Chapter XXIX (1)

SURGICAL DISEASES OF THE HEART AND VASCULAR SYSTEM.

A generation ago a chapter on the surgery of the heart would have been regarded as a surgical fantasy. Today the subject is not only a live one, but experience is constantly accumulating as to the value of surgical intervention in diseases of the heart and pericardium.

MALPOSITIONS OF THE HEART.

The heart may be displaced by congenital or acquired causes. Malpositions of the former type may vary from _dextrocardia_, where the heart is placed upon the right side, and may be accompanied by a general or partial transposition of the viscera, to those cases where there are defects in the diaphragm or the chest wall, through which the heart protrudes. Dextrocardia has an interest for the surgeon, as, for example, in the following case under the writer’s observation: Disease on the left side which simulated appendicitis, in which the diagnosis was confirmed by finding the heart upon the right side, and later by operation. It was a case of complete transposition.

The acquired malpositions may be due to intrinsic or extrinsic causes. They are pressure effects, usually found in connection with intrathoracic aneurysms and other tumors or collections of fluid, or may be due to change in the shape of the spine in pronounced curvatures. Occasionally the heart is hindered in its action by pressure from beneath the diaphragm. These cardiac displacements are surgically interesting when the cause can be removed by operative measures.

WOUNDS OF THE HEART.

Wounds of the heart are mainly of the punctured or gunshot type. It was formerly considered that injuries of the heart were essentially fatal. This has been disproved by human and comparative observations. As far back as 1855, Carnochan reported a case of gunshot wound of the heart where the bullet was found in the heart substance after the patient had lived eleven days. The museums contain many illustrations of penetrating wounds of the heart or of foreign bodies in it, some of which had remained embedded for many years. Nevertheless the fact remains that the majority of wounds of the heart are fatal, either by arrest of its activity, by shock, by the outpour of blood between it and the pericardium or outside the latter, or later by processes which consume at least a few days, either infective or degenerative. Other things being equal the larger the wound the more dangerous, while an injury to the heart muscle which has not opened one of its cavities is less dangerous than one which perforates them. A punctured wound made by a small stiletto or knife-blade, or even by a needle used for homicidal purposes, may leave but small trace and not prove fatal, save through injury to one of the cardiac vessels, especially a coronary artery.[23]

[23] Illustrating the surgery of foreign bodies in the heart,
Jordan has reported the case of a young woman who stated that she
had received a blow on the front of the chest the previous day, and
showed on examination a small projecting point in the lower part of
the third left intercostal space about half an inch from the sternum,
which was tender to the touch and seemed to move or pulsate with
the heart. It gave to the finger the sensation of a hard substance
beneath the skin without any external marking. Upon making an
incision and dissecting partly through the muscle the broken end of a
black steel pin came into view. After removal with forceps it proved
to be a shawl pin, one and one half inches long, with its glass
head broken off. The patient remembered having had such a pin in
her bosom at the time of the accident. On the following day she had
pericarditis. She apparently recovered, but had a relapse, and died
on the twenty-fourth day, the autopsy showing pericarditis.

In practically all of these injuries there will be evidence of some external violence. It is of advantage to ascertain the nature of the accident and the character of the missile or instrument. If the depth of penetration of a knife-blade, for instance, can be ascertained more accurate conclusions can be drawn. The special indications of cardiac injury pertain to disturbance of its own function, that is, embarrassment and uncertainty of action, bellows sounds, enlarged area of dulness owing to distention of the pericardium with blood, dyspnea, and distress, and sometimes pain and syncope. These symptoms and signs do not appear instantaneously, but increase in severity.

=Treatment.=--In such an emergency everything possible should be done to relieve the embarrassment of the heart’s action--the head should be kept low, the body absolutely quiet, and nervous excitement should be allayed at once with a full dose of morphine. Heart stimulants should not be given. Ice applied over the chest will help quiet cardiac activity. If the patient be not failing too rapidly operation is advisable, and should be done in a well-equipped hospital, with trained assistants. The purpose of the operation is to expose the injured portion of the heart substance and close it with suture; at least to remove the fluid or partially coagulated blood within the pericardium.[24] As it is not always possible to expose the heart without opening the pleural cavity, there should be at hand not only the means for a tracheotomy, but an apparatus by which artificial inflation of at least one lung can be effected. _Pneumatic cabinets_ have been devised for this purpose, especially by Sauerbruch, where a difference of pressure can be maintained between the outside and the inside of the cabinet, so that the chest may be widely opened and the lung not collapsed; but such a cabinet is available in few places in the United States. The improved Fell apparatus, by which a mask is kept over the face and pressure maintained with the foot through a bellows, has been found useful. Even in the absence of such apparatus the surgeon should not abstain from the effort, though it may appear less promising.

[24] _Suture of Heart Wounds._--Stewart has tabulated 60 cases of
suture of the heart reported up to May, 1904, with a remarkably
high recovery rate of 38 per cent. (Amer. Jour. Med. Sci., October,
1904). Of the 60 cases 55 were stab wounds and 5 were gunshot wounds,
2 of the latter recovering. In 4 of the cases the coronary artery
was injured, and only 1 of these recovered. The injury occurred
through a puncture while suturing the heart, and an extra suture was
necessary in order to control it. Of the 60 cases the left ventricle
was wounded thirty times, with 30 recoveries. The right ventricle
was wounded 21 times, with 7 recoveries. The operation has only been
practised for about ten years. The results reported certainly justify
its performance in all cases of this kind.

