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THE



HEALING OF ARTERIES



AFTER LIGATURE



IN MAN AND ANIMALS



BY

J. COLLINS WARREN, M. D.,

ASSISTANT PROFESSOR OF SURGERY, HARVARD UNIVERSITY. SURGEON TO THE MASSACHUSETTS

GENERAL HOSPITAL. MEMBER AMERICAN SURGICAL ASSOCIATION. HONORARY

FELLOW PHILADELPHIA ACADEMY OF SURGERY.



NEW YORK
WILLIAM WOOD & COMPANY
1886



Copyright, 1886,
WILLIAM WOOD & COMPANY



The Publishers

Book Composition and Electrotyping Co.

157 AND 159 William St., New York.



Was die Erfindung der Buchdruckerkunst fiir die Wiss-
enschaft, was die Erfindung des Schiesspulvers fiir den
Krieg, was die Erfindung der Eisenbahn fiir den Verkehr
der Volker untereinander, das ist die Erfindung der Arte-
rienunterbindung fiir die Chirurgie.

DiFFENBACH, Die Operative Chirurgie,
Leipzig, 1845, i-) 121.



PREFACE.



The study of the subject of which this monograph treats, has
been carried on, hitherto, in a more or less fragmentary way, different
portions of it having received very minute attention, and from the
hands of the ablest pathologists. The attempt has been made here
to study the question from a more comprehensive standpoint, to ob-
serve not only the behavior of the various tissues concerned in the
process of repair, but also the different phases through which the
vessel passes from the moment of ligature until the condition is
reached after which no further change occurs.

The investigations have, for the most part, been carried on in the
Harvard Medical School, and the writer takes this opportunity to ex-
press his appreciation of the great facilities offered for such work in
the Physiological and Pathological Laboratories.

Experiments were performed also in the Veterinary Department
of the University, with the permission of Professor C. P. Lyman.

Through the courtesy of Dr. J. S. Billings, the very valuable col-
lection of arteries in the Army Medical Museum, at Washington,
was placed at the writer's disposal for study.

Finally the writer wishes to express his indebtedness to Dr. H.
P. Quincy for skilled assistance in many of his experiments.

Boston, March, 1886.



CONTENTS.



I.

PAGE

History, .......... i

II.

Experiments on Animals, ....... 47

III.
Human Subject, .... ..... 82

IV.

Closure of the Fcetal Vessels, . . . . . .111

V.
Summary, ........ 138



Appendix, .......... 153

Bibliography, . . . . . . . . .163

Index, . .. . . . . . . .171



The Ligature of Arteries.



CHAPTER I.

HISTORY.



LiSFRANC well says: "La ligature a ete * * * I'objet de
recherches si multipliees que I'histoire des diverses precedes des
experiences tentees pour connaitre la maniere d'agir des instruments
inventes pour la faciliter ou I'ameliorer pourrait fournir matiere a
plusieurs volumes." It needs but a casual glance at the literature
of this important department of surgery to discover that the ligature
v/as employed by surgeons in early historic times.

Probably the first recorded use of a ligature is that mentioned by
Siisrutas^ 1500 B.C. who employed it in tying the umbilical cord:
no mention, however, is made by him of its use in surgery, nor do
we find any in the writings of the early Egyptians, from whom the
Greek writers of that time obtained their knowledge of surger}^
Had the ligature been in use at that time we should have undoubted
evidence thereof in the writings of Hippocrates- (460-375 b.c). By
some writers he has indeed been regarded as the discoverer of the
ligature. The passage upon which this claim is based is the follow-
ing: " Sanguinem e venis profluentum sistunt animi deliquium,
figura aliorsum tendens venae interceptio, ],inamentum contortum
appositio deligatio."

This rendering of the Greek text is not accepted by some of the
best authorities, and the sixth book, in which it occurs, is regarded
by many as not genuine.*

Praxagoras (335 B.C.) first discovered the difference between

* Both Haeser ^s^ and Greifenberger state emphatically that no traces of the
mention of the ligature are to be found in the writings of the Hippocratic school.
In Adams' " Genuine Works of Hippocrates," there is no allusion to it.

I



2 The Ligature of Arteries.

arteries and veins, and his pupil, Herophius, and a colleague, Era-
sistratus, first bound limbs previous to amputation, to prevent
hemorrhage.

