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literature clearly states that aneurysms of this nature eventually terminate in sudden death by rupture or other painful catastrophes frequently in less than a year after symptoms have become apparent. We, therefore, feel that it is justifiable to continue investigating such cases and operating upon some of them. In the case here reported, the patient's me~ltal disturbance was the crux of his postoperative course. Had it been possible to control this more easily, it would appear that this patient would have been manageable and might have survived. Had he done so, he would have had an adequately reconstructed abdominal aorta and a good peripheral arterial circulation in his lower limb.

SURGERY OF AORTIC AREURYSM EOIN O'MALLEY, M.Ch., F.R.C.S.I. Mat'er Misericordiae Hospital. Dublin. H E surgery of aortic aneurysms has made spectacular strides in recent years. While experimental work still continues on a large scale, the basic principles of operative treatment have been established on a practical basis. It is hoped that this evening's meeting will lead to a pooling of experience and ideas which will be useful to all of us. Before describing the few cases with which I have dealt, I wish to propose a brief statement of the problem of the challenge which has to be met. Anatomically, the diaphragm constitutes an important dividing line: aneurysms of the thoracic aorta are very often syphilitic; they tend to be saceular rather than fusiform; they occur in middle age and are commonly accompanied by classical signs and symptoms. Aneurysms of the abdominal aorta are nearly all arteriosclerotic in origin; they are mostly fusiform; they occur in an older age group and are often silent. The abdominal aneurysm rarely extends far enough proximally to involve the renal arteries--in De Bakey's and Cooley's series of 102 cases only one such extension occurred. Pathologically, arteriosclerosis and syphilis are the two major groups. But there are other small groups which are important : (1) Traumatic: The common site is high in the thoracic aorta just distal to the left subclavian trunk ; the common trauma is motor accidents. These cases are rare, but important in so far as the patient may otherwise have a completely normal cardiovascular system. (2) Another small group includes the aneurysms which form in association with aortic coarctation. These may develop either in the normally dilated post-stenotic segment of aorta or in the dilated intercostal vessels leading into it. (3) Mycotic aneurysms may occur anywhere, mostly in cases of bacterial endocarditis. (4) F i n a l l y " congenital " aneurysms have been described. The biological history of these lesions is not as well known as we might wish, despite the fact that they were well described over a thousand years ago. Aortic aneurysms produce back pain by vertebral erosion and root pain by pressure. In the aortic arch they may produce a large variety of pressure symptoms. More serious, they may rupture.

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In 1927 Colt reviewed 503 thoracic and 121 abdominal aneurysms : the average time of sulwival from diagnosis was less than 2 years. The worst prognosis was in patients under 60 years. In 1950 Estes reviewed 102 cases : 33 per cent. were dead in one year; after 10 years 8 per cent. were still alive; the cause of death was rupture of the aneurysm in 63 per cent. of cases. There is sufficient data to justify drastic measures when attempting to deal with aneurysms of the aorta. What can be done ? The introduction of wire into the aneurysm to promote clotting has not proved successful on a large scale and, moreover, is not applicable in the case of fusiform aneurysms. Wrapping the aneurysm with plastic materials to induce fibrosis and prevent rupture is likewise disappointing. Surgical excision of the aneurysm would seem the only solution. In the case of aortic aneurysms this entails replacement of the excised vessel. Excision and replacement became possible with the general development of vascular surgery over the last ten years and, more particularly, with the introduction of arterial grafts. Dubost in 1951 was the first to excise an aneurysm of the abdominal aorta. He used an arterial homograft for replacement. Recently De Bakey and Cooley of Houston, Texas, have published a series of cases of aneurysm of the abdominal aorta treated by excision and grafting. The mortality rate in ruptured cases was nearly 50 per cent., in non-ruptured cases 13 per cent., the latter figure being particularly impressive in view of the poor surgical material many of these patients provide. The great majority of abdominal aortas are suitable for excision. In De Bakey and Cooley's series of 102 cases only one