THE 
HUNTi™ LIGATION OP ARTERIES 
TO 
RELIEVE AND TO PREVENT DESTRUCTIVE INFLAMMATION 
BY 
HENRY F. CAMPBELL, M. I)., 
PROFESSOR OF ANATOMY IN THE NEW ORLEANS SCHOOL OF MEDICINE; AND, 
DURING THE AVAR, CONSULTING SURGEON TO THE GEORGIA 
HOSPITALS IN RICHMOND, VA. 
[Extract from the August (1866) No. of Southern Journal of the Medical Sciences. 
AUGUSTA, GA. 
Mr HUNTERIAN LIGATION OF ARTERIES 
TO 
HENRY F. CAMPBELL, M. D„ 
PROFESSOR OF ANATOMY IN THE NEW ORLEANS SCHOOL OE MEDICINE, 
And, during the War, Consulting Surgeon to the Georgia Hospitals, Richmond, Va. 
[ Extracted from the Avgust (18€6) No. of Southern Journal of the Medical Sciences,] 
A number of communications have recently appeared in the Medical 
Journals of the country, the object of which was to discuss the value of 
the above procedure as a means of preventing inflammation. All these 
articles refer—generally, with great fairness—to a paper of our own, 
published during the late war. As this paper was, at the time,* put 
forth anonymously, and still more for the reason that the subject 
was therein but imperfectly considered, we feel it our duty, in declaring 
formally our authorship of the publication, to present a more detailed 
account of the cases, together with more extended considerations relat- 
ing to this important measure of practice. 
During the war, just ended, the difficulties of communication attend- 
ing the blockade rendered it impossible to supply the army with con- 
venient and suitable medical works. Dr. S. P. Moore, then Surgeon- 
General of the Confederate States, determined to issue a work on Ope- 
rative Surgery, for the use of medical officers in the field and in the 
hospitals. The necessarily compendious character of the work restricted 
its teachings to only a few of the more prominent subjects of military 
surgery :—A brief chapter on Surgical Diseases ; another on Gunshot 
Wounds; a third on The Arteries ; a fourth on Amputations: nnd 
* Richmond, October, 1863. 2 
THE HUNTERIAN LIGATION OE ARTERIES. 
one on Resections, exhausted the entire scope of this little volume. 
We do not feel at full liberty, without their consent, to divulge 
the names of the distinguished gentlemen who were our colleagues 
in the assigned duty of the preparation of this manual for the 
army. Our own name has been mentioned in connection with the third 
chapter, on Traumatic Haemorrhage and the Arteries, by our friend 
Prof. Daniel F. Wright, formerly of Nashville.* His deep interest in 
the subject of the present paper—Ligation of Arteries for the cure of 
Inflammation—therein incidentally discussed, has been, we confess, most 
gratifying to us, as eminently calculated to direct the attention of the 
profession to the subject, and to elicit discussion on a anode of practice 
which we can but regard as one of the greatest value, under certain cir- 
cumstances, in the treatment of inflammation. 
The method of ligation proposed, or rather revived by Mr. Guthrie, is 
advocated throughout our chapter for nearly all cases of traumatic haemor- 
rhage, whether primary or secondary, while that of Hunter is strongly ob- 
jected to. Certain exceptional cases, however, are discussed, wherein it 
is taught that Guthrie’s double ligature at the seat of injury may be ad- 
vantageously replaced by the method of Anel and Hunter, in which a 
single ligature is applied at some distance above the arterial lesion. 
The most prominent among the exceptional conditions is the one,— 
everywhere dwelt upon—wherein the condition of the wound, and of the 
limb, was such as to indicate a liability to extensive or even destructive 
inflammation. In such cases, our experience and observation, very 
early in the war, had taught us that the risk of haemorrhage by the re- 
current circulation was not to be weighed against the great advantage of 
curing, or at least controlling, the inflammation—indeed, saving the limb 
and the life—by the ligation of the main arterial trunk which supported 
this inflammation. A recent number of the Cincinnati Journal of Med- 
icine! presents a verbatim abstract of our views as found in the chapter 
before referred to, and, indeed, except for the advantage of presenting a 
fuller account of these principles in connection with a more extended 
report of the cases from our private notes, it would be scarcely necessary 
to reproduce any portion of that chapter in the present paper. 
We here present a somewhat fuller abstract, and our further comments 
upon the method of treatment will be added after the report of the 
several cases. (See page 10:2.) 
“We have already intimated that singular combinations of circum- 
stances repeat themselves, often, in every battle. This, however, caia 
scarcely be considered a singular one. A- ball cannot well fracture the 
femur, for instance, in certain portions of its diaphysis without endan- 
gering the femoral artery. How often do we see our hopes of a promis- 
* See Confederate States’ Medical and Surgical Journal. Also Richmond Medical Journal, 
Therapeutic effects of the Ligation of Arteries, by D. F. Wright, of Clarksville, April, IS6S. 
f By Dr. D. L. Duvall, of Franklin Co., Ky. THE HUNTERIAN LIGATION OE ARTERIES. 
ing case of fracture of the thigh clashed by the sudden occurrence of 
either secondary or indeterminate haemorrhage. In such a case, no ne- 
cessity more to be regretted could arise, than that of being compelled to 
make the deep incisions and enter into the tedious search among 
the inflamed and tender soft parts necessary to find and secure the bleed- 
ing vessel at the seat of injury; converting our comparatively simple 
case into one of additional, and most serious, complications—all pertain- 
ing to the immediate seat of the fracture. Here we remember that, ac- 
cording to rule, and not by accident, large arteries, when wounded high 
up, are not quite so subject to recurrent haemorrhage as when wounded 
near the extremity of the vessel; because the collateral communications, 
though sufficient for the purposes of nutrition, are not in such abundance 
as to produce haemorrhage by the recurrent circulation. The Hunterian 
operation, then, may be legitimately performed somewhere below the 
profunda, and the patient saved the greater evil of being operated on in 
the tissues about the fracture, or what, in our opinion, would be less ob- 
jectionable ’ ’ 
,u Hunterian Ligation to Prevent Destructive Inflammation.—After 
the battle of Seven Pines, May 31st, 1862, many of the wounded in the 
General Hospital at this place (Richmond, Va.) suffered from the most 
violent and uncontrollable inflammation. The inflammation from ami- 
shot wounds, for sufficient causes, viz., the shock or jar to all the tissues, 
especially the nerves and blood-vessels of the part, is apt to be more 
intense than in other wounds of the same parts. Wounds of both the 
upper and lower extremities resisted all ordinary measures of treatment. 
