304 often seen to be made. All the tightening of the thread, really necessary, is such as is sufficient to embed it in the arterial coats, so that it shall not be thrown off by the impulse of the blood against it. The employment of a broad ligature, viz., ribbon, tied upon a piece of cork, and removing it some days before ulceration had taken place, was proposed and practised many years ago by the elder CLINE in St. Thomas's Hospital; the first case failed, but the second succeeded; the preparation of the latter is now in the museum of that institution, the patient having died of diseased lungs three months after the operation. But subsequently it was found to produce great irritation, the cork acting as an extraneous body, and therefore the operation was given up. SCARPA, however, used a cylinder of linen, upon which the ligature was tied, thinking it preferable to wood, as being more like a cushion than anything which could bruise. In cases of amputation, when, as occasionally happens, the arteries are ossified, MANEC (a), who objects to tying such vessels at any time with small round ligatures, as likely to break up the diseased coats, in consequence of which bleeding happens between the second and fourth day, recommends the introduction of a piece of bougie into the ossified artery, as practised by DUPUYTREN and Roux. (p. 25.) I have not had any experience in this practice, and I do not remember to have seen bleeding of the wounds of old people, whose arteries are generally more or less ossified, more frequently than in other persons of younger age. Indeed, it occasionally happens, that the whole tube of the artery is filled with earthy matter, and impervious, therefore not requiring to be tied.-J. F. S.] 290. Notwithstanding these objections to the use of the simple round ligature, which cuts through the inner arterial coat, experience is in favour of this kind of ligature, inasmuch as the inflammation excited by it renders the obliteration of the artery more sure, and after-bleeding is more certainly prevented, because the vessel is perfectly closed before ceration of the outer arterial coat has caused the ligature to fall off. This subject will be more fully considered in the treatment of aneurism. 291. In tying arteries the Surgeon must endeavour, as much as possible, to include none of the neighbouring parts in the ligature, and still not completely to isolate the artery. He seizes the mouth of the wounded vessel with the forceps, by laying the points of the instrument on each side of it An assistant carries a round, not very and gently drawing it forwards. thick, but sufficiently strong, waxed silk ligature, about the vessel, ties a single knot, and, whilst he holds the ends of the ligature with both hands, he draws the knot somewhat together, presses with both his fingers upon the artery, draws it sufficiently tight, and then makes a second simple knot. The common forceps is certainly the best instrument to hold the divided vessel, and makes the tenaculum, and all the knick-knackeries which have been added to the forceps, superfluous. In case the surgeon has to perform the ligature of a vessel unassisted, it is best that the forceps should be furnished with a slide. Besides the old broad arterial forceps, must also be here mentioned BROWNFIELD's tenaculum, with the alterations of ZANG and CHARLES BELL; the hook-forceps of ASSALINI; the forceps of BRÜNNINGHAUSEN, of RUST; the forceps, with moveable auxiliary limbs, of BLOEMER and ASSALINI, for projection of the loop; the tenaculum-forceps of WEINHOLD; the double tenaculum of WEIR; the loop-drawer of JACOBSON, for the application and drawing together of the ligature. Compare, HOLTZE, E. G. F., De Arteriarum Ligatura; cum tab. xi. Berol., 1827. 4to. GRAEFE, Beschreibung zweier neuen Instrumenten zur Unterbindung trefleegender [I do not quite agree with CHELIUS as to the incomplete isolation of the artery before applying the ligature; but I do fully participate in his preference of the forceps to any other instrument for drawing out arteries. I always use two pair of forceps for taking (a) Traité théorique et pratique de la Ligature des Artères. Paris, 1832. fol. up a large vessel; drawing it out with one pair, in the way he recommends, and then with the other clearing it entirely of all its surrounding connexions. This was the younger CLINE's practice, and I think very good, as it certainly excludes the accompanying nerve, which often excites severe pain and irritation. I am not, however, sure that the complete separation from the neighbouring parts at all hastens the throwing off the ligature. The tenaculum is the instrument more generally employed in this country for taking up arteries; but I think it objectionable, as