SECTION 2. A SPECIAL SUMMARY OF THE HISTORY OF THE COMMON CAROTID

SECTION 2.

A SPECIAL SUMMARY OF THE HISTORY OF THE COMMON CAROTID

ARTERY.

Class f'Jication of the various Lesions for which the operation was made.

SPECIAL SUBJECT : WOUNDS.

Divided into —

1. Lacerated.

a. Gunshot wounds of military practice.

b. Gunshot wounds of civil practice.

c. Torn wounds other than gunshot.

2. Punctured.

3. Incised.

4. Wounds, the nature of which is not given.

^ For further remarks on tliese cases the reader is referred to the risum^ of the sabclavian arteries.

Total 10

Died 5

Eecovered 5

" 53

" 36

17

" 15

a 14

1

" 18

" 17

1

" 15

" 9

6

SURGICAL HISTORY OF CAROTID ARTERIES. 125

Lacerated Wounds.

The common carotid artery was tied in 134: instances on account of the above lesions. Of these, 87 proved fatal, or 65 per cent.

Gunshot Wou7ids of Military Practice,

Of cranial region . " face alone " face and neck " neck alone " region not stated

111 81 30

Fatal in 73 per cent.

That cranial wounds appear to be not more fatal is probably owing to the fact that when these wounds are serious they are fatal before assistance can be had ; when not penetrating, the hemorrhage is not usually dangerous, and the disturbance is not so great as the terrible lacerations of the neck and face. Naturally the result shows that shot wounds of the face alone are less fatal than those of the neck.

Gunshot Wounds of Civil Practice.

Of the neck alone .... Total 5 Died 1 Recovered 4

" " face "...." 7 "1 " 6

" " neck and face . . . *' 1 "0 ** 1

No region given ....** 3 "2 " 1

16 4 12

Fatal in 25 per cent.

Difiference in favor of civil practice 48 per cent.

Reasons. 1. Military projectiles are larger. Have greater velocity. Cause greater destruction of tissues and more shock.

2. The soldier is excited, the circulation at its height ; as a con- sequence his wounds bleed more freely than an accidental ivound, as are most of those in civil experience. The exigencies of battle prevent him receiving that prompt attention usually bestowed upon the civilian. By the time the surgeon reaches him and ties his *' common carotid," he is already so prostrated by hemorrhage that he either does not rally, or dies from cerebral inanition.

Lacerated Wounds {not Gunshot).

Of face Total 1 Died 1 Recovered

Of face (arrow) ....*' 1 "0 "1

Of throat "5 "1 "4

7 2 5

Fatal in 28 per cent.

126 PRIZE ESSAY.

These were all in civil practice. (In Abernethy's (fatal) case the laceration by cow's horn was very violent and extensive.)

Punctured Wounds.

Total number of cases 88 : died 15, recovered 18 ; rate of mor- tality according to this result, 45 per cent. These wounds were situated mostly in the upper portion of the neck. In 5 of the fatal cases the mistake was made of tying the common carotid when the lesion was in the vertebral,^ the hemorrhage being supposed to be from the branches of the former.

To arrive at a better idea of the rate of mortality following liga- ture of the com7non carotid for punctured wounds, we must exclude from the calculation 5 of the fatal cases, leaving a death-rate of 36 per cent. I consider even this as a high rate of mortality, since punctured wounds as a rule do not cause profuse hemorrhage, exten- sive destruction of tissue, or great shock. Doubtless, some of these cases would have been successful if both ends of the bleeding vessel had been secured in the original wound.

Incised Wounds.

Under this heading there are 18 cases: died 8, recovered 10; mortality 44 per cent.

Wounds^ the Nature of which is not given.

Total of this class 46 : died 21, recovered 25 ; mortality 46 per cent.

The common carotid was tied on account of wounds (other than gunshot and lacerated) in 97 cases, of which 44 died and 53 recov- ered, the rate of mortality being 45 per cent.

SPECIAL SUBJECT : TUMORS.