It is probable that the ligature was first introduced by some sur-
geon of the Alexandrian school, in which great progress was made
in the study of anatomy and surgery; for Celsus,^ (25-30 B.C. 45-50
A.D.) who was deeply versed in the literature of his time, and par-
ticularly that of Alexandria, derived his knowledge of the ligature
from this School.

Aulus (or Aurelius Cornelius) Celsus was one of the first Roman
medical authors. The following quotation from his works gives a
fair idea of the means used to arrest hemorrhage at that day.

" If the hemorrhage be alarming, which may be known by the
situation and size of the wound, and from the violence of the bleed-
ing, the wound is to be filled with dry lint, and a sponge squeezed
from cold water is to be pressed firmly on it by the hand. If the
bleeding does not subside by these means, the pledgets are to be fre-
quently changed, and if not sufficiently powerful whilst dry, they
are to be moistened with vinegar. This last is a powerful agent for
suppressing hemorrhage; and, on that account, some pour it into
the wound; but here again it is to be feared that the matter, by
being powerfully retained there, may subsequently produce high in-
flammation. It is this which prevents one using corrosives, or those
applications which, by their caustic quality, induce an eschar; al-
though most of them check hemorrhage. However, if once in a
way we do have recourse to such, the mildest are preferable. But
should these means fail also, the bleeding vessels should be taken
up, and, ligatures having been applied above and below the wounded
part, the vessels are to be divided in the interspace, that thus they
may retract while their orifices remain closed. When the case does
not admit of this measure, the vessels should be cauterized."

It is supposed that the following passage from the writings of
Celsus indicates that linen thread was the material used; " Qua parte
vero inhserebunt et ab superiore et ab inferiore parte lino vinciendae,
etc." The manner of applying the ligature is thus described: " But,
before excision, these at their extremities ought to be tied with a
thread, its ends being left out of the wound, like as in other veins
requiring ligature."

In amputations, the ligature does not appear to have been used,
probably because Celsus was not familiar with the anatomy of
arteries. When these vessels, after being severed, had retracted



History. 3

beneath the surface of the wound, he did not attempt to find them
and tie them.

The successors of Celsus say Httle about the Hgature, a circum-
stance supposed to be due to the fact that they did not think it
necessary to mention this detail of an operation.* It is doubtful if
the ligature were much used. Amputation was avoided as much as
possible.

Archigenes,s however, who flourished about the end of the first
century of the Christian Era, made such modifications in the methods
of amputation that he was able to resort to it much more freely than
other surgeons of his time. He controlled bleeding by bandages
placed around the limb, applied provisional ligatures to large vessels,
and tied others after the limb had been removed.

Rufus of Ephesus recognized the difference between arteries and
veins. Both he and Heliodorus, a colleague of Archigenes, were
familiar with torsion, as is shown in the following quotation from
Rufus: " Vas immissa volsella extendemus et moderate circumflec-
temus, at ubi ne sic quidem cessaverit (hemorrhagia) vinculo con-
stringemus."

Heliodorus* says in a description of an operation for the radical
cure of hernia, "After laying bare the tunica dartos, the larger
vessels should be tied; the smaller ones should be transfixed with
a hook twisted round several times, and by means of the twisting
closed."

Claudius Galenus^ (13 1-2 11 a.d.) makes mention of the ligature
in many parts of his works. He was, however, not a practical sur-
geon, and avoided the use of the knife. According to some authori-
ties his imperfect knowledge of the vessels led him to recommend
tying the central end of the vessel only. According to Adams he
advises an accurate examination of every deep-seated vessel to as-
certain whether it is an artery or a vein, " after which it is to be
seized with a hook, and twisted moderately. If the flow of blood is
not stopped thereby, he recommends us, if the vessel is a vein, to
endeavor to restrain it without a ligature by the use of styptics, or
things of an obstruent nature, such as roasted rosin, the fine down
of wheaten flour, gypsum, and the like. But, if the vessel is an



* Haeser quotes a passage from Paulus ^gineta in support of this view which
he renders thus: " Having first secured, of course, (wie nati'irlich, w? elKoq) the
vessels." The same passage is, however, rendered by Adams: " Securing, as is
proper, with a thread, any vessel that may come in the way."



