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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.⁷²

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.⁷³

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.⁷⁴

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.⁷⁵

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.⁷⁶

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.⁷⁷

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.⁷⁸

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.⁷⁹ 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.⁸⁰

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.⁸¹ 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.

CHAPTER V.
OPERATIONS ON EYE

Operations on the Eye and its Appendages.

Operations on the Lids.—

Fig. vii. ⁸²

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. ⁸⁴

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. ⁸⁵

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 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.

Fig. xi. ⁸⁶

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 Guérin 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,⁸⁷ 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.