Copyright
Bertram M. (Bertrand Moses) Bernheim.

Surgery of the vascular system online

. (page 1 of 7)
Online LibraryBertram M. (Bertrand Moses) BernheimSurgery of the vascular system → online text (page 1 of 7)
Font size
QR-code for this ebook


F>WEBEM-TED BY

J. B. L1PP1NCOTT CO.
G. s. QEIORGE:



SUTTER
OOAST REPRESENTATIV




THE LIBRARY

OF

THE UNIVERSITY
OF CALIFORNIA

LOS ANGELES



GIFT OF



SAN FRANCISCO
COUNTY MEDICAL SOCIETY



4,'587

SURGERY

OF THE

VASCULAR SYSTEM



BY

BERTRAM M. B_ERNHEIM, A.B., M.D.

INSTRUCTOR IN SURGERY, THE JOHNS HOPKINS UNIVERSITY, BALTIMORE, MD.



WITH S3 ILLUSTRATIONS IN TEXT




PHILADELPHIA & LONDON
J. B. LIPPINCOTT COMPANY



COPTRIGHT, 1913
BY J. B. LIPPINCOTT COMPANY



ELECTROTrPED AND PRINTED BY J. B. LIPPINCOTT COMPANY
AT THE WASHINGTON SQUARE PRESS, PHILADELPHIA, V. S. A.



Ubntr



If 13



TO

H. M. B.



i
I



.



o



PREFACE

THE field of blood-vessel surgery offers great possibilities
for future development, if this present early period of growth
is not impeded by attempts on the part of unskilled operators
to practise it. Brilliant laboratory results achieved in this
work have often lured the inexperienced to try their luck,
only to find that chance here plays no part and that success
is measured only by years of trial, first in the laboratory,
then in the clinic.

This book is intended to be a practical and suggestive aid
to the surgeons interested in this branch of work; in it the
various methods employed in the field of vascular surgery
will be explained as simply as possible, a fundamental knowl-
edge of the condition in hand being always taken for granted.
For example, in considering the subject of aneurisms, the
anatomical, pathological, and etiological sides, already de-
scribed by other, more authoritative, writers, will be omitted ;
and in the descriptions of operative procedures where sev-
eral methods have been devised, the one or two best and
most employed have been selected for detailed exposition.
This course has been pursued not to spare the writer
wearying labor, but to present directly to the reader a
text unhampered by preliminary review and multiplication
of detail.

It is a pleasure to gratefully acknowledge the interest
which Dr. ~W. S. Halsted, himself one of the pioneers in
modern vascular surgery, has shown in my work; to thank
Dr. John M. T. Finney for his sympathetic help and the
clinical opportunities which he and Dr. J. C. Bloodgood have
afforded me; to acknowledge my large debt to Dr. Harvey
Gushing, during whose direction of the Hunterian Lab-



vi PREFACE

oratory for Experimental Medicine my researcli work was
performed.

The enthusiastic co-operation of Mr. .James F. Didusdi.
who, under the supervision of Mr. Max Broedel, furnished the
illustrations for this book, has been much appreciated.

BERTRAM M. BERNHEIM.
BALTIMORE, 1913.



BRIEF HISTORICAL NOTE

A GRADUAL process of evolution, similar to that which
took place in intestinal and other branches of surgery, has
given rise to the present-day technic in blood-vessel work.
The names of Eck, Gliick, Hunter, Jassinowsky, Doerfler.
Murphy, Jaboulay, v. Hirsch, Payr, Hophner, and others will
always be closely linked with this development, which, be-
cause no consistently successful method of suturing vessels
could be devised until a perfect asepsis had been achieved,
marks a real triumph in modern medicine. After the attain-
ment of this most important goal, perfect asepsis, a method
simpler than all those previously suggested, became the
method of choice, and the general technic developed by Carrel
in working up his simple end-to-end suture (1905) formed
the basis for all future endeavor in this field.

