The treatment most generally em ployed, if there is room, is to tie the artery between the sac and the heart, and, if there is not room enough, beyond the sac. This may, however, be followed by embolism, cerebral softening, hemi plegia, syncope, or by secondary hmmor rhage or suppuration.
More than one-third of the deaths following ligation of the common carotid are due to subsequent cerebral disease.
Cerebral softening following ligation of the common carotid, due to embolus, is mainly caused by the arrest of the blood-current. Besides the trunk of the common carotid, the internal carotid should also be ligated, to prevent the return-current, which takes place from the internal to the external carotid. Lampiasi (La Semaine Med., Nov. 11, '91).
Ligation of both common carotid ar teries, at a year's interval; neither oper ation followed by brain symptoms. Gay (Boston Med. and Surg. Jour., Mar. 8, '94).
When both carotid arteries must be tied, it should not be done at the same time, as fatal coma has followed a simul taneous operation.
Gentle handling of cervical aneurisms recommended to avoid the dislodgment of coagula through the internal carotid. Case in which a rough manipulation was followed by immediate paralysis. Hulke (Inter. Med. Mag., Dec., '92).
Subclavian Aneurism.
Symptoms. — Aneurism of the sub clavian attacks more especially the third portion of the artery, appearing as an elongated tumor beneath the clavicular insertion of the sterno-cleido-mastoid.
The special signs of subclavian an eurism are a varicose condition of the jugular veins, a retarded pulse at the wrist, cedema of the arm and hand, pain in the nerves of the brachial plexus, and, if the aneurism is on the right side, a brassy cough from irritation of the re current laryngeal nerve. Two-fifths of the deaths following ligation of the third part of the subclavian are due to intra thoracic inflammation.
Diagnosis. — Aneurism of the sub clavian artery iu its third portion is to be distinguished from carotid aneurism. In the former the pulse at the wrist is found delayed when compared to the pulsation of the carotids.
When both the carotid and radial pulse on the right side are delayed as compared to the left carotid artery, eurism of the innominate artery is to be suspected.
Treatment. — Medical treatment of subclavian aneurism should precede all other methods. Ligature of the innom inate, when supplemented with simul taneous and consecutive ligature of the associated contiguous arteries, or by other expedients equally well intended to aid the cure, is worthy of favorable consid eration. (J. D. Bryant.) Pressure applied by the finger be tween the aneurism and the heart, sup plemented with general measures, has been tried in cases in which the tumor was small. This procedure is not easy, however, on account of the anatomical constitution of the region and has been replaced by direct pressure upon the sac proper.
When compression is unsuccessful the artery may be tied beyond the aneurism. Ligation between the latter and the heart has rarely succeeded.
Method of controlling the circulation in the upper extremity by elastic com pression. A wooden pad is placed over subelavian and held in place by the rubber bandage of the Esmarch appara tus; the bandage carried from the chest over the back and then alternately be tween the thighs and under the opposite axilla. W. W. Keen (Med. and Surg. Reporter, .Tune 27, '91).
Successful ligation of the first portion of the left subclavian artery and excision of a large subclavio-axillary aneurism, probably the only successful case of this kind and the first one of complete extir pation of a subclavio-axillary aneurism. Halsted (Johns Hopkins Hospital Bulle tin, July, Aug., '92).
Simultaneous ligation of the common carotid and subclavian arteries recom mended. The larger the aneurism, the greater the development of collateral circulation. Guinard (Bull. Ga. de Thk., Jan. 13, Feb. 15, 28, '94).
Simultaneous ligation of the right common carotid and right subclavian or axillary artery appears to be the opera tion of choice. Statistics showing six cures and twenty-two improvements out of fifty-six cases. Toivet (Revue des Sciences M6dicales en France et a l'i.ltranger, Jan. 15, '94).