Alexis Thomson and Alexander Miles - Manual of Surgery

A >> Alexis Thomson and Alexander Miles >> Manual of Surgery

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_Treatment._--Digital compression of the vessel against the transverse
process of the sixth cervical vertebra--the "carotid tubercle"--has been
successfully employed in the treatment of aneurysm near the bifurcation.
Proximal ligation in the case of high aneurysms, or distal ligation in
those situated at the root of the neck, is more certain. Extirpation of
the sac is probably the best method of treatment, especially in those of
traumatic origin. These operations are attended with considerable risk
of hemiplegia from interference with the blood supply of the brain.

The _external carotid_ and the cervical portion of the _internal
carotid_ are seldom the primary seat of aneurysm, although they are
liable to be implicated by the upward spread of an aneurysm at the
bifurcation of the common trunk. In addition to the ordinary signs of
aneurysm, the clinical manifestations are chiefly referable to pressure
on the pharynx and larynx, and on the hypoglossal nerve. Aneurysm of the
internal carotid is of special importance on account of the way in which
it bulges into the pharynx in the region of the tonsil, in some cases
closely simulating a tonsillar abscess. Cases are on record in which
such an aneurysm has been mistaken for an abscess and incised, with
disastrous results.

_Aneurysmal varix_ may occur in the neck as a result of stabs or bullet
wounds. The communication is usually between the common carotid artery
and the internal jugular vein. The resulting interference with the
cerebral circulation causes headache, giddiness, and other brain
symptoms, and a persistent loud murmur is usually a source of annoyance
to the patient and may be sufficient indication for operative treatment.

#Intracranial aneurysm# involves the internal carotid and its branches,
or the basilar artery, and appears to be more frequently associated with
syphilis and with valvular disease of the heart than are external
aneurysms. It gives rise to symptoms similar to those of other
intracranial tumours, and there is sometimes a loud murmur. It usually
proves fatal by rupture, and intracranial haemorrhage. The treatment is
to ligate the common carotid or the vertebral artery in the neck,
according to the seat of the aneurysm.

#Orbital Aneurysm.#--The term pulsating exophthalmos is employed to
embrace a number of pathological conditions, including aneurysm, in
which the chief symptoms are pulsation in the orbit and protrusion of
the eyeball. There may be, in addition, congestion and oedema of the
eyelids, and a distinct thrill and murmur, which can be controlled by
compression of the common carotid in the neck. Varying degrees of ocular
paralysis and of interference with vision may also be present.

These symptoms are due, in the majority of cases, to an aneurysmal varix
of the internal carotid artery and cavernous sinus, which is often
traumatic in origin, being produced either by fracture of the base of
the skull or by a punctured wound of the orbit. In other cases they are
due to aneurysm of the ophthalmic artery, to thrombosis of the cavernous
sinus, and, in rare instances, to cirsoid aneurysm.

If compression of the common carotid is found to arrest the pulsation,
ligation of this vessel is indicated.

#Subclavian Aneurysm.#--Subclavian aneurysm is usually met with in men
who follow occupations involving constant use of the shoulder--for
example, dock-porters and coal-heavers. It is more common on the right
side.

The aneurysm usually springs from the third part of the artery, and
appears as a tense, rounded, pulsatile swelling just above the clavicle
and to the outer side of the sterno-mastoid muscle. It occasionally
extends towards the thorax, where it may become adherent to the pleura.
The radial pulse on the same side is small and delayed. Congestion and
oedema of the arm, with pain, numbness, and muscular weakness, may result
from pressure on the veins and nerves as they pass under the clavicle;
and pressure on the phrenic nerve may induce hiccough. The aneurysm is
of slow growth, and occasionally undergoes spontaneous cure.

The conditions most likely to be mistaken for it are a soft, rapidly
growing sarcoma, and a normal artery raised on a cervical rib.

On account of the relations of the artery and of its branches, treatment
is attended with greater difficulty and danger in subclavian than in
almost any other form of external aneurysm. The available operative
measures are proximal ligation of the innominate, and distal ligation.
In some cases it has been found necessary to combine distal ligation
with amputation at the shoulder-joint, to prevent the collateral
circulation maintaining the flow through the aneurysm. Matas' operation
has been successfully performed by Hogarth Pringle.

