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the distal part from within outwards; the threads are then tied and this invaginates the artery. In order to facilitate the invagination a small incision is made parallel to its long axis, extending one-fourth to one-third inch; then four or five interrupted sutures are inserted into the intussuscipiens binding it to the surface of the intussusceptum, the suture in the latter, entering only the tunica adventitia and media. By this method we have secured a large surface contact of vessel, the proximal portion of the vessel being inserted into the distal. The arterial blood pressure tends to press the walls closer, thus preventing hemorrhage and favoring definitive union, By this method of approximation fewer sutures are necessary to secure blood-proof apposition. In experiments it is important to use large-sized vessels as the lumen of small ones is apt to be filled by a thrombus. The work is delicate; the vessels must be handled with all possible care, as every injury to the intima means inflammatory reaction for repair. The veins may be subjected to the same treatment with better results.
The indications for operation are:
I. Injuries to large vessels in operation. 2. Injuries to large vessels from stab, puncture, bullet or lacerating wounds.
3. Traumatic and dissecting aneurisms. 4. Sacculated, fusiform and arterio-venous aneurisms.
In the first class of cases, i. e., injuries to large vessels in operation, the injury to an artery, if less than two-thirds the circumference be involved, should be immediately repaired by suture. If more than two-thirds the circumference be injured, the division. should be made complete and the invagination method used for approximation, care being taken that the invaginating sutures do not penetrate the tunica intima of the invaginated portion, that the external sutures do not injure the intima and are first inserted in the invaginated portion parallel to the long axis of he vessel and then inserted in the overlapping end. (See Fig. II.) By this method the circumference of the artery is not diminished as it is when the suture is inserted transversely to the arterial axis. The sheath should be carefully sutured over the artery, as it gives additional support, and if the general field of operation should suppurate the line of union would thus be protected from infection. The field of operation should always be temporarily drained, as a blood clot prevents primary adhesions. Where the edges of the arterial wound are ragged they should be freshened and clean cut before the suture is inserted.
In the second class of cases, i. e., injuries to large vessels from stab, puncture, bullet or lacerating wounds, the primary hemorrhage as a rule is not excessive, particularly when caused by bullet wounds, except when the ab
dominal aorta or renal vessels are involved, as the tissues are irregularly torn and overlap each other in such a manner as to prevent the escape of blood and favor the formation of aneurism; therefore, we have ample time to make proper preparation for the suture of the vessel. The wound may have existed for weeks or months with the dissecting aneurism and still be amenable to suture, as the opening in the vessel itself enlarges but little with time, the aneurismal sac being formed from the surrounding tissues and laminated coagula. See Fig. XII. The technique of suture in this class of cases should be the same as in
the first, after the aneurismal sac has been enucleated and the opening in the vessel has been exposed and separated from its attachment to the wall of the aneurism.
In the third class of cases, i. e., traumatic aneurisms of long standing, we have the best variety of cases for arterial suture. The opening in the artery is usually small, the arterial wall is healthy and a sufficient quantity of aneurism a 1 stump may be retained to produce a firm line of approximation. See
Fig. XVII. Shows position of Fig. XII. From
perforation of artery and vein in Case II.
standpoint as well as from the result of experiments there is no danger of the formation of aneurism at the point of primary suture for injuries, and should not be for secondary suture as in aneurisms of this class. The vessel should be exposed above and below the aneurism, and temporary hæmostasis obtained by a very mild compression forceps. The aneurismal sac should then be freely opened and dissected down to the position of the opening in the artery. The edges of the opening should be freshened and closed, observing the same technique as in primary
In the fourth class of cases, i. e., sacculated, fusiform and arterio-venous aneurisms, the aneurismal sac should be exposed and dissected down to the position of the healthy coats of the artery, Figs. XIII and XIV, where
it should be amputated, leaving sufficient of the aneurismal coat and arterial wall to admit of a row of sutures involving one-sixteenth of an inch of the margin on either side so that when the suture is complete the size of the vessel will be below its normal caliber. This lessens the arterial tension of the vessel at that point and there should follow a union of the walls. Care should be taken not to produce an approximation of arterial surfaces covered with coagulated laminæ. A study of the aneurismal varix, Figs. XIII and XIV (Treves Surgery, p. 634), shows how the aneurismal sac may be amputated or removed from the opening in the artery and the communicating canal closed by suture, also Warren's case (Boston Medical and Surgical Journal, May 30, 1890). The same can be said of Roland's case (Bryant's Surgery, p. 316). As the longitudinal suture of arteries has been so successful experimentally, little doubt remains but it
Fig. XVIII. Shows the extent of destruction of artery and the portion resected, with appearance after end-to-end approximation in Case II.
