Fig. 72.—Sacculated Aneurysm of Abdominal Aorta nearly filled with laminated clot. Note greater density of clot towards periphery.Fig. 72.—Sacculated Aneurysm of Abdominal Aorta nearly filled with laminated clot. Note greater density of clot towards periphery.
Fig. 72.—Sacculated Aneurysm of Abdominal Aorta nearly filled with laminated clot. Note greater density of clot towards periphery.
In the progress of an aneurysm towards rupture, timely clotting may avert death for the moment, but while extension in one direction has been arrested there is apt to be extension in another, with imminence of rupture, or it may be again postponed.
Differential Diagnosis.—The diagnosis is to be made from other pulsatile swellings. Pulsation is sometimes transmitted from a large artery to a tumour, a mass of enlarged lymph glands, or an inflammatory swelling which lies in its vicinity, but the pulsation is not expansile—a most important point in differential diagnosis. Such swellings may, by appropriate manipulation, be moved from the artery and the pulsation ceases, and compression of the artery on the cardiac side of the swelling, although it arrests the pulsation, does not produce any diminution in the size or tension of the swelling, and when the pressure is removed the pulsation is restored immediately.
Fluid swellings overlying an artery, such as cysts, abscesses, or enlarged bursæ, may closely simulate aneurysm. An apparent expansion may accompany the pulsation, but careful examination usually enables this to be distinguished from the true expansion of an aneurysm. Compression of the artery makes no difference in the size or tension of the swelling.
Vascular tumours, such as sarcoma and goitre, may yield an expansile pulsation and a soft, whifling bruit, but they differ from an aneurysm in that they are not diminished in size by compression of the main artery, nor can they be emptied by pressure.
The exaggerated pulsation sometimes observed in the abdominal aorta, the “pulsating aorta” seen in women, should not be mistaken for aneurysm.
Prognosis.—Whennatural cureoccurs it is usually brought about by the formation of laminated clot, which gradually increases in amount till it fills the sac. Sometimes a portion of the clot in the sac is separated and becomes impacted as an embolus in the artery beyond, leading to thrombosis which first occludes the artery and then extends into the sac.
The progress of natural cure is indicated by the aneurysm becoming smaller, firmer, less expansile, and less compressible; the murmur and thrill diminish and the pressure effects become less marked. When the cure is complete the expansile pulsation is lost, and there remains a firm swelling attached to the vessel (consolidated aneurysm). While these changes are taking placethe collateral arteries become enlarged, and an anastomotic circulation is established.
An aneurysm may provefatalby exerting pressure on important structures, by causing syncope, by rupture, or from the occurrence of suppuration.Pressuresymptoms are usually most serious from aneurysms situated in the neck, thorax, or skull. Sudden fatalsyncopeis not infrequent in cases of aneurysm of the thoracic aorta.
Rupturemay take place through the skin, on a mucous or serous surface, or into the cellular tissue. The first hæmorrhage is often slight and stops naturally, but it soon recurs, and is so profuse, especially when the blood escapes externally, that it rapidly proves fatal. When the bleeding takes place into the cellular tissue, the aneurysm is said to becomediffused, and the extravasated blood spreads widely through the tissues, exerting great pressure on the surrounding structures.
Theclinical featuresassociated with rupture are sudden and severe pain in the part, and the patient becomes pale, cold, and faint. If a comparatively small escape of blood takes place into the tissues, the sudden alteration in the size, shape, and tension of the aneurysm, together with loss of pulsation, may be the only local signs. When the bleeding is profuse, however, the parts beyond the aneurysm become greatly swollen, livid, and cold, and the pulse beyond is completely lost. The arrest of the blood supply may result in gangrene. Sometimes the pressure of the extravasated blood causes the skin to slough and, later, give way, and fatal hæmorrhage results.
Thetreatmentis carried out on the same lines as for a ruptured artery (p. 261), it being remembered, however, that the artery is diseased and does not lend itself to reconstructive procedures.
Suppurationmay occur in the vicinity of an aneurysm, and the aneurysm may burst into the abscess which forms, so that when the latter points the pus is mixed with broken-down blood-clot, and finally free hæmorrhage takes place. It has more than once happened that a surgeon has incised such an abscess without having recognised its association with aneurysm, with tragic results.
Treatment.—In treating an aneurysm, the indications are to imitate Nature's method of cure by means of laminated clot.
Constitutional treatmentconsists in taking measures to reduce the arterial tension and to diminish the force of the heart's action. The patient must be kept in bed. A dry and non-stimulating diet is indicated, the quantity being gradually reduced till it is just sufficient to maintain nutrition. Saline purges are employed to reduce the vascular tension. The benefit derived from potassium iodide administered in full doses, as first recommended by George W. Balfour, probably depends on its depressing action on the heart and its therapeutic benefit in syphilis. Pain or restlessness may call for the use of opiates, of which heroin is the most efficient.
Local Treatment.—When constitutional treatment fails, local measures must be adopted, and many methods are available.
Endo-aneurysmorrhaphy.—The operation devised by Rudolf Matas in 1888 aims at closing the opening between the sac and its feeding artery, and in addition, folding the wall of the sac in such a way as to leave no vacant space. If there is marked disease of the vessel, Matas' operation is not possible and recourse is then had to ligation of the artery just above the sac.
Extirpation of the Sac—The Old Operation.—The procedure which goes by this name consists in exposing the aneurysm, incising the sac, clearing out the clots, and ligating the artery above and below the sac. This method is suitable to sacculated aneurysm of the limbs, so long as they are circumscribed and free from complications. It has been successfully practised also in aneurysm of the subclavian, carotid, and external iliac arteries. It is not applicable to cases in which there is such a degree of atheroma as would interfere with the successful ligation of the artery. The continuity of the artery may be restored by grafting into the gap left after excision of the sac a segment of the great saphena vein.