#Axillary Aneurysm.#--This is usually met with in the right arm of
labouring men and sailors, and not infrequently follows an injury in the
region of the shoulder. The vessel may be damaged by the head of a
dislocated humerus or in attempts to reduce the dislocation, by the
fragments of a fractured bone, or by a stab or cut. Sometimes the vein
also is injured and an arterio-venous aneurysm established.

Owing to the laxity of the tissues, it increases rapidly, and it may
soon attain a large size, filling up the axilla, and displacing the
clavicle upwards. This renders compression of the third part of the
subclavian difficult or impossible. It may extend beneath the clavicle
into the neck, or, extending inwards may form adhesions to the chest
wall, and, after eroding the ribs, to the pleura.

The usual symptoms of aneurysm are present, and the pressure effects on
the veins and nerves are similar to those produced by an aneurysm of the
subclavian. Intra-thoracic complications, such as pleurisy or pneumonia,
are not infrequent when there are adhesions to the chest wall and
pleura. Rupture may take place externally, into the shoulder-joint, or
into the pleura.

Extirpation of the sac is the operation of choice, but, if this is
impracticable, ligation of the third part of the subclavian may be had
recourse to.

#Brachial aneurysm# usually occurs at the bend of the elbow, is of
traumatic origin, and is best treated by excision of the sac.

_Aneurysmal varix_, which was frequently met with in this situation in
the days of the barber-surgeons,--usually as a result of the artery
having been accidentally wounded while performing venesection of the
median basilic vein,--may be treated, according to the amount of
discomfort it causes, by a supporting bandage, or by ligation of the
artery above and below the point of communication.

Aneurysms of the vessels of the #forearm and hand# call for no special
mention; they are almost invariably traumatic, and are treated by
excision of the sac.

#Inguinal Aneurysm# (_Aneurysm of the Iliac and Femoral
Arteries_).--Aneurysms appearing in the region of Poupart's ligament may
have their origin in the external or common iliac arteries or in the
upper part of the femoral. On account of the tension of the fascia lata,
they tend to spread upwards towards the abdomen, and, to a less extent,
downwards into the thigh. Sometimes a constriction occurs across the
sac at the level of Poupart's ligament.

The pressure exerted on the nerves and veins of the lower extremity
causes pain, congestion, and oedema of the limb. Rupture may take place
externally, or into the cellular tissue of the iliac fossa.

These aneurysms have to be diagnosed from pulsating sarcoma growing from
the pelvic bones, and from an abscess or a mass of enlarged lymph glands
overlying the artery and transmitting its pulsation.

The method of treatment that has met with most success is ligation of
the common or external iliac, reached either by reflecting the
peritoneum from off the iliac fossa (extra-peritoneal operation), or by
going through the peritoneal cavity (trans-peritoneal operation).

#Gluteal Aneurysm.#--An aneurysm in the buttock may arise from the
superior or from the inferior gluteal artery, but by the time it forms a
salient swelling it is seldom possible to recognise by external
examination in which vessel it takes origin. The special symptoms to
which it gives rise are pain down the limb from pressure on the sciatic
nerve, and interference with the movements at the hip.

Ligation of the hypogastric (internal iliac) by the trans-peritoneal
route is the most satisfactory method of treatment. Extirpation of the
sac is difficult and dangerous, especially when the aneurysm has spread
into the pelvis.

#Femoral Aneurysm.#--Aneurysm of the femoral artery beyond the origin of
the profunda branch is usually traumatic in origin, and is more common
in Scarpa's triangle than in Hunter's canal. Any of the methods already
described is available for their treatment--the choice lying between
Matas' operation and ligation of the external iliac.

Aneurysm of the _profunda femoris_ is distinguished from that of the
main trunk by the fact that the pulses beyond are, in the former,
unaffected, and by the normal artery being felt pulsating over or
alongside the sac.

In _aneurysmal varix_, a not infrequent result of a bullet wound or a
stab, the communication with the vein may involve the main trunk of the
femoral artery. Should operative interference become necessary as a
result of progressive increase in size of the tumour, or progressive
distension of the veins of the limb, an attempt should be made to
separate the vessels concerned and to close the opening in each by
suture. If this is impracticable, the artery is tied above and below the
communication; gangrene of the limb may supervene, and we have observed
a case in which the gangrene extended up to the junction of the middle
and lower thirds of the thigh, and in which recovery followed upon
amputation of the thigh.

