Historical Note
Matthew M. Fluke, MD
results have been reported for the treatment of femoral pseudoaneurysms by means of ultrasound-guided external compression (1).The concept of treating aneurysms with external compression is not new, having been practiced "since antiquity" (2). Sir John Eric Erichsen, in his book The Science and Art PRoMlslNC
of Surgery Being a Treatise on Surgical Injuries, Diseases and Operations (3) gave a detailed description of the treatment of aneurysm by means of direct pressure in 1867. Reproduced below is his discussion of such treatment.
In consequence of the dangers and difficulties attendant upon the use of the ligature, surgeons have for many years past endeavored to treat aneurism by compression . . . pressure [was applied] directly upon the sac; . . . and several cures [were] effected in this way; but the method was so uncertain in its results, and so dangerous from irritating and inflaming the sac, that it fell into disuse. . . . In the early trials of the cure of aneurism by compressing the artery on the cardiac side of the tumor, the surgeons who employed this method acted on an erroneous theory. . . . It was supposed that it was necessary for the cure to take place that the whole of blood through the artery should be entirely arrested, that inflammation of the vessel at the point compressed should be set up, and that the consolidation of the aneurism depended upon the obstruction of the vessel Index term: Aneurysm, therapy, 9*.73 history
Radiology and radiologists,
JVIR 1992; 3:725-728
From the Department of Radiology, Ochsner Clinic and Alton Ochsner Medical Foundation, 1514 Jefferson Hwy, New Orleans, LA 70121. Received February 27, 1992; revision requested April 27; revision received June 5; accepted June 12. Address reprint requests to the author.
' SCVIR, 1992
consequent upon this inflammation . . . the patient could seldom bear it for a sufficient length of time to effect a cure, sloughing of the skin commonly resulting as a necessary consequence of the severe pressure to which it was subjected. . . . [It was subsequently learned that] it was not necessary for the whole of the circulation through the artery to be entirely and permanently arrested, but merely for it to be lessened in quantity and force to . . . [allow] the formation of laminated fibrine in the sac; and it was clearly shown by examination after death that if the pressure were properly conducted, the artery was in no way injured or occluded at the part compressed. . . . Though I have stated generally that aneurisms, when treated by compression, are cured by the d e ~ o s iof t laminated fibrine. I think this remark eight to be confined to the Aommon sacculated form of the disease. In the tubular variety, which is certainly of far less frequent occurrence in the extremities, the cure of the aneurism takes place by contraction of the sac, and by its becoming filled by fibrine in an . . . irregular manner. . . . The success of the treatment by compression depends greatly upon a scrupulous attention to a number of minor circumstances, which, though trivial in themselves, become of importance when taken as a whole . . . the patient's general health should be attended to in . . . [order to] increase of the fibrination of the blood. The irritability of the heart and arteries must also be subdued, and the irritation of the system lessened, by the use of opiates, and the patient should be put into a comfortable bed . . . so that his Dosition be not changed. . . . The limb having been bandaged smoothly, . . . the apparatus must next be applied . . . which, as it substitutes an elastic force derived from vulcanized India-rubber bands for the unyielding pressure of the screw, accommodates itself better to the limb, and is less likely to produce injurious compression. . . In order to keep up continuous pressure, and a t the same time to prevent any one part of the skin
726
Journal of Vascular and Interventional Radiology
November 1992
being injuriously galled, it is of very great consequence that two instruments should be used a t the same time, so that when one is screwed up the other should be loose; these instruments need not be placed closely together. If the aneurism be in the ham, it will be sufficient for one . . . to be applied to the groin, whilst the other. . . is put upon the middle of the thigh [Fig]. In using the instrument, the great point . . . is to control the circulation with the minimum of Dressure: in order to do this the first instrument s6ould be screwed up so that all pulsation ceases in the tumor, but still not so tightly as to arrest all the flow of blood through it. As the pressure exercised by this becomes painful, it must be slightly loosened, and the second one screwed UD.In this wav an alternation of pressure can be kept up without much pain or inconvenience. If possible the patient should be taught how to manage the instrument himself, and will often find an occupation and amusement in doing so. If however it excite[s] much pain or irritation, as it does in some subjects, it may be necessary to give opiates. The pressure should, if possible, be continued during sleep, but