involved the renal arteries. There is constantly a short segment of aorta distal to the renal arteries which can be clamped and prepared for anastomosis to a graft. If the renal arteries are involved the technical problem of preserving the renal blood supply, while not insuperable, adds tremendously to the difficulties. Nearly 90 per cent. of these aneurysms involve the common iliac arteries: the replacement graft, therefore, must be a bifurcation graft, permitting anastomosis to either the common or external iliac artery on both sides. Until recently the graft used has always been homologous artery obtained from the cadaver and preserved by one of several standard methods. The main disadvantage of these grafts is lack of availability. Furthermore, there is some evidence beginning to accumulate which suggests that these grafts lose their elastic fibres in time and become calcified--ominous signs for the future. Synthetic plastic materials were first introduced four years ago, the first being Vinyon N cloth. Since then Nylon, Orlon and Terylene fabrics have all been used, woven and prepared in various ways. This evening I am presenting two cases in which a graft prepared from polyvinyl alcohol sponge has been used. This material was first reported on in 1955, and in March of this year (1956) Rob, of St. Mary's, London, reported on its use in 21 cases. The material is also known as Ivolon or Prosthex. It is available and cheap. It is readily prepared to the required specification, though bifurcation grafts require some ingenuity. The inside surface is smooth, and when used for large vessels clotting does not occur. There are no seams, suture technique is straightforward. No leakage takes place through the fabric

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itself. It can be handled and clamped like an arterial graft. The homemade article looks rather clumsy and rough, but it is effective. Its use has also been reported for the repair of common duct injuries, for thoracic plombage, and I have myself used it once for oesophageal replacement; the patient is still swallowing satisfactorily at three months after its insertion. CASE 1. A m a n aged 48 w a s referred to t h e M a t e r H o s p i t a l in May, 1956. H i s d o c t o r s u s p e c t e d g a l l b l a d d e r trouble, b u t d i d n o t t h i n k t h e p i c t u r e typical. O n t h e m o r n i n g o f t h e d a y before a d m i s s i o n t h e p a t i e n t h a d b e e n seized b y a s u d d e n s e v e r e p a i n across t h e u p p e r a b d o m e n , which r a d i a t e d all o v e r t h e a b d o m e n a n d into t h e m i d d l e of his back. H e h a d v o m i t e d . W h e n s e e n b y his doctor he w a s g i v e n t a b l e t s a n d t h e p a i n g o t easier. Since t h e n t h e p a i n w a s n o t v e r y b a d , b u t c o n s t a n t . F o r t h e p a s t t e n y e a r s or m o r e h e h a d suffered f r o m a f l a t u l e n t d y s p e p s i a a n d d i s t a s t e for f a t t y foods. Ifie w a s a v e r y big m a n . T e m p e r a t u r e n o r m a l , pulse, 70. B . P . 220/120. H e looked a n x i o u s . H i s a b d o m e n w a s a little d i s t e n d e d , b u t quite soft w i t h no a b n o r m a l palpable m a s s e s . H e w a s v a g u e l y t e n d e r all over t h e a b d o m e n a n d in b o t h loins, p e r h a p s a little m o r e so in t h e r i g h t h y p o c h o n d r i u m . I felt t h a t t h e m a n w a s s e r i o u s l y ill, b u t I w a s a t a loss tbr a diagnosis. W h e n I c a m e in t h e following m o r n i n g I w a s told t h a t , d u r i n g t h e night, h e h a d s u d d e n l y s a t u p in b e d c o m p l a i n i n g of " s o m e t h i n g t e a r i n g " in t h e region of his left loin ; h e h a d b e c o m e p a l e a n d shocked, his p u l s e r a t e w e n t u p to 140 a n d his B . P . d r o p p e d to 80. H e r e s p o n d e d to m o r p h i a , a n d w h e n I s a w h i m h e w a s q u i t e e a s y a g a i n . H i s a b d o m e n , however, w a s m o r e d i s t e n d e d a n d t h e r e w a s a s u g g e s t i o n of r e s i s t a n c e a n d fullness in t h e left loln. R e t r o p e r i t o n e a l haemorrhage from a leaking aneurysm was now suspected. A p l a i n film o f t h e a b d o m e n a t t h i s s t a g e s h o w e d gross distension a n d a n o p a c i t y in t h e left u p p e r a b d o m e n . D u r i n g t h e n e x t few d a y s t h e fullness in t h e left loin b e c a m e q u i t e definite, b u t a t n o t i m e w a s a n y p u l s a t i o n d e t e c t a b l e . I m a d e a s m a l l M c B u r n e y incision in t h e left loin for e x p l o r a t o r y p u r p o s e s . A m a s s of r e t r o p e r i t o n e a l blood clot w a s i m m e d i a t e l y visible a n d p u l s a t i o n w a s