Suppuration, in many, had ceased, and, in its place, a bloody water was 
discharged from the openings and abrasions. The swelling in these 
cases was immense.” 
u Six of the above cases* under our observation were the subjects of 
arterial lesion. The arteries wounded in the lower extremity of three of 
these cases were, severally; in one, the peroneal close to its origin; in 
the other two, the anterior tibia!, near the middle of the leg. Profuse 
secondary haemorrhage occurred in all these cases (see table, page 91, 
cases 30, 32 and 33), respectively, on the fourteenth, twelfth and tenth 
day. Ligation was determined on. The extreme swelling and inflam- 
mation of the limb, extending even above the knee in all, and in one 
(No. 30) marked by large patches of incipient gangrene on the foot, 
presented great embarrassments to the operation at the seat of lesion. 
It was not the difficulties, however, which caused Mr. Hunter’s operation 
to be preferred in all of these cases to Mr. Guthrie’s, notwithstanding 
the risk of recurrent haemorrhage. There ivas a desirable incidental 
benefit hoped to be attained, Avhich Avas of even deeper interest, if possible, 
than the arrest of the haemorrhage. The idea pursued, in departing 
*See Reports of Ist, 2d, and 4th Georgia Hospitals, in office of Surgeon-General—Ligation 
of Arteries. 4 
THE HUNTERIAN LIGATION OF ARTERIES. 
from the rule, was no less than the experimental effort to cure the inflam- 
mation in the. limb, by cutting off its arterial supply, by ligation of the 
main trunk which supported, the inflammation. The femoral artery was 
tied, in each case, near the apex of Scarpa’s triangle. The haemorrhage 
ceased immediately in all three of the cases, the swelling began to de- 
cline within twelve hours, and, in three or four days, the limbs were 
reduced to very nearly their natural size, the discharge having changed 
from bloody water to healthy pus.” 
u Results. Case 30 (J. M. Orr, of present paper), recovered slowly, 
on account of the sloughing out of the patches of gangrene, which had 
shown themselves previous to the ligation. These surfaces granulated 
healthily and cicatrized firmly. The suppuration was profuse and long- 
continued.” 
“ In case 33 (Drury 13. Early, of present paper), the result was most 
satisfactory and complete ; the swelling had disappeared in three days— 
the appearance of the wound wonderfully improved—the discharge be- 
came healthy, and the subsequent progress of the case, rapid and favor- 
able, ending in entire recovery. 
“ In case 32 (S. A. Willingham, of present paper), it was discov- 
ered after the complete subsidence of the swelling, that the fibula was 
broken. Still the case progressed well. The inflammation was entirely 
subdued. On the tenth day after the ligation, recurrent haemorrhage 
supervened, causing great infiltration below the knee in the popliteal 
space, and rupture of the nearly cicatrized gunshot wounds. This pa- 
tient was greatly exhausted and was not thought to be able to bear the 
ligation of the peroneal artery. Amputation above the knee was deter- 
mined on. Only one artery, superficial and of small size, required tying 
in the stump. It is worthy of remark, that the stump healed by the first 
intention—a most unusual result of a secondary amputation. It is not 
unfair to presume that the previous ligation favored this rapid recovery 
of the stump.” 
uln the three cases of arterial lesion in the superior extremity, in 
which ligation of the main trunk in its continuity was preferred, in order 
to subdue inflammation, the arteries wounded, respectively, were the 
brachial near the elbow, in one, and the radial in both the others. The 
inflammation was greatly modified, though not in so marked a manner— 
except in one of them—as in those of the lower extremities. The pa- 
tients all recovered; and in two of them recurrent haemorrhage took 
place, but was controlled without resorting to further ligation. In the ex- 
ception mentioned, no recurrent haemorrhage occurred, and the inflam- 
mation seemed to be completely strangulated throughout the hand and 
forearm by the ligation of the brachial artery.” 
“ It will be observed that, in the above six cases, in which the rule of 
Mr. Guthrie was departed from, recurrent haemorrhage took place in 
three of them, but only in one in such degree as to require an opera- THE HUNTERIAN LIGATION OF ARTERIES. 
5 
tion. The advantages gained in departing from the established rule 
would be more apparent from a detail of the cases than in the above 
very condensed notes. The cases are referred to more in illustration of 
the circumstances in which departure from the rule may be considered 
justifiable, than with any view of advocating the Hunterian practice in 
opposition to the more reliable one of Mr. Guthrie.” 
“And lastly; though there are, doubtless, many other considerations 
which may justify the ligation of an artery in its continuity in tin; 
treatment of hemorrhage, we will refer but to one more: For in- 
stance, suppose a patient in a state of extreme exhaustion, whether from 
haemorrhage or other causes :—Consecutive hemorrhage in some inac- 
cessible artery, for instance, as the peroneal or posterior tibia! high up, 
occurring in a patient of this kind, especially if complicated with great 
tumefaction and consequent change in the histology of the parts, would 
present a case, even for the most practised operator, of unavoidable 
delay. A prolonged and trying—we had almost said blind—search 
among clots and fibrinous masses and condensed infiltrated tissues, 
everyone who has tried it knows full well, is sometimes the only route 
to the open mouth of the bleeding vessel in such cases. This greatly 
exhausts the strength of the patient, and lessens—indeed destroys—his 
chance of life. Under such circumstances, the Hunterian operation 
would be preferable, especially in a wound of the lower extremity. In 
the first place, it arrests the haemorrhage for the time being, at least, 
and affords a chance of even permanent arrest; and secondly, by cutting- 
off the main stream from the support of the inflammation and general 
turgescence, the condition of the limb may be so improved that, in case 
the recurrent haemorrhage should take place, a less embarrassing state 
of things will attend this more desirable operation. The adoption of 
the one operation gives a chance for life ; avc think we have seen the 
adoption of the other, under just such circumstances, take it away.” 
