SECTION 1. Sex, — The statistics contain 789 cases of ligature of the Common (Part 1)

SECTION 1. Sex, — The statistics contain 789 cases of ligature of the Common Carotid. The sex is stated in 712. Males, 538. Females, 174:. Three males being exposed to accidents, or suffering from lesions, necessitating this operation, to one of the opposite sex. Age. — The age is stated in 542 of 789 instances as follows: — Under 1 year old 16 From 1 to 10 years 22 " 10 " 20 " 57 " 20 " 30 " 151 " 30 " 40 " 106 " 40 " 50 " 89 " 50 " 60 " 55 " 60 " 70 " 40 " 70 " 80 " 6 542 The oldest patient was 75 years; the youngest 6 months of age. In the period of life from 20 to 40, about one-half of the opera- tions were performed. Side. — Of the 651 cases noted as to this feature — 361 were tied upon the right side. 290 " " left " The difference in favor of the right side may be explained, inas- much as the carotid of this side is often involved in lesions of the right subclavian^ which last vessel is often the seat of injuries result- ■ (115) 116 PRIZE ESSAY. ing from the use by preference of the right arm, also in aneurism of the innominate. The point of deligation was at the omo-hyoid muscle (its anterior belly) in the vast majority of cases, although not stated. It is given as — Above the omo-hyoid in 56 At " '' " 4 Below " " " 25 The remainder not definitely stated. In one case (No. 789) the left carotid was reached from behind the sterno mastoid. Hemorrhage is given as occurring after the operation of deligation in 144 instances. Unfortunately meagreness of detail in the pub- lished reports renders it impossible for me to specify whether the bleeding was at the seat of ligature or beyond it, in every instance. In 27 instances it is specified that no hemorrhage occurred after the ligature was applied. If there was or was not hemorrhage after deligation, in the 618 remaining cases, it is not specified. If we admit that in these 618 cases no bleeding took place, we would have only 18 per cent, of hemorrhage after ligature of the common carotid. But when we are reminded that many cases proved fatal so soon after the operation that secondary hemorrhage had not the time to occur (the dates of death, in which 288 of the 323 fatal cases are given, show that ^jj died on the day of operation, J within the third day after, and J within the first week), and that the hemorrhage did occur in a fair number of cases in which it is not reported, it is evident that this accident after ligature of the common carotid will occur in a much larger proportion of cases than 18 per cent. Hemorrhage was immediate after deligation in " occurred in from 1 to 5 days ** 5 " i( (( (( (( (( (I (( 4( (I tl (( (( i( (i u (( (( (( u on 10 20 40 80 (( (( 10 " 20 " 40 " 80 " 100 120th day 11th, 14th, and 61st day in with no date given in (( (( (( It 3 cases. 19 n 13 <( 23 (( 10 u 7 (( 1 It 1 it 1 it 66 ti 144 SURGICAL HISTORY OF CAROTID ARTERIES. 117 LIGATURE CAME AWAY. The date of separation of the ligature is obtained in 287 instances as follows : — On the 4th day . . 1 On the 23d dav . . 9 4 5 3 5 7 3 3 1 2 1 2 1 1 1 1 1 1 One is given as not having come away at the end of three months. In some few of the later dated cases the Listercarbolized catgut" "was used as the ligature, and these never came away, being cut oflF, left in the wound, and absorbed. In two cases the artery was ** con- stricted," once with Dr. Speir's constrictor and once with a thread.