John and William Hunter W.
Randolph Chitwood, Jr,
on
Aneurysms
MD
\s=b\ John and William Hunter made important contributions to vascular surgery that have prevailed until today. Their studies of aneurysm formation, pathology, and treatment laid the foundation for many modern surgical concepts. In the Great Windmill School of Anatomy, and subsequently at St George's Hospital, London, the Hunters defined true and false aneurysms. William Hunter, in addition, was the first to describe the arteriovenous aneurysm or fistula. Later, John Hunter developed a successful operation for popliteal aneurysm based on his meticulous laboratory investigations. These Scots showed a unique experimental and clinical genius rarely present in late 18th-century medicine.
WILLIAM HUNTER
1718, William Hunter was born near East Kilbride in Scotland (Fig 1). After an unremarkable grammar educa¬ tion, he spent five years at the University of Glasgow In
Fig 1.—Pyne's portrait of William Hunter. Stephen Paget once said of Hunter, "He never married; he had no country house; he looks, in his portrait, a fastidious, fine gentleman; but he worked till he dropped and he lectured when he was dying" (Trent Collection, Duke University).
(Arch Surg 112:829-836, 1977) the 200 years, Scotland has fathered or educated many men responsible for our modern In particular, the surgeon brothers, William and John Hunter, developed an academic surgical atmosphere in the mid-18th century that was propagated by their illustrious students: Abernethy, Home, Cooper, Shippen, Morgan, and Jenner professed Hunterian ideas and thoughts that pervade surgery today. Born ten years apart in Lanarkshire, near Glasgow, Scotland, the Hunters' motivations and interests were divergent from the start. Detailed biographies, written by Dobson,' Paget,- Foote,:1 Simmons,' and Illingworth"' reflect the Hunters' contrasting development. However, John's and William's attitudes toward scientific investigation and clinical application were from the beginning congruent. Certainly, their understanding of arterial disease and aneurysm pathogenesis reflects a confluence of Hunterian
past Over surgical heritage.
reason.
Accepted
for publication Dec 6, 1976. From the Department of Surgery, Duke University Medical Center, Durham, NC. Reprint requests to Department of Surgery, Duke University Medical Center, PO Box 3025, Durham, NC 27710 (Dr Chitwood).
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for William Hunter's approach to medicine."' His first published paper, entitled, "On the Structure and Disease of Articular Cartilages by William Hunter, Surgeon," clearly established his early professional inclin¬ ations.7 In 1746, he was elected to the Society of Naval Surgeons at Guy's Hospital, and was subsequently ad¬ mitted to the Corporation of Surgeons in 1747. He left the latter in 1756 to join the College of Physicians." After a sixmonth visit to Scotland in 1750, William was awarded the Doctor of Medicine from the University of Glasgow.1 Disturbed by the inadequacy of medical and surgical education, Hunter established a school of anatomy in London, first in Covent Garden and then in Jermyn Street. Ultimately, the famous Great Windmill Street School of Anatomy was constructed in 1768. In both schools, William and his brother, John, who had come from Glasgow in 1749, dissected a variety of specimens. These early experiences formed the primordia for their later thoughts on aneurysm
pathogenesis. During his early
Fig 2.—Jan Van Rymsdyck's large, fold-out drawing of ruptured thoracic aortic aneurysm described in History of Aneurysms of the Aorta With Some Remarks on Aneurysms in General, by William Hunter, 1757 (Trent Collection, Duke University).
Medical Obfirvations and Inquiries. 323 XXVIL The Hißory of an Aneuryfm of the Aorta, ivith fome Remarks on Aneuryfms in general. By William Hunter» M. D% Fig 3.—Title page of William Hunter's classic 1757 paper on aneurysm pathophysiology (Trent Collection, Duke University). Plans to enter theology were altered in befriended by William Cullen, a promi¬ nent Glasgow physician. Cullen exposed young Hunter to the rudiments of medicine throughout the next three years.1"'" During the year 1739, spent in Edinburgh, Hunter was under the tutelage of Alexander Monro (pri¬ mus), a figure who would later become his fiercest an¬ tagonist. William subsequently travelled to London in 1741, where he was introduced to William Smellie and James Douglas. Both men were well-known Scottish acoucher-physicians who had large practices and great influence. He assisted Dr Douglas in his dissecting room while attending didactic sessions at St George's Hospital." It was this combination of anatomy and pathology, studied under the guidance of Dr Douglas, that laid the foundation
studying the arts. 1736, when he
was
London training with Dr Douglas, William became interested in aneurysm formation. Alex¬ ander Monro, Hunter's Edinburgh mentor, made numerous observations and descriptions of aneurysms as early as 1733. However, Douglas has been considered the stimulus of Dr Hunter's aneurysm studies. Dr Douglas read Galen's second-century writings that grouped aneurysms as either of the true or false type. The former occurred as a simple dilation of the arterial wall, and the latter consequent to traumatic rupture of the vessel wall. Douglas, thereafter, classified aneurysms by the categories devised by Galen. Comparing the clinical course of Mr Isaac Bradwell, a pa¬ tient at St George's Hospital, to Douglas' manuscripts, Hunter added an additional variety of aneurysm. William said of Bradwell's case: '
When I first saw him (1749), there was an oblong swelling between Its the cartilages of the second and third ribs of the right side pulsation was strong, and perceptible even to the eye, and corresponded with the pulse in the wrist." ....
