234 



ARTERY, PATHOLOGICAL CONDITIONS OF. 



circumstances is also available here, for if a 

 wound of this species of vessel cannot heal 

 whilst its calibre remains open, neither can an 

 aneurism be cured until the artery from which 

 it springs is completely obliterated at the spot 

 where the aperture into the sac exists. The 

 complete closure of the vessel is to be accom- 

 plished by placing its opposite walls in contact 

 and under the influence of such pressure as 

 will occasion inflammation and the effusion of 

 coagulating lymph, a pressure that can be 

 applied either ab externo by means of com- 

 press and bandage, or from within, by placing 

 the blood in the sac in a condition that will 

 admit of its perfect and complete coagulation. 



Pressure on the tumour, if it could be ex- 

 actly applied and firmly maintained, ought to 

 succeed, and, in truth, has often been success- 

 ful, particularly when the disease is consequent 

 on a wound; but there are so many difficulties 

 to be surmounted and dangers to be encoun- 

 tered in its use, that few entertain much confi- 

 dence in it, and perhaps it never would be 

 resorted to but from a dread of consecutive 

 haemorrhage after a ligature. A bandage, if 

 applied with sufficient firmness to operate with 

 rapidity, occasions such excruciating pain that 

 it can scarcely be endured ; and if loosely, it is 

 liable to slip ; and if even it does finally work a 

 cure, the progress of the case is so protracted 

 that many patients become wearied with the 

 trial. Again, the large trunks of arteries 

 throughout the extremities are generally accom- 

 panied by nerves and veins in such close 

 apposition with them, that a compress can 

 scarcely be applied to one without interfering 

 with the other; and instances have occurred of 

 dreadful mischief having been occasioned by 

 interruption of the venous circulation in such 

 cases, even in the course of one night. Finally, 

 pressure has very frequently caused the rupture 

 of the sac, and the aneurism, from being cir- 

 cumscribed, has suddenly become diffused ; 

 and if there was no other source of apprehension 

 but the possibility of this latter occurrence, it 

 should make a surgeon pause before he adopted 

 so hazardous a mode of treatment. 



Pressure from within is effected by re- 

 moving the impulse of the heart from the 

 blood within the sac for a sufficient time to 

 permit of the sac becoming perfectly filled with 

 blood, and for that blood to become coagulated. 

 This object will be accomplished by interrupt- 

 ing the flow of blood under the impulse of the 

 heart through the leading trunk of the vessel 

 for a given time : in cases of small aneurisms 

 forty-eight hours being sufficient, but the larger 

 and older requiring a longer period. A ligature 

 placed around the vessel between the tumour 

 and the heart effects this purpose ; but it does 

 more than is requisite, for it divides its in- 

 ternal and middle coats, occasions the effusion 

 of lymph and the obliteration of the artery 

 there, and involves the risk of consecutive 

 haemorrhage afterwards on its final separation. 

 To avoid these inconveniences, the presse artere 

 of Deschamps and a number of other con- 

 trivances for arresting the flow of blood through 

 an artery, and admitting of easy removal after 



the object has been accomplished, have been 

 proposed and tried, but success has not been 

 so great as to warrant their general adoption, 

 and the operation by ligature is still very 

 generally preferred. It may be applied either 

 at the cardiac side of the tumour, when it acts 

 in the manner above stated, or between the 

 aneurism and the capillary circulation, in which 

 case the principle of its operation is somewhat 

 different. 



In the former instance, when a ligature is 

 applied to the trunk of an artery, the supply 

 of blood to the limb below it is interrupted for 

 a few moments; the aneurism loses its pulsa- 

 tion, and sinks and diminishes in size more or 

 less according as its contents had been fluid or 

 coagulated. Soon the blood begins to flow 

 through the collateral branches, and enters the 

 aneurismal sac also, but it passes into it slowly 

 and without impetus, and no part of it is again 

 forced back into the circulation. It coagulates 

 and comes to press upon and close the ruptured 

 vessel, which is soon obliterated by lymph, and 

 in process of time becomes degenerated into 

 little more than a ligamentous cord. A beau- 

 tiful illustration of this entire process was seen 

 in Mr. Crampton's case* of ligature of the com- 

 mon iliac artery. The patient had two aneu- 

 risms, one of very large size at the groin, the 

 other in the popliteal space of the same limb, 

 firmer, and of much smaller dimension. A liga- 

 ture of catgut was placed round the common 

 iliac, which either rotted or by some accident 

 became detached on the sixth day : the pulsa- 

 tion returned in the larger tumour, which soon 

 afterwards burst, and the patient perished. The 

 sac of the popliteal aneurism being so much 

 smaller had time to become perfectly filled with 

 blood, which was there coagulated and firm. 

 The ligature had accomplished all that was 

 necessary for it, and the cure would have 

 been complete even although the ligature had 

 loosened whilst the opposite was the fact with 

 reference to the larger tumour. 



Sometimes, soon after the ligature has been 

 applied, pulsation reappears in the tumour. 

 This must always be considered as an untoward 

 circumstance, but does not necessarily involve 

 the failure of the operation; for it may take 

 place under two different conditions of the 

 parts. 1. In aneurisms of very long standing, 

 in situations where there is a free and extensive 

 collateral circulation, probably increased by the 

 pressure of the tumour. In these the pulsation 

 does not return for some time after the vessel 

 has been tied, and is never so strong as before 

 the operation. It may continue for several 

 days, but gradually diminishes in force, and at 

 last ceases. The progress of the case then 

 resembles that of the ordinary forms of the dis- 

 ease, except that in this the cure is much 

 more protracted. Apparently, such was Sir 

 A. Cooper's first successful case f of ligature of 

 the common carotid artery, as also the case of 

 carotid aneurism published in the fifth volume 

 of the Dublin Hospital Reports.} It is not un- 



* Medico-Chirurg. Transactions, vol. xvi. 

 t Medico-Chirurg. Transactions, vol. i. 

 t Page 208. 



