FIG. 128
Transplantation of a portion of the anterior tibial tendon, into the
bone or into the opposed group of muscles. (After Vulpius.)]
So far as technical considerations are concerned these operations
should be performed only with the minutest attention to asepsis. When
this has been secured a permanent dressing may be applied, the limb
being left in the position most desired, and maintained there for
several weeks. For this plaster of Paris makes the best support. The
use of the rubber bandage will permit the operation to be bloodlessly
made, by which it is greatly facilitated. If careful suturing be
practised, there will be but little tendency to subsequent oozing or
interference with repair. Fine discrimination is always needed in the
matter of adjusting the length of tendon ends and the point of their
fixation. A useless tendon which has been long stretched over a curved
joint will have become elongated, and the tendon to be applied to it
should be affixed farther down than would be otherwise necessary. The
disposition of the upper portion of the useless tendon and muscle may
also call for serious attention. It is rarely necessary to extirpate
them. They are already atrophied, and to remove them would be to still
further reduce the dimensions of the part. The excluded portions can
thus be simply discarded. When there has been deformity with more or
less pseudo-ankylosis the malposition should be forcibly redressed and
the tendon grafting deferred until a subsequent time; the latter, to be
successful, should be performed alone.
Incisions are usually made along and over the course of the tendons to
be exposed, but not so close that the cutaneous scar can interfere with
the tendon sheath. The lower end of a paralyzed muscle will appear very
differently from that of one which is healthy; in the former instance
the tissue will have lost its muscular character, and will be yellowish
white and fatty. A fascia which has been stretched out of shape may be
sutured in folds and will serve of itself to give support and shape to
the part which is renewed.
The methods of uniting tendons are so numerous that they can be better
estimated by a glance at the accompanying diagrams after Vulpius than
by description (Figs. 124 to 128). It is not necessary to utilize all
of the tendon of a healthy muscle, as it can be split and a portion
diverted to its new function. It is not to be expected that tendons
thus arranged will perfectly serve their purpose the first time they
are used. There must elapse a period of education of the nerves and
muscles whose relations are thus altered, and improvement in the use of
the parts thus operated will accrue for months and even years. It is
desirable that tendon surfaces thus applied to each other be made broad
and extensive in order that their adhesion may be more firm.
[Illustration: FIG. 129
Showing methods of lengthening tendons. (Burrell.)]
A modification of tendon grafting consists in implanting the tendon
end into the periosteum instead of into some other tendon. There are
various ways of making this implantation, either by simple suture or
by boring into the bone or canalizing under a periosteal bridge. Fig.
129 illustrates how the tendon of the tibialis anticus can be utilized
in both ways. It will thus be seen that a tendon can be given either
tendinous, periosteal, or osteal implantation. Tendons thus utilized
rarely undergo necrosis or degeneration. So long as the possibility
of infection be excluded almost anything can be done with these
structures, in spite of their apparent lack of vascularity and vitality.
There are times when it is necessary to _lengthen a tendon_ as well
as to shorten it. Fig. 129 illustrates methods by which both of these
measures can be performed. Analogous methods have been practised with
muscles themselves, although here the circumstances are different and
nothing similar can be accomplished. Portions of the pectoralis major
have been grafted into the biceps for paralysis of the latter.
_Liberating the ring finger in musicians_, by dividing the accessory
tendons of the extensor communis digitorum, is an expedient suggested
some years ago by Brinton. It is made by an incision less than a
quarter of an inch long, through the skin and fascia, just below the
carpal articulation of the metacarpal bone of the ring finger, and
above the radial accessory slip, parallel with and on the radial
aspect of the extensor tendon of that finger. The point of a narrow
blunt-pointed bistoury is then inserted flatwise beneath the accessory
slip down to a point just in front of the knuckles of the ring and
middle fingers, where the blunt point should be felt beneath the skin.
The bistoury is now turned upward, the middle finger strongly flexed,
and the ring finger extended so as to make the slip tense when it is
divided. The accessory slip on the other side of the extensor tendon
is similarly divided through a distinct incision. Snug compression is
made with a bandage over the wounds, with the thumb free, and after two
days the patient is permitted to use the fingers in piano-playing in
order to prevent reunion of cut surfaces.
MYOTOMY AND TENOTOMY.
