Dr. M. Buchanan of Glasgow has described an operation by which the joint can be excised through a single incision over the external malleolus.

Results.—So far as can be gathered from cases already published, the results are very often (at least in one out of every two cases) unsatisfactory. Sinuses remain, which do not heal, the limbs are useless, and amputation is in the end necessary.

Langenbeck has performed it sixteen times during the last Schleswig-Holstein war (in 1864), and the Bohemian war in 1866, with only three deaths. In these cases the operation was subperiosteal.

EXCISION OF THE SCAPULA.—More or less of the scapula has in many cases been removed along with the arm, and even with the addition of portion of the clavicle.

Excision of the entire bone, leaving the arm, has been performed in two instances by Mr. Syme. The procedure must vary according to the nature and shape of the tumour on account of which the operation is performed. Mr. Syme operated as follows:—

In the first case, one of cerebriform tumour of the bone, he "made an incision from the acromion process transversely to the posterior edge of the scapula, and another from the centre of this one directly downwards to the lower margin of the tumour. The flaps thus formed being reflected without much haemorrhage, I separated the scapular attachment of the deltoid, and divided the connections of the acromial extremity of the clavicle. Then, wishing to command the subscapular artery, I divided it, with the effect of giving issue to a fearful gush of blood, but fortunately caught the vessel and tied it without any delay. I next cut into the joint and round the glenoid cavity, hooked my finger under the coracoid process, so as to facilitate the division of its muscular and ligamentous attachments, and then pulling back the bone with all the force of my left hand, separated its remaining attachments with rapid sweeps of the knife." (Plate III. fig. G.)

Mr. Syme's second case was also one of tumour of the scapula; the head of the humerus had been excised two years before.

He removed it by two incisions, one from the clavicle a little to the sternal side of the coracoid, directed downwards to the lower boundary of the tumour, another transversely from the shoulder to the posterior edge of the scapula. The clavicle was divided at the spot where it was exposed, and the outer portion removed along with the scapula.[71]

The author has in a case of osseous tumour removed the whole body of the scapula, leaving glenoid, spine, acromion and anterior margin with excellent result and a useful arm.

Large portions of the shafts of the humerus, radius, and ulna have been removed for disease or accident, and useful arms have resulted; but as the operative procedures must vary in every case, according to the amount of bone to be removed, and the number and position of the sinuses, no exact directions can be given.

For very interesting cases of such resections reference may be made to Wagner's treatise on the subject, translated and enlarged by Mr. Holmes, and to Williamson's Military Surgery, p. 227.

EXCISION OF METACARPALS AND PHALANGES.—To excise the metacarpal implies that the corresponding finger is left. Except in cases of necrosis, where abundance of new bone has formed in the detached periosteum, the results of such excisions do not encourage repetition, the digits which remain being generally very useless. It is quite different, however, if it is the thumb that is involved; and every effort should, in every case, be made to retain the thumb, even in the complete absence of its metacarpal bone. For the good results of a case in which Mr. Syme excised the whole metacarpal bone for a tumour, see his Observations in Clinical Surgery, p. 38.

The operation is not difficult, and requires merely a straight incision over the dorsum, extending the whole length of the bone.

In the same way the proximal phalanx of the thumb may be excised, and yet, if proper care be taken, a very useful limb be left. I quote entire the following case by Mr. Butcher of Dublin:—

EXCISION OF PROXIMAL PHALANX OF THE THUMB.—

The thumb of the right hand was crushed by the crank of a steam-engine. The proximal phalanx was completely shivered; its fragments were removed, the cartilage of the proximal end of the distal phalanx, and also of the head of the metacarpal bone, were pared off with a strong knife. The digit was put up on a splint fully extended. In about a month cure was nearly complete, a firm dense tissue took the place of the removed phalanx, and the power of flexing the unguinal was nearly complete.[72]

EXCISION OF THE JOINTS OF THE FINGERS.—These operations may be performed for compound dislocation, specially when the thumb is injured; no directions can be given for the incisions.[73]

In cases of disease it is rarely necessary or advisable to attempt to save a finger, but if the metacarpo-phalangeal joint of the thumb be affected, excision should be performed with the hope of saving the thumb. A single free incision on the radial side of the joint will give sufficient access.

EXCISION OF THE OS CALCIS.—In those comparatively rare cases in which the os calcis is alone affected, the rest of the tarsus and the ankle-joint being healthy, a considerable difference of opinion exists as to the proper course to be followed. By some surgeons it is considered best merely to gain free access to the diseased bone, and then remove by a gouge all the softened and altered portions, leaving a shell of bone all round, of course saving the periosteum and avoiding interference with the joint. This operation requires no special detailed instruction. We find many surgeons, among them Fergusson and Hodge, supporters of this comparatively modest operation. The author has many times performed this operation with excellent results. Even when nothing but periosteum is left, the new bone becomes strong and of full size.

Excision of the whole of the diseased bone at its joints, with or without an attempt to leave some of the periosteum, has been deemed necessary by others. Holmes, who has had considerable experience, removes the bone at once by the following incisions, without paying any reference to the periosteum:—

Operation.—An incision (Plate III. fig. F.) is commenced at the inner edge of the tendo Achillis, and drawn horizontally forwards along the outer side of the foot, somewhat in front of the calcaneo-cuboid joint, which lies midway between the outer malleolus and the end of the fifth metatarsal bone. This incision should go down at once upon the bone, so that the tendon should be felt to snap as the incision is commenced. It should be as nearly as possible on a level with the upper border of the os calcis, a point which the surgeon can determine, if the dorsum of the foot is in a natural state, by feeling the pit in which the extensor brevis digitorum arises. Another incision is then to be drawn vertically across the sole, commencing near the anterior end of the former incision, and terminating at the outer border of the grooved or internal surface of the os calcis, beyond which point it should not extend, for fear of wounding the posterior tibial vessels. If more room be required, this vertical incision may be prolonged a little upwards, so as to form a crucial incision. The bone being now denuded by throwing back the flaps, the first point is to find and lay open the calcaneo-cuboid joint, and then the joints with the astragalus. The close connections between these two bones constitute the principal difficulty in the operation on the dead subject; but these joints will frequently be found to have been destroyed in cases of disease. The calcaneum having been separated thus from its bony connections by the free use of the knife, aided, if necessary, by the lever, lion-forceps, etc., the soft parts are next to be cleaned off its inner side with care, in order to avoid the vessels, and the bone will then come away.[74]

Attempts may occasionally be made in such an operation to save a portion of periosteum in attachment to the soft parts, but success or failure in this seems to have very little effect on the future result.

Hancock's Method.—A single flap was formed in the sole, with the convexity looking forwards, by an incision from one malleolus to the other.

Greenhow's Method.—Incisions made from the inner and outer ankles, meeting at the apex of the heel, and then others extending along the sides of the foot, the flaps being dissected back so as to expose the bone and its connections.[75]

EXCISION OF ASTRAGALUS.—A curved incision on the dorsum of the foot extending from one malleolus to the other, and as far forwards as the front of the scaphoid. The chief caution required is to divide all ligaments which hold the bone in place, and dissect it clean on all other parts before meddling with its posterior surface where the groove exists for the flexor longus pollicis tendon near which the posterior tibial vessels and nerve lie.[76]

EXCISION OF ASTRAGALUS AND SCAPHOID.—An incision similar to the anterior one in Syme's amputation at the ankle. The flap was then turned back from the dorsum of the foot. The joint was then opened, the lateral ligaments of the ankle-joint divided, the foot dislocated so as to show the astragalo-calcanean ligaments, and allow them to be divided. The bones were then grasped with the lion-forceps and pulled forwards, while the posterior surface of the astragalus was very cautiously cleaned, so as to avoid the posterior tibial artery.[77]

EXCISION OF METATARSO-PHALANGEAL JOINT OF GREAT TOE.—Butcher performs it by splitting up the sinuses leading to the carious joint, exposing it and cutting off with bone-pliers the anterior third of the metatarsal bone, and the proximal end of the first phalanx. He also cuts subcutaneously the extensor tendons to prevent them from cocking up the toe.[78] Pancoast prefers a semilunar incision. A lateral incision is usually to be preferred.

The author has performed this excision frequently for disease; when the whole cartilages are removed and the wound is freely drained, an admirable result is obtained.

In cases of compound dislocation of the head of the metatarsal bone, it will occasionally be found necessary to excise it either by the original, or a slightly enlarged wound.

The author lately excised one-half of shaft of metatarsal and the corresponding half of proximal phalanx of great toe for exostosis, with antiseptic precautions. The result was a useful toe with a mobile joint.

