F>WEBEM-TED BY 
 
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 COUNTY MEDICAL SOCIETY
 
 4,'587 
 
 SURGERY 
 
 OF THE 
 
 VASCULAR SYSTEM 
 
 BY 
 
 BERTRAM M. B_ERNHEIM, A.B., M.D. 
 
 INSTRUCTOR IN SURGERY, THE JOHNS HOPKINS UNIVERSITY, BALTIMORE, MD. 
 
 WITH S3 ILLUSTRATIONS IN TEXT 
 
 PHILADELPHIA & LONDON 
 J. B. LIPPINCOTT COMPANY
 
 COPTRIGHT, 1913 
 BY J. B. LIPPINCOTT COMPANY 
 
 ELECTROTrPED AND PRINTED BY J. B. LIPPINCOTT COMPANY 
 AT THE WASHINGTON SQUARE PRESS, PHILADELPHIA, V. S. A.
 
 Ubntr 
 
 If 13 
 
 TO 
 
 H. M. B. 
 
 i 
 I 
 
 . 
 
 o
 
 PREFACE 
 
 THE field of blood-vessel surgery offers great possibilities 
 for future development, if this present early period of growth 
 is not impeded by attempts on the part of unskilled operators 
 to practise it. Brilliant laboratory results achieved in this 
 work have often lured the inexperienced to try their luck, 
 only to find that chance here plays no part and that success 
 is measured only by years of trial, first in the laboratory, 
 then in the clinic. 
 
 This book is intended to be a practical and suggestive aid 
 to the surgeons interested in this branch of work; in it the 
 various methods employed in the field of vascular surgery 
 will be explained as simply as possible, a fundamental knowl- 
 edge of the condition in hand being always taken for granted. 
 For example, in considering the subject of aneurisms, the 
 anatomical, pathological, and etiological sides, already de- 
 scribed by other, more authoritative, writers, will be omitted ; 
 and in the descriptions of operative procedures where sev- 
 eral methods have been devised, the one or two best and 
 most employed have been selected for detailed exposition. 
 This course has been pursued not to spare the writer 
 wearying labor, but to present directly to the reader a 
 text unhampered by preliminary review and multiplication 
 of detail. 
 
 It is a pleasure to gratefully acknowledge the interest 
 which Dr. ~W. S. Halsted, himself one of the pioneers in 
 modern vascular surgery, has shown in my work; to thank 
 Dr. John M. T. Finney for his sympathetic help and the 
 clinical opportunities which he and Dr. J. C. Bloodgood have 
 afforded me; to acknowledge my large debt to Dr. Harvey 
 Gushing, during whose direction of the Hunterian Lab-
 
 vi PREFACE 
 
 oratory for Experimental Medicine my researcli work was 
 performed. 
 
 The enthusiastic co-operation of Mr. .James F. Didusdi. 
 who, under the supervision of Mr. Max Broedel, furnished the 
 illustrations for this book, has been much appreciated. 
 
 BERTRAM M. BERNHEIM. 
 BALTIMORE, 1913.
 
 BRIEF HISTORICAL NOTE 
 
 A GRADUAL process of evolution, similar to that which 
 took place in intestinal and other branches of surgery, has 
 given rise to the present-day technic in blood-vessel work. 
 The names of Eck, Gliick, Hunter, Jassinowsky, Doerfler. 
 Murphy, Jaboulay, v. Hirsch, Payr, Hophner, and others will 
 always be closely linked with this development, which, be- 
 cause no consistently successful method of suturing vessels 
 could be devised until a perfect asepsis had been achieved, 
 marks a real triumph in modern medicine. After the attain- 
 ment of this most important goal, perfect asepsis, a method 
 simpler than all those previously suggested, became the 
 method of choice, and the general technic developed by Carrel 
 in working up his simple end-to-end suture (1905) formed 
 the basis for all future endeavor in this field. 
 
 Inspired to renewed efforts by the achievements of Carrel, 
 and founding their work upon his tenets, workers in clinics 
 the world over have carried out many brilliant researches. 
 Numerous modifications of his suture method have been sug- 
 gested, for example, those of Payr, Dorrance, and others, 
 and to a certain extent have been adopted, but all have 
 lacked that perfect simplicity so characteristic of the Carrel 
 method and so essential to success in vascular surgery. 
 
 Previous to the work of Carrel the chief interest in blood- 
 vessel surgery centred about the treatment of aneurisms, and 
 the names of Antyllus, Moore, Corradi, Macewen, Keen, 
 Halsted, Matas, and others are closely connected with this 
 branch of the subject. Now aneurisms, important as is their 
 consideration, demand only part of our attention for the 
 subject has widened to include the repair of injured blood- 
 vessels, the transplantation of arterial or venous segments 
 
 vii
 
 viii BRIEF HISTORICAL NOTE 
 
 between the ends of a resected vessel, end-to-end or lateral 
 anastomosis, and direct transfusion of blood. The operation 
 of transfusion, employed from authoritative records as early 
 as 1492 in a vain attempt to save the life of the then Pope 
 Innocent VIII, has throughout the history of surgery never 
 been lost sight of as a possible procedure, but has always 
 failed of consistent results, until the work of Crile, in our 
 own day and country, put it upon the basis of safety and 
 practicability. 
 
 This brief review must convey the forcible impression of 
 work only begun, and I feel sure that it will be the privilege 
 of some not too distant chronicler to include in his records 
 great progress in this branch of our endeavor.
 
 CONTENTS 
 
 CHAPTER I. PAGE 
 
 GENERAL TECHNIC 1 
 
 CHAPTER II. 
 TRANSFUSION 8 
 
 CHAPTER III. 
 
 END-TO-END SUTURE 28 
 
 CHAPTER IV. 
 LATERAL ANASTOMOSIS 37 
 
 CHAPTER V. 
 TRANSPLANTATION OF A SEGMENT OF VEIN OR ARTERY 46 
 
 CHAPTER VI. 
 ARTERIOVENOUS ANASTOMOSIS REVERSAL OF THE CIRCULATION 53 
 
 CHAPTER VII. 
 VARICOSE VEINS 61 
 
 CHAPTER VIII. 
 SURGERY OF THE HEART 64 
 
 CHAPTER IX. 
 ANEURISMS 68 
 
 CHAPTER X. 
 STATISTICAL STUDY OF THE TREATMENT OF ANEURISMS 81
 
 ILLUSTRATIONS 
 
 FIG. PAGE 
 
 1. Author's ball-tipped forceps 2 
 
 2. Needle and thread mounted and ready for sterilization 5 
 
 3. Flask containing liquid vaseline and four mounted needles 6 
 
 4. Crile cannula 10 
 
 5. Drawing vein through cannula 10 
 
 6. Cuffing vein back over the cannula 11 
 
 7. Vein cuffed and tied in groove nearest handle of the cannula. Artery grasped 
 
 by three mosquito clamps 11 
 
 8. Artery slipped over cannula and tied in the second groove 12 
 
 9. Author's three-pronged modification of Crile's cannula 13 
 
 10. Elsberg's monkey-wrench cannula 13 
 
 11. Artery "set" in Elsberg's cannula; tenacula in position for cuffing 14 
 
 12. Artery everted and impaled on the hooks. Vein grasped by mosquito clamps 14 
 
 13. Cannula slipped into side of vein and tied in position 14 
 
 14. Author's two-pieced transfusion tube 16 
 
 15. Incision in wrist of donor, showing radial artery and vense comites 17 
 
 16. Radial artery separated from vena3 comites, doubly ligated, and divided. ... 18 
 
 17. Cutting oval opening in side of radial artery 19 
 
 18. Slipping male half of tube into the artery 20 
 
 19. Tube tied in place in the artery 21 
 
 20. Female half of tube tied in position in vein of the recipient 22 
 
 21. Tubes invaginated and anastomosis complete 23 
 
 22. Severed ends of an artery showing the over-hang of adventitia 29 
 
 23. Drawing adventitia well out over end of the artery 29 
 
 24. Cutting off adventitia flush with end of the artery 30 
 
 25. Washing out vessels with liquid vaseline and salt solution 31 
 
 26. Three stay sutures placed 32 
 
 27. Stay sutures tied and vessel triangulated 33 
 
 28. Sewing first side of triangle 34 
 
 29. Sewing second side of triangle 34 
 
 30. Sewing third side of triangle 35 
 
 31. Suture complete 35 
 
 32. Diagram showing method and principle of making incision in vessels in lateral 
 
 anastomosis. Method of Bernheim and Stone 37 
 
 33. Incision made in side of artery and being made in side of vein 38 
 
 34. Drawing adventitia away from the oval opening 39 
 
 35. Cutting away the adventitia 40 
 
 36. Washing out the vessel with salt solution and liquid vaseline 41 
 
 37. Starting suture of the vessels 42 
 
 38. Posterior row of sutures being placed 42 
 
 39. Posterior row of sutures completed; anterior row being placed 43 
 
 40. Suture completed and being tied to first knot 43 
 
 41. Clamps removed from vessels. Proximal ligation of vein 44 
 
 xi
 
 xii ILLUSTRATIONS 
 
 42. Washing out a venous transplant with liquid vaseline and salt solution 46 
 
 43. Cutting adventitia away from edges of venous transplant 46 
 
 44. Measuring venous transplant between ends of artery 47 
 
 45. The transplant "set" by stay sutures placed at either end I s 
 
 46. Suture in progress 48 
 
 47. Suture complete; vein flaccid; clamps still on artery 49 
 
 48. Blood going through transplant. Vein bulged and tense from arterial pressure. 
 
 Slight irregularity indicates situation of reversed valves 50 
 
 49. Valves of vein diagram showing necessity for reversal in placing a venous 
 
 transplant 51 
 
 50. Obliterative endo-aneurismorrhaphy (Matas) 71 
 
 51. Restorative endo-aneurismorrhaphy (Matas) applied to sacculated aneurisms 
 
 with a single orifice of communication 71 
 
 52. Restorative endo-aneurismorrhaphy (Matas). Aneurismal sac closed off from 
 
 parent artery 72 
 
 53. A, Halsted's original band and roller in the act of curling a metal strip about 
 
 an artery; B, the improved band roller about to expel a band 79
 
 SURGERY OF THE VASCULAR 
 SYSTEM 
 
 CHAPTER I 
 
 GENERAL TECHNIC 
 
 General Considerations. The success of blood-vessel 
 work, anastomoses, transfusions, repair of injuries, etc., 
 depends almost entirely on the avoidance of a blood-clot 
 and a general technic has been evolved which if properly 
 observed gives most consistent results. 
 
 The wall of a blood-vessel, it is well known, is made up 
 of three separate and distinct layers of tissue, intima, media, 
 and adventitia each of which can be readily separated from 
 its neighbor. Of these three coats the adventitia, or outer 
 layer, is by far the most important to the surgeon engaged in 
 vascular work, because, made up of a most delicate network 
 of fibrous tissue, it hangs over the end of a severed and 
 collapsed vessel, and acts as a sieve for the smallest drop of 
 blood and us a nucleus for the formation of a clot. Its 
 flaccidity would seem to render its removal an easy matter, 
 and so it does ; but this very characteristic, this very mobility, 
 causes still more of it to slip into the needle hole, and if great 
 care be not taken it acts as the starting point of a thrombus 
 in an otherwise perfect suture. True, the scratched intima is 
 an ever-present source of danger, as shown in the classic 
 work on "Thrombosis and Embolism" -of Welch, but one 
 has only to consult the works and writings of those who 
 have done pioneer work in the field of vascular surgery to 
 
 realize that neither the intima nor the media is greatly to 
 
 l
 
 2 SURGERY OF THE VASCULAR SYSTEM 
 
 be feared. The adventitia is the chief foe, and a worthy one 
 at that. 
 
 Blunt Instruments. Perhaps the first principle to be 
 learned is that blood-vessels resent being handled by any 
 other than blunt instruments, and of these instruments the 
 fingers are the most useful and the safest. I am well aware 
 of the fact that this dictum is diametrically opposed to 
 present-day teaching regarding surgery in general, but a 
 careful consideration of all the factors involved has led me 
 to express this view. The blood-vessel wall is only too easily 
 crushed; it should, therefore, never be grasped by a sharp- 
 
 Fio. 1. Author's ball-tipped forceps. Prevent injury to vessel wall, especially scratching of intima. 
 
 pointed or mouse-toothed forceps. But since the work can at 
 times be facilitated by a delicate pair of forceps, I have had 
 one constructed which has a small, polished metal knob about 
 the size of an ordinary pin-head on each end. These knobs 
 enable one to grasp the vessel firmly without doing the 
 slightest damage to the intima (Fig. 1). Small branches 
 should be utilized to lift the mother trunk, or a blunt dissector 
 can be gently inserted beneath the vessel, which can then be 
 raised or put on the stretch with impunity, so long as gentle- 
 ness is employed. 
 
 After a vessel is thus exposed, and has once been 
 mobilized to a certain extent, it can be grasped with the 
 thumb and forefinger. At times it may be more convenient 
 and equally efficacious to insert a soft tape (one-fourth inch
 
 GENERAL TECHNIC 3 
 
 wide) beneath the vessel and use it as a tractor. Thus an 
 artery or vein can be dissected out of its bed without the 
 slightest instrumental insult. 
 
 Salt Solution and Liquid Vaseline. During the entire 
 course of any operation involving blood-vessels, the haemo- 
 stasis must be absolutely perfect, or as nearly so as possible. 
 All branches, large and small capillaries excepted should 
 be cut between two clamps and tied. Despite these precau- 
 tions, however, there will always be a certain amount of 
 staining, which is best removed with gauze sponges wrung 
 out in normal salt solution. In addition to this a stream of 
 warm salt solution should be played on the wound at intervals 
 during the entire course of the operation, especially after 
 exposure of the vessels. This is not alone for the purpose 
 of removing blood and clot, but to prevent drying of the 
 tissues as well a, phenomenon that occurs with striking 
 rapidity in wounds of this character, and one that is to be 
 avoided at all costs. Indeed, so careful must we be in this 
 respect that we have called to our aid another agent better 
 qualified to prevent drying than salt solution liquid vase- 
 line, 1 a neutral lubricant that keeps the tissues soft and 
 pliable, prevents too rapid evaporation, and is tolerated by 
 the organism in almost any quantity. The combination of 
 salt solution and liquid vaseline, each judiciously used, keeps 
 the wound in a beautiful state of pliability that renders all 
 manipulations much easier to accomplish and less liable to 
 damage any of the delicate structures handled. 
 
 Handling the Severed Vessel. If care is necessary in 
 handling the vessel intact, the utmost consideration must be 
 exercised in dealing with it severed. Intima must not be 
 scratched, and yet all blood and every vestige of fibrin must 
 be scrupulously washed out of the vessel. Salt solution 
 
 1 1 use that made by Chesebrough Manufacturing Company of New York.
 
 4 SURGERY OF THE VASCULAR SYSTEM 
 
 thrown on and into the vessel by a blunt-tipped rubber 
 syringe together with restrained stripping with the fingers 
 works wonders, but the overhang of adventitia that occurs 
 as soon as the vessel is cut and soaked in salt solution ob- 
 structs the lumen to such a degree that complete cleansing 
 is impossible until it has been removed. This is accomplished 
 by grasping it with the thumb and forefinger, or a very 
 delicate pair of mouse-tooth forceps, drawing it well down 
 over the end of the vessel, it comes down with remarkable 
 ease, and cutting it off flush with the cut edge. Thus freed 
 from adventitia the mouth of the vessel will at once spring 
 open, permitting the insertion directly into its lumen of the 
 perfectly rounded tip of a medicine dropper filled with salt 
 solution. This is repeatedly injected until all clot and visible 
 fibrin are washed out, whereupon the lumen is filled with 
 liquid vaseline. Even before all clot is displaced it is well 
 to inject a little vaseline into the vessel and around the field 
 of operation in general. 
 
 Blood-vessel Clam-ps. The blood flow is at all times to be 
 obstructed by a rubber-shod clamp, of the variety shown in 
 the illustration. The smaller, or so-called bull-dog clamp, is 
 used on small vessels like the radial, while the larger, or Crile 
 clamp, is employed for vessels of larger calibre. If the jaws 
 of these or other clamps are not serrated, they need not 
 necessarily be rubber-shod, but I have always preferred to 
 use a clamp armed with rubber, believing that it is safer. At 
 times it may be inconvenient or even impossible to use any 
 clamp, in which case the ordinary tape mentioned above when 
 properly placed around the vessel and secured by an ordinary 
 haemostat, will act as a safe and effectual clamp. 
 
 Suture Material. Suture material must be light and 
 delicate, yet strong enough to withstand any arterial pres- 
 sure. Such a silk is the 00000 made by Belding Bros. & Co., 
 of New York. It can be obtained in either the white or 
 black, is beautifully smooth, withstands sterilization without
 
 GENERAL TECHNIC 5 
 
 loss of strength, and has answered every purpose, both ex- 
 perimental and practical. This silk is nicely carried by a 
 No. 12 ground down needle that is made by H. Milward & 
 Sons. This needle has a small round eye, and is one inch 
 long a length that permits of just the right amount of 
 flexibility. 
 
 It is my custom to use black thread, 2 since that can be 
 seen against a white background much more 
 easily than a white thread against a black back- 
 ground, the latter being Carrel's method. I 
 have noticed absolutely no difference in the heal- 
 ing or in the operative results following the use 
 of either the white or the black thread; the dye 
 in the thread used for blood-vessel suture is fast 
 and almost infinitesimal in amount. 
 
 All needles are threaded and sterilized in die 'and ' threTd 
 liquid vaseline before operation, the routine ready n for sterm- 
 being to thread each needle with about twelve 
 inches of the black silk, drawing the ends even and fixing 
 each needle on a separate piece of ordinary writing paper, 
 about one-half inch by one-quarter inch, in such a way 
 that the doubled thread is wound around the needle by 
 a figure-of-eight (Fig. 2), and the final end of the thread 
 caught by a slit in one corner of the paper. Thus prepared, 
 four threaded needles are placed in a small flask containing 
 one or two ounces of liquid vaseline (Fig. 3) and sterilized in 
 the usual way. Just before operation the contents of one or 
 more flasks, oil as well as needles, are poured into a dry 
 sterile medicine glass and placed on the instrument table. I 
 have made it a rule to allow no one but myself to touch these 
 needles at operation, and I leave them lying in the oil until 
 the time for actual suture comes, when I carefully remove 
 
 2 The thread and all instruments used in vascular work are handled by 
 the Chas. Willms Surgical Instrument Company, of Baltimore.
 
 (I 
 
 SURGERY OF THE VASCULAR SYSTEM 
 
 one needle from its paper by going through che reverse figure- 
 of-eight. One end is then shortened to about two inches, and 
 the needle and thread are given a final inspection for any 
 
 defects, such as small spots of 
 
 rust or inequality or roughness 
 in the silk. If this examination 
 is satisfactory the suture is be- 
 gun, a similar procedure being 
 observed for each additional 
 suture that may be needed. 
 
 Rubber gloves are generally 
 worn in blood-vessel operations 
 up to the point of actual suture, 
 though sometimes only to the 
 point where the washing-out 
 
 process of the vessels begins. 
 
 jjjl Their discard at this point is at 
 
 present an unavoidable and un- 
 y V4 fortunate break in technic, 
 
 V i^. which I endeavor to minimize 
 
 by a preparation of the hands 
 JB lasting not less than twenty to 
 
 twenty-five minutes. The deli- 
 
 Fio. 3. Flask containing liquid vaseline nftf > v rf tViA TrmnirmlfltioTKJ and 
 and four mounted needles. Sterilized and CECV OI Hie manipulations dl] 
 
 the fineness of the needles and 
 
 thread necessitate the use of the bare hand, and in order that 
 the skin of the hands may be soft and pliable, it is well to 
 wash them in salt solution immediately after discarding the 
 gloves and then anoint them thoroughly in the liquid vaseline, 
 this process being repeated as often as they become dry. 
 Attention to these and many other details that experience 
 alone can teach is required to secure constant results in this 
 field of surgery, but success will more than compensate for 
 the patience and energy it demands.
 
 GENERAL TECHNIC 7 
 
 REFERENCES 
 
 Artus: Jour, de physiol. et de path. gen.. 1902, iv, 281. 
 
 Eernheim, B. M. : The Relation of the Blood- Vessel Wall to Coagulation of the 
 
 Blood, Jour. Am. Med. Asso., July 23, 1910. 
 Delezenne: Arch, de Physiol., 1897, series 5, i.x, 333. Compt. rend. Soc. de biol., 
 
 1896, p. 782. 
 
 Loeb, L. : Virchow's Arch. f. path. Anat., 1904, clxxv, 10. 
 Morawitz, P. : Beitriige zur Kenntnis der Blutgerinnung, Deutsch. Arch. f. 
 
 klin. Med., 1904, Ixxix. 
 Sahli, H. : Ueber das Wesen der Haemophilie, Ztschr. f. klin. Med., Bd. 56, 
 
 1905. 
 
 Welch, Wm. : Thrombosis and Embolism. Allbutt's System of Medicine, vol. vii. 
 Wooldridge: Die Gerinnung des Blutes, Leipsic, 1891.
 
 TRANSFUSION 
 
 TRANSFUSION, the most employed operation in blood-ves- 
 sel surgery, has presented gratifying results, and in the 
 hands of the careful surgeon is capable of lasting and far- 
 reaching effects. 
 
