it is absolutely required when the tumour encroaches upon and involves
the angle and ramus. It is a more severe operation than excision
of part of the bone, and attended with greater risk; yet it may be
advised and undertaken with a very fair and probable chance of ultimate
success. The incision of the cheek is made to incline more upwards
than those recommended for partial excision, and is extended to over
the articulation of the jaw; from this point, another is made in
the direction of the ramus, and prolonged an inch or more beyond the
angle. A third incision is made perpendicular to the first, or to the
lower lip, over that part of the bone in front which is to be divided.
The flap is turned down, and the muscles and membrane of the mouth
separated from the bone opposite to the last incision; after which,
the finger is passed through to complete the detachment. A preferable
form of incision along the posterior border of the ramus and under the
base of the jaw and tumour to over the point at which the bone is to be
sawn, but without division of the lip, is recommended in the _Practical
Surgery_. This method I have practised repeatedly; the cicatrix is
then completely out of sight, and in the male is entirely covered and
concealed. During the cure, also, the discharges escape more readily,
the opening being quite dependent. The bone is then divided at that
point by the saw and pliers, the tooth in the line of the track having
been extracted previously to the commencement of the operation. The cut
end of the jaw is laid hold of by the left hand, and depressed, and
the bistoury carried backwards along the internal surface, to effect
detachment as far as the angle. The bone is still more depressed, and
the temporal muscle cut from the coronoid process. The mass is thus
loosened, and forced downwards and backwards on the neck; the forepart
of the capsule is then cut, and the bone twisted out. Separation of
the remaining attachments is completed by a few rapid strokes of the
knife, and the whole mass removed. Hemorrhage is then to be permanently
arrested, but instead of immediately tying every open mouth which
presents itself, it is sometimes better to expose the common trunk of
the internal maxillary and temporal arteries—which is easily effected,
as it emerges from under the digastric muscle—and to pass a ligature
beneath it, by means of an aneurism needle. This is more quickly done
than the applying of ligatures to the many branches of this trunk
which have been divided. The other vessels—the facial, branches of
the lingual, &c.—are then tied, the cavity is filled with charpie,
and the incisions of the soft parts are carefully closed. In these,
union by the first intention usually takes place nearly throughout the
whole extent; suppuration occurs from the deep wound; the charpie is
dislodged gradatim, and removed; granulations spring up; and, after
some time, the cavity is obliterated. The cheek must necessarily fall
inward very considerably, but the deformity is not to be compared to
that caused by the tumour. During granulation, the patient is made
comfortable by the frequent use of tepid gargles, lodgement of pus in
the mouth being thereby diminished. Articulation and mastication are
not so perfect as when the jaw was entire and sound; but the patient
gradually becomes accustomed to the want, and these functions improve.
A contrivance described in the _Practical Surgery_ is used to prevent
the remaining portion of jaw from being drawn towards the mesial line,
and to keep the teeth opposite to those of the corresponding side of
the upper jaw. Partial paralysis of the side of the face necessarily
follows, for there is no possibility of accomplishing disarticulation
of the jaw without dividing many branches of the portio dura.
Supposing that the portion of the jaw between the angle and
symphysis had been removed on account of osteosarcoma, and that the
ramus subsequently became affected, it is no easy matter to effect
disarticulation, as I have experienced.—The patient was a female, aged
30, of delicate constitution, and subject to toothache from infancy.
I removed an osteosarcomatous tumour, extending from the angle to
the canine tooth, on the right side. Division was made wide of the
existing disease, and the sawn surfaces appeared quite healthy; but
about five months afterwards, symptoms of return occurred in the
ramus, and ten months after the first operation disarticulation was
indispensable. The operation was accomplished with very considerable
difficulty, on account of there being no lever to overcome the action
of the temporal muscle. After separating the attachments as much as
possible, an attempt was made to force down the coronoid process, from
under the zygoma, by pushing the lower end of the bone backwards, in
order to divide the insertion of the temporal muscle; but this proved
ineffectual. The capsular ligament of the joint was then divided, and
the bone with difficulty turned over from behind, forwards. It was then
detached underneath the coronoid process, pulled down from under the
zygoma, and the temporal muscle at length divided at its insertion.