On Mr Bradwell's death in October of 1752, Dr Hunter examined the ruptured thoracic aortic aneurysm. At the postmortem examination, Jan Van Rymsdyck, Hunter's talented illustrator, made three expertly detailed sketches that were later engraved by Miller (Fig 2). Subsequently, in 1756, Hunter presented this case to the elite Society of Physicians in London, presided over by Dr John Fothergill. William's detailed "History of Aneurysms of the Aorta, with Some Remarks on Aneurysms in General," which was published in Medical Observations and Inquiries in 1757, stemmed from this case (Fig 3)." In this work, he spoke of the third variety or mixed aneurysm as follows:
May not some of the disputes about the nature of aneurysms be The third kind of settled, by dividing them into three kinds aneurysm is mixed, that is, formed partly by a wound or rupture of some of the coats of the artery, and partly by a dilatation of the ....
rest."
early treatise has proved to be an historical classic on aneurysm formation and pathology. In 1762, Dr Hunter reported to the Society two cases of This
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true aneurysms previously attended by Mr Bayford, a London surgeon. Hunter was present at the postmortem examination, and Rymsdyck drew the specimens, which contained aneurysms involving the right subclavian and common carotid arteries as well as the abdominal aorta. In his 1767 description, Hunter said of this specimen and of aneurysms in general: The spontaneous aneurysm wherever seated is much more to be dreaded in its consequences, than one that is the immediate result of external injury. In the one, the disease is local; in the other,
probably
universal."
Previous reports by Hunter did not specifically relate generalized vascular disease as the etiologic agent in aneurysm formation. Hunter, apparently, never used the term atherosclerosis, but by 1762 he clearly understood and accepted that vascular deterioration was from a systemic disease.11' Later, his brother John determined the composi¬
tion of vascular plaques that incite wall degeneration.11 As related in his 1757 treatise, nonoperative therapy was selected for aortic aneurysms. However, he approved of simple ligation for small peripheral aneurysms. Ligature of large central aneurysms did not seem either curative or palliative to Hunter. In Bradwell's case (1757), compression was even advised against in an effort to prevent additional trauma. By 1761, Hunter apparently accepted operative treatment for generalized true aneurysms." The impor¬ tance of collateral vessels surrounding an aneurysm in¬ trigued Hunter, and, as he said: In aneurysms that admit of the operation [ligation], it is advisable, first to attempt the cure by compression; because it sometimes proves effectual, and is always a commendable preparatory step to the operation, in as much as it inlarges (enlarges) the collateral anastomosing branches, and thereby disposes the part to have more free circulation after the operation (1757)."
No doubt William Hunter's best-known contribution to vascular surgery was the definitive description of the aneurysmal varix, or arteriovenous communication. Al¬ though he had speculated the existence of such an entity in 1757, it was not until 1761 that he identified and described this atypical aneurysm." '- Before presenting his cases to the critical Society of Physicians, he reviewed the anti¬ quarian literature for a previous description. After trans¬ lating a comprehensive early Arabian surgical text by Albucasis, Dr Hunter concluded that he alone was the first to describe the aneurysmal varix. Osier," also, proclaimed William Hunter as the original expositor of this vascular abnormality (1915). Hunter's first cases were in a young country girl and in Mr Cheshire, a laboratory assistant at the Middlesex Hospital. Both were victims of an inept "bleeder." Hunter said of these aneurysmal varices: The vein will be dilated or become varicose, and it will have a pulsatile jarring motion on account of the stream from the artery. It will make a hissing noise, which will be found to correspond with the pulse The artery, I apprehend, will become longer in the arm and smaller at the wrist than it was in the natural state.12 ....
Moreover, he related the associated thrill, saying: There is a remarkable tremulous motion both in the bag, and in the dilated vein, as if blood was squirted into it through a small hole. It
Fig 4.—Engraving of Sir Joshua Reynolds' portrait of John Hunter. Original oil portrait hangs in Council Room at Royal College of Surgeons in London. is like what is produced in the mouth the letter "R" in a whisper.1-
by continuing the
sound of
apparently discussed surgical agreed that nonrecounted: William preferred.
The Hunter brothers
treatment for arteriovenous fistulae and
operative therapy was
The one [true aneurysm] is growing every hour, because of the resistance of the arterial blood; and if not remedied by surgery, must at least burst. The other [A V fistula] in a short time comes to nearly permanent state; and if, not disturbed produces no mischief... .'-
By 1770, five cases of arteriovenous aneurysms had been presented to the Society of Physicians, and all had done
well with conservative management." None of William Hunter's specimens of atherosclerotic aneurysms or arte¬ riovenous communications exist today, not even at the University of Glasgow, where the majority of his dissec¬ tions are preserved. Hunter reported and described the first vascular suture to the Society of Physicians in June of 1761. Messieurs Lambert and Hallowell of Newcastle-on-Tyne, England, placed a steel pin through the orifice in an artery and obliterated the opening by wrapping a thread around it.1"'
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William in London in 1748, after little formal education.1 With the elder Hunter as his mentor, he soon became a proficient anatomist and adept teacher. William Cheselden, the famed lithotomist and author of Anatomy of the Human Body (1713) and Osteographia (1733), also taught Hunter.'-17 Beginning in 1751, John was apprenticed to Percival Pott of St Bartholomew's Hospital. From 1754 to 1756, Hunter was house surgeon to St George's Hospital, where he later made his greatest contributions to surgery. During this period, he elucidated details of placental circulation, lymphatic vessels, and nerves of olfaction under William's direction.'-' Based on his military experi¬ ence in Portugal during the Seven Years' War, Hunter later penned his most famous work, A Treatise on Blood, Inflammation, and Gun Shot Wounds (1794).'" After returning to England, he was elected fellow of the Royal Society in 1767, and subsequently inducted into the Corporation of Surgeons. From that time until his death in 1793, he educated young surgeons who became important contributors to vascular surgery during the 19th century (Fig 4). In Britain, they included William Blizzard, John Abernethy, Astley Cooper, Benjamin Bell, Henry Cline, and Everard Home. Edward Jenner, another pupil, represented the epitome of Hunter's scientific spirit, and remained one of Hunter's closest friends. The Hunterian influence prevailed in America through Philip Wright Post, John Morgan, William Shippen, and Philip Syng Physick.'" Thus, a strong, widespread Hunterian influence guided the development of vascular surgery from its
joined
beginning. In his early training, John Hunter had seen four cases of popliteal aneurysms ligated with variable results. Mes¬
5.—Mr Hunter's operation for popliteal aneurysm. This mod¬ drawing shows four individual arterial ligatures in Hunter canal. Note development of adequate collateral channels.
