LIGATION 
OF THE 
Common Carotid. 
EXSECTION 
OF TJIK 
Inferior Dental Nerve. 
By LYMAN B. IIOW, m. d., 
PROFESSOR OK ANATOMY AND PHYSIOLOGY AT DARTMOUTH COLLEGE. 
From Proceedings of N. H. Medical Society. 
CONCORD, X. II.: 
EVANS AND SLEEPER. PRINTERS, CAPITOL STREKf. 
1880. LIGATION 
OF THE 
Common Carotid. 
EXSECTION 
OF THE 
Inferior Dental Nerve. 
By LYMAN B. HOW, m. d., 
PROFESSOR OF ANATOMY AN1) PHYSIOLOGY AT DARTMOUTH COLLEGE. 
From Proceedings of N. H. Medical Society. 
CONCORD, N. II.: 
EVANS AND SLEEPER, PRINTERS, CAPITOL STREEt- 
1880. LIGATION OF THE COMMON CAROTID. 
EXSECTION OF THE INFERIOR DENTAL NERVE. 
BY LYMAN B. HOW, M. D., PROFESSOR OF ANATOMY AT DARTMOUTH 
COLLEGE. 
The two surgical operations I am to briefly report are of so rare 
a kind, and one of them so unique, that a sense of duty to those 
laborious and too often unappreciated members of the profession, 
known as the compilers of statistics, impels me to put them on re- 
cord. 
Charles P., aged 33, a robust man, on the evening of April 26, 
1880, was engaged in removing sand from a newly erected baker’s 
oven (he being entirely inside it) when the oven, covered with a 
bank of sand twenty inches thick, caved in and he was buried alive. 
In about ten minutes he was extracted, and I found him stretched 
on the ground, wildly delirious. Chloroform was at once adminis- 
tered to keep him quiet and allow an examination. He was found 
to have received a fracture of his left thigh, near the junction of 
the upper and middle thirds, attended with a good deal of lacera- 
tion of the muscles, and there was a large and rapidly increasing 
tumor on his head, involving the right eyelids, forehead and temple, 
evidently due to subcutaneous hemorrhage, the source of which 
was incomprehensible till some one arrived who could give me the 
history of the injured man, which is as follows : At the age of 
eighteen months a small tumor appeared under the upper lid. At 
the age of ten it was as large as a cranberry bean. By the time he 
was eighteen the pressure had destroyed the sight. When he was 
twenty-one some sort of an operation was attempted, but abandoned 
on account of hemorrhage. After this it extended all around the 
orbit, involving both lids, and soon the forehead and temple. It 4 
NEW HAMPSHIRE MEDICAL SOCIETY. 
was growing slowly, but painlessly, up to the time of the accident, 
extending four inches above the orbit and from near the median 
line of the forehead to the front of the ear, measuring full five 
inches in its transverse diameter,—all the arteries around the orbit 
and those of the temporal region being involved in it, and it pro- 
jected considerably above the surrounding parts,—the eyelids, 
especially, being very prominent. The disfigurement was great, and 
he reminded me of the Cyclops Polyphemus, after his eye had been 
put out by Ulysses, a “ Monstrum hojrendum cui lumen 
ademptum.” 
This cirsoid aneurism of the orbit and face had got ruptured by 
the falling bricks, and the blood was being rapidly diffused under 
the skin. Ice and compression were tried, but in vain, although 
for a few hours they seemed to be successful. It was hoped that 
the accumulating pressure, aided by cold, might arrest the bleeding, 
but it soon increased and the blood made its way all over the head, 
beneath the scalp, and was extending down the neck. Then the 
overstretched skin began to turn very dark. The upper eyelid was 
enormously distended, and its pulsations could be seen at a distance 
of ten feet. The ear was almost black, and it was evident that the 
integument would soon give way. I invited Drs. C. F. Bonney, Wil- 
liam A. Webster, O. D. Abbott, Leonard French, L. Melville French, 
and Marcel Richard to meet in consultation. They all agreed that 
nothing but ligature of the common carotid would be likely to avail 
anything. Accordingly, ether having been administered, the oper- 
ation was at once performed,—the gentlemen above mentioned 
kindly assisting. 
The usual incision was made, and the sheath opened on the in- 
ner side only enough to bring the artery distinctly into view at the 
point where the vessel was to be tied, the aneurism needle was 
passed behind the artery from without inward and the ligature was 
tied just above the omo-hyoid muscle, the carotid having been first 
carefully examined to ascertain that it did not bifurcate at a lower 
point than usual, and that it had no anomalous branches. The 
sheath was opened on the inner side, to obviate the risk of 
wounding the jugular vein and cutting across the descendens noni 
nerve. The ligature was of ordinary saddler’s silk, doubled and 
waxed. LIGATION OF THE COMMON CAROTID. 