 Transfusion means the giving of blood by one individual 
 to another, and there are two methods by which it is accom- 
 plished, (1) direct and (2) indirect. When the blood-vessels 
 of one individual are directly united with those of another, 
 whether by suture or cannula method, and blood flows from 
 one to the other, we call the procedure direct transfusion; 
 when blood is withdrawn from one individual by means of a 
 needle and syringe and, after being defibrinated, is injected 
 into another individual, we call the procedure indirect trmi*- 
 fusion. I shall deal exclusively with the direct method, wlm-li 
 is, at present, thought by surgeons to give better and more 
 far-reaching results than the indirect method. Indirect trans- 
 fusion in selected cases and handled properly is also of great 
 service. 
 
 To illustrate the use of this operation T wish to state that 
 it shows gratifying success in cases of hemorrhage; for ex- 
 ample, in those tragic cases where fresh blood has been the 
 only means of making up the deficiency caused by accident; 
 in cases of bleeding from a gastric ulcer; typhoid ulcers; 
 ruptured extra-uterine pregnancies; and in other conditions. 
 This emergency use of transfusion in saving life after loss 
 of blood covers only part of the field; transfusion has re- 
 peatedly been successfully employed to raise the resistance 
 of patients too weak to withstand the shock of a necessary 
 operation. A case in point is that of a boy aged seven (pa- 
 8
 
 TRANSFUSION 9 
 
 tient of Dr. J. M. T. Finney) who, suffering from splenic 
 anaemia, had become so dreadfully exsanguinated from re- 
 peated hemorrhages from the stomach that his haemoglobin 
 was too low to register. A splenectomy was successfully 
 accomplished by Dr. Finney during the course of a trans- 
 fusion, and the boy not only withstood the operation but was 
 in better condition at its conclusion than at the start. He 
 made a stormy but successful recovery, only to succumb five 
 months later from another gastric hemorrhage, probably the 
 result of an old cesophageal varix. 
 
 The anaemias pernicious anaemia, leukaemia have not 
 responded well to this operation, but the number of reported 
 cases upon which this conclusion is based is very small. It 
 is possible that in certain of these and other allied anaemias 
 transfusion may be of great service. 
 
 Therapeutically the outlook is bright ; for example, trans- 
 fusion is most auspicious in hemorrhage of the new-born 
 melaena. neonatorum. The depleted circulation in such cases 
 is not only restored but the obscure condition itself is cured 
 in almost all cases. Haemophilia, in general is another illus- 
 tration of the beneficent influence of this operation and cer- 
 tain cases of illuminating gas poisoning, as shown by Crile, 
 can be resuscitated by this means. Beneficial results, even a 
 certain number of cures, have been attained in pellagra fol- 
 lowing transfusion. Cole reports a number of apparent cures 
 and I have had one myself. 1 Shock, that most dreaded and most 
 baffling condition of all surgical complications, can frequently, 
 when all other measures for its relief have been unsuccessful, 
 be overcome by prompt transfusion. Certain of the toxaemias 
 would seem to be amenable to this form of treatment. I 
 have recently transfused in a case of toxaemia of pregnancy 
 
 1 It is impossible to say just how or why transfusion is of service in this 
 condition. It hardly seems likely that it acts as a specific. A more logical 
 deduction would be that it raises the resistance of the patient by restoring the 
 blood picture more nearly to normal.
 
 10 
 
 SURGERY OF THE VASCULAR SYSTEM 
 
 with a most promising outcome. Thus far, only the borders 
 of the field of transfusion have been opened up by pio- 
 neers. It lies full of promise, inviting exploration. 
 A number of instruments have been devised 
 for the purpose of simplifying transfusion, each 
 one with a certain degree of merit. I have 
 selected for description those three which I con- 
 sidered as easiest to manipulate and as giving 
 most favorable results. 
 
 First comes Crile 's cannula (Fig. 4), most 
 widely employed since it was the first clinically successful 
 instrument. Dr. Crile, who has described the technic of its 
 use in a number of papers and finally in his excellent mono- 
 
 Fio. 4. Crile 
 cannula. 
 
 FIG. 5. Drawing vein through cannula. 
 
 graph "Hemorrhage and Transfusion" (1909), briefly c\ 
 plains as follows: 
 
 "The vessels to be anastomosed are exposed (for details 
 see page 16) and, after selection of a cannula of size suitable 
 to the size of the vessel, the end of the vein is pulled through
 
 TRANSFUSION 
 
 11 
 
 the handle end of the tube by means of a single fine suture 
 inserted in its edge (Fig. 5), the needle being left on the 
 suture and passed through the cannula ahead of the vein. 
 The handle of the cannula is then tightly seized by a pair of 
 hsemostats, three mosquito hasmostats are snapped at equi- 
 distant points on the end of the vein, taking care not to 
 have the tips extend up into the lumen more than is necessary 
 
 FIG. 6. Cuffing vein back 
 over the cannula. 
 
 FIG. 7. Vein cuffed and tied in groove 
 nearest handle of the cannula. Artery 
 grasped by three mosquito clamps. 
 
 to get a firm hold. The end of the vein is then cuffed back 
 over the cannula by gentle simultaneous traction on the 
 three haemostats (Fig. 6) and tied firmly in place with a fine 
 linen thread in the groove nearest the handle (Fig. 7). The 
 cuffed part is next covered with sterile vaseline, being careful 
 not to get any into the open end. This facilitates slipping 
 the artery over the cuff. The haemo stats are removed from 
 the full edge and the artery may then be put in place.
 
 12 SURGERY OF THE VASCULAR SYSTEM 
 
 "Owing to the elasticity of the arterial wall, it usually 
 shrinks (contracts) considerably when the pressure from 
 within is removed, as it is at the free end. To obviate this 
 it may be necessary to dilate the end very gently by inserting 
 the closed jaws of a mosquito clamp covered with vaseline and 
 opening them for a short distance. The three 
 haemostats are applied to the edges, just as with 
 the vein, and the artery is gently drawn over 
 slipped over can^ the cuffed vein on the cannula and tied in place 
 
 nula and tied in the . - , . ,. , . , 
 
 second groove. An- with another fine linen suture applied in the 
 
 astomosis complete. . . /TV o\ mi A 
 
 remaining groove (Fig. 8). The mosquito 
 haemostats are removed, and finally the large haemostat which 
 has been snapped on the handle of the cannula during all 
 this time is removed. The process is then completed. After 
 the transfusion the cannula is removed, both artery and vein 
 are ligated, and the wounds are sutured. 
 
 "In making a cannula anastomosis, experience will show 
 what size cannula is suitable for given vessels. As large a 
 size should be used as possible, without injuring the intima 
 of the artery by stretching it too much. Usually there will 
 be no difficulty in obtaining a large vein, but the artery may 
 be very small. If too small a cannula is used, the volume of 
 flow will be diminished. Moreover, too large a vein will take 
 up too much room in the cannula and the amount of flow 
 will be diminished. 
 
 "The exposed vessels should be kept moist and warm with 
 normal salt solution. Not only is drying harmful, but tho 
 flow is increased through gradual relaxation of the arterial 
 wall. 
 
 " Experience has shown that if anything goes wrong in 
 carrying out this technic, it is best to start again from the 
 beginning, and not to try to get around any of the details by 
 substitution." 
 
 It is occasionally quite awkward to properly "set" the
 
 TRANSFUSION 
 
 13 
 
 necessary ties on Crile's cannula. It was to overcome this 
 difficulty that I modified his tube by placing three small 
 hooks on the handle end of it (Fig. 9), thus avoiding the 
 necessity of placing the ties by having each vessel in turn 
 impaled on the hooks. Otherwise the technic 
 of the two instruments is identically the same. 
 The second cannula is an ingenious device 
 of Elsberg. It is built on the principle of a 
 monkey-wrench (Fig. 10) which can be enlarged 
 or narrowed to any size desired by means of a 
 screw at its end. The smallest lumen obtain- 
 able is about equal to that of the smallest Crile 
 cannula, and the largest greater than the lumen 
 of any radial artery. The instrument is cone- 
 shaped at its tip, a short distance from which SSST^orift 
 is a ridge with four small pin-points which are 
 directed backward. The lumen of the cannula at its base is 
 larger than at the tip. The construction of the cannula can 
 be easily understood from the following description of the 
 method of using it : 
 
 FlG 9 ._Author's 
 
 FIG. 10. Elsberg '3 monkey-wrench cannula. 
 
 "The radial artery of the donor is exposed and isolated 
 in the usual manner. The cannula, screwed wide open, is 
 then slipped under and around the vessel. It is then screwed 
 shut until the two halves of the instrument slightly compress 
 the vessel (Fig. 11) / The artery is then tied off about one 
 centimetre from the tip of the cannula. Before the vessel is 
 divided, three small-eye tenacula are passed through the
 
 14 
 
 SURGERY OF THE VASCULAR SYSTEM 
 
 wall of the artery, at three points of its circumference, a few 
 millimetres from the ligature. Small mosquito forceps may 
 also be used. These are given to an assistant, who makes 
 traction on them while the operator cuts the vessel near the 
 ligature. The moment the artery is cut, the stump is pulled 
 back over the cannula by means of the tenacula or forceps, 
 and is held in place without ligation by the small pin-points 
 (Fig. 12). There is no bleeding from the artery, even though 
 no haemostatic clamp has been applied, because the cannula 
 itself acts as a haemostatic clamp. The vein of the recipient 
 
 FIG. 11. 
 
 FIG. 12. 
 
 FIG. 13. 
 
 FIG. 11. Artery "set" in Elsberg's rannula: tenacula in position for cuffing. 
 
 FIG. 12. Artery everted and impaled on the hooks. Vein grasped by mosquito clampg. 
 
 FIG. 13. Cannula slipped into side of vein and tied in position. Anastomosis complete. 
 
 is then exposed (but not freed), two ligatures are passed 
 around it, one is tied peripherally in the usual manner. A 
 small transverse slit is made in the vein, the cannula with 
 the cuffed artery inserted into the vein, a ligature tied around 
 the vein and cannula screwed open (Fig. 13), and the blood 
 allowed to flow. The rapidity of the flow can be varied as 
 desired by the size to which the instrument is screwed or 
 unscrewed, and the lumen of the artery is never diminished. 
 
 "It will be noticed that the artery is cuffed instead of 
 the vein ; this method I believe to be more correct. The vein 
 is the larger vessel and can therefore be more easily tele- 
 scoped over the artery. The vein is only exposed, not freed, 
 and the artery is intubated into it. 
 
 "With this cannula I have been able to make the anasto- 
 mosis in less than four minutes after the artery had been
 
 TRANSFUSION 15 
 
 isolated, and have found the entire procedure a simple one. 
 The advantages of the instrument are the following: 
 
 " (1) One cannula will fit any vessel. 
 
 " (2) The cannula is applied around the vessel instead of 
 the vessel being drawn through the cannula. 
 
 "(3) No ligature of the cuffed vessel is required. 
 
 "(4) The cannula itself acts as a haemostatic clamp. 
 
 11 (5) The cuffing of the artery is easily accomplished with- 
 out stripping back the adventitia, and, therefore, the trau- 
 matism to the artery wall is reduced to a minimum. 
 
 "(6) The vein need only be exposed, not dissected out 
 and cut. 
 
 " (7) As the cannula is unscrewed the blood will flow, the 
 flow can be regulated at will, and the lumen of the artery is 
 not diminished." 
 
 I agree with Elsberg, in general, that it is preferable to 
 cuff the artery rather than the vein, and frequently do prac- 
 tise this method. However, it is best to remember that in 
 children (and even some adults) the vein is more delicate 
 and smaller than the adult radial artery, and to adopt no 
 inflexible rule in this matter. The operator must be prepared 
 to adapt himself to the exigencies of the occasion. 
 
 The third instrument which I shall present is one of my 
 own design. Simple in construction, large enough to work with 
 comfortably, it requires a minimum of dissection and can be 
 rapidly put into action. It is a two-pieced affair (Fig. 14), 
 consisting of two hollow tubes, each 4 cm. long, and each bulb- 
 ous at one end in order to form a neck for a retaining tie, 
 and bevelled to facilitate entrance into the vessel; the other 
 ends are tubular and fitted for invagination. The instrument 
 was originally constructed in two sizes as regards the bore 
 of the smaller ends, but experience has shown that either 
 size will fit the vessels of any individual from an infant up 
 to an adult. 
 
 My reason for having an instrument thus constructed in
 
 16 SURGERY OF THE VASCULAR SYSTEM 
 
 two separate parts was twofold. Firstly, in transfusing an in- 
 fant, it is usually difficult to make the actual union of vessels 
 with a small instrument like that of Crile or Elsberg because 
 of the smallness of the parts and the delicacy of the infant's 
 vessels. Paraffined glass tubes answer the purpose fairly 
 well, but paraffine is not always at hand, nor is a suitable 
 glass tube, and, if it is, the probabilities are that it will be 
 chipped or broken. Secondly, for emergency work I believe 
 that a cannula constructed in two pieces, one of which can be 
 rapidly inserted into the artery of the donor, and the other 
 into the vein of the recipient, by separate crews of operators, 
 is best. Even in cases where haste has not been so urgent, 
 
 FIG. 14. Author's two-pieced transfusion tube. 
 
 the ordeal for the recipient, who is usually anxious and in a 
 precarious state, can be materially relieved by preparing the 
 donor completely before bringing the recipient into the 
 operating room, or even by preparing the two entirely in 
 separate rooms, simply wheeling the stretcher of the donor 
 into the recipient's room, placing them in apposition, and 
 invaginating the two halves of the cannula a matter of only 
 a few seconds. 2 
 
 The technic, then, of a transfusion by means of this two- 
 pieced cannula, as well as the management of transfusion in 
 general, is as follows: The radial artery of the donor is 
 usually united to one of the superficial veins at the elbow of 
 
 An additional advantage possessed by these tubes is that the vessels of 
 donor and recipient do not come in contact, there being a distance of about an 
 inch or inch and a half between them. This is a great comfort in those cases 
 of infectious diseases typhoid, streptococcus, etc. where every precaution 
 must be taken to protect the donor against infection.
 
 TRANSFUSION 
 
 17 
 
 the recipient; occasionally, because of infection at the elbow, 
 it becomes necessary to employ a vein of the leg, generally 
 
 r 
 
 !*!. Flexor carpi i JFiVi : 
 Tendon n. 
 
 FIG. 15. Incision in wrist of donor, showing radial artery and vense comites. 
 
 the internal saphenous, although any available vein may be 
 used. But no matter whether it be arm to arm, or arm to leg, 
 in preparing the patients let the watchword be "left to left, 
 2
 
 18 
 
 SURGERY OF THE VASCULAR SYSTEM 
 
 right to rif/ht" in other words, the left radial should always 
 be united to a vein of the left arm or leg and vice-versa; a 
 few moments' thought will show the anatomical reasons for 
 
 this. Other things being equal, 
 it is always wise to leave the 
 choice of radials to the donor, 
 but where he (or she) has no 
 choice, it is my rule to utilize 
 the left radial, if the patient 
 be right handed and both 
 radials are of the same size 
 (which by the way is not 
 always the case), his right if 
 he be left handed. Thus the 
 donor will be incapacitated as 
 little as possible during the 
 healing of his wound a detail. 
 perhaps, but one that ought to 
 be considered. 
 
 Time will be saved if the 
 radial is dissected out as follows, novocain (0.5 per cent.) 
 being the anaesthetic of choice: (1) expose the artery with 
 its accompanying veins for a distance of about two inches 
 (Fig. 15), (2) free the artery from the veins and tie off 
 all branches doubly with very fine silk, cutting between the 
 ties; (3) tie off the artery doubly at the distal end of the 
 wound and cut between ties, thus allowing about one and 
 one-half inches of the vessel to lie free in the wound (Fig. 
 16) ; (4) tie off all bleeding points in the wound, and keep 
 a constant stream of warm salt solution flowing over the 
 artery, all sponging being done with gauze moistened in 
 the same solution; (5) place a bull-dog clamp on the vessel 
 at the proximal end of the wound. 
 
 Up to this point the technic is the same no matter which 
 method of anastomosis is to be used. If my two-pieced 
 
 FIG. 16. Radial artery separated from venae 
 comites, doubly ligated, and divided.
 
 TRANSFUSION 
 
 19 
 
 cannula is to be employed, a small cut is now made in the 
 upper side of the artery with a fine pair of scissors, the open- 
 ing being made at right angles to the course of the vessel 
 and about half its width (Fig. 17). Next, every visible trace 
 of blood is immediately washed out with warm salt solution 
 and liquid vaseline, the latter being injected into the lumen 
 
 FIG. 17. Cutting oval opening in, side of radial artery. 
 
 of the vessel with a medicine dropper at frequent intervals 
 during the washing process. It keeps the vessel soft and 
 pliable, and prevents too rapid evaporation and consequent 
 drying. Any little bit of adventitia that may get into the 
 opening should be carefully pushed away or cut off. 
 
 The vessel having been carefully prepared, the bevelled 
 end of the male half of the tube is inserted into the artery 
 (Fig. 18) and held there by a tie thrown around its neck
 
 20 SURGERY OF THE VASCULAR SYSTEM 
 
 (Fig. 19). Liquid vaseline is now again injected into the 
 vessel through the tube, and the whole thing wrapped in salt- 
 solution gauze to await the completion of a similar prepara- 
 tion of the vein of the recipient. It is hardly necessary to 
 dissect out more than one inch of the vein, and, as this is 
 always quite superficial, the time required for the whole 
 
 Fio. 18. Slipping 
 
 jbe into the artery. 
 
 procedure of dissection, cleansing, and insertion of the 
 female half of the tube (Fig. 20) amounts to hardly more 
 than five minutes. 
 
 When both patients have been prepared, their stretchers 
 are brought into apposition and the two arms are placed on 
 a table about one foot broad. With a little manipulation the 
 wrist of the donor is brought into such proximity to the
 
 TRANSFUSION 
 
 elbow of the recipient that the tubes can be invaginated 
 (Fig. 21) to the proper degree. When this is accomplished, 
 a steady stream of warm salt solution is started flowing over 
 the artery, tubes, and vein, and the 
 bull-dog clamp is removed from the 
 vein, its place being taken by the 
 thumb and first finger of the right 
 hand of the operator. With great 
 care the clamp controlling the ar- 
 terial flow is now gradually released, 
 coincidently with which the thumb 
 and finger controlling the vein 
 gradually ease up, thus permitting 
 the blood to go over gradually, so 
 as to prevent any possibility of 
 swamping or embarrassing the cir- 
 culation of the recipient by a sudden 
 gush of blood under great pressure. 
 Let it be strongly emphasized here 
 that, with few exceptions, the margin of safety is none too 
 great in any transfusion at any stage. It is my custom, 
 therefore, to control the inflow in the manner above described 
 during the entire course of the transfusion. 
 
 If assistants are at hand, the blood-pressure and pulse 
 of the recipient should be taken at intervals of every three 
 minutes, that of the donor every five minutes. These meas- 
 ures cause but slight annoyance to the patients and are of 
 the utmost importance to the surgeon in judging the con- 
 dition of both individuals. Haemoglobin and red counts, made 
 during the course of the operation, although they are in- 
 teresting and valuable do not give nearly so helpful imme- 
 diate information as do blood-pressure and pulse, and, since 
 they cause more or less discomfort to the patients, we do 
 not make these readings unless there is some special reason 
 for them. It is unnecessary to say, of course, that the blood- 
 
 FIG. 19. Tube tied in place in the 
 artery.
 
 22 SURGERY OF THE VASCULAR SYSTEM 
 
 pressure and pulse of both donor and recipient liavc hccn 
 taken before starting the transfusion, as a control, and that 
 
 Median 
 Cephalic'V. 
 
 FIG. 20. Female half of tube tied in position in vein of the recipient. 
 
 if the facilities are at hand, a complete blood examination- 
 reds, whites, and haemoglobin has been made of both pa-
 
 TRANSFUSION 
 
 
 FIG. 21. Tubes invaginated and anastomosis complete. 
 
 tients, also as a control, for, after completion of the trans- 
 fusion, these data are most valuable in interpreting both the 
 immediate and future results of the operation.
 
 24 SURGERY OF THE VASCULAR SYSTEM 
 
 Where the recipient is practically exsanguinated, and 
 there is no contraindication, it is wise to give him all the 
 blood he can conveniently hold, even occasionally (Crile) 
 going to the extent of using two donors in case one cannot 
 stand any great loss of blood. My routine is to attempt to 
 bring a pulse of say 150 or 160 down to about 100 and to raise 
 a blood-pressure of 50 to 70 up to 110 or 120, figures well 
 within the zone of safety. 
 
 It sometimes happens that it is decidedly unwise, even 
 hazardous, to overload the circulation, an example of such a 
 case being a patient exsanguinated as a result of hemorrhage 
 from typhoid (or other) ulcers of the bowel. To give such 
 an individual much blood would be tempting fate, whereas a 
 small amount, sent in slowly, will decrease the coagulation 
 time, and seal up the mouths of open vessels with life-saving 
 thrombi. In other words, a great amount of blood will 
 simply raise the blood-pressure to such an extent that it will 
 literally blow out any soft young plugs that might be all that 
 is holding body and soul together. 
 
