LIGATION 
OF THE 
Vertebral Arteries 
FOR THE 
RELIEF OR CURE OF EPILEPSY, 
BY 
J. L. GRAY, M. D,, Chicago. 
Read before the Chicago Medical Society, July 19th, 1886. 
Rand, McNally & Co., Printers, Chicago, LIGATION OF THE VERTEBRAL ARTERIES FOR THE 
RELIEF OR CURE OF EPILEPSY. 
Head before the Chicago Medical Society, July 19th, 1886. 
J. L. Gray, M. D., Chicago. 
Tlie question of the value of surgical interference in 
the treatment of epilepsy is one that has never been fully 
settled. It is true that, where depressed bone is found as a 
cause of the epilepsy, no one at the present time questions 
the necessity of relieving the pressure. But in the class of 
operations for the relief of the disease to which I am to call 
your attention, opinions are at wide variance. The major- 
ity of surgeons, I think, look upon the operation of ligating 
one or more of the large vessels furnishing blood to the 
brain as a sort of experiment to which recourse may be had 
in bad cases, but with no certain prospect of benefit to the 
patient. In the present paper it is my purpose to direct 
your attention to some of the points relating to the opera- 
tion of ligating one or both of the vertebral arteries for the 
relief or cure of epilepsy. 
I do not intend to enter into an extended discussion of 
the aetiology or pathology of epilepsy, but shall confine my- 
self to a simple statement of such facts regarding the anat- 
omy and physiology of the structures thought to be 
intimately concerned in the disease, and give only such 
general conclusions regarding its pathology, as are neces- 
sary aids to a proper estimate of the utility of the oper- 
ation. 
The ligation of the large vessels furnishing blood to the 
brain, for the specific purpose of relieving epilepsy, was first 
proposed in 1831, I believe by a Dr. Brown, of Calcutta, in 
a paper published in the Calcutta Medical Journal, though 
I am informed, that, prior to that date, the operation was 
performed successfully in this country by a surgeon upon 
his colored servant. This case, however, is not on record. 2 
LIGATION OF THE VERTEBRAL ARTERIES 
But from that time up, until a very few years ago, the carot- 
ids have been the arteries upon which the operation has 
been performed. In many cases, the ligation of the carotid 
has been of decided benefit in reducing the number and 
severity of the attacks, and, in a few instances, a complete 
recovery has been effected. 
The operation for ligating the vertebral arteries to 
control the epileptic seizures was first advised, I think, by 
Dr. Wm. Alexander, visiting surgeon to the Liverpool 
Workhouse Hospital, in a paper published in the Medical 
Times and Gazette of London in 1881. Since that time 
the operation has been regarded with some degree of favor; 
but it still lacks much that is needful to place it among the 
recognized procedures which may be used in the treatment 
of a disease, which, perhaps more than any other, has tried 
the skill and baffled the treatment of medical men up to 
the present hour. 
In order to fully understand the mode of action by 
which the operation is of benefit in relieving the epilepsy, 
it is necessary to recall certain facts regarding the anatomy 
and physiology of the structures thought to be concerned 
in the production of the disease. 
The vertebral artery arises from the first part of the 
subclavian, passing through the foramina of the transverse 
processes of the cervical vertebrae, from the sixth upward. 
On account of the width of the atlas, the vessel, after pass- 
ing through the transverse process of the axis, is directed 
obliquely upward and outward across the inferior articular 
process of this bone. It enters the corresponding foramina 
of the atlas, and appears on the upper surface of the pos- 
terior arch of this bone, where it lies nearly horizontal in a 
deep groove, and winds abruptly round the posterior edge 
of the superior articular process. Thence it enters the 
cavity of the cranium to pass forward and upward at the 
side of the medulla, between the olivary body and the an- 
terior pyramid. It soon passes beneath the medulla toward 
the median line, where it joins the artery of the opposite 
side, at the spheno-occipital junction, to form the basilar 
artery. 
Upon the posterior arch of the atlas, the artery occupies 
a triangle, of which the inferior oblique muscle forms the 
base, the superior oblique and the rectus posticus major 
the outer and inner sides respectively. Beneath it, on 
the groove of the atlas, is the first occipital nerve. At FOR THE RELIEF OR CURE OF EPILEPSY. 
