A Manual of the Operations of Surgery

CHAPTER XIV.

OPERATIONS ON NERVES

Nerve-stretching.—Surgical literature in last ten years is full of cases in which nerves have been stretched for all manner of diseases with varying success: an example of the operative procedure may suffice:—

1. Stretching of the great sciatic either for sciatica, sclerosis, or locomotor ataxia.

Operation.—A line drawn from the centre of the space between the tuberosity of the ischium or the great trochanter to a corresponding point between the condyles of the femur will give the direction. A free incision in this line three or four inches in length—the nerve lies just below the the femoral aponeurosis, beneath the edge of gluteal fold, requiring no muscular fibres to be divided. It must be raised from its bed and boldly stretched or elongated into a loop. Symington's experiments have shown that in the average adult 130 lb. are required to break the nerve.

2. The facial has been stretched for spasm. The trunk is easily reached by an incision extending from near the external auditory meatus to the angle of the jaw, which enables the parotid to be pushed forward and the edge of the sterno-mastoid pulled backwards.

Neurotomy and Neurectomy.—Chiefly performed for neuralgia of the fifth nerve.

a. This is a very easy operation if directed at the terminal branches only of the nerve, where they make their exit from the frontal, supraorbital, and mental foramina. The author has done it in very numerous cases, and with great relief, if care be taken to destroy the nerve in the foramen to some extent—a sharp-pointed thermo-cautery does this easily and safely.

b. The more severe and radical operation of cutting out a portion of the trunk of the fifth nerve just after it has left the skull, and destroying Meckel's ganglion, has been done pretty frequently, chiefly by American surgeons—in various ways.

1. Carnochan's Operation.—Exposing the whole front wall of antrum, its cavity is opened into from the front by a large trephine. The lower wall of the infra-orbital canal is cut away by a chisel, the posterior wall of the antrum by a smaller trephine, the nerve thus isolated is traced up to and past Meckel's ganglion, which is removed close to the foramen rotundum by cutting the nerve by curved blunt-pointed scissors.

2. Pancoast's Operation.—Expose the coronoid process by a free incision, divide it at its root and throw it up, then expose and tie internal maxillary artery, after which the upper portion of the external pterygoid is to be detached from the sphenoid, thus exposing the nerve leaving foramen ovale; the second portion is deeper and not so easily got at.

3. The spinal accessory occasionally may be divided before it enters the sterno-mastoid in cases of spasmodic wry neck, with great advantage. This operation is an easy one; the sterno-mastoid edge being once fairly exposed, the nerve is easily seen, and a piece should be cut out at least half an inch in length.

Nerve Suture is occasionally practised with great advantage in cases where nerves have been divided either by accident or in operation. Catgut seems to be the best medium, and cases are on record in which, even after months of separation and subsequent paralysis, improvement has followed an operation for refreshing and joining the divided ends.

ADDENDUM TO CHAPTER IX

Dr. Solis Cohen has recently (in a paper read before the Philadelphia College of Physicians, April 4, 1883) collected the notes of sixty-five cases of excision of the entire larynx. Fifty-six of these were done for cancer, and the remainder for sarcomata, papillomata, etc. Of the fifty-six done for cancer, forty are reported as having died, either shortly after the operation from shock or pneumonia, or a few months later from recurrence of the disease. In two instances the disease had recurred, but death had not been reported when the paper was read. Fourteen remain in which neither death nor recurrence had been reported. Dr. Cohen's conclusion is that laryngectomy does not tend to the prolongation of life, and thinks that the greatest good to the greater number appears better secured by dependence on the palliative operation of tracheotomy.

1

This line is placed too low down; it should be in the middle third of the thigh.

2

Erichsen, Surgery. Sixth edition, vol. ii. p. 121.

3

The line 3 in Plate I. shows the direction required. It will not be necessary to carry the incision so far up for the external as for the common iliac.

4

On the Arteries and Veins, p. 421.

5

Cyclopædia of Practical Surgery, vol. i. p. 277.

6

John Bell's Prin. of Surg., vol. i. 421; Dublin Jour., vol. iv. 321.

7

Observations in Clinical Surgery, Syme, pp. 171-3.

8

Brit. Med. Jour. 1867, Oct. 5.

9

International Encyclopædia of Surgery, vol. iii. p. 466.

10

Poland, Guy's Hosp. Report, ser. iii. vol. vi.

11

Mr. W. Thomson's most interesting paper on this subject is full of information down to the latest date.

