Elements of Surgery

by Robert Liston

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.