if it prevent[~]the patient taking his natural rest, . . . unscrewing the instrument slightly, and, when the patient is asleep, gently tightening it again without awakening him, may advantageously be adopted; it is indeed surprising how very little unscrewing will relieve the pain of the compression. . . . The effects upon the tumor vary considerably. In some cases, it rapidly and suddenly solidifies; more commonly, however, this is a gradual process, the aneurism becoming more painful and solid, with less pulsation and bruit. As the solidification takes place, there is usually a good deal of restlessness, a feeling of general uneasiness, and of constitutional disturbance, which is best quieted by opiates. As the pressure is continued, and the tumor begins to harden, the anastomosing vessels enlarge, with a good deal of burning pain in the limb generally, and arterial pulsations in situations where usually none are felt. . . . [In] the treatment of popliteal aneurism by compression, three arteries will be found to be enlarged, one of which passes over the centre of the tumor, another over the head of the fibula, and the third along the inner edge of the patella; . . . the severe burning pain which is felt in these cases, is owing to the artery accompanying the communicans peronei nerve being enlarged. . . . The great question with regard to compression appears to me, after all, to be whether it possesses any special advantages over the ligature. The principal objections that have been urged against compression are that its employment is more
FIG. 181.
Comprcsaor far the p i n .
Fro. 182.
Campresoar for the niiddle of the thigh.
Figure. Reproduction of Erichsen's illustration of the compressors for the groin (left)and for the middle of the thigh (right).
painful and tedious than the use of the ligature, and that those cases that are unpromising to the ligature or that require amputation rather than it, are equally unfavorable to compression and cannot be saved by the employment of this means. To these objections I [respond] that the pain attendant on the employment of compression depends very greatly upon the skill and care with which the apparatus is applied and managed throughout, and that much depends upon the kind of instrument that is used. . . in reality there is but little difference [in the relative tediousness of the treatment under the two plans]; for although some cases in which compression is used, are prolonged over a considerable space of time, yet they do not occupy more than is often consumed when accidents of various kinds follow the use of the ligature; and it not unfrequently happens in compression, what can never occur after the employment of the ligature, that the patient is cured of his disease in a few hours or days . . . we shall find that the treatment lasted [an average of nineteen to] twenty-five days . . . and this is not very different from what happens with the ligature; for of 54 cases . . . in which the femoral artery was tied, the average time for the separation of the ligature was eighteen days, and if to this a week more be added for the closure of the wound, and for the treatment of the various accidents so often accompanying and following the ligature, we should probably . . . bring the duration of the treatment of the two methods to the same level.
Fluke
72 7
Volume 3 Number 4
After all, surgeons will eventually be guided in their estimate of the value of the two plans of treatment, not so much by the question of submitting their patients to a slightly more painful or tedious treatment, as to the comparative risk of life attendant upon one or other method. . . . If, however, we compare the 32 cases of femoral and popliteal aneurism treated [by compression] up to February, 1851 . . . with the results of the 188 cases of femoral and popliteal aneurism . . . in which the artery was ligatured, we shall find that of the 32 compression-cases . . . 6 . . . failed, being, in the proportion of 1to 5.3 cases, and 2 died, being in the ratio of 1to 16. Of the 188 cases in which the artery was ligatured, 142 were cured, . . . deaths after ligature were in the proportion of 1to 4, and the failures or serious accidents, of 1 to 3, showing, clearly a very considerable preponderance in favor of the treatment by compression. Besides which, in many patients who recovered after the ligature, various accidents, such as gangrene, erysipelas, secondary hemorrhage, &c., resulted as the direct consequences of the treatment, and these do not happen when pressure is employed. If the compression fails, the ligature may then often be advantageously applied; and as has been shown by the known cases, with a better success than if compression had not previously been tried, that treatment having caused the collateral circulation to enlarge, and thus lessened the tendency to gangrene. It should also not be forgotten that in some cases, such as when aneurism is complicated with heart disease, or occurs in a very broken and unhealthy constitution, in which the operation necessary for the application of the ligature would scarcely, or not a t all, be admissible, compression may be safely employed.