In none of these operations is there a necessity for preliminary
exposure and ligature of either the carotid artery or its branches; by
so doing, a great addition is made to the patient’s sufferings, the
real operation is only commenced when the patient supposes it should
have been finished, and he is thus annoyed and worn out. The flow of
blood is easily moderated, or altogether arrested, by the pressure of
an assistant’s fingers against the forepart of the vertebræ, below the
angle of the jaw.
The position of the patient is either recumbent, with the face turned
from the operator, or sitting with the head supported and steadied.
The instruments required are, a very strong, sharp-pointed bistoury,
for division of the soft parts; saws, of which Hey’s is to be preferred
for notching the bone; strong and long pliers, for completing its
section; an aneurism needle, for securing the common trunk of the
temporal and internal maxillary artery; dissecting and artery forceps,
hooks blunt and sharp, narrow copper spatulæ, ligatures, &c.
_Wounds of the Face and Neck._—Accidental wounds of the face may
involve the more important blood vessels and nerves, and interfere with
the eye or its appendages, with the nose, or with the mouth. Injury
of these parts is to be avoided in incisions premeditated for the
removal of disease or deformity; and, in such premeditated wounds, the
line of incision should always be, if possible, in the direction of
the muscular fibres. The bleeding seldom proves troublesome; pressure
on the vessels, as they pass over the bones, arrests it temporarily;
and ligature is seldom required, accurate adaptation of the divided
surfaces proving sufficient for effecting permanent closure of the
divided branches. Paralysis, more or less extensive, follows division
of the nerves and muscles. But paralysis of the face also arises
from a variety of other causes; it often remains after injuries of
the head, probably in consequence of extravasation on the brain; it
attends on morbid formations in the substance of the brain, or in its
membranes, and follows long-continued irritation in the neighbourhood
of the nerves. Paralysis from the last-mentioned causes is not likely
to be recovered from; that following simple division of nerve, may
disappear after a considerable time, the nervous tissue reuniting,
and resuming its functions. When there is reason to suppose that the
nervous function is alone deranged, while the structure remains sound
and the continuity undissolved, advantage may follow the application of
strychnine to a raw surface over the course of the affected nerves.
In Tic Doloureux, division of the nerves of the face, as they pass out
of the foramina, is seldom resorted to; nor ought it to be practised,
unless at the urgent request of the patient, and after all other means
have failed to afford relief; and even then the operation is scarcely
warrantable, since it may be said never to have succeeded in affording
permanent relief. We must trust to milder measures, to the removal of
local irritations, to paying strict attention to the digestive organs,
to the administration of purgatives, tonics, and anodynes; occasionally
benefit has resulted from the external use of the nitrate of silver,
applied so as to cause very slight vesication. Ointments containing
veratria and aconitine have been used with advantage, and the endermic
application of the salts of morphia has also been found useful.
Spasmodic action of the muscles of the face, without pain, sometimes
follows wounds and other injuries of the nerves which supply them;
and sometimes no cause can be assigned for the occurrence. In this
affection also, the application of nitrate of silver to the integuments
over the nerves may sometimes be made with advantage.
Division of the parotid duct, or wound of the gland itself, is
occasionally followed by the formation of a fistulous aperture,
discharging saliva over the cheek. We endeavour to prevent this by
accurate union of the recent wound. After the fistula has formed, an
opening is to be made from it into the mouth, and kept pervious; the
external aperture is then closed by suture after excision of the smooth
edges, or is made to contract by the repeated application of a heated
wire; pressure alone is of little use.
All wounds of the face are to be put into the most favourable state
for healing without granulation, so that deformity may be prevented as
much as possible. The twisted suture is best adapted for this purpose;
more accurate coaptation being thereby obtained than by the interrupted
form. In extensive wounds, the parts may be brought somewhat into their
proper position by a few points of interrupted suture; twisted sutures
are then placed in the intervals, and the isinglass plaster is of use
in closing those points which may still gape slightly; in many cases,
the greater part of the approximation may be accomplished by isinglass
plaster alone.[38]
Deep wounds behind the angle of the jaw, and at the lateral and lower
parts of the neck, are highly dangerous; indeed they are almost
certainly and immediately fatal, as can readily be understood when
the large bloodvessels and important nerves are considered which have
their course in these parts, and which must be either wounded or
completely divided. The bleeding has in some cases been arrested by
immediate ligature of the divided extremities of the vessel, by firm
and permanent pressure, or by pressure at first, and ligature of the
trunk of the vessel on the recurrence of hemorrhage after the lapse of
many days; of these methods immediate ligature of each extremity is
certainly the safest and best. In lacerated wounds violent hemorrhage
may take place some time after the infliction of the injury, from
ulceration or sloughing of a large artery; in such circumstances either
permanent pressure may be resorted to, or ligature applied to the
vessel above and below the open point.
