may be explained by congenital defect in some of the deeper veins, thus compelling the venous blood to return through the more superficial channels. These congenital lesions are more common in the lower extremities, but may be seen in all parts of the body. Varices, also, by virtue of their exciting and contributing causes, are most common in the lower extremities and in the lower venous terminals, as in the scrotum, the rectum, etc. Acquired varices usually imply previous lesion in the vein walls, sometimes inflammatory, sometimes toxic. The walls of the veins thus become at first atrophied, this condition being often followed by irritative hyperplasia, by which finally the veins become thickened and strengthened, and sometimes calcified. The enlargements are irregular and sacculations frequently form. In such sacculi thrombi may occur and be followed by calcification, the resulting concretions being known as _phleboliths_. These can often be recognized through the skin in old and chronic cases. Sometimes adjoining sacculi become confluent and there forms what is called an _anastomotic varix_. By such communications cavernous conditions are produced which, when placed subcutaneously, lead to peculiar and distinctive tumor formations.

[Illustration: FIG. 182

Congenital varices. (Park.)]

As already stated, the tendency to varices is indirectly the result of man’s assumption of the upright position, by which greater stress is placed upon the valves and the lower veins than they are prepared to bear. Naturally these conditions occur often in those who are constantly engaged in hard work upon the feet. Varices, then, are lesions, not so much of the leisurely and sedentary as of the active and working classes. Anything which predisposes to venous stasis may be regarded as a contributing cause--thus their relations with weakened hearts and obstructed lungs are indirect, but positive. Many women suffer in this way as the consequence of their first pregnancy, with its pressure upon the pelvic veins; while tight garters, corsets, and belts also predispose to overloading of the lower veins. Slight but almost permanent causes of this kind, through the influence of gravity, thus produce varices in the course of time.

To varices in certain locations have been given special names. To such a dilatation of the spermatic and pampiniform plexus has been given the name _varicocele_. When the hemorrhoidal veins are involved the condition is known as _hemorrhoids_ or _piles_. The former is often credited with being due to the anatomical arrangement of the left spermatic vein, through which blood is not as directly poured into the vena cava as on the right side, while the relation of chronic constipation, with its obstruction to the circulation in the rectal walls, will account for many cases of hemorrhoids, and the disturbance implied by the term cirrhosis of the liver will furnish an explanation for many others. A similar condition in the esophageal veins has given rise to the term _esophageal hemorrhoids_. Most indicative and extraordinary expressions of closing of deep circulation may be seen in some instances of intrathoracic and intra-abdominal diseases, _i. e._, cases in which the superficial veins of the chest and thorax become remarkably enlarged. Such expressions as these are to be regarded as natural efforts to obviate a difficulty, and no attempt should be made to eradicate such varices.

=Symptoms.=--In cases requiring surgical intervention, varicose veins present the following features, which are particularly indicative; they not only enlarge in diameter but elongate, and consequently have to assume a tortuous arrangement to accommodate their increased length; they cause a constant sense of fulness and discomfort, which often amounts to actual pain, especially after laborious effort. This pain is due to the distention of the venous trunks, to pressure upon cutaneous nerves, and often to disturbances of nutrition. In fact, nutrition is so often disturbed as to be accompanied by _skin lesions_, which begin as eczema and terminate in extensive ulcerations. So frequent is this association, and so distinctive its type, that such ulcers are frequently referred to as varicose. If the term be used to imply the association it perhaps may stand; if intended to typify a peculiar type of ulcer it is objectionable, as the ulcer itself is simply such as may happen on any surface whose nutrition is more or less perverted.

The most common causes of varicosities in the lower extremities are previous lesions, such as phlebitis following typhoid, injuries of the limbs or trunk, the pressure of tumors, fecal accumulations, garters or belts, laborious work in the upright position, and the possible complications of all cases from variation in the original anatomical arrangement of veins and their valves; pregnancy also should be added to this list.

The condition is rare in early life. Liability to it increases with age. Varices rarely occur in the upper limbs in connection with certain occupations or athletic sports, _e. g._, baseball and tennis.

