it is still limited to the superficial parts, it may be removed by
the knife; the incisions being made at a considerable distance from
the margins of the ulcer, so that those parts which may be supposed
to have assumed a disposition to malignant action, may be taken away
along with the ulcer. In more advanced cases, it may be necessary
that the incisions should extend in depth to the bone; and it may
be prudent to insist on a portion of the bone exfoliating, the
periosteum being removed, and some potential cautery applied to the
exposed surface,—as the alumen ustum, oxydum hydrargyri rubrum, &c.
The actual cautery cannot be applied with safety to the cranium. Even
where the integuments only are removed, and that to a small extent,
and in a proper form, it is vain to think of approximating the parts
and procuring union by adhesion; the wound must granulate. There is
no difficulty in suppressing hemorrhage; either ligature or temporary
pressure may be employed according to circumstances. Mild dressings
are to be applied, and proper support afforded. The parts should be
kept clean, and for that purpose the surrounding scalp must be shaved
repeatedly.
_Tumours of the Scalp._—Tumours of a sarcomatous nature are seldom
met with in this situation, but the adipose are not so unfrequent.
The latter are easily removed, being seldom of large size, and their
attachments being loose, unless when they have been irritated by
accident or maltreatment. When sarcomatous growths do occur, they are
to be excised, with those precautions which were formerly mentioned
when treating of tumours generally.
Vascular growths not unfrequently form in the scalp, and attain
considerable size; in general they are either congenital, or the
degenerations of nævi materni. They may be so extensive as to forbid
surgical interference; or they may be so indolent, may partake so much
of the nature of simple varix, as not to warrant it. If small, they
can be readily removed by the knife, the incisions being made rapidly,
and wide of the diseased structure. If the tumour be prominent,
extensive, and at all active, the employment of ligature is a more
safe and equally effectual practice. One or two ligatures may suffice
to encircle the swelling, or, as in other parts of the body, it
maybe necessary to pass a great many double ones beneath the part,
to separate their extremities, and to tie them to each other around
the base of the tumour, the last being drawn so as to tighten all the
others. Little benefit can be expected from tying, either at once or
at different periods, the larger arterial trunks whose ramifications
supply the diseased structure, the inosculation amongst the vessels
around the tumour being so extremely free. But, in cases where the
disease cannot be otherwise combated with any hope of success, ligature
of the common carotid, on the affected side, may be tried as a last
resource. The practice has proved successful in some cases of this
disease, involving parts of the head and face to such an extent, or in
such a situation, as to forbid any attempt at removal of the growth.
Encysted tumours frequently form in the scalp, and, if undisturbed,
become large; they seldom occur singly. The disease appears in many
cases to be hereditary, and it frequently happens that several members
of one family are at the same time afflicted with it. The contents of
the tumours vary as to consistence, but are generally atheromatous.
The cyst is thick, and loosely connected with the surrounding cellular
tissue; but as the tumour increases, the adhesions often become firm
and intimate, more especially towards the skin. When the tumour is
of small size, it is unnecessary to adopt any preparatory measures
for its removal, not even to shave the scalp: the surface may be
cleared a little with scissors. The swelling is transfixed, in the
direction of the fibres of the occipito frontalis, by means of a curved
sharp-pointed bistoury, and its internal structure is exposed by the
knife being carried outwards. The soft contents are evacuated, and
the sac is easily extracted by means of common dissecting forceps.
The integuments are then laid down and retained in apposition, no
sutures being necessary, and in many cases the wound heals by adhesion;
sometimes a small coagulum forms between the edges of the wound, and
is detached some days afterwards; then slight suppuration ensues.