(Manual Military Surgery, page 106.) 
In addition to the above abstract from the text of the chapter referred 
to, avc introduce here the following, found on pages 104-5, as containing 
pertinent and direct records of our opinion, as well as facts relating to 
the subject: 
Note.—“As the subject has only a relative bearing on the main ob- 
ject of the present paper (haemorrhage), attention is called, only in a 
note, to the above practice of ligation to subdue or control inflammatory 
action. We believe that the cases of Privates 0. A., Reid and Drury 
B. Early (see table, page 91, cases 31 and 33), ligation in one, June 
sth, in the other, June 11th, 1862, are the first cases on record in Avhich 
this measure Avas adopted Avith reference to the proposed result. In all 
of the six cases, the Hunterian operation Avas chosen with the distinct 
end in view of combatting and checking, if ptossible, the destructive pro- 
gress and, in some, the septic tendency of the inflammation. In all of THE HUNTERIAN LIGATION OF ARTERIES. 
these, the pain, the swelling and turgescence were almost immediately 
relieved, and the most remarkable change was soon presented, as seen 
in the character of the discharges.” 
“ Surgeon A. C. Thom, of the Confederate States Army, has kindly 
furnished us notes of a case in which he subsequently adopted the 
Hunterian ligation of the femoral, and in which the beneficial results 
were exhibited in the most marked degree—1 the inflammation relieved, 
as by magic.’ ” 
u The application of the ligature in cases of elephantiasis, and for 
malignant diseases of the face, does not, it appears to us, interfere with 
any originality which the principles here practised may possess. The 
present operations, besides being applied with an entirely different 
object, fully answered the proposed end, while the others did not. We 
feel confident that this practice will become one of frequent application 
in the treatment of otherwise unmanageable inflammation, under a variety 
of circumstances authorizing its adoption.” 
In order to complete the abstracts bearing upon our subject, we quote 
from page 152, of the same chapter : Subject—Ligation of the Inferior 
Thyroid Artery. Here we must, also, present both text and note : 
u Sir Everard Home, Walther, Theden, Langenbeck and others 
recommended the ligation of these vessels, together with the superior 
thyroids, branches of the external carotid, for the cure of bronchocele ; 
the operation has been long since abandoned for this purpose, on account 
of its difficulties, and still more on account of the unsuccess attending 
the practice.” 
Note.—“ In these cases, the cause of failure is, that the abundant 
anastomosis of the supplying arteries soon re-established the excess of 
nutrition, and the tumor continued to grow, because its feeder could not 
he permanently cut off. Indeed, so long as a part exists, we cannot 
permanently diminish its blood-supply, and hence, whenever the cure 
depends upon that, it fails. The collateral circulation, in time, certainly 
enlarges, so as to be adequate to even the morbid appetite of the hyper- 
trophic parts. The measure of ligation, as applied to inflammation, is 
different; here, the morbid demand for blood is evanescent, existing 
only so long as the causes of irritation at the wound remain. If its 
feeder, the main trunk, is cut off, the diminution in the supply, though 
not permanent, is not required to be so, still it is sufficiently so to allow 
of the recovery 'of the parts before the collateral circulation can be fully 
established. If inflammation was of a nature to demand for its cure 
the permanent diminution of the blood-supply, then ligation of the 
main trunk would be of no avail. It is most fortunate, in the general 
interests of humanity, that we cannot cure tumors and other morbid 
conditions dependent upon excessive nutrition, by cutting off their 
arterial supply. The possession of that power would involve a denial 
to us of one far more important, viz., that of ligating to cure aneurism THE HUNTERIAN LIGATION OF ARTERIES. 
7 
and to arrest haemorrhage—for, in that case, wherever the main trunk 
of a limb Avas ligated, for any object Avhatever, its nutrition would be 
permanently destroyed, and the organ it supplied would consequently 
perish.” 
The cases referred to in the above extracts, Avill be found more fully 
represented in the folloAving report, made up partly from memory, 
but assisted, in all essential particulars, by accurate records made at 
the time the treatment Avas applied : 
I. Ligations of the Femoral Artery. 
Case 1.—C. A. Reid, aged 17 years, a private in one of the Alabama 
regiments, received a gunshot wound with a minnie ball, at the battle 
of Seven Pines, May 31st, 1862. He was brought to Richmond and 
placed in the Second Georgia Hospital, then in immediate charge of 
Surgeon D. C. O’Keeffe. On examination, the ball was found to have 
passed obliquely through the fleshy part of the thigh, near its lower 
third, traversing the region of Hunter’s Canal, in such a manner, as 
that, in passing out of the loAver and outer part of the popliteal region, 
the outer margin of the calf of the leg was deeply grooved. On exam- 
ination of the case, the femoral artery avhs, of course, recognized to be 
in great danger, notwithstanding, as yet, the absence of both haemor- 
rhage and diffused aneurism. He was placed in a comfortable position, 
and closely watched Avhile cold-water dressings were applied to the 
wounds. 
June 2d—Third day after the receipt of the wound. To-day obscure 
pulsations are perceived in the region beloAV the wound, and, on careful 
examination, a considerable tumor is observable in the deeper parts in 
A'olved in the track of the ball. The limb, even thus early, had become 
very painful, andAvas much swollen. 
On the 3d and 4th, the size of the aneurisim was gradually enlarged, 
the pulsations becoming more and, more decided, and, of course, extending 
with the breadth of the tumour. The general tumefaction Avas greatly in- 
creased, and he complained of pain along the course of the nerves of the 
leg, for which reason he was unable to sleep. There was no purulent dis- 
charge from either of the wounds in the thigh, or from the one in the leg, 
but a scanty discharge of bloody serum. 
