and dimensions from the forehead. The cicatrized edges where the nose
formerly rested, must in the first place be dissected off pretty
deeply, so as to be prepared for the attachment of the new appendage.
The size of the lost organ, and the dimensions necessary for its
replacement, are then to be taken into consideration. It is recommended
to make a mould in wax of the part, and after flattening it out, to use
it as a guide for the incisions. But a piece of card or soft leather is
more convenient; this having been cut of the proper size and form, is
laid down on the forehead, the part representing the root of the nose
resting between the eyebrows. It is held firmly by an assistant, whilst
the surgeon traces its dimensions first with ink, or at once with a
knife carried deeply through the integuments. The pattern is then
removed, and the flap dissected down, being laid hold with the finger
and thumb, or with a hook. It is then twisted round, the lower part
being left undisturbed. This attachment at the root of the nose may be
narrow and long, so as to admit of its being twisted, but it is not to
be cut thin; it must embrace the fibres of the corrugator supercilii,
so that its vascular supply may be abundant. The incision on the side
opposite to which it is proposed to make the turn may be brought a
little lower than the other, so as to facilitate the twisting. After
bleeding has ceased, the flap is applied to its new situation, and
retained in apposition with the raw edges of the truncated organ by a
few points of interrupted or convoluted suture; a little oiled lint
is placed in the nostrils to support the flap, but no other dressing
should be applied. To cover the part with pledgets of lint smeared
with ointment, and adhesive strap, can answer no good purpose, and the
subsequent removal of such must endanger the adhesion. The attention
must now be directed to the wound of the forehead; the lower part is
easily brought together, and retained by a stitch; thereby the whole
surface is diminished, and what remains will soon be repaired by
granulation. It is at first dressed merely with a pledget saturated
with tepid water, afterwards some stimulating lotion may be gradually
added. The operation should not be performed in very cold weather,
and even in summer the patient should be enjoined not to leave his
chamber. The lint may be removed in three or four days, and then, too,
some of the stitches may perhaps be dispensed with. The flap will be
found adherent, but loose, and raised by every expiration; very soon
granulations rise from the inner surface, the part derives support from
below, and becoming firm, preserves its form well. It will be necessary
during the cure to keep the nostrils of their proper size and shape, by
means of dossils of lint, or well-fitted tubes.
[Illustration]
Nothing has as yet been said of the columna. In the Indian operation it
is provided for by a slip purposely brought down from the forehead, and
attached to the point which the root of the original columna occupied.
Their flap is shaded as in the following figure. In the greater number
of foreheads, an encroachment must be made on the hairy scalp, in
order to obtain this part of the flap; and after bringing it down and
ingrafting it into the lip, there is a risk of its not adhering, as
happened in a case on which I operated now many years ago. Besides,
during the healing of the internal surface, it will be difficult to
prevent it from shortening, and turning inwards upon itself, and thus
pulling down the apex of the nose. In the case to which I alluded,
a columna was made, after consolidation of the rest of the organ,
from the upper lip, as will be immediately explained; and in again
performing the operation for restoration of the whole nose, I should
proceed on the plan of taking only a flap sufficient for the apex and
alæ from the forehead, and should borrow the columna from the lip. In
this way the risk of failure will be diminished, and the form of the
lip materially improved. The columna might be provided at the same time
with the other parts; but it would be more advisable to delay this part
of the operation till a few weeks after adhesion of the other flap has
been perfected.
Since writing the preceding observation, I have in a very great many
instances performed the operation according to the plan here proposed,
and with the most perfect success. The form of the nasal flap was
this. The little projection was made in order to be turned down, so
as to form the tip of the nose; as well as to constitute a convenient
attachment for the columna, which was subsequently to be made.
[Illustration]
In separating the connexion with the forehead, a thin wedge-like
portion is removed, and the raw surfaces, after the cessation of
bleeding, are laid in apposition, and retained by gentle compression.
But this should not be done till the new nose is consolidated and
perfect.