12

Lancet, Jan. 5, 1867.

13

Lancet, May 1879.

14

Dublin Quarterly Journal, Nov. 1867.

15

W. Zehender—Monatsbl. für Augenheilkunde. 1868.

16

Butcher, Op. and Cons. Surgery, p. 861.

17

Leçons Orales, iv. 530.

18

Ed. Med. and Surg. Journ. vol. xlv.

19

Observations in Clinical Surgery, pp. 148, 149.

20

Edin. Med. Journal, March 1879.

21

See case of recurrence, Fergusson's Practical Surgery 1st ed. p. 222.

22

Operative Surgery, p. 279.

23

Surgical Operations, p. 50.

24

For details see article "Amputation" in Cooper's Surgical Dictionary, and the short sketch of the history in Mr. Lister's paper in the third volume of Holmes's System of Surgery.

25

See a most interesting foot-note to Professor Lister's paper on "Amputation," in Holmes's System of Surgery, vol. iii. pp. 52, 53.

26

This line is placed too low down; it should be in the middle third of the thigh.

27

This line is placed too low down; it should be in the middle third of the thigh.

28

Manuel d'Opérations chirurgicales.

29

As the surgeon will find it most convenient to stand on his own right side of the limb to be removed, the knife will be entered on the palmar side of the radius of the right arm, of the ulna of the left.

30

Teale, On Amputation by Rectangular Flaps, pp. 46-48.

31

Johnson's folio ed., p. 342.

32

Gross's Surgery, 6th ed. vol. ii. p. 1103.

33

International Encyclopædia of Surgery, vol. i. p. 641.

34

Spence's Surgery, pp. 800, 801.

35

Gross's Surgery, 8vo., 6th ed., vol. ii., p. 1106.

36

Excision of Scapula, p. 33.

37

Hey's Observations, 3d ed. pp. 552, 556.

38

Roux's Parallel between English and French Surgery. Translation abridged from Cooper's Surgical Dictionary, p. 106.

39

Syme's Principles, 4th edit. p. 145.

40

International Encyclopædia, vol. 1. p. 655.

41

Observations in Clin. Surgery, p. 48.

42

Monthly Journal of Medical Science for 1849, vol. ix. p. 951.

43

Med. Times and Gazette, June 3, 1865.

44

Operative Surgery, p. 170.

45

Annali Universali de Medicina, Milano, 1857.

46

Med. Chir. Transactions of London, vol. liii., p. 175.

47

Carden's (of Worcester) Pamphlet, pp. 5, 6; and British Medical Journal, 1864.

48

B. Bell's Surgery, 6th ed. vol. vii. pp. 336-339.

49

In diagram the amputation is drawn as if for middle third of thigh.

50

Teale, op. cit., pp. 34, 39.

51

Edin. Med. Journal, for April 1863.

52

Edin. Medical Journal, March 1879.

53

On Diseases and Injuries of Joints, p. 121.

54

For a very large amount of most interesting and valuable information on the whole subject of excisions of joints, I would refer to Dr. Hodge's most excellent work on this subject—On Excisions of Joints. By Richard M. Hodge, M.D., Boston, Massachusetts.

55

See Syme's Observations on Clinical Surgery, pp. 55, 57; Hodge on Excision of Joints, p. 63.

56

Maunder's Operative Surgery, 2d ed. p. 123.

57

Edin. Med. Journal, May 1873.

58

Quoted by Mr. Porter. Dublin Quarterly Journal for May 1867, p. 264.

59

A-A. Deep palmar arch; B. Trapezium; C. Articular surface of ulna; Dotted lines include the amount removed in Lister's earlier operations; Unshaded portions are those removed by Lister in cases where the disease is limited to the carpus. (Reduced from Lister's diagram in Lancet, 1865.)

60

Skey, Op. Surg., 2d ed. p. 438.

61

Abridged from Butcher, Op. and Con. Surgery, p. 208.

62

Science and Art of Surgery, 3d ed. p. 745.

63

On the Surgical Treatment of Children's Diseases, pp. 454-6.

64

Clinical Society's Transactions, vol. xiii. p. 71.

65

Billroth of Vienna and Pelikan of St. Petersburg, quoted from Heyfelder by Hodge on Excision of Joints, p. 161.

66

Operative and Conservative Surgery, pp. 28, 138.

67

On Excision of Knee-Joint, pp. 18, 20.

