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

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.