Maclean recommends the use of eucalyptus globulus for the relief of the distress due to irritation of the pneumogastric nerve.
Issues and blisters upon the back are not advisable, as they interfere with the recumbent position. Relief to dorsal pain will often be obtained by change of position, by turning upon the side or upon the face. Sometimes the application of a heated flat-iron, with the protection of brown paper, over the tender portion of the spine will relieve the boring pain. Iron may be used in anæmic cases.
We have been explicit in giving the details of the Tufnell method for two reasons. In the first place, the Tufnell method means to many people simply putting a man to bed, but it also means keeping him there for a prolonged interval of time; and this is a difficult task, and one that requires great ingenuity and patience in its execution. In the second place, when any method is attempted it should be carried out conscientiously and literally in every detail, and then the results obtained can be legitimately scored to the credit or discredit of the method. But it is neither fair nor honorable to pretend to follow a method, and, neglecting important details, accredit the method with the failures which follow. Tufnell claims to have cured many cases, and he declares that absolute recumbency is the price paid. With regard to the prospects in individual cases, he says that with a strong pulse at the wrist and an excessively strong action of the heart, and a healthy state of the cardiac valves and of the aorta in general, the aneurism is difficult to cure. On the contrary, when the aorta in some part of its course is dilated into a cavity, with its walls so plated with atheroma as to be passively recipient of the blood, and not capable of transmitting it with force, the cure is comparatively easy. If this be true, it would appear that the Tufnell method is best adapted to just these cases which are least amenable to the surgical methods of treatment.
The use of iodide of potash for aortic aneurism was first advised by Nélaton and Bouillaud in 1859, and this treatment has found its warmest advocate in Balfour. The points in favor of this treatment are its simplicity, the ease with which it can be carried out, and the frequent happy results which have followed its employment. The drug may be given with an infusion of cinchona in doses of 20 grains three times daily. It almost invariably lessens the amount of pulsation in an aneurism, and rapidly diminishes the subjective discomforts of the patient.
Balfour rejects entirely the starvation diet, and even bodily repose. He allows his patients to keep about their ordinary employments while under treatment. Kämmerer has shown that iodide of potash destroys the albuminates in the blood, and therefore Balfour is inclined to feed more freely than he formerly did. He avoids any unnecessary amount of fluids in the food, but as the iodide of potash produces free diuresis, this point does not require special attention. Balfour's theory is that iodide of potash lowers the blood-tension of the artery, and also brings about a thickening and contraction of the aneurismal sac. He says: "Post-mortem examinations teach us that under the influence of iodide of potassium coagula are only occasional and concomitant, and that the essential relief is obtained by thickening and contraction of the wall of the sac."
Barwell's Operation.—During the latter part of the last century a French surgeon named Brasdor conceived the idea of placing a ligature beyond an aneurism in cases where it is impossible to tie between the tumor and the heart. A few years later Wardrop carried this idea one step farther, and suggested tying the branches of an aneurismal artery when the main vessel cannot be reached, and Cockle recommended tying the left carotid for aneurism of the aorta. In this way the idea of distal ligature for aortic aneurism was worked up. The operation was attempted a number of times, but was not attended with great success at first. Recently, Barwell of England has revived the operation and elaborated its details, so that now it is attended by encouraging success. Barwell says that one should try the milder measures first, but when a case has resisted the effects of rest, diet, and medicine, then it is time to consider the practicability of surgical interference.
Barwell's operation consists in ligating the carotid and subclavian arteries, and he performs it for aneurisms of the innominate and of the aorta also. Contrary to the ordinary teaching that the inner coat of a vessel must be ruptured in order to ensure the coagulation of the blood after a ligature, Barwell declares that such a rupture of the inner coat is a positive detriment to the operation, and more likely to lead to secondary hemorrhage. He simply endeavors in his tying to bring the inner surface of the artery into contact, and hold it thus; and in order to accomplish this without cutting the arterial tunics, he discards the round ligature in favor of a flat one. Catgut is unsafe, because it is liable to decompose, even in a preservative fluid, and it is also too readily absorbable in a wound. After considerable experimenting, Barwell has adopted the aorta of an ox as the best material for a ligature. The aorta should be obtained perfectly fresh from the butcher. Peel away the outer cellular coat, and then with a pair of scissors cut the middle and inner coats spirally round and round, taking care to keep the breadth equable. The ribbon thus obtained is very elastic, and must be suspended with weights (two to four pounds) attached to it. In this way, the ribbon dries in about six hours into a horny or vellum-like substance. Any irregularities of surface can be easily scraped off, and the cord stored in antiseptic gauze. About fifteen or twenty minutes before it is needed a piece of ribbon can be picked out and soaked in a 3 per cent. solution of carbolic acid, when it will be ready for use. Care should be taken not to bend these ribbons when in the dry state or fibres in them will crack and render them fragile. In view of such chances a piece should be soaked and tested by pulling. (For details regarding the surgical work of this operation one should consult the ordinary authorities upon surgery.)
The manner of the action of the distal ligature is not clear. Brasdor and Wardrop supposed that it reduces the force and velocity of the blood in the aneurism. But the tension and blood-momentum are still transmitted to the sac. Holmes thinks that a clot forms on the proximal side of the ligature and extends down the artery into the sac.
Bennet May, in a recent discussion of this operation, says that 35 cases of double distal ligature for aneurism at the root of the neck have been recorded up to the present time. In 29 operations the two vessels were tied simultaneously. In 6 cases the subclavian artery was tied at varying intervals after the carotid. 23 of these cases died outright or were hastened to a fatal termination by the operation. In 6 cases the progress of the disease was apparently not affected by the operation. A practical cure is claimed for the remaining 6 cases. One patient lived four and a half years, another three and a half years, and the remainder are living from two years downward.
It is a noticeable fact that all the recoveries except one follow operations performed since 1877, and the betterment in result is due to improvements in the method of operating. Barwell acknowledges, however, that "success in great measure depends upon a judicious selection of cases, while want of judgment or insufficient care in examination will most certainly bring a valuable operation into disrepute." He submits the following conclusions from his own experience—