Ligation of the Artery.—The object of tying the artery is to diminish or to arrest the flow of blood through the aneurysm so that the blood coagulates both in the sac and in the feeding artery. The ligature may be applied on the cardiac side of the aneurysm—proximal ligation, or to the artery beyond—distal ligation.
Proximal Ligation.—The ligature may be applied immediately above the sac (Anel, 1710) or at a distance above (John Hunter, 1785). TheHunterian operationensures that the ligature is applied to a part of the artery that is presumably healthy and where relations are undisturbed by the proximity of the sac; the best example is the ligation of the superficial femoral artery in Scarpa's triangle or in Hunter's canal for popliteal aneurysm; it is on record that Syme performed this operation with cure of the aneurysm on thirty-nine occasions.
It is to be noted that the Hunterian ligature does not aim atarrestingthe flow of blood through the sac, but is designed so to diminish its volume and force as to favour the deposition within the sac of laminated clot. The development of the collateralcirculation which follows upon ligation of the artery at a distance above the sac may be attended with just that amount of return stream which favours the deposit of laminated clot, and consequently the cure of the aneurysm; the return stream may, however, be so forcible as to prevent coagulation of the blood in the sac, or only to allow of the formation of a red thrombus which may in its turn be dispersed so that pulsation in the sac recurs. This does not necessarily imply failure to cure, as the recurrent pulsation may only be temporary; the formation of laminated clot may ultimately take place and lead to consolidation of the aneurysm.
The least desirable result of the Hunterian ligature is met with in cases where, owing to widespread arterial disease, the collateral circulation does not develop and gangrene of the limb supervenes.
Anel's ligatureis only practised as part of the operation which deals with the sac directly.
Distal Ligation.—The tying of the artery beyond the sac, or of its two branches where it bifurcates (Brasdor, 1760, and Wardrop, 1825), may arrest or only diminish the flow of blood through the sac. It is less successful than the proximal ligature, and is therefore restricted to aneurysms so situated as not to be amenable to other methods; for example, in aneurysm of the common carotid near its origin, the artery may be ligated near its bifurcation, or in aneurysm of the innominate artery, the carotid and subclavian arteries are tied at the seat of election.
Compression.—Digital compression of the feeding artery has been given up except as a preparation for operations on the sac with a view to favouring the development of a collateral circulation.
Macewen's acupuncture or “needling”consists in passing one or more fine, highly tempered steel needles through the tissues overlying the aneurysm, and through its outer wall. The needles are made to touch the opposite wall of the sac, and the pulsation of the aneurysm imparts a movement to them which causes them to scarify the inner surface of the sac. White thrombus forms on the rough surface produced, and leads to further coagulation. The needles may be left in position for some hours, being shifted from time to time, the projecting ends being surrounded with sterile gauze.
TheMoore-Corradi methodconsists in introducing through the wall of the aneurysm a hollow insulated needle, through the lumen of which from 10 to 20 feet of highly drawn silver or other wire is passed into the sac, where it coils up intoan open meshwork (Fig. 73). The positive pole of a galvanic battery is attached to the wire, and the negative pole placed over the patient's back. A current, varying in strength from 20 to 70 milliampères, is allowed to flow for about an hour. The hollow needle is then withdrawn, but the wire is leftin situ. The results are somewhat similar to those obtained by needling, but the clot formed on the large coil of wire is more extensive.
Fig. 73.—Radiogram of Innominate Aneurysm after treatment by the Moore-Corradi method. Two feet of finely drawn silver wire were introduced. The patient, a woman, æt. 47, lived for ten months after operation, free from pain (cf. Fig. 75).Fig. 73.—Radiogram of Innominate Aneurysm after treatment by the Moore-Corradi method. Two feet of finely drawn silver wire were introduced. The patient, a woman, æt. 47, lived for ten months after operation, free from pain (cf.Fig. 75).
Fig. 73.—Radiogram of Innominate Aneurysm after treatment by the Moore-Corradi method. Two feet of finely drawn silver wire were introduced. The patient, a woman, æt. 47, lived for ten months after operation, free from pain (cf.Fig. 75).
Colt's method of wiring has been mainly used in the treatment of abdominal aneurysm; gilt wire in the form of a wisp is introduced through the cannula and expands into an umbrella shape.
Subcutaneous Injections of Gelatin.—Three or four ounces of a 2 per cent. solution of white gelatin in sterilised water, at a temperature of about 100° F., are injected into the subcutaneous tissue of the abdomen every two, three, or four days. In the course of a fortnight or three weeks improvement may begin. The clot which forms is liable to soften and be absorbed, buta repetition of the injection has in several cases established a permanent cure.
Amputation of the limbis indicated in cases complicated by suppuration, by secondary hæmorrhage after excision or ligation, or by gangrene. Amputation at the shoulder was performed by Fergusson in a case of subclavian aneurysm, as a means of arresting the blood-flow through the sac.
The essential feature of a traumatic aneurysm is that it is produced by some form of injury which divides all the coats of the artery. The walls of the injured vessel are presumably healthy, but they form no part of the sac of the aneurysm. The sac consists of the condensed and thickened tissues around the artery.
The injury to the artery may be a subcutaneous one such as a tear by a fragment of bone: much more commonly it is a punctured wound from a stab or from a bullet.
The aneurysm usually forms soon after the injury is inflicted; the blood slowly escapes into the surrounding tissues, gradually displacing and condensing them, until they form a sac enclosing the effused blood.
Less frequently a traumatic aneurysm forms some considerable time after the injury, from gradual stretching of the fibrous cicatrix by which the wound in the wall of the artery has been closed. The gradual stretching of this cicatrix results in condensation of the surrounding structures which form the sac, on the inner aspect of which laminated clot is deposited.
A traumatic aneurysm is almost always sacculated, and, so long as it remains circumscribed, has the same characters as a pathological sacculated aneurysm, with the addition that there is a scar in the overlying skin. A traumatic aneurysm is liable to become diffuse—a change which, although attended with considerable risk of gangrene, has sometimes been the means of bringing about a cure.