In the operative procedure one may feel inclined to utilize the already existing wound, either as a part of his incision or for exploratory purposes, or he may decide to disregard it. The operation consists in raising an osteoplastic flap on the chest wall, by which the pericardium and then the heart are exposed. The incision through the skin is extended to the bone and only enough of the soft structures separated from the ribs and cartilages to expose them sufficiently for division. Ordinarily it would be preferable to divide the third, fourth, and fifth costal cartilages at their rib terminations, and then to turn up the flap with its base at the sternum, though the procedure can be reversed to almost as good advantage. The cartilages and the ribs may be divided with the costotome and the rest of the structures with stout scissors. The flap, having been gently elevated at the edge, is separated from the underlying cellular tissue and pericardium until its sternal margin has been reached. When detached it may be sprung upward, and thus a complete window is made in the chest wall. When more room is desired bone and cartilage may be cut away with a rongeur.

Result after thoracotomy for heart wound. (E. J. Meyer.)]

The pericardium being thus exposed may be found much distended or altered by the imbibition of blood. It should be opened to an extent sufficient to permit evacuation of its bloody contents and sufficient exposure of the heart to permit not merely inspection but suture of any wound in the heart substance. This is exceedingly difficult on account of motions of the heart, and the insertion of sutures will be as difficult as trying to hit a flying target. Nevertheless it may be done in many cases. Unless imperative, a coronary artery should not be included in the heart suture. Hemorrhage from the heart being checked the pericardium is then to be united, preferably with hardened catgut sutures, with or without drainage. In most instances the former is the better plan, and the drain may be of the cigarette type, that is, gauze wrapped in oiled silk.

Should it be found that the pericardium alone is injured and not the heart the case may be regarded in a more favorable light.

There are sufficient cases on record where procedures analogous to the above have been practised to justify the attempt in every case. Hardened animal sutures may be used in the heart substance, and the interrupted method will probably prove the better. A suture which will hold firmly for three or four days will suffice, as has been proved on animals.

RUPTURE OF THE HEART.

Rupture of the heart can scarcely be considered a surgical condition, though it has frequently been one of medicolegal interest. It may, however, afford a sudden and unexpected termination to surgical cases. The cardiac muscle may be so softened by the poisons of diphtheria and other acute infections as to be greatly weakened, even though an intubation or tracheotomy has apparently afforded security.

TUMORS OF THE HEART.

Primary malignant tumors of the heart are very rare. Secondary and metastatic manifestation are much more frequent. True primary sarcoma has been repeatedly observed, and, with the exception of endothelioma, is practically the only primary cancer that could appear in this location. Carcinoma is found only as a secondary deposit, with which, however, the heart may become so involved as to permit of terminal rupture.

THE PERICARDIUM.

This closed sac is interesting to the surgeon in cases where it becomes filled with air; with blood, as the result of injury (see above); with fluid, as in acute pericarditis, or with pus, as a later stage of the latter, with its consequent _pyopericardium_. With the introduction of the aspirating needle it is possible to draw off collections of serum or pus, and _paracentesis of the pericardium_ is now a conventional minor operation. It is managed in the same way and with the same instruments as when the pleural cavity is involved. It is ordinarily safe, and affords much relief.

The surgeon may go even farther than this and practise _cardicentesis_, as the writer did once by accident while hospital interne. After introducing the needle and withdrawing three or four ounces of pus he discovered that he had given great relief, which, however, was only temporary. The autopsy two days later revealed that he had passed the needle point through the pericardial sac into the heart wall and had tapped the abscess therein. This was in 1877, and was probably the first time that the heart wall was ever thus entered.

Now the operator goes still farther than this and practises intentional cardicentesis in cases of engorgement of the right side of the heart connected with lung disease which is threatening death from dyspnea with an overstrained heart. In such cases the needle may be introduced just above the fourth rib, from one-half to one inch to the right of the sternum, or entrance can be effected just above the fifth rib in an upward direction. From 100 to 250 Cc. of blood may be withdrawn.

For ordinary tapping of the pericardium the needle is inserted two inches to the left of the median line and in the fourth or fifth left interspaces, pushing it carefully until resistance is no longer felt and fluid flows through the tube. For either of these purposes the patient should be recumbent, unless the distress in this position is too great, in order that the heart may fall away from the chest wall. Aspiration can be repeated in case it gives relief. Little or no harm seems to ensue from the wound which a needle-point will make upon the heart substance. As the sac is progressively emptied the needle-point should be gradually withdrawn. When aspiration, exploratory or therapeutic, reveals the presence of pus, the well-known rule will apply, _i. e._, that pus left to itself will do more harm than will the surgeon’s knife. For pyopericardium there is but one successful treatment when aspiration fails, and that is open incision and drainage. This is not so severe a measure as exposure of the heart, as it may not even require the removal of one costal cartilage, although it would probably be better to take out at least one, since the shape of the pericardial cavity will change to such an extent after it is emptied as to raise the opening to a higher level than is given it at first. Open incision, then, with drainage, in these cases is no longer an experiment but a life-saving procedure. It will prove successful in at least half of the cases, which otherwise would certainly perish without it.

PNEUMOPERICARDIUM.

Pneumopericardium implies the presence of air in the pericardial sac, a condition of which there are now about 40 cases on record. The air nearly always enters through an ulcerative perforation from adjoining parts or through a wound, yet in 5 of these cases no opening could be found. In these it was probably due to the presence of a gas-forming bacillus, such as may also cause pneumothorax under certain circumstances. The perforation was in the esophageal wall in 7 cases, in 4 cases it was the result of softening of a lymph node, while in other instances it has followed abscess of the left lobe of the liver, pleuropneumonia and gastric ulcer perforating through the diaphragm. Of the 8 cases of penetrating wound from without, I included the small puncture made by paracentesis, while in 7 cases there had been fracture of the ribs or the sternum, with wound or laceration of the lung or the pericardium.

