THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF SAN FRANCISCO COUNTY MEDICAL SOCIETY 41 SURGERY OF THE BLOOD VESSELS sea- T IURGEEY OF THE BLOOD VESSELS BY J. SHELTONiHORSLEY, M. D, F. A. C. S. SURGEON-IN-CHARGE OF ST. ELIZABETH'S HOSPITAL, RICHMOND, VA.; A FOUNDER AND FELLOW OF THE AMERICAN COLLEGE OF SURGEONS; EX-PRESIDENT OF THE RICHMOND ACADEMY OF MEDICINE AND SURGERY; MEMBER OF SOUTHERN SURGICAL AND GYNECOLOGICAL ASSOCIATION, ETC. ILLUSTRATED ST. LOUIS 0. V. MOSBY COMPANY 1915 COPYRIGHT, 1915, BY C. V. MOSBY COMPANY Press of C. V. Mosbu Company St. Louis edicsi rsr v WC- TO MY WIFE THIS VOLUME IS AFFECTIONATELY DEDICATED Is 593015 PREFACE. To no department of surgical endeavor have Ameri- cans contributed so largely in recent years as to blood- vessel surgery. The first successful end-to-end suturing of a divided artery in man was done by Murphy, of Chicago, in 1897, when he united the femoral by his in- vagination method. The revolutionizing treatment of aneurisms by Matas, who devised endo-aneurismorrha- phy, is considered the most important advance in the therapy of this disease since the days of Hunter. The development of transfusion of blood by Crile, of Cleve- land, is another notable instance of the large share Americans have had in the progress of blood-vessel sur- gery. Halsted, of Johns Hopkins, introduced the prin- ciple of partial or gradual occlusion of an artery by means of malleable metallic bands. Finally, Carrel, an American by adoption, and his former associate, C. C. Guthrie, have carefully worked out the technique of blood- vessel suturing and were the first to place it on a stable basis. A monograph dealing with the various phases of blood-vessel surgery, and particularly with its recent developments, may prove of some interest in a country that has contributed so largely to its progress. It has been the aim of the author to present the scientific and the laboratory features of vascular surgery and particularly its practical aspects that may be of in- terest both to the surgeon and to the general practitioner. Therefore the treatment of hemorrhage, pathologic and traumatic, and such subjects as aneurisms, thrombosis and embolism, congenital nevi, varicose veins, and hem- 7 8 PREFACE. orrhoids are described as well as the history and tech- nique of suturing blood-vessels and transfusion of blood. Probably the most interesting surgical reading is an account of personal experience and original research. Whether the reader approves of the work or not, it may at least present the subject in a new light. It is for this reason that a good portion of the book is taken up with the original work of the author, who is fully aware that the importance of what he has done is not in proportion to the space it occupies. His methods of end-to-end suture of blood-vessels, of transfusion of blood, of lateral suture of blood-vessels, of suturing arteriovenous aneu- risms, of making an Eck fistula, of transplantation of the anterior temporal artery, and of resection or transplan- tation of intestine after embolism of the mesenteric arter- ies are therefore described in considerable detail. It is a most pleasant duty to return thanks to the sur- geons who have invited the author to demonstrate his method of suturing blood-vessels at their clinics, or in their laboratories. Among them are Dr. Donald Bal- four, of the Mayo Clinic, at whose invitation the author performed a transfusion of blood; Dr. A. A. Law, a similar operation being done at his request at the Uni- versity of Minnesota Hospital; Dr. W. L. Rodman, by whose courtesy the author lectured on blood-vessel sur- gery and demonstrated his method of suturing blood- vessels at the Medico-Chirurgical College, of Philadel- phia; Dr. A. D. Bevan, who kindly arranged for a demonstration of this technique on animals at the Eush Medical College; Dr. J. Frank Corbett, at whose invita- tion the technique was demonstrated on animals in the laboratory of experimental surgery at the University of Minnesota; and Dr. H. A. Roj T ster, by whom the author was invited to demonstrate his method of suturing blood- PREFACE. 9 vessels on animals at Raleigh, North Carolina, before the medical society of which Dr. Eoyster was president, There are many others whose suggestions and words of encouragement are deeply appreciated. Naturally, many books and journals have been con- sulted in preparing this book. In the chapters on the history of blood-vessel surgery and of transfusion an effort has been made to follow the chronologic order and references have been given only when the literature was quite recent or where for some other reason it seemed ad- visable. The author feels particularly indebted to the section by Matas, in "Keen's Surgery," on aneurisms, which has been freely drawn from; to Crile's work, "Hemorrhage and Transfusion"; to Warren's "Healing of Arteries"; to the monographs on blood-vessel surgery by Guthrie and by Bernheim, and to various papers by Stephen H. Watts. To Miss Helen L. Lorraine, the artist, a pupil of Mr. Max Brodel, the author is greatly indebted for her ex- cellent drawings. The publishers, The C. V. Mosby Company, at whose suggestion this book was written, have extended many courtesies that are deeply appreciated. J. S. II. January, 1915. CONTENTS. CHAPTER I. THE STRUCTURE AND HISTOLOGIC REPAIR OF BLOOD-VESSELS . CHAPTER II. THE INDICATIONS FOR BLOOD-VESSEL SUTURING ....... 2!) CHAPTER III. HISTORY OF BLOOD-VESSEL SURGERY .......... 31 CHAPTER IV. THE TECHNIQUE OF SUTURING BLOOD-VESSELS ........ 46 CHAPTER V. LATERAL ANASTOMOSIS OF BLOOD-VESSELS, AND REVERSAL OF THE CIRCULATION ................ 80 CHAPTER VI. TRANSFUSION OF BLOOD 95 CHAPTER VII. TRANSFUSION OF BLOOD (Continued) .... CHAPTER VIII. HEMORRHAGE 135 CHAPTER IX. PATHOLOGIC HEMORRHAGE 1(19 CHAPTER X. THROMBOSIS AND EMBOLISM ITti CHAPTER XT. TREATMENT OF OCCLUSION OF THE MESENTERIC BLOOD-VESSELS; RESEC- TION AND TRANSPLANTATION OF INTESTINE 203 CHAPTER XII. ANEURISMS 211 CHAPTER XIII. ARTEBIOVENOUS ANEUBISMS 245 11 12 CONTENTS. CHAPTER XIV. PAGE TUMORS OF THE BLOOD-VESSELS 255 CHAPTER XV. VARICES; VARICOSE VEINS, VARICOCELE, AND HEMORRHOIDS . . . 264 CHAPTER XVI. TRANSPLANTATION OF THE ANTERIOR TEMPORAL ARTERY .... 286 INDEX . . 297 ILLUSTRATIONS PAGE Fig. 1. Endothelium of arteriole after silver staining .... IS Fig. 2. Endothelial cells more highly magnified 18 Fig. 3. Drawing of transverse section of aorta 19 Fig. 4. Drawing of transverse section of artery of medium si/.e . 21 Fig. 5. Drawing of transverse section of vein of medium size . . 23 Fig. 6. Microphotograph of carotid artery of dog, divided and sutured, and the specimen removed eleven days afterwards . . 24 Fig. 7. Microphotograph of carotid artery of dog, divided and sutured, and the specimen removed 173 days afterwards ... 25 Fig. 8. Microphotograph of union of artery and vein sixty-three days after operation 26 Fig. 9. Payr's magnesium tubes and discs for uniting arteries . 35 Fig. 10. Carrel's method of end-to-end suture of arteries .... 38 Fig. 11. Dorrance's method of suturing arteries 41 Fig. 12. Bickham's methods of applying mattress sutures in wounds of arteries 43 Fig. 13. The lumen of a blood-vessel after different methods of sutur- ing 49 Fig. 14. Arterial suture staff 51 Fig. 15. Special instruments used in end-to-end suturing of blood- vessels 53 Fig. 16. Suturing of blood-vessels. Exposing the artery .... 54 Fig. 17. Suturing of blood-vessels. Removing adventitia ... 55 Fig. 18. Suturing of blood-vessels. Anointing the collapsed end with vaseline 56 Fig. 19. Suturing of blood-vessels. Fastening the first guy suture to the suture staff 57 Fig. 20. Suturing of blood-vessels. Inserting the second guy suture 58 Fig. 21. Suturing of blood-vessels. Position for placing the third guy suture 59 Fig. 22. Suturing of blood-vessels. Position for fastening the third guy suture to the staff 60 Fig. 23. Suturing of blood-vessels. All guy sutures in place . . 61 Fig. 24. Suturing of blood-vessels. Suturing first third of blood- vessel wound 62 Fig. 25. Suturing of blood-vessels. Suturing second third ... 63 Fig. 26. Suturing of blood-vessels. Suturing last third .... 64 Fig. 27. Suturing of blood-vessels. The suturing completed. Test- ing for leakage . . ' 66 13 14 ILLUSTRATIONS. PAGE Fig. 28. Suturing a rubber tube into defect caused by removal of a segment of an artery 72 Fig. 29. External view of iliac artery of dog after being sutured . 73 Fig. 30. Lumen of carotid artery of dog after being sutured . . 73 Fig. 31. Transplanted segment of the external jugular vein ... 74 Fig. 32. Specimen of reversal of circulation in the neck .... 75 Fig. 33. Specimen of excision of a segment of the abdominal aorta with rubber tube sutured into defect 76 Fig. 34. Photograph of dog six months after excision of portion of the abdominal aorta 77 Fig. 35. Forceps for lateral blood-vessel suturing .... .85 Fig. 36. Forceps grasping blood-vessel 87 Fig. 37. Removing adventitia before lateral anastomosis .... 87 Fig. 38. Method of incising blood-vessels in creating an Eck fistula 88 Fig. 39. Method of incising blood-vessels in lateral arteriovenous anastomosis 89 Fig. 40. Appearance of blood-vessel and position of traction suture just before beginning the suturing in lateral anastomosis ... 89 Fig. 41. First stage of suturing in lateral anastomosis of blood- vessels 90 Fig. 42. Suturing last half of lateral anastomosis 91 Fig. 43. Lateral anastomosis of blood-vessels completed .... 92 Fig. 44. Specimen of Eck fistula from a dog 92 Fig. 45. Specimen of arteriovenous anastomosis from a dog ... 93 Fig. 46. Crile's method of transfusing blood 101 fig. 47. Brewer's tubes for transfusion 103 Fig. 48. Bernheim's tube for transfusion 105 Fig. 49. Bryan's cannula for transfusion 106 Fig. 50. Elsberg's cannula for transfusion 106 Fig. 51. Curtis and David's apparatus for transfusion .... 108 Fig. 52. Kimpton and Brown's apparatus for transfusion . . . 110 Fig. 53. Kimpton and Brown's apparatus for transfusion in hori- zontal position 110 Fig. 54. Landon's cannula for transfusion 112 Fig. 55. Method of using Landon's cannula 112 Fig. 56. McGrath's forceps for transfusion 114 Fig. 57. Horsley's method of transfusion by suturing 118 Fig. 58. Method of compressing the carotid artery 140 Fig. 59. Method of compressing the subclavian artery .... 141 Fig. 60. Method of compressing the brachial artery 142 Fig. 61. Method of compressing the femoral artery 143 Fig. 62. Incision for approaching the heart and the pulmonary artery 197 Fig. 63. Trendelenburg's instruments for operation on pulmonary embolus 198 Fig. 64. Trendelenburg's operation for pulmonary embolism. Re- moving the embolus 199 ILLUSTKATIONS. 15 PAGE Fig. 65. Closing the wound in the pulmonary artery after removing the embolus 201 Fig. 66. Horsley's method of resecting the bowel; first stage . . 2o.~> Fig. 67. Horsley's method of resecting the bowel; second stage . 20li Fig. 68. Horsley's method of resecting the bowel; third stage . . 207 Fig. 69. Horsley's method of resecting the bowel; operation com- pleted 208 Fig. 70. Transplantation of the ileum after extensive resection of the sigmoid 20!) Fig. 71. Classical methods of applying the ligature for aneurism . 227 Fig. 72. Matas' operation of endo-aneurismorrhaphy 231 Fig. 73. Operation for arteriovenous aneurism by means of clamps for lateral suturing 2.~>1 Fig. 74. Second stage of operation for arteriovenous aneurism . . 2f>2 Fig. 75. Photograph of a boy with angioma of nose 2til Fig. 76. Another view of above boy 201 Fig. 77. Photograph showing results of hot water injection in angioma of nose 2(il Fig. 78. Mayo's operation for varicose veins 26!) Fig. 79. Clamp and cautery operation for hemorrhoids .... 2S2 Fig. 80. Method of inserting tube before removing forceps in clamp and cautery operation for hemorrhoids 283 Fig. 81. Transplantation of anterior temporal artery; first stage . 288 Fig. 82. Transplantation of anterior temporal artery; second stage . 28!) Fig. 83. Transplantation of anterior temporal artery ; third stage; . 290 Fig. 84. Transplantation of anterior temporal artery; operation completed 291 Fig. 85. Photograph of patient with extensive defect in the cheek . 293 Fig. 86. Photograph of same patient after transplantation of an- terior temporal artery with frontal flap 293 Fig. 87. Photograph of patient after removal of recurrent cancer of cheek 294 Fig. 88. Photograph of same patient after transplantation of an- terior temporal artery with frontal flap 29.~> Fig. 89. Photograph of patient shown in Figs. 87 and 88, showing absence of any facial paralysis 295 SURGERY OF THE BLOOD- VESSELS CHAPTER I. THE STRUCTURE AND HISTOLOGIC REPAIR OF BLOOD-VESSELS. A knowledge of the histology of blood-vessels is neces- sary for a proper appreciation of the healing of blood- vessels. Blood-vessels are described as having three coats: an inner, or tunica intima; a middle, or tunica media; and an external, or tunica externa, or, as it is usually called, adventitia. While these coats are to a greater or less extent present in most blood-vessels, their arrangement and their relative proportion vary very greatly. The tunica intima consists of vascular endo- thelium, which is supported by a variable amount of fibro- elastic tissue, the elastic tissue predominating. The capillaries consist practically entirely of the tunica in- tima, which in this instance amounts to but little more than the endothelial lining. The middle coat, or tunica media, is a mixture of smooth muscle, elastic tissue, and fibrous tissue ; while the adventitia, which is very strong but generally thinner than the middle coat, consists of fibro-elastic tissue. The essential coat of the blood-ves- sel is the inner coat, or tunica intima. 1 In arteries the endothelium of the intima is made up of flat, spindle-shaped cells joined together irregularly by i Piersol : Human Anatomy, Vol. I. 17 18 SURGERY OF THE BLOOD-VESSELS. a kind of cement substance that is shown by silver stain- ing. Where these cells come together there are occasion- ally stigmata or points where the junction of the cell is less accurate than usual. The sharp outlines of the en- dothelial cells are less marked in capillaries than in larger vessels. A small oval nucleus in the endothelial cells can be demonstrated (Figs. 1 and 2). Fig. 1. Fig. 2. Fig. 1. Endothelium of arteriole after silver staining, x 200. (After Piersol.) Fig. 2. Endothelial cells more highly magnified, x 500. (After Piersol.) The involuntary or smooth muscle varies greatly in amount. It may form a thin or imperfect layer in the arterioles, or a thick coat in the larger arteries. It is most abundant in arteries of medium size, where it is found in broad bundles between fibers of elastic tissue. In veins there is but little muscle and sometimes it is en- tirely wanting. Connective tissue occurs as fibrous and elastic tissue. Elastic tissue is very conspicuous in all of the arteries except the smallest and is found to a considerable extent in veins. It is very abundant in the larger arteries and, STRUCTURE AND HISTOLOGY OF BLOOD-YKSSKLS. 19 Intimu Media Adventitia Fig. 3. Drawing of transverse section of aorta, x 120. (Original.) 20 SURGERY OF THE BLOOD-VESSELS. as has already been mentioned, forms a basement mem- brane for the endothelium of the intima (Fig. 3). All of the larger vessels are provided with minute nu- trient vessels which usually come from some neighboring artery and are distributed in the adventitia of the blood- vessel. They are called vasa vasormn. Lymphatics and nerves are also found in the outer coats of the blood- vessels. The plexus of nerves that surrounds arteries is particularly abundant. Small nerve fibers from this plexus enter the media and are distributed among the muscle cells. These nerve fibers are chiefly motor in function and are a part of the great vasomotor system. Sensory nerves undoubtedly occur quite constantly ac- companying the vessel wall. This is frequently demon- strated in operations under a local anesthetic when the clamping of a blood-vessel will cause pain even though the surrounding tissue appears to be free from sensation. In an artery of medium size, about half a centimeter in diameter, the intima is seen in section as distinctly corrugated, which is due to the fact that the vessel is collapsed and the internal elastic membrane draws the endothelial lining into folds. Under normal pressure when the artery is functionating these wrinkles would be smoothed out. The intima in such an artery consists of a layer of endothelium that rests on a thin layer of fibrous and elastic tissue and this upon the elastic mem- brane, the total thickness being very small in proportion to the thickness of the other coats. The tunica media, or middle coat, is quite thick and comprises more than one- half of the total thickness of an artery of medium size. It consists of smooth muscle and elastic and fibrous tis- sue. The external layer of the middle coat is an elastic membrane called the external elastic membrane, which is similar in construction to the internal elastic membrane STRUCTURE AND HISTOLOGY OF BLOOD-VESSELS. 21 Intima Media ? >^ v'-~ /'^" >, - T ~^ ~ > <*l- - '" " ; V'! -->-' ''* I -' '' "'."'. '- V V ^;- Kndotheli \ ''-s ^ '' -~S-' '^" *'"-''- '("'^^f^^if-y 1 ^' ' ' *' >M^\N S ,,^ ^ -^ >CS^ i>f^ ^^" Internal ^^f^r^ "*--* ''^i 'j^^'^^^^''''-^-^ "<*. * ^^"^^^^^^ .S^- 5^^ v"^v*^ ^^ "^Li-"^ ' :i - Adventitia r^'^r >^ *ti^'--.s^- --.-^ - External elastic membrane Fig. 4. Drawing of transverse section of an artery of medium size, x 120. (Original.) 22 SURGERY OF THE BLOOD-VESSELS. of the intima. The adventitia is thinner than the media but is exceedingly strong. It is a mixture of fibrous and elastic tissue and contains the vasa vasorum, lymph chan- nels, and the plexus of nerves. As the artery decreases in size, all the coats except the intima diminish. The internal elastic membrane disappears first, then the me- dia. Just before the vessel becomes a capillary the mea- ger amount of muscle cells disappears. In capillaries practically nothing is left except the endothelial lining with a small support of connective tissue. 2 As an artery of medium size becomes larger, the intima and media increase in bulk and the boundary between these two coats becomes less marked, for the elastic tis- sue is a more prominent feature of the middle coat which gradually blends with the internal elastic membrane. The muscular tissue in the media is largely replaced in large arteries by fibro-elastic tissue. The adventitia is somewhat increased and consists of fibro-elastic tissue as in smaller arteries (Fig. 4). It is exceedingly strong. Near the heart some muscle cells resembling cardiac mus- cle may run up for a short distance into the aorta or pul- monary artery. Veins are always thinner than arteries and contain less muscular and elastic tissue. In a vein of medium size (Fig. 5) the intima is of somewhat the same construction as in an artery of similar size, except that the endothelial cells are broad and short instead of being long and spin- dle-shaped as in an artery and the layer of elastic and connective tissue is much thinner than in an artery. The internal elastic membrane of an artery of medium size is practically lacking in a vein of similar caliber. In the tunica media, muscular tissue is scanty. The media is altogether much thinner than in the artery and is dis- zPiersol: Human Anatomy, Vol. I. STRUCTURE AND HISTOLOGY OF BLOOD-VESSELS. 2.6 tinctly deficient in muscle cells as compared with an ar- tery. The adventitia of a vein is frequently thicker than the media and is of similar construction to the adventitia of an artery. In the lower extremities the veins often contain muscle cells arranged longitudinally. The valves of the veins consist of pairs of crescent- shaped folds of intima. They form pockets that look toward the direction of the blood current in the vein, and Intima Media Adventitia Fig. 5. Drawing of transverse section of a vein of medium size, x 120. (Original.) when filled the sides of the valves come together and pre- vent the reflux of blood. In large veins the media is chiefly increased by the ap- pearance of more elastic and fibrous tissue, though in the splenic and portal veins much muscular tissue is in the media. In the larger veins the adventitia is markedly increased and often, as in the vena cava, contains longi- tudinal bundles of smooth muscle. The small veins have only endothelium and connective tissue. Approaching the capillaries, the connective tis- sue decreases, leaving the endothelium alone. The capillaries consist of an endothelial coat with thin walls that favor the passage of the blood plasma into the 24 SURGERY OF THE BLOOD-VESSELS. surrounding tissue. The endothelial cells are elongated cells with oval nuclei. Stomata do not occur in the walls of the capillary. Blood cells gain exit between the endo- thelial cells. In capillaries of the choroid, liver, and the Fig. 6. The carotid artery of a dog which was divided and sutured and the speci- men removed eleven days afterwards. Note the silk which on the surface is completely buried by a thin layer of endothelium. Magnification, 65 diameters. glomeruli of the kidney the endothelial lining seems to be continuous as a kind of syncytial layer. 3 The healing of blood-vessels after ligation has been a subject of study by surgical pathologists for many years 3 Piersol: Human Anatomy, Vol. I. STRUCTURE AND HISTOLOGY OF BLOOD-VESSELS. -!.) and the literature on this subject is abundant. Healing by the so-called organization of a thrombus, accom- panying injured intima, and by a mere approximation of the intima has been investigated experimentally and m Fig. 7. Microphotograph of a carotid artery of a dog which was divided and sutured and the specimen removed 173 days after operation. Note the par- tial regeneration of the coats of the vessel and the well covered silk. Mag- nification, 85 diameters. clinically in many works and has been studied with particular care by J. Collins Warren in a monograph, "The Healing of Arteries," published in 1886. The healing of arteries, however, of chief interest in mod- ern vascular surgery is that which follows suturing and 26 SURGERY OF THE BLOOD-VESSELS. not the ligature. In successful arterial suturing repair in the course of time is complete. The accompanying microphotographs show that the suture material is cov- ered with endothelial lining and the middle and outer Fig. 8. Microphotograph of union of artery and vein sixty-three days after opera- tion. The section was somewhat torn in cutting hut the silk can be easily seen covered with a layer of endothelium. Magnification 57 diameters. coats have begun to regenerate even a few weeks after the suturing (Figs. 6, 7 and 8). In older specimens studied by other experimenters the repair is complete. Matas 4 says that repair which follows a properly sutured 4 Keen's Surgery, Vol. V, page 138. STRUCTURE AND HISTOLOGY OF BLOOD-VESSELS. 2 1 wound in an artery "is equivalent ultimately to a com- plete and perfect regeneration of all the histologic ele- ments which enter into the formation of the arterial wall, the elastic and muscular elements being reproduced as perfectly as the baser elements, if the specimens are exam- ined long enough (at least one hundred days in dogs) to allow the regeneration of the elastic and muscular tissue to be complete." He further says that "clinical experi- ence fully confirms the histologic possibility of the com- plete regeneration of the vessels." An extensive inquiry made by Matas failed to show that any aneurism has formed at the site of a previous suture. Thomaselli 5 studied the histological process of heal- ing in transverse wounds of the blood-vessels. He says the muscular layer is completely regenerated, and the elastic fibers of the media are regenerated and are more numerous along the scar and near the lumen. They do not form a true inner elastic membrane but practically replace it. The elastic fibers in the adventitia are not regenerated, the new adventitia consisting of connective tissue. Close to the sutures there is entire restoration of the three layers, though the muscle cells and elastic fibers are hypertrophied. De Gartano reported perfect restoration of all the ves- sel wall, including the elastic fibers. Stephen H. Watts, after histologic examination of sections from sutured blood-vessels, says that at periods of from twenty-eight to eighty-two days after operation there is a gradual res- toration of the artery at the site of suture and all the ele- ments of the vessel wall except the inner elastic mem- brane are probably regenerated. E. Archibald Smith 6 states that, as the immediate re- 5 Clinica Chirurgia, 1902, No. 6, and 1903, XI, No. 5 ; Central, fur Chirurgie, XX, 1906. 6 Suture of Arteries, Oxford University Press. 28 SURGERY OF THE BLOOD-VESSELS. suit of suturing arteries, necrosis occurs in that portion of the wall of the blood-vessel subject to the direct pres- sure of the stitch. This includes all of the elements, though the elastic tissue withstands more pressure than the muscle or the fibrous tissue, as determined by the fact that elastic tissue reacts longer after special stain. In the center of this small area of necrosis is a micro- scopically narrow cleft that opens into the lumen of the vessel and contains a small thrombus. This thrombus in successful vessel suturing does not protrude to a per- ceptible extent into the lumen of the vessel. A small amount of such thrombus is necessary for complete hemostasis as is more fully described in the chapter on technique (page 46). According to Smith, from the end of the first week granulation tissue is present in the neighborhood of the wound in the vessel. Many new capillaries and fibro- blasts invade the sutured area from without and in this manner the fibrin is absorbed and disappears in ten days. Long before this time, however, endothelium has grown over the fibrin deposited around the sutures and fur- nishes a complete endothelial lining for the vessel. The numerous small capillaries gradually disappear and new spindle forms and fibrous elements are seen. Last of all occurs the formation of specific tissues, of new elastic and muscular elements, in the young scar. This happens from three to four months after operation and follows the normal histologic layers. Elastic tissue appears as extremely delicate fibers. At this time the suture ma- terial exists as a small remnant, being partly disinte- grated by the granulation tissue and gradually pushed away from the lumen of the vessel. CHAPTER II. THE INDICATIONS FOR BLOOD-VESSEL SUTURING. The marked attention paid to surgery of the blood- vessels in recent years has excited unusual interest and has been the cause of many extravagant statements, par- ticularly as regards suturing blood-vessels. The sensa- tional articles that have appeared in the public press have been to a large extent unwarranted, though the modern method of suturing blood-vessels is one of the great ad- vances in surgery. As is stated in the work by C. C. Guthrie on "Blood- Vessel Surgery," " Heterograf ts suc- ceed at first, but inevitably fail after the first few weeks. This is the disappointing but unanimous conclusion of experimenters. Thus there is, at present, no temptation for the enthusiastic surgeon to try and graft one lobe of the thyroid or a kidney taken from a healthy donor. The poor man will not be tempted to exchange one of his sound kidneys for so much hard cash." Lexer 1 says that even in animals transplantation of limbs promises practically nothing, "since, besides ischaemic inflamma- tion and contraction, it is followed by hemorrhagic infil- tration and nerve disintegration." The idea that a new limb can be transplanted and will remain useful, or that a kidney or thyroid can be grafted from one individual to another, is erroneous. These ex- periments even in animals have not been permanently suc- cessful. A kidney transplanted from one dog to an- 1 Annals of Surgery, August, 1914. 29 30 SURGERY OF THE BLOOD-VESSELS. other may functionate for awhile, but sooner or later the fine differences of serum and tissue destroy the organ and prevent ultimate success. However, while compli- cated glands cannot be transplanted, simpler tissue can often be permanently grafted from one animal to an- other, or particularly from one portion of an animal or person to another portion of the body. The simple func- tion of a transplanted blood-vessel can be maintained and it is probable that at least the endothelial and connective tissue of the transplanted vessel is permanent. The modern suturing of blood-vessels has five distinct fields aside from the older method of ligation: (1) The treatment of wounded blood-vessels. Here direct suture can be used, or if much of the vessel has been injured a segment of some vein from the patient's own body, as the saphenous, can be sutured into the defect. (2) Ex- cision of malignant tumors that have heretofore been considered inoperable because of involvement of a large blood-vessel. A section of the vessel can be removed and the vessel repaired as after trauma. (3) Aneurisms can be treated in a similar way, though on account of the diseased condition of the vessel wall in spontaneous aneurisms, suturing is not likely to be quite so satisfac- tory as in traumatic aneurisms. However, several suc- cessful cases have been reported where spontaneous aneurisms have been excised and a segment of vein sub- stituted. (4) Transfusion of blood. This can be done by a variety of methods, but the union by sutures if prop- erly done is probably the most satisfactory method of transfusing blood. (5) Eeversal of the circulation may have a limited field. CHAPTER III. HISTORY OF BLOOD-VESSEL SURGERY. Surgery of the blood-vessels began with the first ef- forts to staunch the flow of blood and is probably the most venerable of any branch of surgery. Warren ' gives the first recorded use of the ligature as occurring in 1500 B. C., when Susrutas employed it in tying the um- bilical cord. But no mention is made by Susrutas of its use in surgery, nor do the early Egyptian writings say anything of the ligature. The Alexandrian school prob- ably employed the ligature but the records of this work were in all likelihood destroyed when the library was burned. Aulus Celsus (25 B. C. to 45 A. D.) who lived about the beginning of the Christian era recommended the ligature in surgery in certain cases. Celsus was classed by Pliny as a man of letters (auctor) rather than a doctor (medicus), and was ignored by the Roman prac- titioner of his day. He wrote very extensively on medi- cal subjects. His seventh book is surgical and contains probably the first account of the use of the ligature in surgery. It is doubtful, however, if his recommenda- tions were put into very extensive practice by his col- leagues. Galen (131-211 A. D.) mentions the ligature frequently. He was not a practical surgeon and avoided the use of the knife unless as a last resort. He used silk and linen and tells where he obtained his ligatures, at * ' the shop on the Via Sacra between the temple Roma and i Healing of Arteries, Wm. Wood & Company. 31 32 SURGERY OF THE BLOOD-VESSELS. the Forum." Antyllus, in the third century, not only used the ligature but devised an operation for aneurism which still bears his name ligating the artery close to the aneurism, both proximally and distally, and incising the sac. This method has given remarkably good re- sults. Paulus ^Egineta (625-690 A.I).) mentions the ligature often. Torsion is not referred to by him though it was described by Oribasus (326-403 A. D.) in connec- tion with an operation on hernia. The actual cautery and various styptics were generally used to control bleed- ing. Ehazes (850-922 A. D.) and Abucasis (1106) used the ligature, but preferred as a rule styptics and the actual cautery. The latter wrote a book on the cautery. Ambrose Pare revived the use of the ligature and in 1552, wrote earnestly advising its employment. He used a mass ligature, without attempting to isolate the vessel. The ligature did not come into general favor, however, for more than a hundred years after Fare's time. Even his pupil and friend, Guillemeau, often employed the cau- tery. When we consider that the ligature of Pare was employed en masse, including the adjacent nerves, and that sloughing and suppuration nearly always followed, and often secondary hemorrhage, we can readily under- stand why surgeons were not enthusiastic about this method of controlling hemorrhage. It is interesting to note that the reputations of the three surgeons, whom Garrison 2 selects as the greatest surgeons of all times, Ambroise Pare, John Hunter, and Lister, are founded chiefly or in large part upon the use of the ligature. John Hunter (1728-1793) devised the principle of treat- ing aneurisms due to arterial disease by means of a single ligature applied on the proximal portion of the artery at some distance from the sac, at a point where the artery 2 History of Medicine, W. B. Saunders Co. HISTORY OF BLOOD-VESSEL SURGERY. was supposed to be healthy. Guillemeau (1594) and Anel (1710) had used the single ligature close to the aneu- rism, and Autyllus two ligatures, proximally and distal ly, and an incision into the sac. AValdrop (1782-1869) cm- ployed the ligature distally in treating aneurism, though Pierre Brasdor (1721-1797) first suggested the use of a distal ligature. In this way all combinations for the application of the ligature were exhausted and a new treatment for aneurisms must be based on something other than the ligature. The history of the suturing of blood-vessels is of much more recent origin than the history of ligation. Hallo- well, an English surgeon, first sutured the brachial artery in man in 1759. This was suggested to him by Lambert. In 1772, Assmann, of Groningen, after unsuccessful ex- periments on dogs, announced that suturing arteries was not feasible. This opinion apparently held good for more than a hundred years as Gluck, in 1881, was one of the first to renew efforts to repair wounded blood-vessels. Gluck found the sutures would often pull out and em- ployed small ivory clamps to close the wound, leaving them in place. He had some successful results. In 1879, Eck, a Russian surgeon, probably first ac- complished the union of two blood-vessels when he estab- lished a communication between the portal vein and the vena cava, which is now known as Eck's fistula. Von Horoch, in 1888, experimented with suturing arter- ies, using silk and catgut, but thrombosis resulted after all his experiments. In 1889, Jassinowsky, after twenty- six experiments on the lower animals, attained consider- able success in repairing variously shaped wounds of the arteries. In many of his experiments the bleeding from the wounded vessel was controlled and its lumen was pre- served. Twenty-two of the twenty-six experiments were 34 SURGERY OF THE BLOOD-VESSELS. successful. He used fine curved needles and fine silk and did not penetrate the intima. The sutures were in- terrupted, and about one millimeter apart, He recom- mended thorough asepsis, smooth edges of the wounded vessel, and penetration of only the two outer coats. His research is one of the most important in establishing ar- terial suturing. Robert Abbe, of New York, published in 1894 the re- sults of his experiments in which he divided an artery and united it again by suturing the ends over a thin glass tube. In 1896, Briau and Jaboulay attempted experi- mentally to unite the divided ends of an artery by an in- terrupted mattress stitch that penetrated all coats and everted the intima. The experiments were not very suc- cessful. They did ten operations on the carotid arteries of dogs, and all of the vessels later became thrombosed. Afterwards they tried the same method on the carotid of a donkey with perfect results. John B. Murphy, in 1897, published a method by which the proximal end of an artery was invaginated into the distal end by means of two mattress sutures, which were inserted so as to draw the proximal end into the distal end. This materially diminishes the caliber and can only be done in large vessels. Of thirteen experiments, three were successful. Murphy reports one case in which this operation was done for a wound of the femoral artery. After the operation was completed there was no leakage and pulsation appeared in the artery below the point of union. The patient made a good recovery. This is the first successful end-to-end union of an artery in man. In 1897 and 1898, Silverberg experimented with arterial suture in dogs. He used the finest silk and, with three exceptions, employed the continuous suture instead of the HISTORY OF BLOOD-VESSEL SURGERY. 35 interrupted. He did not attach much importance to the inclusion of the intima. In 1898, Gluck, who had also done excellent work in the lateral suturing 1 of arteries, devised a method of end-to- end union by which he removed completely a small sec- tion of an artery, slipped it over one end of the artery as Fig. 9. Payr's magnesium tubes and discs for uniting arteries. (A) The mag- nesium ring with a groove, which has been passed over the end of an artery. (B) Transverse section of the completed operation. (C) A later modifica- tion of the tube by Payr. a ring, and after the ends were united it was drawn over the suture line to reenforce the sutures and held in this position by a few stitches. Other substances, he says, such as rings of rubber or decalcified bone may be em- ployed. In 1899, Dorfler published the results of his experi- ments and, according to Guthrie, established the main features of the methods that are now so generally used. Dorfler claimed that the essentials of successful blood- vessel suturing were fine, round needles ; fine silk ; and a continuous suture embracing all coats of the vessels. He 36 SURGERY OF THE BLOOD-VESSELS. did not avoid the intima, but recommended that all coats be included in the continuous suture. Payr, in 1900, gave a great stimulus to surgery of the blood-vessels by devising a ring of magnesium. This was a circular band shaped like a diminutive napkin ring with a groove in its outer surface (Fig. 9). This ring was slipped over the central end of an artery and the artery cuffed back and tied in the groove. The distal end of the artery was then stretched, invaginated over the cuff, and held in position by another ligature. In this manner intima was approximated to intima and the mag- nesium was in the course of time absorbed. The method was tried rather extensively both experimentally and clinically. According to Crile, his transfusion cannula is a modification of the ring of Payr. Payr's idea was that sutures would probably not hold and that this method would withstand arterial pressure. In 1904, Payr pub- lished an article giving his own experiments and those of others and claimed that unsuccessful results were due to the fact that his directions were not followed. He also devised two discs of magnesium with small pins on the periphery of one disc which fit into holes in the opposite disc. The end of the vessel was placed through the disc, opened widely to evert the intima, and fixed by the pins which both transfixed the walls of the vessels and clamped the opposite disc. Bougie, in 1901, introduced a new method of invagina- tion, a modification of Murphy's, in which the ends were invaginated only a short distance and fastened with su- tures that did not penetrate the intima of the proximal end. In 1902, many articles appeared, among which were those of Thomaselli, Salvia and, particularly, Carrel. Salvia experimented upon dogs, donkeys, and sheep and HISTORY OF BLOOD-VESSEL SURGERY. 37 paid special attention to the healing of the arterial wound. He used end-to-end sutures of fine silk. In none of his cases did the lumen remain open. Thomaselli laid much stress upon approximating intima to intima. He used in- terrupted sutures passed through all coats with fine, curved needles and silk. In a later article he says that the method of Salomoni is the best. Carrel published his well known method in 1902. It differs in no essential particular from the work of others, but is a combination of the best features of other work. The results obtained were much better than those secured by any one else. He used very fine, No. 16, round, straight needles, threaded with fine silk impregnated with vaseline. The adventitia is thoroughly removed and the ends of the artery washed out with salt solution, or Ringer's solution. The ends of the vessels are then united by three traction sutures inserted around the ar- tery at equidistant points (Fig. 10). Traction on the sutures converts the circumference of the artery into a triangle, approximates the intima, and renders the su- turing easy. The operator holds one traction suture, the assistant holds another, and the third is caught in a small hemostatic forceps, so as to pull the artery away from the region that is being sutured. After suturing one-third with a continuous overhand stitch the operator takes the suture held by the assistant, the assistant takes the one to which the hemostat was fastened, and the hemo- stat is placed upon the traction suture that the operator originally held. After the second third is finished the traction sutures are again changed, the operator tak- ing the one held by the assistant, who makes tension on the suture that was clamped by the hemostat and the hemostat is placed on the suture just released by the oper- ator. The last third is now completed and the current is 38 SURGERY OF THE BLOOD-VESSELS. turned on gently. Slight pressure usually stops the ooz- ing from the needle holes, and then the full force of the stream is released. Very brilliant results have been secured by this tech- nique in the hands of Carrel, Guthrie, Stephen H. Watts, Fig. 10. Carrel's method of end-to-end suture of arteries. (A) Three guy sutures inserted and ready to be tied. (B) The guy sutures tied and one clamped with a hemostat. (C) The suturing of one-third has almost been completed. (D) The operation completed. and others. Watts reported, in 1907, a remarkable series of experiments on dogs in which this technique was used. Of thirteen circular sutures of the carotid, all were per- fectly successful and there was not the slightest evidence HISTORY OF BLOOD-VESSEL SURGERY. 