{ sartorius.
{ 2. Quadriceps ex- Outside of thigh. Cremasteric,
{ tensor femoris. patellar.
{ 3. Abductors and Front and inside Cremasteric.
{ inner rotators of of thigh.
Lumbar. { thigh.
{ 4. Adductors of Inside of leg, Gluteal.
{ thigh, tibialis ankle, and foot.
{ anticus.
{ 5. Outward rotators Back of thigh and Gluteal.
{ of thigh, flexors leg; outside of
{ of knee and foot.
{ ankle.
{1-2. Muscles of foot, Outside of leg. Plantar.
Sacral. { peronei.
{3-5. Perineal muscles. Perineum, anus, Ankle clonus.
{ sacrum, genitals.
Injuries low in the lumbar segments cause incontinence of urine and
feces because of the location of the centres for the rectum and bladder
at this level. Injuries higher up cause retention by paralyzing the
expulsive muscles of the abdomen. The reflexes which most interest the
surgeon and which are of importance to him in diagnosticating these
and other traumatic conditions are the following, with their method of
detection (Bradford):
Pupillary: Dilatation produced by pinching side of neck.
Scapular: Scratching skin over scapula causes muscles to
contract.
Supinator: Tapping tendon at wrist causes flexion of arm.
Triceps: Tapping tendon at elbow causes extension of arm.
Posterior wrist: Tapping tendons causes extension of hand.
Anterior wrist: Tapping tendons causes flexion of wrist.
Palmar: Scratching palm causes flexion of fingers.
Epigastric: Stroking mammæ causes retraction of epigastrium.
Abdominal: Stroking abdomen causes retraction.
Cremasteric: Stroking inner side of thigh causes retraction of
scrotum.
Patellar: Striking patellar tendon causes extension of leg.
Gluteal: Stroking buttock causes dimpling in gluteal fold.
Plantar: Stroking sole of foot causes flexion and retraction
of leg.
Ankle clonus: Forcible extension causes rhythmical flexion.
Much will depend upon the minute character of the injury, its location,
and the amount of displacement of fragments. Fracture of a spinous
process causes irregularity of the tips of the spines, with frequently
the displacement of a fragment which may be moved beneath the skin,
with or without crepitus. Fracture of one or both laminæ will permit
mobility of the spinous process, with perhaps displacement. It is
difficult to elicit crepitus. The neural arch may thus be broken
without serious involvement of the body of a vertebra. On the other
hand, the body itself may be fragmented, compressed out of shape, or so
loosened as to permit of easy displacement.
DISLOCATION OF THE SPINE.
A limited proportion of serious and paralyzing injuries to the spine
consists of dislocation of some of its component parts without
fractures. These may be considered as pure types of dislocation,
but they constitute less than one-fourth of such cases. In a large
proportion of these spinal injuries the actual lesion consists of the
combination of fracture with the displacement which it permits. Such
conditions are referred to as _fracture dislocations_. Unilateral
dislocation in the cervical region produces a distortion of the neck
simulating wryneck, the face being turned to the opposite side. Except
in very fat individuals irregularity will be perceived in the line
of the cervical spines. When high up dyspnea is a constant feature.
Traumatic dislocations are sharply differentiated, so far as the
treatment is concerned, from those of slow production as the result of
cervical spondylitis. In the acute cases the muscles are spasmodically
contracted on the dislocated side. Irregularity of contour may be
detected with the finger in the pharynx.
[Illustration: FIG. 415
Fracture dislocation with great displacement--patient almost completely
recovered. (Buffalo Museum.)]
In the lower portions of the spine, which are both larger and more
protracted, are more frequent combinations of both injuries and fewer
instances of the single type of either. Except in the cervical region
it is exceedingly difficult to distinguish between these lesions, for
the question of operation or no operation is decided by other and more
conspicuous features (Figs. 416 and 417).
[Illustration: FIG. 416
Dislocation between the fifth and sixth cervical vertebræ. (Erichsen.)]
[Illustration: FIG. 417
Dislocation of the spine forward (Bryant.)]
