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J. A. (Joel Asaph) Allen.

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been recently demonstrated that the rupture of the internal coat
is not essential in the application of a ligature. (Ballance, on the



1. Read before the section for Railway Surgery at the Pan-American Medical Con-
gress, Washington, D. C, September 7, 1893.



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258 MANLKY : TOKSION, ETC., OF DIVIDED ARTEBIES.

Ligation of Arteries in Continuity.) It has been proven, too,
by the same author, that the clot is a foreign body in the vessel
and does not undergo transformation into cellular tissue, as was
formerly taught, but that the cellular infiltration is from the
inner surface of the intima, which, though normally is permeated
by no capillaries, in the event of injury it does possess the
property of active cell-proliferation. It has been found that an
absorbable, assimilable ligature is amply powerful to occlude the
largest arterial trunks and may be safely imbedded in the tissues,
when it is properly prepared, to subsequently soften, liquify, and be
consumed by the phagocytes.

It has been further shown that simple approximation, without
the division of the internal coat, is as effective in the application of
a ligature to effect permanent cicatrization. Prof. Murdock and
others have permanently dammed back the arterial current by the
application of torsion, entirely dispensing with the ligature.

Esmarch's constructor cannot be denied an important place in
the therapy of hemostasis, though all must admit that by its
careless, injudicious, and too general application, it has worked
^reat damage and has caused the needless sacrifice of many limbs
^nd lives, which might have been spared without it.

But the possibility of its employment has taught us a useful
lesson. It has demonstrated that the arteries may endure severe
and protracted pressure without serious detriment to their
integrity, and that the living current will long linger within the
lumen of an artery without coagulating and plugging it.

But the severe pain which its pressure always entails is a
warning to us that its general application is not without danger.
Acupressure, acutorsion, and many other expedients have been
alternately praised and condemned.

In a communication presented to the New York State Medical
Association, in 1889 (IVansactiona of same year), I described
what I designated the Temporary Transfixion lAgature, a simple
and effective means by which any of the arteries of the extremities,
large or small, could be promptly and safely controlled. Since
then, Wyeth, of New York, and Senn, of Chicago, have each
devised special methods to control hemorrhage in hip-joint ampu-
tations, both of which, in certain respects, combine the principles
of this ligature ; the former employing steel . skewers, and the
latter elastic tubing. At an early date I hope to again call the atten-
tion of the profession to this expedient.



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MANLBT: torsion, etc., of divided JLBTBBIES. 259

Thus we see that many and various have been the measures
'employed to subdue arterial hemorrhage, and that recent advances
in our knowledge of the modus operandi of the healing of arteries
and prevention of sepsis permit us to apply measures heretofore
quite inappropriate.

But the ideal is yet to be attained. The materials at our com-
mand even now are, in a large measure, unsatisfactory. All dead
substances are unsatisfactory. Perhaps catgut is the most valu-
able when it can be secured fresh and is properly prepared, though
often it is a source of infection. It may slip, stretch, or melt
down before definite closure of the vessel is secured. Over the
openings in small vessels, unless other tissues are included in the
ligature, it is prone to slip off, so that it cannot be said to hold
well, except on medium-sized vessels. Kangaroo, rat-tail, horse-
hair, and silk, are all objectionable, because of their irritating
tjualities.

Finding all heterogeneous materials more or less objectionable,
and becoming better acquainted with the hemostatic properties
inherent in the arteries themselves, surgeons have turned their
attention to what might be accomplished by the utilization of the
damaged segment of the vessel and the adjacent tissues as
materials which might be utilized for the arrest of bleeding from
arteries.

It had been observed that a very troublesome hemorrhage
might follow the mere puncture of an artery, but that when it is
cut cleanly across it immediately ceases. Vessels caught in the
jaws of an artery-forceps, and held for a few moments, often
promptly cease spouting when this is released. This, however,
will not succeed in closing a vessel in continuity, unless the pres-
sure is continued over considerable time, and. a thrombus has
formed at the proximal end. It has been often noticed that bleed-
ing is seldom abundant from a large artery when a limb has been
shot or torn off.