Dissections for the removal of morbid growths in the situations
just mentioned must be conducted with much caution, and with a full
recollection of the relative anatomy. Unless the tumour be tolerably
loose and defined, it ought not to be interfered with. But it is to
be recollected that tumours of these parts are bound down by their
condensed coverings—the platysma myoides and cervical fasciæ; and that
after division of these, the tumour, if not intimately incorporated
with the neighbouring tissues, is loosened, and often enough can be
readily detached.
From constant external pressure, tumours growing rapidly spread
amongst the deep parts, and often form firm attachments. The parotid
is displaced, and almost entirely absorbed, by the pressure of tumours
growing out of the lymphatic glands which are lodged on its anterior
surface. Such tumours attain a large size, and occupy the exact
situation of the parotid; on their removal, the space betwixt the
angle of the jaw and the mastoid process is completely exposed, and
the styloid and pterygoid processes can be distinctly felt. From these
circumstances many have been led to believe that they have dissected
out the parotid; but this and the other salivary glands seldom if ever
degenerate. And if the parotid do become the seat of carcinoma or
medullary sarcoma, it is impossible to remove it with either safety
or advantage. Even in the healthy state, removal of the parotid is a
troublesome dissection; and the difficulty must be greatly increased
when enlargement has taken place from disease, when neighbouring parts
are involved, when firm and deep connections have been formed, and
important structures encroached upon. I have taken away many tumours
from the site of the parotid, and some of large size, but would
scarcely attempt, or boast, as some have done, of having removed the
diseased gland itself.
The incisions, for the removal of the tumours of which we have been
speaking, are to be made in the direction of the fibres of those
muscles which are interposed betwixt them and the integuments, in the
direction of the bloodvessels and nerves, and towards those points
where the vessels are expected to enter the diseased mass. Attention
to the last recommendation is important in order to save blood. For
when the trunks of the arteries are divided at the commencement of the
dissection, they are easily secured temporarily by the fingers of an
assistant: the operation is proceeded in and accomplished with scarcely
any further hemorrhage, and in many instances no other vessels require
ligature; whereas, if an opposite course be pursued, the same vessels
will be divided three or four different times; the hemorrhage will be
greater, and the operation delayed. By cutting also in the direction of
the vessels and nerves, fewer arteries are divided, and nerves are less
apt to be injured, than if the incisions were made across.
Wounds inflicted with the view of effecting suicide are generally on
the fore and upper part of the neck, and their severity depends on the
resolution of the individual. Some penetrate the integuments merely,
and are consequently of slight extent; there is little bleeding, and
the edges are easily brought together, after the cessation of bleeding
and when the surfaces are glazed, by inclining the head forwards, and
introducing a few points of suture. Others divide the muscles, and
branches of the lingual or of the superior thyroid arteries; such
wounds are gaping, more extensive than the former, and accompanied with
smart hemorrhage. Some penetrate the mouth, separating the os hyoides,
tongue, and epiglottis from the thyroid cartilage. Occasionally the
wound is lower, through the thyroid, or betwixt that cartilage and the
cricoid; and sometimes through these into the gullet; it is seldom
lower. Such are truly horrible; the countenance is contorted, and
presents a frightful expression; inspiration is difficult, hurried,
and noisy, and at each expiration blood frothed with air is forcibly
ejected from the wound. I have seen wounds of the trachea, near the top
of the sternum, but without extensive division of the lateral parts;
large wounds, such as are usually made at the upper part of the neck,
could not be inflicted here without division of the large vessels,
and instant death. Some determined suicides reach the vessels even
high in the neck, dividing everything down to the vertebræ; immediate
dissolution takes place from loss of blood. But, in general, mere
opening of the air-passage is all that is aimed at, there being a
vulgar notion that this is sufficient for the extinction of life. A
considerable quantity of blood is lost, though the branches only of the
external carotid are wounded, and the loss may prove fatal; but the
hemorrhage generally ceases on syncope taking place; and if the patient
be then discovered, means should be immediately adopted for permanently
arresting it. Its recurrence may cause death, on the patient recovering
from the first faint; or he may die some days after, from the effects
of loss of blood. Hemorrhage, though to no very alarming extent, is
always to be dreaded in those advanced in life; though in most cases
the fatal result is not attributable solely to the bleeding, but
is expedited by other circumstances, as defective supply of proper
nourishment, and an unfavourable state of the mind.
