External hemorrhage from trauma has been described since antiquity.1 Therefore, control of this hemorrhage has been the primary concern of military surgeons and other caregivers for multiple centuries until the first documented arterial repair in 1759.2 According to N.M. Rich, ancient Egyptians, Indians, and Chinese technicians used compression, elevation, hot oil, and topical styptics (astringents), including antimony, copper sulfate, and lead sulfate to control external hemorrhage.3
Aulus Cornelius Celsus (25 B.C. to 50 A.D.)4 of Rome wrote De Medicina during his lifetime, but the book was not printed until 1476. He recommended the following treatment when pressure did not control hemorrhage: “The bleeding vessels should be taken up, and ligatures having been applied above and below the wounded part, the vessels are to be divided in the interspace…4.”
Rich3,5 and Rutkow6 and others have described the contributions of Sushruta of India (800 B.C. to 600 B.C.), Rufus of Ephesus (Greece, circa A.D. 100), Heliodorus (Rome, circa A.D. 100), Galen of Pergamum (Asia Minor and Rome, 129–199 A.D.), and Antyllus (second century A.D.). Sushruta, a legendary or apocryphal figure in the Ayurvedic medicine of ancient India, may have compressed bleeding with a tourniquet-like device.7 Also, the tourniquet was reportedly used in the campaigns of Alexander the Great in the fourth century B.C. and in the Roman Empire starting in approximately 200 B.C.8 Rufus is credited with recognizing the different presentations of a partially severed versus a completely transected artery.3 Heliodorus described ligation and torsion of vessels for hemostasis.3 Galen, the most important physician in antiquity despite a long list of errors in his widely distributed writings, commented that the control of hemorrhage was “by placing a finger on the orifice of a bleeding superficial vessel.”1 Also, he is credited with recognizing the need for ligation of deeper bleeding arteries.3 Antyllus (second century A.D.), the “Father of Vascular Surgery,” first applied finger pressure while operating on a patient with rupture of a superficial aneurysm. He then stated that “we pass underneath the isolated part the needle with the double thread” in order to perform proximal and distal ligation.6 In addition, he is credited with describing the collateral circulation after arterial ligation.3
The most important writings on attaining hemostasis over the next 1200 years were by Albucasis (936 to 1013) from Muslim Spain, Hugh of Lucca (1205 to 1298) from Bologna, and Hieronymus Brunschwig (circa 1450 to 1512) from Strasbourg (German at the time). In the Altisrif (collection of 30 manuscripts authored by Albucasis) in the section on “Cauterization in Arterial Hemorrhage,” he describes control of hemorrhage “by cauterization,” by “division of the artery,” “by firm ligature,” and “by the application of remedies.”1 Rutkow9 has described the numerous contributions of Hugh of Lucca as recorded in the writings of his son Theodoric (1205 to 1296)....