June 5 th.—To-day the tumour is greatly enlarged; pulsations very 
strong and widely extended; danger of rupture of pseudo-sac of aneur- 
ism apparently imminent. The general condition of the limb unpromis- 
ing ; the two Avounds upon the thigh, and the superficial wound upon the 
leg, have an unhealthy appearance; their edges are swollen and everted; 
the sanious discharge abundant ; pulse at wrist, good ; the patient cheer- 
ful and Avilling for any operation. 
Having determined upon ligation, the day preA-iously, and regarding 
the Hunterian operation sufficiently safe, as the sac Avas as yet unbroken, 
we made the necesssary incisions in the lower part of Scarpa’s triangle 8 
THE HUNTERIAN LIGATION OF ARTERIES. 
and secured the femoral artery, at about twelve o’clock, M., about one ineb 
above the upper edge of the tumour. The ligature used was white sad- 
dlers’ silk of ordinary size, doubled, for security against breaking, and to 
avoid cutting through the coats of the artery. The wound was closed 
with adhesive strips, with a light compress and loose bandage. 
The pulsation in the tumour ceased from the moment of the tightening 
of the ligature. These did not return, at any time, in any perceptible 
degree, during the progress of the case. On the completion of the dres- 
sing, the patient expressed himself as greatly relieved of the pain in the 
limb, and also of the unpleasant tension in the tumour. He slept well 
luring the night, having no return of pain. 
On the first morning after the operation, a marked diminution in the 
general size of the limb was observable ; there was much less heat, but the 
temperature was not sensibly below that of the other limb. The skin 
over the tumour was quite loose, and the general cutaneous and subcutane- 
ous envelope pale and much shrunken, and more moveable upon the mus- 
cles than before the operation. 
June Bth.—The patient doing well in every particular.—There has 
been a most remarkable diminution in the size of the limb operated on, 
from the rapid absorption of the effused serum in the general subcutaneous 
cellular tissue. The wounds of entrance and exit in the thigh, and the 
slighter wound in the leg, have undergone a marked change in their appear- 
ance ; the large flabby elevations around these openings have shrunken 
into small, red, healthy granulations, covered by a thick cream-like pus, 
and there is no longer any more of the thin sanious water exuding from 
these surfaces. The clots composing the sac do not appear to become 
diffluent, and it is not thought advisable to open the tumour, or even to 
probe it, in the present “ well-doing” condition of the limb. 
On the loth, the tumour had gradually diminished, the wound of 
incision had healed kindly, the ligature as yet remaining. The gun- 
shot wounds were healing rapidly,discharging a small amount of healthy 
pus, sometimes mixed with diffluent blood. The general condition of 
the limb, as to temperature and circulation, were very satisfactory 
throughout the case; the pulsations in the dorsalis pedis artery feeble, 
but plainly perceptible. Swelling of the limb had entirely subsided. 
The case continued to progress favorably, in every particular, and 
the patient left the hospital, on furlough, for his home in Alabama, six 
weeks after the operation. 
Having carefully observed in this, our first case, the remarkable effects 
of the Hunterian ligation upon the tissues supplied by the femoral, as 
shown by the rapid subsidence of the swelling, the disappearance of 
turgescence, the improved condition of the wounds, and the change in the 
discharges from sanious to healthy pus, we could not fail to attribute these 
important results mainly to the diminution in the force and fulness of 
■the circulation caused by the ligation of the main trunk supplying the THE HUNTERIAN LIGATION OF ARTERIES. 
9 
capillaries of these engorged structures. The idea that such ligation, 
in all similar cases of threatening and destructive inflammation, especially 
where haemorrhage gave the occasion, soon, therefore, became familiar, 
and, on repeated reflection, the practice became, to our mind, most rational 
and expedient; hence we determined, at the earliest possible period, to give 
the measure a fair trial in some of the sad cases that were then every day 
presenting themselves in the hospitals under our direction. Fortunately, 
many days did not elapse before a most legitimate opportunity for further 
experiment presented itself in the case of another soldier in the adjoin- 
ing bed, wounded in the same battle. 
Case 11. Drury B. Early, a private in a Georgia Regiment, aged 
1.8 years, received a gunshot wound in the leg, on the second day, 
June Ist, of the battle of Seven Pines, and was admitted to the second 
Georgia Hospital. The ball had entered the lower portion of the calf, 
ranging somewhat upwards and towards the anterior aspect of the leg to- 
wards a point between the tibia and fibula, but not passing out. The di- 
rection of the track was such that either one or both of the tibial arteries 
might have been severed. There being no haemorrhage, and search having- 
been previously made for the ball, which failed, no further operative meas- 
ure was taken. The case was treated with cold-water dressings, to subdue 
the inflammation. The treatment did not appear, however, in the least, 
to arrest its rapid progress. 
Our attention was not particularly called to the case until the tenth 
day after the receipt of the wound, at which time secondary haemorrhage 
took place. The haemorrhage was not very profuse, and the Assistant 
Surgeon in charge of the case kept it in check at first by a compress and 
bandage. The condition of the limb however, and a certainty of a return 
of the haemorrhage determined us on an early operation. 
Having been requested by the Surgeon in charge to operate, on the 
next day we invited to be present Surgeon Gen’l S. P. Moore, Surgeons 
0. H. Smith, A. N. Talley, A. E. Peticolas and James Dunn, with 
each of whom we had repeatedly conversed respecting our views of the 
effect of arterial ligation upon the progress of inflammation. The ap- 
pearance of the limb was so unpromising that our interview partook 
somewhat of the character of a consultation. The measure of amputation 
above the knee, in preference to the proposed ligation, being debated, one 
of the Surgeons present consented good-naturedly to the ligation, intima- 
ting that “ both sides would be accommodated in this case, as amputa- 
tion would ultimately be found necessary.” 
At the time of the operation there was great tumefaction, extending 
fully up to the knee, the skin was mottled from congestion; it was 
stretched tightly over the other tissues, and, in places, had a shining 
appearance. There had appeared, upon the outer and anterior aspect 
of the leg, a dark elevation into which the Assistant Surgeon had made 
an incision, as a counter opening, hoping to find the retained ball. 10 
THE HUNTERIAN LIGATION OF ARTERIES. 
