The early days of arterial surgery.
Severe arterial bleeding must have been a common, much feared and
often fatal complication of trauma since man appeared on Earth. The
early surgeons would have used direct pressure on the wound, which would
only have provided temporary relief, or learned to apply a tight
dressing. If it was an injured limb, this would often result in
gangrene. Application of styptics such as turpentine or the use of the
cautery or boiling oil is described in ancient Greek, Roman, Hindu and
Arab manuscripts. Indeed, boiling oil to cauterise gunshot wounds was
strongly advised by John de Vigo in his surgical textbook that was
widely used in the 16th century.
KEYWORDS Artery / Arterial bleeding / Arterial surgery / Arterial repair
|Publication:||Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Association for Perioperative Practice ISSN: 1750-4589|
|Issue:||Date: Nov, 2011 Source Volume: 21 Source Issue: 11|
|Topic:||Event Code: 310 Science & research|
|Product:||Product Code: 8000410 Surgical Procedures NAICS Code: 62 Health Care and Social Assistance|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
The technique of tying off a spurting artery appears to have been
used by the surgeons of Alexander in Egypt around 250 BC and is
described by the Roman writer Celsus in the 1st century AD. Galen, one
of the most famous physicians of all time, was appointed as a young man
to be surgeon to the gladiators in Pergamum, in Asia Minor, in 158 AD,
and served there for five years. He would undoubtedly have seen numerous
examples of major vascular injury. He treated severed blood vessels by
torsion, ligation or the application of various styptics. However, the
art of arterial ligation seems to have been forgotten in the Middle
Ages, until re-introduced by that great military surgeon, (and a
particular hero of mine!), Ambroise Pare (1510-1590), of Paris, who
strongly advised ligation of major vessels, especially in amputation.
The idea of actually stitching divided vessels together again must have appeared to be an impossible dream to even the most thoughtful surgeons. There was no suitable method of temporarily occluding the injured blood vessel without hopelessly crushing its wall; needles and sutures were large and crude; the lumen of the vessel would rapidly become blocked by clot; the task seemed hopeless!
The first attempt at arterial repair appears to have been made by Alexander Jassinowsky, in Odessa, Russia, in 1891, who experimented on animals using sutures of fine silk.
The first successful repair of an artery in man, a wound of the femoral artery, was performed by J.B. Murphy in Chicago in 1897. J.B. Murphy was one of the most colourful characters in American surgery. Even his name reflects something of his character. He was born of humble Irish immigrants on a farm in Wisconsin and was christened plain John Murphy. However, when he went to school, he noticed that most of the boys had at least two initials. Determined not to be inferior to the others, he added the 'B' He studied Medicine in Chicago, qualified in 1879, worked at the enormous Cook County Hospital, spent two years with the great Theodor Billroth, in Vienna, and became Chief of Surgery at the Mercy Hospital , Chicago until his death at the comparatively early age of 59, from coronary thrombosis.
As well as a vast clinical practice, Murphy spent much time in the animal experimental laboratory. Indeed, his report of the first successful arterial repair in man begins with a 15 page account of his animal experiments carried out in dogs, calves and sheep. In the laboratory, lateral, (side to side), end to end and apposition by invagination of one vessel end into the other were tried. Fine silk was the suture material most often employed and vessel control studied by means of slings and gentle compression clamps. Murphy's clinical opportunity presented when a man of 29 was admitted in 1897 with a gunshot wound of the groin. Two weeks later, there was a loud murmur over the groin and the pulses below the femoral were hardly perceptible. It was proposed to cut down onto the artery and if the wound was more than one half of its circumference, to resect it and perform an end to end anastomosis.
However, at operation, through a five inch long incision along the course of the upper femoral artery, it was found that all but one eighth of an inch of the femoral artery wall remained and that there was an arteriovenous aneurysm between the damaged artery and a large hole in the femoral vein. The vein was dissected free and sutured. A half inch of the damaged femoral artery was resected and the proximal end invaginated into the distal with four double needled silk sutures. When the clamps were removed, pulsation was immediately restored. The patient made a good recovery, with good peripheral pulses and no disturbance of the circulation. Important advances in arterial repair were made in the laboratory by the Frenchman, Alexis Carrel, who commenced his experiments in vascular repair in Lyon, in 1901, using tiny needles and the delicate threads used by the local lace workers or strands of human hair. He moved to the University of Chicago in 1904, where he created a special experimental aseptic theatre to overcome the problems of sepsis, which had ruined so many other vascular operations. From there he moved to the Rockefeller Institute, New York, where he spent most of his professional life. Here he developed his method of triangulating the two ends of the vessels with three stay sutures, then a continuous suture between each third of the artery lumen. He described the vessel patch, which bears his name and is used today, and pioneered organ transplantation. He received the Nobel Prize for Medicine in 1912.