EXCISION OF METATARSAL BONE OF GREAT TOE.—For this operation a quadrilateral flap has been recommended, but this is quite unnecessary. A single straight incision along the inner border of the foot, extending the whole length of the bone, renders it very easy to remove the whole bone from joint to joint. This is an operation, however, which is rarely needed, and which would leave a very useless flail of a toe. The operation, which is at once more commonly required, and also gives promise of a more satisfactory result, is the one performed for cario-necrosis of the shaft only, and in the following manner:—

A straight incision through all the tissues, including the periosteum, right down to the bone; then with nail or handle of the knife to separate the periosteum from the bone; then with a pair of bone-pliers or a fine saw to divide the shaft from both its extremities and remove it entire.[79]

FOOTNOTES:

[52] On Diseases and Injuries of Joints, p. 121.

[53] For a very large amount of most interesting and valuable information on the whole subject of excisions of joints, I would refer to Dr. Hodge's most excellent work on this subject—On Excisions of Joints. By Richard M. Hodge, M.D., Boston, Massachusetts.

[54] See Syme's Observations on Clinical Surgery, pp. 55, 57; Hodge on Excision of Joints, p. 63.

[55] Maunder's Operative Surgery, 2d ed. p. 123.

[56] Edin. Med. Journal, May 1873.

[57] Quoted by Mr. Porter. Dublin Quarterly Journal for May 1867, p. 264.

[58] A-A. Deep palmar arch; B. Trapezium; C. Articular surface of ulna; Dotted lines include the amount removed in Lister's earlier operations; Unshaded portions are those removed by Lister in cases where the disease is limited to the carpus. (Reduced from Lister's diagram in Lancet, 1865.)

[59] Skey, Op. Surg., 2d ed. p. 438.

[60] Abridged from Butcher, Op. and Con. Surgery, p. 208.

[61] Science and Art of Surgery, 3d ed. p. 745.

[62] On the Surgical Treatment of Children's Diseases, pp. 454-6.

[63] Clinical Society's Transactions, vol. xiii. p. 71.

[64] Billroth of Vienna and Pelikan of St. Petersburg, quoted from Heyfelder by Hodge on Excision of Joints, p. 161.

[65] Operative and Conservative Surgery, pp. 28, 138.

[66] On Excision of Knee-Joint, pp. 18, 20.

[67] Operative and Conservative Surgery, p. 169.

[68] Mr. Jones of Jersey, Med. Chir. Trans., vol. xxxvii. p. 68.

[69] Lancet, Oct. 1, 1859.

[70] Barwell On Diseased Joints, p. 464.

[71] Syme On Excision of the Scapula, pp. 13-26, 1864.

[72] Butcher's Operative and Conservative Surgery, p. 225.

[73] For an excellent case, see Annandale on Diseases of the Finger and Toes, p. 261.

[74] Holmes's Surgery, 3d edition, vol. iii. p. 771.

[75] Brit. and Foreign Med. Chir. Review for July 1853.

[76] Mr. Holmes in Lancet for February 18, 1856.

[77] Ibid. for May 1865.

[78] Butcher, Operative and Conservative Surgery, p. 354.

[79] See Butcher, Operative and Conservative Surgery, p. 356.



CHAPTER IV.

OPERATIONS ON CRANIUM AND SCALP.

TREPHINING AND TREPANNING are the names given to operations for the removal of portions of the cranium by circular saws which play on a centre pivot. When the motion is given to the saw simply by rotation of the hand of the operator, as is common in this country, it is called trephining; when (as used to be the case in this country, and still is on the Continent) the motion is given by an instrument like a carpenter's brace, the operation is called trepanning.

The nature of the operation varies according to the nature of the case for which it is performed. Thus (1.) it may be performed through the uninjured cranium in the hope of evacuating an abscess of the diploe or dura mater, or of relieving pressure caused by suppuration in the brain itself, or by extravasation into the brain or membranes; or (2.) it may be required in cases of punctured and depressed fracture for the purpose of removing projecting corners of bone and allowing elevation of the depressed portions; or (3.) it is sometimes used to remove a circular portion of bone in cases of epilepsy in which pain or tenderness is felt at some limited portion of the cranium.

1. In cases where the cranium and its coverings are entire.—There are certain positions where, if it is possible, the trephine should not be applied. These are the longitudinal sinus, the anterior inferior angle of the parietal bone, where the middle meningeal artery is in the way, the occipital protuberance, and the various sutures. These being avoided, a crucial incision is to be made through the skin, and its flaps reflected. The pericranium should then be raised from the centre, for a space large enough to hold the crown of the trephine. The pericranium should never be removed, but carefully raised and preserved, as its presence will greatly aid in the restoration of bone.[80] The centre pin should then be projected for about the eighth of an inch and bored into the bone. On it as a centre the saw is then worked by semicircular sweeps in both directions alternately, till it forms a groove for itself. Whenever this groove is deep enough the pin should be retracted, lest from its projection it pierce the dura mater before the tables of the skull are cut through. Were the cranium always of the same thickness, and even of similar consistence, the operation would always be exceedingly easy; but in both these particulars different skulls vary much from each other, and thus by a rash use of the instrument the dura mater may possibly be injured. The tough outer table is more difficult to cut than the softer and more vascular diploe, and the inner table is denser than either, but more brittle. In many old skulls, however, the diploe is wanting altogether, and the two tables are amalgamated, and often very thin.

Great care must be taken in every case to saw slowly, to remove the sawdust, and examine the track of the saw by a probe or quill, lest one part should be cut through quicker than another. The last turns of the instrument must specially be cautious ones. When the disk of bone does not at once come away in the trephine, the elevator or the special forceps for the purpose will easily remove it. If the abscess, extravasation, or exostosis be then discovered and removed, all that remains is to remove any sawdust or loose pieces of bone, and possibly to smooth off any sharp edges of the orifice by an instrument called the lenticular. This is very seldom required, and now hardly ever used.

2. In cases of depressed or punctured fracture the trephine is occasionally required (when symptoms of compression are present) for the purpose of enabling the depressed portion to be elevated. It is unsafe to apply it to the depressed or fractured bone, lest the additional pressure of the instrument should cause wound of the dura mater or brain. It is generally applied on some projecting corner of sound bone under which the depressed portion is locked, and hence it is rarely necessary to remove a complete circular portion. In fact very many cases of such displacement may be remedied more easily by a pair of strong bone-forceps, or a Hey's saw, applied to remove the projecting portion of sound bone. The same precautions must be used as in the operation already described, and the sawing must be done even more cautiously, as it is rarely more than a semicircle that requires cutting.

In former days trephining was a much more frequent operation than it is now, and apparently more successful. The reason of the greater apparent success can easily be found in the fact that it was performed in many cases merely as a precautionary measure against dreaded inflammation of the brain, which probably never would have appeared at all, and that the operation itself is one by no means dangerous. Very numerous applications of the trephine have been made in the same individual—two, four, six, and even in one case twenty-seven disks having been removed from the same skull, and yet the patients have survived.

TUMOURS OF THE SCALP, Removal of.—By far the most frequent are the encysted tumours, or wens. These consist of a thick firm cyst-wall, which contains soft, curdy, or pultaceous matter, sometimes almost fluid, at others dry and gritty. They are loosely attached in the subcutaneous cellular tissue, and unless they have become very large, or have been much pressed on, are non-adherent to the skin.

The treatment is thus very simple. They should merely be transfixed by a sharp knife, the contents evacuated, and the cyst seized by strong dissecting forceps and twisted out.

If they have once become adherent, they must be dissected out in the usual manner, after the adherent portion of skin has been defined by elliptical incisions.

In the case of large wens on visible parts of scalp or face, the author avoids scar, by the following plan:—

Make a small incision, two lines at most, through skin only, then with a blunt probe separate the cyst from the skin subcutaneously; then, pulling it to the wound with catch-forceps, empty the cyst and gradually pull it out, as if taking out an ovarian cyst. No scar but a dimple will remain.

FOOTNOTES:

[80] See case by the author in the Edin. Med. Jour. for June 1868.



CHAPTER V.

OPERATIONS ON EYE.

Operations on the Eye and its Appendages.

OPERATIONS ON THE LIDS.—

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1. FOR ENTROPIUM OR INVERSION OF THE LIDS, OFTEN COMBINED WITH TRICHIASIS, IRREGULARITY OF THE CILIAE.—As in many cases the entropium seems to depend partly on a too great laxity of the skin of the lid, combined occasionally with spasm of the orbicularis, the simplest and most natural plan of operation is (a) to remove (Fig. VII. a) an elliptical portion of skin, extending transversely along the whole length of the affected lid, including the fibres of the orbicularis lying below it, and then to unite the edges with several points of fine suture. (b) An improvement on this in obstinate cases is proposed by Mr. Streatfeild (Fig. VIII.) He continues the same incision, but in addition removes a long narrow wedge-shaped portion of the tarsal cartilage, grooving it without entirely cutting it through, in such a manner that the retraction of the skin bends the cartilage backwards, thus everting to a very considerable extent the previously inverted ciliae.[83]

2. ECTROPIUM is the opposite condition from entropium; in it the eyelids are everted and the palpebral conjunctiva is exposed.

