Alexis Thomson

“ In _arterial_ haemorrhage the blood is bright red in colour, and escapes from the cardiac end of the divided vessel in pulsating jets synchronously with the systole of the heart. In vascular parts--for example the face--both ends of a divided artery bleed freely. The blood flowing from an artery may be dark in colour if the respiration is impeded. When the heart's action is weak and the blood tension low the flow may appear to be continuous and not in jets. The blood from a divided artery at the bottom of a deep wound, escapes on the surface in a steady flow. ”

“ 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. ”

“ The most common exciting cause is increased pressure within the veins, and this may be produced in a variety of ways. In certain diseases of the heart, lungs, and liver, for example, the venous pressure may be so raised as to cause a localised dilatation of such veins as are congenitally weak. The direct pressure of a tumour, or of the gravid uterus on the large venous trunks in the pelvis, may so obstruct the flow as to distend the veins of the lower extremity. It is a common experience in women that the signs of varix date from an antecedent pregnancy. ”

“ The essential feature of a traumatic aneurysm is that it is produced by some form of injury which divides all the coats of the artery. The walls of the injured vessel are presumably healthy, but they form no part of the sac of the aneurysm. The sac consists of the condensed and thickened tissues around the artery. ”

“ 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. ”

“ We have met with a chronic form of arterial degeneration in elderly women, affecting especially the great vessels at the root of the neck, in which the artery is remarkably attenuated and dilated, and so friable that the wall readily tears when seized with an artery-forceps, rendering ligation of the vessel in the ordinary way well-nigh impossible. ”

“ If no complications supervene, the swelling subsides, and recovery may be complete in six or eight weeks. If the extravasation is great and the skin threatens to give way, or if the vitality of the limb is seriously endangered, it is advisable to expose the injured vessel, and, after clearing away the clots, to attempt to suture the rent in the artery, or, if torn across, to join the ends after paring the bruised edges. If this is impracticable, a ligature is applied above and below the rupture. If gangrene ensues, amputation must be performed. ”

“ 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. ”

“ If a comparatively small escape of blood takes place into the tissues, the sudden alteration in the size, shape, and tension of the aneurysm, together with loss of pulsation, may be the only local signs. When the bleeding is profuse, however, the parts beyond the aneurysm become greatly swollen, livid, and cold, and the pulse beyond is completely lost. The arrest of the blood supply may result in gangrene. Sometimes the pressure of the extravasated blood causes the skin to slough and, later, give way, and fatal haemorrhage results. ”

“ The presence of diseased patches in the wall of an artery diminishes its elasticity and favours aneurysmal dilatation. Such a vessel also is liable to be ruptured by external violence and so give rise to traumatic aneurysm. Thrombosis is liable to occur when calcareous plates are exposed in the lumen of the vessel by destruction of the endothelium, and this predisposes to embolism. Arterio-sclerosis also interferes with the natural arrest of haemorrhage, and by rendering the vessels brittle, makes it difficult to secure them by ligature. ”

“ The primary cause of arterio-sclerosis is not definitely known, but its almost constant occurrence, to a greater or less degree, in the aged suggests that it is of the nature of a senile degeneration. It is favoured by anything which throws excessive strain on the vessel walls, such as heavy muscular work; by chronic alcoholism and syphilis; or by such general diseases as tend to raise the blood-pressure--for example, chronic Bright's disease or gout. It occurs with greater frequency and with greater severity in men than in women. ”

“ 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. ”

“ If an artery is only _partly cut across_, the divided fibres of the tunica muscularis contract and those of the tunica externa retract, with the result that a more or less circular hole is formed in the wall of the vessel, from which free bleeding takes place, as the conditions are unfavourable for the formation of an occluding clot. Even if a clot does form, when the blood-pressure rises it is readily displaced, leading to reactionary haemorrhage. Should the wound become infected, secondary haemorrhage is specially liable to occur. ”

“ Even if a haematoma forms it seldom assumes a great size. In time a swelling is recognised, with a palpable thrill and a systolic bruit, loudest at the level of the communication and accompanied by a continuous venous hum.
If leakage occurs into the tissues, the extravasated blood may occlude the vein by pressure, and the symptoms of arterial aneurysm replace those of the arterio-venous form, the systolic bruit persisting, while the venous hum disappears. ”

