SECTION 3. SUMMARY OP THE SURGICAL HISTORY OF THE INTERN'AL AND (Part 1)

SECTION 3. SUMMARY OP THE SURGICAL HISTORY OF THE INTERN'AL AND EXTERNAL CAROTID ARTERIES. (a) I have found only 18 cases of ligature of the internal carotid in which definite results are given. From these, nothing reliable as to the practicability of this ope- ration can be deduced, since in only one^ instance was this vessel alone the subject of deligation. In this case (No. 9) the operation was successful. The common and internal carotids were tied in 6 cases; 3 recovered and were cured ; 6 died. The external and internal carotids were tied in 3 cases. All re- covered ; 1 was cured. The common^ internal and external carotids were tied in 6 cases; 3 recovered; 2 of these were cured; 3 died. The internal jugular vein and the internal carotid were tied in 1 case. Recovered. The common^ internal and external carotids and the internal jugular vein were tied in 1 case. Recovered. Summary, Total 18. Died 6, or 33 per cent. Of the 12 re- coveries, 8 were cured; 1 not cured; rest noted as recovered. The cause of the operation was — Hemorrhage in 14 cases, of which 5 died. Erectile tumor 1 case, 1 " Aneurism 1 " 16 6 INot given in 2. * Since writing this a second ca«e has heen reported of ligature of this vess^jl atlooe. "^ hoovered ; cured. See foot-note under Statistics of Internal Carotid. 132 PRIZE ESSAY. The cause of death as given is — Pyaemia in 1 case. Exhaustion and hemorrhage in 1 case. " " shock in 1 case. Hemorrhage alone in 1 case. Coma alone in 1 case. (The operation will be considered in the closing summary.) (b) Summary of the ligatures of the external carotid. The statistics give 91 instances in which the external carotid artery has been ligatured. Of these 14 died, or 15 per cent.; but in 10 of these fatal cases the common carotid was also tied, leaving only 4 deaths out of 81 cases in which the ligature of the external was not complicated with that of the coTumon carotid. If however we exclude all complications, and select only those cases in which the external carotid alone was tied, we will have a better idea of the result of this operation. Of these the statistics contain 67 cases,^ with three deaths. Eate of mortality 4J per cent. These three fatal cases were gunshot wounds in military practice^ ac- companied hy prostration and extensive injury. One died on the table from loss of Hood before the operation ; the cause of death is not given in the other two. Of 64 recoveries^ 31 are reported cured ; 12 as not cured; and 1 as improved, Eemainder not noted as to condition. Hemorrhage after ligature in these 67 cases occurred in 5, none of which proved fatal. It was from the seat of lesion beyond the ligature in 4 ; the location not noted in 1 case. Of these 67 cases the sex is given in 47, of which 34 were males; 13 females. V\iQ side of body )^ given in 49 instances.^ Upon the right side in 31; the left in 18. Age— Between 1 and 10 years of age 1 case. 10 " 20 " " " . . . . .4 cases. " 20 " 30 " " " 8 ** " 30 " 40 " '* " 5 " ** 40 " 50 ** '* '* 8 ** " 50 " 60 " •* " 7 " " 60 " 70 " " •' 3 ** 1 On account of the peculiarly abnormal arrangement of the bloodvessels I have omitted Dr. Peugnet's case from this summary. s The artery was tied ou both sides iu the same patient in 6 instances, all of whom recovered. SURGICAL HISTORY OP CAROTID ARTERIES. 133 The ligatures came away as follows (being the only cases noted as to this feature in the entire 91 histories). 5th day . . 1 17th day . . 1 7 " . . . 1 18 " . . 4 8 ** , , . 4 19 " . . 1 10 " . . 2 20 " . . 1 12 " . . 2 21 " . . 1 13 " . . 1 22 " . . 1 14 ^ . . 1 — 15 " . . 4 Total . 26 16 " . . 