with an ivory handle, quite slender, and curved at the extremity, which
is fashioned after the manner of a fenestrated speculum, and not more
than a third of an inch in width. These instruments may be conveniently
replaced by a common speculum and the fingers of an assistant: still,
they are very useful, and I prefer them to any other contrivance. The
hook for fixing the ball is double (Fig. 2.), resembling that contained
in some of the older eye-cases. It ought not to exceed five inches in
length, and should be provided with a movable slide, to allow of the
proper separation of the branches, each of which, two lines in width,
terminates in a short hook as delicate as the finest needle. The
forceps need not be quite the ordinary size; and, as to the scissors,
the common pocket-case pair will answer the purpose much better than a
curved or more delicate instrument. The knife I rarely use. A curved
director (Fig. 3.) is serviceable, as it enables the operator to judge
of the extent of his incisions.
[Illustration: _Fig. 1._]
[Illustration: _Fig. 3._]
[Illustration: _Fig. 2._]
In performing the operation, the patient may be either in the
semi-erect or reclining posture, with his head supported by an
assistant, or properly elevated by pillows. I generally prefer the
latter, as the eye is more manageable, and the patient less apt to
faint than when sitting. The face should look towards the light, and
the sound eye be covered with a bandage, to enable the patient the
better to roll the other outwards. If the surgeon be ambidexter, it
does not matter where he stands: but if he uses one hand more adroitly
than the other, he should place himself on the right side when he
wishes to operate on the left eye; and, conversely, on the left if he
wants to operate on the right. Only two assistants are necessary; one
of whom, standing at the head of the patient, elevates the upper lid,
and fixes the eye by inserting the sharp hook into the sclerotic coat,
about two lines behind the cornea: the branches of the instrument
being separated one-fourth of an inch, and the interval between them
accurately corresponding with the horizontal axis of the eye. This
precaution is important, and should never be neglected, otherwise it
will by no means be so easy to find the affected muscle. The points
of the hook should be fairly implanted into the substance of the
sclerotic tunic, but no more. If it be passed simply through the
conjunctiva, it will be impossible to steady the eye, to say nothing
of the danger of lacerating that membrane, and thus inflicting
unnecessary pain upon the patient. On the other hand, if it be pushed
through the fibrous coat, violent inflammation might be set up. The
other assistant, placed on the side of the affected eye, depresses the
lower lid, and hands the sponges to the operator. It is sometimes more
convenient to let this assistant steady the eye.
[Illustration]
Everything being thus arranged, the operator pinches up a small fold of
the conjunctiva, just behind the hook, or, in other words, about three
lines behind the cornea, and makes a vertical incision into it with the
knife or scissors, as he may prefer. Relinquishing the forceps, the
edges of the wound will at once retract, exposing thereby a surface
from four to six lines in length by two or three in breadth. At this
moment there is usually some degree of hemorrhage, amounting often to
more than half a teaspoonful, especially if the incision has been made
too far back near the semilunar valve, where the parts are always more
vascular than further forward. To arrest this a small sponge, pressed
out of cold water, should be repeatedly applied; or, if it prove
troublesome, the operation may be suspended until it ceases. The ocular
fascia[33] is next divided, when the muscle, now fairly exposed, is to
be cut across with the scissors, one of the blades of which is passed
behind it. The moment this is accomplished, the eye, from the force
exerted upon it by the hook, springs towards the opposite side, and the
muscle retracts within its sheath, especially if it has been thoroughly
liberated from its connexions with the surrounding parts. To effect
this, which I regard as of paramount importance, the scissors should be
carried for some distance around the ball, nearly as far, indeed, as
the margins of the adjacent straight muscles.
As soon as the affected muscle is divided, the eye usually at once
resumes its natural position in the orbit, moving, if the other be
sound, in perfect harmony with it. Occasionally, however, it retains
some degree of its original obliquity; in which case it becomes
necessary to reapply the instruments, to ascertain the cause of it.
This will generally be found to depend upon an imperfect division of
the muscle, or of the surrounding cellular tissue, by which the muscle
is prevented from retracting sufficiently within its sheath. In some
instances it remains without any assignable cause, but rarely beyond a
few minutes, or, at farthest, a few hours.