4 The Ligature of Arteries.

artery, he says one of two things must be done, either a ligature
must be appHed to it, or it must be cut across. He adds, we are
even obhged sometimes to apply a ligature to large veins and cut
them across." He used silk thread and thread of Celtic linen, and
also gut, not in the Lister sense, but simply for the purpose of
securing a durable material; he even mentions the place where he
obtained his ligatures, "The shop on the Via Sacra between the
temple Roma and the Forum." In this connection the fact is inter-
esting that in the Naples Museum are to be seen a pair of sliding
forceps found at Pompeii, which were evidently intended to be used
with the ligature. Galen was afraid that an aneurism might develop if
the ligature did not come away before the wound was closed by new
growth. He thought that the vessels were healed by a growth from
the surrounding tissues; " quje namque caro in abscisis vasorum par-
tibus coalescit, ea pro operculo est ac osculum eorum claudit."

Ant3-llus, at the end of the third century, not only invented an
operation for the cure of aneurism which, with slight modification,
still bears his name; but he also speaks of the same method of
dealing with vessels in removing tumors. He says: " If the vessel
cannot be pushed aside, it should be tied on both sides of the wound
and cut through; if the tumor were under the carotid or jugular it
would be unsafe to try this method, as it might produce instant
death."

Among the latest of the Greek writers are Aetius^ (5°2-575), and
Paulus ^gineta^ (625-690); the latter mentions the ligature more
frequently than any other ancient writer. "When the bleeding is
stopped," he says, " endeavor, if it is a vein, to restrain the blood
without a ligature by the same medicine; but if it is an artery one
of two things must be done, — either apply a ligature around it or
cut the vessel asunder, by which means you will restrain the blood.
Sometimes too we are obliged to apply a ligature to large veins, and
also occasionally to cut them asunder transversely. * * * You
ma)^ know whether it is a vein or an artery that pours forth the blood,
from this: that the blood of an artery is brighter and thinner, and is
evacuated by pulsation, whereas that of the vein is blacker and
without pulsation. The following passage has special significance,
showing that the ligature was not confined to small vessels before
the time of Pare. "But if the weapon has lodged in any of the
larger vessels, such as the internal jugular or carotid and the large
arteries in the armpits or groins, and if the extraction threaten a
great hemorrhage, they are first to be secured with ligatures on both



History. 5

sides, and then the extraction is to be made." This practice was,
however, Umited to the class of injuries mentioned, and rarely ex-
tended to amputation and other surgical operations. Torsion is not
mentioned by Paulus, although it was in use in the time of Oribasus
(326-403) who, in a quotation from Heliodorus, describing the radi-
cal cure of hernia, states that after laying bare the tunica dartos, the
larger vessels are to be tied, the small ones to be seized with a hook,
and twisted round several times, and by this means closed. It is
probable that, in later times, the more frequent use of the actual
cautery displaced this method.

The Arabian physicians, who transmitted the writings of these
authors to the Italian and French surgeons, although they mentioned
the ligature, rarely used it, confining themselves almost entirely to
the actual cautery. During the period at which this school flourished^
little or nothing was done for the advancement of surgery. This
was due to the insufferable prejudices of that time: religion forbade
the study of anatomy, and the medical man regarded it as a disgrace
to be employed in any manual labor, and contented himself with
writing prescriptions, leaving the use of the cautery and the knife
to subordinates. Avenzohar'^ (1113-1162) says: "Omnia hace ad
dictos servitores medicorum habent pertinere ad medicum autem
honoratum nihil aliud pertinere dicimus nisi ut consilium preestet
solummodo ciborum medicinarumque infirmi absque aliqua opera-
tione manuum quemadmodum non convenit ei facere sirupos et
electuaria suis manibus."

Avicenna" (980-1037) also says of amputations of the arm and
thigh, " et medicus debet ab eo fugere." Rhazes (850-922) used
linen thread ligatures, and recommends them for large vessels, but
he generally advises the more fashionable styptic and cautery.
Avicenna has but little to say about the ligature, which he confines
to arteries alone.

Albucasis or Abulcasis'* (1106), the most prominent man of this
school, was more familiar with the writings of Paulus yEgineta, and
used the ligature more freely, although he devoted a whole book to
the cautery. He thus describes the ligature: "At sin arteria magna
sit oportet illam in duobis locis ligare cum filo duplicato forti, sit
vero filum ex serico vel ex testudinis chordis ne festinet illis corrup-
tio antequam vulnus consolidetur, accideret enim hemorrhagia.
Turn amputa, quod superfluum est, inter duas ligaturas." Before
removing tumors he tied the large vessels, excising the growth a day
or two later. He performed the operation of Antyllus for aneurism.