In larger tumours, however, a straight and narrow knife is perhaps
the most convenient instrument for accomplishing removal. The part
is transfixed, and in most cases it is necessary to take away an
elliptical portion of the integuments, a part of the cyst corresponding
to which is of course simultaneously removed; the remainder of the sac
is pulled out by the forceps. If the adhesions at certain points are
firm, they may be touched with the extremity of the knife, so as to
expedite the extraction; and if after the operation there is reason
to believe that the whole of the secreting surface has not been taken
away, a pointed piece of caustic potass may be applied to the suspected
parts. If the tumour is very large, the cyst can often be removed
without difficulty unopened, sufficient integument being left to cover
the exposed surface. In consequence of such operations on the scalp,
erysipelas often supervenes, and precautions ought therefore to be
adopted to prevent its occurrence, by a little preparation beforehand,
by keeping the patient’s bowels freely open, confining him to moderate
and mild diet, and avoiding exposure to moist atmosphere and easterly
winds.
Osseous tumours of the cranium seldom attain any great size, and are in
general neither troublesome nor dangerous. Small ivory exostoses are
the tumours most frequently met with in this situation, and require no
treatment whatever.
Tumours of malignant character occur, though rarely; commencing either
in the diploe of the skull or on the surface of the dura mater, soon
enlarging, and involving the parts around. Two or more sometimes form
in one patient; they are attended with excruciating pain, and rapid
destruction of the bone, and are followed by extinction of life either
at an early or remote period. They are entirely beyond the reach of
surgery; as are also those tumours, occasionally met with in children,
which project through the cranial sutures and contain fluid; such are
analogous to the disease named spina bifida, hereafter to be spoken of.
I may here remark, that puncture of the brain, with the view of
abstracting fluid in chronic hydrocephalus, is an operation not often
likely to be followed by success, and it may even accelerate the
fatal issue. Some cases are recorded in which benefit is said to have
arisen from the practice. Pressure was applied and kept up after the
evacuation of the fluid.
DISEASES OF THE EYE AND ITS APPENDAGES.
_Of Inflammation and Abscess of the Lachrymal Passages._—In former
times, all affections of the lachrymal passages, and of the parts in
the neighbourhood, were denominated fistula lachrymalis, and were all
treated nearly in the same manner, by opening the sac, and inserting
probes, knives, terebræ, scalpra, caustics, and red-hot irons; the
anatomy of the various parts being then ill understood, and the
opinions as to the origin and nature of the diseases being founded on
erroneous theories regarding the defluxion of acrid humours, formation
of imposthumes, fungous growths, &c. The term, however, which was
indiscriminately applied to all diseases in the inner corner of the
eye, accompanied with derangement of the lachrymal secretion, is now
confined to a distinct form of disease, as will afterwards be mentioned.
Inflammation sometimes occurs in the loose cellular tissue covering the
lachrymal sac,—whilst that cavity remains free of all disease,—and is
attended with some obstructions to the passage of the tears in their
natural course, on account of the eyelids becoming swollen, from an
extension of the inflammation. The morbid action resembles erysipelas
in its nature, and usually terminates in unhealthy suppurations; thin
purulent matter lodges in the opened out cellular membrane, a soft
boggy tumour is formed, and the superimposed integuments become of a
bluish colour, as in the case of other scrofulous collections.
Though the affection is at first unconnected with the lachrymal sac,
this organ may ultimately be involved. It may become the seat of a like
unhealthy inflammation, and matter may consequently form within its
cavity; or, on account of the pressure of interstitial deposit around,
the parietes of the sac may ulcerate before the abscess of the cellular
tissue in front has discharged externally. Thus, the cavities of the
lachrymal sac, and of the external abscess, will communicate with each
other. If, after an external aperture has been made either by nature or
by art, any doubt exist as to whether the sac is involved or not, such
doubt will soon be removed by dexterous use of the probe.
In the treatment of this affection, it will be necessary, at the
commencement, as in all other local inflammatory diseases, to attempt
the accomplishment of resolution, by attention to the general health,
local abstraction of blood, and warm fomentations. When matter has
formed, it ought to be evacuated as soon as possible by a small
incision, as there will then be less risk of the deeper parts becoming
secondarily affected; or if the integuments have sloughed, and the
matter has been discharged spontaneously, the natural opening may be
enlarged either with the knife, or with the caustic potass. If it be
discovered that the lachrymal sac is opened into, the same treatment is
necessary as if it remained entire; the matter is to be allowed free
exit, and granulation encouraged; in most cases, the aperture in the
sac is soon repaired, and the parts heal as quickly and soundly as if
the disease had been confined to the external cellular tissue. Light
dressing during the cure, preferable in all cases, is more especially
necessary in this situation.
