it. Hence arises much inconvenience to the patient; he is much reduced
by the profuse secretion and loss of saliva; the surrounding parts
are excoriated and irritable; his clothes are wetted; his speech is
very indistinct; his teeth become thickly coated with tartar; and he
is in short kept in a state of constant annoyance. The part may be
supplied from under the chin; but this reparative operation should
not be performed at the same time with the removal of the original
and carcinomatous lip. By making two operations, with a considerable
time intervening, the chance of success is greater, and indeed the
difficulty is much diminished. After removal of the disease, allow
the parts to fill up by granulation and contract as far as they will,
then form a new lip. I have done so in several instances; in one case,
the parts had perished by external violence; in another, they had
been destroyed by some powerful escharotic. A piece of soft leather,
of the size and shape of the under lip, is placed under the chin, and
a corresponding portion of the integuments is reflected upwards, an
attachment being left at the symphysis menti. The callous margins of
the space formerly occupied by the original lip are pared; and the
flap, having been twisted round, is adapted to the edges of the wound,
and retained by points of interrupted or convoluted suture. To insure
adhesion, the attachment at the chin should be left thick and fleshy;
the flap should not consist of mere integument, but contain no small
share of the subcutaneous cellular and adipose tissues, in order that
circulation may be vigorous in the part. The integuments below the chin
are naturally lose, and consequently the margins of the wound there are
readily approximated. The flap soon becomes œdematous, and remains so
for some weeks; it must be supported by a compress and bandage. After
adhesion of its upper part is completed, the mental attachment, which
prevented the lower portion from uniting, is to be removed; a bistoury
is introduced beneath the non-adhering point, and carried down so as
to divide the attachment, which is then removed by a second stroke
of the knife. The lower part of the flap is now laid flat and close
to the chin, and supported by a bandage. In the adult, union may be
retarded by the edges of the flap twisting inwards, and interposing the
hairs upon them between the opposed surfaces; when such is the case,
the offending margins must be pared away. The advantages of such an
operation, when successful, are too evident to require detail.
Removal of glands in the neck or beneath the jaw, that have become
diseased in consequence of malignant disease in the lip, is attended
with danger, and not followed by any benefit. But for this disease I
have known most bloody and cruel operations undertaken,—even portions
of the jaw to which the glandular tumours adhered have been cut out.
Such proceedings cannot be too strongly reprobated.
_Congenital Deficiencies of Lips, Palate, &c._—Congenital deficiency
of the lip uniformly occurs in the upper one; it is either simple or
complicated. Frequently there is only a fissure on one side of the
mesial line. This may, though seldom, be combined with division of the
soft or of the hard palate; or there may be a fissure on each side of
the mesial line, with an intervening flap. The flap may be either of
the same length as the rest of the lip, or more or less shortened; and
it may be either free, or attached to part of the alveolar process.
In such cases as the latter, the central alveolar processes and
teeth often project considerably beyond the arch of the hard palate,
greatly increasing the deformity. The deficiency of the lip produces
a disgusting and horrible deformity of the countenance; and when
there is division of the palate, the voice is indistinct, or almost
unintelligible.
The simple fissure of the lip, without deficiency of the palate, is
easily remediable by operation. As already mentioned, the fissure is to
one side of the mesial line; and its edges, covered by a continuation
of the prolabium, are rounded off at their lower part. The operation is
not attended with much loss of blood, nor is it very painful. It can
be performed at any period of life, but in young children it is not
advisable to have recourse to more severe operations on these or other
parts. Children bear the loss of blood badly, and their nervous system
is apt to be shaken; convulsions are induced, and often terminate
fatally. The most proper age for removing deformity by operation is
from two and a half to four years; there is then no danger incurred,
and during the growth of the individual the parts recover more and more
their natural and healthy appearance.