The treatment is governed by the same principles as apply to the pathological varieties, but as the walls of the artery are not diseased, operative measures dealing with the sac and the adjacent segment of the affected artery are to be preferred.
An abnormal communication between an artery and a vein constitutes an arterio-venous aneurysm. Two varieties are recognised—one in which the communication is direct—aneurysmal varix; the other in which the vein communicates with the artery through the medium of a sac—varicose aneurysm.
Either variety may result from pathological causes, but in the majority of cases they are traumatic in origin, being due to such injuries as stabs, punctured wounds, and gun-shot injuries which involve both artery and vein. In former times the most common situation was at the bend of the elbow, the brachial artery being accidentally punctured in blood-letting from the median basilic vein. Arterio-venous aneurysm is a frequent result of injuries by modern high-velocity bullets—for example, in the neck or groin.
Inaneurysmal varixthe higher blood pressure in the artery forces arterial blood into the vein, which near the point of communication with the artery tends to become dilated, and to form a thick-walled sac, beyond which the vessel and its tributaries are distended and tortuous. The clinical features resemble those associated with varicose veins, but the entrance of arterial blood into the dilated veins causes them to pulsate, and produces in them a vibratory thrill and a loud murmur. In those at the groin, the distension of the veins may be so great that they look like sinuses running through the muscles, a feature that must be taken into account in any operation.
As the condition tends to remain stationary, the support of an elastic bandage is all that is required; but when the condition progresses and causes serious inconvenience, it may be necessary to cut down and expose the communication between the artery and vein, and, after separating the vessels, to close the opening in each by suture; this may be difficult or impossible if the parts are matted from former suppuration. If it is impossible thus to obliterate the communication, the artery should be ligated above and below the point of communication; although the risk of gangrene is considerable unless means are taken to develop the collateral circulation beforehand (Makins).
Varicose aneurysmusually develops in relation to a traumatic aneurysm, the sac becoming adherent to an adjacent vein, and ultimately opening into it. In this way a communication between the artery and the vein is established, and the clinical features are those of a combination of aneurysm and aneurysmal varix.
As there is little tendency to spontaneous cure, and as the aneurysm is liable to increase in size and finally to rupture, operative treatment is usually called for. This is carried out on the same lines as for aneurysmal varix, and at the same time incising the sac, turning out the clots, and ligating any brancheswhich open into the sac. If it can be avoided, the vein should not be ligated.
Thoracic Aneurysm.—All varieties of aneurysm occur in the aorta, the fusiform being the most common, although a sacculated aneurysm frequently springs from a fusiform dilatation.
Theclinical featuresdepend chiefly on the direction in which the aneurysm enlarges, and are not always well marked even when the sac is of considerable size. They consist in a pulsatile swelling—sometimes in the supra-sternal notch, but usually towards the right side of the sternum—with an increased area of dulness on percussion. With the X-rays a dark shadow is seen corresponding to the sac. Pain is usually a prominent symptom, and is largely referable to the pressure of the aneurysm on the vertebræ or the sternum, causing erosion of these bones. Pressure on the thoracic veins and on the air-passage causes cyanosis and dyspnœa. When the œsophagus is pressed upon, the patient may have difficulty in swallowing. The left recurrent nerve may be stretched or pressed upon as it hooks round the arch of the aorta, and hoarseness of the voice and a characteristic “brassy” cough may result from paralysis of the muscles of the larynx which it supplies. The vagus, the phrenic, and the spinal nerves may also be pressed upon. When the aneurysm is on the transverse part of the arch, the trachea is pulled down with each beat of the heart—a clinical phenomena known as the “tracheal tug.” Aneurysm of the descending aorta may, after eroding the bodies of the vertebræ (Fig. 71) and posterior portions of the ribs, form a swelling in the back to the left of the spine.
Fig. 74.—Thoracic Aneurysm, threatening to rupture externally, but prevented from doing so by Macewen's needling. The needles were left in for forty-eight hours.Fig. 74.—Thoracic Aneurysm, threatening to rupture externally, but prevented from doing so by Macewen's needling. The needles were left in for forty-eight hours.
Fig. 74.—Thoracic Aneurysm, threatening to rupture externally, but prevented from doing so by Macewen's needling. The needles were left in for forty-eight hours.
Inasmuch as obliteration of the sac and the feeding artery is out of the question, surgical treatment is confined to causing coagulation of the blood in an extension or pouching of the sac, which, making its way through the parietes of the chest, threatens to rupture externally. This may be achieved by Macewen's needles or by the introduction of wire into the sac. We have had cases under observation in which the treatment referred to has been followed by such an amount of improvement that the patient has been able to resume a laborious occupation for one or more years. Christopher Heath found that improvement followed ligation of the left common carotid in aneurysm of the transverse part of the aortic arch.
Abdominal Aneurysm.—Aneurysm is much less frequent in the abdominal than in the thoracic aorta. While any of the large branches in the abdomen may be affected, the most common seats are in the aorta itself, just above the origin of the cœliac artery and at the bifurcation.
Theclinical featuresvary with the site of the aneurysm and with its rapidity and direction of growth. A smooth, rounded swelling, which exhibits expansile pulsation, forms, usually towards the left of the middle line. It may extend upwards under cover of the ribs, downwards towards the pelvis, or backward towards the loin. On palpation a systolic thrill may be detected, but the presence of a murmur is neither constant nor characteristic. Pain is usually present; it may be neuralgic in character, or may simulate renal colic. When the aneurysm presses on the vertebræ and erodes them, the symptoms simulate those of spinal caries, particularly if, as sometimes happens, symptoms of compression paraplegia ensue. In itsgrowth the swelling may press upon and displace the adjacent viscera, and so interfere with their functions.
Thediagnosishas to be made from solid or cystic tumours overlying the artery; from a “pulsating aorta”; and from spinal caries; much help is obtained by the use of the X-rays.
