Injections of Gelatin into the subcutaneous tissue in some part of the body independent of the locality of the sac has in some cases effected the cure of large internal aneurisms beyond the reach of direct surgical measures. The rationale of the treatment consists in the power of the to increase the coagulability of the blood so as to favour lamination on the inner surface of the sac walls, especially in saccular aneurisms of the thoracic aorta where the current is languid. The only danger of this new method lies in the possibility of tetanus arising from the great difficulty inherent in the efficient sterilisation of gelatin solutions; 5 oz. (2 per cent.) solution may he injected anywhere into the loose areolar tissue every 4 or 6 days, or double this amount of a r per cent. solution may be employed. Poggio publishes three successful cases of aortic aneurisms by the intramuscular injections of Sclavo's Iodo-gelatin in combination with mouth administration; 2 c.c. was injected daily for 3o days. One great advantage of these plans is that they may be com bined with the follcm. ing dietetic and rest method: Tufnell's method, or the combined plan of Tufncll and Bellingham, commonly spoken of as the Aledical treatment of aneurisms, first intro duced by Valsalva, is often the only means of dealing with inoperable internal cases, though it has been successfully employed also in external cases. The chief clement in this treatment consists in absolute rest in bed for a period varying from 3 to 6 months, the patient not being per mitted to leave the horizontal position for a moment if possible, though he may he allowed to turn occasionally from side to side with slow deter mination, the object being, by mild starvation and rest, to so reduce the total amount of blood in his vessels and the force and frequency of the ventricular systole that the sac walls arc less distended and the deposition of fibrinous lamination is encouraged on their internal surface. After wards, by judiciously feeding, the blood is to be slowly enriched with the view of still further causing deposition of firm fibrin and of producing complete and permanent obliteration of the aneurismal dilatation. In plethoric subjects small quantities of blood were formerly extracted by repeated bleedings. The total allowance of solid food should not exceed io oz. daily, consisting of well-cooked meat or fish and biscuit, a similar weight of liquids being permitted. Bellingham's dietary consisted of bread and butter for breakfast 2 oz., meat and bread for dinner 2 oz. each, bread for supper 2 oz., with 2 oz. milk at each meal. Alcoholic stimulants as a rule are prohibited, though light claret was permitted by Tufnell. The writer has found that the greatest practical difficulty in carrying out this method of treatment is the use of the bedpan, especially as the small amount of food ingested tends to constipation, in order to avoid which laxatives or mild salines should be frequently administered, or enemata may be skilfully employed, otherwise the pressure exercised in the expulsion of small masses of firm scybala will vitiate the entire treatment. After a period of 6 or 8 weeks the dietary should be gradually improved, and in cases of aortic regurgitation or where tertiary syphilitic Manifestations have reduced the patient to a state of debility a less sparing dietary must be substituted from the start. The hest nursing skill will be necessary in all cases. and a large bed with a firm hair mattress should be selected, so that the patient may he occasionally gently moved from one side of it to the other to minimise the danger of bedsores and dis comfort.
An essential in the modern method of carrying out this plan of treat ment consists in the administration of full doses of Iodides throughout the period of rest. No real scientific explanation of the action of iodides in aneurism is vet forthcoming, but there is not the shadow of a doubt that they are always highly beneficial. The Iodide of Sodium or Potas sium (the former is preferable) should be given in doses of at least 20-30 grs. thrice daily after food. The drug almost invariably relieves the weary ing nocturnal pains even of eroding aneurismal tumours, and it is believed to improve the tone of the cardiac muscle without increasing the pulse rate or raising the general blood-pressure, whilst at the same time there are good reasons for believing that the deposition of firm fibrinous deposit is facilitated. Considering the large proportion of cases in which tertiary
syphilis plays such a prominent part, one explanation of its beneficial action may he guessed at, since we know that it causes the absorption of the low-celled formations causing thickening and partial occlusion of the small arteries which are a factor in the general peripheral resistance; it is, however, difficult to conceive that its administration leads to thicken ing of the walls of the sac, as Drummond and others believe.
As already stated, the Gelatin injections may he used as an adjuvant to Tufnell's treatment. and in suitable cases Mace yen's method may also have a trial when the physician thinks it advisable to summon the aid of the skilled surgeon to supplement the medical treatment. In many cases anodynes or hypnotics must he administered to induce sleep, even when pain is entirely relieved by iodides, since in many patients extreme restlessness often is created by the enforced horizontal posture. All un necessary coughing, which is often a distressing symptom, must be met by Morphia, and not by drenching the patient with expectorant agents. Cyanosis and urgent dyspncea, when not relievable by Amyl, may be met by venesection ; tracheotomy is generally useless. The dangers arising from a too prolonged course of the above starvation and rest cure must not be lost sight of; these were brought home to the writer many years ago in making a post-mortem on a subject in whom the treatment had been successfully carried out to the extent of complete solidification and absolute occlusion of a sacculated aneurism of the arch of the aorta. The debility following the treatment in the apparently otherwise healthy patient ended in the establishment of tuberculosis, which caused death within 6 months of the cure of the aneurism.
In cases where Tufnell's or Bellingham's dietary is obviously insuffi cient to support life without an intolerable degree of discomfort being induced the physician will do well to try a less sparing regimen which can he increased or diminished according to the requirements of the case. Sometimes a patient who rebels during the first week may he gradually brought into line by commencing anew with rest in bed and ordinary diet, which is gradnally reduced to the minimum imon which his health and comfort can he maintained. Tt is in such cases that Gelatin and the following agent should have a fair trial.
Chloride of Calcium has been strongly advocated by Wr'ght, with the view of coagulation of the blood in the sac. and the writer had once under his care the case of a large abdominal aneurism, in which Sir Almroth had commenced this treatment in the patient. After some few months of rest and the further use of the lime salt he passed from observa tion with the aneurism apparently completely obliterated.
Abrams of California claims to have discovered a " specific " for aortic aneurisms. This consists in forcibly percussing the seventh cervical spine by means of a special apparatus, or in the absence of such appliance by a pleximeter of wood or ivory, the strokes being continued for T5 minutes daily. The rationale of this treatment lies in the theory that " the subsidiary centre of the vaso-constrictor nerves of the aorta is in the spinal cord in proximity to the spinous process of the seventh cervical vertebra, and by stimulation of the centre by percussion the aorta is made to contract." He states that a cure follows in a few weeks, and he reports three such.
No mention need he made of Lecithin, Nuclein, Strontium, and the Iodide substitutes—Todipin, Todival, Todol, &c.—which have from time to time been advocated as specifics, though the newer iodine compounds maybe substituted for the older salts when these latter cannot be tolerated, which is not often.