DISCUSSION Interested readers are directed to a concise biography of Sir John Eric Erichsen by Dahl-Iversen (4). Erichsen was born in Copenhagen in 1818 and educated in England. His extensive surgical career there was distinguished by many honors and publications, particularly his textbook excerpted above, for which Dahl-Iversen states he became world famous. Although not considered to have done pioneering work, he was considered an eminent teacher. Among his house surgeons were Baron Joseph Lister, who introduced the use of antiseptic agents into surgical practice. Erichsen died in 1896. The clarity and detail of Erichsen's clinical observations indicate that he must have been a dedicated observer and documenter of the
natural history of disease and the outcomes of available thera~ies. Despite Erichsen's advocacy, the concept of treating aneurysms with compression apparently was never widely accepted, as later references to the technique are not readilv available. Clinical and ex~erimental experience with ligature (2), as well as advances in antisepsis, probably led to the abandonment of the technique. Many of Erichsen's key concepts parallel remarkably those of Fellmeth et a1 (1).He points out that ( a )it is unnecessary and usually harmful to completely occlude the artery leading to the aneurysm; ( b )excessive pressure can lead to skin necrosis; ( c ) successful therapy depends on the patient's ability to form thrombus; ( d l therapy may fail if the patient cannot tolerate the discomfort of the compression; and ( e ) in properly selected cases the results of compressive therapy compare favorably with those of open repair, and compression can be used in patients who are not candidates for open repair. The compressor for the groin bears a remarkable resemblance to compression devices that are currently used for groin compression following angiography (5,6). In his discussion of the classification and origins of aneurysms (7), Erichsen does differentiate between true aneurysms and pseudoaneurysms, but in his discussions of compressive therapy, he does not. He does refer to the "common sacculated form of the disease" and does state that "the tubular varietv . . . is certainly of far less frequent occurrence in the extremities." He notes that "it is during the middle period of life, about the ages of thirty and forty, that aneurisms are most frequently met with," usually in those "whose muscular system is called upon to make sudden violent and intermittent exertions," such as "soldiers, sailors and members of the higher classes of society," in a male-to-female proportion of 13:l. Although Erichsen himself believed that primary atheromatous disease was the key factor in allowing the aneurysms to form, considering the era in which he lived and practiced, with shorter life spans and limited therapies for vascular injuries, it is reasonable to conclude that many, if not most, of his cases were posttraumatic pseudoaneurysms. References 1. Fellmeth BD, Roberts AC, Bookstein JJ, et al. Postangiographic femoral artery injuries: nonsurgical repair with US-guided compression. Radiology 1991; 178:671675. 2. Wangensteen OW, Wangensteen, SD. Vascular surgery. In: The rise of surgery. Minneapolis: University of Minnesota Press, 1978; 255-264. 3. Erichsen JE. The treatment of aneurism by compression. In: The science and a r t of surgery. American ed. Philadelphia: Lea, 1867; 507-512.
728
Journal of Vascular and Interventional Radiology
November 1992
4. Dahl-Iversen E. Sir John Eric Erichsen, bt. Acta Chirurg Scand 1961; 283(S):1-7. 5. Semler HJ. Transfemoral catheterization: mechanical vs manual control of bleeding. Radiology 1985; 154:234235.
6. Colapinto RF, Harty PW. Femoral artery compression device for outpatient angiography. Radiology 1988; 166: 890-89 1. 7. Erichsen JE. Aneurism. In: The science and art of surgery. American ed. Philadelphia: Lea, 1867; 482-484.