If the result of cicatrix, of a burn, or of disease of bone, the treatment must be varied according to circumstances, and in many cases, skin must be transplanted to fill the gap.

In the more usual cases resulting from chronic inflammation the following simple operations are required:—1. In mild cases the excision of an elliptical portion of conjunctiva may suffice, the edges must not be left to contract, but should be brought carefully together. 2. In more chronic cases, where all the tissues of the lid are very lax, it is necessary to remove (Fig. VII. b) a V-shaped portion of lid and skin, and then stitch it very carefully up with interrupted sutures.

TUMOURS OF EYELIDS.—1. Encysted tumours; cysts of the lids; tarsal tumour.—Under these and similar names are recognised a very frequent form of disease, chiefly in the upper lid: small tumours which rarely exceed half a pea in size, convex towards the skin, which is freely moveable over them; they give no pain, and are annoying only from their bulk and deformity.

Operation.—Evert the lid, incise the conjunctiva freely over the tumour, insert the blunt end of a probe and roughly stir up the contents of the cyst, thus evacuating it. If the tumour is large and of old standing it may be requisite to cut out an elliptical or circular portion of its conjunctival wall. The probe may require to be reapplied once or twice at intervals of two or three days, and in certain rare cases it may be necessary as a last resource freely to cauterise the inside of the cyst with the solid nitrate of silver.

In no case is it ever necessary to excise the tumour from the outside of the eyelid; when this has been done in error there frequently remains an awkward and unsightly scar.

2. Fibrous cysts, frequently congenital, are met with in one situation, just over the external angular process of the frontal bone. These are larger in size than the preceding, ranging from the size of a barley pickle to that of an almond. Their treatment is excision by a prolonged and careful dissection from the periosteum, to which they almost invariably are adherent.

OPERATIONS ON THE LACHRYMAL ORGANS.—In a system of ophthalmic surgery, various operative procedures might be detailed under this head, authorised and sanctioned by old custom. Excision of a diseased lachrymal gland, and removal of stones in the gland or ducts, need no special directions for their performance, and the operation immediately to be described, under the head of Mr. Bowman's operation, is applicable in almost every one of the diseased conditions of the lachrymal canal, sac, and nasal duct, to the exclusion of all the older methods.

Mr. Bowman's Operation.—In cases of obstruction of the punctum, canaliculus, and nasal duct, resulting in watery eye, accumulation of mucus in the canal, and dryness of the nose, great difficulty used to be experienced in the treatment. To pass a probe along the punctum was extremely difficult, in fact, possible only with a very small one, while the common operation of opening the dilated sac, through the skin, and then passing probes through this artificial opening, was found quite useless from the rapid closure of the wound, unless the treatment was followed up by the insertion and retention of a style in the nasal duct. This was painful, unsightly, often unsuccessful; and even in some cases dangerous, from the amount of irritation, suppuration, and even caries of the nasal bones which is set up.

The principle of Mr. Bowman's most excellent operation is, that the punctum, canaliculus, and nasal duct resemble in many respects the urethral passage, and in cases of stricture require to be treated on the same principle. If, then, it were possible to pass instruments gradually increasing in size through the seat of stricture, it would be gradually dilated. It is, however, in the normal state of parts, impossible to pass any instrument beyond the size of a human hair past the curve which the canaliculus makes on its entrance to the duct, hence the proper dilatation cannot be performed. Again, it is found that the puncta, specially the lower one, are themselves very often to blame, in cases of watery eye, sometimes because they are inverted or everted, more often because, sympathising with the lid, they are turgid, angry, and inflamed, pouting and closed like the orifice of the urethra in a gonorrhoea.

Mr. Bowman found that by slitting up the inferior punctum and canaliculus as far as the caruncula, several advantages were gained:—(1.) The swollen, angry, displaced punctum no longer impeded the entrance of the tears; (2.) and chiefly when the canaliculus was slit up, the curve, or rather angle, which impeded the passage of probes, was done away with, and the nasal duct could be readily and thoroughly dilated.

Operation.—The surgeon stands behind the patient, who is seated, and leans his head on the surgeon's chest. The affected lid is then drawn gently downwards on the cheek, so as to evert and thoroughly expose the lower punctum. Into this the surgeon introduces a fine probe of steel gilt, the first inch of which is very thin, especially at the point, and deeply grooved on one side, exactly like a small (and straight) Syme's stricture director.

Keeping the canal relaxed by relaxing his hold on the lid, the surgeon now gently wriggles the probe along the canaliculus, gradually stretching it as the probe advances, so as to avoid catching of the sides of the canal before the point of the instrument, till he is satisfied that it has fairly entered the nasal duct. He then stretches the eyelid, brings the handle of the probe out over the cheek so as to evert the punctum as much as possible, and then with a fine sharp-pointed knife enters the groove (Fig. IX.), and fairly slits up the punctum and the canal to the full extent. The incision should be as straight as possible, and through the upper wall of the canaliculus. A dexterous turn of the instrument upwards on the forehead will generally enable it to be passed at once fairly into the nose through the nasal duct, the usual rule being observed of passing it downwards and slightly backwards, the handle of the probe passing just over the supraorbital notch.

]

For several days after the operation the probe will have to be passed, both to prevent the wound in the canaliculus from healing up, which it is too apt to do, and also to gradually dilate the nasal duct if it has been previously strictured. Probes and directors of various sizes are required; in fact very much the same instruments (in miniature) as are required for the treatment of stricture of the urethra.

Mr. Greenslade has invented a very ingenious little instrument, of which, through his kindness, I am able to show a woodcut (Fig. X.), for slitting up the canaliculus without having to fit the knife in the groove.



PTERYGIUM, the reddish fleshy triangular growth, with its base at the inner canthus, and its apex spreading to and often over the cornea, requires invariably a small operation for its removal. In most cases it will be found sufficient merely to raise the lax portion over the sclerotic with forceps, and divide it freely, removing a transverse portion. If it has encroached upon the cornea, the portion interfering with vision must be dissected off with great care and removed.

In some cases, however, it has been found that after removal of a large pterygium, a retraction of the caruncle and the semilunar fold is apt to take place, which renders the eyeball unpleasantly prominent. To avoid this the pterygium may be carefully dissected up from its apex to near its base, and then displaced laterally either upwards or downwards, its apex and sides being stitched to a previously prepared site of conjunctiva.

OPERATION FOR CONVERGENT STRABISMUS.—Division of the internal rectus.—Subconjunctival operation.—The spring-wire speculum (C) separating the lids, the surgeon divides the conjunctiva by a pair of scissors in a horizontal line (Fig. XI. A A) from the inner margin of the cornea, a little below its transverse diameter to the caruncle, then snipping through the sub-conjunctival tissue, he passes a blunt hook bent at an obtuse angle under the tendon of the internal rectus, and endeavours by depressing the handle to project the point of the hook at the wound. Then with successive snips of the scissors he divides the tendon on the hook, close to its sclerotic margin. Lest it should not be freely divided, various dips with the hook may be made to catch any stray fibres left untouched; but very great care should be taken not to wound the conjunctiva beyond the first horizontal cut in it. The tendon being divided satisfactorily, the edges of conjunctiva should be replaced, and the eye closed for a few hours.

]

The original operation of Dieffenbach, now rarely practised, consisted in making an incision, B B, across the tendon, then, by cutting the areolar tissue exposing the insertion of the tendon, and dividing it freely; after which the sclerotic in the neighbourhood was to be cleaned and any band of fibres divided. There are risks on the one hand of a most unseemly exophthalmos with divergent squint, and on the other of a retraction of the semilunar fold, so that the sub-conjunctival operation is always preferable.

OPERATIONS FOR DIVERGENT SQUINT.—This very serious deformity is often the result of the operation for convergent squint, and is associated with a fixed, leering, and prominent eye, and frequently with most annoying double vision.

1. In a simple case of primary divergent strabismus (very rare) it is sufficient simply to divide the external rectus in the manner already described for division of the internal.

2. If secondary to an operation for convergent squint, the indication is to restore the cut internal rectus to a position on the sclerotic a little behind its previous one, as the cause of the divergence is found in a complete detachment of the internal rectus. This is attempted in various ways.

(1.) Jules Guerin carefully divided the conjunctiva over it, and sought for the remains of the internal rectus, freeing it from its attachments. He then passed a thread through the sclerotic on the outer side of the globe, and by pulling on it and fixing it across the nose, rotated the eye inwards, in the hope that the remains of the internal rectus would secure a new attachment.

(2.) Graefe's modification of this is more certain. Without any minute dissection he merely separated the internal rectus, along with the conjunctiva, and fascia over it, so that it can be pulled forwards, then cut the external rectus, and inverted the eyeball to a sufficient extent by means of a thread passed through the portion of the tendon of the external rectus, which remains attached to the sclerotic. The risk of all these operations, in which both muscles are divided, is protrusion of the eyeball from the removal of muscular tension.