3 
the transverse process the rectus capitis lateralis separates 
the vessel from the occipital artery. 
Before entering the transverse processes of the vertebrae, 
the artery lies to the outer side of the common carotid. It 
lies in the triangular space of which the subclavian is the 
base, the anterior scalenus muscle the lateral, and the 
longus colli the median, border. 
The internal jugular vein is in front, and behind the 
artery is the inferior cervical ganglion of the sympathetic. 
During its course through the transverse processes of the 
vertebrae, the artery is surrounded by filaments of the sym- 
pathetic nerve ; the vertebral vein lies in front of the artery, 
while behind it are the nerves tributary to the cervical 
ple*xus on their way to the intervertebral foramina. 
The vertebral arteries, with their branches, furnish 
the blood supply of the medulla, pons, cerebellum 
and posterior third of the cerebrum, while the carotids 
furnish the blood supply for the anterior two-thirds of 
the cerebrum. 
The nerve supply of the great vessels going to the head 
is very intricate arid profuse ; the three cervical ganglia of 
the sympathetic are situated opposite the third, fifth and 
seventh cervical vertebrae. They have numerous filaments 
communicating above with the cranial and cervical nerves 
of the cerebro-spinal system. Branches also pass from the 
superior ganglion situated opposite the third cervical ver- 
tebra to the internal carotid, forming, in part, the carotid 
and cavernous plexuses, and branches also pass from this 
ganglion to the cranial ganglia. These ganglia also send fila- 
ments which unite with branches of the pneumogastric and 
glosso pharyngeal, forming the pharyngeal plexus; and 
plexuses are also found on the external carotid, the vertebral 
and the thyroid arteries, following their distribution. 
Three cardiac nerves also rise from these cervical gang- 
lia of the sympathetic. These ganglia, with the filaments 
which are distributed to the various vessels about and 
within the head, contain the vaso-motor nerves for the 
vessels in question. That these filaments do contain vaso- 
motor nerves, is shown by section of the sympathetic. If 
the sympathetic be divided, dilation of the vessels results, 
with a marked elevation of the temperature. If the divided 
ends of the sympathetic be stimulated by a galvanic cur- 
rent, contraction of the vessels in the area to which the 
nerves are distributed results, while, if the stimuli be suffi- 4 
LIGATION OF THE VERTEBRAL ARTERIES 
ciently strong, a state of spasm of tlie blood-vessels is the 
result. 
The relation between the sympathetic nerves and ver- 
tebral artery is very close indeed, and, during its course 
through the transverse processes of the vertebrse, the artery 
is surrounded so closely by fibres of the sympathetic that 
they can not be isolated without injury to its coats. 
These points in regard to the anatomy and physiology 
of the nerve supply of the vessels in question have been 
dwelt upon thus fully, because they have a distinct bearing 
upon the utility of the proposed operation, and, still 
further, upon the location where the ligature should be 
applied. 
The two principal factors in the classical attack of epi- 
lepsy are loss of consciousness and the convulsive disorder. 
The latter condition I do not propose to discuss : the former, 
that is, loss of consciousness (without which no true epilepsy 
can exist) is in all probability due to sudden contraction of 
the blood-vessels distributed to the posterior third of the 
cerebrum and the cerebellum. This spasm is reflex in its 
origin, the irritation causing the contraction being, in all 
probability, in the great vaso-motor centres in the medulla 
oblongata. 
It is generally admitted, I think, that the real seat of 
local disease in epilepsy is in the great group of centres in 
the medulla,, more especially the vaso-motor centres and 
the regions closely related thereto, as, for example, the 
convulsive centre pointed out by Nothnagel. The exact 
character of this disease is not well understood at present; 
but it consists, essentially, in some peculiarity of develop- 
ment or abnormal irritability of the centres in question to 
impressions received from without. This local disease, once 
present, it is probable, continues through life, and is of such 
an enduring character that it is capable of transmission by 
heredity. 