Matthew M. Fluke, MD
results have been reported for the treatment of femoral pseudoaneurysms by means of ultrasound-guided external compression (1).The concept of treating aneurysms with external compression is not new, having been practiced "since antiquity" (2). Sir John Eric Erichsen, in his book The Science and Art PRoMlslNC
of Surgery Being a Treatise on Surgical Injuries, Diseases and Operations (3) gave a detailed description of the treatment of aneurysm by means of direct pressure in 1867. Reproduced below is his discussion of such treatment.
In consequence of the dangers and difficulties attendant upon the use of the ligature, surgeons have for many years past endeavored to treat aneurism by compression . . . pressure [was applied] directly upon the sac; . . . and several cures [were] effected in this way; but the method was so uncertain in its results, and so dangerous from irritating and inflaming the sac, that it fell into disuse. . . . In the early trials of the cure of aneurism by compressing the artery on the cardiac side of the tumor, the surgeons who employed this method acted on an erroneous theory. . . . It was supposed that it was necessary for the cure to take place that the whole of blood through the artery should be entirely arrested, that inflammation of the vessel at the point compressed should be set up, and that the consolidation of the aneurism depended upon the obstruction of the vessel Index term: Aneurysm, therapy, 9*.73 history
Radiology and radiologists,
JVIR 1992; 3:725-728
From the Department of Radiology, Ochsner Clinic and Alton Ochsner Medical Foundation, 1514 Jefferson Hwy, New Orleans, LA 70121. Received February 27, 1992; revision requested April 27; revision received June 5; accepted June 12. Address reprint requests to the author.
' SCVIR, 1992
consequent upon this inflammation . . . the patient could seldom bear it for a sufficient length of time to effect a cure, sloughing of the skin commonly resulting as a necessary consequence of the severe pressure to which it was subjected. . . . [It was subsequently learned that] it was not necessary for the whole of the circulation through the artery to be entirely and permanently arrested, but merely for it to be lessened in quantity and force to . . . [allow] the formation of laminated fibrine in the sac; and it was clearly shown by examination after death that if the pressure were properly conducted, the artery was in no way injured or occluded at the part compressed. . . . Though I have stated generally that aneurisms, when treated by compression, are cured by the d e ~ o s iof t laminated fibrine. I think this remark eight to be confined to the Aommon sacculated form of the disease. In the tubular variety, which is certainly of far less frequent occurrence in the extremities, the cure of the aneurism takes place by contraction of the sac, and by its becoming filled by fibrine in an . . . irregular manner. . . . The success of the treatment by compression depends greatly upon a scrupulous attention to a number of minor circumstances, which, though trivial in themselves, become of importance when taken as a whole . . . the patient's general health should be attended to in . . . [order to] increase of the fibrination of the blood. The irritability of the heart and arteries must also be subdued, and the irritation of the system lessened, by the use of opiates, and the patient should be put into a comfortable bed . . . so that his Dosition be not changed. . . . The limb having been bandaged smoothly, . . . the apparatus must next be applied . . . which, as it substitutes an elastic force derived from vulcanized India-rubber bands for the unyielding pressure of the screw, accommodates itself better to the limb, and is less likely to produce injurious compression. . . In order to keep up continuous pressure, and a t the same time to prevent any one part of the skin
726
Journal of Vascular and Interventional Radiology
November 1992
being injuriously galled, it is of very great consequence that two instruments should be used a t the same time, so that when one is screwed up the other should be loose; these instruments need not be placed closely together. If the aneurism be in the ham, it will be sufficient for one . . . to be applied to the groin, whilst the other. . . is put upon the middle of the thigh [Fig]. In using the instrument, the great point . . . is to control the circulation with the minimum of Dressure: in order to do this the first instrument s6ould be screwed up so that all pulsation ceases in the tumor, but still not so tightly as to arrest all the flow of blood through it. As the pressure exercised by this becomes painful, it must be slightly loosened, and the second one screwed UD.In this wav an alternation of pressure can be kept up without much pain or inconvenience. If possible the patient should be taught how to manage the instrument himself, and will often find an occupation and amusement in doing so. If however it excite[s] much pain or irritation, as it does in some subjects, it may be necessary to give opiates. The pressure should, if possible, be continued during sleep, but if it