Elements of Surgery

by Robert Liston

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.