Besides this local disease in the medulla, there is weaken- 
ing of the inhibitory power, or power for control, in the brain. 
Supposing, then, this local disease to be present in the 
medulla, as already stated, and once present to continue 
throughout the life of the individual, how may we explain 
the phenomena of an attack of epilepsy ? In other words, 
why is it that, with local disease in the central nervous sys- 
tem always present, there are no constant symptoms of 
that disease ? FOR THE RELIEF OR CURE OF EPILEPSY. 
5 
It is true that we may believe the local disease to be 
always present in the centres in question in the medulla 
in a case of epilepsy ; but the morbid excitations which 
arouse these centres to unhealthy action must come from 
regions outside the centres themselves; that is, the local 
disease may be present for years, and yet no tit occur, pro- 
vided stimuli of sufficient intensity to rouse the centres to 
unhealthy action are prevented from reaching them. 
In the vast majority of cases of epilepsy, the excitations 
which give rise to the attack start in some part of the diges- 
tive tract from the mouth down, or in the genito-urinary 
apparatus. These excitations are propagated by way of 
the splanchnic and pneumogastric nerves, as well as other 
portions of the sympathetic, up into the medulla, there to 
excite to unhealthy action the abnormally irritable centres 
situated in its depths. These excitations are thence trans- 
mitted outward along vaso-motor nerves which go to the 
vessels of the head, and contraction, or spasm, takes place, 
with the result that the patient loses, for the time being, 
consciousness. Excitations may come from other regions 
of the body, as, for example, from the brain itself; but, in 
the majority of cases, as already said, the excitations start 
in some region of the body below the level of the atlas 
or axis. 
Such, in mere outline, is the mechanism through which 
unconsciousness in an attack of epilepsy is produced. Any 
measures therefore, which can be adopted to render the 
centres in the medulla less sensitive on the one hand, and, 
on the other, prevent unhealthy excitations reaching them, 
will go far toward rendering the individual free from the 
attacks. There are two theories which have been advocated 
in support of the benefit to be derived from ligating the 
vertebral arteries for the relief of epilepsy. The one which 
was first proposed, is that held by Alexander. In brief, 
his theory is, that the operation is of benefit in modifying 
the circulation by diminishing the quantity of blood sent 
to the diseased and hyper-sensitive centres. 
He says “ the epileptic centres may be rendered hyper- 
sensitive through some powerful shock. The circulation 
is, in many cases, restored to the normal, and the hyper- 
excitability is shown by only one fit or a series of fits. 
“In other cases the hyper-sensibility exists, but only 
produces epileptic attacks in consequence of peripheral ex- 
citement, etc.” 6 
LIGATION OF THE VERTEBRAL ARTERIES 
A full exposition of the views of Alexander, who has, 
perhaps, performed the operation more often than any other 
man, have been so fully set forth in articles in the Medical 
Times and Gazette, Brain and the Medico-Chirurgical 
Review, as to make it unnecessary for me to restate them. 
But, as already said, the principal effect which he considers 
to be produced is a modification of the quantity of blood 
distributed to the centres in the brain and medulla. There 
are several objections to the adoption of this theory of the 
modification of the blood supply to the parts of the brain 
and central nervous system in which the disease is. 
There can be no doubt that ligation of both vertebrals 
produces a profound effect upon those portions of the brain 
and medulla supplied by them; but that effect is not, in my 
judgment, sufficiently permanent to account for the cessa- 
tion of the attacks. 
First of all, after ligation of both vertebrals, the part 
of the brain which had been supplied with blood by these 
arteries receives its blood supply from the carotids through 
the posterior communicating arteries of the circle of Willis. 
It is probable, that, within a very short time, these commu- 
nicating arteries dilate to such an extent as to allow of 
nearly as great a blood supply to the posterior third of the 
cerebrum as it received before the ligation of the arteries. 
It does not, as Alexander leads us to suppose, take months 
or years to have the collateral circulation established. If 
this were the case, we should observe those symptoms which 
accompany cerebral anaemia; for, after ligature of the ver- 
tebrals, the posterior third of the cerebrum can only receive 
blood through the posterior communicating arteries, and 
they must of necessity enlarge in order to maintain func- 
tional activity of the region of the brain in question. But, 
as a rule, in cases in which the operation has been per- 
formed, no evidence of anaemia is observable immediately 
after the operation. 