Fig
ern
Subsequently, Lambert communicated the facts of the case to Dr Hunter, who published it in Medical Observations and Inquiries in 1762.1" Hunter stated Mr Lambert's thoughts as follows: If it should be found by experience that a large artery, when wounded, may be healed up by this kind of suture, without becoming impervious, it would be an important discovery in
surgery.'" It remained for other
pioneer vascular surgeons, like Carrel, Lexer, Bernheim, Guthrie, and Murphy, to extend Lambert's idea into the reality of present vascular surgical techniques. JOHN HUNTER John Hunter's enthusiasm for vascular surgery was kindled in his brother William's schools of anatomy. John
sieurs Pott and Bromfield, both well-established London surgeons, were profound skeptics of arterial ligations, and voiced their opinions widely. Pott once said of a particular case, "I shall only remark that the patient died."20 Many surgeons preferred initial amputation to attempts at liga¬ tion. It was in this atmosphere of disbelief that Hunter developed, through experimentation, his ideas of aneurysm therapy. Sir D'Arcy Power has alleged that John Hunter's primary interest in popliteal aneurysms developed from a case of Mr Edward Ford, surgeon to the Westminster Dis¬ pensary.-' As early as September 1785, John examined this patient, who was, in time, spontaneously cured of his symptoms by thrombosis. Even though Ford completely opposed ligations, Hunter obtained some notion of extant collateral circulation from the case.'"-1 Previously, John developed great interest in the elas¬ ticity and muscular motion of arteries. From examination of equine arterial physiology, he had prepared part of his Croonian Lectures, which were delivered between 1776 and 1782."" On these foundations and his investigative exper¬ tise, he set about to develop a suitable curative operation for popliteal aneurysms. John Hunter's understanding of collateral circulation in human extremities mainly evolved from specific animal experiments. A great deal of controversy surrounds some of these, as results were often verbally transferred rather
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6.—John Hunter's surgical instruments, made by Savigny and preserved in Hunterian Museum. Similar set was destroyed in London blitz in 1941 (Royal College of Surgeons of England, Hunterian Museum).
Fig
of coachman's popliteal aneurysm. Operation was performed in December 1785 at St George's Hospital in London (Royal College of Surgeons of England, Hunterian Museum).
Fig 7.—Original specimen
than transcribed. However, the impact of these studies disputed. While living at Leicester Square in London around 1785, Hunter prepared a number of spec¬ imens relating to growth of deer antlers. Many of these are preserved today at the Hunterian Museum in London. Thereafter, he apparently ligated the external carotid artery of a deer from Richmond Park."-1 Spontaneous pulsations ceased in the capillary network of one antler. To Hunter's amazement, microcirculation was reestablished in this area within one week, owing to collateral revascularization.
cannot be
A second important experiment was related much later John Hunter's brother-in-law, Everard Home."' Albrecht von Haller had professed that mere vessel weak¬ ness was prerequisite for aneurysmal formation. Hunter, however, conjectured that a discrete disease process must also be present. Perturbed by contrasting ideas, Mr Hunter dissected a canine carotid artery free of its adventitia and media, leaving solely the intact intima. He surmised that if weakness alone predisposed to dilation, then a nidus for aneurysmal formation was certainly present. At the end of three weeks, no aneurysm had formed, although weakness
by
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Fig 8.—Hunterian specimen of large left external carotid artery aneurysm. Note intact tongue and thyroid and deviated trachea (Royal College of Surgeons of England, Hunterian Museum). still present. Hunter therefore concluded that intrinsic vessel disease must be present for aneurysms to form, and that hemorrhage near an aneurysmal sac often encoun¬ tered after ligation occurred because of wall deterioration. Home said of Hunter's experiment: was
that the
cause
of failure in the
common
operation arises from
tying a diseased artery, which is incapable of union.-' ...
