KATY DID, AND KATY DIDN’T. * 
AN INQUIRY CONCERNING 
PRIORITY IN TIIE LIGATION OY/A 
THE INTERNAL CAROTID ARTERY. 
BY WILLIAM K. BOWLING, M. D., 
EMERITUS PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE, 
In the Medical Department of the University of Nashville. 
NASltYULLR, .TENNESSEE: 
PRINTED AT THE “UNION AND AMERICAN” BOOK AND JOB OFFICE. 
1874. IvATY DID AND KATY DIDN’T. 
AN INQUIRY CONCERNING PRIORITY IN THE LIGATION OF 
THE INTERNAL CAROTID ARTERY. 
BY W. K. BOWLING, M. D., 
EMERITUS TROFESSOR OF MEDICINE IN TIIE UNIVERSITY OF NASHVILLE. 
Dr. Gross, in his biography of McDowell, says that his 
hero liked to refer to Surgery as the “ certain part of Medi- 
cine,” and yet great surgeons not unfrequently, under the cha- 
grin and mortification of defeat, exclaim, “the glorious uncer- 
tainty of Surgery!” We have often said that wc were thank- 
ful we were no surgeon, and yet, had we shone with a steady 
brightness in that profession, we might have been more thank- 
ful still that we were a member of it. While a physician 
only, we have, since early manhood, had a passion for Surgery, 
and watched its progress with an interest not surpassed by 
that of our contemporaries who illustrate and adorn it. We 
have said it is uncertain, but so are most of the efforts of man, 
as well, indeed, as man himself; so what is common to all 
things, cannot be logically urged as an objection to any one 
thing. It must, therefore, be conceded, that Surgery is un- 
certain ; and it will not be successfully denied that, for this 
very reason, its brilliant successes should not only be faithfully 
recorded, but that its votaries should feel that it was impera- 4 
LIGATION OF THE 
tively demanded of them, at least, that they should be familiar 
with the record. 
The great libraries contain a collection of all medical publi- 
cations, flowing through legitimate channels, from that which 
humbly trickles down the mountain side, mirroring the daisy 
and offering drink to the bonnie lark, to that which rolls its 
interminable length along the lowland plain, refreshing cities 
and villages and hamlets, embosoming half the sky, and car- 
peting with green a landscape bounded in every direction by 
the horizon. The rill and the Amazon alike find their way to 
the ocean; so likewise a medical journal from the wilderness 
of trees and cascades, enlivened by singing birds and frisking 
squirrels, and made awfully grand by armies of buffalo, in 
stately and silent march to “the springs,” find ultimate com- 
panionship with that from a wilderness of chimneys and masts 
and streets and wheels and people, in a common library. 
Search, and ye shall find, is the law here as elsewhere. 
We do not wish to be understood as reflecting injuriously 
upon the publication of any one, but desire only to assert that 
it is the bounden duty of medical authors, as well as of au- 
thors in general, before going forward with any inquiry, to be 
assured of the thoroughness of their research in the past, be- 
fore they add a new chapter; and the importance, as well as 
the reasonableness of this rule, addresses itself the more forci- 
bly to our understanding in a surgical inquiry, where a seem- 
ingly slight omission of a fact may rob a surgeon of a large 
part of his wealth, the whole of which oftentimes consisting 
alone in his truthfully-recorded achievements. 
We were not a little surprised, the other day, upon reading, 
in the New York Medical Journal, an account of the ligation 
of the internal carotid artery. All surgeons know that it re- 
quires the highest order of skill, as well as all the minor qua- 
lities of a great surgeon, of which skill is a culmination, to 
successfully deal with a hemorrhage of which the internal ca- 
rotid artery is the Jons et oriejo. Now, as we desire to venti- 
late the inquiry as to who has done this thing—who has thus 
added his name on the scroll of fame to the verv few it can INTERNAL CAROTID ARTERY. 
5 
exhibit upon this subject, we shall quote the entire case from 
the New York Medical Journal to begin with: 
A Case of Hemorrhage from the Internal Carotid Artery 
treated successfully by the Ligature. By II. B. Sands, 
M. I)., Surgeon to the Bellevue and the Roosevelt Hos- 
pitals, etc. 
The following case is believed to be unique, and to constitute an import- 
ant contribution to the annals of operative surgery: 
On October 22, 1872, I performed disarticulation of the left half of the 
lower jaw, on account of a malignant scirrhous tumor, occurring in a gen- 
tleman, fifty-three years of age, and developed chiefly on the inner aspect 
of the ramtls and body of the bone, near the angle. The usual incision 
having been made, the jaw was divided on the left of the median line, 
through the socket of the corresponding canine tooth. The bone was then 
forcibly everted, while I quickly severed, by means of a pair of stout scis- 
sors, the soft parts covering the internal surface of the tumor, and then 
completed the disarticulation. Copious arterial hemorrhage, checked tem- 
porarily by the pressure of the left fore-finger, attended this manoeuvre, 
and, on subsequent examination of the tumor, there were found running 
through it an inch of the trunk of the external carotid artery, and portions 
of about equal length of the digastric muscle and the hypoglossal nerve. 
These parts were necessarily divided and removed, together with the tumor. 
