carotids

Fifty years ahead of his time

I’m writing this post on the 122nd anniversary of the first attempt at heart surgery, which took place in Norway on September 4th 1895. The surgeon, Axel Cappelen, opened the chest of a man who had been stabbed, and sutured his lacerated heart muscle. The procedure went smoothly, but the man died a few days later from infection and bleeding from an undetected injury to a blood vessel.

The operation is still regarded as a landmark, even though it was a failure, because it was the first brave attempt to operate on the heart after decades in which surgeons had avoided touching it. It’s a rare exception: failures are usually forgotten. Take this case, for example, which was published in The Lancet in 1837:

ligature of the internal carotidSamuel Edmonds, aged 41, on the evening of Tuesday the 26th of March, being intoxicated, fell forwards, with a pipe in his mouth, which broke, and wounded the soft palate. He was confident that no part of the pipe had remained in the wound.

As is well known, the judgement of an inebriated patient can always be trusted in such matters.

The throat swelled during the night, and on the following morning he swallowed with great difficulty. Thus matters continued until Thursday the 30th, when he applied for relief at this hospital, and was admitted as an in-patient. At 12 o’clock, on the same day, Mr. Mayo saw him. The soft palate was swollen on the right side, and elastic to the touch, as if it contained fluid.

Herbert Mayo (1796 – 1852) was a physiologist and surgeon not terribly well regarded in his profession: it seems he had a talent for rubbing people up the wrong way. In case you’re wondering, he’s unrelated to William Worrall Mayo, who emigrated to the US in the 1840s and whose famous sons founded the Mayo Clinic.

On the middle of the soft palate there had been an oblique lacerated wound, which appeared nearly healed. Supposing the swelling to be an abscess, Mr. Mayo punctured it with a lancet, at the lower part, and near the middle of the soft palate, when about a teaspoonful of matter, mixed with blood, escaped, and then pure blood, partly liquid, partly clotted. In five or six minutes, three or four ounces of blood thus came away

The patient was told to rinse his mouth with cold water, and the bleeding soon stopped. But that wasn’t the end of the affair; far from it.

In the evening the house-surgeon thought that he saw something projecting out of the wound, which he drew away. It proved to be a piece of tobacco-pipe, two inches in length. The removal of this body was followed by profuse arterial haemorrhage; a quart of blood came away, in seven or eight minutes, during which time the house-surgeon ineffectually compressed the carotid arteries. The haemorrhage then seemed to cease spontaneously.

This was an alarming moment – the blood came out in a pulsating jet, a clear indication that it was coming from a major artery. It must have been obvious to the house surgeon that the affected vessel was one of the carotid arteries, which supply blood to the neck and face. He (and his unfortunate patient) was hugely lucky that it stopped of its own accord: at this date surgery of the blood vessels was rudimentary, and essentially limited to placing a ligature around an artery or vein to stop any bleeding. Nobody had yet succeeded in stitching two ends of a severed vessel together, or even suturing a wound in the side of an artery.

Mr. Mayo saw the patient on the same night again, and directed the external application of cold.

This was intended to reduce the flow of blood through the injured vessel and promote clotting. It did not make much difference, however, and a junior house surgeon was instructed to sit up watching the patient through the night.

On the following morning, 31st March, at nine o’clock, the haemorrhage recurred, and the patient lost ten ounces of arterial blood in a few minutes.

Around half a pint: worrying, but not enough to immediately threaten to his life. The bleeding again stopped spontaneously. A few hours later Mr Mayo and his colleagues met to discuss what to do next. They agreed that one of the carotid arteries must be injured, and that unless they did something to repair it there would inevitably be another episode of haemorrhage, from which the patient would probably die.

They, therefore, agreed that the trunk of the right common carotid should be tied, which operation Mr. Mayo performed on Friday afternoon.

The right common carotid is a major artery in the neck, providing a good proportion of the brain’s blood supply. Tying it closed was not something to be undertaken lightly – although it is at least relatively accessible to the surgeon via a simple incision. But he would have to get a ligature around the artery with a patient who was awake and in considerable discomfort.

The internal carotid, as illustrated in Gray’s Anatomy (1918)

The patient complained of faintness directly after the operation, but revived upon a cold towel being applied to his forehead; and, on drinking some port-wine and water, he said that his throat felt easier, and that he swallowed better.

Dilute port was used as a stimulant; a strong painkiller might have been more useful.

He passed the day tranquilly, and slept at intervals during the night. On the following morning, April 1st, haemorrhage again supervened; six or seven ounces of arterial blood, partly clotted, came away from the throat, rapidly, as before.