Nathaniel Rumsey's shorthand notes of Hunter's lectures in 1785 and 1786 show that John's discerning knowledge of aneurysmal formation existed before his definitive arterial ligation.-" In these lectures, Hunter mentioned that some component of perivascular support was important in the prevention of aneurysms. This, he said, is reflected when carotid and thoracic aneurysms form circumferentially while those of the subclavian artery and abdominal aorta project anteriorly. Thus, supporting structures such as cartilage and bone usually divert aneu¬ rysm formation in an opposite direction. Moreover, he also noted that erosion may occur when the aneurysm contacts bone. The younger Hunter based his later vascular procedures on rational ideas derived from the animal experiments previously mentioned. Mainly, two basic principles relating to arterial ligation made John's operations successful while other surgeons failed. Ligation of the femoral artery at a distance from the diseased aneurysmal sac minimized arterial erosion and postoperative hemorrhage. Second, by placing occluding ligatures in the thigh rather than the
Fig
9.—Thoracic aortic arch aneurysm that has eroded into
trachea, creating a fistula. Specimen was dissected, described, and preserved by John Hunter (Royal College of Surgeons of England, Hunterian Museum).
popliteal fossa, minimal disturbance to valuable collaterals occurred. Perhaps his greatest contribution was expansion of knowledge relating to arterial collateral development. After John Hunter's era, attention to collateral vessel
protection was generally manifest. Relying on these principles, Mr Hunter first performed his famous operation for popliteal aneurysm in December 1785 on a 45-year-old coachman." The patient had been symptomatic for three years, and the condition of his extremity had progressed to severe distal ischemia. Accordingly, Hunter performed the operation by making an incision on the anterior and inner part of the thigh, rather below its middle The fascia which covers the artery was A double ligature then laid bare about three inches in length was passed behind it [the artery], by means of an eyed probe. The doubling of the ligature was cut so as to form two separate ligatures. The artery was now tied by both these ligatures, but so slightly as to only compress the sides together. A similar applica¬ tion of ligature was made a little lower. The reason for four ligatures, was to compress such a length of artery as might make up for want of tightness, it being wished to avoid great pressure on the vessel at any one part. The ends of the ligatures were carried directly out of the wound, the sides of which were now ...
....
....
...
brought together.... (Fig 5).-'" These arterial ligatures were placed within the fascial tunnel formed in the anterior thigh, between the femoral triangle and opening in the adductor magnus muscle. Within this compartment, now commonly called the Hunter canal, the femoral artery and vein and the saphe-
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nous nerve are
Fases /// ó'uiyenj-
found.
The
original description of the Hunterian operation, published in the London Medical Journal in 1786, was later reprinted in the Transactions of a Societyfor the Improve¬ ment of Medical and Chirurgical Knowledge (1793).23-24 After a month of confinement at St George's Hospital, the patient returned to his "hackney coach" and did well until
March 1787, when he died of a "remittent fever." After the patient's death, John Hunter examined the extremity and ascertained that the operation had no apparent influence on the patient's demise. By 1793, five similar operations had been successfully performed by the younger Hunter.2" Later, he modified the operation by simply using a single ligature around the artery.1" Subsequent to these early cases of popliteal artery aneurysms, Hunter established primary indications for operative intervention. Certainly, no damage to surround¬ ing structures should be present. Good arterial collateralization was always prerequisite for the optimum result. He instructed that the arterial mass must be well circum¬ scribed and remain pulsatile prior to ligation.2" With these criteria met, Hunter encouraged: The earlier, therefore, the operation for aneurysm is performed the better, not waiting with expectation that the increased size of the aneurysm will produce an increased size of collateral branches.2"
He declared it safe to ligate aneurysms of the carotid, femoral, and subclavian arteries by these surgical
techniques.
A number of John Hunter's instruments used in his vascular procedures are seen in Fig 6. Even the coachman's aneurysm, just described, is still preserved at the Royal College of Surgeons in London (Fig 7). Another intact Hunterian popliteal aneurysm ligated 50 years before the patient's death bears witness to the success of his opera¬ tion.2"' Other aneurysm specimens prepared by Hunter include those of the aortic arch, abdominal aorta, common carotid, subclavian, femoral, and pudendal arteries. Specific specimens in the Hunterian Museum deserve mention, as they illustrate the master's expertise at dissec¬ tion. A peculiar aneurysm of the left external carotid artery is magnificently preserved, along with the adjacent pharynx, larynx, tongue, and thyroid (Fig 8). The sac has displaced the majority of nuchal structures, and infinite detail is preserved. Trachéal erosion occurred in the large thoracic aortic aneurysm shown in Fig 9. Hunter was also the first to describe localized ventricular aneurysms." Within the Hunterian collection, a specimen (P 1149) shows two large ventricular aneurysms filled with laminated coagulum."-2"' Notations on these and other specimens are contained in the Catalogue of the Patholog¬ ical Series in the Hunterian Museum." Undoubtedly, John Hunter's curiosity for the aneu¬ rysmal varix developed from William's dissections and descriptions. John's account in Cases in Surgery of John Apperly's arteriovenous communication can be improved little today. He expounded on the associated thrill,
saying:
S??nturijm The Case ofjî.B.vrAt duefaé ¿ff Gccyesf/rfud oftwo JneufiStM m ¿hi ïïatnâ
//tí/'fit rrtUrrd
.terni
¡fí/r àtrte. a/f, 6t fieirtivrd r
a
a
orTbfiâ/iuU'Jr/er¿eS. />/u»J,
tux/fin* tin
.Vínu/ar
me
£u>c¿á,uf
fn
efiii
/fir. a/fie*"*
/lim /fitfr ¿urArrued, tin,/ fix- éer/mu fa**r in -m/ñ. ''f?"1' •/¡f/ítn Ar ratnr ttdr //' IßjfiUa/. /fit« ttitA* 6ru>mr cWSe~ de-rttv&f Saw «¿/¿I nt &tr»nafidt&aÂm. i*i mt*n ffléumJ veYt/ *tw*A rmarta/rd, a*td aA/i'*fd '"ry u*iáea//£y. Jn S**n Ort&ÊC» J uraí tti dnacr/. tv/*J uraJ 6rj/ €fi ¿f dan*. vif' 'J4MeS"er fo 6/>i for»/ //fr Í '/irt/f/ron fi>y /pe ^ne/tr/Jm a+n/u¿/t7¿e- i *™ :
.