it commonly lifts up a large mass of soft parts which ought not to be included in the ligature. It may not be amiss to observe here, that tying a ligature requires rather more attention than is commonly paid to it. Generally it is necessary to pass one end of the thread only once through the other, but some surgeons prefer twice, and sometimes this is convenient if the operator be short of assistants. Each thread is to be held by the forefinger and thumb of the corresponding hand, as near the wound as possible, and as the ends are drawn tight the middle finger of each hand is to be carried below the former upon the thread as close to the knot as possible, so as to pull upon the vessel with the least disturbance of its position. This is infinitely preferable to pulling at the ends of the thread two or three inches from the tie, and thereby dragging the artery up from its bed, as too commonly practised. Neither in making the second tie to complete the knot should one end of the thread be kept constantly in the same hand, and the other turned round it and then passed through the loop, as by this practice the knot is unsafe and often slips. But the first tie having been made, the finger of an assistant should be pressed slightly on, so as to keep it steady, whilst the two ends are carried across and made to change hands, after which the end not passed through the first loop should be put through the second, and the tie made as before. In this way both ends equally participate in the knot, and render it secure and safe. I have been particular in describing this seemingly trivial operation, because in reality it is a very serious one, as upon the fixity of the knot depends the patient's safety.-J. F. S.] 292. If the mouth of an artery have so retracted that it cannot be taken hold of, it is better to lay it bare by a careful incision, and to tie it alone, than to dip for it, (als sie zu umstechen,) that is, to carry, with a semicircular movement, a common-handled needle armed with a ligature through the neighbouring parts, on both sides of the vessel, and then to draw the threads sufficiently tight. The dipping is only necessary when the vessel has such firm adhesions that it cannot be taken hold of. If a pretty large injured artery cannot be laid bare within the wound, it is better to expose it between the wounded part and the heart, and tie it there. On large arteries, (the branches of which anastomose freely,) whether partially or completely divided, it is necessary to apply two ligatures, one above and another below the division, to prevent after-bleeding, which may take place by regurgitation of the blood from the lower end of the artery. On this account, also, in wounds of the larger branches of a large artery, if the latter be tied above the wounded part, after-bleeding ensues from the quickly established collateral circulation (a). [Another point in reference to taking up wounded arteries is also not to be overlooked, namely, that if that side of the limb at which the wounding instrument have entered be at a greater distance from the artery than the sound side, it is preferable to cut down upon the vessel at the uninjured part. I recollect some years ago seeing this practice adopted with great success by my friend TRAVERS. The patient had received a scythe wound on the outside of the leg, and the scythe passing across had wounded the posterior tibial artery, but did not penetrate the skin on the inside of the leg. Attempts were made to get hold of the vessel by enlarging the wound, but its depth was so great that they were fruitless. An incision was then made along the inner edge of the shinbone, and the artery without difficulty secured.-J. F. S.] 293. One end of each ligature should be cut off near to the knot, and the other taken, by the shortest course, over the edge or the angle of the wound. If this be done, no accidents, which can properly be ascribed to the ligatures, ever happen. Ligatures separate, even on the largest arteries, in from fourteen to sixteen days; on the smaller ones in a shorter space (a) BECK, über die Anwendung der Ligatur bei Schlagader-Wunden. Freiburg, 1836. VOL I. X 306 of time. If they remain longer, they are retained by the surrounding granulations, and must be separated by repeated pulling and twisting. Cutting off both ends of the thread near the knot, as recommended especially by LAWRENCE (a), HENNEN (b), DELPECH (c), WALTHER (d), and others, is advantageous, inasmuch as the quick union is less disturbed, the remaining knot being either enclosed in a cellular capsule, or separated and absorbed. Numerous experiments, however (e), prove that re-opening of the wound, suppuration, fistulous passages, and the like, may be produced by the knots remaining; and, if the first-mentioned mode of tying the vessels have been employed, no inconvenience has been observed from the retention of small single threads, as I am convinced from repeated experience. For the purpose of helping the solution and absorption of the remaining knot, it has been recommended that the ligature should be made with softened catgut, or with the substance called by the English, silk-worm-gut," [the silk tubes of the silk-worm containing the secretion from which the silk is spun, stretched and dried.