 It is a most difficult matter to judge as to the exact 
 amount of blood that has gone or is going over. No prac- 
 tical method of measuring the amount of blood flow has been 
 devised, and until this much-desired instrument is placed at 
 our disposal we shall be compelled to depend upon clinical 
 signs for an index of the amount of blood transfused. It 
 must be recognized that a number of factors must of necessity 
 enter into any calculation of bulk. The blood-pressure, be- 
 cause of the psychic disturbance in every operation of this 
 sort, is by no means constant. The loss of blood is another, 
 perhaps the chief, factor in determining the instability of 
 the blood-pressure and therefore the amount that goes over 
 in bulk. The pulse-rate varies, too, from time to time and 
 this must be considered in any determination of amount. 
 There are still other factors, such as the viscosity of the 
 blood, etc., which need not be considered in a work of this
 
 TRANSFUSION 25 
 
 character. It is sufficient to say that to the careful, ex- 
 perienced surgeon all the factors above mentioned can be 
 determined with a surprising degree of accuracy by the thumb 
 and forefinger guarding the entrance at the vein. This knowl- 
 edge and constant observation of the actual blood-pressure 
 reported by the assistants, the general appearance of the 
 patients, and the actual time that the blood has been flowing 
 all this serves as a guide to the amount of blood going 
 over and the proper time to cease transfusing. 
 
 In regard to the duration of actual flow in transfusion 
 in general, there are various questions to be considered. An 
 infant will require but a small amount of blood, children 
 need far less than adults, and, as a rule, women less than 
 men, always considering that the patient is exsanguinated. 
 A big husky man will generally have a larger radial than a 
 small man, and his pressure will enable a much larger and 
 more powerful stream to be thrown by his vessel. Likewise, 
 a female donor may give less blood in a given time than 
 a man provided the man is not too badly frightened. Thus 
 the actual time of transfusion varies, from three to five 
 minutes to one hour or even an hour and a quarter, if a very 
 small cannula is used, or if the blood has been permitted to 
 go over very slowly. For most transfusions the average 
 duration of the flow is from twenty to forty minutes. 3 
 
 The welfare of the donor in transfusion must be carefully 
 watched. I have transfused from one donor for over an 
 hour without any signs of distress, while in another case 
 fifteen minutes were sufficient to produce great anxiety. In 
 general a sudden fall of twenty to thirty points in blood- 
 
 3 1 have proved both experimentally and clinically that, if the proper 
 technic has been observed, blood will flow through my two-pieced cannula from 
 fifteen to thirty-five minutes without clotting. When a clot does occur, it 
 requires but a few moments to remove the tubes, wash out both vessels with 
 salt solution and liquid vaseline, and insert another set, the flow being again 
 started in the usual manner. Even when there is no clot I have occasionally 
 found it of advantage to arrest the transfusion for five or ten minutes in order 
 to ease and reassure the patients.
 
 26 SURGERY OF THE VASCULAR SYSTEM 
 
 pressure should warn the operator that the limit has about 
 been reached. Unfortunately, however, a blood-pressure 
 apparatus is not always at hand and even where it is the 
 fall in pressure, sudden or gradual, does not always occur. 
 In such instances any sudden pallor, accompanied by naus<>a 
 and vomiting, continued and increasing thirst, great restless- 
 ness, together with a decrease in blood-pressure as shown by 
 the finger of the operator on the donor's radial, may serve 
 as the needed danger signal. The bleeding should never be 
 permitted to exceed the limit of safety; the donor ought 
 never be allowed to collapse utterly. A proper appreciation 
 of his own responsibility as well as the moral rights of those 
 courageous individuals, generous enough to give of their own 
 blood that another might live, should always be pre-eminent 
 in the mind of the surgeon who undertakes work of this 
 nature. 
 
 The danger of haemolysis following transfusion has always 
 been vastly over-rated and unwarrantably feared. In a 
 rather large series of transfusions, done for the relief of 
 many and varied conditions, I have never seen it occur, and 
 I know of but one authentic instance where it complicated 
 matters. This was in a case of Dr. John L. Yates of Mil- 
 waukee (personal note), who transfused a patient exsanguin- 
 ated as a result of hemorrhage from a gastric ulcer. There 
 was a rather marked but temporary haemolysis following the 
 operation, the patient making a good recovery. Crile reports 
 a personal case in his book on "Hemorrhage and Trans- 
 fusion" and calls attention to its occurrence, although he, 
 too, regards it as more of a theoretical than a practical 
 menace. 
 
 I believe that the proper course to pursue and have so 
 practised is to have the haemolytic tests of donor's and 
 recipient's blood made, if the case is not urgent and when 
 the proper facilities and trained laboratory workers are at 
 hand. If the case is urgent, I never even consider such a
 
 TRANSFUSION 27 
 
 thing as haemolytie tests, contenting myself with a most care- 
 ful physical examination of the donor in order to rule out 
 the possibility of transmitting syphilis or some other disease 
 to the recipient; for it must be remembered that haemolytie 
 tests, even at best, are not entirely conclusive, and do not 
 absolutely protect against haemolysis. The blood of one in- 
 dividual may haemolize that of another in the test tube, but 
 not in the body after transfusion, and, vice versa, the 
 laboratory tests may pronounce an individual a suitable 
 donor, and yet haemolysis may occur after transfusion. So 
 that until some absolutely reliable, uninvolved test has been 
 found, the rather remote danger of haemolysis may be disre- 
 garded in emergency cases, in the home, and in institutions 
 where the facilities for making these tests are not at hand. 
 
 REFERENCES 
 Bernheim, B. M. : A Modification of the C'rile Transfusion Cannula, Annals of 
 
 Surgery, Oct., 1909. 
 Bernheim, B. M. : An Emergency Cannula; Transfusion in a Thirty-six-hour 
 
 Old Baby Suffering from Melaena Xeonatorum, Jour. Amer. Med. Assoc., 
 
 April 6, 1912. 
 
 Brewer, G. E.: Jour. Amer. Med. Assoc., Jan. 30, 1909, p. 412. 
 Cole. H. P.: Transfusion in Pellagra, Journ. Amer. Med. Assoc., Feb. 25, 1911, 
 
 No. 8. 
 
 Crile. G. W. : Hemorrhage and Transfusion, Appleton & Co., 1909. 
 David, V. C., and Curtis, A. H. : Experiments in the Treatment of Acute Anaemia 
 
 by Blood Transfusion and by Intravenous Saline Infusion, Surgery. Gynae- 
 cology, and Obstetrics, Oct., 1912. 
 
 Elsberg: Jour. Amer. Med. Assoc., 1909, vol. Hi. p. 887. 
 
 Hahn, Milton: Haemophilia Treated by Transfusion, Med. Record, Oct. 8, 1910. 
 Hepburn: Annals of Surgery, Jan., 1909. 
 Keator, H. M.: Transfusion in Case of Toxaemia of Early Pregnancy with 
 
 Unusual Hemorrhagic Manifestations. Amer. Jour. Obstet. and Dis. of 
 
 Women and Children, vol. Ixv, No. 414, pp. 937-1131, June, 1912. 
 Morawitz: Die Behandlung schwerer Anamien mit Blut Transfusionen. Munch. 
 
 med. Woch.. April 16. 1907. 
 Moss, W. L., and Gelien. J. : Serum Treatment of Hemorrhagic Diseases, Johns 
 
 Hopkins Hosp. Bull., vol. xxii. No. 245. July. 1911. 
 Payr. E.: Zur Technik der arterio-venosen Bluttransfusion, Munch, med. Woch., 
 
 Bd. 59, April 9. 1912. 
 Pepper and Xesbit: Fatal Haemolysis Following Direct Transfusion of Blood 
 
 by Arteriovenous Anastomosis, Jeur. Amer. Med. Assoc., Aug. 3, 1907. 
 Vincent, Beth: Blood Transfusion. Methods and Results, Bost. Med. and 
 
 Surg. Jour., Aug. 22, 1912.
 
 CHAPTER III 
 
 END-TO-END SUTURE 
 
 Classical End-to-end Suture. Exposure of Vessel; IIV/.s//- 
 ing Process. During the exposure of a vessel all sources of 
 hemorrhage should be scrupulously controlled, the tissues 
 should be handled gently and sponged with gauze, w<-t with 
 normal salt solution. For an end-to-end suture of an artery 
 two Crile clamps, armed with soft rubber tubing, should 
 be applied, the moment the vessel is sufficiently exposed, at 
 a distance of about two inches apart, all branches that 
 come off between them being clamped, tied, and severed. 
 The vessel is then divided (Fig. 22) and the blood imme- 
 diately washed out of both ends with normal salt solution, 
 eye droppers or pipettes armed with rubber bulbs being found 
 most suitable for this purpose. If their ends have been 
 previously carefully rounded by flaming they can be intro- 
 duced within the lumen of the vessel without danger of 
 injuring the intima. 
 
 Treatment of Adventitia. This washing is done with the 
 utmost care, but is usually interfered with by a soggy layer 
 of whitish tissue hanging over the end of the vessel and 
 more or less obstructing the lumen. This is the adventitia. 
 which, practically devoid of elastic tissue, fails to contract 
 on severance of the vessel and drops lifeless over the cut 
 ends, thus obstructing the way. It should be picked up with 
 the first finger and thumb, or preferably with a delicate 
 mouse-toothed forceps, pulled well out over the ends of the 
 vessel (Fig. 23), and snipped off flush with the cut edge 
 (Fig. 24). Occasionally all of it will be gotten the first tinio. 
 but if any loose edges are left they should again be treated 
 
 28
 
 END-TO-END SUTURE 
 
 in the same way, following which, with a delicately pointed 
 forceps, the remaining adventitia should be stripped back 
 
 well away from the cut edge. Dur- 
 
 . , . . ,. , ,. 
 
 ing this time, which in reality 
 consumes only a minute or two, 
 the washing process should be 
 continued by an assistant. When 
 
 FIG. 22. Severed ends of an artery 
 showing the over-hang of adventitia. 
 
 FIG. 23. Drawing adventitia well out 
 over end of the artery. 
 
 the adventitia is completely removed, the tip of the pipette 
 should be inserted into the lumen of the vessel and every 
 visible trace of blood washed out; then with another pipette
 
 30 
 
 SURGERY OF THE YASULAR SYSTEM 
 
 the vessel should be washed and soaked outside and inside 
 with I'ujnid raxrlim' to prevent drying and keep the tissues 
 soft and pliable (Fig. 25). The process of washing and 
 soaking with salt solution and liquid 
 vaseline should be continued all during 
 the process of the operation, and an 
 eye should constantly be kept on the 
 adventitia, which, despite the utmost 
 care, will often literally creep down to 
 the cut edge and insinuate itself in the 
 line of suture. 
 
 Hi ay Sutures; Formation of Tri- 
 angles. Following the technic so beau- 
 tifully developed by Carrel and later 
 by Stich the cut ends of the vessel or 
 vessels, e.g., artery or vein, to be united 
 are first brought together by three stay 
 sutures placed at points equidistant around the lumen 
 (Fig. 26). These sutures, passed in such a way that the 
 knots will be on the outside of the vessel, are tied (Fig. 27), 
 and the union is then secured by sewing in succession 
 each side of the triangle thus formed, using either one con- 
 tinuous thread with a tie at each stay suture, or using the 
 long end of each stay to sew the corresponding side of the 
 triangle. During the process of the suture, 1 the operator holds 
 in his left hand one stay suture while the assistant holds in 
 his hand the corresponding one, thus forming a straight line 
 of the edges to be sewed (Fig. 28). A light clamp should be 
 allowed to hang on the third stay in order to keep the other 
 edges from being caught in the stitch. 
 
 Over-and-over Stitch. As one side is finished the next 
 
 FIG. 24. Cutting off adventitia 
 flush with end of the artery. 
 
 1 In all drawings of anastomosis in this and succeeding chapters the femoral 
 vessels are taken as a type.
 
 END-TO-END SUTURE 
 
 31 
 
 is brought into position by rotation of the stay sutures (Figs. 
 29 and 30). At each stroke the needle passes through all 
 
 FIG. 25. Washing out vessels with liquid vaseline and salt solution. 
 
 three coats of both vessels, starting on the outside of one, 
 and ending on the outside of the other, thus placing all knots 
 outside the lumen. The stitch is a simple over-and-over one,
 
 32 SURGERY OF THE VASCULAR SYSTEM 
 
 each needle hole being placed just far enough back from the 
 cut edge of the vessels to secure comfortably all three coats. 
 No set rule can be laid down as to the number of stitcho in 
 any one side of the triangle or in the whole triangle; Iliis 
 must of necessity depend on the size of the vessels, but the 
 
 placed. 
 
 sutures must neither be placed too close together nor too 
 far apart. The approximation of the cut edges of the vessels 
 should and can be made so perfect that almost no irregularity 
 is apparent to the naked eye (Fig. 31). Despite all caution,
 
 END-TO-END SUTURE 
 
 33 
 
 however, it frequently happens that after the blood flow 
 is started there are one or two little leaks that must be 
 caught up with an interrupted stitch. This is best done 
 
 Fid. 27. Stay sutures tied and vessel triangulated. 
 
 during a temporary interruption of the circulation, and 
 if the usual care be observed no apprehension need be felt 
 by operator. 
 
 Toilet of Completed Line of Suture. Before placing any
 
 34 
 
 SURGERY OF THE VASCULAR SYSTEM 
 
 secondary sutures, however, really before allowing the blood 
 to flow, the line of suture should be carefully wrapped in 
 dry gauze and a slight compression exerted in order to throw 
 
 FIG. 28. Sewing first side of triangle. 
 
 Fio. 29. Sewing second side of triangle ; vessel partially rotated. A tie is placed at each stay suture. 
 
 the whole strain of the circulation gradually on the sutures. 
 A gentle rolling motion massage-like is given the vessel 
 at the same time, the whole process being continued for about
 
 END-TO-END SUTURE 
 
 35 
 
 five minutes, during which time the little needle holes and 
 
 any interspaces that are not too large will fill up with clot. 
 
 If this seemingly small detail is conscientiously carried out 
 
 and a gradual relaxation allowed to follow, many a secondary 
 
 stitch that under other circumstances 
 
 would be needed may be avoided. It 
 
 might be added that in starting the 
 
 blood flow after the completion of a 
 
 suture the distal clamp should always 
 
 be released first ; otherwise the sudden 
 
 rush of blood, peremptorily checked 
 
 just an inch or so beyond the line of 
 
 suture, will throw a terrific strain on 
 
 FIG. 30. Sewing third side of 
 triangle; vessel completely rotated. 
 Instead of complete rotation, re- 
 verse rotation may be practised in 
 order to bring the third side of the 
 triangle into view. 
 
 FIG. 31. Suture complete. 
 
 the line of suture that is both unnecessary and dangerous. 
 Any one who can perform this classical end-to-end anas- 
 tomosis successfully need have no hesitation about attempting 
 the other methods, for mechanically they are all easier to 
 carry out, and the general technic is identically the same.
 
 36 SURGERY OF THE VASCULAR SYSTEM 
 
 BEPEBENCES 
 
 Bernheim, B. M.: A Note on Sonic Methods <>f Anastomosing Blood- Vessels, 
 
 Johns Hopkins Hospital Bull., April, 11)0!). 
 Carrel, A.: The Surgery of the Blood-vessels, etc., Johns Hopkins Hosp. Mull., 
 
 Jan., 1907. 
 Carrel, A.: Lea anastomoses vasculaires, leur technique operatoire ct lours 
 
 indications; 2 e Congres des mf-decins le langue franchise de rAnu'rique <lu 
 
 Nord, 1904. 
 
 Carrel, A.: La technique operatoire des anastomoses vasculaires et de la trims- 
 plantation des visceres, Lyon Me'dical, 1902. 
 Carrel and Guthrie: Uniterminal and Biterminal Venous Transplantations, 
 
 Surgery, Gynaecology, and Ohstetrics, March, 1906. 
 Carrel and Morel: Anastomose bout a bout de la jugulaire et de la carotidc 
 
 interne, Lyon Medical, 1902, vol. xcix, p. 114. 
 Dorrance: An Experimental Study of Suture of Arteries, with a Description of 
 
 a Xew Suture, Annals of Surgery, 1906, vol. xliv, p. 409. 
 Hoepfner: Ueber Gefilssnaht Gefsisstransplantationen und Replantation von 
 
 amputirten Extremitiiten, Inaugural Dissertation, Berlin, 1903. 
 Payr, R.: Zur Frage der circuliiren Vereinigung von Blutgefiissen mit rcsorliir- 
 
 baren Prothesen, Arch, fiir klin. Chir., 1904, vol. Ixxii, p. 32. 
 Stich, Makkas, Dowman: Beitriige zur Gefiisschirurgie, Beitriige x.ur klin. 
 
 Chirurgie, Bd. 53. 
 Stich and Zoeppritz: Zur Histologie der Gefassnaht, des Gefass u. Organtran.-.- 
 
 plantationen, Beit, zur path. Anat., xlvi, 1909, p. 337. 
 Watts: The Suture of Blood-vessels: Implantation and Transplantation of 
 
 Vessels and Organs; An Historical and Experimental Study, Johns Hopkins 
 
 Hospital Bulletin, 1907, vol. xviii, p. 153.
 
 LATERAL, anastomosis of blood-vessels is chiefly employed 
 in uniting an artery with a vein, and only within the last year 
 or so has serious attention been directed toward developing 
 this suture to the same degree of perfection that has been 
 attained with the end-to-end method. The tardy develop- 
 ment of this operation can be explained by the fact that it 
 has only become a working necessity since our recent realiza- 
 
 FIG. 32. Diagram showing method and principle of making incision in vessels in lateral anasto- 
 mosis according to the method of Bernheim and Stone. 
 
 tion that, in cases of threatened gangrene of the extremities, 
 where arterial flow must be transferred into venous channels, 
 this procedure (lateral anastomosis) seems not only theo- 
 retically more correct but gives better results in practice 
 than the end-to-end suture (see chapter on Reversal of the 
 Circulation). 
 
 Several methods of uniting vessels side to side have been 
 suggested one by Carrel, another by Hadda, still another 
 by Jeger but I believe that none answers the purpose so 
 
 37
 
 38 SURGERY OF THE VASCULAR SYSTEM 
 
 Fio. 33. Incision made in side of artery and being made in side of vein.
 
 LATERAL ANASTOMOSIS 
 
 39 
 
 well, theoretically and practically, as that devised by me, 
 Dr. Harvey B. Stone collaborating, in 1910, the details of 
 which are as follows : 
 
 The artery and vein between which the communication 
 is to be established are carefully dissected out, and bull-dog 
 or Crile clamps, rubber-shod, are applied to each vessel at 
 corresponding points. The incision in the artery is made 
 first. A sharp cataract knife, held transverse to the long 
 
 / f 
 
 FIG. 34. Drawing adventitia away from the oval opening. 
 
 axis of the vessel (Fig. 32), is plunged through the artery in a 
 direction oblique to the horizontal plane in which the vessel 
 lies, so as to form a sector of the lumen with its arc equal 
 to about one-third of the circumference. The knife is thrust 
 in with its cutting edge upward and toward the adjacent vein. 
 The overlying one-third of the artery wall is then divided. 
 At once the retraction of the longitudinal muscle and elastic 
 fibres causes this transverse incision to gape and become an 
 open ovoid. Owing to the fact that the knife was entered
 
 40 
 
 SURGERY OF THE VASCULAR SYSTEM 
 
 obliquely and not perpendicularly, this <>v<>i<l ( Fig. 33) looks 
 toward the vein and also somewhat upward. The posterior 
 edge of the opening is thus easily accessible for suturing. As 
 soon as the artery is opened all blood is washed out with salt 
 solution, the adventitia stripped off carefully (Figs. .'14 and 
 35), and the lumen and other surfaces freely bathed with 
 liquid vaseline (Fig. 36). The artery is then protected with 
 vaseline-soaked gauze, and a similar incision, corresponding 
 
 in size and position, is 
 made in the vein so that it 
 looks toward the artery 
 and upward. 
 
 The suture is started 
 by passing the needle 
 through the wall of the 
 artery from without in- 
 ward, then crossing to the 
 vein and passing here from 
 within outward (Fig. 37). 
 When this suture is tied 
 the knot lies outside the 
 vascular lumen. From this 
 starting point a simple 
 
 Fio. 35.-Cutting away the adventitia. COntinUOUS SUturG (Fig. 38) 
 
 is carried around the 
 
 openings in the two vessels, care being taken to avoid purse- 
 stringing ! (Fig. 39). The operation is completed by tying 
 the last suture to the remaining long end of the first tie 
 (Fig. 40). No difficulty is experienced in approximating 
 the edges of the incisions, and there is no more tension 
 on the thread than in an end-to-end anastomosis. After 
 completion of the suture, the proximal end of the vein 
 having been doubly ligated with heavy silk about one-half 
 
 1 In reality the thread is so delicate that purse-stringing is almost an 
 impossibility.
 
 41 
 
 to three-fourths of an inch above the site of anastomosis, 
 the clamps are removed first from the vein, as in all vascular 
 surgery. If any marked leakage occurs, the weak spots are 
 reinforced by one or two extra sutures. Then the arterial 
 flow is gradually allowed to go over (Fig. 41). During the 
 suturing, intima is not always approximated to intima, but 
 with the establishment of the arterial stream through the 
 
 FIG. 36. Washing out the vessel with salt solution and liquid vaseline. 
 
 anastomosis, the "pull" in opposite directions between the 
 two vessels helps to bring about an accurate approximation. 
 This method has been employed with great satisfaction a 
 considerable number of times in animals, and was equally 
 simple in execution in the four clinical cases in which I have 
 so far had the opportunity to try it. The rationale of this 
 method has been deduced from a consideration of the cases 
 of arteriovenous aneurism met with in the clinic. Previous 
 laboratory anastomoses have been performed by making 
 longitudinal rather than transverse incisions in the vessels. 
 In the clinical cases following trauma there seems little doubt
 
 42 SURGERY OF THE VASCULAR SYSTEM 
 
 that the wounds are transverse. A bullet, knife-blade, or 
 other object wounds the adjacent surfaces of artery and vein 
 
 /-* 
 
 ; ' ^mf^F 
 
 FIG. 37. Starting suture of the vessels. The knot is placed outside the lumen. 
 