Restoration of the columna is an operation which, in this, and other
civilized countries, must be even more frequently required than
the restoration of the whole nose. This latter operation came to
be practised in consequence of the frequency of mutilations as a
punishment; the punishment for some of our sins is left to nature, and
she generally relents before the whole of the organ disappears. The
columna is very frequently destroyed by ulceration, a consequence,
as before stated, of injury or of constitutional derangement. The
deformity produced by its loss is not far short of that caused by
destruction of the whole nose. Happily, after the ulceration has
been checked, the part can be renewed neatly, safely, and without
much suffering to the patient. The operation which I have for some
years practised successfully, and in a great many instances, is
thus performed:—The inner surface of the apex is first pared. A
sharp-pointed bistoury is then passed through the upper lip, previously
stretched and raised by an assistant, close to the ruins of the former
columna, and about an eighth of an inch on one side of the mesial
line. The incision is continued down, in a straight direction, to the
free margin of the lip; and a similar one, parallel to the former, is
made on the opposite side of the mesial line, so as to insulate a flap
composed of skin, mucous membrane, and interposed substance, about a
quarter of an inch in breadth. The frænulum is then divided, and the
prolabium of the flap removed. In order to fix the new columna firmly
and with accuracy in its proper place, a sewing-needle—its head being
covered with sealing-wax to facilitate its introduction—is passed
from without through the apex of the nose, and obliquely through the
extremity of the elevated flap; the small spear-pointed harelip
needle answers even better: a few turns of the thread suffice to
approximate and retain the surfaces. It is to be observed, that the
flap is not twisted round as in the operation already detailed, but
simply elevated, so as to do away with the risk of failure. Twisting
is here unnecessary, for the mucous lining of the lip, forming the
outer surface of the columna, readily assumes the colour and appearance
of integument, after exposure for some time, as is well known. The
fixing of the columna being accomplished, the edges of the lip must
be neatly brought together by the twisted suture. Two needles will be
found sufficient, one being passed close to the edge of the lip; and
they should be introduced deeply through its substance; two-thirds, at
least, of its thickness must be superficial to them. Should troublesome
bleeding take place from the coronary arteries, a needle is to be
passed so as to transfix their extremities. The whole cut surface is
thus approximated; the vessels being compressed, bleeding is prevented;
and firm union of the whole wound is secured. The ligature of silk,
which is twisted round the needles, should be pretty thick and waxed;
and care must be taken that it is applied smoothly. After some turns
are made round the lower needle, the ends should be secured by a double
knot; a second thread is then to be used for the other needle, and
also secured. With a view of compressing and coaptating the edges of
the interposed part of the wound, the thread may be carried from one
needle to the other, and twisted round them several times; but in doing
this, care must be taken not to pull them towards each other, else the
object of their application will be frustrated, and the wound rendered
puckered and unequal. Last of all, the points of the needles are to be
cut off with pliers. No farther dressing is required; as previously
remarked, no good end can be answered by any application, and the
separation of dressing may afterwards be troublesome; discharges from
the neighbouring passages are retained by it, fetor is produced, and
union interrupted. The needles may be removed on the second or third
day; their ends are cleared of coagulated blood, and, after being
turned gently round on their axes, they are to be cautiously withdrawn,
without disturbing the thread or the crust which has been formed about
them by the serous and bloody discharge. This often remains attached
for some days after removal of the needles, and forms a good protection
and bond of union to the tender parts. Some care is afterwards required
from the surgeon and patient in raising up the alæ, by filling them
with lint, and thus compressing the pillar, so as to diminish the
œdematous swelling which takes place to a greater or less degree in
it, and to repress the granulations. It is besides necessary to push
upwards the lower part of the columna, so that it may come into its
proper situation; and this is done by the application of a small round
roll of linen, supported by a narrow bandage passed over it and secured
behind the vertex.
Independently of the great improvement produced on the patient’s
appearance by the restoration of the lost part of so important a
feature, it may be observed, that, when the columna has been destroyed,
the lip falls down, is elongated, and becomes tumid, particularly at
its middle, so that borrowing a portion from it materially ameliorates
the condition of the part; the cicatrix being in the situation of the
natural fossa, is scarcely observable.
