repeated, and a fatal termination can only be prevented w lien it is possible
to secure the artery above the aneurysm.

tSponfnneous Cure. — Mention has already been made of the fact that
sometimes aneurvsms s])ontaneously diminish in size, even to the point
of disappearance, lose their pulsation, and are, in fiict, permanently
cured. As the processes by which this arrest or cure is effected have
furnished the principles upon which tlie treatment of aneurysm has been
largely based, they deserve separate consideration. The cure may be
effected either by the continuous deposition of laminated clot or by the



THE COMMON CmCVMSCRIDED AyEVEYSM. 381

sudden clotting- uf all tlie bliiod in the sac, aiul citlier of these pi'ocesses
may be the result of a variety of circumstances. Thus, we have seen
that the deposit of layers of fibrin upon the wall is apparently the result
of slowing of the stream or of change in the character of the inner
surface of the sac, and possilily also of change in the character of the
blood ; conseciucntly, anything which produces these changes may exert
a favorable influence upon the progress of the affection, and may even
arrest it permanently. In like manner, the sudden clotting of the blood
in the sac may be excited by important changes in the wall or by plug-
ging of the orifice of the aneurysm or of the artery above or below the
orifice.

The influence of change in the character of the lilood is shown l)y
those cases in which arrest of growth has taken place during serious
acute diseases. Barwell quotes one of a subclavian aneurysm cured
during an attack of enteritis, and one of the femoral during an attack
of acute rheumatism, and the many cases of imjirovcment and some of
cure bv the internal achninistration of drugs thought to increase the
coagulaliility of the blood, combined with rest and low diet, might be
quoted also in illustration, although in all these cases the quieting effect
upon the circulation of the enforced confinement to bed must be taken
into account.

The slowing of the circulation as a factor may be either general or
local. Absolute quiet in bed, combined with a low and unstimulating
diet, cardiac sedatives, and sometimes venesection, has long been recog-
nized as a potent aid in the treatment of internal aneurysms not suitable
for surgical interference. The infiuence is most marked in sacculated,
pouched aneurysms (as compared with fusiform), and probaljly the main-
tenance of the recumbent position has a notable effect upon the circu-
lation witiiin sucli an aneurysm for physical, mechanical reasons, even
wiien it has little or none upon the general circulation.

Slowing of the circulation witiiin the sac itself must depend upon a
variety of conditions, such as the size of the orifice, the shape of the sac,
the pressure of clots ; and doubtless the blood in every aneurysm varies
greatly in its rate of movement and change in different parts of the sac
and at different times. There is reason to sujipose that portions of clot
sometimes become detached from the wall and lodge in the orifice, thereby
greatly cliecking the flow of lilood tlirough it, and thus effect a cure, or
that a similar condition is produced by the growth of a clot at the edge
of the orifice. Probably a complete clot formed within some well-defined
pouch may, under favoring conditions, increase rapidly and fill the entire
sac. A [)iece of laminated elot detached from the wall and carried out
into the artery l)y the blood may lodge in the artery a short distance
below, usually at a bifurcation, and either i-educr' the amount of blood
that passes through the vessel, and thus slow the circulation in tlie aneur-
ysm, or obstruct the vessel entii'ely, either immediately or by its subse-
quent increase in size, and thus arrest the stream and lead to the forma-
tion of a large soft clot that fills the aneurysm and the artery below it.

It has been claimed that a sacculated aneurysm has itself in some
cases occluded the artery by pressure u]ion it above or below the orifice,
but the alleged cases are not demon.sti'ative.

Where the inner surface of the sac is smooth and lined with endothe-



382 ASEURYSM.

Hum tlie tendency to the formation of laminated clot is slight or absent;
Init where such a j)r()tective surface is not present, as in sacs of rapid
growth, the deposit is favored ; and when rupture takes place the blood
that has escaped into the adjoining tissues appears to be prone to clot in
bulk, and such a clot may be the starting-point of one that will fill the
aneurysm entirely. To a still greater degree an inflamed sac is favorable
to the complete clotting of the blood and to the cure of the affection, if
the patient does not perish by heuiorrliagei)!- if the resulting interference
witii the venous flow does not lead to gangrenous changes that necessitate
amputation. A few cases have been reported in which such inflamed
sacs have ruptured externally, with discharge of clots and li(juid blood,
and the patients have recovered ; but the accident is full of danger.

