Part 40
The distortion in question can be remedied only by a surgical operation, it having no tendency to a spontaneous cure. On the contrary, it generally manifests a disposition to increase, particularly in children of a nervous, excitable temperament. In fact, the very worst forms of squint I have ever witnessed were in persons of this description. The question then arises, at what age ought we to operate? My opinion decidedly is the sooner the better. Provided the child be in good health, and not under one year of age, I would not hesitate a moment to resort to the knife for its relief. And why should we? The operation itself is not particularly painful, and if it be done at an early period it will commonly be necessary to perform it only on one eye, whereas if it be postponed until the age of ten or twelve, as some have suggested, we shall not be able to effect a cure without dividing the corresponding muscle of the opposite side. Moreover, the sight in the meantime will become considerably impaired, the retina will lose its insensibility, and the individual be an object of ridicule and insult; all of which may thus be obviated. But it may be urged that a resort to the knife at this tender age will be both difficult and dangerous; difficult, because of the struggles of the little patient, and dangerous, because of the great susceptibility of the nervous system. In regard to the first of these points, it may be stated that the resistance, however great, may be easily enough surmounted by proper management; and, as it respects the latter, that it has been vastly overrated. Operations much more severe are frequently performed even at a much earlier period. I have seen the primitive carotid artery successfully tied in an infant of less than six months; and I have myself repeatedly operated, with similar results, for harelip, and that too in the very worst forms of that malformation. I do not, therefore, in these objections, see sufficient reason for deferring the division of the affected muscle.
The instruments which I employ for the operation, are two lid-holders, a double sharp-pointed hook for fixing the eye, a pair of dissecting forceps for pinching up the conjunctiva, and a scalpel or pair of scissors. The surgeon should also be provided with two or three small sponges and a basin of cold water.
The lid-holders (Fig. 1.) are each about six inches long, made of steel 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.
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.
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.
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.