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VOL.18. SEPTEMBER, 1857. NO. 9.
Ligature of the Primitive Carotid Artery for Malignant Ditea*e. By Geo. C. Blackman, M. D., Professor of Surgery in the Medical College of Ohio; Surgeon to the Commercial Hospital.
Dr. Jas. R. Wood, one of the Surgeons of the Bellevue Hospital, N. Y., published in the New York Journal of Medicine for July an elaborate paper entitled, "Early History of Ligature of the Common Carotid Artery, with a Report of the unpublished operations in the city of New York." In seventeen of these cases, the operation was performed for malignant disease of the head or face. It is stated that in four, there was " an apparent cure of the original disease ; ten were decidedly benefited, growth of tumor being for a time arrested; two died; one not noted." In one of the fatal cases hemiplegia supervened twenty-four hours after operation, and death occurred in sixty hours; in the second case, death occurred three or four days after the operation, from exhaustion.
We have had occasion in several instances to ligate the primitive carotid in the removal of malignant tumors of the neck, and have been satisfied that in these cases the return of the disease has been retarded, and life prolonged by the operation.
From an examination of the dates of the operations per5* formed by the New York surgeons, in cases of malignant disVol. xvm.—41.
ease, it appears that one of our own is entitled to priority This was reported in the American Journal of Medical Sciences for Oct., 1845, and as the sequel of the report goes to show, we advocated the propriety of the proceeding in similar cases, although our course was then denounced by some who have since resorted to it, under similar circumstances, with success. It is due to Dr. Alexander E. Hosack to state that although his name does not appear in Dr. Wood's collection, he did ligate the primitive carotid for the purpose of arresting the growth of a parotid tumor, even before our own case, and long before him, the late Dr. Granville Sharp Pattison had strongly recommended the same operation in malignant disease of the antrum, as may be readily learned from his edition of Burns' "Surgical Anatomy of the Head and Neck." But to return to our own cases.
Case 1.—On the 17th of June, 1843, a farmer, set. thirty, sought our advice for a large encephaloid tumor on the right side of his neck, which was of some two years' standing. In the April preceding, the tumor had been opened by his family physician, with the expectation of finding " matter." About a pint of blood followed this proceeding, and the hemorrhage was with difficulty arrested. The tumor was from four to fire inches in height, and at its base the diameter was six inches. In the center was an opening sufficiently large to admit two fingers, and this extended to the sheath of the carotid artery. There was a profuse discharge of bloody matter from the surface, amounting nearly to a pint during the day. This was rapidly exhausting his strength, and as there was reason to believe that death would soon result from ulceration of the carotid artery, I resolved to apply a ligature to this vessel. On the 21st of June the operation was performed. The weather was intensely warm, the thermometer ranging for several days in succession at 90° Fahr. The wound was lightly dressed, and for a few hours the patient was very comfortable. .In the evening considerable reaction had taken place, and he was bled to the extent of ten ounces. During the night he
became somewhat delirious, and on the next day there was paralysis of the left side. His bowels were constipated, and the catheter was required for the evacuation of his urine. On the third day the pain in his head had greatly diminished, and on the fourth he had some power of moving the left hand and foot, and was able to pass his urine without the catheter. On the fifth he again lost all power over the left side of the body. On the sixth he was evidently sinking; he had cough, and there was some accumulation of mucus in his throat. On the seventh the wound, which had united, except around the ligature, re-opened, and about a tablespoonful of blood was lost, which greatly alarmed the attendant, but was easily arrested by compression. The patient became comatose, and died on the eighth day after the operation.