The external carotid, together with some smaller arterial vessels, having 
been tied, I was about to close the wound, when free venous bleeding took 
place from a small opening that I had accidentally made in the internal 
jugular vein. After some reflection as to the best course to pursue, I seized 
the margins of the wound in the vein, and applied a lateral ligature, not 
occluding the calibre of the vessel. The wound was then closed by sutures, 
except at its middle part, where an opening, half an inch long, was left 
for the exit of the ligatures. During the operation, it was noticed that the 
upper part of the common carotid, and the internal carotid artery, from its 
origin to the base of the skull, were exposed, and could be seen pulsating 
at the bottom of the wound. 
On the tenth day after the operation, at ten o’clock in the evening, while 
my partner, Dr. Curtis, was engaged in cleaning the wound, a sudden es- 
cape of blood took place, bdth from the external opening and through the 
mouth. Dr. Curtis at once compressed the common carotid with the left 
hand, and, ripping open the upper end of the original incision, passed in 
two fingers of the right hand, and made pressure over the line of the inter- 
nal carotid. The hemorrhage ceased at once, about two ounces of blood 
having been lost, whose color gave no certain indication of the source of 
the bleeding. Pressure was successfully maintained until my arrival, at the 6 
LIGATION OF THE 
end of about half an hour. In was then found that one of the upper two 
fingers covered the bleeding point, which was evidently above the carotid 
bifurcation, and Dr. Curtis was relieved by my pupil, Mr. Shatter. The 
ligatures were then examined, and that on the internal jugular vein identi- 
fied and found to be attached far below the bleeding point. No ligature 
could be identified as belonging to the external carotid artery. After look- 
ing at the ligatures, I, without giving ether, prolonged the opening in the 
neck downward along the anterior edge of the sterno-mastoid muscle, and 
endeavored to reach the common carotid high up. Owing to the altered 
condition of the parts, this proved impracticable; so, having divided the 
omo-hyoid muscle, I exposed the artery just below it, where the tissues 
were normal, and passed, rvithout tightening it, a ligature. 
The common carotid was then compressed between the ligature and the 
finger, and pressure relaxed upon the bleeding point. A very vigorous 
spurt of blood followed, and pressure was resumed. 
An examination of the surface, immediately above the seat of hemor- 
rhage, revealed a very soft pulsation, just beneath the granulations along 
the line of the internal carotid. The latter vessel I directed Dr. Curtis to 
dissect, while I controlled the bleeding. The internal carotid was exposed 
by scratching through the condensed tissues with the point of a grooved 
steel director; a ligature was passed, and was immediately tightened, as 
was just afterward the one encircling the common carotid. I then lifted 
my finger from the bleeding point, and no gush followed, but a bleeding 
continuous in character, and small in amount. This was easily controlled 
by pressure just below the opening, and for the first time the exact seat and 
nature of the latter were completely open to inspection. 
The blood was found to come from a small, circular, clean-cut ulceration 
in the side of the internal carotid artery, situated an inch below the upper 
ligature, and the same distance above the upper border of the thyroid car- 
tilage. Through this opening the white and glistening surface of the inner 
coat of the opposite side of the arterial wall was distinctly visible. After 
ascertaining the opening to be in the side of the internal carotid, I readily 
exposed this vessel two or three lines below the opening, and applied a 
ligature, thus cutting off the source of the trifling hemorrhage which had 
persisted after the tightening of the first two ligatures. This hemorrhage 
must have been caused by the recurrent circulation through branches 
springing from the stump of the external carotid. The lower portion of 
the wound was then closed by a few silk sutures, and the rest lightly filled 
with dry lint. t 
The operation, which lasted about two hours, was wonderfully well 
borne, the patient making no complaint. He lost altogether, both during 
the operation and the antecedent hemorrhage, not more than four or five 
ounces of blood, aud the pulse continued firm throughout. Milk and iced 
brandy were administered through the night, aud the patient obtained sleep 
without anodynes. INTERNAL CAROTID ARTERY. 
7 
The subsequent progress of the case was eminently satisfactory. The 
two ligatures on the internal carotid separated on the ninth day, that of 
the common carotid on the fourteenth day, and that of the internal jugular 
vein on the seventeenth day, after their application. The upper ligature 
on the internal carotid had, in its noose, an offensive white slough of the 
artery, three-eighths of an inch long, and another hemorrhage was feared. 
None occurred, however, and the patient recovered completely without any 
further unpleasant symptoms. 
licmarks.—Lesions of the internal carotid are usually so rapidly fatal, 
that no opportunity is afforded for surgical treatment. But, even when 
the surgeon interferes, success is not generally attainable, and, so far as I 
have been aide to ascertain, there is only one other example of recovery 
recorded besides the one herewith reported. This case occurred in 1807, 
in the practice of Dr. Twitchell, of Keene, New Hampshire, and, in many 
respects, it resembled my own. The hemorrhage was secondary, and took 
place, ten days after a gunshot injury, while Dr. Twitchell was in the pa- 
tient’s house. lie applied a ligature on the cardiac side of the opening in 
the wad of the internal carotid, * but was obliged to check the recurrent he- 
morrhage by means of a graduated compress, as the opening was in that 
part of the artery which lies just beneath the base of the skull. 
From various sources, I have collected the following instances of hemor- 
rhage from the internal carotid. Some were treated, and others were not, 
while all terminated fatally: 
1. A hunter received a penetrating bullet-wound in the face. Hemor- 
rhage occurred on the third day, after the administration of an emetic. 
Death took place on the fourth day, during an attempt to tie the common 
carotid. At the autopsy, the bad was found lying behind this vessel, op- 
posite the bifurcation. The internal carotid showed a longitudinal rent 
one-fourth of an inch in length. 