palpable in it. I t o o k t h e o p p o r t u n i t y o f e s t i m a t i n g t h e size of his a o r t a w h e r e it w a s palpable p r o x i m a l to t h e h a e m a t o m a , a n d also a t t h e r i g h t c o m m o n iliac a r t e r y . T h e left c o m m o n illac w a s o b s c u r e d b y t h e h a e m a t o m a . A few d a y s later, Dr. Counihan, of t h e Cardiac D e p a r t m e n t , p a s s e d a c a t h e t e r into his thoracic a o r t a v i a t h e r i g h t radial a r t e r y a n d Dr. O ' S u l l i v a n took a o r t o g r a m s . T h e pictures d e m o n s t r a t e t h e a n e u r y s m a n d s h o w it to c o m m e n c e below t h e r e n a l arteries. A few d a y s l a t e r operation for r e s e c t i o n o f t h e a n e u r y s m w a s u n d e r t a k e n . A midline incision w a s m a d e in t h e a b d o m e n f r o m x i p h i s t e r n u m to pubis. T h e s m a l l bowel w a s e v i s c e r a t e d to t h e r i g h t a n d a large retroperitoneal h a e m a t o m a w a s s e e n in t h e left a b d o m e n . T h e l i g a m e n t of Treitz w a s divided, t h e t h i r d s t a g e of t h e d u o d e n u m a n d lower b o r d e r of t h e p a n c r e a s were e l e v a t e d a n d t h e a o r t a m o b i l i s c d j u s t below t h e r e n a l arteries. A t a p e w a s p a s s e d a r o u n d it. T h e c o m m o n iliac arteries were likewise mobilised, j u s t p r o x i m a l to t h e i r r e s p e c t i v e bifurcations, a n d t a p e s passed a r o u n d t h e m . T h e p e r i t o n e u m w a s incised a l o n g t h e l e n g t h of t h e a o r t a a n d t h e inferior mesenteric artery, w h i c h b y n o w w a s t h r o m b o s e d , w a s d i v i d e d . ]Y~obilisation of t h e a n e u r y s m w a s n o w c o m m e n c e d . W h e n t h e s t a g e w a s r e a c h e d a t w h i c h f u r t h e r dis. section w a s n o t possible w i t h o u t e n t e r i n g t h e h a e m a t o m a , t h e a o r t a w a s c l a m p e d j u s t below t h e r e n a l arteries, a n d t h e c o m m o n iliac arteries were d i v i d e d b e t w e e n c l a m p s . T h e a n e u r y s m , w h i c h i n v o l v e d t h e p r o x i m a l 1" o f c o m m o n iliac a r t e r y on e i t h e r side, w a s n o w dissected u p w a r d s till t h e relatively n o r m a l a o r t a j u s t distal to t h e r e n a l a r t e r i e s w a s r e a c h e d a n d t r a n s e c t e d a t t h a t level. A plastic bifurcation p r o s t h e s i s h a d p r e v i o u s l y b e e n p r e p a r e d f r o m p o l y v i n y l alcohol s p o n g e . T h e p r o x i m a l a o r t a a t t h e site of section, t h o u g h n o t a n e u r y s m a l , was g r o s s l y a t h e r o m a t o u s , a n d t h e d i s e a s e d i n t i m a w a s flaking i n w a r d s f r o m t h e o u t e r c o a t s ; t h e s e coats h a d first to be s u t u r e d t o g e t h e r w i t h i n t e r m l p t e d stitches. T h e p r o x i m a l e n d of t h e g r a f t w a s t h e n s t i t c h e d to t h e a o r t a b y a c o n t i n u o u s overa n d - o v e r s t i t c h of arterial silk. T h e c o m m o n iliacs were in t u r n s t i t c h e d to t h e two arms of the prosthesis; that on the right made a satisfactory anastomosis; the left c o m m o n iliac, however, w a s c o n s i d e r a b l y s m a l l e r a n d h a d to be c u t on t h e bias to m a t c h t h e p r o s t h e s i s ; e v e n t h e n t h e j o i n t w a s a n a w k w a r d one, t h o u g h b l o o d t i g h t . W h e n t h e o p e r a t i o n h a d b e e n c o n c l u d e d %here were good p u l s e s in t h e r i g h t lower limb, poor in t h e left lower l i m b . T h e p a t i e n t ' s general c o n d i t i o n w a s satisfactory. D u r i n g t h e first few post-operative d a y s a b d o m i n a l d i s t e n s i o n w a s a p r o b l e m , b u t this s u b s i d e d . T h e left lower l i m b p u l s e s were poor, b u t t h e l i m b a t no t i m e g a v e rise to anxiety. W h e n seen six m o n t h s later, t h e c o n d i t i o n in t h e l i m b s w a s s a t i s f a c t o r y . H e is, however, suffering f r o m severe h y p e r t e n s i o n w i t h evidence o f considerable left veto tricular strain, a n d chest films s h o w c o m m e n c i n g d i l a t a t i o n o f t h e thoracic aorta.

SURGERY OF AORTIC ANEURYSM The u l t i m a t e outlook, therefore, in m a n y i n s t a n c e s in w h i c h t h e as m a n y o f t h e s e p a t i e n t s h a v e p a r t i c u l a r l y t r u e in t h e y o u n g e r

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is n o t good. Such, u n f o r t u n a t e l y , will be t h e case i m m e d i a t e surgical i n t e r v e n t i o n h a s b e e n successful, e x t e n s i v e v a s c u l a r d i s e a s e ; t h i s w o u l d s e e m to b e a g e groups.

