Pg. 338

¶ 1 Leave a comment on paragraph 1 0 828                                               CLINICAL LECTURES, BY F. C. SKEY, ESQ., F.R.S.

¶ 2 Leave a comment on paragraph 2 0 circulation in spite _tof the ligature, is an occasional sequence of the operation, it is by no means a universal one; and I think I am right in saying that it is not a general consequence. If so, what can fill the sac but a coagulum of the detained blood ? It appears to me also, that the evidence of Dr. Bellingham is in­adequate to general conviction, that the deposit of coagulum would be, the precursor of either abscess or secondary aneurism. This is something like begging the question. I Can readily believe that in the treatment by compression, deposit of fibrin is accompanied, by all the supposed advantages attached to it; but beyond this I cannot go. Look at any aneurismal sac, and you will find, however universal may be the concentric laminae of fibrin which line the sac from which the red particles of the blood have separated, yet the centre is invariably composed of coagulum, holding a greater or less proportion to the whole mass. On this subject I am unwillingly compelled to differ from the opinions of Dr. Bellingham. On another, also, neither is my opinion concurrent with his.

¶ 3 Leave a comment on paragraph 3 0 It is deemed an objection of considerable importance in select­ing the locality on which to apply the pressure, to avoid that spot under which the proximity of the Vein and nerve renders it impossible to avoid including them in the general pressure. To my mind this evil is unavoidable under any circumstances. It will not be asserted that the femoral artery is equally wide with the pad usually employed. If the centre of the pad occupy the centre of the artery, I have no doubt that both vein and nerve are implicated in the pressure. Surely this is inevitable.  In­deed, as regards the brachial artery, how is it possible to avoid the median nerve in any part of its course; and yet I am not aware that permanent mischief arises in any cases. However, after all that may be said, and that is worth saying, the subject is a secondary one, if it merit even that rank. One thing is un­doubted, that the treatment is successful, whether the con­tiguous parts be involved in the pressure or not involved.

¶ 4 Leave a comment on paragraph 4 0 It remains that I state the objections that have been set forth in opposition to the operation of compression. They are comprised under three heads: – 1st, that it renders the subsequent operation by the ligature more difficulty by changing the struc­ture and the relations of the artery; 2nd, that it is an ineffectual method of cure, because it is not permanent ; 3rd, that the treat­ment is protracted.

¶ 5 Leave a comment on paragraph 5 0 In various parts of this lecture I have stated facts as quoted by the Surgeons of Dublin, contradictory to, and at variance with, these allegations.

¶ 6 Leave a comment on paragraph 6 0 As regards the first ground, it is perhaps singular how slight is the effect produced by continuous pressure of many weeks or months. In only one case do I observe evidence of change of structure in the artery, and in that case it was preceded by active inflammation of the limb. In regard to thus objection, therefore, I think it may not unfairly be inferred, that if these cases, as recorded by the Dublin Surgeons, are to be believed at all, we have no ground for distrusting the statement as to the condition of the vessel.  With regard to the permanency of the cure, years have elapsed since the renewal of the operation, and there is no evidence of relapse. But why expect it ? What is meant by the term cure in aneurism, but that the sac is ab­sorbed, and the artery necessarily obliterated ? Suppose it pos­sible that the artery should resume its patency and its functions, and the sac re-form. Is that any argument against the form of treatment, be it what it may ? In both treatment by the liga­ture and by compression, the artery is obliterated, and the sac is absorbed. What more is required, or what more can Nature herself contemplate ? If the disease in question resembled a tumour which, treated by one method, was found liable to return, and in another not, we can understand that one system or prin­ciple may be preferable to another. But with regard to aneurism, in which the sac is shrivelled to a nonentity, it is of little moment by what manner or on what principle this is accomplished, so that it  is effected with security to the patient. As regards the duration of treatment, it is sometimes protracted and sometimes brief. Its average duration in 22 cases was 35 days!  Is a period of five weeks for the final cure of a large and dangerous disease to be deemed an exorbitant term ? Look tp the frequent detention, in our Hospital wards, Of patients, on- account of diseases neither large nor dangerous; and, indeed, in. comparing the term of thirty-five days with that required inoperations by the ligature, I doubt whether we are not absolute gainers of time by the treatment by compression.