=Treatment.=--The injury having been localized, so far as deformity
and careful study of its paralytic features will permit, the questions
of prognosis and treatment become insistent. In the pure type of
dislocation the prognosis will depend, first, upon whether reduction
can be accomplished, and, secondly, upon the amount of damage suffered
by the cord previous to such reduction. Every injury of the cervical
spine is of most serious import because of the possible damage to the
phrenic nerves. Rapidly ascending changes may terminate life in two
or three days even though reduction be accomplished. The injuries to
the lower part of the spinal column which produce paraplegia threaten
life much less directly, but too frequently terminate fatally after the
lapse of weeks or months, as the result of infections from spreading
bed-sores, or infections through the urinary tract permitted by the
constant necessity for and carelessness in the use of the catheter. The
prognosis, then, in almost every case of these severe spinal injuries
is unfavorable, at least if it be let alone (Fig. 415).
It becomes, then, a question of what can be done to improve the local
conditions. Certain cases of cervical spinal dislocation have been
reduced by forcible traction upon the head, assisted by rotation
and manipulation with the hands in the direction indicated by the
displacement of the patient’s head, as well as by such indications as
may be secured in the pharynx. A considerable degree of traction may
be necessary in this effort, and there is the possibility not only of
failure but even of serious harm, and perhaps immediate death, since a
fragment loosened may be made to produce promptly fatal pressure upon
the cord. Such a measure, then, should be undertaken with the greatest
care, and not without a complete understanding with those interested
regarding its dangers (Fig. 418).
[Illustration: FIG. 418
Method of reducing dislocations of the cervical vertebræ by
manipulation. (Lejars.)]
In most cases it is impossible from the exterior to estimate either
the damage to the cord or the amount of fluid outpour until the spinal
canal be opened. If there be complete loss of reflexes, with absolute
insensibility and motor paralysis, then complete transverse destruction
of the cord may be inferred. In these instances it may be decided not
to operate. On the other hand it may be felt that unless the damage
appear irremediable an open operation for inspection and relief should
be performed at the earliest possible moment, since pressure on the
cord allowed to persist even for a few hours causes damage for which
there is no compensation. These cases may then be viewed in this
light--if left to themselves they are almost hopeless. It therefore is
a question simply of what can be accomplished by operation. On one hand
the patient’s condition _may_ be materially improved; on the other it
is scarcely possible to make him worse. The dangers of such operations
inhere especially in the anesthetic and in the possible introduction of
sepsis; not that the operation itself cannot be properly conducted, but
that it is often difficult to keep these cases free from contamination
during the subsequent course of events. To operate through bruised or
infected skin would probably be fatal. These operations, then, are
begun as explorations intended to reveal deep conditions. When one has
freed the spinal cord from pressure and has removed the products of
hemorrhage he has done nearly all that can be accomplished in such a
case.
Until recently it has been supposed that complete transverse division
or crushing of the cord was necessarily hopeless and fatal. As
previously mentioned, Estes, Harte, and Fowler have reported instances
of complete division of the cord, with subsequent approximation by
suture and with at least partial restoration of function, that have
lent an element of hope to cases previously regarded as hopeless.
For my own part, although I regard these cases as discouraging, I
do not feel like withholding from patients the only possibility of
improvement which can be offered them, but I am more and more impressed
with the necessity for prompt intervention if this benefit is to be
obtained. To wait a few days, then, until it has been made evident that
nothing can be done, save by operation, or until a tardy consent is
obtained, is to rob the patient of the hope which it may afford. The
operative treatment should be begun immediately after the diagnosis
is made, providing that this be promptly done. Delay is more than
inexpedient--it is absolutely dangerous. As Burrell has pointed out
it is scarcely fair to decide upon a course of treatment from a study
of statistics alone, as lesions vary within widest limits, as do also
results of individual operators. Let each case, then, be decided upon
its merits, _but let whatever is done be done promptly_. If there be
excuse for delay it is in those cases where paralysis is incomplete and
where the cord apparently has not been seriously compromised. But these
would afford the most promising results after operation.
The operation itself will be described at the conclusion of this
section, and in connection with other operations practised for exposure
of the cord when involved in other lesions.
HEMATORRHACHIS AND HEMATOMYELIA (INTRASPINAL HEMORRHAGES).