CAs~. 2. T h i s w a s a w o m a n a g e d 36 w h o p r e s e n t e d w i t h a thoracic a n e u r y s m . I n J u l y (1956) s h e h a d a r o u t i n e c h e s t x-ray. T h i s s h o w e d a r o u n d e d , lightly calcified o p a c i t y a b o u t 5 c m . X 4 c m . j u s t a n t e r i o r to t h e u p p e r thoracic aorta. She w a s referred to D r . L. K . Malley. I-Ie f o u n d h e r to h a v e t h e classical signs o f aortic eoarctation. H e r blood p r e s s u r e w a s 170/90 in t h e u p p e r l i m b s , 130 in t h e lower l i m b s ; t h e r e w a s a d e l a y in t h e f e m o r a l p u l s e ; t h e r e w a s a preeordial systolic m u r m u r , also h e a r d posteriorly ; collateral v e s s e l s were p a l p a b l e a r o u n d t h e s c a p u l a e a n d t h e c h e s t film s h o w e d a n a b s e n t aortic k n u c k l e , a n d rib n o t c h i n g . A n g i o g r a m s were m a d e in t h e Cardiac D e p a r t m e n t b y D r . T. C o u n i h a n . T h e s e s h o w e d a e o a r c t a t i o n of t h e thoracic a o r t a a b o u t 2 c m . distal to t h e left s u b c l a v i a n a r t e r y ; j u s t distal to t h e coarctation, a n a n e u r y s m w a s d e m o n s t r a t e d a r i s i n g f r o m the a o r t a anteriorly a n d c o r r e s p o n d i n g to t h e s h a d o w s e e n on t h e plain film. T h e r e m i g h t be s o m e h e s i t a t i o n a b o u t o p e r a t i n g o n s y m p t o m l o s s c o a r c t a t i o n a t t h e a g e o f 36, b u t t h e presence of a n a n c u r y s m m a d e o p e r a t i o n i m p e r a t i v e to relieve an imminently dangerous situation. T h e left c h e s t w a s e n t e r e d t h r o u g h t h e f o u r t h i n t e r c o s t a l space. T h e a o r t a a b o v e a n d b e l o w t h e a n e u r y s m w a s first d i s s e c t e d a n d r u b b e r t o u r n i q u e t s p a s s e d a r o u n d . T h e a n e u r y s m itself w a s t h e n s}owly a n d carefully dissected. I t w a s hard, t h i n - w a l l e d a n d a d h e r e n t to t h e b a c k of t h e l u n g root. T w o p a i r s of i n t e r c o s t a l vessels were e n t e r i n g it posteriorly. T h e a n e u r y s m itself h a d originated as a b l o w . o u t f r o m t h e a n t e r i o r a s p e c t o f t h e aorta, t h r o u g h a n o p e n i n g a b o u t 2 c m . long. F i n a l l y t h e a o r t a w a s c l a m p e d a b o v e a n d below, t h e l i g a m e n t u m a r t e r i o s u m tied, t h e e n t e r i n g i n t e r c o s t a l s tied, a n d t h e a n e u r y s m r e s e c t e d . T h e r e w a s s o m e h a e m o r r h a g e f r o m one o f t h e intercostals, b u t this w a s easily controlled once t h e a n e u r y s m w a s r e m o v e d . T h e aorta, p r o x i m a l a n d d i s t a l to t h e c o a r c t a t i o n a n d a n e u r y s m , w a s 1.6 c m . wide, a n d t h e walls were h e a l t h y . A s i m p l e t u b e of p o l y v i n y l alcohol o f t h e s a m e d i a m e t e r a n d 4 c m . long, w a s n o w s t i t c h e d e n d - t o - e n d to t h e a o r t a , p r o x i m a l l y a n d distally, b y s i m p l e c o n t i n u o u s s u t u r e of 0000 arterial silk. P o s t o p e r a t i v e l y t h e r e w a s a m o d e r a t e t a c h y c a r d i a for s o m e d a y s , b u t t h e p a t i e n t g a v e rise to no a n x i e t y . W h e n s e e n s o m e m o n t h s l a t e r t h e p a t i e n t w a s well. Blood pressure w a s 150/90 a n d a p p r o x i m a t e l y e q u a l in all l i m b s . I n t h i s p a r t i c u l a r t y p e of thoracic a n e u r y s m , n a m e l y , t h a t a s s o c i a t e d w i t h coarctation, t h e t e c h n i c a l p r o b l e m is g r e a t l y simplified o w i n g to t h e presence of a good collateral circulation a r o u n d t h e coarctation. T h i s allows one to c r o s s - c l a m p t h e a o r t a for long periods w i t h o u t fear of d a m a g e to t h e cord, liver or k i d n e y s . I n t h e m o r e c o m m o n t y p e of thoracic a n e u r y s m t h i s is n o t so, a n d special p r o b l e m s arise. I f t h e a n e u r y s m is saccular it m a y be possible to c l a m p t h e n e c k of t h e sac a n d a v o i d c r o s s - c l a m p i n g t h e a o r t a ; if t h i s m a n o e u v r e is n o t applicable it is n e c e s s a r y e i t h e r to u s e h y p o t h e r m i a , w h i c h p r o b a b l y allows safe c l a m p i n g for a b o u t 189 hours, or else to u s e a t e m p o r a r y s h u n t o f plastic m a t e r i a l or o f h o m o g r a f t or heterologous graft. W h e n t h e a n e u r y s m i n v o l v e s t h e a r c h m u l t i p l e s h u n t s m a y b e n