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¶ 1 Leave a comment on paragraph 1 0 386

¶ 2 Leave a comment on paragraph 2 0 CLINICAL LECTURES, BY F. C. SKEY, ESQ., F.R.S.

¶ 3 Leave a comment on paragraph 3 2 be obtained by resorting to the two latter means, purgation and abstinence; and even to these a limit should be placed. I con­ceive that it is preferable to devote a few additional days, when practicable, to such preparation, and by that means to habituate our patient to a novel condition of his system, than to subject him to the consequences of sudden deprivation. It is very true, that so long as he remains at rest he is scarcely conscious of weakness; but we must recollect, that although the cure may be said to be proximately accomplished by the mechanical consolida­tion of the blood, yet that certain vital principles are involved, which are indispensable to his final recovery; and, consequently, if the powers are unnecessarily reduced, the subsequent progress will be, in the same ratio, protracted. Of the three forms, that which accomplished the object most gradually, although, per­haps, with somewhat more of suffering, is abstinence; and the food, and especially the use of liquids, should be restricted to about half-a-pound of each, solid and liquid. To reduce the quantity beyond this total may possibly justify the resort to the treatment at an earlier period; but I do not think enough is gained by that practice to warrant the painful degree of abstinence required for it. It is only a question of a few days at most, pos­sibly the difference only between 4 and 8 or 10, the former being the period of deprivation allotted to the treatment by Dr. Bel­lingham and other Dublin Surgeons. It is less injurious to the system to withhold the materials for making blood, than to re­move it when it has become a part of the system. The one process is sudden, the other gradual. I would let the quantity of food be regulated by the pulse, instead of laying down any imperative rule which may vary according to age and constitu­tion. The great and vital question is, whether it is desirable, whether it is auspicious of the future success in the treatment, that we commence the pressure on a hard and full condition of the arterial system. On this matter I think there cannot be much difference of opinion, even though we were deprived the advantage of the Dublin antecedents,—that experience should be our guide, and I am persuaded we shall only repudiate it with disadvantage to our future patients.

¶ 4 Leave a comment on paragraph 4 2 I now arrive at the important question, What is the mode and form of pressure most eligible in such cases ? The old tourniquet possesses one essential requisite, viz., that it forms as it were a part of the limb, from which no movement of the body can displace it. But its demerits greatly preponderate over this advantage, in two important particulars. 1st. That it arrests, in an equally positive degree, the venous as well as the arterial circulation, and congests the limb to an extent which favours the oedema so commonly attendant on popliteal and femoral aneurism; and, 2dly. The pressure is too obtuse to be easily regulated. The Surgeons of Dublin have adopted, by common consent, an elastic pressure, obtained by the agency of vulcanized India rubber,—to which they attach the highest importance, as the most efficient and the most endurable. This was the inven­tion of Dr. Carte, and, I believe I may say, is universally pre­ferred and adopted by those enlightened members of our Pro­fession. I am not certain that I am an entire convert to their opinions. I, am not now disputing the soundness of the prin­ciple itself, but that I have some doubt whether the principle is carried out in the mechanism employed. A certain pressure is requisite—be it positive and active, or passive pressure; active by means of the screw—or passive, by the agency of a simple weight placed over the artery. In regard to the latter, Mr. Tufnel says, “ The weight is a most efficient means of con­trolling pulsation, and has no drawback of which I am aware, unless its being applicable only to one spot of the artery.” By such approval of the principle of the simple weight expressed on more than one occasion, Mr. Tufnel rather shelves the question of elasticity, supposing the only objection to the simple weight to refer to its inapplicability to other than one spot; for assuredly it carries no elasticity in its application.

¶ 5 Leave a comment on paragraph 5 0 The invention of Dr. Carte, which is on the principle of elasticity, consists of a hip apparatus of metal covered with leather,—to the side of which a strong upright rod is fixed. To the top of this rod is attached a sliding bar—to the extremity of which is fixed the screw, regulated by two vulcanized India- rubber bands. I have no doubt that Dr. Carte is a most efficient instrument for effecting the object required, and it has been deemed by men of high authority a valuable addition to the mechanism hitherto employed.