In the second place, if the benefit derived is due to 
diminishing the blood supply to the brain, the operation 
ought to prove of as great benefit in those cases where the 
excitation starts in the cortex and is propagated downward 
into the medulla as in those cases where the excitation 
arises in some region outside the central nervous system,— 
say in the digestive tract. But such is not the case. Thus 
far, I believe, the operation has proved of no benefit what- 
ever in those cases of epilepsy due to cortical disease of FOR TIIE RELIEF OR CURE OF EPILEPSY. 
7 
the brain, or where the attack is produced by strong emo- 
tional excitement of any kind. 
Tlie second theory upon which the operation has been 
recommended is that proposed by Dr. Jewell, of this city. 
He says: “The mere tying of the blood-vessel itself lias 
never appeared to me to be a rational procedure; for the 
blood supply to the brain, derived from one of these blood- 
vessels, is speedily made good through the free anastomoses 
of cerebral and cerebellar arteries in the circle of Willis 
and its accessories. Any good done by these operations 
can not depend, therefore, on cutting off blood supply for 
any considerable length of time from those parts of the 
brain supplied by the ligated vessel. According to my 
view of the pathology of epilepsy, it is. in great measure, a 
disease of the vaso-motor division of the nervous system, 
particularly involving, directly or indirectly, those great 
centres of the nervous system that lie at various heights in 
the medulla. 
“ Vaso motor nerves pass out from the vaso-motor centres 
involved in disease in epilepsy, and these, at the time of 
the attack, are the pathways of intense discharge to the 
small muscular arteries of the blood-vessels to which the 
nerves in question may happen to go, and the contractions 
and enlargements of which these arteries control. My belief 
is, that, at the time of the attack in typical epilepsy, loss of 
consciousness is due to sudden vasal spasm within greater 
or less areas of the brain, more particularly of its cortex. 
“In this way is consciousness lost not only, but the inhib- 
itory power of the brain over reflex activities accomplished 
through the gray spinal axis is left to play without needful 
control, such as is exercised by the cerebrum during the wak- 
ing state. My opinion is, in respect to these operations, 
that they do good only when the nerves are tied that 
accompany the vessels. In this way are the vessels that 
are finally distributed to the brain itself, cut off from com- 
munication with the tricky, unstable centres of the medulla, 
just as a muscle is made to cease its spasm or irregular 
movements by dividing its motor nerve. In so far as the 
nerves can be included in the ligature, and completely cut 
off or severed, ought the operation to be successful, theo- 
retically speaking. 
“ From what we know at present of wounds of the sym- 
pathetic, and of experimental wounds done to portions of 
the same in the lower animals, it would seem that a firm 8 
LIGATION OF THE VERTEBRAL ARTERIES 
physiological basis is laid for basing this doctrine. I have 
been led to believe that it is more important to tie the 
vertebral than the carotid, because the former supplies more 
directly the cerebrum and the medulla itself, and, so far as 
now appears, most of that portion of the brain in which the 
co-ordinating apparatus of the nervous system must culmi- 
nate. They also supply, to no small extent, the great sen- 
sitive regions of the cortex of the brain. Running up, as 
they do, through openings in the transverse processes of 
the vertebrae, they are pretty closely invested with an inter- 
twining network of vaso-motor nerves. When it can be 
determined, as is often impossible, which half of the brain 
is first invaded during an attack, the blood-vessels supplying 
that side of the brain are the ones chosen for ligation. In 
such cases, I have come to believe that both the carotid and 
the vertebral should be tied on the same side, if not at the 
same operation. But in other cases, in which the invasion 
is evidently bilateral, the operation, to be successful, if at 
all, should be done on both sides. But, in either case, in 
intractable examples of the disease, the operation, in my 
judgment, is justified for both sides, and at different times, 
for the vertebral arteries. 
“Guided by theoretical considerations, I have recom- 
mended the operations done as high up as practicable.” 