From tins opening the haemorrhage had emerged. From the posterior 
wound, and from certain superficial abrasions, was there issuing a thin, 
sanious discharge, which had taken the place of the pus when suppuration 
ceased three or four days previously. The general condition of the patient 
could not he considered very bad ; the haemorrhage had not been ex- 
cessive, and his depression appeared to he the result of the loss of sleep 
and of extreme suffering, from extensive local inflammation, rather than 
from general and more permanent exhaustion of the vital powers. 
The femoral artery was ligated in the lower part of Scarpa’s space. 
The wound was closed with adhesive strips, and a light compress and 
bandage applied. The limb was placed in a comfortable position, and 
the cold-water dressings ordered to be discontinued. 
June 12th. The patient slept well during the night, and is free from 
pain ; general appearance of the leg greatly improved; color of skin 
more natural; temperature somewhat above that of the sound limb ; 
lips of wounds less 'tumefied than on the day previous. The general 
swelling of the limb is so greatly reduced to-day, that the ball, which, 
until now, had not been found, is readily discovered by its prominence 
under the skin, upon the anterior and outer aspect of the leg where it 
had been lodged, and is now removed by a slight incision. The dis- 
charge is still sanious. No examination made of wound of operation. 
June 14th. Patient doing well in every particular. The general 
tumefaction of the limb entirely gone, the skin being now wrinkled 
and loose, from its recent over distension. In place of the bloody water, 
the toounds of the leg are all discharging a moderate amount of healthy 
pus. The granulations have contracted in size ; they are red, florid, 
and healthy. 
A full report of Early’s case would not be tedious, for it was one of 
short duration, ending in recovery; but it is unnecessary to encumber 
our paper with trivial details, all tending in one direction. His wounds 
soon ceased to suppurate, and cicatrized firmly; he had no recurrent 
haemorrhage, nor any other untoward symptom. We cannot here state 
the exact time of our last visit to him, as the books have been des- 
troyed, but he was well and ready to go home on furlough, and had to 
Avait many days for Reid, Avhose ligation was six days previous to his. 
Indeed, we do not remember to have treated any case, during the war, 
the results of which more promptly and abundantly fulfilled our expec- 
tations in e\Tery particular, than this one of Drury B. Early. 
Case ITT.—Private S. A. Willingham, of Georgia Regiment, 
received a gunshot wound in the leg, in “ The Seven Days’ Battle 
around Richmond,” June 26th, 1862. He Avas brought the day after 
to the first Georgia Hospital, then in charge of Surgeon J. A. S. Milli- 
gan. We did not see him until the eighth of July, the twelfth day after 
the receipt of the wound, at which time a profuse secondary haemorrhage 
occurred. We were uoaat called in consultation, and requested to operate. THE HUNTERIAN LIGATION OF ARTERIES. 
11 
The patient was much exhausted by the sudden loss of a considerable 
amount of blood. The limb was very much inflamed, and swollen to 
nearly twice its normal dimensions. The inflammation and swelling 
extended above the knee. The ball had, apparently, entered behind, 
considerably above the junction of the middle and upper third of the 
calf at the inner side, and ranged forwards and outwards, passing out in 
front of, and somewhat below, the head of the fibula. There was no 
purulent discharge from either wound. Suppuration had ceased several 
days previously. 
A track thus situated, in the enormously swollen condition of the 
parts, left it questionable which might be the particular artery wounded ; 
whether the posterior tibial, the peroneal, or the popliteal. Guthrie’s 
operation, it is true, might have been performed successfully, so far as 
the haemorrhage was concerned; but it was decided, in consultation, 
that, in addition to the difficulties of the operation, under the circum- 
stances, such a procedure, involving parts so near the knee-joint, 
already advanced almost towards a putrefactive condition, would com- 
promise all chances for the patient’s limb, and, perhaps, for his life. 
We say here u for his life,” because it is well known to the Confed- 
erate Surgeons, about Richmond, that but a lamentably few of our 
soldiers recovered after an amputation above the knee, in what is known 
as the secondary period—they nearly all died. 
Under these circumstances, and with the very encouraging cases of 
Reid and Early still under our observation, we decided upon the Hun- 
terian operation. . 
The patient, after a stimulating potation of brandy, was put under the 
full influence of chloroform, and the ligation was made by an incision 
some distance above the apex of Scarpa’s triangle. The haemorrhage 
ceased at once. The limb was placed in a comfortable posture, upon 
pillows, the foot somewhat elevated, and the Assistant Surgeon advised 
to order a decided dose of laudanum, after the patient had fully recov- 
ered from the chloroform. We did not advise artificial warmth, or even 
flannel wrappings in this case, nor, indeed, in either of the preceding- 
cases, as, according to our theory, upon which the measure of ligation, 
under the present circumstances, is founded, such precautions are not ne- 
cessary. 
A marked improvement in the condition of the limb was observed on 
the morning after the operation. The skin was much less congested, 
the surface more natural in temperature, and the tumefaction greatly 
reduced. Suppuration from the wounds was fully re-established on the 
third day, and the limb rapidly resumed its natural size and appearance, 
with the exception of the wrinkling of the skin over the leg and foot, 
resulting from the sudden subsidence of the swelling* At this time, on 
particular examination of the parts about the wound, a discovery, impossi- 
ble before, on account of the great tumefaction, was made, that the 
fibula was fractured a short distance below the neck of the bone. 12 
THE HUNTERIAN LIGATION OF ARTERIES. 
For brevity, we shall complete the history of this case of Willingham 
in the words of our former published report :* “ Still the case progres- 
sed well. The inflammation was entirely subdued. On the tenth day 
after the ligation recurrent liannorrhage supervened, causing great infiltra- 
tion below the knee and in the popliteal space, and rupture of the nearly 
cicatrized gunshot wounds. The patient was greatly exhausted and was 
not thought to be able to bear the ligation of the peroneal artery. 