5 
The only antipseptic precautions were to have clean instruments 
and fingers ; to use new, thoroughly cleansed sponges ; to wash out 
the wound clean with a weak solution of carbolic acid; to dip the 
ligature, also, in it, and to apply to the incision after the sutures 
were put in, several layers of carbolized gauze. The dressings were 
not disturbed for four days. 
On the seventh day my entrance into the patient’s room awoke 
him from a dreamy sleep, whereupon he clutched his neck and tore 
open the wound. Instantly the blood ran so freely across his neck 
that I thought he must have pulled open his carotid. I applied 
pressure, and this proving effectual, it was evident that the blood 
came from the superficial descending branch of the superior thyroid, 
which artery alone had required a ligature during the operation. 
This artery had apparently enlarged after the operation, and when 
he pulled the ligature off the blood flowed freely from it and from 
the congested capillaries of the wound. This delayed the healing 
of the incision, and there was after this a quite profuse suppuration. 
The ligature came away on the twenty-seventh day spontaneously, 
having remained about ten days longer than in the average of re- 
ported cases. It might, perhaps, have been removed sooner, but 
the pulsation Sof the arteries at the root of the neck were so strong 
that I was glad to have it remain as long as it did. 
As soon as the carotid was tied a free incision was made through 
the integument in the temporal region, and enough blood and clots 
removed to relieve the distension, care being taken not to disturb 
the clots near the orbit, lest there should be secondary hemorrhage 
through the large orbital vessels when the collateral circulation was 
established. 
A drainage tube was introduced as soon as the discharge from 
the incision in the temporal region began to be offensive, and car- 
bolized water was frequently injected for a month, when the dis- 
charge ceased. The very dark color of the external ear and upper 
lid, and indeed of the whole integument of the right side of the 
head, deepened to a black after the operation, and in another day 
a very suggestive greenish hue was added to the blackness of the 
ear, which made us apprehensive that he would loose it. It was 
sponged frequently with warm carbolized water, and the whole re- 
gion kept well covered with cotton. With the establishment of 6 
NEW HAMPSHIRE MEDICAL SOCIETY. 
the collateral circulation the natural color was gradually restored, 
and there was no sloughing of the integument. The head and 
shoulders were kept in an elevated position to allow the venous 
blood to escape readily from the head,—the “ vis a tergo ” being 
weak,—a position the patient insisted on keeping for five weeks 
afterward, to prevent headache. He had no so-called “ cerebral 
symptoms.” 
As soon as the carotid was tied the pulsation of the upper lid 
was arrested, but in an hour it began anew and in another hour 
was quite distinct. An artery of considerable size was found run- 
ning from the left angular artery across to the right and to the orbit. 
This was compressed digitally by my students for several hours. 
The pulsation of the lids gradually diminished and is not now dis- 
cernible. 
There now (September) remains in front of the right ear a tumor 
about a third as large as an egg, composed of loose integument 
containing, apparently, a mass of impervious blood vessels, and the 
loose skin around the orbit has under it a thin layer of the same 
tissue. But this has been slowly and steadily diminishing, and the 
originator of this novel but highly successful method of getting rid 
of a large cirsoid aneurism has the satisfaction of finding both his 
personal appearance and prospect for a long life both greatly in- 
creased. 
According to Dr. John Wyeth, in his prize essay on the Surgical 
Anatomy and History of the Carotid Arteries, published in the 
proceedings of the American Medical Association for 1878, the 
common carotid has been tied fifty-two times for the cure of non- 
malignant tumors of the orbit, with a result of forty-six recoveries 
and six deaths,—a mortality of eleven and one half per cent. Of 
the forty-six recoveries, twenty-eight are returned as cured, five as 
improved, and six as not improved. 
Ligation of the common carotid has been performed by the fol- 
lowing surgeons of New Hampshire : Muzzey, ligation of both 
carotids; successful. Twitchell, in 1807, ligation of right carotid 
for gun-shot wound of neck and face ; successful. T. R. Crosby, in 
1864, for gun-shot wound through left temporal bone ; successful, al- 
though on account of secondary hemorrhage he tied the artery 
again. EXSECTION OF THE INFERIOR DENTAL NERVE. 
7 
As the mortality after this operation, for all causes, is, according 
to Dr. Wyeth, forty-one per cent, the record of our New Hamp- 
shire surgeons, though brief, is a fortunate one. 