2. Abemethy tied the common carotid for hemorrhage from a wound of 
the neck inflicted by a cow’s horn. The patient died thirty hours after the 
operation, with symptoms of hemiplegia. At the post-mortem operation, 
the facial, lingual, superior thyroid, and internal carotid arteries, were 
found tom. 
3. Langenbeck tied the common carotid for hemorrhage from the inter- 
nal carotid, caused by the ulceration of an epithelial cancer. Death oc- 
curred soon after the operation, and an ulcer, not larger than the head of a 
pin, was found in the coats of the internal carotid. 
* “ He applied,” Fays Dr. Sands, “a ligature on the cardiac side of the opening in the wall 
of the internal carotid.” Of course the reader is led to believe, especially as ligature of tho 
internal carotid is the subject being discussed, that Dr Twitchell tied that artery. But the 
Doctor himself says he did not. He says : “I made an incision downwards to more than an 
inch below the point where the external branch was given off. * * * Passing my finger 
under it, I raised it up sufficiently for my assistant to pass a ligature around it. She tied it 
with a surgeon’s knot, as I directed, about half an inch below the bifubcation.”—See 
Twitched, as quoted by Guthrie.—Ed. 8 
LIGATION OF THE 
4. A. Smith ligated the common carotid for hemorrhage from the inter- 
nal carotid, caused by a phagedenic ulcer of the tonsil. The patient died 
in six hours. 
5. In the “Medical and Surgical History of the War of the Rebellion,” 
a case is reported in which the common carotid was tied for hemorrhage 
from the internal carotid, caused by a gunshot wound. The hemorrhage 
recurred, and carried off the patient. 
6. Baizeau tied the common carotid for hemorrhage from the internal 
carotid, caused by disease of the ear. The bleeding was not arrested, and 
proved fatal on the third day. At the autopsy, an opening was found in 
the internal carotid, produced by caries of the walls of the tympanum. 
7. Broca performed an operation, like the one last described, and with a 
fatal result due to hemorrhage. 
8. Billroth, in a case of hemorrhage from the right ear, due to ulceration 
of the internal carotid, tied the right common carotid, and, a fortnight 
subsequently, the left common carotid. Death from hemorrhage occurred 
two days after the last operation. 
9. Dupuytren reports the case of a man who received a perforating bul- 
let wound of the neck, at the level of the inferior maxilla. Hemorrhage, 
which pressure failed to arrest, occurred on the tenth day, and proved fatal 
on the twelfth day. At the autopsy, a wound, one-half an inch in length, 
was discovered in the internal carotid, two inches above its point of 
origin. 
10. Heyfelder relates that a soldier received a penetrating wound of the 
left side of the neck, and died of hemorrhage eight hours after the injury. 
Ice-bags were the only means employed to check the bleeding. The inter- 
nal carotid was found to be almost completely divided, three and a half 
lines above its origin. 
11. Beclard states that a traveling charlatan wounded the internal caro- 
tid while attempting to excise an enlarged tonsil. The operator fled, and 
Beclard was summoned just in time to see the patient die from hemorrhage. 
A wound of the internal carotid was found post mortem. 
In some of the cases above mentioned, namely, those in which the he- 
morrhage was due to disease of the petrous bone, the application of a liga- 
ture on the distal side of the arterial lesion was impossible, and the case 
that I have reported is the only one, so far as I am aware, in which a lesion 
of the internal carotid has been treated by the application of a double liga- 
ture to the injured vessel, one on the proximal and the other on the distal 
side of the bleeding-point. 
The result affords additional evidence of the soundness of the rule laid 
down by Mr. Guthrie—a rule Avhich is too often neglected, as is shown by 
the surgical reports of the late civil war, even at the present day. It is 
not, perhaps, difficult to explain why a surgical maxim, so generally ad- 
mitted to be binding, should be so often disregarded. The application of 
a double ligature to the bleeding vessel is simple in principle, but generally INTERNAL CAROTID ARTERY. 
9 
difficult, and sometimes impossible, in practice. The deep situation of the 
bleeding vessel, its relation to other important parts, and, in cases of se- 
condary hemorrhage, the infiltration of the surrounding textures with in- 
flammatory products, offer serious, and sometimes insuperable obstacles to 
the application of a double ligature near the opening in the arterial walls. 
In these circumstances, the temptation to apply a simple ligature to the 
main trunk is very great, and experience shows that this operation, either 
alone, or, as in Dr. Twitchell’s case, in conjunction with pressure, may 
sometimes insure the desired result. Yet success in such an operation can 
never be expected, and the surgeon should in no case perform it except as 
a last resort, and after an attempt has been fairly made to apply a double 
ligature according to the rule admitted, by nearly every surgical writer, as 
imperative. 
* In the present case it is plainly evident that, unless the ligature had been 
applied above as well as below the bleeding-point, death from hemorrhage 
would have rapidly and inevitably followed, as it was noticed that the sim- 
ple interruption of the circulation through the common carotid produced 
no appreciable diminution in the violence of the bleeding, which, however, 
ceased almost entirely, when a ligature was applied to the internal carotid 
beneath the base of the skull. The slight recurrent hemorrhage still going 
on was controlled by the third ligature, placed just below the bleeding- 
point. This ligature I should have applied at first, instead of tying the 
primitive carotid, had the state of the parts rendered the requisite dissec- 
tion practicable. 
