Compression by the Esmarch Bandage. —In this method it is sought to produce red blood-clot, such as is formed when the blood no longer circulates, and not the fibrinous, or white, blood-clot, such as is formed when the blood is in mo tion. Such a clot contracts, but does not become organized, and acts mainly by forming a thrombus in the afferent and efferent vessels.
Pressure by means of an Esmarch bandage was first successfully employed by Reid, of the British navy, in 1875, though in 1864 Murray had already succeeded in treating an aneurism of the abdominal aorta by anmsthetizing the patient and checking the circulation completely by means of an instrument. The patient should first be given an hypodermic injection of morphine, then just enough ether as an antesthetic to prevent pain and insure quiet.
After placing a piece of chamois-skin over the artery to prevent chafing, the limb is firmly wrapped in an elastic band age from its extremity up to the tumor; the latter, however, is lightly covered over; but, as soon as it is passed, the bandage is again firmly applied, thus allowing a certain amount of fluid blood to remain in the sac.
A tourniquet is then placed above the aneurism, to prevent disintegration of the clot in the sac and of the thrombi in the arteries by the circulation, and left in situ from sixteen to twenty-four hours. The pressure is then gradually decreased by unscrewing the tourniquet, while due attention is paid to the state of the circulation, to avoid gangrene by too prolonged pressure, and to avoid disturbing the clot before it is solid.
A collateral circulation is soon formed. Danger may arise in some cases from the sudden rise and fall of blood-pressure or from rupture of the sac; pressure on the nerves, gangrene, and momentary renal disorders are possible sequelte.
Pressure may be advantageously aided by the administration of iodides and a limited albuminous diet.
The contra-indications to this treat ment are vascular degeneration elsewhere than in the aneurism, renal disease, or inflammation of the sac.
But few appropriate cases in which compression in some form has been faith fully persevered in for a long time have been unattended with improvement.
The method of applying compression preferred by Tillmann is to envelop the limb with an elastic bandage from its extremity up to near the aneurism for about an hour and a half; a tourniquet should then be applied above the aneu rism, and removed with the bandage an hour and a half later. Digital or instru mental compression should follow for from six to twelve hours.
Compression by Flexion.— This method. which was first employed in 1S5S by Hart, can only be used for the arm and leg. It consists in bandaging
the entire extremity, and then flexing it strongly: the forearm upon the arm, the leg upon the thigh, or the thigh upon the pelvis.
The effects of this method are to com press the sac itself, to retard the circu lation through it, and occasionally to cause a small clot to be dislodged, by means of which the month of the latter becomes occluded.
Flexion of the joint can be used only in aneurisms of small or medium size; when the tumor is large the sac might be ruptured. It is an unsafe procedure when the sac is inflamed or when there is much oedema of the leg.
Flexion is especially indicated when the tumor is of small size, the sac not inflamed, and the joint not involved.
An argument in favor of flexion is that if unsuccessful no harm follows the procedure.
Afaceiven's Metkod.—The object of this method is to form white thrombi within the sac, by lightly scratching the inter nal surface of the sac with needles thrust through the previously-asepticized wall. The needles arc thus left in contact with the sac until the entire wall has thus been lightly irritated. The position of the needle-points should be changed at intervals of ten minutes. It may be nec essary to continue this for forty-eight hours, the sittings being repeated from time to time for weeks or even months. Besides the effect upon the aneurismal currents there occur an infiltration of the parietes with leucocytes and a seg regation of them from the blood-stream at the point of irritation.
The advantage of white thrombi over the red is in the less marked tendency of the former to shrink in volume or to undergo penetration by leueocytes or yellow softening. The object is to ob tain an adhesion of leucocytes to the vessel-wall, and to promote successive accretions of these bodies (a parietal thrombus) until complete occlusion oc curs. For this purpose a slender pin of sufficient length is employed to transfix the aneurism and to permit manipula tion, in order to scratch the inner sur face of the opposite wall at various points over its entire extent. Sometimes this can be accomplished by one inser tion, but it may be necessary to thrust the pin in at several points. Antiseptic precautions are, of course, to be observed. The length of time during which the pin is to be kept in place varies, but should never exceed forty-eight hours, and may be much less. In the case of a very large aneurism several pins may be introduced at various points, but they should not be too close together. Every aneurism contains within itself a potential cure as the essential matter, whatever may be the method devised for inducing its action. Macewen (Lancet, Nov. 22, '90).