39 of thrombus formation. In two instances when the femoral artery was sutured, thrombosis occurred. Thir- teen times the jugular vein was divided and sutured with ten successes. Microscopical examination of the arterial specimens at periods varying from twenty-eight to eighty- two days after operation showed a gradual restoration of the artery at the site of suture, all elements of the vessel wall being regenerated except the inner elastic membrane. Watts also reversed the circulation in the neck by sutur- ing the central end of the carotid artery to the distal end of the external jugular vein. This was done four times, all being successful. Examination of the veins from one to three months after operation showed a dilatation of the vein with thickening of the walls. Microscopic ex- amination showed changes very much like those found in arteriosclerotic arteries. He excised and reimplanted a section of the femoral artery but thrombosis occurred. Twice he transplanted a section of vein between an artery, using a section of the external jugular between the ends of the carotid in one instance and between the di- vided femoral in another. The carotid experiment was successful, but the transplantation into the femoral artery resulted in thrombosis. In 1901, Clermont reported experiments on suture of the veins. He used a continuous mattress stitch of fine silk and everted the edges of the vessel. He devised a method by which the intima was united to intima by a continuous mattress suture of fine silk with a second row of overhand running sutures uniting the edges. In 1903, Jensen published an article on the circular suturing of blood-vessels, which was very complete. He preferred silk and sutured all coats of the vessel with a continuous stitch. Hoefner, in 1903, gave a history of lateral and circular suturing of blood-vessels in ani- 40 SUEGEEY OF THE BLOOD-VESSELS. mals and man, and also the results of his own experi- ments, using the magnesium ring of Payr. In the same year Amberg reported experimental work in which the ends of the vessel were split longitudinally so as to afford a greater surface of intima. This prac- tically converted the vessel end into two flaps which were united by sutures. The experiments, however, were only fairly successful, as in only half of the operations was the lumen preserved. Da Gaetano reported, in 1906, a method in which he used a small spindle-shaped glass bobbin for suturing lat- eral wounds of vessels or for end-to-end union. After the sutures are placed and before they are drawn tight, the bobbin is removed. He used fine silk and a round needle and did not perforate the intima. He reported satisfactory results functionally and histologically, find- ing new muscle and elastic tissue in the vessel scar within four months. In 1906, Dorrance published an article in which he recommended that vessels be sutured by a continuous mat tress stitch in which every third stitch was a back stitch so as to lock the line of sutures. After completing the suturing in this manner another row of overhand stitches was placed to reenforce the sutures after the manner of Clermont (Fig. 11). In a personal communication, Dr. Dorrance says he has dispensed with the second row of sutures as being unnecessary. Stich, Makkas and Dowman, in 1907, reported results of experiments with a technique very similar to that of Carrel, using fine needles and silk which they immerse in liquid paraffin before using. They not only did circular suture of the arteries, but successfully transplanted a seg- ment of a cat's aorta between the ends of a divided caro- tid of a dog. HISTORY OF BLOOD-VESSEL SUEGERY. E. Archibald Smith, 3 in a small monograph, reviews the literature of blood-vessel suturing and gives in detail flu- results of experiments with a method of his own. This consists of a "quill" suture in which chromic catgut is used for "quills." Interrupted mattress sutures are placed, everting the intima, and a strand of chromic cat- gut is carried under the loop of each suture, as in the old Fig. 11. Dorrance's method of suturing arteries. (A) The artery is partly sutured with a mattress stitch which drops back about every third stitch. (B) The operation completed with an overhand, reenforcing stitch. Dorrance has now abandoned the overhand stitch as being unnecessary. quill suture. Another strand of chromic catgut is placed between the ends of each suture and the suture is tied snugly on the catgut. Less than a third of his experi- ments were successful. Lespinasse, Fisher and Eisenstaedt, of Chicago, 4 pub- lished excellent results of experimental work on end-to- end anastomosis of blood-vessels and on closing wounds 3 Suture of Arteries, Oxford University Press, 1909. 4 Journal A. M. A., November 19, 1910. 42 SUEGEEY OP THE BLOOD-VESSELS. in arteries or veins. For lateral wounds they recom- mend perforated plates of magnesium. A perforated plate is placed on each side of the wound and holds the intima of the wound in contact by means of mattress sutures that are passed through the perforation and both lips of the wound. For end-to-end union, the magnesium is in the shape of discs or rings, resembling the second device of Payr, which have a number of small holes along the periphery. The end of the vessel is carried through the rings and fastened by four sutures to these holes. This flares open the end of the vessel and exposes the in- tima. Both ends are placed through the magnesium rings in this manner and then the rings are brought together and fastened firmly by mattress sutures passed through the opposing perforations. The Journal of the American Medical Association, May 10, 1913, page 1474, says : "Lexer of Jena, showed a case of ideal operation for aneurism and transplantation of the vessels. The patient was operated on according to the rules established by Lexer in 1907. To maintain the circulation in its normal channel, the spindle-shaped aneu- rism beginning above Poupart's ligament and extending below the arteria profunda was removed and the defect of the vessel repaired by the introduction of a piece of saphenous vein, 18 cm. long. The wall of the artery markedly changed by arteriosclerosis allowed the thread of the running suture of Carrel to cut through. On the other hand, the continuous protruding mattress suture gave very good service ; the thread not only held well but also prevented hemorrhage. The large differences in lumen of the piece of vein and that of the still enlarged artery caused little difficulty in suture. The brilliant re- sult also shows that the piece of vein must have under- HISTORY OF BLOOD-VESSEL SURGERY. 4o gone an increase in size, as in experimental work. The patient was a man aged sixty-two and the case testifies beyond cavil that a transplanted vessel may remain thor- oughly permeable. The arteries in the foot now pulsate as powerfully as those on the other side, but they imme- diately become pulseless when the femoral artery in the region of the transplanted vessel is compressed. The pa- 1!. Fig. 12. (A) Mattress suture applied in a lateral wound as recommended by Bickham. (B) Mattress suture with it reenforcing stitch in a transverse wound. (Bickham.) tient, who was operated on nine months ago, is completely free from symptoms." Soresi, of New York, described before the Seventeenth International Medical Congress an apparatus for sutur- ing blood-vessels which consists of a small clamp that kept the vessels approximated. Minute hooks held a turned back cuff and exposed the intima. The intima 44 SURGERY OF THE BLOOD-VESSELS. was then approximated to intima by means of very small gold wire clamps somewhat after the fashion of Michel skin clamps. 5 Christian and Saunderson G described a device for unit- ing blood-vessels by means of two metal rings and a holder. From the surface of each ring several very small bearded points project. The vessel is cuffed back over each ring and held by the sharp points. The two rings are fastened together with small pliable wires one- fourth of an inch long which project from the side of the ring and which are fastened together by being twisted with pliers. John W. Price, Jr., 7 of Louisville, has devised a method of suturing blood-vessels by means of a new instrument. "This instrument is a cannula-forceps. The cannula portion is spooled slightly at one end. The instrument is made in several sizes, so that a cannula will have a bore of 11/2 mm., 2 mm., 2y 2 mm., 3 mm., or larger if de- sired. The cannula-forceps may be used in making a temporary anastomosis between two blood-vessels, as for a transfusion; for making a permanent end-to-end or end-to-side anastomosis between two vessels. "1. The cannula is opened and then closed to include one vessel about 3 to 4 mms. from its cut end (the spooled end of the cannula is toward the cut end of the vessel) ; the end of the vessel is then caught by three iris hooks from within and cuffed over the spooled portion of the cannula and held. "2. The end of the second vessel is now caught from within by three iris hooks and pulled over the everted vessel on the end of the cannula, thus the endothelial sur- 5 Journal A. M. A., September 16, 1913, page 800. 6 New Orleans Medical and Surgical Journal, November, 7 The Lancet-Clinic, January 25, 1913. 1913. HISTORY OF BLOOD-VESSEL SUEGERY. 45 face of one vessel is brought next to the endothelial sin- face of the other. "3. Two iris hooks are now passed through both vessels and held, the first set of hooks being removed. "4. A continuous mattress suture is inserted through all the coats of both vessels at their approximated ends. "5. Hooks are removed. "6. The cannula is then slipped out of the cuff (away from the line of sutures), opened and removed. "7. The Crile clamp on the vessel distal to the anasto- mosis is removed first, then the proximal clamp is re- moved, which allows the blood to flow. Additional sutures are added to control any oozing." Muir 8 describes a method of uniting blood-vessels by means of a bone cylinder with a ridge for the retention of the ligature. The cylinders are made in different sizes. The artery is cuffed back from the cylinder and ligated; the operation is similar to the technique used in Payr's magnesium rings, or in the cannula of Crile. The bone is said to absorb, leaving no foreign body. 8 Journal-Lancet, April, 191-1. CHAPTER IV. THE TECHNIQUE OF SUTURING BLOOD- VESSELS. The chief difficulty to overcome in suturing blood-ves- sels is occlusion by clotting, and improvements in tech- nique are intended to prevent an excessive amount of clotting. The physiology of thrombus formation is still rather vague, as it is impossible to isolate chemically some of the substances that are involved in this process, and their presence has to be taken for granted in order to support a reasonable hypothesis. There are certain general reactions, however, that all physiologists acknowl- edge. The direct formation of a thrombus is due to the action of fibrin ferment on fibrinogen. Fibrinogen exists normally in blood plasma. Fibrin ferment is built up from various substances and is probably formed from the action of a thromboplastic substance, called by some thrombokinase, upon thrombogen in the pres- ence of a solution of calcium salts. Thrombokinase is not a true kinase in the sense of acting solely as a fer- ment, for it is used up in the process of clotting. Throm- bokinase is the key to the situation, and whether it acts directly, or indirectly, as Howell claims, by combining with antithrombin in the blood and thus liberating pro- thrombin (thrombogen), it nevertheless is essential to clotting and to a large extent regulates the amount of thrombus formed. Thrombokinase is supposed to be present in all tissues of the body and also comes from 46 TECHNIQUE OF SUTURING BLOOD-VESSELS. 47 disorganized blood corpuscles, particularly the platelets. It seems abundant in the adventitia of blood-vessels. The practical bearing of these facts upon blood-vessel surgery is evident, for thrombokinase can only be liber- ated from injured tissue. As the amount of clotting is directly proportionate to the amount of thrombokinase, it is readily seen that any undue injury to blood-vessels by rough handling, or by drying of the endothelial cells of the intima, or by the presence of too much foreign sub- stance in the lumen, or by chemical or bacterial injuries, will result in the liberation of so much thrombokinase that excessive thrombus is formed and the vessel is oc- cluded. Even the most successful suturing of blood- vessels is accompanied by some clotting, but a limited amount is essential as it serves to fill the punctures from the needle holes and to bridge over the line of contact. In successful vessel suturing, however, the injury is so slight that very little thrombokinase is released and con- sequently only a small amount of thrombus is formed, just enough to plug the punctures made by the needle and not enough to obstruct the lumen. We recognize, then, as the principles for successful blood-vessel suturing that a continuous surface of vascu- lar endothelium must line the lumen and that as little in- jury as possible must be done this endothelium. The im- portance of presenting to the lumen of the vessel a con- tinuous surface of vascular endothelium, is appreciated when we recall what has been learned in a somewhat coarser fashion by intestinal suturing. Here it is a well recognized principle, as it is in blood-vessel suturing, that the endothelial surfaces must be approximated accu- rately. In the case of the bowel, the endothelium is on the outside and it is necessary to turn in a small flange or shelf to secure accurate apposition of the peritoneal endo- 48 SURGERY OP THE BLOOD-VESSELS. thelium. In blood-vessels the endothelium is on the in- side and it is essential to turn out a flange in order to ap- proximate the endothelial lining- of the blood-vessel. The usual method of suturing blood-vessels consists in first placing three guy sutures and then whipping the edges of the vessel together by an overhand stitch. This neces- sarily cannot approximate the endothelial surface on the inside as accurately as would a mattress stitch that turns out a flange and compels the apposition of the intima. No one would think of suturing a bowel in a similar man- ner and claim that the peritoneum could be accurately brought together by merely whipping over the margins of the bowel wound as in suturing skin. If this cannot be done in intestinal surgery, the same thing holds equally in blood-vessel surgery. The presence of foreign substances in the lumen of a blood-vessel promotes clotting. Some substances favor clotting more than others. A coating of vaseline or par- affin retards clotting. Other things being equal, however, the larger the amount of foreign substance or raw sur- face in the blood vessel, the greater the likelihood of ex- tensive clotting. A mattress suture which turns out a flange not only approximates the intima more accurately but leaves almost no thread exposed in the lumen; whereas the continuous overhand stitch leaves a consider- able amount of thread in the lumen. This is readily seen from the accompanying cut (Fig. 13a) which is repro- duced from Guthrie's work on blood-vessel surgery and shows the inside of the vessel soon after being sutured by the usual method. The mattress suture which is parallel to the wound also secures a better hold upon the tissues than the overhand stitch which is at right angles to the wound and the mattress stitch is, consequently, less liable to cut (Fig. 13c). This is due to the fact that in TECHNIQUE OF SUTURING BLOOD-VESSELS. 4!) the mattress suture the tension is more equally distrib- uted along the whole loop of the stitch, whereas in the overhand stitch the tension is concentrated at one point, that is, at the end of the suture farthest from the wound. This fact has been brought out by Lexer in a case that has already been referred to (page 42). Lexer excised A. B. 0. Fig. 13. (A) This drawing, reproduced from Guthrie, shows the appearance of the lumen of a blood-vessel immediately after it is sutured by the method of Carrel. Note the large amount of thread exposed in the lumen. (B) This drawing, also from Guthrie, shows the appearance of the lumen of a blood-vessel several weeks after successful suturing. The stitches have been covered by endothelium which is still partly transparent. The older the specimen, the thicker and more opaque becomes the covering over the sutures until, after several months, the stitches are completely hidden from view. This is true of any method of suturing whether the mattress or overhand stitch is used. It is the first day or two after the suturing (before the stitches are covered) that the amount of thread in the lumen is important. Sutures seem to work away from endothelial surfaces toward the lumen in the intestine and toward the surface in blood-vessels. (C) This drawing shows the aversion of the intima caused by the double mattress stitch and the consequent absence of any raw surface left in the lumen of the vessel. Note the very small amount of thread left exposed to the blood current as compared with "A." Note also the strong grip that the loop of the mattress stitch has on the tissue. an aneurism and sutured a piece of the saphenous vein into the defect. "The wall of the artery markedly changed by arteriosclerosis allowed the threads of the running suture of Carrel to cut through. On the other hand, the continuous protruding mattress suture gave very good service ; the thread not only held well but also prevented hemorrhage. ' ' 50 SURGERY OF THE BLOOD-VESSELS. Asepsis in blood-vessel suturing should be as nearly perfect as possible, just as it should be in abdominal sur- gery, brain surgery, or bone surgery. If the tissues around the blood-vessels are infected no suturing can be expected to be satisfactory. Yet even in the presence of infection it is not invariably a failure, as the author has one successfully sutured femoral artery in a dog in which the tissues around the vessel suppurated for several weeks. As a rule, however, infection will result in fail- ure and the proper aseptic technique should be insisted upon. Particularly should dust be avoided. The oper- ator should wear a mask over his mouth and the floor of the operating room should preferably be moist. In labo- ratory work the floor should be flushed with water an hour or two before operating. The manner of handling tissues is most important, for gentleness is an absolute essential. No matter how careful the aseptic technique, good results cannot be secured by one who uses the same methods of handling tissue in blood-vessel surgery as would be adopted in bone surgery. The vascular endo- thelium should not be permitted to dry and should not be touched with any instrument. As for instruments, the author uses No. 16 straight needles threaded with 00000 twisted black silk. They are threaded with silk about fourteen inches long and a single knot is tied on the eye of the needle to prevent it becoming unthreaded. The short end should be cut within half an inch of the needle to avoid unnecessary loose ends dangling about. Five of these threaded needles are run through a piece of gauze of double thick- ness about two inches wide and as long as the thread. This gauze is then placed in a small can or ointment jar that is one-third full of white vaseline. More vaseline is put over the gauze and the jar is closed and sterilized. TECHNIQUE OF SUTURING BLOOD-VESSELS. 51 Fig. 14. Arterial suture staff. 52 SURGERY OF THE BLOOD-VESSELS. The needles are not removed until they are to be used, when they are taken from the gauze and the gauze, which is thoroughly impregnated with vaseline, is laid beneath the artery to protect it from the surrounding tissue. To place the cobbler's stitch satisfactorily, it is necessary to have an instrument called "an arterial suture staff" which the author has devised in an effort to simplify the technique. This instrument (Fig. 14) consists of a small steel shaft which curves at one extremity into a shorter shaft. The long shaft, or handle, is six inches long, and the short shaft is one and three-quarters inches long and is placed at an angle of about sixty degrees to the long shaft. The curved portion is flattened to form a spring. There are five buttons ; one on the main shaft as close as possible to the curved spring, one at the extremity of the short shaft, one just below this, and two on the main shaft at points about opposite the buttons on the short shaft. These buttons hug the instrument closely and are so con- structed that the guy sutures are securely held by simply wrapping them twice around the buttons. 1 In order to occlude the vessel, either a rubber covered Crile clamp is used, or the ordinary serrefine, or bulldog clamp, uncov- ered, which has a spring so weakened that the clamp can grasp the skin of the forearm without pain. The inside of the vessel should never be caught with forceps, though sometimes it is necessary to grasp the outside. For this purpose the ordinary thumb forceps called "frog for- ceps" by the instrument dealers and sold for biological dissection are excellent. Several mosquito hemostatic forceps are needed (Fig. 15). Aside from these special instruments, the usual instruments may be employed. The knife and scissors should be sharp. 1 The arterial suture staff is made by The Kny-Scheerer Company, of New York, and by Sharp & Smith, of Chicago. Powers & Anderson, Inc., Richmond, Virginia, keep in stock the staff and the set of instruments and sutures used in vessel suturing. TECHNIQUE OF SUTURING BLOOD-VESSELS. Fig. 15. Special instruments used in end-to-end suturing of blood-vessels. On the left is the arterial suture staff and next to it a small thumb forceps called "frog forceps." On the right is a "mosquito" hemostatic forceps and next to it two serreflnes, or "bulldog" forceps. 54 SURGERY OF THE BLOOD-VESSELS. The vessel is exposed, keeping the tissues as dry as possible. A serrefine is placed on the portion of the vessel nearest the heart, and the vessel is then gently grasped between the thumb and finger and stripped of blood to the other angle of the wound, where another Fig. 16. The artery is exposed, blood stripped from it and serrefine clamps are placed. Gauze soaked in vaseline is under the artery. The dotted line shows the proposed incision. serrefine is placed. This leaves the artery dry and flat like a ribbon. The vaselinized gauze from which the needles have been removed is now placed beneath the vessel (Fig. 16), after stopping all bleeding in the wound, and the artery is divided with one stroke of sharp scissors. The fingers are wiped free of blood and moist- TECHNIQUE OF SUTURIXG BLOOD-VESSELS. OO ure on a dry towel and the left finger and thumb grasp one of the ends of the artery rather firmly and pull the adventitia over its cut end. The adventitia is cut off on a level with the rest of the artery (Fig. 17). It then retracts, leaving the middle and inner coats exposed. Fig. 17. The artery is severed by sharp scissors. The adventitia curls over the ends of the artery. Illustration shows the finger and thumb grasping the ad- ventitia from one end of the artery and pulling it up. This redundant adventitia is cut away and the rest then retracts, leaving a clear-cut margin of the artery. Both ends are treated in a similar manner. Any remaining clots in the vessel are stripped out with the thumb and finger and the end is held firmly between the thumb and finger of the left hand and sponged with dry gauze (Fig. 18). As the artery is collapsed and its end held between the finger and thumb the gauze cannot 56 SURGERY OF THE BLOOD-VESSELS. touch the intima but merely wipes the wounded portion and so removes any excess of thrombokinase. The tip of a finger of the right hand is then dipped in white vaseline and the end of the artery is smeared over with vaseline Fig. 18. The thumb and finger of the left hand grasp the end of the artery cfter the adventitia has heen removed and a finger of the right hand anoints the collapsed end with vaseline. immediately after being sponged. This serves to keep back any further juices from the severed artery and also prevents drying of the intima. The other end of the vessel is treated in the same manner. All of these manipulations are done rapidly for it is essential to complete the suturing as quickly as possible after the intima has been exposed. One of the sutures which has been prepared as directed is inserted from without inward at one end of the artery and from within outward at the other end. An artery is quite tough and a small bite will be sufficient. If too much is taken, the intima cannot be properly everted. The first loop of a knot is tied, bringing the ends of the vessel together. The second loop of the knot is tied while holding the ends TECHNIQUE OP SUTURING BLOOD-VESSELS. .)/ of the suture taut, running the knot down in this manner to prevent the first loop from slipping. After tying this suture, the arterial suture staff is placed under the artery with the short shaft pointing toward the operator. The guy suture is fastened by wrapping it two or three times around the lowest button on the long shaft, and is cut short (Fig. 19). The length of the suture from the but- ton to the vessel should be about half an inch. The sec- ond suture is placed about one-third of the way around 58 SURGERY OF THE BLOOD-VESSELS. the circumference of the vessel and should be on the side away from the operator. The suture staff can be laid flat so that the short shaft is not in the way and the ves- sel ends can rest upon the long shaft, thus making it Fig. 20. The handle of the arterial suture staff is depressed away from the operator and the short shaft may be turned flat and caught so as to manipulate the ends of the artery into a more convenient position for inserting the second suture. The second suture is inserted, tied, and wrapped around one of the upper buttons on the long shaft. easier to insert the second suture (Fig. 20). The second suture is inserted and tied in the same manner as the first and is wrapped around one of the upper buttons on the long shaft. The threaded end is left long for future suturing but the other end is cut close to the button. As TECHNIQUE OF SUTURING BLOOD-VESSELS. 59 two guy sutures are now fixed to the long shaft, the third one is easily inserted by raising 1 up the long' shaft when the point of insertion of the third suture is indicated by the retraction of the margins of the artery. The needle Fig. 21. The threaded end of this guy suture is left long for future suturing. The unthreaded end is cut short. The vessel can now be lifted on the staff when the apex of the retracted margins will indicate the point for insertion of the third guy suture. This staff makes the insertion of the second and, particu- larly, the third guy suture much easier. is inserted at the apex of the retracted margin (Fig. 21). After this suture is tied, the short shaft is slightly com- pressed toward the long shaft and this guy suture is wrapped around one of the buttons on the end of the short shaft (Fig. 22). The threaded end is left long and 60 SURGERY OF THE BLOOD-VESSELS. l-Mg. 22. After insertion of the third guy suture, it is tied in the usual manner. a'il sutures being about equidistant. The suture staff is then grasped by the handle in the manner indicated in this drawing, and the short shaft is slightly compressed toward the long shaft. While held in this position, the third guy suture is wrapped around one of the buttons on the end of the short shaft. TECHNIQUE OF SUTURING BLOOD-VESSELS. ()1 the unthreaded end is cut close, as in the second suture. It is important to have no unnecessary ends hanging loose. The short shaft is released and the spring makes tension on the margins of the artery, converting its cir- cumference into a triangle, and everting the intima (Fig. 23). The three guy sutures are inserted in the same way when an artery is joined to a vein of much larger caliber as when a divided artery is united. Sometimes it is a SURGERY OF THE BLOOD-VESSELS. little more difficult when a small artery is sutured to a large vein, but after the guy sutures are once inserted, the rest of the procedure is identical whether vessels of equal or unequal caliber are to be united. Fig. 24. The handle of the staff is upright and the whole instrument is lifted up so as to increase the eversion of the intima. The continuous, double mat- tress, or cobbler's stitch, is begun by using the threaded ends of the last two guy sutures. The needles are thrust through the margins of the artery near the second guy suture and should be inserted at right angles to each other so they can be handled better. The suturing in this third is done toward the operator, that is, from the second to the third guy suture. We now have two needles from the two guy sutures last inserted. A needle is taken in each hand and thrust through both margins of the artery in the region where the second suture was tied. The threaded needle from the third guy suture at the end of the short shaft will, of TECHNIQUE OF SUTURING BLOOD-VESSELS. course, carry a little loop of thread which is of no conse- quence. The instrument is lifted up so as to elevate the upper third of the wound and increase the eversion. The suture is then applied in the manner of the double mat- tress, or cobbler's stitch, going from the second guy suture to the third (Fig. 24). At the angles particular Fig. 25. The handle of the staff is depressed until it is horizontal and points away from the operator. Then the whole instrument is shoved toward the operator so as to increase the eversion in the second third. The suturing is continued as a cobbler's stitch. care should be taken to go beneath the insertion of the guy sutures; otherwise, the tension of the guy sutures may produce a wound in the endothelium which would be exposed to the lumen of the vessel. After the first third 64 SURGERY OP THE BLOOD-VESSELS. lias been sutured, the handle of the instrument is de- pressed away from the operator and the instrument shoved toward the operator so as to increase the eversion of this third of the margin of the vessel (Fig. 25). The suturing is continued as a cobbler's stitch. When the Fig. 26. The handle of the staff is then brought over to a horizontal position pointing toward the operator. The instrument is lifted tip so as to increase the eversion of the last third. The suturing is continued toward the second guy suture. second third is finished, the instrument is brought to its original position and each needle carried under the vessel so as to be ready for suturing the last third. The handle is then depressed toward the operator and held in such a manner as to lift up the last third and so increase its eversion (Fig. 26). The suturing is continued through TECHNIQUE OF SUTURING BLOOD-VESSELS. UO the last third and when this is finished the instrument is brought back to its original position and the suturing car- ried about two stitches beyond the point of commence- ment, where the threads are tied to each other. Each stitch must be drawn snugly when it is placed, else the intima will not be securely approximated and there will be leakage. In the carotid of a dog of medium size about five stitches are put in each third of the artery. Sometimes, particularly in old dogs, retraction of the ends of the artery is marked and the sutures cannot be properly placed as they will tend to cut out or break under the tension. If the adventitia of the vessel is grasped with curved mosquito forceps about one and one- half inches from the severed ends, the two ends of the vessel can be shoved together by an assistant without tension on the sutures and without his hands being in the way of the operator. This is better than trying to approximate the ends by the serrefine clamps which may either come off or loosen and flood the vessel with blood. After the suturing has been completed, the short shaft is slightly compressed toward the main shaft so as to relax the tension on the guy sutures and the distal clamp on the vessel is slowly released (Fig. 27). If there is marked spurting at any point, an extra suture should be placed there. With a little experience spurting rarely occurs, though there is usually oozing of a few drops of blood. The guy sutures are then cut and the instrument is removed. The sutured vessel is very gently com- pressed with dry gauze and the distal clamp is entirely removed. After about a minute the proximal clamp is slowly removed. In this time the needle holes should be plugged with fibrin and there should be no leakage. The vessel must not be returned to its bed until leakage has ceased. The whole procedure of suturing the vessel, 66 SURGERY OF THE BLOOD-VESSELS. Helen korrarn*. i*f. Fig. 27. The handle of the instrument is brought to a vertical position and, the suturing having been carried about two stitches beyond its point of com- mencement, the threads are tied to each other. The distal clamp is slowly removed and the staff somewhat compressed so as to relax the guy sutures and demonstrate if there is any spurting point along the suture line. After a minute, the other clamp is removed, and if no spurting exists the guy sutures are cut. If any spurting does occur, the clamps can be reapplied and an extra stitch taken at the spurting point. With a little practice, however, this is rarely necessary. TECHNIQUE OF SUTURING BLOOD-VESSELS. 67 from the insertion of the guy sutures to the last stitch, can easily be done in from ten to fifteen minutes and often in less time. Any competent surgeon who trios this technique experimentally a few times can master it. This method has been mentioned in several journals. - The arterial suture staff has not been altered and the general principle of approximating the intima has always been adhered to. However, several details of applying this principle have been changed, and it is the author's opinion that these changes acid to the value of the technique. The staff holds the vessels so that the edges are everted and each stitch is inserted under the same tension from the first to the last. It greatly facilitates the suturing and makes possible the carrying out of the principles that have already been noted. The ar- terial suture staff not only renders easier the placing of the last two guy sutures, but holds all of them in proper position and under uniform tension throughout the operation. By means of this instrument the tension is kept even at all points along the arterial wound. There are no long ends of sutures to become entangled and there is no necessity for several changes with the alternate increase and relaxation of tension when the sutures are handled in the ordinary way, which neces- sarily interferes with the regularity and accuracy of the suturing. Any one can hold it; an assistant trained in blood-vessel surgery is not needed. The changes are as follows : 1. A double mattress or cobbler's stitch is now used instead of the single mattress stitch as originally ad- vised. It was found that when the single mattress stitch was used there were points between sutures with but 2 Annals of Surgery, February, 1912; Journal A. M. A., July 6, 1912, and December 14, 1912; Surgery, Gynecology & Obstetrics, May, 1914. 68 SUEGERY OF THE BLOOD-VESSELS. little compression and no raw surface. This sometimes made a small amount of leakage that was difficult to con- trol; also a little diverticulum would be formed that was a weak spot and would occasionally result in secondary hemorrhage. The double mattress stitch does away with these objections and approximates the iiitiina firmly as by a fine clamp around the entire margins of the vessel; at the same time it exposes no more thread in the lumen, than is exposed by the single mattress stitch. The use of this stitch can be readily acquired by any one who tries it. It has been most successfully used in intesti- nal suturing by Crile, and is much more needed in ves- sel suturing, as there is more pressure in a blood-vessel than in the bowel. As the operator must use both hands while inserting the cobbler's stitch, it would be difficult to place this stitch evenly and satisfactorily with- out the suture staff, as the three guy sutures would have to be manipulated by hand. 2. No salt solution is now used to wash out the vessels. It has been the object of this technique to eliminate as far as possible every procedure that is not essential to success. Washing out the ends of the vessel with salt solution not only adds somewhat to the trauma of the endothelium, makes a sloppy wound, and prolongs the procedure, but according to Guthrie, rather tends to in- crease clotting than diminish it. 3. In order to strengthen the second and third guy sutures both ends of these sutures are now wrapped around the buttons, instead of merely using the un- threaded ends, as was formerly advised. Instead of first inserting the guy sutures and then placing them on the suture staff, it is better to fix them on the staff as they are inserted. This not only relieves the necessity of handling the sutures twice, when once will do, but it is TECHNIQUE OF SUTURING BLOOD-VESSELS. () ( J much easier to place the second and third sutures when the first has been fastened to the staff, as the staff can then be so maniuplated as to bring the margins of the vessel wound into a more advantageous position for suturing. The technique as described is quite simple and the serv- ices of a trained assistant are not needed. It can be acquired as readily as the technique of suturing in- testines. Dr. E. L. Caudill, an intern at St. Elizabeth's Hospital, Richmond, Va., who had never done an opera- tion, but merely assisted in a few surgical operations on patients and in suturing arteries on animals, divided the carotid artery of a dog and united it by this technique three times. This was done without any assistance ex- cept that of a medical student and of the orderly who gave the anesthetic. Xo one else was present. Of the three operations two of them were successful and showed a lumen free from any thrombus two weeks and six weeks, respectively, after the operation. The third oper- ation was unsuccessful, as the artery was occluded by thrombus. He undertook experimental work on suturing intestines and according to his own expression found it much more difficult to unite a divided bowel successfully than to unite a divided artery. There seems no reason why surgeons who are likely to need the technique of blood-vessel surgery should not easily acquire it. The transplantation of a segment of a vein, or of an artery, or of a rubber tube involves the same technique as suturing a divided vessel. It is best, however, to have two arterial suture staffs instead of one. Three guy sutures should be placed at one end but only the first two fastened to the staff. Then the other end of the transplant can be sutured with another staff in the usual way. After this is completed, the first staff is taken up, 70 SURGERY OF THE BLOOD-VESSELS. the third guy suture fastened to the end of the short shaft, and the suturing completed. In this way there is no inconvenience from the presence of two suture staffs in the wound at the same time, but if all three guy sutures were placed in position on the first suture staff, the short end of the staff would project so as to interfere with the suturing at the second suture staff. A transplant can be taken either from a vein or artery, or a piece of rubber tubing can be used. For practical purposes the vein is best. In experimental work the external jugular of the dog is the most suitable vein to transplant. It is readily accessible, is large, and has but few branches. Trans- plantation after resection of the carotid is more likely to be successful in experimental work than transplanting in the femoral because the neck is much less likely to be in- fected than the leg. This has been pointed out by Watts. Some attention must be given to securing a section of the vein that is to be transplanted. The saphenous is the best vein to use as a transplant in man. The vein must be exposed and handled gently. A much longer portion should be taken than is supposed to be necessary for it contracts greatly after being removed and it is a simple matter to cut off any excess if it is too long. The vein should be dissected free while it is distended with blood and the adventitia of that portion of the vein which is to be cut should be very carefully removed while the vein is distended, otherwise it retracts within the adventitia and as the vein is exceedingly thin, cleaning away the adventitia is difficult after the col- lapsed segment has, been removed. When the adventitia has been sufficiently removed, any pressure that caused the vein to become distended is released and a ligature placed on the distal portion of the vein. The blood is TECHNIQUE OF SUTURING BLOOD-VESSELS. 