Some patients seem to be going on most favourably towards a cure, but,
within two days after the injury, are suddenly seized with difficult
breathing, and die in a few minutes. On the examination of such,
blood is sometimes found in the ramifications of the bronchial tubes,
and the lungs can contain little or no air; or the bronchial tubes
and ramifications are loaded with adherent mucus; in either case the
patients die from asphyxia. In others, nothing remarkable is observed;
perhaps passage of the air may have been prevented by inspissated mucus
lodging in the windpipe around the wound, and closing the aperture,
or by faulty adaptation of the divided surfaces. Likewise, during
motion of the head, or attempts to swallow, either the upper or lower
part of the windpipe may change its relative position; the continuity
of the tube will be thereby destroyed, either partially or wholly,
and suffocation ensue. When the wound is large and transverse, as
the majority of such wounds are, there is difficulty in freeing the
air-passage from mucus. This result becomes evident, when we consider
how coughing is effected in the healthy state of parts—that the upper
part of the windpipe is contracted by its own muscles, and the air
driven through, by sudden action of the muscles of the chest, in a
forcible and small stream, so as to carry the mucus along with it. This
process cannot be accomplished when the muscles employed in contracting
the orifice of the larynx are injured, or when an opening is formed
below the glottis, through which the patient breathes, either wholly or
in part.
[Illustration]
In other cases, death is more slow. The patient is seized with
dyspnœa, great anxiety, and occasional spasmodic action of the
muscles of respiration, which symptoms gradually become more urgent
and alarming. They are attributable to awkward position of the
parts, to swelling around the wound, inflammatory or œdematous and
rapid or slow, or to bronchitis. To the latter affection patients
breathing through artificial openings in the larynx or trachea are
peculiarly subject, probably from the inspired air not being heated,
as in natural respiration, before it enters the bronchial tubes. A
view from behind is here introduced of the larynx of a patient who
some weeks previously attempted suicide by wounding the forepart of
the neck. By some mismanagement the edges of the incision were kept
asunder, and they cicatrised. The patient was seized with difficult
breathing, the inspirations were rare, long, and laborious; he had
threatening of suffocation during his disturbed sleep. These symptoms
were disregarded. He started up suddenly in the night, caught hold of
the patient in the next bed, and fell down in a state of asphyxia,
from which he could not be recovered. The œdematous swelling of the
rima glottidis is remarkable; beyond that is seen the rounded opening
betwixt the thyroid cartilage and epiglottis, which is in a normal
state.
The bleeding is to be arrested as speedily as possible by ligature,
and the patient placed in bed with the head and shoulders raised. The
edges of the wound are brought together by attention to the position
of the head; but, provided the patient breathes easily with the wound
open, closure should not be attempted till after eight, ten, or twelve
hours—that is, not until all oozing of blood has ceased; the time
depends on the extent to which the air-tube has been divided. There
is little chance of immediate union taking place; and the wound not
being approximated when recent and bleeding, does not diminish the
chance, but on the contrary augments it. Adhesion is prevented by the
insinuation of air and mucus betwixt the edges, by frequent motion of
the edges on each other, by the slightest change in the position of
the head, either rotatory or nodding, by the action of the muscles of
the os hyoides, and by attempting to swallow food or saliva. Every
circumstance is opposed to complete approximation and immediate union
of transverse wounds of the throat.
Plasters and bandages surrounding the part are inapplicable, and
unwarrantable from the interruption thereby caused to breathing and
circulation; they likewise prevent the escape of mucus and air.
Emphysema is apt to occur in consequence, and may prove troublesome;
the cellular tissue of the neck becomes filled, so as to interfere
with free respiration, and the infiltration of air extends over the
face and chest. Neither can many stitches be used without bad effects.