The alæ of the nose, deficiencies in the upper, anterior, or lateral
parts of the organ, in the forehead, &c., may be supplied from the
neighbouring integument, on the same principle as the preceding
repairs. In many of these operations the flap can be so contrived
and cut out, as that it can be applied without its attachment being
twisted. The form of such flaps is here given.
[Illustration]
It is merely necessary to bring the portion which has been dissected
from the subjacent parts of the forehead, cheek, or lip, to the part
prepared for its reception, by effacing the angle betwixt it and the
connecting slip. A flap to supply the greater part or even the whole of
the organ may thus be transplanted.
The integuments covering the apex and alæ of the nose are sometimes
opened out in texture by interstitial deposit, forming a lipomatous
tumour, lobulated, discoloured, and intersected by fissures. The
sebaceous follicles are enormously enlarged, so as sometimes to
admit the point of a small quill. On making a section of the parts,
accumulations of sebaceous or atheromatous matter are found inclosed
in cysts of considerable capacity. Turgid veins ramify superficially;
and the surface is of a reddish blue or a purple colour, varying its
hue from time to time, according to the state of the health, and
the changes in the circulation. The enlargement often attains great
magnitude, producing much deformity. Vision is obstructed, and the
introduction of food, both solid and liquid, interfered with: the lobes
tumble into the wineglass, spoon, and cup, and sometimes they are so
elongated as to require being pulled aside in order to uncover the
mouth. Breathing is also impeded more or less, by encroachment on the
nasal orifices. The disease may be often attributable to hard living;
but many, not intemperate, labour under it.
It is desirable to have the tumour removed, even before it has become
large; and it can readily be conceived that local applications must
fail in bringing the skin and cellular tissue into a healthy condition.
Incision is required. If both sides of the nose are affected, a
small scalpel is carried down in the mesial line through the altered
structure, and, whilst an assistant places his finger in the nostril,
the surgeon lays hold of the integument with a sharp hook, and
carefully dissects away the diseased parts, first on one side, and
then on the other, so that they may correspond exactly, or present the
same uniform appearance. The vessels are then tied, and sometimes a
considerable number bleed smartly; oozing may continue, but is readily
suppressed by continued pressure, the nostrils being well stuffed.
Afterwards such dressings are to be employed as agree with the stages
of the sore. After cicatrization, the comfort and appearance of the
patient are much enhanced; and there is no risk of reproduction—the
disease is one of the skin, and all that is affected has been removed.
Sketches taken from one, of very many patients, on whom I have operated
for the removal of this shocking deformity, are given in the _Practical
Surgery_, p. 306-8.
[Illustration]
_Inflammation of the antrum maxillare_ is occasionally met with; but
the surgeon is more frequently called upon to treat the consequences
of this action in it. The symptoms of inflammation of the antrum
are violent throbbing pain, referred to the part affected, to the
temple, and to the teeth implanted in the alveolar processes that
form the lower part of the cavity; the side of the face is swelled
from infiltration of the soft parts, and the Schneiderian membrane
of the corresponding nostril is generally observed red and swollen.
The affection can frequently be traced to exposure to cold; it may
be the result of external violence; but is usually an extension of
disease in the sockets of decayed teeth. Unless active and early
measures are taken to subdue the inflammatory attack, the antrum
becomes distended by increased and vitiated discharge from its lining
membrane. The swelling of the cheek becomes more apparent, since, to
increased infiltration of the soft parts, enlargement of the cavity is
superadded. The enlargement of the side of the face, and the bulging
into the orbit are seen in the accompanying cut. The membrane covering
the small aperture through which the antrum and nostril communicate
partakes of the general thickening, and thus no outlet is left for the
accumulating fluid. The escape of matter from the nostril, on the head
being turned to the opposite side, has been laid down as an indication
of accumulation or abscess in the antrum; the statement is incorrect,
and is a result of surgery being professed by those who have not
practised it, but judge of morbid states and their signs and symptoms
by the healthy condition of parts only. In the skeleton, fluid no doubt
will run over from the osseous shell, in some positions of the skull;
but it cannot escape from the cavity when covered with membrane, and
that membrane subject to vital actions. In short, the symptom is not
observable in the disease in question.[35] Extensive ulceration of the
parietes of the antrum towards the nose may, perhaps, take place, as a
consequence of the accumulation, and the matter may then escape by the
nostril, if not allowed an exit otherwise; but such is not a common
occurrence.
