John Hunter and the Vasculature

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“If Hunter were to return to life, nothing, I believe, would grieve him so much as the fact that tying the femoral artery where its coats are sound for the treatment of popliteal aneurysm is counted one of ‘his major contributions to surgery.’ That operation was merely a side issue in a great chain of discoveries that revealed the nature of the vascular system. Hunter was the first to discover the mechanism of arteries. He demonstrated that they had an inherent and independent life and action.” — Arthur Keith, M.D., in What Did John Hunter Do for Medicine?

John Hunter, born in 1728, was the brother of the great anatomist William Hunter (1718-1783), whose interest in vascular surgery was easily transmitted to his younger sibling. He achieved surgical mastery in an era when the application of science to medicine was in its thriving infancy.

William Hunter was best known in vascular surgery for his identification of arterial-venous communication as an atypical aneurysm, most often caused by the then common practice of venesection. In 1757, William Hunter published “The History of an Aneurysm of the Aorta with Some Remarks on Aneurysms in General,” in which he added the category of “mixed” aneurysm to those of true (spontaneous) and false (traumatic). Mixed aneurysms, he stated, were caused by a wound or rupture of the coats of the artery and partly by a dilatation of the rest. William was also responsible for reporting the Lambert and Hallowell repair of a lacerated brachial artery, which “would stimulate the first concerted effort to repair arteries more than a century later,” according to Dr. Steven G. Friedman in “A History of Vascular Surgery.”

At the age of 20, John Hunter joined his brother in London at William’s Covent Garden Anatomy School, where he became proficient in anatomy and dissection. He then went on to study with Dr. Percival Pott of St. Bartholomew’s Hospital and became the master of anatomy at Surgeon’s Hall. As house surgeon at St. George’s Hospital from 1754 to 1756, he made some of his most important discoveries, including descriptions of the lymphatic vessels in birds and the circulation of the uterus and the placenta.

In 1760, he joined the British army fighting in Portugal during the Seven Years’ War, becoming one of the early examples of vascular surgeons who developed their skills and observations during military service. Many ascribe this experience as the groundwork for his famous work published posthumously in 1794, “A Treatise on Blood, Inflammation, and Gun-Shot Wounds.” In this work Hunter provided not only the first comprehensive mechanistic framework for the inflammatory response, but also appears to be the first person to discover the connection between the erythrocyte sedimentation rate (ESR) and inflammation (blood cells sedimented faster during inflammation). He also noted that the change in ESR was not restricted to the blood in the local area of the inflammation, but was systemic. With such observations, Hunter was one of the strongest supporters of blood as a living, changeable entity.

In 1767, John Hunter was elected a Fellow of the Royal Society and a member of the Corporation of Surgeons. Hunter was responsible for teaching some of the most important physicians and surgeons of the next generation, including Edward Jenner, the father of vaccination.

One of the things that Hunter is credited for—the discovery of collateral circulation via an experiment on stag horns—is not tenable, given the fact that such collateral circulation was already known by his contemporaries. According to some historians, however, it is probable that his recognition of the significance of collateral circulation in preserving the vitality of a deer’s antlers after ligation of the external carotid artery may have proved inspirational in his treatment of aneurysms.

John Hunter’s most famous operation occurred on December 12, 1785, when he successfully treated a 45-year-old coachman suffering from a large spontaneous popliteal aneurysm by ligating the superficial femoral artery at the distal end of the subsartorial canal, leaving the aneurysm intact. This “departed radically from the teaching of two thousand years,” according to an article published in honor of the bicentennial of his operation. Traditional treatment promulgated by the Greek, Antyllus, in the 3rd century B.C. consisted of ligation of the artery above and below the lesion and then evacuation of its contents. Collateral circulation maintained the viability of the limb.

In the era in which Hunter operated, techniques for this treatment were often crude; ligatures often included surrounding structures, and were coarse, wide, and had ends left hanging from the wounds. It was expected that purulent ligatures would ultimately be expelled. In addition, the tremendous lesion produced by removing the often enormous aneurysm was another source of infection. The success rate, or rather lack thereof, can be imagined.

In fact, Dr. Percival Potts, Hunter’s early mentor, believed that treating popliteal aneurysms was futile, and Dr. Bradford Wilmer stated in 1779 that “with regard to aneurysm of the popliteal artery, there is not, that I know, a single case upon record where that operation has succeeded.” Amputation, where possible, was considered by many to be the only real solution.

However, Hunter’s patient not only survived but thrived for 15 more months, at which point he died of a “remittent fever.” Hunter performed a necropsy on the treated limb and found it was entirely free from putrefaction.

Hunter performed his operation on four more patients between 1787 and 1793, with 3 successes and 1 failure. Surprisingly, Hunter thought so little of the operation compared with his other accomplishments that he never published on it himself. Instead, the technique was promulgated by his brother-in-law and assistant, Dr. Everard Home, in several publications.

Hunter’s operation was supplanted by the advent of Dr. Rudolph Matas’ endoaneurysmorrhaphy treatment for aneurysms a century later. In that era, antiseptic methods became more readily available and the feasibility of emptying or ablating the aneurysm sac once more became viable.

John Hunter died in 1793. He was the victim of a syphilitic ascending aortic aneurysm, a condition resulting from his earlier investigations into venereal disease. In 1767 he self-inoculated his penis with a specimen taken from a patient with gonorrheal urethritis who also, unbeknownst to him, carried syphilis, for which there was then no cure.

More information about John Hunter can be found in the following sources used for this article:

• “John Hunter, Velvet and Vascular Surgery” (Ann. R. Coll. Surg. Engl. 1984;66:214-18).

• “John Hunter and Vascular Surgery” (Ann. R. Coll. Surg. Engl. 1995;Spec. No. 26-31).

• “Popliteal Aneurysm: A Celebration of the Bicentennial of John Hunter’s Operation” (Ann. Vasc. Surg. 1986;1:118-26).

• “Giving Credit Where Credit is Due: John Hunter and the Discovery of Erythrocyte Sedimentation Rate” (Lancet 2005;366:2140-41).

• “What did John Hunter do For Medicine?” (Brit. Med. J. 1919;2:485-87).

• “A History of Vascular Surgery” by Steven G. Friedman, M.D. (Mount Kisco, N.Y.: Futura Publishing Co. 1989).

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