These occur, as do hemorrhages within the cranial cavity, with or
without serious other lesions of the investing structures. They are
expressions, of course, of transmitted violence, depending so far as
known essentially upon injury, whether the hemorrhage occurs within the
central canal of the cord, within its structure, or within the subdural
or even extradural spaces. Everywhere within these regions bloodvessels
abound, from which may occur sufficient outpour of blood to make
pressure upon the cord to a degree producing complete paralysis. The
duration of time between reception of injury and the occurrence of
diagnostic paralysis will be to some degree a measure of the rapidity
of such outpour, while a study of the paralyses themselves will permit
of localizing the injury. The symptoms consist mainly of pain in the
spine radiating to some distance, often referred to the distribution of
the nerves most involved. This pain is often associated with muscular
spasm, while paralysis may be a very early or somewhat tardy symptom.
=Treatment.=--Once the fact of pressure upon the cord is established
these cases come under practically the same rule as above. While there
is a possibility that a moderate amount of bloody outpour might be
absorbed there is nearly as much danger of its organization and of
permanent involvement of the cord. In fact there is more reason for
operating in cases of spinal hemorrhage than in cases of fracture,
since it may be possible to thereby accomplish more.
The _non-operative treatment of fractures or dislocations_ consists
mainly in external support, preferably by a plaster-of-Paris corset
properly applied, and by maintaining elimination and nutrition, while
affording physiological rest for a sufficient length of time. These
cases will need massage and electricity, _i. e._, stimulation of
the compromised muscles, and _extreme care should be given to the
prevention of bed-sores_, to which they are peculiarly liable. _Every
precaution should be taken also against any possible retention of
urine or feces. The incontinence of an overdistended bladder should
not be mistaken for that of paralysis of its sphincter apparatus._
The specimen of dislocation from which Fig. 415 was taken was removed
from a patient who almost completely recovered from the effects of the
injury, but who became careless about the condition of his bladder and
who suffered an ascending urinary infection that terminated his life.
Of these cases it may also be said, then, that a much better prospect
of exact diagnosis and atonement for harm done is afforded by
exploration, since as between compression of the cord by clot or by
bone there is little essential difference.
The subjoined table may afford assistance in the diagnosis of the
injuries above considered:
_Differential Diagnosis of Diseases and Injuries of the Spine and
Spinal Cord._
_Fracture._ _Dislocation._ _Hematomyelia._
_Onset._ Immediate. Immediate. Immediate.
_Anesthesia._ Immediate. Immediate. Immediate.
_Paralysis._ Hemiplegia or Hemiplegia. In Paraplegia.
(Is of hemiplegic type paraplegia. partial dis-
when compression is location may
unilateral, paraplegic be absent.
when bilateral, and
local when single nerve
roots are involved.)
_Deformity._ Usually Present. Absent.
present.
_Temperature._ Rises after Same. Same.
second or
third day.
_Bowels and Bladder._ Paralyzed. Paralysis Same.
usual.
_Hematorrhachis._ _Acute Poliomyelitis._
_Onset._ Progressive. Slow.
_Anesthesia._ Incomplete. Absent.
_Paralysis._ Hemiplegia or Paraplegia.
(Is of hemiplegic type paraplegia.
when compression is
unilateral, paraplegic
when bilateral, and
local when single nerve
roots are involved.)
_Deformity._ Absent. Absent.
_Temperature._ Same. Precedes the paralysis of
degeneration.
_Bowels and Bladder._ Affected late if No paralysis.
at all.
COCCYGEAL OR PILONIDAL SINUS.
In the neighborhood of the coccyx, usually below its tip, between it
and the anus, sometimes above the tip, a small depression or sinus
mouth is occasionally seen. This is usually known as the _pilonidal
sinus_. It is the persistent remnant of the original fetal termination
of the spinal canal. It varies in size from a mere dimple to a
cul-de-sac, in which sebaceous matter, with any other epithelial
products, hair, etc., as well as foreign material and dirt from the
skin, may collect and excite suppuration. In this way an abscess of
considerable size may form. Sometimes its contents will be found to be
principally hair; hence the name pilonidal. Frequently this sinus can
be traced down to the periosteum and into the remains of the original
neurenteric canal. When it is distended so as to give trouble it needs
only to be freely incised and thoroughly cleaned.
CONGENITAL COCCYGEAL TUMORS.
