the tumour, and thus intercepting or weakening the flow of blood into
the cavity, so as to allow complete coagulation to take place, is of
comparatively modern invention, and is the one now practised with
almost invariable success. To John Hunter without doubt belongs the
merit of proposing and putting it in practice; it has been claimed also
for the celebrated Desault. This operation has been variously modified.
Some have advocated the temporary application of a ligature, conceiving
that the effects produced will be as complete and permanent when it
has been allowed to remain only for a certain time, as when it is left
undisturbed and ultimately separated by nature. Such a theory, however,
has proved to be incorrect in most of the instances in which it has
been reduced to practice on the human subject; and the operation is
at best very uncertain, and not to be relied on. Others have employed
a double ligature, and some of the Continental surgeons have applied
a great many; some were tightened, others left loose, and looked upon
as ligatures of reserve to be tightened, should hemorrhage take place,
an occurrence likely enough to follow their clumsy and unsurgical
proceedings. A thick broad ligature like tape has also been used, from
an ill-grounded apprehension that all the coats of the artery would
be cut completely through by the tight application of a thin and firm
one. With the same view, a roll of linen or plaster has been interposed
betwixt the noose and the vessel, and this practice has been advocated
even by good surgeons—as Scarpa. Such complications can do no good,
and may do much mischief. The artery must be greatly detached from its
surrounding connections before the numerous and flat ligatures can be
applied, in consequence of which its coats will be apt to slough or
ulcerate, and hemorrhage occur. When, from any cause, the vessel has
been detached to a greater extent than is sufficient for the passing of
one ligature, two ought undoubtedly to be used, and one applied close
to each extremity where it is attached to the surrounding parts.
Again, it has been proposed, after the application of a double
ligature, that the vessel should be cut through betwixt the two
deligated points; it being supposed that in this way the closure of
each extremity will be more rapid, the cut ends retracting, and being,
in fact, in the same circumstances as the extremities of arteries
which have been tied on the face of a stump. Mechanical contrivances
have also been invented for the compression of the artery,—such as the
serrenœud and presse artere; these, however, are clumsy, insufficient,
and often injurious.
The single ligature, when properly applied, is the most safe, and
preferable to any other, for arresting permanently the flow of blood
in a vessel. In its application, the artery must not be separated from
its connexions farther than is barely sufficient for the passage of the
armed needle beneath it; but the external incision ought to be free,
in order that this may be readily effected, and that the operation
may be easily and speedily performed. By the firm application of a
single ligature, the vessel is rendered impervious; the internal and
middle coats are divided, so that the ligature only encircles the outer
or cellular one, which resists the influence of any moderate degree
of force by which it may be tightened. The blood coagulates above
the deligated point,—the coagulum is of greater or less extent, in
proportion to the vicinity of a collateral branch, and is of a conical
form, the apex of the cone pointing to the free portion of vessel.
Incited action in the vessel takes place at the deligated point; the
divided margins of the internal and middle coats secrete lymph, by
which they adhere, and so obliterate the canal of the artery. Lymph is
also effused on the external surface, and in this deposit the ligature
becomes imbedded. The direct influx of blood into the aneurismal sac
is thus intercepted, and time is allowed for coagulation of the blood
which it contains; the artery for a considerable distance below the
ligature becomes ultimately converted into a firm and impervious
chord. The coats of the vessel above the ligature are much thickened,
and the internal membrane is occupied with the transverse rugæ
occasioned by projecting fasciculi of the fibres, which are always
apparent after obstruction of an artery. If this operation be properly
conducted, success must almost uniformly follow. Before determining
on its performance, however, the state of the arterial system ought
to be examined as carefully as possible; for not unfrequently the
degeneration of the coats is almost universal, and therefore an artery,
or even arteries, may be diseased at more points than one; and if this
aneurismal diathesis exist, the patient may be found to labour under
an internal aneurism of the aorta. In such a case, an operation could
not with propriety be undertaken for the cure of the external aneurism;
there might be no inconsiderable danger of the patient’s death being
suddenly accelerated by the operation, the sac of the internal aneurism
giving way perhaps during its performance: such a circumstance has
actually occurred.
