A dictionary of practical surgery : comprehending all the most interesting improvements ... an account of the instruments ... the etymology and signification of the principal terms ... / by Samuel Cooper ; with numerous notes and additions ... together with a supplementary index ... by David Meredith Reese.

  • Cooper, Samuel, 1780-1848.
Date:
1844
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Licence: Public Domain Mark

Credit: A dictionary of practical surgery : comprehending all the most interesting improvements ... an account of the instruments ... the etymology and signification of the principal terms ... / by Samuel Cooper ; with numerous notes and additions ... together with a supplementary index ... by David Meredith Reese. Source: Wellcome Collection.

Provider: This material has been provided by the Woodruff Health Sciences Center Library at Emory University, through the Medical Heritage Library. The original may be consulted at the Woodruff Health Sciences Center Library, Emory University.

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    dnce a distinct pulsation; a fact (says Mr. Norman) or practical importance, as it shows, that though the ligature on the iliac artery stops the direct influx of blood into the tumour, and is the means by which the disease is cured, yet that there exists a. necessity for employing strict rest, the antiphlogistic regimen, and, in some cases, the abstraction of blood, to assist na- ture in her operation of obliterating the aneurism. And in another instance, after the same gentleman had tied the femoral artery for the cure of popliteal aneu- rism, the pulsation, though stopped for a time in the tumour, afterward recurred in such a degree, that much doubt was entertained whether the disease, ■would have been cured by the ligature on the femoral artery, had not continued and rather powerful pres- sure been adopted.—(Med. Chitv Trans, vol. 10, n. 99. 118, dec.) M. Roux, in a late work, has. offered some criticisms on the English method of operating for aneurisms. It would hardly be fair play to endeavour to offer a seri- ous refutation of them, because, when he wrote, it was his misfortune not to be duly informed of all the. facts and experiments recorded in the inestimable trea- tise on hemorrhage by the late Dr. Jones. Still less confident than we are csays Roux) in the treatment by compression, and in the use of topical remedies for the i cure of external aneurisms, the English surgeons have immediate recourse to the operation with the ligature. Hunter's method is that which they universally prac- tise. They will riot even allow, that there are any cases in which the operation by opening the sac should be preferred, dtc. And it is singular, the very same motive which would incline us in some cases of aneu- risms, properly so called, to adopt the operation of opening the sac, is alleged by the English surgeons as a circumstance in favour of the Hunterian method. Let us suppose an aneurism so formed, that near the centre of the tumonr or rather near the opening, by winch the artery communicates with the swelling, are situated the orifices of the collateral arteries, which would be useful for the re-establishment of the circu- lation. Here it is clear, that in practising the opera- tion by the Hunterian method, that is to say, in tying the artery above the tumour, the last ramifications are not, indeed sacrificed ; but the orifices and first branches of these collateral arteries. Let there be, for example, at the upper part of the femoral artery an aneurism, which, though formed originally below the origin of the profunda, now extends above it. Here it is mani- fest that in tying the femoral artery above the swell- ing, we should lose the important resource of the pro- funda for re-estatilishing the circulation in the lower part of the limb. The.desire and hope of saving the profunda would in such a case make us adopt the ope- ration of opening the sac. in preference to the Hunter- ian method ; and Scarpa himself, so great an advo- cate for this last mode, Scarpa, who seems only to have composed his work to cry up this method, makes an exception of the case, which I have just been suppos- ing. The English surgeons, on the contrary, would urge the following objection to the operation by open- ing the sac in this and other analogous examples They contend that the ligatures would be applied too near to the origin of the collateral arteries, which are to receive tne blood after the operation. They are pre- possessed with the idea, that when an arterial trunk is tied at a given point, the too great proximity of the principal collateral arteries disposes to subsequent he- morrhage, &c. (p. 256, 257) : a circumstance which Mr. Roux seems to doubt. Now, before attempting to reply to th^se observa- tions, we ought to know what exact distance Roux means, when he speaks of the profunda, or a large col- lateral artery, originating near the opening by which the aneurism communicates with the main artery. Here he is not at all precise; and were he to tie the fe- moral artery immediately below the point where'the profunda arises, he would expose his patient to great danger of .bleeding. I say this, well aware of the case which he has addnced to prove the contrary. In the example brought forward, he applied several ligatures (p. 260), some of which were the ligatures d'attente, or loose ligatures left ready to be tightened in case of need. These were of course higher up than the ligature which was tightened. 