211. The precept so strongly insisted upon, that no operation should
be done on a wounded artery unless it bleed, and at the place from
which it bleeds, has been particularly opposed with reference to the
neck, the opponents believing that placing a ligature on the primitive
carotid is an operation not attended with much risk, and that it may
therefore be done as a precautionary measure when the wounded part
does not bleed; this statement is an error. Of thirty-eight cases
collected by Dr. Norris in 1847, in which this vessel was tied for
aneurism, twenty-six died, and twelve suffered from affection of the
brain, the frequency of which occurrence has been singularly overlooked
by practical surgeons; although proving, in a very marked manner,
that the operation of tying the primitive carotid is not a trifling
affair, and that the success, when compared with the failures, is only
as one and one. A much more important objection is the difficulty of
deciding, in many cases of wounds of the neck, what artery is wounded,
and what trunk should be tied; whether it be the external carotid or
its branches, or the internal, or the vertebral artery. Errors have
been committed on all these points by men of the greatest anatomical
and surgical knowledge; the trunk of a sound artery having been tied
instead of that of a wounded one, inflicting thereby on the patient a
second and useless wound, more dangerous, perhaps, than the original
one it was intended to relieve.
When Professor of Anatomy and Surgery to the College of Surgeons in
1830, I stated that in wounds of the neck which rendered it advisable
to place a ligature on some part of the carotid, on account of the
supposed impracticability of laying bare the bleeding orifice, it was
generally the _external_ carotid which should be secured, rather than
the primitive trunk; there not being sufficient reason for cutting off
the supply of blood to the head by the internal carotid, unless the
operation on the external carotid should fail. This direction should be
implicitly followed.
212. A man was wounded by a ball in the side of the neck, and suffered
severely from secondary hemorrhage. Some days after being brought into
the hospital, M. Breschet, unable to arrest the bleeding, was about to
apply a ligature to the common carotid, when the man died in time to
prevent it. On examination after death, the vertebral was found to be
the artery wounded, between the second and third vertebræ. The ligature
of the carotid, had he lived a little longer, would have been a useless
addition to his misery.
Professor Chiari, of Naples, tied the trunk of the left common carotid
on the 18th of July, 1829, on account of a false aneurism below the
mastoid process, consecutive to a wound made by a sharp-pointed
instrument under the angle of the jaw. The man died on the ninth day,
and the wounded artery was found to be the vertebral, between the
transverse processes of the first and second vertebræ. M. Ramaglia
says, a man, thirty-nine years of age, was wounded by a sharp-cutting,
penetrating instrument, below the left ear, from which an aneurismal
swelling resulted. The common carotid was tied, but as this did not
arrest the pulsations of the aneurism, the ligature was removed, and
the patient, after suffering from various accidents, died, when the
vertebral was found to be the artery wounded.
M. Maisonneuve, of Paris, lately laid the following most instructive
case before the Academy of Medicine: A lady was shot by her husband,
who stood close to her, with a pistol loaded with ball. The wound was
inflicted on the anterior part of the neck, on a level with the left
side of the cricoid cartilage. The hemorrhage had been considerable
when the surgeons, Messrs. Maisonneuve and Favrot, arrived, though
the wound looked at first as if the ball had not penetrated deeply.
There were pain and numbness of the left arm; respiration, voice, and
deglutition were, however, normal. On examining with the probe, it was
found that the cricoid cartilage had been bared, and that the ball
had then run from above downward, leaving the trachea and œsophagus
internally, and the common carotid artery, the internal jugular vein,
and the pneumogastric nerve externally, and was impacted in the body
of the sixth cervical vertebra, where it could easily be felt. Some
attempts at extraction were made, but they caused so much pain that
they were given up. The patient was bled six times in four days,
and had large doses of opium; she improved considerably under this
treatment, and the inflammation was very moderate.
On the eighth day hemorrhage occurred at the wound, and again on the
ninth, but it ceased of itself on each occasion. When, however, it
broke out a third time, the surgeons proceeded at once to search for
the bleeding vessel. An incision about three inches long was made on
the anterior edge of the sterno-mastoid muscle, a little external to
the wound inflicted by the ball; the carotid sheath was then brought
into view, and the vessels were found intact. The cricoid cartilage
and the first rings of the trachea were afterward seen to have been
grazed by the ball, which was found implanted in the body of the sixth
cervical vertebra, whence it was easily extracted. Severe hemorrhage
ensued immediately upon the removal of the ball, the blood seeming to
proceed from the vertebral artery, which appeared to have been wounded
within the canal formed by the foramina of the transverse processes.