71 then gently stripped out of the vein and another ligature placed at the proximal end. The vein is cut across with sharp scissors, at one stroke if possible. After the blood has been stripped from the vein it should be entirely collapsed and like a ribbon. When the end is cut it is sponged with dry gauze and thoroughly anointed with white vaseline, as mentioned in the technique of vessel suturing (page 56), only more vaseline should be used here. The other end is then divided and treated in a similar manner. The vein is placed on a sterile towel and should be used as quickly as possible. The vein should not be removed until the other dissection has been completed, so that suturing of the vein into the de- fect can be proceeded with at once. There is no occasion for washing out the segment of vein or for keeping it in salt solution. If for any reason it is necessary to keep the segment awhile, it may be placed on a towel or piece of gauze that has been wrung out of salt solution, and another piece of gauze similarly wrung out is placed over it. It is not necessary for the salt solution to be warm. It has been proven that cold tends to retard thrombus formation and segments of vessels can be kept in cold storage for weeks and then sutured success- fully. The author has used experimentally rubber tubing of various kinds to replace an arterial segment (Fig. 28). This in most instances becomes readily covered with tissue that resembles the adventitia of a blood-vessel. It is well known that rubber when properly prepared is very slightly irritating to the tissues. Dentists make frequent use of it. If, then, adventitia can be thrown around the rubber tube as an encapsulation, it would probably support the blood current after the rubber had degenerated. The high reproductive power of vascular 72 SURGERY OF THE BLOOD-VESSELS. endothelium is frequently observed in the rapid lining of aneurisms that have suddenly enlarged, and it seems possible that this endothelium might cover the inner surface of the rubber tubing. In this way a strong adventitia and an intima may, possibly, be secured. Ex- perimentally, however, the author has not been able to obtain such a result. Though the tube is often encapsul- Fig. 28. A piece of rubber tube sutured in between the cut ends of an artery. Note the complete absence of any sharp margin of the tube and the absence of thread in the lumen. This cannot be done by the regular overhand suture. ated with a membrane that resembles adventitia, its in- ternal surface has so far been invariably blocked, sooner or later, by thrombus. Tubes have varied from thick, black rubber to very thin rubber, and have been coated with vaseline or paraffin. While it would be impossible to suture tubes, especially thick tubes, by the overhand stitch, and at the same time make an accurate approx- imation and avoid sharp edges of the tube pointing TECHNIQUE OF SUTURING BLOOD-VESSELS. inward, by using a mattress suture and preferably the double mattress with the staff that has been described, the sharp edges are everted. While so far the author has not met with success in having the rubber tube re- main permanently patent, the thrombus formation in some instances at least must have been slow. Clinic- ally, it is just as satisfactory to have a slowly form- ing thrombus in a tube of this character, which would Fig. 29. Fig. 30. Fig. 29. An iliac artery of a dog which was removed a few minutes after suturing after the blood had been turned on and no leakage appeared. Note the ever- sion of the intima constituting a flange without diminution of the caliber. Fig. 30. The lumen of the carotid artery of a medium sized dog. The blood had been allowed to flow for a few minutes and there was no leakage. Note the absence of thread in the lumen. permit collateral circulation to form, as it is to have the tube remain permanently open (Fig. 28). The possibilities of using a rubber tube in this man- ner clinically have been suggested by an experiment in which the author resected a portion of the abdominal aorta of a dog and transplanted a piece of rubber tube SURGERY OF THE BLOOD-VESSELS. to fill the defect. The portion resected was below the renal arteries. The tube was a soft, black rubber tube coated with paraffin. It was much thicker than was Fig. 31. A segment of an external jugular vein which was sutured in the place of a resected portion of the right carotid of a large dog. Note the valves about the middle of the specimen in one of which is a small clot. The specimen was dilated at this point, probably from the force of the blood stream in overcoming the valves. Otherwise the intima is perfectly smooth and the sutures are mostly buried from view. The specimen was removed 63 days after operation. really necessary, and the suturing was more difficult than if a thinner tube had been used. The dog was a medium sized female mongrel. There was very little TECHNIQUE OF SUTURIXG BLOOD-VESSELS. 75 leakage, which was easily controlled by pressure. The peritoneal tissues were sutured over the tube and the abdominal \vound was closed in layers. The dog- made Fig. 32. Specimen of reversal of circulation in the neck. The proximal end of the carotid was sutured to the distal end of the external jugular vein in a medium sized dog. This specimen was removed after thirty-nine days. The sutures are distinctly buried, though the endothelium over them is still transparent at places. The line of suturing is smooth. A short distance from the line of sutures are the crumpled-up valves which were forced and broken down by the blood stream. a satisfactory recovery, there being no paralysis of the hind legs. As function had apparently not been inter- fered with it was hoped that the tube had remained 76 SURGERY OF THE BLOOD-VESSELS. Fig. 33. Photograph of a specimen in which a rubber tube was sutured into the defect caused by excision of a part of the abdominal aorta. The tube was removed after six months. The suturing was done according to the method recommended. The tube was completely encapsulated, though it was occluded. TECHNIQUE OF SUTURING BLOOD-VESSELS. ~t patent. Six months after this operation, the dog ap- peared in perfect health. The dog was then photo- graphed, killed with chloroform, and the specimen re- moved. The lumen of the tube, however, was occluded with -thrombus. There was no dilatation nor any evi- . ^ Fig. 34. Photograph of a dog: in which a portion of the abdominal aorta was re- sected and a rubber tube sutured in to fill the defect. The dog made a per- fect recovery. The photograph was taken six months after operation. The dog was then killed and the specimen removed. The tube was completely en- capsulated' but was occluded. The occlusion was evidently gradual, as there were no bad symptoms and no paralysis of the legs. Gradual occlusion which permits time for collateral circulation is clinically as satisfactory as if the tube had remained patent. dence of formation of an aneurism. The outline of the tube is plainly seen in the photograph. The external caliber of the tube was considerably larger than the ex- ternal caliber of the artery. (Figs. 33 and 34.) Ligation of the aorta in man has been universally fatal. This experiment suggests a possible substitute for liga- tion. 78 SUEGERY OF THE BLOOD-VESSELS. Lateral and Incomplete Transverse Wounds of Blood-Vessels. The preliminary steps in suturing lateral or transverse wounds of blood-vessels are the same as those outlined under the description of end-to-end suturing. The wound should be a clean cut. If ragged or bruised, the margins are trimmed with sharp scissors. If a trans- verse wound involves more than half the circumference of a vessel, the vessel should be completely divided and then united by the end-to-end method. If the whole cir- cumference is contused or lacerated, the damaged section must be excised, and if the ends of the vessel cannot be sutured together without too much tension, a transplant of vein may be used (page 69). The method to be adopted in suturing these wounds depends partly upon the nature of the wound, but largely upon the accessibility of the blood-vessel. When pos- sible, the vessel should be freely exposed by a long in- cision. The adventitia along the edges of the wound should be trimmed away with sharp scissors, blood-clots removed, and the edges of the wound and the intima anointed with white vaseline. If the wound is parallel with the vessel, it may be grasped with the forceps used for lateral anastomosis of blood-vessels (described on page 84) and sutured with a cobbler's stitch, using fine, straight needles (No. 14 or 16) and fine black silk steril- ized in white vaseline. If the wound is transverse, the suture staff (page 52) may be placed under the vessel, a guy suture of the usual material is inserted at one end of the wound and wrapped around an upper button on the long shaft, and another guy suture is placed at the oppo- site end of the wound and fastened to a button on the short shaft while it is being compressed toward the long TECHNIQUE OF SUTURING BLOOD-VESSELS. ( \) shaft. When the short shaft is released, it will make ten- sion on the wound, and evert the intima. A cobbler's stitch can then be placed with the threaded ends of the gny sutures, as in suturing the first third of an end-to-end union. Care should be taken to secure the beginning of the suture line by going well beyond the wound and taking a back stitch. Occasionally a transverse or a lateral wound may be so inaccessible that neither of these meth- ods can be used. In such instances a long guy suture may be placed at each end of the wound and held by an assistant while the wound is closed with a continuous overhand stitch of black silk in a curved, round needle (a number three French intestinal needle) sterilized in vase- line. There will be more leakage from the needle-holes after this method and thrombosis is more frequent, but in deep wounds it may be the only technique applicable. CHAPTER V. LATERAL ANASTOMOSIS OF BLOOD-VESSELS, AND REVERSAL OF THE CIRCULATION. Lateral anastomosis of blood-vessels is used either in uniting a vein to a vein, as in the Eek fistula when the portal vein is joined to the vena cava, or in uniting an artery to a vein when it is desired to reverse the circu- lation. The indications for Eck fistula are few, if any, so far as its clinical application is concerned. The op- eration was described by Eck, a Russian surgeon, in 1877, and again in 1879. It has been performed a few times by German surgeons in cirrhosis of the liver, 1 but the metabolic products from the portal circulation sooner or later produce a toxic effect when discharged into the gen- eral circulation at a rate as great as the Eck fistula per- mits. Again, it is possible that the ascites may be due to irritation of the peritoneum and not solely to portal ob- struction. The indications for reversal of the circulation are still under much dispute. Halstead and Vaughan 2 reviewed the literature and reported personal experience. They conclude that the operation for reversal of the circula- tion has no practical value. Coenen, of Breslau, opposes the operation and gives his reasons at some length. They are that the valves must be forced, that it is prob- able the arterial blood following the route of least re- sistance goes through the first anastomotic vein back to iRosenstein: German Surgical Congress, 1912. 2 Surgery, Gyneeology & Obstetrics, January, 1912. 80 LATERAL ANASTOMOSIS REVERSAL OF CIRCULATION. 81 the heart and rarely if ever reaches the terminal branches of the vein, that in arteriovenous aneurism it takes weeks and sometimes months for valves to be forced sufficiently to detect pulsation in the smaller veins, and that the arterial blood in venous capillaries must have some manner of return which has not yet been fully studied. There are many pathological conditions in man such as arteriosclerosis, thrombo-angeitis obliterans, diabetes and Raynaud's disease that do not occur in ex- perimental work. When the vessel itself is diseased at the site of the anastomosis, or when the veins are in- volved in the disease, reversal of the circulation is use- less. When gangrene has already occurred, of course, operation for reversing the circulation cannot bring re- lief. The practical utility of reversal of the circulation is doubtful. Some experiments which the author has re- cently performed and which are not yet ready for full report seem to show that in reversal of the circulation the blood returns to the heart by anastomotic venous branches a short distance below the site of the opera- tion and that the arterial blood in a reversed femoral vein never reaches the foot and usually goes but little below the knee. If the circulation is to be reversed, it should be done by lateral anastomosis and not by an end-to-end union. When the vein and artery are both cut across and the ar- tery is united to the vein end-to-end, the distal channel of the artery is sacrificed, whereas if lateral anastomo- sis is performed and the vein ligated on the cardiac side, there will be two channels for the arterial blood instead of one. The original arterial channel is not put out of commission and at least no harm will be done even if no good is accomplished. This was originally pointed out 82 SURGERY OF THE BLOOD-VESSELS. by J. B. Murphy and has later been demonstrated and in- sisted upon by Bernlieim and others. When the main artery to a limb is partially occluded and the veins are healthy, the arterial blood in the capillaries is probably drained off more quickly than normal. Tims the tissues are not bathed with arterial blood sufficiently long to be nourished properly. Ob- structing a large vein may prevent this rapid passage of arterial blood and so equalize the circulation and improve the condition of the limb. In this way may be explained some of the reported improvements that have followed reversal of the circulation in a limb, particularly after the end-to-end method. Ligation of the femoral vein should be equally beneficial. When doing a lateral anastomosis of artery and vein, Bernlieim and Stone 3 recommend making the opening in the vessels by transfixing them with a cataract knife and cutting from within out about one-third of the circum- ference. The vessels are then cleaned with normal salt or Kinger's solution, anointed with liquid vaseline, and united by a continuous suture of fine silk. Bernlieim and Boegtlin 4 discuss the question of whether an Eck fistula is compatible with life and de- scribe a new method for making this fistula. The portal vein and vena cava are first sewed together with a small curved needle and silk, using a continuous suture and No. 3 curved, French intestinal needle with double thread. Another row of sutures is made parallel with this and an especially constructed scissors with sharp points is partly opened, and one blade plunged into the vena cava and the other into the portal vein. The par- tition is then cut. A previously inserted suture is 3 Annals of Surgery, October, 1911. 4 Bulletin of Johns Hopkins Hospital, February, 1912, page 33. LATERAL ANASTOMOSIS REVERSAL OF CIRCULATION. 83 quickly tied at the point of the puncture of the scissors. They claim that Eck fistula in dogs is consistent with life for a long period of time provided the diet is regulated, though certain hepatic functions are decreased when an Eck fistula is present, notably, tolerance for sugars, the formation of bile, and the hemolytic function of the liver. The technique of Bernheim is similar to that of Sweet, who, in 1904, described a method in which a fine platinum wire was passed into the veins and an electric current connected, after the two rows of sutures had been placed, so burning an opening. The technique of Carrel and Guthrie involves dissect- ing the vena cava and the portal vein and clamping them above and below the site of operation, which is difficult and tedious. The union is made with straight arterial needles. If a lateral anastomosis is to be done on easily accessi- ble vessels the technique is simple, but if the vesesls are difficult to expose, or if hemostasis cannot be complete, it becomes very trying. In an effort to standardize a technique that could be used in all cases of lateral an- astomosis, whether in making an Eck fistula, or in unit- ing an artery and a vein in a difficult location, the author has devised a forceps that takes a lateral hold either on the entire caliber of each vessel, or on any portion of it as desired. The necessity for such a forceps was suggested by an operation done by the author at the clinic of Prof. "W. L. Rodman, in Philadelphia, through the courtesy of Prof. Rodman. The case was an ar- teriovenous aneurism of the femoral artery and vein, too close to Poupart's ligament for the application of a tourniquet. After dissecting the artery and vein above and below the aneurism, placing Crile clamps on these vessels above and below the lesion, clamping the 84 SURGERY OF THE BLOOD-VESSELS. profunda and controlling the internal branches, an at- tempt was made to dissect behind the aneurism. This was difficult and bloody, but it was thought that the blood was what remained in the sac and tissues. An incision into the communication between the vessels was followed by profuse bleeding that was controlled with considerable difficulty. It was suggested by Prof. Rod- man and by Dr. Stewart Rodman, who kindly assisted in the operation, that a forceps that could clamp these vessels before dividing them would be advantageous. On looking up the matter afterward, the author found three kinds of forceps for clamping vessels for lat- eral suture. One was Joani's clamp. 5 The author has never seen this instrument but from the illustration the points appear frail and the handles are at such an angle to the blades as to interfere with suturing. The forceps of Stewart, 6 the jaws of which consist of large ovals, could not be used in arteriovenous aneurism. The in- strument of Jeger, 7 a diminutive Roosevelt gastro-enter- ostomy clamp, has straight blades and the middle blade is objectionable. It was devised for making an Eck fistula. After experimentation and several changes a model was devised that seems to obviate the objections of the other instruments (Fig. 35). These forceps for lateral suture are five inches long, have thin, well-tempered curved blades with longitudinal grooves, and handles that extend in the axis of an imaginary line drawn from the tip to the heel of the blades. The blades fit accurately but are soft enough to be clamped on the skin of the forearm without pain. They can hardly injure the intima but to make this even surer soft, pure rubber tubing is slipped over the blades. The tubing should not be too 5 Keen's Surgery, Vol. 5, page 128. c Journal A. M. A., August 20, 1910. 1 Presented at German Surgical Congress, 1912. LATEEAL ANASTOMOSIS REVERSAL OF CIRCULATION. 85 close to either the heel or the tip of the blades as this might interfere with the pressure in the middle of the blades and so cause leakage. Such forceps can be used for suturing lateral wounds of large blood-vessels without entirely obstructing the blood-current. In creating an Eck fistula, the axis of the handles makes it possible for the handles to lie flat in the abdomen and so be out of the way. These forceps can be used where no tourniquet Fig. 35. Forceps for lateral blood-vessel suturing. They are made with very light blades which can be clamped on the skin of the forearm without pain. The handles lie in the axis of a line drawn from the tip to the heel of the blades. In this way the handles will lie flat even in a deep wound and be out of the operator's way. In order still further to prevent injury to the intima, the blades may be covered with soft rubber tubing. can be applied, as on the iliac vessels ; or in operations on an arteriovenous aneurism where hemostasis is not satis- factory by other means. Even where hemostasis is com- plete, they serve to steady the walls of the blood-vessel while sutures are inserted and lessen the amount of in- tima exposed, so preventing it from drying. These forceps have other uses than for lateral anasto- mosis, or the cure of arteriovenous aneurism. For in- stance, they can be employed for hemostatic forceps in- stead of the Crile clamp, acting in the same manner as 86 SURGERY OF THE BLOOD-VESSELS. the forceps of Matas, which are designed for temporary occlusion of the vessel. As the blades are very soft, they can be quickly applied and locked without fear of injury to the intima. The author lias also used the forceps satisfactorily in a gastro-enterostomy in an in- fant four weeks old when an operation was necessary on account of pyloric stenosis. In lateral anastomosis of blood-vessels, whether unit- ing veins as in Eck fistula, or an artery to a vein, the same general principles of blood-vessel suturing men- tioned in the chapter on end-to-end suture should be ob- served (see page 47). Asepsis should be rigid, hemo- stasis complete, the tissues should be handled gently, the adventitia should be removed, and after the intima is exposed the operation should be completed as quickly as possible by uniting intima accurately to intima and leav- ing but little foreign substance or suture material ex- posed in the lumen. The vessels are exposed as fully as possible and are mobilized. It is not necessary to dissect both vessels entirely free from their beds, if they are close together. The adventitia over the parts of the vessel to be incised is dissected off and the lateral clamps described are applied, catching a deep hold on the vessel wall (Figs. 36 and 37). Both are applied in the same direction. It is bet- ter, if possible, for the vessel to be stripped of blood while placing the clamps. After both clamps are fast- ened, the vessels are anchored together with two stay su- tures of fine silk sterilized in vaseline and placed at a little distance from the two extremities of the proposed anas- tomotic opening. The ends should be left long and the vessels manipulated by these stay sutures and not by the handles of the clamps which might slip or pull off with too much traction. An incision is then made into the LATERAL ANASTOMOSIS REVERSAL OF CIRCULATION. S? Fig. 36. One forceps is shown covered with rubber and grasping the vessel pre- paratory to making a lateral anastomosis. If it is deemed unwise to occlude all of the vessel, only a portion of it can be caught. Fig. 37. The two vessels to be anastomosed have been clamped. The adventitia is being lifted and cut away. SURGERY OF THE BLOOD-VESSELS. vessels (Figs. 38 and 39). This is done when an artery and vein are united by incising the artery transversely for about one-third of its diameter with sharp scissors (Fig. 39). The wound retracts, leaving an oval opening, and is smeared with white vaseline by dipping a finger of the left hand in vaseline and anointing the wounded ves- Pig. 38. The openings in the two vessels are being made. The method illustrated in this drawing is that which should be employed in an Eck tistula. A small point of the vein is caught with the fine thumb forceps, lifted up, and the apex cut away with scissors parallel with the vessel. This is done on each side after the two stay sutures have fastened the veins together near the end of the proposed incision. After a small hole has been cut, a guy suture is inserted in the wall of the vena cava on the operator's left and is clamped with forceps but is not tied. Another suture is inserted in the wall of the , portal vein on the operator's right by passing the needle from without inward. The needle is left attached but the 'suture is not tied. By pulling on these sutures, the small openings are exposed and can be enlarged as a slit with scissors. If a transverse opening is made here, the ends of the transverse incision will retract in the deep wound. sel. The opening in the vein is made in a similar manner and should be slightly larger than the opening in the ar- tery. A fine thumb forceps, or "frog" forceps, holds the vessel wall while it is being incised and enables the sur- geon to make the opening more accurately. A tractor suture of fine silk sterilized in vaseline is placed in the left margin of the opening in the left vessel. This is not LATERAL ANASTOMOSIS REVERSAL OF CIRCULATTOX. Fig. 40. The two stay sutures and two tractor sutures are inserted and the openings are ready for suturing. 90 SURGERY OF THE BLOOD-VESSELS. tied but clamped with mosquito forceps. A similar trac- tor suture is placed in tlie right margin of the right ves- sel, but the needle end is left attached and the suture is inserted from without inward (Fig. 40). The sewing is now begun with a small curved, arterial needle (or No. 3 French intestinal needle) and fine silk sterilized in vase- line, starting from the angle of the incision nearest the Fig. 41. Suturing has been begun by using a very fine curved needle and black silk. It is started by going from without inward on one side and from within outward on the other side. The thread is then tied which leaves the knot out- side of the lumen. The end of the thread is caught in a clamp. The needle is then thrust through the artery near the knot and suturing begins as an over- hand continuous stitch. It is important to have the knot placed at the angle of the incision. handle of the forceps. The needle is thrust through the wall of the vessel at the angle, going from without in- ward on one side and from within out on the other. The thread is then tied, holding the ends of the thread taut while running down the second knot to prevent slipping. This leaves the knot outside the lumen. The short end is clamped with mosquito forceps. The needle is again thrust through the blood-vessel wall near the knot, and a LATERAL ANASTOMOSIS REVERSAL OF CIRCULATION. continuous overhand suture is applied, uniting the intiina accurately (Fig. 41). This can be easily done, using a mosquito forceps for a needle holder if necessary, and pulling on the tractor and stay sutures as indicated to expose the margins of the vessel wound. At the other angle care is taken to place the sutures closely for leak- age is likely to occur here. After this angle lias heen Fig. 42. The suturing is continued and, after the upper angle is readied, the tractor suture on the left is removed and the needle and tractor suture on the right thrust through the margin of the left vessel. This is tied and when lifted up brings the sides accurately together and renders the suturing easier. After the thread has reached its original starting point, it should be carried about one stitch be\ ond the knot and tied snugly to the end that was clamped in forceps. sutured, the left tractor suture is removed and the nee- dle on the right tractor suture is thrust through the wall where the left tractor suture was and this suture is then tied (Fig. 42). The excess of vaseline is squeezed out, the tractor suture is lifted up so as to evert the intiina, and the sewing is continued as an overhand stitch. When the original knot in the continuous suture is reached, about one stitch is taken beyond it and the 92 SURGERY OF TTTE BLOOD-VESSELS. Fig. 43. The lateral anastomosis is completed. The technique is practically the same for an Eck fistula or an arteriovenous anastomosis except as shown in Figs 38 and 39. Fig. 44. Drawing of a specimen of an Eck fistula in a dog six days after the opera- tion. There is no thrombosis. Magnified about three times. LATERAL ANASTOMOSIS REVERSAL OF CIRCULATION. thread tied to the end that was left clamped in mosquito forceps (Fig. 43). The clamp from the vein is first slowly removed and the line of suturing slightly com pressed with dry gauze. After a minute the arterial clamp is slowly relaxed and then removed if no marked!) spurting point occurs. If it does, the clamp is reapplied and a suture placed at the spurting point. A ligature Fig. 45. Lateral anastomosis between the carotid artery and external jugular vein in a dog. Note the clear opening and .just below the opening a valve in the vein. Drawing magnified about three times. Specimen was removed twenty- one days after the operation. is put on the cardiac side of the vein to prevent the blood being immediately returned to the heart (Figs. 44 and 45). In creating an Eck fistula, this same technique is fol- lowed except in incising the blood-vessels it was found that a transverse incision was not practical in large, thin vessels in such a deep wound, for it was difficult to su- ture the deepest portion of the transverse incisions. 9-1 SURGERY OP THE BLOOD-VESSELS. The opening in the veins is made as follows : A very small bite of the vena cava about the middle of the pro- posed incision is caught with the ' ' frog ' ' forceps or with mosquito forceps and pulled up to form a cone whose apex grasped in the forceps is cut oft' with curved scis- sors (Fig. 38). A tractor suture is inserted in the outer wall of this small opening in a similar manner as in arteriovenous anastomosis. The same procedure is car- ried out on' the portal vein and a tractor suture inserted from without inward and the needle left attached. These openings are then enlarged longitudinally as far as de- sired. The rest of the technique is followed exactly as described for arteriovenous anastomosis. It is possi- ble, however, to use successfully a coarser needle and thread in Eck fistula than in arteriovenous anastomosis as the pressure is very low in the large veins. CHAPTER VI. TRANSFUSION OF BLOOD. One of the applications of blood-vessel surgery is transfusion of blood. This operation, which consists in transferring blood from the vessels of one animal or per- son to those of another, is very old, though the earlier methods of performing it were far from successful. References to it are found in the Metamorphoses of Ovid, where the sorceress, Medea, took blood from healthy young men, mixed it with certain juices from vegeta- bles, and then injected the mixture into the veins of old men who desired to renew their youth. The ancient Egyptians alluded to transfusion in their writings and probably practiced it. "The Book of Wisdom" of Tana- quila, the wife of Tarquin, refers to transfusion. It is also mentioned in the sacred book of the priests of Apollo, and in the works of Pliny and of Celsus. The earliest authentic case on record occurred in 1492, when according to Villari's "Life of Savonarola," Pope Innocent VIII was transfused. He had fallen into a coma and could not be aroused. The blood of the pope was passed into the veins of a youth, "whose blood was trans- ferred into those of the old man. The experiment was tried three times, and at the cost of the lives of the three boys, probably from air getting into their veins, but with- out any effect to save that of the pope." Libavius advocated arterial transfusion by silver tubes as early as 1615. 95 96 SURGERY OF THE BLOOD-VESSELS. Giovanni Colle, of Padua, in 16-8, mentioned transfu- sion as a means of prolonging life. In 1665 Lower, of Oxford, bled animals to the point of syncope and then revived them by the injection of blood from other animals. His results were published two years later. He used a quill to connect the artery of the donor to the vein of the recipient. In the celebrated diary of Samuel Pepys is a note under date of November, 1666, in which transfusion of blood in dogs is described, one dog being almost bled to death and then transfused from another. Pepys says, "This noon I met with Mr. Hooke, and he tells me the dog which was filled with another dog's blood, at the college the other day, is very well and like to be as ever, and doubts not its being found of great use to men ; and so did Dr. Whistler, who dined with us at the tavern. ' ' In 1667, Denys, of France, repeated the experiments of Lower. He also transfused a fever patient with ten ounces of lamb's blood, and the patient recovered. He treated an insane patient by injecting several ounces of calf's blood and recovery from the insanity was reported. However, three months afterwards the disease recurred and Denys attempted to open the vein in the patient's arm, but found no blood. The patient promptly died and his wife accused the surgeon of killing her husband and the surgeon accused the wife of poisoning her husband. There was considerable excitement in Paris as a result of the case and the operation was very much discredited. Finally, a law was passed which practically forbade the performance of transfusion. In 1667, a German surgeon, Mayer, performed trans- fusion of blood. Kaufmann and Purmann, in 1683, claimed to have cured a leper by the repeated injections of lamb's blood. TRANSFUSION OF BLOOD. 97 In 1682, Ettenmuller, of Leipsic, advised transfusion in fevers, scurvy, and hypochondriasis. Xuck seems to have had advanced views on transfusion. In 1714, he gave a history of transfusion in his book, advocating the employment of this operation when considerable blood had been lost, and advising against the use of blood of lower animals when transfusing man. In 1749, Cantwell, of the Faculty of Paris, said trans- fusion should not be forbidden in desperate cases. Michael Rosa, in 1783, made experiments in transfu- sion with lower animals and concluded that transfusing blood from one animal to another of the same species could be done without danger to life and that an exsan- guinated animal could be revived by this means. About this time, Laine claimed that the blood of calves and animals contained some material that was necessary for the development of peculiar tissues, such as horn and hoofs, which belong to these animals and therefore these elements would be disastrous when injected into the veins of a human being. Harwood, in Cambridge, resuscitated an exsanguin- ated dog by transfusion in 1792, and in the same year it is reported that Eussell successfully transfused for hy- drophobia with lamb's blood. In 1796, Darwin advised transfusion in certain dis- eases when proper nutrition was difficult. In 1802, Scheele wrote an extensive review on trans- fusion and Diefenbach published an article reviewing transfusion in 1828. In 1825, James Blundell, of London, revived the opera- tion. He experimented on dogs by first bleeding them until pulse and respiration had ceased and then transfus- ing with fresh blood. He demonstrated that animals which were apparently dead for three or four minutes 98 SURGERY OF THE BLOOD-VESSELS. could be resuscitated by transfusion, but transfusion was of no avail after five minutes. His work greatly stim- ulated interest in transfusion. Blundell's transfusions upon man were not as successful as those performed on the lower animals. His first cases all failed but after- wards he met with considerable success. Dumas and Prevost, in 1825, first showed the injurious effect of the blood of one species upon that of another. About 1838, Bishoff introduced defibrination of blood for transfusion and concluded that venous blood is harmful but arterial blood is free from danger. Panum and Brown-Sequard, in 1858, performed nu- merous experiments independently and both came to the conclusion that defibrination of the blood was one of the chief factors in the success of transfusion. In 1863, Blasius collected one hundred and sixteen transfusions, all that had been done in the previous forty years. Fifty-six of these were reported as having re- sulted favorably. All were indirect transfusions and only two were from animals, though those two are said to have been successful. Of the fourteen cases in this series that were done with undefibrinated human blood all were fail- ures. From the time of publication of this article until 1883, when von Bergmann published a paper on transfu- sion, this operation excited a great deal of interest. Transfusion of blood was tried indiscriminately, and Emerson in "Works and Days," in 1870, refers to it as "the boldest promiser of all, which in Paris, it is claimed, enables a man to change his blood as often as his linen." In the Franco-Prussian War thirty-seven transfusions of defibrinated human blood were recorded and thirteen of these were reported to be successful. Geselius and Hasse, in 1874 and 1875, attempted to revive transfusion TRANSFUSION OF BLOOD. 99 of blood from animals to human beings. Lamb's blood was supposed to be particularly efficacious because the red blood cells are smaller than those of man. When Landois discovered, in 1875, that red blood cells are de- stroyed when mixed with blood of a different species, further attempts at transfusion from lower animals to man were abandoned. By 1889, the opinion was generally held that it was exceedingly dangerous to inject the blood from one spe- cies of animals into another. More modern work lias confirmed this idea. Landois and others showed that blood from the same species might be transfused without destruction of the cells and that the blood would functionate normally. It began to be recognized that defibrinated blood was not free from danger and, in 1877, A. Koehler showed that the intravenous injection of defibrinated blood, even in animals of the same species, might cause clotting within the vessels because of the large amount of fibrin ferment contained in defibrinated blood. Cohnheim claimed that the injection of any blood in which coagulation had taken place was a grave error. In 1883, von Bergmann reviewed transfusion of blood and came to the conclusion that only direct transfusion of blood from artery to vein was justifiable and here co- agulation was likely to occur in the cannula. This seemed to put a quietus on transfusion for more than twenty years. Transfusion in America was largely stimulated by the work of Crile, who began experiments in 1898, and by the work of Carrel, who so vastly improved the technique of arterial suture in 1902. According to Crile, Queirolo was the first to adopt an anastomosis tube in blood-vessel surgery as is employed at the present time. The method 100 SUKGERY OP THE BLOOD-VESSELS. of Crile consists in using a canimla which varies from the smallest size of one and a half millimeters to three millimeters inside diameter. The size that seems best suited for the caliber of the artery is selected. The artery is dissected free, usually taking the radial ar- tery, the lower end is tied and a small ('rile clamp, or serrefine, is placed on the artery at the upper extremity of the wound. The vein in the forearm is next dis- sected, ligating it at the distal end and clamping it with a Crile clamp, or serrefine, at the upper angle of the wound. Care should be taken to select a large vein, which is usually found without difficulty about the elbow. These dissections can be done with local anesthesia, either one-fifth of one percent solution of cocaine or one-half of one percent of novocaine to which a small amount of adrenalin has been added. Tablets of novo- caine and suprarenal extract are on the market. The region of the artery is infiltrated. The dissection should be made under a good light. Each bleeding point is caught with small mosquito hemostats so the field can be kept clear. Small branches of the radial artery must be clamped and tied with fine silk. The vein is freed in a similar manner. The artery is then cut across near the ligature and its adventitia removed, as described in the technique of suturing blood-vessels, by pulling it over the end of the vessel with the thumb and finger and cut- ting it off. Or it may be grasped with small dissecting forceps and cut away. The end of the artery is anointed with sterile vaseline. The vein is treated in a similar manner. The handle of the Crile cannula is clamped with a pair of hemostats and the vein threaded through the cannula, entering at its base at the handle. The vein is then caught by three mosquito hemostats and cuffed back over the cannula by traction on all three mosquito hemo- TRANSFUSION OF BLOOD. 101 Fig. 46. (A) Crile cannula. (B) Thread in the vein to draw it through cannula. (C) The vein is caught by three mosquito hemostats and cuffed back over the cannula, and at (D) is tied over the ridge next to the handle. It is lightly smeared with oil or vaseline and the artery slipped over the cuffed vein and fastened with a suture on the ridge farthest from the handle. (E) The opera- tion completed. 