Alexis Thomson and Alexander Miles - Manual of Surgery

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If the patient is placed on a couch and the limb elevated, the veins are
emptied, and if pressure is then made over the region of the saphenous
opening and the patient allowed to stand up, so long as the great
saphena system alone is involved, the veins fill again very slowly from
below. If the small saphena system also is involved, and if
communicating branches are dilated, the veins fill up from below more
rapidly. When the pressure over the saphenous opening is removed, the
blood rapidly rushes into the varicose vessels from above; this is known
as Trendelenburg's test.

The most marked dilatation usually occurs on the medial side of the
limb, between the middle of the thigh and the middle of the calf, the
arrangement of the veins showing great variety (Fig. 67).

There are usually one or more bunches of enlarged and tortuous veins in
the region of the knee. Frequently a large branch establishes a
communication between the systems of the great and small saphenous veins
in the region of the popliteal space, or across the front of the upper
part of the tibia. The superficial position of this last branch and its
proximity to the bone render it liable to injury.

[Illustration: FIG. 67.--Extensive Varix of Internal Saphena System on
Left Leg, of many years' standing.]

The small veins of the skin of the ankle and foot often show as fine
blue streaks arranged in a stellate or arborescent manner, especially in
women who have borne children.

_Complications._--When the varix is of long standing, the skin in the
lower part of the leg sometimes assumes a mahogany-brown or bluish hue,
as a result of the _deposit of blood pigment_ in the tissues, and this
is frequently a precursor of ulceration.

_Chronic dermatitis_ (_varicose eczema_) is often met with in the lower
part of the leg, and is due to interference with the nutrition of the
skin. The incompetence of the valves allows the pressure in the varicose
veins to equal that in the arterioles, so that the capillary circulation
is impeded. From the same cause the blood in the deep veins is enabled
to enter the superficial veins, where the backward pressure is so great
that the blood flows down again, and so a vicious circle is established.
The blood therefore loses more and more of its oxygen, and so fails to
nourish the tissues.

The _ulcer_ of the leg associated with varicose veins has already been
described.

_Haemorrhage_ may take place from a varicose vein as a result of a wound
or of ulceration of its wall. Increased intra-venous pressure produced
by severe muscular strain may determine rupture of a vein exposed in the
floor of an ulcer. If the limb is dependent, the incompetency of the
valves permits of rapid and copious bleeding, which may prove fatal,
particularly if the patient is intoxicated when the rupture takes place
and no means are taken to arrest the haemorrhage. The bleeding may be
arrested at once by elevating the limb, or by applying pressure directly
over the bleeding point.

_Phlebitis and thrombosis_ are common sequelae of varix, and may prove
dangerous, either by spreading into the large venous trunks or by giving
rise to emboli. The larger the varix the greater is the tendency for a
thrombus to spread upwards and to involve the deep veins. Thrombi
usually originate in venous cysts or pouches, and at acute bends on the
vessel, especially when these are situated in the vicinity of the knee,
and are subjected to repeated injuries--for example in riding.
Phleboliths sometimes form in such pouches, and may be recognised in a
radiogram. In a certain proportion of cases, especially in elderly
people, the occurrence of thrombosis leads to cure of the condition by
the thrombus becoming organised and obliterating the vein.

_Treatment._--At best the treatment of varicose veins is only
palliative, as it is obviously impossible to restore to the vessels
their normal structure. The patient must avoid wearing anything, such as
a garter, which constricts the limb, and any obvious cause of direct
pressure on the pelvic veins, such as a tumour, persistent
constipation, or an ill-fitting truss, should be removed. Cardiac,
renal, or pulmonary causes of venous congestion must also be treated,
and the functions of the liver regulated. Severe forms of muscular
exertion and prolonged standing or walking are to be avoided, and the
patient may with benefit rest the limb in an elevated position for a few
hours each day. To support the distended vessels, a closely woven silk
or worsted stocking, or a light and porous form of elastic bandage,
applied as a puttee, should be worn. These appliances should be put on
before the patient leaves his bed in the morning, and should only be
removed after he lies down at night. In this way the vessels are never
allowed to become dilated. Elastic stockings, and bandages made entirely
of india-rubber, are to be avoided. In early and mild cases these
measures are usually sufficient to relieve the patient's discomfort.

