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.

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.

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.

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.)

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]

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).

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).

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.

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).

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).

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.

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).

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.

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.)

The Anterior Tibial Artery.

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

THE VEINS.

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

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

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

PHLEBITIS.

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

Acute Phlebitis.

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

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

In most of the surgical infections acute phlebitis has an extravascular origin, the lymphatics of the outer wall communicating the infection to the inner coats, and so distributing it that coagulation occurs, after which the path of infection from the containing veins to the contained clot is direct. The thrombi thus formed may completely or only partially occlude the vessel. As a continuation of the lesion we have infiltration and separation of the coats of the vein from each other, and finally their necrosis. Thus in the terms of the pathologist an acute phlebitis may lead to a phlebitis desicans, and this to phlebitis gangrænosa. In every case where the patient survives such conditions as these the veins lose their identity and become obliterated by the very violence of the process in which they have participated.

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

Chronic Phlebitis.

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

Symptoms.

—Phlebitis may occur without known cause or may follow as an expected result from deep or surface lesions. The deeper the involved veins the more obscure the case. Involvement of superficial veins, especially in acute cases, is easily made known by the dark-bluish or dusky red cord which occupies the place of the previously healthy vein. As its contained clot becomes firmer the clot becomes harder. This is accompanied by more or less fever, with extreme tenderness, often pain. If a single vein only be involved the disturbance will be quite local; if thrombosis be general there will be edema of the parts to which the vein is distributed. Involvement of certain veins implies the establishment of a collateral circulation through others. If there be no others available then danger from venous insufficiency threatens, and it may not be possible to avert gangrene. “Milk leg,” or so-called phlegmasia alba dolens (“painful white swelling”), is an expression of portal, pelvic, and femoral thrombophlebitis. In many instances in which it does not kill it may cripple the individual for life. Phlebitis of the deep veins can be inferred rather than detected. Phlebitis of the hemorrhoidal veins frequently follows inflammation and suppuration of piles, while that of the pelvic veins, especially the perivesical, frequently follows gonorrhea and prostatitis. Mesenteric phlebitis and pylephlebitis frequently follow the ulcerative infections of the intestines, while in the newborn a phlebitis of the umbilical vein plays an important part in the mortality of infants. The cranial sinuses are likely to be affected in connection with middle-ear disease, while in acute osteomyelitis there are distinctive pictures of the lesion in the veins of the bone and the marrow. No matter where the lesions may centre they are of the most serious character. The role of the veins in the production of metastatic foci has been described in the chapter on Pyemia. The danger attending the liquefaction of a thrombus and the escape of its fluid debris into the general circulation stamps an acutely infected clot with a dangerous character. This fact justifies such measures as are now pursued in connection with the cranial sinuses and mastoid disease, where there is not only a sinus exposed by removal of a portion of the temporal bone but the jugular opened low in the neck and the entire intervening channel freed from its putrefying contents by the probe and the irrigating stream. In other words, a recognition of the pathology of thrombosis and sepsis may lead to the performance of difficult operations.

Treatment.

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

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

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

INJURIES OF VEINS.

Rupture of Veins.

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

Air Embolism.

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

Treatment.

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

VARICES AND PHLEBECTASES.

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