102 SURGERY OF THE BLOOD-VESSELS. stats at the same time. It is tied firmly with fine linen in the groove next to the handle and is covered with sterile vaseline, care being taken not to get any vaseline in the open end. A pair of closed mosquito hemostats is anointed with vaseline and inserted into the end of the artery very gently. It is opened gradually so as to dilate the artery. Three mosquito hemostats then grasp the artery at equally distant points and pull it over the cuffed vein on the cannula. It is tied in position on the groove farthest from the handle (Fig. 46). In this way noth- ing but endothelium is exposed to the blood current. Often the artery contracts very greatly and may appear to be too small, but after dilatation it can usually be slipped over the cuffed vein. Sometimes, three guy su- tures may be used instead of the hemostats. Occasion- ally the vein or artery is kinked, but by making a little tension on it in the axis of the vessel first toward the artery and then toward the vein the kink may be straight- ened out. The clamp on the vein should be first removed and then the clamp on the artery is gradually loosened. Another very popular method of transfusion of blood and one that is simple in application is by means of a tube. This was first brought prominently to attention as a practical measure by Brewer and Ligget. The older methods of tubes and syringes, such as the Aveling trans- fusion apparatus, were found impracticable because of the rapid clotting of blood. It has been known, how- ever, that blood clots less rapidly on a smooth surface and in the presence of oil, or paraffin. Brewer's tubes are made of thin glass and vary in size. One end is usu- ally larger than the other for insertion in the vein. They are slightly flared at each end to prevent the liga- tures slipping off (Fig. 47). When ready for use the vein and artery are prepared, as already indicated, TRANSFUSION OF BLOOD. KK> though it is not necessary to dissect out quite as much artery or vein as would be the case if direct suture or a Crile cannula were used. The tubes are sterilized by boiling and just before being used are dipped in melted paraffin, the excess of the paraffin being shaken out of the lumen so as to prevent occlusion of the lumen. Cumol or liquid albolene or some paraffin oil may be used in- stead of paraffin. The artery is dilated by the insertion of a closed mosquito forceps covered with vaseline and 1 t Fig. 47. Brewer's glass tubes for transfusion. They are of different shapes and sizes, made from thin glass, and have flared ends to hold ligatures. is so stretched that the small end of the tube can be in- troduced. The artery is drawn over this end by three mosquito hemostats. A ligature fastens the tube in the artery. The vein is also caught with three mosquito hemostats at equally distant points and a small spurt of blood is allowed to come through the cannula to expel the air. The large end of the tube is then inserted into the vein and fastened with a ligature. The clamp is re- moved first from the vein and then from the artery. Numerous modifications of the Brewer tube have been made. Fauntleroy, of the United States Navy, has suggested 104 SURGERY OF THE BLOOD-VESSELS. a S-sliaped tube and makes the anastomosis from vein to vein. Bernheim, of Baltimore, constructs the tube of metal and in two pieces which are accurately fitted, and after their insertion into the vein and artery, respec- tively, the two halves can be joined and the blood cur- rent turned on (Fig. 48). He claims that in case of clot- ting, the clots can be removed without the necessity of taking the tube from the artery and the vein, as would be necessary if clotting occurred in the Brewer tube. Modifications of the Crile cannula, which itself has been modeled on the tube of Payr, are numerous. Bern- heim has modified the Crile cannula by prolonging the handle and placing three small hooks on the base of the cannula so the vein after insertion and being cuffed back can be fastened on to these hooks instead of being tied. Hepburn has also modified the Crile cannula by adding a wide flange at its base which is perforated with four holes. These perforated holes aid in cuffing back the vein and in drawing the artery over the vein. Here su- tures are used instead of mosquito hemostats for cuffing back the vein. Robert C. Bryan and F. R. Ruff, of Richmond, de- vised an ingenious modification of the Crile cannula, which is made as a hinged tube. The vein is placed in the open cannula and the cannula is then closed. This avoids the necessity of threading the vein through the cannula, which is sometimes difficult. Bryan's modi- fication includes a longer handle and a cannula of larger caliber than the regular Crile cannula (Fig. 49). The cannula of Elsberg is built on the principle of the monkey-wrench. It can be enlarged or narrowed by turning a nut at the end of the handle (Fig. 50). The cannula is first opened and slipped under and around the artery and is then closed so as to compress the TRANSFUSION OF BLOOD. 105 106 SURGERY OF THE BLOOD-VESSELS. artery. The artery is tied, cut a third of an inch from the cannula, cuffed back over the cannula, and fastened on little hooks. The vein is exposed and the artery Fig. 49. Modification of Crile cannula by Robert C. Bryan, which facilitates placing the vein in position. on the cannula is slipped through a small slit in the vein. The cannula is then gradually opened until blood flows freely and until the wound in the vein is tense and does not leak. Ottenberg employs a silver ring with two grooves on Fig. 50. Cannula of Elsberg which works on the principle of the monkey-wrench. its surface. The technique of using it is similar to that of Crile, except that he has a special instrument to hold the ring and fastens the vessel to the ring with silver wire. Soresi employs double cylinders, which open on a TRANSFUSION OF BLOOD. 107 pivot. These cylinders slide on a small bar. The vessel is placed in the open cylinder, which is then closed, and the vessel is cuffed back over each cylinder and caught on hooks, which hold it in this position. The cylinders are adjusted on the sliding bar until the intima of each ves- sel is in contact, then the blood stream is turned on. 1 Ie advocates vein-to-vein transfusion. Janeway uses for transfusion an instrument consist- ing of two parts, which may be joined together and fas- tened securely, each half resembling a thumb forceps, each blade of which terminates in half a cylinder. The vessels are placed within the cylinders which are then ad- justed by the thumb screw on the blade of the forceps. Each vessel is cuffed back. The two halves are joined together by means of a shoulder from one-half of the instrument which is called the male half and fits into a socket in the other half of the instrument, the female half. If desired and one vessel is much larger than the other the smaller vessel can by this instrument be in- vaginated into the larger vessel and sutured in this posi- tion. Frank and Baehr advise that preserved blood-vessels be used as the links between the artery and vein in trans- fusion. The end of each link is fitted with a Crile can- nula and the link cuffed back. In transfusion one end of the link is inserted into the vein and the other into the artery. Hartwell suggests stripping the adventitia from the end of the artery and then rolling some of it back so as to form a ridge about one and a half inches from the cut end of the artery, which is well anointed with vase- line and inserted into the vein by means of three sutures of fine silk passed at equally distant points through the cut end of the vein. The vaselined end of the artery is 108 SUEGEEY OF THE BLOOD-VESSELS. fixed in position by passing one of the sutures through the ridge of adventitia on the artery. The surplus cir- cumference of the vein is taken up by a small clamp or by the other two sutures. Dorrence and Ginsburg advocate vein-to-vein transfu- sion. The advantages they claim are that it is easier and that there is no danger of dilatation of the heart. Two superficial veins are connected on the forearm usually by means of a cannula such as the tube of Brewer, or by the cannula of Crile. The distal end of the vein in the Fig. 51. Curtis and David's apparatus for transfusion. donor is connected with the proximal end of the vein in the recipient. A light tourniquet on the arm of the donor above the point of anastomosis hastens the flow. Indirect transfusion may be done by drawing the blood into a large syringe that is coated with albolene or liquid vaseline, and then injecting it immediately into the vein of the recipient. Curtis and David used a Y-shaped cannula for vein- to-vein transfusion (Fig. 51). The cannula is coated with sterile vaseline, one arm is inserted into the proxi- mal end of the recipient's vein and the other in the distal TRANSFUSION OF BLOOD. 109 end of the donor's vein. A glass syringe, the interior of which has been coated with vaseline, is now fitted to the neck of the cannula. The vein of the recipient is clamped and the vein of the donor is loosened while the syringe draws up blood, then the vein of the donor is clamped and the clamp on the vein of the recipient is re- leased while the syringe forces the blood into the vein of the recipient. This procedure is repeated until the proper amount of blood has been transferred. Tuffier, of Paris, 1 describes a simplified technique for transfusion in which he uses three silver tubes coated with paraffin. He connects the internal saphenous vein of the patient to the radial artery of the donor. Lateral wounds are made in the vessels and one end of the tube is inserted in the artery and the other end introduced into the vein. The operation is on the principle of Brew- er's tube. Other measures, such as bleeding the donor into salt solution and injecting the mixture intravenously, have been suggested. Kimpton and Brown 2 devised a large glass tube which is coated with paraffin on the inside. The upper end is closed with a cork stopper. A side tube runs out from the main tube a short distance below the cork. The lower end of the tube is drawn out into a small cannula which is bent so as to form a trap when the large tube is placed horizontal. From the last bend the cannula should not be more than two or three inches long and should taper gradually into a bevelled and smooth point about two to three millimeters in diameter (Figs. 52 and 53). When ready for use a small piece of paraffin is placed in the cylinder, the cork inserted, and the whole 1 Presse Medicale, July 31, 1912. 2 Journal A. M. A., July, 1913, page 117. 110 SURGERY OF THE BLOOD-VESSELS. Pig. 52. Kimpton and Brown's apparatus for transfusion. Fig. 53. Kimpton and Brown's cannula in horizontal position, showing the trap which prevents the entrance of air in the cannula. TRANSFUSION OF BLOOD. Ill apparatus wrapped in a towel and sterilized in the auto clave with the dressings. After removing the tube it is heated over a Bunsen burner and the paraffin carefully coated over the interior of the tube, the excess running out of the cannula. The cannula should then be cooled as quickly as possible without breaking. Sterile absorb ent cotton is placed in the side tube. AVhen in use the cannula is inserted into a wound in the artery and the tube held vertical!}" until it is filled with blood. The tube is then brought to a horizontal position and the cannula inserted into the vein. The tube is again brought to a vertical position and the blood allowed to run into the vein. A bulb, as from a Paquelin cautery, is attached to the side tube and with very little air pressure the ap- paratus empties itself through the cannula. The can- nula may hold 250 cubic centimeters and two cannulas may be used so one can be filled while the other is being emptied. The vein of the donor, instead of the artery, may be used. Edward Lindeman, 3 of New York, describes a new method of indirect transfusion. A small needle, the size of a small aspirating needle, surrounded by two cannulas is used to enter the vein of the donor and another simi- lar set for the recipient. The cannulas may be lined with a film of albolene. A series of Record syringes that fit the outer cannula and of a twenty cubic centimeter capacity is sterilized. When the vein of the recipient is entered and blood appears in the cannula a syringe filled with warm, normal salt solution is immediately at- tached to the cannula and a very slow flow of salt solu- tion is established to prevent clotting in the cannula. The veins of both donor and recipient are treated simi- larly. An empty syringe is then fitted to the cannula in 3 American Journal of Diseases of Children, July, 1913. 112 SUKGEEY OF THE BLOOD-VESSELS. the donor by an assistant, filled with blood and passed quickly to the operator, who at once injects the blood into the cannula of the recipient. A little normal salt solu- tion is injected through the cannula of the recipient after- each syringe full of blood to prevent clotting in the can- Fig. 54. Landon's cannula with forceps for applying it. nula. Each syringe should be thoroughly washed out with normal salt solution before being used again. No skin incision is necessary. Usually the median basilic is the vein punctured, with a light tourniquet on the donor. In infants the external jugular is better. L. H. Landon, 4 of Philadelphia, describes a new self- rig. 55. Method of using Landon's cannula. retaining tube for transfusion of blood (Figs. 54 and 55). This tube is a short cannula of metal made in three different sizes. One end of the tube is smooth and the other has five sharp points which are slightly everted. Two perforations in the side of the cannula enable it to 4 Journal A. M. A., August 16, 1913, page 490. TRANSFUSION OF BLOOD. 113 be held by special forceps. Either the artery or the vein is threaded through the cannula, and cuffed back; then the other vessel is drawn over. Both are fastened to the hooks. H. A. Fraund, 5 of Detroit, describes a method of trans- fusing fresh blood by means of a well-fitting aspirating syringe holding twenty cubic centimeters, a two-way stop cock irrigator with a glass cylinder attached, and two tubes with needles leading from each tube. The glass cylinder has a small stop cock and the whole apparatus is mounted on an inclined wooden base. Normal salt solution is poured into the glass cylinder and taken into the syringe and both needles are then held so that the normal salt solution will go through them and remove the air. Blood is then drawn through one of the needles inserted into a vein and thoroughly mixed with the salt solution. It is then introduced into the recipient. Satterle and Hooker 6 describe an indirect method of transfusion of blood in which the blood is drawn into a paraffin lined receptacle and injected into the vein of the recipient. B. F. McGrath, of the Mayo Clinic, has devised three different methods for transfusion in order to meet the various conditions as to size of artery, measurement of blood, etc. When exact estimation of amount of blood is required, he recommends a modification of the old Aveling operation. A rubber bulb of about thirty cubic centimeter capacity and having two small tips is filled with salt solution. The tips are fastened into the veins of the donor and recipient, respectively, the vein of the donor is clamped with a serrefine, and the bulb squeezed, forcing the salt solution into the vein of the recipient. 5 Michigan State Medical Society Journal, September, 1913. 6 Archives of Internal Medicine, January, 1914. 114 SURGEHY OF THE BLOOD-VESSELS. The serrefine is tlien transferred to the vein of tlie re- cipient, and the bull), released, draws in blood from the donor. The serrefine is again transferred to the vein of the donor while the bulb is compressed. In this man- ner thirty cubic centimeters of blood are forced into the recipient with each emptying- of the bulb. There is some danger of forcing in clots by this method. McGrath 7 Fig. 56. Transfusion forceps of McGrath. has also a transfusion forceps which can be separated and locked like obstetrical forceps. At the end of each half is a short cannula through which the blood-vessel is threaded, cuffed back, and fastened on small hooks (Fig. 56). The forceps are then put together, gently locked and the blood turned on. McGrath 8 advises transfusion 7 Journal A. M. A., January 3, 1914. 8 Journal A. M. A., April 25, 1914. TRANSFUSION OF BLOOD. 115 by suture when the vessels are small and has devised a tripod which fits over the artery, the three legs being points of attachment for the three guy sutures. A. Crotti 9 describes his method of using indirect trans- fusion of blood by means of a syringe with a blunt needle in which the blood is aspirated into the syringe and injected into the recipient. The procedure can be re- peated if the syringe is washed out carefully with normal salt solution each time after the injection. This is simi- lar to the method of Lindeman. ~W. L. Moss, 10 of Johns Hopkins, describes a method of indirect transfusion with defibrinated blood. The blood is withdrawn from the donor's vein into small glass flasks by means of an aspirating needle and a rubber tube lined with a thin coating of paraffin. The blood is defi- brinated by being shaken in the flask with a half ounce of glass beads. It is then filtered through sterile gauze into an infusion bottle containing 300 cubic centimeters of normal salt solution and injected into a vein of the recipi- ent. The chief objection to the use of defibrinated blood in transfusion was pointed out by A. Koehler, von Berg- mann and others (page 99) and consists in the fact that there is an excess of fibrin ferment which may cause clot- ting within the vessels. 9 Surgery, Gynecology & Obstetrics, February, 1914. 10 American Journal of the Medical Sciences, May, 1914. CHAPTER VII. TRANSFUSION OF BLOOD. (Continued.) Transfusion is divided into two types, the direct and the indirect. In the former, blood flows in a continuous stream from the donor to the recipient, while in the in- direct method the blood is drawn from the donor and in- jected into the veins of the recipient. Sometimes the blood is diluted with salt solution or defibrinated before being introduced into the recipient, and frequently it is injected quickly before it can clot. In considering the various methods of transfusion, two things should be borne in mind, efficiency and simplicity. The objection to any special apparatus is, of course, ob- vious. Usually, this apparatus consists of cannulas that are required to fit the various calibers of the artery or vein. In cannulas that permit contact of blood with their walls, such as the Brewer tube, there is the possi- bility of clotting to be considered. If these instruments work satisfactorily, nothing more can be desired, but if the proper size is not at hand, if the device is out of order, or if a clot forms in the cannula, it may be impos- sible to do the transfusion, which is always an operation of great necessity. The suture method avoids these ob- jections. The vein in the recipient should be chosen near some branch. The branch is dissected out, divided and clamped with mosquito forceps. The main vein is then clamped at the proximal end of the wound with a serre- 116 TRANSFUSION OF BLOOD. 117 fine, ligated at the distal end and divided and sutured to the artery, as described under the technique of arterial suturing (pp. 50-67). The arterial suture staff makes it as easy to suture a small artery to a large vein, if the dis- parity is not too great, as to suture vessels of equal caliber (Fig. 57). After the suturing is completed the clamp on the vein is removed first and the clamp on the artery is gradually loosened. If there is no spurting point, but merely a slight oozing, the guy sutures to the staff can be cut and the instrument removed. If for any reason clot- ting occurs or an excess of vaseline blocks the lumen, the finger can be placed on the vein of the recipient just above the venous branch, and the mosquito forceps released, while the thumb and forefinger of the other hand gently manipulate the sutured area. The thrombus is blown out through the venous branch. Sometimes a valve ex- ists in the branch and in this case it can be overcome by inserting a closed pair of mosquito forceps, which have been anointed in vaseline, and gently dilating the valve. Not infrequently in transfusion the artery contracts to such a degree as almost to stop the flow of blood. If the artery is kept covered with gauze wrung out of warm salt solution, this is not so likely to occur. Sometimes, however, even in spite of this, contraction of the artery is marked. If it is too great, a smooth silver probe, such as a lachrymal probe, is thoroughly anointed with vase- line, introduced through the venous branch, and carried well up into the radial artery. This procedure will at once be followed by a full flow of blood, but it cannot be done where a cannula is used, only when the union is made by sutures. Usually after four or five minutes a clot will reform on account of the injury by the probe. The probe can then be reinserted. A strong flow of blood for fifteen minutes is ordinarily sufficient, and it is better 118 SURGERY OF THE BLOOD-VESSELS. Pig. 57. Showing suturing applied to transfusion of blood. On the right is a vein which is somewhat larger than the artery. The vein has a branch through which a smooth probe covered with vaseline can be inserted and pushed up into the artery if an obstruction occurs, or if the artery contracts too much. By pressing on the main trunk of the vein, clots may be blown out through the branch. TRANSFUSION OF BLOOD. 11!) to use the probe several times in this manner than to eral way, but occasionally thrombi are found tliat arc difficult to explain. The thrombo-phlebitis of the left- leg following operations has been referred to as an ex- ample of this. Occasionally, after an operation, espe- cially after an abdominal operation, thrombosis of the left femoral or saphenous vein occurs. This is often found after slight suppuration or particularly after a septic course, but not infrequently thrombosis occurs when there is evidence of a clean wound and perfect heal- ing. Clark has written extensively on this subject and thinks thrombosis is due to the retractors which trau- matize the abdominal wall and cause thrombosis of the superficial or deep epigastric veins, and that this throm- bus extends to and involves the iliac and femoral veins. He explains left-sided thrombosis after an operation on the right side of the abdomen by the free communication between the veins of the two sides. The left side is the one most frequently involved. The reasons usually given are that the course of this vein including the iliac trunk is slightly longer than that on the right side, it is compressed by the arteries in the pelvis under which it passes, and often it is also further compressed by an overloaded sigmoid. The symptoms appear about the second or third week. The left leg is affected twice as frequently as the right, and sometimes both legs are in- volved. The disease rarely begins earlier than eight days, nor does it appear later than thirty. The second week after operation is the most favorable time for the development of thrombosis. Pain in the calf of the leg and tenderness over the course of the saphenous vein which begin the second week of convalescence from an abdominal operation are always suggestive of phlebitis and if there is a rise of temperature accompanied by some swelling, the diagnosis can readily be made. 184 SURGERY OF THE BLOOD-VESSELS. The treatment of this condition is not very satisfac- tory. Conservative treatment consists of rest in bed, elevation of the leg, enclosing it in cotton, which is lightly bandaged, and the application of opium and lead water or belladonna ointment. These remedies usually give relief in the course of time, though swelling will be present, particularly after walking, for weeks or months. In septic thrombosis in the leg or arm, the treatment should be directed largely toward the source of infec- tion. If the infection is in the leg and the patient runs a high temperature with pyemic symptoms, the vein should be excised or ligated, or amputation should be performed if the symptoms are severe. In amputation of the leg in which there is sepsis and thrombosis of the veins, great care should be taken in the operation. Eough handling, the application of an Esmarch, or even a tourniquet, may loosen the clots and force into the cir- culation a fatal dose of sepsis. Amputation in such in- stances should be done by the dissection method without a tourniquet, cutting the flaps carefully and controlling small bleeding points by forceps and accurately dis- secting out the large vessels, tying or clamping them before division. The limb should not be moved until it is completely severed from the body. In this way but little damage is done to the tissues, the traumatizing effect of the tourniquet is dispensed with, and the pos- sibility of the tourniquet forcing septic thrombi further along in the veins is obviated. In thrombosis of the lateral sinus and the internal jugular vein, which most frequently occurs as a result of sepsis following mastoid or middle ear suppurative disease, the vein should be promptly ligated or excised. Manipulation must be as gentle as possible, first expos- ing the vein near the root of the neck and ligating it be- EMBOLISM. 185 fore any clot is dislodged. In one case of thrombosis of the internal jugular from a mastoid suppuration, the au- thor excised the jugular; in another instance when sepsis came from the lower jaw, the jugular was care- fully dissected free and the branches which emptied into it were ligated. Both patients were very septic witli rapid and feeble pulse. Both recovered after a stormy convalescence. Embolism. Embolism literally means blockage of an artery or vein by some substance that did not originate in the region at which the blockage occurs. The substance is the em- bolus. The most frequent source of an embolus is a thrombus, particularly a septic thrombus which easily breaks up and gives rise to showers of small clots that form emboli. This is the generally accepted description of pyemia. Emboli more commonly come from a throm- bus, but may be from fat, air, pieces of foreign body, portions of a tumor, or parasites. The formation of an aneurism in the mesenteric artery of a horse from the strongylus armatu-s is a well known example of an embo- lus from a parasite. Pieces of tumor or calcareous mat- ter or, occasionally, in leukemia, large masses of leuco- cytes may form emboli. Cases have been recorded in which a bullet entering the heart or large blood-vessels has acted as an embolus and has been carried by the blood stream until arrested by the narrowing caliber of the artery. Naturally, emboli occur more frequently in arteries than in veins, though venous emboli are by no means un- common. The portal vein is particularly liable to em- boli because it acts somewhat as an artery by receiving blood and eventually emptying it into smaller channels. 186 SURGERY OF THE BLOOD-VESSELS. Venous emboli in the general circulation occur in two ways, by retrograde movement in which the current of blood is temporarily reversed, and by the persistence of the foramen ovale through which a thrombus may be forced back into a vein. Cardiac emboli are very rare, because even a large thrombus from a vein is usually carried through the heart and arrested in the pulmonary arteries. Some- times, however, the heart may be completely blocked, which, of course, results in sudden death. Emboli are more likely to lodge in the arteries of the lower extremi- ties because of the fact that their large vessels are more directly in the axis of the main arterial current. It is probable that many emboli carried into the legs do not give serious symptoms, and as an embolus in the cerebral or in the mesenteric arteries is usually a very grave or a fatal condition, the incidence of emboli in these lat- ter situations has appeared abnormally great. The pul- monary artery is frequently the site of emboli from a detached thrombus that goes from the systemic veins into the right side of the heart. Welch, whose classical article on thrombosis and em- bolism in Albutt's " System of Medicine" is the basis of most writings on this subject, believes that embolism is most frequently detected in the renal, splenic, cerebral, iliac, and other arteries of the lower extremity, axillary arteries of the upper extremity, ceoliac axis, the central artery of the retina, the superior mesenteric, the inferior mesenteric, the abdominal aorta, and the cardiac coronary arteries. This, he says, is the relative order of frequency so far as symptoms appear, though more than likely the actual occurrence of embolism is in a different ratio as has already been explained, because of the fact that in many of the arteries first mentioned the slightest embolus will EMBOLISM. 187 give symptoms, whereas an embolus may occur in ar- teries of the lower extremities with but few if any symp- toms. A "paradoxical" or "crossed" embolus results from a thrombus that originated in the venous side and is found plugging one of the systemic arteries. This, of course, can only take place by the passage of the embo- lus through the patent foramen ovale. The persistence of a patent foramen ovale is by no means uncommon and it is said that in one out of three hearts some such com- munication exists, though it is usually small and valve- like. In some cases, however, it is large and direct. The capillaries of the lungs are quite large and easily distended. It is possible for articles of considerable size, even tissue cells, to pass through the capillaries of the lungs without being arrested. Adami mentions an experiment in which scraped material from the liver of a rabbit was injected into the systemic vein of another rabbit. After a few minutes the second rabbit was killed and small masses of liver cells were found in the arteri- oles of the kidney. Examination of the heart showed the foramen ovale was closed. Capillary emboli occur from small masses that are numerous and yet are not large enough to arrest the cir- culation in a large artery. It has been noticed that the pigment remains of the malarial parasite may be ar- rested in the fine capillaries of the brain and kidney, re- sulting in functional disturbance of these organs. Bac- teria and cells from malignant tumors often form emboli in the capillaries. The presence of air as emboli is more or less danger- ous, depending upon the vein into which the air was taken, and the suddenness of the intake as well as the amount of air aspirated. Such an accident was not uncommon in preanesthetic days, when the patient 188 SURGERY OF THE BLOOD-VESSELS. would often hold his breath from the pain and suddenly take a deep inspiration. The hissing, sucking sound of the air entering is very noticeable. The slow entrance of air into a vein at some distance from the heart can usually be taken care of without any untoward event. Nitrogen and oxygen are normally carried in solution in the blood stream, either in combination with the cells or in the plasma of the blood, and a small amount of air introduced slowly is readily dissolved. The amount of air that can be given in an ordinary hypodermic syringe, if injected slowly into a distal vein, would in all proba- bility occasion but little if any disturbance. However, air injected suddenly into the veins of the neck near the heart produces serious symptoms at once. Formerly many deaths from supposed air embolism were probably cases in which gas formed after death, such as occurs from the bacillus aerogenes capsulatus, but even includ- ing such instances death from air embolus has undoubt- edly been more frequent in preanesthetic days than now. Air when taken in and warmed by the temperature of the blood expands and forms a much larger volume than it would naturally have in the normal temperature of the room. Though air embolism is not common, such accidents occasionally occur now. Within the last ten years the author has had two cases, one of them terminating fa- tally. In this case the author operated upon the neck for a large recurrent carcinoma, which had infiltrated and blocked the internal jugular vein. Contraction of the cancer had distorted the anatomy and pulled the internal jugular considerably out of its normal posi- tion. As the head of the patient was slightly elevated and the vein blocked it was constantly collapsed and re- sembled a band of fascia. In an effort to dissect the EMBOLISM. IS!) common carotid, this vein was cut, as it seemed merely a band of connective tissue. It was picked up and was seen to have a shining internal surface. Air rushed in imme- diately and the vein was then clamped. It was recog- nized at once that a mistake had been made, though no blood at any time escaped through the vein. The pa- tient's head was lowered and he seemed to improve for a short while. He was given intravenous salt solution with adrenalin and his pulse was better for about five minutes. Then his head was raised and his pulse be- came weaker. He died in about fifteen minutes from the time the vein was cut. In the second case, during a dissection of tubercular sinuses and tissue over the sternum where there were sev- eral superficial veins, one of them was cut and immedi- ately the hissing sound of air entering the vein was heard. The vein was at once compressed with the finger and then a wet compress was placed upon it and the tis- sue sutured. The patient's pulse became rapid and rather weak, though after a few minutes it improved and he made a satisfactory recovery. The mode of death after air embolism has been a sub- ject of considerable controversy. The two main theo- ries are, first, that it is a cardiac death. The air is warmed and expands rapidly. It accumulates behind the tricuspid valves and renders them inefficient. The pressor terminals in the heart are unaccustomed to air instead of fluid blood and are also deranged. The second theory is that death is caused by multiple air emboli in the pulmonary capillaries of the lungs. These small bubbles of air cannot pass through the capillaries of the lung but block them; thus death occurs in the same man- ner as when the pulmonary arteries themselves are oc- cluded. It is thought by some that gas may eventually 190 SURGERY OF THE BLOOD-VESSELS. make its way to the left side of the heart and that the emboli in the brain may be the cause of death. This is not as probable as the other two theories and accord- ing to the experiments of Wolff the theory of death from air emboli in the pulmonary capillaries is more reason- able. A form of embolism from air or from gas that is fre- quently fatal occurs in those who work in compressed air and is supposed by many to be the cause of the so-called ''caisson disease." After working in compressed air for some time if the individual emerges suddenly he often be- comes a victim of nervous disturbances that may quickly prove fatal. There are various paralyses and other symptoms showing lesions of the spinal cord. These are probably due to the fact that the tissues take up under increased pressure much more gas than under or- dinary atmospheric pressure, and when the pressure is suddenly removed the gas is released. If the pressure is quickly reduced, the blood and tissues can no longer hold the excess of free nitrogen in solution, though the oxygen may be taken care of. The nitrogen separates in the form of bubbles that grow in size as the pressure is diminished and are carried by the blood stream, form- ing gas emboli. This is most serious when the brain and spinal cord are affected. The results of emboli depend upon their location and are the same as after occlusion of an artery. If derived from a thrombus, the changes and termination following the localization of the emboli depend partly upon whether there is infection and whether the infection is localized by a sterile layer of thrombus around the infected ma- terial. The treatment of embolism depends upon its form and location. In air embolism various suggestions have been EMBOLISM. li'l made. One is that a rubber tube or catheter be inserted in the right internal jugular vein and pushed into the heart, the air being drawn off by this means. It is rather impracticable, for it is likely that more air will be introduced by this method, particularly as the tube will probably not fit the vein accurately. The main treat- ment should be directed toward general stimulation of the heart, together with lowering -the head, and the ad- ministration of oxygen. The heart is stimulated in or- der to prevent collapse and at the same time to force the air through the capillaries of the lungs and to hasten its solution in the blood stream. Of course, the imme- diate treatment at the wound consists in pressure on the injured vein. This should be done with the finger at first and later with a moist compress which is fastened securely in position for several days. Usually the trunk of the vein can be compressed toward the heart and the vein clamped and tied; though the application of a moist compress or the finger should be maintained until the patient has somewhat reacted or until it is entirely cer- tain that ligation or clamping can be done without the possibility of more air entering. The preventive treatment of air embolism should be borne in mind when operating on the neck and in the axilla, as only the regions that are nearest the heart and consequently subject to the so-called venous pulse are in danger of admitting air. The deep jugular vein is fixed rather firmly to the fascial planes of the neck, which to some extent prevents it from collapsing readily. When such a vein is inflamed and the walls made stiff, the dan- ger is still greater. In injuries to the femoral or saphe- nous veins or even to the veins in the pelvis there is but a slight chance of air embolism, though such cases have been reported. Usually here the pressure is positive 192 SURGERY OF THE BLOOD-VESSELS. and the distance is too great from the heart for the ve- nous pulse. In operations upon the neck or axilla the incision should be sufficiently long to enable the operator to identify the structures. It is best to make the incision low in the neck first and if the internal jugular is not distended, a sponge or a wad of gauze shoved in behind the clavicle, as suggested by Mayo, will produce enough pressure upon the vein to keep it distended. With ordi- nary skill there should be no danger in dissecting a dis- tended jugular vein. It is when it becomes collapsed that there is great risk of injury. Fat embolism occurs from the rupture of fat cells and the discharge of their contents into the blood stream. It comes on particularly after injuries to long bones in which the fat marrow is involved, for the veins in the haversian canals cannot readily collapse as they are fixed to the bony wall. It may result from injuries to the mesentery or to the fat beneath the skin. Fat embolism appears later than shock or air embo- lism and except in the region drained by the portal vein it is always found first in the lungs. About sixty per- cent of all cases are caused by fractures and about sev- enty-five percent are caused either by fractures or by some inflammatory disease of the bone. Other cases are due to injuries or suppuration of the soft parts. The fat from fracture of a bone enters the veins about the third day after the injury because the veins in the haversian canals are held open by the bone and so are prevented from collapsing and their thrombi may loosen at this time. Fat embolism occurs as a rule from thirty-six to seventy-two hours after injury, though oc- casionally it may be much later. There may be death from the sudden blocking of the pulmonary vessels. The EMBOLISM. 