By placing the finger on the hole left by the ball, the orifice whence
the blood issued was distinctly seen; forceps were applied to it, and
held firmly for a little while to arrest the hemorrhage. An aneurismal
needle, with a very small curve, was then made to carry a double thread
behind the vessel. One of these was used to tie the artery above, and
the other below the aperture whence the blood issued.
The operators at first thought they were mistaken in supposing that
they had tied the vertebral artery, as the vessel seemed quite free,
while it is known to be protected by the transverse processes in
that locality, and believed they had secured the inferior thyroid.
The hemorrhage ceased at once, and some smaller vessels were then
tied, among which was the inferior thyroid artery. Everything went
on favorably at first; the threads fell on the ninth day after the
deligation of the vessel, and the patient remained in a satisfactory
state for the next five days, when severe febrile symptoms, unpreceded
by shivering, set in; and on the eighteenth day after the operation,
the twenty-seventh after the infliction of the wound, the patient was
suddenly seized with a violent pain in the cervical region, cried out
loudly, and fell into deep coma, which lasted for about seven hours,
when she expired, notwithstanding the most strenuous means were used to
rouse her.
On the post-mortem examination, the course of the ball was found as
stated above, viz., it had run from the integuments to the body of the
sixth cervical vertebra, leaving the trachea and œsophagus internally,
and the carotid sheath and its contents externally, untouched. The
inferior thyroid artery was wounded just before it reaches the thyroid
gland, and had a firm clot, about half an inch in length, filling its
cylinder. The transverse process of the sixth cervical vertebra was
fractured, and had left the wounded vertebral artery unprotected.
The vessel above and below the wound in its coats was filled with a
firm clot for about an inch in each direction. The body of the sixth
cervical vertebra had been perforated by the ball, which had dug for
itself a canal communicating with the cavity of the spine by a small
aperture, evidently of very recent formation. This aperture resulted
clearly from the necrosis of the thin shell of bone which formed the
bottom of the canal. The cancelous texture of the body of the vertebra
was infiltrated with pus, and a sero-purulent fluid was found in the
spinal canal, both in the cellular tissue external to the dura mater
and in the sub-serous texture of the meninges. No other lesion existed
in any other part of the frame.
213. M. S., a female, aged fifty-three, was admitted into the
Westminster Hospital, with a large, movable tumor in the neck, under
the sterno-mastoid muscle of the right side. An operation having been
commenced for its removal, the tumor was found to be of a more than
doubtful character, and to dip down between and behind the great
vessels of the neck. In the course of the operation, the external
carotid was opened a little above its bifurcation, and a ligature
was applied on the common carotid. The bleeding was not in the least
arrested; a ligature was then placed on the external carotid above
the hole in the artery, which still continued to pour out blood; a
third ligature was now put upon the internal carotid, with no better
success. A fourth ligature was then applied on the external carotid,
below the hole in it, including the superior thyroid, which was given
off at that part; after which the bleeding ceased, and never returned.
Three ligatures came away in three weeks; the fourth remained during
five weeks. The patient recovered from the operation, but the tumor
grew again, and the woman died exhausted at the end of six months. On
examination after death, the arteries referred to were found to be
obliterated for some distance above and below the parts injured.
The utter inefficiency of everything but the two ligatures, the one
immediately above, the other immediately below the part opened, could
not be more distinctly proved, if a case were even invented for the
purpose; and the fact could not be more satisfactorily shown that in
every case of wounded--not aneurismal--artery in the neck, one ligature
should be applied above, and another below the opening in the injured
vessel, and not one alone on the common trunk, even if that should be
the part injured.
It is argued that when a man has his internal carotid cut on the inside
of his throat, by a foreign body of any kind thrust through his mouth,
the artery cannot be tied by two ligatures at the wounded part through
the mouth, not even if it were enlarged from ear to ear. What, then,
is to be done? The artery should be secured by ligature by an incision
made on the outside of the neck. This being admitted, the question then
is, shall the wounded artery be laid bare at the part injured, or two
inches or so lower down, where the main trunk can be most easily got at
by men of even very moderate anatomical knowledge?--an operation which
has frequently failed, although it has frequently succeeded, and is
therefore most approved. _I am willing, for the present_, to consider
it nearly impracticable to tie the internal carotid safely from the
outside of the neck, at the part wounded, without great anatomical
knowledge, and to accept, for the moment, as the proper operation, the
ligature of the common trunk of the carotid, at the distance of two
or more inches, being the operation of Anel; but I venture to ask,
with what fairness can this operation, thus done on one side of the
neck, at the distance of two inches, the other side remaining sound,
be considered similar to that of Mr. Hunter, done on the thigh for a
wound in the calf of the leg, at the distance of perhaps twenty inches,
with all the intervening collateral branches perfectly sound? It cannot
be considered an analogous operation, with propriety or fairness, nor
ought the one to be compared with the other, although it is done; and
thus the subject is mystified to all those who do not understand it
thoroughly. It is because English surgeons miscall this the operation
of Hunter, that French surgeons claim the operation of Hunter as that
of Anel, and deny the priority of Hunter, although the two operations
are essentially distinct. The operation of Anel for _aneurism_ of the
popliteal artery would be destructive; the operation of Hunter for _a
wound_ of the popliteal artery would be equally so.