(3.) Solomon's operation for the radical cure of extreme divergent strabismus,[86] is at first sight a very curious one. Without going into all the details, the steps are as follows:—

a. A square-shaped flap, with its attached base at the nasal side, is raised, containing the remains of the inner rectus and its adjacent parts.

b. A flap similar in shape and size, but different in the position of its attached base, is made on the other side of the cornea. It is made by dividing the external rectus just behind its tendon, and then reflecting forwards the tendon with its conjunctiva.

c. These two flaps are united over the vertical meridian of the cornea by sutures, three generally being sufficient. This entirely hides the cornea for a time, but eventually shrivels and contracts, and the remnants are to be cut off with scissors three weeks after the operation.

PUNCTURE OF THE CORNEA.—Paracentesis of the Anterior Chamber.—Tapping of the Aqueous Humour.—This very simple operation is in many cases extremely useful. In cases of corneal ulcer, the result either of injury or disease, where there is much pain in the bone, and evidence of tension of the globe, it gives great relief, and when repeated at short intervals greatly hastens a cure. Sperino of Turin recommends its frequent use in cases of chronic glaucoma.

Operation.—The surgeon stands behind the patient, who is seated; the lids being fixed, the upper by the surgeon's left hand, and the lower by an assistant, the cornea is punctured a little in front of the sclerotic margin, either with a broad needle, or, what is as good, a well-worn Beer's knife. Care must be taken on entering the knife, on the one hand, not to wound the iris, which is sometimes arched forwards in the cases of commencing glaucoma, and, on the other, fairly to enter the anterior chamber, not merely split up the layers of the cornea. On withdrawing the cataract knife, the aqueous humour gets out by its side, aided by a slight turn of the knife, sometimes with great force, and in much larger quantity than usual. If the operation has been done by a needle, a blunt probe requires to be introduced on the removal of the needle. Once punctured, the remarkable fact is that the same wound suffices for many succeeding tappings, which are effected by pressing the probe into the wound day after day, sometimes several times a day, with great relief to the symptoms. If the probe is to be used for succeeding evacuations, the operator must be careful to remember the exact spot at which the needle or knife was entered. To facilitate remembering it, it is best, when nothing prevents it, to operate always in the same spot. Sperino chooses the horizontal meridian of the cornea at the temporal side, at the junction of the cornea and sclerotic.

CATARACT OPERATIONS.—Here we cannot enter into any discussion of the pathology of cataract and the varieties of it. Enough for our purpose to know that the lens is in some cases hard, in others soft, and that thus in the latter it may be removed piecemeal, and by a small incision, while in the former, removal must be almost entire, and by a larger opening.

In cataract, the lens, which should be transparent, has become opaque, and the object of treatment is to get it out of the line of sight, to prevent it from obstructing, now that it can no longer assist sight.

The operations used for this end may be classed under three heads:—

1. Operations for the removal of the lens out of the way without its removal from the eye.—These used to be extensively practised under the name couching, and are of two kinds,—Depression, where the lens is simply pushed down from its place by a needle; Reclination, in which it is shoved backwards (turning on its transverse axis) as well as downwards. These are relics of old surgery, and very rarely practised by any oculists of eminence, as, though easy to perform, and with very flattering immediate results, the risks of chronic inflammation of the whole globe and injury to the retina are very great.

2. For solution.—THE NEEDLE OPERATION.—Suitable (among other cases) especially in congenital cataracts in infants, and in cases of diabetic cataract.

The principle of this operation is that the lens, once the capsule is freely opened in front and the aqueous humour admitted, is found rapidly to become absorbed and disappear, if the cataract has been a soft one.

Operation.—A needle with a lance-shaped head is to be used. It should be so made that the rounded shaft of the needle is just large enough to play freely in the wound made by the broader point, and yet not so small as to allow the aqueous humour to escape rapidly. The pupil has been dilated, the patient is lying on his back, and the globe is fixed by forceps attached to the conjunctiva of the inner side of the eye, and held by an assistant. The surgeon then enters the needle close to the sclerotic margin of the cornea, carries it fairly on in the anterior chamber, till the centre of the pupil is reached. He then, by bringing forward the handle, projects the point backwards against the anterior capsule, which he freely lacerates with the point and edge in several directions.

In infants, where processes of repair go on very rapidly, the whole lens may be freely broken up. In diabetic cataract, or indeed in all cases of solution, where the patient is adolescent or adult, or the eye at all weak, only a small portion of the lens should be attacked at one sitting.

The needle should then be withdrawn gradually and with great care, that the broad axis of the blade be in exactly the same position in which it entered, i.e. flat and parallel with the iris, lest the iris be wounded, entangled, or prolapsed.

The eye is then to be closed for twenty-four hours; if there is much pain, atropia must be freely used.

Varieties in the Operation.—Some use two needles at once for breaking up the lens. Some surgeons prefer to enter the needle through the sclerotic; this complicates the operation and renders it less certain, as the point of the needle is of course out of sight in its progress between the iris and the lens.

Even in children this operation requires in most cases to be repeated at least once, while in adults it may be required at short intervals for many months.

3. By Extraction.—In these operations the lens is at once removed from the eye—

(1.) By linear, or perhaps, more correctly, rectilinear incision. This method is specially suited for cases of soft cataract.

Operation.—A fine spear-shaped needle is very cautiously introduced through the cornea, about a line from its outer margin, and the anterior capsule lacerated, and the lens broken up, great care being taken not to injure the posterior capsule. The pupil must then be kept freely dilated, the wound heals at once, and the aqueous humour reaccumulates.



From three to six days after this first operation, a linear incision (Fig. XII.) is made in the outer side of the cornea by a straight stab from a double-edged knife, or rather spear. The size of the incision must vary with the size and consistence of the lens, and can be regulated by the breadth of the knife and the distance to which it is entered. By careful withdrawal of the knife, in many cases a large portion of the soft lens can be removed along with it, and then what remains must be cautiously lifted out by a flat spoon introduced through the wound, and behind the remains of the lens.

Care must be taken lest any of the lens substance remain in the wound; with this precaution the incision generally heals rapidly, and with much less risk of general inflammation of the ball than in the ordinary flap operation of extraction.

EXTRACTION OF SOFT CATARACT BY SUCTION.—Mr. T. P. Teale, of Leeds,[87] has invented an instrument by which the removal of soft cataract is made more easy, through a linear incision by suction, applied through the medium of a hollow curette furnished with an india-rubber tube and mouth-piece.

The curette is of the usual size, but is roofed in (instead of being merely grooved) to within one line of its extremity, thus forming a tube flattened above, but terminating in a small cup. This is screwed into an ordinary straight handle, which is hollow for a short distance, far enough to join with a second tube fixed at right angles to the handle, and into which the india-rubber pipe and mouth-piece, through which suction is to be made, is attached. In many cases it seems to serve its purpose extremely well.

Certain points require attention:—1. That the puncture to admit the curette is large enough; 2. That its end be sufficiently rounded; 3. Its open end must be held in the area of the pupil, and not allowed to pass behind the iris, else there is great risk of the iris being drawn in. Among other advantages claimed by its inventor, the chief seems to be a more thorough removal of the lens than by the ordinary means, and consequently less risk of opaque deposit in the posterior capsule.

(2.) EXTRACTION BY FLAP.—When properly performed in a suitable subject, and when free from accident, this operation is one of the most thoroughly beautiful and satisfactory in the whole domain of surgery; but it is difficult, and liable to many risks which neither skill nor caution can completely guard against.

It is required in many cases of hard cataract, which are amenable neither to solution nor linear extraction.

Operation must be considered in various stages:—

a. To make a flap of cornea large enough to permit of the removal of the entire lens without pressure or bruising. To make it of cornea only, to prevent the escape of the vitreous, and to avoid injury of the iris.

The great difficulty in making the required section of the cornea is, that we are debarred from using scissors or any ordinary knife or scalpel in making it, for this reason, that the sawing movements required in all ordinary cutting are inadmissible here, as any withdrawal of the blade, however slight, would permit evacuation of the aqueous humour, and at once be followed by prolapse of the iris before the knife. Hence we are compelled to make the requisite flap by one steady push of a knife, which, too, must be of such a shape as in its entrance constantly to fill up the wound it makes. Very various shapes and sizes of knives have been proposed, the one called Beer's knife being the sort of model or common parent from which all the others are derived. It is triangular in shape, with a straight back, about 12-10ths of an inch in length, and 4-10ths broad at the base of the blade, tapering at a straight edge from its base to its point, and also diminishing in thickness to the point.

Considerable difference of opinion exists as to the relative merits of an upper or lower section of the cornea. The general view at present seems to be that an upper section is to be preferred; but in cases where the surgeon is not ambidexterous, it is better that he should make the section which lies easiest to his hand than attempt an upper section in a less favourable position.