II. 
The next report is, in this State, of a rarer operation,—excision 
of the inferior dental nerve for intractable neuralgia. 
J. H., a healthy farmer, sixty years of age, began to suffer from 
neuralgic pain in the right half of his lower jaw in August, 1868. 
It was not severe at first, but by the following March he was unable 
to work. September 18th, he came to Manchester, and although 
he had been already well saturated with drugs, more of them were 
tried for nearly one month, during which time he grew steadily 
worse. Dr. C. F. Bonney also saw him. and when the anti-neural- 
gic remedies of modern therapeutics had proved unavailing, con- 
curred with me in recommending surgical treatment. 
His symptoms corresponded exactly to those of Trousseau’s 
Epileptiform Neuralgia. After a short interval of rest, all at once, 
like electric shocks, flashes of intense pain would shoot through his 
jaw, his features would be hideously distorted by epileptiform con- 
tractions of the facial muscles, tears would stream from his eyes, 
and his agonizing cries would pierce the hardest heart. These 
lightning-like stabs of pain would succeed each other rapidly for a 
short time, and then would come an interval of heavenly repose 
which would sometimes last several hours if he was well drugged 
with morphia and atropia. But during this bivouac the fiends of 
pain were all the time industriously loading up their artillery, and 
ere long a volley all along the line would be the only notice that 
the truce was ended, the poor victim seizing his jaw, falling on his 
knees and shrieking for the mercy that was only perhaps after an 
hour reluctantly yielded. The pain extended the whole length of 
the inferior dental nerve and streamed out through the mental for- 
amen to the integument of the chin. There were no sensitive 
places to be found on the jaw and no reflex cause operating from 
the system at large could be discovered. It was possible, perhaps 
probable, that the cause was centric, but we recommended an 
operation with the belief that even a brief respite from such pain 
was worth all the risk. 8 
NEW HAMPSHIRE MEDICAL SOCIETY. 
He joyfully took the chance, and Oct. io, 1879, assisted by Drs. 
C. F. Bonney, J. W. Mooar and L. Melville French, I operated as 
follows : An incision was made behind the ramus and below the 
body of the jaw so that the resulting cicatrix might be as far as 
possible concealed. The line of incision behind the ramus ex- 
tended through the integument only down to the parotid gland, 
which was then turned back a little and a flap, including the mas- 
seter muscle, was dissected up. The periosteum was turned to 
either side from a central incision and a trephine applied to the 
ramus, with its point opposite the entrance to the inferior dental 
canal. The facial artery and vein being next drawn forward the 
trephine was next applied to the body of the jaw. The external 
table of the jaw, between the two openings, was removed with bone 
chisels, so that the nerve and its canal could be examined. Noth- 
ing abnormal could be detected, but two inches of it were removed 
and the proximal end was stretched. The accompanying artery 
having been wounded by a slipping of the point of the trephine, it 
was tied at the point where it entered the canal. 
The wound was sponged out clean with carbolized water, new 
sponges only being used, as is my custom, the periosteum and soft 
parts were replaced with extreme care, and the whole covered with 
carbolized gauze, which was not disturbed for five days. There 
was not, during the whole aftertreatment, a half an ounce of dis- 
charge of any sort from the wound. The neuralgic pain ceased 
at once, no opiates were required after the second day, and a rapid 
convalescence ensued. Mr. H. soon returned to his farm and re- 
sumed work, and now, although nine months have elapsed, he has 
not had a twinge of pain. 
Excisions of the first and second divisions of the fifth pair of 
nerves, even when Meckel’s ganglion has been removed, have not 
fulfilled the confident expectations that were formed a few years 
ago,—the pain having returned a few months afterward, in several 
of them. Out of thirteen cases tabulated by Prof. P. S. Conner, 
the pain is known to have recurred in seven. In one of the seven 
in one month, in one within two months, in one in three months, 
in one in eight months, in another in sixteen months, and in one at 
a time unknown. Among the six other cases, we learn that one 
was exempt from pain for several years, one for several months, LIGATION OF THE COMMON CAROTID. 
9 
one for fourteen months, one for two months, one for twenty-eight 
days, and in one the result is given as dubious. 
Operations on the inferior dental nerve were formerly unsuccess- 
ful, because they were sometimes merely sections at the mental 
foramen, or excisions of short portions of the nerve, not enough of 
the nerve having been removed to prevent reunion of the several 
ends. But later operations, in which more of the nerve has been 
exsected, have been more encouraging. 
The perfect relief that has been procured in this case, even 
should it last no longer than the nine months past, has, I believe, 
fully justified the operation.