_Of Inflammation of the Lachrymal Sac._—When the lachrymal sac becomes
inflamed, it enlarges considerably; the swelling is small, hard,
circumscribed, deeply seated, and extremely painful, more especially on
pressure. At first the integuments are of their natural appearance, the
increased action being confined to the sac, but they are soon involved,
and often to a considerable extent; they become red and swollen, and
as the surrounding parts are affected, the swelling increases. In some
cases, the eyelids, the caruncle, and the conjunctival covering of
the eye, participate in the inflammatory action. The inflammation is
in most instances caused, or at least preceded, by some obstruction
in the nasal duct, in consequence of which, the tears are interrupted
in their natural course downwards, and either accumulate in, and
distend the sac, or flow over on the cheek, the puncta lachrymalia
remaining open. After increased vascular action has been produced,
the lachrymal secretion is increased to a greater or less degree, and
much inconvenience is caused to the patient by the profuse discharge
following an unnatural course. When inflammation is intense, lymph is
effused into the passages, producing obstruction sometimes complete.
The mucous lining of the nasal duct becomes swollen, from the vascular
excitement, either throughout its whole extent, or at one point only;
and in either case the flow of the tears must be interrupted, either
partially or wholly, according to the degree of swelling. The vitiated
secretion of the part may also contribute towards narrowing the canal,
by lodging and concreting there. But a more complete and permanent
obstruction is formed by effusion of lymph, under or on the mucous
lining, as happens in other canals of similar construction: and in this
case also, the stricture may be partial or complete, according to the
quantity of effused matter, and the extent of surface affected.
As the inflammation abates, mucous fluid is copiously effused from
the surface of the sac, and the swelling increases, though the pain
is less. The collected fluid may be partially evacuated through
the puncta, either spontaneously, or in consequence of the patient
instinctively pressing with his finger on the swollen part; or the
puncta may be obstructed by the same causes as the nasal duct, and
then the discharge of the fluid is prevented in both directions; it
consequently accumulates still more, and causes greater bulging.
Fluctuation is perceptible, and the collection protrudes outwards and
forwards, being least resisted in these directions. It is seldom that
the puncta are obstructed, and consequently the swelling does not
attain any great size, the sac being relieved by some of its contents
always flowing upwards, after a certain degree of distension. As the
inflammation farther subsides, the mucous secretion diminishes, and
the accumulation and swelling are less: in fact, the patient may at
this period prevent a tumour from forming in the corner of his eye, by
from time to time pressing gently on the sac, and forcing the lachrymal
secretion upwards, as it begins to accumulate. This state of matters
may continue for a long period, without causing much inconvenience,
and getting neither better nor worse; the patient is merely obliged to
apply his finger and handkerchief more frequently to his eye than would
otherwise be required. In almost all cases, the obstruction of the
nasal duct is complete, or nearly so, and consequently the fluid cannot
pass downwards into the nose, though it may occasionally appear to do
so, on account of the discharge from the Schneiderian membrane being
increased at the same time with that of the lachrymal sac. The ductus
ad narem, though wide in the skeleton, is of very limited dimensions
in the living body, and is in consequence readily made impermeable to
mucous fluid, by even slight thickening of its lining membrane.
It has been already observed that the above-mentioned condition of
the parts may continue for a considerable period; but in other cases
purulent matter soon forms within the distended sac; or, at least, the
contents of that organ are so altered in colour and consistence as to
resemble intimately purulent fluid. The secretion may or may not be
pus, probably it is not in some cases; but as the decision of this
point is practically unimportant, the description of it as purulent
can scarcely be objected to. In most cases, when the puncta either are
or become clear, no suppuration, or deterioration of mucus into fluid
like pus, occurs; merely chronic distension of the sac continues, the
patient being able to avert incited action, by occasionally squeezing
out the contents, and thereby removing tension. There is merely an
Epiphora; or, as it is otherwise called, Blenorrhœa, or Stillicidium
lachrymarum. The last term is by some applied to increased lachrymal
secretion, without affection of the sac, the tears being secreted more
quickly than the puncta can carry them away, and consequently running
over on the cheeks, excoriating the surface, and producing an irritable
condition of the eye. The simple epiphora may be of long duration,
yet the parts are extremely liable to assume inordinate action, in
consequence of slight injury, or exposure to cold; thus suppuration
will ensue.