[Illustration]
The operation for single harelip consists in paring off freely the
edges of the fissure, and removing completely the rounded corners
at the free margin, thus. This is most neatly, quickly, and easily
accomplished by passing a straight bistoury through, from without
inwards, so as to penetrate the membrane of the mouth, above the angle
of fissure. The parts are stretched by the fingers of the surgeon
or assistant, whilst the instrument is carried downwards, so as to
detach a flap composed of the edge and rounded corner. Unless the
rounded portions are taken clean away, an unseemly notch is left in
the prolabium, where in the natural structure is prominent. A similar
proceeding is followed on the opposite side. Hemorrhage is prevented
by the assistant making gentle pressure whilst he stretches the lip.
Two sewing needles, the heads covered with a small nodule of sealing
wax, are introduced as directed after the operation for removal of
diseased parts in the lower lip, and the twisted suture completed. For
some years I have used pins made purposely; they are spear-pointed
and tempered near their points. From their length they can be easily
inserted without being fixed in a handle, or provided with a head. One
needle should always be passed close to the free margin of the lip.
No further dressing is required, for reasons already assigned. The
forceps of different kinds for holding the edge during its removal are
worse than useless; and paring with scissors is to be reprobated, as
an effectual means of preventing immediate union. By the plan above
recommended, bruising is avoided, and union takes place rapidly.
[Illustration]
Fissures, more or less extensive, of the hard palate, generally
attend double harelip. The position and size of the intermediate
portion of the lip, and of the superior maxillary bone, are various;
and the operator, in forming his plan of procedure, must be guided
by the state of the parts. If the fissures are not very wide—if the
intermediate portion of bone, that adhering to the septum narium, is
not prominent—and if the soft parts covering this are free and long,
the operative procedure is simple. Two such operations as are described
for single harelip, the latter performed at an interval of some weeks,
are required. Thereby the intervening flap is united first to one side,
and then to the other.
If the flap is short and free, without osseous projection, the
operation may be concluded at once, thus:— The edges are pared on both
sides, and the parts brought together as in single harelip, the small
intervening flap not preventing apposition below. One pin is passed at
the prolabium, the other traverses the flap. In all cases, in fact, the
operation may be concluded at once.
When the bone projects, and the flap is long, the parts may be rendered
favourable for the operation by gentle and continued pressure; the
osseous prominence being reduced, so as to restore the natural position
of the soft parts.
When, as not unfrequently occurs, there is projection of the bone,
and the soft and hard parts seem to be incorporated with the apex of
the nose—when, in short, little or no intermediate flap exists, the
protruding portion of bone may be removed by cutting forceps down to
the level of the palatine arch; and then the soft parts can be brought
together by one operation, as for single harelip.
In some cases, when the space between the palatine plates of the
superior maxillary bone is wide, it may be necessary, by mechanical
contrivance, fitting on metallic apparatus possessing a strong spring,
to approximate the bones before attempting to unite the lip. The cases
must be very rare, where the soft parts cannot be otherwise brought
together: when they can be united, their equable and continued pressure
will have the effect of gradually approximating the hard parts.
When the hard palate is deficient, the patient is subjected to great
inconvenience from food escaping into the cavities of the nose, and, in
later life, horrid wretchedness of articulation occurs. It can readily
be understood, that surgery is of very little avail here. Recourse
must be had to mechanical contrivance. A plate of metal (gold or
platina), or a piece of ivory, or of sea-horse bone, may be fitted to
the opening, and retained either by accurate adaptation, having sponge
or caoutchouc attached to the upper surface, or by wires, elastic or
not, resting on the neighbouring teeth. It may be made of a piece with
artificial teeth, if any are required. The sponge is objectionable,
as retaining the discharge, and thereby imparting an unpleasant odour
to the expired air. But it is no easy matter, and often altogether
impracticable, to retain such apparatus when the soft palate is also
deficient. The time at which such contrivance is to be adapted may
admit of some dispute. If done early in life, the natural tendency
of the parts to approximate may be interfered with and subverted; if
dispensed with till a later period, the patient gets into a habit
of snuffling and speaking so indistinctly, that the closing of the
aperture is productive of little or no improvement. Perhaps the period
of commencing the child’s education should be delayed till he be seven,
eight, nine, or even ten years of age, and then the artificial palate
may be applied advantageously in every respect.