68

Operative and Conservative Surgery, p. 169.

69

Mr. Jones of Jersey, Med. Chir. Trans., vol. xxxvii. p. 68.

70

Lancet, Oct. 1, 1859.

71

Barwell On Diseased Joints, p. 464.

72

Syme On Excision of the Scapula, pp. 13-26, 1864.

73

Butcher's Operative and Conservative Surgery, p. 225.

74

For an excellent case, see Annandale on Diseases of the Finger and Toes, p. 261.

75

Holmes's Surgery, 3d edition, vol. iii. p. 771.

76

Brit. and Foreign Med. Chir. Review for July 1853.

77

Mr. Holmes in Lancet for February 18, 1856.

78

Ibid. for May 1865.

79

Butcher, Operative and Conservative Surgery, p. 354.

80

See Butcher, Operative and Conservative Surgery, p. 356.

81

See case by the author in the Edin. Med. Jour. for June 1868.

82

a. Elliptical incision for entropium; b. wedge-shaped incision for ectropium.

83

Ophthalmic Hospital Reports, vol. i. p. 121.

84

Fig. viii. illustrates 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.

85

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 canaliculus.

86

Diagram of operations for convergent squint—A A, line of sub-conjunctival incision; B B, line of Dieffenbach's operation; c, wire speculum.

87

The Radical Cure of Extreme Divergent Strabismus. J. Vose Solomon, F.R.C.S., 1864.

88

Ophthalmic Hospital Reports, vol. iv. part ii. p. 197.

89

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.

90

Ophthalmic Hospital Reports, vol. i. p. 224.

91

Streatfeild on Corelysis. Ophthalmic Hospital Reports, vol. ii. p. 309.

92

a iris; b lens; c cornea. The hook is seen applied to the adhesion between lens and iris.

93

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.

94

Resulting stump after the stitches are inserted.

95

Ophthalmic Hospital Reports, vol. iv. part 1.

96

Operation for formation of a new nose from the cheeks; a a, flaps approximated in middle line; B B, outer part of bed of flaps stitched up; C C, triangle at each side left to granulate.

97

The Restoration of a Lost Nose by Operation, p. 57; an excellent monograph on the subject.

98

Operation for formation of a new nose from the forehead:—a, prominence of flap which is to be used as septum; b, left-hand corner of flap, which is twisted and fastened at c; d, one of the tubes or quills over which the nose is moulded.—(Modified from Bernard and Huette.)

99

Syme's Observations in Clinical Surgery, p. 132.

100

Diagram of V-shaped incision; A B A, dots showing points for sutures.

101

Diagram of incision for scooping out a shallow tumour by scissors.

102

Diagram of incisions:—C A C, outline of incision for removal; C A D, outline of flap on each side; b, prominence of chin; C C, dotted lines, showing incisions to enlarge mouth, if required.

103

Diagram of flaps in position:—A A, corners of flaps brought up and approximated by silver sutures; C C, new lip got by lateral incisions, skin and mucous membrane being united by silk threads; E E, gap left to granulate.

104

Fig. xxiii. shows the incision bounding the cleft.

105

Fig. xxiv. shows the diamond-shaped wound before the sutures are applied.

106

Diagram of operation for double harelip:—a, stitch through both sides and wedge-shaped portion, which also aids the septum; b, other stitches approximating edges.

107

Diagram of double harelip, with projecting bone:—a, central piece of lip, dotted lines showing incision; b, projecting bone bearing teeth, which are generally small and stunted.

108

Diagram of operations on the jaws:—a, incision for removal of the whole upper jaw; b, incision for removal of alveolar portion and antrum; c, incision for removing the larger half of lower jaw; the opposite side is the one supposed to be operated on, and the incision is crossing the symphysis and turning up at a right angle.

109

Operative Surgery, p. 265.

110

Lancet, July 1, 1865.

111

Temporary compression of the facial can be easily managed, in cases where it is of much importance to avoid loss of blood, by passing a needle from the outside through the skin above the vessel, then under the vessel, and out again through the skin below. A figure-of-eight suture can then be thrown round both ends of the needle, and the artery thus thoroughly compressed.

112

Syme, Contributions to the Path. and Practice of Surgery, p. 21; Carnochan of New York, Cases in Surgery.

113

Contributions to the Path. and Prac. of Surgery, pp. 23, 24.

114

Lancet, July 1, 1865.