#Popliteal Aneurysm.#--This is the most common surgical aneurysm, and is
not infrequently met with in both limbs. It is generally due to disease
of the artery, and repeated slight strains, which are so liable to occur
at the knee, play an important part in its formation. In former times it
was common in post-boys, from the repeated flexion and extension of the
knee in riding.

The aneurysm is usually of the sacculated variety, and may spring from
the front or from the back of the vessel. It may exert pressure on the
bones and ligaments of the joint, and it has been known to rupture into
the articulation. The pain, stiffness, and effusion into the joint which
accompany these changes often lead to an erroneous diagnosis of joint
disease. The sac may press upon the popliteal artery or vein and their
branches, causing congestion and oedema of the leg, and lead to gangrene.
Pressure on the tibial and common peroneal nerves gives rise to severe
pain, muscular cramp, and weakness of the leg.

The differential diagnosis is to be made from abscess, bursal cyst,
enlarged glands, and sarcoma, especially pulsating sarcoma of one of the
bones entering into the knee joint.

The choice of operation lies between ligation of the femoral artery in
Hunter's canal, and Matas' operation of aneurysmo-arteriorrhaphy. The
success which attends the Hunterian operation is evidenced by the fact
that Syme performed it thirty-seven times without a single failure. If
it fails, the old operation should be considered, but it is a more
serious operation, and one which is more liable to be followed by
gangrene of the limb. Experience shows that ligation of the vein, or
even the removal of a portion of it, is not necessarily followed by
gangrene. The risk of gangrene is diminished by a course of digital
compression of the femoral artery, before operating on the aneurysm.

_Aneurysmal varix_ is sometimes met with in the region of the popliteal
space. It is characterised by the usual symptoms, and is treated by
palliative measures, or by ligation of the artery above and below the
point of communication.

_Aneurysm_ in the #leg and foot# is rare. It is almost always traumatic,
and is treated by excision of the sac.

CHAPTER XV

THE LYMPH VESSELS AND GLANDS

Anatomy and Physiology--INJURIES OF LYMPH VESSELS--_Wounds of
thoracic duct_--DISEASES OF LYMPH VESSELS--Lymphangitis:
_Varieties_--Lymphangiectasis--Filarial
disease--Lymphangioma--DISEASES OF LYMPH
GLANDS--Lymphadenitis: _Septic_; _Tuberculous_;
_Syphilitic_--Lymphadenoma--Leucocythaemia--TUMOURS.

#Surgical Anatomy and Physiology.#--Lymph is essentially blood plasma,
which has passed through the walls of capillaries. After bathing
and nourishing the tissues, it is collected by lymph vessels, which
return it to the blood stream by way of the thoracic duct. These lymph
vessels take origin in the lymph spaces of the tissues and in the
walls of serous cavities, and they usually run alongside blood
vessels--_perivascular lymph vessels_. They have a structure similar to
that of veins, but are more abundantly provided with valves. Along the
course of the lymph trunks are the _lymph glands_, which possess a
definite capsule and are composed of a reticulated connective tissue,
the spaces of which are packed with leucocytes. The glands act as
filters, arresting not only inert substances, such as blood pigment
circulating in the lymph, but also living elements, such as cancer cells
or bacteria. As it passes through a gland the lymph is brought into
intimate contact with the leucocytes, and in bacterial infections there
is always a struggle between the organisms and the leucocytes, so that
the glands may be looked upon as an important line of defence, retarding
or preventing the passage of bacteria and their products into the
general circulation. The infective agent, moreover, in order to reach
the blood stream, must usually overcome the resistance of several
glands.

Lymph glands are, for the most part, arranged in groups or chains, such
as those in the axilla, neck, and groin. In any given situation they
vary in number and size in different individuals, and fresh glands may
be formed on comparatively slight stimulus, and disappear when the
stimulus is withdrawn. The best-known example of this is the increase in
the number of glands in the axilla which takes place during lactation;
when this function ceases, many of the glands become involuted and are
transformed into fat, and in the event of a subsequent lactation they
are again developed. After glands have been removed by operation, new
ones may be formed.

The following are the more important groups of glands, and the areas
drained by them in the head and neck and in the extremities.