¶ 7 Leave a comment on paragraph 7 0 Such are the objections to the new operation. In some minor respects, however, the operation of compression labours under some disadvantages, as compared with the rival operation. Under the administration of an anaesthetic agent, the operation by the ligature may be said to be painless ; it is also brief; and, indeed, the whole treatment is concentred in it. In compres­sion, on the other hand, under all  circumstances, great inconve­nience attends its progress. The restricted postage of the limb, and, indeed, of the entire person, is most irksome; and the pain­ful extent of the requisite pressure is often oppressive, and occa­sionally unbearable. These are drawbacks on the merits of the treatment by compression, which, quantum valeant, should at least not be withheld. But they may, notwithstanding, be classed among the objections of the patient, rather than of the Surgeon. They intrude largely on his rest, his comfort, and his convenience, but not on that issue which is the especial charge of the Surgeon, viz., his life.

¶ 8 Leave a comment on paragraph 8 0 I have placed before you, in their true colours, the main fea­tures of the treatment of aneurism by compression. It appeal’s to me that the evidence is all on one side. Now let us examine very briefly the facts of the case as they are given by these gen­tlemen, and from whose works I have so largely quoted.

¶ 9 Leave a comment on paragraph 9 0  From three unexceptionable sources of information, we find that; in the treatment of external aneurism by ligature nearly 25  per cent prove fatal.  The proportion certainly appears larger  than I had myself calculated on; but if it be granted that these statistics form even an approach to the truth, the propor­tion of deaths is yet/so great as to afford but a frail support to the advocates of the ligature.

¶ 10 Leave a comment on paragraph 10 0 On the other hand, we have a list of 39 cases, of which 9 are shown to be cither the subjects of other and necessarily fatal disease, or of some peculiarity  in their cases or constitution which would, with the exception of 2, disqualify them for the ligature. Of the remaining 30, in which alone the treatment by compression was fully carried out, every case was cured. In 37 cases treated in America, 35 were cured. “ Compression,” says Dr. Bellingham, “ has proved eminently successful in Dub­lin as a mode of treating popliteal and femoral aneurism, and has so completely superseded the ligature, that the latter has hot been resorted to for several years past in a single case either in Hospital or in – private practice.” Can there be a doubt on the mind of any rational man what will constitute the largely- predominant practice of the Profession hereafter ? In consider­ing the causes of the equivocal success that have attended the introduction of the treatment into  England and Scotland, which includes some twenty-five cases, we are driven to the alternative either of inferring some difference in the case or in the treat­ment. It cannot be said that the Dublin cases are selected; for, if so, it would appear in the evidence; and, besides which, 39 cases of aneurism, almost exclusively popliteal and femoral, within nine years, is rather a large proportion of such popula­tion as would supply the Dublin Hospitals with this particular form of disease. If the cases were selected cases, the supply of Irish aneurism must indeed be immense. It is not, I presume, too much to infer identity of disease between these published cases and such  as occur to human nature throughout the world. If So, we must look to the treatment as constituting the remarkable difference in the results. We must follow our leaders more implicitly. We must adopt their practice, and imitate, With exactness, their   details of management. The Dublin Surgeons constitute an important section of the Medical community.  They are men of high education, and their schools are not surpassed, for strictness of intellectual discipline, throughout the world. Perhaps it is happy for English Surgery that we do not succumb to rivals of inferior calibre. It is our duty, as it is our interest, to lay aside, if it exist at all, all rivalry, all jealousy, to confess our inferiority, and, by pursuing a similar career, to reach the same eminence. which has placed them, in this department of Surgery, so much in advance of other Schools. I feel justified in these remarks by the knowledge that This onward step in conservative Surgery has been assailed with suspicion, with detraction, and even with abuse. Notwithstand­ing these temporary obstructions, which vulgar and unscrupulous men have not hesitated to resort to, we may look forward with the -utmost certainty to the treatment of aneurism by compres­sion as the future law of our Profession.

¶ 11 Leave a comment on paragraph 11 0 Death of Lord Denman.—-This nobleman died on the 22nd inst., in the 76th year of his age. He was born on the 23rd of July, 1779, in the house of his father, Dr. Thomas Denman, who practised Medicine with distinction in the Metropolis in the latter half of the last century. His mother Was an aunt of Sir Benjamin Brodie; aud it is a curious instance of the connexion of the Den­man family with the Medical Profession, that one of the sisters of Dr. Denman married Sir Richard Croft, and the other Dr. Baillie, the two leading Physicians of their time.