Joseph Bell - A Manual of the Operations of Surgery

It might have been expected that the sudden arrest of so large a proportion of the vascular supply of the body, so very near the heart, would cause serious, or even fatal symptoms; this, however, is not the case, no serious inconvenience of this sort being experienced; yet hitherto every case has proved fatal, either from secondary hæmorrhage or inflammation of lungs and pleura.

In fifteen well-authenticated, and in three more doubtful cases, the ligature has been applied; all of these died at periods varying from twelve hours (as in Hutin's case), to forty-two days as in Thomson's, and sixty-seven days (Graefe's). 11

A successful case of ligature of the innominate along with the right carotid and (after secondary hæmorrhage) the right vertebral, in a mulatto aged thirty-two, for a subclavian aneurism, has been put on record by Dr. Smyth of New Orleans, in the American Journal of Medical Science for July 1866.

And here we may also note that Mr. Heath has lately treated a case of innominate aneurism by simultaneous ligature of the third part of the subclavian and the carotid. Both ligatures separated on the eighteenth day, and the tumour was much smaller some months afterwards. 12

Mr. R. Barwell has reported several most interesting cases in which simultaneous ligature of carotid and subclavian have proved of marked benefit in aortic as well as in innominate aneurisms. 13

In four cases the operation was attempted, but the operators had to desist before the application of the ligature, in consequence of the diseased state of the arterial coats. Of these, three died, and one (Professor Porter's of Dublin) case recovered, the patient leaving the hospital with the aneurism nearly consolidated.

Dr. Peixotto of Portugal applied a precautionary ligature to the innominate in a case where secondary hæmorrhage occurred from the carotid. The ligature was not tightened beyond what was necessary merely to cause flattening of the vessel. The patient made a good recovery.

Professor George Porter of Dublin records an interesting case of subclavian aneurism, in which, after failing to close the axillary artery by acupressure, he applied L'Estrange's compressor to the innominate itself for three days, with temporary benefit. The patient eventually died of hæmorrhage. 14

For a very full and interesting account of ligatures of vessels in root of neck we may refer to vol. iii. of the 1883 edition of Holmes' Surgery , pp. 119-122.

Ligature of Common Carotid.—Though the anatomical relations of the right and left carotid are different at their origin, they so precisely resemble each other in the whole of that part of their course which is at all amenable to surgical treatment, that one description will suffice for both, and the necessary anatomy will be brought out quite sufficiently in the description of each operation.

From its giving off no collateral branches, the common carotid artery may be tied at any part of its course.

It has been tied successfully at the distance of only three-quarters, or, in one case by Porter, hardly to be imitated, one-eighth of an inch from the innominate, and up to an equal distance from its bifurcation. In choosing the part of the vessel for operation, the operator must be guided by the position of the aneurism, if on the vessel itself, but if the aneurism be distant, as in scalp or orbit, he need have regard to position simply as facilitating the operation.

The easiest position in which to apply the ligature is just above the omohyoid muscle, the vessel being there superficial.

Ligature above Omohyoid.—Using the anterior border of the sterno-mastoid as a guide, but leaving it gradually above to a little nearer the mesial line, an incision ( Plate IV.fig. 1), varying in length according to the depth of fat and cellular tissue in the neck, but with its central point opposite the upper border of the cricoid cartilage, must be made through skin, platysma, and superficial fascia. While making the incision the head should be held back, and the face slightly turned to the opposite side; the parts being now relaxed by position, the edges of the wound must be held apart by blunt hooks or copper spatulæ, and the deep fascia carefully divided over the vessel, which will be recognised by the pulsation. It may be noted here that even in thin subjects the sterno-mastoid edge invariably overlaps the vessel, though in many anatomical diagrams it would appear to be in part subcutaneous.

The descendens noni may possibly be seen, but this is by no means invariably the case, crossing the sheath of the vessel very gradually from without inwards in its progress down the neck. It must be carefully displaced outwards.

The sheath of the vessel is then to be cautiously opened to the extent of about half an inch. The internal jugular vein, possibly much distended, may overlap the artery on its outer side, and will require to be pressed, emptied, and held out of the way. A small portion of the artery being thoroughly separated from the sheath, the aneurism-needle must be passed from without inwards to avoid the vein, and keep as close to the artery as possible to avoid the vagus.

The tendon of the omohyoid muscle, or, in muscular subjects, a portion of its anterior fleshy belly, may be seen crossing the vessel from above downwards and outwards at the lower angle of the wound.

An enlarged lymphatic gland has occasionally given much trouble, by being mistaken for the vessel and cleaned, while the ligature has even been placed on a carefully isolated fasciculus of muscular fibres.

Ligature of Carotid below the Omohyoid.—An incision in precisely the same direction as the former, but at a slightly lower level, is required, but the dissection is rather more difficult. The edge of the sterno-mastoid when exposed must be drawn outwards; the sterno-hyoid and thyroid inwards; the omohyoid upwards; the sheath opened, and the descendens noni or its branches drawn to the tracheal side. The jugular vein and vagus are both at the outer side, and must be avoided, while the inferior thyroid artery and sympathetic nerve both lie behind the vessel, and may be included in the ligature if care be not taken.

Varieties.— Sedillot's Operation. —To secure the artery still lower in the neck: An incision two and a half inches long, from the inner end of the clavicle obliquely upwards and outwards in the interval between the sternal and clavicular attachments of the sterno-mastoid; this divides the superficial textures; the two portions of muscle must then be drawn apart. The internal jugular vein lies in the interval, and must be drawn to the outside before the artery can be seen at all, and it is this that makes this operation very difficult and dangerous, especially on the left side, where the vein is close to the artery, and probably even crossing it from left to right. The thoracic duct is behind.

Malgaigne's modification of the above is an improvement: to expose the external attachment of the muscle, to cut it through and turn it to the outside, as in the operation for ligature of the innominate, then to divide or pull inwards sterno-hyoid and sterno-thyroid, thus exposing the sheath. The needle must be passed from without inwards.

Results. —Pilz has collected 600 cases, of which 43.16 per cent. died. The united tables of Norris and Wood give 188 cases, with a mortality of sixty, or nearly one in three. These tables include cases in which the vessel was tied for wounds, and as a preparatory step in the operation of removal of tumours of the jaw, etc. Later statistics give a very much lessened mortality, due chiefly to the use of animal ligatures.

Of thirty-one cases in which it was tied for pulsating tumours of the orbit, only two died from the operation. 15Rivington's statistics to a later date give forty-six cases on forty-four patients with six deaths.