A wounded artery is essentially a structure seriously, if not
totally, curtailed in function ; blood circulating through it only
under difficulties. All the tissues superjacent, or contiguous to it,
become inflamed, and contract down on its walls ; the vessel itself,
after division, retracts within its sheath. The intima so coils
on itself as to form a cuff of soft, filmy tissue, which, with the embo-
lus, for the time at least, effectually aids in the arrest of hemor-
rhage. It has been claimed by Ballance, Zieler, Cornel, and Ran-



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260 manlbt: torsion, btc, of divided abtbries.

Tier, that an embolus forms no essential part in the reparative
processes of divided arteries.

My own observations incline me to the same view, for I wholly
agree with those who regard the clot as always the result of septio
infection, and, as Ballance so aptly puts it, << As much a foreign
body in an artery as in the stump of an amputation." (Ballance and
Edmunds, Ligation of Arteries in Continuity, page 127.)

There is every reason to believe, then, that auto-hemostasis is
practicable when the secret methods by which it may be rendered
efficient and practicable are revealed.

A long step in this direction was made when methodical
asepsis became an accepted principle in wound treatment.

Baumgartner and Bottcher declare that no thrombus is ever
formed if the vessel heals without suppuration (Ballance and
Edmunds, pages 156 and 157). Perhaps, it is not sufficiently borne
in mind that the various arteries of the body possess wide anatomic
cal and physiological differences, and undergo certain definite
changes at different stages in life, and that later researches, by
more accurate and precise means than we now command, will
show that there is a difference in the innate recuperative power,
not only of various organs and parts, but in special elements of
the same viscus, or member.

Dr. Murdock, after a careful survey of the history and prin*>
ciples of hemostasis, a long and ripe experience in general surgery,
returned to first principles, with a strong conviction that with the
aids which modern science have placed in our hands, the homo^
logons occlusion of arieries as a general method in the hemostasis
of traumatisms was feasible and practicable ; therefore, he recom^
mends the revival of the torsion of arteries on a large scale.

In Warren's late work on the Healing of Arteries, he tells
us that Kocher, of Hamburg, related to Ve1pe|iu that he had not
ligated an artery for twenty years ; and that Velpeau himself was
a strong advocate of torsion. The safety of torsion, he thought,
depended on three things, — viz., the twisting of the external coat^
retraction of the intima, and the coagulum. Ogston says (The
Properties of Arteries and Their Ligation, p. 117,) that the normal
•blood pressure is from three to eight pounds to the square inch,
and that a twisted vessel possessed less resistance than one
ligatured.

I had but shortly cogitated seriously on the line of experi-
mental work which had been confided to me by Dr. Murdock,



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manley: tobsion, btc, of diyidbd abtbbiss. 261

when it oocarred to me if the blood-oarrent can be arrested
through an artery by a twist of it, why not by a knot ; in other
words, why not tie it with its own elements, and therewith commit
it to the grip of its own living walls, as well as occlude, by turn*
ing the vessel on its own axis ?

With a determination of testing the practicability of torsion and
homologous ligation, I commenced a series of experiments on the
dog, and, as far as the opportunity offered, extended my observa-
tions on the human being, but, I regret to say, that since I
commenced I have not had an opportunity to test this expedient
on any of the larger vessels of man ; and, because of many diffi*
culties which will be removed later, I was unable to conduct mj
work with entire satisfaction on the dog.

In the present instance, my aim will have been accomplished if
t succeed in simply calling attention to the possibilities in the
future of securely occluding the bleeding orifices of arteries with*
out the employment of any sort of foreign substance to embrace
the artery ; by torsion, when the cleavage of the vessel is on a line
with the surfaee of the divided tissues, and by homologous ligation
of the vessel, by means of its own walls, in those extensive mutila*
tions in which, formerly, the surplus vessel was sacrificed with
the other tissues. It had occurred to me whether or not, in many, we
might not utilize a ribbon of the intermuscular, fibrous septa,
the aponeurosis, or other fibrous tissues, for this purpose !

OPERATIVE TECHNIQUE IN TORSION OF T^E ARTERIES ; IN EXPERI-
MENTAL PROCEDURES, AND ON THE HUMAN BEING.