4 In the 67 cases of ligature of the external carotid alone, the causes of operation were, as far as given, as follows : — On account of tumors of the parotid gland (before, during, or after removal of). Non-malignant 17 ; all recovered. Cured 15 ; not cured 1 ; noted as recovered 1. Malignant 3 ; all recovered. Not cured 2 ; cured 1 = 20 cases. For affections termed malignant (other than those of parotid). Fungus of palate ; recovered 1. Fungus of neck and fauces ; recovered 1. Sar- coma of tongue and face ; recovered, not cured, 1. Carcinoma ;' recovered, cured, 4 ; recovered, not cured, 2 ; noted as recovered 3 = 12 cases. [If to these 12 cases are added the 3 other " malignant" cases of the parotid, we have 15 instances in which this artery was tied to relieve or cure so-called malignant growths, with 5 cures and no deaths.] Gunshot wounds of lower jaw 3 ; recovered 2 ; died 1. Gunshot wounds of malar region and sup. max. 3 ; recovered 2 ; died 1. Gunshot wounds of orbit 1 ; died 1 = 7 cases. For wound of external carotid " " facial artery .... Hemorrhage, removal of tongue abscess of submax. region . polypus of nose .... remov. pulsating tumor temp. , ** tumor pharynx Aneurism in the parotid .... Varicose aneurism of ear .... Vascular growth (naevi, etc.) of cheek . ** ** head and face growth back of head growth* cheek, lip, and nose Removal of sup. maxilla osteo-sarcoma . (( u It n n fi tt II It it 2 Recovered, cured i n n ti 11 li 11 ti it It It (( 11 u 11 improved. n It not cured. tl no better. 11 cured. 11 ' In three of these both carotids were tied. 2 Both carotids tied. 181 PRIZE ESSAY. Facial neuralgia II n Cause unknown* ii n . 1 II 1 Recovered, no improvement. 1 " cured. 1 " cured. ti (( HEMORRHAGE. Of the 91 cases given in the table, hemorrhage is stated to have occurred after ligature of the external carotid either at the seat of ligature or beyond it in 12 instances, or about 13 per cent.^ In 6 of these 12 it was deemed expedient to tie the common or internal carotids or both, afterwards. In one case the external carotid was re-ligatured successfully. The remaining cases were treated by cold, astringents, or compress. [On a previous page it is stated that hemorrhage occurred ili only 5 out of 67 cases in which the external carotid alone was tied.] COMPARATIVE SUMMARY AND CONCLUSIONS. The rate of mortality after ligature of the common carotid artery, as given heretofore, is 41 per cent. After ligature of the external carotid the death-rate is 4J per cent. There can be but one conclusion to this comparison. The common carotid should never be tied for a lesion of the external carotid^ or its branches^ when there is room enough between the lesion and the bifurca- tion of the primitive carotid to permit the ligature of the external, I am led to this conclusion not only by the comparison of the analysis of 769 cases of ligature of the common trunk, with the 91 instances in which the external carotid was tied, but also from the analysis of 121 dissections of these vessels, made to determine the relations of these arteries and their branches to each other. It would be a waste of time to cite the eminent authorities in surgery who advise the ligature of the common trunk instead of the external. The teaching and practice is almost universal. It is as wrong as it is general. It is as false as it is dangerous. It is 41 per centum of deaths in the one, to 4J per centum in the other. 1 Double ligature. • < Dr. Peuguet's case is not iuoluded on accouut of the abnormal arrangement of tbe Vessels. SURGICAL HISTORY OF CAROTID ARTBRIE3. 185 This "History" carries its own proof of the generality of this practice. I have selected out of the statistics all the instances in which the common carotid was tied when the external carotid might have been secured between its origin from the common trunk and the lesion. I have omitted all cases in which meagreness of detail leaves the least doubt as to the seat of lesion, and furthermore, all the cases of malignant growths of the antrum, where, owing to the exaggerated nutrition of the diseased structures, the anastomosis had probably been very freely established between the ophthalmic and the internal maxillary, facial, and temporal arteries, so that ligature of the com- mon trunk became the surest method of "starving out" the disease. With these numerous omissions there were 251 out of a total of 789, and of these 108 died (or 43 per cent.). [They are Nos. 2, 3, 4, 5, 6, 11, 13, 15, 16, 17, 19, 