Inspired to renewed efforts by the achievements of Carrel,
and founding their work upon his tenets, workers in clinics
the world over have carried out many brilliant researches.
Numerous modifications of his suture method have been sug-
gested, for example, those of Payr, Dorrance, and others,
and to a certain extent have been adopted, but all have
lacked that perfect simplicity so characteristic of the Carrel
method and so essential to success in vascular surgery.

Previous to the work of Carrel the chief interest in blood-
vessel surgery centred about the treatment of aneurisms, and
the names of Antyllus, Moore, Corradi, Macewen, Keen,
Halsted, Matas, and others are closely connected with this
branch of the subject. Now aneurisms, important as is their
consideration, demand only part of our attention for the
subject has widened to include the repair of injured blood-
vessels, the transplantation of arterial or venous segments

vii



viii BRIEF HISTORICAL NOTE

between the ends of a resected vessel, end-to-end or lateral
anastomosis, and direct transfusion of blood. The operation
of transfusion, employed from authoritative records as early
as 1492 in a vain attempt to save the life of the then Pope
Innocent VIII, has throughout the history of surgery never
been lost sight of as a possible procedure, but has always
failed of consistent results, until the work of Crile, in our
own day and country, put it upon the basis of safety and
practicability.

This brief review must convey the forcible impression of
work only begun, and I feel sure that it will be the privilege
of some not too distant chronicler to include in his records
great progress in this branch of our endeavor.



CONTENTS

CHAPTER I. PAGE

GENERAL TECHNIC 1

CHAPTER II.
TRANSFUSION 8

CHAPTER III.