Occasionally aneurysms that have long remained (piiescent, apparently
cured, Ijegin again to increase in size : such rarely ])ulsate or have a
bruit, and tliey probal)ly receive their blood by a recurrent flow thi'ough
the distal jxirtion of the artery.

Diagnosis. — The diagnosis of an aneurysm that is developing in the
usual manner, and has not undergone any of the important complicating
changes above mentioned, and which is accessible to inspection and pal-
pation, is usually easy. The well-defined outline of the tumor, its con-
sistency, expansile pulsation and murmur, and its position on the course
of an artery are all readily recognizable, and in addition we have its
steady, rather rapid growth, the absence of the signs of inflammation,
the diminution in size when the artery is compressed above it, its sphyg-
mographic trace, and the diminution of pulsation and the change in the
si)iiyguiograiihic trace of the artery below it. (j)n the other hand, aneur-
ysms in the tliorax or aljdomen or at the root of the neck may be wholly
inaccessible to palpation, or so slightly so as not to attbrd positive diag-
nostic signs, and those of the limbs may have undei-gone changes or com-
plications tiiat abolish or mask such signs. Furthermore, other affections
may resemble aneurysms quite closely. Many errors of diagnosis, some
of them disastrous in their results, have been made, such as mistaking a
rapidly -growing aneurysm for an abscess or a shrunken, quiescent one
for an enlarged lymphatic gland ; but, as ]\Ir. Barwell says, the greater
number of these disasters have been due to insufficient caution — to resort
to the knife without having made a careful examination ; and he calls
attention again to the importance of a strict observance of the old rule,
which forbids the opening of any swelling in the course of or over a
large artery without a previous tliorough search for the signs of aneurysm.
The same caution should be used in the case of swellings on the front of
the chest.

The difliculties in diagnosis arise from the fact that some aneurysms
present few of the chai-acteristic signs of the affection, and, on the other
hand, that tumors of an entirely different character may present some
of them. (_)f the characteristic signs, pulsation and bruit are those
whose presence in other affections or whose absence in aneurysm is most
likely to mislead. As we have seen, they are absent when the aneurysm
is consolidated or when the artery sup})lying it is occluded or compressed,
and they may be absent or so slight as to be recognized only with great
difficulty if the aneurysm is widely ruptured or if the surrounding parts
are mucli inflamed and swollen. The diagnosis must be made by the aid



THE CO.M.VOX CIRCVMSCPdBED ASEURYSM. 383

of the history, and possibly I>y cliaiiyc in tiio pulse in the distal branches
of the artery. If the condition permits of delay in order to watch the
subsec(uent progress of the case, the diagnosis may become clear, for con-
solidated aneurysms do not increase in size, while malignant tumors do.

Pulsation is the symptom which is most likely to lead the surgeon to
mistake a tumor of another character for an aneurysm. Such pulsation
may be due to the vascularity of the tumor itself or may be eomnnuii-
cated to it from an untlerlying artery. Tumors which possess a pulsation
of their own are (in addition to other forms of aneurysm than those
now under consideration, such as arterio-venous and cii'soid aneurysms)
certain verv vascular carcinomata and sarcomata, especially certain ones
of bone. The diagnosis in such cases must be made by attention to the
character of the pulsation, which is more distinctly expansile in aneur-
ysm, to the absence of fluctuation in vascular tumors, and to their
slighter loss of bulk when the afferent artery is compressed. In the
bone-tumors careful examination may show change in the shape of the
bone and the presence of bony outgrowths or plates in tlie wall of the
tumor near its base.

Tumors, solid or liquid, overlying an artery and receiving pulsation
from it may be recognized by the absence of expansion and of shrinkage
Avhen the artery is compressed, and by the cessation of the pulsation
when the tumor is lifted up from the artery. It must be borne in mind
that the pulsation communicated to a solid tumor may seem to be expan-
sile when the paljiating iingcrs cannot be pressed down to its equator : as
the tumor is lifted at each beat a wider portion is pressed in between the
fingers and separates them exactly as expansile pulsation does. A
murmur may be present in vascular tumors or when a solid or liquid
tumor presses upon an artery.