Myotomy is a measure seldom practised. It is performed either
subcutaneously or by open incision. _Tenotomy_ is indicated whenever
contracted tendons need simply to be divided, either in chronic
orthopedic cases or after injuries or operations when it is desired
to put muscles temporarily at rest. The tendo Achillis has thus been
divided to prevent the consequences of muscle spasm when dealing with
certain fractures, especially compound fractures of the leg. There are
obvious advantages obtaining in subcutaneous tenotomy when properly
performed; the freedom from hemorrhage, the minuteness of the opening,
the rapidity of healing, are all in its favor. It is performed with
a small-bladed knife, known as the tenotome, with either sharp or
blunt point, the cutting portion being from 1 to 2 Cm. in length.
The sharp-pointed tenotome suffices for its own insertion, the blunt
one being used after an opening has been made with a sharp one. The
puncture is made obliquely through the skin, which should be drawn
a little aside from the site of the deeper opening in order that it
may be hermetically closed as it slips back into place. Whether the
cutting blade should be turned outward or inward will depend largely
on the preference of the operator and the location of the tendon. In
some locations, as about the hamstring tendons, the puncture should be
made with the sharp instrument and the deeper tenotomy with the blunt
one. If the tendons alone have been divided there will be trifling
hemorrhage and the puncture can be occluded without entrance of air.
Similarly an _aponeurotomy_ may be performed. Not only may the tendons
be divided by the open method, but everything else which resists. This
is practised more in contracted knee-joint and in club-foot, when
operated on by Phelps’ method, than anywhere else. Special indications
for the operation will be given in other parts of this work.
GANGLION.
This term is applied to a cyst of new-formation, which occurs in
connection with the sheath of a tendon, having a lining membrane
continuous with the sheath and containing thick, gelatinous, mucoid
fluid. It is termed “_weeping sinew_.” It is often seen on the back
of the wrist in connection with the extensor tendons, but may occur
in various parts of the body. It probably begins as a hernia of the
synovial membrane through a weak spot in the tendon sheath, which tends
to increase in size, weakening surrounding structures by pressure,
and interfering more or less with the function of the tendon whose
sheath is involved. These cysts sometimes connect with joint cavities,
especially those occurring behind the knee-joint; as a rule, however,
they do not. At first they constitute merely a disfigurement; later
they produce natural impairment of function. In the majority of cases
the sac becomes finally shut off from the tube with which it originally
connected.
When these lesions are new they may be successfully dealt with by
forcible rupture, such as can be made by firm pressure. When old, or
when rupture has failed, they should be treated by incision, practised
the same as a tenotomy, by moving the skin to one side, pricking the
sac, turning the blade of the tenotome so as to permit the fluid to
be emptied by pressure, and then, by manipulating the point, irritate
and do some damage to the sac lining. Such provocation as this will be
followed by a hemorrhage, and the resulting clot may obliterate the sac
by organization and cicatricial contraction. This failing, excision is
the only expedient which promises success. The slightest operation upon
a ganglion should be done under aseptic precautions.
FELON, OR WHITLOW.
Felon, or whitlow, was discussed in the previous chapter, especially
the form which has its origin around the root of the nail. It often
originates in tendon sheaths and even in bone or close to it. It is so
often accompanied by a suppurative _thecitis_, _i. e._, tendosynovitis
of destructive form, especially when not primarily incised, that the
necessity for early treatment needs to be emphasized. It gives rise
to excessive pain, with throbbing, and to swelling of livid hue and
intense degree. The parts involved are too essentially fibrous and
resisting to yield, hence the intensity of the pain. Deep incision at
the earliest moment, for the purpose of relieving tension, is the only
proper treatment. To temporize with hot poultices, etc., is to invite
necrosis and sepsis. This incision may be made with local anesthesia.
Even though little pus be obtained the relief of tension will afford
the greatest comfort (Figs. 130, 131 and 132).
[Illustration: FIG. 130
Felon of thumb. (Burrell.)]
[Illustration: FIG. 131
Neglected suppurating thecitis resulting in palmar abscess. (Burrell.)]
[Illustration: FIG. 132
Same, dorsal aspect. (Burrell.)]