The condition usually proves fatal, either by the aneurysm bursting into the peritoneal cavity, or by slow leakage into the retro-peritoneal tissue.
The Moore-Corradi method has been successfully employed, access to the sac having been obtained by opening the abdomen. Ligation of the aorta has so far been unsuccessful, but in one case operated upon by Keen the patient survived forty-eight days.
Innominate aneurysmmay be of the fusiform or of the sacculated variety, and is frequently associated with pouching of the aorta. It usually grows upwards and laterally, projecting above the sternum and right clavicle, which may be eroded or displaced (Fig. 75). Symptoms of pressure on the structures in the neck, similar to those produced by aortic aneurysm, occur. The pulses in the right upper extremity and in the right carotid and its branches are diminished and delayed. Pressure on the right brachial plexus causes shooting pain down the arm and muscular paresis on that side. Vaso-motor disturbances and contraction of the pupil on the right side may result from pressure on the sympathetic. Death may take place from rupture, or from pressure on the air-passage.
Fig. 75.—Innominate Aneurysm in a woman, æt. 47, eight months after treatment by Moore-Corradi method (cf. Fig. 73).Fig. 75.—Innominate Aneurysm in a woman, æt. 47, eight months after treatment by Moore-Corradi method (cf.Fig. 73).
Fig. 75.—Innominate Aneurysm in a woman, æt. 47, eight months after treatment by Moore-Corradi method (cf.Fig. 73).
The available methods of treatment are ligation of the right common carotid and third part of the right subclavian (Wardrop's operation), of which a number of successful cases have been recorded. Those most suitable for ligation are cases in which the aneurysm is circumscribed and globular (Sheen). If ligation is found to be impracticable, the Moore-Corradi method or Macewen's needling may be tried.
Carotid Aneurysms.—Aneurysm of thecommon carotidis more frequent on the right than on the left side, and is usually situated either at the root of the neck or near the bifurcation. It is the aneurysm most frequently met with in women. From its position the swelling is liable to press on the vagus, recurrent and sympathetic nerves, on the air-passage, and on the œsophagus, giving rise to symptoms referable to such pressure. There may be cerebral symptoms from interference with the blood supply of the brain.
Aneurysm near the origin has to be diagnosed from subclavian, innominate, and aortic aneurysm, and from other swellings—solid or fluid—met with in the neck. It is often difficult to determine with precision the trunk from which an aneurysm at the root of the neck originates, and not infrequently more than one vessel shares in the dilatation. A careful consideration of the position in which the swelling first appeared, of the direction in which it has progressed, of its pressure effects, and of the condition of the pulses beyond, may help in distinguishing between aortic, innominate, carotid, and subclavian aneurysms. Skiagraphy is also of assistance in recognising the vessel involved.
Tumours of the thyreoid, enlarged lymph glands, and fatty and sarcomatous tumours can usually be distinguished from aneurysm by the history of the swelling and by physical examination. Cystic tumours and abscesses in the neck are sometimes more difficult to differentiate on account of the apparently expansile character of the pulsation transmitted to them. The fact that compression of the vessel does not affect the size and tension of these fluid swellings is useful in distinguishing them from aneurysm.
Treatment.—Digital compression of the vessel against the transverse process of the sixth cervical vertebra—the “carotid tubercle”—has been successfully employed in the treatment of aneurysm near the bifurcation. Proximal ligation in the case of high aneurysms, or distal ligation in those situated at the root of the neck, is more certain. Extirpation of the sac is probably the best method of treatment, especially in those of traumatic origin. These operations are attended with considerable risk of hemiplegia from interference with the blood supply of the brain.
Theexternal carotidand the cervical portion of theinternal carotidare seldom the primary seat of aneurysm, although they are liable to be implicated by the upward spread of an aneurysm at the bifurcation of the common trunk. In addition to the ordinary signs of aneurysm, the clinical manifestations are chiefly referable to pressure on the pharynx and larynx, and on the hypoglossal nerve. Aneurysm of the internal carotid is of special importance on account of the way in which it bulges into the pharynx in the region of the tonsil, in some cases closely simulating a tonsillar abscess. Cases are on record in which such an aneurysm has been mistaken for an abscess and incised, with disastrous results.
Aneurysmal varixmay occur in the neck as a result of stabs or bullet wounds. The communication is usually between the common carotid artery and the internal jugular vein. The resulting interference with the cerebral circulation causes headache, giddiness, and other brain symptoms, and a persistent loud murmur is usually a source of annoyance to the patient and may be sufficient indication for operative treatment.
Intracranial aneurysminvolves the internal carotid and its branches, or the basilar artery, and appears to be more frequently associated with syphilis and with valvular disease of the heart than are external aneurysms. It gives rise to symptoms similar to those of other intracranial tumours, and there is sometimes a loud murmur. It usually proves fatal by rupture, and intracranial hæmorrhage. The treatment is to ligate the common carotid or the vertebral artery in the neck, according to the seat of the aneurysm.
Orbital Aneurysm.—The term pulsating exophthalmos is employed to embrace a number of pathological conditions, including aneurysm, in which the chief symptoms are pulsation in the orbit and protrusion of the eyeball. There may be, in addition, congestion and œdema of the eyelids, and a distinct thrill and murmur, which can be controlled by compression of the common carotid in the neck. Varying degrees of ocular paralysis and of interference with vision may also be present.
These symptoms are due, in the majority of cases, to an aneurysmal varix of the internal carotid artery and cavernous sinus, which is often traumatic in origin, being produced either by fracture of the base of the skull or by a punctured wound of the orbit. In other cases they are due to aneurysm of the ophthalmic artery, to thrombosis of the cavernous sinus, and, in rare instances, to cirsoid aneurysm.
If compression of the common carotid is found to arrest the pulsation, ligation of this vessel is indicated.