prevent[~]the patient taking his natural rest, . . . unscrewing the instrument slightly, and, when the patient is asleep, gently tightening it again without awakening him, may advantageously be adopted; it is indeed surprising how very little unscrewing will relieve the pain of the compression. . . . The effects upon the tumor vary considerably. In some cases, it rapidly and suddenly solidifies; more commonly, however, this is a gradual process, the aneurism becoming more painful and solid, with less pulsation and bruit. As the solidification takes place, there is usually a good deal of restlessness, a feeling of general uneasiness, and of constitutional disturbance, which is best quieted by opiates. As the pressure is continued, and the tumor begins to harden, the anastomosing vessels enlarge, with a good deal of burning pain in the limb generally, and arterial pulsations in situations where usually none are felt. . . . [In] the treatment of popliteal aneurism by compression, three arteries will be found to be enlarged, one of which passes over the centre of the tumor, another over the head of the fibula, and the third along the inner edge of the patella; . . . the severe burning pain which is felt in these cases, is owing to the artery accompanying the communicans peronei nerve being enlarged. . . . The great question with regard to compression appears to me, after all, to be whether it possesses any special advantages over the ligature. The principal objections that have been urged against compression are that its employment is more
FIG. 181.
Comprcsaor far the p i n .
Fro. 182.
Campresoar for the niiddle of the thigh.
Figure. Reproduction of Erichsen's illustration of the compressors for the groin (left)and for the middle of the thigh (right).
painful and tedious than the use of the ligature, and that those cases that are unpromising to the ligature or that require amputation rather than it, are equally unfavorable to compression and cannot be saved by the employment of this means. To these objections I [respond] that the pain attendant on the employment of compression depends very greatly upon the skill and care with which the apparatus is applied and managed throughout, and that much depends upon the kind of instrument that is used. . . in reality there is but little difference [in the relative tediousness of the treatment under the two plans]; for although some cases in which compression is used, are prolonged over a considerable space of time, yet they do not occupy more than is often consumed when accidents of various kinds follow the use of the ligature; and it not unfrequently happens in compression, what can never occur after the employment of the ligature, that the patient is cured of his disease in a few hours or days . . . we shall find that the treatment lasted [an average of nineteen to] twenty-five days . . . and this is not very different from what happens with the ligature; for of 54 cases . . . in which the femoral artery was tied, the average time for the separation of the ligature was eighteen days, and if to this a week more be added for the closure of the wound, and for the treatment of the various accidents so often accompanying and following the ligature, we should probably . . . bring the duration of the treatment of the two methods to the same level.
Fluke
72 7
Volume 3 Number 4
After all, surgeons will eventually be guided in their estimate of the value of the two plans of treatment, not so much by the question of submitting their patients to a slightly more painful or tedious treatment, as to the comparative risk of life attendant upon one or other method. . . . If, however, we compare the 32 cases of femoral and popliteal aneurism treated [by compression] up to February, 1851 . . . with the results of the 188 cases of femoral and popliteal aneurism . . . in which the artery was ligatured, we shall find that of the 32 compression-cases . . . 6 . . . failed, being, in the proportion of 1to 5.3 cases, and 2 died, being in the ratio of 1to 16. Of the 188 cases in which the artery was ligatured, 142 were cured, . . . deaths after ligature were in the proportion of 1to 4, and the failures or serious accidents, of 1 to 3, showing, clearly a very considerable preponderance in favor of the treatment by compression. Besides which, in many patients who recovered after the ligature, various accidents, such as gangrene, erysipelas, secondary hemorrhage, &c., resulted as the direct consequences of the treatment, and these do not happen when pressure is employed. If the compression fails, the ligature may then often be advantageously applied; and as has been shown by the known cases, with a better success than if compression had not previously been tried, that treatment having caused the collateral circulation to enlarge, and thus lessened the tendency to gangrene. It should also not be forgotten that in some cases, such as when aneurism is complicated with heart disease, or occurs in a very broken and unhealthy constitution, in which the operation necessary for the application of the ligature would scarcely, or not a t all, be admissible, compression may be safely employed.
