Pg. 337

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November 2, 2020

¶ 1 Leave a comment on paragraph 1 0 CLINICAL LECTURES, BY F. C. SKEY, ESQ., F.R.S,

¶ 2 Leave a comment on paragraph 2 0 337

¶ 3 Leave a comment on paragraph 3 0 The construction of the bed, the form and number of the pil­lows, the attitude of the patient, and every point relating to his personal comfort; the careful examination of the surface to be pressed, the removal of the short hair by the razor, and even the hour, is determined for performing this necessary operation; the dusting the surface over with finely levigated French chalk— all these matters, insignificant though they appear, constitute an aggregate of importance which will not be neglected with im­punity, if we contemplate a success at all commensurate with that of our brethren in Ireland.

¶ 4 Leave a comment on paragraph 4 0 I have already, in an earlier part of this lecture, given the statistical results of the operation by ligature. I will remind you that the cases of popliteal and femoral aneurism so treated are successful in the ratio of about 78 per cent, only, or less than four-fifths recover. Gentlemen, you know the value of recorded cases, and, if you do not, I will simply observe that we have stronger inducements to make known the results of our treat­ment when successful, than when unsuccessful, and that for the most part publicity is not obligatory upon us. From this fact you will probably infer with me the possibility of error in these records—the liability we are under to become oblivious of cir­cumstances that do not convey to the mind recollections the most pleasing. Perhaps, making allowances for very natural weaknesses, I may place the failures, in treatment by the liga­ture, even at 25 per cent. Indeed, I have the authority of Mr. Phillips for believing the mortality to exceed this computation. Who will Venture to assert, on examining statistics such as these, that the operation for applying a ligature around the femoral artery is unattended with danger ?

¶ 5 Leave a comment on paragraph 5 0 Now, let us look at the statistics of treatment by compression, as given by the Surgeons of Dublin, to whom this operation, whatever its merits or its demerits, owes everything. I will not offend these gentlemen by bestowing a commendation which would infer a superiority, I am not entitled to; but it is sufficient for me to say, that the statistics are the issue of cases treated by the elite of the Surgeons of the city of Dublin, and men of the highest character throughout the profession. They embrace a period of eight years, or from 1842 to 1851; and include a list of 39 cases, as given by Mr. Tufnel, whose work was pub­lished in the latter year.

¶ 6 Leave a comment on paragraph 6 0 Of these 39 cases, 30 were perfectly cured within an average period of five weeks, or 35 days. Nine cases remain to be ac­counted for; and it is highly important that we examine into the cause of their failure.

¶ 7 Leave a comment on paragraph 7 0 In the first, the progress of the cure was tardy and incomplete, when the patient discontinued the treatment for the purpose of resuming his work. The aneurismal increase, however, was per­manently arrested, though the disease was not cured.

¶ 8 Leave a comment on paragraph 8 0 The second patient exhibited “ excessive irritability,” which rendered him unable to support any form of pressure; and the artery was tied with success.

¶ 9 Leave a comment on paragraph 9 0 In the third, compression on the brachial artery failed to con­trol the pulsations in the sac, caused by a high division of that artery,—both were tied.

¶ 10 Leave a comment on paragraph 10 0 In three cases amputation was performed.

¶ 11 Leave a comment on paragraph 11 0 The first of these was a direct rupture of the femoral trunk, the ends being separated to the space of an inch.

¶ 12 Leave a comment on paragraph 12 0 In the second, the case of a soldier, in whom the disease appeared suddenly, and was attended by considerable swelling of the knee joint, and his health rapidly declined, the disease was found to have commenced on the anterior surface of the artery, and the bones were bared and softened, of both femur and tibia.

¶ 13 Leave a comment on paragraph 13 0 The third case of amputation was required by increasing in­flammation of the knee joint, with pulpy fibrinous deposit.

¶ 14 Leave a comment on paragraph 14 0 In the three last of these nine cases death ensued during the treatment. The first was treated for twenty days by compres­sion ; pulsation ceased. The man died suddenly forty-eight hours afterwards from diseased heart. In the second, death ensued from erysipelas of the leg,—a disease prevalent in the hospital at the time, and to which he would have been at least as liable had the cure been attempted by ligature.

¶ 15 Leave a comment on paragraph 15 0 The third patient had extensive disease of both lung and heart, the latter weighing twenty-one ounces, with dilated cavi­ties and thickened aortic valves.