Subdivided into ligature on account of —

1. Malignant growths (not in orbit).

2. Non-malignant growths (not in orbit).

' The differential diagnosis in these cases is necessarily very difficult when consider the free anastomosis through the circle of Willis. Pressure below which onl occluded the carotid would not arrest, but would rather increase the escape of blooc from the vertebral^ while pressure directly backward, below the transverse process o the 6th cervical, would diminish or temporarily arrest the bleeding from the vertebral

SURGICAL HISTORY OP CAROTID ARTERIES. 127

3. Hemorrhage from abscess or ulcer.

4. Eemoval of superior maxilla.

5. Eemoval of inferior maxilla.

6. Ligature of the Common Carotid artery on account of malig-

nant growths of the antrum of Highmore, parotid gland, of face, etc. etc. (not of orbit). Total 87 : died 38, recovered 49 ; death-rate 44 per cent. Of the 49 recoveries, 13 are re- ported cwedj 12 as improved, 10 as not cured, remainder re- ported as recovered.

2. For (lesions) growths termed non-malignant (other than of

orbit) the common carotid was tied in 75 cases. Died 30, recovered 45 ; death-rate 40 per cent. Of 45 recoveries, 16 are reported cured, 2 as improved, 4 as not cured. It is a little surprising that the death-rate in malignant diseases should be no higher as compared to non-malignant affections. It is probable that some of the cases classed as malignant would have been placed with the non-malignant tumors, had they been investi- gated in the light of more recent pathology.

3. On account of hemorrhage resulting from ulcerations, abscess,

etc., the primitive carotid was tied in 13 cases. Eecovered 5, died 8; death-rate 61 per cent. All the recoveries are re- ported cured.

4. Preparatory to or after removal of the superior maxilla.

Total 11: recovered 8, died 3; mortality 28 per cent. Of the 8 recoveries, 2 are given as cured, 3 as not cured.

5. Eemoval of inferior maxilla 18 cases. Eecovered 12, died 6 ;

mortality 50 per cent. 5 of the recoveries are reported cured. Summary of the foregoing 5 classes: Total 204: recovered 119, died 85; mortality 41 J per cent. Of 119 recoveries^ 41 are reported curedy 14 as improved, 17 as not cured, the remainder as recovered.

LIGATURE OF THE COMMON CAROTID ARTERY FOR RELIEF OF

ERECTILE AND PULSATING TUMORS.

1. Non-malignant.

2. Malignant.

3. Non-malignant tumors of the orbit. Total 52 cases: recov- ered 46, died 6 ; mortality 11 J per cent. Of 46 recoveries, 28 are marked cured, 5 as improved, 6 as not imjiroved.

128 PRIZE ESSAY.

The above result must be considered as very favorable indeed. The distance of the diseased structures from the seat of ligature, where the artery is in a healthy condition, and which allows a firm clot to form before the ligature cuts through, is probably an impor- tant factor of such a marked success.

2. Malignant vascular tumors of the orbit. Total 8: died 4;

death-rate 50 per cent. One of the 4 recoveries is noted

cured (the eye being extirpated at the same time), 2 are

given as not cured.

Ligature on account of aneurism by anastomosis (other than those

of the orbit). Total 71: recovered 51, died 20; death-rate 28 per

cent. Of the recoveries 20 are noted cured, 9 as improved, and 16

not cured,

LIGATURE OF THE COMMON CAROTID FOR CURE OF ANEURISM {i, e. A SACCULATED BLOOD-TUMOR COMMUNICATING WITH AN ARTERY).

Subdivided into —

1. Ligature between the aneurism and the heart.

2. Ligature by mistake (the carotid tied for vertebral aneurism).

3. Ligature on the distal side of the aneurism.

4. On the Cardiac Side of the Tumor,

Total 106: recovered 69, died 87 ; death-rate 35 per cent.

Subdivided into —

(rt) For aneurism of the external carotid or its branches. Total

22 : died 5 ; mortality 23 per cent. Of the 17 recoveries,

16 cured, I improved, (V) For aneurism of the internal carotid or its branches. Total

6 : died 4 ; or 66 per cent. Of the 2 recoveries, 1 is reported

as cured. (c) For aneurism of the common carotid alone. Total 16: died

7; mortality 44 per cent. Of 9 recoveries, 8 are given as

cured, {d) For aneurism (the seat of lesion not given). Total 62 : died

21 ; mortality 34 per cent. Of 41 recoveries, 35 are noted

cured, 2 improved, and 2 as no better. Summary of above. Of 69 recoveries, 60 were cured, and 3 are given improved, Eest not noted. The lesions of the external carotid^ being least fatal, those of the internal (as far as judged by such a small number of cases) most fatal.

SURGICAL HISTORY OP CAROTID ARTERIES. 129

2. Ligature of the Common Carotid^ for supposed Carotid^ hut in

reality Vertebral Aneurism,

Total 5. All fatal.