.
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,-
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"
of /Ar fn/¿K ftvAtcÂ\}'Aaffen&t'
Randolph Chitwood, Jr,
on
Aneurysms
MD
\s=b\ John and William Hunter made important contributions to vascular surgery that have prevailed until today. Their studies of aneurysm formation, pathology, and treatment laid the foundation for many modern surgical concepts. In the Great Windmill School of Anatomy, and subsequently at St George's Hospital, London, the Hunters defined true and false aneurysms. William Hunter, in addition, was the first to describe the arteriovenous aneurysm or fistula. Later, John Hunter developed a successful operation for popliteal aneurysm based on his meticulous laboratory investigations. These Scots showed a unique experimental and clinical genius rarely present in late 18th-century medicine.
WILLIAM HUNTER
1718, William Hunter was born near East Kilbride in Scotland (Fig 1). After an unremarkable grammar educa¬ tion, he spent five years at the University of Glasgow In
Fig 1.—Pyne's portrait of William Hunter. Stephen Paget once said of Hunter, "He never married; he had no country house; he looks, in his portrait, a fastidious, fine gentleman; but he worked till he dropped and he lectured when he was dying" (Trent Collection, Duke University).
(Arch Surg 112:829-836, 1977) the 200 years, Scotland has fathered or educated many men responsible for our modern In particular, the surgeon brothers, William and John Hunter, developed an academic surgical atmosphere in the mid-18th century that was propagated by their illustrious students: Abernethy, Home, Cooper, Shippen, Morgan, and Jenner professed Hunterian ideas and thoughts that pervade surgery today. Born ten years apart in Lanarkshire, near Glasgow, Scotland, the Hunters' motivations and interests were divergent from the start. Detailed biographies, written by Dobson,' Paget,- Foote,:1 Simmons,' and Illingworth"' reflect the Hunters' contrasting development. However, John's and William's attitudes toward scientific investigation and clinical application were from the beginning congruent. Certainly, their understanding of arterial disease and aneurysm pathogenesis reflects a confluence of Hunterian
past Over surgical heritage.
reason.
Accepted
for publication Dec 6, 1976. From the Department of Surgery, Duke University Medical Center, Durham, NC. Reprint requests to Department of Surgery, Duke University Medical Center, PO Box 3025, Durham, NC 27710 (Dr Chitwood).
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for William Hunter's approach to medicine."' His first published paper, entitled, "On the Structure and Disease of Articular Cartilages by William Hunter, Surgeon," clearly established his early professional inclin¬ ations.7 In 1746, he was elected to the Society of Naval Surgeons at Guy's Hospital, and was subsequently ad¬ mitted to the Corporation of Surgeons in 1747. He left the latter in 1756 to join the College of Physicians." After a sixmonth visit to Scotland in 1750, William was awarded the Doctor of Medicine from the University of Glasgow.1 Disturbed by the inadequacy of medical and surgical education, Hunter established a school of anatomy in London, first in Covent Garden and then in Jermyn Street. Ultimately, the famous Great Windmill Street School of Anatomy was constructed in 1768. In both schools, William and his brother, John, who had come from Glasgow in 1749, dissected a variety of specimens. These early experiences formed the primordia for their later thoughts on aneurysm
pathogenesis. During his early
Fig 2.—Jan Van Rymsdyck's large, fold-out drawing of ruptured thoracic aortic aneurysm described in History of Aneurysms of the Aorta With Some Remarks on Aneurysms in General, by William Hunter, 1757 (Trent Collection, Duke University).
Medical Obfirvations and Inquiries. 323 XXVIL The Hißory of an Aneuryfm of the Aorta, ivith fome Remarks on Aneuryfms in general. By William Hunter» M. D% Fig 3.—Title page of William Hunter's classic 1757 paper on aneurysm pathophysiology (Trent Collection, Duke University). Plans to enter theology were altered in befriended by William Cullen, a promi¬ nent Glasgow physician. Cullen exposed young Hunter to the rudiments of medicine throughout the next three years.1"'" During the year 1739, spent in Edinburgh, Hunter was under the tutelage of Alexander Monro (pri¬ mus), a figure who would later become his fiercest an¬ tagonist. William subsequently travelled to London in 1741, where he was introduced to William Smellie and James Douglas. Both men were well-known Scottish acoucher-physicians who had large practices and great influence. He assisted Dr Douglas in his dissecting room while attending didactic sessions at St George's Hospital." It was this combination of anatomy and pathology, studied under the guidance of Dr Douglas, that laid the foundation
studying the arts. 1736, when he
was
London training with Dr Douglas, William became interested in aneurysm formation. Alex¬ ander Monro, Hunter's Edinburgh mentor, made numerous observations and descriptions of aneurysms as early as 1733. However, Douglas has been considered the stimulus of Dr Hunter's aneurysm studies. Dr Douglas read Galen's second-century writings that grouped aneurysms as either of the true or false type. The former occurred as a simple dilation of the arterial wall, and the latter consequent to traumatic rupture of the vessel wall. Douglas, thereafter, classified aneurysms by the categories devised by Galen. Comparing the clinical course of Mr Isaac Bradwell, a pa¬ tient at St George's Hospital, to Douglas' manuscripts, Hunter added an additional variety of aneurysm. William said of Bradwell's case: '
When I first saw him (1749), there was an oblong swelling between Its the cartilages of the second and third ribs of the right side pulsation was strong, and perceptible even to the eye, and corresponded with the pulse in the wrist." ....