can be more successful clinically as asepsis and antisepsis can be more effectually carried
Following are reports of two cases in the human subject:
Case I: Carl A. B., American, age 33, married, a salesman, received a bullet wound in the left Scarpa's triangle (22 caliber ball), at 2 o'clock in the afternoon of October 4. He was taken to the County Hospital, where I saw him, through invitation of Dr. Craig, at 6:45 the same evening. The man had profuse hemorrhage from the wound before he was brought to the hospital. There was considerable puffing for four inches below Poupart's ligament; there was no pulsation nor bruit in this swelling. The left posterior tibial artery pulsated synchronously with the right and was of the same force and tension. It was believed from these conditions, from the position of the wound and the severity of the hemorrhage that the femoral artery was not injured, but that the vein was probably punctured.
Operation: An incision five inches long was made, extending downward from Pou
part's ligament parallel with the femoral artery; the internal saphenous vein was exposed and found to be perforated. An opening existed on its anterior and posterior surfaces, the bullet having passed through the middle. These were sutured with a continuous silk suture No.8 floss needle. The dissection was continued and the common femoral vein exposed and found injured. The femoral vein had an opening on its anterior surface three-fourths of an inch above the junction of the profunda, and on its posterior surface one-eighth of an inch above the vena profunda femoralis, Fig. XV. It was difficult to control the hemorrhage as the blood returned through the vena profunda when the clamps were placed upon the femoral vein above and below the wound. It was soon found that the posterior opening could not be exposed without dividing the profunda. A double ligature was placed on the profunda and it was divided between. The posterior surface of the vein was now turned forward and the opening closed with a continuous suture as above. After this was completed the clamps were removed and a little blood escaped from the posterior inferior angle of the wound in the vein; after the insertion of an additional suture in the angle the hemorrhage ceased. The femoral artery had a fragment of tissue torn off the side of its sheath, but the vessel wall was not injured. The bullet was not located. The vein wall was split by the bullet, no part of it being carried away, the usual result of a bullet wound of a vein. There was not a drop of blood escaping from either of the veins when the compresses were finally removed. The field of operation was sponged out with a per cent solution of carbolic acid, the wound closed and the leg elevated. No drainage.
The greatest difficulty in the operation was experienced in exposing the posterior surface of the common femoral vein on account of the close relation of the wound to the vena profunda. The patient's temperature began to rise after the operation, and on October 8 had reached 104 degrees F. The wound was opened and a gauze drain inserted. The temperature gradually dropped and by October 12 was below 100 degrees F., and remained below 100 degrees F. until November 6, when it reached 101 F.; November 7, in the morning, 102.2 degrees F. The wound had been suppurating all the time, although the external opening was almost closed. On the morning of November 7 there was considerable hemorrhage, which was believed to be due to suppuration of the sutures in the vein. On November 8 temperature 102 degrees, pulse 130; more bleeding; November 9, pulse 144: temperature 100; patient was coughing and expectorating a bloody mucous. On November 10 I saw the patient for the first time in a week; his temperature was then 101.6 degrees and his pulse 104. Examination revealed
a large swelling of the upper third of the thigh, the tension of the tumor was very great; blood was oozing from the small opening which still remained, and a dark clot could be seen inside the opening. There was no pulsation in the swelling. It was not auscultated. Patient was anesthetized, the opening enlarged, a clot four inches in diameter was shelled out, and in the bottom, bright arterial blood flowed persaltum into the wound; digital compression controlled it until the field was entirely cleared. The inner side of the femoral artery for one inch was eroded and had a number of perforations. It was carefully dissected out, about one and one-half inches resected, a single ligature placed on the distal and a double one on the proximal end. The cavity was cleansed and drained. The femoral vein could not be located. Some fragments of the femur which had been broken off by the bullet were removed.
November 27: From that time the patient has been doing very well. There has been no disturbance of the circulation of the leg, and the cavity is almost closed; December 8 there is a very small sinus remaining; patient is in excellent condition. The infection was probably produced by the bullet and the continued suppuration favored by the fragments of bone. January 4 patient completely recovered; no oedema and no disturbance of circulation of limb.
Case II: H. V., Italian, peddler, age 29. Shot at II o'clock September 19. Was brought to the hospital two hours later. The case was transferred to my service through kindness of Dr. F. S. Hartmann.