Finally, it may be interesting to note the success which attended the ap- 
plication of a lateral ligature to the internal jugular vein. In spite of the 
weight of authority in favor of treating wounds of large veins by the use 
of a double ligature, completely surrounding the vein above and below the 
bleeding-point, I am strongly inclined, if the wound be small, to trust to a 
single ligature, applied laterally, so as to include merely the edges of the 
wound, and not to interrupt the current of blood through the injured ves- 
sel. In case the wound were of large size, however, I should then regard 
the complete ligature of the vein as affording the best guarantee of 
success. 
Mr. Guthrie, on the ligation of the internal carotid artery, 
says: 
The inutility of tying the primitive trunk for a wound of the internal 
carotid is distinctly shown in this case, which is no less valuable from the 
fact demonstrated, that if the internal carotid can be exposed and injured 
within the angle of the jaw by an accident, it can be exposed and secured 
by ligature at the same part by an operation. 
When, then, the internal carotid is wounded through the mouth, what 
operation is to be performed ? That of placing a ligature above, and £n- 10 
LIGATION OF THE 
other below the opening made into it; and after much consideration, and 
many trials, the following operative process is recommended to the atten- 
tion of those who are best acquainted with the subject: 
An incision is to he begun opposite to and on the outside of the extremity 
of the lobe of the ear, and carried downward in a straight line, until it 
reaches a little below the angle of the jaw, at the distance of nearly half 
an inch, more or less, as may be found most convenient from the form of 
the neck. This incision exposes the parotid gland without injuring it. A 
second is then to be made from the extremity of the first, extending at a 
right angle forward, under or along the base of the lower jaw, until the 
end of it is opposite the first molar tooth. This incision should divide the 
skin, superficial fascia, platysma myoides muscle, and the facial artery and 
vein. The second molar tooth should then be removed, and the jaw sawn 
through at that part. Then cut through the deep fascia, the mydo-hyoi- 
deus muscle, and the mucous membrane of the floor of the mouth, expos- 
ing the insertion of the internal pterygoid muscle, 'which is to he divided. 
The surgeon will next be able to raise and partially evert the angle of the 
jaw, and thus obtain room for the performance of the remaining part of 
the operation, which should be effected by the pointed but blunt end of a 
scalpel, or other instrument chosen for the purpose of separating, but not 
of cutting. The styloid process of the temporal bone may then be readily 
felt, and exposed by the separation of a little cellular membrane, and with 
it the stylo-hyoid muscle, whicli is to be carefully raised and divided. The 
external carotid artery will thus be brought into view, together with the 
stylo-pharyngeus muscle and the glosso-pharyngeal nerve attached to it. 
These are to be drawn inward by a blunt hook, when, if care be taken to 
avoid the pneumogastric nerve, the internal carotid may be felt, seen, and 
secured by ligature with comparative facility outside the tonsil, there being 
between them the superior constrictor of the pharynx, which, in a case of 
wound through the mouth, must have been divided. The pneumogastric 
nerve should be drawn outward, and the external carotid artery also, if in 
the wTay. The division of the jaw will not lead to further inconvenience, 
as the bone always reunites, when divided, with little difficulty. That this 
operation requires a thorough knowledge of the anatomy of the parts, is 
true; and this can only be acquired by repeated dissections. 
u The nearest successful case,” says Mr. Guthrie, “ to the 
operation thus recommended, was performed by Dr. Keith, of 
Aberdeen ” : 
E. Kennedy, aged 25, accidentally swallowed a pin, the head of which 
could be felt below and behind the left tonsil, covered by the lining mem- 
brane of the pharynx; it could not be extracted by any attempt made for 
its removal. The membrane was snipped by a pair of probe-pointed scis- 
sors, to expose the head of the pin. This was followed by the discharge INTERNAL CAROTID ARTERY. 
11 
of mouthfuls of arterial blood, and it was evident that the internal carotid 
artery had been injured. Pressure ou the common carotid stopped the 
bleeding, and the operation of placing a ligature on the internal carotid 
was effected in the following manner: The patient’s head being supported 
by a pillow, her face was turned toward the right shoulder, when an inci- 
sion was made from below the.ear along the ramus of the lower jaw to be- 
low its angle. No hemorrhage occurred, and the vessel was speedily ex- 
posed and secured by a double ligature passed under it, with less difficulty 
than the depth of the vessel would lead one to expect. One ligature ar- 
rested the flow of blood, and the other was therefore withdrawn. The 
woman recovered, without any return of the bleeding. Dr. Keith, aware 
of the necessity for tying the other end of the artery, if it should bleed, 
watched the case day and night until the period of danger had passed away. 
The pin gave no trouble, until felt by the patient as about to go down the 
oesophagus, which it did, to her great satisfaction and relief from further 
anxiety. 
There are many peculiarities in this case: 
1st. “ Pressure on the common carotid stopped the bleed- 
ing.” It will be seen, presently, that ligature of the common 
carotid did not slop the bleeding; and as pressure did in Dr. 
Keith’s case, it is amazing that he did not at once throw a 
ligature around that vessel, before attempting to ligate the 
internal carotid. 
2nd. But, stranger still, after having thrown a double liga- 
ture around the internal carotid, he could atford to withdraw 
one, as one ligature arrested the flow of blood at that time. 