The most characteristic sign is a splashing, gurgling sound, synchronous with the heart beats, such as the French have called the “water-wheel bruit.” These sounds are louder than in hydropneumothorax, and are heard distinctly over the heart. The area of precordial dulness will change with position.

In unmistakable cases operation is indicated, the trap-door exposure being the best, the inner end of the fifth and sixth ribs being elevated. Irrigation and drainage will be necessary. It is encouraging to know that 11 of the 40 cases above mentioned have recovered.

CARDIOLYSIS.

Cardiolysis refers to the operative release of the heart from adhesions which have formed between it and the pericardium or the chest wall. When with every contraction the heart itself is subjected to the strain of an adhesion the work proves excessive and it will finally succumb. It has been suggested by Delorme, Peterson, and Simon to either temporarily resect the chest wall, open the pericardium and break down or divide the adhesions, or else to resect those bony portions of the chest wall, _i. e._, the sternum, cartilages, or ribs, which are so inflexible as not to yield, not removing the bands but making them harmless.[25]

[25] Those interested in the modern surgery of the heart and lungs
should consult Rickett’s recent work on this subject.

THE ARTERIES.

There are few parts of the body which adhere more closely to the normal standard than do the larger arteries. Even here malformations and congenital defects are met with. In calculating the chances of a given procedure the surgeon should consider the condition of the venous and lymphatic systems before deciding to operate on a portion of the arterial system. This is particularly true when ligating the femoral artery for elephantiasis of the leg.

Thrombosis and embolism have already been considered in the chapter on the Blood. Nevertheless it may be well to remind the student at this point that thrombus means a blood clot, while thrombosis refers to the process of its formation; that embolus means something which has passed into the blood current of an artery and plugged it, the obstruction usually being a fragment of clot or tissue, though it may be a droplet of fat or a bubble of air. Emboli, like thrombi, may be sterile, and in this respect innocent, or it may be composed of material loaded with septic, tuberculous, or cancerous germs.

Anastomosing circulation in sartorius and pectineus of dog, three months after ligature of femoral. (After Porta.)]

Collateral venous circulation, from a woman aged forty-seven, under the care of W. W. Gull, in whom the inferior vena cava was completely obstructed from cancer. (Guy’s Hosp. Mus., Drawing 44⁴⁰.)]

Direct anastomosing vessels of right carotid of goat, five months after ligature. (After Porta.)]

The readiness with which vessels, both arteries and veins, lend themselves to the exigencies of extra work has long been recognized, and the natural provision for collateral circulation is one of which surgeons have for centuries availed themselves. On the contrary, vessels which are no longer needed or whose function is lost will undergo atrophy almost to obliteration; thus after amputation of the thigh the corresponding iliac vessels become much reduced in size (Figs. 137, 138 and 139).

ARTERITIS; ENDARTERITIS.

That arterial walls are resistant is shown by the fact that they are usually the last tissues to yield to gangrene. Whether a primary acute arteritis often occurs is a question of less interest in this place than the fact that even arterial walls will succumb to infection and that secondary hemorrhages from ulcerative processes are by no means rare. The pathological processes which occur in the various structures of the heart are repeated in the arterial walls; thus there may be a _periarteritis_ corresponding to pericarditis, a _mesarteritis_ which in many ways resembles myocarditis, and an _endarteritis_ which corresponds more or less closely to endocarditis, and all of these in their acute or chronic forms. The acute forms which concern the surgeon are due usually to the presence of infected emboli, which have the same effect upon the arterial walls that infected thrombi have upon the venous walls, _i. e._, they lead to occlusion, infiltration, and suppuration.

Of the more chronic types those produced by syphilis are the most common. Here it is usually the outer and inner coats which suffer most. Tuberculous infection of an artery is of frequent occurrence and pertains only to those vessels which are in intimate relation with previous tuberculous lesions, while the syphilitic forms are diffuse and generalized and as likely to involve one part of the body as another. It is well known that arteritis in various degrees of intensity may be met with in most of the infectious diseases. Whether they are due to the living germs or to toxins generated during the process concerns us at this point but little. It is of importance, however, to realize that vessels so compromised may thus receive their first impetus to degeneration and subsequently form aneurysm. The degenerative types of greatest interest to the surgeon are _fatty degeneration_, which occurs in the interior rather than the exterior, and _calcification_, which is rather an involvement of peripheral vessels and which occurs mainly in the middle and the outer coats. The latter may be limited or may involve an entire vessel. When the radial arteries are involved the condition may be appreciated at the wrist. Calcification frequently follows other degenerations, especially fatty, of the intima, and then may be seen in the interior of an artery. A true ossification has been described, but is exceedingly rare.

ARTERIOSCLEROSIS.