The corners of an extensive wound may be kept together by points of
suture; and one may be placed at the middle, through the integuments
only, to prevent overlapping or inversion of the edges. The head is
placed in a comfortable position, inclined forwards, and secured by
a bandage passed round it, with the ends brought down and fixed to a
band round the chest. In many cases the patient requires to be watched
attentively, to have the motions of his hands restrained by proper
means, in order to prevent him from interfering with the wound, or
committing other insane acts which might prove dangerous. The state
of the breathing and of the pulse must be strictly attended to;
inflammatory symptoms must be actively combated, and swelling prevented
from gaining a dangerous extent, by bleeding, general and local. But
depletion is indeed very seldom necessary, the loss of blood in the
first instance proving a pretty effectual preventive of inflammation;
it is more frequently requisite to administer nourishment or even
stimulants; but these must be given gradually in those advanced in
life, and in those who have lost much blood.
The slightest difficulty or noisiness of breathing must be closely
watched, and on the occurrence of any alarming symptoms, energetic
measures adopted. Swelling about the wound, producing difficult
expectoration and a diminished current of air, may require the making
of a longitudinal opening into the trachea below the wound, and the
insertion of a tube. Thus the respiration is quickly relieved; and
the patient is soon able to regulate the size of the aperture; he is
readily taught to apply his finger over part of the orifice of the
tube, when it is wished to clear the passage from mucus. The operation
of tracheotomy should be had recourse to in such cases without
hesitation or delay; there is no danger from its performance, but much
from its being withheld.
If the mouth or gullet have not been opened by the cutting instrument,
or only slightly, the patient may be allowed to swallow naturally;
though it is true that even the slightest motion of the parts affects
the wound injuriously. But, as already observed, immediate union is
not to be expected; swallowing, or attempting to swallow, saliva,
produces an involuntary action of the muscles, quite as prejudicial as
the swallowing of liquids in large quantity does; and these motions
cannot be prevented, since the patient has no control over them. If the
wound of the mouth or gullet is extensive, portions of the ingesta are
apt to interfere with the air-tube, particularly if the wound is high,
and the epiglottis cut away or difigured. In such cases, soups and
other nutritious fluids are conveyed through an elastic tube, passed
by the mouth over the root of the tongue to beyond the injured part,
and introduced only when it becomes necessary to administer food; or a
small tube may be passed by the nostril, and retained. If the wound is
very severe, and the necessity for thus conveying nourishment likely
to continue long, the latter method is adopted; it is more difficult
in execution than the former, but when the instrument is once passed,
no further trouble is given to either the patient or surgeon. Small
quantities of nourishment are to be given frequently, of such strength
as the symptoms indicate; many patients have died from inattention on
this score.
Many have died suddenly and unexpectedly (though this should not be,
if symptoms and circumstances were attended to) from the effects of
apparently slight wounds; whilst others have recovered, when recovery
was unlooked for, after dreadful injuries, and these perhaps not
treated in the most approved manner. In illustration, I shall briefly
detail, though it did not fall under my own observation, an interesting
and remarkable case of recovery. A criminal under confinement attempted
suicide by transverse wound of the throat. The larynx was severed at
the upper part of the cricoid cartilage, and the cut extremities had
retracted at least three inches; the œsophagus was also cut across,
but the extent to which it had receded was not ascertained. A large
quantity of blood had been lost; attempts were made to bring the parts
together, but were abandoned on account of the violent dyspnœa which
was induced. The attendant endeavoured in vain to pass an elastic gum
tube into the gullet, from the nose and from the mouth. The patient was
kept alive by nutritious enema. On the second day after the accident,
the cut extremities of the larynx were approximated by two ligatures;
and, the retraction being thereby diminished, it was then discovered
that there was another wound between the cricoid cartilage and the
trachea. All ingesta by the mouth passed through the upper wound. On
the fifth day, the ligatures separated, and the larynx again retracted.
On the sixth, an elastic gum catheter was passed into the inferior
cut extremity of the gullet, and through this nutritious fluids were
regularly administered. The wound granulated, and filled up in some
measure; the patient continued to receive both air and nourishment
through tubes introduced downwards from the wound in the throat. Whilst
pouring in food, saliva was secreted in the mouth in great profusion.
The sense of smelling remained tolerably acute, and he also possessed
the power of imperfect whispering articulation.