Hcemorrhage is most common in cases where recurrent pulsation has occurred; if suppuration is delayed, no haemor rhage may occur, owing to the arteries communicating with the sac having be come sufficiently occluded.
Gangrene occurs usually from the third to the tenth day. It is always moist gan grene, and is most frequent in the lower limb. In some cases it may be prevented by opening the sac and removing its con tents in order to relieve the pressure on the veins. When gangrene is really pres ent, the upper limb should be removed at the shoulder-joint, in most cases, and amputation at the junction of the upper and the middle thirds of the thigh, in the lower limb. (Ashhurst.) Ligation Below the Sae.—Among the methods best known are Brasdor's, in which the artery is tied below the sac, thus completely arresting the circula tion, and Wardrop's operation, in which the artery or a branch is tied below the aneurism, so as to allow the passage of the blood through another branch or branches, thus only partially arresting the circulation. Brasdor's operation is used in aneurism of the carotid, external iliac, etc., and Wardrop's operation in aneurism of the innominate artery or of the arch of the aorta, where the carotid or subclavian or both may be tied. Liga tion below the sac is considered as very unreliable. The sac is likely to increase in size, being still subject to the impulse of the heart.
Extirpation was first proposed in the fourth century by Philagrius, of Mace don.
After cutting down freely upon the an eurism, two ligatures are placed around the artery above the sac, and the artery is divided between them. The sac, with its contents, is then dissected out, and a double ligature is applied to the artery below the sac. The vessel is divided be tween these two, ligatures.
This operation presents certain special advantages over compression, proximal ligation, or other methods, namely: the permanence of the cure, the absence of secondary haemorrhage, and the absence of danger of emboli or of infection.
Its mortality, too, is lessened, having been estimated by Delbet at 11 per cent., whereas that of proximal ligation is 18 per cent. Again, gangrene occurs in but 3 per cent. after total extirpation, against about S per cent. after proximal ligation.
Extirpation is indicated when the sac has ruptured, when other methods have been unsuccessfully tried, and, above all, in traumatic aneurisms, especially those of the extremities. It is especially in
dicated in all aneurisms of the forearm and leg, where the sac has ruptured and caused sudden enlargement, and where rupture is impending. It is also recom mended in recent traumatic aneurisms, and in arterio-venous aneurisms where operation is indicated.
Statistics of treatment by extirpation: In 1sSS the mortality was between 11 and 12 per cent., but in the 76 cases since reported there is not a single death. Of 100 cases treated by simple ligature, 12 had gangrene, while, of the 76 cases extirpated, there were only 7 instances of this accident, and in 4 of these the gangrene existed before the operation. Recurrence is also one of the dangers of ligation, but it is much less apt to take place with extirpation—if, indeed, it is possible. Delbet (La Semaine Oct. 30, '95).
Ilesults of 86 cases treated by extir pation. Of these, 27 were idiopathic, 59 traumatic, 29 occurred in the popliteal artery, 14 in the femoral, and the others were distributed tolerably equally over the remainder of the arterial system. Only 3 deaths ensued: 1 from liinor rhage during the operation, 1 from sec ondary leniorrhage, and 1 after amputa tion for gangrene. Gangrene occurred in only 2 cases (2.3 per cent.), and second ary haemorrhage in but 1 (1.1 per cent.). In contrasting this method with others. it becomes evident that the percentage of cases in which gangrene occurs is less than after ligature of the main trunk above, while there is here no possi bility of local relapses. The advantages claimed over the old-fashioned method of Antyllus are the following: 1. The length of the after-treatment is im mensely diminished, since in many eases it is possible to obtain primary union. 2. The risk of subsequent bleeding is greatly lessened, since all the collateral branches are secured, and it was from these that it usually arose, and not so much from the main trunk. 3. The presence of a thickened cicatrix, which included the doubled-up and wrinkled sac-wall, was likely to lead to interfer ence with the utility of the part, when, as at the knee, the aneurism occurred in the flexure of a limb. Kopfstein (Wiener klin. Eund., Nos. 11-16, '96).