On Mr Bradwell's death in October of 1752, Dr Hunter examined the ruptured thoracic aortic aneurysm. At the postmortem examination, Jan Van Rymsdyck, Hunter's talented illustrator, made three expertly detailed sketches that were later engraved by Miller (Fig 2). Subsequently, in 1756, Hunter presented this case to the elite Society of Physicians in London, presided over by Dr John Fothergill. William's detailed "History of Aneurysms of the Aorta, with Some Remarks on Aneurysms in General," which was published in Medical Observations and Inquiries in 1757, stemmed from this case (Fig 3)." In this work, he spoke of the third variety or mixed aneurysm as follows:
May not some of the disputes about the nature of aneurysms be The third kind of settled, by dividing them into three kinds aneurysm is mixed, that is, formed partly by a wound or rupture of some of the coats of the artery, and partly by a dilatation of the ....
rest."
early treatise has proved to be an historical classic on aneurysm formation and pathology. In 1762, Dr Hunter reported to the Society two cases of This
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 06/15/2015
true aneurysms previously attended by Mr Bayford, a London surgeon. Hunter was present at the postmortem examination, and Rymsdyck drew the specimens, which contained aneurysms involving the right subclavian and common carotid arteries as well as the abdominal aorta. In his 1767 description, Hunter said of this specimen and of aneurysms in general: The spontaneous aneurysm wherever seated is much more to be dreaded in its consequences, than one that is the immediate result of external injury. In the one, the disease is local; in the other,
probably
universal."
Previous reports by Hunter did not specifically relate generalized vascular disease as the etiologic agent in aneurysm formation. Hunter, apparently, never used the term atherosclerosis, but by 1762 he clearly understood and accepted that vascular deterioration was from a systemic disease.11' Later, his brother John determined the composi¬
tion of vascular plaques that incite wall degeneration.11 As related in his 1757 treatise, nonoperative therapy was selected for aortic aneurysms. However, he approved of simple ligation for small peripheral aneurysms. Ligature of large central aneurysms did not seem either curative or palliative to Hunter. In Bradwell's case (1757), compression was even advised against in an effort to prevent additional trauma. By 1761, Hunter apparently accepted operative treatment for generalized true aneurysms." The impor¬ tance of collateral vessels surrounding an aneurysm in¬ trigued Hunter, and, as he said: In aneurysms that admit of the operation [ligation], it is advisable, first to attempt the cure by compression; because it sometimes proves effectual, and is always a commendable preparatory step to the operation, in as much as it inlarges (enlarges) the collateral anastomosing branches, and thereby disposes the part to have more free circulation after the operation (1757)."
No doubt William Hunter's best-known contribution to vascular surgery was the definitive description of the aneurysmal varix, or arteriovenous communication. Al¬ though he had speculated the existence of such an entity in 1757, it was not until 1761 that he identified and described this atypical aneurysm." '- Before presenting his cases to the critical Society of Physicians, he reviewed the anti¬ quarian literature for a previous description. After trans¬ lating a comprehensive early Arabian surgical text by Albucasis, Dr Hunter concluded that he alone was the first to describe the aneurysmal varix. Osier," also, proclaimed William Hunter as the original expositor of this vascular abnormality (1915). Hunter's first cases were in a young country girl and in Mr Cheshire, a laboratory assistant at the Middlesex Hospital. Both were victims of an inept "bleeder." Hunter said of these aneurysmal varices: The vein will be dilated or become varicose, and it will have a pulsatile jarring motion on account of the stream from the artery. It will make a hissing noise, which will be found to correspond with the pulse The artery, I apprehend, will become longer in the arm and smaller at the wrist than it was in the natural state.12 ....
Moreover, he related the associated thrill, saying: There is a remarkable tremulous motion both in the bag, and in the dilated vein, as if blood was squirted into it through a small hole. It
Fig 4.—Engraving of Sir Joshua Reynolds' portrait of John Hunter. Original oil portrait hangs in Council Room at Royal College of Surgeons in London. is like what is produced in the mouth the letter "R" in a whisper.1-
by continuing the
sound of
apparently discussed surgical agreed that nonrecounted: William preferred.