Ligatures composed of animal substance, such as catgut, have been
proposed as preferable to all others, on the supposition that they
would be absorbed, and occasion less irritation; the fallacy of any
such theory has already been adverted to. After the ligature has been
applied for some time, it induces ulceration of the external coat which
it envelopes, by which means it becomes detached from the vessel;
acting as a foreign body, and causing a slight degree of suppuration,
it makes its way by nature to the surface and is discharged. The
period at which it separates may be said to be from the tenth to the
twentieth day; sometimes sooner, seldom later. If, however, much of
the surrounding parts have been extensively included along with the
vessel, a longer period will probably elapse before the separation of
the ligature. One end only of the ligature should be cut away close
to the artery, the other being left hanging from the external wound;
perhaps it is even safer to leave both, unless a third knot is made
upon it; thus the extraneous body, when detached, can be gently pulled
at so as to hasten the separation: this must be done with very great
caution. When both ends are cut short, and the knot closed in, there is
a risk of secondary hemorrhage, from the ligature causing formation of
matter round it, perhaps detaching the vessel from its connections, and
causing ulceration of its coats.
The operation ought to be performed at as early a period of the disease
as possible. Some recommend that it should be delayed in recent cases,
with the view of allowing sufficient time for the anastomosing vessels
to enlarge, in order that the circulation may be more vigorous in the
smaller branches after obstruction of the principal vessel. Such delay
prolongs the patient’s sufferings, which are in many cases extremely
acute, and the precaution is altogether unnecessary, as has been amply
proved by experience. On the same principle, the previous application
of pressure to the vessel has been recommended; but few surgeons,
if any, are now afraid of trusting to the resources of Nature when
the principal vessel of a limb is obliterated, and that suddenly,
without previous dilatation of the anastomoses. Cases are on record,
in which the abdominal aorta has been completely obstructed by a
natural process, without much impeding the inferior circulation; and
in one remarkable instance of this description, the inconvenience was
so slight that the disease was not suspected during the life of the
patient, the lower limbs retaining their usual size and activity. In
plethoric habits it may sometimes be prudent to abstract blood, even
more than once, previously to the operation.
When the ligature is placed immediately below a collateral branch
of considerable size, a bloody coagulum is not formed, though
adhesion may occur; but if the excited action should extend to the
collateral branch, and its canal become thereby obliterated, a
coagulum is speedily deposited. In consequence of the enlargement of
the anastomosing branches, and the increasing circulation in them,
pulsation generally returns in the tumour, to a slight degree, some
days after the operation. This, however, is by no means a sign that
the operation has been ineffectual; for the renewed pulsation almost
always disappears in the course of a very short time. In one instance
only have I found it assume a more permanent and troublesome aspect; in
that case, it recurred about ten months after the performance of the
operation, but speedily disappeared under the careful use of a compress
and bandage.
On account of the aneurismal diathesis, it occasionally happens,
that after the cure of one aneurism, another appears in a different
situation; in two instances, I operated on both thighs, at a
considerable interval, successively and successfully, for popliteal
aneurism, in the same patients.[17]
When the tumour is so situated as not to admit of the application of a
ligature between it and the heart, it has been proposed to place the
ligature on the distal side of the aneurism, upon the supposition that
coagulation will occur within the sac in this case as after the common
operation.[18] The practice has been made trial of, but its expediency
appears very doubtful; neither has the success attendant upon it been
such as is generally supposed: the _post mortem_ examinations have been
very unsatisfactory in some of the cases. The application, indeed, of a
ligature in that situation can seldom be of any advantage, the artery
being already obliterated, in aneurisms of some standing, a long way
beneath the tumour; and it is, perhaps, from this circumstance that, in
such operations, great difficulty has been experienced in securing the
vessel, and that it has been thought necessary even to pass a needle
under a thick mass, somewhat in the situation of the artery. It would
appear, in some instances, that the artery when pervious had even
remained untouched, not being even exposed by the burrowing process
employed by some of the operators; and that if any vessel was tied, it
was not the trunk in which the disease existed. It would appear that a
very correct diagnosis had not been formed in some of the cases.