21, 24, 25, 27, 28, 29, 30, 40, 45, 46, 48, 49, 60, 61, 62, 63, 67, 68, 76, 78, 82, 86, 87, 88, 91, 92, 94, 99, 102, 103, 116, 123, 124, 132, 133, 134, 137, 143, 147, 148, 151, 158, 159, 168, 169, 186, 187, 189, 190, 192, 197, 198, 202, 232, 234, 237, 239, 240, 241, 246, 249, 265, 266, 267, 268, 269, 270, 271, 276, 320, 321, 338, 341, 349, 361, 352, 353, 368, 370, 371, 374, 378, 380, 381, 382, 898, 401, 403, 406, 408, 415, 416, 421, 443, 448, 449, 450, 451, 457, 458, 464, 498, 510, 512, 613, 619, 520, 625, 528, 553, 664, 572, 573, 675, 579, 580, 585, 609, 611, 615, 616, 628, 630, 634, 636, «56, 657, 668, 663, 664, 667, 668, 671, 680, 681, 683, 684, 694, 698, 699, 703, 733, 734, 735, 738, 739, 744, 746, 748, 768, 772, 773, 786, 788, 789, in the statistics.] ,170, 172, ,209, 211, ,260, 252, ,279, 298, , 359, 360, ,, 884, 386, ,424, 425, :, 468, 469, , 533, 534, ,586, 587, ,640, 643, ,672, 673, ,705, 708, ,751, 766, 173, 177, 179 213, 217, 223 264, 257, 261 299, 306, 313 361, 362, 363 388, 391, 393 428, 429, 436 471, 472, 486 535, 541, 646 594, 599, 603 644, 645, 646 674, 677, 678 710, 712, 713 758, 764, 765 184, 227, 263, 319, 366, 397, 442, 496, 551, 606, 649, 679, 716, 767, CONCLUSIONS. 1. In all intra-cranial lesions involving alone the internal carotid or its branches, this vessel should be tied. If this procedure is not successful, then the external carotid shonldi be secured at the crossing of the digastric. If the facial be given off below this point, it should t>e secured by a separate ligature. Since one of the dangerous results of ligature of the common caro- 136 PRIZE ESSAY. tid is cerebral ansemia, it is evident that this danger will be partially avoided by leaving the anastonnotic channel, between the facial, in- ternal maxillary, and temporal branches of the external carotid, and the branches of the ophthalmic from the internal carotid, uninter- rupted. If this collateral current should, however, prove to be an impediment to a cure, it should be stopped. For lesions of the internal carotid in the neck (excepting aneurism) it should be tied alove and helow the lesion in all cases. The opera- tion on the cardiac side alone, be the common or internal trunk the seat of the ligature, is not justifiable, death having occurred in many instances through the descending current from the circle of Willis. In aneurism of this artery the single ligature on the cardiac side will sufiice. 2. When the lesion (excepting aneurism) exists within one-half inch of the bifurcation of the common carotid, involving this vessel, or the external or internal or both, the common trunk must be tied on the cardiac side, and the other two arteries upon the distal side of the legion. The superior thyroid and any other branches of the external carotid, between the ligature upon this vessel and the bifur- cation, should also be secured. In case of aneurism in either of these points the single ligature on the cardiac side will usually suffice. 3. In erectile or pulsating tumors of the orbit (intra-orbital aneu- rism) ligature of the common carotid is to be advised. The vessel should be secured at the omo-hyoid, a double ligature applied, the artery divided between, and each end twisted ("torsion" of Bryant). If the disease is malignant the entire contents of the orbital cavity should be removed. Since the anastomoses between the terminal branches of the ex- teimal and internal carotids, through the orbit, are more or less exag- gerated in intra-orbital aneurism, and since in the 52 recorded instances of this operation (in non-malignant conditions) the death- rate was only 11 J per cent., I am of the opinion that the ligature of the commort carotid is the surest and safest operation. If, however, the operation of enucleation be determined upon (the eye being already destroyed), it may not be necessary to tie the common carotid. Pressure upon the artery of the affected side will in most cases control the hemorrhage, until the operation is completed, when the compress in the orbit will most probably con- trol the bleeding; the danger of interfering with the intra-cranial circulation being thus avoided, or deferred until the necessity exists. SURGICAL HISTORY OF CAROTID ARTERIES. 