There is no little confusion in the narrative of this opera- 
tion. The author says “ an incision was made from below the 
ear along the ramus of the lower jaw to below its angle. No 
hemorrhage occurred, and the vessel was speedily exposed and 
secured by a double ligature passed under it.” We have 
caused these words to be printed in italics. John Hunter 
would have expected this procedure to succeed, and it did suc- 
ceed, but we are sure no surgeon of to-day would trust it. 
Mr. Guthrie says: “ With what fairness can this operation, 
thus done on one side of the neck, at the distance of two 
inches, the other side remaining sound, be considered similar 
to that of Mr. Hunter, done on the thigh, for a wound in the 
calf of the leg, at the distance of perhaps twenty inches, with 12 
LIGATION OF THE 
all the intervening collateral branches perfectly sound? * * 
* One ought not to be compared with the other, although it 
is done, and thus the subject is mystified to all those who do 
not understand it thoroughly.” 
The law laid down by Mr. Guthrie for controlling the he- 
morrhage from a wound of the internal carotid artery, is to 
reach the vessel from without, and place a ligature above and 
below the wound. He admits the difficulty of the operation; 
nay, he says in italics, “ I am willing, for the present, to con- 
sider it nearly impracticable to tie the internal carotid safely 
from the outside of the neck, at the part wounded, without 
great anatomical knowledge.” 
Mr. Guthrie gives the following case in illustration of the 
soundness of this doctrine : 
M. S , a female, aged 53, was admitted into tlie Westminster Hospi- 
tal, with a large movable tumor in the neck, under the sterno-mastoid mus- 
cle of the right side. An operation having been commenced for its remo- 
val, the tumor was found to be of a more than doubtful character, and to 
dip down between and behind the great vessels of the neck. In the course 
of the operation, the external carotid was opened a little above its bifurca- 
tion, and a ligature was applied on the common carotid. The bleeding was 
not in the least arrested ; a ligature wras then placed on the external carotid, 
above the hole in the artery, which still continued to pour out blood; a 
third ligature was now put upon the internal carotid, with no better success. 
A fourth ligature was then applied on the external carotid, below the hole 
in it, including the superior thyroid, which was then given off at that part; 
after which the bleeding ceased, and never returned. Three ligatures came 
awray in three weeks; the fourth remained during five weeks. The patient 
recovered from the operation, but the tumor grew again, and the woman 
died exhausted at the end of six months. 
On examination after death, the arteries referred to were found to be ob- 
literated for some distance above and below the parts injured. 
The utter inefficiency of everything but the two ligatures, the one imme- 
diately above, the other immediately below the part opened, could not be 
more distinctly proved, if a case were even invented for the purpose; and 
the fact could not be more satisfactorily shown that in every case of wound- 
ed—not aneurismal—artery in the neck, one ligature should be applied 
above, and another below the opening in the injured vessel, and not one 
alone on the common trunk, even if that should be the part injured. 
We are compelled to admit Dr. Keith’s case, because he has 
recorded it, and Mr. Guthrie quotes it. This Mr. Guthrie INTERNAL CAROTID ARTERY. 
13 
docs with an incomprehensible introduction. It is clear, as 
far as one can go in that direction, that Dr. Keith overturns 
the doctrine of Mr. Guthrie, for this gentleman relied upon a 
single ligature; for although he had thrown two under the 
artery, he only tied one, withdrawing the other. Yet Mr. 
Guthrie says, with a naivete and incomprehensibility alike de- 
liciously cool, “the nearest successful case to the operation 
here recommended, was performed by Dr. Keith,” &c. The 
italics arc ours. The case performed by Dr. Keith is only re- 
markable for contradicting the rule of Mr. Guthrie, and nearly 
the entire mass of experience of surgeons since then. 
The case referred to by Dr. Sands as the only successful one 
before his own, ought not to be insisted on as a case at all. It 
is given by Mr. Guthrie as follows: 
I)r. Twitchell, of Keene, N. H., United States, says a soldier, in a sham 
fight, in 1807, received a wound, from the wadding of a pistol, on the 
right side of the head, face, and neck, which was much burned. A large 
wound was made in the mouth and pharynx; nearly the whole of the pa- 
rotid gland, with the temporal, masseter, and pharyngeal muscles, was 
destroyed. The neighboring bones were shattered, and the tongue injured. 
The hemorrhage was not copious, although the external carotid and its 
branches were divided. 
Ten days after the accident, the sloughs had all separated, and left a 
large circular aperture of from two to three inches in diameter, at the bot- 
tom of which might be seen distinctly the internal carotid artery, denuded 
from near the bifurcation of the common trunk to where it forms a turn 
to enter the canal in the temporal bone. Directly on this spot there was a 
dark speck, of a line or two in diameter, which suddenly gave way while 
Dr. Twitchell was in the house. With the thumb of his left hand he com- 
pressed the artery against the base of the skull, and effectually controlled 
the hemorrhage. The patient fainted. 
“As soon as he recovered,” the doctor says, “I proceeded to clear the 
wound from blood, and having done this 1 made an incision with a scalpel 
downward, along the course of the artery, to more than an inch below the 
point where the external branch was given off, which, as stated above, had 
been destroyed at the time of the injury. Having but one hand at liberty, 
I depended upon the mother of the patient to separate the sides of the 
wound, which she did, partly with a hook, and occasionally with her 
fingers. At length, partly by careful dissection, and partly by using my 
fingers and the handle of the scalpel, I succeeded in separating the artery 
from its attachments; and, passing my linger under it, 1 raised it up suffi- 14 
LIGATION OF THE 
ciently for my assistant to pass a ligature around it. She tied it with a 
surgeon’s knot, as I directed, about half an inch below the bifurcation.” 