The measure of the distention of veins can often be taken by the sensation of fulness and muscle cramp. In few surgical lesions do appearances give as much aid in diagnosis. This is particularly true of superficial varices. Varicosities of the deeper veins maybe suspected when patients complain of discomfort, pain, cramp, and swelling of the feet after hard work.

Varices would rarely lead to ulceration were it not for the superficial infections incurred in many obvious ways--sometimes by the finger-nails of the individual, who is constantly tempted to scratch or rub the area in which he feels such incessant discomfort.

=Treatment.=--Suitable treatment of varices of the internal veins, varicocele, hemorrhoids, etc., will be indicated in its proper place. In this chapter only _varices of the extremities_ will be considered. When a tendency to the varicose condition is noted early, and a cause can be discovered, removal of the cause may be all that is needed. When the condition is well established, and yet not sufficiently prominent to justify radical treatment, it should consist largely in support by bandages or elastic stockings, applied discriminatingly, with sufficient pressure to prevent undue distention and not sufficient to cause edema. It frequently affords much relief and prevents aggravation of the condition; on the other hand, once the veins become accustomed to this support they yield more readily upon its withdrawal, and the treatment by gentle constriction once begun, which is sufficient for many cases, can rarely be discontinued, even after a lapse of time.

A maximum of rest and elevation of the limb are requisite in the non-operative treatment of varicose veins. The compression exercised by elastic stockings is of only temporary benefit, and is simply such an assistance as is a crutch to a cripple. The less the patient remains upon the foot and the less he takes hot baths or indulges in other relaxing measures the better. Cold shower or tub baths are far preferable, with massage of the deeper muscles, the large veins being avoided. Such a patient should never walk slowly, but always rapidly, and rest as soon as fatigued. All diathetic conditions should receive attention.

When it is not possible to early and speedily remove the existing cause there is but one cure for varices, and that is by _radical surgical treatment_. A generation ago this was effected by the injection into the veins of perhaps one of the iron salts, in order to produce artificial and instantaneous thrombosis, by which later occlusion of the vein could be induced. The coagulating effects were decided, and so also were the effects of the germs introduced at the same time, in the absence of ordinary antiseptic precautions. Thus it resulted that the mortality, even after this trifling procedure, was tremendous and led to its abandonment. When it had been demonstrated, through Lister’s achievements, that the surgeon could be clean about such work, it was learned also that veins could be more radically treated than had been previously realized. With the advent of the antiseptic era came more effective and extensive operations upon veins. Now we know that with strict asepsis they can be handled with absolute impunity, and open methods of treatment have replaced the subcutaneous. No hesitation is at present felt in exposing the veins at one point, or numerous points, and applying ligatures; these, however, have been found to be less effective than a long incision made over a vein, with its complete _extirpation_. Thus the long internal saphenous should nearly always be excised, though it take an incision twenty inches in length, in order to take off the weight of its column of blood. It is ordinarily a simple matter to clamp and tie each branch as it is divided, and, after removal of the principal trunk, to bring together the entire incision with subcutaneous or continuous sutures. In the same way numerous incisions may be made in the leg. It is possible, however, to meet with so many enlarged veins that the surgeon may feel that he cannot thus eradicate each one. In such cases it is my custom to extirpate the principal trunk or trunks involved above, and then to combine this with _Schede’s suggestion to completely or partly circumcise the leg_, below the knee, down to the deep fascia, cutting across every vein and tying on each side those which bleed to any extent. After all these veins are ligated the incision is usually brought together again, as above. By this means all communication between the subcutaneous veins above and below the line of incision is cut off. Wound healing is accompanied by a temporary edema of the foot and leg, especially when these are held down, and by more or less numbness of the skin due to division of the cutaneous nerves; but circulation and nerve supply both rearrange themselves in time, and the result is usually satisfactory.[28]

