SURGERY OF BLOOD VESSELS.*

BY JOHN B. MURPHY, M. D., LL. D., CHICAGO.

The subject to be considered cursorily this morning is the surgery of the blood vessels, purely from its practical application rather than from the theoretical problems involved in its development. Surgery of the blood vessels, as it presents itself to the practical surgeon, may be classified under three heads: (1) The treatment of blood vessels at the end of stumps; (2) the treatment of blood vessels injured in continuity, and (3) the treatment of blood vessels exposed by trauma or operation without rupture and without laceration.

In considering the treatment of blood vessels at the ends of stumps we take up the subject of the arrest of hemorrhage and the best method of permanently closing these vessels. We know that in the preantiseptic period this was a subject of vital importance; but to the surgeon who operates on cases of election in the absence of sepsis this has ceased to be a question of moment. To the railway surgeon it is still a vital question because many of his cases are necessarily septic; many stumps become infected at the time of the injury and, therefore, have the same dangers that existed in the preantiseptic period, namely, necrosis and secondary hemorrhage. Many of the gentlemen present can remember when the danger from secondary hemorrhage was enormous. It was due to what? It was due to necrosis of the blood vessels on the distal side of the ligathe blood vessels on the distal side of the liga

*Read at Joint Meeting, Chicago, June 1, 2, 3, 1904.

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ture, and to the failure of clot formation within the vessel on the proximal side of the ligature. Many of you will recall the able paper published by Senn years ago on the subject of ligation in which, in endeavoring to overcome that danger, he advised the application of two ligatures and while he met the situation, the same danger from infection existed in the stump. There was the same danger of necrosis from the second ligature as from the application of the first. Then the surgeons pursued the study of the process of repair in the ends of the vessels after ligation. This process consisted of a deposit of cells on the traumatized intima; that is, if the intima of the vessel be injured sufficiently at the point of ligature and on the proximal side to produce a deposit of leucocytes and blood plates, and these become adherent to the traumatized surface, you have within the artery a permanent clot that re

mains regardless of sepsis once it has started to form within the vessel. Therefore, a phase of the subject of vital interest is, how can we induce, how can we pre-ordain a definite uniform deposit of cells within the vessel on the proximal side of the ligature?

In endeavoring to repair vessels by suture and coaptation, I found the greatest obstacle which I had to overcome was to prevent the deposit of cells and the formation of a clot within the vessel after I once manipulated it. I found that whenever I clasped the blood vessel with a hemostat, or clasped it severely and continuously for many minutes with ordinary dissecting or tissue forceps, there was a deposit within the blood vessel at that point-a clot. That was the key to the situation of the treat

ment of terminal blood vessels in amputation stumps, namely, while the ligature is being placed, one or two forceps should be applied to the blood vessel, and the ligature placed on the distal instead of on the proximal side of the forceps. It has been my custom since 1897 in amputating to place a ligature on the arterial stump, draw the blood vessel well out and compress the artery above the ligature with the needle forceps. A heavy hemostat will answer the purpose just as well as the needle forceps; this produces a fracture of the intima, and there commences the immediate formation of a clot which plugs the vessel within. Therefore, in all amputations where large vessels are involved, the one important element is to produce a fracture of the intima on the proximal side of the ligature; the changing the relation of the forceps to the ligature is all that is necessary. In the general practice of surgery, aside from amputations, I have applied this same principle, that is, in the pedicles of ovarian cysts, in the pedicles of the uterus, etc., I always produce compression with a heavy hemostat, or with a uterine clamp, which is the most convenient for the purpose, at the site of or on the proximal side of the ligature. If the ligature should be displaced in twenty-four hours to forty-eight hours, and it had not produced injury to the intima, the fracture of the intima by the forceps will have produced a de ́posit of cells within the vessel and we have thus great security by these clamps.