Prognosis. — This is always serious, although the actual danger to life
or limb may vary greatly in different cases and at different periods in the
same case. In general terms, the nearer to the heart the greater the
danger to life. Except in the comparatively rare cases of spontaneous
cure, the progress is steady toward ultimate rupture, and the larger the
vessel the more certain is such a rupture to lead to a fatal hemorrhage,
and the smaller is the prospect of being able to arrest the progress by
treatment.

Treatment. — The treatment of aneurysm may be medical or surgical.
The former term is applied to that method which seeks to effect a cure
by rest, diet, and internal medication ; the latter includes all other
methods in which some external agent is brought to bear upon the
aneurysm, its contents, or the artery upon which it is developed.

The medical treatment of aneurysm, first systematized by Valsalva
and more recently brought into prominence by iNIr. Joliffe Tufnell, '
seeks to ]>romote the processes of sjiontaneous cure l»y the deposition of
laminated fibrin, by quieting the heart-action, and by increasing the co-
agulability of the blood. The main agents in this attempt are prolonged
absolute rest in the recumbent position, restriction of food and drink
almost to the mininnun necessary for the supjtort of life, the internal
administration of certain drugs, and SDmetimes venesection. The method
has been employed exclusively for internal aneurysms and those in which

' Tufnell, Tlie Successful I'reatmcni nf Internal Aneunjxinf, 1S64.



384 AJyEUIiyS3I.

ojH'rative metliods were contraiiulicateil. It requires much resolution
and fortitude on the jtart of tlie patient to continue the treatment for the
necessary length of time, seldom less than six weeks.

The details, as given by Barwell, are — absolute confinement to bed
and one of the two following systems of diet, known as the " low " and
the "dry." The "low" diet consists of bread, 10 ounces; butter, 1
ounce ; rice or tapioca pudding, 6 ounces ; milk, 1 pint — divided into
three or four meals; once or twice a week a little fisJi or boiled meat
maybe added if the patient becomes restless under tlie deprivation. The
" dry " diet is as follows : for breakfast and supper, bread, 4 ounces ; butter,
^ ounce ; milk, 2 ounces ; for dinner, meat, 3 ounces ; bread, 3 ounces ;
water or milk, 3 ounces. The return to ordinarj' diet at the end of
treatment must be gradual. Barwell tliinks that venesection at the
beginning c)f the treatment, and jierhaps repeated during it, would be
advantageous ; and Holmes says its moderate use " api)ears both rational
and, as far as we can judge from recorded cases, successful."

The drugs used are belladonna, hydrocyanic acid, aconite, and ver-
atrum to reduce the heart-action, and bromide of potassium to control
])ain and irritation. Acetate of lead and iodide of potassium have also
been used, especially the latter, but without demonstrated benefit. Flint'
reportctl a case of aneurysm of the al)dominal aorta which was appa-
rently cured by the use of the chloride of barium in doses of from one-
fifth to two-fifths of a grain three times daily for about five months,
after Tufnell's method had failed. The most rapid improvement coin-
cided with the smaller dose.

Sunjieul Treatment. — The history of the surgical treatment of aneur-
ysva. is mainly the story of the invention and ajjjtlication of a great
variety of measures designed to diminish the risk to life involved in the
effort to accomplish one of two results — the evacuation of the sac and
the abolition of its connection with the artery, or the obliteration of its
cavity by " active " or " passive " clots. With few exceptions the imme-
diate ol)ject of the different operations has been to initiate or promote
the processes of spontaneous cure, and the stimulus to the introduction
of new methods in such numbers and variety has been found in the risk
to life, or the uncertainty of result, or the inapplicability to certain
aneurysms of those previously in use. The great advance made in
recent years in securing the prompt and easy healing of surgical wounds
has practically deprived most of these methods of all but an historical
interest ; and, curiously enough, the operative method wliieh has most
recently received the stamj) of approval and has been put forward as
the method of choice is practically the one that stands at the other end
of the long list — the one employed and described in the second and
third century A. D. by Antyllus.

According to Broca," to whose thorough search and exce]itional oppor-
tunities we are indebted for our knowledge of the early history of the
subject, the art of surgery previous to the time of Antyllus acknowledged
itself powerless to treat aneurysms. The affection was known to be
dangerous, its gravity was attriljujed to noxious elements in the blood
contained in the tumor, and doulitless attempts had been made to relieve

' Flint, Practitioner, 1S79, vol. xxiii. p. 31.
' Broca, Des Anevrysmes, Paris, 1856.