 FIG. 38. Posterior row of sutures being placed. 
 
 at the same level. The vessels are held closely together by 
 their investing sheaths, the transverse incisions gape, as
 
 43 
 
 illustrated in these sketches, and the gaping lips soon adhere. 
 The method described in this paper is practically a copy of 
 this accidental anastomosis occurring in nature. 
 
 FIG. 39. Posterior row of sutures completed; anterior row being placed. One continuous suture. 
 
 FIG. 40. Suture completed and being tied to first knot outside the lumen of both vessels.
 
 44 SURGERY OF THE VASCULAR SYSTEM 
 
 Fio. 41. Clamps removed from vessels. Proximal ligation of vein. Blood is goim? down both 
 
 artery and vein.
 
 LATERAL ANASTOMOSIS 45 
 
 I think that this anastomosis, with a ligation of the vein 
 on the cardiac side of the point of union, offers a much 
 easier and safer method for reversal of the circulation than 
 the present procedure of end-to-end anastomosis of artery 
 and vein, with ligation of the proximal stump of the vein and 
 the distal stump of the artery. When the latter method is 
 used a failure of the anastomosis imperils the knee or elbow, 
 owing to the complete division of the arterial trunk; and 
 as a rule the disease process which leads one to do an 
 arteriovenous anastomosis is not in itself so advanced as to 
 threaten the larger joints. In the few experiments with the 
 new method in which thrombi developed, they never obliter- 
 ated the arterial lumen but were entirely lateral. Moreover, 
 by this procedure the inflow of blood into a threatened ex- 
 tremity still has whatever arterial channels remain patent, 
 and the venous trunk in addition may be utilized to carry 
 some of the needed excess. It is important to ligate the vein 
 above the anastomosis, to protect the heart from a direct 
 back flow of blood under arterial pressure into its right 
 chamber. 
 
 In brief conclusion, this method is presented because of 
 its easy execution, making it superior to the longitudinal in- 
 cision for experimental work, and because of its safety, 
 making it better than the end-to-end for reversal of the 
 circulation and other clinical conditions. 
 
 REFERENCES 
 Bernheim. B. M., and Stone, H. B.: Lateral Vascular Anastomosis, Annals of 
 
 Surgery, Oct., 1911, p. 496. 
 Carrel. A.: Les anastomoses vasculaires. leur technique operatoire et leurs 
 
 indications: 2e Congrs des medecins le langue franc.ais de 1'Amerique du 
 
 Nord, 1904. 
 Carrel, A.: The Surgery of the Blood-vessels, etc., Johns Hopkins Hosp. Bull., 
 
 Jan., 1907. 
 Hadda. S. : Anlegung arterio- venose Anastomosen bei erhaltenem Blutkreislauf, 
 
 v. Langenbeck's Archiv, Bd. 94, Hft. 3, 1911. 
 Jeger, Ernst: Eine neue Klemme zur Herstellung von Seit-zu-seitanastomosen 
 
 zwischen Blutgefassen ohne Unterbrechung des Blutstromes, Zentralb. f. 
 
 Chir., Xo. 18, p. 004, 1912.
 
 CHAPTER V 
 
 TRANSPLANTATION OF A SEGMENT OF VEIN OR ARTERY 
 
 IT sometimes occurs that the continuity of a vessel in- 
 terrupted by accident or operation cannot be restored by 
 simple end-to-end suture because of the length of the defect. 
 In such instances, where it is either unwise or undesirable 
 simply to ligate the ends of the vessels and drop them back, 
 
 it becomes necessary to bridge 
 the defect by transplanting a 
 
 Fio. 42. Washing out a venous trans- 
 plant with liquid vaseline and salt solu- 
 tion. 
 
 FIG. 43. Cutting adventitia away from 
 edges of venous transplant. 
 
 piece of artery or vein. The segment to be transplanted is 
 best taken from another part of the body of the patient, 
 although one removed from another individual will answer. 
 Indeed, the recent work of Carrel tends to show that vessels, 
 removed and properly prepared, can be kept in cold storage 
 without deterioration for months before being subjected to 
 46
 
 TRANSPLANTATION OF SEGMENT OF VEIN 47 
 
 transplantation. It goes without saying that the transplant 
 must be from the same species as the patient. The cold 
 storage tissue is not at present practically available. 
 
 FIG. 44. Measuring venous transplant between ends of artery.
 
 48 
 
 SURGERY OF THE VASCULAR SYSTEM 
 
 While transplants, as stated above, may be either arterial 
 or venous, they are in reality nearly always venous, because 
 arteries cannot be spared from the body as can veins. For 
 example, it would be unwise to say the least to remove a 
 segment of the femoral or brachial artery of a patient 
 or one of his friends to supply a defect in his popliteal 
 
 Fio. 45. The transplant "set" by 
 stay sutures placed at either end. 
 
 FIG. 46. Suture in progress. 
 
 artery created by removal of an aneurism. However, he 
 could well spare a piece of his internal saphenous vein, and 
 as experiments have shown that a segment of vein interposed 
 between two ends of an artery rapidly becomes able to with- 
 stand the arterial pressure by a hypertrophy of its walls, it 
 is customary for purposes of transplantation to utilize a seg-
 
 TRANSPLANTATION OF SEGMENT OF VEIN 49 
 
 ment of the internal saphenous vein (Figs. 42 and 43) or 
 some other easily accessible. 
 
 The operation is always accomplished by means of an 
 end-to-end suture according to the method described in Chap- 
 ter III. One or two additional suggestions, however, may 
 be in order. In the first place a careful inspection of the 
 lumen of the vein should always be 
 made to ascertain the presence or 
 absence of valves. This can nearly 
 always be definitely determined by 
 inspection of the intact vein before 
 removing the segment, and it can also 
 be determined after removal by in- 
 jecting salt solution or liquid vaseline 
 through the lumen. If valves are 
 present the fluid will pass easily 
 through the vessel in one direction, but 
 going the opposite way it will be ob- 
 structed and the vein will bulge at the 
 site of the valves. By taking this 
 precaution one can " reverse" the vein 
 segment, or in other words interpose 
 it between the cut ends of the artery 
 with the valves facing distally. 
 
 Secondly, the segment must be" the 
 proper length. This is not so easily FIG. 47. suture complete; vein 
 
 Tin , 'TJ_ i flaccid; clamps still on the artery. 
 
 accomplished as it might seem, because 
 
 the segment contracts (decreases in length) the moment it 
 is removed, and expands (increases in length) almost to 
 the normal as soon as it is transplanted and the blood flow 
 started. Obviously, then, unless great care is exercised, the 
 transplant will be so short that the delicate thread used in 
 suturing will be unable to stand the tension necessary to 
 "set" the ends, or it will be so long that when the blood goes
 
 50 
 
 SIRGERY OF THE YASCTLAR SYSTEM 
 
 through, the segment will form a half curve, even an S, iu 
 the line of the parent artery. Generally speaking, the usual 
 
 FIG. 48. Blood going through the transplant. Vein bulged and tense from arterial pressure. 
 Slight irregularity indicates situation of reversed valves. 
 
 procedure is to start out with a segment that is definitely 
 too long and to trim it down with a pair of very sharp
 
 TRANSPLANTATION OF SEGMENT OF VEIN 51 
 
 scissors or preferably a sharp knife. A good working rule 
 is to have the segment finally about one-quarter of an inch 
 or even one-half inch shorter (Fig. 44) than the actual defect 
 it is to fill. 
 
 Thirdly, it is always wise to attach both ends of the 
 transplant to the parent vessel by means of the usual three 
 stay sutures (Fig. 45), before beginning the actual suture of 
 either end (Fig. 46). There will thus be less handling and 
 consequently less danger of injury to the vessel. 
 
 As soon as both lines of suture are completed (Fig. 47), 
 the segment transplanted is carefully wrapped in dry gauze 
 and the blood flow gradually started 
 
 by removing the distal clamp en- . ^^Bfc. 
 
 tirely, the proximal only partially. 
 As the vessel is felt to bulge under 
 the gauze, the fingers start a gentle 
 massage-like motion over the suture 
 lines, exerting a little pressure at 
 the same time. If there is no alarm- 
 ing hemorrhage, the proximal 
 clamp, previously loosened, is now 
 entirely removed, and the massage- 
 like motion and pressure are con- 
 tinued for about five minutes, after which there is a gradual 
 cessation of the pressure and a careful removal of the en- 
 circling gauze (Figs. 48 and 49). 
 
 If the sutures have been carefully made and the above- 
 mentioned details have been observed, there will be little 
 need for any secondary stitches. They are, however, occa- 
 sionally required in spite of all efforts, and are best placed 
 as interrupted stitches during a temporary stoppage of the 
 circulation, the gauze and pressure being reapplied as the 
 flow is started. 
 
 FIG. 49. Valves of vein diagram 
 showing necessity for reversal in placing 
 a venous transplant.
 
 52 SURGERY OF THE VASCULAR SYSTEM 
 
 When all bleeding has once been successfully controlled, 
 it is most unlikely to recur if the proper care is exerted in 
 closing the wound. 
 
 REFERENCES 
 
 Bernheim, B. M. : Arteriovenous Anastomosis Reversal of the Circulation a* 
 a Preventive of Gangrene of the Extremities, Annals of Surgery, Feb., IS) 1:2. 
 
 Borst and Enderlen: Ueber Transplantation von Gefiissen und ganzen Organen, 
 Deut. Zeit. f. Chir., Bd. 99, Heft 1-2. 
 
 Carrel, A.: Anastomosis and Transplantation of Blood-vessels, American Medi- 
 cine, August, 1905. 
 
 Carrel, A.: Latent Life of Arteries, Jour, of Exper. Mfd., I'.HO. vol. xii. 
 pp. 460-486. 
 
 Faykiss, Franz v. : Ueber Gefiisstransplantationen, Beitr. /.ur klin. C'liir., Bd. 78, 
 Heft 3. 
 
 Goecke: Extirpation eines Aneurysina der Art. poplitea und ersatz des Defekts 
 durch freie Transplantation eines Sttickes der Vena saphena, Med. Klinik. 
 1912, p. 105, No. 3. 
 
 Omi, K. : Beitriige zur idealen Aneurysma-operation. Ueber die zirkulr.sc 
 Gefiissnaht und fiber die Transplantation der Gefasse am Menschen, Dent. 
 Zeit. f. Chir., 1912, Bd. 118, Heft 1-2. 
 
 Watts, Stephen H. : The Suture of Blood-vessels; Implantation and Transplan- 
 tation of Vessels and Organs; An Historical and Experimental Study. Johns 
 Hopkins Hosp. Bull., 1907, vol. xviii, p. 153. 
 
 Yamanouchi: Ein Beitrag zur idealen Operation des arteriellen Aneurysma. 
 Deut. Zeit. f. Chir., 1912, Bd. 118, Heft 1-2.
 
 CHAPTER VI 
 
 ARTERIOVENOUS ANASTOMOSIS REVERSAL OF THE CIRCULATION 
 
 ARTERIOVENOUS anastomosis or so-called reversal of the 
 circulation l is an operation charily employed at present, but 
 capable of great development for the relief of many condi- 
 tions. To illustrate the use of the procedure, in the supposed 
 case of an obstruction in an artery caused by a thrombus or 
 growth, where it is inconvenient or impossible to make a 
 complete arterial or venous transplant, after resection of the 
 artery its proximal end can be united to the distal end of a 
 severed vein. After extirpation of an aneurism or a growth 
 involving the vessels, an arteriovenous anastomosis may be 
 the most desirable operation to overcome the break in the 
 circulation. In cases of threatened gangrene of the extrem- 
 ities resulting from obstruction of the arterial channel, this 
 operation may be the only means of saving the limb. 
 
 The operation may be accomplished either by means of the 
 end-to-end method of Carrel, or by a lateral suture. Since 
 the- union of the vessels for the relief of this condition is 
 always made in Scarpa's triangle in the leg, and in or just 
 below the axilla in the arm, the end-to-end method requires 
 the vessels to be severed in regions which are usually far 
 above the site of the obstruction. In the method of lateral 
 anastomosis the artery, being undisturbed, is left to carry 
 the blood as far as the obstruction, the burden of carrying it 
 further being shifted to the vein. In other words the end- 
 to-end method unnecessarily destroys entirely a channel 
 that is only partially blocked, while the lateral method 
 leaves it intact, simply adding another channel by means of 
 which the blood may be carried as far as necessary. For 
 
 1 First performed by San Martin y Satrustegui in 1902. 
 
 53
 
 54 SURGERY OF THE VASCULAR SYSTEM 
 
 this reason those who have had most experience with this 
 operation now exclusively employ the lateral method, unlos. 
 as happened in one of my cases, the artery is blocked almost 
 throughout its entire course. 
 
 During recent years a number of attempts to reverse the 
 circulation of a limb have been made, most of them ending 
 in failure. In February, 1912, I collected and reported 52 
 cases myself, only 15, or 30 per cent, of the total number, 
 being considered successful. The seemingly poor result > in 
 this field of work had previously given rise to a certain amount 
 of scepticism as to the possibility of performance of this 
 operation from a physiological standpoint, and had caused a 
 discussion between- Coenen of Breslau and Wieting 2 of Con- 
 stantinople as to the efficacy of an arteriovenous anastonm-i- 
 reversal of the circulation in preventing the spread of a 
 real or threatened gangrene in the extremity of a human. 
 
 Coenen claims that Carrel's statements and experiments 
 in regard to the possibility of reversing the circulation in a 
 dog are not conclusive; that, in fact, the valves of the veins 
 do not give way as Carrel asserts, and that as a result a true 
 and complete reversal is never attained, the blood being 
 simply shunted off to another vein and promptly returned to 
 the heart without ever getting to the foot or hand. He further 
 asserts that the procedure is both anatomically and physio- 
 logically wrong, and he therefore warns against the indis- 
 criminate use of the operation. 
 
 Wieting, on the other hand, claims that in his hands the 
 operation is clinically quite successful, although he admits 
 that several questions, such as the return of the blood to 
 the heart, are still unsettled. He is of the opinion that tin-so 
 
 *This operation is known abroad as Wietinp's operation. If it is to go by 
 any man's name it should be that of San Martin y Satrustegui, who, as noted 
 above, first performed the operation clinically. I prefer to call it reversal of 
 the circulation.
 
 ARTERIOVENOUS ANASTOMOSIS 55 
 
 doubtful points can be solved only through clinical experi- 
 ence, theories and experimental work not having given the 
 required solution. 
 
 After his first utterance on the subject Coenen continued 
 his experimental work and claims in later publications to 
 have obtained additional evidence in support of his views, 
 while Wieting continues to have a varying amount of success 
 clinically with the operation. 
 
 I feel that there can be little doubt as to the correctness 
 and truth of Carrel's assertion that complete reversal of the 
 circulation is possible in the dog. Experienced, careful 
 worker that he is, unexcelled as a technician, his articles must 
 convince any unbiased reader, and his beautiful specimens, 
 showing destruction of the vein valves by the arterial current, 
 speak for themselves. Even Gruthrie ("Blood Vessel Sur- 
 gery," p. 161) admits the possibility of reversal in the limb 
 of a dog, while denying this for the human, although his ex- 
 perience with the latter was nil, and his deductions entirely 
 theoretical. My own animal experiments are in accordance 
 with those of Carrel and Guthrie, and it is inexplicable to me 
 why Coenen was unable to get similar experimental results. 
 
 Practically, in dealing with the human, the matter is some- 
 what different. Pathological considerations, such as arterio- 
 sclerosis, thrombo-angeitis obliterans, etc., give rise to com- 
 plications not encountered in experimental work. The opera- 
 tion must not be attempted in the presence of these conditions, 
 not only because the blood cannot be driven through a channel 
 that is obstructed or obliterated, but also because vessels 
 diseased, hardened, thickened, and roughened inside do not 
 permit of a successful suture a thrombus will invariably 
 form at the line of suture because the endothelial lining of 
 the vessel is abnormal or even at times lacking. 
 
 It is likewise a mistake to attempt to save a limb already 
 lost, one that is so far advanced in the process of gangrene
 
 56 SURGERY OF THE VASCULAR SYSTEM 
 
 as to put beyond question any hope of its rescue. These and 
 other factors related to the subject I have tried to emphasize 
 in articles written during the last four years. It is impossible 
 to bring the dead back to life ; it is a hopeless task to attempt 
 the rejuvenation of sclerosed or thrombosed blood-vessels; 
 yet this has all but been attempted, not once but many times. 
 One has but to read the reports of the various cases to 
 realize the absolute hopelessness of many of those chosen. 
 It is little wonder that doubt arose as to the possibility of 
 accomplishing this operation, which, by exercising proper 
 care in selecting the case, and in the hands of an operator 
 skilled in the suturing of blood-vessels, is an entirely feasible 
 procedure. 
 
 Cases must be secured before actual gangrene arises 
 that is, in the stage of threatened gangrene. If gangrene has 
 already set in, it is best to let the process subside or localize, 
 and then to do the reversal in the hope of preventing further 
 encroachments. The age of the patient has little or nothing 
 to do with the question; the condition of his limb and the 
 age and condition of his vessels are paramount in importance. 
 
 It must be remembered that senile gangrene is not the 
 only form of gangrene. Certain cases of Raynaud's disease 
 frequently progress to the stage of threatened or real gan- 
 grene, and occasionally an embolus lodging in an artery will 
 give rise to most alarming circulatory disturbances, some- 
 times causing actual gangrene. 3 All such cases, properly 
 selected, should be subjected to reversal of the circulation 
 rather than amputation, an operation that is being gradually 
 discarded by the modern surgeon. 
 
 I have reversed the circulation in the hope of preventing 
 gangrene nine times, with six successes, one doubtful case, 
 
 *No case of diabetic gangrene has as yet presented itself for operation. 
 I Bee no reason why the operation should not be done in this condition in 
 suitable cases.
 
 ARTERIOVENOUS ANASTOMOSIS 57 
 
 and two failures, amputation being required in the last two. 
 There was no mortality, and in my opinion there is no reason 
 for a greater mortality following this operation than after 
 any other of equal severity. I hold this view notwithstanding 
 the discouraging records of similar cases in the hands of 
 other surgeons, who, I think, have met such ill success prin- 
 cipally because their patients were so weakened at the time 
 of operation that they could not withstand its shock, just 
 as they would have been unfit to withstand the shock of any 
 other operative measure. Unfortunately, convalescence in a 
 number of the recorded cases has been cut short by infection. 
 In answer to the contention of Coenen and his followers 
 that the blood is unable to force the vein valves and that 
 therefore it does not flow down the vein to any great extent, 
 I wish to cite the case of one of my patients, a young woman 
 now twenty-eight years of age, in whom I have successfully 
 reversed the circulation of all four extremities to prevent 
 both real and threatened gangrene and to relieve excruciating 
 pain in a severe case of Raynaud's disease. In February, 
 1911, I performed an end-to-end anastomosis of the femoral 
 artery and vein (in Scarpa's triangle) of the left leg, and in 
 May of the same year a lateral anastomosis, according to the 
 method of Bernheim and Stone, 4 of the femoral vessels of the 
 right leg. Complete relief was obtained in the left limb, but 
 the intervention of another surgeon ten days previous to my 
 operation lessened the degree of success in the right. In the 
 hope of avoiding the vascular operation in this leg, the 
 sciatic nerve of the patient had been stretched after which 
 the pain not only was augmented but paraesthesia of the lower 
 limb and a foot-drop occurred conditions which the reversal 
 which followed could not be expected to relieve. The circu- 
 lation in this limb, however, was restored, and its general con- 
 
 4 See chapter on Lateral Anastomosis.
 
 58 SURGERY OF THE VASCULAR SYSTEM 
 
 dition has improved but the pain has persisted, though 
 lessened. 
 
 Early in 1912, the same condition pain, actual and threat- 
 ened gangrene necessitated reversal of the circulation in 
 both arms of this patient. This was successfully performed 
 on January 23, 1912, in the left arm, and on March 5 of the 
 same year in the right arm, lateral anastomosis of the 
 brachial artery and vein at the lower edge of the axilla being 
 the operative procedure in each instance. 
 