Arteriosclerosis is a term generally applied to a combination of these degenerations, with thickening and diminution of caliber. The changes combined are comprehended in the term _atheroma_, which is seen as a localized lesion in nodules or plaques in the aorta and larger vessels and in diffuse form in the smaller. Atheroma, as a complex degeneration, constitutes an interesting study, as it leads to well-marked changes in the vessel walls, which are softened at points by fatty changes, the little mass of debris resulting being called an _atheromatous abscess_ (an unfortunate name), which may empty into the vessel, leaving a small cavity and opening known as the _atheromatous ulcer_. Around this occur usually the calcific changes above described. The disturbance and the roughening thus produced lead to the formation of fibrinous thrombi, which attach themselves firmly at these points. When to such a weakening of the vessel wall as is thus produced are added the elements of compensatory cardiac hypertrophy, and the sudden changes of blood pressure produced by certain occupations and alcoholic and other excesses, it will be seen how atheromatous patches constitute points of least resistance, where blood pressure may cause a vessel wall at least to bulge and thus to afford the beginnings of an aneurysm; while, by combination of various processes, final rupture may result.

The conditions are not so very different in the more diffuse forms, especially in patients who have not only a tendency to vascular disease but to increase it by the added toxemias of gout and syphilis, of various excesses and bad habits, in which not only do arterial coats suffer, but the heart muscle and lining as well. The relations then of systematic toxemias to arterial disease and finally to surgical conditions are not so circuitous as may at first appear.

ANEURYSM.

_An aneurysm is a tumor communicating with an artery and containing circulating or coagulated blood, or both._ It may be formed entirely from the wall of the vessel, or some portion of it may be formed by surrounding tissue. Several varieties of aneurysm are indicated by descriptive adjectives. They are divided, first, into _true_ and _false_, the former being composed of all the vascular coats and being small and infrequent; the false aneurysms imply those in which the entire arterial wall does not participate. Aneurysms inside the body cavities are called internal, and those involving the limbs external. The terms _spontaneous_ and _traumatic_ apply here as elsewhere. _Fusiform_ aneurysm implies a spindle-like dilatation of the vessel in somewhat regular form. The _sacculated_ aneurysm is essentially a pouch protruding from one side of the vessel with which it communicates. When the sac ruptures the aneurysm becomes _diffuse_. If the outer coat gives way and the inner protrudes there is a _hernial_ aneurysm. The _dissecting_ aneurysm is one formed by separation between the arterial coats, so that blood coagulates or flows between them. Such an aneurysm tends to assume a sacculate form and to rupture. A _varicose_ aneurysm is a sac through which an artery and adjoining vein communicate. A _cirsoid_ aneurysm corresponds to a varix on the venous side of the circulation, and implies dilatation of an artery and its branches. (See Figs. 140 to 145.)

True aneurysm; the sac formed by all the coats. (Holmes.)]

False aneurysm; the sac formed by the outer coat only. (Holmes.)]

Traumatic aneurysm; the sac formed by the tissues around the vessel. (Holmes.)]

Dissecting aneurysm. (Holmes.)]

Hernial aneurysm; the sac formed by the inner coat only. (Holmes.)]

Sacculated aneurysm of ascending aorta. Death by pressure. (Erichsen.)]

The formation of an aneurysm implies _previous disease_ of the bloodvessel _or traumatism_, by either of which its coats must have been weakened or divided. The previous disease which leads to this change is either of syphilitic or other toxic origin, and usually of the type of the endarteritis already alluded to, or its continuation into atheroma. A so-called atheromatous ulcer may lead to giving way of the intima and the passage of blood between the coats of the vessel. It is in this way that most dissecting aneurysms are formed. On the other hand, violent strain may stretch the vessels already weakened by increasing blood pressure, or those conditions which induce abnormally high blood pressure may produce it by slow processes. Lastly a vessel may be partly divided, as by a bullet or stab wound, or its adjoining supports may have been weakened by disease or by accident to such an extent that it constitutes a weakening of the arterial wall. The result of this will be expansion in the direction of least resistance and the formation of a _sacculated_ aneurysm.

As a morbid condition spontaneous aneurysm seems to be less frequent now than in the past. Certain features pertain to all cases, the most essential being a pulsating tumor, giving physical signs of its presence by pressure, which causes pain, sometimes paralysis, and nearly always absorption of surrounding tissues as the tumor expands. _Pulsation_ is characteristic and pathognomonic of aneurysm, but an aneurysmal sac may have become so filled with clots as to minimize the prominence of this symptom. The same is true of the _aneurysmal bruit_ or murmur which is heard on auscultation. This sound and pulsation, especially of the _expansile_ type, when present will rarely deceive. They may, however, be simulated by a solid tumor which overlies a large vessel and transmits its pulsation or even some of its murmur. Even in this case the significant expansile character of the pulsation will be lacking.

The _progress_ of an aneurysm may be checked by spontaneous or surgical processes, but no vessel involved in this way can return to its previous condition. As the vessel expands the tendency is to fortification of its weakened walls by coagulation of the blood around the periphery of the sac. This process may be a continuous one or may occur at intervals in such a way as to produce laminated coats of blood clot, complete or incomplete, which in certain specimens can be peeled off, one after another, much as an onion can be peeled, the innermost portion representing the most recent coagulum. In this way an aneurysm is strengthened and thickened, and rupture postponed for an indefinite period. On the other hand, as the aneurysmal tumor grows slowly but steadily it tends to make way for itself at the expense of every other tissue in the body. The hardest bone will disappear before the constant advance of such a growth, and this permits aneurysms which have had their origin in the thorax to develop into large extrathoracic tumors whose walls, lacking resistance, become thinner and finally give way, death from hemorrhage being the result. In fact, _rupture is the natural tendency_ of such lesion, the question being whether it may be averted by spontaneous or non-operative methods, or whether it should be subjected to operation (Fig. 146).

Thoracic (aortic) aneurysm. Death from external rupture.]