#Head and Neck.#--_The anterior auricular (parotid and pre-auricular)
glands_ lie beneath the parotid fascia in front of the ear, and some
are partly embedded in the substance of the parotid gland; they drain
the parts about the temple, cheek, eyelids, and auricle, and are
frequently the seat of tuberculous disease. _The occipital gland_,
situated over the origin of the trapezius from the superior curved line,
drains the top and back of the head; it is rarely infected. _The
posterior auricular (mastoid) glands_ lie over the mastoid process, and
drain the side of the head and auricle. These three groups pour their
lymph into the superficial cervical glands. _The submaxillary_--two to
six in number--lie along the lower order of the mandible from the
symphysis to the angle, the posterior ones (paramandibular) being
closely connected with the submaxillary salivary gland. They receive
lymph from the face, lips, floor of the mouth, gums, teeth, anterior
part of tongue, and the alae nasi, and from the pre-auricular glands. The
lymph passes from them into the deeper cervical glands. They are
frequently infected with tubercle, with epithelioma which has spread to
them from the mouth, and also with pyogenic organisms. _The submental
glands_ lie in or close to the median line between the anterior bellies
of the digastric muscles, and receive lymph from the lips. It is rare
for them to be the seat of tubercle, but in epithelioma of the lower lip
and floor of the mouth they are infected at an early stage of the
disease. _The supra-hyoid gland_ lies a little farther back, immediately
above the hyoid bone, and receives lymph from the tongue. _The
superficial cervical (external jugular) glands_, when present, lie along
the external jugular vein, and receives lymph from the occipital and
auricular glands and from the auricle. _The sterno-mastoid
glands_--glandulae concatinatae--form a chain along the posterior edge of
the sterno-mastoid muscle, some of them lying beneath the muscle. They
are commonly enlarged in secondary syphilis. _The superior deep cervical
(internal jugular) glands_--from six to twenty in number--form a
continuous chain along the internal jugular vein, beneath the
sterno-mastoid muscle. They drain the various groups of glands which lie
nearer the surface, also the interior of the skull, the larynx, trachea,
thyreoid, and lower part of the pharynx, and pour their lymph into the
main trunks at the root of the neck. Belonging to this group is one
large gland (the tonsillar gland) which lies behind the posterior belly
of the digastric, and rests in the angle between the internal jugular
and common facial veins. It is commonly enlarged in affections of the
tonsil and posterior part of the tongue. In the same group are three or
four glands which lie entirely under cover of the upper end of the
sterno-mastoid muscle, and surround the accessory nerve before it
perforates the muscle. The deep cervical glands are commonly infected by
tubercle and also by epithelioma secondary to disease in the tongue or
throat. _The inferior deep cervical (supra-clavicular) glands_ lie in
the posterior triangle, above the clavicle. They receive lymph from the
lowest cervical glands, from the upper part of the chest wall, and from
the highest axillary glands. They are frequently infected in cancer of
the breast; those on the left side also in cancer of the stomach. The
removal of diseased supra-clavicular glands is not to be lightly
undertaken, as difficulties are liable to ensue in connection with the
thoracic duct, the pleura, or the junction of the subclavian and
internal jugular veins. _The retro-pharyngeal glands_ lie on each side
of the median line upon the rectus capitis anticus major muscle and in
front of the pre-vertebral layer of the cervical fascia. They receive
part of the lymph from the posterior wall of the pharynx, the interior
of the nose and its accessory cavities, the auditory (Eustachian) tube,
and the tympanum. When they are infected with pyogenic organisms or
with tubercle bacilli, they may lead to the formation of one form of
retro-pharyngeal abscess.

#Upper Extremity.#--_The epi-trochlear and cubital glands_ vary in
number, that most commonly present lying about an inch and a half above
the medial epi-condyle, and other and smaller glands may lie along the
medial (internal) bicipital groove or at the bend of the elbow. They
drain the ulnar side of the hand and forearm, and pour their lymph into
the axillary group. The epi-trochlear gland is sometimes enlarged in
syphilis. _The axillary glands_ are arranged in groups: a central group
lies embedded in the axillary fascia and fat, and is often related to an
opening in it; a posterior or subscapular group lies along the line of
the subscapular vessels; anterior or pectoral groups lie behind the
pectoralis minor, along the medial side of the axillary vein, and an
inter-pectoral group, between the two pectoral muscles. The axillary
glands receive lymph from the arm, mamma, and side of the chest, and
pass it on into the lowest cervical glands and the main lymph trunk.
They are frequently the seat of pyogenic, tuberculous, and cancerous
infection, and their complete removal is an essential part of the
operation for cancer of the breast.