The operation being over, the eye is bathed in cold water, to rid it of
any blood that may remain in the wound, and the patient is confined in
a dark apartment. Low diet should be enjoined for a few days, and, if
inflammation arise, recourse must be had to antiphlogistic measures. In
no case have I yet been obliged to abstract blood; a dose of aperient
medicine being all that was required. Locally cold or tepid water may
be used, as may be most agreeable to the patient’s feelings. When there
is a good deal of pain in the eye, with more or less constitutional
disturbance, such as slight shivering, headache, and nausea, warm
drinks and an opiate will be required. The ecchymosis which attends
this operation, and which is sometimes considerable, demands no
particular treatment: no inconvenience arises from it, and it commonly
disappears in a few weeks. I have never known suppuration or abscess
to follow the division of the muscles of the eye; such an occurrence
implies unusual violence, and cannot be too much condemned. The same
remark is applicable to the wounding of the sclerotic coat, and the
escape of the humours of the organ; an accident which has happened
several times in the hands of ignorant bunglers.
A few hours after the operation is completed, the margins of the
incision become coated with coagulating lymph, which is sometimes
effused in such quantities as to give rise to considerable pain, and
a sensation like that produced by the presence of a foreign body.
The vessels in the parts around are somewhat enlarged, there is more
or less lachrymation, and the lids feel stiff and uncomfortable. The
sclerotic coat at the bottom of the wound remains visible for five or
six days, when it becomes covered with granulations, which, uniting
with those at the sides, gradually fill up the gap; the whole process,
from the commencement to the completion of the cicatrization, occupying
from three to four weeks.
Now and then the process of cicatrization is retarded by the
development of fungous granulations. When this is found to be the case,
they should be snipped off with the scissors; a procedure decidedly
preferable to the application of the nitrate of silver, which is not
only painful but rarely effective.
It has been recommended by some surgeons that, as soon as the soreness
occasioned by the operation has subsided, the patient should begin to
turn his eye in a direction opposite to that in which it was held by
the contracted muscle, and that these efforts should be continued daily
until it regains its natural position in the orbit. In my early cases,
before I had devoted much attention to the subject, I adopted and acted
upon this suggestion, but the result in every instance disappointed me.
Nor do I now perceive any good reason for following it, since it does
not seem to me to be founded upon correct principles. Where the eye
still retains some degree of obliquity after the operation, it may be
positively assumed that the section of the affected muscle, or of the
fasciæ by which it is invested, has been imperfect; and when this is
the case it would be in vain to expect Complete success. Again, the eye
operated on may be entirely straight, and yet not move in concert with
the other. This I have witnessed repeatedly, and hence my invariable
rule is to divide at once the corresponding muscle of the opposite
side, for the reason already mentioned—that the distortion generally
involves both organs.
The operation for strabismus is liable to occasional failure, the
principal causes of which may be thus enumerated:—1. Imperfect section
of the affected muscle, or of the ocular and submuscular fasciæ. To
this subject I have already several times alluded, and it is not
necessary, therefore, to offer any further remarks concerning it in
this place, than to say that the operator should never neglect to
divide these structures most thoroughly. In bad cases the scissors must
be carried up and down as far as the contiguous straight muscles, so
as to denude completely the sclerotic coat for more than one-third of
its circumference. The fasciæ must be effectually raked up, otherwise
it will be impossible for the muscle to retract fully within its
sheath. 2. Excision of a portion of the conjunctiva, eventuating in
contraction of this membrane during the process of cicatrization, may
be stated as another cause of failure. As there can be no necessity for
such a procedure, since it does in no wise facilitate the operation,
I need hardly say that it should be studiously avoided. 3. Strabismus
is sometimes complicated with other diseases, such as convulsions,
epilepsy, hydrocephalus, and analogous lesions. When this is the case,
the operation cannot be performed with any prospect of success, and
had better be declined altogether. The existence of amaurosis does
not necessarily lead to failure; if cataract be present, it should be
broken or depressed either at the time of the operation or before. 4.
But the most powerful cause of all, in my opinion, and one which has
not been sufficiently insisted upon by writers, is the coexistence of
strabismus in both eyes, and the fact that our operative procedures
are usually limited to one of these organs; a circumstance at variance
alike with good practice and common sense. In several instances in
which only partial success attended my efforts, the whole difficulty
was fairly ascribable to this cause; and so thoroughly am I persuaded
of its importance, that I have laid it down as a rule never to
operate on one eye only when it is certain both are affected. The
only exception to this is where the patient is very young, when the
section of a single muscle will sometimes, though even then not always,
be sufficient. 5. A fifth cause of failure is the readherence of the
posterior extremity of the muscle to an unfavourable point of the
sclerotica, by which it is again enabled to exert an undue influence
over the movements of the eye. The manner of obviating this occurrence
has been already indicated.
The effect upon vision is at first rather disagreeable, at least in
some instances. It is only by degrees that the affected organ recovers
its functions, and in many cases a considerable period must necessarily
elapse before this is brought about. Occasionally, in fact, the retina,
from long disease or other causes, is so effectually paralysed that the
sight is never restored, and it is in instances of this description
that a slight return of the distortion may be looked for, however
well the operation may have been executed. Another effect sometimes
witnessed is double vision. This is obviously dependent upon a want
of agreement between the optic axes, and rarely lasts more than a few
days, unless the obliquity has been only partially remedied.
