Before anesthetics, before antibiotics, before surgery had even become a scientific discipline, surgeons throughout history did not shy away from the treatment of aneurysms, aortic or otherwise. However varied their success, these ancient surgeons pioneered techniques that would become perfected in much later eras, clearly demonstrating the quest for innovation in helping their patients that has been and is still a hallmark of the surgeon’s art.
What follows is a brief summary of a few of those pre-Hunterian pioneers. For more extensive reviews see the sources below.
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Galen (c. 129 – 200 A.D.)
According to Dr. William Osler (1849 -1914), aneurysm, probably posttraumatic, was first described in the Ebers Papyrus from Egypt around 4000 years ago. The famous Greco-Roman physician, Galen (circa 129 -200 A.D.), later defined an aneurysm as a “localized pulsatile swelling which disappeared on pressure.”
But the most influential surgeon with regard to aneurysm treatment in the ancient era was Antyllus, who lived during the first half of the second century A.D. Although his original works were lost, they are discussed in the later writings of Oribasius (c. 320 – 400), who described Antyllus’ methods for performing many different operations, including tracheotomy and the extraction of cataracts. Of particular interest is his operation for aneurysm, which remained the standard until the era of John Hunter in the 18th century.
Oribasius reported Antyllus as declining to operate on exceptionally big aneurysms, but for those others in the extremities, the limbs, and the head, he applied ligatures to the arteries that entered and left the aneurysm and then cut into the aneurysm sac, evacuated the contents, and packed the cavity. Antyllus did not resect the aneurysm sac and was quoted as saying: “Those who tie the artery, as I advise, at each extremity, but amputate the intervening dilated part, perform a dangerous operation. The violent tension of the arterial pneuma often displaces the ligatures.”
According to Dr. David Berqvist, the influence of Middle Eastern medicine on how to look at aneurysmal disease is exemplified by The Synagogue Medica, written by Oribasius (325–403), which classified aneurysms into true and false aneurysms at a remarkably early period :
“There are two types of aneurysms: the first is due to dilatation of the arteries and the second is caused by rupture of the artery emptying blood into the tissues. When an aneurysm is due to dilatation, the form is cylindrical, while the one caused by injury is round.”
In his survey of surgical history, Dr. Michael DeBakey discussed the writings of Aetius of Amida, during the seventh century who wrote De vasorum dilatatione (On the Dilatation of the Vessels), which is now in the Vatican library. The volume discusses aneurysms, and it suggests that the author had some knowledge of the Antyllus operation, as evidenced by the quoted passage:
“An aneurysm located in the bend of the elbow is treated thus. First we carefully trace the artery leading to it, from armpit to elbow, along the inside of the upper arm. Then we make an incision on the inside of the arm, three or four finger-breadths below the armpit, where the artery is felt most easily. We gradually expose the blood vessel and, when it can be lifted free with a hook, we tie it off with two firm ligatures and divide it between them. We fill the wound with incense and lint dressing, then apply a bandage. Next we open the aneurysm itself and no longer need fear bleeding. We remove the blood clots present, and seek the artery which brought the blood. Once found, it is lifted free with the hook, and tied as before. By again filling the wound with incense, we stimulate good suppuration.”
Similarly, Albucasis (Abu-al Quasim) of Cordoba (936–1013) wrote a textbook on surgery and instruments, recording how to treat an aneurysm, as well, following much the same recommendations as given by Antyllus 800 years earlier: after a longitudinal skin incision, the aneurysm is dissected free, the arteries on both sides ligated, and then the aneurysm is punctured with a knife. The wound is left open and dressed until healing.
More than 500 years later, with little having changed, Andreas Vesalius (1514-1564) described thoracic and abdominal aortic aneurysms. His friend and colleague Ambroise Paré (1510-1590) advocated use of a proximal ligature to treat aneurysms, but argued that the sac should not be opened because of the danger of lethal bleeding. Paré described a case of ruptured aneurysm of the thoracic aorta and commented that, “The aneurysms which happen in the internal parts are incurable.”
In medieval times the antecubital fossa aneurysm was quite common as a complication of the common practice of bloodletting by puncture of the median basilic vein, and by 1680, Matthaus Gottfried Purmann (1649-1711) was reporting on an operation on an antecubital space aneurysm in which he ligated the artery above and below the aneurysm and removed the sac.
It is unfortunate for this development of medicine that there was a great discontinuity between the classical world and the modern due to the decline of the transmission of earlier knowledge and the decline in medical and surgical activities in the Medieval period, according to Dr. DeBakey. As a prime example, he described how, when John Hunter finally developed his method for treating aneurysms, “he never referred to Antyllus, who performed basically the same procedure about 15 centuries previously, or that of Aetius, who also performed a similar procedure about 1,000 years earlier.”
But whatever the discontinuities, medical development took a tremendous leap forward in a rapid amount of time, and Hunter’s refinements of the technique for treating aneurysms helped launch the modern vascular surgery era.
Sources and additional information
1) Thompson, J. E., Early history of aortic surgery. J. Vasc. Surg. 1998;28: 746-52.
2) Bergqvist, D., Historical aspects on aneurysmal disease. Scandinavian J. Surg. 2008; 97: 90-9
3) DeBakey, M., A surgical perspective. Ann. Surg. 1991; 213: 499-531.