A more striking example of similar trouble is that which gives
rise to _palmar abscess_, the suppurative process extending up the
wrist beneath the annular ligament, and down into the little finger
and thumb. This is not infrequently the result of infection of
callosities in the palm of the hand. Infection may travel rapidly,
and when confined beneath resisting structures will prove exceedingly
destructive; the muscles of the forearm may melt down and great
permanent damage be done.
Here, as when the finger alone is involved, early, free, and deep
incision will prove the salvation of the part. These incisions should
be made as indicated in Figs. 133 and 134, _i. e._, parallel with the
nerves, tendons, and vessels, all of which should be spared, as well
as the palmar arch. Should the latter be divided, the vessel ends may
be ligated or the wound packed. If cavities be left by the destructive
process they should be opened and the part treated by continuous
immersion in warm water, or the openings may be packed with gauze
saturated in brewers’ yeast. A few days of this treatment will clean up
all sloughs.
[Illustration: FIG. 133
Diagram of palmar incisions.]
[Illustration: FIG. 134
Diagram of dorsal incisions. (Burrell.)]
SURGICAL DISEASES OF THE MUSCLES.
CONTUSIONS OF THE MUSCLES.
Muscles react like other tissues under the influence of contusions.
Hemorrhages not too copious are gradually absorbed, and muscle tissue
repairs itself, as indicated in the chapter on Wounds and their Repair.
Much outpour of blood into a muscle will temporarily seriously impair
its function, while pigmentation or ecchymosis may result after a few
hours or days, according to the depth of the injury. There is the same
liability to suppuration after infection of muscles as elsewhere. A
large hematoma can scarcely form within a muscle, save in consequence
of a rupture of a considerable portion of its substance. _Strains_ and
_sprains_ of lesser degree of violence provoke impairment of function
proportionate to their severity. In nearly every instance there is a
certain amount of rupture of muscle fiber and outpour of blood.
RUPTURE OF THE MUSCLES.
Complete rupture across a muscle is unusual. It may occur in the belly
of the muscle or near one of its terminations. A tendon may be torn out
of a muscle or may itself snap. These accidents are almost invariably
accompanied by symptoms that indicate both the nature and location of
the injury. A severe strain followed by intense pain, with a sensation
of yielding, leaves little doubt as to what has happened. Unless the
muscle lie deeply its parting may be appreciated by palpation, though
the depression or interval may be obliterated by the outpour of blood.
The large tendons of the arm and shoulder have been ruptured by a
violent effort, the abdominal muscles by contusions and by such efforts
as wrestling, the sternomastoid by excessive traction during forceps
delivery, and the tendons of the legs and ankles by jumps during such
games as lawn tennis, etc.; while the frequency with which the muscles
of the perineum and even the sphincter ani are torn during parturition
is well known. It is also well known that muscles are weakened by the
exanthemas and the infectious diseases.
=Treatment.=--An injury of this kind and of moderate degree seen early
may be treated by physiological rest and position. (See chapter on
Treatment of Wounds.) When, however, there is marked impairment of
function, such as will follow the yielding of one or more tendons or
muscle insertions, then suturing offers the greatest promise of a cure.
When the quadriceps tendon is torn away from the patella or the tendo
Achillis from the heel, prompt suture under aseptic precautions will
save a long period spent in partial recovery of function.
Occasionally one or more tendons will be completely _avulsed_, as when
a finger is torn out of the hand and brings with it one or more of the
tendons belonging to it. In accidents of this kind six to twelve inches
of tendon and muscles may be lost. In such a case nothing can be done
except to care for the wound resulting from the injury.
DISLOCATION OF TENDONS AND MUSCLES.
Tendons and muscles are occasionally dislocated, that is, forced from
their normal positions. Accidents of this kind usually occur with the
long tendon of the biceps, which is torn from its bicipital groove;
the peronei and the posterior tibial in the leg, the extensor muscles
of the thigh, and those of the back of the wrist. The lower angle of
the scapula is normally held down by a small portion of the latissimus
dorsi; should this be displaced the scapula rises somewhat in wing
form. These injuries lead to more or less loss of function, and, when
they become disabling, may justify operation, which would include
incision, exposure of the tendon in its abnormal position, and its
restoration to its proper place where it should be held by sutures.
Such operation should be followed by enforced physiological rest of the
part.
HERNIA OF MUSCLES.