Amputation above the knee was determined on. Only one artery, su- 
perficial and of small size, required tying in the stump. It is worthy 
of remark, that the stump healed hy the first intention—a most unusual 
result of a second,ary amputation. It is not unfair to presume that the 
previous ligation favored the rapid recovery of the stump.” 
It will here be seen how briefly we were forced to interpret the elo- 
quent facts of this most significant and instructive case. The simple 
statement that 11 the previous ligation favored the rapid recovery of the 
stump,” was all that, with propriety, we could introduce on the pages 
of a work, the intent and purpose of which was, to serve as a terse and 
portable manual for medical officers in the field. The mention of these 
cases was barely admissible—a lengthy discussion of them, impossible. 
Simply to record the prolific data, and to preserve, somewhere, the 
essentials of a practice we considered valuable, as well for the future, 
as for that distressing present, was all that those momentous times could 
be asked to tolerate. 
Willingham’s case, taken in connection with the others, requires, now, 
no special comment. To ottr mind, the fact is unquestionable that the 
rapid healing of the stump was due, and alone due, to the favorable con- 
dition of the tissues of the flap brought about by the previous ligation of 
the femoral artery. The value of this fact of healing by the first intention 
can scarcely be appreciated except by those who were familiar with the 
hospital experience of this particular period of the war. At that time, 
to amputate a lower extremity above the knee, during the secondary 
period, that is, after inflammation had been established, was not only to 
entail upon the patient a protracted, tedious, and exhausting time of 
drainage and suffering, but, in the vast majority of cases, to sign his 
death-warrant. As wo have said before, they nearly all died. Such a 
thing as healing by the first intention after a secondary amputation was 
unheard of, not only at that time, but at any time, before or after, during 
the continuance of the war. 
A dissection of the amputated leg showed that the peroneal artery 
bad been severed within a quarter of an inch of its branching oft' from 
the posterior tibial, leaving no room for the application of a ligature, 
had we chosen Mr. Guthrie’s method of ligation. 
While yet engaged in this operation of amputation, we were solicited, 
*See Manual of Military Surgery prepared for the use of the Confederate Army. Chap 111. 
On the arteries, page 104, THE HUNTERIAN LIGATION OF ARTERIES. 
13 
with great earnestness, to visit another case of a gunshot wound of the 
leg, in the case of a soldier, at a private house, on Church Hill, who was 
described as a case of secondary haemorrhage. In one or two particu- 
lars, this case is more remarkable than any of those already recounted. 
Case IV.—Joseph M. Orr, aged 18 years, a private in one of the 
early Georgia Regiments, was wounded with a Minnie ball in the 
“ Seven Days’ Battle around Richmond,” June 27th, 1862. He Avas 
carried to one of the hospitals at that post, but was transferred, by per- 
mission, to the private quarters where he Avas treated. Secondary 
haemorrhage occurred on the morning of the fourteenth day after the 
receipt of the wound. He Avas under the care of a practitioner of the 
city, and avc did not see him till nine o’clock, v. M., of the day of the 
bleeding. 
We found the patient in a feeble condition, from haemorrhage, from 
loss of sleep, and from irritative fever. The ball had entered on the 
front aspect of the leg, about the junction of the upper and middle third, 
and on the line of the anterior tibial artery; the Avound of entrance was, 
therefore, between the tibia and fibula. There Avas a wound of exit 
posteriorly, corresponding with the general direction of the track. The 
hsemorrhage had issued from the anterior opening, but the bleeding had 
ceased spontaneously, as it had done sewera! times during the day, be- 
fore avc arrived. From the clots in the Avound, the direction of the 
track, and all the circumstances of the case, avc Avere confident that the 
anterior tibial artery was the subject of lesion. We determined on 
ligation, and, as the bleeding had been controlled, appointed an early 
hour, next morning, to meet the attending physician. 
We find it difficult to give any adequate idea of the general condition 
of the Avounded limb, as it presented itself on the morning of the opera- 
tion. The patient was a youth of extremely delicate “build;” he Avas 
very tall, near six feet, but slim, and Avitliout a particle of fat, and but 
little flesh anywhere. His lower extremities were very long, and the 
sound limb little more than skin and bone. The wounded limb Avas enor- 
mously swollen ; the skin, in places, was purple with congestion, shining 
from the extreme tension, and stretched to the utmost limit of its capa- 
city. The temperature of the foot Avas beloAv that of the opposite limb, 
and the nails were bluish from arrested circulation. Indeed, the turges 
cence had passed beyond the point of active circulation, and a general 
stasis seemed to prevade the entire limb, progressively increasing as our 
examination approached the foot. This stasis, more the result of theoArer- 
Avhelming congestion than from paralyzed innervation of the capillaries, 
was evidently the initial stage of the termination by mortification. This 
Avas proved by the fact that there teas an extensive blister, filled with 
bloody scrum, covering nearly the xohole dorsum of the foot, and another, 
of a similar character, above the heel, in the region of the tendo-Achillis. 
The swelling extended fully up to the knee, which Avas also somewhat 14 
THE HUNTERIAN LIGATION OF ARTERIES. 
tumefied. The anterior wound was occluded by the clots, but the pos- 
terior opening was discharging a large quantity of Moody serum. Sup- 
puration had ceased for several days. 
Even with the convincing experience in the benefit,—with these un- 
mistakable evidences of gangrene before us, we would have been glad 
to have amputated the leg could we have formed a flap of sound tissues 
below the hnee. Amputation above the knee, under the circumstances, 
was out of the question on account of the universal fatality attending 
secondary oqerations in this region at that time. The feature of haemor- 
rhage, we may say, was submerged in the far greater interest, involving 
the life of the patient, presented in the grangrenous condition of the 
limb. The preference between Guthrie’s and Hunter’s operation was 
not debated. We at once determined on the Hunterian ligation, dis- 
tinctly with the view of improving the condition of the tissues to an ex- 
tent sufficient to authorize amputation helcw the hnee. This was the 
most we expected from the operation. 
