CASE OF ANASTOMOSIS BETWEEN THE FEMORAL SUBSEQUENT TO THROMBOSIS OF THE LEFT EXTERNAL ILIAC DURING TYPHOID FEVER.

By A. N. M'GREGOR, M.D., F.F.P.S.G., Assistant Surgeon, Glasgow Royal Infirmary.

This case of varicosity of the veins of the lower part of the abdominal wall is interesting on account of its rarity, and it presents some features of difficulty in the matter of causation and treatment.

W. S., set. 26, a brakesman, was admitted to Ward 23 of the Infirmary on 31st December, 1903, Glasgow" Royal complaining of swollen veins of the front of the ." The patient enjoyed perfect health until seven years ago, when he suffered from enteric fever. During the course of that illness his left leg became very painful, and since then it has been a little larger than his right leg, especially when at work. There has been no pain in the leg from that date, but it feels stiff at times. Four years ago lie had a second attack of enteric fever while in South Africa, and about six months after that he had a slight attack of malaria during his stay in Beira. It was shortly after this that he noticed the swollen veins on his abdomen. They gradually increased in size until about eight months ago, but since then he thinks they have been stationary. 254 Dr. M'Gregor?Anastomosis between the Femoral Veins.

He has had neither pain nor discomfort from them, but he seeks treatment on account of his fear that they may burst. He has had no haemorrhoids for the last year, but during the three previous years he was slightly troubled with them. He " has never had though he has had one or two bilious " jaundice, attacks after over-indulgence in alcohol. The family history reveals no item of importance. Present condition.?On inspection of the abdomen a plexus of veins is seen occupying the lower segment of the abdominal wall, triangular in shape, the apex being situated at the

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umbilicus, and the two inferior angles corresponding to the apices of Scarpa's triangle. The main trunks of this plexus occupy the situations of, and are presumably, the superficial epigastric and superficial external pudic veins of both sides. They are, however, much altered in shape, being distended and somewhat tortuous. The left posterior angle of this triangle is a bulbous swelling, apparently the extreme upper end of the internal saphenous vein, from wThich a large venous trunk proceeds upwards and inwards to the inner end of Poupart's ligament. There it divides into two branches, one directed horizontally across the Dr. M'Gregor?Anastomosis between the Femoral Veins. 255 pubis, and being directly continuous with a similar vein of the opposite side, the other extending upwards and inwards towards the umbilicus, thus forming the left side of the triangle. The right side of the triangle is formed in a similar manner. These two sides communicate directly at the apex and indirectly by means of a collateral branch about the upper third of the triangle. The left internal saphenous vein is not visible in the thigh; the short saphenous is normal; there is a dilated vein (super- ficial circumflex iliac) situated in the front of the thigh, about 2 inches below, and parallel to, Poupart's ligament, the blood in which flows upwards instead of towards the internal saphenous vein. The left leg below the knee is somewhat cyanosed as compared with the right; otherwise the veins of the leg appear to be normal. In the right leg the veins are normal below the junction of the superficial epigastric and superficial external pudic branches of the internal saphenous vein. On testing the flow of blood in these dilated veins, it is noticed that on the left side the blood flows from the saphenous opening across the pubis to the right, and through the left superficial epigastric vein upwards towards the umbilicus, where it anastomoses with its fellow on the right side in which the blood flows normally, i.e., downwards. When the patient lies supine this plexus of veins is empty, turned on his right side they remain empty, but if turned on his left side they gradually fill. When he lies supine the elevation of either leg has no effect, but depression of the left leg over the bed causes slow dilatation. The circumference of the left calf measures 1J inch more than the right; there is no oedema of the limb.