 At the time of operation on the left arm, the little finger 
 of that hand was partially gangrenous and amputation was 
 postponed only in the hope that reversal might save it. I am 
 happy to report that the circulation improved in that finger 
 immediately after the operation and remained so good that ;i 
 slough formed and the finger healed perfectly within a short 
 time thereafter. 
 
 The patient has been relieved of all symptoms in all ex- 
 tremities except the right leg, where the lack of complete 
 success has been explained. She is now active and able to 
 attend to her duties. A definite pulsation can be felt at the 
 sites of all four anastomoses and can be followed down the 
 veins of both arms well below the elbows. Indeed, pulsation 
 can even be seen in the veins of the arms. In the legs pul- 
 sation can only be felt a few inches below each fistula, but 
 this is due to the great thickness of the tissues overlying the 
 vessels in the lower extremities. In addition to the palpable 
 pulsation, there is a definite thrill at the site of each anasto- 
 mosis which is easily felt. It can be followed down the lower 
 extremities with the fingers only an inch or so, because of the 
 thickness of the overlying tissues, but in the arms it is beau- 
 tifully traced to and below the elbow. With the stethoscope 
 these thrills are heard to be quite powerful, humming-top 
 in character. In the lower extremities they can be traced 
 down into the popliteal spaces, in the arms to both wrists. 
 
 The patient was shown before The Interurban Orthopedic
 
 ARTERIOVENOUS ANASTOMOSIS 59 
 
 Club which met at the Johns Hopkins Hospital, November 18 
 and 19, 1912. At that time, in addition to being examined by 
 the members of the club, she was examined by Dr. W. S. 
 Halsted and Dr. John M. T. Finney, all of whom agreed that 
 the blood was definitely going down the veins. The case has 
 also been passed upon by Dr. Joseph C. Bloodgood, in whose 
 clinic at St. Agnes' Hospital and by whose courtesy I was 
 privileged to do the operations. 
 
 I have given a detailed account of this case because it is 
 the only existing record of successful reversal of the circu- 
 lation in all four extremities of the same individual, and I 
 offer it as incontrovertible substantiation for upholding this 
 operation. 
 
 I summarize herewith the necessary precautions to be ob- 
 served before proceeding to operation in a case of this sort : 
 
 1. Select the cases with utmost care, (a) ruling out those 
 in which a fulminating gangrene is present; (b) ruling out, 
 or postponing until the condition is improved, those in which 
 the patient is so debilitated as to be unable to withstand any 
 operative procedure; (c) ruling out those in which the vessels 
 (artery and vein) are evidently obstructed or markedly 
 sclerosed. 
 
 2. If there is any doubt about any case, cut down upon 
 and expose the vessels; then, if they are suitable for anas- 
 tomosis, the operation can proceed ; if not, it is best to resort 
 immediately to amputation. 
 
 3. Last and most important, the operator must be a man 
 of experience and good judgment in vascular surgery. 
 
 I conclude this chapter with emphasis of the fact that 
 relief from pain cannot always be relied upon to follow im- 
 mediately after operation. Sometimes it does, but in other 
 cases it is withheld for days, sometimes weeks. Anodynes 
 should be freely given. The limb should be kept in a plaster 
 cast for three weeks. At the end of the first week it should
 
 60 SURGERY OF THE VASCULAR SYSTEM 
 
 be removed for the taking out of skin stitches and for an 
 examination by stethoscope of the anastomosis. If at this 
 time a thrill can be heard and the gangrene is checked or 
 averted, the operator is justified in anticipating success. The 
 absence of the thrill, however, at this time need not be in- 
 terpreted as an indication of failure, unless the gangrenous 
 condition has become aggravated. 
 
 REFERENCES 
 
 Bernheim, B. M., and Stone, H. B. : Lateral Vascular Anastomosis, Annals of 
 
 Surgery, Oct., 1911, p. 4!(i. 
 Bernheim, B. M. : Arteriovenous Anastomosis Reversal of the Circulation as 
 
 a Preventive of Gangrene of the Extremities, Annals of Surgery, Feb., l!M2, 
 
 p. 195. 
 Bernheim, B. M. : Arteriovenous Anastomosis Successful Reversal of the 
 
 Circulation in all Four Extremities of the Same Individual, Jour. AHUM. 
 
 Med. ABSOC., Feb., 1913, p. 360. 
 Buerger, L. : Thrombo-angeitis Obliterans; a Study of the Vascular Lesions 
 
 Leading to Presenile Gangrene, Amer. Jour. Med. Sc., 1908, vol. cxxxvi, 
 
 p. 567. 
 Buerger, L. : The Veins in Thrombo-angeitis Obliterans, with Particular 
 
 Reference to Arteriovenous Anastomosis as a Cure for the Condition, Jour. 
 
 Amer. Med. Assoc., 1900, vol. Hi, 1913. 
 Carrel, A., and Guthrie, C. C. : The Reversal of the Circulation in a Limb, 
 
 Annals of Surgery, 1906, vol. xliii. 
 
 Coenen, H.: Miinch. med. Woch., 1912, Bd. 59, No. 29. 
 Coenen, H., and Wiewiorowski : Ueber das Problem der Umkehr des Blutstromes 
 
 und die Wietingsche Operation, Beit. z. klin. Chir., 1911, Bd. 75, Hft. 1 
 
 and 2. 
 Daviea, H. Morriston: The Value of Arteriovenous Anastomosis in Gangrene of 
 
 the Lower Limb, Annals of Surgery, June, 1912, p. 864. 
 Glasstein: Ueber die Behandlung der angiosklerotischen Gangriin der untcn-n 
 
 Extremitiit mittels arteriovenoser Anastomose, Berl. klin. Woch., No. 41, 
 
 1911. 
 Heyman: Zur Gefiisschirurgie, Arterien-Venen-verbindung, Deut. med. Woch., 
 
 No. 34, 1911. 
 Oppenheim: Zur Lehre von den Neurovaskxiliiren Erkrankungen, Deut. Zeit. f. 
 
 Nervenheilkunde, Bd. 41, Heft 4-6, 1911. 
 Wieting, Pasha: Die angiosclerotische Gangriin und ihre operative Behandlung 
 
 durch Ueberleitung des arteriellen Blutstromes in das Venensystem, Deut. 
 
 Zeit. f. Chir., 1911, Bd. 110, p. 364. 
 Wieting, Pasha: Die erfolgreiche Behandlung der angiosklerotischen ErTiiili- 
 
 rungsstorungen durch die Arteriovenose Anastomose, Deut. Zeit. f. Chir., 
 
 Nov., cxix, Nos. 5 and 6, pp. 369-590.
 
 CHAPTER VII 
 
 VARICOSE VEINS 
 
 VARICOSE veins are usually seen in the lower extremities 
 in adults, although they may occur in any part of the body. 
 Many causes have been assigned to this condition obstruc- 
 tion to the venous return from pregnancy, tumor of the pelvis 
 or some other form of pressure, cardiac weakness, congenital 
 venous defect, etc., but whatever may be its origin in a given 
 case there is a gradual but progressive valve failure in the 
 superficial veins, amounting in the last analysis to complete 
 destruction and insufficiency. Once this condition has arisen, 
 it can be cured only by operation, although the symptoms can 
 be frequently relieved to a greater or lesser extent by baths, 
 change of occupation, pressure bandage, and a number of 
 other well-known measures. 
 
 The operation of Schede, and its modifications, and that 
 of Trendelenburg and its modifications, have been widely 
 employed and have been followed by varying measures of 
 success. The first consists in a division by partial or com- 
 plete circular incision in the upper third of the leg of all the 
 superficial veins, including the long and short saphenous, 
 down to the deep aponeurosis. Two such incisions may be 
 made, or there may be one spiral incision circling the leg two 
 or three times, according to the various modifications, all of 
 which have for their purpose the division of the superficial 
 veins of the limb at different levels. 
 
 Trendelenburg 's operation, consisting of division and 
 ligation of the long saphenous at the point of junction of the 
 lower and middle thirds of the thigh, was subsequently 
 modified by its author by ligating the saphenous in two addi- 
 tional places just above the internal condyle and just below 
 
 61
 
 62 SURGERY OF THE VASCULAR SYSTEM 
 
 the knee. The vessel is exposed through small incisions at 
 right angles to its course and ligated between two ligatures, 
 each end being doubly ligated. The operation is usually per- 
 formed under local anaesthesia. 
 
 Better than either Schede's or Trendelenburg's operation 
 is the method of resecting the offending veins. This may 
 be either partial or complete, and is best accompli si led l>y 
 two incisions one extending from the upper end of the 
 saphenous vein down to the upper limits of the knee, the 
 other extending from the lower limits of the knee down to 
 the ankle, or as far as the varices extend. It is necessary to 
 interrupt the incision at the knee in order to avoid scar 
 formation, which is frequently painful and might cause un- 
 necessary functional disturbance of the joint. The vein at 
 the knee is easily removed subcutaneously by working down 
 from the upper incision and up from the lower incision. If 
 all varices cannot be removed by making the two cardinal 
 incisions, as outlined, additional incisions must be resorted 
 to. The operation is rather a formidable one, but the results 
 justify its use in practically all cases where operation is 
 indicated. 
 
 The subcutaneous method of removing varicose veins 
 by means of a vein enucleator as suggested by C. H. Mayo 
 in 1906 has not stood the test of time and need only be 
 mentioned in passing. 
 
 In 1906 Delbet suggested and carried out an operation, 
 saphenofemoral anastomosis, by which he proposed to relieve 
 a certain group of varices by reimplantation of the saphenous 
 vein, the valves of which have become incompetent, into the 
 femoral vein at a site 10 or 12 cm. lower than the original 
 and normal junction and below one or more sets of com- 
 petent valves. Delbet reported eight cases, and at the German 
 Surgical Society in 1911, Hesse and Schaack brought the 
 number of cases up to forty-eight, one death from infection
 
 VARICOSE VEINS 63 
 
 having occurred in their own series of twenty-three cases, 
 the other twenty-two being considered cured, although 
 sufficient time had hardly elapsed to permit of any such 
 determination. 
 
 It is not my intention to give the details of this operation 
 nor to discuss its theoretical possibilities. Those interested 
 may refer to the original papers, references to which are 
 appended. I do, however, wish to go on record as un- 
 qualifiedly condemning this operation as a pernicious use of 
 the blood-vessel suture. It is dangerous, in that it converts 
 a condition that in the great majority of cases can be relieved 
 by simple and practically harmless measures into one that 
 requires for its relief a most delicate major operation, one 
 that in unskilled hands will most certainly be followed by 
 dire consequences. So far as I am aware the operation has 
 not been practised in this country. 
 
 Simple ligation, excision, partial or complete these are 
 measures practically devoid of danger, and as the condition 
 itself is in the majority of cases more annoying than serious, 
 it seems unnecessary and unwise to employ a difficult and 
 dangerous operation where other far simpler means offer 
 relief. 
 
 REFERENCES 
 
 Delbet, P.: Traitement des variees par 1'anastomose saphenofemorale, Le Bul- 
 letin medical, 1900, Xo. 99. 
 
 Hesse, E., and Sehaack, W. : Die sapheno-femorale Anastomose, eine Ueberpflanz- 
 ung der Vena saphena in die Vena femoralis nrittelst Gefassnaht als 
 operative Behandhmgs-methode bei Varicen, Verhandlung der deutsche 
 Gesellschaft fur Chirurgie, 1911, Xo. 40, p. 147. Also Annals of Surgery, 
 1912, vol. Iv, p. 170; Arch. f. klin. Chir., Bd. 59, 1911. 
 
 Madelung: Verhandl. der deutsch. Gesellschaft f. Chir., 1884. 
 
 Mayo, C. H. : Surgery, Gynaecology, and Obstetrics, 1906. 
 
 Miller, R. T.: Bull. Johns Hopkins Hosp., Sept., 1906. 
 
 Schede, M.: Arch. f. klin. Chir.. Bd. 43, 1892. 
 
 Trendelenburg: Beitriige zur klin. Chir., Bd. 58, 1908.
 
 CHAPTER VIII 
 
 SURGERY OF THE HEART 
 
 SURGERY of the heart consists chiefly in attempting to 
 suture bullet and stab wounds, accidental or self-inflicted, 
 although there is an increasing number of recorded cases of 
 pericardiotomy drainage of the pericardium and of cardio- 
 lysis resection of the ribs overlying an adherent pericardium. 
 
 Coincident with the advance of surgical teclmic, there 
 has been a gratifying increase in the self-confidence of the 
 modern surgeon, so that those individuals unfortunate enough 
 to receive an injury to the heart now have a pretty fair 
 chance for life provided they live long enough to be b rough t 
 to a well-equipped hospital. The usual method in such n 
 case, a proper diagnosis having been made, or, when this is 
 impossible, signs and symptoms sufficient to warrant explora- 
 tion having been obtained, is hurriedly but freely to expose 
 the heart either by resecting the two or three ribs overly inir 
 it or by making a trap-door exposure. If the pleura has not 
 been wounded it should be displaced outward. The peri- 
 cardium is opened by a longitudinal incision, the heart is 
 grasped by the left hand and lifted out, the tip of a finger 
 being placed over any wound that may be encountered in 
 order to control bleeding. With a large, round, curved 
 needle, threaded with catgut (silk, too, may be used), the 
 wound is closed either by a simple through-and-through con- 
 tinuous stitch or by several interrupted stitches, after which, 
 all blood having been removed from the pericardial cavity, 
 the heart is carefully replaced in its bed. 
 
 In a paper on "Experimental Surgery of the Mitral 
 Valve," written in 1909, I remarked that it seemed to me 
 more conservative never to close completely the pericardium 
 
 64
 
 SURGERY OF THE HEART 65 
 
 after it had been opened to suture a wound of the heart. A 
 small opening left at the most dependant part of the in- 
 cision would take care of any little ooze or leakage that might 
 occur, which in a closed sac might seriously embarrass the 
 heart action. I still hold to this opinion to the extent of 
 advising that its adoption as a rule might in the great ma- 
 jority of instances obviate the necessity of inserting a drain 
 in the pericardium; any collection of fluid, pus, serum, or 
 blood would be forced out into the pleural cavity or, if this is 
 intact, into the tissues beneath the incision, where signs of 
 its presence would soon be given. 
 
 In cases where the patient is exsanguinated and in col- 
 lapse, an intravenous infusion of warm salt solution should 
 be started while the preparations for operation are in 
 progress. As a last resort direct transfusion of blood may 
 be given either during the course of the operation or imme- 
 diately upon its conclusion. 
 
 It is probable that many unsuccessful attempts to suture 
 heart wounds are never reported; therefore any statistics 
 that may be given must not be accepted too literally. Rehn 
 in 1907 collected and reported 124 cases with 49 recoveries 
 (39.5 per cent.) and 75 deaths (60.5 per cent.). Of the 75 
 fatalities, 16 died on the operating table, 17 died from loss 
 of blood and collapse within two days, 30 died of infection- 
 purulent pericarditis and empyema. In many cases the 
 urgency of the case prevented disinfection of the field a 
 difficulty that the iodine technic should overcome in future 
 cases. One patient (Cferzen's) died of sudden hemorrhage 
 on the fifty-third day. 
 
 Statistics later than those of Rehn's are those reported 
 by Hesse, who gives 219 cases with 103 recoveries (47 per 
 cent.) and 106 deaths (53 per cent.), and of Simon, who re- 
 ports 241 cases with 117 recoveries (49 per cent.) and 124 
 5
 
 66 SURGERY OF THE VASCULAR SYSTEM 
 
 deaths (51 per cent.). It will thus be seen that the number 
 of cases saved is gratifyingly large. 
 
 Cardiolysis is an operation that was introduced in 1902 
 by Brauer of Heidelberg for the relief of adherent peri- 
 cardium. It consists of a subperio steal resection of the pre- 
 cordial ribs, to the under surface of which the pericardium is 
 adherent. A number of successful cases have been reported 
 not only by Brauer but by others, and this simple method of 
 treatment promises to revolutionize the therapy of adherent 
 pericardium. 
 
 According to Hirschf elder, "As regards the indications 
 for cardiolysis, it would appear that since the adherent peri- 
 cardium cannot otherwise be relieved, this operation is 
 worthy of trial whenever symptoms of cardiac weakness 
 occur and recur in a patient with well-marked adhesions to 
 chest wall (tugging in of the lower ribs, fixation of the left 
 border of flatness on inspiration, immobility of the apex) 
 and recur in spite of general cardiac hygiene." 
 
 Pericardiotomy is an operation in which the pericardium 
 is freely opened and drained, and is most frequently resorted 
 to for purulent effusions, although it may be required to 
 relieve a simple serous ha?mo- or pneumopericardium. Ex- 
 posure of the pericardium is usually obtained by resecting 
 close to the sternum the fourth, fifth, and sixth costal car- 
 tilages; sometimes a satisfactory exposure will be obtained 
 by resecting only one costal cartilage, while in other instances 
 two or even all three will have to be removed. The chief 
 dangers are wounding of the internal mammary artery and 
 entering the pleural cavity, accidents that can be avoided by 
 careful work in the vast majority of cases. The opened peri- 
 cardium should be thoroughly irrigated with warm salt 
 solution, the operation being performed under light anaes- 
 thesia. A soft rubber tube or protective wick should be left
 
 SURGERY OF THE HEART 67 
 
 to drain the pericardium and the whole wound should remain 
 open in order that further irrigation may be instituted should 
 necessity arise. 
 
 REFERENCES 
 
 Bernheim, B. M. : Experimental Surgery of the Mitral Valve, Johns Hopkins 
 
 Hosp. Bull., 1909, vol. xx, 107. 
 Brauer, L.: Cardialyse, Miinchen. med. Woch., 1902, Bd. 49, 982. Untersuch- 
 
 ungen an herzen Cardiolysis und ihre Indikationen, Arch. f. klin. Chir., 
 
 Berl., 1903, Bd. 71, 258. 
 Delatour, A. B. : Surgery of the Pericardium and Heart, Am. Jour. Surgery, 
 
 1909. 
 Delorme, E., and Mignon: Sur la ponction et incision du pericarde, Rev. de 
 
 Chir., Par., 1895, vol. xv, pp. 797, 987, and 1896, vol. xvi, p. 56. 
 Hesse, Erich: Beitr. z. klin. Chir., Bd. 75, Heft 3. 
 Hirschfelder, A. D.: Diseases of the Heart and Aorta, 1912. 
 Rehn, L. : Zur Chirurgie des Herzens und des Herzbeutals, Arch. f. klin. Chir., 
 
 1907, Bd. 83, 723. 
 Simon: Ueber Schusverletzungen des Herzens, Deut. Zeit. f. Chir., Bd. 115, 
 
 Heft 3-4. 
 Wagner, A.: Beitrag zur Chirurgie des Herzens, Deut. Zeit. f. Chir., 1912, 
 
 Bd. 119. 
 Mitchell, Charles F. : Stab- wound of the Heart; Recovery after Suture, Annals 
 
 of Surgery, Feb., 1913, p. 296. 
 Konig: Technic for Access to Suture of the Heart, Deut. Zeit. f. Chir., vol. cxii, 
 
 Nos. 4 and 6. 
 Poole: Annals of Surgery, April, 1912.
 
 CHAPTER IX 
 
 ANEURISMS 
 
 THERE are several different methods of dealing with 
 aneurisms, speaking generally, and I shall take up, in detail, 
 those that have given the best results. Before opening the 
 subject, I wish to call the attention of the reader to the fact 
 that, due to anatomical conditions, in certain regions of the 
 body there is little or no choice of operation; in others, there 
 is a very wide choice, and the success or failure of the pro- 
 cedure may depend on the type of operation selected. For 
 example, aneurisms involving the arch of the aorta lend them- 
 selves to practically but one form of surgical interference- 
 wiring while those involving the popliteal artery may he 
 treated by any one of several different methods simple 
 ligation, endo-aneurismorrhaphy, excision, extirpation and 
 arterial suture, etc. Aneurisms of the abdominal aorta are 
 usually best handled by wiring, especially those occurring 
 above the renal vessels, but Halsted's aluminum band has 
 been successfully applied, and actual ligation of the aorta has 
 been performed. Arterial suture may possibly be of service 
 here provided the aneurism is of such size and position that 
 it can be excised. It is a question as to whether Matas's endo- 
 aneurismorrhaphy will ever be successfully applied to the 
 aorta, although it should always be kept in mind. On the 
 other hand there is little or no choice when it comes to 
 handling aneurisms involving the great vessels at the root of 
 the neck. Halsted's band has a certain usefulness, and it is 
 possible that Matas's operation may be of limited service, 
 but in the great majority of cases simple ligation is the only 
 measure that offers the slightest hope of success, and this is 
 
 68
 
 ANEURISMS 69 
 
 often as difficult and delicate and dangerous a piece of work 
 as falls to the lot of the surgeon. 
 
 It is unnecessary to devote a special section to the method 
 of extirpating an aneurism or of ligating an artery. The 
 application of general surgical principles is all that is re- 
 quired, care being exercised to obtain a proper exposure. In 
 the tying of all vessels, two ligatures are commonly used; 
 these should be separated by an interval of from a quarter 
 to half an inch. Both ligatures should be of heavy ma- 
 terial so as to minimize as much as possible the liability of 
 cutting through the vessel wall and consequent hemorrhage. 
 Kangaroo tendon is an excellent material it is heavy, strong 
 and has the very slight degree of elasticity that is greatly to 
 be desired. 
 