[Illustration]
The appearance of the vessel after the application of a ligature
above the tumour has been already shown. The obliteration of the sac
proceeds, in some cases, very rapidly; it assumes a harder feel,
decreases, and disappears; being connected with the vessel by means
of a dense impervious chord, to which condition that portion of the
artery has been reduced. The anastomosing vessels enlarge more and
more, carry blood freely from above to below the ligature, and thence
to below the tumour; some even passing to the latter situation directly
from above the ligature. Along with the muscular and other branches,
the neurilemmal vessels also become enlarged, and compress the nervous
filaments; and to this are to be attributed the annoying pains which
sometimes occur in a limb after the operation for aneurism. The
enlargement of the arteries of the neurilemma can be distinctly shown
by dissection.
Immediately after the operation, the circulation in the limb cannot
be so vigorous as before; its temperature is consequently diminished,
and it possesses less power of resisting the influence of stimuli. The
limb ought to be kept only moderately warm; for if too much heat be
applied, there is a risk of gangrene. The temperature afterwards rises,
and soon gets above the natural standard; the blood, from obstruction
in the internal parts, being chiefly determined to the surface. After
the collateral circulation has been completely established, the limb
regains its natural temperature.
Secondary hemorrhage is occasionally a consequence of this operation;
nor is it to be wondered at, should one ligature only be used, seeing
that this is often clumsily applied; the cellular tissue being
lacerated, and the vessel detached from its connections by the use of
blunt instruments, directors, and silver knives. When many ligatures
are employed and foreign substances placed in the wound, the patient
can scarcely be expected to escape profuse bleeding. If, however, the
operation by single ligature be properly performed, and the coats of
the artery be sound at the deligated point, the occurrence of secondary
hemorrhage must be rare. It generally supervenes when the ligature
is about to separate: at first there is a thin bloody discharge,
afterwards the quantity of blood is more copious; it is evacuated at
first in a gentle and continued stream, but afterwards _per saltum_,
and in profusion. The discharge not unfrequently stops for a short
time, but, on the circulation being excited, it again returns; and
the patient soon dies, unless active measures be practicable, and
immediately resorted to. Compression can be of no use; nor can
astringents, nor venesection, which I have actually seen practised in
such cases. The application of a ligature betwixt the heart and the
open point of the vessel affords the only chance of saving the patient;
the surgeon must interfere, and do what is in his power—he cannot look
on and see the patient bleed to death.
Occasionally the aneurismal sac deviates from its usual structure and
appearance. Sometimes osseous or calcareous matter is found deposited,
to a greater or less extent, in the substance of the parietes of the
sac, or between the laminæ of fibrin which it contains. The tumour
may also occupy unexpected situations, occurring after fracture of
the bones and laceration of an artery, and perhaps from more slight
external injuries. A disease of bone, somewhat resembling aneurism in
that tissue, will be afterwards noticed.
OF ANEURISM BY ANASTOMOSIS.
This disease is generally seated in the external cellular tissue. It
has been supposed to attack occasionally the internal organs; and
a case is related in which it was situated in the cellular tissue,
between the vagina and rectum. Frequently the congenital marks of
children, termed Nævi, degenerate into this disease: occasionally,
though very rarely, it occurs in sound skin and in adults. A good
case of this kind will be found in the _Practical Surgery_, p. 336.
When the cutaneous tissue is involved, the colour of the tumour is
a dark red, or inclining to purple; it is irregular on its surface,
and has a soft, spongy feel. Often it is raised distinctly above the
surrounding parts; at other times it is flat, scarcely prominent, and
seems to enlarge chiefly in a lateral direction. The skin is then
frequently unaffected; pulsation, in some instances, is perceived;
often, however, the tumour is of an inactive character, affords
no pulsation, and, on being handled, feels like a doughy, elastic
intumescence, appearing to be composed of a congeries of distended
vessels, in which the blood circulates slowly, and resembling varix.