When purulent matter forms, fluctuation becomes more distinct, the pain
increases, and there is slight headache and fever. The integuments
inflame more and more, and, if the case is neglected, ultimately
give way by sloughing. A small ragged opening, often indirect, is
formed, and the contents of the sac are not thereby all discharged;
the thinner fluid only escaping, whilst the more viscid remains and
clogs the aperture. The swelling is not much diminished; the margins
of the aperture thicken, become indurated, and contract, the purulent
contents of the sac are gradually discharged, and the tears afterwards
flow through the opening. The parts are now in that condition to
which the term _Fistula lachrymalis_ is with propriety applied. The
swelling of the canal may gradually subside, the tears resume their
wonted course, and the opening may then contract, and the parts
cicatrise; but frequently the fistula remains open for a long period,
gradually diminishing in diameter, and only a small passage, almost
imperceptible, ultimately remaining, through which a few drops of
lachrymal fluid are occasionally discharged. Sometimes the fistula
closes entirely without the obstruction of the nasal duct having been
removed, and the lachrymal sac remains in consequence distended; then
the tears or mucus, either clear or turbid, can generally be squeezed
through the puncta.
[Illustration]
It frequently happens that the meibomian glands are the seat of morbid
action, along with the lachrymal passages; their secretion is changed,
becoming in some cases thick and caseous, in others puriform. By some,
affection of the meibomian glands has been considered as the cause of
inflammation and abscess of the lachrymal sac. This opinion, however,
cannot be agreed to, for the diseases are not always coexistent; and
besides, the affection of the surface of the lachrymal sac and ductus
ad narem is as likely to be the consequence of morbid action, extending
upwards from the nostrils, as of morbid secretion from the eyelids
blocking up and irritating the puncta and the lachrymal passages.
Disease of the meibomian glands in the under eyelid often exists along
with disease of the lachrymal passages, but the latter is generally the
primary affection; the conjunctival covering of the eyelid is at the
same time inflamed, swollen, and often granulated.
In some cases of abscess in the lachrymal sac, before the integuments
give way, the subjacent bone becomes diseased in consequence of the
pressure of the confined matter; portions are affected by necrosis,
and after their separation considerable deformity is produced. The
exfoliation is often very tedious, and is attended with discharge
of fetid thin fluid from the nostril, and from the ill-conditioned
lachrymal fistula.
Fistula lachrymalis is often merely one of the symptoms of disease
in the bones of the nose, with obstruction of the nasal duct,—as in
patients who have suffered from mercury.
_Treatment._—In the treatment of epiphora or blenorrhœa—that is,
chronic collection of a mucous fluid in the lachrymal sac, with weeping
of the eye—a primary object of attention is the state of the general
health. The habit of the patient will commonly be found weak, and, if
not decidedly strumous, at least inclining towards that diathesis. In
such cases the digestive organs must, if possible, be brought into a
vigorous state by tonics and nourishing regimen. The local treatment
chiefly consists in applying stimulants to the internal surfaces of the
palpebræ and lachrymal sac. For this purpose, solutions of stimulating
and astringent substances, termed collyria, and various ointments, are
employed. At first they ought to be used of rather a mild nature, and
their stimulating power must be afterwards increased gradually. The
applications are placed between the eyelids, and, becoming mixed with
the natural secretion, pervade the diseased surfaces; and, being taken
up by the puncta lachrymalia, are afterwards conveyed into the sac. It
was formerly the custom to inject the fluids into the sac; but this
is unnecessary so long as the puncta and canaliculi remain pervious,
and the permeability of these can be readily ascertained by means of a
small probe. Permanent pressure on the sac can be productive of no good
effect, and is extremely liable to do harm. The repeated application of
very small blisters over the sac has been found useful.
