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¶ 1 Leave a comment on paragraph 1 0 Medical Times & Gazette.                   [Sept. 30, 1854.

¶ 2 Leave a comment on paragraph 2 0 ORIGINAL LECTURES.

¶ 3 Leave a comment on paragraph 3 0 TWO LECTURES ON THE TREATMENT OF ANEURISM BY COMPRESSION.

¶ 4 Leave a comment on paragraph 4 0 DELIVERED AT THE

¶ 5 Leave a comment on paragraph 5 0 Royal College of Surgeons.

¶ 6 Leave a comment on paragraph 6 0 By F. C. SKEY, F.R.S., Professor of Surgery to the College.

¶ 7 Leave a comment on paragraph 7 0 (Continued from page 313.)

¶ 8 Leave a comment on paragraph 8 1 It appears that the treatment of aneurism by compression was adopted by Mr. Todd as far back as the year 1820, who employed it as a measure preparatory to the operation for tying the artery, and that, in the year 1825, he actually treated a case of aneurism with success by means of a truss not unlike the common hernia truss. But as many years elapsed before the experiment was repeated, during which period Mr. Todd died, and little, if any, record was kept of his operation, the author of the “Practical Remarks on the Treatment of Aneurism by Compression,” as it appears to me, rather withholds from the memory of Mr. Todd the merit to which he is justly entitled, that of having resumed and carried into execution, even though on one occasion only, the very operation on which the Dublin Surgeons justly claim the concurrence of the Profession. The absence of all record of his insulated case, while it cannot detract from the merit of Dr. Hutton, by whom the project was again successfully brought to the test of inquiry, surely places Mr. Todd at least on an equality with others who, more fortunate in a prolonged life, acquired extended opportunities of carrying their united conceptions into execution.

¶ 9 Leave a comment on paragraph 9 2 The principle on which the treatment is recommended consists in the employment of so much pressure on the trunk of the parent vessel as shall regulate, and at the same time reduce, the quantity of blood poured into the sac, and thus to promote the process of solidification. The sac becomes solidified by fibrin­ous deposit, and the disease is cured.

¶ 10 Leave a comment on paragraph 10 0 There is no part of the treatment recommended by the Dublin Surgeons, as expressed by Dr. Bellingham and Mr. Tufnel, more imperative than this—the necessity of moderate and regulated pressure, “to command the circulation with the minimum amount of pressure.”. Let me, then, ask, Has the requisite atten­tion been paid to this condition, deemed so indispensable by the greatest authorities on this interesting subject ? So far as my own means of observing go, I am inclined to say not. The inju­rious effects of excessive pressure of firm material on the soft integument of the body is that of severe pain in the part pressed. It is not easy for a man inexperienced in the form of suffering to conceive the intensity of pain so caused. The physical suffering occasioned by the repetition of even slight concussion on the same spot, or of continued pressure, was retained among the refined cruelties of an age of the Inquisition, .and, unhappily, in our country but recently abolished. The evidence is conclusive in the fact, that neither the moral endurance nor the constitu­tional powers of the patient can bear it, and serious though tem­porary illness follows; and it is only temporary because its imme­diate removal is compulsory.

¶ 11 Leave a comment on paragraph 11 1 This rock submerged in our track, which presents at the same time so much plausibility, and so much fascination to the young Surgeon, who not unreasonably argues, that if moderate pressure be good, firm pressure must be better, apparently constitutes the great difficulty of the treatment, since the degree of force em­ployed must vary in every case in order to obtain the same end; and We can have no positive guage of its degree. Still the princi- ple holds, and disobedience is danger. But if we possess no guage, no absolute criterion, by which to determine the mechanical force employed, or rather the force required, we possess a valuable measure by which the pressure should be regulated ; and that consists  in its influence on the sac. The rule is clearly defined, that pressure be increased by the screw, until the pulsations of the sac are arrested to the sense of touch, but not to the ear. Nothing can be more precise or definite; and we can readily see why this point of pressure should be reached, but not exceeded. It must be obvious, that this object will be effected by varying degrees of force according as the orifice leading from the artery into the sac be large or small, for less pressure will be required in proportion as there exists less freedom of communication between the two. Moreover the sound is changed, rather per­haps in intensity than in quality, on the first application; but in

¶ 12 Leave a comment on paragraph 12 1 [No. 783.—New Series, No. 222.] quality alone as the treatment progresses, by reason of the in­creasing deposit of fibrin which coats the inner layer of the sac.