The patient should be placed flat on his back, the lids should be gently opened, the upper one by the surgeon, the lower one by his assistant, who is to press the lid downwards against the malar bone without exercising any pressure on the ball. The eye should be still further steadied by the conjunctiva and subjacent cellular tissue on the inner side being seized by a pair of catch-forceps, still with no downward pressure on the ball. The point of the knife must then be introduced about a line from the outer sclerotic margin of the transverse diameter of the cornea (Fig. XIII.), the blade being held parallel with the fibres of the iris, pushed steadily across the anterior chamber, and protruded as nearly as possible at the corresponding spot at the inner side of the cornea. The aqueous humour should not escape till the section is completed. If it does, the iris is almost certainly projected forwards and entangled in the blade of the knife, a most annoying accident, and one which is not easily remedied. The books tell us of various manoeuvres by pressure or otherwise, by which the iris may be pushed back. Practically, however, if it has once occurred it is not easily saved from being cut. If a small portion only is involved, it is not of much consequence; if a large portion be in danger, it is sometimes necessary to withdraw the knife before the section is completed, and finish it with a probe-pointed, curved bistoury.

If, however, the flap is safely finished, the lids should be gently allowed to close for a few seconds.

On opening them again the surgeon must decide whether the corneal flap is sufficiently large to allow the lens to come out without force; if not, he must enlarge it either by the narrow probe-pointed "secondary knife" or by a pair of sharp scissors. Occasionally the lens, and even a little vitreous humour, may escape at once on the section being completed, but this is not to be desired.

b. Laceration of the Capsule of the Lens.—This is performed by insinuating a sharp curved needle under the corneal flap, avoiding the iris, and then tearing up the anterior capsule through the dilated pupil, the chief point to be attended to being that the capsule be lacerated in its entire length.

c. Removal of the Lens.—This must be done with the most extreme caution and gentleness, lest the vitreous humour be also evacuated. The surgeon's object is to tilt the lens so as to turn it slightly on its transverse axis, and cause the edge nearest the section to rise out of the capsule and appear at the wound. This is best done by gentle pressure at the required spot by the back of the needle, or by a common probe. When the lens begins to protrude the pressure must be very, gentle, lest it be forced out suddenly and the vitreous follow it.

Soft portions of the lens are apt to remain adherent to the wound in the cornea. These must be removed by scoop or probe.

Varieties in the method of Flap Extraction.—Jacobsen of Koenigsberg in every case gives chloroform. He always makes his flap in the boundary line of the cornea and the sclerotic, through a vascular structure, and he believes that union is on this account more rapid, and after extraction removes that portion of the iris which appears to have been most exposed to bruising during the exit of the lens.

The operation of extraction may in many cases be either preceded or followed by iridectomy, as proposed by Mooren, Von Graefe, and others. The following operation seems to diminish the risks to a very great extent:—

Professor Von Graefe's Operation.—The lids are separated by a speculum, and the eyeball is drawn down by forceps placed immediately below the cornea. The point of a small knife, of which the edge is directed upwards, is inserted at a point fully half a line from the margin of the cornea near its upper part, so as to enter the anterior chamber as peripherally as possible. The point should not be directed at first towards the spot for counterpuncture; nor till the knife has advanced fully three and a half lines within the visible portion of the anterior chamber, should the handle be lowered and the point directed so as to make a symmetrical counterpuncture, which will give the external wound a length of four and a half or five lines. As soon as the resistance to the point is felt to be overcome, showing that the counterpuncture is effected, the knife must at once be turned forward, so that its back is directed almost to the centre of the ideal sphere of the cornea, whether the conjunctiva is transfixed or not, and the scleral border is divided by boldly pushing the knife onwards and again drawing it backwards. This portion of the operation is concluded by the formation of a conjunctival flap a line and a half or two lines in length. A section thus made is almost perpendicular to the cornea, a circumstance much facilitating the passage of the lens, and the line of incision is nearly straight, so that the wound does not gape. The iris should be excised to the very end of the wound, and the capsule most freely opened by a V-shaped laceration. Any lens, even the hardest, may then be removed without the introduction of an instrument into the eye, but Von Graefe's experience shows it to be advisable to assist the evacuation by the hook in about one case in eight. In a certain number of cases the lens will escape without difficulty when the operator presses on the posterior lip of the wound, especially when the back of the spoon is made to glide along the sclera; should this not occur, Von Graefe uses a peculiar blunt hook, or occasionally, though rarely, a spoon. A compressing bandage is applied, and replaced at intervals.[88]

We are recommended to perform it in two sets of cases:—

1. Those in which the eye is known to be unhealthy and liable to inflammations, specially of iris, retina, or choroid. In cases where the patient has already lost an eye, Von Graefe thinks iridectomy should always precede extraction. In the above, then, it is a precautionary measure, and, if convenient, should be performed three, four, or even six weeks before the extraction.

2. It is recommended to be performed at the same time as extraction in all cases in which the operation has presented any special difficulties, or has not gone smoothly, e.g. in cases where the lens has required much force to expel it, either from the flap of cornea being too small, or from adhesions between the lens and capsule; or, again, in cases in which there is a tendency to prolapse of the iris, in which any of the cortical substance has been necessarily left behind, or in which old adhesions had existed between the iris and capsule, or between the cornea and iris.

OPERATIONS FOR ARTIFICIAL PUPIL.—The cases are by no means unfrequent in which it is necessary to remove or destroy a portion of the iris to admit light to the retina. In cases of excessive prolapse of the iris after extraction of the lens, where the iris has formed adhesions to the wound, and still more frequently in cases where central opacities of the cornea have fairly occluded the natural pupil, the only chance for vision is to enlarge the old one, or make a new pupil by removal of the iris.

Very various operations have been proposed, and exceedingly numerous and complicated instruments invented for this purpose. We can notice here only one or two of the most approved procedures:—

1. Incision is the simplest.

This is practicable and effectual only in cases where the iris is so far healthy as still to retain its contractile power, and so far free from adhesions as to be able to make use of it. The best example of such a case is that of a cataract, in which after extraction a prolapse of the iris has occurred to such an extent as to obliterate the pupil, and where, at the same time, the only adhesions are to the wound, none to the cornea.

Operation.—A double-edged needle is introduced through the cornea near its margin; on arriving at the place where the pupil ought to be, one edge is drawn against the iris, and divides it transversely, if possible, without injuring the lens; the fibres of the iris start back, contract, so that a sufficiently large central pupil may be obtained.

2. Excision.—In the far more frequent cases in which there exist adhesions between iris and cornea, or iris and anterior capsule, incision is not sufficient, and it is necessary to excise a portion of the iris.

The simplest and safest operation is the following:—

The patient recumbent, and the lids held apart by a speculum, the eyeball should be steadied by the forceps of an assistant. A broad cutting needle should then be introduced at the lower or outer edge of the corneal margin. This must be very gently withdrawn so as to retain as much aqueous humour as possible. Into the wound thus made the surgeon must introduce the blunt hook (known as Tyrrell's) at first with its point forwards, then, on arriving opposite the edge of the pupil, which it is intended to enlarge or replace, with its point turned backwards, so as to hook over the edge of the iris and thus drag on it. Once the hook has fairly got hold, it must again be rotated forwards, and withdrawn in the same direction as it was put in. The iris thus pulled out of the wound is to be cut off with a pair of fine scissors, so as to remove a sufficient amount to make a new pupil of the required size.

But in those cases in which the whole or greater part of the pupillary margin is adherent, the blunt hook will not do, because there exists no edge round which to hook it. One of two plans is generally chosen to remedy this:—

(1.) A free incision made with a double-edged needle; through this a pair of canula forceps is introduced, with which a portion of iris is seized and dragged to the external wound; it can then either be cut off or tied (see Iridesis); or,

(2.) A previous attempt may be made to free a portion to form an edge to catch hold of, either by incision or by Corelysis (q.v.)

IRIDESIS.—Critchett's Operation of Ligature.[89]—Patient being put under chloroform, the ball is fixed by the wire speculum, and also by a fold of conjunctiva being seized by forceps. An opening is then made with a broad needle through the margin of the cornea, close to the sclerotic, just large enough to admit the canula forceps, with which a small portion of iris close to its ciliary attachment is seized and drawn out; a piece of fine floss silk, previously tied in a small loop round the canula forceps, is slipped down and carefully tightened round the prolapsed portion. This speedily shrinks, and the loop may generally be removed about the second day. The chief advantage claimed for this method is the ease with which the size of the new pupil can be regulated. It is also suitable in cases of conical cornea, where it is wished to change the form of the pupil into a narrow slit.

N.B.—The ends of the ligature must be left sufficiently long to avoid any risk of their being drawn out of sight into the substance of the cornea, or even into the ball, by retraction of the fibres of the iris.

CORELYSIS.—Freeing of the Pupil.—An operative procedure for separating posterior adhesions of the iris to the lens. In it the surgeon hopes to act, not on the iris, as in the operations for artificial pupil, but only on the bands of false membrane which distort the pupil.