_Operative Treatment._--In aggravated cases, when the patient is
suffering pain, when his occupation is interfered with by repeated
attacks of phlebitis, or when there are large pouches on the veins,
operative treatment is called for. The younger the patient the clearer
is the indication to operate. It may be necessary to operate to enable a
patient to enter one of the public services, even although no symptoms
are present. The presence of an ulcer does not contra-indicate
operation; the ulcer should be excised, and the raw surface covered with
skin grafts, before dealing with the veins.

The _operation of Trendelenburg_ is especially appropriate to cases in
which the trunk of the great saphena vein in the thigh is alone
involved. It consists in exposing three or four inches of the vein in
its upper part, applying a ligature at the upper and lower ends of the
exposed portion, and, after tying all tributary branches, resecting this
portion of the vein.

The procedure of C. H. Mayo is adapted to cases in which it is desirable
to remove longer segments of the veins. It consists in the employment of
special instruments known as "ring-enucleators" or "vein-strippers," by
means of which long portions of the vein are removed through
comparatively small incisions.

An alternative procedure consists in avulsing segments of the vein by
means of Babcock's stylet, which consists of a flexible steel rod, 30
inches in length, with acorn-shaped terminals. The instrument is passed
along the lumen of the segment to be dealt with, and a ligature applied
around the vein above the bulbous end of the stylet enables nearly the
whole length of the great saphena vein to be dragged out in one piece.
These methods are not suitable when the veins are brittle, when there
are pouches or calcareous deposits in their walls, or where there has
been periphlebitis binding the coils together.

Mitchell of Belfast advises exposing the varices at numerous points by
half-inch incisions, and, after clamping the vein between two pairs of
forceps, cutting it across and twisting out the segments of the vein
between adjacent incisions. The edges of the incisions are sutured; and
the limb is firmly bandaged from below upwards, and kept in an elevated
position. We have employed this method with satisfactory results.

The treatment of the complications of varix has already been considered.

ANGIOMA[4]

[4] In the description of angiomas we have followed the teaching of the
late John Duncan.

Tumours of blood vessels may be divided, according to the nature of the
vessels of which they are composed, into the capillary, the venous, and
the arterial angiomas.

CAPILLARY ANGIOMA

The most common form of capillary angioma is the naevus or congenital
telangiectasis.

#Naevus.#--A naevus is a collection of dilated capillaries, the afferent
arterioles and the efferent venules of which often share in the
dilatation. Little is known regarding the _etiology_ of naevi beyond the
fact that they are of congenital origin. They often escape notice until
the child is some days old, but attention is usually drawn to them
within a fortnight of birth. For practical purposes the most useful
classification of naevi is into the cutaneous, the subcutaneous, and the
mixed forms.

_The cutaneous naevus_, "mother's mark," or "port-wine stain," consists
of an aggregation of dilated capillaries in the substance of the skin.
On stretching the skin the vessels can be seen to form a fine network,
or to run in leashes parallel to one another. A dilated arteriole or a
vein winding about among the capillaries may sometimes be detected.
These naevi occur on any part of the body, but they are most frequently
met with on the face. They may be multiple, and vary greatly in size,
some being no bigger than a pin-head, while others cover large areas of
the body. In colour they present every tint from purple to brilliant
red; in the majority there is a considerable dash of blue, especially in
cold weather.

Unlike the other forms of naevi, the cutaneous variety shows little
tendency to disappear, and it is especially persistent when associated
with overgrowth of the epidermis and of the hairs--_naevoid mole_.

The _treatment_ of the cutaneous naevus is unsatisfactory, owing to the
difficulty of removing the naevus without leaving a scar which is even
more disfiguring. Very small naevi may be destroyed by a fine pointed
Paquelin thermo-cautery, or by escharotics, such as nitric acid. For
larger naevi, radium and solidified carbon dioxide ("CO_2 snow") may be
used. The extensive port-wine stains so often met with on the face are
best left alone.

The _subcutaneous naevus_ is comparatively rare. It constitutes a
well-defined, localised tumour, which may possess a distinct capsule,
especially when it has ceased to grow or is retrogressing. On section,
it presents the appearance of a finely reticulated sponge.