The only other effect which it is necessary to notice here, as
attendant upon this operation, is a peculiar prominence of the eye.
This is generally well-marked, though not equally so in all cases, and
imparts to the organ a full, bold expression; it is accompanied with a
considerable separation of the lids, and is caused by the liberation of
the organ from its confined situation.
The preceding remarks have special reference to convergent strabismus;
with slight modifications they are applicable to the other forms of the
lesion. From the more exposed situation of the eye the outer straight
muscle is much more easily approached and divided than the internal;
as to the relative facility of operating on the upper and lower, I
can say very little from personal experience, but should suppose the
difference, if any, to be trifling. As to the oblique muscles, I have
not had occasion to divide them in a single instance, nor should I,
from the knowledge I have on the subject, deem such a step necessary,
it being very doubtful whether they have any agency in the production
of strabismus. In several instances in which these fasciculi were
divided by Lucas, Calder, and others, no impression whatever was made
upon the distortion, and nearly all surgeons agree in the opinion that
they should not be interfered with.
Attempts have been recently made to disparage the operation for
strabismus, on the ground of the alleged tendency of the eye to return
to its original malposition, or the occurrence of a new deviation. No
proof, however, of such a result, founded upon an adequate number of
statistical facts, has been given to the profession. In my own cases,
so far as my information extends, not a single relapse has taken place
where the operation was performed on both eyes, although nearly a year
has expired since some of them submitted to it. Confirmatory of this,
it may be stated that Dr. F. B. Dixon[34] of Norwich, England, has
recently published a list of forty-one cases of convergent strabismus,
in thirty-one of which, twelve months after the division of the
internal rectus, both eyes were perfectly natural; in five, where one
organ alone was operated on, there was slight obliquity of the other;
in two, the squint was changed to a leer, and in three others, the eye
returned to its former malposition. These results, which are in the
highest degree gratifying, are sufficient to show that the operation
in question, first performed by Professor Dieffenbach of Berlin, in
October, 1839, deserves to be classed among the established resources
of surgery, which rarely exhibits such an amount of successful
terminations.]
_Of Nasal Polypi._—These tumours vary in texture and disposition, as
formerly stated: but the soft mucous or benign polypus is, fortunately,
by much the most frequent. Generally a great many coexist in one
or both nostrils, growing from different parts of the Schneiderian
membrane. Sometimes there is but one tumour, of a large size; and
in some cases a large cyst, containing colourless fluid, fills the
nostril. When numerous, they are in different stages of growth, and
generally adhere to the membrane by a narrow neck, though sometimes
several are attached by the same pedicle. It is not uncommon to remove
ten or twelve polypi, or even a greater number, before the nostril is
cleared. The parietes of the narrow passage betwixt the anterior and
posterior nares is their most common situation, though their bases may
proceed from the cells of the superior spongy bone.
The membranous covering of the inferior spongy bone, or of the anterior
cavity of the nostril, is often at the same time relaxed: indeed, this
of itself causes slight obstruction to the passage of air, and may be
mistaken for polypus by the patient and the unexperienced. Projection
of the cartilaginous septum to one side, with thickening of its
covering, may also give rise to the same mistake. This formation is not
uncommon, indeed it is rather frequent; and the projection is generally
to the left side, with corresponding depression of the right. The
circumstance may perhaps be accounted for by the pressure of the thumb
overbalancing that of the fingers in the habitual practice of clearing
the emunctory.
[Illustration]
In polypus, the passage of air is obstructed, the patient feels as if
labouring under a common cold—his head is stuffed: in cold and dry
weather air passes through the cavity, though with difficulty; in a
damp day the obstruction is complete. The tumour evidently increases,
comes lower down, and even projects upon the lip. There is watering
of the eyes, the lachrymal secretions being prevented from flowing
into the nostrils; and, in cases of old standing, the patient is deaf,
from the pressure of the tumours on the extremities of the Eustachian
tubes. This latter symptom is not constant, but depends on the position
of the tumours. I recollect an old gentleman, an elder of the kirk,
afflicted with nasal polypus, who for thirty years had not heard his
clergyman, though for twenty of these years he had attended service
regularly, and from a sense of duty. On removal of the tumours hearing
was perfectly restored.
The nose changes its form, is expanded and flattened. If the disease
is extensive, and particularly if the tumour is malignant, the bones
are separated, the eyes are protruded, and pushed outwards; indeed,
the face is so distorted as to have been compared to that of a frog.