Dr. Twitchell removed his thumb and sponged away the blood, not 
doubting that the hemorrhage was effectually controlled; but, to his sur- 
prise and disappointment, the blood immediately began to ooze from the 
rupture in the artery, and in less than ten minutes it flowed with a pulsating 
jet. He compressed it again with his thumb, and began to despair of sav- 
ing his patient, but resolved to make another attempt. 
Raising his thumb, he placed a small piece of dry sponge directly over 
the orifice in the artery, and renewed the compression till a rather larger 
piece of sponge could be prepared. He placed that upon the first, and so 
went on, pressing the gradually enlarged pieces obliquely upward and back- 
ward against the base of the skull, till he had filled the wound with a firm 
cone of sponge, the base of which projected two or three inches externally. 
He then applied a linen roller in such a manner as to press firmly upon the 
sponge, passing it in repeated turns over the head, face, and neck. 
On the 30th of December, the patient was discharged cured, several 
fragments of bone and two teeth from the upper jaw having been cast off. 
Some deformity remained, in consequence of the depression on the side of 
the face. 
Dr. Twitchell tied the common carotid, not the internal ca- 
rotid ; and surgeons now know that he might have spared 
himself the anxiety and his patient the hazard from a pro- 
longed operation to ligate the common carotid—of no possible 
benefit, and might have successfully resorted to the sponge at 
first, possibly, as he did at last. This case has certainly no- 
thing to do with the ligation of the internal carotid artery, 
which was not ligated. 
This case is referred to by the contributor to the New York 
Medical Journal as the only successful one that preceded his 
own—his being the second. If medical records exhibit but 
this case before that of Dr. Sands, this gentleman might make 
a very plausible show of priority. But the mountain rill, 
which, in its native fastnesses, gently steals along beneath the 
cast-off garniture of forest denizens, with here and there 
breathing-holes, to dally with and flash back the intruding 
sun-light, to lose itself in a more pretentious stream, and reach 
the sea by proxy, modestly asserts its rights. Undoubtedly 
the most brilliant operation for the arrest of hemorrhage from 
a wound of the internal carotid artery, ever achieved, occurred INTERNAL CAROTID ARTERY. 
15 
in the amphitheatre of our Medical College, and is recorded 
in the Nashville Journal of Medicine and Surgery for March, 
1871, as follows: 
Traumatic Aneurism of the Internal Carotid Artery, the result 
of a Puncture—Ligation of the Internal Carotid at the 
Seat of the Injury. By W. T. Briggs, M. D., Professor 
of Principles and Practice of Surgery in the University 
of Nashville. 
Thomas B , aged 23 years, was admitted into St. Vincent’s Hospital 
on the 22nd of February last [1871], on account of a tumor in the left pa- 
rotidean region. The tumor was as large as the closed hand, circumscribed 
—smooth upon its surface, with a strong expansive pulsation when the 
hand was pressed on it. The swelling was lessened by pressure on the 
common carotid, and a loud bruit was heard when the ear was applied. 
Upon the anterior part of the swelling was a wound half an inch in width, 
in a state of almost complete cicatrization. The patient complained of 
great pain and tension in and around the tumor, with difficulty of swallow- 
ing. lie was feeble, with frequent quick pulse, pallid countenance, no ap- 
petite, and was very apprehensive about his condition. 
Upon inquiry it was learned that, about six weeks previous, in an affray, 
he had received a stab at the point now marked by the cicatrix, which had 
bled freely at first, but was easily checked by pressure of the hand. On 
the following day his wounds were dressed by Dr. Sneed, with the com- 
press and bandage. In a few days afterwards, hemorrhage occurred, which 
was arrested before Dr. S. reached him. 
Several times, during the next few weeks, the hemorrhage recurred, but 
was each time easily restrained by pressure. Two weeks since, the doctor 
recognized the formation of the aneurismal tumor, and called me to his 
assistance. 
"W e thought it best, at the time, to try the effect of continued pressure 
over the tumor, but finding that it was enlarging daily, and the skin becom- 
ing thinner, especially at one point, it was determined that an operation 
was imperatively demanded. The patient was therefore admitted into the 
hospital, as before mentioned, and the next morning was appointed for the 
operation. 
Fully aware of the gravity of the case, and the great responsibility in- 
volved—two lives, possibly, depending on the issue,—I sought the assist- 
ance of several of my professional friends, to whom I am much indebted 
for very valuable aid. In consultation, it was determined to make an in- 
cision into the tumor, turn out the clots, and try to ligate the artery wound- 
ed ; and if the artery was so deeply seated that it could not be fo«nd, or 
reached, to ligate the common carotid. 16 
LIGATION OF THE 
The patient was brought into the amphitheatre of the College, before 
the class, and anaesthetized with ether. Having been placed on his back, 
with his head turned toward the opposite side, I pushed the knife into the 
most prominent part of the tumor, and followed it quickly with my finger, 
so as to prevent the loss of blood. I then searched through the sac for the 
wound of the artery. I failed to satisfy myself of the position of the 
wound, but felt the pulsation of a large vessel, which I supposed to be the 
external carotid. Keeping my finger steadily on this vessel, I enlarged the 
opening into the sac upward and downward. Immediately large clots were 
discharged, followed quickly by a furious gush of arterial blood, which I 
arrested by stuffing compressed sponge into the cavity. Withdrawing the 
sponge, one part at a time, I attempted to get my finger on the wound of 
the vessel, which, after another terrific gush of blood, I succeeded in doing. 