193 symptoms are usually pulmonary at first, severe pain in the chest, difficult breathing, cyanosis, and sometimes expectoration of blood. Temperature at first is subnor- mal but soon rises. The physical signs are rather in- definite, though there are many coarse rales and later consolidation occurs. If the patient does not die soon some of the fat is forced through into the systemic cir- culation and symptoms of embolism of the brain, such as convulsions, paralyses, or coma, may occur. The kid- neys are also affected and often fat may be demonstrated in the urine. Fat, however, is frequently found in the urine in small amounts after fractures when there are no symptoms of embolism. It is probable a great many cases of fat embolism occur that produce such slight symptoms they are not recognized. Only the severe cases are reported. The treatment of fat embolism consists partly of pre- ventive measures, such as avoiding unnecessary injury to fat during operations, particularly to the fat marrow of bone. Large quantities of fat when injured should be drained. It is well not to sew fat but if sutured the ten- sion on the stitches should be very slight. Several cases of fat embolism have been reported after so-called blood- less operations for congenital dislocation of the hip, and it is one of the dangers of this procedure. Kiener ad- vises placing a constricting band to render the limb blood- less and after the operation, before the band is removed, he inserts a cannula into the upper end of the saphenous vein pushing it on to the femoral and so draws off the first flow of blood, which is supposed to contain fat. This, however, is very radical. Treatment on general princi- ples is about all that can be done. Cardiac stimulation, artificial respiration if necessary, and the administration 194 SURGERY OP THE BLOOD-VESSELS. of oxygen are indicated. Oxygen not only makes the most of the impaired lung that is left, but tends to favor the elimination of fat by oxidation. Pulmonary Embolism. Pulmonary embolism occupies a unique position be- cause embolism here occurs in an artery, usually from a thrombus formed in some of the systemic veins. It is a condition that often comes without warning in a patient who is apparently convalescing satisfactorily. For this reason it is peculiarly distressing and tragic. The em- bolus originates from a systemic vein or from the heart and while it may be composed of various substances it is usually from the loosened clot of a thrombus. What- ever predisposes to the formation of a thrombus, neces- sarily tends towards causing pulmonary embolism. Phlebitis, whether traumatic or septic, and operations involving a venous plexus are marked predisposing causes. More than one-half of all cases of pulmonary embolism are from operations upon the uterus or its an- nexa. The appendix is drained by the portal circula- tion, but thrombosis of the systemic veins may occur after operations on the appendix, as explained under "thrombosis" (page 183). Hysterectomy is responsible for about one-third of the cases, and appendicitis for about one-tenth. Two fatal cases of the author's fol- lowed suprapubic cystotomies. When operation is fol- lowed by the necessity of remaining in bed for a long time with slow blood current in the veins, the possibility of a loosened thrombus is much greater. The symptoms of pulmonary embolism depend, of course, upon the effect on the lung and this in turn upon the size of the embolus and the location of the obstruc- tion. Undoubtedly many minute emboli occur without PULMONARY EMBOLISM. any obvious symptoms. Very probably the pain in the side of the chest that patients often complain of after operation is due to a slight enibolus near the pleur; 1 ,, though if small the physical signs may not be noted. Larger emboli give more symptoms with an area of con- solidation. If there is sepsis the symptoms and signs of septic pneumonia are present, but if the emboli do not contain septic germs, the symptoms will be dependent upon the size of the embolus and the amount of lung 1 tissue that is put out of commission. Sometimes bloody expectoration occurs. The larger emboli either cause instant death or death within a few minutes. This occurs most frequently from the second to the fourth week after operation. The pa- tient may be feeling perfectly well, but following some operation upon the pelvic organs, he sits up, the thrombus is loosened and lodges in the pulmonary arteries. The patient complains of pain about the heart and becomes purple, the pulse ceases and if the embolus is large death occurs in a few minutes. If the pulmonary artery is nut entirely plugged he may live for hours or sometimes even for days. Occasionally, recovery after the most alarming symptoms has been noted. The patient is cya- notic, respirations are rapid, and the eyes protrude. The pulse is very weak, quick and irregular. The pupils dilate and the veins in the neck are swollen. The pa- tient is covered with a cold sweat. Occasionally there is delirium, coma, or convulsions if death is not immediate. These symptoms occurring suddenly and after rather quick movement of the body or legs, such as the first ef- fort to rise in bed, make the diagnosis almost certain. The treatment depends upon the type of case. If the embolus is small and symptoms slight, treatment on gen- eral principles is all that can be done. Cardiac stim- 196 SURGERY OF THE BLOOD-VESSELS. ulants together with the proper nourishment to carry the patient over the critical stage and prevent infec- tion are indicated. Possibly the administration of large doses of urotropin, fifteen or twenty grains four times a day for two days, which is partly eliminated from the mucous membrane of the bronchi is also advis- able. The preventive treatment has already been men- tioned under "thrombosis." It has been advised to give citric acid several times a day in such diseases as ty- phoid where there seems to be an increased tendency to clotting. Decalcifying milk by adding citrate of soda has also been suggested as the lactate of calcium in- creases clotting and the citrate of soda is supposed to neutralize the effect of the lactate of calcium. If sepsis occurs the ordinary treatment for pneumonia is carried out. In large emboli oxygen and cardiac stimulants should be given. Direct treatment has been advocated by Trendelen- burg. He has elaborated an operation based on experi- mental work. He introduced into the internal jugular vein of a calf a piece of lung tissue aseptically removed from another animal. As soon as the symptoms of pul- monary embolism appeared, operation was done and the embolus removed. The calf, w T hich was eight weeks old, recovered from the operation and three months later was killed and the specimen consisting of the heart and large blood-vessels adjoining was exhibited before the German Surgical Congress at Berlin in April, 1908. The technique of this operation wliich is from the de- scription by Willy Myer 2 is as follows : A horizontal incision about four inches long is made upon the second rib on the left side, beginning at the left border of the sternum and dividing the skin, fascia, and 2 Annals of Surgery, August, 1913. PULMONARY EMBOLISM. 197 pectoralis major muscle. This incision is crossed l>y a perpendicular cut which begins below the sternoclavic- ular articulation and passes the cartilage of the third rib about one inch outside of the border of the sternum. It so avoids the internal mammary artery (Fig. (>-). The two triangular flaps formed by this T-shapcd in Fig. 62. Various incisions for approaching the heart and pulmonary artery. That marked in a heavy line on patient's left is the incision of Trendelenburg for extracting a pulmonary emholus. cision are then turned back. The second rib is isolated and divided at the external end of the incision. The rib is raised, twisted loose from its cartilage, and removed. The cartilage is then removed. The third cartilage is divided in a perpendicular line to give more space. If the pleura has not been opened by this time a T-shaped incision should be made through it corresponding to the original incision. The lung is allowed to collapse, which exposes the pericardium. The phrenic nerve and pul- 198 SUKGERY OF THE BLOOD-VESSELS. monary vessels are easily seen. The pericardium is di- vided just internal to the phrenic nerve. The wound is lengthened in an upward and backward direction until the entire upper half of the pericardium is incised. The lower portion is not cut and the heart is left in its normal position. All this is supposed to be done in five minutes. If ppssible either intratrachial anesthesia or differential on the extreme right. (After Willy Myer.) Fig. pressure should be used, but it is not necessary. With the help of an instrument devised by Trendelenburg and called a sound, a rubber tube is quickly drawn through the transverse sinus of the pericardium surrounding the ascending aorta and the pulmonary artery and is pulled up for compression immediately before the surgeon in- cises the pulmonary artery. A thin layer of fat with the PULMONARY EMBOLISM. 1!)!) Fig ig. 64. Pulmonary artery has been incised and forceps inserted to remove the embolus. (Willy Myer.) 200 SURGERY OF THE BLOOD-VESSELS. viscera layer of pericardium is torn through and an in- cision of about one-half inch is made in the pulmonary artery. A special curved blunt forceps (Fig. 63) is in- troduced first into the main trunk of the pulmonary artery and then into the branches and any embolus or thrombus is grasped and extracted (Fig. 64). This must be done in forty-five seconds because interruption of the general circulation is not tolerated longer. The margins of the wound in the vessel are then lifted by special forceps (Fig. 63), and closed by a clamp, after which the assist- ant relaxes the elastic compression (Fig. 65). The cir- culation is thus reestablished and the heart begins to beat very violently if it has not altogether ceased. If necessary, the constriction can again be tightened and another search made for the embolus, though the circula- tion must never be cut off for more than forty-five sec- onds at any one time. Closure of the wound in the pul- monary artery is done by interrupted stitches, while the clamp partly but not completely constricts the pulmo- nary artery. The wound in the artery should be quickly sutured, using fine silk. The pericardium and chest wounds are closed in the usual way. According to Trendelenburg, in fifty percent of pul- monary embolisms only one branch of the pulmonary artery is first obstructed and here death does not occur until ten to sixty minutes after the first onset of symp- toms. Fifteen minutes is supposed to be at the disposal of the surgeon in most of these cases and, with prompt operation, Trendelenburg claims some patients can be saved. The results of the operation show that no pa- tient so far has survived, though one lived for four days and another died from pneumonia five days after opera- tion. Twelve cases in all have been operated upon at Trendelenburg 's clinic without a permanent recovery. PULMONARY EMBOLISM. 201 Fig. 65. The embolus has been removed and the incision has been temporarily closed by a rubber covered clamp. It should now be sutured. Insert on lower right shows forceps (illustrated in Fig. 63) keeping the incision open and elevating it so it can be grasped bv the forceps for temporary closure. (Willy Myer.) 202 SURGERY OF THE BLOOD-VESSELS. The suddenness of the symptoms, the difficulty of the op- eration, the necessity for trained assistants, make it un- likely that such a procedure can be followed by success except under extraordinary conditions. CHAPTER XL TREATMENT OF OCCLUSION OF THE MESKX- TERIC BLOOD-VESSELS; RESECTION AND TRANSPLANTATION OF INTESTINE. Thrombosis or embolism of the mesenteric vessels is always serious whether due to a septic or an aseptic thrombus. The blood supply to the intestinal tract is practically terminal and the occlusion of even a small branch of the superior mesenteric artery usually results in gangrene of the intestine. Thrombi may begin from injury to the artery or vein and both the artery and vein may be occluded. So far as the effect upon the intestine is concerned the treatment would be the same whether the vessels are occluded by thrombi or emboli. Throm- bosis occurs from local disease in the vessel wall, from injury such as a blow or a wound, from volvulus, or par- ticularly from compression by a hernial ring as in strangulation. One of the author's cases followed reduction of a strangulated hernia. The constriction from a strangu- lated hernia, particularly in a stout man, is often severe enough to injure the intima of the artery or vein and even after the intestine is returned thrombosis may oc- cur and gangrene result. The symptoms are sometimes difficult to differentiate from those of acute obstruction as indeed obstruction sooner or later develops. At first the temperature is subnormal, but rises when peritonitis sets in. In the early stages, however, there is intense pain of a colicky nature, more or less intermittent; usu- 203 SURGERY OF THE BLOOD-VESSELS. ally there is vomiting, and sometimes the passage of a bloody stool. Occasionally a mass may be felt in the ab- domen. The abdomen is rigid and there is no distention at first. If this occurs in a child, intussusception is sus- pected. If in an adult, particularly after a history of trauma or hernia, thrombosis or some obstruction of the mesenteric arteries or veins must be borne in mind. Treatment of this condition consists solely in opera- tion. On abdominal section the affected intestine is seen to be a different color from the neighboring loops. It is dark red or even black and gangrenous. It is Usually not adherent at first and is readily brought into the wound. It should be excised as promptly as possible but the greatest care must be taken to go well beyond the disease and into bowel that has a normal blood sup- ply. If after dividing the bowel an abundant flow of arterial blood is not obtained the resection should be made at still greater distance from the disease where the blood supply is normal. If the bowel is merely brought into the wound and drained, the contents of the small intestine empty freely on the skin of the abdomen and a marasmic and septic condition is often initiated which practically precludes any further operation and terminates fatally. If drain- age is considered wise, it should be done in the loop of intestine just above the point of resection by means of a rubber catheter fixed into the intestine, after the method of Witzel. A large, soft rubber catheter will drain off fluid material satisfactorily and will give exit to the gas. In doing a resection care must be taken to divide and tie the mesentery before the bowel is opened. In many techniques the bowel is first opened and the same scis- sors or knife with which the bowel is cut also divides the mesentery. This infects the triangular area at the OCCLUSION OF MESEXTERIC BLOOD-VESSELS. mesenteric border where the layers of the peritoneum separate to envelop the bowel. This area is rich in lymphatics and small blood-vessels and the instrument which has become septic by incising the intestinal mucosa promptly inoculates this area. After it has been inocu- lated, closing by sutures does not prevent subsequent infection here and breaking down of the stitches. Fig. 66. Before the bowel is divided, its mesentery is cut close to the bowel wall and the triangular space, caused by separation of the layers of the mesentery just before they cover the bowel, is clamped with a hemostat and ligatcd with silk or linen. Thi,s area is composed of areolar tissue rich in blood-vessels and lymphatics which absorb quickly, and even though it is closed after it has been inoculated, the germs are merely sealed in and are likely to cause breaking down of the union at this point later on. The procedure indicated in the cut obviates this and also brings together the peritoneum at this point. In order to obviate this, the mesentery must be cut close to the bowel and this area clamped and tied; after it has been sealed in this way the lumen of the bowel may be opened (Fig. 66). The bowel is then divided and its ends cleaned with moist antiseptic gauze. The first stitch begins in the end of the bowel at the operator's right hand, about one-third of an inch from the mesen- 206 SURGERY OF THE BLOOD-VESSELS. teric border. It is a mattress stitch and starts from the mucosa of the right bowel penetrating all coats. Then the needle is carried across to the left end of the bowel and penetrates all coats, entering on the peritoneal sur- face and emerging from the mucosa. It comes back in Fig. 67. The first stitch starts in the end of the bowel at the operator's right hand about one-third of an inch from the mesenteric border. It is a mattress stitch and penetrates the wall of the right bowel from within out. The needle is then carried across to the left end of the bowel and penetrates all coats, en- tering on the peritoneal surface and emerging from the mucosa. It comes back in the reverse direction, entering the mucosa and emerging on the peri- toneal surface, then enters on the peritoneal surface of the right bowel and emerges on the mucosa. The thread is tied, leaving an end about four inches long which is grasped in hemostatic forceps. The needle is then passed back and forth through all coats of the bowel, suturing away from the operator, and making a continuous mattress stitch. After about one-third of the cir- cumference has been sutured, the needle emerges from the lumen of the right end of the bowel and is then thrust through all walls of the right end from within out, appearing on the peritoneal surface of the right end. The stitch is then continued as a right-angled suture penetrating all coats of the bowel. the reverse direction, entering the mucosa of the left bowel and emerging on the peritoneal surface, entering the peritoneal surface of the right bowel and emerging from the mucosa. The thread is tied, leaving an end about four inches long which is clamped with a light OCCLUSION OF MESENTERIC BLOOD-VESSELS. 2.0 1 hemostatic forceps. The needle is then passed back and forth through all coats of the bowel, suturing away from the operator, making a continuous mattress stitch. Care must be taken to include a portion of the mesentery that has been tied, else it will slip back and will not be fas- tened by the suture. Each suture must be very snugly approximated. After about one-third of the circum- ference of the bowel has been sutured, the needle emerges from the lumen of the right end of the bowel, and is thrust through all walls of the right end, appearing on the peri- toneal surface (Fig. 67). The stitch is continued as a right angle stitch penetrating all coats (Fig. 68). Snug approximation should be made with each stitch and at about every third or fourth stitch a back-stitch should be 208 SURGERY OF THE BLOOD-VESSELS. taken in order to prevent the thread being drawn too tightly, and so diminishing unduly the caliber of the bowel. This is done by taking two consecutive stitches on the same side, the last one being slightly farther back than the preceding stitch. It is very important to have the first third of the suture line that unites the mesen- teric border drawn tightly, but after this unless the back- Fig. 69. The suturing has been completed, the last stitch being- taken in the left end of the bowel slightly beyond the lowest point where the original end of the thread comes out. The knot should be snug and should be tied parallel to the line of sutures so that it will sink in easily. The ends should be cut short and will disappear in the lumen. stitch is taken at intervals, pulling the thread may di- minish the lumen so much as to produce obstruction. The suture is continued toward the operator and is car- ried a short distance, about a stitch, beyond the lowest point where the original thread left when the knot was tied comes out. This last stitch is in the left-hand side of the bowel. The thread is then tied firmly to the orig- inal end that is grasped in the hemostat. The knot should OCCLUSION OF MESENTEEIC BLOOD-VESSELS. 201) Fig. 70. The sigmoid has been resected, the ileum cut across near the ileo-cecal valve, and its distal end closed by invagination. The ileum has been sutured to the distal portion of the sigmoid, end-to-end, and the descending colon is drained into the ileum by an end-to-side anastomosis. In this way, the de- fect left by excising the sigmoid is bridged over by transplanting the ileum, and the secretions from the large bowel are drained into the ileum. 210 SURGERY OF THE BLOOD-VESSELS. be tied parallel to the line of suturing so as to sink in easily and should be tied quite snugly (Fig. 69). If a back-stitch has been taken at proper intervals, there is no danger of reducing the lumen by tying the knot too tightly. It had best be tied three times and then cut short ; the ends will disappear within the bowel. This method is simple, leaves all knots within the bowel, and there should be no leakage when it is properly used. The danger of obstruction to the lumen is obviated by placing occasional back-stitches and by properly approx- imating each stitch as it is made. The thread is prac- tically all buried, leaving almost no thread exposed on the peritoneal surface, and the whole suturing can be done very quickly. All of these features are important and particularly so after a rather extensive operation such as transplantation of the bowel after resection of the sigmoid. If the thrombosis occurs in the inferior mesentery, whether from injury or from volvulus, rather extensive gangrene of the sigmoid and descending colon is likely to result. After such an extensive excision it will be impossible to unite the ends of the bowel, and the usual procedure is to make an artificial anus or else to excise the remainder of the large bowel and do an ileo-sigmoidos- tomy, which greatly prolongs the operation and is often out of the question here. An artificial anus in the cecum can be made without the dangers that would attend an opening higher up in the small intestine. If the pa- tient's condition warrants it, the ileum should be divided near its termination, united by end-to-end suture to the distal part of the sigmoid or rectum by the technique de- scribed above, and the transversed colon drained into the ileum higher up by a lateral or, better, an end-to-side an- astomosis (Fig. 70). CHAPTER XII. ANEURISMS. The term aneurism is applied to a cavity which com- municates with circulating arterial blood. The two gen- eral classifications of aneurism are the true and the false. A false aneurism is formed from a hematoma and is equivalent to the later stages of the so-called pulsating hematoma. If in an injury to an artery, blood is poured out and a hematoma forms sufficient to prevent further bleeding, the cavity in the center of the hematoma may become lined with endothelium and the tissues in the neighborhood form a connective tissue sac. This is a typical false aneurism. A true aneurism is not a tumor in the ordinarily accepted meaning, for a tumor is new tissue that has sprung from a matrix of cells. A true aneurism is a dilatation of a previously existing vessel and is not in any real sense new tissue. Aneurisms are divided into (1) congenital, (2) spon- taneous or idiopathic, (3) traumatic, (4) embolic, and (5) aneurisms by erosion. The so-called cirsoid aneu- rism is not an aneurism but a true tumor, as it springs from a matrix of angioblasts and produces vessels where normally they do not occur. Congenital aneurisms are exceedingly rare and chiefly occur in persistence of the ductus arteriosus of the fetus. Idiopathic aneurism is due to disease of the arterial walls, nearly always of the middle coat. It may be initiated by a sudden rise of blood pressure or a local trauma, but these things would not in a normal vessel cause an aneurism. Spots in the 211 212 SURGERY OP THE BLOOD-VESSELS. middle coat become soft and weakened from disease, or considerable areas sometimes may be similarly affected. If it is localized to a small area a sac is first formed but if the whole artery gives way, a spindle-shaped aneurism occurs. Later, these aneurisms may alter their form, so a spindle-shape becomes sacculated or vice versa. If, for instance, an aneurism that begins spindle-shaped has firm support on one side, as would be the case in the popliteal artery, the bone and solid tissue in front would eventually cause the posterior wall to give way more freely and an aneurism that began spindle-shaped be- comes sacculated. If the weakening of the middle coat, which caused a sacculated aneurism extended around the artery, a spindle-shaped or cylindrical aneurism would probably result. If blood breaks through the intima it may dissect the coats of the vessel for some distance and return to the main artery at another point. This is particularly likely to occur in the aorta, and sometimes this new channel is lined with endothelium. The idio- pathic aneurisms are by all means most numerous. Traumatic aneurisms are supposed to be due to direct injury of the arterial wall and are very likely to be false aneurisms, or arteriovenous aneurisms. Various parts of the sac occasionally give way and one aneurism may be engrafted upon another, so pro- ducing a multilocular sac. Embolic aneurisms are due to an embolus, which may or may not be infectious. The embolus may consist of a foreign body that has lodged in some portion of an artery and causes dilatation either mechanically or from infec- tion. Erosion aneurisms are practically abscesses or local- ized deposits that form along the course of an artery and weaken the arterial wall, eventually communicating with ANEURISMS. 213 the artery. These should be classed under false aneu- risms. A true aneurism is practically always of spon- taneous type and has one or more coats of the artery in its sac. The middle coat is always lacking except in the very beginning of the aneurism when some trace of the media may be seen. The sac of an aneurism may be cylindric, fusiform, or sacciform, and one of these forms may change into the other either on account of the anatomical surroundings, as has already been mentioned, or on account of the loca- tion near a joint, or from the change of direction of the blood stream. The location of an aneurism has a great deal to do with its shape. Aneurisms of the aorta, where the viscera of the thorax or abdomen offer but little re- sistance, may attain large size. Aneurisms developed in dense tissue grow in the direction of least resistance. The sac of an aneurism is lined with endothelium, and frequently contains an old white blood clot that has been partly or fully organized and may practically form an- other layer of the sac. Sometimes a number of these clots occurs. It was formerly thought that white clots were different from the softer or red clots, but there is usually a gradual transition from the red clot to the white clot. The red clot becomes partly organized, its coloring matter is absorbed, the fibrin contracts, its sub- stance is penetrated by blood-vessels, and it forms a dis- tinct layer. Occasionally, but not often, the sac is completely filled with clots which organize and cure the aneurism. Such an occurrence is so infrequent as to be counted a surgical curiosity. The tendency of an aneurism is to grow until rupture occurs or until death results in some other way. In the abdominal aorta three-fourths of the aneurisms re- sult fatally by rupture. Death may also be caused by 214 SURGERY OF THE BLOOD-VESSELS. pressure upon the lungs or trachea, by infection and sloughing of the sac, or by gangrene in the extremities, but the most usual termination is by rupture. The direct cause of the vast majority of aneurisms is, as has already been stated, a disease of the middle coat of the artery. This form of arteriosclerosis is one of the handicaps of civilization. No lower animal has aneu- rism except the horse which sometimes has a form of em- bolic aneurism from a parasite, strongylus armatus. In fact, it is practically impossible to produce experiment- ally aneurisms in the lower animals that correspond to the idiopathic aneurism in man. Some pathologists have created aneurisms in animals by the injection of supra- renal extract or other toxic substances that cause de- generation of the middle arterial coat. This has been done in rabbits, but under ordinary conditions the idio- pathic aneurism is unknown in the lower animals. The influence of civilization is best shown by the fact that in slavery days aneurisms in the negroes were almost un- known, whereas now it is four times more frequent in negroes than in the white race. More than seventy per- cent of aortic aneurisms are due to syphilis. Syphilis combined, as it often is, with alcoholic excesses and some- times with hard manual labor, practically constitutes the sum total of the direct causes of idiopathic aneurisms. As Osier has said, Venus, Bacchus, and Hercules are the etiologic trinity of aneurisms. Syphilis and alcohol cause degeneration of the middle muscular or elastic coat and exertion or undue pressure from any cause produces a giving away at this point, similar to what the automo- bilist calls a blow-out. As might be expected, the main artery, which has the chief burden of blood pressure to bear, is the most fre- quent seat of aneurism. According to Matas in one hun- ANEURISMS. - 1 ") dred and seventy-two cases of aneurism compiled by I lol- combe, they were distributed as follows : in the thoracic aorta, seventy; in the abdominal aorta, thirty-six; popli- teal, twenty-one; femoral, ten; innominate, nine; sub- clavian, eight; common carotid, five; external iliac, two; brachial, two; axillary, two; and one each in the verte- bral, ulnar, radial, celiac axis, splenic, occipital, and temporal artery. It is interesting to note that after the aorta, aneurisms of the popliteal are most frequent. This is due not to the unusual pressure in this vessel, but to the trauma from the frequent flexion and extension of the knee. Aneurism in young children is practically unknown. It occurs most often between forty and fifty years and is not infrequent in old age. As we would expect, it is chiefly a disease of the male and in the proportion of about two to one. After the fifth decade, however, it seems to occur equally in both sexes. The etiologic factors that have already been mentioned will readily suggest why it is chiefly a disease of man. The size of an aneurism depends partly upon its location. An aneu- rism may attain enormous proportions in the thorax or abdomen, whereas in the brain and particularly in the region of the fourth ventricle, a very small aneurism may be fatal. Symptoms and Signs. Usually an aneurism is readily recognized, but some- times when numerous clots have been deposited within the sac its diagnosis is exceedingly difficult. Before the advent of the X-ray a mistake was by no means rare. Such surgeons as Dupuytren, Esmarch, Pirogoff, and many others have made disastrous errors in the diagnosis of this condition, which, however, would hardly be justi- 216 SURGERY OF THE BLOOD-VESSELS. fiable at the present time. The history of the case is always of great importance and should he carefully taken wherever there is a possibility of aneurism. A history of syphilis, or the presence of a positive Wassermann, in connection with any growth along the blood-vessels would make a diagnosis of aneurism very much more probable. The age of the patient, race, sex and habits are also sug- gestive. The history of the growth, the presence of pain, the presence or absence of a leukocytosis, particularly a high count of polynuclear white cells, may serve to dif- ferentiate between an abscess and an aneurism. The physical examination to be made depends to a large extent upon the location of the aneurism. If in the thoracic aorta it attains a large size before the sac can be palpated. Here, however, the physical signs should give some indication, for there is dullness on percussion and possibly the presence of a thrill that may be felt. Bronchial breathing, shortness of breath, visible enlarge- ment of the veins of the neck and arms, sometimes swell- ing of the arms and neck, pain referred to the intercostal nerves, hoarseness, cough, or even paralysis of the left vocal cords caused by pressure on the recurrent laryn- geal, disturbances from pressure upon sympathetic nerves as contraction or dilatation of the pupil, sometimes diffi- culty in swallowing and frequently trachial tugging are the chief signs and symptoms of a thoracic aneurism. Trachial tugging is best brought out by extending the head and neck, when the larynx is seen to be pulled upon by the trachea at each beat of the heart. Probably the most important diagnostic aid in thoracic aneurism is the X-ray. The refinement of modern skiagraphy can show the presence of a thoracic aneurism of even small size and should always be appealed to in making a diag- nosis of this condition. ANEURISMS. 217 The signs and symptoms of aneurisms in other por- tions of the body depend to some extent upon the loca- tion. In an aneurism situated in one of the extremities or in the neck there is a difference in the pulsation of the artery distal to the aneurism when compared with the corresponding artery in the other limb or on the other side of the neck. This is due to the fact that a great deal of the pressure in the blood stream is taken up in the aneurism and the artery distal to it has lower pressure than the corresponding artery on the other side of the body. The beat is usually somewhat delayed for the same reason. Frequently the pressure of the aneu- rism on the veins in the neighborhood will produce edema or swelling distal to the aneurism and also enlargement of the veins. Occasionally the venous collateral circula- tion is made evident by the dilated veins under the skin. If, however, pressure upon the vein is not too great there is but slight dilatation of the superficial veins as the venous flow, even when partially obstructed, can re- turn the diminished arterial supply unless the pressure in the artery is so interfered with by the aneurism that the blood cannot be properly forced through the vein. Pressure upon nerves often causes pain and sometimes muscle spasm and trophic disturbances. There may even be erosion of the bone which can be demonstrated by X-ray. As a rule, however, aneurisms in the extremities grow in the direction of least resistance and that wall which is opposed by solid bony tissue will lie supported and the aneurism will be forced to enlarge in other di- rections. Sometimes infection of the sac occurs. This seems peculiarly liable to happen in the external iliac and upper femoral arteries and has been the cause of many disastrous mistakes. The inflammatory thickening of the tissues together with the increased coagulability of 218 SUKGERY OF THE BLOOD-VESSELS. the blood, which may cause deposit of clots in the sac, frequently obliterates any pulsation that normally would be present. The signs of inflammation and probably the actual presence of pus may lead the operator to believe there are several pockets, and in his effort to be thorough the aneurism may be opened. With the history of the case and a good X-ray picture, such mistakes should be very infrequent in modern times. The physical, local signs of aneurism are expansile pulsation, thrill, and bruit. Pulsation can be detected by sight and by palpation. An aneurism, the walls of which are too thick for pulsations to be distinctly expansile, should be distinguished from a solid tumor, and some- times from an inflammatory mass that rests upon the ar- tery and transmits pulsations. The character of the expansile pulsation can usually be told by resting two fingers close together upon the enlargement and observ- ing that they are not only lifted up but that they are to some extent separated at the height of each pulsation. A more accurate way of determining this would be to mark two points on the skin over the enlargement and. test the distance between them with calipers during sys- tole and during diastole. A thrill is often felt by palpation with the fingers or with the whole hand. It is not so marked in aneurisms as in arteriovenous aneurisms. Bruit is detected by auscultation and is heard most distinctly over the growth, though it may be transmitted along the course of the artery for some distance. This is not due to vi- bration of the opening, as was formerly thought, but the sound is made by the current of blood. Direct pressure on an aneurism usually diminishes it, but when the pressure is removed the aneurism returns to its original size. All of the characteristic signs are ANEURISMS. abolished when the main trunk of the artery between the aneurism and the heart is compressed. Treatment. The treatment of aneurisms is divided into medical and surgical. Medical treatment consists in the direc- tion of diet, and personal hygiene, together with the ad- ministration of such drugs as create a tendency to clot- ting in the sac. This is supposed to be obtained by di- minishing the blood pressure on the one hand, and by in- creasing the coagulability of the blood on the other. Medical treatment was first introduced by Valsalva and Albertini in 1728. According to the original method it consisted of absolute physical and mental rest, and re- peated bleedings. In this manner the blood pressure was reduced and the coagulability of the blood increased. Very little fluids were given and only 125 grams of food were permitted in a day. This treatment has been made much less severe and now ordinarily consists of rest in bed and a light diet, without bleeding, together with the administration of such drugs as increase the coagulabil- ity of the blood or lower the blood pressure. Iodide of potash appears to be the most effective; nitroglycerine and the nitrates are used. Calcium chloride is given in doses from ten to twenty grains three times a day with the idea of increasing the coagulability of the blood. The injection of gelatin has received a great deal of attention. Great care should be taken in sterilizing the gelatin, as not infrequently cases of tetanus have been caused by imperfect sterilization. While at one time it was extensively used in thoracic aneurisms, it is now but seldom employed. A good many observers, however, have reported very striking results. Ennion Gr. Wil- 220 SURGERY OF THE BLOOD-VESSELS. Hams l reported two cases of thoracic aneurism in which he used gelatin with temporary benefit in one case. He recommends injecting fifty cubic centimeters of a five to ten percent solution in water, great care being taken to sterilize the gelatin thoroughly. The time of coagulation of the blood decreased from two and a half minutes be- fore injection to a minute and a half after injection in one of his cases. Bollenstein, in 1904, reported forty-six per- cent of favorable results in 126 cases. These, however, do not necessarily mean cures. The action of gelatin seems to be chiefly in the destruc- tion of white blood cells, thus liberating the elements that go to form fibrin ferment. It may be administered as a ten percent solution in ordinary salt solution giving fifty cubic centimeters, or as a three percent solution in Locke's fluid, injecting 250 cubic centimeters in the lum- bar or glutial regions every five or six days until twenty injections are given. This may be continued over a pe- riod of several months. The diet recommended in these cases is, for breakfast, two ounces of bread and butter and two ounces of milk; for dinner, three ounces of meat, two ounces of bread and potatoes, and four ounces of water; for supper, two ounces of bread and butter and two ounces of tea. This may be varied to some extent, particularly in the line of decreasing meats and tea. Milk may be substituted for meat. The symptomatic treatment consists in the administra- tion of drugs that relieve pain, such as morphine and atropine or codein, or such remedies as aspirin. Com- presses of lead water and opium or an ice bag placed over the skin, which should be fully protected, often af- ford some relief. Old Dominion Medical Journal, August, 1903. ANEURISMS. 