A Manual of the Operations of Surgery by Joseph Bell (best e reader for epub txt) π
Operation.--The ligature may be applied in one of two ways, the choice being influenced by the nature of the disease for which it is done.
1. A straight incision (Plate I. fig. 1) in the linea alba, just avoiding the umbilicus by a curve, and dividing the peritoneum, allows the intestines to be pushed aside, and the aorta exposed still covered by the peritoneum, as it lies in front of the lumbar vertebræ. The peritoneum must again be divided very cautiously at the point selected, and the aortic plexus of nerves carefully dissected off, in order that they may not be interfered with by the ligature. The ligature should then be passed round, tied, cut short, and the wound accurately sewed up.
2. Without wounding the peritoneum.
A curved incision (Plate I. fig. 2), with its convexity backwards, from the projecting end o
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Operation.βA 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.βIn 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:β
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 This must be very gently withdrawn so as to retain as much aqueous humour as possible.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 Once the hook has fairly got hold, it must again be rotated forwards, and withdrawn in the same direction as it was put in.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:β
(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.βCritchett's Operation of Ligature.[89]βPatient 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.βThe 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.βFreeing of the Pupil.βAn 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:βThe 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.
Iridectomy.βIn 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.βThe 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.βThere 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.
Fig. xv. [92]
Fig. xvi. [93]
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.βThree, 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.β1. Of the Eyeball only.βA 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.βThis 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 hΓ¦morrhage 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.
CHAPTER VI. OPERATIONS ON THE NOSE AND LIPS.Rhinoplastic Operations.βThe 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.β1. 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.βWhen 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.)
The flaps are then raised from their attachments to the upper jaw-bone, and approximated in the
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