Subclavian Aneurysm.—Subclavian aneurysm is usually met with in men who follow occupations involving constant use of the shoulder—for example, dock-porters and coal-heavers. It is more common on the right side.
The aneurysm usually springs from the third part of the artery, and appears as a tense, rounded, pulsatile swelling just above the clavicle and to the outer side of the sterno-mastoid muscle. It occasionally extends towards the thorax, where it may become adherent to the pleura. The radial pulse on the same side is small and delayed. Congestion and œdema of the arm, with pain, numbness, and muscular weakness, may result from pressure on the veins and nerves as they pass under the clavicle; and pressure on the phrenic nerve may induce hiccough. The aneurysm is of slow growth, and occasionally undergoes spontaneous cure.
The conditions most likely to be mistaken for it are a soft, rapidly growing sarcoma, and a normal artery raised on a cervical rib.
On account of the relations of the artery and of its branches, treatment is attended with greater difficulty and danger in subclavian than in almost any other form of external aneurysm. The available operative measures are proximal ligation of the innominate, and distal ligation. In some cases it has been found necessary to combine distal ligation with amputation at theshoulder-joint, to prevent the collateral circulation maintaining the flow through the aneurysm. Matas' operation has been successfully performed by Hogarth Pringle.
Axillary Aneurysm.—This is usually met with in the right arm of labouring men and sailors, and not infrequently follows an injury in the region of the shoulder. The vessel may be damaged by the head of a dislocated humerus or in attempts to reduce the dislocation, by the fragments of a fractured bone, or by a stab or cut. Sometimes the vein also is injured and an arterio-venous aneurysm established.
Owing to the laxity of the tissues, it increases rapidly, and it may soon attain a large size, filling up the axilla, and displacing the clavicle upwards. This renders compression of the third part of the subclavian difficult or impossible. It may extend beneath the clavicle into the neck, or, extending inwards may form adhesions to the chest wall, and, after eroding the ribs, to the pleura.
The usual symptoms of aneurysm are present, and the pressure effects on the veins and nerves are similar to those produced by an aneurysm of the subclavian. Intra-thoracic complications, such as pleurisy or pneumonia, are not infrequent when there are adhesions to the chest wall and pleura. Rupture may take place externally, into the shoulder-joint, or into the pleura.
Extirpation of the sac is the operation of choice, but, if this is impracticable, ligation of the third part of the subclavian may be had recourse to.
Brachial aneurysmusually occurs at the bend of the elbow, is of traumatic origin, and is best treated by excision of the sac.
Aneurysmal varix, which was frequently met with in this situation in the days of the barber-surgeons,—usually as a result of the artery having been accidentally wounded while performing venesection of the median basilic vein,—may be treated, according to the amount of discomfort it causes, by a supporting bandage, or by ligation of the artery above and below the point of communication.
Aneurysms of the vessels of theforearm and handcall for no special mention; they are almost invariably traumatic, and are treated by excision of the sac.
Inguinal Aneurysm(Aneurysm of the Iliac and Femoral Arteries).—Aneurysms appearing in the region of Poupart's ligament may have their origin in the external or common iliac arteries or in the upper part of the femoral. On account of the tension of the fascia lata, they tend to spread upwards towards the abdomen, and, to a less extent, downwards into the thigh.Sometimes a constriction occurs across the sac at the level of Poupart's ligament.
The pressure exerted on the nerves and veins of the lower extremity causes pain, congestion, and œdema of the limb. Rupture may take place externally, or into the cellular tissue of the iliac fossa.
These aneurysms have to be diagnosed from pulsating sarcoma growing from the pelvic bones, and from an abscess or a mass of enlarged lymph glands overlying the artery and transmitting its pulsation.
The method of treatment that has met with most success is ligation of the common or external iliac, reached either by reflecting the peritoneum from off the iliac fossa (extra-peritoneal operation), or by going through the peritoneal cavity (trans-peritoneal operation).
Gluteal Aneurysm.—An aneurysm in the buttock may arise from the superior or from the inferior gluteal artery, but by the time it forms a salient swelling it is seldom possible to recognise by external examination in which vessel it takes origin. The special symptoms to which it gives rise are pain down the limb from pressure on the sciatic nerve, and interference with the movements at the hip.
Ligation of the hypogastric (internal iliac) by the trans-peritoneal route is the most satisfactory method of treatment. Extirpation of the sac is difficult and dangerous, especially when the aneurysm has spread into the pelvis.
Femoral Aneurysm.—Aneurysm of the femoral artery beyond the origin of the profunda branch is usually traumatic in origin, and is more common in Scarpa's triangle than in Hunter's canal. Any of the methods already described is available for their treatment—the choice lying between Matas' operation and ligation of the external iliac.
Aneurysm of theprofunda femorisis distinguished from that of the main trunk by the fact that the pulses beyond are, in the former, unaffected, and by the normal artery being felt pulsating over or alongside the sac.
Inaneurysmal varix, a not infrequent result of a bullet wound or a stab, the communication with the vein may involve the main trunk of the femoral artery. Should operative interference become necessary as a result of progressive increase in size of the tumour, or progressive distension of the veins of the limb, an attempt should be made to separate the vessels concerned and to close the opening in each by suture. If this is impracticable, the artery is tied above and below the communication; gangrene ofthe limb may supervene, and we have observed a case in which the gangrene extended up to the junction of the middle and lower thirds of the thigh, and in which recovery followed upon amputation of the thigh.
Popliteal Aneurysm.—This is the most common surgical aneurysm, and is not infrequently met with in both limbs. It is generally due to disease of the artery, and repeated slight strains, which are so liable to occur at the knee, play an important part in its formation. In former times it was common in post-boys, from the repeated flexion and extension of the knee in riding.