The operation is briefly as follows:—The eye being firmly held by a wire speculum, and forceps pinching up the conjunctiva, a broad needle is passed rapidly through the cornea at a point which may give easy access to the adhesion to be torn through. This point is generally at the opposite margin of the irregular pupil, so that the needle may pass through the cornea in front of the one side of the iris, then through the orifice of the pupil, so as to reach the back of the other side. The needle is withdrawn gradually, so as to lose as little of the aqueous humour as possible, and then the spatula hook, called after the inventor of the operation, Mr. Streatfeild, is introduced. It is used first as a spatula, that is, with its blunt, though polished edge, to separate the adhesions, and if this is unsuccessful, as a hook (FIG. XIV.), so as to catch and tear them. In cases which resist the instrument used in both of these ways, Mr. Streatfeild has used very fine canula-scissors to cut the adhesions.[90] Such a further complication of the operation practically alters its character into an operation for artificial pupil, q.v.

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IRIDECTOMY.—In cases of acute glaucoma, irido-choroiditis, and all deep inflammations of the eye in which the ocular tension is increased, also in certain cases of flap extraction already alluded to, the operation of iridectomy as originally proposed by Von Graefe will be found of use.

Operation.—The patient recumbent, and the eye absolutely fixed by speculum and forceps, a linear incision, varying in length from one-sixth to one-fourth of an inch, is made just at the margin of the cornea. The point of election is the upper pole of the cornea. The lens must not be wounded. The best instrument for making the section is an ordinary linear extraction knife, bent at an angle to admit of its being introduced from above. The iris will protrude through the wound, or, if adherent, must be drawn out by forceps, and then is to be cut off with scissors. The operation is rarely successful, unless a third, or at least a fourth, of the iris be removed.

EXCISION OF A STAPHYLOMATOUS CORNEA.—There are certain cases in which the whole or greater part of the cornea bulges forward in a great blue projecting tumour. It is very ugly as it protrudes between the lids and prevents their closure; besides this, from its exposure it frequently inflames, even ulcerates, and has a most injurious effect on the other eye. In the cases suitable for operation vision is completely gone, without hope of its restoration by any operative procedure.

The best thing for the patient is to have just enough of the staphyloma removed to enable the remains of the eyeball to form a good stump for an artificial eye. Various means have been suggested for doing this, varying in extent and severity from a mere shaving off the apex of the staphyloma to excision of the whole eyeball.

By far the best method of operating is the one proposed and practised by Mr. Critchett.

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The object of it is to remove an elliptical portion of the front of the staphyloma, or the whole staphyloma, when it is possible, and at the same time to prevent as far as possible the escape of the vitreous.

Operation.—Three, four, or five small curved needles armed with thread are passed through the staphyloma from above downwards, being each entered a little above the line of the intended upper incision, and brought out a little below the line of the intended lower one (Fig. XV.)

To remove the included elliptical portion, Mr. Critchett pierces the sclerotic with a Beer's knife, just in front of the tendinous insertion of the external rectus. Through this incision a pair of probe-pointed scissors is introduced, and the piece cut just within the points of the needles. On the removal, the needles, which have retained the vitreous by their pressure, are drawn through and the threads cautiously tied.

Union by first intention very often occurs, and an excellent stump is left with a narrow depressed transverse cicatrix[94] (Fig. XVI.)

EXTIRPATION OF THE EYEBALL.—1. Of the Eyeball only.—A circular incision should be made with curved scissors through the conjunctiva, a little beyond the corneal margin, then, beginning with the external rectus, muscle after muscle should be raised with the forceps, and divided, after which the optic nerve is cut through with the scissors. A slight preliminary extension outwards of the optic commissure will facilitate the dissection, and must be secured with metallic sutures; any vessels should be tied, and the orbit filled up with a light compress of charpie secured with a bandage.

2. Of the contents of the Orbit.—This may be required for malignant disease, but with a very poor prognosis. The optic commissure should be freely divided, and then, by bold strokes of curved scissors, or curved probe-pointed bistoury, the orbit may be fairly emptied by scooping out its contents. Even the periosteum may require to be scraped off, and the optic nerve divided as far back as possible. The haemorrhage may be pretty smart, but can generally be easily checked by compresses; if necessary, these can be soaked in the solution of the perchloride of iron.

The author has done this operation many times, in cases extensive and of old standing, for malignant disease, melanotic and encephaloid. All have recovered, and in no instance has there been any trouble in stopping the bleeding.

FOOTNOTES:

[81] a. Elliptical incision for entropium; b. wedge-shaped incision for ectropium.

[82] Fig. VIII. illustrates Streatfeild's operation for entropium.—a. section of skin; b. section of levator palpebrae; c. section of cartilage of lid; d. section of conjunctiva; e. wedge-shaped portion excised.

[83] Ophthalmic Hospital Reports, vol. i. p. 121.

[84] Rough diagram of Bowman's operation, showing the grooved director in the punctum, and the knife in the groove just before it slits up the canaliculus.

[85] Diagram of operations for convergent squint—A A, line of sub-conjunctival incision; B B, line of Dieffenbach's operation; C, wire speculum.

[86] The Radical Cure of Extreme Divergent Strabismus. J. Vose Solomon, F.R.C.S., 1864.

[87] Ophthalmic Hospital Reports, vol. iv. part ii. p. 197.

[88] Biennial Retrospect for 1865-66. Syd. Soc. pp. 363-4. For a thorough discussion of the merits of this operation, see papers by Von Graefe in Brit. Med. Jour. for 1867, vol. i. pp. 379, 446, 499, 657, 765.

[89] Ophthalmic Hospital Reports, vol. i. p. 224.

[90] Streatfeild on Corelysis. Ophthalmic Hospital Reports, vol. ii. p. 309.

[91] a iris; b lens; c cornea. The hook is seen applied to the adhesion between lens and iris.

[92] The staphyloma with the needles inserted, the lids held asunder by a spring speculum. The elliptical dotted line shows the amount to be removed; the vertical one, the position of the preliminary incision with the Beer's knife.

[93] Resulting stump after the stitches are inserted.

[94] Ophthalmic Hospital Reports, vol. iv. part 1.



CHAPTER VI.

OPERATIONS ON THE NOSE AND LIPS.

RHINOPLASTIC OPERATIONS.—The operations for the restoration or repair of lost or mutilated noses are so various, and the minuteness of detail necessary for full description of them so great, that a complete account in a manual such as this is impossible; a brief notice of some of the most important varieties of the operation is all that can be given.

Principles.—1. It is necessary in every case that a suitable edge be prepared on which to fix the flap of skin, however obtained. To be suitable, this edge, should be (a) made in healthy skin, not in old or weak cicatrices; hence no trace of the original disease should be left; (b) it should be made thoroughly raw, by the removal of an appreciable amount of its edge; it should be pared, not merely scraped.

2. It is useless to attempt to restore a nose unless the patient is in good general health, well nourished, and perfectly free from all remains of disease in the nose or its neighbourhood. The flaps which are to form the new nose may be obtained either from (1.) the cheeks; (2.) the forehead; (3.) a distant part either of the patient or of another person.

(1.) From the Cheeks.—When the cheeks are healthy, and specially if they are tolerably full and lax, the flaps from the cheeks produce much the most satisfactory result. As performed by Mr. Syme, the operation consists in the shaping of two equal flaps (A, A) from the skin of the cheek at each side, having the attachment above. A site for each flap is formed by the careful paring away of the whole thickness of the edge of the cavity of the lost organ (see Fig. XVII.)

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The flaps are then raised from their attachments to the upper jaw-bone, and approximated in the middle line by several points of metallic suture and the outer edges stitched to the raw surface on each side at a proper distance from the nasal orifice. If any septum remains of the old nose, it may be made very useful as a fixed point, a straight needle being thrust through one flap close to its outer lower edge, then through the septum, and out at a corresponding point of the other flap. The edges of the wound left in the cheek at each side can generally be, to a certain extent, approximated by silver stitches (B, B) and the triangular portion (C, C), which is necessarily left to heal by granulation, proves an advantage, as by its depression it enhances the apparent height and prominence of the new organ. The cavity should be very gently distended with lint, and may be supported by the blades of a small pair of forceps, applied so as to embrace the nose.

(2.) From the Forehead.—The Indian operation may be used as a last resource, in cases where, from disease, the cheeks also have suffered, and are not to be trusted to for flaps.