Aneurysms may be minute and multiple, or single and large. The former are seen in the brain in connection with syphilis, and in the mesentery (Fig. 147). No artery in the body is necessarily exempt, though obviously the larger arterial trunks are the more frequent sufferers.

Spontaneous cure by natural methods is brought about in one of the following ways: (_a_) By consolidation of laminated clots. (_b_) A portion of the clot may become detached and plug the vessel on the distal side, effecting the same occlusion there that is produced with a ligature; in some cases the vessel may be occluded above the sac by a clot from the heart. (_c_) That which occurs naturally may be caused by accident as the result of some trifling injury. (_d_) The clot contained within the sac may have become infected, so that suppuration with necrosis of the sac contents is produced. In connection with this there is sufficient acute arteritis to occlude the vessel, and the resulting abscess within the sac may be opened and its contents cleared out. This method is extremely rare and can only terminate happily when the surgeon intervenes promptly.

In an aneurysm in which spontaneous cure has occurred there may be progressive condensation of its contents, obliteration and partial reduction in size, and a slow process of absorption.

The importance of collateral circulation, in recovery from aneurysm, cannot be overestimated, as only by taking advantage of it is it possible to furnish blood for the needs of the part affected. There is no vessel with which the surgeon can interfere where natural provisions in this direction appear insufficient (Fig. 148).

Certain conditions predispose to aneurysm of the idiopathic type, such as age, with its accompaniment of arteriosclerosis; _syphilis_, with its well-known tendency to chronic endarteritis; _occupation_ and _sex_, in that it is most frequent in those who are liable to violent exertion and dissipation, because of the well-known tendency to arterial structural changes after excesses of all kinds. Again, aneurysm may be the secondary result of embolism when an embolus leads to a local arteritis with disorganization.

Multiple aneurysms of the mesenteric arteries. (Eppinger.)]

Change in the trunk after ligature; with anastomosing vessel. (Erichsen.)]

=Classification.=--For surgical purposes there is no better classification than the one used by Eve:

1. _Sacculated aneurysm._
(_a_) Hernial;
(_b_) Diffuse, being a form of false aneurysm.

2. _Fusiform, cylindrical, or tubular aneurysm._

3. _Dissecting aneurysm, which may become_
(_a_) Sacculated;
(_b_) Diffuse and false; or
(_c_) Circumscribed.

4. _Traumatic aneurysm._
(_a_) Circumscribed;
(_b_) Diffuse;
(_c_) Arteriovenous.

5. _Arterial varix, cirsoid or racemose aneurysm._

6. _Angioma or aneurysm by anastomosis._

1. =Sacculated Aneurysms.=--The sacculated are the most common. They assume various shapes and dimensions, and may be seen anywhere in the body. The opening between the sac and the main vessel may vary in size. These sacs are usually strengthened by plastic exudate in and around them, and condensation of surrounding tissue. In thickness they vary from 1 Cm. to the thinnest which will sustain blood pressure. In old scars may be found a stratiform or layer-like arrangement, especially where the blood stream is less active. Should spontaneous cure take place the sac may be obliterated, while later calcific or other changes in the old scar may occur. When the outer portion of such a sac has disappeared and the inner coat is pushed out so as to assume, apparently, a secondary aneurysmal arrangement, the condition is referred to as a _hernial_ aneurysm. When the ordinary sacculation gives way as the result of necrosis, of pressure from within, or loss of support from without, the opening first made is usually small and the extravasation outside the true sac will depend upon the nature and resistance of the surrounding tissues. In this way a _diffuse_ aneurysm is formed, which is one of the varieties of false aneurysm.

2. =Fusiform Aneurysms.=--Fusiform aneurysms are more or less tubular and spindle-like dilatations of arterial trunks, in whose walls may occur the changes common to all these lesions, the dilatation rarely being sufficiently large to permit of laminated coagula unless a sacculation occurs later at some particular portion (Fig. 149).

Fusiform aneurysm of popliteal artery, due to arterial disease (man aged 59), requiring amputation of thigh on account of gangrene. (Lexer.)]

3. =Dissecting Aneurysms.=--The dissecting aneurysms are nearly always expressions of previous atheromatous changes, by which blood is forced between the arterial coats, separating them and causing them to bulge at one or more points into sacculations or distortions. In a _false aneurysm_ there is no true arterial coat; the sac is made up of surrounding tissue.

Traumatic aneurysm of axillary artery. (Park.)]

4. =Traumatic Aneurysms.=--Traumatic aneurysms are generally sacculated by the time they come under the surgeon’s observation. They are circumscribed and diffuse. According to their age and other circumstances they may contain old and dense laminated clots as well as those which are fresh and stratified. Much will depend upon whether the artery has been extensively injured or only slightly punctured, and also upon the location and distensibility of the surrounding tissue. Such a case seen in a fresh state will show infiltration of blood and ecchymosis (Fig. 150). _Arteriovenous_ aneurysms are now seldom seen. When venesection was more frequently performed the artery and one of the veins at the bend of the elbow were often thrown into communication, as the result of the indifferent performance of this operation and the use of the old-fashioned lancet. When the communication is direct such a condition is known as an aneurysmal varix; when indirect and through the sac it is called a _varicose aneurysm_ (Figs. 151, 152 and 153.)

Aneurysmal varix. (Bryant.)]

Arteriovenous aneurysm at bend of elbow: _a_, brachial artery; _b_, radial artery; _c_, basilic vein; _d_, median basilic vein; _e_, aneurysmal sac; _f_, dilated vein. (Lenoir.)]