Thus proving that they had tied the wrong blood vessel, since the bleeding continued as before. Mr Mayo and his colleagues met for another discussion. They concluded that the source of the bleeding was a vessel much deeper in the neck – probably the internal carotid artery.

One thing they agreed in, namely, that if it were possible to tie the internal carotid, near the base of the skull, the haemorrhage would be completely restrained; but they greatly doubted the possibility of affecting this.

Rightly: it had never been done before, because it was horrendously difficult. The internal carotid lies deep in the neck, close to the upper part of the spinal column. Reaching it was dangerous to start with, but on a conscious patient it would be close to impossible.

Nevertheless, the case was considered so desperate as to authorise the attempt.

Mr Mayo went to the dissection room and attempted the procedure on a cadaver, which he found he could do ‘without much difficulty’.

The obstacles to be apprehended in the living body did not seem to be insurmountable. Accordingly, he thought it justifiable to attempt it in the patient.

So the formidable operation went ahead. Mayo began by making a three-inch incision in the skin above the mastoid process, a bone at the base of the skull just behind the lower jaw. He then separated the muscle underlying the skin and dissected away the parotid gland, a large salivary gland. This gave him access to the styloid process, a bony projection just below the ear. He broke its end off with a forceps and was then able to see the second vertebra of the neck.

Remember, the patient was wide awake throughout this procedure.

It was at this point that he expected to be able to secure the artery, but he was unable to separate the vessel from the adjacent parts.

This part of the internal carotid is surrounded by the carotid sheath, a protective covering of connective tissue, and numerous crucial structures including nerves and other blood vessels. It’s little surprise that he had difficulty dissecting around it.

After long and reiterated trials, he passed the needle under what he supposed included the artery, but he could not, at that great depth, and in so narrow a cavity, (there being no sensible pulsation, as the trunk had been tied below) succeed in identifying the artery, and separating it from the nerves which accompany it. At the close of the operation, he extended the incision downwards, in the hope of making out the trunk of the vessel lower down, and then tracing it upward; but here he found that the previous inflammation had obliterated all distinction of parts, so that he was compelled, however reluctantly, to give up the attempt.

It took enormous courage to get as far as he did, so you can understand his (probably wise) decision to go no further.

For fifty hours after the operation there was no recurrence of haemorrhage. The patient was otherwise doing favourably. His mind was perfectly collected; tongue moist, but slightly furred; pulse 94, and soft. He swallows liquids easily, and with less pain than before the removal of the portion of broken pipe. Very little blood was lost in the attempt to secure the internal carotid. 

That’s something, at least.

In describing the case at the close of his surgical lecture, April 3rd, Mr. Mayo said, that he ventured to entertain strong hopes of the recovery of this patient, and that he thought it certainly not impossible, that the disturbance of parts, attending the second operation, might have contributed to render the recurrence of haemorrhage less likely than it otherwise would have been.

And there this surgical tale ends: alas, Mr Edmonds and his internal carotid artery then disappear from the view of the historian. Mr Mayo’s lecture took place only a week after the patient’s admission to hospital, and there is no further reference to the case in the literature. I suspect this means that he died, since the surgeon would surely have been keen to record a successful result in the literature.

Not only that: if he had succeeded it would have been a world first. Ligating the common carotid artery had first been reported in 1793 by a German surgeon called Hebenstreit, and then repeated several times by the celebrated Sir Astley Cooper twenty years later. But doing the same for the internal carotid was not achieved until 1885 by the University College Hospital surgeon Victor Horsley. He had the enormous advantage of general anaesthesia, which allowed him to operate at leisure on an unconscious patient. Had Mayo managed to get his ligature round the elusive blood vessel he might have been as well-known as his famous namesake.

Update: A reader has kindly emailed me with further information about the fate of the unfortunate Samuel Edmonds. A report in The Kentish Mercury published on May 6 1837 makes clear that he died a few days later:

On Saturday an inquest was held in the board room of the Middlesex Hospital, before Mr. Stirling, on view of the body of Samuel Edmonds, aged 41. It appeared that the deceased was a coachman.  On Thursday week last he was at a public house in Theobald’s-road, when a quarrel took place between him and a man named Mapleson, which ended in a scuffle, and both fell to the floor. In the fall the tobacco-pipe, which the deceased was smoking, broke, and some of the pieces penetrated some depth into the roof of the mouth. He was removed in a coach to the above hospital, where the medical officers immediately attended upon him, and, after great difficulty, extracted the piece of tobacco-pipe, when a considerable effusion of blood took place, which was not stopped until several arteries were take up. Subsequently inflammation and ulceration of the throat, arising from the wounds, took place, and, notwithstanding every surgical skill, ended in the unfortunate man’s dissolution on Thursday last. Verdict – Accidental Death.

Many thanks to Laura for this information.

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