Only the larger arteries were sought for.

The superficial femoral having been exposed and lifted out of
its sheath, was seized between two clamps and divided with the
scissors, directly across its long axis. There was an immediate
separation of more than a centimeter of the ends.

The proximal end was put on extreme tension, when a
second forceps was applied about two centimeters from the one
which held the end. Now, the segment of the vessel was again
stretched, when it was twisted until its outer superficial fibers
were seen to rupture. Then, a fine suture was carried through the
outer coat of the free end, to leave in situ for the purpose of draw*
ing down the vessel in the event of torsion failing. The vessel
was then liberated, when its twisted end disappeared in the tissues,
There was no hemorrhage. The proximal end of the vessel



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203 manlbt: torsion, etc., of divided abtbbies.

having been safely disposed of, the distal was now taken up«
Immediately on removing the clamp, which had held the orifice
in a tight grip for ten minates, blood spoated through it with
great energy. The clamp was re-applied in the same position^
with another a little more than a centimeter farther down, when
the vessel was treated as the preceding, with the same result.

The common carotid on another dog was treated by torsion^
which failed at the proximal end. I have tried this, experimentally,
on no other arteries thus far ; but, since taking up this study, I have
generally employed nothing else as a hemostatic agent in occluding
those smaller bleeding vessels, divided in abdominal and all sur^
face operations.

The very few imperfect observations which I have made thus
far on hemostasis by torsion, have convinced me that this is an
expedient of great value in appropriate cases, when all its details
of technique are fully carried out.

It would appear that it is especially valuable in those small
vessels with thick coats of yellow elastic tissue. When these are
imbedded in muscular tissue, torsion should whoUydsupplant every
description of ligature. But there are many arteries which form
channels for themselves in the tissues through which they pass, as
those of the scalp, and others in which the vessels' coats and
■heaths are so intimately incorporated with the parts through
which they pass, as in the palmar surface of the hand and the
plantar surface of the foot, that they do not permit of sufficient
displacement forward and outward to allow of ample twisting for
effective occlusion.

Enough has not been accomplished from experimental
and clinical -observations to enable us to estimate just how far
torsion is a practicable and useful expedient in the obturation of the
major arteries, though much has been written on the subject. A
definite and precise manual is essential in the performance of
torsion.

The bleeding orifice must be seized separately from other
tissues. Gradual, but considerable, tension must be made on the
free end of the vessel in order to clear it from adhesions with
adjacent tissues, and, besides, to put the longitudinal fibers on a
full stretch. Now, a second clamp seizes the vessel at its upper-^
most point, while a rotatory motion is commenced below, when
the twisting is carried to the point of rupturing the outer coatt
Then the forceps last applied is removed, when two or three more



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MANLBT : TOBSION, ETC., OP DIVIDED ABTEBIES. 263

turns are given the end of the vessel. The latter is once more
slightly stretched when we let go, and the stamp of the vessel
disappears in the tissues.

In order to give support to the mangled artery, and pro-
vide against secondary hemorrhage, it is always well to carry a
light catgut suture through the tissues in which the crushed end
of the artery is imbedded. In young people the collateral tribu-
taries are so abundant that the distal end of the vessel must be
effectually sealed before we finally close the wound, or complete
the dressing. Now, the smooth, firm bandage over an abundance
of aseptic, fluffy dressings, with the limb, stump, or part, in a
comfortable position, the patient is placed on a proper regimen.
Nature will promptly do the work of repair, and it may be said
that in many cases the primary dressings need not be distirrbed
until the healing processes are complete.

This is the ideal to which we all should aim, but it is practicable
and safe only under favorable circumstances. In order to realize
it, every facility must be within easy command. Our patient^
after operation, must always be placed in complete and perma-
nent physiological rest until the healing processes are consum-
mated.

HOMOLOGOUS LIGATION.

Oftentimes, in the course of our studies, experimentation, and
clinical observations, a new idea flashes through our mind, and at
once, perchance, we imagine we have made a discovery.