-J. F. S.,] or with leather (f). Attempts to tie arteries with fine metal wire have also been made (g). 66 For special apparatus to remove long retained ligatures, see A. LAU (h), KLUGE and VON GRAEFE (i). [The practice of cutting off both ends of the ligature was first made public by HAIRE, of Southminster, in Essex, as long back as 1786. He says (k):-"The ligatures someAn intimate friend of mine, a surtimes become troublesome, and retard the cure. geon of great abilities, proposed to cut the ends of them off close to the knot, and thus leave them to themselves. By following this plan, we have seen stumps healed in the course of ten days. The short ligature, thus left in, commonly made its way out by a small opening in a short time, without any trouble, or the patient being sensible of pain." (p. 390.) In 1813, HENNEN (1)says that he adopted this practice at the suggestion of one of his assistants, who believed it to have been an American invention. He treated several cases in this way, and observes :-" As no inconvenience whatever followed, nor did the small particle of silk left behind give rise to any apparent irritation, I made a favourable report of the short-cut ligatures." He adds, however, that, " of the small circles of silk, a part had come away with the dressings, whilst some had floated out on opening the little pustules which formed over the face of the stump, at the points where the arteries had been tied. Some few of the ligatures never made their appearance, and the patients complained of no uneasiness whatever." (p. 176.) GUTHRIE mentions that this practice was followed out successfully in the campaign of 1813; and that, in June of the following year, DELPECH showed him several cases doing well at Montpellier. In this year, also, LAWRENCE read the paper already alluded to, advocating the practice of cutting off the threads just above the knot, and closing the wound. But latterly he does not seem to hold so closely with this practice; for, after making an observation about which it is scarcely possible there can be any difference of opinion, viz., that “in every instance where you have an expectation that the wound will suppurate, you may cut off both ends, because the knot will come away with the suppuration," he more recently says (m):-" If the wound, however, is likely to unite by adhesion, perhaps the safest and best method is to cut off one of the ends, and leave the other hanging out of the wound." (p. 116.) I must confess I prefer retaining one end of the ligature, and bringing it out of the wound, to cutting off both, as scarcely ever do we desire or encourage suppuration in a wound, but take every precaution to favour adhesion. If there be an open wound, either by a portion of the skin being lost in the accident, and the edges incapable of (a) Medico-Chirurgical Transactions, vol. vi. p. 156. (b) Observations on some important Points in the Practice of Military Surgery, and the Arrangement and Police of Hospitals. Edinburgh, 1818. 8vo. (c) Mémoire sur la Complication des Plaies et des Ulcères connues sous le nom de Pourriture de l'hôpital, p. 29, Paris, 1815; and, Chirurgie Clinique de Montpellier, vol. i. Paris et Montpellier, 1823. 4to. Observations et Réflexions sur la Ligature des principales Artères, p. 85 (d) FRAENKEL, Pres. WALTHER, Dissert. de Laqueis Arteriarum Deligatione inservientibus prope ad nodum revinctum resecandis. Bonnæ, 1824.DIEFFENBACK, über das Abschneiden der Unterbindungs faden nahe am knoten; in RUST's Magazin, vol. xxiv. part i. p. 17. (e) GUTHRIE, G. J., On Gunshot Wounds of the Extremities, requiring the different operations of Amputation; with their After-treatment. London, 1815. 8vo.-GROSS ; in London Medical Repository, vol. vii. p. 363. (f)JAMESON, J. H. G., Observations on Traumatic Hæmorrhage; in the Medical Recorder for Medicine and Surgery, vol. xi. Jan. 1827. (9) LEVRET; in American Journal of Medical Sciences, May, 1829. (h) Ueber die Lösung zu lange liegenbliebender oder eingeheilter Gefäss Ligaturen; in Rust's Magazin, vol. xxiv. part i. (i) in VON GRAEFE and VON WALTHER's Journal, vol. xvii. p. 339. (k) Remarks on Mr. LUCAS's Practical Observations on Amputation; in SIMMONS' London Medical Journal, vol. vii. 1786. (1) Principles of Military Surgery. 