THE COMMOX CIRCUMSCRIBED AyEURYSM 385

by evacuating' the blood. Wliat the consequences of sucli attempts were
it is easy to imagine, and until some less dangerous remedy could be
found it is plain that abstention must have been the rule. Of the
writings of Antyllus upon the subject we j^ossess only what has been
preserved through quotation by others, especially by Oribasius, who,
writing in the fourth century A. D., quoted among others his chapter
upon aneurysm. Tiie forty-tifth book of Oribasius, in wiiicii this quo-
tation occurs, was long supposed to have been lost, and was only found
about 1825 among other Ciireek manuscripts in the Vatican. After
describing two kinds of aneurysm (apparently our spontaneous and
arterio-venous), he says : " It is not right to abandon all aneurysms to
their fate, as the ancient surgeons taught, but it would be extremely
dangerous to ojjerate on all. 80 we abstain from toucJiing aneurysms
of the axilla, groin, and neck, both because of the size of the vessels
and of the impossibility or extreme difficulty of ligating them. We also
do nothing for very large aneurysms, in whatever part of the body they
may be. We operate upon aneurysms of the extremities, the limbs, and
the head in the following manner." He then desci'ibes the operation by
a straight incision along the course of the vessel, the exposure of the
aneurysm, the drawing aside of the vein, and the placing of a ligature
upon the artery al)ove and below the sac. The latter is then opened by
a small incision and " its contents evacuated without danger of hemor-
rhage."

According to Broca's translation, it would seem that Antyllus dis-
sected the aneurysm entirely free from end to end, but tliis appears to
be not only intrinsically imjirohable, but also not in harmony with the
rest of the description. Wliatever the reason may have been — difficulty
of execution, secondary hemorrhage, or the general lowering of the
intellectual level — we find the operation restricted in the fifth century
to a4ieurysms at the bend of the elbow (with the interesting addition of
preliminaiy double ligation and intermediate division of the brachial
artery two or tlu'ce inches l)elow tiie axilla — Aetius) and wholly al)au-
doned a few centuries later. A\'ith the Eenaissance it again appeared in
its original form — ligature above and below, incision of the sac — but
still restricted to aneurysms at the bend of the elbow : the invention of
the tourni([uet in 1674 made its execution easier and encouraged surgeons
occasionally to extend its application to other aneurysms; but, on the
other hand, the discovery of the circulation of tiie lilood checked its use,
through the fear of causing gangrene of the limb by cutting off the
supply of the blood, and led to a variety of attempts to secure, after
incision of the sac, the closing of the opening into the artery without
ligating the latter. In the mean time (1710), Anel, a French surgeon
living in Eome, operated upon a large aneurysm g,t the elbow, due to an
unskilful venesection, by tying tiic artery only above and without opening
the sac. In the reasons which lie gave for thus departing from the usual
practice he says he was confident that the blood contained in the sac
would flow out through the distal part of the artery, that the sac once
emptied would not fill again, that its walls would shrink and the tumor
would disa|>pcar ; " which did not fail to take place as I had anticipated."
Although Anel's operation gave rise to an acrimonious discussion and
was repeated two or three times with success, it had no lasting effect upon

Vol. II.— 25



386 ANEVBYSM.

practice, and was soon forgotten, and until the latter part of the eigh-
teenth century the only direct method of treatment in use appears to
have been the old operation of opening the sac and tying the vessels that
opened into it. The results were so bad that even this appears to have
been but rai-ely resorted to, most surgeons j)i'eferring amputation, at least
in the case of jiopliteal and femoral aneurysms. It is true that direct
compression of the tumor had been occasionally employed from the
earliest times and had furnished a few notable successes, but there was
nothing in its record, no constancy in its action, no underlying principle,
to give it any standing as a reasonaljle mode of treatment. As we now
understand it, its few successes were in part in traumatic aneurysms in
which the wound in the artery had time and opportunity to heal, and in
part, probably, in cases in which an intercurrent or consequent inflam-
mation of the sac produced a cure.