In general, the cavity is considerably enlarged before the matter comes
to the surface. If not interfered with, it usually escapes through
the sockets of decayed teeth, or, the anterior thin parietes being
absorbed, it comes down by the side of the canine or small molar teeth,
and is discharged slowly, so as to annoy the patient by its flavour and
fetor, without the abscess being emptied, or a chance of cure afforded.
Accumulations of fluid sometimes takes place in this cavity, give
rise to great enlargement of the sinus, and continue for many months,
without pain or much inconvenience, and without any matter escaping.
The bony parietes are attenuated, yield to slight pressure, and
return to their original level with a crackling noise, such as is
produced by parchment. The contained fluid is thin, greyish, and
contains flocculent solid particles. In short, the antrum maxillare is
occasionally the seat of chronic, as well as of acute abscess.
Cancerous ulceration sometimes takes place in the cavity; the matter
is not long confined, the parietes soon soften, the teeth drop out,
the alveolar processes disappear, and a large opening is formed, which
furnishes a fetid, sanious discharge.
In inflammation of the antrum, carious teeth must be removed, blood
must be abstracted from the neighbourhood of the affected part—leeches
being applied to the gums, the Schneiderian membrane, and the
integuments—and fomentations to the cheek should be frequently and
assiduously employed. When the cavity has become distended with
fluid—mucous, muco-purulent, or purulent—such must be evacuated without
delay; and the opening must be of such size, and so situated, that the
fluid may escape as soon as secreted. In removing diseased or crowded
teeth opposite the part, an opening may be made from the extremities of
the fangs having projected into the cavity; it is in a good situation,
but cannot easily be made of sufficient size; an aperture of but small
extent may be sufficient for the draining of an abscess in soft
parts, but here the divided texture is unyielding, and the perforation
must be free. Bad teeth are taken away with the view of abstracting
a source of irritation which may give rise to, keep up, or induce a
return of collection in the antrum; but extraction of sound teeth, to
obtain an exit for the matter, is not warrantable. Even when they are
extracted for a different reason, and discharge of matter follows, the
surgeon must not be contented, but must make another and more efficient
opening. The membrane of the mouth is to be divided on the forepart
of the maxillary bone, immediately above the first small grinder, and
a large perforator then pushed into the antral cavity; little force
is required, for the parietes are soft and partially absorbed. The
perforation should be of a size sufficient to admit the little finger;
thereby a free and dependent exit is allowed for the concrete as well
as the fluid matter. Curdy and very offensive stuff is sometimes found
in great abundance in this cavity. If the discharge is very fetid, and
long of drying up, and if there is an appearance of disease in the
osseous parietes, injections into the cavity may be required, though
seldom. They are occasionally useful in dislodging the atheromatous
matter. In general the discharge gradually diminishes, the membrane
of the antrum resumes its healthy condition and functions, and the
aperture in its parietes is shut by a fine ligamentous substance.