Hernia of muscle is the name applied to the escape of muscle through
a ruptured fascial or aponeurotic covering. Such a protrusion will be
recognized only during the contraction of the muscle and will disappear
at other times. When the diagnosis is made the edges of the rent in the
fascia should be united by sutures and the part put at rest.
WOUNDS OF MUSCLES.
Wounds of muscles in no way differ from other wounds which have
been considered in the chapter on Wounds and their Treatment. If
circumstances permit there is every indication for the suture of a
divided muscle in order that its function may be less impaired after
the wound is healed. These sutures, when inserted, should be made to
separately include the divided fascia or aponeurosis with which the
injured muscle is in relation.
MYALGIA.
There are numerous painful affections of muscles known as _myalgia_.
It is questionable whether a rheumatism of muscle fiber ever occurs.
That which patients describe as muscular rheumatism is not that which
it is termed. Sometimes it is the result of previous exudate between
muscle fibers, sometimes the result of hemorrhage of interstitial type.
Muscles thus affected are more or less tender and give pain when used.
It will usually be found that there is some marked toxic condition,
such as uric acid, syphilis, or lead poisoning, behind it.
=Treatment.=--Many of the muscle pains of which patients complain after
operation, which are also toxic, are relieved by the administration of
aspirin in 0.5 Gm. doses. The injection of a small amount of atropine
into the body of the muscle will often give relief. Those remedies
which hasten elimination, including hot baths and massage, are often of
great value.
MYOSITIS.
This may be _non-inflammatory_ and be due to prolonged use of a member,
as in writers’ cramp; or _toxic_, as in lead palsy; or _traumatic_,
caused by minute lacerations and hemorrhage. The more acute forms may
be due to extension from neighboring foci or to direct infection. A
form of infection involving both muscles and tendon sheaths, and lately
recognized, is the postgonorrheal. It has been shown that _gonorrhea_
may produce an active disturbance in synovial sheaths and in muscle
structures and a _gonococcus myositis_, as well as a _gonococcus
tendovaginitis_, are now well recognized. These do not always proceed
to suppuration, but may provoke loss of function for some time.
The suppurative form of myositis is seen more often after typhoid and
gonorrhea than after the other internal infections, but may occur after
any of them. In these cases abscess results in the belly of the muscle
involved, while the pus evacuated will show the appropriate organism.
It is met with less often in endocarditis and erysipelas.
Any or all the active and destructive infections may occur primarily in
muscle structure. They are usually the result of an extension, although
they maybe even in this way very disastrous. The amount of muscle
destruction that may be seen in a limb after an infected and neglected
compound fracture is astonishing.
=Myositis Calcificans.=--Calcification and ossification of muscles
are alike due to deposition of calcium salts, but under different
circumstances. _Myositis calcificans_ may be the result of tuberculous
disease following caseation, as it does in lymph nodes and in other
parts of the body, or occurring as a general deposit throughout the
muscles, essentially an infiltration, as is seen in the muscles of the
legs. _Myositis ossificans_ implies a formation of true bone in muscle
substance. A peculiar form arising in the adductor longus results from
the pressure of the limb against the saddle; this has been known as
_rider’s_ or _cavalryman’s bone_. Something similar in the deltoid
has been called _drill bone_, because usually seen in soldiers who
carry their weapons upon the shoulders; while a form which occurs in
the brachialis anticus has been referred to as _fencer’s bone_, and
one in the calf muscles as _dancer’s bone_. It occurs in two types,
one of which is characterized by ossification in succession of the
various muscles, this occurring first in the trapezii, latissimi, and
rhomboidei. In explanation of these lesions, it has been suggested
that all of these connective mesoblastic tissues may manifest certain
atavistic tendencies and thus revert to bone. The question is certainly
not one of periosteal origin. Binnie has shown, in a remarkable case
reported by himself, that ossification is both of the fibrous and
cartilaginous type. Only in the localized forms can the periosteum be
suspected. In these it may be that there has been detachment of some
of its tissue or escape of some of its cells into the muscle area.
The ossifying lesions of surrounding muscles will sometimes interfere
with the motions of joints after they have been injured. Any localized
calcareous or ossific deposit which can be recognized may be removed.