END-TO-END SUTURE 28

CHAPTER IV.
LATERAL ANASTOMOSIS 37

CHAPTER V.
TRANSPLANTATION OF A SEGMENT OF VEIN OR ARTERY 46

CHAPTER VI.
ARTERIOVENOUS ANASTOMOSIS REVERSAL OF THE CIRCULATION 53

CHAPTER VII.
VARICOSE VEINS 61

CHAPTER VIII.
SURGERY OF THE HEART 64

CHAPTER IX.
ANEURISMS 68

CHAPTER X.
STATISTICAL STUDY OF THE TREATMENT OF ANEURISMS 81



ILLUSTRATIONS

FIG. PAGE

1. Author's ball-tipped forceps 2

2. Needle and thread mounted and ready for sterilization 5

3. Flask containing liquid vaseline and four mounted needles 6

4. Crile cannula 10

5. Drawing vein through cannula 10

6. Cuffing vein back over the cannula 11

7. Vein cuffed and tied in groove nearest handle of the cannula. Artery grasped

by three mosquito clamps 11

8. Artery slipped over cannula and tied in the second groove 12

9. Author's three-pronged modification of Crile's cannula 13

10. Elsberg's monkey-wrench cannula 13

11. Artery "set" in Elsberg's cannula; tenacula in position for cuffing 14

12. Artery everted and impaled on the hooks. Vein grasped by mosquito clamps 14

13. Cannula slipped into side of vein and tied in position 14

14. Author's two-pieced transfusion tube 16

15. Incision in wrist of donor, showing radial artery and vense comites 17

16. Radial artery separated from vena3 comites, doubly ligated, and divided. ... 18

17. Cutting oval opening in side of radial artery 19

18. Slipping male half of tube into the artery 20

19. Tube tied in place in the artery 21

20. Female half of tube tied in position in vein of the recipient 22

21. Tubes invaginated and anastomosis complete 23

22. Severed ends of an artery showing the over-hang of adventitia 29

23. Drawing adventitia well out over end of the artery 29

24. Cutting off adventitia flush with end of the artery 30

25. Washing out vessels with liquid vaseline and salt solution 31

26. Three stay sutures placed 32

27. Stay sutures tied and vessel triangulated 33

28. Sewing first side of triangle 34

29. Sewing second side of triangle 34

30. Sewing third side of triangle 35

31. Suture complete 35

32. Diagram showing method and principle of making incision in vessels in lateral

anastomosis. Method of Bernheim and Stone 37

33. Incision made in side of artery and being made in side of vein 38

34. Drawing adventitia away from the oval opening 39

35. Cutting away the adventitia 40

36. Washing out the vessel with salt solution and liquid vaseline 41

37. Starting suture of the vessels 42

38. Posterior row of sutures being placed 42

39. Posterior row of sutures completed; anterior row being placed 43

40. Suture completed and being tied to first knot 43

41. Clamps removed from vessels. Proximal ligation of vein 44

xi



xii ILLUSTRATIONS

42. Washing out a venous transplant with liquid vaseline and salt solution 46

43. Cutting adventitia away from edges of venous transplant 46

44. Measuring venous transplant between ends of artery 47

45. The transplant "set" by stay sutures placed at either end I s

46. Suture in progress 48

47. Suture complete; vein flaccid; clamps still on artery 49

48. Blood going through transplant. Vein bulged and tense from arterial pressure.

Slight irregularity indicates situation of reversed valves 50

49. Valves of vein diagram showing necessity for reversal in placing a venous

transplant 51

50. Obliterative endo-aneurismorrhaphy (Matas) 71

51. Restorative endo-aneurismorrhaphy (Matas) applied to sacculated aneurisms

with a single orifice of communication 71

52. Restorative endo-aneurismorrhaphy (Matas). Aneurismal sac closed off from

parent artery 72

53. A, Halsted's original band and roller in the act of curling a metal strip about

an artery; B, the improved band roller about to expel a band 79



SURGERY OF THE VASCULAR
SYSTEM

CHAPTER I

GENERAL TECHNIC

General Considerations. The success of blood-vessel
work, anastomoses, transfusions, repair of injuries, etc.,
depends almost entirely on the avoidance of a blood-clot
and a general technic has been evolved which if properly
observed gives most consistent results.

The wall of a blood-vessel, it is well known, is made up
of three separate and distinct layers of tissue, intima, media,
and adventitia each of which can be readily separated from
its neighbor. Of these three coats the adventitia, or outer
layer, is by far the most important to the surgeon engaged in
vascular work, because, made up of a most delicate network
of fibrous tissue, it hangs over the end of a severed and
collapsed vessel, and acts as a sieve for the smallest drop of
blood and us a nucleus for the formation of a clot. Its
flaccidity would seem to render its removal an easy matter,
and so it does ; but this very characteristic, this very mobility,
causes still more of it to slip into the needle hole, and if great
care be not taken it acts as the starting point of a thrombus
in an otherwise perfect suture. True, the scratched intima is
an ever-present source of danger, as shown in the classic
work on "Thrombosis and Embolism" -of Welch, but one
has only to consult the works and writings of those who
have done pioneer work in the field of vascular surgery to

realize that neither the intima nor the media is greatly to

l



2 SURGERY OF THE VASCULAR SYSTEM

be feared. The adventitia is the chief foe, and a worthy one
at that.

Blunt Instruments. Perhaps the first principle to be
learned is that blood-vessels resent being handled by any
other than blunt instruments, and of these instruments the
fingers are the most useful and the safest. I am well aware
of the fact that this dictum is diametrically opposed to
present-day teaching regarding surgery in general, but a
careful consideration of all the factors involved has led me
to express this view. The blood-vessel wall is only too easily
crushed; it should, therefore, never be grasped by a sharp-




Fio. 1. Author's ball-tipped forceps. Prevent injury to vessel wall, especially scratching of intima.

pointed or mouse-toothed forceps. But since the work can at
times be facilitated by a delicate pair of forceps, I have had
one constructed which has a small, polished metal knob about
the size of an ordinary pin-head on each end. These knobs
enable one to grasp the vessel firmly without doing the
slightest damage to the intima (Fig. 1). Small branches
should be utilized to lift the mother trunk, or a blunt dissector
can be gently inserted beneath the vessel, which can then be
raised or put on the stretch with impunity, so long as gentle-
ness is employed.

