A Manual of the Operations of Surgery Part 16

[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 s.p.a.ce 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.--

[Ill.u.s.tration: FIG. VII.[81]]

[Ill.u.s.tration: FIG. VIII.[82]]

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 circ.u.mstances, 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 st.i.tch 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 ca.n.a.l, sac, and nasal duct, to the exclusion of all the older methods.

_Mr. Bowman's Operation._--In cases of obstruction of the punctum, ca.n.a.liculus, and nasal duct, resulting in watery eye, acc.u.mulation of mucus in the ca.n.a.l, and dryness of the nose, great difficulty used to be experienced in the treatment. To pa.s.s 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 pa.s.sing 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, ca.n.a.liculus, and nasal duct resemble in many respects the urethral pa.s.sage, and in cases of stricture require to be treated on the same principle. If, then, it were possible to pa.s.s 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 pa.s.s any instrument beyond the size of a human hair past the curve which the ca.n.a.liculus 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 ca.n.a.liculus 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 ca.n.a.liculus was slit up, the curve, or rather angle, which impeded the pa.s.sage 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.