Varicose aneurysm removed from its connections. (Erichsen.)]

Cirsoid aneurysm. (Bruns.)]

5. =Cirsoid or Racemose Aneurysms.=--Cirsoid or racemose aneurysms constitute vascular tumors of irregular shape and outline, according to the extent of the arterial system involved.

Cirsoid aneurysm of femoral artery and telangiectasis, with lengthening of affected limb from hypernutrition. (Parker.)]

6. =Angioma or Aneurysm by Anastomosis.=--The difference between _angiomas_ and cirsoid aneurysms is more artificial than natural. When a single vessel is involved with all its branches it constitutes an elongated tumor and partakes of the nature of a varix. When the growth is a collection of small arteries the condition is then known as an angioma. Between these there may be all varieties of vascular changes. Fig. 154 illustrates a case of this kind in the scalp, while Fig. 155, contributed by Parker, illustrates a congenital involvement of the vessels of an entire limb, with overgrowth of the same from increase of blood supply.

=Diagnosis.=--All aneurysm so constituted as to be easily palpated can scarcely be mistaken for a tumor of any other kind. It can be recognized by its circumscribed nature; its pulsation, which is always of the expansile type; its bruit, which is synchronous with systole. It can be emptied by pressure, fills somewhat slowly if pressure is made above it, but more rapidly if pressure is made below it, being in this respect the counterpart of a venous angioma. Its size and rapidity of pulsation are influenced by position, and its location is usually that of one of the large arterial trunks. The murmur, heard through the stethoscope, is sometimes more than a mere bruit, and may be of a tumultuous, almost roaring character, the sounds being modified by the smoothness or roughness of the interior blood channel as well as by the thickness of the parts outside. Naturally the sounds can be altered by pressure. The overlying integument is at first unchanged, but if an aneurysm is working its way toward the surface and threatening rupture the skin will be stretched and discolored and may finally ulcerate. Blood pressure as measured by the sphygmomanometer is not altered in a limb which is affected by aneurysm.

Signs and symptoms which are not local are also produced in most cases, their variety being great and depending upon the location of the primary disturbing cause; for example, there is generally edema with venous congestion of parts situated distally, these features being so extreme in some cases as not only to threaten but even to occasion gangrene. By pressure upon nerves both pain and paralysis are produced and important functions impaired.

The tendency in all aneurysms is to increase in size and cause atrophy or disappearance of the tissues upon which they exercise their present influence.

Varices of saphenous and branches (phlebectasis). (Lexer.) Compare with Fig. 153.]

=Regional Indications. Innominate Aneurysms.=--Innominate aneurysms usually appear behind the right sternoclavicular joint. As they increase in size they cause pain and edema of the right arm and the right side of the face, cough, dyspnea, and dysphagia. As the swelling increases it rises above the rib and sternum, pushing forward the sternomastoid and the clavicle. After being displaced the bones and cartilages in front begin to disappear by erosion, and the growth makes its way to the surface, where pulsation can be easily seen as well as felt and heard. In proportion to their increase other significant pressure symptoms, with venous turgescence, will occur. Innominate aneurysms can sometimes be differentiated from aortic by the sign, described by Porter, of _tracheal tugging_. This is elicited by causing the patient to sit up and bend the head forward, after which the cricoid is grasped and drawn forcibly upward, thus stretching the trachea. If with each cardiac impulse a well-marked tugging sensation be felt it may be attributed to the pulsation of an aortic aneurysm.

=Subclavian Aneurysms.=--Subclavian aneurysms of the first part of the vessel present similar features, only that the bruit is propagated down the axillary artery rather than up the carotid, and is not influenced by carotid pressure, while the pressure symptoms are limited mostly to the arm. In _axillary_ aneurysm the radial pulse is more delayed.

=Carotid Aneurysms.=--Carotid aneurysms are not always easy of early diagnosis, as at the root of the neck solid tumors often transmit a deceiving pulsation and convey an exaggerated vascular sound. They may also give rise to the same pressure symptoms as do subclavian aneurysms. Non-vascular tumors do not have an expansile pulsation, nor is the arterial sound conveyed upward along the carotid as in true aneurysm. In aneurysms of the _external carotid_ there may be paralysis of the tongue as well as difficulties in speech and deglutition. Aneurysms of the _internal carotid_ tend to extend inward rather than outward. _Intracranial aneurysms_ are difficult of diagnosis, but they usually give the symptoms of brain tumor, with possibly a bruit that may be heard and described by the patient himself, especially in certain positions of the head.

Wardrop used to formulate the diagnostic features of certain aneurysms at the base of the neck, as follows: Innominate aneurysms generally monopolize the episternal notch or rather its right side, taking up this whole space, even though not rising high. They first present to the inner side of the right sternomastoid, while carotid aneurysms appear in the interval between the sternal and clavicular heads, and subclavian aneurysm to the outer side of this muscle.

In the _abdomen_ the _aorta_ is most frequently involved, and sometimes its larger branches. An aneurysm of the renal or mesenteric arteries can easily be mistaken for an aortic aneurysm. The aorta proper terminates at the level of the umbilicus. A pulsating tumor below this level should belong to one of the _iliacs_. Recognition will depend largely upon the thinness of the abdominal wall and the absence of fat. In many cases expansile pulsation can be detected even here, while the pain is radiated along the well-known branches of the sympathetic, and the location to which it is referred may be of aid in deciding the part of the aorta most involved. Aortic pulsation is communicated by growths overlying it, and the surgeon is liable to be deceived by a certain abnormality of the natural pulsation through this trunk, as it is often exaggerated and appears pathological when it is not. _Abnormal pulsation of the abdominal aorta was first described_ by Cooper, and has served as a topic for surgical essays ever since. Schede’s test may be applied here to advantage: if firm pressure be made simultaneously upon both femoral trunks the extra blood pressure thus caused inside the tumor will give rise to pain, whereas in the absence of aneurysm it produces no such effect.