DISCUSSION Interested readers are directed to a concise biography of Sir John Eric Erichsen by Dahl-Iversen (4). Erichsen was born in Copenhagen in 1818 and educated in England. His extensive surgical career there was distinguished by many honors and publications, particularly his textbook excerpted above, for which Dahl-Iversen states he became world famous. Although not considered to have done pioneering work, he was considered an eminent teacher. Among his house surgeons were Baron Joseph Lister, who introduced the use of antiseptic agents into surgical practice. Erichsen died in 1896. The clarity and detail of Erichsen's clinical observations indicate that he must have been a dedicated observer and documenter of the
natural history of disease and the outcomes of available thera~ies. Despite Erichsen's advocacy, the concept of treating aneurysms with compression apparently was never widely accepted, as later references to the technique are not readilv available. Clinical and ex~erimental experience with ligature (2), as well as advances in antisepsis, probably led to the abandonment of the technique. Many of Erichsen's key concepts parallel remarkably those of Fellmeth et a1 (1).He points out that ( a )it is unnecessary and usually harmful to completely occlude the artery leading to the aneurysm; ( b )excessive pressure can lead to skin necrosis; ( c ) successful therapy depends on the patient's ability to form thrombus; ( d l therapy may fail if the patient cannot tolerate the discomfort of the compression; and ( e ) in properly selected cases the results of compressive therapy compare favorably with those of open repair, and compression can be used in patients who are not candidates for open repair. The compressor for the groin bears a remarkable resemblance to compression devices that are currently used for groin compression following angiography (5,6). In his discussion of the classification and origins of aneurysms (7), Erichsen does differentiate between true aneurysms and pseudoaneurysms, but in his discussions of compressive therapy, he does not. He does refer to the "common sacculated form of the disease" and does state that "the tubular varietv . . . is certainly of far less frequent occurrence in the extremities." He notes that "it is during the middle period of life, about the ages of thirty and forty, that aneurisms are most frequently met with," usually in those "whose muscular system is called upon to make sudden violent and intermittent exertions," such as "soldiers, sailors and members of the higher classes of society," in a male-to-female proportion of 13:l. Although Erichsen himself believed that primary atheromatous disease was the key factor in allowing the aneurysms to form, considering the era in which he lived and practiced, with shorter life spans and limited therapies for vascular injuries, it is reasonable to conclude that many, if not most, of his cases were posttraumatic pseudoaneurysms. References 1. Fellmeth BD, Roberts AC, Bookstein JJ, et al. Postangiographic femoral artery injuries: nonsurgical repair with US-guided compression. Radiology 1991; 178:671675. 2. Wangensteen OW, Wangensteen, SD. Vascular surgery. In: The rise of surgery. Minneapolis: University of Minnesota Press, 1978; 255-264. 3. Erichsen JE. The treatment of aneurism by compression. In: The science and a r t of surgery. American ed. Philadelphia: Lea, 1867; 507-512.
728
Journal of Vascular and Interventional Radiology
November 1992
4. Dahl-Iversen E. Sir John Eric Erichsen, bt. Acta Chirurg Scand 1961; 283(S):1-7. 5. Semler HJ. Transfemoral catheterization: mechanical vs manual control of bleeding. Radiology 1985; 154:234235.
6. Colapinto RF, Harty PW. Femoral artery compression device for outpatient angiography. Radiology 1988; 166: 890-89 1. 7. Erichsen JE. Aneurism. In: The science and art of surgery. American ed. Philadelphia: Lea, 1867; 482-484.