Fissure of the soft palate is usually accompanied with separation
of the bones from which it is suspended. The size of the fissure is
various, and depends very much upon the state of the hard parts. In
some cases, the extent of separation is great; in others, the edges
are readily approximated by making the patient throw the muscles
into action. The latter class admit of operation with a view to
permanent union of the edges of the fissure. But it is a proceeding
which, to insure success, requires not only great steadiness,
coolness, and dexterity on the part of the operator, but the utmost
courage, submission and self-denial on the part of the patient. These
qualifications can scarcely be expected in patients under twelve or
fourteen; and, consequently, the operation should not be attempted till
after that time of life.
Before proceeding to operate, it should first be ascertained that the
fissure is not of such extent as to prevent apposition of its edges,
without great dragging of the parts; for, if the separation be wide,
temporary approximation may perhaps be effected by ligatures strongly
applied, but the apposition will not be complete or accurate throughout
the whole fissure, and adhesion will not take place; the palate will be
too much stretched, as to throw off the ligatures by ulceration at the
transfixed points of its margins. The patient must be made aware of the
nicety of the operation, of the responsibility that rests upon himself,
and be exhorted to steadiness and patience. A single exclamation of
pain may subvert the whole proceedings. He is seated opposite to a
strong light, and made to open the mouth wide; if necessary, the jaws
may be kept separate by a wooden wedge, placed so as not to interfere
with the operator. The head is thrown back, and held steadily by an
assistant. The operator depresses the tongue by the forefinger of the
left hand. A long, narrow, sharp-pointed bistoury is passed through
the velum, close to its attachment with the palatine plate, and about
a sixteenth part of an inch from the edge of the fissure: it is then
carried downwards to the point of the uvula, so as to detach a narrow
slip from the whole edge. The same is done on the opposite side of the
fissure during the proceeding, and to facilitate it the point of the
uvula on each side may be held by long and properly pointed forceps.
After allowing the patient a short rest, the coagula and mucus are
cleaned away from the parts, to prepare for union. Long bent needles,
in fixed handles, and armed, are passed through the pared edges on each
side. On one side the ligature is thin, the opposite thick and strong;
the former is attached to the loop of the latter, and withdrawn,
leaving the strong ligature passed through both apertures; and by this
the margins are gradually approximated, and retained by a firm knot. A
second point of suture, and a third, if necessary, is applied in the
same way, and as represented in the “Practical Surgery,” p. 558. Or a
single short curved needle may be used. It is introduced by means of a
portaiguille, with a long handle, and passed through, first from the
outside of one edge, and then from the inside of the other. A ligature,
either of thread or of pewter wire, can thus be conveyed at once; if
the latter is employed, it is secured by twisting, and the ends cut off
by pliers; the needle is attached to the wire by a female screw in its
end. It is advisable to make incisions in the direction of the fissure
on each side, through the mucous lining, in order to take off the
strain from the stitches.
Afterwards, success depends on the patient. All attempts at
articulation, and even deglutition, must be strictly forbidden for
three, four, or five days.
_Inflammation_ of the Soft Palate, Uvula, and Tonsils, requires in
general little surgical treatment. Reiterated attacks may sometimes be
traced to the progress of a wisdom-tooth, or to the presence of stumps
in the posterior part of the upper or lower jaw. Perhaps the most
common cause is sudden suppression of the discharges from the skin, and
from the adjoining mucous surfaces, in consequence of exposure to cold.
The affection is accompanied with pain and difficulty in swallowing,
and frequent and difficult excretion of mucus. The secretion of the
saliva is increased, the attempts to swallow it are frequent, and the
inflamed parts being thereby put in motion, the pain is aggravated.
From the inflammatory action extending along the Eustachian tube, the
patient describes the pain as shooting towards the ear. The parts are
red, and soon becomes swollen; in some cases to so great an extent,
as completely to prevent deglutition; occasionally the breathing is
impeded; but the inflammatory swelling must be very great indeed,
to obstruct the openings into both mouth and nostrils, and thereby
threaten suffocation. The voice is hoarse, croaking, and husky; and,
when the swelling is considerable, the patient speaks only in a
whisper. The internal swelling is often accompanied by an external
painful tumour of the lymphatic glands, and the pain is much increased
by external pressure. There is more or less concomitant fever, preceded
by slight shivering.