 The following methods, then, of dealing with aneurisms 
 will be described: (1) Matas's endo-aneurismorrhaphy; (2) 
 the Moore-Corradi wiring operation; (3) Halsted's method 
 of gradual occlusion. 
 
 ENDO-ANEURISMORRHAPHY ( MATAS ) 
 
 This operation commonly known as the "Matas opera- 
 tion" was first practised by its author on March 30, 1888, 
 the patient being a man who was suffering from an aneurism 
 of the brachial artery that had resisted proximal and distal 
 ligature. Success crowned Matas's effort, and the operation 
 as it has been developed has come to be one that can be relied 
 upon to give constant results in a class of cases which 
 formerly tried the patience and resources of both patient 
 and surgeon, and not infrequently ended in the crippling or 
 destruction of the former. 
 
 The method comprises two separate and distinct forms 
 of operation, the choice of one of these being entirely depend- 
 ent on the type of aneurism under consideration. The first
 
 70 SURGERY OF THE VASCULAR SYSTEM 
 
 and most widely used form, the obliterative endo-aneurismor- 
 rhaphy, is used "in those aneurisms in which the parent 
 artery is entirely lost at the site of the aneurism by expand- 
 ing into the aneurismal sac throughout its circumference; 
 also those in which the friability or diseased state of the 
 sac wall is such as to preclude all possible use as plastic 
 material (atheroma, calcareous degeneration). In these 
 cases there are always two orifices within the sac separated 
 by variable intervals, and there is no visible outline of the 
 main artery in the interior of the sac. Except in unusual 
 conditions no attempt is made to restore the continuity of 
 the parent artery; the blood stream is interrupted in that 
 part of the vessel which directly opens into the sac, and the 
 arterial orifices are simply closed by suture, thus shutting 
 off the sac cavity from all visible source>s of blood supply." 
 
 The second form, the restorative or reconstructive endo- 
 aneurismorrhaphy, has a more limited field of usefulness in 
 that it is only indicated in definite saccular aneurisms, or 
 those in which there is a "well-defined and deep furrow or 
 gutter leading from the inlet to the outlet of the sac. This 
 deep groove or fissure furnishes the outline of the parent 
 artery, which is easily restored without obliterating the 
 main channel." 
 
 In the obliterative type of operation, after all pulsation 
 and bleeding into the sac has been absolutely controlled by 
 temporary ligatures or the application of Crile clamps to 
 the vessels outside the aneurism, a longitudinal incision is 
 made through the wall of the sac, so as thoroughly to ex- 
 pose all visible orifices within it. If any loosely adherent 
 clots are present, as they usually are, they should be care- 
 fully wiped out, after which all orifices are closed (Fig. 50) 
 by rather deep interrupted or continuous sutures of chromic 
 catgut, No. 1, 2 or 3, according to the size of the aneurism,
 
 ANEURISMS 
 
 71 
 
 threaded on half or full-curved round needles. The cavity 
 of the sac is then totally obliterated by rows of sutures 
 placed in its walls. This is occasionally difficult to accom- 
 plish because of the frequent large size of the cavity, the 
 thickness of the sac wall, and the general density of the 
 surrounding tissues, but by taking advantage of the natural 
 
 FIG. 50. Obliterative endo-aneurismorrha- 
 phy (Matas). Orifices in aneurismal sac being 
 obliterated by suture, when restoration or recon- 
 struction of arterial channel is impracticable. 
 (Keen's Surgery, vol. v.) 
 
 FIG. 51. Restorative endo-aneurismor- 
 rhaphy (Matas) applied to sacculated aneu- 
 risms with a single orifice of communication. 
 Orifice being closed by continuous suture, 
 without obliterating parent artery. (Keen's 
 Surgery, vol. v.) 
 
 folds in the sac wall and by the exercise of a bit of ingenuity, 
 it can nearly always be accomplished without infolding 
 sliding skin flaps, a method to which one must resort very 
 occasionally. Emphasis is laid upon this point because it 
 is always unwise to drain an unruptured, uninfected aneu- 
 rismal cavity. In those that are ruptured or infected at the
 
 72 
 
 time of operation, drainage and healing by granulation 
 should be the method of choice, rather than any attempt to 
 obliterate. the cavity. 
 
 In the restorative or reconstructive form of endo-aneu- 
 rismorrhaphy, after opening the sac an attempt is made to 
 close off the parent artery (Fig. 51) from the sac without 
 
 obliterating the lumen of the 
 artery (Fig. 52). Where the 
 aneurism is of the purely sac- 
 cular variety, and there is only 
 one small opening into the side 
 of the artery, it is a rather 
 simple affair to close this off by 
 interrupted or continuous sut- 
 ures of No. to 00 chromic cat- 
 gut threaded on small curved 
 needles. 
 
 But where a furrow running 
 through the floor of the aneurism 
 is all that remains of the parent 
 artery, conditions are altered and 
 it is a difficult matter to recon- 
 struct the vessel. The use of a 
 catheter, placed in the bed of the 
 vessel, as a guide in suturing 
 facilitates matters, but it would 
 seem best in cases where there 
 is extreme need for the preser- 
 vation of circulation through the main channel to perform 
 an arterial or venous transplantation after complete excision 
 of the aneurism. 
 
 After restoration or reconstruction of the artery the 
 cavity of the sac is obliterated in the usual way, great care 
 being used to make it complete and absolute. 
 
 FIG. 52. Restorative endo-aneuris- 
 morrhaphy (Matas). Aneurismal sac 
 closed off from parent artery. (Keen's 
 Surgery, vol. v.)
 
 ANEURISMS 73 
 
 The chief advantages of the Matas operation over other 
 forms are : 
 
 (1) The collateral circulation of the extremity is. left 
 practically undisturbed. 
 
 (2) There is very little danger of injuring the parent 
 vein a real danger in extirpation and one markedly increas- 
 ing the danger of gangrene. 
 
 (3) The parent artery is obliterated over the least 
 possible extent. 
 
 Statistically Matas reported in 1908 the following: 1 
 
 85 cases operated by 52 surgeons 
 
 59 were of the obliterative type (69 per cent.) 
 
 26 were of the restorative or reconstructive type (30.8 per cent.) 
 
 Recoveries 78 
 
 Deaths 7 
 
 Gangrene 4 
 
 Relapses , 4 
 
 All reconstructive cases 
 
 Secondary hemorrhage 2 
 
 WIRING 
 
 This operation, which is only indicated in certain forms 
 of thoracic and abdominal aneurisms otherwise necessarily 
 inoperable, was devised in 1864 by Moore, of London, and 
 subsequently modified by Corradi, the procedure being at 
 present known as the Moore-Corradi method of wiring 
 aneurisms. 
 
 According to Dr. John M. T. Finney, who has probably 
 had a wider experience with this method of treating 
 aneurisms than any one else in this country, all that is neces- 
 sary as regards technic is a hollow needle not too large in 
 size, insulated with the best quality of French lacquer to 
 within a short distance of its point. Through this a wire 
 made from a silver and copper alloy (Hunner) in the pro- 
 portion of 75 parts copper to 1000 parts silver is passed. 
 
 1 For detailed statistics see Keen's Surgery, vol. v, pp. 279 and 280.
 
 74 SURGERY OF THE VASCULAR SYSTEM 
 
 The wire should be previously wound tightly upon a wooden 
 spool in order to give it a coil, and care should be taken to 
 avoid kinking, as this interferes with its passage through 
 the needle. 
 
 After the skin has been cocainized (supposing a thoracic 
 aneurism is to be treated) and drawn to one side, the needle 
 is inserted slowly until the arterial blood appears in jets 
 through its lumen. The end of the wire which has been 
 previously passed into the needle, but not so far as the point, 
 is now passed directly into the aneurism until the amount 
 wound upon the spool has been introduced into the aneurismal 
 cavity. This amount is arbitrarily chosen to be ten feet. 
 Freeman and some others hold the opinion that the greater 
 the amount of wire introduced into the sac the better, but 
 the prevailing objection to this view is that it prevents the 
 contraction of the resulting clot in the course of its subse- 
 quent organization. 
 
 If the needle is not well insulated, or if it is pushed so 
 far into the aneurismal sac that its non-insulated shoulder 
 comes in contact with the skin, there is danger that an 
 electrolytic burn may result along the needle's track. The 
 consequent slough decreases the strength of the aneurismal 
 wall and is likely to cause leaking at that point. Hare, who 
 also has had considerable experience with the wiring opera- 
 tion, calls particular attention to the necessity for care in 
 this detail. 
 
 With the positive pole attached to the wire and the 
 negative pole at the patient's back, the current is gradually 
 turned on, the routine being 10 milliamperes for the first 
 ten minutes, 20 ma. for the second ten minutes, 30 ma. for 
 the third ten minutes, and so on until about 70 or 80 ma. 
 have been attained; then the current is reduced by the same 
 succession of intervals by which it was advanced, the whole 
 procedure lasting from one to one and a half or even two
 
 ANEURISMS 75 
 
 hours. After the current has been passed through the 
 aneurism for the given time, the needle should be carefully 
 withdrawn with a slight rotary motion, not disturbing the 
 wire, which is, of course, left in the sac. When the needle 
 is entirely withdrawn the wire is cut as short as possible, 
 depressing the skin with the point of the blunt scissors. The 
 skin should then be pinched up with the fingers, until the 
 end of the wire is completely buried beneath its entire thick- 
 ness, and if the precaution of drawing the skin to one side 
 before insertion of the needle has been taken, as suggested, 
 the end of the wire will not remain opposite the skin puncture. 
 This seems a small point, but it is important in order to 
 prevent a certain amount of irritation and the possibility 
 of infection extending down along the course of the wire. 
 Pressure over the wound should be applied immediately upon 
 the withdrawal of the needle, in order to prevent the forma- 
 tion of a haematoma due to the escape of blood into the sub- 
 cutaneous tissue. 
 
 In the case of aneurisms of the abdominal aorta, it is of 
 course necessary to open the abdomen and expose the aneu- 
 rismal sac, at least in part, before insertion of the needle. 
 For the manipulations within the peritoneal cavity > it is 
 usually necessary to give a few whiffs of ether, but the pa- 
 tient is allowed to come out of the anaesthesia and remain 
 conscious during the entire time "that the current is running, 
 the abdominal contents being packed off so as to allow the 
 needle to protrude. Ether may again be necessary in closing 
 the peritoneum, but if morphine has been judiciously used 
 very little will be required. 
 
 The immediate risks of the operation, especially in 
 aneurism of the thoracic aorta, are not great. They consist 
 in the possibility of an end or loop of the wire sliding along 
 the wall of the aorta in the direction of the heart and inter- 
 fering with the action of its valves (its presence in the aorta
 
 76 SURGERY OF THE VASCULAR SYSTEM 
 
 giving rise to no symptoms), or in the formation of emboii 
 which may be swept off by the blood current. These com- 
 plications have occurred only in rare instances. In a case 
 treated by Pasham a loop of wire entered the cavity of the 
 heart without fatal result, the condition being found acci- 
 dentally at autopsy some time after wiring. In another in- 
 stance an embolus necessitated amputation of an arm, but 
 since the patient's aneurism was cured he was content, saying 
 "that he would rather have one arm and no aneurism than 
 two arms with an aneurism." 
 
 The remote risks arise from emboii or sloughing due to 
 a too strong current, sepsis, and from rupture of the 
 aneurismal wall, due to the shunting of the blood current by 
 the new-formed clot against another portion of the aneu- 
 rismal sac. With the possible exception of the last-mentioned 
 risk, others in this advanced day are apparently negligible. 
 
 The immediate benefits of this operation are most striking. 
 Perhaps the most remarkable of all is the diminution of pain, 
 which often begins before the operation is finished. In a 
 number of instances, the patient while still on the operating 
 table has stated that the pain was appreciably decreasing. 
 From this encouraging result one is justified in promising 
 the patient a marked relief from pain, even if no other benefit 
 is derived; and frequently one can guarantee a diminution of 
 the dyspnrea, sometimes so pronounced in advanced cases. 
 
 As a rule the hardening of the clot as shown by the lessen- 
 ing or disappearance of expansile pulsation does not take 
 place for some days or even weeks, but immediate marked 
 diminution in the pulsation of the tumor has been observed 
 in a number of cases. Complete rest in bed for a term of 
 weeks or even months after the wiring is an absolute necessity 
 for the success of the procedure, and it is often difficult to 
 restrain the patient who feels so well two or three weeks after
 
 ANEURISMS 77 
 
 the operation. Hirschfelder especially lays emphasis on the 
 need for bodily and mental rest, and suggests that the ad- 
 ministration of calcium salts both before and after the opera- 
 tion might be of advantage. He further says that, " . . . the 
 treatment (preliminary and post-operative) is quite as im- 
 portant as the operation itself. In justice to both himself 
 and the patient, the surgeon should, before undertaking the 
 case, insist that the patient consent to remain under treat- 
 ment and absolute rest for from three to five months, at least 
 a month of which should precede the operation, and at least 
 another month should elapse after the last trace of expansile 
 pulsation has been felt in the tumor. Only threatened rup- 
 ture of the aneurism or intolerable symptoms justify an 
 operation without prolonged preliminary treatment." 
 
 Finney 2 reported twenty-three personal cases, of which 
 only two were alive at the time of the report, one nearly three 
 years, the other not quite one year after the operation. All 
 patients were men, mostly young men, only two being over 
 fifty years of age. One-half gave a history of lues, and one, 
 who denied it, had a positive Wasserinann. Over 25 per cent, 
 admitted the excessive use of alcohol. In three instances the 
 trouble was apparently of traumatic origin. 
 
 There is little to be hoped for in the way of permanent 
 cure by this operation. The condition is always desperate 
 and with few exceptions absolutely hopeless from the outset. 
 But when one takes into consideration the prompt, almost 
 constant, marvellous relief from that terrific pain so uni- 
 formly suffered by individuals afflicted with aortic aneurism, 
 the almost certain prolongation of life frequently extending 
 over months and years, during which time the patient is up 
 and about and the utter hopelessness for the patient under 
 
 2 Since his original report. Dr. Finney has wired an additional number of 
 cases, the results of which have been extremely gratifying.
 
 78 SURGERY OF THE VASCULAR SYSTEM 
 
 any other form of treatment, it is evident that wiring is a 
 justifiable operation in every case of abdominal and thoracic 
 aneurism where it is not especially contraindicated. 
 
 It has been a recognized fact for years that if the parent 
 vessel of an aneurism could be occluded by some process 
 slow enough to permit a concomitant development of satis- 
 factory collaterals, a great step forward in the treatment of 
 this condition would have been taken. Many surgeons have 
 worked on the subject, always a fascinating one, and numer- 
 ous methods have been suggested and tried out, only to be 
 discarded later on as worthless. The method devised by 
 Professor Halsted in 1905, and practised since then by him 
 and others, has stood the test of time and has proved to be 
 of undoubted value in certain forms of aneurism. Jt consists, 
 in brief, in partially constricting the vessel by means of an 
 aluminum band rolled around the vessel by means of an in- 
 strument specially constructed for that purpose, the idea 
 being that, ''When the lumen had been, perhaps, not quite 
 occluded, complete obliteration might result spontaneously 
 with the conversion of the arterial wall embraced by the band 
 into a solid cylinder of living tissue. This may be considered 
 the ideal closure of an artery." 
 
 The aluminum used varies in thickness from No. 25 to 
 No. 46 (American scale), the finer numbers being used on 
 small vessels, the heavier on larger ones like the aorta. For 
 the common carotid of the human, No. 33 does very well, 
 while perhaps No. 35 or No. 36 would be better for the aorta. 
 Coming as it does in sheets, the metal is cut in strips to fit 
 the band roller, the length of the strip being about that of 
 the circumference of the full artery, the width varying accord- 
 ingly, being about 1 cm. for the thoracic aorta and innominate
 
 ANEURISMS 
 
 79 
 
 artery in man. The distal end must be rounded and "mani- 
 cured" with a nail file to facilitate coiling; the edges are 
 simply smoothed and the proximal end is left square. If 
 these precautions are taken and the aluminum sterilized only 
 once repeated boilings render it too brittle for perfect roll- 
 ing there is practically no danger of a vessel cutting itself 
 on the band, unless it is markedly sclerosed and brittle in 
 which case the band had best not be used at all. 
 
 FIG. 53. A, Halsted's original band roller in the act of curling a metal strip about an artery; 
 B, the improved band roller about to expel a band. 
 
 The band roller is so beautifully illustrated that a detailed 
 description is superfluous (Fig. 53, A and B). It is enough 
 to say that the band, all properly cut and manicured, is 
 ' ' loaded ' ' into the instrument and is curled around the artery 
 by means of a piston or driving-rod, the instrument being 
 gradually withdrawn as the curling proceeds. "The band 
 should be long enough to encircle the artery in its expanded 
 state and the metal should be sufficiently thick and wide to 
 sustain the curl given it by the instrument. If perfectly
 
 80 SURGERY OF THE VASCULAR SYSTEM 
 
 rolled, the inside and outside circles of the metal (there are 
 usually about one and one-half or two circles) touch cadi 
 other at all points of the surfaces of contact and, in con- 
 sequence, the cohesion force is greatest." 
 
 Experience must determine the degree to which a vessel 
 should be occluded, although one may make the general state- 
 ment that if after the rolling instrument has been removed, 
 there is any pulsation below the site of occlusion, the band 
 should be carefully tightened up by a gentle coiling motion 
 of the thumb and first finger until pulsation is imperceptible. 
 This is, of course, perfectly possible without complete stop- 
 page of the blood flow. 
 
 REFERENCES 
 
 Finney, J. M. T. : The Wiring of Otherwise Inoperable Aneurisms, Annals of 
 
 Surgery, May, 1912, p. 661. 
 
 Freeman, L. : Transactions of the Amer. Surg. Assoc., vol. xix, 1901. 
 Halsted, W. S. : Partial, Progressive and Complete Occlusion of the Aorta and 
 
 Other Large Arteries in the Dog by Means of the Metal Band. Jour. Exper. 
 
 Medicine, 1909, vol. xi, p. 373. 
 
 Hare, H. A.: Therap. Gazette, 1900, 1903, and 1905, July, p. 433. 
 Hirschfelder, A. D. : Diseases of the Heart and Aorta, Lippincott, 1912. 
 Lusk, W. C. : The Treatment of Large Aneurisms with Gold Wire and Klec- 
 
 trolysis, with Report of a Case: Experimental Results, Transac. of the Xt-\v 
 
 York Surg. Soc., April 27, 1910. 
 Matas: Keen's Surgery, vol. v.
 
 STATISTICAL, STUDY OF THE TREATMENT OF ANEURISMS 
 
 MOST of the recent statistical studies on the treatment of 
 aneurisms have failed of practical satisfaction because, for 
 the greater part, they have been incomplete and practically 
 all have dealt with the affection in a single vessel and by a 
 single method of treatment. These studies have reviewed 
 the field from the early days of pre-antiseptic surgery and 
 have compared the results of the last half century with those 
 of to-day an interesting but not practically profitable survey. 
 
 It has seemed best to me, therefore, to include in this 
 chapter an analytical study of modern methods and present- 
 day results in such form that it can be of immediate practical 
 help. For example, the surgeon who has in charge a case of 
 aneurism of the subclavian artery or the femoral artery or 
 any of the larger vessels can by the use of the tables which 
 follow ascertain at once the statistics as to mortality, per- 
 centage of cure, liability of gangrene of the extremity or dis- 
 turbance of circulation and function, and the best method 
 of treatment. The painstaking study of Dr. Halsted on the 
 "Common Iliac Artery" 1 gives , such information, but only 
 for the one vessel. 
 
 There is one entirely complete review of the whole sub- 
 ject of aneurisms that by Monod and Vanvert. 2 These 
 authors have made a most remarkable series of studies of 
 blood-vessels in almost every phase of surgery, giving to 
 surgeons of all countries an inestimably valuable work. 
 
 1 W. S. Halsted : The Effect of Ligation of the Common Iliac Artery on 
 the Circulation and Function of the Lower Extremity, Bull, of the Johns 
 Hopkins Hospital, July, 1912. 
 
 2 Revue de Chir., vols. xli and xlii, 1910. 
 
 6 81
 
 82 SURGERY OF THE VASCULAR SYSTEM 
 
 Their carefully compiled tables of results and methods, con- 
 densed and studied in a way somewhat different from the 
 original, are here in grateful acknowledgment incorporated. 
 I shall not state the method of operation done in each 
 case that resulted fatally nor the other small factors that 
 combined to cause the unfortunate result, unless there be 
 some special reason for so doing. The age of patients and 
 the condition of their vessels will likewise be omitted in gen- 
 eral. A consideration of these details, important though 
 they are, would thwart the purpose of this chapter, which, as 
 stated above, is to give to the busy surgeon a concrete idea 
 of the treatment and results of aneurisms in general, to let 
 him know in as short a space of time as possible and as 
 accurately as a study of statistics will permit how he had 
 best' handle a given form of aneurism and what, in general, 
 he might expect if he does follow the advice given. To those 
 who wish to go into the subject at greater length, I would 
 recommend a perusal of Monod and Vanvert 's original 
 memoirs and a study of some of the less pretentious mono- 
 graphs on the subject, references to which are appended. 
 
