Chapter 26

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.

INDEX.

Abdomen, operations on, 222.

Abernethy on ligature of external iliac, 8.

Adams on anatomy of common iliac, 4. on hip deformity, 133.

Ægineta, Paulus, on excision of joints, 108.

Allarton on median lithotomy, 269.

Amputation and excision contrasted, 113.

Amputation at ankle-joint (Syme's), 78. of anterior portion of foot (Hey's), 73. of arm, 62. at elbow-joint, 61. through femur, condyles of, 92. of fingers, 51-54. of fore-arm, 58. at hip-joint, 102. at knee-joint, 92. of penis, 286. at shoulder-joint, 63. at tarsus (Chopart's), 75. at thigh, 94. double primary of thigh, 106. of toes, 69. at wrist-joint, 56.

Amussat's operation, 252.

Anchylosis of elbow, excision for, 122.

Ankle-joint, excision of, 137.

Annandale on staphyloraphy, 203.

Anus, artificial, operation for, 252. artificial, removal of, 254.

Arendt, ligature of external iliac, 12.

Astragalus, excision of, 145.

Auchincloss on ligature of subclavian, 36.

Avery, hard palate, fissures of, 203.

Barwell on excision of ankle-joint, 139. on excision of tongue, 199.

Baudens on amputation at elbow-joint, 61. on amputation of anterior portion of foot, 75. on amputation at knee-joint, 92.

Bauer on recto-vesical lithotomy, 272.

Begbie, Dr. Warburton, on paracentesis thoracis, 220.

Bell, Benjamin, on amputation, 49. on amputation of ankle, 86. on amputation of thigh, 96.

Bell, Sir Charles, on ligature of femoral, 22.

Bell, George, on supra-pubic lithotomy, 271.

Bell, John, on ligature of gluteal, 14.

Bey, Gaetani, on amputation above the shoulder-joint, 70.

Bigelow, Dr., on litholapaxy, 276.

Billroth, Dr., on fissure of palate, 200.

Bladder, puncture of, 284.

Bonnet on radical cure of hernia, 245.

Botal on amputation, 47.

Bowditch on paracentesis thoracis, 221.

Bowman's operation, lachrymal canal, 153.

Brachial, ligature of, 242.

Brodie, Sir B. C., on lithotomy, 262. on lithotrity, 274.

Bromfield, amputation of leg, 86.

Brown, Baker, ovariotomy, 231.

Bryant, on excision of joints, 112.

Buchanan, Dr. A., on lithotomy, 269.

Buchanan, Dr. G., on excision of tongue, 198.

Buchanan, Dr. M., on excision of ankle, 140.

Buck's operation for anchylosis, 136.

Butcher, ligature of subclavian, 35. excision of joints, 110. excision of wrist-joint, 128. excision of knee-joint, 135. excision of metacarpals. 142.

Campbell, Professor, on ligature of gluteal, 15.

Carden's amputation at condyles of femur, 50, 94.

Carmichael on ligature of gluteal, 14.

Carnochan on neurectomy, 300.

Carotid, ligature of common, 28. ligature of external, 32.

Cataract operations, 160.

Celsus on amputation, 48. on excision of joints, 108.

Chamberlaine, on ligature of axillary, 40.

Chassaignac on tracheotomy, 206.

Cheiloplastics, Syme on, 178.

Cheselden on amputation, 49. on lithotomy, 260.

Chopart's amputation, 75.

Civiale on lithotrity, 275.

Club-foot, operations for, 297.

Cock on oesophagotomy, 216. paracentesis thoracis, 220. on puncture of bladder, 285.

Colles on ligature of brachial, 44.

Cooper, Sir Astley, on ligature of aorta and iliacs, 3, 10. on perineal section. 276.

Cornea, puncture of, 159. staphylomatous, excision of a, 168.

Corelysis, 170.

Crampton, Sir Philip, on excision, 119.

Crichton on lithotomy, 262.