Removal of the local cause, and mild antiphlogistic measures, are
usually sufficient to effect resolution, and put a stop to the disease.
General bleeding will seldom be required; blood is abstracted locally,
either by scarifying the internal surface, or by applying leeches at
the angle of the jaw. Fomentations afford much relief, and may be
applied either externally, or internally by inhalation of the steam of
water, or of water and vinegar. The greatest benefit is experienced
from this remedy during the early stage, it being then employed either
to promote salutary effusion and effect resolution, or at a later
period to forward the secretion of purulent matter. At the same time,
antimonials, purgatives, warm drinks, diaphoretics, and the pediluvium,
are not to be neglected. In the relaxed state of the parts, after
subsidence of the violent symptoms, stimulating and astringent gargles
may be used with advantage.
But in neglected cases, or those originally violent, suppuration,
sometimes extensive and dangerous, occurs in the cellular tissue,
betwixt the pillars of the soft palate, or betwixt the layers of the
velum. The swelling thereby formed may be so large as to impede the
passage of air by both the mouth and nostrils. The mouth is opened with
difficulty and pain; deglutition is seriously impeded, or altogether
impracticable; the voice is weak and indistinct; and the countenance
is swollen and discoloured. Life is endangered by the risk of the
purulent matter bursting out suddenly during the painful and laborious
efforts at respiration, and escaping into the air passages; fatal
results have thus taken place, and to prevent such the abscess should
be opened early. When the swelling is large, and attended with alarming
symptoms, the matter is most conveniently evacuated by a flat and long
trocar and canula. If the abscess be small, and the breathing not
affected, there will be no danger in allowing the collection to burst
spontaneously. Suppuration may also occur in the external glandular
tumour, or in the surrounding cellular tissue. When sloughing to any
extent takes place, it is in patients of an extremely debilitated habit
of body, or when the affection is attendant on disease of a malignant
character. Metastasis may take place to the larynx, to the trachea,
or to the lungs, either spontaneously, or in consequence of repellent
applications.
_Chronic abscesses_ are occasionally met with in these parts, or
behind the upper part of the pharynx, unconnected with disease of the
subjacent bones. The matter must be evacuated as soon as its existence
is ascertained. No great accumulation should be allowed to take place
in any situation, far less in the immediate neighbourhood of important
parts.[36]
Scarification of the tonsils and surrounding membrane is seldom
required. A lancet concealed in a canula, with a spiral spring
to withdraw its point, is used for this purpose, and for opening
abscesses; but dangerous and fatal results may ensue, and have actually
followed such incisions of these parts. A sharp instrument directed
outwards, made to penetrate either by the rash thrust of an ignorant
and careless practitioner, or by a hurried movement of an unsteady
patient, may reach the common trunk of the temporal and internal
maxillary arteries, or even the internal carotid. The sheathed lancet
may be useful in the hands of such as are not habituated to the use
of instruments; but scarification of the parts and puncturing of
abscesses can be effected safely by a straight, sharp-pointed bistoury,
covered with a slip of lint to within three-quarters of an inch of its
point. The patient’s head is steadied by an assistant, the point of
the instrument directed backwards, not at all outwards, and its edge
upwards so as to avoid wounding the tongue, which is also to be kept
out of the way by the forefinger of the left hand.
New formations about the isthmus faucium are rarely met with. Small
warty excrescences, and small pendulous, fatty, or polypous tumours,
are occasionally seen. These, if productive of inconvenience, can be
easily removed by cutting instruments.
Enlargements of the uvula and tonsils are common, impeding deglutition,
and producing indistinct and burring articulation. If large,
respiration is interfered with.
_Elongation and Enlargement of the Uvula_ attends inflammatory attacks
in the fauces, but may continue for a long time afterwards. The
organ is increased in volume, both in length and in breadth, from
interstitial deposition of new organised substance, and from unusual
vascularity. The inconvenient size produces nausea and cough; it is
even said that the tumour has, in some instances, got entangled in the
rima glottidis, suffocating the patient, or at least giving rise to the
most alarming symptoms. In some cases the elongation appears to have
kept up cough and expectoration for months or years.