Although it may be noticed at, or within a few days of, birth, a
subcutaneous naevus is often overlooked, especially when on a covered
part of the body, and may not be discovered till the patient is some
years old. It forms a rounded, lobulated swelling, seldom of large size
and yielding a sensation like that of a sponge; the skin over it is
normal, or may exhibit a bluish tinge, especially in cold weather. In
some cases the tumour is diminished by pressing the blood out of it, but
slowly fills again when the pressure is relaxed, and it swells up when
the child struggles or cries. From a cold abscess it is diagnosed by the
history and progress of the swelling and by the absence of fluctuation.
When situated over one of the hernial openings, it closely simulates a
hernia; and when it occurs in the middle line of the face, head, or
back, it may be mistaken for such other congenital conditions as
meningocele or spina bifida. When other means fail, the use of an
exploring needle clears up the diagnosis.

_Mixed Naevus._--As its name indicates, the mixed naevus partakes of the
characters of the other two varieties; that is, it is a subcutaneous
naevus with involvement of the skin.

It is frequently met with on the face and head, but may occur on any
part of the body. It also affects parts covered by mucous membrane, such
as the cheek, tongue, and soft palate. The swelling is rounded or
lobulated, and projects beyond the level of its surroundings. Sometimes
the skin is invaded by the naevoid tissue over the whole extent of the
tumour, sometimes only over a limited area. Frequently the margin only
is of a bright-red colour, while the skin in the centre resembles a
cicatrix. The swelling is reduced by steady pressure, and increases in
size and becomes tense when the child cries.

[Illustration: FIG. 68.--Mixed Naevus of Nose which was subsequently
cured by Electrolysis.]

_Prognosis._--The rate of growth of the subcutaneous and mixed forms of
naevi varies greatly. They sometimes increase rapidly, especially during
the first few months of life; after this they usually grow at the same
rate as the child, or more slowly. There is a decided tendency to
disappearance of these varieties, fully 50 per cent. undergoing natural
cure by a process of obliteration, similar to the obliteration of
vessels in cicatricial tissue. This usually begins about the period of
the first dentition, sometimes at the second dentition, and sometimes at
puberty. On the other hand, an increased activity of growth may be shown
at these periods. The onset of natural cure is recognised by the tumour
becoming firmer and less compressible, and, in the mixed variety, by the
colour becoming less bright. Injury, infection, or ulceration of the
overlying skin may initiate the curative process.

Towards adult life the spaces in a subcutaneous naevus may become greatly
enlarged, leading to the formation of a cavernous angioma.

_Treatment._--In view of the frequency with which subcutaneous and mixed
naevi disappear spontaneously, interference is only called for when the
growth of the tumour is out of proportion to that of the child, or when,
from its situation--for example in the vicinity of the eye--any marked
increase in its size would render it less amenable to treatment.

The methods of treatment most generally applicable are the use of radium
and carbon dioxide snow, igni-puncture, electrolysis, and excision.

For naevi situated on exposed parts, where it is desirable to avoid a
scar, the use of _radium_ is to be preferred. The tube of radium is
applied at intervals to different parts of the naevus, the duration and
frequency of the applications varying with the strength of the
emanations and the reaction produced. The object aimed at is to induce
obliteration of the naevoid tissue by cicatricial contraction without
destroying the overlying skin. _Carbon-dioxide snow_ may be employed in
the same manner, but the results are inferior to those obtained by
radium.

_Igni-puncture_ consists in making a number of punctures at different
parts of the naevus with a fine-pointed thermo-cautery, with the object
of starting at each point a process of cicatrisation which extends
throughout the naevoid tissue and so obliterates the vessels.

_Electrolysis_ acts by decomposing the blood and tissues into their
constituent elements--oxygen and acids appearing at the positive,
hydrogen and bases at the negative electrode. These substances and gases
being given off in a nascent condition, at once enter into new
combinations with anything in the vicinity with which they have a
chemical affinity. In the naevus the practical result of this reaction is
that at the positive pole nitric acid, and at the negative pole caustic
potash, both in a state of minute subdivision, make their appearance.
The effect on the tissues around the positive pole, therefore, is
equivalent to that of an acid cauterisation, and on those round the
negative pole, to an alkaline cauterisation.