_Iliac_ and _femoral_ aneurysms may be made difficult of recognition by obesity, but the bruit can almost always be heard, and this, with such extra aid as the rectal or vaginal examination may afford, coupled with pressure symptoms confined to one limb, will usually facilitate diagnosis. Fig. 157 illustrates what features a tumor of this kind may present when located in the upper part of the thigh.

Sacculated aneurysm of femoral artery. (Parmenter.)]

=Treatment.=--The general purpose of the treatment of aneurysms is to favor _coagulation_ and to effect a cure in this way. In the pre-antiseptic era it is not strange that men resorted to the method of starvation, by which the coagulability of the blood was much increased, or to the rest treatment, with the use of cardiac sedatives, by which the heart’s activity and power were greatly reduced. Nor was it strange that non-operative, yet mechanical, methods were used, in order to minimize the danger attending operative procedures. With the confidence, however, which Lister and his followers have given, it is generally conceded that with an aneurysm which can be made accessible by an operation radical methods are more satisfactory. To the surgeon belong all aneurysms except, perhaps, those of the aorta and the innominate, and even these have not been exempt from surgical methods. The following operative measures are worthy of discussion in these cases: (1) _Ligature._ (2) _Open operation._ (3) _Extirpation._ (4) _Opening and suture._ (5) _Introduction of wire, with or without electrolysis._

1. Ligation includes the application of a ligature in one of the following situations: (_a_) Proximal ligation (Anel’s) at a convenient point shortly above the sac; (_b_) proximal ligation (Hunter’s) at a distance from the sac; (_c_) distal ligation, either of the main trunk just below the sac (Brasdor’s) or of the highest main branch given off below the sac (Wardrop’s). Thus proximal ligation could be practised in case of aneurysm, either of the external or internal carotid, by tying the main trunk, or in the case of popliteal aneurysm (Hunter’s suggestion), by tying the femoral in Hunter’s so-called canal. Brasdor’s distal ligation may be illustrated by ligature, in Hunter’s canal, of the femoral for aneurysm in the groin, while Wardrop’s modification would consist in tying one of the tibials for popliteal aneurysm, or one of the lesser carotids for aneurysm of the common trunk. Should _ligation_ be determined upon, circumstances will dictate where the ligature should be applied, and the surgeon will decide the character of the suture material. The methods of attack upon the large vascular trunks will be considered later. Inasmuch as it takes time to establish collateral circulation, attention should be given to physiological rest, as well as to all other general measures calculated to make any operation successful.

Anel’s operation.

Hunter’s operation.

Distal operation.

(Erichsen.)]

Brachiocephalic aneurysm; ligature of the subclavian only.

Brachiocephalic aneurysm; ligature of the carotid only.

Brachiocephalic aneurysm; ligature of the subclavian and carotid.

Different schemes for application of the ligature according to the necessities of the case. (Erichsen.)]

2. _Open division_ was first suggested in the fourth century by Antyllus. It soon fell into disuse and was taken up during the middle of the past century by Syme, to whom the operation has been frequently credited, although it was really the revival of an antique method; but Syme gave it so much of his anatomical exactness and brilliancy of operative skill that he almost made it his own. The method was essentially one by long and free incision, through which the interior of the sac was fully exposed, its contained clots turned out, its vascular openings plugged, while a ligature was applied above and below in order to prevent further arterial communication. Performed before the days of anesthesia or of antisepsis it was an exceedingly bold procedure, yet in Syme’s hands it gave brilliant results.

3. The _open division_ has been replaced by the more perfect procedure of _extirpation of the sac_, based upon the general principle that an aneurysm is a _tumor_ and should be extirpated, the parts being sutured and expected to heal promptly. It constitutes in many cases the ideal method of treatment. There could be but one improvement on it, namely, that suggested by Matas, of _arteriorrhaphy_, as one of the radical methods which is often applicable to aneurysms of the extremities, or to those where rupture has occurred or is imminent. The part should be made bloodless, as in this way perfect control can be secured; should this be impracticable, the vessel should be ligated above the aneurysm before proceeding to its excision. This done, and the vessels secured above and below, the wound may be closed as after any other operation, and in this way radical cure achieved within a few days.

Fig. 160 illustrates a recent case of this kind in the author’s hands, where an aneurysm of the common carotid, of about the size of a lemon, was treated in this way, the patient leaving the hospital in eight days, and having no unpleasant complications.

Aneurysm of the common carotid successfully treated by complete extirpation. (Park.)]

4. _Open division with arteriorrhaphy_ has been proposed by Matas and Murphy and in their hands has been successful. Its greatest usefulness is found in traumatic aneurysms of long standing where the arterial opening is usually small and the vessel wall healthy, so that after excision of the sac a sufficient amount of aneurysmal wall or stump may be retained in order to afford a firm surface for union. The circulation being controlled the sac is exposed, opened, and dissected down to a location near the arterial opening. Here the arterial walls are trimmed and freshened, turned in or rolled in, and a row of sutures applied, one line apart, through the outer and middle coats. Matas suggests that after the suture is complete the size of the vessel should be less than its normal, in order that pressure may be reduced at this point and more perfect union follow. The method may also be resorted to in certain fusiform aneurysms, where the arterial wall is still sufficiently healthy to sustain sutures. Here an elliptical piece can be excised, or it may be possible to infold the coats of the sac and apply sutures through a series of folds, on the same principle that they are applied in cases of dilatation of the stomach. Arterial suture as practised in these cases is similar to the Lembert suture used in intestinal surgery. It is necessary to support the tissues around the sutured artery by other buried sutures in such a manner as to fortify them against yielding of the arterial coats.