There are today, remarkable to say, many who firmly believe
that Harvey alone discovered the circulation, while admitting that
centuries before this profound investigator was born the properties
of the arteries and veins were well understood ; and so there are
others who would give all the credit of pulmonary physics to
LannaeC) and, besides, proclaim that Lawson Tait was the first to
discover purulent masses in the Fallopian tubes. But it is said
that " There is nothing new under the sun," and, surely enough,
soon after one has come forth and vaunted his new discovery, and
feels himself safe as the sole recipient of its honors, great is his
chagrin £o learn that there is nothing original in his contribution,
and that it had long since gone into oblivion because it possessed
no practical value, and was hence cast aside as useless.

Is the same fate in store for the Homologous Ligation of the
Arteries ? Is there anything in the principle of utilizing the
waste or excess of a vessel to close its own lumen ?



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264 HANLBY : TOBSION, ETC., OP DIVIDED ABTBRISS.

Is there anything original in the utilization and appropriation
of a living ligature to close a vessel ?

Has this an application to other organic elements and struc-
tures besides the blood-vessels ?

And, lastly, have others given this procedure a trial ?

Does the theory rest on a substantial rationale ?

Bone, we know, can only undergo repair or reproduction by
bone. Destroyed integument can be replaced with the same tissue
only. The same law applies to all the organic elements. Ballance
tells us that even the most aseptic catgut, wound around an
artery, is a foreign substance, which the phagocytes attack and
assimilate as heterogeneous elements. All of which points, as this
eminent author avows, to the fact that the ligation of arteries is
yet in a very unsatisfactory state.

In the near past, when << laudable suppuration " was regarded
as an important phenomenon in all flesh wounds, the presence of
extraneous materials was not regarded as harmful. But, in our
time, the elimination of suppuration, absolute and complete, is
demanded as the sine qtca non of sound surgery in all contamin-
ated wounds. The methods of the past will not do for the
present. Accordingly, in order to have our therapy in accord and
harmony with modem biological studies and pathological doc-
trines, further advances must be made in many directions.

When the thought dawned on me that the homologous ligation
of the arteries was a practicable expedient, it was soon apparent
that it would only apply to certain definite phases of hemorrhage.
This I was quite certain of, though it occurred to me that in many
instances when the vital elements of the arterial walls were too
scant to be used in this way, the heterogeneous tissues might
be drawn on, in the immediate vicinity, for a similar purpose.
Yet, there remained many situations in which obturation might be
impracticable. In the vast majority of those cases, by the appro-
priate utilization of torsion, we can efficiently obturate the vessel.

Homologous ligation promises the most happy results in the
larger arteries, as the femoral, brachial, carotid, and the larger
arteries of the forearm and leg. It seemed to me a simple and
practicable expedient in closing the arteries of the spermatic
cord, as the cremasteric and spermatic are long, thread-like vessels,
which could be firmly knotted when divided close to the gland.

This expedient seemed to me likewise specially adapted to those
cases of primary amputation in which the limb is immediately and



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manlet: torsion, etc., of divided abtebibs. 266

permaneiitlj destroyed beyond every hope, yet, in which many of
the vessels and nerves preserve their vitality varying distances
beyond the point at which an amputation mast be made.

In the smaller arteries, when sufficient of the caliber of the
vessel can be exposed without doing violence to adjacent parts, it
might serve a most useful purpose.

That homologous ligation, in continuity, has a place in surgery,
is yet to be determined. If, however, the principle on which it
rests is a rational one, then there can be no question but that it
may be utilized in this class with advantage.

TECHNIQUE OP HOMOLOGOUS LIOATUBE.

This may be divided into three stages :

1. l%e isolation of the vessel. 2. Its bisection and ligation.
S. Vascular fixation and approximation of the tissties.

In the mangling of tissues, which we so generally find in very
serious compound fractures, and when the trunk of the vessel to be
treated lies free and close to the surface, under the torn integu-
ment and other tissues, it may be easily detached from its loose
<M>nnections, raised from its bed, and drawn out sufficiently for
homologous ligation without difficulty. But when the artery is
torn in two, the question may arise as to whether, if the distal
divided end preserve vitality, it may not, in this manner, be util-
ized for ligating the proximal end.

