A Manual of the Operations of Surgery Part 19

[82] Fig. VIII. ill.u.s.trates 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 ca.n.a.liculus.

[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 st.i.tches 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 sc.r.a.ped.

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.)

[Ill.u.s.tration: FIG. XVII.[95]]

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 st.i.tched 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 st.i.tches (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.

[Ill.u.s.tration: FIG. XVIII.[97]]

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 st.i.tched 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 st.i.tched 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 pa.s.sed 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.

[Ill.u.s.tration: FIG. XIX.[99]]

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 st.i.tched to the mucous membrane by numerous points of interrupted suture.

[Ill.u.s.tration: FIG. XX.[100]]

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 st.i.tching 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_.