¶ 16 Leave a comment on paragraph 16 0 If from these 9 cases we deduct 4—one in which the patient voluntarily discontinued the treatment, one which ter­minated fatally by an endemic disease at that time prevalent in the Hospital, one from peculiar irritability of habit, and one from peculiar arterial distribution, we have 5 cases remain­ing in which the treatment was unsuccessful; one from rup- ture of the artery, prior to treatment, two from diseased knee joint, and two from disease of the heart. In the appendix to Dr. Norris’s paper he gives the results of the treatment by com­pression, in 37 cases of popliteal and femoral aneurism. Of these 35 were cured, one failed, and one died during the treat­ment.

¶ 17 Leave a comment on paragraph 17 0 It is not pretended by the most sanguine advocate of compres­sion, that every example of popliteal or femoral aneurism is . amenable to this treatment; but these records clearly proclaim how large a proportion of these diseases are recoverable by an appeal to it. Indeed we find no one case of absolute failure re­corded against the principle, which professes to cure true aneur­ism on the principle of compression, under all circumstances not complicated by other diseases or by eccentricity of arterial distribution. These are contingencies which equally involve the treatment by ligature, and are therefore not to be urged as con­tra-indicatory of treatment by compression. Subtracting the 9 cases, then, it does not appear unreasonable to assert that the Dublin Surgeons can boast the successful issue of 30 consecu­tive cases treated on the principle of compression.

¶ 18 Leave a comment on paragraph 18 0 It is important that we understand, and desirable, perhaps, that we concur in, the principle on which these cures are effected. The tendency of an aneurismal sac is to increase in size, by virtue of the propelling power of the heart; the object of the treatment, whether by ligature or by compression, is to cut off that power, and the aneurism is absorbed. The object to be kept in view by the advocate of compression is to restrain the current through the supplying artery to just such a degree as will permit it to convey blood in small quantity only into the sac, where it coagulates in layers, separates from its red particles, and becomes adherent in fibrinous layers to the internal surface of the sac. Thus the sac is thickened, and, being thickened, is strengthened also. In anaemic subjects, this end will not be attained so readily as in persons of tonic health, and hence the necessity of abstaining from copious depletion in any form. When the sac, hitherto soft and flabby, becomes flrm and circum­scribed—a change that may occur at the expiration of a few days from the first application of the agent of pressure—we infer that the case is progressing favourably. In order to effect this desir­able object, the pressure on the artery should be so regulated as to admit of slight pulsation in the sac being yet perceptible. Under these circumstances, it will not infrequently happen that the limb, previously cold, will regain its natural temperature. The laminae of fibrin increase in thickness, till somewhat sud­denly, and without apparent cause, the aneurism becomes ex­cessively painful for a few hours, and consolidation follows. The case is cured. During this process, whether occupying a period of days, weeks, or months, the condition neither of that portion of the artery nor the vein under the pad undergo any change.. In one or two cases in which the ligature has been subsequently applied, some slight condensation of the surrounding tissues occurred; but no change has hitherto been detected incompatible with a future resort to the ligature, if required. This principle is, of course, essentially distinct from that which was attempted by many Surgeons in the early part of this century, in which obliteration of the vessel was proposed. Here the artery retains its patency, and continues to supply not only the limb, but the sac, until the case has progressed some way towards its cure, when collateral vessels, usually three or four in number, be­come developed about the tumour, and the main artery is obli­terated at the sac by the encroachment of the coagulum on its calibre. It is important to make known this condition of the vessel at the point of pressure, because, among the opponents of compression, (and they have been neither few nor powerless, strange as it may sound,) this condition of the vessel has been reported as unfavourable to the operation of tying. Fortunately for the credit of the principle, the opportunities of judging have not been very numerous; but I believe I do not overstate the case in asserting, that no instance has been yet known in which the femoral artery, subject to compression, even, as in one case, for a period of three months, has been in any degree altered in structure, or that the operation has been in any degree increased in difficulty, or that any additional doubt of the result has arisen to the mind of the operator.

¶ 19 Leave a comment on paragraph 19 0 The reader of Dr. Bellingham’s work will notice with some attention his remarks on the important distinction between fibrinous deposits and coagula, as the medium of consolidation of the sac. This subject demands a few words of consideration. Dr. Bellingham entertains the opinion, that fibrinous deposit is the only material employed by Nature with which to solidify the sac, asserting his belief that the principle of cure between the cases of compression, and cases cured Spontaneously by the hand of nature, are identical. But when a ligature is applied around the main trunk of the vessel, this is impossible, because; al­though pulsation in the sac, which gives evidence of continued