The effect of the operation on the tumor was all that could have been desired. In twenty-four hours it was evident that the whole mass would soon slough, and five days afterwards, the physicians who examined my patient were highly pleased with his appearance, and on the day of his death the tumor was so rotten that it was necessary to handle it with the greatest care to prevent it from falling into pieces. This case, as before mentioned, was reported in the American Journal of Medical Sciences for October, 1845, and in connection with it, we offered the following remarks:
Could this operation have been performed at an earlier period and at a more favorable season of the year, I sincerely believe that even if the patient had not been cured, his life would have been considerably prolonged. Dr. Mott has reported a case similar to my own in the New York Hospital Med. and Surg. Register, for 1820. He says, 'in consultation it was agreed, that an operation which would lessen the flow of blood to the fungus, and permit as much of the tumor to be removed as possible, afforded the only possible means of prolonging the existence of the patient or of mitigating his sufferings.' This operation was performed in November, and the patient lived only three months. But he was laboring under pulmonary difficulties previous to its performance, which were aggravated for a week or two in consequence, and Dr. M, gives it as his opinion,4 that his death may, -withmore propriety, be attributed to the pulmonary than the fungous disease.' It is evident that if the patient derived any benefit from the proceedings of Dr. Mott, it could not have been from the removal of the external portion of the tumor, but it must have been owing to 'the cutting off of its supply of blood' by the ligature of the carotid.
From the researches of pathologists it would seem reasonable to expect, that tying the principal artery supplying the tumor should be attended with good results. Mr. Walshe observes, that 1 the general impression derived either from the aspect of the vessels of encephaloid or from the results of injection, appears to have been that they were essentially arterial. In 1830, Prof. Berard injected with all necessary care, the arteries and veins of the neck of a subject who had died with two non-ulcerated encephaloid tumors in that region. On dividing )he masses in different directions, the usual characters of arterial injection were discovered,' etc., etc.
M. Magendie assures us that he tied the carotid with the effect of permanently stopping the growth of an enormous scirrho-encephaloid tumor on the side of the head and face, which had twice been reproduced after partial ablation. Sir Astley Cooper declares that ' this disease has a continual disposition to slough, and in this manner, occasionally receives a natural cure, for instances have been known where the entire tumor has sloughed, the wound healed kindly, and the person has been permanently cured.' Mr. Cline also states that he has seen a complete cure by sloughing. Now what method is more likely to produce this sloughing of the tumor than the ligature of its principal artery, and, if necessary, the constant application of ice?
Having the testimony of such men as Mott, Dupuytren, Magendie, Maunoir, Lucas, M. Jobert, Pattison and Hosack, in favor of this operation, and having witnessed its decided effect in arresting the flow of blood to the tumor in my own patient, I shall feel bound in similar cases, to give it a preference over every other method hitherto suggested in the treatment of this most formidable disease. Cases do occur, as Copland, Maunoir, Lobstein and Velpeau have remarked, in which, as in my patient, the disease has not invaded the digestive or assimilating organs, where the absorption of the morbid matter has not taken place to a great amount, and where the patients still retain their natural color. In these cases, when some external part only is affected, and when the general health, as in Mr. B.,remains unimpaired, but the patient is sinking from the excessive discharge from the tumor, the course which I adopted has certainly some important arguments in its favor.
Case 2.—In August, 1847, a son of Gideon Birdsall, set. 18, residing in Ulster co., N. Y., came under our care for the treatment of a malignant growth proceeding from the right maxillary sinus, and filling the nostril of that side. The disease at first had been regarded as a polypus, and an attempt to extract it was made by one of the most distinguished surgeons in the country. Alarming hemorrhago followed, and the operator dismissed the patient with the advice never to submit to another effort of the kind, but if he suffered any thing more to be done, to have a ligature placed upon the carotid artery of that side, for the purpose of arresting the growth of the tumor and prolonging his life. When I was first consulted by him, he was subject to frequent attacks of bleeding, and both nasal apertures were blocked so as to interfere with respiration. The cheek was greatly swollen, and every thing presented a most unfavorable prospect. On the 24th of August I ligated the right primitive carotid, in the presence of a number of physicians residing in the vicinity. Nothing worthy of note occursed during or after the operation, so far as the latter is concerned. The ligature came away on the thirteenth day, and the whole wound was soon healed. The immediate effect of the operation was most decided in arresting the growth of the morbid mass, and in diminishing the tumefaction of the cheek. In the course of a fortnight, however, he began to complain of uneasiness about the junction of the upper lip with the right ala of the nose, at which point there was some swelling. A fungous growth soon appeared beneath the upper lip, and this increased so rapidly that in the course of four or five days it protruded something like an inch below its margin, and prevented the patient froai taking solid food. The mass protruding from ti e nose at the