I will next take up the injury of vessels in continuity; from a practical standpoint and particularly from the viewpoint of the railway surgeon, the most important ones are the traumas of the popliteal, femoral and axillary vessels. In perforating, penetrating, bullet and stab wounds, laceration of the femoral vessel is met with quite frequently, but more often we have laceration of the popliteal. The greatest mortality to limbs follows lacerations and punctures of the popliteal; that is, obliteration of the popliteal produces gangrene of the leg much more frequently than obliteration of the femoral vessel. Fortunately for the surgeon, the popliteal is the one most easily manipulated and conserved after trauma. If we have a punctured or lacerated wound that tears the popliteal artery and vein, and both are ligated,

it is practically certain that gangrene of the leg will follow. If we can preserve either the vein or the artery by suture, or by subsequent approximation, we are fairly sure that the limb will be preserved.

Now we come to the consideration of the technic of repair. In the approximation of all large vessels, wherever there is end-to-end union, there is final definitive closure of that vessel. It finally becomes obliterated in every single case by an obliterating endarteritis. Therefore, we reason from that statement, what good will it do to make approximation if the lumen of the vessel eventually becomes closed? Let me say to you, that while the lumen of the vessel is closing, the collateral circulation is developing and the life of the limb is preserved if the closure be sufficiently gradual and the time is flexible. I found in my experiments that in some cases as early as four days after the end-to-end suture the lumen of the vessel was closed without disturbance of the circulation below, while in the control experiments, with immediate ligation of the vessel, the limb became gangrenous. Now we see what immediate closure means; it means immediate ischemia or anemia of the limb which produces the necrosis. In the pathologic museum in London there are to be seen a number of specimens of occlusion of the thoracic aorta. In those, while the thoracic aorta had been occluded, there was no history of any disturbance of the circulation in the extremities, and the collateral circulation around the main trunk of the vessel was sufficient to carry on the circulation because the occlusion had taken place gradually. Therefore, the ultimate occlusion of a vessel after end-to-end union has nothing to do with its effectiveness in the preservation of the limb from a practical standpoint.

In lacerated wounds of the popliteal, the femoral and axillary arteries, where more than two-thirds of the circumference of the vessel is divided, it can not be sewed in a longitudinal direction, but it must be divided completely, invaginated, and united end to end. This can be done with much less difficulty than one would at first imagine. Here is a drawing showing the method of producing invagination. There should be as little trauma as possible inflicted

on the vessel at the time the stitches are being inserted; the proximal end should be drawn into the distal.

I have had two cases of perforating wounds of vessels by bullets, one of which involved both femorals, the superficial and profunda. Invagination was made; circulation returned in the foot and continued undisturbed, with final and complete recovery. The other was a bullet wound of the axillary artery, in which the area involved in hematoma extended from a line a little in front of the middle line in the back to the middle of the sternum and from the clavicle to the crest of the ilium. This was an enormous hematoma. In the operation I exposed the first portion of the axillary vessel

Method of Inserting Sutures to
Produce Invagination.

below the clavicle, passed around that a silk thread, which was not tied, but compressed by an assistant by placing his finger on the vessel and compressing it against the silk thread. If this finger should represent the vessel (indicating), the ligature was passed under and the finger compressed the vessel against the wall in place of tying it. Tying would have lacerated the intima and would have insured the formation of a clot immediately after the operation. After the invagination the circulation returned and continued in the arm without apparent change; the radial pulse immediately returned. During the time of the gradual obliterating endarteritis the collateral circulation developed sufficiently to care for it. This case was seen

three years after, and the circulation was normal.

The frequency with which surgeons have to operate in connection with these two principal vessels is not great. The frequency with which we should operate in injuries of the popliteal is greater than we have heretofore estimated. In a case in which the popliteal is supposed to be injured or crushed, with scarcely any external evidence of it, and in which we hear a bruit from contusion or perforation of the vessel, the vessel should be exposed, examined, and if it be injured it should be approximated a large dissecting aneurism forms. These injuries to vessels should not be allowed to go on for days and days until a dissecting aneurism forms, as is the present practice. In these aneurisms the opening in the wall of the vessel does not enlarge for years after the perforation; but the neighboring structures are dilated, compressed and layer after layer of cells are deposited on the lining of the hematoma within and the lining of the aneurism, until we have an enormous amount of connective tissue. This can be dissected away and the original sized opening in the vessel exposed. This can be sewed with a linen suture, unless over two-thirds of its circumference is involved; catgut may be used, but I think linen is the better of the two. At first, after suturing, when the compression on the proximal side is removed, the union leaks like a sieve, as it spurts in all directions; one feels that the patient will lose all his blood in 15 to 20 minutes, but after a mild compression of the sutured area for from forty to seventy seconds no blood will escape from around the stitch-holes. The pressure should be partially removed and reapplied; then gently increased and diminished gradually, and in about seventy seconds hemorrhage will cease and the miniature clot which forms around the stitch will occlude the opening.