221 Surgical treatment includes various methods, such as wiring, electric puncture, direct and indirect compres- sion, ligature, incision, obliteration of the sac, and exci- sion of the sac alone or combined with the substitution of a segment of vein. We will first consider the methods particularly appli- cable to aneurisms of the aorta as these aneurisms can- not be reached by the direct attacks employed elsewhere. "Needling" was advised by McEwen in 1890. The method is quite uncertain, though McEwen reports sat- isfactory results. It consists of the introduction into the sac of a long, fine needle which scratches thoroughly all of the lining of the sac. This is followed by the disposi- tion of fibrin and according to McEwen the fibrin thrown down after needling is peculiarly firm. The operation, however, has not been adopted by many surgeons. The introduction of wire into an aneurism was first done by Moore, of London, in 1864. It has been widely used, particularly in connection with the modification by Corradi, in 1879, of passing a galvanic current through the wire. Finney, of Baltimore, has had very favorable experience with it and reports several cases much bene- fited and some apparently cured. Finney recommends the wire originally proposed by Hunner, which consists of a silver alloy containing seventy-five parts of copper to 1,000 parts of silver. This wire is wound tightly on a wooden spool, in order to make it coil, and should be of such size as will readily pass through the ordinary as- pirating needle. The needle is insulated with a coat of the best French lacquer to within a short distance of its point. This prevents an electrolytic burn that might be the seat of a subsequent hemorrhage. Under local anes- thetic the needle is inserted into the skin which is drawn to one side so when the needle is removed the opening in 222 SURGERY OF THE BLOOD-VESSELS. the skin is not opposite the opening in the sac. Finiiey uses ten feet of wire, claiming that a larger amount may prevent the contraction of the clot in the sac. The nee- dle is inserted slowly until arterial blood appears in spurts through the needle. The end of the wire should be engaged in the lumen of the needle before the needle is inserted. At first a small amount of blood will spurt around the wire. The wire is then threaded through into the aneurism, care being taken that no portion of the needle that is not protected with lacquer comes in contact with the skin. The positive pole of a galvanic battery should then be connected with the wire, a nega- tive pole being placed at the patient's back. This is im- portant as the negative pole to the wire will cause dis- organization of the clot rather than hasten its formation. The current, according to Finney, should be not greater than seventy-five m.a., but should be continued at least an hour. In abdominal aneurisms, the aneurism should, of course, be fully exposed and the viscera packed away. This is done under local anesthesia. After the current has been passed at least an hour in thoracic aneurisms the needle is slowly removed, twisting it somewhat in order to withdraw it gradually. The skin is depressed around the wire and the wire cut flush with the skin. The skin is then pinched up and the end of the wire will disappear under the skin. If the skin has originally been drawn to one side, there is no direct communication be- tween the hole in the skin and that in the sac. Aneurisms of the aorta should first be carefully stud- ied with the X-ray before being subjected to wiring. A diffuse dilatation or a spindle-shaped aneurism obviously cannot be treated by such a measure, which should be reserved for the distinctly sacculated type. Attempts have been made to cure aneurisms of the abdominal aorta ANEURISMS. by ligature, and the abdominal aorta lias so far been ligated for various causes, chiefly for aneurism, about twenty times with fatal result in each case. In some ab- dominal aneurisms the metal band introduced by Ilal- sted seems indicated. By this means the circulation can be greatly diminished though not entirely obliterated, and after collateral circulation has been sufficiently es- tablished the band may be removed and a ligature ait- plied. If, however, important arteries, such as the renal or the coeliac axis, arise from a prominent portion of the sac the case would seem utterly hopeless, as any method that obliterates the sac would, of course, occlude these arteries with the necessity of a fatal result. In the treatment of aneurisms of the extremities it is important to develop the collateral circulation to as great an extent as possible before any attempt is made to ex- cise the aneurism or to close the sac. This may be done by hot packs around the limb several times a day, ex- tending over a period of a half to one hour at a time. Digital pressure on the artery or pressure by a special apparatus may also be used. The circulation should be tested, as suggested by Matas, by applying a firm Es- march bandage from the extremity of the limb to the trunk. The main artery is then compressed, the Es- march removed, and note made of the returning circu- lation which is carried on collaterally. In the leg a hyperemic flush extends quickly to the knee, but may go much more slowly or not at all to the foot. If the flush does not reach the ankle, operation should be post- poned and treatment with hot packs or local compression of the artery is instituted until collateral circulation has been satisfactorily established. The most serious objec- tion to this method of testing is that it is inapplicable in negroes or in people with a very dark skin. 224 SURGERY OF THE BLOOD-YESSKLS. A method of treatment in many instances and a most satisfactory means of developing collateral circulation in all cases is the use of a metal band, first devised by W. S. Halsted. The original Halsted band has been further modified by Matas and by Halsted and in its simplest form consists of a small band of aluminum, about one- fourth of an inch wide, which can be rolled around the artery with the fingers. Halsted originally devised a special instrument for this. The band is not rolled tightly enough to occlude the artery but merely to an ex- tent that will reduce its circulation to a minimum. In this manner collateral circulation is developed, while at the same time there is a small current through the main artery. After a week or two the band is removed and the artery either occluded by a tight ligature or the an- eurism obliterated by the operation of Matas, with but little danger of gangrene. Mayetti 2 describes a method of occluding large vessels by strips of fascia or tendon instead of metal bands. The fascia is taken from the animal or individual and constitutes an autograft. Mayetti recommends fascia lata. A strip is placed around the vessel and fastened with a silk suture. In his experimental work, the artery could be reduced to one-third of its natural size without signs of thrombosis. Matas and Allen in some excellent experimental work demonstrated the feasibility of partial obliteration of the aorta in dogs. The results of their experiments were read before the American Surgical Association in May, 1913, (Annals of Surgery, September, 1913). They show that the aorta, if healthy, can be partially occluded by in- folding it with layers of sutures. This, of course, cannot be done except in healthy blood-vessels which unfortu- 2 Policlinico, Rome, January 12, 1913. ANEURISMS. nately is the exception rather than the rule near aneu- risms. Scalone 3 gives a method for partially obliterating 1 blood-vessels by placing sutures with a curved needle through the superficial layers of the blood-vessel in such a manner that the vessel is infolded just as the pylorus is sometimes infolded. The external tissues are brought firmly around the vessel to maintain and support the ob- struction. Compression is recognized as one of the oldest methods of treating aneurisms. While various appliances have been used they have not been quite so satisfactory as digital compression properly applied. It requires a number of assistants who can relieve each other from time to time. The skin where pressure is to be made is covered with French chalk. Each assistant is instructed as to the amount of pressure necessary, the direction in which it must be made, and the manner of changing from one assistant to another, so at no time during the treat- ment is the artery without compression at or about the same point. The femoral artery below Poupart's liga- ment is the most favorable location for digital compres- sion. Each sitting lasts four hours. Sometimes one sit- ting will result in a cure, but usually ten or even twenty sittings are necessary. This method is unsatisfactory and uncertain in comparison with modern methods and is by no means free from danger of gangrene. The elastic compression of Eeid consists of bandaging the limb by means of an elastic bandage up to the aneu- rism and then skipping the aneurism, but bandaging the limb above it. In this way the blood is shut off above and below the aneurism and clotting is often produced. The bandage, however, should not be left on longer than 3 Policlinico, September, 1913. 226 SURGERY OF THE BLOOD-VESSELS. an hour and a half and in elderly people half this time is much safer. According to Delbet, this treatment leads to gangrene twice as often as digital compression. Extreme flexion has been suggested by a number of surgeons, but is often called the method of Hart. It is applicable in the treatment of aneurisms developing in the popliteal region, in the groin, or in the elbow. It consists of forced flexion which must be maintained about fourteen days. It is exceedingly painful and cures only about one-third of the cases. The classical methods of using the ligature for 4 the cure of aneurism have been long established. The op- eration of Antyllus has been practiced since the second century of the Christian era, and has on the whole given exceedingly satisfactory results. It consists of ligating the artery close to the aneurism, both centrally and dis- tally, and then incising the sac (Fig. 71). In preanti- septic days the suppuration following this method made the mortality high, but in spite of that the percentage of cures has been gratifying. Anel's method, first used in 1710, is ligating the artery centrally but as close as possible to the sac. In preanti- septic days where suppuration was a rule, secondary hemorrhage was frequent. It was thought this was partly due to the fact that the artery near the sac was very likely to be diseased; so John Hunter established a new principle of ligating, in 1785, by applying the liga- ture centrally, but at some distance from the aneurism. In this method branches are given off from the main ar- tery between the ligature and the aneurism. It is still used to some extent but has many disadvantages. First of all, it assumes that the artery is less diseased at a dis- tance from the aneurism than close to it. This is by no means always true. Secondly, the liability to gangrene ANEURISMS. 227 is increased, because if the sac is occluded by a clot there will be two obstructions to the current instead of one, the obstruction at the site of ligature and another farther Brasdor. Warirop . Fig. 71. Diagram illustrating the various methods of ligation for aneurisms. down where the aneurism is closed by clots. Then the collateral circulation between the ligature and the sac is greatly diminished and the blood has to pass through two sets of collateral branches, one from above the ligature SURGERY OP THE BLOOD-VESSELS. to the vessels between the ligature and the aneurism and one from this last set to the vesesls below the aneurism, in order to maintain the nutrition of the limb. If, how- ever, the collateral circulation is free, the aneurism may not be sufficiently occluded by clots and no cure will re- sult. With modern technique and absorbable ligatures the operation of Anel is far superior to that of Hunter. Brasdor instituted the method of distal ligation in 1798, ligating distally the main trunk. Wardrop, in 1825, applied ligatures distally to one or two of the main branches of the artery. This was used in aneurisms of the innominate where the carotid artery was often tied. The application of a ligature immediately above and be- low without opening the sac is called Pasquin's method and was first applied in 1812. Ligation on each end and close to the aneurism with extirpation of the sac has been known as the operation of Purmann, who used it in 16.80. This method has been recently very extensively employed on the continent. It is necessary to have complete hemostasis either by the tourniquet, or by clamping, or by temporary ligatures. Often large collateral vessels open into the sac, so a cen- tral ligature may not completely control the hemorrhage. It is also important to preserve the vein in extirpating the sac, for if the vein is injured or ligated, gangrene is much more likely to occur. Bleeding should be con- trolled by sutures, which do not go deeper than neces- sary, as packing if depended upon to stop bleeding may also interfere with the collateral circulation. Gangrene occurs in mass or in patches merely involv- ing small localized areas. It is particularly important to follow the usual after-treatment, to stimulate the heart by drugs and by the introduction of salt solution by rec- tum. The whole limb should be well wrapped in cotton ANEURISMS. -'20 and moderately elevated in order to secure venous drain- age, but not too much elevated as this might interfere with the arterial circulation. Hot air ovens may be used. After the wound has begun healing, hot baths and mas- sage with active and passive motion are instituted. Ligation with extirpation of the sac compares very favorably in results with simple ligature, as it has a some- what lower mortality in a large number of cases than the Hunterian method of ligation, and the dangers of gan- grene are about the same. The greatest improvement in the treatment of aneu- risms in modern times is the operation of Matas, which was first performed by him in 1888, on a brachial aneu- rism that had not been cured by either proximal or dis- tal ligature. The operation is subdivided into three dif- ferent types, though the principle is the same in each. The fact that extirpation of the sac, and that the Syme operation in which the artery is ligated within the sac, is followed by a comparatively low mortality and a high rate of cure makes it quite evident that the nearer the ligature is placed toward the sac, other things being- equal, the better the results will be. The objections to extirpation are obvious. The operation is not only dif- ficult and involves the enucleation of considerable tissue, but there is a likelihood of injury to the veins or nerves, and, most important of all, the tissues enucleated often carry collateral vessels that are highly important. The three types of the operation of Matas are oblitera- tive endo-aneurismorrhaphy, restorative endo-aneuris- morrhaphy, and reconstructive endo-aneurismorrhaphy (Fig. 72). The obliterative type may be used in any form of aneurism, but it was particularly designed for cases in which there are two openings in the sac some distance apart, or when the sac is peculiarly friable. 230 SUEGERY OF THE BLOOD-VESSELS. Hemostasis is obtained by a tourniquet if possible, or if this is impracticable by ("rile, Matas or the author's clamps on the artery and its main branches both above and below the sac. The sac should not be dissected out, so wherever a tourniquet can be used instead of a clamp it should always be preferred. By bearing in mind the principle on which the operation is founded conserving every possible collateral branch in the sac and surround- ing tissues the operation can be carried out more intelli- gently. After the tourniquet has been applied an ample incision is made through the skin over the aneurism. If it is impossible to place the tourniquet, the vessel is ex- posed centrally and peripherally a few inches from the aneurism, and clamps applied, as mentioned above. The sac is then opened without separating it from the sur- rounding tissue and clots are thoroughly removed. A suture of chromic or tanned catgut in a small, round, curved needle is passed around the openings of the artery taking care to tie the openings snugly but not using too much force as the suture may cut out. The sac is searched for other openings of collateral arteries or branches and these are also closed. Then the sac is obliterated by rows of sutures of chromic or tanned catgut, the first row running preferably from one arterial opening to another. After this has been finished another row is placed. In intraperitoneal aneurisms the peritoneum is sutured so as to cover the raw surface. The manner of treating the sac after the two tiers of obliterative sutures have been placed depends largely upon the condition of the sac and must of necessity be left to the judgment of the surgeon, as in plastic work. The essential features are to close the arterial openings into the sac and to place at least two rows of continuous chromic or tanned catgut, obliterat- ing the sac as far as possible from one of the main arte- ANEURISMS. 231 Fig. 72. Rndo - aneurismorrhaphy. (A) The apertures in the aneurismal sac with sutures inserted, some of which are tied. (B)The second layer of Futures is being placed. (C) Mattress sutures are passed partly through the skin for further closure of the sac. (D) Cross-section of obliterative endo - aneurismorrhaphy. (E) reconstructive en do-aneurism morrhaphy with sutures placed but not tied and catheter in the artery. (F) Catheter be- ing removed just before sutures are tied. (G) Cross-section of reconstructive endo-aneurism. (After Matas.) 232 SURGERY OF THE BLOOD-VESSELS. rial openings to the other. After this, the recesses of the sac are folded upon themselves if possible, or sutures are carried through a double thickness of the sac and tied in the margin of the wound, or else brought out through the skin (Fig. 72). All dead spaces should be obliterated and the wound closed without drainage. The blood current is gradually turned on before the skin is sutured and the infolded sac is pressed upon. Usually but little if any oozing occurs, though if it is marked the tourniquet should be reapplied and the leak stopped by additional sutures. The smooth membrane lining the in- side of the sac is vascular endothelium and requires no freshening or injury to heal, but merely snug approxi- mation just as in peritoneum. Restorative endo-aneurismorrhaphy is applicable when the sac is tough and resistant and when there is only one opening. In other words, when the aneurism springs from one side of the artery and the whole of the artery's circumference is not involved. This does not occur very frequently. In such cases the opening is su- tured either by surrounding it with a purse-string suture or by whipping it over with a continuous stitch. The rest of the procedure is identical with the obliterative method. Reconstructive endo-aneurismorrhaphy is recom- mended by Matas in cases in which the two openings are close together, where there is but little atheroma, and where the sac is tough and holds sutures well. The sac is cleaned of clots and washed out with salt solution and the region of the two openings is anointed with white vaseline. Matas recommends that a soft rubber cathe- ter well anointed with vaseline and which fits snugly into the arterial openings be inserted and interrupted sutures of chromic catgut be placed at close intervals over the ANEURISMS. 233 catheter. After the sutures have been placed the cathe- ter is withdrawn and the sutures tied snugly. The rest of the sac is obliterated as in the other methods. In all of these methods care should be taken not to take a deeper bite with the sutures than is necessary to secure a firm hold. The needle may wound the accom- panying vein or nerve, or if inserted too deeply, may oc- clude some collateral vessel. It is doubtful if reconstructive endo-aneurismorrha- phy does not sooner or later become obliterative. The fact that in several instances thrombi formed after the reconstructive operation which later were dislodged and acted as emboli, is also a serious objection to this method. In the light of modern blood-vessel suturing, we can hardly expect the reconstructed artery to remain patent. In experimental work under the best conditions with comparatively healthy blood-vessels and using the finest sutures of silk and the finest needles, it is impossible to avoid obliteration in a considerable number of cases even after some experience in this work. This being the case, we can hardly expect suturing with comparatively coarse needles and catgut in tissue that is diseased to reproduce a permanently patent artery. If there is merely a small opening the restorative method may be indicated, but the eventual result will probably be better if the oblitera- tive method is always used instead of the reconstructive type. The only advantage in the reconstructive opera- tion is the fact that for a short time blood flows through its natural channel and the consequent strain upon col- lateral circulation will not be so great. This advantage, however, seems offset by the t dangers of sudden emboli from the breaking loose of the thrombus, by the fact that sooner or later the channel in all probability becomes ob- literated, and by the further fact that recurrences are 234 SURGERY OF THE BLOOD-VESSELS. much more common after the reconstructive than after the obliterative method. Matas has collected statistics which prove beyond doubt that wherever endo-aneurismorrhaphy can be ap- plied it is far more satisfactory than either ligature or extirpation; not only is the mortality rate less but gan- grene is exceedingly rare. Extirpation of aneurisms has been done in a few in- stances with direct suture of the artery by the end-to- end method. This is only applicable where the site of the aneurism involves a very short section of the artery and where the ends of the artery are comparatively healthy. It has been done by Lexer, Stich, and Ender- len in popliteal aneurisms. The limb is flexed and kept in this position for several weeks by plaster of Paris. After the sixth week the knee may be gradually extended. This method has, of course, a very limited application. The ideal treatment of aneurism is to excise the sac and at the same time to restore the arterial channel. This is accomplished by substituting a segment of vein. The vein that accompanies the artery has been used, though it would be much better to utilize some other vein. Obviously when the direct circulation is deficient on ac- count of the aneurism and collateral circulation is poor, closing the main artery by ligature or obliteration of the sac even by the excellent method of Matas is fraught with great danger and the indications are if possible to reestablish the circulation by the ideal method. In a diseased artery, arterial sutures would not seem to be satisfactory, and it is certainly more desirable to su- ture healthy arteries in traumatic aneurisms than the diseased vessels of spontaneous aneurisms. However, the brilliant case of Lexer, already referred to above, in which he excised an aneurism involving a portion ANEURISMS. of the external iliac and femoral arteries and sutured into the defect a segment of the saphenous vein with per- fect success, shows the great possibilities of this opera- tion. If success is to be attained in suturing diseased arter- ies the best possible technique should be used. As already pointed out, it is not likely that reconstructive endo-aueu- rismorrhaphy in which comparatively coarse needles and catgut are used, will result in a permanently open chan- nel. Certainly in experimental work such technique would invariably be followed by thrombosis even in healthy arteries, and in diseased arteries we have no right to expect better results. It is practically impossi- ble, however, to use the technique of arterial suturing in the bottom of a sac where the tension on the stitches must be considerable, but after the sac is excised a seg- ment of vein can be sutured into the ends of the artery with the regular technique for end-to-end suture. While there is some danger of the segment becoming occluded by thrombus, it would seem for the reasons mentioned and particularly in the light of Lexer's case that if it is necessary to reestablish the current of the blood, it should be done not by the reconstructive method of Matas, but by excision of the sac and suturing into the defect a segment of vein. Reversing the circulation and then excising the aneurism has also been tried. This has none of the advantages of transplantaion of a vein. Treatment of Aneurism of Special Arteries. Aneurisms of the thoracic aorta are by far the most frequent kind of aneurisms, which would naturally be ex- pected from the strain to which this great vessel is sub- ject. The proper treatment is the medical treatment that has already been outlined, though in sacculated tho- 236 SURGERY OF THE BLOOD-VESSELS. racic aneurisms the Moore-Corradi method may be used. The technique as employed by Finney is probably the most satisfactory (page 221). A thorough examination by X-ray should be done before this operation is at- tempted. The average course of a thoracic aneurism is a little more than a year. There has been one effort to cure a thoracic aneurism by ligating the aorta. This was done by Guinard, of Paris, in 1904, the chest being- opened posteriorly by an osteoplastic flap and a ligature placed on the thoracic aorta just below the end of the arch. When the ligature was tightened, pulsation in the femoral artery stopped and the lower part of the body became pale and cold, but in a few minutes the circula- tion was reestablished through the intercostal and other vessels. However, the blood pressure through collat- eral circulation was not sufficient for the renal arteries and the patient died. Aneurisms of the abdominal aorta are scarcely amena- ble to other direct treatment than the Moore-Corradi method. If the aneurism is above the renal arteries or involves the mesenteric, its obliteration will necessarily result fatally on account of interference with the func- tion of the kidneys or from gangrene of the intestines. Below the inferior mesenteric artery, the outlook seems more hopeful, but the results are practically equally as disastrous. Of about twenty cases of ligature of the abdominal aorta none has been successful. The strain thrown upon the heart by the increased blood pressure after such a ligature is enormous and this high pressure and a competent heart are essential to the proper estab- lishment of collateral circulation. Most of these patients have hearts that are far from competent and even in healthy animals, ligation of the abdominal aorta usually results in a cardiac death. In a case of Keen's the ab- ANEURISMS. 23 1 dominal aorta was ligated and the patient lived until the forty-eighth day. Even if the heart should survive the strain, which it does not do in the vast majority of eases, there is still the risk of hemorrhage and the possibility of sepsis and shock. The iliac arteries have been ligated for abdominal aneurism, following the principle of Bras- dor and Wardrop, but this too has proved fatal. Vari- ous methods of compression have been advocated and even endo-aneurismorrhaphy has been tried, but unsuc- cessfully. The aluminum band of Halsted which would produce a partial but not a complete occlusion of the aorta seems to offer the most satisfactory method of treatment, if wiring and galvanism are not indicated. Various problems, particularly the strain upon the heart, render treatment of aneurism of the aorta a very unsat- isfactory procedure. Experimentally, a portion of the abdominal aorta has been resected and a tube successfully sutured into the defect (page 73). Aneurisms of the innominate seem to offer a field for the Moore-Corradi method, though they have been treated successfully by ligature. Apparently the best operation is distal ligation after Wardrop or Brasdor. Ligation of the right common carotid and the right sub- clavian is done during the same operation, tying the caro- tid first to avoid the possibility of a cerebral embolus. Aneurisms of the external carotid are quite rare, but occasionally occur. Treatment by ligature, placing the ligature as. far as possible from the bifurcation of the common carotid, may be employed. The injection into the external carotid of boiling water after the sugges- tion of Wyeth might be indicated, as the collateral cir- culation with the carotid of the other side is so free as to render simple proximal ligation much less likely to cure here than in most other arteries. Aneurisms of the com- 238 SURGERY OF THE BLOOD-VESSELS. mon carotid or of the internal carotid are of grave sig- nificance because of the disastrous effect on the brain that often follows when these arteries are ligated. The dan- ger of ligation of the common carotid increases enor- mously after forty years of age and is due to the dimin- ished blood supply to the brain. In the young with elastic arteries ligation of the common carotid is comparatively free from danger, but after forty years of age, and par- ticularly in the presence of arteriosclerosis, the occur- rence of cerebral symptoms, from the inability of the other arteries to dilate sufficiently, is frequent. The op- erative measures that have been used are the classical methods of ligation, though of these extirpation with the double ligature has proved most successful. Proximal ligature is particularly liable to cause thrombi in the sac with the possibility of a piece of thrombus becoming loose and causing an embolus in the brain. This, of course, is in addition to the danger of cerebral symptoms from the mere occlusion of the artery. Distal ligation or extirpation to a large extent avoids the danger of embolus. It has been found that cerebral symptoms may often be avoided if the channel of the artery can be reestab- lished within a few hours after its occlusion. The prob- lem in connection with the carotid artery is different from that in most other parts of the body, not only be- cause of the immediate dangers to life, but because of the fact that we have a method of determining from the patient's sensations and symptoms whether occlusion of the artery is safe. Before applying a ligature to the carotid, except in cases of grave necessity, the common carotid should be exposed under local anesthetic and gradually occluded, preferably by a rubber covered Crile clamp. If this is followed by cerebral symptoms of a ANEURISMS. 239 psychic nature, by paralysis or convulsions, the ml cry should be opened at once. If no immediate symptoms occur, the clamp may be left on for forty-eight hours and then a ligature applied to occlude the artery with comparative safety. However, cerebral symptoms some- times appear after several days, though they are usually manifest within twenty-four hours after occlusion of the artery. If complete closure is not possible the metal band of Halsted may be rolled around the artery in such a manner as partially to occlude it. If this is sufficient to cure the aneurism no further treatment is necessary; but if not the band may be left in place for one or two weeks until the other arteries have taken up the circula- tion, and then a ligature can be applied. If even a par- tial occlusion is not borne the outlook is almost hopeless, though the possibility of excision and the substitution of a segment of vein should be considered. Subclavian aneurisms have been subjected to numer- ous methods of treatment, including the intrasaccular ligation of Syme. They have been treated by ligature, both distal and proximal, and the innominate artery has also been ligated in efforts to cure. The results have usually been unsuccessful, the mortality being large, though since 1890, the mortality has fallen from about eighty percent in preantiseptic days to twenty-two per- cent. The metal band may also be used here. Excision of the sac seems to have been followed by quite satis- factory results as compared to other methods of treat- ment. Endo-aneurismorrhaphy has been attempted, though in not a great number of cases, and the results have usually been most satisfactory. Axillary aneurisms may be treated by ligature, by band, or by the operation of Matas. In certain cases where the circulation can be controlled, excision of the 240 SURGERY OF THE BLOOD-VESSELS. aneurism with substitution of a piece of vein may be considered. This has been done by Lexer and while the patient died from gangrene of the limb it was found that the occlusion from thrombus occurred where the clamp was placed, the transplanted section of vein being patent and in good condition. Treatment of aneurism of the iliac arteries is subject to somewhat the same objections as treatment of aneu- rism of the aorta, for ligation of these large arteries produces great strain upon the heart. The intrasaccu- lar method of Matas offers in certain cases excellent re- sults, though hemostasis may be difficult or impossible except by compression of the aorta. The common and external iliac may be regarded as practically an extension of the aorta. Aneurisms affect- ing all of the iliac arteries are lined in front with peri- toneum. They tend to dilate quickly as there is but little resistance in front and they rupture easily for the same reason. When rupture occurs it is usually immediately fatal, though occasionally the blood may form a large hematoma under the peritoneum. The treatment of aneurisms of the iliac arteries is confined to some form of ligature, to a partial constriction by the band of Halsted, or to endo-aneurismorrhaphy. Digital com- pression is not practical, though it may be tried by open- ing the abdomen and compressing the common iliac or the aorta. In extirpation or in endo-aneurismorrhaphy, temporary hemostasis can be effected by digital pressure on the abdominal aorta, or else upon the trunk of the common iliac near the bifurcation. Even pressure upon the aorta may not give an entirely dry field as some blood comes through the distal end by the deep epigastric artery. Pressure upon the iliac is often unsatisfactory because of the free anastomosis with the internal iliac of ANEUKISMS. '241 the other side. Aneurisms of the external iliac have oc- casionally been treated by digital compression. Com- pression of the abdominal aorta through the abdominal wall is possible in thin patients, but is best done within the abdomen. In a thin patient the method of Mom- burg, constricting the abdomen with a rubber tube, may be tried. This will give a completely dry field, but there is always some danger from an abdominal tourniquet, such as injury to the intestines, though the originator of this method claims otherwise. The treatment of aneu- rism of the iliac has been largely by means of the liga- ture. Double ligation, distal and proximal, with extir- pation has given satisfactory results. The iliac should be ligated intraperitoneally. The older method of strip- ping up the peritoneum and making an extensive raw surface is unnecessary. The patient may be put in the Trendelenburg position with the intestines packed off, and ligation of either the common iliac or its two branches can be readily done. Endo-aneurismorrhaphy has been tried in a few cases with satisfactory results. Ligation of the common iliac carries a heavy mortality rate. Matas says that in modern times, since 1880, the death rate is nearly fifty percent. This high mortality rate, as explained by Halsted in an article on aneurisms of the iliac, is largely due to complications and would probably now be considerably lower. The fact, however, that the mortality from simple ligation is much higher than from extirpation or endo-aneurismorrhaphy should cause the later method to be employed wherever possible. Aneurisms of the upper femoral require a similar hemostasis to aneurisms of the iliac, as it is impractical to place a tourniquet at this level. The external iliac gives off but few branches whereas the upper part of the femoral has a very abundant collateral circulation. For SURGERY OF THE BLOOD-VESSELS. this reason in preantiseptic days ligation of the femoral just below the groin was avoided whenever possible. The collateral circulation was so free at this point that formation of a thrombus was prevented or retarded and as suppuration usually took place secondary hemorrhage would occur in about half of all cases ; consequently, the external iliac whose branches are few could be ligated much more safely. However, now with the absorbable ligature and careful asepsis, these objections no longer hold. In aneurisms of the upper femoral it is exceedingly difficult to obtain even temporary hemostasis unless the same measures are employed as in aneurisms of the iliac ; that is, direct compression of the abdominal aorta or the common iliac after opening the abdomen. The commu- nications of the profunda, which is almost always in the sac of an aneurism in this neighborhood, together with other collateral branches make the field very vascular. The necessity for controlling bleeding by intraabdominal pressure in such cases should be considered most seri- ously whenever it is desired to open the sac of an upper femoral aneurism. Aneurism of the branches of the internal iliac prac- tically always occurs either outside of the pelvis or else partly without and partly within the pelvis. It usually involves the sciatic or the giuteal arteries. Formerly, the most satisfactory treatment was the method of An- tyllus where the vessel is ligated both proximally and distally and the sac incised. The better method is endo- aneurismorrhaphy with either temporary or permanent closure of the internal iliac by ligature. When the aneu- rism begins in the pelvis, which is very unusual, merely ligating the internal iliac may be all that is necessary. Aneurism of the lower femoral can be treated most ANEURISMS. '24'.\ satisfactorily by endo-aneurismorrhaphy and lie re, as elsewhere, either the obliterative or, sometimes, the restorative operation is done. The reconstructive method, an attempt to build up a new channel out of the wall of the sac, should not be attempted. If after test- ing the collateral circulation it appears deficient and the patient's condition is otherwise good, the possibility of excising the aneurism and substituting a piece of the saphenous vein from the other leg should be considered. Popliteal aneurisms may involve the whole of the ar- tery in the later stages, but in the early stages they are often of the saccular form in which a very small portion of the artery is affected. In several instances the aneu- rism has been excised and the ends of the artery united by end-to-end suture. Aneurisms arising from the up- per part of the popliteal are much less likely to cause gangrene than those from the lower portion of this ar- tery, because most of the collateral circulation from the articular, azygos, and muscular branches opens into the lower portion of the popliteal. The former treatment of popliteal aneurism was peculiarly unsuccessful. Va- rious methods of ligation have been used. As popliteal aneurisms comprise about one-third of all aneurisms, ex- cepting those of the aorta, the clinical material for op- erative treatment has been very largely drawn from those of the popliteal type. Of the various methods of ligation the Hunterian has been the most popular, but the radical operation consisting either of extirpation of the sac or the operation of Antyllus, a distal and a prox- imal ligature and incision of the sac, has given better results. Endo-aneurismorrhaphy is peculiarly applica- ble to popliteal aneurisms and in sixty-two cases there was only one death which was due to tetanus and two cases of gangrene, and in both of these instances the vein 244 SURGERY OF THE BLOOD-VESSELS. that accompanied the artery was injured and had to be ligated. This, of course, was not a fault of the method. In all others recovery occurred. There were secondary hemorrhage and relapse in four cases, but in these the reconstructive method was used, proving the wisdom of adopting the obliterative type of endo-aneurismorrhaphy. In one of the author's cases in which the obliterative op- eration was done for a popliteal aneurism, the result was entirely successful. CHAPTER XIII. ARTERIOVENOUS ANEURISMS. Arteriovenous aneurisms are lesions in which there is a communication between an artery and a vein. The vein may be a sinus in the dura mater. They are usu- ally subdivided into two forms, varicose aneurism, in which the communication between the artery and vein is indirect and a sac exists between the two vessels; and aneurismal varix, in which the blood flows directly through the opening from the artery into the vein. There are many combinations such as a sac in the artery opposite the opening into the vein or there may be two sacs, one on the artery opposite the opening and one be- tween the artery and the vein. The vein becomes di- lated, particularly the proximal vein, unless the parts around it form a firm support. Dilatation of the vein is called varicose aneurism by dilatation. Secondary arteriovenous aneurisms are found in the region of the heart and around the aorta where a pre- existing aneurism has ruptured into a vein. The most frequent cause of arteriovenous aneurism is trauma, a gunshot wound being the common form of traumatism. The modern bullet which makes a small puncture is very likely to cause an injury of this nature. Formerly, when bleeding was in vogue, arteriovenous aneurism at the elbow with a communication between the brachial or the ulnar artery and a vein, was comparatively fre- quent. Fractures, stabs, or indirect injuries may also result in arteriovenous aneurism, but occasionally it oc- 245 246 SURGERY OF THE BLOOD-VESSELS. curs spontaneously, which is rare and is probably due to some degeneration in the wall of the artery that per- mits perforation at this point. The distal portion of the artery becomes contracted and narrow, since it is subject to less than its normal pressure as a portion of the blood intended for it is delivered to the vein. The central segment of the artery, however, is much dilated. This was supposed at one time to be due to a kind of atrophy and thinning of its walls, but is now believed to be a genuine hypertrophy of the vessel itself in an effort to bring enough blood to the seat of the lesion to sup- ply the distal parts satisfactorily even in the presence of the leak into the vein. The vein is also dilated dis- tally up to the first valve and centrally for a much longer distance. Sometimes the valves are forced by the pres- sure of the blood stream or by damming back of the blood and a large varicose tumor may result. The dila- tation of the vein is very much influenced by the sur- rounding tissue. The vein gradually thickens and be- comes more and more like an artery. Owing to the marked activity of the circulation in ar- teriovenous aneurisms and the great difference in pres- sure between the venous and the arterial trunks, clots rarely form and the prospect of spontaneous cure is very slight indeed. The liability to rupture depends to a large extent upon the size and location of the sac. An aneurismal varix rarely ruptures. Sometimes the crowding of the arterial blood into the vein causes swell- ing from damming back of the venous blood, and at the same time nutritional disturbances may appear because too little blood enters the artery distal to the lesion. All of these things, however, depend entirely upon the loca- tion of the arteriovenous aneurism and the size of the opening. A very small leak will interfere but little, ARTERIOVENOUS ANEURISMS. 