The tumour is formed by enlargement, tortuosity, and increased activity
of the capillary and other vessels; in some cases the arteries are
chiefly affected, in others the veins. That such is its structure, can
be distinctly proved by dissection; the vessels are found enlarged to
many times their natural size, and their coats are much attenuated;
it is certainly not cellular, as some have supposed. The tissue is
similar to that of the cavernous and spongy bodies of the penis, and
has hence been named erectile. A natural structure of the same kind
is met with in the lower animals in different situations. The tumour
is much increased on the general circulation being hurried, as by
crying in children, by fits of passion, by the excitement of ardent
liquors or venery, and during or before the menstrual discharge. On
such occasions the surface frequently gives way, hemorrhage ensues,
and is often profuse; in females it sometimes takes the place of the
regular discharges. The tumour, in general, increases rapidly in
size, and bleeds from time to time; now and then, however, it becomes
stationary, even in circumstances where it could hardly be expected,
and remains so during the remainder of the patient’s life. Again, in
children, the surface of the tumour is not unfrequently ulcerated,
even to a great extent, without hemorrhage occurring; when such is
the case, the ulceration for the most part extends, with surrounding
induration and condensation of the parts. The whole or part of the
adventitious tissue may thus be destroyed; the parts cicatrise, and a
spontaneous cure is sometimes accomplished. In other cases, though the
disease is not extensive, frequent and most violent hemorrhage occurs.
A hemorrhagic tendency also occasionally occurs in affections of a
different nature,—a trifling sore pouring out blood on the slightest
touch. In some constitutions, leech-bites, trifling punctures, or the
extraction of a tooth, have been followed by dangerous hemorrhage. The
disposition very often exists in many members of the same family, and
is sometimes hereditary. Great trouble has been experienced in staying
the bleeding; large vessels have been tied without effect, and some
patients have even perished notwithstanding every exertion on the part
of the attendants. It becomes a difficult matter to treat surgical
diseases in such constitutions: openings cannot be made with the knife
for the evacuation of matter or any other purpose. A good case will be
found in the _Lancet_, 1838-39.[19] The same patient again presented
himself with a very large and deep abscess of the hip, which was opened
by caustic, though nearly one inch and a half from the surface. It is
not easy to account for this disposition to bleed so profusely, or
from slight causes. The blood is in a diseased state, probably as in
the patient here referred to, in whom it contained pus globules, and
coagulated slowly; there is probably also a want of tone in the vessels
themselves. Many such cases are on record. The cause, or causes, of
aneurism by anastomosis are also unknown.
In very slight cases of erectile tumour, or in nævus threatening to
assume an aneurismal action, cold and pressure are sometimes, though
very rarely indeed, sufficient for the prevention or removal of the
disease. The most effectual remedy is excision, though this can very
rarely indeed be had recourse to with safety; for when the disease is
extensive, the vessels in its neighbourhood are much enlarged, and
their action increased; so that any attempt to remove the tumour by
the knife is followed by profuse, and often an uncontrollable, flow of
blood. When excision is practicable, it ought to be accomplished by
cutting very clear of the disease; the tumour, like every other, must
be cut out, not cut into. If the incisions encroach on the substance of
the tumour, or are made in the immediate neighbourhood of the diseased
part, the tremendous bleeding which invariably ensues will convince
the practitioner of the impropriety of his conduct, and rashness of
the proceeding. Attempts have been made to arrest the progress of
the diseased action, by tying the principal arterial trunks entering
the tumour; but these have proved ineffectual, as might be expected,
considering the unusually free and numerous inosculations which then
exist. In a few instances, ligature of the carotid artery, on the same
side with a tumour on the face or head, has put a stop to the disease;
in the others, it has been unavailing.