The parts may be touched with a bit of sponge, dipped in the tinct.
muriatis ferri; but a more useful remedy is the powder of alum, applied
either on a spatula, or by insufflation. Astringent decoctions, or
solutions, are of little use. But in cases of large and long continued
enlargements, the swelling cannot be expected to subside under
such treatment, and recourse must be had to curtailment by cutting
instruments, of which the best for this purpose are long blunt-pointed
scissors and forceps, with hooked points. The patient is made to open
his mouth wide; the surgeon then introduces the instruments into the
month, and watching an opportunity when the uvula is nearly stationary,
suddenly seizes and clips off a sufficient portion. This is followed by
instant relief.
Frequently an œdematous swelling of the uvula, of a crystalline
appearance, resembling a large grape, accompanies ulceration in the
neighbourhood; puncturing of the part, and attention to the cause of
the affection, are sufficient for the cure. When the bloodvessels of
the uvula are in a state of chronic enlargement, scarification is also
employed with advantage.
_Chronic Enlargement of the Tonsils_ occasionally takes place in
children, but generally in persons from eighteen to twenty-four
years of age, or in such adults as are subject to irritations in the
neighbourhood of the organs. A delicacy of constitution is supposed to
be indicated by the affection. One or both tonsils may be enlarged,
usually both. The surface of the tumour is irregular; the mucous
follicles are enlarged, and often filled with sebaceous matter. The
swellings in each side gradually approach each other, meet, and by
narrowing the isthmus, seriously interfere with the functions of the
parts. Little pain is felt, and that is dull, occasionally shooting
through the ear. Respiration is at all times fettered, and during
sleep noisy. Occasionally the swellings exceed their usual size,
from some accidental excitement of the circulation. They may subside
very considerably on the removal of the cause, or abatement of its
operation, for there is nothing malignant in their nature. It is true,
as I have seen, that the tonsils may be involved in malignant disease
spreading from the neighbouring parts; but in the affection under
consideration, no mark of malignancy appears, as far as I know. There
is mere enlargement and opening out of the texture, without much, if
any, change in structure or consistence; the part may be cut into
without the risk of exciting unhealthy action, and the divided surface
cicatrises readily.
Deobstruents, and iodine, as the most efficient, may be given, with
perhaps some effect. In the adult, when the affection is troublesome,
permanent, and of long duration, the exuberant matter must be removed,
and this is accomplished either by ligature or by incision. The
former method is the more difficult, tedious, painful, inconvenient,
and dangerous. It is seldom that one ligature, with a simple noose,
suffices; it is necessary to transfix the tumour, and, separating
the portions of the ligature, to include the upper and under halves
in distinct nooses. The latter method is the preferable. It is not
requisite to cut out the whole tonsil, and there is risk in attempting
such a measure, but that part only is removed which projects beyond the
arches of the palate and the natural level of the gland. Long curved
scissors may be employed, but the straight probe-pointed bistoury
is more convenient; and this, to insure security, may be blunted to
within an inch and a half of its point, or rolled so far in lint.
To facilitate incision, the tumour is laid hold of by a sharp hook,
or, what is better, by a vulsellum. Occasionally violent attempts
at retching occur during the operation; but there is little pain or
hemorrhage. The complicated machines invented for this purpose are
worse than useless. The healing of the sore is hastened by fomentations
and mild gargles, and by either stimulating or soothing applications,
as circumstances require.
Excision of the tonsils is said to produce the bad effect of changing
the pitch of the voice—taking from the high, and adding to the
low notes. I have performed the operation, as above described, on
professional vocalists, to remedy indistinctness of articulation and
constant hoarseness, with the desired effect, and without altering
either the pitch, quality, or compass of the voice. No doubt,
unpleasant results might follow extensive incisions of the parts, as
division of the anterior fold of the palate, and removal of the whole
tonsil; but by paring off the prominent parts of the glands no risk is
incurred.