This point must, however, be pressed further. Let us suppose that the
internal carotid has been opened by a wound inflicted through the
mouth, and death is about to follow, unless the hole in the artery
can be tied up. How is it to be done? The Hunterian theorists say it
is _impracticable_ to tie the artery at the wounded part, and the
primitive trunk must therefore be secured.
Let us now suppose that a ligature has been placed on the common
carotid, and the bleeding continues; what is to be done? By the
Hunterian and Anellian theorists there is nothing more to be done--the
patient _must_ die. By my theory there is another operation to be done,
and the patient need not necessarily die. As there is already a wound
in the neck made by the surgeon, there would be little difficulty, by
extending it, in ascertaining that the blood came from the brain, and
that nothing but a ligature on the internal carotid artery above the
part wounded through the mouth could save the patient; and why not do
this operation at first, and place a ligature above and another below
the wound in the artery?
214. It is with great satisfaction I quote the opinion of M. Velpean
on this subject, as showing the greater advance Parisian surgeons have
made than even many of high attainments in London: “In hemorrhage from
the neck, the mouth, the throat, the ear, or the skull, everything
should be done to reach the branch of the carotid which has been
wounded, rather than tie the carotid itself.” Alluding to a wound of
the inferior pharyngeal artery, he says: “The search for this artery
will cause but little or no inconvenience, for the same incision will
suffice for the ligature of the external or internal carotid, the
lingual, the facial, or the superior thyroid artery, if it become
necessary, each artery being capable of being taken hold of and
compressed, until the one which is really wounded is ascertained.” He
further adds: “Surgeons found it formerly more convenient and sure
to tie the primitive trunk of the carotid, for all arterial diseases
of the head, than to tie the external or internal carotid or their
branches; _but this is not admissible in the present day_.” Operating
for a tumor on the left temple, which he considered aneurismal, he
first tied the common trunk of the carotid, and then the internal. The
tumor diminished in size, but hemorrhage took place from the wound,
and was frequently repeated until the sixteenth day, when the patient
died hemiplegic. The hemorrhage came from the external carotid, and the
blood escaped through the upper opening of the common carotid. He says
himself he ought to have tied the external carotid also; or, after the
first bleeding, have applied a ligature on the upper end of the common
trunk.
215. Dr. Twitchell, of Keene, N. H., United States, says a soldier,
in a sham fight, in 1807, received a wound, from the wadding of a
pistol, on the right side of the head, face, and neck, which was much
burned. A large wound was made in the mouth and pharynx; nearly the
whole of the parotid gland, with the temporal, masseter, and pharyngeal
muscles, was destroyed. The neighboring bones were shattered, and the
tongue injured. The hemorrhage was not copious, although the external
carotid and its branches were divided. Ten days after the accident,
the sloughs had all separated, and left a large circular aperture, of
from two to three inches in diameter, at the bottom of which might be
seen distinctly the internal carotid artery, denuded from near the
bifurcation of the common trunk to where it forms a turn to enter the
canal in the temporal bone. Directly on this part there was a dark
speck, of a line or two in diameter, which suddenly gave way while
Dr. Twitchell was in the house. With the thumb of his left hand he
compressed the artery against the base of the skull, and effectually
controlled the hemorrhage. The patient fainted. As soon as he
recovered, the doctor says: “I proceeded to clear the wound from blood,
and having done this I made an incision with a scalpel downward, along
the course of the artery, to more than an inch below the point where
the external branch was given off, which, as stated above, had been
destroyed at the time of the injury. Having but one hand at liberty, I
depended upon the mother of the patient to separate the sides of the
wound, which she did, partly with a hook, and occasionally with her
fingers. At length, partly by careful dissection, and partly by using
my fingers and the handle of the scalpel, I succeeded in separating the
artery from its attachments; and, passing my finger under it, I raised
it up sufficiently for my assistant to pass a ligature round it. She
tied it with a surgeon’s knot, as I directed, about half an inch below
the bifurcation.” Dr. Twitchell removed his thumb, and sponged away the
blood, not doubting that the hemorrhage was effectually controlled;
but, to his surprise and disappointment, the blood immediately began to
ooze from the rupture in the artery, and in less than ten minutes it
flowed with a pulsating jet. He compressed it again with his thumb, and
began to despair of saving his patient, but resolved to make another
attempt. Raising his thumb, he placed a small piece of dry sponge
directly over the orifice in the artery, and renewed the compression
till a rather larger piece of sponge could be prepared. He placed
that upon the first, and so went on, pressing the gradually enlarged
pieces obliquely upward and backward against the base of the skull,
till he had filled the wound with a firm cone of sponge, the base of
which projected two or three inches externally. He then applied a linen
roller in such a manner as to press firmly upon the sponge, passing
it in repeated turns over the head, face, and neck. On the 30th of
December the patient was discharged cured, several fragments of bone
and two teeth from the upper jaw having been cast off. Some deformity
remained, in consequence of the depression on the side of the face.