When the tumour is so situated, or of such a size, as to render
the expediency of excision doubtful, it may often be safely and
expeditiously removed by ligature. In some cases the tumour is
prominent, so that it readily allows of the application of a ligature
around its base; in others, it is flat and broad; in which case, a
long needle, or needles, armed with a double ligature, can be passed
beneath it, and the ligatures can then be separated, and so disposed as
to cause sufficient constriction of the entire mass.—Vide _Practical
Surgery_, p. 331, 336. In many cases, incisions may be made with great
advantage, either before or after introducing the ligatures; the
diseased mass is thus more effectually included and strangled, and much
pain and deformity are avoided. The disease, however, occasionally
occupies such situations as are totally beyond reach. The application
of potass has been recommended; and this caustic is certainly
sufficiently powerful to destroy the diseased parts; but its use is
attended with danger from profuse hemorrhage. Superficial nævi may
occasionally be got rid of by the application of nitric acid, but it
requires to be applied over and over again; and, after all, some more
effectual means must probably be resorted to. Stimulating injections
into the substance of the growth have been sometimes employed. Cures,
it is said, have followed the use of setons, or the repeated puncturing
and breaking up of the tissue with a needle. None of these means are
to be depended upon. The cases are innumerable in which I have been
obliged to employ the ligature in an effectual manner, combined or not
with incision, where caustics, injections, puncturings, setons, and
even imperfectly applied ligatures, had been previously resorted to in
vain. Besides, in children there is as much resistance and crying, and
as much anxiety in parents, produced by a slight operation, as by a
more effectual one.[20]
OF INFLAMMATION OF VEINS.
Veins are very susceptible of inflammation, and the action is very
apt to extend along the coats rapidly; in some cases it reaches the
right side of the heart, producing most violent symptoms, and speedy
dissolution.
Inflammation in the venous, as in the other tissues, may terminate in
resolution. Otherwise, lymph is secreted, whereby the coats of the
vessel become thickened, and its internal surface agglutinated, causing
obliteration of the canal to a greater or less extent. Suppuration
also occurs, and the pus may be deposited in a cyst formed amongst
the coats of the vessels; or, as is most frequently the case, it is
secreted from the internal coat, and occupies the canal of the vein.
It then generally accumulates, its passage into the circulation being
prevented by a deposition of lymph sufficient to occupy the calibre of
the vessel betwixt the heart and the seat of the purulent matter. The
termination in purulent secretion is accompanied with a high degree of
constitutional irritation, and typhoid symptoms, more especially if any
pus finds its way into the circulation.
The integuments in the course of the inflamed vessel or vessels are of
a dark red colour, and great pain is caused by pressure. Often there is
a considerable œdematous swelling of the limb, occasionally followed
by the formation of unhealthy pus, diffused in the cellular membrane,
causing sloughing of that tissue, or of the soft parts more deeply
seated.
This disease generally follows an accidental wound or operation, as
venesection or amputation; it is also of frequent occurrence after the
application of a ligature to the extremity of a vein. Many patients
have died of this disease, induced by the application of a ligature
to the vena saphena major, for the cure of varix. Wounding of large
veins ought to be studiously avoided; and if wounded, the bleeding
from them should, if possible, be arrested by pressure. When from any
cause the extremity of a large vein in a wound is not closed, when it
is not plugged up by plastic matter, pus seems to enter it readily, and
by mixing with the circulating fluid causes dreadful mischief; great
constitutional disturbance accompanies the purulent deposits which
follow in the solid viscera and in the joints.
Inflammation of veins is a very unmanageable disease; the exhibition of
purgatives and antimonials will be prudent, in order to evacuate the
bowels, produce diaphoresis, and diminish the force of the circulation;
the pain will also be much relieved by the application of warm
fomentations to the affected part. General depletion is not admissible
unless at the very commencement of the disease, and local bleeding
must be had recourse to with very great caution; for by copious
abstraction of blood, gangrene may be induced, or at least hastened.
The limb must be altogether disused and elevated, the patient being
kept in a state of complete rest, and not exposed to any excitement or
anxiety. Blisters have been employed, but with no good effect. If the
vein is much distended, and it is evident that it contains a confined
accumulation of pus, it ought to be treated as a common abscess, the
matter evacuated by an incision, and various dressings employed,
according to circumstances. Such practice I have found successful, and
not followed by any untoward symptoms. The abscess is often limited at
each extremity by the deposition of lymph in the canal of the vessel;
and after the evacuation of its contents, the cavity contracts, and the
portion of the vessel which has been the seat of suppuration becomes
completely impervious.