Critchett's operation of iridesis, 169. operation for staphyloma, 172.

Croft, Mr., on hip disease, 132.

Culbertson on excision of hip, 132.

Cullerier on phymosis, 287.

Curling on operation for artificial anus, 253.

Cusack on treatment of brachial aneurism, 43.

Davies, Redfern, on radical cure of hernia, 244.

Davy's (Mr. Richard), lever, 105.

Desault on ligature of axillary, 40.

Dieffenbach on excision of upper jaw, 191.

Dieulafoy's aspirateur, 284.

Dionis' amputation of leg, 87.

Dubrueil, amputation at wrist, 57.

Duncan, Mr. J., on artificial anus, 254.

Dupuytren on ligature of iliac, 11. on ligature of subclavian, 36. amputation at elbow-joint, 62. removal of artificial anus, 254. on bilateral lithotomy, 268.

Durand, case of hæmorrhage from iliac, 12.

Durham on thyrotomy, 215.

Dzondi on radical cure of hernia, 246.

Elbow-Joint, amputation at, 62.

Ellis on anatomy of iliac arteries, 6.

Ectropium, 152.

Entropium, 151.

Erichsen on excision of hip, 130.

Esmarch on excision of joints, 110.

Excision and amputation contrasted, 112.

Excision of ankle-joint, 138. of astragalus, 145. of elbow-joint, 118. of hip-joint, 128. of jaw, upper, 188. of jaw, lower, 191. of knee-joint, 133. of mamma, 216. of scapula, 139. of shoulder-joint, 115. of testicle, 290. of tongue, 197. of tonsils, 203. of wrist-joint, 125.

Eye, operations on, 151.

Eyeball, extirpation of the, 173.

Eyelid, tumours on the, 152.

Fayrer, Sir J., on tracheotomy, 212. on radical cure of hernia, 248.

Femoral, ligature of, 18. superficial, ligature of, in Scarpa's space, 19. in Hunter's canal, 21.

Femur, amputation through condyles of, 92.

Fergusson, Sir W., on ligature of subclavian, 38. on amputation at shoulder-joint, 70. on excision of joints, 110. on excision of upper jaw, 191. on excision of lower jaw, 195. on fissures of palate, 201. on lithotomy, 262.

Filkin on excision of joints, 110.

Fingers, amputation of, 51.

Fissures in the palate, soft, 200. in the palate, hard, 202. of anus, 292.

Fistula, salivary, operations for, 192. in ano, operation for, 291.

Fore-arm, amputation through the, 58. ligature of vessels in, 44.

Forster, Mr. Cooper, on gastrotomy, 224.

Furner, ligature of both subclavians, 38.

Gastrectomy, 224.

Gastrostomy, 223.

Gastrotomy, 223.

Gersdorf, Hans de, on amputation, 48.

Gerdy on radical cure of hernia, 246.

Gilbert, amputation above the shoulder-joint, 68.

Gillespie on excision of wrist-joint, 128.

Gluteal, ligature of, 12.

Gosselin on colotomy, 253.

Graefe on strabismus, 158. on cataract operations, 166. or iridectomy, 171.

Green on ligature of subclavian, 38.

Greenhow on excision of os calcis, 144.

Greenslade on Bowman's operation, 156.

Gritti's amputation, 93

Gross on amputation at elbow-joint, 61. on amputation, 81-87. on excision of hip, 132. on lithotomy, 262. on rhinoplastic operation, 178. on excision of lower jaw, 192.

Guérin, Jules, on amputation of toes, 76. on operation for strabismus, 158.

Guersant on excision of tonsils, 205.

Guillemeau on amputation at knee-joint, 91.

Gurlt's statistics, 118, 124.

Hæmorrhoids, operations for, 294.

Hæmatocele, operation for, 289.

Hamilton on rhinoplastic operations, 177.

Hancock on excision of hip, 130. on excision of ankle, 138. on excision of os calcis, 144.

Harelip, operations for, 183.

