Case of multiple aneurism. No. 1, 'In guinal" aneurism; No. 2, Femoral aneurism; No. 3, Small aneurism, which had not been discovered during the patient's life; No. 4, Popliteal an eurism, which ruptured; A, Orifice of femoral artery; B, Inferior orifice of same; C, Continuation of poplit eal; E, Aneurismal sac. (.1/onro.) Case of double aneurism of left thigh: one, the size of an egg, at Scarpa's tri angle; the other, as large as a cocoa-nut, at the opening through the abductor magnus. Superficial femoral ligated in middle of Searpa's triangle, suppuration and two secondary haemorrhages ensu ing; wound enlarged and bleeding ends tied. Only one case on record of cure of double aneurism of superficial femoral artery by operative procedure. Souchon (N. Y. Med. Jour., Nov. 2, '95).
Treatment.—In idiopathic aneurism of this artery digital or instrumental com pression above the sac is to be preferred. If this proves unsuccessful, ligation is to be resorted to. If the aneurism is in Hunter's canal, the artery should be li gated above; if it is in Searpa's triangle, ligation of the common femoral gives the best results, although ligation of the ex ternal iliac is usually preferred, owing to the absence of branches where the liga ture is usually applied.
The favorable statistics of the last decade may be greatly increased by adoption of this method of suture: an obliteration of the sac, instead of the classical ligation of the arteries, with or without extirpation; the closure of the arterial orifice, supplying the sac, whether single or multiple, by sutures; and within the sac simplified technique of the other operation. A favorable ease—namely: saccular aneurism, with one orifice into the trunk is best. It is possible, by these sutures, to close the lumen without narrowing the main channel. In fusiform, traumatic aneu risms, and in all with a healthy, friable sac, lost continuity of the arteries may be renewed by building a new channel and connecting the main orifices of communication. The fear that atheroma and degeneration will interfere with healing has been exaggerated, especially since it has been shown that amputa tions in aged patients with sclerosed arteries may well succeed. The failure and danger of the old operation of Antyllus lie in the fact that ligation of the main artery, above and below the sac, will not always control the bleeding from collateral vessels opening into the aneurism, or into the main trunk between the arteries of the sac and the seat of ligation. The cutting
of the sac away has the danger of in terfering with collateral circulation. The operation of Antyllus, moreover, leaves the sac as an open cavity in the bottom of the wound, which heals by granulation, and induces infection, suppuration, and secondary hemor rhage. All these difficulties are in creased by the extirpation. R. Matas (Annals of Surgery, Feb., 1903).
In traumatic aneurism of the femoral the artery should be compressed on the edge of the pelvis by means of a tourni quet, the sac opened, and both ends of the divided artery tied.
Aneurism in Searpa's triangle, in which instrumental compression above was em ployed for eighteen days, but had to be abandoned on account of the irritation of the skin which it caused. The aneu rism gradually diminished in size and recovery followed. Molloy (Med. and Surg. Reporter, Apr. 22, '93).
Case of extirpation of a femoral aneu rism, in a little girl of 11, extending from near Poupart's ligament to the lower part of Hunter's canal; it had been growing for fifteen months, and was not attributable to injury. The main trunk was first secured above the sac, and the whole mass enucleated; thirty-five dilated arterial twigs required ligature, and about five and a half inches of the femoral vein were also removed. The patient made a good recovery. Heurtaux (Bull. et Mem. de la Soc. de Chir., Nos. 9, 10, '95).
Two cases of femoral aneurism treated by excision. The vessel is li gated at its end instead of in its con tinuity and by removal of the sac. Pro vision is made against relapse through diseased or injured vessel, while the presence of more branches for recurrent circulation is insured. The first case was still well three years after the last operation. The second case died the second day from pulmonary congestion and oedema. G. R. Fowler (Med. Record, Mar. 23, 1901).
Popliteal Aneurism.
The popliteal artery being peculiarly liable to atheroma, it is the most corn mon seat of aneurism after the aorta. Flexion and extension of the knee, if exaggerated but slightly when the vessel is diseased, act as exciting causes. The aneurism sometimes develops in this re gion without any apparent mechanical cause, and may present itself on either side. It usually grows posteriorly, rap idly penetrating the surrounding alveolar tissue and assuming large proportions. At other times it forms anteriorly, and presses against the bone or the posterior ligaments. Supported by these hard sur faces its growth is much slower.