Introducing minute gold probes through the puncta has been much
recommended, but in the generality of cases can be of little service.
The probes are too limber for removing mechanical obstruction, or for
affecting in any way the contracted or strictured duct. But passing
of the probe may tend to remove the irritability of the passage,
as happens in the urethra, and thence some relief may follow. Much
dexterity is required in using either the probe or syringe. The puncta
are often very small, and it is in general necessary to dilate them by
means of the point of a common pin, before any instrument can be passed
through them into the sac. The point of the probe being introduced
into the punctum, either superior or inferior, must first be carried
towards the nose for about 2-10ths of an inch, the instrument being
lightly held betwixt the fore and middle fingers of the right hand. It
is then directed downwards and backwards. Care must be taken to prevent
entanglement in folds of the membrane. Should obstruction be felt, the
instrument is withdrawn a little, and then carefully and gently carried
in the right direction. The small syringe is managed with one hand,
whilst, with the forefinger of the other, the punctum not occupied by
the pipe is compressed.
Neither can much or any benefit be expected to follow attempts to force
obstruction in the lachrymal passages, by the weight of a column of
mercury. A plan of dilating and rectifying the nasal duct by styles
introduced through the puncta has been proposed, but scarcely deserves
to be mentioned as a means of cure.
When suppuration is threatened, with increase of the swelling,
inability of the patient to empty the sac by pressure, redness of the
integuments, &c., an early opening should be made into the tumour, in
order to prevent further and more serious mischief. A small opening
into the sac cannot be productive of so much injury as forcible
dilatation of the canaliculi, followed by and causing ulceration. The
point of a straight narrow bistoury is to be entered into the sac,
and carried on into the nasal duct, the knife being pushed downwards,
backwards, and a little inwards, in the direction of that passage. The
point to be punctured can always be readily ascertained by feeling for
the firm ligament which attaches the orbicularis palpebrarum to the
nasal process of the superior maxillary bone, as the upper orifice
of the ductus ad narem is situated immediately below this tendon; by
introducing the knife below the ligament, and within the sharp edge
of the orbit, and then carrying it forward in the direction already
mentioned, the surgeon cannot fail to enter the nasal duct. The knife
should be followed by a probe, and ought not to be entirely withdrawn
till the probe is fairly lodged in the duct, otherwise the surgeon will
experience much difficulty in the after proceedings. If the knife be
not pushed into the duct, a blunt instrument can scarcely be introduced
afterwards. Some force is required, but is not hurtful, provided it be
made in the proper direction, so as to remove the obstruction in the
duct without injuring the bones and other parts in the neighbourhood.
After the operation, some drops of blood should escape from the
corresponding nostril, showing that it has fairly entered this passage;
or the patient being made to expire forcibly, the nostrils being at the
same time compressed with the fingers, air, blood, and mucus are forced
upwards through the opening made.
Many and various modes have been pursued with a view of securing a
pervious state of the nasal duct. Instruments of different kinds have
been introduced through the puncta, through the opening in the sac,
and through the termination of the duct under the spongy bone, and
have been retained for a longer or shorter period, according to the
fancy, or theory, or plan of the surgeon. The first of the methods
of introduction is abandoned, as already stated. By the ancients the
passages in fault were got rid of altogether, being either cauterised
or destroyed by escharotics.
The passing of probes into the duct from its lower aperture is useful
in removing trifling obstructions caused by concretion of deteriorated
mucus, or slight thickening of the lining membrane, and in chronic
dilatation of the sac with probable contraction of the duct. But, at
the same time, it is an operation requiring much dexterity, and which
ought not to be attempted till after much practice on the dead body.
The first introduction of the instrument is always the most difficult,
from obstruction by a valvular projection of the membrane at the lower
orifice, the use of which in the healthy state of the parts must be
apparent. Destruction of it renders after-introduction of instruments
much more easy.