In the region of the coccyx and lower part of the sacrum there appear
tumors of congenital origin which are often present at birth or may not
develop until later. These assume various sizes and aspects, varying
from mere protuberances to large pendulous tumors. While covered with
integument their internal structure varies within wide limits, and
they are usually made of such a mixture of embryonal elements as to
entitle them to be considered true teratoma. Even organized tissues or
rudimentary organs may be found therein. They are rare and constitute
practically surgical curiosities. Such a tumor, if troublesome,
calls for removal, which should be accomplished with the strictest
precautions, as the spinal canal may perhaps be opened during the
procedure and most inflammable tissue thus exposed to infection from
the perineum.
The sacrum, like the coccyx, is also the site of numerous congenital
cysts and tumors which may appear posteriorly or anteriorly.
Occasionally they form within the bone itself. Cysts that connect with
the spinal canal will be found filled with cerebrospinal fluid, and
some of them are essentially _spina bifida occulta_. The sacral region
is also the site of predilection for those teratomas which consist in
whole or in part of vestiges of an attached fetus. The advisability of
operation must be determined for itself in each of these cases. (See
Fig. 412, p. 627.)
COCCODYNIA; COCCYGODYNIA.
Under this name are included severe and chronic neuralgias of the
coccygeal region, including its joint, which occur most often in women,
and usually as the result of contusion or direct injury. Occasionally
it results from an injury inflicted during parturition. It gives rise
to a degree of pain and tenderness which sometimes is almost disabling.
Because of the insertion of the levator ani into the tip of the coccyx
defecation may become distressing, to an extent which leads to fecal
impaction in the rectum from postponement of evacuation as long as
possible. The symptoms are subjective, but the tenderness is frequently
exquisite.
In regard to treatment subcutaneous division of the tissues around the
bone may afford relief, but in most instances, particularly those of
traumatic origin, an excision of the coccyx will afford the only cure.
(See below.)
OPERATIONS ON THE SPINE.
These are included under the general heading _laminectomy_, which is
used in a comprehensive sense, as is also the term trephining.
In a general way the measure is about as follows: Through a long median
incision over the spines of the region where the lesion is localized
their tips are exposed, while the muscle groups on either side and
posterior to the laminæ are separated by the knife and by retractors.
Dense fibrous bands may be nicked. In this way the posterior aspect of
the neural arches is exposed to the desired length. The exposed spines
should be removed by cutting them off at their bases with bone forceps,
although they may be left and later removed with the posterior bony
arches. To clear them away, however, affords a better view of the field
of operation. The ligamenta subflava are then divided transversely
at their upper and lower margins, after which, either with cutting
forceps, saw, or chisel, the laminæ are divided on either side, and the
section which is loosened pried out from the bed in which it rests.
More or less fatty tissue will be found outside of the dura and in this
tissue veins, sometimes of considerable size, freely ramify. These may
be seized and divided, those of considerable size being tied. Great
care should be given during the procedure to avoid perforation of the
spinal membranes by the points of the instruments used. The cutting
forceps are preferable to the saw or chisel, except for work in the
lower lumbar region, where the parts are stout and strong. Especially
in case of fracture, and at the upper end of the spine particularly,
care should be given, with the force used, that no loose fragment be so
handled as to increase the damage already done to the cord.
The dura being thus exposed and the blood cleared away, inspection may
or may not reveal the nature of the lesion. A probe, gently handled,
passed upward and downward into the canal, will reveal whether the
cause of the pressure has been cleared away or not. According to
the nature of the lesion it can then be decided whether to open the
dura. To open it is to pave the way for fatal infection, unless the
strictest aseptic technique has prevailed. On the other hand, to leave
it unopened is to fail to appreciate the actual condition of the cord
and to leave an important matter still undetermined. The dura if opened
should be closed by suture.
Reference has already been made, in three cases now on record,
to suture of the cord as a whole. Such sutures may be applied,
if necessary, in a manner to do the least possible damage to the
structures of the cord. If cerebrospinal fluid escape too freely the
patient may be operated in a position with the head lower than the
trunk, avoiding leakage.
_Osteoplastic methods_ of temporary resection of the posterior arches
of the vertebræ have been devised and practised, but they offer no
particular advantages, and are attended by disadvantages which have
caused them to be almost abandoned, save in rare instances and by
individuals of large experience. (See Plate XLVII.)
In regard to wiring fragments of a fracture or displaced spine, Hadra,
of Texas, was perhaps the first to carry out the measure. It comprises
simply the fixation of fragments by wire sutures or ligatures which
bind them together after they have been replaced through a more or less
open wound, such as is included in the term laminectomy. But resort to
wire is to be left to the judgment of the operator and the needs of the
case. There is no reason, however, why it may not be used here, as in
other fractures which are thus made compound, if there would seem to be
prospect of benefit attaching to its use.