^ 4tl] I day 1 n the 23d day 5 n 1 24 (( 7 u 4 25 tt 8 it 5 26 tt 9 u 6 27 tt 10 u 10 28 tt 11 tt 12 29 tt 12 tt 19 30 it 13 tt 25 31 tt 14 tt 34 33 tt 15 tt 16 34 ti 16 it 12 35 tt 17 tt 14 36 tt 18 tt 17 39 tt 19 tt 7 45 it 20 tt 9 48 tt 21 tt 23 60 tt 22 tt 11 96 ti RESULT. Of 789 cases in which the common carotid was tied for all causes, 323, or 41 per cent., died. Condition after Recovery. — 466 patients recovered^ as reported by the operator, and the condition is stated in 371 of these, as follows : — As cured 253 ' improved 49 " temporarily benefited 14 " not cured 33 . Cured of original disease, but with paralysis of opposite side as a result of the ligature 2 As not benefited 19 " worse than ever 1 Of the reported cases 68 per cent, were cured, in the true sense of that term, and it is probable that this percentage will represent the correct proportion o{ cures in the entire number of recoveries. 1 In Porchers case (see Appendix to Common Carotid Statistics), catgut ligature w as used, which became loose, and the artery was not occluded. 118 PRIZE ESSAY. DATE OF DEATH AFTER DELIGATION. Of 323 fatal cases in the total of 789, death Immediately ("upon the table") in On the same day of the operation in From 1 to 3 days after in (( 3 (( 7 (( (( it 7 n 14 (( t( ic 14 n 21 (( (( <( 21 11 28 u It (( 28 u 35 (( it (( 35 11 42 (( It (( 42 a 50 (( tl (( 50 (( 60 (( it 4( 60 (( 70 u it (( 70 (( 80 (( it (( 80 (( 90 u tt (( 100 (( 120 t( it (( 120 (( 150 (( a Several weeks after • No date given • • occu irred — 4 instances . 18 4( 43 (i . 64 (( . 57 (( . 40 it 12 tt 10 tt 9 tt 9 ti 3 ti 9 it 4 ti 1 tt 2 it 2 tt 1 tt 35 tt 323 Or 7J per cent, died within 24 hours, 23 per cent, within 3 days, 45 per cent, within 1 week, 64 per cent, within 14 days, and 75 per cent, within 21 days of the date of operation of deligation. CAUSE OF DEATH. In only 200 of the 323 fatal cases is the caitse of death stated. From cerebral complications alone, following the ligature, there Q16u ••.•.... From cerebral complications, with " exhaustion'* . " " hemorrhage . " ** injury or shock " " pyaemia " " original disease " " gastric fever From meningitis 54 cases. 4 6 1 1 2 1 1 1 " " with hemorrhage Thus of 200 fatal cases, 27 per cent, died from interference with the functions of the cerebrum alone, by cutting off the supply of blood through one or both common carotids. While in 15 additional instances (7J per cent.) interference with the cerebral circulation was an important factor of death. SURGICAL HISTORY OP CAROTID ARTERIES. 119 This point demands the most earnest consideration. I do not think it has heretofore been emphasized sufficiently. I hold it to be an overwhelming argument against tying the common carotid^ when the lesion is in the external carotid or its branches, at a point suffi- ciently removed from the bifurcation of the primitive carotid to allow the ligature on the cardiac side. This will be more fully shown in the comparison of the sum- maries of the external, with that of the common carotid. HEMORRHAGE AS A CAUSE OF DEATH. Of 200 cases in which the cause of a fatal result is stated — Died from hemorrhage alone from the carotid 44 with " exhaustion" 12 " shock 2 " " ** inflammation of thoracic yiscera . . 2 " " " erysipelas 1 " " " spasm of the glottis .... 1 " diarrhoea 1 " asphyxia 3 66 This gives a ratio of mortality of 22 per cent, from hemorrhage alone after the Jigature, while in 33 per cent. (22 additional cases) bleeding was a factor of death, following the deligation. (Indirect and fatal hemorrhage came from the vertebral in several instances, from the jugular vein in 2, and from the lungs in one instance.) " exhaustion" as a CAUSE OF DEATH. From exhaustion alone there died 23 cases. This vague term may imply cerebral interference, hemorrhage, suppuration, etc., and is necessarily useless, unless the particular cause of the exhaustion is also given. (See Hemorrhage and Cere- bral Complications for other cases in which "Exhaustion" is noted as a factor of death.) The original disease for the cure of which the operation was per- formed was the cause of death in 7 cases. Intercurrent disease was the cause of death in . . . 