[Illustration]
_Ulcers of Lips._—The prolabium is liable to ulceration from various
causes; from long-continued irritations, as sharp corners of teeth,
rugged tartar on the external surfaces of the teeth, the habitual use
of a short tobacco-pipe; from external violence; from the application
of acrid matter; or from an ulcerative disposition unconnected with
external circumstances. The constant and free motion of the parts is
prejudicial to healing, and consequently the sores often remain long
open. Though ulcers on the lips are generally of a bad character, it
does not follow that all are so. Many are simple; but these, after
remaining long, are apt to degenerate. Others from the first assume
malignant action, and unfortunately they are more frequently met with
than simple and well-disposed sores. The malignant sore often commences
in a warty excrescence which ulcerates at the base; the ulceration
extends, the warty appearance is succeeded by ragged and angry fleshy
points, the surrounding parts become indurated, and the stony hardness
spreads. The appearance which the sore presents is that of open
cancer, described at page 147, and represented on preceding page. The
ulceration may either be limited in depth and extent to a small part
of the lip, or may involve the greater part of the prolabium, and that
without much induration. It is generally situated on the right side
of the lower lip; sometimes in the angle of the mouth; the upper lip
is rarely affected. I have removed a few malignant ulcers from this
last situation. Sooner or later the lymphatic glands participate in
the disease; a chord of indurated lymphatic vessels is felt passing
over the jaw in the course of the facial artery, and the glands with
which these are more immediately connected, soon enlarge and become
hard. This disease, though by some pathologists said to be “improperly
called cancer,” differs apparently in no respect in its progress,
and is in all respects as malignant as the disease commencing in any
other structure and in any other way. Indurated swellings over the
jaw, lymphatic or not, usually depend on the labial disease; they in
some instances increase very slowly, in others acquire such volume
as to induce by their pressure on neighbouring parts alarming and
dangerous symptoms at an early period. Without much increase of size
they sometimes attach themselves firmly to the bone, and involve it
in the disease. The malignancy seems to acquire fresh virus, the skin
ulcerates with fetid discharge, all the neighbourhood is speedily
infected, and the patient sinks slowly under the evil.
Simple ulcers of the lips may be made to heal readily,—by abstracting
the exciting cause, preventing the motion of the lip by the restraint
of a bandage, disusing the part as much as possible, and by employing
such applications to the sore as are best suited to the character and
appearance which it may present; but it must be borne in mind that
all remedies can be of little service unless motion of the lip be
prevented. Sores of a bad kind must be attacked early, otherwise no
hope of success can be entertained. Escharotics are not to be trusted
to; the knife is the only effectual means of removing the disease.
When the sore does not involve much of the lip, the molar teeth
having been lost, and the alveolar processes absorbed, the cheeks
are thus rendered flabby and relaxed: in such circumstances, all the
diseased part is taken away with facility, and the features are not
thereby deformed, but rather improved. The part cut away resembles
the letter V, the angle being towards the chin: this form of incision
is preferable, on account of the diseased portion being chiefly in
the prolabium, and the parts afterwards coming together very neatly
and readily. The lip is stretched by the operator and his assistant
laying hold of the prolabium on each side of the portion destined to
be taken away; a narrow straight bistoury is passed through the lip,
at the angle of the form of incision; and the operator, standing in
front of the patient, makes the first incision towards himself, by
bringing the knife up to the prolabium. He then takes hold of the
part to be removed, and laying the edge of the knife on the prolabium
at the other side of the induration, cuts down to the point where
the instrument originally entered. The incisions must always be made
far from the indurated parts. The edges of the wound are retained
in apposition by means of convoluted suture, as formerly described.
When the wound is extensive, as when a considerable part of the cheek
is involved, approximation may be accomplished by a few points of
interrupted suture, and afterwards the parts may be more securely and
accurately fixed by convoluted sutures placed between the interrupted.
When a large portion of the cheek is removed, as for disease which had
commenced at the angle of the mouth and extended around, all the parts
cannot be brought into contact, and some of the deficiency remains
to be filled up by granulation. The neighbouring parts stretch, and
the deformity that may be the immediate result of the operation in a
great measure disappears after some time. In cases of superficial and
malignant ulceration of great extent, no attempt can be made to bring
the parts together after excision: great deformity, and almost total
closure of the mouth, would be the consequence. The diseased parts must
be freely removed (for this is the primary and essential part of the
operation, all other considerations yielding to it), and the deformity
will prove much slighter than might be supposed: granulations arise,
and considerable reparation of the lost parts thence ensues. Still
there is a risk of the sore, at first healthy and active, gradually
assuming the nature of that for which the incisions were made.