A Manual of the Operations of Surgery by Joseph Bell (shoe dog free ebook .txt) 📖
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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.
CHAPTER V. OPERATIONS ON EYE.Operations on the Eye and its Appendages.
Operations on the Lids.—
Fig. vii. [81]
1. For Entropium or Inversion of the Lids, often Combined with Trichiasis, irregularity of the Ciliæ.—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 ciliæ.[83]
Fig. viii. [82]
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 gonorrhœa.
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.
Fig. ix. [84]
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.
Fig. x.
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
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