Remarks.?The patient's desire is to get rid of these veins because, as his occupation requires him to jump in and out of waggons, he fears that they may burst or be injured. Not- " withstanding the statement of Deaver1 that these veins may be enormously varicose where the return circulation through the inferior vena cava is not disturbed," it is evident that in this case the dilatation of the veins is eminently purposeful. Not only are they dilated, but the blood in them flows from left to right between the saphenous veins. At first sight it seems as if this anastomosis had developed for the relief of an obstruction of the left common femoral or external iliac veins, 1 Surgical Anatomy, vol. iii, p. 46. 256 Dr. M'Gregor?Anastomosis between the Femoral Veins. but examination reveals the patency of these veins, for with the patient in the erect position, and the saphenous and femoral veins compressed below the junction of the dilated veins, this plexus, being emptied, fills up rapidly. So, too, when the patient lies on his back, the vessels are empty. Authorities differ as to the presence of valves in the external iliac and femoral veins; in this case they are evidently absent or inefficient.1 It is difficult at this date to say what veins were thrombosed during the first attack of enteric, as at present no localising sign can be detected. Osier'2 gives the proportion of veins affected as follows:?"In 16 out of 829 cases?7 in left femoral, 4 in popliteal, 4 in long saphenous, and 1 in a superficial vein. The more common occurrence in the left crural vein is due possibly, as suggested by Liebermeister, to the fact that the left common being crossed by the right iliac the flow of blood is not so free as in the right vein." In my case the obstruction must have been below the level of the junction of the iliac veins, since the right takes up the work of the left.3 The question arises?May these dilated veins be ligatured safely ? My own feeling is that there is now sufficient patency of the common femoral and external iliac veins to carry on the circulation, and that, in any case, if extra accommodation were required the deeper branches of the iliac vein would take up the circulation more safely (the deep epigastric, deep circum- flex iliac, and pudic) than those presently affected. It has been suggested that, on account of the history of haimorrhoids and bilious attacks, this dilatation is for the relief of the portal circulation, through the communicating veins of the umbilicus.4 If this were the case, however, the blood would flow downwards through the superficial veins of both sides.

1 Quain, tenth edition, vol. ii, part 2, p. 539?External iliac, one valve, rarely two ; common femoral, three or four values ; ilio-femoral, valve of Bennett at Poupart's ligament. Cleland and Mackay, p. 481?External iliac, one or two valves. Prof. of Bonn, Med. Annual, " Trendelenburg, 1893, p. 546?says, the vena cava, iliaca, and trunk of vena femoralis immediately below Poupart's ligament have, with few exceptions, as is well known, no valves." 34 Prin. and Prac. of Med., fourtli edition, p. 21. 3 Keen, in his Surgical Complications and Sequels of Typhoid Fever, discusses the occurrence of venous thrombosis very thoroughly (pp. 68 et seq.), and quotes a case, similar to the present, reported by Macintosh, Glasgow Medical Journal, 1892, vol. xxviii, p. 54. 4 Schiff, quoted by Deaver, loc. cit. Dr. M'Gregor?Anastomosis between the Femoral Veins. 257

In January, 1904, the patient was shown to the Glasgow Pathological and Clinical Society, when the foregoing paper was read. In the discussion which followed, the general opinion was that ligature of the veins would not be safe, as the large flow of the blood through the dilated veins seemed to indicate continued obstruction of the common or external iliac veins. Mr. Maylard suggested the use of a truss experimentally in such a way that the anastomosing veins would be com- pressed, and so the patency of the normal channels would be tested. This suggestion was adopted, careful measurements being taken before and after the wearing of the inguinal truss on two consecutive days, the patient being allowed to walk about the ward all day. The circumference of the affected leg at a point 11 inches above the tip of the external malleolus was 14f inches in the morning, and there was practically no difference in the evening of either day. The operation of ligaturing the superficial pudic veins was performed on 30th January, and the patient made a good recovery. After an interval of about six months the only veins prominent were those of the apex of the triangle, namely, the two superficial epigastric veins and their intercommunicating branches. These were ligatured on 8th June of the same year, and the patient was dismissed "well" on 27th of that month. On inspection at this date (October, 1905), no superficial veins are prominent or visible; palpation fails to distinguish them. The patient has been at work continuously since the second operation wound healed (27th June, 1904). In need only be said, in conclusion, that the experiment with the truss gave a distinct indication that the capacity of the left iliac veins was sufficiently restored to accommodate all the blood passing from the limb of that side. The distended superficial veins were no longer necessary; they constituted a danger to the patient, and, as they showed no signs of diminishing spontaneously, the operative procedures were undertaken. An examination of the patient eighteen months afterwards showed them to have been successful.

No. 4. R Vol. LXVI.