In 1()73, Genja had successfully healed a wound of the bracliial artery
at the ellww by compression of the vessel above, and his example had
been followed in several cases, but it was not until 1765 that the ])ian
was applied in the treatment of aneurysm. In that year Guattani, a
surgeon at Rome, cured a popliteal aneurysm by prolonged compression
of the femoral artery by means of a long ]iad and a circular bandage.
His idea appears to have been merely to diminish the amount of blood
coming to the sac, not to interrupt the stream entirely, for he feared gan-
grene of the limb if the latter should l)e done. He repeated it in several
cases, generally with success, and his example was followed by others ;
and it seems probable that the method would have been generally accepted
had not proximal ligation of the artery at some distance above the sac
been introduced shortly afterward. Notwithstanding the immediate success
attending the latter, compression was still regarded as a valuable method
of treatment, and indeed toward the middle of the nineteentli century,
under the impulse given by the Dublin surgeons, it was, as will ap])ear,
extensively employed, not only in cases in which the ligature was thought
to be exceptionally hazardous, but also in others as the method of choice.
Its great advantage was tlie avoidance of the risk of secondary hemor-
rhage ; its defects were tii<' difficulty of adequately ap|)lying it, the pain,
the length of time required, and the occasional faihn-es or relapses.

Ligation of the artery on the proximal side at some distance above the
sac was first done in June, 1785, by Desault, and in December of the
same year by Hunter. Various cii'cumstances combined to make Hun-
ter's part in it prominent : he has been generally credited with its inven-
tion, and the method is known as "the Hunterian." It is also claimed
that he based it npon a profound knowledge and consideration of facts
and principles of which no other surgeon of his time had any conception,
and that, although Desault's operation was earlier, it was entitled to no
cre<lit, because it was done ignorantly tmd without appreciation of its
importance or of the princi]iles involved. This claim I believe to have
no better foundation than ignorance of what Desault (and even Anel
seventy-five years earlier) actually knew and planned, and the crediting
of Hunter before his operation with knowledge which he ol)tainod at a
later period. This is not the place to discuss the matter in detail ; the
reader who is interested in it is referred to other works.' It is sufficient

' Cf Brnca, he., cit., p. 449 ; Stimsoii, N. Y. Med. Joum., Nov. 1, 1S84.



THE COMMON CIRCUMSCRIBED ANEURYSM. 387

here to point out that Hunter's declared objeet ' was to tie the artery
without opening the sac ; to place tiie ligature at a point where the artery
Mas likel}' to be healthy, thus to diminish the risk of secondary hemor-
rhage ; and iinally, if the latter did occur, to be able to place a second
ligature upon the artery without having to make a second incision, or, as
he says, without " breaking new ground — a thing to be avoided, if pos-
sible, in all operations." Not a word is said in the acccnnit about col-
lateral branches between the ligature and tlic aneurysm, or about the
sutticiency of diminishing the flow of blood instead of arresting it entirely,
upon which so much stress was afterward laid. In short, he was seeking
only to make the current method of operating safer, and had no thought
of introducing any new principle affecting the coagulation of the blood
within the sac.^

The success of the new method — ibr, although its mortality was about
one-third, this was a great improvement upon what had preceded — gave
a great impetus to the operative treatment of aneurysm, and within a
comparatively few years brought under the ligature nearly every large
artery in the body : at the same time the associated risk of secondary
hemorrhage and the inappliiability of the method, or its extreme danger
when ap])lied, to the aneurysms of the largest vessels, as at the groin and
root of the neck, led to great activity in devising modifications and sub-
stitutes, and out of the results of this activity came a much more extended
and accurate knowledge of the mode of cure, especially the deposit of
filjrinous layers, and the conditions favoring it. It was soon learned that
total arrest of the arterial stream was not necessary, but that its diminu-
tion was sufficient ; that such diminution might be efficient even if effected
interruptedly, instead of permanently or continuously ; and that it might
be produced by ligature or compression at the distal side of the aneurysm.

The distal ligature for cases in which the proximal ligature was
deemed impossible or too hazardous was first suggested, according to tra-
dition, by Brasdor, a French surgeon, as early as 1790, but he never put
it in practice, and left no printed record of the suggestion. The operation
was first done by Deschamps in 1798 for aneurysm of the upper part of
the femoral artery, and a second time shortly afterward by Sir Astley
Cooper for aneurysm of the external iliac. Both patients died, and the