The question as to the best place to ligate the artery in 
view of all the facts, is not an unimportant one. Dr. Alex- 
ander has operated at the sixth cervical vertebra. His mode 
of operating is as follows: “A linear incision commencing 
opposite the lower end, and on the outer side, of the external 
jugular vein, and about an inch above the clavicle, is carried 
upward for three inches along the external border of the 
sterno-mastoid. The layers of fascia are cut through, to 
the same extent, until the fatty tissue over the anterior 
scalenus is reached. With the finger the sulcus between 
the anterior scalenus and the longus colli can be opened up, 
and the sixth cervical vertebra reached by judicious teasing 
with a strong blunt probe or director. The artery will be 
generally easily found, provided no veins are injured. If 
the vessel is not found there, it will be found running up to 
the inner side. The sterno-mastoid and the external and 
internal jugular veins should be well protected and retracted 
by good retractors during the operation.” 
If the artery is ligated at this point the communication 
between the middle and superior cervical ganglion of the FOR THE RELIEF OR CURE OF EPILEPSY. 
9 
sympathetic and the medulla is not severed. This allows 
morbid excitations to reach the medulla through the carotid 
and cavernous plexuses and the pneumogastrics,—a fact that 
should not be lost sight of if the theory of Dr. Jewell is 
adopted. 
The high operation, so called, seems to be the preferable 
one if we wish to sever, in the most complete manner, 
communication through the sympathetic between the per- 
ipheral nervous system and the excitable centres in the 
medulla. Between the axis and atlas, Dr. Fenger’s mode of 
operating is as follows: “ The patient is placed on his side, 
with the head turned to the opposite side from that on 
which the operation is performed. An incision is made 
from the mastoid process perpendicularly downward three 
inches through the skin down to the sterno-oleido-mastoid. 
This muscle, together with the splenius capitis and longis- 
simus capitis, is divided by a blunt instrument until the 
transverse process of the atlas is felt. This process, with the 
transverse process of the axis, is laid bare, and, if the latter is 
especially prominent, it is nipped off with bone forceps. 
The fibres of the oblique capitis inferior are then separated 
by a blunt instrument, and immediately below it we find the 
artery at its backward and outward convex arch, accom- 
panied by its vein, and imbedded in a small amount of con- 
nective tissue. It is needful to carefully isolate the artery, 
because the vein is very easily torn, and the ensuing hemor- 
rhage makes it exceedingly difficult to bring the artery into 
view that the ligature may be passed. In passing the 
needle very great care is necessary, for the position of the 
artery is such that the concave side of the arch is very 
close to the bone; and it is only with difficulty that injury to 
the coats of the artery by the needle pressing against the 
body of the vertebrae, is prevented. It is best to ligate 
double; but it is doubtful if the artery should be cut, on ac- 
count of the comparative ease with which the ligature may 
slip in this position. 
Dr. Alexander has reported (in Brain. July, 1882), twenty- 
one cases in which the operation has been performed. These 
cases were all inmates of the Liverpool workhouse, and 
were of the most aggravated character. At the time of the 
report of these twenty-one cases, three had been quite well 
for nearly a year, nine others were so free from fits for 
such a space of time that it might be said a cure would 
probably result, and eight improved to such an extent that 10 
LIGATION OF THE VERTEBRAL ARTERIES 
the operation would be justified were no better results 
ever obtained. One case, a little girl, died from septic 
poisoning. 
In this city the operation has been performed seven 
times. Dr. E. Andrews, in 1883, ligated the right vertebral 
between the atlas and axis in a man aged twenty-two, who 
had had epilepsy for five years, apparently as a result of 
severe mental shock. He had from twelve to fifteen 
attacks in twenty-four hours at the time of the operation, 
and was insane. Eleven days after the operation the 
patient left the hospital. After the operation, during a 
period of three weeks, he had only one fit. Since that 
time his mental condition has much improved, and the 
attacks, if they occur at all, are much less severe than 
prior to the operation. 
