Wardrop used to formulate the diagnostic features of certain aneurysms at the base of the neck, as follows: Innominate aneurysms generally monopolize the episternal notch or rather its right side, taking up this whole space, even though not rising high. They first present to the inner side of the right sternomastoid, while carotid aneurysms appear in the interval between the sternal and clavicular heads, and subclavian aneurysm to the outer side of this muscle.
In the abdomen the aorta is most frequently involved, and sometimes its larger branches. An aneurysm of the renal or mesenteric arteries can easily be mistaken for an aortic aneurysm. The aorta proper terminates at the level of the umbilicus. A pulsating tumor below this level should belong to one of the iliacs. Recognition will depend largely upon the thinness of the abdominal wall and the absence of fat. In many cases expansile pulsation can be detected even here, while the pain is radiated along the well-known branches of the sympathetic, and the location to which it is referred may be of aid in deciding the part of the aorta most involved. Aortic pulsation is communicated by growths overlying it, and the surgeon is liable to be deceived by a certain abnormality of the natural pulsation through this trunk, as it is often exaggerated and appears pathological when it is not. Abnormal pulsation of the abdominal aorta was first described by Cooper, and has served as a topic for surgical essays ever since. Schede’s test may be applied here to advantage: if firm pressure be made simultaneously upon both femoral trunks the extra blood pressure thus caused inside the tumor will give rise to pain, whereas in the absence of aneurysm it produces no such effect.
Iliac and femoral aneurysms may be made difficult of recognition by obesity, but the bruit can almost always be heard, and this, with such extra aid as the rectal or vaginal examination may afford, coupled with pressure symptoms confined to one limb, will usually facilitate diagnosis. [Fig. 157] illustrates what features a tumor of this kind may present when located in the upper part of the thigh.
Fig. 157
Sacculated aneurysm of femoral artery. (Parmenter.)
Treatment.
—The general purpose of the treatment of aneurysms is to favor coagulation and to effect a cure in this way. In the pre-antiseptic era it is not strange that men resorted to the method of starvation, by which the coagulability of the blood was much increased, or to the rest treatment, with the use of cardiac sedatives, by which the heart’s activity and power were greatly reduced. Nor was it strange that non-operative, yet mechanical, methods were used, in order to minimize the danger attending operative procedures. With the confidence, however, which Lister and his followers have given, it is generally conceded that with an aneurysm which can be made accessible by an operation radical methods are more satisfactory. To the surgeon belong all aneurysms except, perhaps, those of the aorta and the innominate, and even these have not been exempt from surgical methods. The following operative measures are worthy of discussion in these cases: (1) Ligature. (2) Open operation. (3) Extirpation. (4) Opening and suture. (5) Introduction of wire, with or without electrolysis.
1. Ligation includes the application of a ligature in one of the following situations: (a) Proximal ligation (Anel’s) at a convenient point shortly above the sac; (b) proximal ligation (Hunter’s) at a distance from the sac; (c) distal ligation, either of the main trunk just below the sac (Brasdor’s) or of the highest main branch given off below the sac (Wardrop’s). Thus proximal ligation could be practised in case of aneurysm, either of the external or internal carotid, by tying the main trunk, or in the case of popliteal aneurysm (Hunter’s suggestion), by tying the femoral in Hunter’s so-called canal. Brasdor’s distal ligation may be illustrated by ligature, in Hunter’s canal, of the femoral for aneurysm in the groin, while Wardrop’s modification would consist in tying one of the tibials for popliteal aneurysm, or one of the lesser carotids for aneurysm of the common trunk. Should ligation be determined upon, circumstances will dictate where the ligature should be applied, and the surgeon will decide the character of the suture material. The methods of attack upon the large vascular trunks will be considered later. Inasmuch as it takes time to establish collateral circulation, attention should be given to physiological rest, as well as to all other general measures calculated to make any operation successful.
Fig. 158