[Illustration: PLATE XLVII
Osteoplastic Resection of Posterior Vertebral Arches. (Urban.)]
_Laminectomy_ is practised also in _Pott’s disease_, with the hope
of relieving pressure upon the cord, due to the deformity or to the
presence of tuberculous foci. It is possible that in some of these
cases an incomplete operation will serve the purpose. Sufficient should
be done, however, to relieve pressure if such a measure be indicated.
When laminectomy is practised for the purpose of attacking a _tumor
of the spinal cord_ the exposure of the cord should be followed by
the removal of the tumor. Some of these are so placed as to make
the procedure simple, while at other times it will be exceedingly
difficult, if not impracticable. If the growth has so extended as to
involve the bones themselves, then the measure will be futile and
should be abandoned; but an isolated tumor, either within or without
the dural space, in or on the substance of the cord, can usually be
removed by a process of blunt dissection. Sometimes the small wounds
thus made will ooze considerably and hemorrhage may prove troublesome;
it should be checked before the parts above it are closed. Pressure
forceps and ligatures and the occasional use of adrenalin solution will
afford the necessary means for combating bleeding.
For nearly all of these operations upon the spine the chisel and the
cutting forceps will suffice. Some operators, however, prefer a small
saw, like that suggested by Doyen, which has a guard that can be so
set as to determine the depth to which the instrument may pass. No
matter what instrument be used, great care should be taken lest it pass
through and beyond the bone in such a way as to lacerate the dura or
the plexus of veins outside of it.
The _sacrum_ is rarely attacked except in connection with some of those
tumors already described.
The _coccyx_ is easily removed through a median incision, the parts
around it being entirely separated and the bone thus freed removed at
the joint with stout scissors or cutting forceps. The instruments used
should be kept in contact with the bone and not allowed to injure the
veins between it and the rectum. Such a wound should not be closed
completely, as a cavity always remains, which it is better to pack and
permit to heal by granulation. (See Coccodynia.)
CHAPTER XXXIX.
THE FACE AND EXTERIOR OF THE NOSE AND MOUTH.
Monsters are born with almost complete absence of the face, which is
called _aprosopia_. They have also been observed with double faces.
Again a condition of congenital hypertrophy is known involving one or
both sides. On the other hand congenital atrophy is also occasionally
noted, affecting one or both sides. The former is likely to be of
syphilitic origin (hereditary), in which case it will be accompanied by
other indications such as corneal opacity, irregularity of teeth, or
other evidences of its luetic origin.
Among the most interesting congenital defects are those connected with
_imperfectly closed branchial fistulas_ and the various outgrowths
therefrom. These may lead to fissures extending from the ear to the
mouth. Fibrocartilaginous growths occur along the regions of the
original branchial clefts, either as tags of skin upon the face or
so-called _supernumerary auricles_ or auricular appendages. While these
are covered with skin they usually contain a cartilaginous nucleus.
They are most common in front of or on the tragus. They may be single,
multiple, or symmetrical. They sometimes increase in size and at others
remain stationary.
Fissures are seen more often upon the central portions of the face,
especially in the nose or between it and the cheek. About the root
of the nose and the orbit dermoids are somewhat common. They may be
connected with fissures or fistulas, and extend upward and involve the
dura.
Absence of the mouth is known as _astomia_, and of the lips as
_acheilia_. These malformations are exceedingly rare. Atresia, or
narrowing of the mouth, is more common. While the lips and mouth may be
apparently well formed there may be imperfections. These conditions of
narrowing call for division on each side and union of skin to mucous
membrane. _Fistulas of the lip_ are extremely rare, but are found
occasionally, especially opening upon the lower lip. Branchial fistulas
opening upon the lips have also been observed.