#Lower Extremity.#--_The popliteal glands_ include one superficial gland
at the termination of the small saphenous vein, and several deeper ones
in relation to the popliteal vessels. They receive lymph from the toes
and foot, and transmit it to the inguinal glands. _The femoral glands_
lie vertically along the upper part of the great saphenous vein, and
receive lymph from the leg and foot; from them the lymph passes to the
deep inguinal and external iliac glands. The femoral glands often
participate in pyogenic infections entering through the skin of the toes
and sole of the foot. _The superficial inguinal glands_ lie along the
inguinal (Poupart's) ligament, and receive lymph from the external
genitals, anus, perineum, buttock, and anterior abdominal wall. The
lymph passes on to the deep inguinal and external iliac glands. The
superficial glands through their relations to the genitals are
frequently the subject of venereal infection, and also of epithelioma
when this disease affects the genitals or anus; they are rarely the seat
of tuberculosis. _The deep inguinal glands_ lie on the medial side of
the femoral vein, and sometimes within the femoral canal. They receive
lymph from the deep lymphatics of the lower limb, and some of the
efferent vessels from the femoral and superficial inguinal glands. The
lymph then passes on through the femoral canal to the external iliac
glands. The extension of malignant disease, whether cancer or sarcoma,
can often be traced along these deeper lymphatics into the pelvis, and
as the obstruction to the flow of lymph increases there is a
corresponding increase in the swollen dropsical condition of the lower
limb on the same side.

The glands of the _thorax_ and _abdomen_ will be considered with the
surgery of these regions.

INJURIES OF LYMPH VESSELS

Lymph vessels are divided in all wounds, and the lymph that escapes from
them is added to any discharge that may be present. In injuries of
larger trunks the lymph may escape in considerable quantity as a
colourless, watery fluid--_lymphorrhagia_; and the opening through which
it escapes is known as a _lymphatic fistula_. This has been observed
chiefly after extensive operation for the removal of malignant glands in
the groin where there already exists a considerable degree of
obstruction to the lymph stream, and in such cases the lymph, including
that which has accumulated in the vessels of the limb, may escape in
such abundance as to soak through large dressings and delay healing.
Ultimately new lymph channels are formed, so that at the end of from
four to six weeks the discharge of lymph ceases and the wound heals.

_Lymphatic Oedema._--When the lymphatic return from a limb has been
seriously interfered with,--as, for example, when the axillary contents
has been completely cleared out in operating for cancer of the
breast,--a condition of lymphatic oedema may result, the arm becoming
swollen, tight, and heavy.

Various degrees of the conditions are met with; in the severe forms,
there is pain, as well as incapacity of the limb. As in ordinary oedema,
the condition is relieved by elevation of the limb, but not nearly to
the same degree; in time the tissues become so hard and tense as
scarcely to pit on pressure; this is in part due to the formation of new
connective tissue and hypertrophy of the skin; in advanced cases there
is a gradual transition into one form of elephantiasis.

Handley has devised a method of treatment--_lymphangioplasty_--the
object of which is to drain the lymph by embedding a number of silk
threads in the subcutaneous cellular tissue.

#Wounds of the Thoracic Duct.#--The thoracic duct usually opens at the
angle formed by the junction of the left internal jugular and subclavian
veins, but it may open into either of these vessels by one or by several
channels, or the duct may be double throughout its course. There is a
smaller duct on the right side--the right lymphatic duct. The duct or
ducts may be displaced by a tumour or a mass of enlarged glands, and may
be accidentally wounded in dissections at the root of the neck; jets of
milky fluid--chyle--may at once escape from it. The jets are rhythmical
and coincide with expiration. The injury may, however, not be observed
at the time of operation, but later through the dressings being soaked
with chyle--_chylorrhoea_. If the wound involves the only existing main
duct and all the chyle escapes, the patient suffers from intense thirst,
emaciation, and weakness, and may die of inanition; but if, as is
usually the case, only one of several collateral channels is implicated,
the loss of chyle may be of little moment, as the discharge usually
ceases. If the wound heals so that the chyle is prevented from escaping,
a fluctuating swelling may form beneath the scar; in course of time it
gradually disappears.

An attempt should be made to close the wound in the duct by means of a
fine suture; failing this, the duct must be occluded by a ligature as if
it were a bleeding artery. The tissues are then stitched over it and the
skin wound accurately closed, so as to obtain primary union, firm
pressure being applied by dressings and an elastic webbing bandage. Even
if the main duct is obliterated, a collateral circulation is usually
established. A wound of the right lymphatic duct is of less importance.