6 TJie Ligature of Arteries.

Neither Avenzohar, nor his pupil, Averroes/^ the later representa-
tives of the Arabian school, has much to sa)^ about the ligature.

The Italian school naturally suffered from the influence of its
predecessor: medical literature was studied only by the clergy, and
the religious prejudices of that time presented the same obstacles to
the advance of surgical science that it had to the Arabian school.
The chief improvement was the introduction of the mediate ligature
applied with a needle, like a stitch, by Roger of Parma (12 14), as
recorded by his pupil Roland; and his example was followed by
almost all other Italian surgeons. Bruno (1252), gives the advice,
when other means fail, to seize the artery with a hook, and lift it up
before passing the ligature. In Lanfranchi's Surgery,'^ which was
written in the middle of the tenth century, occurs the following
passage: " Oportet te tunc aut venam ligare et ipsam de loco ex-
trahere et caput vens vel arterice contorquere aut ferro candente
sanguinem sistere," showing that the old teaching had not been
wholly forgotten. Guy de Chauliac,''' his pupil, followed Galen's
advice to apply the ligature to the central end of the vessel when
other means failed, a custom which most of the Italian surgeons
followed. Silk was the material used by de Chauliac.

With the study of anatomy, which was revived towards the close
of the middle ages, surgery made its first modern advances; but the
ligature was still chiefly confined to cases of injury where large
vessels were implicated. Among the principal changes introduced
at this time was the transfixion of the vessel by a needle armed with
a double ligature by Bertaplagia,^* a Paduan professor, who flourished
about the middle of the fifteenth century. Giovanni Vigo has been
accredited by some with the discovery of acupressure on the strength
of the following passage: " modus ligationis aliquando efficitur in-
tromittendo acum sub vena desuper filum strigendo. " A process
sonftWhat similar to acupressure we first find mentioned about this
time by Mariano Santo, ""' a traveling Italian surgeon, who passed a
deep stitch through the flap of a wound including the end of the
vessel. In Naples, Alfonzo Ferri "^ used a sickle-shaped needle,
with blunt edges, armed with a double ligature; Angelo Bolog-
nini,^ founder of the school of Bologna, used silk ligatures, but
only to a limited extent. The cautery and styptics still retained
their hold as popular methods, and were largely employed. After
the impetus given to surgery in France by the arrival of Lanfranchi
in Paris in 1295, and by his pupil Guy de Chauliac, little progress
was made in that country. Among those who were the imme-



History. y

diate predecessors of Pare were Jacques Houllier, who used both
the hook and the forceps, but timidly; and Jean Tagault, who
was professor both in Paris and .Bologna, and followed the teach-
ings of Chauliac. In Germany at this period the ligature was known
to Braunschweig, the " Senior of German surgery," to Gersdorf and
to Ryff.

When Ambroise Pare^-* began to practice surgery the ligature
had been in use for nearly two thousand years, but its range in sur-
gery, it will be seen, was extremely limited. Large vessels were
tied only when severe injuries forced the surgeon to resort to the
ligature, and in surgical operations it was confined chiefly to vessels
of moderate calibre. The few instances recorded by the ancients
of its use in amputations appear to have been forgotten, and the
primitive methods employed at that time for removing limbs have
been justly declared to be more worthy of the butcher than of the
surgeon. This great surgeon is, therefore, entitled to the credit of
not only appreciating fully this method of arresting hemorrhage, but
of making the ligature universally applicable. To him this contribu-
tion to surgery, which occurred in J 552, naturally appeared in the
light of a discovery original with himself, for, with isolated excep-
tions, the fashion of the day undoubtedly differed little from that in
vogue a thousand years before. In the English translation of his
works occurs the following passage: " Therefore, I would earnestly
entreat all chirurgeons, that leaving this old and too, too cruel way
of healing, they would embrace this new, which I think was taught
me by the special favor of the sacred Deity: for I learnt it not of
my masters, nor of any other: neither have I at any time found it
used by any: only I have read in Galen that there was no speedier
remedy for staunching of blood than to bind the vessels toward their
roots; to wit, the Liver and the Heart." Pare did not attempt to
isolate the vessel, but resorted to the mediate ligature. He -.ays:
" II te ne faut estre trop curieux de ne pinser seulement que les dits
vaisseaux: pource qu'il n'y a danger de prendre avec eux quelque
portion de la chair des muscles, ou autres parties: car de ce ne
peut aduenir aucun accident: ainsi avec ce I'union des vaisseaux se
fera mieux et plus surement, que s'il n'y avoit seulement que le
corps des dits vaisseaux compris en la ligature. Ainsi tires on les
doit bien lier avec bon fil qui soit en double." He sometimes passed
the ligature around the vessel by means of a needle, and he also
used the forceps. Occasionally the needle and thread were passed
through the flap, the skin being protected by a compress, over which