It was not, however, until my finger had passed its full length into the 
wound, and was pressing against the vertebral column, that the effusion of 
blood was checked. In view of the depth of the vessel, and its confined 
position between the ramus of the jaw and mastoid process, I again stuffed 
the cavity of the sac with compressed sponge, and proceeded to ligate the 
common carotid artery, at the point of election, in the usual way. 
On the removal of the sponge from the wounded artery, the hemorrhage 
was as violent as before. I plunged my finger into the cavity of the sac, 
and at once arrested it. Dr. Y. S. Lindsley then compressed the opposite 
common carotid, so as to cut off the blood from that source; but the effu- 
sion of blood, when the pressure of the finger was relaxed, again returned. 
Satisfied that nothing but a ligature on each side of the wound in the ar- 
tery would arrest the flow of blood, I held my finger on the aperture of the 
vessel while I divided all the tissues between the two incisions I had already 
•made, making a wound fully seven inches long. The edges of the incision 
were held apart with curved spatula;. The angle of the jaw was found 
very much in the way, and the propriety of sawing through it, so as to 
turn it aside, was considered ; but 1 concluded to make tire attempt to ap- 
ply the ligatures first, without. The forefinger of the left hand was kept 
on the opening of the wounded artery, while the tissues on each side 
were divided, by scratching through with the handle of a knife, held in 
the right hand. The artery-needle, armed with silk ligature, was then, 
guided by the finger that rested on the artery, passed around it, and it was 
drawn out so far as to show that nothing else was taken up with it, when 
the needle was withdrawn, and the ligature tied on the distal side of the 
opening. I could now remove my finger with impunity. Another ligature 
was applied on the proximal side of the wound in the artery. Between 
the two ligatures, a small circular opening, made by the point of the knife, 
was found on the side of the artery, through which the blood had issued. 
Several smaller vessels, which bled when all pressure had been removed, 
were lighted, and the clots of blood sponged out, and we could now see 
what had been done. INTERNAL CAROTID ARTERY. 
17 
In the upper part of the wound, the parotid gland had been spread out 
by the aneurisnml sac, so that it could not be recognized; but at its lower 
part, it had been divided through its middle; of course the branches of the 
facial nerve had been divided, causing paralysis of the muscles supplied by 
it. In the bottom of the wound the styloid process could be seen and felt, 
while just anterior and internal to it, the ligatures were seen coming from 
the artery. All the parts around were covered over with the smooth serous- 
looking membrane that lined the sac. 
The ligatures having been brought out, the extensive wound was brought 
together with the silver suture and adhesive plaster. 
The patient bore the protracted and tedious operation very well, and has 
not had, up to the present time (the tenth day), an unpleasant symptom. 
He suffers no pain, sleeps well, has appetite, etc. etc. 
These cases of traumatic aneurism are the most troublesome and respon- 
sible with which the surgeon has to contend. The doubt as to the artery 
wounded, the almost inevitable hemorrhage which occurs upon opening the 
sac, and the danger of the patient dying on the table, causes him to wish 
that they had fallen into some other hands than his. In the case under 
consideration, it was impossible to say what arterial branch had been punc- 
tured ; but, from the size of the tumor, and from its strong pulsation, it 
was presumed to be one of considerable magnitude. 
Preparations were made to meet every emergency, yet the hemorrhage, 
upon opening the sac, was appalling, and many of the students left the 
amphitheatre under the impression that the patient would die on the table. 
The arterial lesion proved to be a puncture in the internal carotid, and the 
ligation of the common carotid had no effect, even to moderate the current of 
blood passing out. Neither did perfect compression of the opposite common 
carotid control the hemorrhage, though it did lessen it to some extent. The 
vertebrals still carried enough blood into the terminal branches of the inter- 
nal carotids to have given rise to a fatal recurrent hemorrhage. The pa- 
tient’s life depended on placing ligatures on the artery above and below the 
wound. Guthrie has immortalized himself by proving that, in wounded 
arteries, hemorrhage will recur even after the ligation of the main trunk, 
whenever the collateral circulation is sufficient to maintain the life of a 
part, and that the only prevention is the application of a ligature on each 
side of the wound in the vessel. This is indeed the golden rule, to which 
there are very few exceptions. When it is impossible to reach the wound- 
ed artery, we have to depend on the Hunterian operation, but it is a poor 
dependence. Yet we find that many modern works on Surgery still advise 
the Hunterian operation in traumatic aneurisms. 
In the article on Traumatic Aneurism, in “Holmes' Surgery,” written 
by himself, he says: “If, therefore, the tumor be deeply seated, audit 
would be difficult to expose the vessel, as it leads into it, no hesitation need 
be entertained in trusting to the Hunterian method; while if (as is usually 
the case at the bend of the elbow) the tumor, and the artery on which it is 18 
LIGATION OF THE 
seated, be superficial, the old operation of opening the sac, and tying both 
ends of the vessels, offers no special difficulties, and is certain to succeed. ” 
* * * “Still, the great majority of traumatic aneurisms have yielded 
to the proper application of pressure, and few of those which have not 
done so, are known to have resisted the Hunterian operation. It is only in 
cases in which the tumor is superficially seated, and the operation compa- 
ratively easy and bloodless, that the majority of surgeons would prefer the 
old operation.” 