In the application of surgery to vessels exposed in continuity without division, a line of action must be pursued if we desire to avoid the dangers of the condition, viz., thrombosis, necrosis, hemorrhage and cicatricial compression; we find occasionally the vessel wall exposed for 1 or 2 inches. How many times have we seen the jugular exposed from one end

to the other in operations upon the neck for enlarged glands? When we think we have mastered that rather disagreeable operation, the patient progresses nicely until the third or fourth day, when he complains of a mild irritation of the throat, followed a day or two later by a fluttering of the heart and slight bloody expectoration. Examination reveals that he has a pulmonary clot as the result of thrombosis of the jugular vein. Following the trauma a clot forms which may be either septic or aseptic, because in many of these suppurative cases of adenitis there is pus in close contact with the wall of the vein. If it be an aseptic clot, the patient will recover, as the clot is arrested in the lung; it passes into the right side of the heart and over into the lung as a first filter. If it be a septic clot, an abscess will form at the infarct. There will be thrombosis in the pulmonary veins and escape of septic emboli, when we have manifestations of general sepsis. In injuries of vessels we should consider the fact that a vein exposed to infection for a long time will finally become thrombosed; we know also that thrombi form in the iliac veins, by extension from the uterine veins to the iliac, following sepsis after parturition, due to the exposure of a vein; we know that in dissections of the axilla the vein is frequently exposed for a long distance and the cicatricial contraction subsequently occludes the vein so as to produce enormous edema of the hand, forearm and arm; these conditions can all be avoided. An exposed vein is always situated in close contact to fascia except in the popliteal space. This fascia or a muscle should be split and the vein carefully covered by the flap thus formed, so that it is not exposed in the wound. In operations on the neck, axilla, femoral and popliteal spaces it is no trouble to cover exposed veins; in the neck the sterno-mastoid, in the axilla the pectoral, in the thigh the fascia lata, and in the popliteal the vastus internus, may be appropriated for this purpose. The danger is much The danger is much less from the exposure of an artery; we rarely have a clot from sepsis or from the exposure of an artery. If clots should form in arteries alone they are less dangerous than when they form in veins, although I recently saw gangrene of the leg following a hysterectomy from thrombosis of the iliac by extension. Therefore, we should

cover all exposed vessels by a flap of neighboring connective tissue; finally, in doing all of this work, particularly where the continuity of the vessel is preserved, we should avoid trauma to the intima.

DISCUSSION.

Dr. James H. Ford, of Indianapolis, Ind.: Two years ago Dr. Taylor read a paper at St. Louis on "Aneurisms of the Popliteal Artery.". Some three or four months ago a man came to see me who had a popliteal aneurism, due to the bursting of a torpedo. He placed the torpedo on the track and started to run away, when the torpedo exploded. The explosion injured the popliteal space and wounded the artery. The man had a good-sized aneurism. Having heard Dr. Taylor's paper, and knowing how small a hole may cause aneurism, I decided to see if I could repair the injury. Having known of Dr. Murphy's work, and that of Dr. Crile, I used their devices. Around my house I found two worn-out clothes-pins. I put them in my sterilizing apparatus, cut down on the vessel, I strung these pins on the artery, putting gauze between the wings, being careful not to wound the intima. I found a hole in the popliteal space not much larger than the lead in a lead pencil, but there was an aneurism probably as large as a hen's egg. I dissected off the walls of the aneurism and found the walls of the artery were not involved. I took sterilized catgut and sewed up the hole in that artery, being careful not to wound the intima. Taking the outer coat of the artery, I kept the wound open with some degree of pressure, and gradually unloaded the vessel into the artery. In two or three days I had no bleeding from the wound, and closed it up. The man recovered without any sign of gangrene or of anemia in the lower part of the limb. He disappeared from the hospital without my permission, and I have not been able to get my hands on him since to find out the condition below.