As the process is painful, a general anaesthetic is necessary. The
current used should be from 20 to 80 milliamperes, gradually increasing
from zero, without shock; three to six large Bunsen cells give a
sufficient current, and no galvanometer is required. Steel needles,
insulated with vulcanite to within an eighth of an inch of their points,
are the best. Both poles are introduced into the naevus, the positive
being kept fixed at one spot, while the negative is moved about so as to
produce a number of different tracks of cauterisation. On no account
must either pole be allowed to come in contact with the skin, lest a
slough be formed. The duration of the sitting is determined by the
effect produced, as indicated by the hardening of the tumour, the
average duration being from fifteen to twenty minutes. If pallor of the
skin appears, it indicates that the needles are too near the surface, or
that the blood supply to the integument is being cut off, and is an
indication to stop. To cauterise the track and so prevent bleeding, the
needles should be slowly withdrawn while the current is flowing. When
the skin is reached the current is turned off. The punctures are covered
with collodion. Six or eight weeks should be allowed to elapse before
repeating the procedure. From two to eight or ten sittings may be
necessary, according to the size and character of the naevus.

_Excision_ is to be preferred for naevi of moderate size situated on
covered parts of the body, where a scar is of no importance. Its chief
advantages over electrolysis are that a single operation is sufficient,
and that the cure is speedy and certain. The operation is attended with
much less haemorrhage than might be expected.

#Cavernous Angioma.#--This form of angioma consists of a series of large
blood spaces which are usually derived from the dilatation of the
capillaries of a subcutaneous naevus. The spaces come to communicate
freely with one another by the disappearance of adjacent capillary
walls. While the most common situation is in the subcutaneous tissue, a
cavernous angioma is sometimes met with in internal organs. It may
appear at any age from early youth to middle life, and is of slow growth
and may become stationary. The swelling is rounded or oval, there is no
pulsation or bruit, and the tumour is but slightly compressible. The
treatment consists in dissecting it out.

#Aneurysm by Anastomosis# is the name applied to a vascular tumour in
which the arteries, veins, and capillaries are all involved. It is met
with chiefly on the upper part of the trunk, the neck, and the scalp. It
tends gradually to increase in size, and may, after many years, attain
an enormous size. The tumour is ill-defined, and varies in consistence.
It is pulsatile, and a systolic bruit or a "thrilling" murmur may be
heard over it. The chief risk is haemorrhage from injury or ulceration.

[Illustration: FIG. 69.--Cirsoid Aneurysm of Forehead in a boy aet. 10.

(Mr. J. W. Dowden's case.)]

The _treatment_ is conducted on the same lines as for naevus. When
electrolysis is employed, it should be directed towards the afferent
vessels; and if it fails to arrest the flow through these, it is useless
to persist with it. In some cases ligation of the afferent vessels has
been successful.

#Arterial Angioma# or #Cirsoid Aneurysm#.--This is composed of the
enlarged branches of an arterial trunk. It originates in the smaller
branches of an artery--usually the temporal--and may spread to the main
trunk, and may even involve branches of other trunks with which the
affected artery anastomoses.

The condition is probably congenital in origin, though its appearance is
frequently preceded by an injury. It almost invariably occurs in the
scalp, and is usually met with in adolescent young adults.

The affected vessels slowly increase in size, and become tortuous, with
narrowings and dilatations here and there. Grooves and gutters are
frequently found in the bone underlying the dilated vessels.

There is a constant loud bruit in the tumour, which greatly troubles the
patient and may interfere with sleep. There is no tendency either to
natural cure or to rupture, but severe and even fatal haemorrhage may
follow a wound of the dilated vessels.

[Illustration: FIG. 70.--Cirsoid Aneurysm of Orbit and Face, which
developed after a blow on the Orbit with a cricket ball.

(From a photograph lent by Sir Montagu Cotterill.)]

The condition may be treated by excision or by electrolysis. In excision
the haemorrhage is controlled by an elastic tourniquet applied
horizontally round the head, or by ligation of the feeding trunks. In
large tumours the bleeding is formidable. In many cases electrolysis is
to be preferred, and is performed in the same way as for naevus. The
positive pole is placed in the centre of the tumour, while the negative
is introduced into the main affluents one after another.

ANEURYSM

An aneurysm is a sac communicating with an artery, and containing fluid
or coagulated blood.

Two types are met with--the pathological and the traumatic. It is
convenient to describe in this section also certain conditions in which
there is an abnormal communication between an artery and a
vein--arterio-venous aneurysm.

PATHOLOGICAL ANEURYSM

In this class are included such dilatations as result from weakening of
the arterial coats, combined, in most cases, with a loss of elasticity
in the walls and increase in the arterial tension due to
arterio-sclerosis. In some cases the vessel wall is softened by
arteritis--especially the embolic form--so that it yields before the
pressure of the blood.