Assisted by Surgeon W. D. Hoyt, we ligated the femoral artery in 
Scarpa’s space in the usual manner at 1:2 M., (July 12th), of the fifteenth 
day after the receipt of the injury. The day after the operation—July 
13th—we found the patient in a most satisfactory condition. He was 
entirely free from pain, had slept well, and was in good spirits. The sub- 
sidence in the tumefaction of the wounded limb was truly wonderful; 
the leg had shrunken down to very nearly its normal dimensions, the 
skin was loose and disposed in folds and wrinkles upon the subjacent 
tissues. The congestion had disappeared, and the surface was rather 
paler than natural; the temperature, however, was certainly not much 
below that of the sound limb. There had been an abundant discharge 
of sanious serum from the wounds, as shown by the wide-spread stains 
upon the bed-clothing, but no return of haemorrhage. We evacuated 
the large bullae on the foot by rupturing the cuticle, directing the appli- 
cation of poultices to these surfaces. The patient was ordered a gen- 
erous diet, with liberal potations of port-wine or brandy-toddy. 
On the third day, suppuration became quite abundant. The entire 
extent of the surfaces occupied by the bulla;, on the dorsum of the foot 
and above the heel, had assumed the dull-greyish appearance of dead 
tissue, and it was plain that these patches had been gangrenous before 
ligation, and were about to separate in two large sloughs. The line of 
demarkation was already apparent. 
July 21st. At this time the limb had been so far reduced in size, 
that there could not be said to be any difference between it and the 
sound leg. There was no external evidence of inflamation. The pa- 
tient was doing well in every respect. The suppuration was far more 
abundant than could be accounted for by the simple track and the two 
wounds. A consultation was called by us, and we made a careful 
examination into the condition of the parts about the wound. An abscess THE HUNTERIAN LIGATION OF ARTERIES. 
of large .size was found near the lower part of the calf. This collection 
seemed to result more from the gavitation of the pus; from the general sub- 
cutaneous cellular tissue to the most dependent part, than from phlegmo- 
nous inflammation; there was no distinct sac, and the cavity communica- 
ted freely with the track of the ball. In making a counter opening 
near this point, we encountered and removed about half of a large Min- 
nie ball. The ball had struck the outer border of the tibia, which was 
notched, and was probably thus divided, and this portion diverted from 
its course. 
The general cutaneous envelope of the leg seemed sound, but there 
appeared to have existed extensive pa tches of cellulitis in different parts 
of the leg. At these places the skin seemed to be undermined by the 
destruction of the connective tissue, which, it is well known, ever is the 
first of all the tissues to succumb to septic influences affecting any re- 
gion of the body. Shreds of this gangrenous cellular tissue were daily 
separating and being picked away in the dressing of the wounds. It 
was very evident that the limb had hardy escaped general gangrene, 
from the intensity of the inflammation, and that a large portion of the 
cellular envelope had yielded, and was now sloughing away from under 
the skin after the cause—destructive inflammation—had been overcome 
by the arterial ligation. 
Amputation below the knee was now considered practicable, and was 
debated in consultation, but the operation was deferred for another meet- 
ing, as the gangrene on the foot had not extended a hair-breadth since 
the ligation of the artery, and as the gradual separation of the sloughs 
was disclosing a healthy granulating surface beneath; and further, 
we now began to have hopes of saving even the limb, as well as the 
life of the patient. 
Orr continued rapidly to improve. The consultation to determine the 
fate of his limb never convened ; the very profuse suppuration gradu- 
ally abated to a reasonable amount for such a condition of parts; the 
extensive sloughs,on the foot slowly separated; that upon the dorsum, 
at first left some of the white tendons of the digital extensions exposed, 
and when the one came away from behind the ankle, the destruction 
was so deep, that u daylight was seen through” the interval between 
the tibia and tendo-Achillis. 'flic bone was nowhere exposed, however, 
though this posterior slough extended far enough forward to destroy the 
skin and cellular tissue over the internal malleolus. The vigor of gran- 
ulation in all these parts was truly remarkable ; cuticle rapidly extended 
from the edges, and in a short time, little islands of new skin were 
everywhere to be seen over the dorsum of the foot. His general health 
had so far improved that, at the end of about six weeks, he accompa- 
nied his uncle, who had nursed him most faithfully in Richmond, to 
Clark County, in Georgia. Repeated letters informed us, from time to 
time, of the favorable progress of his case, and, finally, of his being well 
and able to walk about. 16 
THE HUNTERIAN LIGATION OF ARTERIES. 
In addiition to tlie four cases of Hunterian ligation for inflammation in 
the lower extremity, above carefully detailed, we, as before mentioned, 
ligated the brachial in three cases of intense inflammation of the fore-arm 
and hand, with the most satisfactory results, which have already been 
presented in former paragraphs of the present paper. We kept no 
private notes of these arm cases, and used those of the attending assistant 
surgeons in the respective hospitals in making up the condensed state- 
ment of the results, to be formed in our published chapter on the arteries.* 
These notes are not accessible at present, but we hope, at some future 
time, to be able to furnish a full detail of the cases again, through 
the courtesy of these very intelligent and pains-taking gentlemen. 
Before leaving this portion of our subject, we will state that, from our 
observation of the three cases of Hunterian ligation for inflammation of 
the hand and forearm, we strongly incline to the belief, that, while the 
measure is not followed by such decided and striking results as in 
femoral ligations, on account of the more abundant inosculations and 
anastomoses in the terminal and collateral circulation, yet, for that rea- 
son, they are safer and may be more frequently practised with less ap- 
prehension of the evils that may result from a deficient blood-supply to 
the tissues. 
Besides our own seven cases, herein discussed, we would call attention 
to the five valuable cases, two of the upper and three of the lower 
extremity, reported by our friend, Prof. Daniel F. Wright, in the April 
Number of the Richmond Medical Journal. These cases demonstrate 
great benefit from the practice, not only in inflammation, but also in those 
more specific and less understood conditions attending hospital gangrene. 
We cannot regard any of our cases as belonging strictly to this class. 