137 4. Wounds of the superior thyroid artery, too near its origin to permit a ligature on the cardiac side of the lesion, require deligation of the commoTh^ external^ and internal carotids^ and torsion of the distal end of the wounded vessel. 5. In incised^ punctured^ lacerated^ and gunshot wounds of the ex- ternal carotid^ or its branches, where it is deemed inexpedient to secure the vessel at the seat of injury, the external carotid of one or both sides should be secured, below the origin of the lingual (the point of election, see Anatomy). If the lingual or any other branch is in immediate contact with the ligature, it (or they) should be also secured. The common trunk should never be tied under such circumstances except as a last resort. 6. Hemorrhage of the tonsils and pharynx, if not arrested by liga- ture of the external carotid, as advised, will require either the sepa- rate ligature of the pharyngea ascendens or of the common and inter- nal carotids. 7. It must be assumed that when ligature of the external carotid below the origin of the lingual does not arrest hemorrhage from the pharynx, the bleeding is from the ascending pharyngeal, and that this branch originates from the bifurcation or the internal carotid. (See Surgical Anatomy.) (The history gives one or two deaths from hemorrhage from the tonsils after ligature of the common trunk alone,) 8. Aneurism of the external carotid or its branches (excepting the superior thyroid) demands deligation of the external carotid alone, when a sufficient space exists between the tumor and the bifurca- tion to admit the ligature with safety. 9. Aneurism of the internal carotid should be treated by ligature of this vessel alone, when there is sound artery enough between the tumor and the bifurcation to admit the ligature with safety. 10. Aneurism of the common carotid {i^ digital compression shall have been abandoned) should be treated by ligature of this vessel as far from the tumor (on its cardiac side) as possible. 11. Ligature of the common carotid for aneurism of the arch of the aorta is of doubtful propriety. In deference to the opinion of the eminent surgeons who advise it, it may be considered as sub judice. From my own researches I could not conscientiously advise or perform the operation. 12. Ligature of the common carotid alone, for the cure of innomi- iriate aneurisin^ is an exceedingly dangerous procedure ; 12 of 17 cases proved fatal from the operation. Only 2 were cured. 138 PKIZE ESSAY. I cannot justify the operation. 13. The common carotid and the suhclavian artery were both tied for the relief of innominate {combined with aortic aneurism in some instances) aneurism in 14 cases. Died 10. This operation is only justifiable when every more conservative method shall have been exhausted. (See conclusions to History of the Subclavian, where result of different methods is given.) 14. Ligature of the carotid artery alone, or with the innominate^ for aneurism of the subclavian artery is not a justifiable procedure. Nature left to her own resources is safer than this. Conservative surgery (see History of Subclavian) is superior to both. 15. In case of aneurism of the carotid alone, too near the bifur- cation of the imnominate^ or the arch of the aorta, to permit the ligature being placed on the cardiac side, thedeligation of the carotid on the distal side would be advisable, provided the conservative method of direct (elastic) pressure upon the tumor ^ combined with per- fect quiet and careful dietetic treatment, had been previously and persistently tried and had failed. (An element of danger in interrupted pressure upon an aneurismal tumor of the carotid is, that particles of the newly formed clot may escape into the cranial circulation.) 16. In epilepsy, while the danger of. death as a result of the ope- ration is comparatively slight (5 per cent.), the proportion of cxires or improved cases is not great enough to commend this procedure to the