A condition of arrest of development of one or both jaws leads to
unnatural smallness of the mouth known as _microstoma_. The opposite
condition, _macrostoma_, is produced usually by fissure of the cheek
on one or both sides, extending upward and backward from the labial
junction and due to incomplete closure of a branchial cleft. The
most common congenital defect of the lip known as _hare-lip_ is a
median fissure involving the upper lip. This occurs in all degrees,
from a trifling notch at the vermilion border to a hideous defect,
in which, through a wide cleft, projects a relatively overdeveloped
intermaxillary bone, with a small downward projection of skin, known
surgically as the philtrum. This defect may involve much more than
the lip alone, for there may be failure to unite, along the median
line between the lip and the uvula, of those portions of the superior
maxillary which should develop symmetrically, and coalesce as they are
formed from the rudimentary maxillary processes. Any portion, then, of
the hard or soft tissues may show failure to unite in the middle line.
Hypertrophy of a lip is known as _macrocheilia_. It is not uncommon in
strumous subjects. Another form is known as mucous ectropion. (See p.
373.)
The chin may be malformed in the direction either of atrophy or the
reverse, as in the so-called double chin. A deviation forward, known as
_galoche chin_, is also recognized. A peculiar malformation, consisting
of the implantation of a supernumerary inferior maxilla by its own
symphysis upon that of the subject, is known as _hypognathy_. Such
a tumor will occasionally develop to considerable size, with cystic
degeneration or other irregular changes.
Aside from the common forms of hare-lip most of the congenital defects
that occur about the face are to be explained through incomplete
closure of the branchial clefts or the development of dermoid cysts
and tumors therefrom. Deviations rather than defects appear more
commonly about the nose than anywhere else. They produce disfigurements
known as pug-nose, saddle-nose, parrot-nose, etc. Again, double noses
exist, each being more or less well formed. In such a case the surgeon
should endeavor to remove a part of each and unite the remaining
portions in one, unless one of them be placed away from the middle
line, in which case it may be extirpated.
ACQUIRED MALFORMATIONS OF THE FACE.
These are usually the result either of mutilation or of some ulcerative
morbid process. Injuries of the face, unless extremely carefully and
promptly attended to, are commonly followed by scars, which may cause
great disfigurement. This is invariably true of severe burns, which, by
subsequent contraction, draw features badly out of shape, and sometimes
close the mouth or pull the lower jaw down upon the neck and the chin
upon the chest. Serious contused wounds are frequently accompanied
by fracture of parts beneath, and should be treated as a compound
fracture. Considerable portions of the facial mask are sometimes torn
away, producing hideous appearances. By punctured wounds the maxillary
sinus, orbit, or brain cavity may be perforated and foreign bodies
carried in. A wound may be so placed as to sever Stenson’s duct. All of
these injuries may be accompanied by serious brain disturbance, as the
result of the contusion. Gunshot wounds will present either punctures
or extensive lacerations, according to the proximity and the weapon.
In no part of the body are gunpowder stains more observable or more
deplored than upon the face. In order to prevent them each grain of
powder must be picked out with a small spud or needle, after a careful
scrubbing of the face. Every grain of gunpowder allowed to remain will
produce a minute area of staining.
Injuries to the nose may require plastic reconstruction or the
formation of a new nose by one of the rhinoplastic methods later
described, or an artificial nose, carried by spectacles, may be worn.
The cartilages of the nose are frequently dislocated, thus producing
deformity, and the same result may follow fractures. As already
indicated in the chapter on Fractures, prompt and complete replacement
with support are usually sufficient to give a satisfactory result.
Deviations of the nose, and especially cosmetic defects which result
from injuries or disease, producing the so-called saddle-nose, when
not extreme, may often be remedied by the injection of paraffin, the
patient being either under cocaine or general anesthesia.
Burns, injuries, and serious ulcerations about the cheeks and lips
produce conspicuous disfigurement (perhaps none more so than a serious
form of cancrum oris) with a considerable loss of substance. In this
way may be produced an acquired microstoma, or adhesion of cheek to
jaw, which is known as _syncheilia_. More superficial lesions may
produce ectropion or eversion of the lips, or acquired macrostoma.
Cretins, idiots, and patients with facial paralysis acquire gradually
a chronic swelling of the lower lip with drooling of saliva. The lip
may enlarge to such an extent as to ulcerate as the result of exposure.
_Frostbite_ also produces serious deformity by ulceration of the skin.
When a puncture of the cheek occurs at the opening of Stenson’s duct,
_i. e._, opposite the second upper molar tooth, there may occur a
salivary fistula. In a recent clean wound the duct ends may be stitched
together. In old wounds Souchon recommends to introduce catgut into
the distal end, and then by pressure on the parotid to discover the
proximal end and stitch it with the catgut in the divided portion; or
the wound may be enlarged and the proximal end turned into the mouth
and there retained.
