Ligature

“ When the ligature is applied to the lower third of the vessel, the collateral circulation will be comparatively free through the anastomoses of the two profundi and anastomotic branches with the radial, interosseous, and ulnar recurrent branches. If the artery happen to divide in the upper part of the arm into either of the branches of the forearm, or into all three, a ligature applied to any one of them will, of course, be insufficient to arrest the direct circulation through the forearm, if this be the object in view. ”

“ Of the various methods by ligature, that of the ligation of the cord with its envelopes is applicable to [105] small animals only. That upon the cord alone is liable to be followed by hemorrhage, or by the excessive retraction of the cord into the abdominal cavity, drawing the ligature with it. That of the efferent canal, and of the cord by the subcutaneous mode are not admitted in general practice, while that of the artery alone has not been extensively performed on large animals, so far as we are informed, except by certain Massachusetts veterinarians. ”

“ Ligature of Femoral.—Under this head we practically mean cases of ligature of the superficial femoral, for the common femoral, or (as called by some anatomists) the femoral, before the profunda is given off, very rarely requires to be tied. If it is wounded, of course the bleeding point must be sought, and the artery tied above and below it, but if an aneurism on the superficial femoral renders ligature of that trunk impossible, experience teaches that ligature of the external iliac gives better results than ligature of the common femoral. ”

“ When arteries are unhealthy, the selection and proper application of a ligature are points of great importance. A larger although yet a small, round ligature should be fairly, evenly, and firmly, although not so forcibly applied as on a sound artery ”

“ A ligature should always be round and small, provided it be sufficiently strong. The strength of a ligature is variously estimated; some surgeons trying it by the strength of their own fingers, others by what they conceive to be the resisting power of the coats of the artery, in which perhaps they may err. The only way in which a surgeon can hope to acquire correct information on this point is by trying on the dead body what force of fingers is required to cut the inner coats of arteries of various sizes ”

“ It is also necessary that another Ligature be made in the lower part of the Artery, by reason that the little lateral Arteries might otherwise let out Blood.
The Artery ought not to be cut between the two Ligatures, lest the first Ligature shou'd be forc'd by the Impulsion of the Blood; but the Thread must be let fall, that it may rot with the Suppuration. Then the Wound may be dress'd with Pledgets, Bolsters strew'd with Astringent Powders and a Plaister; a Bolster being also laid in the Fold of the Elbow. ”

“ Then came Lord Lister's work on the absorb able ligature; and out of this and much other g " experimental work has come the present use of the ligature in f its utmost perfection-a thread that can be tied, cut short, and left in the depth of the wound, with absolute certainty "' that the wound may at once be closed from end to end and °| nothing more will ever be heard of the ligatures left buried in the B tissues. The choice of materials for the ligature is wide. Some surgeons prefer catgut, variously prepared; others prefer silk ”

“ When this clamp is used the pedicle need not be tied until the wound is ready to be closed. The stalk must be cut off at a distance from the ligature of not less than three-fourths of an inch, so as to leave a button of tissue sufficiently large to prevent the loops from slipping off. In short and broad stalks the outer or broad ligament portion, which is thin and membranous and sustains most of the tension strain, is liable to slip out of its ligature and cause a fatal hemorrhage. ”

“ To tie veins, artery, nerves, vas deferens, and cellular tissue, in one mass, would lead to most serious mischief, not to mention the immediate and excruciating pain occasioned. It has been recommended either to pass a temporary ligature round the chord, before its division, to prevent retraction, or to tie the artery before it is cut across. I have never found either practice necessary; the latter retards the operation; the fingers of an assistant are generally as effectual as a ligature, and inflict less injury to the parts, and less pain to the patient. ”

“ On the finger these muscles may be safely divided to the full extent of the external incision. The deep circumflex iliac artery if possible should not be divided, but may bleed smartly and require a ligature.
The peritoneum must then be very cautiously raised from the tumour, and supported, along with the intestines, by copper spatulæ. The surgeon will rarely succeed in obtaining anything like a satisfactory view of the vessel, but can expose it for the ligature by the aid of his finger-nail. An ordinary aneurism-needle will generally suffice for the conveyance of the ligature. ”

“ Now let anyone make an experiment upon the arm of a man, either using such a fillet as is employed in bloodletting, or grasping the limb tightly with his hand; let a ligature be thrown about the extremity and drawn as tightly as can be borne. It will first be perceived that beyond the ligature the arteries do not pulsate, while above it the artery begins to rise higher at each diastole and to swell with a kind of tide as it strove to break through and overcome the obstacle to its current. ”

“ The ligature of nerves is rarely followed by these accidents, because the communication with the brain is interrupted, by the very means that irritate, and because the medullary substance is flattened and its sensibility destroyed. However accidents have often happened from tying a nerve in the operation for aneurism, and though there is no real danger in making the ligature, all good practitioners advise that it should be avoided. ”

“ Those who from timidity, avoid a surgical operation may be treated with the ligature, as recommended by Hippocrates. For Hippocrates directs us to pass a raw thread, consisting of five pieces, through the fistula by means of a probe having a perforation, or a double-headed specillum, and to tie the ends of the thread and tighten it every day until the whole intermediate substance between the orifice be divided and the ligature fall out. ”

“ On the other hand, there is the remarkable success attained by surgeons who have constantly practised, with great skill, the ligature. The success of Mr. Syme in the ligature of the femoral artery for popliteal aneurism has been so great that any one who might fairly expect to attain nearly the same measure of skill would undoubtedly follow the ligature rather than the pressure. ”