Clinical history: The patient was shot twice, one bullet passing into the abdominal wall just above the great curvature of the stomach without penetrating the abdomen; the other entered Scarpa's triangle below Poupart's ligament. There was no bruit at this point nor increased pulsation noticed at the time the patient was admitted to the hospital. I saw the patient first October 4; examination revealed a loud bruit; it could be heard with the ear placed six inches from the thigh. There was no tumor and but slight increase in pulsation. The pulsation in the popliteal, dorsalis-pedis and posterior tibial arteries was scarcely perceptible. I examined the case again on October 6 and demonstrated it to a class of students. A thrill could be felt and a bruit could be heard and the latter was the loudest to which I had ever listened. The pulsation though very feeble could now be felt in the dorsalis-pedis, but not in the posterior tibial.
Diagnosis: Penetrating wound of the common femoral artery about one and one-half inches below Poupart's ligament. It was decided to cut down and expose the artery, and if a penetrating wound of more than one-half
of the circumference was found to make a resection and unite it end to end. Operation Oct. 7, 1896. An incision five inches long was made from Poupart's ligament along the course of the femoral artery. The artery was readily exposed about one inch below Poupart's ligament; it was separated from its sheath and a provisional ligature thrown around it but not tied. A careful dissection was then made down along the wall of the vessel to the pulsating clot. The artery was exposed one inch below that point and a ligature thrown around it but not tied; a careful dissection was made upward to the point of the clot. The artery was then closed above and below with gentle compression clamps and was elevated, at which time there was profuse hemorrhage from an opening in the vein. A cavity about the size of a filbert was found posterior to the artery, communicating with its caliber, the aneurismal pocket. A small aneurismal sac about the same size was found on the anterior surface of the artery over the point of perforation, Fig. XVI. The hemorrhage from the vein was very profuse and was controlled by digital compression. It was found that one-eighth of an inch of the arterial wall on the outer side of the opening remained, and on the inner side of the perforation only a band of one-sixteenth of an inch of the adventitia was intact, Fig. XVI and Fig. XVIII. The bullet had passed through the center of the artery, carried away all its wall except the strands described above, and passed downward and backward, making a large hole in the vein in its posterior and external side just above the junction of the vena profunda, Fig. XVII. Great difficulty was experienced in controlling the hemorrhage from the vein. After dissecting the vein above and below the point of laceration and placing a temporary ligature on the vena profunda, the hemorrhage was controlled so that the vein could be sutured. At the point of suture the vein was greatly diminished in size, but when the clamps were removed it dilated about one-third the normal diameter, or one-third the diameter of the vein above and below. There was no bleeding from the vein when the clamps were removed. Our attention was then turned to the artery. Two inches of it had been exposed and freed from all surroundings. The opening in the artery was three-eighths of an inch in length; one-half inch was resected and the proximal end was invaginated into the distal for onethird of an inch with four double-needled threads which penetrated all the walls of the artery.
The adventitia was peeled off the invaginated portion for a distance of onethird inch; a row of sutures was placed around the edge of the overlapping distal end, the sutures penetrating only the media of the proximal portion; the adventitia
was then drawn over the line of union and sutured. The clamps were removed. Not a drop of blood escaped at the line of suture. Pulsation was immediately restored in the artery below the line of approximation, and it could be felt feebly in the posterior tibial and dorsalis-pedis. The sheath and connective tissue around the artery were then approximated at the position of suture with catgut so as to support the wall of the artery. The whole cavity was washed out with a 5 per cent solution of carbolic acid, and the edges of the wound accurately approximated with silkworm gut sutures. No drainage.
The time for the operation was approximately two and one-half hours, most of that time being consumed in suturing the vein. The artery was easily secured and sutured, and the hemorrhage from it readily controlled. The patient was placed in bed, leg elevated and wrapped in cotton.
A pulsation could be felt in the dorsalispedis on October 11, four days after the operation. There was no œdema of the leg and no pain. The circulation was good continuously from the time of operation. The wound suppurated; drainage was inserted, but at no time did the patient's temperature exceed 100.8 degrees Fahrenheit. Dec. 8, 1896, the circulation is perfect, the wound has healed with the exception of a small superficial ulcer one-third of an inch in diameter. The patient has not had an unpleasant symptom since the operation.
January 4: Patient is walking about the hospital, has no cedema and no disturbance of circulation.
I desire to thank Dr. W. A. Evans for the microscopical work, and Dr. E. H. Lee for his assistance in the experiments. 34 Washington street.
Extensive Surgery to the Skull, With Recovery.
BY T. L. ARMITAGE, M. D., LILLY, CAMBRIA COUNTY, PA.