3 " Pyaemia alone ' " ♦* ... 12 '* " with pleuritis " " . . . 1 " 120 PRIZE ESSAY. Inflammation of thoracic viscera alone was the cause of death in 4 cases. Tetanus alone 1 " Glossitis alone 1 " (Edema of the glottis alone 2 " Diarrhoea alone 1 " Asphyxia alone 3 " Inflammation of aneurismal sac 2 " CASES IN WHICH SYMPTOMS OF CEREBRAL DISTURBANCE WERE NOTED AS A RESULT OF TYING THE COMMON CAROTID ARTERY (FATAL AND NON-FATAL CASES). Hemiplegia opposite to side of ligature is noted in . . .43 cases. •* " " with aphasia . . 1 " " on same side as ligature is noted in . . . 1 " Paralysis of face on same side, and of body on side opposite to that of ligature, is noted in .... 2 " Paralysis of opposite arm (none of leg) in . . . . 5 " Imbecility as result of ligature in 1 " Delirium, convulsions, headache, and other light symptoms of cerebral disturbance (not counting difficult deglutition which was in most cases a mechanical hindrance) occurred in 18 other instances. If then it is accepted that paralysis followed ligature of the com- mon carotid in only 52 of the 789 given cases, we have not quite 7 per cent, in which we may expect this danger to ensue. It is very important in this connection to remember that 7J per cent, of the 323 fatal cases terminated within a few minutes to 24 hours after the deligation ; 23 per cent, inside of three days ; 45 per cent, within one week ; 64: per cent within 14 days ; 76 per cent, within 21 days, and that after either of these dates paralysis might have resulted. Secondly, remember that paralysis very likely did occur in some of the cases to which no history proper is attached. Thirdly, that paralytic symptoms would probably not be recog- nized in patients operated upon in conditions of extreme prostration, when both motion and intelligence were suspended. Taking these points into consideration, I am of the opinion that a larger percentage than that given in the foregoing summary should be present in the mind of the operator who has the choice between deligation of the common and external carotids. In exceptional cases paralysis will remain after recovery from the operation as a permanent malady. In 42 cases of the entire statistics it is noted that there were " no symptoms of cerebral disturbance." SURGICAL HISTORY OF CAROTID ARTERIES. 121 REPORT OF AUTOPSY. Post-mortem examinations were reported in only 85 of the 323 fatal instances. In 18 of these the brain was not examined. The points of interest in connection with this organ are as follows : Brain, softened in 16 ' inflamed 8 " anaemia of 1 ** extravasation of, blood 1 ** abscess of 7 " " and softening 1 34 Showing that in 67 examinations of the brain 51 per cent, de- veloped important changes to have occurred. SYNOPSIS OF LIGATURE OF THE COMMON CAROTID WITH ONE OR MORE OF ITS BRANCHES, OR OF THE INTERNAL JUGULAR VEIN. Common, external, and internal carotids tied in the same patient. Died 2 ; cured 2 = 4 cases. Common, external, and internal carotids, and the internal jugular. Died 1 ; re- covered 1 a= 2 cases. Common and internal carotids in same case. Died 4 ; cured 2^6 cases. Common and external carotids in same case. Died 5 ; recovered 4 ; cured 3 ^ 9 cases. Common carotid and internal jugular vein. Died 7 ; recovered 2 ; cured, 1 = 9 cases. Common carotid and external and internal carotid and sup. thyroid. Died 1 = 1 case. Common carotid and sup. thyroid. Died 1 ; cured 1 = cases 2. " lingual. Died 1 = 1 case, temporal, auric, and occipital. Recovered 1 = 1 case, and internal maxillary. Recovered 1 ; cured 1^2 cases. " temporal. Recovered 1 = 1 case. %i It i( it RE-LIGATURE OF THE COMMON CAROTID. The same vessel was twice tied in 8 instances. Of these 6 died. The same vessel was tied a third time to arrest hemorrhage. It proved fatal. 