“ If a divided artery is _ligated at its cut end_, the tension of the ligature is usually sufficient to rupture the inner and middle coats, which curl up within the lumen, the outer coat alone being held in the grasp of the ligature. An internal clot forms and, becoming organised, permanently occludes the vessel as above described. ”

“ In other words it is necessary that there should be a drop or fall, or at least the weight of the body, to produce the characteristics of hanging. The jerk of the fall or sudden dependence of the body upon the ligature causes a much greater constriction of the ligature on the neck, and in a different direction, than in strangulation; and also a much greater pressure on the blood-vessels and nerves of the neck. ”

“ When, from a rupture of the peritoneum, the omentum is prolapsed, and either becomes livid or black, the part anterior to the black portion may be included in a ligature, for fear of hemorrhage, and then the part behind the ligature is to be cut off, and the extremities of the ligature allowed to hang from the under part of the sewed wound of the abdomen, in order that they may readily escape when cast off by the suppuration of the wound. ”

“ When it is required to ligature the artery in the middle of the arm, the median nerve will be found, in general, at its outer side, between it and the biceps; but as the course of the artery is from the inner side of the biceps to the middle of the bend of the elbow, so we find it passing under the nerve to gain this locality, C, Plate 16, where the median nerve, D, then becomes situated at the inner side of the vessel. ”

“ The sutures are inserted very much in the same manner as in the ordinary operation for ruptured perineum. The advantage of this plan of treatment is that primary union is secured and the patient recovers in a shorter time than would have been the case after one of the operations which aims to secure union by granulation.
Treatment by Ligature.—There are two methods of using the ligature, which we may term the immediate and the mediate. ”

“ If the bite is on any part of the hand, the ligature should be made above the wrist, by means of a garter or cord, lapped several times round the arm, and rendered as tight as possible, by a small stick thrust betwixt the folds of the cord or garter, and twisted round very hard, to prevent the circulation of the blood betwixt the part bitten and the other part of the body. Ligatures of the same kind, applied by any one present, or the man himself, will frequently save a person's life, where, by accident, an artery in any of the limbs is wounded, and no surgeon is at hand. ”

“ He, however, who has any feeling for the poor animal on which he is operating, considers that the only use of the ligature is to compress the blood-vessels and prevent after-hemorrhage, and, therefore, saves a great deal of unnecessary torture by including them alone in the ligature, and afterwards dividing the rest of the cord. ”

“ The same thing will also appear in regard to ligatures, and wherefore they are said to draw; though this is neither from the heat, nor the pain, nor the vacuum they occasion, nor indeed from any other cause yet thought of; it will also explain the uses and advantages to be derived from ligatures in medicine, the principle upon which they either suppress or occasion hemorrhage; how they induce sloughing and more extensive mortification in extremities; and how they act in the castration of animals and the removal of warts and fleshy tumours. ”

“ Yet this plan continued more or less in vogue down to the discovery of the ligature in the 16th century, and was practised even later in Germany by the celebrated Hildanus (1641) ; although he subsequently adopted the new method. According to another fashion, the surgeon, after making a tedious division of the flesh down to the bone, with studied endeavour not to divide the arteries until the last moment, relied on applications of red-hot irons, or of some styptic fluid, usually a powerful acid or astringent, to arrest the bleeding. ”

“ In using this instrument the loop of the ligature being passed over the tumor around the cord, is carried into the inguinal canal as high up as possible, pressure being made by holding the instrument against the cord, while strong traction is made on the ends of the ligature, which is then secured by a knot upon a small stick placed across the opening of the instrument, with a view to the prevention of slipping. If an increase of pressure is found to be necessary, it can easily be obtained by tightening the ligature from day to day as required. ”

“ Whenever a tight ligature applied to a limb makes the lower part swell, whenever too long standing, a perpendicular position of the superior extremities, &c. produce the same effect, it is to be presumed that the effusion depends upon the compression of the lymphatics, and takes place then like venous dilatations in similar circumstances, because the lymph finds it difficult to circulate. ”

“ The first methods to be practised were elongation, ligature (Collier) , section (Gardner and Giles) , or resection, of the spinal accessory. The last of these was performed for the first time by Campbell in 1866, then by Southam, Mayor, Collier, Pearce Gould, Edmond Oxen, Appleyard, Atkins, etc. Eliot [202] was convinced of the value of this measure, and made a special study of the technique. Coudray [203] recognised the insufficiency of section or resection of the accessory, yet decided in its favour. ”

“ If a small quantity only of blood has escaped, its diffusion and increase may be prevented by the bandage: but a cyst will nevertheless be formed in the cellular tissue; its parietes will communicate with the margins of the aperture in the artery, its cavity with the canal of the vessel; an aneurism of the false kind will be established, and will run the course of one arising spontaneously.
A ligature, well applied, is the only means that can be relied on. ”

“ Even this operation, however, in two cases of femoral varix failed to effect more than a temporary cessation of the symptoms, although the ligatures were placed but a short distance from the communication. Failure is due to the presence of collateral branches, which are not easy of detection. Even when the vessels lie exposed, the even distribution of the thrill renders determination of the exact point of communication difficult, and the difficulty is augmented by the temporary arrest of the thrill following the [Pg 148] application of a proximal ligature to the artery. ”

“ These considerations will enable anyone to understand the nature of the attraction that is exerted by ligatures, and perchance of fluxes generally; how, for example, when the veins are compressed by a bandage of medium tightness applied above the elbow, the blood cannot escape, whilst it still continues to be driven in, by the forcing power of the heart, by which the parts are of necessity filled, gorged with blood. ”