G. Short, aged five years and five months, was carried into my office on the evening of the sixth of May, having about sixteen minutes previously been struck by a railroad engine. She was completely unconscious when I saw her. Upon superficial examination I found a very extensive fracture extending across the skull from ear to ear, with a wound running from the left ear to crown. Her hair was shaved and an incision made, continuous with the wound, downward, outward and forward, extending one and a half inches in front of the external auditory meatus; this flap was raised, when a piece of bone two and one-half
inches long, three-fourths inch wide, was found crushed into the brain. The dura and brain was bulging round it, but the dura was still intact. This piece of bone was extracted, when the dura immediately bulged out of wound, appeared tumified. It was incised in four separate places, each incision being a quarter of an inch in length, an iodoform gauze drain was placed in the wound and flap adjusted with about six stitches. No anæsthetic was used, the child being still unconscious. After being dressed she received a hypodermic injection of half a grain of sulphate of strychnine, when her parents carried her home. Four hours afterward she was again given ten minims of liquor strychninæ hypodermically, and that line of treatment carried on three times a day for six days. The bowels were moved by large enemata of water every morning, and shortly after evacuation, a nutrient enemata, containing one tablespoonful of brandy, one whipped egg, and a half pint of milk was thrown into the bowel, and repeated noon and evening for four days, when the bowel would no longer retain it. Upon the fifth day, oral feeling was begun, but had to be watched very carefully, as she strangled when a full teaspoonful of milk was put into her mouth. Her right arm and leg was completely paralyzed, and her eyelids closed. About the twelfth day cornstarch and whipped egg was added to the milk, and a cold bath was given from this time forward daily. The wound was dressed every day for two weeks. About the middle of the third week a piece of bone sloughed out, one-half inch long and one-half inch wide; after this it was only dressed once or twice weekyl until healed.
In presenting this case to the profession at large, it is with two objects in view, viz.: The intense amount of shock recovered from, together with the extensive destruction of bone and concomitant fracture; and, secondly, the large quantity of strychnine employed as a remedial agent. Her first dose after extraction of bone was half a grain hypodermically, and it was continued for four days, until the physiological effect was obtained, when it was discontinued for three days and then resumed. In all, inside of two weeks, she had taken six grains of strychnine. It was four days before an attempt was made to feed her orally; she remained eighteen days without opening her eyes; twenty days from the injury she began to talk, and then only very imperfectly (exactly in the same manner as case of gunshot wound of head reported in the Medical Standard last year); about seventy-two days before an attempt was made at walking, and the gait was very peculiar, just like a child learning-she held to a chair for some time. Now, August 17, she can talk, walk and run just as before injury, whilst bone is forming in the vacant space.-Medical Standard.
All who were present at the ninth annual meeting of the National Association of Railway Surgeons at St. Louis will recall the brilliant remarks made by the president, Dr. J. B. Murphy, upon the subject of the suture of veins and arteries, injured in their continuity, and the discussion which followed. Although Dr. Murphy, used no notes, he had in his pocket the manuscript of a paper which has since been much amplified and which fills the better part of the present issue of The Railway Surgeon. Since the St. Louis meeting many additional experiments have been performed, the results of which are now given, and Dr. Murphy has had additional clinical experience fully confirming his conclusions. This seems to us now to be the most important paper which has been published in the columns of
The Railway Surgeon, and we believe that it will mark an epoch in traumatic surgery. Only those who have done similar experimental work can form any idea of the time and labor which the author has given to the preparation of this magnificent paper.
We recall vividly the speech which Dr. Murphy made at the close of the Chicago meeting of the National Association of Railway Surgeons, in accepting the presidency of the association for 1896 and the earnest appeal which he made for original research by our members. What a splendid example he set for us. There is more work to be done; there are new paths to be found. May we not hope that the publication of this paper will furnish a new stimulus to railway surgeons to do more and better work and to let their fellows know of it?
The editors of The Railway Surgeon are gratified to notice an increased interest on the part of the members of the National Association of Railway Surgeons, in both the association and its official journal. We shall be glad to hear from our readers whenever they have anything to communicate that will advance the interests of either. The members can, if they will, add a great deal to the usefulness of the journal by advising us of any incidents in their practice that embrace novel or interesting features. Regrettable as it may be, railway accidents are constantly occurring and there is scarcely an accident that does not reveal some features that if properly illustrated and described in the columns of The Railway Surgeon would be of great value to our readers. We earnestly urge the members of the National Association to bear this constantly in mind.
A Good Local Anæsthetic.
A good local anesthetic for spraying abscesses before lancing is made with half a drachm of chloroform in an ounce of ether.— The Medical Summary.
Dr. G. W. H. Kemper of Muncie, Ind., has been appointed local surgeon at Muncie for the Big Four, in place of Dr. H. M. Winans, who resigned some time since. Dr. Kemper continues as surgeon at the same point for the L. E. & W. railway.