 ANEURISMS OF THE BASE OF THE NECK. 3 
 
 Included in the monograph of Monod and Vanvert on 
 aneurisms is a series of thirty aneurisms which are arbitrarily 
 classified under the heading "Aneurisms of the Base of the 
 Neck" probably because they do not fit into any one cate- 
 gory, such as subclavian, aortic, or innominate aneurisms, 
 but are, so to speak, hybrid, in that all the vessels at the 
 root of the neck may or may not be involved. And as this is 
 the case it necessarily follows that all these vessels have to 
 be reckoned with in the treatment, a different combination 
 being involved in each instance. 
 
 * Monod and Vanvert, Rev. de Chir., vol. xli, 1910.
 
 TREATMENT OF ANEURISMS 83 
 
 The study and tabulation have been exceedingly difficult 
 and rather unsatisfactory, because, owing to the desperate 
 nature and situation of many of the aneurisms and the con- 
 sequent necessity of ligating one or more of the largest vessels 
 given off from the aorta, but little can be expected in the 
 way of a permanent cure. An improvement and prolongation 
 of life in comfort should in this series constitute a successful 
 result of the operation. To regard the figures in any other 
 light would but give an erroneous picture of the results ob- 
 tained in a condition desperate in practically every aspect. 
 
 I have, therefore, studied and tabulated these cases in the 
 following way : 
 
 1. Cases that are considered complete recoveries by the respective 
 
 authors are classified as such. 
 
 2. Cases which have lived a considerable length of time but have 
 
 ultimately succumbed to the original condition are classified 
 as improved. 
 
 3. Cases which have died on the table or within a few days after 
 
 the operation from whatever cause are classified as imme- 
 diate mortality. 
 
 4. Cases which have been observed for a short time only and then 
 
 lost sight of are classified as doubtful. 
 
 All cases collected between the years 1885 and 1909 : 
 
 Per cent. 
 
 Number of cases 30 
 
 Recoveries 10 = 37 
 
 Improved 7 = 25.9 
 
 Total v 62.9 
 
 Immediate mortality 10 =37 
 
 Doubtful 1 
 
 Eliminated in computation of percentages. 
 
 Unimproved 2 
 
 Eliminated in computation of percentages. 
 
 Immediate death caused by : 
 
 Cases 
 
 Hemorrhage 3 
 
 Suffocation (hemorrhage?) 1 
 
 Cerebral anaemia 1 
 
 Hemiplegia 1 
 
 Exhaustion '. 1 
 
 Coma 1 
 
 Not stated . . 2
 
 84 SURGERY OF THE VASCULAR SYSTEM 
 
 Cause of death in the improved cases : 
 
 C MM 
 
 Rupture of aneurism into pleura 1 
 
 Six months post-operative. 
 
 Rupture of aneurism into pleura 1 
 
 Two years post-operative. 
 
 Not stated 5 
 
 In one case there was apparently complete loss of function in one 
 of the arms, while in another there was partial loss. In no case did 
 gangrene occur. 
 
 Operative procedures: 
 
 1. Ligature of common carotid and subclavian 4 19, with following 
 
 results: 
 
 Deaths 7 
 
 Recoveries 5 
 
 Recoveries with weak arms 2 
 
 Improved 4 
 
 Doubtful 1 
 
 2. Ligature of common carotid alone 1 
 
 One improved. 
 
 3. Ligature of common carotid and subclavian and first part axil- 
 
 lary 1 
 
 One recovery. 
 
 4. Ligature of common carotid and first part axillary 4 
 
 Three recoveries. One death coma. 
 
 5. Ligature of common carotid and innominate 2 
 
 Two deaths. 
 
 6. Ligature of innominate alone 3 
 
 Three deaths. 
 
 In considering these results, depressing though they are, 
 one cannot help but be forcibly impressed with the peculiarly 
 dastardly results following ligation of the innominate artery. 
 Attention to this fact has been called by Savariaud, 5 who 
 collected 12 cases of ligation of this vessel between the years 
 1884 and 1906, no ligations of choice being done after 1895, 
 but two being necessitated during those years by post- 
 
 4 Part of the subclavian stated in about half of the cases only, so I thought 
 l>est to leave out this feature. 
 
 5 Rev. de Chir., 1906, xxxiv, 1.
 
 TREATMENT OF ANEURISMS 85 
 
 operative hemorrhage after ligation of other vessels, one 
 getting well, the other ending fatally. Of the entire 12, one 
 case is not reported completely, four recovered (not stated 
 for how long), and seven died. It follows then as Ellsworth 
 Elliott, Jr., 6 has said, "That ligation of the innominate should 
 have been discarded as a matter of choice is more than 
 justified by the successful results achieved by distal ligation 
 for aneurisms of the innominate or the first part of the sub- 
 clavian or both. Of distal ligation for aneurism of the first 
 part of the subclavian Savariaud has collected nine cases 
 without a death. In four of these in which the common carotid 
 was tied as well, three were completely cured." 7 
 
 ANEURISMS OF THE COMMON CAROTID ARTERY 8 
 
 All cases collected between the years 1894 and 1908 : 
 
 Per cent. 
 
 Number of cases 26 
 
 Recoveries 20=76.9 
 
 Deaths... 3 = 11.5 
 
 Doubtful 2 
 
 Eliminated in computation of percentages. 
 
 Arrested / 1 
 
 Eliminated in computation of percentages. 
 
 Cause of death : 
 
 From hemorrhage during operation 1 
 
 From post-operative pneumonia (35th day) 1 
 
 From hemiplegia and oedema of lungs (3rd day post-operative) .... 1 
 
 Complications : 
 
 Pupillary disturbances, temporary 2 
 
 Mental disturbances, temporary 2 
 
 Facial paralysis 1 
 
 Hemiplegia (one fatal) 2 
 
 8 Annals of Surgery, July, 1912, p. 86. 
 
 7 In all the others there was considerable improvement, as a result of 
 which Savariaud recommends distal ligation of the third part of the subclavian 
 for aneurisms of the first part of that artery, with ligation of the common 
 carotid as well, should the innominate be dilated. 
 
 "Monod and Vanvert, Rev. de Chir., vol. xli, 1910.
 
 86 SURGERY OF THE VASCULAR SYSTEM 
 
 Operative procedures : 
 
 Proximal ligature 8 
 
 Seven recoveries and one doubtful case. 
 
 Distal ligature 3 
 
 One recovery and one doubtful and one arrested case. 
 
 Incision 2 
 
 One recovery and one death. 
 
 Extirpation 12 
 
 Ten recoveries and two deaths. 
 
 A glance at these tables will show that there was no 
 mortality in the 11 cases of simple ligation, but that two 
 deaths occurred in a like number of extirpations. This, it 
 seems to me, is about what one would expect. It is usually 
 more difficult to extirpate an aneurism than to do a simple 
 ligation no matter what vessel is being dealt with, because, 
 owing to the friability of the aneurismal wall and adhesions 
 between it and adjacent structures, especially veins, there is 
 always the prospect of hemorrhage which may at times be 
 uncontrollable. Radical extirpation, therefore, should not be 
 resorted to where some other simpler operation like ligation 
 or Matas's operation of endo-aneurismorrhaphy will answer 
 the purpose just as well. 
 
 LIGATION OF THE INTERNAL CAROTID EXTRACRAXIALLY 
 
 Nine cases collected between the years 1890 and 1906 
 no mortality. 
 
 In one case there was paralysis of the hypoglossal nerve 
 following injury in course of the operation extirpation of 
 the sac of the aneurism. No other complications. 
 
 ANEURISM OF THE SUBCLAVIAN ARTERY 9 
 
 All cases collected between years 1898 and 1908: 
 
 Per cent. 
 
 Number of cases 18 
 
 Recoveries 15 = 83.3 
 
 Deaths 1 = 5.5 
 
 Improved 2 = 11.1 
 
 Secondary hemorrhage 
 
 Gangrene 
 
 * Monod and Vanvert, Rev. de Chir., vol. xli, 1910.
 
 TREATMENT OF ANEURISMS 87 
 
 Cause of death : 
 
 Uncontrollable hemorrhage during course of operation, which 
 consisted of ligation of innominate and common carotid and incision 
 of sac. 
 
 Complications : 
 
 Paralysis of arm 1 
 
 Disturbance of circulation 1 
 
 Operative procedures: 
 
 Subclavian ligated (3 alone.) 10 
 
 First part - 8 
 
 Second part 1 
 
 Third part 1 
 
 Not stated 1 
 
 Innominate and first part subclavian and common carotid 1 
 
 Cure, recurrence having taken place after ligature of 
 innominate alone. 
 
 Innominate and first part subclavian 1 
 
 One cure. 
 
 Innominate and common carotid and incision of sac 1 
 
 One death. 
 
 Innominate ligated distally alone 1 
 
 One cure. 
 First part subclavian and inferior thyroid and vertebral and third 
 
 part axillary 1 
 
 Cure, recurrence having taken place after ligation of 
 first part subclavian. 
 
 First part subclavian and common carotid 1 
 
 One cure. 
 
 Third part subclavian and common carotid 1 
 
 One cure. 
 
 First part subclavian and first part axillary 1 
 
 Paralysis of arm. 
 
 First part subclavian and axillary 1 
 
 Circulatory disturbance. 
 
 Ligation of carotid 3 
 
 One death and two cures. 
 
 Extirpation 4 
 
 Four cures. 
 
 We thus see that in 10 out of the 18 cases it was neces- 
 sary to ligate two or more vessels in order to effect a cure, 
 and that in this series all the mishaps occurred. This multiple 
 ligation was done in several cases at a second operation, a
 
 88 SURGERY OF THE VASCULAR SYSTEM 
 
 recurrence having taken place after ligation of a single vessel. 
 Worthy of note, too, is the fact that, in both of the cases of 
 trouble in the arm, ligation of the axillary artery was part 
 of the operative procedure, thus bearing out the well-known 
 observation that "the further away from the heart at which 
 the main arterial trunk is ligated, the greater the danger of 
 functional disturbance and gangrene." 
 
 ANEURISMS OF THE AXILLARY ARTERY 10 
 
 All cases collected between the years 1895 and 1909 : 
 
 Number of cases " 24 
 
 Per cent. 
 
 Recoveries 23 =95.8 
 
 Deaths 1 = 4.2 
 
 Gangrene 
 
 Functional impairment 5 = 20.8 
 
 Post-operative hemorrhage 2 = 8.4 
 
 Operative procedures: 
 
 Extirpations 12 14 
 
 Functional impairment 3 
 
 Death 1 
 
 In this case after extirpation a venous transplant was sutured be- 
 tween the ends of the artery, patient dying of delirium tremens 
 several days later. 13 
 
 Ligation of subclavian 9 
 
 Functional impairment 2 
 
 Post-operative hemorrhage 2 
 
 One case resulted from infection. 
 
 The striking feature of this series of cases is the number 
 of functional impairments, which after all should be. the 
 criterion of success or failure in aneurisms of the extremities, 
 there being little or no occasion for mortality. It would seem 
 
 "Monod and Vanvert, Rev. de Chir., vol. xli, 1910. 
 
 11 Monod and Vanvert cite one other case which I threw out because the 
 aneurismal sac was removed when an exarticulation of the shoulder-joint was 
 done. 
 
 a During the course of these extirpations the vein was resected three times 
 without apparent complications. 
 
 "Lexer, Arch. f. klin. Chir., 1907, Ixxxiii, 458.
 
 TREATMENT OF ANEURISMS 89 
 
 as if Matas's operation offers better results in these aneurisms 
 than either extirpation or ligation. 
 
 ANEURISMS OF THE BRACHIAL ARTERY 14 
 
 All cases collected between the years 1895 and 1909 : 
 
 Number of cases 22 
 
 Recoveries 22 
 
 Gangrene 
 
 Functional disturbances 2 
 
 Operative procedures: 
 
 Extirpation 18 
 
 Vein was resected once without complications. 
 
 Functional disturbances 1 
 
 Proximal ligature 2 
 
 Functional disturbance 1 
 
 Incision 2 
 
 In several of these cases the radial pulse reappeared after 
 a number of days ' absence once after 46 days. Its presence 
 or absence cannot, therefore, be of any great prognostic value. 
 In both of the noted cases of functional disturbance it was 
 present almost immediately after operation, although in one 
 it was barely perceptible. In one of the cured cases it was 
 never present after operation. 
 
 LIGATION OF THE COMMON ILIAC ARTERY 15 
 
 All cases collected between years 1880 and 1912: 
 
 Per cent. 
 
 Number of cases 30 
 
 Recoveries : 16 =53.3 
 
 Deaths 14 =46.6 
 
 Gangrene 12 =40 
 
 In most all of these cases there were complications (see page 90) 
 other than the simple ligation of the vessel, which contributed 
 quite materially to the bad result. So marked were these com- 
 plications that Dr. Halsted came to the conclusion, after careful 
 consideration of each individual case, "that the uncomplicated 
 ligation of the common iliac artery is not likely to be followed by 
 gangrene, the percentage being from 3.3 to 6.6. instead of 33.3 
 
 14 Monod and Vanvert, Rev. de Chir., vol. xli, 1910. 
 
 15 W. S. Halsted, Bull. Johns Hopkins Hospital, July, 1912.
 
 90 SURGERY OF THE VASCULAR SYSTEM 
 
 (as given by Mataa in vol. v of Keen's Surgery); and that the 
 mortality . . . is at most 10 per cent, and probably not more than 
 6.6 per cent., or it may even be as low as 3.3 per cent." 
 
 Gangrene: 
 
 In two of the 12 cases of gangrene, the condition was present 
 before operation and in three other cases it was very slight. 
 
 Recoveries: 
 
 In five out of 16 recoveries there was some functional impair- 
 ment, usually slight. 
 
 Cause of death: 
 
 Difficult and prolonged operation and hemorrhage 2 
 
 Infection 2 
 
 Both cases were done in the pre-antiseptic era, 1871-79, but 
 were not reported till 1880 and 1885 respectively. 
 
 Nephritis 1 
 
 Possibly due to increased blood-pressure. 
 
 Pre-operative gangrene and hemorrhage 1 
 
 Peritonitis, thrombosis, and gangrene 1 
 
 Hemorrhage and gangrene 1 
 
 Hemorrhage 1 
 
 Ligation of aorta 37 days after ligation of common iliac. 
 
 Pre-operative gangrene of scrotum, hemorrhage and diarrhoea . 1 
 
 Miliary tuberculosis , 1 
 
 Arteriosclerosis and gangrene 1 
 
 Hemorrhage 1 
 
 Not stated 1 
 
 I have thus tabulated the various causes of death in each 
 case in order to show how easily one could be misled if he 
 merely consulted the table and its accompanying percentages, 
 and I went into the details of the gangrene cases for a similar 
 purpose. The percentage of gangrene is by no means 40 nor 
 is the mortality anywhere near 46.6. In nearly every case 
 there were contributing causes other than simple ligation 
 of the common iliac artery. For example, in two cases the 
 gangrene was present before operation and in the list of 
 deaths there were two fatalities, which, done in pre-antiseptic 
 times but not reported till well in the antiseptic era, died of 
 infection. Another case died of miliary tuberculosis, several 
 died of hemorrhage, and so on. Dr. Halsted has given a most 
 valuable contribution to the study of aneurisms and I recom-
 
 TREATMENT OF ANEURISMS 91 
 
 mend a perusal of the original article to those who are in- 
 terested in the subject especially those who have a case of 
 aneurism of the common iliac artery to handle. 
 
 ANEURISMS OF THE EXTERNAL. ILIAC ARTERY 16 
 
 All cases collected between the years 1895 and 1909 : 
 
 Per cent. 
 
 Number of cases , 24 
 
 Recoveries 15 =62.5 
 
 Deaths 9 =37.5 
 
 Gangrene 4 = 16.6 
 
 Functional impairment 2 = 8.3 
 
 Post-operative hemorrhage 
 
 Operative procedures: 
 
 Ligature of aorta (alone) 1 
 
 One death. 
 
 Ligature of common iliac (alone) 5 
 
 Two deaths, one of which had gangrene. Three recoveries, one 
 of which had impairment of function. 
 
 Ligature of external iliac (alone) 7 
 
 One death, five recoveries and one case lost sight of. 
 
 Compression 1 
 
 One recovery. 
 
 Extirpation 4 
 
 Two deaths, one of which died of embolus after end-to-end suture 
 of external iliac. Two recoveries. 
 
 Ligature of common iliac and femoral 1 
 
 One recovery after gangrene and amputation. 
 
 Ligature of external iliac and femoral . . . ! 4 
 
 Two deaths, one of which had gangrene. One functional 
 
 impairment. One recovery. 
 Ligature of external iliac and aorta, necessitated by post-operative 
 
 hemorrhage after ligature of external iliac 1 
 
 One death. 
 
 It has been generally understood that gangrene of the 
 leg is a common occurrence following ligation of the external 
 iliac artery and the above figures substantiate this belief, at 
 least to a certain degree. The exact reason for this mishap 
 has never been 'satisfactorily explained. Until the question 
 
 "Monod and Vanvert, Rev. de Chir., vol. xli, 1910.
 
 92 SURGERY OF THE VASCULAR SYSTEM 
 
 has been definitely settled it would seein advisable to use 
 Ilalsted's method of gradual occlusion of vessels in handling 
 aneurisms of this artery. Matas's procedure, too, might be 
 productive of better results here. 
 
 ANEURISMS OF THE FEMORAL, ARTERY 17 
 
 All cases collected between the years 1895 and 1909: 18 
 
 Per cent. 
 
 Number of cases 66 
 
 Recoveries 58 = 92 
 
 Deaths 5 = 7.9 
 
 Gangrene 4 = 6.3 
 
 Functional disturbance 1 
 
 Lost sight of 3 
 
 Eliminated in figuring percentages. 
 
 Operative procedures : 
 
 Ligature external iliac 19 12 
 
 One death. One case lost sight of. Ten recoveries. 
 
 Ligature external iliac and femoral 19 2 
 
 Two recoveries. 
 
 Ligature femoral artery 5 
 
 Four recoveries. One gangrene and amputation. 
 
 Ligature femoral and popliteal arteries 1 
 
 One death (cardiac). 
 
 Extirpation 41 
 
 Thirty-two recoveries. Three deaths: 1 post-operative hemor- 
 rhage; 1 oedema of lungs; 1 erysipelas; 1 functional impairment; 
 1 gangrene and amputation; 2 superficial gangrene; 2 cases lost 
 sight of. 
 
 Incision 4 
 
 Four recoveries. 
 
 Compression 1 
 
 One recovery. 
 
 "Monod and Vanvert, Rev. de Chir., vol. xlii, 1910. 
 
 " Monod and Vanvert divided these cases into two groups, (a) those of the 
 inguinal femoral and (6) those of the superficial femoral. We do not make this 
 distinction in this country so far as I am aware, so I have considered the cases 
 altogether, making one group. 
 
 "These ligations of the external iliac really amounted to a rather high 
 femoral ligature in that most of them were not far above Poupart's ligament.
 
 TREATMENT OF ANEURISMS 93 
 
 The results of this series of cases are quite favorable, but 
 I believe even better results will be secured if a more general 
 use of Matas's endo-aneurismorrhaphy is made in aneurisms 
 of this vessel. In the three cases of gangrene which followed 
 extirpation, the vein, being quite adherent to the sac, was 
 either ligated or resected during removal of the sac. This 
 should teach us, I think, that every effort should be made to 
 preserve the vein intact, no matter what operative procedure 
 is adopted. In case of its unavoidable injury it should be 
 repaired. If its resection is required a venous transplant 
 had best be done immediately. It must be admitted, however, 
 that the vein was ligated in several other instances in which 
 there was no disturbance, but this does not alter the facts 
 as above stated. Matas's operation probably offers the best 
 solution. The ideal operation of complete excision of the 
 aneurism followed by arterial anastomosis will also be of 
 service in selected cases. 
 
 ANEURISMS OF THE POPLITEAL ARTERY 20 
 
 All cases collected between the years 1895 and 1909 : 
 
 Per cent. 
 
 Number of cases 151 
 
 Recoveries 147 =97.3 
 
 Deaths 21 4 = 2.6 
 
 Gangrene 22 22 = 14.5 
 
 Superficial gangrene 2 
 
 Functional disturbance. . . 6= 3.9 
 
 20 Monod and Van vert, Rev. de Chir., vol. xlii, 1910. 
 
 21 One of the deaths resulted from septicaemia. 
 
 ~ In two or three instances the gangrene had started before operation on 
 the aneurism; it continued to progress after operation. 
 
 Of the 22 cases of gangrene, amputation of the leg or foot was necessitated 
 in 18 cases, amputation of the toes in four cases. One of these cases was a 
 trophic disturbance and not a true gangrene, but inasmuch as amputation was 
 required it is classified as a case of gangrene.
 
 25 per cont. 25 
 Per cent. 
 
 94 SURGERY OF THE VASCULAR SYSTEM 
 
 Operative procedures: 
 
 Per cent 
 
 Extirpations n 104 
 
 Recoveries 102 =98 
 
 Deaths 2 = 1.9 
 
 Gangrene 13 = 12..', 
 
 Superficial gangrene 2 
 
 Functional disturbance 4 = 3.8 
 
 Vein was ligated or resected at time of extir- 
 pation 24 Per cent. 
 
