SECT. XXXVII.—ON ANEURISM.
Aneurism is a tumour soft to the touch and yielding to the fingers, having its origin from blood and spirits. Galen says “an artery having become anastomosed (i. e. dilated) the affection is called an aneurism; it arises also from a wound of the same, when the skin that lies over it is cicatrized, but the wound in the artery remains, and neither unites nor is blocked up by flesh. Such affections are recognised by the pulsation of arteries; but, if compressed, the tumour disappears in so far, the substance which forms it returning back into the arteries.” Thus Galen.—But we distinguish them from one another in this way: That formed from anastomosis of an artery appears longer, is deep seated, and when pressed upon by the fingers, a sort of sound is heard; whereas no noise is heard in the cases arising from rupture, and these, moreover, are more rounded, and feel superficial. Those therefore which form in the armpits, groin, and neck, and those in other parts of the body, which are very large, we must decline operating upon, on account of the largeness of the vessels. But those which occur in the extremities, the limbs, or the head, we operate upon thus. We make a straight longitudinal incision in the skin, and then having separated the lips with hooks, as we mentioned in the operation of angiology, and having dissected away the skin, and separated it with the instruments used for operations on membranes, we lay bare the artery, and passing a needle under it, and tying it with two ligatures, and having first divided the intermediate part of the artery with a lancet used for bleeding, and evacuated its contents, we have recourse to the suppurative treatment until the falling off of the ligatures. If the aneurism be occasioned by rupture of the artery, we must seize in the fingers along with the skin as much as possible of the aneurism, and then below what we hold in our hand we push a needle having a double thread, and after it has passed through we cut the double, and thus with the two threads we bind the tumour on this side and on that, as we mentioned for staphyloma. If any apprehension be entertained from the falling off of the ligatures, we must push another needle entirely through, in the course of the first, having in like manner a double thread, and, cutting the noose into four pieces, we may bind the tumour. Or, having opened the tumour in the middle, after the evacuation of its contents, we cut away what is redundant of the skin, leaving what is secured with the ligatures, and applying an oblong compress soaked in wine and oil, we have recourse to the treatment by lint.
Commentary. Galen, we believe, is the first author who treats of aneurism. He states that he had known cases in which an aneurism had been occasioned by a wound of the artery at the bend of the arm in performing venesection. He relates the case of a cure having been accomplished by the application of a sponge with bandages. (Meth. Med. v, 7.) The passage quoted by our author is from his work De Tumoribus (11.)
Aëtius gives a most interesting account of aneurism. He states that it arises most frequently in women during labour, owing to the breath being violently retained, but that it may take place in any part of the body from a wound, as when an unskilful surgeon in opening a vein at the bend of the arm, opens an artery at the same time. It proceeds, he says, either from rupture or dilatation, and its contents are blood and spirits. The symptoms of an aneurism are a swelling of a smaller or larger size, without change of colour, free from pain, of a spongy softness, disappearing upon the pressure with the fingers, and returning again when they are removed; this last symptom being particularly characteristic of aneurism from dilatation. But when it arises from a wound the tumour is not equally soft, as the blood becomes coagulated. With regard to the treatment, he declares that aneurisms in the neck and head ought not to be interfered with; but when the disease arises at the bend of the arm he directs us to proceed in the following manner. In the first place having marked the course of the artery from the armpit to the fore-arm, we are to make a simple incision, three or four fingers’ breadth below the armpit along the inside of the arm, where the artery is most superficial; and having laid it bare and separated it from the surrounding parts, to seize the artery with a blunt hook and bind it with two ligatures; after which it is to be divided between them, and the wound filled with fine frankincense, and a suitable pledget of lint bound over it. The swelling at the bend of the arm may then be opened without any fear of hemorrhage. When the coagula have been cleared away the artery from which the blood was discharged is to be seized with a hook, secured and divided like the former; after which the wound is to be filled with fine frankincense, and suppuration promoted. (xv, 10.)
Albucasis treats of aneurism in the following terms. When an artery is divided, and the skin heals over it, a tumour frequently is the consequence, and the same thing sometimes happens from the wound of a vein. Aneurism of an artery is characterized by a deep-seated tumour in the situation of an artery, the swelling subsiding when pressed upon by the fingers, and being attended with a hissing sound. When it arises from the wound of a vein it is round and exposed. He adds, to open such tumours, especially if seated in the armpits, groins, and neck would be a fatal mistake. When the aneurism arises from dilatation of the artery, we are to make a longitudinal incision, and having dissected away the artery from the surrounding parts, to pass below it a needle armed with a double thread, and to tie the threads in two places as recommended in angiology. The part between the two ligatures is then to be divided and the blood evacuated. Suppurative applications are then to be made, until the ligatures fall out; after which suitable ointments are to be applied. If the disease arise from the opening of a vein, we are to grasp as much as possible of the tumour in the hand, to push a needle through it armed with a double thread, when the aneurism is to be firmly bound with the threads in the manner described in the operation for staphyloma. When danger is apprehended from the falling out of the threads, we are to introduce another needle armed with another thread under the whole tumour at the opening made by the first needle, and to tie the threads in four places. The aneurism is then to be cut in its middle, and its contents evacuated, when the superfluous skin is to be removed, and a compress dipped in wine and oil applied. (Chirurg. ii, 49.) The threads which he speaks of are meant to decussate one another like the letter Χ. This part of his description is somewhat obscure.
We need scarcely remark that the operation of Albucasis is exactly the same as our author’s.
Rhases borrows his account of aneurism from Antyllus and Paulus. The operation of Antyllus consisted of tying the artery above and below the tumour, and then evacuating its contents. (xiii, 7.) He states that when the disease occurs in the hams, groins, or neck, it is dangerous to meddle with it, but that when seated in the extremities it is easily cured. All the cases in which he had known the artery to be opened during the performance of venesection had terminated in aneurism, except one in which a cure was effected by compression. (Cont. xxviii.)
Haly Abbas directs us when an artery has been wounded in bleeding, to dissect away the parts about it, and having applied a silk thread on each side of the wound, to divide the artery in the middle. When an aneurism takes place he recommends a plan of treatment similar to that recommended by Albucasis. (Pract. ix, 45.)
Avicenna and Alsaharavius do not describe the operation. Alsaharavius directs us when an artery has been opened in bleeding at the arm, to attempt a cure by means of compresses and tight bandages. (Pract. xxix, 11.)
It will be perceived from the foregoing account of the practice recommended by Aëtius, that the ancient surgeons were aware of the advantages of securing the artery above the seat of the aneurism, as practised by the late Mr. John Hunter, and that they actually had recourse to two ligatures in the manner directed by Mr. Abernethy; but that they afterwards opened the tumour and evacuated its contents, not having yet learned from experience to trust to the absorbent powers of the system. It will likewise be remarked that carotid, axillary, and inguinal aneurisms were in ancient times abandoned as incurable; so that modern surgery may undoubtedly boast of having so far improved upon the practice of the Greeks and Arabians.
Sprengel gives an interesting history of the operation for aneurism. (Hist. de la Méd. xviii, 3.) According to him, John de Vigo was the first who conceived the idea of curing aneurism by compresses and styptics. This, however, is not exactly true, for, as mentioned above, Galen, Rhases, and Alsaharavius recommended compresses and bandages to prevent aneurism after the accident which most commonly gives rise to it.