Even in the benign form, when of long duration, great deformity of the
features is produced, and the patient rendered very uncomfortable.
Besides the symptoms already detailed, he suffers from acute pain in
the forehead—he breathes loudly and with difficulty, particularly when
asleep—he has lost the sense of smell, and does not relish food or
drink—and there is often profuse discharge of a dirty mucous fluid,
both externally and into the pharynx.
Soft mucous polypus may exist for many years, without depressing the
palate, or projecting into the fauces. The anterior nasal cavity is
its most frequent seat, and it widens and fills up the fissure between
the anterior and posterior cavities: frequently it projects backwards,
but is not visible, though it may be felt with the finger behind the
soft palate. Its growth is slow. It may become malignant, as well as
other adventitious structures equally simple; but such an occurrence
is extremely rare. It may exist for many years; and, when at length
removed, will be found of simple structure; and, if the operation
be well conducted, no reproduction will take place. The tumours are
supposed to be easily regenerated; but the truth is, that they are
seldom eradicated completely. In general some are left, and these,
emerging from the narrow space or cells in which they were confined,
soon become fully developed—they expand, and speedily take the place of
those which were removed. They can never be got rid of at one sitting:
the operation requires repetition once and again; and of this the
patient should at the first be made aware.
_Malignant Polypi_ are met with in different degrees of advancement.
Many are firm and fibrous, with an irregular surface and wide
attachment—do not grow with great rapidity—furnish a sanious and bloody
discharge, and give rise to painful feelings. If interfered with, their
increase is accelerated. If removed completely, reproduction may not
take place.
Tumours with broad bases, and of soft medullary consistence, attended
with extensive change in the structure of the membrane, and softening
of the bones and cartilages, grow very rapidly, fill the cavities and
expand them, giving rise to great deformity, as seen opposite. They
show themselves on the face, through the nostrils—protrude through
the floor of the orbit—get into the mouth behind the palate, through
the tuberous processes of the superior maxillary bone—or project
through the alveolar processes. The discharge from them is profuse
and fetid, and in some cases blood flows in no small quantity. Such
growths usually commence in one or other of the sinuses connected with
the cavity of the nose—sometimes, though rarely, in the frontal sinus.
When seated in the antrum maxillare, pain is experienced in the cheek
for a short time before swelling occurs. Soon the part enlarges, its
coverings are thickened, the bony cavity expands, and the patient’s
sufferings are excruciating. The teeth loosen, and sanious matter is
discharged from their roots. The tumour extends into the nostril, and
soon runs the course already mentioned. Malignant disease sometimes,
though rarely, commences in the anterior cavity of the nostril.
No satisfactory cause can be assigned for the appearance of either the
benign or malignant form of polypus.
The nostrils can be readily cleared of benign polypi, but seldom
completely, as already stated, by one operation: in several cases,
wherein only one or two tumours obstructed the cavities, I have had no
occasion to repeat my interference. If the attachments are broad and
extensive, a small curved blunt-pointed bistoury, or probe-scissors,
may be employed for their separation. Sometimes the tumours can be
pushed off by the finger, or by a probe with a blunt and forked
extremity: then they either are blown out by the patient, or fall
into the posterior cavity, thence into the pharynx, and are coughed
up or swallowed. In cases such as are usually met with, forceps and a
small vulsellum are the best instruments. The forceps should be about
half the size of those generally used or sold by cutlers as polypus
forceps. The patient is seated facing a good light and the body of the
prominent tumour is laid hold of by the vulsellum; the forceps are then
introduced, with the blades expanded, and carried backwards so as to
reach its neck, which is then to be firmly grasped by the instrument,
and gently twisted, so as to separate its connexions with the membrane.
No force, no jerking or pulling, is allowable. It may happen, even with
the gentlest and most careful management, that a small fragment of bone
comes away along with the tumour; but this generally can or should be
avoided: the cure is not rendered more certain by such an occurrence,
as has been supposed. One tumour being thus detached, the same process
is repeated with the others, till the cavity is cleared so far as
hemorrhage or the patient’s fortitude will admit. Both nostrils, if,
as is usually the case, both are stuffed, may be emptied at the first
sitting, so as to enable the patient to blow through them. When the
tumours filling the passage to the throat have been removed, so as to
allow the ready egress and ingress of air, and when the forceps can be
passed along the floor of the cavity, and are expanded and shut without
meeting any obstruction, examination is to be made with the finger. In
those who have long laboured under the disease, the fissure between
the cavities is so much expanded as to admit the little finger easily,
and by it the situation of the remaining tumours is ascertained, and
instruments guided to them.