=Myositis Syphilitica.=--This occurs in gummatous form, no muscles
being exempt; those of the tongue are most frequently involved. It is
seen also in the sternomastoid. Not infrequently these gummas have
been mistaken for malignant tumors. Sometimes they degenerate and
sometimes suppurate. A lesion of this kind will usually be multiple,
but it may have enough infiltration around it to be difficult of
recognition. Lesions of this kind are also seen in hereditary cases. A
more distinctively interstitial affection of muscles leads sometimes to
their contracture, as seen about the arms, beginning with malaise and
incoördination, and extending to disabling lesions. These will yield to
properly directed antisyphilitic treatment.
=Myositis Tuberculosa.=--This affection is usually the result of
extension from adjoining foci. As in the case of syphilis it may
assume the infiltrating or the gummatous type. It is more frequently
encountered than the muscular expressions of syphilis; it does not
yield nearly as readily to treatment, and calls for excision of the
affected area and for cauterization or other protection as against
re-infection.
PARALYTIC AFFECTIONS OF MUSCLES.
More or less permanent paralysis is sometimes the result of contusion
or direct injury of a nerve trunk. Thus the paralysis of the deltoid
which follows injury to the circumflex nerve in connection with
dislocations of the shoulder is a frequent accident. It does not
require continued pressure upon the nerve to produce this. It may
follow a dislocation reduced within a few moments. Again, paralysis
of the arm muscles is occasionally the result of pressure made by
crutches. It has been known to occur from similar pressure while the
patient was upon the operating table with his arm hanging over the
table’s edge. This is an accident which should be carefully avoided.
Moreover, it follows sometimes from mere violent muscle effort. The
condition, while simple in its etiology, is difficult and sometimes
impossible to cure.
=Treatment.=--The treatment should consist mainly of massage and
electricity, with the elimination of all possibility of toxemia. The
resources of tendoplasty (see above) should also be considered, as well
as those of neuroplasty.
ATROPHIES AND CONTRACTURES OF MUSCLES.
Muscular paralysis is always followed by atrophy, which will lead
to marked diminution in size of the part; when the atrophy concerns
a single muscle or muscle group it will frequently be followed by
deformity due to action of the opposing muscles. Tonic spasm of muscles
unopposed may lead to contractures, often with ankylosis. The degree of
deformity which is produced may eventually require amputation of a limb.
Other forms of contractures are produced either as the result of
central or spinal scleroses or as expressions of irritative spasm
provoked by a neighboring bone or joint trouble. The two types may
cause similar deformities, which vary widely in their etiology. The
former are seen in certain cases of brain and spinal-cord diseases, the
latter especially in connection with tuberculous arthritis. Inasmuch as
the flexors are stronger than the extensors these deformities consist
largely of hyperflexion. Ultimately the shape and growth of bones and
the nutrition, appearance, and function of the part are influenced.
Muscle atrophy which is the result of confinement in one position, as
after the treatment of fractures, is of minor importance and tends to
disappear spontaneously as soon as function is resumed.
=Treatment.=--In most of these instances patience may be easily
overtaxed while waiting the tardy results of massage and such
correction as apparatus may afford. Very frequently the additional help
of an anesthetic, with forced movements, often with tenotomies and
sometimes with tendon grafting, will be required. When contractures
can be foreseen, as they may be in connection with many lesions which
produce them, such as burns and others not specifically mentioned, they
should be guarded against by splints, apparatus, or whatever may best
serve the purpose.
PARASITIC AFFECTIONS OF THE MUSCLES.
The parasitic affections of muscles are rare. Trichinosis rarely
produces tumors which come under the surgeon’s hands. Still there may
result from it a form of myositis with formation of cysts which may
so far interfere with muscle function as to demand removal. _Hydatid
cysts_ and _cysticercus_ are extremely rare, especially in this country.
DISEASES OF THE BURSÆ.
There are two types of bursæ in the body: first, the _subcutaneous_,
or _mucous_, which are loose sacs containing a clear mucoid fluid.
They develop regularly when bony prominences are exposed to friction
and develop adventitiously wherever undue irritation is produced. Thus
beneath every _bunion_ there will be found a good-sized and thickened
bursa.
_Synovial bursæ_, the second type, are met with in close proximity to
joints, and between tendons which play upon each other. They frequently
communicate with the joint which they overlie, and infection may easily
spread from one to the other. They are liable to traumatism, either
extrinsic or intrinsic, the former from chafing or more direct injury,
the latter by excessive muscle exertion. When infected they suppurate,
forming abscesses of conventional type. As the result of contusions
they are frequently filled with blood, in which case there is a _bursal
hematoma_. _Acute bursitis_ usually merges into localized abscess.