For these radical methods, either by excision or this combined with suture, the arteriovenous aneurysms afford an inviting class of cases. The parts having been made bloodless and the vessels separated, sutures may be applied, if there be sufficient room for them without too much occlusion of the vessels, which would afford but little advantage over ligatures.

In spite of what has been said about the rarity of these lesions, which is true in civil life, it has been shown, during recent wars, that bullets of small caliber having high velocity have produced instances of this character.

5. For cases so situated as to make any of the above methods inexpedient there is still the more or less promising method of treatment by the _introduction of wire, coupled perhaps with the use of the electric current, and the injection of gelatin solutions_. While ligation of the abdominal aorta has been practised with temporary success it has not yet proved so encouraging as to justify its performance, save in exceptional cases, but into any intrathoracic or intra-abdominal aneurysm, which appears to be otherwise inoperable, a number of feet of fine steel wire may be introduced, in the attempt to coil it up irregularly within the sac and thus to afford a sort of skeleton framework, upon which coagula will more readily form and by which they may be retained. In some cases the end of this wire has been attached to the negative pole of a galvanic battery, the other pole being affixed to an external electrode, and a weak galvanic current has been passed for a period of say from five to thirty minutes, the time varying in accordance with the strength of the current. By this procedure coagulation is much encouraged. In cases of intra-abdominal aneurysm the abdomen may be opened and the sac more or less completely exposed, after which this insertion may be more minutely performed.

Occasionally surgeons have exposed an aortic aneurysm and endeavored to externalize or exclude it by producing adhesions around it, while some portion of the sac is exposed to the outer world. After adhesions have formed such methods of treatment can be repeated as may be desired. They may also be combined with the subcutaneous use of 2 per cent. sterile gelatin solution, or this may be thrown into the sac in small amounts. It is true, however, that cases of this character are desperate, and while life has been in perhaps half of the operated cases more or less prolonged, but few instances of final recovery have been recorded.

The after-treatment consists of physiological rest of the part operated upon, and rest and abstention from violent exertions of any kind. During this time elimination should not be neglected, emotional excitement should be avoided, and, in the presence of syphilitic disease or a well-founded suspicion of it, conventional antispecifics should be administered in sufficient amounts. When the aneurysm is of traumatic origin and there is no general vascular or cardiac disease, there will be a quick restoration of the integrity of parts as well as of their usefulness. Massage and an elastic bandage will be useful, in order to atone for the results of a disturbed circulation.

SUTURE OF BLOODVESSELS.

This is almost a new topic in surgery, especially suture of the arteries. Surgeons have learned that the walls of the arteries and of the veins, when not too much diseased, will tolerate sutures and unite easily. The larger the vessel the easier it is to apply a suture, as its walls are thicker and the method easier. The greater, too, will be the need of suture when the vessel is an important one. Small vessels are relatively so unimportant as not to demand so formal a procedure. The vessels to which the method is most applicable are the common carotid, the subclavian, axillary, brachial and femoral, with their accompanying veins, including the common jugular. It is applicable when it is an injury to the vessel which has necessitated an operation, or when, during its performance, some trunk has been torn out or torn open, as in separating adhesions. It is serviceable, also, when both artery and vein have been involved, as in the groin, where the danger of gangrene of the limb would be enhanced if both the outflow and the inflow of the blood were shut off.

End-to-end suture of a divided artery, permitting a certain degree of invagination. (After Murphy.)]

_Lateral suture of injured bloodvessels_ may be regarded as a standard procedure, as it is nearly always possible to temporarily control the circulation on both sides of the field of operation, either by elastic constriction or temporary ligation or clamping. For this purpose fine silk makes the best suture material. It should be threaded into round needles and the sutures should include only the two outer coats. After completing the suture the distal provisional closure of the vessel should be first removed. As the blood backs up in the artery it will test the efficacy of the sutures. Should there be no leakage the proximal clamp may be removed, and then if the condition appear satisfactory the arterial sheath should be carefully closed, and over this the other tissues, with buried sutures.

_End-to-end suture_ of bloodvessels is a recent measure, for which we are indebted to Murphy. It is applicable to vessels which have been divided circularly and completely or almost completely. In the event of the adoption of this method the ends should be divided squarely and then reunited by sutures threaded upon the needles, passing through all the coats, about 1 Mm. from the margin of division, as well as about the same distance apart. If the upper end can be drawn into the lower one, and gently held there by a series of U-shaped stitches, it may be considered the best method.[26] (See Fig. 161.)

[26] There are now before the profession three methods of repairing
arteries--by _invagination_, by _suture of the two outer coats_, by
the _through-and-through method_--each of which has its advantages
and disadvantages. The presence of sutures in the interior of the
vessel does not seem to produce coagulation, even though the intima
of the vessel is injured by the passage of the same. Nevertheless
sutures must be kept out of the blood stream. Liability to secondary
hemorrhage is reduced if a double line of sutures can be used.

LIGATION OF ARTERIES.