8 The Ligature of Ai'teries.

the knot was tied. He used both single and double ligatures: his
successors generally used several. He adopted the view of Galen,
that the granulations closed the mouth of the vessel.

In spite of the support given to this method by so great an author-
ity, the example of Pare found but few imitators. Even Guillemeau,''^
who was the champion of his friend and teacher, and was suffi-
ciently interested in the operation to invent a new forceps, confined
the use of the ligature to primary amputations, and used cautery in
case of gangrene.

Harvey's discovery, which occurred in 1619, gave but a feeble
impetus to the ligature. Richard Wiseman, =^ who has been called
the "Father of English Surgery," and the "English Pare," made
experiments for staunching the blood of arteries and veins. He
preferred the use of a "royal styptic," or the cautery. Cooke, of
Warwick, refers in 1675 to Pare for a description of the method of
"stitching" the vessels; and adds that it "is almost wholly re-
jected." Fabricius Hildanus,"^ in Germany, favored the ligature,
but after him there was a decadence of surgery in that country,
and the ligature was rarely used. Cornelius Van Soligen^" modified
the forceps so that the jaws remained closed after seizing the artery;
but although he and his colleagues were familiar with the ligature,
and performed Antyllus's operation for aneurism, there was little
progress to record. Fallopio, in 1660, described the operation
accurately. He recommended that the nerves and arteries should be
carefully separated with the finger nail, and asserted that the sheath
need not be opened, as it causes but little pain to include it in the
ligature. He observed the return of the circulation in a limb one
year after ligature of the .popliteal, but thought it took place in the
ligatured vessel. Marcus Aurelius Severinus (1580-1656) was the
first to tie the femoral artery at Poupart's ligament. Gaspare Taga-
liacozzi (Taliacotius) still depended, in his rhinoplastic operations,
however, upon cautery and styptics.

In spite of the invention of the tourniquet by Morel ""^ in 1674,
and of the aneurism needle by Barthelemy Sayiard^' (1656-1704),
(a blunt needle, " fait expres pour faire la ligature des arteres "),
the imperfect knowledge of anatomy and of the physiology of the
circulation prevented surgeons of that day from appreciating the
advantages of the ligature, and, at the opening of the eighteenth
century, the actual cautery was still the customary method of arrest-
ing hemorrhage at the Hotel Dieu. The contrast between the liga-
ture and the cautery was not found to be so great as might have



History. 9

been supposed. A glance at Fare's plates shows the forceps, an
instrument of rude and clumsy pattern; and it is not surprising to
learn that the new method was dreaded by some more than the
cautery. No attempt was made to isolate the vessel, but veins,
nerves, and arteries were indiscriminately bound together by the
" mediate " method. No wonder that patients complained of great
pain, with cramps and twitchings, in the stump. And even Petit,
with whom modern investigations on the healing of arteries may be
said to have begun, (1731), actually proposed compression as a sub-
stitute for the ligature.

Sharp, 32 in his " Critical Enquiry into the Present State of Sur-
gery in England " about this time, states that the ligature was used
sparingly from a " horrid apprehension of compressing the nerves."
But Alexander Munro ^^ soon showed the advantages of the direct
ligature, and that it could be applied without danger to the vessel,
as did also Pierre Dionis '^- in France, at the beginning of the eigh-
teenth century. The latter used chiefly the ligature "en masse,"
and introduced a sliding forceps, the " A^alet a Patin," but he only
tied the central end of a vessel.

Petit 35 first called attention to the agency of the thrombus in
checking hemorrhage; the blood effused around the end of the vessel
he termed the " couvercle:" that found within the lumen he named
the "bouchon." Its protective action he showed was only provi-
sional, but it remained for some time closely adherent to the inter-
nal wall, and eventually disappeared when permanent cicatrization


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Online LibraryJohn Collins WarrenThe healing of arteries after ligature in man and animals → online text (page 1 of 20)