Clotting remained a serious problem. Heparin was isolated from the liver in 1916, (the Latin for liver is 'hepar'), but did not come into clinical use until the 1930s.
In spite of these advances, major arterial injuries in World War II were nearly always treated by arterial ligation--often with loss of the limb--and it was not until the Korean War, much due to the inspiration of Michael de Bakey, that vascular repair was widely used. He went on to make his unit at Houston, Texas a centre for innovative vascular surgery.
Provenance and Peer review: Commissioned by the Editor; Peer reviewed; Accepted for publication December 2010.
Image Source Wikipedia: this photograph is in the public domain because its copyright has expired
June Champion, Co-Director Risk and Governance, Belfast Health and Social Care Trust, Belfast
Felicia Cox, Senior Nurse, Pain Management, Royal Brompton & Harefield NHS Foundation Trust
Marie Digner, Matron/Clinical Lead, Outpatients, Royal Bolton Hospital
Luke Ewart, Senior Lecturer/Pathway Director Pre-reg ODP, Canterbury Christ Church University
Jill Ferbrache, Practice Educator, Aberdeen Royal Infirmary
Eleanor Freeman, Theatre Sister and Education Lead Scrub, Theatres, Queen Elizabeth Hospital, Gateshead
Lois Hamlin, Senior Lecturer, Director, Postgraduate Programs, University of Technology, Sydney, Australia
Jenny Jepson, Senior Lecturer, University of Southampton
Melody Johnson, Sister, Day Surgery Unit, Ashford Hospital
Adrian Jones, Orthopaedic Surgical Care Practitioner, Trauma & Orthopaedic Department, Norfolk & Norwich University NHS Trust
Moyra Journeaux, Clinical Educator/ Lecturer, Harvery Besterman Education Centre, Jersey General Hospital
Sue Lord, Head of Department, Allied Health and Medicine, Faculty of Health & Social Care, Anglia Ruskin University
Rosanne Macqueen, Clinical Educator, Theatres, Royal Hospital for Sick Children, Edinburgh
Andy Mardell, Practice Educator, Main Theatres, University Hospital of Wales, Cardiff
Shirley Martin, Surgical Care Practitioner and Robotics Specialist Nurse, St Mary's NHS Trust
Karen McColgan, Teaching Fellow, School of Nursing and Midwifery, Queen's University Belfast
Lucy Mitchell, Psychology Research Assistant, University of Aberdeen
Amanda Parker, Director of Nursing, Queen Victoria Hospital NHS Foundation Trust, West Sussex
Julie Quick, Surgical Care Practitioner, Day Unit Theatres, Manor Hospital, Walsall
Paul Rawling, Senior Lecturer, ODP Education, Edge Hill University, Ormskirk
Julie Seed, Trainee Surgical Care Practitioner, Royal Preston Hospital
Brian Smith, Head of Technology Enhanced Learning, Senior Lecturer, Edge Hill University, Ormskirk
Susan Tame, Lecturer, University of Hull
Professor Judith Tanner, Chair of Clinical Nursing Research, De Montfort University and University Hospitals, Leicester
Vanessa Tuthill, Clinical Coordinator, Royal Berkshire Hospital
Linda Walker, Senior Nurse, Cardiff and Vale NHS Trust
Paul Wicker, Head of Perioperative Studies, Edgehill University and Visiting Professor at Nanjing Medical University, China
Marilyn Williams, Senior Lecturer, School of Health, University of Wolverhampton (retired)
by Professor Harold Ellis
Correspondence address: Department of Anatomy, University of London, Guy's Campus, London, SE11UL.
Professor Harold Ellis
Emeritus Professor of Surgery, University of London; Department of Anatomy, Guy's Hospital, London
No competing interests declared
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