The principles involved in the application of ligatures to wounded arteries may be. briefly stated in two axioms: 1. Cut directly down on the wounded part, and tie the. vessel there; 2. Apply the ligature to both ends of the wounded vessel if iebe divided,. or, if it be only punctured, to both distal and proximal sides of the puncture; or, in other words, in either case tie the artery in two places. The principles are: if we wish to get at both ends of the vessel conveniently, we should exit directly down to the point of injury • we tie both ends of the divided vessel, or on both sides of the wound in it, because the proximal side (that towards the heart) alone is tied, vascular connections which may exist between the distal portion of the artery and other vessels may cause recurrent hemorrhage. If it does not take place soon after the application in the form; of arterial blood, venous blood will be likely to make its appearance in the course of two or three days.
At first ligatures were applied to arteries, in operations for aneurism, near the sack, and on the proximal side (that nearest the heart). The vessel so near the aneurism rarely being healthy, generally soon gave way, and the operation proved fatal. John Hunter, as above mentioned, made the improvement of tying at a distance from the tumor. and also on the proximal side, and that is still the most favorable position; but Brasclor after , wards conceived the idea of tying on the distal side, because the flow of blood may be ; arrested in this way, and consolidation effected in the usual way by the laminated I depositof fibrine. The proximal operation is, however, preferable when anatomical dif ficulties do not prevent or greatly interfere. Tlie immediate object of applying a ture for aneurism is to cause consolidation in the parts, thereby producing a condition which will prevent the rupture of the vessel by the heart's action. This consolidation it produces by producing coagulation of blood within the vessel, and a deposit of plastic lymph around it. In successful cases, after consolidation and formation of tissue have advanced sufficiently, the tissues give way which are included in the ligature, and this. may be easily reinoved. The success of the operation depends upon the re-establish ment of the circulation in those parts which are supplied by that portion of the vesseL which is severed from its connection with the heart. This is effected by nature in, establishing anastomosing circulation with collateral branches. The bleeding which may result after the lio-ature of an artery is called secondaryliemorrhage, and may arise from the giving way ot'f the coats of the vessel, because it may not have been properly tied, or because the condition of the patient is not such as to allow of natural coagula tion of the blood.
The great operations in arterial ligature are the tying of the subclavian, innomi nate, carotid, and iliac arteries. See CIRCULATION, ante. The axillary, brachial,. femoral, and smaller arteries of the limbs are frequently tied for various reasons; but sonietirnes success is rendered difficult, even in these minor operations, from liability to gangrene of the limb. in consequence of the deprivation of circulation; and the opera
tion is justified where an aneurism has burst or a ligature of an already tied artery has given way. Lifc is sometimes prolonged for many hours and even several days, which, under some circumstances, is a matter of great hnportance. The lig,ation of arteries often demands the greatest dexterity, skill, and surgical knowledge. Tissues which lie. at considerable depths require to be divided by the knife; much of the work has to be done without the aid of the sight.
The abdominal aorta has been tied in seven instances. The first operation was per t formed by the great English surgeon, sir Astley Cooper, in 1817, the patient surviving - 48 hours. The next was by James of Exeter, in 1829, the patient living only a few hours afterwards. Murray, at the cape of Good Hope, in 1834, performed the next operation, which terminated fatally in 24 hours. Monteiro of Rio Janeiro, in 1842, had the most remarkable prolongation of life under this operation, the patient living 10, days. South of London performed the fifth operation in 1856, with 43 hours' lease of life. McGuire of Richmond, U. S. A., performed the sixth operation in 1868, the patient surviving 12 hours. Stokes of Dublin tied the artery in the seventh instance in 1869. with a fatal issue in 13 hours.
The common arkry, according to statistics of Dr. Stephen Smith of New York, has been ligated 40 times, with 10 recoveries. Of 14 cases in which this vessel was tied for hemorrhage, 13 proved fatal. The majority of the recoveries took place after ligature for aneurism, which coustituted about one-half of the cases. The first time a ligature was ever placed around this artery in the living subject was by Dr.Wil liam Gibson of Philadelphia, in 1812, in a case of gun-shot wound. The patient died on the 13th day of peritonitis and secondary hemorrhage. It was tied in 1827 by Dr. Valentine Mott, with a successful result. The operation lasted less than one hour. It was performed ou Mar. 15, and the ligature was removed on April 3 following. On May 20 tbe patient made a journey of 25 miles. The internal iliac artery was limatured for the first time in 1812 by Stevens of St. Croix, since which it has been tied 19'times, in 6 .cases with success—viz., by Arndt, Dr. White of Hudson, N. Y. (on a tailor 60 years old), Valentine Mott, Syme, Morton, and Gallozzi. The external iliac artery was first tied by the celebrated Dr. Abernethy of London, in 1796, in a case of fernoral aneurism (Power). Durin„..• the following 50 years the operation was performed in 100 recorded .eases for inguinal aneurism (Norris), with a result of 73 cures and 27 deaths. In one remarkable case hoth external Macs were tied, with a successful result, by Tait (Erich sen). In 1814 sir Astley Cooper had performed the operation sevon times, with success in four cases. In 1860 it had been tied for aneurism of the femoral artery 43 times Crowe r).