e c e s s a r y to m a i n t a i n blood flow to t h e carotid v e s s e l s as well as to t h e d e s c e n d i n g aorta. T h e technical p r o b l e m t h e n b e c o m e s v e r y c o m p l e x , a n d t h e s u r g e r y v e r y a r d u o u s i n d e e d for all concerned. CASE 3. I n t h i s p a t i e n t t h e o u t c o m e was, u n f o r t u n a t e l y , n o t successful. T h e a n e u r y s m i n v o l v e d t h e c o m m o n iliac a r t e r y a n d p r e s e n t e d following r u p t u r e . W h i l e n o t s t r i c t l y a n aortic lesion, t h e p r o b l e m is t h e s a m e . I n O c t o b e r 1956 a m a n a g e d 65 w a s a d m i t t e d t h r o u g h t h e C a s u a l t y D e p a r t m e n t o f t h e M a t e r H o s p i t a l as a case o f c o r o n a r y occlusion. T h e s t o r y w a s one of a c u t e a n d severe p a i n in t h e lower b a c k which, a f t e r a n h o u r or so, s p r e a d to t h e lower a b d o m e n . H e w a s s e e n later, in a m e d i c a l w a r d , b y Mr. H e d d e r m a n (Surgical Registrar). H e f o u n d h i m p r o f o u n d l y shocked, w i t h n o d e t e c t a b l e pulse. A s h e w a t c h e d h i m , a m a s s d e v e l o p e d in t h e left a b d o m e n . T h e p a t i e n t r e s p o n d e d to blood t r a n s f u s i o n a n d n o r a d r e n a l i n e . H e h a d four p i n t s o f blood in all. I s a w h i m in t h e m o r n i n g . H e w a s t h e n q u i t e w e l l - - p u l s e 90, blood p r e s s u r e 110/90. H e w a s s l i g h t l y c y a n o s e d . H e h a d a large t e n d e r n o n . p u l s a t i n g m a s s in t h e left a b d o m e n . H e g a v e a h i s t o r y of chronic c h e s t t r o u b l e a n d d y s p n o e a o n v e r y m o d e r a t e effort. B l o o d w a s procured, a n d a r r a n g e m e n t s m a d e for o p e r a t i o n t h a t d a y . T h e a b d o m e n was o p e n e d t h r o u g h a long m i d l i n e incision. A v e r y large r e t r o p e r i t o n e a l h a e m a t e m a w a s s e e n filling t h e entire left a b d o m e n a n d pelvis, w i t h t h e d e s c e n d i n g colon p e r c h e d on t o p o f it. T h e a o r t a w a s first m o b i l i s e d p r o x i m a l to t h e coeliac axis, w h i c h w a s above t h e h a e m a t o m a , a n d a t o u r n i q u e t placed in position. T h e a o r t a w a s n o w approached a t t h e s u b r e n a l level, w h i c h w a s o b s c u r e d b y clot, a n d a second t o u r n i q u e t

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placed in position. The right c o m m o n iliac a r t e r y was also dissected and controlled. The a o r t a w a s n o w clamped at the s u b r e n a l level ; the p e r i t o n e u m along the a o r t a w a s incised and the h a e m a t o m a e v a c u a t e d . I t w a s now found t h a t the aorta p r o p e r was intact ; the bleeding had come f r o m a rupture~l a n e u r y s m of the left c o m m o n illac artery. The a n e u r y s m w a s partially filled w i t h clot, w a s a b o u t 4 cm. X 4 era. and involved the c o m m o n iliac a r t e r y at its bifurcation. The left c o m m o n , e x t e r n a l and internal iliac arteries were n o w mobilised and controlled and the a n e u r y s m excised. The left u r e t e r w a s very closely a d h e r e n t to the a n e u r y s m and w a s dissected off w i t h difficulty. The internal iliac a r t e r y w a s tied. I t was n o w f o u n d t h a t the mobilised c o m m o n a n d external iliac arteries could be b r o u g h t t o g e t h e r c o m f o r t a b l y w i t h o u t tension. A n end-to-end anastomosis w a s effected b e t w e e n t h e m / in v i e w of t h e disparity in size and the gross a t h e r o m a t o u s changes, this w a s difficult enough, b u t a blood-tight junction w a s e v e n t u a l l y secured. Following operation all s e e m e d well. All pulses were present, w i t h good v o l u m e . Systolic blood pressure was a b o u t 110; colour was good. S p o n t a n e o u s respiration, however, did not r e t u r n and assistance had to be continued. Five hours later t h e patient s u d d e n l y died. Post m o r t e m e x a m i n a t i o n s h o w e d tuberculosis of the left lung w i t h destruction of the u p p e r lobe, gross e m p h y s e m a of the right lung ; gross a t h e r o m a of the cerebral and c o r o n a r y vessels. The precise cause of death w a s not obvious. This t y p e of case requires deep relaxation for several hours, and I feel t h a t such pathological lungs just could n o t cope w i t h the v e n t i l a t o r y p r o b l e m s involved a n d respiratory acidosis m a y h a v e resulted.