I have cited this little experience to show that it is possible to relieve these conditions. without having gangrene occur. As railway surgeons we see more acidents to the popliteal vessels than any other class of men. They occur in a region most liable to be injured, and we should save a limb, if possible, because, as a

rule, you will have gangrene below if you put a ligature upon the vessel and occlude it suddenly.

Dr. H. C. Fairbrother, of East St. Louis, Ill. : I was very much pleased with Dr. Murphy's remarks. I think they may help me in saving a leg in future. I have given some attention to injuries of the popliteal artery recently, and the point referred to by Dr. Murphy, that we may have this artery injured with very little external opening, and, in fact, sometimes with no external opening at all, is true. Several cases have occurred in my practice in railway surgery of injury to this artery sufficient to produce its complete occlusion by dislocations those complete disorganizations of the joint that occur when a railroad man gets under and rolls over and over beneath the engine or car, coming out with a dislocated or disorganized knee, and in a few hours finding gangrene of the leg. It is a question in my mind whether I should not cut down and repair that artery. I amputated a leg recently and found the artery unruptured, but occluded by a severe contusion produced by a dislocation. After hearing this paper, I think I should be induced to go right down upon the artery as soon as I saw approaching death of the leg, or bad circulation in the leg, and attempt to repair the popliteal artery.

Dr. C. B. Stemen, of Fort Wayne, Ind.: Dr. Murphy's remarks have been intensely interesting to me, especially the one point he brought out with reference to the establishment of rapid collateral circulation, and the gradual occlusion of the artery.

I presume most surgeons have had cases where they have had to ligate the femoral above or below the parts, and afterward found it necessary to make an amputation. That has been my experience. I recall one case in particular where Professor Conner and myself, forty-eight hours after having ligated the femoral artery, had to amputate the limb. Instead of one or two bleeding vessels, we had thirty-six to ligate. Nature was making an effort to establish collateral circulation, so that we had thirty-six bleeding vessels to ligate, showing the correctness of the statement of Dr. Murphy of the effort on part of Nature to establish collateral circulation. The paper has been

of great interest to me from the fact that in these dislocations of the knee and injuries described by Dr. Fairbrother, I have had frequently to amputate, although there has been an effort on the part of Nature to establish collateral circulation.

Dr. George Ross, of Richmond, Va.: I do not rise to discuss the paper of Dr. Murphy, because I am incompetent to do so. There are few men competent to give us a paper approaching in value the one that has been read by the essayist today.

I recall the case of a very dear friend of mine who is today walking about Washington City without a leg. In this case the injury. happened many years ago, and I am certain that had I known as much then as I do now, after listening to this splendid paper, I might have saved his leg. These are reflections which come to us and fill us with many regrets that we did not know as much in years gone by as we do now. The popliteal artery was injured, and as time passed on an effort was made by nature to establish collateral circulation; but gangrene began to develop; the patient's temperature was 106°; he became delirious, and it was absolutely necessary to do an amputation in order to save the man's life. This operation would not have been done if I knew at that time what I know today, after listening to this charming and most instructive paper. I do not think I should do myself justice if I did not thank Dr. Murphy for the able paper he has presented to us. If I had heard nothing else since I came here, and should hear nothing else after it, I should feel richly compensated for the trouble I have taken in coming to this meeting, and I am delighted to have heard the ideas expressed.

Dr. W. H. Condit, of Minneapolis, Minn.: I would like to ask Dr. Murphy one or two questions. He said nothing about the formation of emboli after injury to a vein, whether accidental or natural. For instance, if there be a small organized clot and it is stitched to the intima, if the clot should be loosened in any way it may form an embolus. I have not had any experience with surgery of this nature in the human being; but in animal experiments, in a small percentage of them, invariably we have small emboli in the distal parts. I would