The inutility of tying the primitive trunk for a wound of the internal
carotid is distinctly shown in this case, which is no less valuable
from the fact demonstrated, that if the internal carotid can be exposed
and injured within the angle of the jaw by an accident, it can be
exposed and secured by ligature at the same part by an operation.
216. When, then, the internal carotid is wounded through the mouth,
what operation is to be performed? That of placing a ligature
above, and another below the opening made into it; and after much
consideration, and many trials, the following operative process is
recommended to the attention of those who are best acquainted with the
subject:--
An incision is to be begun opposite to and on the outside of the
extremity of the lobe of the ear, and carried downward in a straight
line, until it reaches a little below the angle of the jaw, at the
distance of nearly half an inch, more or less, as may be found most
convenient from the form of the neck. This incision exposes the parotid
gland without injuring it. A second is then to be made from the
extremity of the first, extending at a right angle forward, under or
along the base of the lower jaw, until the end of it is opposite the
first molar tooth. This incision should divide the skin, superficial
fascia, platysma myoides muscle, and the facial artery and vein. The
second molar tooth should then be removed, and the jaw sawn through
at that part. Then cut through the deep fascia, the mylo-hyoideus
muscle, and the mucous membrane of the floor of the mouth, exposing the
insertion of the internal pterygoid muscle, which is to be divided. The
surgeon will next be able to raise and partially evert the angle of the
jaw, and thus obtain room for the performance of the remaining part of
the operation, which should be effected by the pointed but blunt end of
a scalpel, or other instrument chosen for the purpose of separating,
but not of cutting. The styloid process of the temporal bone may
then be readily felt, and exposed by the separation of a little
cellular membrane, and with it the stylo-hyoid muscle, which is to be
carefully raised and divided. The external carotid artery will thus be
brought into view, together with the stylo-pharyngeus muscle and the
glosso-pharyngeal nerve attached to it. These are to be drawn inward by
a blunt hook, when, if care be taken to avoid the pneumogastric nerve,
the internal carotid may be felt, seen, and secured by ligature with
comparative facility outside the tonsil, there being between them the
superior constrictor of the pharynx, which, in a case of wound through
the mouth, must have been divided. The pneumogastric nerve should be
drawn outward, and the external carotid artery also, if in the way.
The division of the jaw will not lead to further inconvenience, as the
bone always reunites, when divided, with little difficulty. That this
operation requires a thorough knowledge of the anatomy of the parts, is
true; and this can only be acquired by repeated dissections.
217. The nearest successful case to the operation thus recommended was
performed by Dr. Keith, of Aberdeen.
E. Kennedy, aged twenty-five, accidentally swallowed a pin, the head
of which could be felt below and behind the left tonsil, covered by
the lining membrane of the pharynx; it could not be extracted by any
attempt made for its removal. The membrane was snipped by a pair
of probe-pointed scissors, to expose the head of the pin. This was
followed by the discharge of mouthfuls of arterial blood, and it was
evident that the internal carotid artery had been injured. Pressure on
the common carotid stopped the bleeding, and the operation of placing
a ligature on the internal carotid was effected in the following
manner: The patient’s head being supported by a pillow, her face was
turned toward the right shoulder, when an incision was made from
below the ear along the ramus of the lower jaw to below its angle. No
hemorrhage occurred, and the vessel was speedily exposed and secured by
a double ligature passed under it, with less difficulty than the depth
of the vessel would lead one to expect. One ligature arrested the flow
of blood, and the other was therefore withdrawn. The woman recovered,
without any return of the bleeding. Dr. Keith, aware of the necessity
for tying the other end of the artery, if it should bleed, watched the
case day and night until the period of danger had passed away. The
pin gave no trouble, until felt by the patient as about to go down
the œsophagus, which it did to her great satisfaction and relief from
further anxiety.