“ For example, a patient may be recovering from an operation such as the removal of an epithelioma of the mouth, pharynx or larynx and the associated lymph glands in the neck, and be able to be up and going about his room, when, suddenly, without warning and without obvious cause, a rush of blood occurs from the mouth or the incompletely healed wound in the neck, causing death within a few minutes. ”

“ 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. ”

“ The aneurysm usually forms soon after the injury is inflicted; the blood slowly escapes into the surrounding tissues, gradually displacing and condensing them, until they form a sac enclosing the effused blood.
Less frequently a traumatic aneurysm forms some considerable time after the injury, from gradual stretching of the fibrous cicatrix by which the wound in the wall of the artery has been closed. The gradual stretching of this cicatrix results in condensation of the surrounding structures which form the sac, on the inner aspect of which laminated clot is deposited. ”

“ With the limb still elevated the tourniquet is firmly applied, a part being selected where the vessel can be pressed directly against a bone, and where there is no risk of exerting injurious pressure on the nerve-trunks. The tourniquet should be applied over several layers of gauze or lint to protect the skin, and the first turn of the tourniquet must be rapidly and tightly applied to arrest completely the arterial flow, otherwise the veins only are obstructed and the limb becomes congested. In the lower extremity the best place to apply a tourniquet is the middle third of the thigh ”

“ Carotid Aneurysms.#--Aneurysm of the _common carotid_ is more frequent on the right than on the left side, and is usually situated either at the root of the neck or near the bifurcation. It is the aneurysm most frequently met with in women. From its position the swelling is liable to press on the vagus, recurrent and sympathetic nerves, on the air-passage, and on the oesophagus, giving rise to symptoms referable to such pressure. There may be cerebral symptoms from interference with the blood supply of the brain. ”

“ The bruising of the vessel wall, especially if it is diseased, may result in the formation of a thrombus which occludes the lumen temporarily or even permanently, and in rare cases may lead to gangrene of the limb beyond.
Subcutaneous Rupture.#--An artery may be ruptured subcutaneously by a blow or crush, or by a displaced fragment of bone. This injury has been produced also during attempts to reduce dislocations, especially those of old standing at the shoulder. It is most liable to occur when the vessels are diseased. ”

“ A tourniquet should never be applied tighter or left on longer than is absolutely necessary.
The screw tourniquet of Petit is to be preferred when it is desired to intermit the flow through the main artery as in operations for aneurysm.
When a tourniquet cannot conveniently be applied, or when its presence interferes with the carrying out of the operation--as, for example, in amputations at the hip or shoulder--the haemorrhage may be controlled by preliminary ligation of the main artery above the seat of operation--for instance, the external iliac or the subclavian. ”

“ In exceptional cases, blisters form over the seat of the effusion, or the skin may even slough, and the clinical features may therefore come to simulate closely those of an acute suppurative condition. When the skin sloughs, an ulcer is formed with altered blood-clot in its floor like that seen in scurvy, and there is a remarkable absence of any attempt at healing. ”

“ When an _artery and vein are simultaneously wounded_, the features peculiar to each are present in greater or less degree. In the limbs gangrene may ensue, especially if the wound is infected. Punctured and gun-shot wounds implicating both artery and vein are liable to be followed by the development of arterio-venous aneurysm. ”

“ When a large arterial trunk, such as the external iliac, the femoral, the common carotid, the brachial, or the popliteal, has been partly divided, for example, in the course of an operation, the opening should be closed with sutures--_arteriorrhaphy_. The circulation being controlled by a tourniquet, or the artery itself occluded by a clamp, fine silk or catgut stitches are passed through the outer and middle coats after the method of Lembert, a fine, round needle being employed. The sheath of the vessel or an adjacent fascia should be stitched over the line of suture in the vessel wall. ”

“ The skin is disinfected and the limb wrapped in cotton wool to conserve its heat, and elevated to such an extent as to promote the venous return without at the same time interfering with the inflow of blood. A careful watch must be kept on the state of nutrition of the limb, lest gangrene occurs. ”