¶ 6 Leave a comment on paragraph 6 0 Having carefully examined this instrument, however, I con­fess I am inclined to attribute the remarkable success which has attended the treatment of aneurism in Dublin to other causes than to this, and chiefly to the enforcement of the im­portant principle of judiciously modified pressure. Against my own absolute approval of the instrument in question, there appear to me two objections: the first is, that in the instrument employed—and the one which I have before me is made from one manufactured in Dublin, where they may be supposed to be indigenous, and, consequently, perfect in construction—the sphere or capacity of the elasticity is not in a ratio with the weight of pressure—that is to say, that the weight recommended as desirable is insufficient to bring into play the elasticity of the india-rubber; and if so, the instrument of Dr. Carte does not compress on the principle of elasticity, but owes its superiority to other conditions, and not to that. The weight recommended and figured by Mr. Tufnel is equal to 71bs. Now, if we apply a weight of 7 lbs. on the pad of Dr. Carte’s instrument, the india- rubber bands are not elongated by the twelfth of an inch, and 121b. or even 151b. will only elongate them to the extent of one- quarter of an inch.

¶ 7 Leave a comment on paragraph 7 0 If you require a certain amount of pressure for any given pur­pose, it appears to me that it cannot signify in what form the pressure is made. If elastic material be employed, it is necessary to screw down the pad to a pressure equivalent to the required weight.

¶ 8 Leave a comment on paragraph 8 0 Secondly, elasticity of pressure implies a varying range of action of the instrument,—the pressure on the artery is greater. or it is less, according as the elasticity is brought into play. But, by what means can the elasticity be made serviceable, or at least applicable ? It is obvious, from its construction, that this elasticity cannot be obtained by pressure from above, or inwards; but only by pressure from the centre to the circumference, that is, pressure of the integuments against the pad, and not of the pad against the integuments. How is this effected ? For, if we allow that the pressure is already sufficient, any amount beyond this is superfluous and injurious. But the limb is at rest the most absolute; and one does not see in what manner pressure from the limb against the pad can be effected. On full reflec­tion, I confess my inability to appreciate the merits of the so- called elastic pressure; for it does not appear to my mind to involve the principle ; and if it did so, I cannot persuade myself that it would be a desideratum in the treatment. I cannot but think, with all respect for our Dublin instructors, that when screwed home with the force of pressure requisite for the pur­pose of arresting the circulation in the sac, to all intents and purposes it performs the office of a dead weight. In other words, of steady unalterable pressure, with a proximity to the artery, which the compressibility of the soft structures under­neath it has already determined as the exact distance which will effect its object. If the application of pressure by elasticity be a desideratum, I confess, I think it may be more efficiently obtained, and effect more comfort for the patient, by being applied through the medium of an elastic pad, composed of a ball of India-rubber placed in contact with the skin. It would be a matter worthy of inquiry, whether, since the intro­duction of this principle, real or supposed, any additional success or advantage has attended the operation. So far as I can judge from the published records, it appears to me that the question must be answered in the negative. Indeed, at the period of the publication of Dr. Bellingham’s work on compression,—a work of very high order and full of good material for reflection,—27 cases were successfully treated by compression, without an exception ; and this was anterior to Dr. Carte’s invention.

¶ 9 Leave a comment on paragraph 9 0 A far more important condition in the treatment of aneurism by compression, and which may be said to owe its discovery to Dr. Bellingham, in the year 1844—is the resort to a double point of pressure, instead of a single one. By this means, the com­pression of the artery may be made in two situations, which, by alternating with each other, greatly limits the evil attendant on either one, by affording relief to the present suffering without suspending the treatment for a moment. This expedient has been universally adopted by the Surgeons of Ireland, by Messrs. Kirby, Cusack, Porter, Macdonald, and others,—than which no better evidence can be adduced of its value. It will not be denied, by any one who will trace the career of this operation, as it has been practised in Dublin, that the greatest care, and the utmost observance of what may be called management, have attended its application to every individual case ; and without the repetition of such watchful care, I believe that the remark­able success which has been obtained during the last ten years could never have been achieved. This is an important and valu­able lesson, and without which I fear we must, on this side of the channel, be content with the very equivocal success that has hitherto attended our efforts to accomplish the same results. (a)

¶ 10 Leave a comment on paragraph 10 0 (a) Since the date of the delivery of these lectures at the College in Maylast, many cases of aneurism, successfully treated by English Surgeons, by the agency of pressure, have been communicated to the Author.