¶ 13 Leave a comment on paragraph 13 1 Some emphasis is laid on a description of case of popliteal aneurism, which, so far as I know, has not been generally recog­nised by the Profession. Its essence consists in the rupture of the vessel on its anterior surface, by which the sac becomes early compressed against the posterior surface of the knee-joint. It would appear from the above records, that certain cases are marked by symptoms of more than usual intensity. The pain is  more persistent and wearing to the patient. It is characterised . by. a permanently bent limb, which is deemed ominous of future evil. It leads to softening and absorption of both bones and cartilage, to destruction of ligaments, and rupture of the sac into the joint. On examination of such aneurisms, the sac appears formed between the artery and the articulation, and such are deemed among the most intractable forms of these diseases. This is indeed an important diagnosis, and merits every inquiry and investigation.

¶ 14 Leave a comment on paragraph 14 0 Intimately connected with the subject of treatment by com­pression is that of the size and form of the sac, but more espe- cially of the latter. The question of size, whether large or small, and even that of the structure of the sac, are intimately involved in this consideration.       

¶ 15 Leave a comment on paragraph 15 3 The curative power of the screw will be proportioned to the size of the communicating opening. If it be large, the difficulty will be greater, and especially if the sac itself be large; and still more if the sac be attenuated, whether by reason of its age, being of long standing, or unusually rapid in its growth. The more favourable cases involve the converse of all these conditions—a small aneurism, with the bruit of a small orifice; the sac itself being firm, thick, and the contents more than usually solid. But much depends on the form of the tumour, which itself, however, holds an important, and even a necessary; relation to the size of the point of lesion in the coats of the artery. An aneurismal tumour, formed by the external coat of the artery which com­municates with the interior of the vessel by a rounded or by an oval orifice, through which a portion only of the blood circulat­ing through the vessel passes, will, by reason of its form, create an eddying current highly favourable to consolidation, when re­tarded by the screw; but in cases of true dilatation of the vessel  in which the tumour may be said to be formed by the entire artery, the area of the tumour is placed more directly within the influence of the circulating blood. These aneurisms are in figure fusiform, and in them the process of solidification is necessarily slow, however well regulated in the pressure. I do not know that we pay any marked attention in our metropolitan Hospitals to the form of the sac,—at all events the knowledge, if obtained at all, does not usually qualify our treatment.

¶ 16 Leave a comment on paragraph 16 1 In the study of a case about to be subjected to treatment by the agency of compression, we should not lose sight of the nature of the aneurism, as regards its origin and progress, whether its form, which is readily ascertainable by the hand, or the size of the orifice in the artery, which is also ascertainable by the nature of the bruit, and by observing how many pulsations of the vessel will fill the sac ; or, finally, the nature of the contents, whether fluid or solid.

¶ 17 Leave a comment on paragraph 17 2 Among other elements of success in the treatment of aneurism by compression, is the question of previous depletion. In per­sons of full and active circulation, this practice is strongly re­commended, as likely to promote early solidification ; and the suggestion would appear to be a reasonable one. The ground taken by Dr. Bellingham is, that the softer and the less frequent the pulse, the less pressure is required. If blood be taken from a healthy person, (for the presence of popliteal aneurism does not necessarily contra-indicate health,) the pulse will rise in fre­quency in the same degree as it loses in power. But if the circu­lation be reduced in power by the gradual abstraction of food, and by the careful administration of laxative medicine, coupled with a few days of. absolute rest and freedom from all cause of excitement, the pulse will not only lose power, but it will lose frequency of pulsation. And doubtless this is the best condi­tion of the system in which to undertake the treatment by pres­sure ; and not only because a modified pressure will accomplish more with a weakened circulation, but because the blood itself, under circumstances of reduced power of the heart, and dimi­nished quantity, is more prone to separate into its constituent parts than that which it circulates through the vessels of a vigorous and perfectly healthy man. There are three modes of depletion adopted in such cases:—1, the direct abstraction of blood by the lancet; 2, the indirect abstraction by means of hydragogue cathartics; and, 3, the negative loss by the reduction of the ordinary quantity of the food. Of these, except in cases of absolute and positive repletion, all the required advantage may