Harrison on anatomy of iliac, 6. on brachial aneurism, 44.

Hart, Mr. Ernest, on flexion of limbs, 24.

Heath's case of aneurism of innominate, 28.

Heine on excision of hip, 130.

Hernia, strangulated inguinal, 232. strangulated femoral, 237. strangulated umbilical, 242. strangulated obturator, 243. radical cure of, 244.

Heurtloup on lithotrity, 274.

Hey on amputation, 48, 73.

Heyfelder on excisions, 110, 130.

Hildanus, Fabricius, on amputation, 47, 91.

Hip-joint, amputation at the, 102. excision of, 128.

Hippocrates on excision of joints, 108.

Hodgson, statistics of aneurism, 12. ligature of axillary, 40.

Hodge on excisions 112, 132.

Hoin on amputation at knee-joint, 92.

Holmes on excision of hip, 130, 132, 144.

Holt's operation for stricture, 279.

Howse, Mr., on gastrotomy, 224.

Hughes, Dr. on paracentesis thoracis, 220.

Huguier on colotomy, 253.

Hunter on ligature of femoral, 21.

Hutchinson's statistics, 20.

Hydrocele, operation for, 288.

Iliac, ligature of common, 3. ligature of external, 7.

Iliac, ligature of internal, 6.

Innominate, ligature of the, 26.

Iridectomy, 171.

Iridesis, 169.

Jacobson on cataract operations, 166.

Jäger on excision of hip, 130.

James, Mr., on ligature of aorta, 3.

Jameson on radical cure of hernia, 246.

Jaw, excision of upper, 188. excision of lower, 191.

Johnston, Dr., on amputation at ankle-joint, 84.

Joints, excision of, 108.

Jones on excision of joints, 110, 134, 136.

Jordan, Mr. F., on amputation, 106; on excision of tongue, 199.

Keith, Dr. Thomas, on ovariotomy, 224-227.

Kirby, Mr., on ligature of iliac, 12.

Knife, Beer's description of, 164.

Knee, amputation below and above, 90, 91. amputation at, 91. joint, excision of, 132.

Lachrymal organs, operations on the, 153.

Lane, Mr., on amputation at knee-joint, 91.

Langenbeck on excision of joints, 110, 140. on fissure in hard palate, 203. on radical cure of hernia, 245.

Larrey on amputation at shoulder, 64. on excision of joints, 109.

Larynx, operations on the, 206.

Laryngectomy, 216. Dr. Solis Cohen on, 302.

Laryngotomy, 214.

Laryngo-tracheotomy, 215.

Layraud, Dr., case of hæmorrhage from iliac, 12.

Lee, Mr. Henry, amputation of leg, 88.

Ligature of the aorta, 2. of the axillary, 38, 39, 40. of the brachial, 42. of the carotid, common, 29, 30. of the carotid, external, 32. of the femoral, 18, 21. of the gluteal, 12. of the iliac, 3. of the iliac, external, 7. of the iliac, internal, 6. of the innominate, 26. of the lingual, 32. of the popliteal, 22. of the subclavian, 33-37. of the vessels in fore-arm, 45.

Lips, operations on the, 180.

Lisfranc on amputation, 52, 74.

Lister, Professor, on Syme's amputation, 87. on excision of wrist, 125.

Liston, Mr., on ligature of subclavian, 36, 37. on rhinoplastic operations, 177. on excision of upper jaw, 186. tracheotomy, 213. on femoral hernia, 240. on lithotomy, 262.

Litholapaxy, Dr. Bigelow on, 276.

Lithotomy, 255.

Lithotrity, 278.

Little on club-foot, 297.

Lloyd on harelip, 187.

Lorinzer on obturator hernia, 244.

Louis on amputation, 48.

Lower extremity, amputations of, 68.

Lupus, operative treatment of, 179.

Macilwain on tracheotomy, 208.

Mackenzie, Dr. Morell, on thyrotomy, 215.