115

Rough diagram of operation for salivary fistula:—a, section of cheek close to buccal orifice; b, section of zygoma, muscles, etc.; c, the duct of the parotid; d, the fistulous opening of the cheek; E E, the thread knotted inside the mouth; f, the palate.

116

Lancet, Feb. 4, 1865.

117

Med. Times and Gazette for Feb. 10, 1866.

118

Lancet, April 20, 1872.

119

Transactions International Medical Congress, 1881, vol. ii. p. 460.

120

Gross's Surgery, vol. ii. p. 472.

121

Langenbeck, Archiv, ii. p. 657.

122

Med. Chir. Trans. for 1867-8.

123

Diagram of staphyloraphy, chiefly to illustrate the passing of the threads:—a, the first thread; b, the second. The dotted line at edge of fissure shows amount to be removed; the other dotted lines showing size and position of the incision through the mucous membrane above.

124

Holmes's Surgery, vol. ii. pp. 504-513.

125

Edinburgh Medical Journal for Jan. 1865, Mr. Annandale's instructive paper on "Cleft Palate."

126

Diagram of fissure of hard palate:—a, anterior palatine foramina; b, posterior palatine foramina with groove for artery; c, incisions requisite to free the soft structures.

127

Holmes's Diseases of Children, p. 555.

128

Leçons sur la Trachéotomie, p. 10.

129

Rough diagram of larynx and trachea:—A, crico-thyroid space, laryngotomy; B B, dotted outline of thyroid isthmus and lobes, defines the upper and lower positions for tracheotomy; C, thyroid—D, cricoid cartilages; E, dotted outline of thymus gland in child of two years; F F, outline of clavicles and jugular fossa.

130

Surgical Observations, p. 335. See also Harrison On the Arteries, vol. i. p. 16.

131

Leçons sur la Trachéotomie, p. 9.

132

Lectures on Surgery, 3d ed., vol. ii. p. 900.

133

Clinical Surgery in India (1866), p. 143.

134

Mr. John Wood, Path. Soc. Trans., vol. xi. p. 20.

135

South's Chelius, vol. ii. p. 400; and case recorded by Spence, in Ed. Med. Journal, for August 1862.

136

Med. Chir. Transactions of London, 1872.

137

British Med. Journal (Nos. 643, 644), 1873.

138

Gross's Surgery, 6th ed., vol. ii. p. 342.

139

Guy's Hospital Reports for 1858.

140

Both in Guy's Hospital Reports, second series, vol. ii.

141

Edinburgh Medical Journal for June 1866.

142

Description of Sir Spencer Wells's Trocar.—"It consists of a hollow cylinder six inches long, and half an inch in diameter, within which another cylinder fitting it tightly plays. The inner one is cut off at its extremity, somewhat in the form of a pen, and is sharp. The sharp end is kept retracted within the outer cylinder by a spiral spring in the handle at the other end, but can be protruded by pressing on this handle when required for use. When thus protruded it is plunged into the cyst up to its middle; the pressure on the handle is taken off, and the cutting edge is retracted within its sheath. The fluid rushes into the tube, and escapes by an aperture in the side, to which an india-rubber tube is attached, the end of which drops into a bucket under the table. The instrument is furnished at its middle with two semicircular bars, carrying each four or five long curved teeth like a vulsellum. These teeth lie in contact with the outer surface of the cylinder, but can be raised from it by pressing two handles. When the cyst begins to be flaccid by the escape of the fluid, these side vulsellums are raised, and the adjoining part of the cyst is drawn up under the teeth, where it is firmly caught and compressed against the side of the tube."

143

For further details on the operations described above, reference may be made to Sir Spencer Wells's work on ovarian disease, and to the very valuable papers contributed by Dr. Thomas Keith to the Edinburgh Medical Journal. To the latter especially the author is indebted for much oral instruction, and for the opportunity of seeing his careful and dexterous mode of operating.

144

Lect. on Surgery, 3d ed., vol. ii. p. 998.

145

Operative Surgery, p. 462.

146

Rough diagram of abnormal course of obturator and its relation to the neck of a hernia. Parts seen from the inside: h, femoral hernia; a, femoral artery; v, femoral vein; e, epigastric artery; o, obturator from epigastric (dangerous); s o, obturator from epigastric (safe); n o, normal course of obturator; i r, internal inguinal ring; Sp c, spermatic chord and its vessels; g, Gimbernat's ligament; +, in triangle of Hesselbach.