The two eases of ruptured abdominal aneurysm reported here underline the significant points in the clinical picture. They are: (1) Pain, which is referred to the back, perhaps also to the abdomen. (2) Shock--due to blood loss and retroperitoneal stripping--it may be catastrophic, or relatively transient. (3) The appearance of an abdominal mass; this may not show demonstrable pulsation. (The femoral pulses will usually be present.) In the presence of these signs death is imminent and operation must be undertaken, though mortality will be considerable. What are the indications for operation in arteriosclerotic aneurysms of the abdominal aorta which are diagnosed before rupture ? Statistically, most of them will die within two years if untreated. An attempt has to be made to assess the whole cardiovascular system and decide if the prognosis in the absence of an aneurysm is reasonably good. I f it is, then operation should probably be undertaken. Pain as a symptom is very suggestive of impending rupture, and makes operation more urgent. Finally, when done as an operation of election, operative mortality should be reasonable: in the best hands it is no higher than for other major abdominal surgery in this age group. Finally, it should be said that these cases are time-consuming, and, particularly when done as emergencies, they put a considerable strain on surgical, anaesthetic and nursing staff. I am most grateful to our Surgical Registrars, Mr. F. O'Connell and Mr. W. Hedderman, to the staff and resident anaesthetists--all of whom in turn lent a willing and skilful hand, and to the Sisters, nurses and housemen for whom cases of this type mean really hard work.

Summary. (1) A short review is presented of the surgery of aortic aneurysms. (2) Three cases are reported : (a) Ruptured aneurysm of the abdominal aorta, treated by resection and polyvinyl alcohol sponge replacement. (b) Thoracic aneurysm complicating coarctation of the aorta treated by resection and polyvinyl sponge replacement.

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(c) Ruptured aneurysm of the left common iliac artery treated by excision and end-to-end anastomosis. References. Colt, G. I-I. (1927). Quarterly J. Med. 20, 331. Estes, J. E. (1950). Circulation, 2, 258. l~ob, C. (1956). Brit. J. Surg., 181, 30. Dubost, C., Allary, M. and Oeconomos, N. (1952). Arch. Surg. 64, 405. De Bakey, M., Cooly, D. A. a n d Creech, O. (1955). Symposium on Cardiovascular Surgery, I~enry F o r d Hospital, 468. Saunders, Philadelphia.