Mackenzie, Dr. R., on modification of Syme's amputation, 83. on excision of joints, 110, 134.

Malgaigne on Chopart's amputation, 77. on harelip, 187.

Mamma, excision of, 218.

Manec on ligature of axillary, 40.

Maunder on excision of the elbow-joint, 122.

Maclennan, Dr. G., on amputation above the shoulder-joint, 69.

Metacarpals, amputation of, 54. excision of, 141.

Metatarsals, amputation of, 72.

Miller on amputation of penis, 288.

Monteiro, Dr., on ligature of aorta, 3.

Mooren on cataract operations, 166.

Moreaus, the, on excision of joints, 109, 114, 120, 132, 134.

Morel, tourniquet invented by, 47.

Morton, Dr., on radical cure of hernia, 245.

Murray, Dr., on ligature of aorta, 3.

Mussey, case of amputation, 70.

Mynors on amputation, 48.

Nasal polypi, removal of, 179.

Needle operation for cataract, 160.

Nelaton on harelip, 184.

Nerve-stretching, 299.

Nerve suture, 300.

Neurectomy, 299.

Neurotomy, 299.

Norris's statistics, 12, 20, 31.

Nunneley on excision of tongue, 198.

Oesophagotomy, 216.

Ollier on excision of joints, 110.

Os calcis, excision of, 143.

Ovariotomy, 224.

Paget on excision of tongue, 198.

Palate, fissures in soft, 200. fissures in hard, 202.

Pancoast, Professor, on rhinoplastic operations, 178. on radical cure of hernia, 245. on neurectomy, 300. on club-foot, 297.

Paracentesis thoracis, 219. abdominis, 222.

Paré, Ambrose, on amputation, 47. on amputation at elbow-joint, 60.

Park on excision of joints, 110.

Peixotto, Dr., on ligature of innominate, 27.

Penis, amputation of, 287.

Perineal section, operation of, 273.

Percy on excision of joints, 109.

Phymosis, operation for, 285.

Pirogoff's modification of Syme's amputation, 80, 84.

Pollock on excision of lower jaw, 193.

Polypi, nasal, removal of, 179. anal, removal of, 293.

Popliteal, ligature of, 22.

Porta's statistics, 20.

Porter, Professor, on ligature of innominate, 27. on ligature of common carotid, 28. statistics of amputation, 122.

Post on ligature of iliac, 10.

Pritchard, Mr., radical cure of hernia, 248.

Prolapsus ani, 292.

Pterygium, operation for, 156.

Puncture of bladder, 284.

Pupil, operations for artificial, 168.

Purmannus on amputation, 48.

Quain on anatomy of iliac, 4. on anatomy of brachial, 43.

Regnoli on excision of tongue, 199.

Rhinoplastic operations, 175.

Richter on radical cure of hernia, 245.

Ricord on amputation of penis, 287.

Rigaud on amputation above the shoulder-joint, 67.

Ritchie, Dr. Charles, on ovariotomy, 224.

Rodgers, Dr., on ligature of subclavian, 36.

Rothmund on radical cure of hernia, 247.

Roux on ligature of subclavian, 38. on ligature of axillary, 40, on Chopart's amputation, 77, 78.

Sabatier on excision of joints, 109.

Salivary fistula, operation for, 196.

Sanson on recto-vesical lithotomy, 271.

Scalp, tumours of the, removal of 149.

Scapula, excision of (Syme), 140.

Schuh on radical cure of hernia, 245.

Schmucker on radical cure of hernia, 246.

Scultetus on amputation, 46.

Sedillot's operation for ligature of carotid, 30. on excision of hip, 132.

Shoulder-joint, amputation at the, 66. excision of, 115.

Signoroni on radical cure of hernia, 247.

Sims, Dr. M., on lithotomy, 272.

Smith, Dr. Nathan, on amputation at knee-joint, 91.

Smith, Thomas, on staphyloraphy, 200.

Smith, Dr. Tyler, on ovariotomy, 231.