The aneurysm is usually of the sacculated variety, and may spring from the front or from the back of the vessel. It may exert pressure on the bones and ligaments of the joint, and it has been known to rupture into the articulation. The pain, stiffness, and effusion into the joint which accompany these changes often lead to an erroneous diagnosis of joint disease. The sac may press upon the popliteal artery or vein and their branches, causing congestion and œdema of the leg, and lead to gangrene. Pressure on the tibial and common peroneal nerves gives rise to severe pain, muscular cramp, and weakness of the leg.
The differential diagnosis is to be made from abscess, bursal cyst, enlarged glands, and sarcoma, especially pulsating sarcoma of one of the bones entering into the knee joint.
The choice of operation lies between ligation of the femoral artery in Hunter's canal, and Matas' operation of aneurysmo-arteriorrhaphy. The success which attends the Hunterian operation is evidenced by the fact that Syme performed it thirty-seven times without a single failure. If it fails, the old operation should be considered, but it is a more serious operation, and one which is more liable to be followed by gangrene of the limb. Experience shows that ligation of the vein, or even the removal of a portion of it, is not necessarily followed by gangrene. The risk of gangrene is diminished by a course of digital compression of the femoral artery, before operating on the aneurysm.
Aneurysmal varixis sometimes met with in the region of the popliteal space. It is characterised by the usual symptoms, and is treated by palliative measures, or by ligation of the artery above and below the point of communication.
Aneurysmin theleg and footis rare. It is almost always traumatic, and is treated by excision of the sac.
Surgical Anatomy and Physiology.—Lymph is essentially blood plasma, which has passed through the walls of capillaries. After bathing and nourishing the tissues, it is collected by lymph vessels, which return it to the blood stream by way of the thoracic duct. These lymph vessels take origin in the lymph spaces of the tissues and in the walls of serous cavities, and they usually run alongside blood vessels—perivascular lymph vessels. They have a structure similar to that of veins, but are more abundantly provided with valves. Along the course of the lymph trunks are thelymph glands, which possess a definite capsule and are composed of a reticulated connective tissue, the spaces of which are packed with leucocytes. The glands act as filters, arresting not only inert substances, such as blood pigment circulating in the lymph, but also living elements, such as cancer cells or bacteria. As it passes through a gland the lymph is brought into intimate contact with the leucocytes, and in bacterial infections there is always a struggle between the organisms and the leucocytes, so that the glands may be looked upon as an important line of defence, retarding or preventing the passage of bacteria and their products into the general circulation. The infective agent, moreover, in order to reach the blood stream, must usually overcome the resistance of several glands.
Lymph glands are, for the most part, arranged in groups or chains, such as those in the axilla, neck, and groin. In any given situation they vary in number and size in different individuals, and fresh glands may be formed on comparatively slight stimulus, and disappear when the stimulus is withdrawn. The best-known example of this is the increase in the number of glands in the axilla which takes place during lactation; when this function ceases, many of the glands become involuted and are transformed into fat, and in the event of a subsequent lactation they are again developed. After glands have been removed by operation, new ones may be formed.
The following are the more important groups of glands, and the areas drained by them in the head and neck and in the extremities.
Head and Neck.—The anterior auricular (parotid and pre-auricular) glandslie beneath the parotid fascia in front of the ear, and some arepartly embedded in the substance of the parotid gland; they drain the parts about the temple, cheek, eyelids, and auricle, and are frequently the seat of tuberculous disease.The occipital gland, situated over the origin of the trapezius from the superior curved line, drains the top and back of the head; it is rarely infected.The posterior auricular (mastoid) glandslie over the mastoid process, and drain the side of the head and auricle. These three groups pour their lymph into the superficial cervical glands.The submaxillary—two to six in number—lie along the lower order of the mandible from the symphysis to the angle, the posterior ones (paramandibular) being closely connected with the submaxillary salivary gland. They receive lymph from the face, lips, floor of the mouth, gums, teeth, anterior part of tongue, and the alæ nasi, and from the pre-auricular glands. The lymph passes from them into the deeper cervical glands. They are frequently infected with tubercle, with epithelioma which has spread to them from the mouth, and also with pyogenic organisms.The submental glandslie in or close to the median line between the anterior bellies of the digastric muscles, and receive lymph from the lips. It is rare for them to be the seat of tubercle, but in epithelioma of the lower lip and floor of the mouth they are infected at an early stage of the disease.The supra-hyoid glandlies a little farther back, immediately above the hyoid bone, and receives lymph from the tongue.The superficial cervical (external jugular) glands, when present, lie along the external jugular vein, and receives lymph from the occipital and auricular glands and from the auricle.The sterno-mastoid glands—glandulæ concatinatæ—form a chain along the posterior edge of the sterno-mastoid muscle, some of them lying beneath the muscle. They are commonly enlarged in secondary syphilis.The superior deep cervical (internal jugular) glands—from six to twenty in number—form a continuous chain along the internal jugular vein, beneath the sterno-mastoid muscle. They drain the various groups of glands which lie nearer the surface, also the interior of the skull, the larynx, trachea, thyreoid, and lower part of the pharynx, and pour their lymph into the main trunks at the root of the neck. Belonging to this group is one large gland (the tonsillar gland) which lies behind the posterior belly of the digastric, and rests in the angle between the internal jugular and common facial veins. It is commonly enlarged in affections of the tonsil and posterior part of the tongue. In the same group are three or four glands which lie entirely under cover of the upper end of the sterno-mastoid muscle, and surround the accessory nerve before it perforates the muscle. The deep cervical glands are commonly infected by tubercle and also by epithelioma secondary to disease in the tongue or throat.The inferior deep cervical (supra-clavicular) glandslie in the posterior triangle, above the clavicle. They receive lymph from the lowest cervical glands, from the upper part of the chest wall, and from the highest axillary glands. They are frequently infected in cancer of the breast; those on the left side also in cancer of the stomach. The removal of diseased supra-clavicular glands is not to be lightly undertaken, as difficulties are liable to ensue in connection with the thoracic duct, the pleura, or the junction of the subclavian and internal jugular veins.The retro-pharyngeal glandslie on each side of the median line upon the rectus capitis anticus major muscle and in front of the pre-vertebral layer of the cervical fascia. They receive part of the lymph from the posterior wall of the pharynx, the interior of the nose and its accessory cavities, the auditory (Eustachian) tube, and the tympanum. When they are infected withpyogenicorganisms or with tuberclebacilli, they may lead to the formation of one form of retro-pharyngealabscess.