After a vessel is thus exposed, and has once been
mobilized to a certain extent, it can be grasped with the
thumb and forefinger. At times it may be more convenient
and equally efficacious to insert a soft tape (one-fourth inch



GENERAL TECHNIC 3

wide) beneath the vessel and use it as a tractor. Thus an
artery or vein can be dissected out of its bed without the
slightest instrumental insult.

Salt Solution and Liquid Vaseline. During the entire
course of any operation involving blood-vessels, the haemo-
stasis must be absolutely perfect, or as nearly so as possible.
All branches, large and small capillaries excepted should
be cut between two clamps and tied. Despite these precau-
tions, however, there will always be a certain amount of
staining, which is best removed with gauze sponges wrung
out in normal salt solution. In addition to this a stream of
warm salt solution should be played on the wound at intervals
during the entire course of the operation, especially after
exposure of the vessels. This is not alone for the purpose
of removing blood and clot, but to prevent drying of the
tissues as well a, phenomenon that occurs with striking
rapidity in wounds of this character, and one that is to be
avoided at all costs. Indeed, so careful must we be in this
respect that we have called to our aid another agent better
qualified to prevent drying than salt solution liquid vase-
line, 1 a neutral lubricant that keeps the tissues soft and
pliable, prevents too rapid evaporation, and is tolerated by
the organism in almost any quantity. The combination of
salt solution and liquid vaseline, each judiciously used, keeps
the wound in a beautiful state of pliability that renders all
manipulations much easier to accomplish and less liable to
damage any of the delicate structures handled.

Handling the Severed Vessel. If care is necessary in
handling the vessel intact, the utmost consideration must be
exercised in dealing with it severed. Intima must not be
scratched, and yet all blood and every vestige of fibrin must
be scrupulously washed out of the vessel. Salt solution

1 1 use that made by Chesebrough Manufacturing Company of New York.



4 SURGERY OF THE VASCULAR SYSTEM

thrown on and into the vessel by a blunt-tipped rubber
syringe together with restrained stripping with the fingers
works wonders, but the overhang of adventitia that occurs
as soon as the vessel is cut and soaked in salt solution ob-
structs the lumen to such a degree that complete cleansing
is impossible until it has been removed. This is accomplished
by grasping it with the thumb and forefinger, or a very
delicate pair of mouse-tooth forceps, drawing it well down
over the end of the vessel, it comes down with remarkable
ease, and cutting it off flush with the cut edge. Thus freed
from adventitia the mouth of the vessel will at once spring
open, permitting the insertion directly into its lumen of the
perfectly rounded tip of a medicine dropper filled with salt
solution. This is repeatedly injected until all clot and visible
fibrin are washed out, whereupon the lumen is filled with
liquid vaseline. Even before all clot is displaced it is well
to inject a little vaseline into the vessel and around the field
of operation in general.

Blood-vessel Clam-ps. The blood flow is at all times to be
obstructed by a rubber-shod clamp, of the variety shown in
the illustration. The smaller, or so-called bull-dog clamp, is
used on small vessels like the radial, while the larger, or Crile
clamp, is employed for vessels of larger calibre. If the jaws
of these or other clamps are not serrated, they need not
necessarily be rubber-shod, but I have always preferred to
use a clamp armed with rubber, believing that it is safer. At
times it may be inconvenient or even impossible to use any
clamp, in which case the ordinary tape mentioned above when
properly placed around the vessel and secured by an ordinary
haemostat, will act as a safe and effectual clamp.