Smyth on subclavian aneurism, 27.

Skey on ligature of subclavian, 38. on amputation, 74, 91. on excision of wrist, 127. on rhinoplastic operation, 178. on lithotomy, 262.

Solis Cohen, Dr., on laryngectomy, 302.

Solomon on strabismus, 158.

South on ligature of aorta, 3.

Spence, Professor, on amputation, 50, 66, 89, 100. on excision of shoulder, elbow, and wrist joints, 118, 124, 128, 136.

Sperino on puncture of cornea, 159.

Stanley on excision of shoulder, 117.

Steven, Professor, on ligature of internal iliac, 15.

Strabismus, convergent, 156. divergent, 157.

Streatfeild on entropium, 151. on corelysis, 170.

Stricture, operation for, 276.

Stokes's amputation, 94.

Stromeyer on excision of joints, 110.

Subclavian, ligature of right, 34. ligature of left, 35.

Surgeon-General, United States, statistical report by, 82.

Syme, Mr., on amputation at ankle-joint, 78. on amputation through condyles of femur, 92. on amputation at hip-joint, 106. on amputation above the shoulder-joint, 73. on modified circular amputation, 101. on axillary aneurism, operation for, 41. on cheiloplastic operation, 181. Chopart's amputation introduced by, 77. on excision of lower jaw, 191. on excision of joints, 111-120. on excision of scapula, 140. on excision of tongue, 197. on ligature of femoral, 20. on ligature of gluteal, 14, 15. on radical cure of hernia, 247. on Hey's operation, 73. on oesophagotomy, 216. on removal of polypi, 180. on rhinoplastic operation, 175. on stricture, 278-282.

Tait on ligature of iliac, 10, 12.

Taliacotian operation, 178.

Tarso-metatarsal joint, amputation at, 72.

Tarsus, amputation through the, 75.

Teale on amputation, 50. on amputation of fore-arm, 59. on amputation of arm, 63. on amputation of leg, 89. on amputation of thigh, 98. on amputation of penis, 288.

Teale, T. P., on cataract, 163.

Tenotomy, 296.

Testicle, excision of, 290.

Textor on amputation at elbow-joint, 60.

Thigh, amputations of, 96.

Thompson on lithotrity, 275. on stricture, 277.

Thorax, operations on the, 218.

Thyrotomy, 215.

Toes, amputations of, 68.

Tongue, excision of, 197.

Tonsils, excision of, 203.

Tracheotomy, 206-214.

Trephining and trepanning, 147.

Trichiasis, 151.

Tripier's amputation, 78.

Trocar of Sir S. Wells described, 227.

Tumours of scalp, removal of, 149. of eyelids, removal of, 152.

Tyrrell on treatment of brachial aneurism, 43.

Upper extremity, amputation of, 50.

Urethra, stricture of, 276.

Velpeau on ligature of iliac, 12. on ligature of subclavian, 38. on amputation at elbow-joint, 60. on amputation at knee-joint, 91. on radical cure of hernia, 245.

Vermale on amputation of thigh, 102.

Verneuil on Chopart's amputation, 78.

Vessels of fore-arm, ligature of, 44.

Wakley on stricture, 279.

Warren on fissure of hard palate, 203.

Watson, Dr. P. H., on excision, 135. on excision of elbow-joint, 123. on laryngectomy, 216.

Wells, Sir Spencer, on ovariotomy, 224-229. trocar, 227. hernia, radical cure of, 247.

White on amputation of leg, 86. on excision of joints, 110.

Whitehead, Mr. W., on excision of tongue, 199.

Willet on oesophagotomy, 216.

Wood's statistics, 30. on joints, 134. on radical cure of hernia, 248-251.

Wry neck, operation for, 296.

Wrist-joint, amputation at, 55. excision of, 124.

Wützer on radical cure of hernia, 247.

Wyeth, Dr., statistics, 36, 38.

Young, James, tourniquet introduced by, 47.

Zehender's statistics, 30.