2nd Edit. Edinburgh, 1820, 8vo. (m) Lectures; in Lancet. being brought together, or if, in a sloughing sore, an artery be opened by ulceration, then both ends may be cut off without hesitation; but otherwise it is best to retain one, were it only that its separation proves that another cause may produce the fistulous passages which occasionally form in wounds, of which, perhaps, nearly the whole, excepting these, has healed quickly and kindly. The employment of silk-worm gut was first proposed by Dr. M'SWEENY, of Cork, Ireland (a), that of leather, or the animal ligature, consisting of chamois leather rolled, was recommended in 1814 by PHYSICK, of Pennsylvania, who, according to Dr. REESE (b), thinks that, as it is "made of animal matter, the knot, which is all that is left in the wound, will serve long enough to obliterate the artery, and be speedily removed by the absorbents, thus avoiding the difficulty arising from a foreign body, however small.” ASTLEY COOPER had at one time a fancy for catgut ligatures; he says (c) :—“ Catgut, employed as a ligature, being more of the nature of the animal matter in which it is embedded, will be more easily absorbed than silk, or, if even not absorbed, will be less likely to excite irritation in the parts." (p. 126.) He tied the femoral artery, in a case of popliteal aneurism, with this substance previously soaked in water heated to 100° Fahrenheit, cut off both ends, and closed the wound with adhesive plaster; on the fourth day after the operation the wound was completely united; in three weeks he walked about the ward with a crutch; no kind of untoward symptoms appeared, and he was perfectly cured by the fifty-fourth day. This practice may have been pursued with two or three cases, but was soon given up, though I do not recollect for what reason. I have also an indistinct notion of COOPER having on one occasion used an isinglass ligature, but I have not any note on the subject to refer to. He, however, commonly used Dutch twine. The material now generally employed is silk of various thickness, according to the size of the artery to be tied. It should be well twisted and round, and should be slightly waxed when used. As regards the time required for the separation of ligatures, it is very various, and may depend on the constitutional powers of the patient, or on accidental causes. I have known a ligature on the femoral artery come away in ten days; but in the last case of popliteal aneurism on which I operated it did not come out till the fortieth day. My friend CALLAWAY tells me, that very recently, in a similar case, he has withdrawn a ligature four months after its application; and my friend GUTHRIE, that a short time ago he had pulled away a ligature from the brachial artery which had remained four months after amputation of the arm. There is also in the museum of St. Thomas's a preparation of a ligature which had been applied to the femoral artery, and remained in the stump. I cannot exactly say upon the artery, till death, six months after. Sometimes the ligature has been allowed to remain for many weeks in consequence of the agonizing pain produced when even very gently pulled. In such cases it may be presumed that a nerve has been included in the ligature, as happened with a a patient of CHOPART's, in which it remained till death; and the parts are in our museum at St. Thomas's. The like untoward accident befel our celebrated naval hero, Lord NELSON, whose arm was amputated at the attack on Teneriffe; the ligature was retained several months, and caused him violent agony, but was at last removed by Dr. BEATTIE. Occasionally it happens that the artery is not perfectly sealed up after the application of a ligature; and when the thread begins to ulcerate the vessel begins to bleed: this occurred many years ago, in a case in which my friend GREEN tied the subclavian artery for axillary aneurism. On the fourteenth day after the operation, an arterial bleeding to the amount of a pint occurred from the wound; it was, however, stopped by a quarter of an hour's firm pressure, after which cold wet linen was applied, no further bleeding ensued, and on the twenty-seventh day the ligature came away. The wound healed, except a small sinus from whence there was only a slight discharge, which continued open. From this about midnight of the 31st of October, exactly thirteen weeks after the operation, a sudden jet of blood occurred whilst he was asleep, but was easily stopped by pressure. On the following evening, whilst he was voiding his water, the arterial bleeding again recurred in a jet and as large as the aperture of the sinus would permit. Pressure, however, soon checked it, and, after having been kept for an hour was withdrawn and cold wash only applied. He slowly recovered without further accident. This, although an extreme and very uncommon case, is a good example of the advantage of leaving the parts at rest and undisturbed, if the hæmorrhage can be stayed (a) Edinburgh Medical and Surgical Journal, vol. xiv. p. 18. (b) REESE and JAMIESON'S Edition of SAMUEL COOPER'S Dictionary. (c) On the Ligature of the Aorta; in his and TRAVERS' Surgical Essays. 