Suture Material. Suture material must be light and
delicate, yet strong enough to withstand any arterial pres-
sure. Such a silk is the 00000 made by Belding Bros. & Co.,
of New York. It can be obtained in either the white or
black, is beautifully smooth, withstands sterilization without




GENERAL TECHNIC 5

loss of strength, and has answered every purpose, both ex-
perimental and practical. This silk is nicely carried by a
No. 12 ground down needle that is made by H. Milward &
Sons. This needle has a small round eye, and is one inch
long a length that permits of just the right amount of
flexibility.

It is my custom to use black thread, 2 since that can be
seen against a white background much more
easily than a white thread against a black back-
ground, the latter being Carrel's method. I
have noticed absolutely no difference in the heal-
ing or in the operative results following the use
of either the white or the black thread; the dye
in the thread used for blood-vessel suture is fast
and almost infinitesimal in amount.

All needles are threaded and sterilized in die 'and ' threTd
liquid vaseline before operation, the routine ready n for sterm-
being to thread each needle with about twelve
inches of the black silk, drawing the ends even and fixing
each needle on a separate piece of ordinary writing paper,
about one-half inch by one-quarter inch, in such a way
that the doubled thread is wound around the needle by
a figure-of-eight (Fig. 2), and the final end of the thread
caught by a slit in one corner of the paper. Thus prepared,
four threaded needles are placed in a small flask containing
one or two ounces of liquid vaseline (Fig. 3) and sterilized in
the usual way. Just before operation the contents of one or
more flasks, oil as well as needles, are poured into a dry
sterile medicine glass and placed on the instrument table. I
have made it a rule to allow no one but myself to touch these
needles at operation, and I leave them lying in the oil until
the time for actual suture comes, when I carefully remove

2 The thread and all instruments used in vascular work are handled by
the Chas. Willms Surgical Instrument Company, of Baltimore.



(I



SURGERY OF THE VASCULAR SYSTEM



one needle from its paper by going through che reverse figure-
of-eight. One end is then shortened to about two inches, and
the needle and thread are given a final inspection for any

defects, such as small spots of

rust or inequality or roughness
in the silk. If this examination
is satisfactory the suture is be-
gun, a similar procedure being
observed for each additional
suture that may be needed.

Rubber gloves are generally
worn in blood-vessel operations
up to the point of actual suture,
though sometimes only to the
point where the washing-out

process of the vessels begins.

jjjl Their discard at this point is at

present an unavoidable and un-
y V4 fortunate break in technic,

V i^. which I endeavor to minimize

by a preparation of the hands
JB lasting not less than twenty to

twenty-five minutes. The deli-

Fio. 3. Flask containing liquid vaseline nftf > v rf tViA TrmnirmlfltioTKJ and
and four mounted needles. Sterilized and CECV OI Hie manipulations dl]

the fineness of the needles and

thread necessitate the use of the bare hand, and in order that
the skin of the hands may be soft and pliable, it is well to
wash them in salt solution immediately after discarding the
gloves and then anoint them thoroughly in the liquid vaseline,
this process being repeated as often as they become dry.
Attention to these and many other details that experience
alone can teach is required to secure constant results in this
field of surgery, but success will more than compensate for
the patience and energy it demands.




GENERAL TECHNIC 7

REFERENCES

Artus: Jour, de physiol. et de path. gen.. 1902, iv, 281.

Eernheim, B. M. : The Relation of the Blood- Vessel Wall to Coagulation of the

Blood, Jour. Am. Med. Asso., July 23, 1910.
Delezenne: Arch, de Physiol., 1897, series 5, i.x, 333. Compt. rend. Soc. de biol.,

1896, p. 782.

Loeb, L. : Virchow's Arch. f. path. Anat., 1904, clxxv, 10.
Morawitz, P. : Beitriige zur Kenntnis der Blutgerinnung, Deutsch. Arch. f.

klin. Med., 1904, Ixxix.
Sahli, H. : Ueber das Wesen der Haemophilie, Ztschr. f. klin. Med., Bd. 56,

1905.

Welch, Wm. : Thrombosis and Embolism. Allbutt's System of Medicine, vol. vii.
Wooldridge: Die Gerinnung des Blutes, Leipsic, 1891.