Upper Extremity.—The epi-trochlear and cubital glandsvary in number, that most commonly present lying about an inch and a half above the medial epi-condyle, and other and smaller glands may lie along the medial (internal) bicipital groove or at the bend of the elbow. They drain the ulnar side of the hand and forearm, and pour their lymph into the axillary group. The epi-trochlear gland is sometimes enlarged in syphilis.The axillary glandsare arranged in groups: a central group lies embedded in the axillary fascia and fat, and is often related to an opening in it; a posterior or subscapular group lies along the line of the subscapular vessels; anterior or pectoral groups lie behind the pectoralis minor, along the medial side of the axillary vein, and an inter-pectoral group, between the two pectoral muscles. The axillary glands receive lymph from the arm, mamma, and side of the chest, and pass it on into the lowest cervical glands and the main lymph trunk. They are frequently the seat of pyogenic, tuberculous, and cancerous infection, and their complete removal is an essential part of the operation for cancer of the breast.
Lower Extremity.—The popliteal glandsinclude one superficial gland at the termination of the small saphenous vein, and several deeper ones in relation to the popliteal vessels. They receive lymph from the toes and foot, and transmit it to the inguinal glands.The femoral glandslie vertically along the upper part of the great saphenous vein, and receive lymph from the leg and foot; from them the lymph passes to the deep inguinal and external iliac glands. The femoral glands often participate in pyogenic infections entering through the skin of the toes and sole of the foot.The superficial inguinal glandslie along the inguinal (Poupart's) ligament, and receive lymph from the external genitals, anus, perineum, buttock, and anterior abdominal wall. The lymph passes on to the deep inguinal and external iliac glands. The superficial glands through their relations to the genitals are frequently the subject of venereal infection, and also of epithelioma when this disease affects the genitals or anus; they are rarely the seat of tuberculosis.The deep inguinal glandslie on the medial side of the femoral vein, and sometimes within the femoral canal. They receive lymph from the deep lymphatics of the lower limb, and some of the efferent vessels from the femoral and superficial inguinal glands. The lymph then passes on through the femoral canal to the external iliac glands. The extension of malignant disease, whether cancer or sarcoma, can often be traced along these deeper lymphatics into the pelvis, and as the obstruction to the flow of lymph increases there is a corresponding increase in the swollen dropsical condition of the lower limb on the same side.
The glands of thethoraxandabdomenwill be considered with the surgery of these regions.
Lymph vessels are divided in all wounds, and the lymph that escapes from them is added to any discharge that may be present. In injuries of larger trunks the lymph may escape in considerable quantity as a colourless, watery fluid—lymphorrhagia; and the opening through which it escapes is knownas alymphatic fistula. This has been observed chiefly after extensive operation for the removal of malignant glands in the groin where there already exists a considerable degree of obstruction to the lymph stream, and in such cases the lymph, including that which has accumulated in the vessels of the limb, may escape in such abundance as to soak through large dressings and delay healing. Ultimately new lymph channels are formed, so that at the end of from four to six weeks the discharge of lymph ceases and the wound heals.
Lymphatic Œdema.—When the lymphatic return from a limb has been seriously interfered with,—as, for example, when the axillary contents has been completely cleared out in operating for cancer of the breast,—a condition of lymphatic œdema may result, the arm becoming swollen, tight, and heavy.
Various degrees of the conditions are met with; in the severe forms, there is pain, as well as incapacity of the limb. As in ordinary œdema, the condition is relieved by elevation of the limb, but not nearly to the same degree; in time the tissues become so hard and tense as scarcely to pit on pressure; this is in part due to the formation of new connective tissue and hypertrophy of the skin; in advanced cases there is a gradualtransitioninto one form of elephantiasis.
Handley has devised a method of treatment—lymphangioplasty—the object of which is to drain the lymph by embedding a number of silk threads in the subcutaneous cellular tissue.
Wounds of the Thoracic Duct.—The thoracic duct usually opens at the angle formed by the junction of the left internal jugular and subclavian veins, but it may open into either of these vessels by one or by several channels, or the duct may be double throughout its course. There is a smaller duct on the right side—the right lymphatic duct. The duct or ducts may be displaced by a tumour or a mass of enlarged glands, and may be accidentally wounded in dissections at the root of the neck; jets of milky fluid—chyle—may at once escape from it. The jets are rhythmical and coincide with expiration. The injury may, however, not be observed at the time of operation, but later through the dressings being soaked with chyle—chylorrhœa. If the wound involves the only existing main duct and all the chyle escapes, the patient suffers from intense thirst, emaciation, and weakness, and may die of inanition; but if, as is usually the case, only one of several collateral channels is implicated, the loss of chyle may be of little moment, as the discharge usually ceases. If the wound heals so that the chyle is prevented from escaping, a fluctuating swellingmay form beneath the scar; in course of time it gradually disappears.
An attempt should be made to close the wound in the duct by means of a fine suture; failing this, the duct must be occluded by a ligature as if it were a bleeding artery. The tissues are then stitched over it and the skin wound accurately closed, so as to obtain primary union, firm pressure being applied by dressings and an elastic webbing bandage. Even if the main duct is obliterated, a collateral circulation is usually established. A wound of the right lymphatic duct is of less importance.
Subcutaneous rupture of the thoracic ductmay result from a crush of the thorax. The chyle escapes and accumulates in the cellular tissue of the posterior mediastinum, behind the peritoneum, in the pleural cavity (chylo-thorax), or in the peritoneal cavity (chylous ascites). There are physical signs of fluid in one or other of these situations, but, as a rule, the nature of the lesion is only recognised when chyle is withdrawn by the exploring needle.