Erichsen, in his most excellent work on Surgery, advises, in diffused 
traumatic aneurism, laying open the tumor, and ligating the artery above 
and below the wound in it; but when there is a circumscribed aneurism, 
more especially when the sac is formed by dilatation of the cicatrix in the 
external coat and sheath of the artery, he recommends ligature, or com- 
pression of the artery leading to the sac. Many other authors advise the 
application of the ligature above and below the aperture in the vessel, if it 
can be easily done, but intimate that the Hunterian method will be suffi- 
cient, if it cannot. 
My experience sustains the teachings of Guthrie, that there is no assu- 
rance against hemorrhage in traumatic aneurism, whether diffused or cir- 
cumscribed, except by a ligature above and below the wound in the vessel. 
A case which came under my observation during last summer will serve as 
an illustration. 
A young man let his knife, which he held open in his hand, fall, the 
point entering about two inches below Poupart’s ligament, directly over the 
Sartorius muscle, passing obliquely downward and inward to the extent of 
an inch or more. A gush of arterial blood escaped at'tlie time, but hemor- 
rhage was arrested by pressure, and the wound healed promptly. In a few 
days afterwards, an aneurismal tumor formed at the point of injury to the 
artery, as large as a goose egg, and perfectly circumscribed. 
Four weeks after the injury, the skin over the tumor becoming very thin, 
I was summoned to operate. Making an incision over the tumor, from the 
the upper to the lower part, the femoral artery was exposed just as it en- 
tered the sac. I placed a ligature on it at that point. Every physician 
present was satisfied that there would be no hemorrhage when the sac was 
opened. To prove to them that there would be considerable hemorrhage 
from the lower end of the artery, I placed a tourniquet on the limb below 
the wound, loosely, with directions to my assistant to tighten the moment I 
made an incision into the sac. As soon as I did so, a few clots were dis- 
charged, and then a stream of blood was thrown three or four feet in height, 
which was promptly arrested by screwing up the tourniquet, when I pro- 
ceeded to sponge out the sac and place a ligature on each side of the punc- 
ture in the vessel. The patient was well in a short time. 
I will allude to another case, which occurred in my practice several years 
since. A gentleman received a gunshot wound in the inner and upper part 
of the thigh, the ball ranging inward toward the femoral artery. In a few INTERNAL CAROTID ARTERY. 
19 
days, a circumscribed aneurism formed just below Poupart’s ligament. I 
ligated the external iliac artery. The tumor was very much diminished in 
size, and its pulsation almost checked. 
Four weeks afterwards, the sac having inflamed and suppurated, it opened 
spontaneously, and such a discharge of blood followed as reduced the pa- 
tient to an extreme condition before the nurse, who had been fully instruct- 
ed, could arrest it by pressure. When a free incision had been made into 
the sac, the wound of the artery was found, after a tedious search, and a 
ligature applied to the lower end of the artery. He recovered after an ill- 
ness of two months or more. 
In the present case, I applied a ligature to the common carotid because it 
did seem almost impossible to put a ligature on the wounded artery before 
the patient would bleed to death. Finding, however, that it did not con- 
trol the hemorrhage, I was compelled, of necessity, to ligate the vessel on 
on each side of the wound, which was effected only after great difficulty. 
It will be perceived that Dr. Briggs made no work for him- 
self, but solely remedied the disasters from other sources. Dr. 
Sands made a splendid display of surgical ability, that com- 
mends him, as an operator, to his city, his state, and his coun- 
try at large; we are only sorry that we cannot commend, also, 
his research for the last three years. He finds Twitched, as 
far back as 1807, who. did not tie the internal carotid, but 
cannot find Briggs, his contemporary, only as far back as 
1871, who did! We know that the Nashville Journal con- 
taining Dr. Briggs’ case is in every medical library of any 
importance in New York. We witnessed this operation, and 
shall never forget our feelings of triumph when, after the last 
ligature, the sponging left the wound dry, the surgeon, physi- 
cally and mentally exhausted, looked up for the first time 
since the commencement of the operation, and exclaimed, 
“Saved!” The man operated on is now, three years after 
the operation, well, and daily on our streets. 
Dr. Bartlett, author of The Fevers of the United States, hav- 
ing never seen yellow fever, declares that he feels himself all 
the more competent to give a faithful history of it. We, the 
Senior Editor of this Journal, and no surgeon, will not insist 
that we are the more competent umpire in surgical disputes, 
but we insist that we endeavor to place medical matters in 
controversy fairly before our readers. 20 
LIGATION OF THE INTERNAL CAROTID ARTERY. 
In summing up, Dr. Sands says: “ The case that I have re- 
ported is the only one, so far as I am aware, in which a lesion 
of the internal carotid has been treated by the application of 
a double ligature to the injured vessel, one on the proximal 
and the other on the distal side of the bleeding vessel.” This 
was in October, 1872. Our colleague did this precise thing in 
February, 1871—eighteen months before. Dr. Sands’ re- 
searches back of Dr. Briggs seem quite exhaustive and relia- 
ble. If so, then Dr. W. T. Briggs is the first surgeon, from 
the institution of Surgery, to treat a lesion of the internal 
carotid by the application of a double ligature to the injured 
vessel, one on the proximal and the other on the distal side of 
the bleeding vessel.