Assuming, however, that we propose dealing only with the
proximal end and utilize it for its own occlusion, many difficulties
may present themselves. If the brachial artery, as an instance, is
torn through at the inferior end of the insertion of the pectoralis
major, close to where the internal and external cords of the
brachial plexus form a Y, and the main trunk passes immediately
into and under it, the isolation of it without damage to the nerves,
or sacrifice of many of the numerous axillary branches, may seem
quite impossible.

In an amputation we may have little consideration for those
contingencies. Hence, if a large nerve trunk lies in the way, we
divide it, lift the vessel up through the gap, then replace the
nerve ends, pass a fine catgut suture through the neurilemma, and
replace the nerve. If the section of the main trunk is convenient
to a large branch, in amputation cases, this may be caught between
two forceps and divided.

At least two inches of the extent of the vessel must be liber-
ated and exposed with its sheath intact if possible, when gradual



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266 manlbt: tobsion, etc., of pividbd abtebies.

but steady tension is made on the vessel in the direction of the
long axis of the trunk until it is fully stretched ; at which time
another clamp forceps is firmly fixed as close to its point of
emergence from the tissues as possible. This completes the first
stage of the operation.

BI-SEOTION AND LIGATION.

It will be noticed that thus far our initiation varies but slightly
from that of torsion, which, indeed, this is a species of. Its con-
trasting features consist only in that ^instead of twisting the
vessel on itself we utilize its walls fOr a tnot.

The clamp on the free end of the vessel is now removed, and
we will deal with it according to its caliber in two different ways.
If it be a smaller vessel, it is tightly knotted on itself in two or
three places. When each knot is drawn, tension is maintained
until the elasticity of the vessel is overcome ; and now that the
knotting is completed, the vessel is liberated.

With a large trunk, a somewhat different technique must be
observed. The initial steps, however, are similar to those
employed on more diminutive vessels. The vessel is bisected
or trisected, while I have succeeded by merely dividing the
vessel and tying either end. Later experiments have assured
me that to split the vessel in three segments, employing one
to turn on itself and plug the open lumen of it, and then
ligate with the other, a more effective obturation is secured
than on using but two strands. In all these cases of section
of the vessel, the division was carried up to within about
two lines of the point, at which the uppermost margin of the
artery appeared through the tissues. Now the free ends are again
moderately stretched, when they are tied with a reef-knot, singly,,
doubly, or trebly. The knotting being completed, the free ends
are firmly drawn on and tension continued from two to four
minutes, when the upper forceps are removed and the vessel is
released.

The third and final stage embraces Vascular Fixation^ and
approximation of the tissues. With the larger vessels, with this
procedure, an adjustment ligature of strong catgut, carried well
into the tissues and firmly knotted, serves a most valuable
auxiliary purpose. The integumental suture will serve this
purpose in the majority of cases, but if an accessory suture or two-
are regarded as necessary, we should not hesitate to insert them.



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MANLET : TOB8ION, ETC., OF DIVIDED ABTEBISS. 267

It goes without saying that in every instance the possible
■access of homologous ligation of the arteries depends on an
aseptic wound.

Every description of straining and bodily movement should be
prevented, as far as possible, for the first forty-eight hours after
operation. Vomiting, coughing, or straining at stool, all greatly
increase arterial tension, and should be avoided until the immedi-
ate danger of secondary hemorrhage is past.

CONCLUSIONS.

Whether homologous ligation or obturation of arteries, the
former by a living tissue, and the latter by torsion of the vessel,,
possess any enduring value, experimental work and clinical
observations alone will decide. Torsion is a very ancient
expedient, which suffices for the diminutive and superficial vessels ;
but, for those very deeply lodged, or those of very large caliber^
it has not been very generally trusted until recent times. Since
the attention of the profession has been called to the subject by
Prof. John B. Murdock, who has revived it on a large scale, and
has shown that with the perfected technique, with modern dress-
ings, and the elimination of suppuration from fresh wounds, its
application has a very large field.

As for homologous ligation, I am firmly convinced that, with
the onward march of progress, in the near future, the question of
perfected hemostasis will be definitely settled, and that on the



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 27 of 78)