Operation.—1. It should be decided as to the shape and size of the portion of skin necessary, by fitting on pieces of soft leather or moulding wax. To allow for shrinking, the flap should be made at least one-third larger than is at first apparently necessary. The exact boundaries of the flap to be raised should then be marked out on the forehead by lightly pencilling it with nitrate of silver, the mark from which is not effaced by blood, as is sure to be the case with an ink line. Various shapes have been proposed for the flap varying in length of neck, in the shape of the angles, and especially in the arrangements made for the formation of a columna. Some (as Liston) prefer afterwards to provide for the columns separately, by a flap raised from the upper lip in a subsequent operation. The flap is then to be raised from the forehead, care being taken not to injure the periosteum. The incision is to be carried lower down on the side (generally the left), to which the flap is to be twisted. The flap is then to be brought round (Fig. XVIII.) and carefully fitted on to the edges previously prepared for its reception. The neck must be left as lax as possible, lest by tight twisting the supply of blood be cut off, and the flaps thus deprived of nourishment. Both silk and metallic sutures are recommended. Hamilton of Dublin,[96] after a large experience of both, prefers the former.

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There are various risks; sloughing of the whole flap at once, shrinking of it after weeks or even months; certain inevitable drawbacks, as the cicatrix on the forehead, the very various and ludicrous changes of colour to which the new organ is subject,—these cannot be remedied by further operation. Two points generally require a second use of the knife a few weeks after:—(1.) The neck of the flap is sure to be redundant and prominent, but can be pared. (2.) The columna almost always requires improving, and, in Liston's method, to be made. He pared the inner surface of the apex of the nose, and then raised a central flap of the lip in the middle line, about a quarter of an inch broad, and extending from the remains of the old septum to the free border, raising it from the gum, and stitched the free end of it to the prepared apex, bringing together the two divided portions of the lip by ordinary harelip sutures. Tho columna, if redundant, could be shaved down, and it was found that the mucous surface very quickly became like skin on exposure.

For other points with regard to the operation, reference may be made to the works of Liston and Skey, and Hamilton's monograph, referred to above.

Note.—The tongue and groove suture proposed by Professor Pancoast, and recommended by Professor Gross, is said to be specially suitable for such plastic operations. It is very complicated, as it requires one edge to be bevelled to a wedge shape, the other being grooved to include the wedge, thus opposing four raw surfaces, which are retained in contact by being transfixed by fine silk sutures.

(3.) There are certain cases in which neither cheeks nor forehead are available for flaps, and yet the patients press very much for some operation. If they have patience and determination, the Taliacotian or Italian operation may be attempted.

Without going into detail, the principle of it is as follows:—1. A piece of skin of suitable size was marked out over the left biceps, and defined by two longitudinal incisions, and raised from the subcutaneous cellular tissue, thus being left attached by its two ends only; a piece of linen was pulled below it. 2. After a few days the upper end was also divided, and the flap thus contracted. In a few days more the sides of the old nose were made raw, and the upper free surface of the flap also made raw and stitched to them, the arm being fastened up by a most elaborate series of bandages. 3. After a fortnight in this position, the last attachment of the flap to the arm was severed, and the new nose could then be modelled at pleasure.

The literature of the subject is exceedingly curious, especially the cases in which the new material was obtained from an accommodating friend or servant.

OPERATIVE TREATMENT OF LUPUS.—We may here notice a mode of treatment which has admirable results. The patient being put deeply under an anaesthetic, the surgeon with a sharp spoon carefully pares away all the diseased tissues, and then destroys the base either by nitric acid or a strong solution of chloride of zinc. The author has done this in a great number of cases with excellent effect.

NASAL POLYPI, Removal of.—Of these there are different kinds.

1. ORDINARY MUCOUS POLYPI.—These grow from the spongy bones, generally the superior one, are non-malignant in their character, soft and vascular, often fill up the whole of both nasal cavities, and frequently hang down behind into the pharynx. The practical point to remember is that, however large and numerous they may be, they invariably have their origin from a comparatively limited spot, the edge of the spongy bone, and always hang from a narrow neck. Hence the treatment is easy and satisfactory, if the neck be attacked, and not the body of the tumour.

Slightly curved, narrow-bladed forceps should be passed along by the side of the superior spongy bone, with their blades open, till the neck of the polypus is seized. Holding it firmly, the forceps should then be slowly twisted round till the neck is destroyed and the polypus detached. This should be repeated till the patient can blow freely through both nostrils. If attempts are made to seize the body of the polypus, it will break down under the forceps, bleed, and give much trouble.

2. THE FIBROUS POLYPUS.—This form is fortunately much more rare than the other. It is almost invariably single, is attached to the posterior margin of the nares by a narrow but very strong root, is extremely firm in consistence, may grow to a large size so as to obstruct both nostrils, generally gives rise to severe and frequent haemorrhages. The haemorrhage during any attempt to remove it is generally of the most severe character, but ceases immediately on its complete detachment.

We owe nearly all that we do know about the treatment of this form of polypus to Mr. Syme. His method is—By the ordinary polypus forceps described already, he seized the tumour through the nostril, and then with the fore and middle fingers of the left hand introduced behind the soft palate, he attacked the point of attachment, and by his nails, aided by the forceps, detached it from its narrow base.[98]

3. MALIGNANT POLYPI should not be meddled with unless it is absolutely certain that the whole of the bone from which they grow can be removed also. This is very rarely the case. (See Excision of Superior Maxilla.)

OPERATIONS ON THE LIPS.—1. Epithelial cancers of the lower lip are very frequent, and require removal.

If the tumour or ulcer is small, and involves a considerable thickness of the lip, it is most easily removed by a V-shaped incision (Fig. XIX. A B A). Its shape permits the most accurate apposition of the cut surfaces; and if the lips are full and the tumour small, very slight trace of the operation will remain.

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Again, if the tumour be more extensive, involving a large portion of the prolabium, and yet not extending deeply into the substance of the lip, it may be very easily removed by a pair of curved scissors, applied in the direction shown in the diagram (Fig. XX. A B). The skin must then be stitched to the mucous membrane by numerous points of interrupted suture.

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But if the tumour be at once extensive and deep, mere removal is not sufficient, but some provision must be made for supplying the blank left by the operation.

In cases where a third, or even a half, of the lower lip has thus been removed, it may be found sufficient freely to dissect what is left of the lip from the gums, and thus approximate the cut surfaces in the middle line.

This alone, however, would so much diminish the buccal orifice, and twist its corners, as to cause great deformity. The addition of an incision horizontally outwards, at one or both angles of the mouth, will do away with such risk, and allow the surfaces to come together without puckering; while by stitching the skin and mucous membrane together in the course of these horizontal incisions, we can increase the size of the buccal orifice almost ad libitum.

Lastly, when the lower lip has been entirely removed, it is still possible to supply its place in the following manner, which was devised by Mr. Syme: The tumour being fairly isolated by a V-shaped incision (Fig. XXI.) C A C including the whole thickness of the lip, each of the incisions should be prolonged downwards and outwards, as shown by the dotted lines A D, A D. The flaps thus marked out must be separated from the bone, brought upwards, and approximated in the middle line. Possibly it may be necessary still further to enlarge the buccal orifice by short lateral incisions, C C. Whether these are required or not, silk stitches are to be introduced to unite the skin and mucous membrane along the lines A C. The gap left between D B D must be left to granulate, but in most cases may be very much diminished in size by additional sutures at its outer corners, near D. The granulating surface E E very rapidly heals up, leaving a dimple on each side, which rather improves the appearance, by adding to the prominence of the chin, B.

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THE OPERATIONS FOR HARELIP, though all conducted on the same general principles, vary considerably in extent required according to the position and size of the fissure or fissures to be remedied.

1. For Single Harelip.—Where the fissure extends only from the prolabium up to the attachment of the lip to the gums: this is very easily remedied, the chief risk being lest the surgeon should not remove enough of the edges of the fissure.

Operation.—Bleeding being controlled by an assistant, the surgeon fixes a pair of spring artery forceps into the mucous membrane and skin at the salient angle at each side of the fissure. Taking one of these in his left hand, he puts the edge to be pared on the stretch, and then with a sharp narrow straight bistoury he transfixes the lip at the point just beyond the upper angle of the fissure, and cuts outwards, being careful to remove the whole thinner part of the lip, and to leave the edge rather concave than convex. If left convex, or even quite straight, there is a risk that, after union has taken place, an angle remain showing the position of the cleft. The same is then to be done on the other side. The bleeding is then to be controlled by twisting the larger vessels, and if oozing still continues from the smaller ones, a pad of lint should be placed in the wound, and a few minutes' delay given, as, to facilitate immediate union, it is of the greatest importance that all haemorrhage should have ceased before the edges are brought together.

When the bleeding has ceased, the edges should be approximated by two or more points of interrupted metallic suture inserted very deeply through the tissues, and taking a good hold of the edges of the wound. If the edges do not fit accurately, one or two horse-hair sutures will help. Some surgeons still prefer the old harelip needles secured by a figure-of-eight suture. A silk suture inserted through the prolabium is of great advantage, as it keeps the inner surface of the wound closed, which without it is very apt to be kept open by the pressure of the teeth or gums, and in infants by the movements of the tip of the tongue.