247 whereas a larger one may switch back so much of tin- blood that nutrition is greatly impaired. In large arteries an opening of considerable size may cause so much pressure in the venous system as to pro- duce dilatation or hypertrophy of the heart. In a case that the author operated upon (page 252) there was a large opening between the upper femoral artery and vein, and all four valves of the heart were incompetent. The lesion may appear immediately after the infliction of the injury or more frequently after an interval of time. Some cases are reported in which the symptoms occur months or years after the injury, but this is un- usual and is probably due to yielding of the scar. Usually the clots and the pressure from the surrounding exudate will prevent a free communication for several days. The thrill is marked in all arteriovenous communica- tions. It can be felt distinctly at the site of the lesion and along the course of the vein both distally and cen- trally. The bruit can be heard and is much more dis- tinct than in simple aneurisms of arteries. Often the vibrations along the course of the vein can be seen. The thrill is continuous but is most intense with each systole of the heart and at the exact site of the anastomosis. The noise has been compared to the buzzing of machin- ery, or to the sound made by a bee in a paper bag. This sound varies in character and in pitch but is present in some degree at all times. It ceases completely when the artery is compressed on the cardiac side of the le- sion. It is caused by the vibration produced from the rapid whirl of the blood current in going suddenly from a vessel of high pressure to a cavity of low pressure, just as a noise is made by the passing of water from a high pressure pipe to one of low pressure. Neither the edges of the opening nor the vessels have anything to do with 248 SURGERY OF THE BLOOD-VESSELS. the sound, which is produced solely by the blood cur- rent. The pulse in the artery is stronger above the lesion and weaker below the lesion than it would be normally. It is also somewhat delayed below the lesion. Pulsa- tion in the vein is sometimes felt, though this depends upon the size of the opening and also upon the size of the artery. Pressure upon the artery centrally to the lesion not only stops the sound but also causes a marked diminution in the size of the tumor. Superficial veins in the neighborhood are usually enlarged. The tempera- ture of the limb distal to the aneurism is lowered, at least until a satisfactory collateral circulation has formed. If a large communication exists between the aorta or the iliac arteries and the adjoining vein, the prognosis is most unfavorable. The decrease in blood pressure be- cause of the large leak from the arterial system into the venous system, which has a much larger capacity, might so lower the blood pressure as to cause death. The prognosis of arteriovenous aneurisms depends upon three things : first, the location, whether in a large or a small vessel; second, the size of the opening; and third, the presence or absence of a sac. A large open- ing in large vessels, even if the blood pressure could be maintained, is likely to put too great a strain upon the heart. On the other hand, an arteriovenous aneurism in a small artery is of but little significance and would interfere very slightly with function or with the general health. There is but slight chance of rupture, when com- pared with aneurisms of the arteries, and this infre- quency of rupture with the difficulty of cure has led the older surgeons to avoid interference in arteriovenous aneurisms. AKTEEIOVENOUS ANEUEISMS. l!4(> Treatment. It has been the experience of most surgeons who have had considerable clinical material that unless there is grave danger it is best not to operate upon these in- juries too soon. The patient should be given the benefit of rest and kept as quiet as possible to reduce blood pressure. This treatment is continued for two or three months after the injury unless there is a marked tend- ency for the lesion to become worse. At this time what- ever sac may have occurred will be firmly organized and the collateral circulation will be amply established. Re- cent experience in the Balkan wars, however, seems to indicate that immediate operation is best. Immediately after the injury, pressure over the lesion and on the main artery by a firm dressing and bandage and absolute rest are indicated. The various methods of ligation have not proved very satisfactory. Proxi- mal ligation is often followed by recurrence and distal ligation alone is, of course, never indicated. The quad- ruple ligation, tying artery and vein both above and be- low, with or without extirpation of the sac, has cured most cases, but is often followed by gangrene owing to the fact that both the artery and vein are sacrificed at the same time. The ideal method of treatment is restoration of the lumen of both the artery and vein. Where a sac exists, the method of Matas, the restorative endo-aneurismor- rhaphy, may be practiced in some cases. The fact, how- ever, that the sac is practically always a false sac and is not continuous with any of the coats of either artery or vein would make the application of this method a little less certain than in a restorative endo-aneu- rismorrhaphy on a spontaneous aneurism. If a sac ex- 250 SURGERY OF THE BLOOD-VESSELS. ists it is opened, and the aperture in the artery sutured with interrupted catgut stitches. AVlien the artery and vein are both closed in this manner the sac is partly obliterated by catgut stitches which tuck a por- tion of the sac over each opening. In an aneurismal varix the vein may be incised and the opening into the artery is closed within the vein, then the vein itself is sutured. This latter procedure probably causes a throm- bus in the vein even if the suturing in the artery held. If it is possible to secure complete hemostasis the most satisfactory way is to dissect free both the artery and vein and to suture the wound in each vessel, follow- ing the technique of arterial suturing. This, of course, would necessitate the edges of the wound in the artery and vein being carefully cut away with sharp scissors, the adventitia removed, and the wound approximated ac- cording to the technique described under the head of su- turing lateral or transverse wounds in blood-vessels. As much tissue as possible should be preserved so that a double mattress stitch may be used, approximating ac- curately the intima and at the same time not sacri- ficing the lumen. The dilatation of the vessels toward the heart, together with the contraction below the lesion, places considerably more strain upon the sutures than would be the case after an ordinary wound of the vessel. This strain should be relieved by the application of a strip of fascia, a large absorbable ligature, the Halsted aluminum band or infolding the artery according to Matas and Allen, in order partly to occlude the vessel proximal to the lesion. Or a ligature may be thrown around the artery with instructions to tie it quickly if secondary hemorrhage occurs. If there is no infection the danger from secondary hemorrhage should be over in a week or ten days. AETERIOVENOUS ANEUKISMS. When it is impossible or impracticable to secure com- plete liemostasis by a tourniquet the problem is much more difficult. If the nutrition of the limb is seriously affected, or if the heart shows signs of failing under the extra strain on the venous side, operation should be at- tempted. In a heart that is already incompetent, pres- sure upon the aorta or ligation of a large vessel might result disastrously and the safer method under such I - . m^mmim^m H.V-V Fig. 73. This shows how the clamps for lateral suture may be applied on an arteriovenous aneurism without the necessity of fully dissecting out the aneurism. circumstances would be to reestablish the circulation in both the artery and vein. Here it is advisable to dissect both vessels carefully, exposing the lesion and then to grasp the artery and the vein with curved forceps for lateral suture of blood-vessels (page 85). After grasp- ing the artery and vein their communication is severed, the edges of the wound in the vessels properly trimmed, and with a cobbler's stitch in straight arterial needles or an overhand stitch in a curved needle, the opening in the artery and then in the vein is closed (Figs. 73 and 252 SURGERY OF THE BLOOD-VESSELS. 74). If possible without too much constriction of the lumen, a continuous reenforcing stitch over this may also be used. The lumen of the artery should be par- tially occluded on the cardiac side, as already mentioned. A case of arteriovenous aneurism between the femoral artery and vein about two inches below Poupart's liga- ment on which the author operated at a clinic in the Medico-Chirurgical College, through the courtesy of Prof. W. L. Rodman, may be of interest in this connec- Fig. 74. The 1. The communication between the artery and vein has been divided an( the vessels are being sutured. It is best to use a cobbler's stitch and fin< arterial needles in the artery, but if this is impossible, a fine curved needl may be used. tion. Four years ago, the patient, a pullman car por- ter, had fallen on a sharp stick and injured his left thigh about two inches below Poupart's ligament. Sev- eral months after the wound had healed, he noticed a swelling in this location. It would sometimes be quite large. Gradually the pain became greater and greater and it was difficult for him to work. On admission to the Medico-Chirurgical Hospital, all valves of the heart were found incompetent and the thrill and bruit in the ARTERIOVENOUS ANEURISMS. 2."))} region of the scar were intense. The pressure in the venous system was evidently so great as to affect his heart most seriously and the indication was to relieve his heart by an attempt to cure the arteriovenoiis aneu- rism. The location was too high for a tourniquet and the condition of the patient's heart rendered it unwise to compress the aorta. After carefully dissecting free the vessels involved, the femoral artery just above the lesion was found greatly enlarged and the femoral vein much dilated. In an effort to free the artery posteriorly, considerable bleeding was encountered. The profunda artery was clamped and the vessels going internally cut and tied, as they hindered the dissection. Adhesions from the scar tissue posteriorly and numerous vessels here that tore easily rendered the dissection behind the femoral impossible. Though a Crile clamp was placed on the artery above and below the lesion and also similarly on the vein, and though the profunda was clamped, the communication between the femoral artery and vein when incised bled freely. The tip of the index finger was at once inserted and in this manner the bleeding was checked. The vein was clamped by a soft Doyen intestinal clamp. Pressure over the artery in certain directions controlled the collateral branches that evidently came in from be- hind. No attempt was made to follow the regular tech- nique of arterial suturing as the vessels would bleed pro- fusely after pressure was removed and it was impossible to do the suturing in a perfectly dry field. The thread, however, was anointed with vaseline and the wound in the artery was closed by a continuous stitch of moder- ately fine silk in a curved needle. The wound in the vein was easily sutured. The distal clamp was removed and the proximal clamp was gradually loosened. The ex- ceedingly large size of the femoral artery above and the 254 SURGERY OF THE BLOOD-VESSELS. impossibility of carrying out the regular technique of arterial suturing made it doubtful whether the sutures in the artery would hold. At the same time it was recog- nized that ligation of the dilated femoral would throw so much extra strain upon a heart whose valves were already incompetent that a cardiac death might result. Conse- quently, ligatures were placed around the artery and vein, both above and below the lesion, with the idea of ty- ing these ligatures if serious hemorrhage occurred later. The wound was perfectly dry when closed. There was a small drainage provided at both the upper and lower angles. The night following the operation considerable hemorrhage occurred and the ligatures were tied and an additional ligature placed on the artery. The next morning the patient's pulse was good and the leg was warm and seemed to be well supplied with blood. He did well for fifteen days when he had a severe secondary hemorrhage, for which Dr. Rodman ligated the external iliac. This completely controlled the hemorrhage and the patient was apparently improving until the twenty- first day after the operation, when symptoms of acute cardiac dilatation occurred and he died within twenty- four hours. There had been no further hemorrhage, however, and a post-mortem examination showed there was no bleeding, but that death was due to dilatation of the heart. Such cases are always desperate but if they can be treated before the heart becomes so markedly dis- eased the prognosis would be better. CHAPTER XIV. TUMORS OF THE BLOOD-VESSELS. A true tumor of the blood-vessels springs from a ma- trix of cells that is formed either in the embryo or in later life. It is not a part of the normal anatomical structure. Tumors of blood-vessels may consist chiefly of arteries, chiefly of veins, or chiefly of capillaries, but all have to some extent other types of blood-vessels. They are named, however, after the predominant type. The kind very commonly found is composed of dilated capillaries that lie within the skin. They produce the color often referred to as "port-wine mark," due to the large number of new dilated capillaries. If chiefly from the arterioles, the color is decidedly red; if the dilata- tion is largely on the venous side it is dark purple. The skin is usually not elevated above the normal and the appearance is suggestive of a deep and irregular stain. Some authors have claimed that these capillary angiomas follow the distribution of the branches of the fifth nerve, though these findings are not generally borne out by other observers. Gushing suggested that these angiomas are often found in the dura when present on the face and not in- frequently cause hemorrhage, which may be serious. Such a possibility should be borne in mind in all cases in which sudden cerebral symptoms arise in a patient who has a capillary angioma on the face. The histologic appearance shows a large number of well formed capillaries and small blood-vessels, and fre- 255 256 SURGERY OF THE BLOOD-VESSELS. quently many lymph vessels. The growth is painless, though the disfigurement is so marked that it may be the cause of nervous symptoms in a person of sensitive na- ture. Treatment depends to some extent upon the location and extent of the growth. If small and conspicuous it can usually be excised and the skin around the edges undermined so as to bring the margins of the wound to- gether in a straight line. The skin should be sewed sub- cutaneously to leave but little scar. A subcuticular stitch of tanned catgut makes a very satisfactory union. This may be reenforced by the epithelial stitch of Hal- sted, fine silk in a fine round needle, merely taking the edges of the epidermis. If, however, the angioma is ex- tensive as is often the case, other measures are prefer- able. The many kinds of treatment formerly employed, such as the application of nitro-muriatic acid, cauterization with the actual cautery, or the injection of astringent so- lutions, have now been practically abandoned. If the nevus is too extensive for excision it should be treated either by electricity, carbon dioxide snow, or liquid air. The older method of electrical treatment consisted in inserting a needle into the growth at various spots and connecting it with the negative pole of a galvanic battery. A current of about twenty milliamperes was turned on for about ten minutes and increased shortly before withdrawing the needle. This has to be repeated often and frequently leaves considerable scar. The mod- ern electrical treatment by desiccation is far better. The bare electrode does not come in contact with the tissues, but the current from one pole is thrown from a metal part through a small air space in the form of sparks of high frequency. The other pole is grounded. If deeper ef- TUMORS OF BLOOD-VESSELS. _)< feet is desired the bipolar method is used. Here the metal point touches the tissues and a large passive elec- trode is placed on some other portion of the body. A static machine with an output of from two and a halt' to three and a half milliamperes produces a satisfactory initial current which is gradually increased. Desicca- tion seems to dry the tissues and sterilize them. It causes a rapid dehydration and ruptures the cell capsule. It has the power of penetrating the tissues for as much as an inch, though usually it penetrates efficiently only for a much shorter distance. A small growth may possibly be destroyed at one sitting but a large growth requires sev- eral treatments. The desiccated tissue causes a reac- tion and hyperemia which usually produces rapid repair. The crust that forms separates in a few days or a week. Often regeneration will occur without scar. The appli- cation is not very painful, but if the individual is sensi- tive a local anesthetic may be employed. This treat- ment should not be used, however, when there is any reasonable suspicion of malignancy. Another method of treating extensive nevi or birth- marks is refrigeration. It gives most satisfactory re- sults. Carbon dioxide, which is employed for freezing, is readily procurable in iron drums from soda water manufacturers or from saloons where beer is sold. To collect the frozen gas or "snow," as it is called, the iron drum is tilted till the outlet is at a low point. This in- sures the exit of the liquid. A piece of chamois skin is then tied around the outlet and collects the frozen gas. Special attachments are also on the market for collect- ing the gas. If chamois skin is employed the "snow" can be rolled in the chamois skin or packed in hard rub- ber molds to form a stick or pencil. Any grade of re- frigeration may be obtained, depending upon the dura- 258 SURGERY OF THE BLOOD-VESSELS. tion of the application and the amount of pressure. For small lesions, about the size of a nickel or smaller, one application usually suffices. For larger growths, sev- eral are necessary. For the ordinary flat nevus an ap- plication of from ten to thirty seconds is enough. When used on large nevi that are somewhat deeper and with a thick skin, an application of a minute or more may be necessary. Some authorities claim that exposure to X- ray renders the tissue more susceptible to freezing. The treatment is followed by a disagreeable burning sensa- tion and usually by blistering. Ordinary dusting pow- der of borated talcum is used as a simple after-treat- ment. The principle of both refrigeration and desicca- tion is that the endothelial cells of the blood-vessels are destroyed and consequently the vessels disappear. In capillary nevi, "port-wine marks," the small capil- laries are dilated either in a spindle-shape or in a sac- cular form. In the cavernous or venous angioma, the vessels are larger and more deeply situated and desicca- tion or freezing is inapplicable, as these remedies cannot penetrate deeply enough to destroy all of the elements of the anigoma without causing an extensive slough. A cavernous angioma is raised above the surface and sometimes attains very large proportions. It is soft and easily compressible, the blood, however, filling up the growth quickly whenever pressure is removed. A venous angioma may arise as a growth of new veins or it occasionally occurs as a sequence of a capillary angi- oma that tends to grow deeper into the tissue, its ves- sels communicating and forming large lakes of blood. The walls of a cavernous angioma are very thin and they may be easily injured. A wound of such a growth is followed by profuse and sometimes fatal bleeding. Cavernous angiomas are seen on the face frequently, as TUMORS OF BLOOD-VESSELS. 259 is the capillary angioma or nevus, and are also found in the liver, muscles, and sometimes in the kidney and other organs. The nose or the margins of the eye are favor- ite portions of the face for this growth. It is said that it is likely to occur where the fissures of the face are obliterated. The treatment for capillary angioma or nevus is hardly applicable to cavernous or venous angiomas, except so far as they may be excised. Radium, however, can be used for any kind of angioma. It seems to have a special tendency to cause obliteration of blood-vessels. Care should be taken in excision not to cut through the tumor tissue itself, as almost uncontrollable hemorrhage may be encountered. If such a growth lias been acci- dentally injured it is useless to attempt to catch the indi- vidual vessels but sterile gauze should be packed in the wound and firm compression made. This packing should not be removed for several days. In excision the cut is made in healthy tissues where normal vessels are encoun- tered and the blood supply dealt with in the usual man- ner. In large angiomas, however, this would be imprac- ticable and often the excision of so much tissue leaves a very bad deformity. Most angiomas have a congeni- tal origin and sometimes grow rapidly, and the effects of their pressure upon the surrounding tissue, even upon the bone itself, may cause atrophy and leave 1 marked deformity. Another objection to excision in any but the smallest tumors is the fact that frequently ma- trices of the blood-vessels, angioblasts, may exist around the margin of the growth in what appears to be healthy tissue; small blood-vessels from the growth also jut out irregularly. In order to include these, a wide margin of healthy tissue would have to be removed, else some of the abnormal vessels left may renew the growth. 260 SURGERY OF THE BLOOD-VESSELS. The treatment devised by John A. \Vyetli, of New York, is most satisfactory for cavernous angiomas that cannot readily be excised. This consists of the injection of boiling water into the growth. The water mixes with the blood and the heat destroys the endothelial lining of the blood-vessels. In a large growth a series of in- jections are required. The injections are made with an all metal syringe capable of holding about two ounces of water. A moderately coarse aspirating needle is used. The syringe is filled with boiling water and the barrel of the syringe heated over an alcohol flame or a Bunsen burner. The patient is anesthetized and the eyes and the skin surrounding the growth as well as the growth itself are anointed with sterile vaseline. The rest of the face is covered with moist gauze to prevent scalding, as a few drops of water may escape from the syringe. The syringe is held with dry gauze or a dry towel. If the gauze or towel is wet it cools the syringe too much. The needle should not be too fine as it would make the stream of water so small as to reduce its tem- perature unduly. After plunging the needle into a prominent portion of the growth, blood flows for a few seconds, but is readily controlled by the hot water. The water is injected rapidly until the tissues become tense. The needle is then shoved to another portion of the growth and a further injection given. Even in a large growth an effort should be made to cover the most promi- nent parts at the first sitting. If the injection is made too slowly the heat is so reduced as to prevent its in- jurious effect upon the vascular endothelium. Consid- erable swelling follows for several days and gradually subsides. No other injections should be made for ten days or two weeks. If at the end of that time soft areas show where blood-vessels have not been destroyed, an- TUMORS OF BLOOD-VESSELS. 201 Fig. 75. Fig. 76. Fig. 75. Fig. 76. Photograph of a boy, J. P., thirteen months old with a large angioma of the nose which was growing rapidly. Another view of the angioma of boy shown in Fig. 75. Fig. 77. A photograph of J. P. about eighteen months later after a series of in- jections of hot water by the method of Wyeth. 262 SURGERY OF THE BLOOD-VESSKLS. other treatment can be given. The patient should then wait for at least a month before further injections, as the injurious effect of the anesthetic, together with the absorption of the products of the injured cells are too irritating to permit treatments in rapid succession. The author has used this method successfully in sev- eral angiomas of the face and in a large angioma of the umbilical region. The accompanying photographs of a little boy show the results of injection of hot water in a large cavernous angioma of the nose. About fifteen in- jections were made extending over a period of eighteen months (Figs. 75, 76 and 77). There is but little danger from emboli if the injection is made quickly, for the large blood cavities will rapidly form clots that are too big to enter a small vessel. The usual antiseptic precautions should be taken, but the sterilizing effect of hot water is sufficient to insure against septic clots. Sometimes if the skin is very thin it may slough. The heat often produces a blister. The skin is dusted with boric acid or some antiseptic oint- ment is applied immediately after the injection. This treatment is hardly suitable for capillary angiomas, as these vessels are so superficial that the heat neces- sary to destroy them may also destroy the skin. It is well suited for a cavernous or venous angioma, as the hot water will follow the various sinuses and vessels and destroy vessels that could not be excised except by tak- ing out a great deal of healthy tissue. The old method of running threads through an angi- oma or leaving other foreign bodies in its substance has been generally abandoned. Not only is it usually inef- ficient but small clots may form which cause emboli and the danger of sepsis is great. Arterial angioma, or cirsoid aneurism, which goes un- TUMORS OF BLOOD-VESSELS. l2()o cler many names, is usually found about the face or hands. It consists largely of masses of arteries that are very tortuous and communicate with each other. Their pulsation sometimes causes erosion of the bone. Knp- ture of these vessels often results in an alarming or even fatal hemorrhage. Arterial angiomas frequently arise from small nevi and occasionally follow an injury. The large vessels may become confluent and form a cav- ity. A thrill and bruit may exist over the region of these angiomas. The treatment of such, a condition has not been satis- factory. Subcutaneous ligation has been tried but is not often followed by cure. The best treatment is liga- tion of the main artery that supplies the aneurism, as, for instance, in cirsoid aneurism of the forehead ligation of the external carotid. Often communications with other arteries are so large and numerous that this is not effective. Following the method of Wyeth, the artery that directly opens into the cirsoid aneurism can some- times be dissected free, the central end ligated, and hot water quickly injected into the distal end. Pressure should be maintained around the margins of the growth to prevent a too quick return of the hot water into the veins. The injection of astringents would hardly be wise. CHAPTER XV. VARICES; VARICOSE VEINS, VARICOCELE, AND HEMORRHOIDS. Varicose veins are merely dilatations of previously existing veins and so, of course, differ from true tumors considered in the previous chapter, which consists of new growths composed of abnormal vessels. Varicose veins of the leg are more common in the left leg for the same reasons that phlebitis is more frequent in the left leg than in the right. The manner of the left iliac veins crossing under the iliac arteries, the slightly longer course of the left iliac vein, the pressure of the distended sigmoid, are all given as factors that make varicose veins in the left leg more frequent than in the right leg. The pressure of a tumor or growth in the pelvis or in the iliac fossa may also be a cause as well as some defect in the valves that permits blood from the femoral vein to run backward into the saphenous. Varicose veins are more prominent when the patient is standing and vary from a slight dilatation to large, bluish masses that disappear on pressure. They are always tortuous and in advanced cases extend from the ankle to the saphenous opening. The veins sometimes vary in size, becoming larger or smaller at different times. It is quite common to find varicose veins much worse during pregnancy. This is not due solely to the pressure of the uterus, because the veins often begin to enlarge in the first month of pregnancy before pressure begins. The dilatation may be fusiform or sacculated 264 VARICOSE VEINS. ( and only certain portions of the saphenous vein may In- affected. The sluggish circulation promotes clotting which causes a still further damming back of the blood and so increases the dilatation of the vein. The dan gers of embolism from varicose veins are obvious. Sometimes the vein is so large and thin that it ruptures and serious hemorrhage may occur. In the advanced stage all the valves of the saphenous become inefficient, and the long column of blood has no support except at its base. Trendelenburg tested the efficiency of the valves by elevating the leg for a short time, stroking the blood to- ward the heart and then compressing the saphenous trunk. With the saphenous still compressed the patient stands up and the dilated veins below gradually fill with blood from the foot and leg. When the compression is removed the blood suddenly rushes into the saphenous from the femoral vein. If, however, the valves are ef- ficient this latter phenomenon does not occur. Various disturbances arise due to the obstruction of the venous circulation. The skin of the leg and foot be- comes bluish-red, infiltrated, and liable to inflammatory affections, particularly to eczema. The slightest injury heals over with difficulty and ulcers readily form. The ankle, foot, and sometimes the leg swell after standing for some time. In chronic cases, new connective tis- sue forms and produces a permanent thickening. The fat over the veins disappears and the veins become ad- herent to the skin. If a vein ruptures and a thrombus occurs the skin in the immediate neighborhood often breaks down readily. The patient has muscular weak- ness, and complains of indefinite pains and aching in the leg and foot. Sciatica may occur. Some patients suffer a great deal, while others apparently have but little dis- 266 SURGERY OF THE BLOOD-VESSELS. comfort. The rupture of small veins beneath the skin is often followed by brownish pigmentation of the skin. This is very common about the ankle. Inflammation of the veins is readily accompanied by thrombosis. Bone in the vicinity of the ulcers sometimes becomes necrotic. Varicose veins are very insidious in their growth and frequently accompany diseases that either directly affect the circulation, such as heart disease, or weaken the gen- eral resistance of the patient. It is undoubtedly true that many families have a tendency to varicose veins. Varicose veins usually begin in the small, superficial veins about the middle of the leg, though they may orig- inate from the veins about the ankle or even in the neigh- borhood of the knee joint. They are bluish or purplish in color and radiate from one spot. Occasionally, the large trunks of the leg or thigh are first involved. Some authors claim that varicose veins originate in the deep veins and extend to the superficial, though this is not borne out by most observers. When varicose veins are limited in character they are usually found where the large perforating branches enter the superficial veins from the deep veins. There are three forms of veins in the lower extremity ; (1) those without valves in which the blood may run either way, (2) veins in which the valves direct blood toward the surface, and (3) those in which the valves direct the blood toward the deep veins. The perforating branches are most numerous in the middle and lower part of the leg. In the middle of the leg they are surrounded by muscle and these are frequently the first to dilate. Often the process extends from this point to the other veins. The veins are elongated and become very tortu- ous and the walls in the later stages are thick from con- nective tissue. Standing is much more likely to produce VARICOSE VEINS. 1^)7 varicose veins than walking, for the tension on the mus- cles compresses the deep veins constantly in standing, whereas in walking or in running there is alternate ten- sion and relaxation which serves to empty the vein. The complications that often occur are pigmentation of the skin, eczema, ulceration, and neuralgic pain. Some of these complications are supposed to be trophic. Occasionally the pain may be very severe and may even involve the sciatic nerve. Ulcers are difficult to heal permanently unless the varicose vein, which is the cause of the ulcer, is excised. Club-foot has been mentioned as one of the sequelae of varicose veins due to muscular changes and to the trophic and nervous disturbances. This, however, must be exceedingly rare. The treatment of varicose veins may be operative or nonoperative. Nonoperative treatment should be used in mild cases. The indications here are to improve the general health and regulate the nutrition and personal hygiene. Particularly should constipation be overcome. If an employment requires constant standing the occu- pation should be changed or the patient required to sit, elevating the legs whenever possible. In the absence of phlebitis massage toward the heart is of some value. Any constriction, such as circular garters or tight bands around the waist, should be prohibited. If the varicose vein is localized and without disagreeable symptoms no other treatment is necessary. If, however, it tends to extend, some form of compression should be used. Stockings made of rubber and silk are probably the best. The toes and the heel should be left exposed, and the stockings should not go above the knee. Flannel band- ages or bandages made of some washable webbing that can be cleaned and reapplied when necessary are cheaper and often just as effective as the most expensive elastic 268 SURGERY OF THE BLOOD-VESSELS. stockings. Any treatment depends, of course, upon the cause of the varicose veins. If due to heart disease elas- tic stockings or bandages that increase blood pressure are contraindicated. The operative treatment consists of ligatures or ex- cision of the veins. These two operations are of very ancient origin, though they have been modified from time to time. The injection of astringent material into the veins has also been advocated, though it is not prac- ticed to any extent at the present day and is undoubt- edly liable to cause thrombosis and embolism. The liga- tion may be merely tying the main trunk or using many ligatures in such operations as advocated by Schede or Friedel. Schede completely encircles the leg with an in- cision about the junction of the upper and middle thirds, cutting all veins and tissues down to the fascia of the muscle. The veins are then tied and the skin sutured. Friedel makes a spiral incision starting below the knee and encircling the leg five times, ending on the back of the foot. All veins are tied but the wound is left open to drain away the lymph. Multiple ligation of the main trunk with its branches has been advised, some surgeons using as many as thirty or forty ligatures. Resection of the saphenous vein may be partial as recommended by Trendelenburg, who ligates and resects the saphenous vein in three places, at the middle of the thigh, and above and below the internal condyle. Total resection can be done by a long incision made from the saphenous opening to the posterior border of the inter- nal condyle and then continued to the internal malleolus. If an ulcer is present the incision does not reach as far as the ulcer so as to avoid infection. A better method of excision is that recommended by C. H. Mayo and con- sists of multiple short incisions over the course of the VARICOSE VEINS. 269 saphenous vein (Fig. 78). The vein is ligated and stripped subcutaneously. This may be done by thread- ing it through a special instrument such as has been de- vised by Mayo. The upper incision is made just below the saphenous opening. The vein is doubly tied and di- vided between ligatures. The lower end is threaded through a special instrument that resembles somewhat a Fig. 78. Method of Charles H. Mayo of stripping out varicose veins through mul- tiple short incisions. Two special instruments for stripping veins are shown at the bottom of the illustration. blunt curet. The instrument is shoved down on the vein, so stripping it from the surrounding tissues and tearing many small branches. When the vein is stripped as far as possible in this manner an incision is made over the elevated beak of the instrument. The vein is brought up at this point and the instrument withdrawn from the first incision and inserted into the second incision. The 270 SURGERY OF THE BLOOD-VESSELS. vein is again stripped. Xo incision should he made on the level of the knee as the scar may interfere with the motion of the joint later on. If the varicose veins are extensive, it is impossible to strip them much below the knee as the branches in this region are large and quite numerous. Here an incision may be made either curved or straight, so as to expose the greatest number of veins, which are then excised. The methods of strip- ping the veins from below upward are dangerous be- cause of the possibility of thrombus and embolism. Bab- cock and others have devised an instrument somewhat like a long probe with a bulbous end, resembling a bougie with a long handle. The handle is inserted into the vein, the bulbous end being too large to enter. The handle is cut down upon and the vein in this way turned wrong side out. The operation suggested by Delbet of anastomosing the internal saphenous to the femoral vein at a lower junction than normal is hardly justifiable. Varicocele. Variococele is the name applied to dilated veins in the spermatic cord. It is common in boys about fifteen or sixteen years of age and in young men. Unfortunately quacks and advertisers have so exaggerated the signifi- cance of this trouble, that many young men have an er- roneous idea of its importance. It is normal for the veins to enlarge somewhat at certain times of life. If, however, the enlargement is excessive the condition be- comes one that should be treated. The local signs and symptoms are quite characteristic, Varicocele is more frequent on the left side than on the right. This is prob- ably due to the fact that the left spermatic vein empties at practically a right angle into the left renal vein, VARICOCELE. 271 whereas the right spermatic vein has a shorter course and empties obliquely into the vena cava. Constipation with a chronically filled signioid may also be a causative agent here as well as in varicose veins of the leg 1 . If the condition becomes aggravated, the veins are exceedingly prominent and the scrotum is much elongated, particu- larly in warm weather. The veins resemble the old de- scription of "feeling like a bunch of earth worms." Often there is an impulse on coughing, which is not eas- ily confused with the impulse from hernia on account of the peculiar consistency and distribution of the varico- cele. When the patient lies down the veins are emptied and the swelling to a large extent disappears, though in old cases where the walls of the veins have thickened they can be felt even when the patient is reclining. If the condition is aggravated and prolonged, sometimes atrophy of the testicle occurs as a secondary change from passive hyperemia. Dull aches and a dragging sensation are frequently complained of. There are often various nervous symptoms that may merely ac- company, and not be caused by, varicocele. One of the most important things about varicocele is its diagnostic significance of a tumor of the left kidney. As the left spermatic vein empties into the left renal vein, a tumor of the left kidney that compresses the renal vein is likely to cause a left varicocele. Varicocele is a disease of youth. Xo particular importance can usually be attached to its development in the young. However, in the middle aged or old the rather sudden occurrence of marked varicocele on the left side should always at- tract the attention of the surgeon to the possibility of a tumor of the left kidney. The treatment of varicocele in boys or young men often requires merely moral reassurance that the condi- 272 SURGERY OF THE BLOOD-VESSELS. tion is not a serious one. Cold baths each day, regula- tion of the bowels, and personal hygiene should he rec- ommended. If the varicocele is marked, a snugly fitting suspensory should be advised. If the condition has ex- isted many years and the scrotum is much relaxed, and particularly if accompanied by dragging or neuralgic pain, operation should be performed. The operation consists either in ligation or excision of the veins. Formerly, subcutaneous ligation was much practiced, but this operation has justly fallen into dis- repute. Ligation should be done through an open in- cision, which may be high in the upper part of the scro- tum and lower portion of the inguinal canal, or low down about the center of the scrotum. 