The Hunter brothers
treatment for arteriovenous fistulae and
operative therapy was
The one [true aneurysm] is growing every hour, because of the resistance of the arterial blood; and if not remedied by surgery, must at least burst. The other [A V fistula] in a short time comes to nearly permanent state; and if, not disturbed produces no mischief... .'-
By 1770, five cases of arteriovenous aneurysms had been presented to the Society of Physicians, and all had done
well with conservative management." None of William Hunter's specimens of atherosclerotic aneurysms or arte¬ riovenous communications exist today, not even at the University of Glasgow, where the majority of his dissec¬ tions are preserved. Hunter reported and described the first vascular suture to the Society of Physicians in June of 1761. Messieurs Lambert and Hallowell of Newcastle-on-Tyne, England, placed a steel pin through the orifice in an artery and obliterated the opening by wrapping a thread around it.1"'
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William in London in 1748, after little formal education.1 With the elder Hunter as his mentor, he soon became a proficient anatomist and adept teacher. William Cheselden, the famed lithotomist and author of Anatomy of the Human Body (1713) and Osteographia (1733), also taught Hunter.'-17 Beginning in 1751, John was apprenticed to Percival Pott of St Bartholomew's Hospital. From 1754 to 1756, Hunter was house surgeon to St George's Hospital, where he later made his greatest contributions to surgery. During this period, he elucidated details of placental circulation, lymphatic vessels, and nerves of olfaction under William's direction.'-' Based on his military experi¬ ence in Portugal during the Seven Years' War, Hunter later penned his most famous work, A Treatise on Blood, Inflammation, and Gun Shot Wounds (1794).'" After returning to England, he was elected fellow of the Royal Society in 1767, and subsequently inducted into the Corporation of Surgeons. From that time until his death in 1793, he educated young surgeons who became important contributors to vascular surgery during the 19th century (Fig 4). In Britain, they included William Blizzard, John Abernethy, Astley Cooper, Benjamin Bell, Henry Cline, and Everard Home. Edward Jenner, another pupil, represented the epitome of Hunter's scientific spirit, and remained one of Hunter's closest friends. The Hunterian influence prevailed in America through Philip Wright Post, John Morgan, William Shippen, and Philip Syng Physick.'" Thus, a strong, widespread Hunterian influence guided the development of vascular surgery from its
joined
beginning. In his early training, John Hunter had seen four cases of popliteal aneurysms ligated with variable results. Mes¬
5.—Mr Hunter's operation for popliteal aneurysm. This mod¬ drawing shows four individual arterial ligatures in Hunter canal. Note development of adequate collateral channels.
Fig
ern
Subsequently, Lambert communicated the facts of the case to Dr Hunter, who published it in Medical Observations and Inquiries in 1762.1" Hunter stated Mr Lambert's thoughts as follows: If it should be found by experience that a large artery, when wounded, may be healed up by this kind of suture, without becoming impervious, it would be an important discovery in
surgery.'" It remained for other
pioneer vascular surgeons, like Carrel, Lexer, Bernheim, Guthrie, and Murphy, to extend Lambert's idea into the reality of present vascular surgical techniques. JOHN HUNTER John Hunter's enthusiasm for vascular surgery was kindled in his brother William's schools of anatomy. John
sieurs Pott and Bromfield, both well-established London surgeons, were profound skeptics of arterial ligations, and voiced their opinions widely. Pott once said of a particular case, "I shall only remark that the patient died."20 Many surgeons preferred initial amputation to attempts at liga¬ tion. It was in this atmosphere of disbelief that Hunter developed, through experimentation, his ideas of aneurysm therapy. Sir D'Arcy Power has alleged that John Hunter's primary interest in popliteal aneurysms developed from a case of Mr Edward Ford, surgeon to the Westminster Dis¬ pensary.-' As early as September 1785, John examined this patient, who was, in time, spontaneously cured of his symptoms by thrombosis. Even though Ford completely opposed ligations, Hunter obtained some notion of extant collateral circulation from the case.'"-1 Previously, John developed great interest in the elas¬ ticity and muscular motion of arteries. From examination of equine arterial physiology, he had prepared part of his Croonian Lectures, which were delivered between 1776 and 1782."" On these foundations and his investigative exper¬ tise, he set about to develop a suitable curative operation for popliteal aneurysms. John Hunter's understanding of collateral circulation in human extremities mainly evolved from specific animal experiments. A great deal of controversy surrounds some of these, as results were often verbally transferred rather
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6.—John Hunter's surgical instruments, made by Savigny and preserved in Hunterian Museum. Similar set was destroyed in London blitz in 1941 (Royal College of Surgeons of England, Hunterian Museum).
Fig
of coachman's popliteal aneurysm. Operation was performed in December 1785 at St George's Hospital in London (Royal College of Surgeons of England, Hunterian Museum).
Fig 7.—Original specimen
than transcribed. However, the impact of these studies disputed. While living at Leicester Square in London around 1785, Hunter prepared a number of spec¬ imens relating to growth of deer antlers. Many of these are preserved today at the Hunterian Museum in London. Thereafter, he apparently ligated the external carotid artery of a deer from Richmond Park."-1 Spontaneous pulsations ceased in the capillary network of one antler. To Hunter's amazement, microcirculation was reestablished in this area within one week, owing to collateral revascularization.
cannot be
A second important experiment was related much later John Hunter's brother-in-law, Everard Home."' Albrecht von Haller had professed that mere vessel weak¬ ness was prerequisite for aneurysmal formation. Hunter, however, conjectured that a discrete disease process must also be present. Perturbed by contrasting ideas, Mr Hunter dissected a canine carotid artery free of its adventitia and media, leaving solely the intact intima. He surmised that if weakness alone predisposed to dilation, then a nidus for aneurysmal formation was certainly present. At the end of three weeks, no aneurysm had formed, although weakness
by
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Fig 8.—Hunterian specimen of large left external carotid artery aneurysm. Note intact tongue and thyroid and deviated trachea (Royal College of Surgeons of England, Hunterian Museum). still present. Hunter therefore concluded that intrinsic vessel disease must be present for aneurysms to form, and that hemorrhage near an aneurysmal sac often encoun¬ tered after ligation occurred because of wall deterioration. Home said of Hunter's experiment: was
that the
cause
of failure in the
common
operation arises from
tying a diseased artery, which is incapable of union.-' ...