Lymphangitis.—Inflammation of peripheral lymph vessels usually results from some primary source of pyogenic infection in the skin. This may be a wound or a purulent blister, and the streptococcus pyogenes is the organism most frequently present.Septiclymphangitis is commonly met with in those who, from the nature of their occupation, handle infective material. Agonococcalform has been observed in those suffering from gonorrhœa.
The inflammation affects chiefly the walls of the vessels, and is attended with clotting of the lymph. There is also some degree of inflammation of the surrounding cellular tissue—peri-lymphangitis. One or more abscesses may form along the course of the vessels, or a spreading cellulitis may supervene.
Theclinical featuresresemble those of other pyogenic infections, and there are wavy red lines running from the source of infection towards the nearest lymph glands. These correspond to the inflamed vessels, and are the seat of burning pain and tenderness. The associated glands are enlarged and painful. In severe cases the symptoms merge into those of septicæmia. When the deep lymph vessels alone are involved, the superficial red lines are absent, but the limb becomes greatly swollen and pits on pressure.
In cases of extensive lymphangitis, especially when there arerepeated attacks, the vessels are obliterated by the formation of new connective tissue and a persistent solid œdema results, culminating in one form of elephantiasis.
Treatment.—The primary source of infection is dealt with on the usual lines. If the lymphangitis affects an extremity, Bier's elastic bandage is applied, and if suppuration occurs, the pus is let out through one or more small incisions; in other parts of the body Klapp's suction bells are employed. An autogenous vaccine may be prepared and injected. When the condition has subsided, the limb is massaged and evenly bandaged to promote the disappearance of œdema.
Tuberculous Lymphangitis.—Although lymph vessels play an important rôle in the spread of tuberculosis, the clinical recognition of the disease in them is exceptional. The infection spreads upwards along the superficial lymphatics, which become nodularly thickened; at one or more points, larger, peri-lymphangitic nodules may form and break down into abscesses and ulcers; the nearest group of glands become infected at an early stage. When the disease is widely distributed throughout the lymphatics of the limb, it becomes swollen and hard—a condition illustrated by lupus elephantiasis.
Syphilitic lymphangitisis observed in cases of primary syphilis, in which the vessels of the dorsum of the penis can be felt as indurated cords.
In addition to acting as channels for the conveyance of bacterial infection,lymph vessels frequently convey the cells of malignant tumours, and especially cancer, from the seat of the primary disease to the nearest lymph glands, and they may themselves become the seat of cancerous growth forming nodular cords. The permeation of cancer by way of the lymphatics, described by Sampson Handley, has already been referred to.
Lymphangiectasisis a dilated or varicose condition of lymph vessels. It is met with as a congenital affection in the tongue and lips, or it may be acquired as the result of any condition which is attended with extensive obliteration or blocking of the main lymph trunks. An interesting type of lymphangiectasis is that which results from the presence of thefilaria Bancroftiin the vessels, and is observed chiefly in the groin, spermatic cord, and scrotum of persons who have lived in the tropics.
Filarial disease in the lymphatics of the groinappears as a soft, doughy swelling, varying in size from a walnut to a cocoa-nut; it may partly disappear on pressure and when the patient lies down.
The patient gives a history of feverish attacks of the natureof lymphangitis during which the swelling becomes painful and tender. These attacks may show a remarkable periodicity, and each may be followed by an increase in the size of the swelling, which may extend along the inguinal canal into the abdomen, or down the spermatic cord into the scrotum. On dissection, the swelling is found to be made up of dilated, tortuous, and thickened lymph vessels in which the parent worm is sometimes found, and of greatly enlarged lymph glands which have undergone fibrosis, with giant-cell formation and eosinophile aggregations. The fluid in the dilated vessels is either clear or turbid, in the latter case resembling chyle. The affection is frequently bilateral, and may be associated with lymph scrotum, with elephantiasis, and with chyluria.
Thediagnosisis to be made from such other swellings in the groin as hernia, lipoma, or cystic pouching of the great saphenous vein. It is confirmed by finding the recently dead or dying worms in the inflamed lymph glands.
Treatment.—When the disease is limited to the groin or scrotum, excision may bring about a permanent cure, but it may result in the formation of lymphatic sinuses and only afford temporary relief.
Lymphangioma.—A lymphangioma is a swelling composed of a series of cavities and channels filled with lymph and freely communicating with one another. The cavities result either from the new formation of lymph spaces or vessels, or from the dilatation of those which already exist; their walls are composed of fibro-areolar tissue lined by endothelium and strengthened by non-striped muscle. They are rarely provided with a definite capsule, and frequently send prolongations of their substance between and into muscles and other structures in their vicinity. They are of congenital origin and usually make their appearance at or shortly after birth. When the tumour is made up of a meshwork of caverns and channels, it is called acavernous lymphangioma; when it is composed of one or more cysts, it is called acystic lymphangioma. It is probable that the cysts are derived from the caverns by breaking down and absorption of the intervening septa, as transition forms between the cavernous and cystic varieties are sometimes met with.
Thecavernous lymphangiomaappears as an ill-defined, soft swelling, presenting many of the characters of a subcutaneous hæmangioma, but it is not capable of being emptied by pressure, it does not become tense when the blood pressure is raised, as in crying, and if the tumour is punctured, it yields lymph instead of blood. It also resembles a lipoma, especiallythe congenital variety which grows from the periosteum, and the differential diagnosis between these is rarely completed until the swelling is punctured or explored by operation. If treatment is called for, it is carried out on the same lines as for hæmangioma, by means of electrolysis, igni-puncture, or excision. Complete excision is rarely possible because of the want of definition and encapsulation, but it is not necessary for cure, as the parts that remain undergo cicatrisation.