Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

LECTURE XIII.

WOUNDS OF THE ARTERIES, ETC.

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.