'If is therefore impossible, that this last cdurd have been close to the origin of the profunda. There must have been room left for the application of the ligatures d'attente; and be it also recollected, that the French still persist in the use of large flat cords, and not small firm round ligatures, which are now found to be most advantageous.—(See Hemorrhage.) In this part of the Dictionary we shall find that the -nearness of a collateral vessel impedes the formation of the internal coagulum, which has a material share in the process by which the artery is closed. With respect to the circumstance of hemorrhage be- ing more likely to follow when the ligature is placed ciose below, than at. some distance from a great colla- teral artery, there cannot be a doubt of the fact. Roux when in London saw an occurrence of this kind him. self, and has published it in his book. It was a case in which Sir A. Cooper tied the external iliac artery ; but the patient died of hemorrhage a fortnight afterward, and, on opening the body, it was ascertained that the obturator artery, which usually arises either from the trunk of the internal iliac, or from the epigastric, pro- ceeded from the external iliac, and arose immediately above the point to which the ligature, was applied.— (.See ParalleUe de la Chir. Angloise avec la Chir. Fran- goise, <fec. p. 278,279.) Prom a preparation, spoken of by Mr. Travers, and some experiments made by the same gentleman, it would appear, that the presence of a collateral branch hinders the formation of the internal coagulum, bnt will not always prevent the closure of the vessel by the adhesive inflammation. In the preparation refer- red to, a ligature ,was applied to the external iliac, be- tween the epigastric and circumflex iliac arteries, and having been in contact with the former at the an- gle which it makes at its origin from the iliac, ulcera- tion had taken place, and the bleeding had proved fa- . tal. There was no coagulum formed in the iliac trunk, though the operation had been performed several days, / the circulation through the epigastric having continued. But the lymph-plug at the seat of the ligature on the iliac artery was complete.— Med. Chir. Trans, vol. 6, p. 656.) Indeed, it must be allowed, with this gen- tleman, that the fluidity of the blood does not prevent the adhesi ve process, a fact which, he observes, is also proved in the indirect obstruction of a vessel, by means of a temporary ligature or compressor. When, therefore, the vicinity of a large branch to the ligature is spoken of as a circumstance conducive to secondary hemorrhage, I mean, that it is so inasmuch as ihe in- ternal coagulum is useful in promoting the closure of the vessel, and its formation is prevented. Brasdor first, and afterward Desault, conceived, that when an aneurism was so situated that a ligature could not be applied to the artery leading to the swell- ing, a cure might possibly arise from tying the vessel on that side of the tumour which was most remote | from the heart. Desault conjectured that by this | means, the circulation through the sac would be stop- ped, the blood in it would coagulate, that the circula- tion would go on by the collateral arteries, and that the tumour would be finally absorbed. Descharops tied the femoral artery below an inguinal aneurism; but the progress of the disease, instead of being checked, seemed to be accelerated by the experiment. The ope- rator was obliged, as a last resource, to open the tu- mour, and try to take up the vessel. In this attempt the patient lost a large quantity of blood, and died eight hours afterward.— SeeCEuvresChir.de Desault par Bichat, t. 2, p. 563 ; and Rpcueil P. riodique de la Societf de M'decine de Paris, t. 5, No. 17.; The operation of tying the artery below the tumour was repeated by Sir A. Cooper, not for an aneurism of the femoral artery in the groin, but for an aneurism (if the external iliac, where tying the arfery above the swelling was ^practicable. The femoral artery was therefore tied immediately below Poupart's ligament between the origins of the epigastric and the profunda'' I he pulsations of the tumour continued; but the uro- gress of the disease was checked. After a time in deed, the swelling decreased, and this in so considera- ble a mariner, that hopes began to be entertained that perhaps the external iliac artery might soon admit of being tied above the disease. The ligatures came away without any unfavourable occurrence, and when the wound was healed, the patient was sent into the country for the benefit of the change of air After- ward, however, the tumour gave way an extra™* tion of blood took place in the abdomen and Su aV membrane of the pelvis, and the oalionl %e HE