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.
LECTURE XIV.
LIGATURE OF THE COMMON ILIAC ARTERY, ETC.