Nathaniel Rumsey's shorthand notes of Hunter's lectures in 1785 and 1786 show that John's discerning knowledge of aneurysmal formation existed before his definitive arterial ligation.-" In these lectures, Hunter mentioned that some component of perivascular support was important in the prevention of aneurysms. This, he said, is reflected when carotid and thoracic aneurysms form circumferentially while those of the subclavian artery and abdominal aorta project anteriorly. Thus, supporting structures such as cartilage and bone usually divert aneu¬ rysm formation in an opposite direction. Moreover, he also noted that erosion may occur when the aneurysm contacts bone. The younger Hunter based his later vascular procedures on rational ideas derived from the animal experiments previously mentioned. Mainly, two basic principles relating to arterial ligation made John's operations successful while other surgeons failed. Ligation of the femoral artery at a distance from the diseased aneurysmal sac minimized arterial erosion and postoperative hemorrhage. Second, by placing occluding ligatures in the thigh rather than the
Fig
9.—Thoracic aortic arch aneurysm that has eroded into
trachea, creating a fistula. Specimen was dissected, described, and preserved by John Hunter (Royal College of Surgeons of England, Hunterian Museum).
popliteal fossa, minimal disturbance to valuable collaterals occurred. Perhaps his greatest contribution was expansion of knowledge relating to arterial collateral development. After John Hunter's era, attention to collateral vessel
protection was generally manifest. Relying on these principles, Mr Hunter first performed his famous operation for popliteal aneurysm in December 1785 on a 45-year-old coachman." The patient had been symptomatic for three years, and the condition of his extremity had progressed to severe distal ischemia. Accordingly, Hunter performed the operation by making an incision on the anterior and inner part of the thigh, rather below its middle The fascia which covers the artery was A double ligature then laid bare about three inches in length was passed behind it [the artery], by means of an eyed probe. The doubling of the ligature was cut so as to form two separate ligatures. The artery was now tied by both these ligatures, but so slightly as to only compress the sides together. A similar applica¬ tion of ligature was made a little lower. The reason for four ligatures, was to compress such a length of artery as might make up for want of tightness, it being wished to avoid great pressure on the vessel at any one part. The ends of the ligatures were carried directly out of the wound, the sides of which were now ...
....
....
...
brought together.... (Fig 5).-'" These arterial ligatures were placed within the fascial tunnel formed in the anterior thigh, between the femoral triangle and opening in the adductor magnus muscle. Within this compartment, now commonly called the Hunter canal, the femoral artery and vein and the saphe-
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nous nerve are
Fases /// ó'uiyenj-
found.
The
original description of the Hunterian operation, published in the London Medical Journal in 1786, was later reprinted in the Transactions of a Societyfor the Improve¬ ment of Medical and Chirurgical Knowledge (1793).23-24 After a month of confinement at St George's Hospital, the patient returned to his "hackney coach" and did well until
March 1787, when he died of a "remittent fever." After the patient's death, John Hunter examined the extremity and ascertained that the operation had no apparent influence on the patient's demise. By 1793, five similar operations had been successfully performed by the younger Hunter.2" Later, he modified the operation by simply using a single ligature around the artery.1" Subsequent to these early cases of popliteal artery aneurysms, Hunter established primary indications for operative intervention. Certainly, no damage to surround¬ ing structures should be present. Good arterial collateralization was always prerequisite for the optimum result. He instructed that the arterial mass must be well circum¬ scribed and remain pulsatile prior to ligation.2" With these criteria met, Hunter encouraged: The earlier, therefore, the operation for aneurysm is performed the better, not waiting with expectation that the increased size of the aneurysm will produce an increased size of collateral branches.2"
He declared it safe to ligate aneurysms of the carotid, femoral, and subclavian arteries by these surgical
techniques.
A number of John Hunter's instruments used in his vascular procedures are seen in Fig 6. Even the coachman's aneurysm, just described, is still preserved at the Royal College of Surgeons in London (Fig 7). Another intact Hunterian popliteal aneurysm ligated 50 years before the patient's death bears witness to the success of his opera¬ tion.2"' Other aneurysm specimens prepared by Hunter include those of the aortic arch, abdominal aorta, common carotid, subclavian, femoral, and pudendal arteries. Specific specimens in the Hunterian Museum deserve mention, as they illustrate the master's expertise at dissec¬ tion. A peculiar aneurysm of the left external carotid artery is magnificently preserved, along with the adjacent pharynx, larynx, tongue, and thyroid (Fig 8). The sac has displaced the majority of nuchal structures, and infinite detail is preserved. Trachéal erosion occurred in the large thoracic aortic aneurysm shown in Fig 9. Hunter was also the first to describe localized ventricular aneurysms." Within the Hunterian collection, a specimen (P 1149) shows two large ventricular aneurysms filled with laminated coagulum."-2"' Notations on these and other specimens are contained in the Catalogue of the Patholog¬ ical Series in the Hunterian Museum." Undoubtedly, John Hunter's curiosity for the aneu¬ rysmal varix developed from William's dissections and descriptions. John's account in Cases in Surgery of John Apperly's arteriovenous communication can be improved little today. He expounded on the associated thrill,
saying:
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