Repeated and sudden raising of the arterial tension, as a result, for
example, of violent muscular efforts or of excessive indulgence in
alcohol, plays an important part in the causation of aneurysm. These
factors probably explain the comparative frequency of aneurysm in those
who follow such arduous occupations as soldiers, sailors,
dock-labourers, and navvies. In these classes the condition usually
manifests itself between the ages of thirty and fifty--that is, when the
vessels are beginning to degenerate, although the heart is still
vigorous and the men are hard at work. The comparative immunity of women
may also be explained by the less severe muscular strain involved by
their occupations and recreations.

Syphilis plays an important part in the production of aneurysm, probably
by predisposing the patient to arterio-sclerosis and atheroma, and
inducing an increase in the vascular tension in the peripheral vessels,
from loss of elasticity of the vessel wall and narrowing of the lumen as
a result of syphilitic arteritis. It is a striking fact that aneurysm is
seldom met with in women who have not suffered from syphilis.

#Varieties--Fusiform Aneurysm.#--When the _whole circumference_ of an
artery has been weakened, the tension of the blood causes the walls to
dilate uniformly, so that a fusiform or tubular aneurysm results. All
the coats of the vessel are stretched and form the sac of the aneurysm,
and the affected portion is not only dilated but is also increased in
length. This form is chiefly met with in the arch of the aorta, but may
occur in any of the main arterial trunks. As the sac of the aneurysm
includes all three coats, and as the inner and outer coats are usually
thickened by the deposit in them of connective tissue, this variety
increases in size slowly and seldom gives rise to urgent symptoms.

As a rule a fusiform aneurysm contains fluid blood, but when the intima
is roughened by disease, especially in the form of calcareous plates,
shreds of clot may adhere to it.

It has little tendency to natural cure, although this is occasionally
effected by the emerging artery becoming occluded by a clot; it has also
little tendency to rupture.

#Sacculated Aneurysm.#--When a _limited area_ of the vessel wall is
weakened--for example by atheroma or by other form of arteritis--this
portion yields before the pressure of the blood, and a sacculated
aneurysm results. The internal and middle coats being already damaged,
or, it may be, destroyed, by the primary disease, the stress falls on
the external coat, which in the majority of cases constitutes the sac.
To withstand the pressure the external coat becomes thickened, and as
the aneurysm increases in size it forms adhesions to surrounding
tissues, so that fasciae, tendons, nerves, and other structures may be
found matted together in its wall. The wall is further strengthened by
the deposit on its inner aspect of blood-clot, which may eventually
become organised.

The contents of the sac consist of fluid blood and a varying amount of
clot which is deposited in concentric layers on the inner aspect of the
sac, where it forms a pale, striated, firm mass, which constitutes a
laminated clot. Near the blood-current the clot is soft, red, and
friable (Fig. 72). The laminated clot not only strengthens the sac,
enabling it to resist the blood-pressure and so prevent rupture, but, if
it increases sufficiently to fill the cavity, may bring about cure. The
principle upon which all methods of treatment are based is to imitate
nature in producing such a clot.

Sacculated aneurysm, as compared with the fusiform variety, tends to
rupture and also to cure by the formation of laminated clot; natural
cure is sometimes all but complete when extension and rupture occur and
cause death.

An aneurysm is said to be _diffused_ when the sac ruptures and the blood
escapes into the cellular tissue.

#Clinical Features of Aneurysm.#--Surgically, the sacculated is by far
the most important variety. The outstanding feature is the existence in
the line of an artery of a globular swelling, which pulsates. The
pulsation is of an expansile character, which is detected by observing
that when both hands are placed over the swelling they are separated
with each beat of the heart. If the main artery be compressed on the
cardiac side of the swelling, the pulsation is arrested and the tumour
becomes smaller and less tense, and it may be still further reduced in
size by gentle pressure being made over it so as to empty it of fluid
blood. On allowing the blood again to flow through the artery, the
pulsation returns at once, but several beats are required before the sac
regains its former size. In most cases a distinct thrill is felt on
placing the hand over the swelling, and a blowing, systolic murmur may
be heard with the stethoscope. It is to be borne in mind that
occasionally, when the interchange of blood between an aneurysm and the
artery from which it arises is small, pulsation and bruit may be slight
or even absent. This is also the case when the sac contains a
considerable quantity of clot. When it becomes filled with
clot--_consolidated aneurysm_--these signs disappear, and the clinical
features are those of a solid tumour lying in contact with an artery,
and transmitting its pulsation.