In the “Transactions of the Illinois State Medical 
Society for 1885,” Dr. D. R. Brower reported the case of a 
child, six years of age, who had the first fit during denti- 
tion, the next one in about 6 months, and since then more 
frequently until they averaged one in five days. They 
had stopped the development of the mind, so that the child 
was an imbecile. The artery was tied between the axis 
and atlas, on one side, and five weeks after the operation 
there was every evidence that it had been beneficial to the 
child. 
Dr. Fenger has performed the operation three times, the 
first two cases being patients of Dr. Jewell. The first, a man 
aged twenty-seven, married, was first seen September 20, 
1883. He had had epilepsy for over two years. He had 
had a cut on the forehead at the root of the nose, and had 
been shot on the middle of the nose. He had had both the 
petit mal and the grand mal, the attacks varying in number 
from one in six months to two in a single day. A diagnosis 
of cortical epilepsy was made, the usual treatment with 
bromides was advised, with no marked benefit, and the oper- 
ation was suggested. The right vertebral was ligated be- 
tween the axis and atlas, and an attempt was made to ligate 
the left; but there was some anomaly in the course of the 
artery, so that it could not be found. For a time after the 
operation, the patient was much improved ; but, from a 
recent report, I learn that his condition is not perceptibly 
improved to what it was before the ligation of the artery. 
The second case was that of a young lady who had been 
subject to nocturnal epilepsy for years. Every form of FOR THE RELIEF OR CURE OF EPILEPSY. 
11 
medication seemed to be of no benefit in relieving the dis- 
order. As a last resort she begged to have the operation 
performed. Dr. Fenger ligated the left vertebral between 
the axis and atlas. Within twenty-four hours after the 
operation she commenced to have violent borborygmi, and 
soon after bloody dysentery set in. The abdominal symp- 
toms did not yield to any treatment which was advised, and 
the patient died on the third day after the operation. In con- 
nection with this case it should be stated, that, through the 
mistake of an attendant, an over dose of chloral was ad- 
ministered; but whether this had any effect upon the final 
termination of the case, I know not. 
The third case was a patient in Cook County Hospital. 
He had had epileptic fits for fifteen years. Three months 
before operation, while under the influence of bromides, he 
had one fit every day. During the three weeks prior to the 
operation, he had four attacks. On June 9, both the ver- 
tebral arteries were ligated between the axis and atlas, and 
tied double, but not cut. On June 12, he was dressed by 
Dr. Bernauer, and at six o’clock he suddenly got out of bed 
and attacked a patient in the next cot, and had to be put 
back by force. The patient said it was an epileptic fit. On 
July 9, he left the hospital, having had five attacks since 
the operation. 
The operation has been performed twice since in the 
County Hospital; but sufficient time has not elapsed to 
enable us to judge of the results. 
The artery has been tied once in St. Louis and once in 
Louisville; but the operations were done so recently as to 
make it impossible to form any conclusions regarding the 
benefit to be derived. 
The operation thus far has not in this country been per- 
formed a sufficient number of times to allow any sound 
conclusions to be drawn. The reports of Dr. Alexander are 
certainly encouraging, giving, as they do, the results in the 
most intractable cases possible to imagine. From all the 
evidence at hand, I think we may draw the following conclu- 
sions: 
1. Ligation of the vertebral arteries should take its 
place as a recognized procedure in the treatment of certain 
cases of epilepsy. 
2. The operation should be confined to those cases in 
which the exciting causes of the attacks come from some 
region outside the brain. 12 
LIGATION OF ARTERIES IN EPILEPSY. 
3. The arteries should be tied as high up as practicable, 
and the ligature should include all the fibres of the sym- 
pathetic accompanying the vessel. 
4. Where the side of the brain which is first invaded 
by the disease can be determined, the artery of that side 
should be ligated. 
5. Where the invasion of the disease is apparently 
bilateral, both vertebrals should be ligated. 
6. This operation should not be done as a substitute, 
but as an aid to other forms of treatment for the relief or 
cure of epilepsy. 
In the preparation of the present paper, I have received 
many valuable suggestions from Dr. Jewell, and could not 
have had access to all the literature on the subject but for 
his kindness in allowing me the free use of his library. I 
have also had many valuable suggestions from Dr. Fenger 
regarding the surgical phase of the discussion.