Discussion. Mr. C. K. B Y R N E S : These a n e u r y s m s are not so u n c o m m o n as we think. I recall seeing at least five in the last 15 y e a r s in St. Laurence's. I w o u l d like to h e a r a little more a b o u t the clinical diagnosis of the a b d o m i n a l aorta. I n these aortograms, w h a t is the p u r p o s e of p u t t i n g the c a t h e t e r into the a r t e r y ? I c o n g r a t u l a t e our three speakers for bringing d o w n this very difficult subject. Mr. J. CORCORAN: A b d o m i n a l a n e u r y s m s are more c o m m o n t h a n we think. I n the p a s t y e a r I have seen at least four in the Mater. I n one instance I w a s called to see a m a n believed to have an a p p e n d i x abscess. H e h a d h a d this for some days and the m e r e placing of a h a n d on his a b d o m e n gave the diagnosis. I t m u s t h a v e been leaking for a couple of days before. A feature of these a n e u r y s m s is t h a t t h e y get p r o f o u n d shock and low blood p r e s s u r e w h e n t h e y bleed. A f t e r a few p i n t s of blood the i m p r o v e m e n t is r e m a r k a b l e . I t h i n k Mr. O'~YIalley w o u l d agree t h a t in these cases of acute a b d o m i n a l a n e u r y s m we should operate v e r y rapidly. I t is m u c h b e t t e r to go ahead and to use the m a t e r i a l available and get on w i t h it. I would n o t be particularly keen on this operation. I t is a six to eight h o u r job, v e r y tedious, and it is really s u r g e r y of salvage. U n d e r t h e circumstances, ~r O'Malley is to be congratulated on h a v i n g a living p a t i e n t ; it is b y no m e a n s easy surgery. Mr. S. O'BYRNE (Galway): I h a v e no personal experience of the resection of a n e u r y s m s , b u t a couple of y e a r s ago I h a d a m a n w i t h a r u p t u r e d a b d o m i n a l a n e u r y s m ; I opened the a b d o m e n and p u t wire in the a n e u r y s m and he died four d a y s later. The wiring of a n e u r y s m s only s e e m s to offer palliation of pain. I v a l o n grafts s e e m to be effective ; can these be p r e p a r e d in different sizes a n d k e p t ? Do t h e y deteriorate if k e p t for a n y length of t i m e ? Dr. DICKENSON : W h a t has s t r u c k me, from m y reading, is the diversity of figures for the causes of these aortic a n e u r y s m s . P a u l W h i t e s t a t e s t h a t 90 p e r cent. of a n e u r y s m s are syphilitic. Y o u s a y t h a t the Seattle figures are completely different. None of the speakers m e n t i o n e d w h e t h e r a W.P~. h a d b e e n done on a n y of their patients. Mr. W. P. ]-~EDERI~AN .* These p a t i e n t s baffled the house m e n w h o saw t h e m because their s y m p t o m s changed every t e n m i n u t e s . A recent p a t i e n t s t a r t e d off w i t h pain in his back, and five m i n u t e s later looked v e r y shocked. A n E.C.G. w a s ordered rapidly but, w i t h i n five minutes, before it w a s done the left side of his a b d o m e n had become~rigid and we t h o u g h t t h a t he had perforated. W h a t s t r u c k m e w a s t h a t he was so shocked and pulseless. H e responded amazingly to a little blood a n d noradrenaline. H e h a d j u s t t w o p i n t s and a n o t h e r t w o d u r i n g the night, w i t h a little noradrenaline, and n e x t m o r n i n g he h a d recovered. I a m sure there is a lesson to be learnt f r o m this acute pain a n d the rapidly changing s y m p t o m s . Dr. REYNOLDS: I was interested in the r e m a r k s a b o u t grafts and t h a t we would never h a v e a good s u p p l y in I r e l a n d . I was associated in getting a graft f r o m a corpse for Mr. Corcoran ; it did not take m u c h trouble to get it out, b u t to get the permission was m o s t difficult. I t m e a n t d r i v i n g out to the s u b u r b s in t h e middle of the night and asking permission from people w h o did not y e t k n o w t h a t the p a t i e n t h a d died. I t was a m o s t difficult situation. To take the graft itself is only a m a t t e r of k n o w i n g the procedure and knowing how to go a b o u t it. I t h i n k it would be necessary for someone to organise this and to organise a b a n k . The Blood B a n k said t h e y could not preserve it for us. Professor H. ROGERS (Belfast) : I s y m p a t h i z e w i t h the last speaker. We in Belfast have formed an a r t e r y bank, and it is a feat to get the relations to give their consent. We have been in touch with the Coroner ; he is on our side, b u t I feel t h a t y o u are morally b o u n d to get the relative's permission. We found t h a t in the last t w e l v e cases there has been so m u c h emotional upset on the p a r t of t h e relatives t h a t it con-