Various methods have been devised to utilise, if possible, the portion of the edge of the lip which is separated during the operation of refreshing the edges, for the purpose of filling up the sort of cleft or gap which is apt to be noticed at the edge of the prolabium. The most ingenious and simplest of these is that proposed by M. Nelaton, for use in cases where the fissure does not extend so far up as the nose. It consists in leaving the two portions which are pared off (Fig. XXIII.) the sides of the cleft attached to each other as well as to the free edge of the lip, then pulling them down, so as to bring their bleeding surfaces into apposition, and make a diamond-shaped wound instead of a triangular cleft (Fig. XXIV.) When brought together by sutures a projection is left at the edge of the lip; this, in most cases, disappears; if it does not, it can easily be pared down.

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2. When the fissure, though single, extends upwards into the nose, the operation is more difficult, and the result frequently less satisfactory. The first thing to be done is to separate the lips from the gums, so as to make them more freely mobile. The whole edges of the cleft require refreshing.

3. Double Harelip, without bony deformity, and where the intervening portion of the skin is vertical, does not project, and can be made useful for the new lip. Such cases are not very common, but when they do occur the question arises, How are they to be managed—in two separate operations or at once? I believe, in every case, at once. The central wedge-shaped portion is not large enough to extend downwards as far as the prolabium, but still should not be removed altogether, as it may be of great use, especially in bearing the columna nasi, and allowing its full development. The edges should be pared in the same way, and to the same extent as in single harelip, with the addition that the intervening portion should have its edges completely removed, and be left in the form of a wedge, with its apex downwards. The highest suture should be passed through first one side, then the base of the wedge, and then the other side; the second one through both, and the apex of the wedge; and a third should unite the prolabium, not including the wedge.

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4. Double Harelip combined with fissures of the hard palate, and projection of a central bone. This is the analogue of the inter-maxillary bone in the lower animals, and bears the two middle incisor teeth, and projects very variously in different cases. In some it projects horizontally forwards in the most hideous manner, in others it lies at an angle more or less oblique; in very few does it maintain its proper position; when projecting forwards, and as the teeth also share in its projection, it entirely prevents approximation of the edges of the fissures by operation, so it must first be dealt with in one of two ways, either—

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(1.) It may be at once removed with bone-pliers, the piece of skin over it being saved. This is the best that can be done in cases of old standing after the first year or two, though attempts have been made to break the neck of the projecting portion, and thus permit of its being shoved back.

(2.) By gradual pressure by a spring truss, strapping, or a bandage, it may be forced back. This is possible only in cases where the deformity has been comparatively slight, and the patient has been seen early. The edges must then be pared and approximated as directed above.

One or two points about the operation for harelip require a special notice:—

1. When to operate.—Great differences in opinion exist. Some say not before two or three years, others within two or three days, or even hours, after birth.

Probably the safest time is not much earlier than the second month in very strong children, the fifth in weakly ones, up to the commencement of the first dentition; and when once dentition has commenced it is not so safe to operate till it is over.

Prior to dentition the operation is attended with rather more risk, but again, if delayed, there is great risk that the teeth do not come in properly.

2. With regard to the most delicate part of the operation, the management of the prolabium.—Some are satisfied, and I believe rightly, with careful apposition by a silk suture after a sufficient amount of the edges has been removed; others have proposed various plans to obviate any risk of an angle remaining.

Malgaigne proposes to retain a small portion of the parings of the edge to make small flap at each side; Lloyd a single one from the long half of the lip, and brings it up under the opposite one, securing it with a stitch.

FOOTNOTES:

[95] Operation for formation of a new nose from the cheeks; A A, flaps approximated in middle line; B B, outer part of bed of flaps stitched up; C C, triangle at each side left to granulate.

[96] The Restoration of a Lost Nose by Operation, p. 57; an excellent monograph on the subject.

[97] Operation for formation of a new nose from the forehead:—a, prominence of flap which is to be used as septum; b, left-hand corner of flap, which is twisted and fastened at c; d, one of the tubes or quills over which the nose is moulded.—(Modified from Bernard and Huette.)

[98] Syme's Observations in Clinical Surgery, p. 132.

[99] Diagram of V-shaped incision; A B A, dots showing points for sutures.

[100] Diagram of incision for scooping out a shallow tumour by scissors.

[101] Diagram of incisions:—C A C, outline of incision for removal; C A D, outline of flap on each side; B, prominence of chin; C C, dotted lines, showing incisions to enlarge mouth, if required.

[102] Diagram of flaps in position:—A A, corners of flaps brought up and approximated by silver sutures; C C, new lip got by lateral incisions, skin and mucous membrane being united by silk threads; E E, gap left to granulate.

[103] Fig. XXIII. shows the incision bounding the cleft.

[104] Fig. XXIV. shows the diamond-shaped wound before the sutures are applied.

[105] Diagram of operation for double harelip:—a, stitch through both sides and wedge-shaped portion, which also aids the septum; b, other stitches approximating edges.

[106] Diagram of double harelip, with projecting bone:—a, central piece of lip, dotted lines showing incision; b, projecting bone bearing teeth, which are generally small and stunted.



CHAPTER VII.

OPERATIONS ON THE JAWS.

1. EXCISION OF THE UPPER JAW.—With regard to the morbid conditions for which this operation is undertaken, it may be sufficient here to observe, that in no case can the operation be called justifiable in which the disease extends beyond the upper jaw-bone and the corresponding palate-bone, for unless the morbid growth be entirely removed, recurrence is inevitable, and no advantage is gained by the operation. It is undertaken for the removal of tumours of the antrum and of the alveolar margins, in all which cases the section for its removal must be made through healthy bone, and wide of the disease, so as to insure that the whole is removed. There are other cases in which the whole or part of the upper jaw has been removed for the purpose of giving access to disease behind, for example, to naso-pharyngeal polypi with extensive attachments.

In describing the operation for the excision of the entire upper jaw, we have to consider—(1.) what incisions through the soft parts will expose the tumour best, and with least deformity; (2.) what bony processes require to be divided, and where. Very various incisions have been recommended by various authors; some describing three, in various directions, forming flaps of different sizes, while others, again, are satisfied with a very small division of the upper lip into the nose, or even attempt removal of the bone without any incision through the skin at all. These discrepancies depend in great measure on different views of what constitutes excision of the upper jaw, the more complicated ones contemplating removal of the whole bone anatomically so called, including the floor of the orbit, while the less complicated ones are suitable for cases in which a much less extensive removal is required.

To remove the whole bone, an incision (Fig. XXVII. A) of the skin must extend from the angle of the mouth upwards and outwards in a slightly curved direction with its convexity downwards, as far on the malar bone as half an inch outside of the outer angle of the eye. The flaps must then be raised in both directions, the inner one specially dissected off the bones, so as to expose thoroughly the nasal cavity. It is of great importance thoroughly to display the floor of the orbit, so that the attachment of the orbital fascia may be accurately cut through, the inferior oblique muscle divided at its origin, and the eye and the fat of the orbit cautiously raised from its floor.

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Three processes of bone then require attention and division.

(1.) The articulation with the opposite bone in the hard palate. To divide this, one incisor tooth at least must be drawn, the soft palate divided by a knife to prevent laceration, and the thick alveolar portion sawn through in a longitudinal direction from before backwards.

(2.) The articulation with the malar bone at the upper angle of the incision through the skin. This must be notched with a small saw in a direction corresponding to the articulation, and then wrenched asunder by a pair of strong bone-pliers.

(3.) The nasal process of the upper jaw must now be divided by the pliers, one limb of which is cautiously inserted into the orbit, the other into the nose. If the disease extends high up in this process, it may be necessary partially to separate the corresponding nasal bone, and thus reach the suture between the nasal process and the frontal bone. The pliers must now be inserted into the groove already made by the saw on the hard palate, and the separation continued to the full extent backwards. A comparatively slight force exerted on the tumour either by the hand, or (when the tumour is small) by a pair of strong claw forceps, will suffice to break down the posterior attachments of the bone and remove it entire. The necessary laceration of the soft parts behind is so far an advantage, as it lessens the risk of haemorrhage from the posterior palatine vessels.

The haemorrhage from this operation was at one time much dreaded, but is rarely excessive; very few vessels require ligature, except those divided in the early stages in making the skin flaps; the hollow left should be stuffed with lint, which may be soaked in the perchloride of iron should there be any oozing.

The incisions recommended for this operation have been very various, and a knowledge of some of them may occasionally be useful, on account of specialities in the shape and size of the tumour. Liston "entered the bistoury over the external angular process of the frontal bone, and carried it down through the cheek to the corner of the mouth. Then the knife is to be pushed through the integument to the nasal process of the maxilla, the cartilage of the ala is detached from the bone, and lip cut through in the mesial line; the flap thus formed is to be dissected up and the bones divided."[108] Dieffenbach made an incision through the upper lip and along the back or prominent part of the nose, up towards the inner canthus, from whence he carried the knife along the lower eyelid, at a right angle to the first incision as far as the malar bone.