[Illustration: PLATE XXX
Foreign Body (Broken Needle) in Foot. Buffalo Clinic. (Skiagram by Dr.
Plummer.) Illustrating the Value of this Method of Exactly Locating a
Foreign Body and involving the Tissues Considered in Chapter XXVIII.]
[Illustration: FIG. 135
Hygroma of a prepatellar bursa (“housemaid’s knee”). (Lexer.)]
_Chronic bursitis_ constitutes a circumscribed collection of fluid,
often with thickening of the bursal sac, and frequent deposition
of products of exudation. Here, too, pus may form as the result of
infection, while calcification sometimes takes place in old cases. A
chronic bursitis is likely to be either of syphilitic or tuberculous
origin. It is usually seen beneath old bunions, and in the prepatellar
bursa, which is equally exposed to irritation, and which also gives
rise to _housemaid’s knee_. This lesion used to be considered as always
of syphilitic character, but this is far from correct.
_Hygroma_, or _hydrops_, is a term frequently applied to these
localized collections of fluid. The former is more likely to be of
tuberculous origin, and the retained fluid may contain rice-grain
bodies. A chronic bursitis, originally of traumatic origin, may become
infected and present a tuberculous lesion, or it may be influenced
if not caused by a syphilitic diathesis, especially about the knee,
where these conditions generally occur. Other bursæ which produce
disturbances that eventually take the patient to a surgeon are met with
in the following locations: _beneath the ligamentum patellæ_, which
will give a prominence on each side of the ligament, particularly when
the knee is flexed; _over the tubercle of the tibia_; _beneath the
quadriceps extensor tendon_, which will cause a swelling two or three
inches above the upper border of the patella; _between the tendon
of the semimembranosus and inner head of the gastrocnemius_, which
will present in the popliteal space as a somewhat globular swelling;
_beneath the deltoid_; _beneath the gluteus muscles_, where the tendons
pass over the great trochanter; _between the tendo Achillis and the
calcis_; _over the outer malleolus_, occurring in tailors by virtue
of the position in which they work. Large bursæ often develop on the
_outer sides of club-feet_, on the ends of amputation stumps, and
wherever there is prolonged irritation of mild degree.[21]
[21] A bunion is in many instances due to flat-foot, causing the
great toe to turn out. This condition should be remedied by the usual
arch, or raising the inner border of the shoes. Four out of the five
tendons attached to the great toe tend also to draw it outward. If
the tripod of the foot can be restored without operation this should
be done.
The treatment of acute bursitis is that of threatening phlegmon in
any other part of the body. As soon as the presence of pus can be
determined, or even before, a free incision should be made. Such an
incision should not be entirely closed after evacuation of the sac, but
should be permitted to heal by granulation.
Chronic bursitis, whether with or without formation of granuloma, is
best treated by _excision_, when the sac has become thickened and a new
formation has practically occurred. Housemaid’s knee, for instance,
like bunion, is more satisfactorily treated by a clean excision of
all diseased tissue than by any other less radical method. Every
tuberculous lesion of this kind should be rigorously extirpated, and
every syphilitic lesion should be treated by constitutional as well as
by local measures, the former being, save in exceptional instances, the
more important of the two.[22]
[22] _The Radical Cure of Bunions._--The term bunion is generally
used to indicate a painful swelling over the inner aspect of the
ball of the great toe; it is never seen on the feet of those who go
barefooted, but is the result of badly fitting shoes, almost all
of which crowd the great toe outward, thus making its base more
prominent and exposing it to irritation and pressure. The inner
border of the foot is nearly a straight line, but shoes are rarely
made to conform to this. The result of the consequent partial
dislocation of the toe, and of the pressure made at its base, is
chronic periostitis, and the development of a bursa. It becomes
greatly thickened and forms a small tumor, usually sensitive and
painful. The dislocation often proceeds to such a degree that the
great toe lies across the others, either over them or under them, in
such a position as to receive and deserve the name _hallux valgus_,
which is generally given it when this is pronounced. There is nothing
to do but to exsect the head of the first metatarsal bone, and at the
same time excise the bursa and some of the overlying and thickened
skin.
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.