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s t i t u t o s a n e n o r m o u s p r o b l e m . W e s e t o u r s e l v e s a t i m e l i m i t o f six h o u r s a n d f o u n d it v e r y difficult. T h e p r o b l e m , I t h i n k , is t h a t one is d e a l i n g w i t h a progressive disease from w h i c h a large n u m b e r of t h e m will die. W e h a v e f o u n d t h a t t h o s e w i t h t h e b e s t p r o g n o s i s a r e t h e ladies w i t h l o n g - s t a n d i n g b e n i g n h y p e r t e n s i o n . In these the a n a t o m y o f t h e a o r t a m a k e s it v e r y difficult to r e m o v e . O n e s u c h p a t i e n t I t o o k o v e r to L o n d o n to C h a r l e s R o b . T h e p o i n t w a s m e n t i o n e d o f t h e l a r g e t e a m n e c e s s a r y to do t h e s e operations. W e s t a r t e d a t 9 a . m . a n d s e v e r a l a s s i s t a n t s w o r k e d for a while each. A b o u t 5 p . m . R o b h i m s e l f t o o k over. T h e p a t i e n t h a d t h e n h a d over 20 p i n t s o f blood. B e t w e e n 7.30 a n d 8 p . m . s h e died. I m u s t s a y that I was most impressed with the set-up. I think that the arterio venous aneurysm m u s t be v e r y rare, b u t we h a v e b o o n f r i g h t e n e d into t y i n g a r t e r i e s a n d v e i n s s e p a r a t e l y . Most o f Mr. R o b ' s b e s t c a s e s h a v e b e e n t r a u m a t i c a n d if o n l y for t h e s e I t h i n k t h a t one n e e d s to h a v e all t h i s s e t - u p t o s a v e a l i m b or a life. Mr. O']~ALLEY (reply). W i t h r e g a r d to t r e a t m e n t t h e r u p t u r e d a n e u r y s m is a n e m e r g e n c y , a n d y o u j u s t h a v e to g e t o n w i t h it. I f it b e c o m e s operable, y o u j u s t m u s t do it. I n t h e a c u t e c a s e s it is difficult to s p o t t h e m s t r a i g h t a w a y ; t h e first sign is a c u t e p a i n in t h e b a c k . Y o u will n o t be able to m a k e t h e d i a g n o s i s u n t i l t h e m a s s appears. Do n o t e x p e c t to find it p u l s a t i n g . Chronic eases are r a t h e r d i f f e r e n t . T h e r e are o f t e n classical s i g n s in t h e c h e s t films. I t is n o t so m u c h a q u e s t i o n o f d i a g n o s i n g t h e s e a s it is o f k n o w i n g w h a t to do w i t h t h e m . T h e y are difficult to d e a l w i t h . T h o s e w h o h a v e d o n e m a n y of t h e s e are g e t t i n g g o o d results, b u t I t h i n k y o u n e e d careful selection. T h e r e is a b o u t a 60 p e r c e n t . c h a n c e t h a t if a p a t i e n t h a s a n a n e u r y s m it will r u p t u r e w i t h i n a year. All t h e c a s e s t h a t we t a l k e d a b o u t w e r e r u p t u r e d . O n e of t h e big difficulties is o r g a n i z a t i o n . Y o u h a v e to organize w i t h i n a v e r y s h o r t space o f time. You need at least three good assistants and three anaesthetists. I think you could m a k e m a n y of t h e s e g r a f t s in d i f f e r e n t s h a p e s a n d sizes a n d k e e p t h e m r e a d y , b a t it w o u l d be a l m o s t i m p o s s i b l e to g e t all t h e s h a p e s . Mr. FITZGERALD (reply). A s to t h e W a s s e r m a n n tests, I t h i n k it w o u l d be a l m o s t i m p o s s i b l e to a v o i d h a v i n g one d o n e w h e n in hospital a n d I a m s u r e t h i s one w a s done. I f i r m l y a g r e e t h a t a n e u r y s m s b e l o w t h e d i a p h r a g m are arterio-sclerotic. I w o u l d s u g g e s t t o Dr. D i c k e n s o n a c h a n g e o f tex~.-book. W i t h r e g a r d to t h e r u p t u r e , if a r e s i d e n t tells y o u t h a t h e s a w a m a s s a p p e a r i n g s u d d e n l y , believe h i m : it does occur. I t does c o m e u p for a s h o r t while. W i t h r u p t u r e d a b d o m i n a l a n e u r y s m y o u a l m o s t a l w a y s h a v e p u l s a t i o n in t h e l i m b s d i s t a l to t h e a n e u r y s m . Mr. Krm~EAR (reply). T h e d a n g e r o f a o r t o g r a p h y d o e s n o t lie in t h e m e t h o d in w h i c h t h e d y e is introduced, b u t w h e r e it goes a f t e r it g e t s in. T h e presence of atherom a t o u s p l a q u e s in t h e arteries to b e u s e d as a g r a f t s h o u l d n o t m a k e t h e g r a f t u n u s a b l e : q u i t e p o s s i b l y t h e y w o u l d be o f little i m p o r t a n c e .

Books Received. BEERWALTS, JOHNSON, SOLA~aL Clinical Use of Radioisotopes. S a u n d e r s . 80]6. HEWITT, 1~. ~r The Physician-Writer's Book. S a u n d e r s . 63[-. FURLONG, R . Injuries of the Hand. Churchill. 36]-. JOHNSTON, T. B. Synopsis of Regional Anatomy. Churchill. 8 t h E d . 28/-. DOUTnWAITE, A . H . (Hale White's) Materia Medica. Churchill. 3 0 t h E d . 24/-. C~AMB~RLAIN, E . N . Symptoms and Signs in Clinical Medicine. ~ r i g h t . 6 t i l E d . 35/-. RENDL~-SHORT, J. Synopsis of Children's Diseases. W r i g h t . 2 n d E d . 35]-. LOCXET, S. Clinical Toxicology. K i m p t o n . 105]-. At.BF~aTSONet:al. Meat Hygiene. W . H . O . 50/-.