[28] _Extirpation of the Internal Saphenous._--Keller has quite recently suggested a new method of extirpating these varicose veins without extensive scarring. He exposes the vein at two points a considerable distance apart, and ties above and below after separating it from its surroundings. The vein is then cut below the proximal end, the upper end of the section to be removed split and a strong ligature tied to it, care being taken to include no more tissue in the ligature than will pass through the lumen of the vessel. Then from the lower end a wire loop or probe is passed upward, a ligature is threaded into its eye and the probe is then withdrawn, carrying the ligature, after which traction is made upon the latter, the edges of the vein being inverted into its own lumen, it being thus extirpated by being turned inside out and withdrawn from its sheath. With the internal saphenous, when a slight puckering is seen about midway between the incisions, indicating that the anterior branch of the vessel has been reached, a third incision is made, the branch is ligated and divided, and then the traction renewed until the vein is entirely pulled through the lower opening. Several cases thus treated have been very successful.

Should ulcer, _i. e._, the so-called _varicose ulcer_, be present, it may also be attacked radically, and at the same time completely, by _excising_ the affected area, _with its indurated border_, down to the level of the deep fascia, and covering the surface thus denuded with Thiersch skin grafts from some other portion of the body. Should such an ulcer require treatment after this fashion it is best to attend to excision of the infected area first, in order to clear away all material which might harbor germs. The usual procedure, then, should be excision of the ulcer, extirpation of the veins, to be concluded by skin grafting. A limb thus radically treated should be included in a comfortable dressing, and then be affixed to some splint or other device by which absolute rest and repose may be maintained.

In milder cases, where no single large dilated vein seems to call for extirpation, it may suffice to practise Schede’s operation alone. Experience has taught this fact, that in dealing with extensive varices the surgeon is more likely to err on the side of leniency than on that of thoroughness.

VENOUS ANGIOMAS.

These have already been mentioned in the chapter on Tumors as constituting one variety of the angiomas. Many of them are of congenital origin. In many instances they produce erectile tumors. They frequently occur in the liver, in the thyroid, and other internal organs, as well as on the body surface.

A venous tumor, composed of good-sized veins, distended perhaps far beyond their normal capacity, constitutes a _compound varix_, of which the best expression is a hemorrhoid or a varicocele. Another form is composed almost entirely of capillary veins, which are increased not only in size but also in number. These constitute the growths called “_mothers’ marks_,” “_strawberry growths_,” etc. Technically they are _venous nevi_, which vary in size from trifling lesions to large tumors of varying shapes. These growths are always most conspicuous about the hands and face, because these are the visible parts of the body. They may, however, occur at any point, but mainly about the face and the orbit. A diffuse form, whose area may be almost unlimited, but usually circumscribed, is that called “port-wine mark,” which occurs more frequently about the face. It has been attributed to mental impressions during pregnancy, but there seems little to justify this view. The affected surface is sometimes pigmented and generally more hairy. Surface markings of this kind may accompany that form of neuroma described as plexiform neuroma. Fig. 183, from Holloway, illustrates another form of congenital growth of this kind. These growths rarely occur in the nasopharynx, where they not only obstruct but are sources of actual danger from hemorrhage.

[Illustration: FIG. 183

Congenital venous nevus. (Holloway).]

=Treatment.=--The most satisfactory treatment of a limited growth of this kind is _excision_, especially if this can be made at an early age. The resulting scar will be smaller, the healing more prompt, and the result in every way better. When excision seems impracticable _electrolysis_ should be employed, one or both poles of a galvanic battery of six to ten cells being connected with needles, which are inserted directly into the growth, and whose position is constantly changed, so that the coagulating effect of the electric current may be equably distributed throughout the growth. Occasionally the growth may be so shaped as to permit of _ligature_, and it is best employed either with or without the use of a needle, after which it may be excised or will slough off. This is essentially one method of treating external hemorrhoids. Methods by injection of coagulants are all open to serious objection, are hazardous, and should be abandoned. A port-wine mark may be sometimes treated by a tattooing process, which should, however, be practised with strict antiseptic precautions. Electrolysis may also be practised over a small area at a time. The more destructive method, by use of the cautery, is likely to leave scars almost as conspicuous as the original condition. Occasionally a lesion of this kind will be so shaped and placed as to justify excision with an autoplastic operation.

##