TRANSFUSION

TRANSFUSION, the most employed operation in blood-ves-
sel surgery, has presented gratifying results, and in the
hands of the careful surgeon is capable of lasting and far-
reaching effects.

Transfusion means the giving of blood by one individual
to another, and there are two methods by which it is accom-
plished, (1) direct and (2) indirect. When the blood-vessels
of one individual are directly united with those of another,
whether by suture or cannula method, and blood flows from
one to the other, we call the procedure direct transfusion;
when blood is withdrawn from one individual by means of a
needle and syringe and, after being defibrinated, is injected
into another individual, we call the procedure indirect trmi*-
fusion. I shall deal exclusively with the direct method, wlm-li
is, at present, thought by surgeons to give better and more
far-reaching results than the indirect method. Indirect trans-
fusion in selected cases and handled properly is also of great
service.

To illustrate the use of this operation T wish to state that
it shows gratifying success in cases of hemorrhage; for ex-
ample, in those tragic cases where fresh blood has been the
only means of making up the deficiency caused by accident;
in cases of bleeding from a gastric ulcer; typhoid ulcers;
ruptured extra-uterine pregnancies; and in other conditions.
This emergency use of transfusion in saving life after loss
of blood covers only part of the field; transfusion has re-
peatedly been successfully employed to raise the resistance
of patients too weak to withstand the shock of a necessary
operation. A case in point is that of a boy aged seven (pa-
8



TRANSFUSION 9

tient of Dr. J. M. T. Finney) who, suffering from splenic
anaemia, had become so dreadfully exsanguinated from re-
peated hemorrhages from the stomach that his haemoglobin
was too low to register. A splenectomy was successfully
accomplished by Dr. Finney during the course of a trans-
fusion, and the boy not only withstood the operation but was
in better condition at its conclusion than at the start. He
made a stormy but successful recovery, only to succumb five
months later from another gastric hemorrhage, probably the
result of an old cesophageal varix.

The anaemias pernicious anaemia, leukaemia have not
responded well to this operation, but the number of reported
cases upon which this conclusion is based is very small. It
is possible that in certain of these and other allied anaemias
transfusion may be of great service.

Therapeutically the outlook is bright ; for example, trans-
fusion is most auspicious in hemorrhage of the new-born
melaena. neonatorum. The depleted circulation in such cases
is not only restored but the obscure condition itself is cured
in almost all cases. Haemophilia, in general is another illus-
tration of the beneficent influence of this operation and cer-
tain cases of illuminating gas poisoning, as shown by Crile,
can be resuscitated by this means. Beneficial results, even a
certain number of cures, have been attained in pellagra fol-
lowing transfusion. Cole reports a number of apparent cures
and I have had one myself. 1 Shock, that most dreaded and most
baffling condition of all surgical complications, can frequently,
when all other measures for its relief have been unsuccessful,
be overcome by prompt transfusion. Certain of the toxaemias
would seem to be amenable to this form of treatment. I
have recently transfused in a case of toxaemia of pregnancy

1 It is impossible to say just how or why transfusion is of service in this
condition. It hardly seems likely that it acts as a specific. A more logical
deduction would be that it raises the resistance of the patient by restoring the
blood picture more nearly to normal.



10



SURGERY OF THE VASCULAR SYSTEM



with a most promising outcome. Thus far, only the borders
of the field of transfusion have been opened up by pio-
neers. It lies full of promise, inviting exploration.
A number of instruments have been devised
for the purpose of simplifying transfusion, each
one with a certain degree of merit. I have
selected for description those three which I con-
sidered as easiest to manipulate and as giving
most favorable results.

First comes Crile 's cannula (Fig. 4), most


1 3 4 5 6 7

Online LibraryBertram M. (Bertrand Moses) BernheimSurgery of the vascular system → online text (page 1 of 7)