The difficulty of distinguishing vertebral from carotid aneurism in the neck arises from the fact that direct pressure from before backwards, in the lower portion of the neck, will interfere with or arrest pulsation in aneurisms of both vessels.

If, however, the head be flexed upon the chest, and the sterno- mastoid muscle thus relaxed, the carotid can be compressed by grasping the muscle between the thumb and finger, which are pressed deeply behind the outer and inner borders. This will not involve the vertebral.

Again ; if the carotid be forcibly compressed by the thumb, back- ward and inward, low against the vertebral column, at any point above the transverse process of the 6th cervical, the vertebral will not be included, since it is protected by the processes.

3. Ligature of the Common Carotid Artery on the Distal Side of the

Aneurism. ^

Subdivided into —

(a) For aneurism of the arch of the aorta. (6) For aneurism of the innominate, (c) For aneurism of the subclavian. {d) For aneurism of the carotid.

(a) 13 cases are reported in which the aneurism was situated upon the arch of the aorta (or was supposed to be).' 6 died. Of the 7 recoveries^ 5 are noted improved. In 4 of the 13 in- stances the subclavian was also tied, 3 of these 4 proving fatal. (These four were thought to be innominate.) [Nos. 8, 104, 106, 113, 274, 275, 288, 387, 495, 577, 652, 779, 784, respectively.]

(i) Innominate aneurism, in which —

(1) The carotid alone was tied.

(2) The carotid and subclavian were tied.

(1) Total 17. Died 12, or 71 per cent. Of 5 recoveries^ 2 are cured^ and 2 improved, and 1 not cured. [Nos. 80, 176, 203, 210, 283, 300, 302, 315, 417, 434, 435, 542, 543, 544, 550, 715, 771.]

1

See notioe of death of Barwell's case, which terminated fatally since writing above.

9

130 PRIZE ESSAY.

(2) Total 14. Died 10. Of the 4 recoveries^ 2 are most probably cured; 1 improved ; and 1 improved temporarily, dying in five months. [Nos. 191, 196, 200, 208, 2b9, 379, 591, 752, 753, 778, 781, 782, 783, 784.] (The aorta was involved also ' in some of these.)

(c) Subclavian aneurism. Total 5. Eecovered 1 (No. 638). In 2 cases the innominate was also tied (Nos. 638, 473). In 2 others the subclavian was also tied (Nos. 129, 358). The case (No. 638) died, about ten years later, of the old aneurism, which had disappeared and then reformed from the recurrent collateral circulation.

{d) Aneurism of the carotid. Total 5. Died 2. [Nos. 77, 328, 736, 737, 757.] Cured 2 ; improved 1.

(e) In 1 other case the subclavian was also tied. Eecovery (No. 336), ''not curedP

Summary of Cases of Ligature of the Common Carotid,

On account of aneurisms. Total 166 cases. Died 76, or 46 per cent. Cured 66, of 90 recoveries.

On cardiac side of aneurism. Total 106. Died 37, or 35 per cent. Recovered 69 ; cured 60.

On distal side of aneurism.^ Total 60. Died ^9 ^ or 65 percent. Recovered 21 ; cured only 6.

LIGATURE OF THE COMMON CAROTID ARTERY FOR THE RELIEF OF

NERVOUS DISORDERS.

Subdivided into —

1. Epilepsy.

2. Neuralgia.

3. Hemiplegia.

4. Headache.

e

1. Epilepsy. Total 20. Died 1. Mortality 5 per cent. Of tl 19 recoveries^ 3 are reported cured ; 10 improved (three of these onL 3 temporarily); and 3 not henefited,

2. Neuralgia (of Head or Face). Total 14. Died 1. Of t 13 recoveries^ 6 were cured, 4 temporarily improved, 1 not benefited,

I I have iucladed here the five oasea in which the vertebral was the seat of t aueariam.

SURGICAL HISTORY OF CAROTID ARTERIES. 131

3. Hemiplegia. Total 4. All recovered; three of these are improved; 1 not benefited,

4. Headache 2. Both recovered. Improved 1. No benefit 1.

Summary of Ligatures for Nervous Disorders,

Total 40. Died 2. Mortality 5 per cent. Of 38 recoveries, 9 were cured; 18 were benefited; no benefit in 6; condition not given in rest.

(The fact that so few of these patients died from an operation of such magnitude is probably due in great measure to the healthy condition of the artery at the seat of ligature, and also to the fact that these patients had not been exhausted by hemorrhage.)