 Gangrene 3 = 12.5 
 
 Superficial gangrene 1 
 
 Circulatory disturbance 1 
 
 (Edema of the leg 24 1 
 
 Ligature of femoral artery 32 
 
 Recoveries 31 =96.8 
 
 Death 1 = 3.1 
 
 Gangrene 8 = 25 
 
 Functional disturbance 1 
 
 Post-operative hemorrhage M 2= 6.2 
 
 Ligature of popliteal artery 2 
 
 Recoveries 1 
 
 Death 1 
 
 Gangrene of great toe in this case. 
 
 "In one of these cases after excision of the aneurismal sac, the vein \\;i* 
 resected and the resected part transplanted successfully between the two ends of 
 the artery. (J. Goyanes, El Siglo med., 1906, liii, p. 561.) 
 
 In another case after excision of the sac, the arterial ends were sutured, 
 the knee being acutely flexed so as to approximate the ends. They were 4 cm. 
 apart. Case successful. (Enderlen, Deutsch. med. Woch., 1908, xxxiv, p. l.">si., 
 
 ** This case was cured one year after operation by transplanting a segment 
 of vein l>etween the two ends of the resected vein. (E. Doyen, 22d Cong. fr. de 
 Chir., 1909, 178.) 
 
 28 This percentage is given to show that in 25 per cent, of those cases in 
 which the vein was ligated or resected at the time of operation some circulatory 
 disturbance occurred, thus, I think, proving conclusively that a serious attempt 
 ought always be made to save the vein. It is more than likely, too, that some 
 circulatory disturbance occurred in cases other than those in which it was noted. 
 
 "One of these cases was saved by ligating the femoral higher up in its 
 course. In the other this did not stop the hemorrhage, so the external iliac w;i< 
 ligated. The foot then became gangrenous and had to be amputated. These are 
 the only two cases of post-operative hemorrhage reported in the entire series of 
 151 cases. One of them was clearly the result of arteriosclerosis. Neither case 
 was infected.
 
 TREATMENT OF ANEURISMS 95 
 
 Per cent. 
 
 Compression 27 9 
 
 Recoveries 9 
 
 One of which was merely improved. 
 
 Incision 2 
 
 Recoveries 2 
 
 In one of which there was functional disturbance. 
 
 Forced flexion (compression) 2 
 
 Recoveries 2 
 
 There can be little question, I believe, that a painstaking 
 preliminary study of the collateral circulation of the limb in 
 cases of popliteal aneurism will avert many cases of gangrene 
 that might otherwise occur. It would seem, too, that Matas's 
 endo-aneurismorrhaphy is peculiarly well adapted to the 
 treatment of these aneurisms, and, where conditions warrant, 
 excision of the aneurism followed by a vascular transplant 
 and suture might well be practised. 
 
 ARTERIO VENOUS ANEURISMS OF THE SUBCLAVIAN VESSELS M 
 
 CASE I. Done in 1845: 
 
 Double ligature of third part of subclavian artery. 
 Infection. 
 
 Secondary hemorrhage. 
 Death. 
 
 CASE II. Done in 1906: 
 
 Attempted excision of sac. 
 
 Hemorrhage from jugular vein. 
 Death two hours after operation. 
 
 CASE III. Done in 1906: 
 
 Ligation of innominate artery. 
 Recurrence. 
 Excision of sac. 
 Recovery. 
 Improvement of palsy of arm present before operation. 
 
 7 Compression was tried in a number of cases and failed, some other opera- 
 tion like ligation or extirpation being then instituted. 
 K Monod and Vanvert, Rev. de Chir., vol. xlii, 1910.
 
 96 SURGERY OF THE VASCULAR SYSTEM 
 
 ABTEKIOVENOUS ANEURISMS OF THE VESSELS OF THE NECK '-"' 
 
 All cases collected between the years 1889 and 1910 : 
 
 I\T cent. 
 Number of cases 11 
 
 Cured 9=81.8 
 
 Improved 2 = 18.1 
 
 Deaths 
 
 Operative procedures : 
 
 Extirpation 4 
 
 Proximal ligature of carotid 2 
 
 These were the cases in which improvement occurred. 
 
 Distal ligature of carotid 2 
 
 Quadruple ligature 3 
 
 There were apparently no complications and no post- 
 operative disturbances that were not present before operation, 
 and most of these disappeared, only a few minor ailments 
 remaining. 
 
 There were one case of arteriovenous aneurism of the 
 internal carotid (extracranial) and three cases of the external 
 carotid, all of which were cured without difficulty by opera- 
 tion, the first by ligation of the external carotid at its origin, 
 the common carotid and the jugular vein (case of W. W. 
 Keen, Times and Register, Philadelphia, 1894, xxvii, 151). 
 The last three were cured by extirpation. 
 
 ARTERIOVENOUS ANEURISMS OF THE AXILLARY VESSELS 29 
 
 All cases collected between the years 1885 and 1908 : 
 
 Number of cases 10 
 
 Cures 7 
 
 Improved 2 
 
 Circulatory disturbance 1 
 
 Deaths 
 
 "Monod and Vanvert, Rev. de Chir., vol. xlii, 1910.
 
 TREATMENT OF ANEURISMS 97 
 
 Operative procedures : 
 
 Extirpation 6 
 
 Resection of vein in one case without complication. Circulatory 
 disturbance, one. 
 
 Compression 2 
 
 Both cases improved. 
 
 Ligature 1 
 
 Separation of vein and artery followed by suture of holes in each ... 1 
 
 Successful. 
 
 ARTERIOVENOUS ANEURISMS OF THE BRACHIAL VESSELS 30 
 
 All cases collected between the years 1891 and 1909 : 
 
 Number of cases 14 
 
 Cures 12 
 
 Functional impairment 2 
 
 Deaths 
 
 Operative procedures : 
 
 Extirpation 11 
 
 Resection of the vein once without complications. Functional 
 impairment, two. 
 
 Ligature 2 
 
 Resection of vein once without complications. 
 Lateral suture of artery 1 
 
 ARTERIOVENOUS ANEURISMS OF THE FEMORAL VESSELS 30 
 
 All cases collected between the years 1890 and 1909: 
 
 Number of cases 58 
 
 Recoveries 54 
 
 Deaths 4 
 
 One from septicaemia after ligature of common iliac. One from 
 hemorrhage during operation. Two followed gangrene and am- 
 putation after ligature of external iliac. 
 
 Gangrene . 10 
 
 (a) In eight cases amputation was necessary, two of these 
 patients dying. External iliac was ligated four times with two 
 deaths. Femoral artery was ligated four times, twice proximal 
 and distal twice proximal. 
 
 "Monod and Vanvert, Rev. de Chir., vol. xlii, 1910.
 
 98 SURGERY OF THE VASCULAR SYSTEM 
 
 (6) In two of these cases the gangrene was only superficial and 
 followed ligature of the external iliac once and extirpation once. 
 
 Functional disturbance 2 
 
 In both cases the leg was a little weak and followed ligature of 
 the external iliac once and extirpation once. 
 
 Operative procedures: 
 
 Extirpation 40 
 
 Recoveries :;~> 
 
 Deaths 1 
 
 Slight superficial gangrene _' 
 
 In one of these cases the external iliac was ligated before the 
 extirpation. 
 
 Slight weakness of leg 2 
 
 In one of these cases the external iliac was ligated before the 
 extirpation. 
 
 Ligature of femoral artery proximal and distal or proximal 9 
 
 Recoveries 5 
 
 Gangrene 4 
 
 Proximal and distal ligation twice; proximal alone twice. 
 
 Ligature of external iliac artery 7 
 
 Recoveries "> 
 
 Deaths 2 
 
 Gangrene 4 
 
 Weakness of leg 1 
 
 Ligature of common iliac 1 
 
 Death 1 
 
 From septicaemia. 
 
 Incision 1 
 
 Recovery. 
 
 A study of these tables reveals the fact that arteriovenous 
 aneurisms of the femoral vessels is a more serious affection 
 than aneurism of the artery alone. It also shows pretty 
 clearly that the external iliac artery had best be given a wide 
 berth. But the most surprising thing of all is the splendid 
 results following simple extirpation and the comparatively 
 poor results following ligation of the femoral artery without 
 extirpation. Perhaps some future study will explain this 
 apparent contradiction. In excising an aneurism of this char- 
 acter, the vein must necessarily be included, and this means 
 ligation of both vessels, a procedure that ought to be more
 
 TREATMENT OF ANEURISMS 99 
 
 dangerous to life and limb than simple ligation and more 
 productive of gangrene and functional disturbance. I have 
 gone over the cases carefully and offer the figures for what 
 they are worth, though I must confess they do not "look 
 right. ' ' 
 
 ARTERIOVENOUS ANEURISMS OF THE POPLITEAL VESSELS 31 
 
 All cases collected between the years 1891 and 1908 : 
 
 Number of cases 35 
 
 Recoveries 34 
 
 Deaths 1 
 
 Followed extirpation. 
 
 Gangrene 6 
 
 In two cases amputation was necessary, extirpation being done 
 in one case, ligature of femoral artery and vein in other. 
 
 In four cases gangrene was only superficial, extirpation being 
 done in three cases, quadruple ligature in one case. 
 
 Functional disturbance 6 
 
 In one case leg was oedematous. In one case there was pain 
 
 and claudi cation. 
 
 In four cases there were muscular contractures, limited motion, 
 
 pain and paralysis of foot. In all four cases extirpation of the sac 
 
 was done and in each instance the leg was practically useless. 
 
 Operative procedures : 
 
 Extirpations 32 28 
 
 Cures. . . i 17 
 
 Gangrene 4 
 
 Functional disturbance 6 
 
 Deaths 1 
 
 Quadruple ligatures 4 
 
 In one case gangrene of toes. In three cases recovery. 
 
 Ligature of femoral artery and vein 3 
 
 Recovery in two cases. Gangrene and amputation in one case. 
 
 Here we have what I expected to find in the study of 
 arteriovenous aneurisms of the femoral vessels disastrous 
 results following extirpation of the aneurismal sac. The 
 figures speak for themselves and discussion is all but super- 
 
 31 Monod and Vanvert, Rev. de Chir., vol. xlii, 1910. 
 
 32 In two cases of extirpation an end-to-end suture of the artery was done 
 with perfect recovery in each case.
 
 100 SURGERY OF THE VASCULAR SYSTEM 
 
 fluous. I cannot refrain, however, from railing attention to 
 the two successful end-to-end sutures that were done after 
 the aneurism had been extirpated. The one was done by 
 Lexer, 33 the other by Stich. 34 
 
 This, of course, is the ideal method of dealing with these 
 and a great many other aneurisms, but the general run of 
 surgeons is not ready yet to do a successful arterial suture. 
 And inasmuch as Matas's operation gives such splendid and 
 uniform results, perhaps it is just as well that such is the 
 case. 
 
 Arch. f. kl. Chir., 1907, Ixxxiii, p. 438. 
 Deutsoh. Zeit. f. Chir., 1908, xcv, p. 577.
 
 INDEX 
 
 Adventitia, importance cf, 1 
 
 treatment of, for end-to-end suture, 
 
 28 
 Aluminum bands, Halsted's method of 
 
 rolling, 79 
 Anastomosis, art erio venous. See Arterio- 
 
 venous anastomosis 
 lateral, 37 
 saphenofemoral. See also Lateral 
 
 anastomosis, 62 
 
 technic of, with Bernheim's two- 
 pieced cannula, 18 
 
 Aneurismal sac, drainage of infected, 71 
 of ruptured, 71 
 of uninfected, 71 
 of unruptured, 71 
 obliteration of, 71, 72 
 Aneurisms, arteriovenous, statistics of 
 
 treatment of, 95 
 of axillary vessels, 96 
 of brachial vessels, 97 
 of femoral vessels, 97 
 of popliteal vessels, 99 
 of subclavian vessels, 95 
 of vessels of neck, 96 
 endo-aneurismorrhaphy (Matas) for, 
 
 68, 69 
 
 extirpation of, 68, 69 
 Halsted's method of gradual occlu- 
 sion of blood-vessels for, 69, 78 
 Matas operation for, 68, 69 
 methods of treatment, 68, 69, 73, 78 
 arterial suture, 68 
 endo-aneurismorrhaphy, 68, 69 
 excision, 68 
 extirpation, 68, 69 
 Halsted's aluminum bands, 68, 
 
 78 
 
 ligation, 68 
 wiring, 68, 73 
 
 Moore-Corradi method of wiring, 
 technic of, 73 
 
 Aneurisms, occlusion of blood-vessels in 
 
 treatment of, 78 
 of abdominal aorta, 68 
 
 wiring of, 75 
 of arch of aorta, 68 
 of popliteal artery, 68 
 of vessels at root of neck, 68 
 operations for, 68, 69, 73, 78 
 statistics of treatment of, 81-100 
 of axillary artery, 88 
 of brachial artery, 89 
 of common carotid artery, 85 
 of external iliac artery, 91 
 of femoral artery, 92 
 of popliteal artery, 93 
 of subclavian artery, 86 
 of vessels of base of neck, 82 
 wiring of, 69, 73 
 benefits from, 76 
 complications from, 75, 76 
 indications for, 73 
 Moore-Corradi method of, 73 
 post-operative treatment, 76 
 preliminary treatment, 77 
 prognosis, 77 
 statistics of, 77 
 Arteriovenous anastomosis. See also 
 
 Reversal of circulation, 53 
 employment of, 53 
 methods of, 53 
 statistics of, 54 
 Artery, ligation of, 69 
 
 Ball-tipped forceps, 2 
 Bernheim's three-pronged modification 
 of Crile's transfusion cannula, 13 
 transfusion cannula, 15 
 
 value of, 16 
 
 Blood flow, amount of, during transfu- 
 sion, 24 
 
 duration of, in transfusion, 25 
 tests during transfusion, 22 
 
 101
 
 102 
 
 INDEX 
 
 Blood-pressure during transfusion, 21, -'2 
 Blood-vessel clamps, 4 
 Blood-vessels, exposure of, 2 
 
 for end-to-end suture, 28 
 handling of, 2 
 
 of severed, 3 
 
 occlusion of, in treatment of aneu- 
 risms, 78 
 structure of, 1 
 surgery of, hjcmostasis during, 3 
 
 instruments for, 2 
 
 liquid vaseline in, 3 
 
 needles for, 5 
 
 preparation of hands for, 6 
 
 rubber gloves in, 6 
 
 salt solution in, 3 
 
 technic of, 1 
 
 Cardiolysis, 64, 66 
 
 indications for, 66 
 
 Carrel's method of arteriovenous anasto- 
 mosis, 53 
 Circulation, reversal of. See Reversal of 
 
 circulation 
 Clamps, bull-dog, 4 
 Crile, 4 
 rubber shod, 4 
 Crile's transfusion cannula, 10 
 
 Bernheim's modification of, 13 
 technic of use of, 10 
 
 Elsberg's transfusion cannula, 13 
 Endo-aneurismorrhaphy (Matas), 68, 69 
 
 advantages of, 73 
 
 methods of, 69, 70 
 
 obliterative, 70 
 reconstructive, 70 
 
 restorative, 70, 72 
 methods of, 72 
 
 statistics of, 73 
 End-to-end suture, 28 
 
 completed line of, 33 
 
 exposure of blood-vessels for, 28 
 
 leakage in, 33 
 
 massage of blood-vessels after, 34 
 
 starting blood flow after, 35 
 
 treatment of adventitia in, 28 
 Exposure of blood-vessels for end-to-end 
 suture, 28 
 
 Forceps, ball-tipped, 2 
 
 Glass tubes, paraffined, for transfusion. 
 16 
 
 Hiemostasis during blood-vessel opera- 
 tions, 3 
 
 Ha-molysis following transfusion, 26 
 Halsted's metal bands for occlusion of 
 
 blood-vessels, 78 
 metal band roller, 79 
 method of occlusion of blood-v 
 
 69, 78 
 
 degree of occlusion, 80 
 technic of, 79 
 method of rolling aluminum bands. 
 
 79 
 Handling of blood-vessels, 2 
 
 of severed blood-vessels, 3 
 Hands, preparation of, for blood-vessel 
 
 surgery, 6 
 
 Heart, exposure of, 64 
 injury to, 64 
 suture of, 64 
 surgery of, 64 
 statistics of, 65 
 transfusion in, 65 
 use of salt solution, 65 
 Historical note, vii 
 
 Injuries to the heart, 64 
 Instruments, blunt, 2 
 Intima, role of, 1 
 
 Lateral anastomosis, 37 
 
 development of thrombi, 45 
 
 employment of, 37 
 
 leakage after, 41 
 
 methods of, 37 
 
 proximal ligation of vein follow- 
 ing, 44 
 
 suture of, 40 
 
 technic of, according to method of 
 Bernheim and Stone, 39 
 
 transverse incision of vessels for, 
 39 
 
 value of, 45 
 Liquid vaseline, effect of, on tissues, 3 
 
 in blood-vessel surgery, 3
 
 INDEX 
 
 103 
 
 Ligation of common iliac artery, statis- 
 tics of, 89 
 
 of internal carotid extracranially, 
 statistics of, 86 
 
 Matas operation, 69 
 
 (See also Endo-aneurismorrhaphy) 
 
 Media, role of, 1 
 
 Moore-Corradi method of wiring aneu- 
 risms, 73 
 
 Needles, 5 
 
 insulation of, for wiring aneurisms, 74 
 preparation of, 5 
 
 Over-and-over stitch, 30 
 
 Pericardiotomy, 64, 66 
 Pericardium, drainage of, 67 
 exposure of, 66 
 
 dangers in, 66 
 
 salt solution in, 66 
 
 Physical examination for transfusion, 26 
 Pulse during transfusion, 21, 22 
 
 Reversal of circulation, 53 
 case of, 57 
 
 conditions warranting, 56 
 contra-indications for, 55 
 controversies concerning, 54 
 employment of, 53 
 formation of thrombus, 55 
 in four extremities, 57 
 . methods of, 53 
 pain after, 59 
 possibility of, 55 
 
 precautions to be observed in, 59 
 statistics of, 54 
 vein valves in, 54, 57 
 
 Salt solution, effect on tissues, 3, 4 
 in blood-vessel surgery, 3 
 in exposure of pericardium, 66 
 in heart surgery, 65 
 Saphenofemoral anastomosis, 62 
 Schede's operation for varicose veins, 61 
 Statistics of endo-aneurismorrhaphy, 73 
 
 Statistics of heart surgery, 65 
 
 of reversal of circulation, 
 
 of treatment of aneurisms, 81-100 
 
 of wiring of aneurisms, 77 
 Stay sutures, 30 
 Stitch, over-and-over, 30 
 Subcutaneous method of removing vari- 
 cose veins, 62 
 Suture, completed line of end-to-end, 33 
 
 end-to-end, 28 
 
 material, 4 
 
 stay, 30 
 
 Tissues, effect of liquid vaseline on, 3 
 
 of salt solution on, 3, 4 
 Transfusion, 8 
 
 amount of blood flow during, 24 
 
 anaesthetic in, 18 
 
 blood-pressure during, 21, 22 
 
 blood tests during, 22 
 
 cannula, Bernheim's modification of 
 
 Crile's, 13 
 two-pieced, 15 
 
 technic of use of, 16 
 value of, 16 
 Crile's, 10 
 
 technic of use of, 10 
 Elsberg's, 13 
 
 method of using, 13 
 conditions warranting, 8 
 direct, 8 
 
 dissection of radial artery for, 18 
 duration of blood flow in, 25 
 haemolysis following, 26 
 in anaemia, 9 
 in gastric ulcers, 8 
 in haemophilia, 9 
 in hemorrhage, 8 
 in heart surgery, 65 
 in illuminating gas poisoning, 9 
 indirect, 8 
 in infants, 9 
 in leukaemia, 9 
 in melaena'neonatorum, 9 
 in pellagra, 9 
 in ruptured extra-uterine pregnancy, 
 
 8 
 in shock, 9
 
 104 
 
 INDEX 
 
 Transfusion, instruments for, 10, 13, 15 
 in 1 1 ixn'ii ii;i>. 9 
 
 of pregnancy, 9 
 in typhoid ulcers, 8 
 methods of, 8 
 
 physical examination for, 26 
 pulse during, 21, 22 
 technic of, 10, 13, 16 
 welfare of donor during, 25 
 Transplantation of blood-vessels, 46 
 arterial, 46, 48 
 cold storage tissue for, 46 
 hemorrhage following, 51 
 sutures used in, 51 
 technic of, 49 
 venous, 46, 48 
 
 Trendelenburg's operation for varicose 
 veins, 61 
 
 Triangles, formation of, 30 
 
 Valves of veins, in reversal of the circula- 
 tion, 54, 57 
 Varicose veins, 61 
 
 methods of resecting, 62 
 saphenofemoral anastomosis for, 
 
 62 
 
 Schede's operation for, 61 
 subcutaneous method of removing, 
 
 62 
 
 treatment of, 61, 63 
 Trendelenburg's operation for, 01 
 Veins, resection of, 62 
 complete, 62 
 partial, 62 
 valves of, 54, 57 
 
 Wiring of aneurisms, 73
 
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 168 urgery of the 
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 1913 
 
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