ANEURISM.
The treatment of this affection is a wide subject, and since surgical methods, when these are admissible, should be undertaken only by experienced operators, their detailed discussion in a work like the present is unnecessary. The most radical and satisfactory surgical procedure which is suitable for nearly all small aneurisms, and in some cases carotid ones, is to make an incision over the sac for its entire length, apply a ligature to the proximal artery, which is then cut across and the sac dissected out, the distal vessel and any branches arising from the sac being securely tied at the same time, and the wound treated on the antiseptic principles after the complete excision of the pulsating tumour.
A less formidable operation is by ligature : this may he applied to the proximal side of the vessel close to the sac (Anel's operation). or at a dis tance on the proximal side (Hunter's method). Brasdor's plan of only ligaturing the distal trunk and Wardrop's practice of applying the liga ture to one or more of the distal branches are still sometimes adopted with the view of causing coagulation in the distal end of the artery, which may finally lead to the solidification of the entire contents of the sac. In the plan of Antyllus the vessel is ligatured both above and below the sac in ruptured or bleeding aneurisms. The method of Matas by suturing the artery after opening the sac is a suitable one in arterio-venous tumours. It has the advantage of interfering least with the already established collateral circulation. In regard to the operative treatment of aneurism, two important facts have recently been established: (I) That it is safer, in ligaturing above and below an aneurism, to ligature the vein at the same time; and (2) that it is often possible to do an end-to-end anastomosis of the artery when the vessel is of the same size and the sac small after complete excision.
The introduction of coagulating agents like perchloride of iron directly into the sac has been abandoned owing to the danger of embolism and suppuration. Silver or gold wire. catgut and horsehair have been inserted
in coils of considerable length with the same intention. and though not so dangerous as chemical coagulants this practice is not to be lightly undertaken, as already many mishaps have occurred. The method by Galvano-puncture has been pursued in cases of otherwise inoperable aneurisms, but with unpromising results. Two needles, with insulated stems, being inserted into the sac, the current is allowed to flow between their free points till coagulation is started.
Macewen's plan of treating large aneurisms, as those arising at the base of the neck and from the aorta in the chest and abdomen, gives somewhat more hopeful results than the latter-mentioned methods, and is less dangerous. It consists in the introduction deeply into the sac under strictest antiseptic precautions of a needle whose free point is then made to systematically touch and irritate the internal wall on the opposite side at many points so as to cause the deposition of white clot on the slightly inflamed or irritated surface. The needle being withdrawn and inserted into the opposite side of the sac, the operation is repeated till the whole interior has been scratched. Pressure exercised by the fingers placed on the artery above the sac by relays of trained assistants, by tourniquets, padded splints, Esmarch's bandage, &e.. has been practically abandoned; it is applicable to aneurisms in the limbs. which can be more safely and satisfactorily treated by other surgical methods under better control, and never shou'd be undertaken except in the surgical wards of well-equipped institutions. It has sometimes been employed in the treatment of aneurisms of the abdominal aorta. Injections of Eraotin into the tissues around the sac with the view of causing condensation of the aneurismal walls is at best a most unsatisfactory plan and is liable to excite suppuration.