Orr’s was, undoubtedly, a marked case of gangrene, but, in our view, of 
a nature differing from what is known to us as hospital gangrene, the 
mortification, in his case, resulting from the overwhelming congestion, 
amounting to complete arrest of the circulation in certain portions of the 
limb, and thus these portions were as effectually hilled as though every 
capillary, throughout their entire structure, had been strangulated by lig- 
atures. Here, verily, u extremes do meet” in one common fatal result: 
the animal tissues die when the capillaries carry too little blood, because 
the nutrient material does not reach their intimate structure; and they 
die just as certainly and as effectually whenever the capillaries are 
ovenchelmed with blood, because blood-movement and blood-change, so 
necessary to all the processes of life, are mechanically nullified and 
abolished. 
Inflammation is a condition of the living tissues which, it must be 
acknowledged, is far better described than defined. The old traditional 
characteristics : redness, heat, pain and swelling, have been the refuge of 
pathologists for ages past, and perhaps no better device can now be 
* See Manual of Military Surgery, p. 104. THE HUNTERIAN LIGATION OF ARTERIES. 
17 
resorted to, to convey accurately or exactly tlie state to be defined. 
Underlying these four constant elements of inflammation, all acknowl- 
edge tliat there is a hypersemia or distended condition of the blood-vessels, 
and so invariable is this turgescence, as a concomitant of inflammation, 
that it is regarded by all as the proximate cause of the condition—tin* 
ipse morhus. Our limits will not allow us to enter into a discussion of 
the subject, but suffice it to say, that whatever may be the theory upon 
this point, nearly all measures of treatment appear to recognise the fact 
that u too much blood in the part” is the chief cause of the local distress, 
and to remove or lessen this redundancy is the chief desideratum of 
practice. Hence, position, pressure, whether on the artery or by bandage 
over the entire limb, the application of cold, scarification, and many other 
measures tending to the same end, of either preventing blood from 
going into a part, or of removing blood from the part, have been 
used, from time immemorial, as at least valuable adjuncts to what- 
ever other treatment might be applied. This end, we may claim, 
and have shown, is, at least sometimes, more effectually accomplished by 
cutting off the main stream of blood from the engorged region. Tin- 
veins are left of their original calibre to drain away the superabundant 
blood, both the volume and the force of the arterial current are vastly 
diminished, and the over-distended capillaries soon recover their normal 
calibre and resume their normal action. Redness, heat, pain, and 
swelling disappear; and the unhealthy sanious effusion is replaced by 
healthy suppuration. 
We are fully aware that one of the great dangers of all serious arterial 
lesions is, that the necessity of ligation in the case of a large trunk 
endangers by mortification, sometimes the whole, and very often a 
considerable portion, of the region it may supply, on account of the failure 
in the collateral circulation. Hence the difference in the results of ligations 
for traumatic haemorrhage and those for the cure of aneurism; in the one 
case, the complete obstruction of the large channel of a main artery is 
necessarily accomplished suddenly, and the collateral circulation cannot 
be established in time to meet the organic demands of the region it had 
supplied; whereas, in the case of the aneurism, the long sustained and 
gradually increasing interruption of the main trunk has afforded time 
for, and brought about, the dilatation of the collateral vessels, and the 
final completion of the obstruction by the ligature produces, at last, 
often little or no disturbance in the nutrition of the tissues. In our cases 
of inflammation, the general turgescene which had continued, perhaps in 
most of them for many days, seems to have established, in the mul- 
titudinous capillaries and small vessels, a sufficently ample collateral 
circulation to answer all the demands of nutrition after the ligation of the 
main artery, Hence we find that, in not a single one of our cases, does 
there occur any thing even approaching to gangrene as the effect of 
insufficient blood-supply; while in every one of them the processes of 18 
THE HUNTERIAN LIGATION OF ARTERIES. 
nutrition are vastly improved, and the tissues brought safely out of a 
state of apparently impending mortification. 
It must be observed, and this we wish distinctly understood, that we 
do not recommend, nor have we, in any case, practised the ligation of a 
main vessel to prevent sound tissues from becoming inflamed. Our pre- 
cept and our practice pertained to tissues already in a state of very high 
inflammation, and had for their object tbe preventing of that inflammation 
from progressing to the extent of becoming fatal to the tissues by the 
overwhelming turgescence of the capillaries. There is a vast difference in 
the two measures;—the one, long and universal experience has shown, 
as in ligations for traumatic haemorrhage, would be highly dangerous, 
resulting often in mortification; the other, as shown by Dr Wright’s five 
cases, Dr. Thom’s one case, and our own seven cases,'has been entirely 
free from any thing even approaching such a result. 
We would not recommend the uniform ligation of arteries for in- 
flammation, even though they be of a very grave character. The operation 
is indeed a serious one—and it should never lightly be determined on ; 
but under the circumstances, and within tbe limits faithfully attempted to 
be defined in this paper, we regard the measure, not only a legitimate 
one, but one of imperative and bounden duty. 
Having encountered, under circumstances tbe most favorable for study, 
the facts and experience detailed in this report-—an experience which, 
at the time, we were entirely unaware, as our publication will show, that 
any one had even approximated before us—we conscientiously believe 
that, within proper limits, Hunterian ligation must be found a most valuable 
and available means of reducing the progress of septic inflammation to 
bounds that are safe and perfectly compatible with the life of the tissues* 
And lastly, whether the principle be adjudicated as a new one, or 
simply as the revival of an old one, long lost and unjustly neglected, 
we derive, as a practical deduction from our cases, corroborated and 
confirmed by subsequent cases of others herein mentioned, the ever-safe 
Conservative Precept: That no hand, wrist, fore-arm or elboAv ; no foot, 
ankle, leg or knee, should ever be amputated, for excessive or destructive 
inflammation, especially those cases resulting from traumatic causes 
—without resorting, whenever the state of the patient will admit of it, 
to a previous experimental ligation of tin1 artery supplying the affected 
region. 
In extremities already condemned to amputation, if time be allowed, 
the procedure can certainly do no harm,—on the other hand, it will often 
save a useful limb, or, at least, contribute to a more rapid healing of the 
stump.