'When the scrotum is not shortened the high operation offers many advan- tages. The incision is about two inches long, its upper end corresponding to the external inguinal ring. The structures of the cord are freed and drawn into the wound. The vas is recognized by its denseness, feeling like a wire or whip-cord. The vas should be separated with a few veins and the spermatic artery from the rest of the cord and held aside by a piece of gauze. Care should be taken not to bruise the vas by strong traction or by catching it with forceps. The rest of the veins and tissues of the .cord are then ligated close to the upper angle of the incision, using catgut. The ligatures are tied very tightly, preferably holding the first turn of the knot with forceps while the second turn is run down. Two ligatures are applied about one-fourth of an inch from each side. The ends of the lower ligature are left long. A sufficient amount of the veins is pulled up to draw the testicle well up from the bottom of the scrotum. Two ligatures are applied at the lower end in the same manner as the upper end. The intervening segment of VARICOCELE. veins is excised and the two venous stumps tied together by the long ends of the ligatures. Each bleeding spot is tied and the wound closed without drainage. A sus- pensory bandage should be worn for some months after the operation. A hard mass around the ligatures may exist for a month or more. As a rule, when an operation for varicocele is indi- cated, the scrotum should be resected. A relaxed scro- tum that does not afford support to the testicle but per- mits the testicle to dangle from shortened cords will not give an ideal result. Most varicoceles are accompanied by relaxed scrotums, so the operation should be devised to accomplish both the resection of the veins and short- ening the scrotum. If a transverse incision is made, its two ends form projecting points or teats, which fre- quently become irritated, and the scar is always wide. A better plan is to resect the scrotum along the middle line, parallel with the median raphe. As much of the scrotal tissue as should be removed is taken up and clamped with one or two pairs of curved pedicle forceps. This redundant scrotum is then cut away with a sharp knife or scissors on the proximal side of the clamp, so as to leave no bruised tissue for healing. This should be done quickly and the bleeding points all carefully clamped, otherwise they retract and leave a hematoma. After they have been clamped and tied with fine catgut, the cord is dissected free and the vas deferens is isolated with a few veins and the spermatic artery. Gessner, of New Orleans, has recently shown experimentally that if the spermatic artery is tied the testicle eventually be- comes functionless. The excessive length of the veins is then resected as described above, the testicle being- elevated by tying together the ends of the ligatures of the stumps. The scrotum is sutured with a con- 274 SURGERY OF THE BLOOD-VESSELS. tinuous mattress stitch of medium catgut. The mat- tress suture prevents the turning in of the margins of the scrotum. It is best to reenforce this with a few in- terrupted sutures of silkworm gut, for catgut may be ab- sorbed too soon. The incision is closed in such a man- ner as to simulate the median raphe. If each bleeding point is tied there is no necessity for drainage. The wound is dressed in the usual way with sterile gauze held in position by adhesive plaster and a sling or suspensory bandage. The patient should be in bed about a week and should wear a snugly fitting suspensory bandage for two or three weeks longer. This operation not only does away with the veins, but also has the advantage of con- verting the scrotum into a support for the testicles and thus obviates the necessity of constantly wearing a sus- pensory bandage. Hemorrhoids. Hemorrhoids, or piles, are dilated or abnormal veins or capillaries that form in the lower part of the rectum or in the anus, and are accompanied by excessive con- nective tissue and thickening of the coats of the vessels involved. The predisposing causes may be regarded as, first, the upright position; second, the absence of valves in the portal vein ; third, the manner in which the muscular coat of the rectal wall is perforated by veins; and, fourth, the lack of a proper support for the blood-vessels in this locality as the mucous membrane is very loosely attached to the submucous coat. The damming back of blood in the portal vein, into which empties the superior hemor- rhoidal, is as constant in sitting as in standing. The length of the column of blood must be measured from the lowest extremity of the rectum to the entrance of the HEMORRHOIDS. portal vein into the liver and is about fourteen indie Unlike varicose veins in the extremities, the sitting ture offers no relief, but on the contrary may tend to promote further congestion of the hemorrhoidal veins, as bending the body and pressure on the liver increase the pressure in the portal circulation. In some families there is a hereditary tendency toward hemorrhoids. Constipation, excesses in diet, straining at stool are causes. Diseases of the heart, liver, or kidneys produce hemorrhoids, particularly diseases of the liver that cause partial obstruction of the portal vein. One of the most significant signs of malignancy in the large bowel, especially in the sigmoid, is the presence of hemorrhoids. When severe hemorrhoids appear in the middle aged or elderly without apparent cause it should always create a suspicion of cancer of the colon or sig- moid, as the contraction from cancer or pressure of a malignant tumor may dam back the blood in the lowest portion of the portal circulation. Hemorrhoids are classed as external, internal, or mixed. External hemorrhoids arise as a rule from the inferior hemorrhoidal vein and are external to the sphincter. They may give but little trouble. If they become inflamed the pain will be considerable and they should be removed. Often small thrombi occur. As the result of old thrombi or inflammation in external hemor- rhoids, tags or projections of connective tissue some- times form. The most frequent kind of external hemorrhoids is the thrombotic pile. This usually comes suddenly from ex- ertion, and particularly after straining at stool. The thrombus may be due to breaking the inthna of the vein, which permits its lumen to be filled with clots, or to a rupture of the vein itself and the formation of a 276 SURGERY OF THE BLOOD-VESSELS. hematoma in the surrounding tissues. The size of a thrombotic hemorrhoid varies from one-eighth to one inch in diameter. Usually there is a feeling of some- thing giving away followed by aching. After a few hours or a day, as the clot hardens, the sensation be- comes much more disagreeable and the aching and burn- ing may be excessive. If the clot is very small, the symptoms are often insignificant. The only treatment that affords real relief is incision and turning out the clot. This can be done under local anesthetic, using a half of one percent novocaine solu- tion. After cleansing the mucous membrane and the skin, the tissue over the thrombus is injected and an in- cision made down to the clot. No matter how the throm- bus is situated, the incision should radiate from the cen- ter of the anus so as to be parallel with the normal folds. The clot is removed and the cavity packed lightly with gauze, which is kept in position one or two days. Par- ticular care should be taken to cleanse the anus thor- oughly with soap and water after each bowel movement. If the clots are multiple and small, the tissue containing them may be excised. The sphincter should not be cut. Usually, however, they are either single or so large that each clot can be opened by a separate incision. If the clots are left they may be absorbed, but more fre- quently they become organized into connective tissue, or even calcined, and prove a constant source of irritation. Sometimes the clot is infected and an abscess occurs. Operations about the anus heal quickly if the ordinary rules of cleanliness and antiseptic surgery are followed, even though it is necessarily difficult or impossible to render the parts surgically clean. Nature has appar- ently provided some immunity against infection for the tissues here, else wounds would be always infected. HEMORRHOIDS. 2/7 Internal hemorrhoids are usually venous, but may con- sist of a capillary growth which is small, resembling a raspberry, and bleeds easily, as it is covered by a very thin layer of epithelium. Capillary hemorrhoids do not protrude and can hardly be located by touch. They constitute what is known as the blind, bleeding pile, and bleed readily upon slight contact of instru- ments on examination. As a rule, the amount of blood lost is never great but the frequent bleeding soon pro- duces marked anemia. The best treatment for this type of hemorrhoid is cauterization, which may be done through a speculum with a Paquelin or electric cautery. The most frequent form of internal hemorrhoids is that which develops from the superior hemorrhoidal vein just within the sphincter. Often the first symptom is slight oozing of blood; later, there is some protrusion. Bleeding may recur from time to time and may be very slight. This varicose condition is increased by anything that raises the blood pressure in the lower part of tho rectum. Constipation or irregular diet will often cause it. Frequently there is no pain except when there is protrusion, and then it is more a sense of discomfort. There is often present, however, a constant sense of weight and dull aching in the region of the rectum. Dig- ital examination will disclose the smooth, velvety feel of partly collapsed hemorrhoids. Reflex nervous symp- toms may occur, particularly in patients who are in- clined to be neurotic. Treatment of internal venous and of mixed hemor- rhoids is practically the same. If bleeding is frequent and if discomfort is considerable, operation should be performed. However, palliative treatment sometimes cures in the early stages when the disease is mild and if for any reason the patient rejects operation, palliative 278 SURGERY OF THE BLOOD-VESSELS. treatment should be given. Rest in the horizontal posi- tion and cold applications are very beneficial. Often pressure on the anus is effective. In order to lessen the congestion in internal hemorrhoids, it is necessary to change the position of the body so the portal circulation will easily drain the blood from the pelvis. A slight ele- vation of the foot of the bed may be necessary. Enemas of cold water and careful regulation of the bowels should be recommended. Alcohol must be prohibited or cur- tailed in amount. The patient must take some exercise in the open air and the bowels be induced to move at a regular time every morning. Cold baths after arising are beneficial. If the bowels are constipated, mild ca- thartics such as cascara are given. If hemorrhoids tend to prolapse, they should be cleansed thoroughly before being returned and some ointment or solution applied. Suppositories are not satisfactory because they slip above the region of the hemorrhoid. Occasionally passage of a rectal bougie of full size once a day and allowing it to remain in the grasp of the sphincter for five or ten min- utes will overcome spasm. Operative treatment, which should be the regular treat- ment for hemorrhoids that develop sufficiently to give considerable discomfort, may be the injection method, ligature, excision, or clamp and cautery. The injection method formerly had considerable vogue but has now rather fallen into disrepute. In certain cases, however, where there are only one or two isolated hemorrhoids and when the sphincter is relaxed, the injection method if properly used often gives satisfactory results. The size of the hemorrhoid is no contraindication to this operation. Formerly too strong a solution was used and very disagreeable results would follow. Tuttle's modification of Shuford's solution is probably the best. HEMORRHOIDS. -<:' This consists of two drams of Calvert's carbolic acid, one-half dram of salicylic acid, one dram of biborate of soda, and glycerine, a sufficient quantity to make one ounce. The fluid should be perfectly clear. It' milky white it is due to imperfect solution and should not In- used until it becomes perfectly clear. The amount of this solution to be injected into any individual hemor- rhoid depends upon the size; from two to ten minims are sufficient. The injection can be made with the ordinary hypodermic syringe. The anus is cleansed and the hem- orrhoid drawn down into view. The index finger of the left hand is introduced into the anus and a hypodermic needle is inserted at the lowest part of the hemorrhoid and carried well toward its center. A small amount of the solution is slowly injected while moving the point of the needle backward and forward to distribute the injected fluid. The needle is left in position for one or two minutes to prevent the solution escaping from the puncture, and is then withdrawn. A small piece of cot- ton soaked in alcohol is placed over the puncture imme- diately after the needle is withdrawn. The hemorrhoid is kept outside the sphincter for a few minutes in order to prevent forcing the solution elsewhere. After it is reduced a small compress is placed upon the anus, se- cured by a T-bandage, and the patient is required to lie down for ten or fifteen minutes. The day after the in- jection the pile will be found to consist of a tense, hard mass which in a few days begins to shrivel, and if the treatment is successful it eventually disappears. There is but little pain if the injection is properly done. The bowels should be confined for forty-eight hours and then moved with a simple laxative or a cold water enema. A great many cases can be cured in this manner at the office that would not submit to a more radical procedure. 280 SURGERY OF THE BLOOD-VESSELS. While this method should only be employed when the sphincter is weak and when there are only one or two hemorrhoids, and while it does not always result in a cure, it has a field of usefulness. Before an operation for hemorrhoids, the patient's bowels should be thoroughly moved by a dose of oil taken the day before and by an enema five or six hours before the operation. Before applying any operative proced- ure except injection, the sphincter must be thoroughly dilated. This is best done with the finger and thumb, gently stretching and massaging the sphincter so its paralysis is gradually accomplished. In this way neither the sphincter nor the mucous membrane is torn, which is often the case with too forcible dilatation. In the ligature operation, after cleansing the hemorrhoid thor- oughly and using some antiseptic solution, such as boric acid or weak bichloride, the pile is caught in forceps and an incision made with scissors at Hilton's white line where the skin and mucous membrane join. The pile is dissected from below upward, partly with scissors and partly with dry gauze, using as little force as possible, and getting the pedicle down to a small piece of tissue. The pedicle is tied firmly with silk or linen and the hem- orrhoid cut off not too close to the ligature. Each pile is treated in a similar manner. This can often be done under local anesthesia. The excision operation, which is based upon the method of Whitehead, has been variously modified, and consists of excision of the pile bearing area. An inci- sion is made around the anus following closely Hilton's white line. The mucous membrane is dissected up until all of the piles can be drawn down without tension. The whole lower cuff of the pile bearing area of mucous mem- brane is excised by cutting a short distance and immedi- HEMOERHOIDS. 1_N ] ately suturing. This prevents retraction of the mucous membrane. Tuttle has modified this operation by merely making- an incision at the posterior portion <>r Hilton's line and then bluntly dissecting free the mucous membrane from this incision. There are many ot I id- methods of excision. In Earle's operation the pile is clamped by special forceps of his device. It is cut away and sutures are placed around the forceps including tin- pedicle of the pile. After the sutures are placed tin- forceps are removed and the sutures tied. In any method the skin should not be caught, as it is unneces- sary and makes convalescence much more painful. The most satisfactory operation, as a rule, for hemor- rhoids and one that has well stood the test of time is the clamp and cautery. If carefully performed it should not result in stricture. Ligature methods are followed by a certain amount of necrosis and in excision the su- tures must necessarily be bathed in fecal contents, but the great advantage of the clamp and cautery is that the heat sterilizes the tissues and also seals the wound with an aseptic eschar. The operation is simple, though it should be carefully done in order to secure the best re- sults. After thoroughly dilating the sphincter each hemorrhoid is caught at its apex with a hemostat. It is dragged well down into the wound and clamped with Ferguson's pedicle forceps parallel with the anal folds. These forceps have blades that are flat and hold the hem- orrhoid firmly. No skin should be included within the bite of the forceps. It is best not to make an incision with scissors or knife because this leaves a raw surface that may be a portal of infection. The object of the clamp and cautery operation should be to leave nothing that is not thoroughly covered with an eschar. With a little care a good hold can be obtained upon the hemorrhoid 282 SURGERY OF THE BLOOD-VESSELS. without including the skin. All of the hemorrhoids are caught with Ferguson's clamps in a similar manner. There are rarely more than three. After all the piles have been clamped, the last one clamp< d is pulled down so the tip of the Ferguson forceps emerges from the Fig. 79. Three hemorrhoids have been, clamped with Ferguson forceps, two having been, cut away while the third is still in the grasp of the forceps. Each for- ceps should be surrounded by wet gauze and the base of the hemorrhoids thoroughly cauterized. anus. A small piece of wet gauze is wrapped around the base of the hemorrhoid just beneath the forceps. This protects the surrounding tissues from heat. The pile is cut off about one-fourth of an inch from the forceps. This can be done with the Paquelin cautery. The stump HEMORRHOIDS. 283 is then thoroughly burned, taking at least one-half min- ute in order that the pedicle contained in the grip of the forceps is cooked by the heat. The wet gauze is then removed and the next hemorrhoid is treated in a similar way. After cauterizing the hemorrhoid, the forceps are not removed but are merely returned to such a position as is least in the way. This is usually accomplished by Fig. 80. Hemorrhoids have been removed, the pedicles cauterized, and the forceps have been replaced within the anus. The rubber tube is in position. The forceps can now be gently released without disturbing the eschar. placing the tip of the forceps in the rectum and shoving the pedicle in its grasp gently up into the rectum (Figs. 79 and 80). After the last hemorrhoid is cauterized a rather firm rubber tube about three inches long and one- third of an inch in diameter is anointed with sterile vaseline and inserted into the rectum. A safety pin is fixed in its outer end. Then each Ferguson clamp is removed gently so as to avoid breaking up the eschar. 284 SURGERY OF THE BLOOD-VESSELS. The parts are thoroughly dusted with bicarbonate of soda and sterile gauze is wrapped around the outer end of the tube under the safety pin to prevent the safety pin from pressing on the anus. More gauze is placed and a T-bandage applied. If care is taken in the cauterization as has been mentioned, there is practically no danger of hemorrhage because the tissue is cooked well down into the grasp of the forceps. There is no danger of stricture because an ample amount of healthy mucosa is between each forceps, and at the same time the contraction of the scar from the burn, which is notoriously greater than from an incision, tends to obliterate still further any varicose vessels in the neighborhood. The tube gives exit for gas and makes the patient more comfortable. If for any reason there is bleeding, it will appear at once through the tube. The after-treatment consists of rest in bed for sev- eral days, preferably three or four days at least, and morphine if the pain is severe. About the third day after operation an enema of several ounces of sweet oil is injected through the tube and the tube clamped and allowed to come away. The skin around the anus should be kept clean. If there is noi much irritation a dry dusting powder is used. If the irritation is disa- greeable, some ointment or carbolated vaseline can be applied. The bowels should move regularly after the third day. A laxative is given in order to insure that the movements will be soft. The patient may leave the hospital within a week or ten days, or in the simpler cases even earlier. There is always swelling for the first few days after an operation of this type and the pa- tient should be informed before the operation that this will occur. The swelling gradually disappears and the redundant tissue is usually taken up within a few weeks HEMORRHOIDS. -IS.") or at least a few months. If, however, any unnecessary tags of skin are left after several months they may lie readily removed under a local anesthetic. A great many rectal operations are done under local anesthesia, even the clamp and cautery operation. The sphincter can be dilated and a ligature applied in pa- tients who are not too nervous. The anesthetic should be one-half of one percent novocaine solution. ( hie finder is passed into the anus and the hypodermic needle in- serted first about one inch back of the posterior margin of the anus. The solution is injected quickly, the needle being carried up first on one side and then on the other and the injection made just beneath the skin and not into it. The point of the needle is guided partly by the fin- ger in the rectum. Both sides are injected from the same puncture. After as much tissue has been infil- trated as possible, the needle is withdrawn and rein- serted at the upper limit of the injected area first on one side and then on the other until the anus is completely surrounded. The injection may then be made somewhat deeper. It will be found that in many cases the sphinc- ter can be dilated and hemorrhoids excised after local anesthesia of this type with practically no pain. CHAPTER XVI. TRANSPLANTATION OF TILE ANTERIOR TEMPORAL ARTERY. Occasionally defects of the cheek, caused by accidents, or as a result of operation for malignant disease, or from a gangrene, are so extensive that plastic correction is exceedingly difficult. The margins of the defect are fixed to the bone and do not permit much stretching. If flaps are taken from the arm, the character and texture of the skin is so different from the skin of the face that the contrast is very noticeable. Then, too, it is fre- quently necessary to have an epithelial lining on the in- side of the mouth, and though a mucous membrane lining is preferable to one of skin, it is often impossible to se- cure' mucous membrane. Flaps from the forehead are used to remedy these de- fects, and are taken with the pedicle either from the tem- poral region or from the middle of the forehead. This, of course, necessitates cutting the pedicle later and re- turning it to its original position. If the anterior tern poral artery is included in the pedicle, the flap is thus de- prived of an important blood supply. Frequently flaps that cover defects of the cheek obtain their sole nourish- ment around the edges, and if a flap has also been turned in to make a lining, there is a still greater demand upon the external flap for blood supply. Dunham, of New York, has met this objection by dissecting the temporal artery from the flap after the flap has healed in its new position and returning the pedicle minus the artery. This, of course, is an improvement, but it necessitates 286 TRANSPLANTATION OF ANTERIOR TEMPORAL AKTI.HY. "2^1 two operations and the dissection of the temporal artery from the transposed and infiltrated pedicle is more diffi- cult than a dissection from the normal tissue at the original operation. On two occasions the author has transplanted the an- terior temporal artery, dissecting* it free from its origin to the margin of the proposed flap. The anterior temporal artery presents peculiar ad- vantages for transplantation. It is not essential to the nourishment of the forehead or scalp, which has an abun- dant anastomosing blood supply. It is tortuous and when dissected free, even with some surrounding tissue, it may be straightened and will reach much farther than before dissection. This permits placing the flap in posi- tions distant from the origin of the artery, and the main- tenance of an abundant blood supply. The patient should be prepared for rectal anesthesia according to the method of Gwathmey. The bowels are opened by a dose of oil the night before, followed by soap sud enemas two to three hours before the operation. An hour before the operation a suppository of five to ten grains of chlorotone is given. A hypodermic of a quarter of a grain of morphine and l/120th of a grain of atropine is administered a half hour before the opera- tion, and the injection of oil and ether is begun slowly about ten minutes later. The mixture consists of pure olive oil and ether varying from equal parts in children, to three parts of ether and one of oil in cases difficult to anesthetize. In adults, usually two parts of ether to one of olive oil is a satisfactory mixture. The amount in- jected is one ounce of the mixture to every twenty pounds of body weight, but in any case it should not exceed eight ounces of the seventy -five percent solution of ether in oil. This is given slowly in the room, with the patient turned 288 SURGERY OF THE BLOOD-VESSELS. on liis left side, and should take from five to ten minutes. The patient usually goes under the anesthetic gradually. If anesthesia seems too profound, especially as indicated by cyanosis and disturbance of the respiration or by a Fig. 81. First step of transplantation of the anterior temporal artery with a frontal flap. Outlines of the flap on the neck and of the frontal flap, together with the incisions for dissecting out the anterior temporal artery, and for burying it in its new location are shown. bad pulse, some or all of the mixture can be withdrawn through a rectal tube. About five minutes before the operation is concluded all of the mixture is withdrawn, the rectum and sigmoid are irrigated with cold water, and several ounces of pure olive oil are slowly injected and allowed to remain. This anesthesia in the author's TRANSPLANTATION OF ANTEEIOR TEMPORAL ARTKKY. L'SD hands has been most satisfactory for surgery of the neck, for plastic work about the face, and particularly for such an operation as transplantation of the anterior tem- poral artery. Fig. 82. The flap on the neck has been dissected free and drawn under the bridire of skin separating its base from the defect in the cheek. The artery has been partially dissected. Insert shows a section of the artery with ligation of posterior temporal artery when necessary to secure greater length. The cheek is prepared for the new flap by trimming away the scar tissue along the margins of the defect and by undermining the skin slightly. The position of the flap to be transplanted is outlined on the forehead with the point of a knife, going as near to the hair line as pos- sible. An incision is made over the region of the an- 290 SURGERY OF THK BLOOD-YESSELS. terior temporal artery, extending from its origin to the point at which the artery enters the proposed flap.. This incision should be straight, no matter what the course of the artery. Great care is taken not to injure the artery Fig. 83. The flap from the neck has been sutured in position. The anterior tem- poral artery and frontal flap have been freed, and are ready to be trans- planted. and not to grasp it with forceps. It can be easily han- dled by picking up the tissue around it with delicate thumb forceps. Considerable tissue is included with the artery in order not only to avoid injury to the artery, but also to preserve its nerve supply. After the artery has been freed, the flap is cut and placed in position. TRANSPLANTATION OF ANTERIOR TEMPORAL ARTERY. This gives an idea where the artery shall lie buried ( K'm>. 81, 82, 83 and 84). The flap is covered with cloths wrung out of warm salt solution and an inci>ion for burying the artery is made just through the skin. Tin- Fig. 84. The anterior temporal artery with the frontal flap has been Irani-planted and the flap sutured in position. The raw surface left on the forehead lias been diminished by sutures at its angles. margins of this incision are undermined freely, but not too deeply. In this way the branches of the facial nerve are not injured. The flap is placed in position and fastened with a few sutures. It should not be su- tured too tightly, because the flap has too much nutrition and unless there is some point where the excess of blood 292 SURGERY OF THE BLOOD-VESSELS. can ooze out for the first day or two, the tension in the flap from the arterial pressure may be so great as to cause partial necrosis. A few stabs in the flap also re- lieves the venous congestion. This, in fact, is the chief danger, not too little but too much blood supply. If it is necessary to have an epithelial lining, a flap may be turned up from the neck and sutured with the skin side toward the cavity of the mouth before the anterior tem- poral artery is transplanted. The illustration shows the manner of doing this. Or, if the defect is not too large, mucous membrane from the tongue, as suggested by Wil- lard Bartlett, can be used. By the second day the flap is swollen and becomes a dark purple color. If it is too tense every few hours a sharp knife can be inserted in the stab wounds or along the edges of the flap to scrape it a little to promote bleed- ing and relieve the tension. After a week the swelling begins to disappear and the new venous capillaries drain away the blood. The efficiency of the artery can be dem- onstrated months after the operation by pressing upon it and noting the change in color of the flap. In two cases in which this operation was done the ar- tery has remained patent and is pulsating several months after the operation. In the first case, all of the flap took. In the second, a middle aged woman in poor health, about two-thirds of the flap sloughed away on ac- count of excessive passive hyperemia. The first case, Mr. W. H. D., aged 22 years, was in- jured on February 2, 1914, by a shot gun while trying to quell a disturbance among the laborers of a mine of which he was superintendent. The gun was discharged at short range and blew out his left eye, a good portion of the left maxillary bone, and the septum of the nose, together with the soft tissues over the cheek. The ac- TRANSPLANTATION OF ANTERIOR TEMPORAL ARTEHV. Fig. 85. Photograph of H. D. about three weeks after the injury, showing a large cavity communicating with the nasal fossa. Fig. 86. Photograph of H. D. three weeks after operation in which a frontal flap with anterior temporal artery attached was transplanted to cover the defect. Note the incision for dissecting the artery and also incision for burying it. The artery can be distinctly felt pulsating in its new bed. 294 SURGERY OF THE BLOOD-VESSELS. companying photograph shows his condition about three weeks after the injury. A large cavity was left con- nected with the nasal fossa (Fig. 85). This was closed by transplanting from the forehead a flap with the anterior temporal artery. The technique was as de- scribed above. All of the flap took. The photograph taken about three weeks after this operation shows the line of incision for dissection of the artery and also the incision under which the artery was transplanted (Fig. 86). Mrs. S., aged 47 years, was referred to the author for a recurrent cancer of the cheek. She had been operated Fig 87. Photograph of Mrs. S. about thre.e weeks after removal of recurrent cancer of the cheek with Paquelifl cautery. The tongue, alveolar process, and some denuded bone can be seen. upon a few months before by another surgeon and as re- currence was prompt and the glands of the neck were involved the prognosis seemed bad. A block dissection was first done on the upper part of the neck, removing glands, fat and fascia in one mass. The cancer in the cheek, which was about an inch and a half in diameter, TRANSPLANTATION OF ANTERIOR TEMPORAL ARTKKY. I'D.) Fig. 83. Mrs. S. The defect in the cheek practically closed. About two-tliirds of the frontal flap sloughed away, but enough remained to close tin- upper portion of the wound. Pig. 39. Mrs. S., with eyes closed, showing there is no paralysis of am branch of the facial nerve. 296 SURGERY OF THE BLOOD-VESSELS. was then excised with a Paquelin cautery. The photo- graph shows the condition about ten days after this op- eration (Fig. 87). The defect was, of course, extensive and the deformity great. A flap of skin was turned un- der as shown in the accompanying illustrations, and su- tured to the wound with the skin surface inward. The anterior temporal artery with a flap from the forehead was then transplanted as in the previous case. The flap became purple and tense, but on scraping its edges and letting out some blood its color would again become nor- mal. The growth of capillaries was poor, and about two-thirds of the flap sloughed off on account of the in- tense passive hyperemia. To the well nourished rem- nant, however, flaps from neighboring tissues were later attached and grew satisfactorily. The photographs show her condition before and after the plastic operations (Figs. 87, 88, and 89). NOTE. Since the page proof has come, the attention of the author has been called to the fact that Dr. George H. Monks, of Boston, trnnsplanted the anterior tem- poral artery with an attached flap to restore the lower evelid, and reported the operation in the Boston Medical and Surgical Journal of October 20, 1898. The author was unaware of the work of Dr. Monks. While the operation described in this chapter differs in several details, the principle involved is the same, and, of course, Dr. Monks is entitled to priority. INDEX. INDEX. A Abbe, Robert, suturing blood-vessels, 34 Air embolus, 187 Allen, infolding the aorta, 224 Ariel's ligation, 226, 227 Anemia, accommodation for, 123 Aneurism, 211 Ariel's ligation for, 226, 227 Antyllus' ligation for, 32, 226, 227 arteriovenous, 245 Brasdor's ligation for, 227, 228 cause of, 214 cirsoid, 262 excision of, 42, 228, 234 Hunter's ligation for, 226 of aorta, 235 ligation for, 236 wiring, 221 of axjllary artery, 239 of common carotid, 237 of external carotid, 237 of femoral artery, 241 of iliac artery, 240 of innominate, 237 of internal carotid, 238 of popliteal artery, 243 of subclavian artery, 239 Purmann's ligation for, 228 symptoms and signs of, 215 treatment of. 219 treatment of, gelatin in, 219 Wardrop's ligation for, 227, 228 Aneurismorrhaphy, 229 Angioma, 255 Antyllus' ligation for aneurism, 32, 226, 227 Aorta, aneurism of, 235 constriction of, 224, 237 treatment of aneurism of, 219 Arteries, healing of, 24 indications for suturing, 29 instruments for suturing, 50 principles of suturing, 47 structure of, 17 wounds of, 78 Arteriovenous aneurism, 245 treatment of, 249 Artery, anterior temporal, transplantation of, 286 Axillary artery, aneurism of, 239 299 300 INDEX. B Bernheim, lateral anastomosis of blood-vessels, 82 method of transfusion, 104, 105 on Eck fistula, 82 Bladder, hemorrhage from, 162 Blood, clotting of, 46, 176 transfusion of, see transfusion Blood-vessels, 17 healing of, 24 histology of, 17 history of surgery of, 31 indications for suturing, 29 lateral anastomosis of, 80 principles of suturing, 47 structure of, 17 suturing wounds of, 78 technique of suturing, 50 tumors of, 255 Bowel, gangrene of, 203 hemorrhage from, 159 resection of, 204 transplantation of, 209, 210 Brasdor's ligation for aneurism, 227, 228 Brewer, transfusion of blood, 102 By ford, accommodation anemia, 123 Capillaries, structure of, 23 Carrel, Eck fistula, 83 suturing blood-vessels, 37, 38 Carotid arteries, aneurism of, 237 Circulation, reversal of, 81 Cirsoid aneurism, 262 Common carotid, aneurism of, 237 Crile, hemorrhage and shock, 137 transfusion of blood, 99, 101 D Donor in transfusion, 121 Dorfler, suturing blood-vessels, 35 Dorrance, suturing blood-vessels, 40 Duodenal ulcer, hemorrhage from, 158 E Eck fistula, 80 Elsberg, method of transfusion, 104, 106 Embolism, 185 of mesenteric arteries, 203 pulmonary, 194 Embolus, 185 air, 187 "crossed," 187 fat, 192 "paradoxical," 187 pulmonary, 194 Trendelen burg's operation for pulmonary, 196 Endo-aneurismorrhaphy, 229 External carotid, aneurism of, 237 INDEX. ;joi Fat embolus, 192 Femoral artery, aneurism of, 241 Finney, wiring aneurism, 221 Fishbein, test for liemolysis, 125 G Gastric ulcer, hemorrhage from, 157 Guthrie, suturing blood-vessels, 48, 49 H Halstead, reversal of circulation, 80 metal band, 224, 237 Hemolysis in transfusion, 125 in transfusion, test for, 125 Hemophilia, 169 treatment of, 171 Hemorrhage, 135 during operation, control of, 149 from bladder, 162 from brain, 153 from bowel, 159 from chest, 156 from extremities, 167 from face, 153 from gastric or duodenal ulcer, 157 from jaundice, 175 from kidneys, 161 from liver, 157, 160 from nose, 153 from prostatectomy, 151, 162 from rectum, 160 from scalp, 152 from stomach, 157 from urethra, 165 from uterus, 165 Momburg's tourniquet in, 141 pathologic, 169 symptoms of, 135 shock and, 136 treatment of, 137 Hemorrhoids, 274 operation for, under local anesthesia, 285 treatment of, 276, 277 treatment of, by clamp and cautery, 281 treatment of, by excision, 280 treatment of, by injection, 278 treatment of, by ligature, 280 History of blood-vessel surgery, 31 Horsley, J. S., healing of blood-vessels, 26 lateral anastomosis of blood-vessels, 86 report of cases of transfusion, 130 resection of intestine, 204 substituting a tube for a segment of an artery, 71 suturing blood-vessels, 54 transfusion of blood, 116, 118 transplantation of anterior temporal artery, 286 30'2 INDEX. transplantation of intestine, 21 Hi, ^Kt Horsley, Victor, bone wax. 14.5 Hunter, -John, ligation for aneurism. 22i> Hypodermoclysis, 14U Iliac arteries, aneurism of, 240 Infusion, intravenous, 14(j Innominate artery, aneurism of, 237 Internal carotid artery, aneurism of. 238 Intestine, gangrene of, 203 resection of, 204 transplantation of, 209, 210 K Kidneys, hemorrhage from, 161 Kimpton, method of transfusion, 109 L Lespinasse, suturing blood-vessels, 41 Lexer, excision of aneurism, 42 transplantation of saphenous vein, 42 Lindeman, transfusion of blood, 111 Liver, hemorrhage from, 157 Locke's solution, 147 M Magnesium rings in blood-vessel surgery, 3(3, 41 Matas, aneurisinorrhapliy, 229 infolding the aorta, 224 metal band, 224 Mayo, C. H., treatment of varicose veins, 268 Mayo, W. J., hemorrhage after nephrectomy, 139 McGrath, transfusion of blood, 113 Melena neonatorum, 169, 175 Mesenteric blood-vessels, occlusion of, 203 Momburg, tourniquet, 141 Moore-Corradi method of wiring aneurisms, 221 Murphy, John B., first suture of blood-vessels, 34 reversal of circulation, 82 X Xevus, 255 Wyeth's treatment of, 260 Xose-bleeding, 153 Pare, Ambroise, use of ligature by, 32 Payr, magnesium rings, 36 Piles, see hemorrhoids Popliteal artery, aneurism of, 243 Prostatectomy, hemorrhage from, 151, 162 Prothrombin, 46 IXDEX. Purmann's ligature for aneurism, 228 Pulmonary embolism, 194 operation for, 196 Purpura, 174 E Recipient in transfusion, 123 Rectum, hemorrhage from, 160 Reversal of the circulation, 81 Ringer's solution, 147 S Smith, E. A., healing of blood-vessels, 27 suturing blood-vessels, 41 Stomach, hemorrhage from, 157 Stone, lateral anastomosis of blood-vessels, 82 Subclavian artery, aneurism of, 239 Sweet, Eck fistula, 83 T Temporal artery, transplantation of, 286 Thomaselli, healing of blood-vessels, 27 Thrombogen, 46 Thrombokinase, 46 Thrombosis, 46, 176 of mesenteric blood-vessels, 203 septic, 184 Tourniquet, 140, 167 of Momburg, 141 Transfusion of blood, concerning the donor in, 121 concerning the recipient in, 123 dangers of, 119 defibr mated blood in, 98, 99, 115 hemolysis in, 125 history of, 95 indications for, 128 method of Bernheim, 104, 105 method of Brewer, 102 method of Crile, 99, 101 method of Elsberg, 104, 106 method of Horsley, 116, 118 method of Kimpton and Brown, 109 method of Lindeman, 111 method of McGrath, 113 operating room technique, 127 use of quill in, 96 Transplantation of anterior temporal artery, 280 of organs, 29 of saphenous vein, 42, 69 of veins, 69 Trendelenburg, operation for pulmonary embolus, 196 Tube, suturing in, for. defect in artery, 69, 71 Tumors of blood-vessels, 255 U Ulcer, gastric or duodenal, hemorrhage from, 157 304 INDEX. Urethra, hemorrhage from, 165 Uterus, hemorrhage from, 165 Varices, 264 Varicocele, 270 treatment of, 271 Varicose veins, 264 treatment of, 267 Veins, structure of, 22 transplantation of, 42, 69 varicose, 264 W Wardrop's ligation for aneurism, 227, 228 Watts, healing of blood-vessels, 27 Welch, thrombosis and embolism, 186 Williams, E. G., gelatin in treatment of aneurism, 219 Wounds of blood-vessels, suturing, 78 Wveth's treatment of nevi, 260 UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. OCT 2 6 Form L9-10m-3,'48(A7920)444 i'HB LIBRARY UNIVERSITY OF CALIFORNIA LOS ANGELES A 000 648 005 168 H787s Biraiedtel library