308 by pressure and cold lotions. Had the ligature been pulled about in the first instance, I believe the safest and best plan is, generally speaking, to leave the ligature to be ejected from the wound by the suppurating process. It should never be pulled violently till some weeks after it has been applied; nor should it ever be jerked under the notion of favouring its abstraction. The degree of its fixity should be daily ascertained by steady and gentle pulling; if it yield, it may be presumed to have separated from the vessel, though such is not always the case, as a coil of the thread may have remained accidentally in the wound, and unwinds by the pull; but if the ligature continue to follow Sometimes the the draught upon it, usually it can be withdrawn. If it will not come out forthwith it must be left, and the same practice repeated daily till it does come out. thread has not ulcerated through the vessel, of which the obliteration is not completed in the usual time, and then, if the ligature be violently dragged, secondary bleeding will ensue; or the ligature may have separated, and its knot be entangled by the granulations around it. This obstacle is commonly soon overcome by absorption of the granulations between the knot and the skin, and may be usually waited for without inconvenience to the patient. It must not therefore be supposed that if the ligature do not come away, it is necessarily still around the artery, which is generally not the case. Some surgeons, when a ligature has been long retained, pass a probe by its side, as low as it will descend, and then twist thread and probe round till both come away together. But I prefer the younger CLINE's practice of putting a thin whalebone spring upon the thread, the constant pull of which upon the knot makes it press against the obstacle which prevents its coming away, and produces ulceration, which sets it free often in the course of the day; but if not, the thread must be daily twisted on the spring, so as to keep it tight till it comes away. Another method is to roll the thread close up to the wound, on a bit of bougie or wood, and prevent its uncoiling by fixing it with adhesive plaster, but the former plan is preferable.-J. F. S.] 294. Torsion, or the twisting of arteries, (Torsio Arteriarum,) distinctly mentioned of old by GALEN (a), has, in modern times, been proposed, and proved by experiments on animals, by AMUSSAT (b) and THIERRY (c), as a safe mode of stanching the bleeding from arteries. LIBER (d) has repeated the same experiments in Germany. VElpeau first used torsion on the human subject. AMUSSAT, FRICKE, DieffenBACH, and others, have made numerous experiments of the kind (e). 295. The changes produced by the torsion of arteries are, 1st, the inner and middle coats of the arteries are circularly divided or torn for some lines above the opening of the vessel, they approximate and shrink away from the cellular coat, and, by retracting into the canal, form a blind sac or valve, which may be called the inner valve; 2nd, an external valve (like a monk's hood) is formed out of the above-named cellular coat, which completely closes the mouth of the artery; 3rd, a blood-clot is invariably formed, which fills up the cavity of the artery; 4th, inflammation and plastic exudation taking place in the torn inner and middle arterial coats, closing the mouth of the artery, and its walls which touch each other become united; 5th, suppuration and ulceration may, indeed, occur in the arteries in question, but hitherto they have not been noticed, neither are they, in any case, necessarily connected therewith; 6th, the canal of the (d) HECKER's Annalen, vol. xv. p. 185-196. Feb. 18.0. (a) GALEN (Meth. Medic. lib. v. cap. iii. p. 318. Edit. KÜHN) says, on this point: xai xórsga φλεψ, ἢ ἀρτηρία ἐςί μὲτα δὲ ταυτα διαπήιρας ἀγκίςρῳ ἀνατεινέτω τε καὶ περιστρεφέτω μετρίως. (b) Archives Générales de Médecine, vol. xx. Aug. 1829, p. 606. (c) De la Torsion des Artères. Paris, 1829. (e) SCHRADER, Dissert. de Torsione Arteriarum. Berol., 1830. 8vo.-VELPEAU, Mémoire sur la Ces sation spontanée des Hémorrhagies traumatiques et les moyens, qui dans quelques cas pourraient servir des succedanes à la ligature des artères; in the Gazette Médicale, vol. i. No. 48. Nov. 1830. |