122 PRIZE ESSAY. Stxopsts op Casrs in which both Common Carotids were tied. CAUSE. Age, y'rs. • 53 Interval. Result. Cause of death. i Operator. Malig. dis. antram. 2| mos. Died 38th day. ■ Exhaustion. Wood. (( (( 45 1 ' Rec. (Not impd.) Parker. (( <( 38 28 days. ** improved. t( ff it 21 8 mos. (( (I V. Mott. " no»e. ? 10 ** " cured. (( " orbit. ? 6 " Died 4th day. « " parotid. ? 15 min. ! " 48 hours. Coma. (( FuDgns hsemat. 15 3 weeks. Recovered. Blackraan. Anear. anast. 5i 4 mos. 1 « 1 Gundelach and Moeller. " occiput. 53 2\ " " cured. Kuhl. tt ti 20 1 year. ■ It a Pirogoff. Palsat. tamor, orbit. 20 28 days. 1 1 Foote. " botli orbits. ? 30 " ** better. Macgill. Aneur. orbit. 22 14 mos. " cured. Buck. Erect, tumor, face. 23 30 days. " better. Warren. " ear. 19 1 year. Died 3d day. Exhaustion. Ullmann. " frontal. 19 8 mos. Recov'd ; better. Roberts. " head. 11 6 years. " not cured. • •• Van Buren. ** scalp. 20 14 mos. " better. Mussey. Elephnutiasis, face. 34 6 " (( (( Carnochan. Hem. polypus uose. 19 13 " 1 Paul F. Eve and V. Mott. " internal carotid. 27 13 days. Died 3d day. Hem. ; coma. Billroth. " shot wound. 21 4 " Recov'd : cured. Elli.s. (t a f same dy Died same day. ? Unknown. u u ? 3 days. : " 5th day. Hemorrhage. Murdock. U (( ? 6 ' " 38 hours. ? Longmore. (t (( ? 4 " ! " 5th day. f Lewis. Epilepsy. 20 17 " Recov'd ; better. Weber. Ct^ ? 6 mos. 1 it « V. Mott. (1 18 6 " " cured. Hamilton. " and hemipl. 51 2V " " no better Preston. Paralysis. 24 4 " ; '* better. ti Unknown. H ! " cured. 1 1 MttUer. Total, 33. Died 9, or 27 per cent. Of the 24 recoveries, 8 are noted as cured, 11 as improved, 2 as no better, and 1 as not cured. Of the 9 fatal cases, 4 were for gunshot wounds and 1 for hemor- rhage. The intervals in these 9 cases were, respectively, same day, 8, 4, 6, and 13 days, 15 minutes, 2J months, 5 months, and 1 year. It is impossible not to be impressed with the comparatively light mortality following so formidable an operation. Among the most dangerous complications of ligature of the com- mon carotid is the following, which relates to ligature of the right subclavian, the operations being simultaneous or with a varying interval. SURGICAL HISTORY OF CAROTID ARTERIES. 123 SIMULTANEOUS LIGATURE OF COMMON CAROTID AND SUBCLAVIAN ON THE RIGHT SIDE. (FIRST DIVISION.) Liston, subclavian aneurism, Died 1 3th day. hemorrhage. Rossi, innominate " " 6th " cerebral ansBmia. Parker, subclavian " " 42d " hemorrhage. Hobart, aortic " " 16th " Cuvellier, bayonet wound " 10th " " Kuhl, vas. tum. frontal region " 2d " not known. Of the 4 cases in which hemorrhage was the cause of death, the leeding came from the subclavian in 3, from the carotid in one case. [MULTANEOUS LIGATURE OF COMMON CAROTID AND SUBCLAVIAN ARTERIES ON THE RIGHT SIDE (THE LATTER IN ITS THIRD DIVISION). Durham, innominate aneurism. Died 6th day, shock. Eliot, " ' " 25th " hemorrhage. Ensor, aortic and " " " 65th " Holmes, innominate ' " 57th " Hodges, " '* " 11th " Weir, " " " 11th " Maunder ** ** " few days (?) Sands, aortic " receded. (Died 13 months later from aneurism.) Heath, innominate ** " (Died 4 years later from the aneurism.) Lane, " " ** (No improvement.) Little " or aortic " " Probable cure, 1 year later doing well. Barwell,' innom. aortic, caret, and subclav. " " 3 mos. " " (Hemorrhage occurred from the carotid in one of these cases.) ASES IN WHICH THE CAROTID WAS FIRST TIED AND THE SUBCLAVIAN IN ITS THIRD DIVISION AT A LATER PERIOD. Bickersteth, aneurism innom. and aorta. Died^ 21st day ; suffocation. Carotid tied 7 weeks previously. Wickham, aneurism innominate. Died* 3 months. Carotid tied 3 mos. before. Speir, aneur. aorta. Died