Considerable emphysema may follow contusions of the face, especially
those causing fracture of the nose. In this way a face may be so
distended as to produce almost a caricature of its former appearance;
this, however, will subside within a few hours.
By virtue of its extreme vascularity wounds and injuries of the face
heal with a surprising degree of promptitude and certainty. This
affords the reason for the satisfactory results of extensive plastic
operations. For the same reason secondary hemorrhages may easily occur
and additional precautions should be taken. Exact hemostasis, before
closure of wounds, will afford protection as against this event. Wound
edges should be neatly trimmed and _subcutaneous sutures_ may often be
used to advantage to minimize the resulting scars. A lesson “how not
to do it” may be learned from the faces of German university students
who have indulged in the common but senseless sport of duelling, and
who are said to rub salt and alum into their cuts in order to make the
scars as conspicuous as possible.
NEUROSES AND CONSEQUENCES OF INJURIES OF NERVES OF THE FACE.
Anesthesia of parts supplied by the trifacial necessarily follows
division of its various portions. It may also occur as the result
of a deep-seated or central lesion. In course of time more or less
sensibility will return, apparently due to an anastomotic process.
_Facial paralysis_, so-called Bell’s palsy, may be of central origin,
or be due to the effects of a “cold” following exposure, apparently
with inflammation of and an exudate around the trunk of the facial
nerve as it passes through its bony canal in the temporal bone. It
is also the result of a division of the nerve trunk either outside
of the bone or in the bony canal, where it is occasionally wounded
in operations upon the mastoid or in removal of the parotid for
malignant tumor. _Facial neuralgia_ is an affection of one or more of
the branches of the fifth nerve, and, when assuming a spasmodic and
intermittent type, is often spoken of as _tic douloureux_. Its exciting
cause may be a carious tooth, even though it give no pain, while other
causes are lesions in the neighborhood, such as callus, foreign bodies,
tumors, bone disease, and the like. Its special treatment has already
been indicated in the chapter dealing with the Cranial Nerves. Many of
these cases of neuralgia gradually diminish the patient’s strength.
ULCERATIVE AND GANGRENOUS LESIONS OF THE FACE.
The serious ulcerative lesions of the face are usually due to
_tuberculosis_, _syphilis_, or _malignant disease_. In all of these
conditions there will be enlargement of the neighboring lymphatics.
This is true also of the lesions of _actinomycosis_, which should
not be forgotten as a possible cause. The free border of the lips
is occasionally ulcerated in patients with pulmonary tuberculosis.
Otherwise tuberculous lesions are uncommon upon the lower lip, while
in the upper lip they show a tendency to invade and spread. Syphilitic
ulcers may be either primary chancres, which are most common on the
lower lip, or the results of mucous patches, or other secondary or
tertiary lesions. Of the cancerous ulcerations, which tend always to
break down and spread, without any tendency to healing in the centre,
_epithelioma_ is the most common form. It is a frequent disease in men,
occurring much oftener on the lower than upon the upper lip. In women
it is exceedingly rare at this point. The difference is explained by
the liability to constant irritation incurred by those who smoke pipes
or are particularly careless about their teeth. Of epithelioma there
are, as is well known, various types, including the so-called rodent
ulcer, which, however, is less frequent here. The location of the
lesion subjects it to constant irritation, as well as maceration from
the moisture of the mouth. Such a growth may be superficial and raw,
or it may be covered by scale or crust. It will nearly always have an
indurated and raised periphery. A papillary form, with non-indurated
edges, is also known, as well as a diffuse form, where several minute
lesions seem to coalesce, with elevation of the central portion.
This is perhaps the most malignant of all, as it has no well-defined
boundaries. In nearly every well-marked case involvement of the
submaxillary lymphatics can be detected. All of these cancers of the
lip and face should be removed, with plastic re-arrangement of the
parts. Growths of this kind seen early, before much tissue is involved,
can be removed with permanent success. Error is made on the side of not
doing sufficient rather than doing too much. (See Chapter XXVI.)
_Cancrum oris_ has already been described in the chapter on Gangrene.
The extensive destruction which it may cause is also described there.
The condition, when seen and recognized early, has been successfully
treated by local applications of bromine and the actual cautery. It is,
however, a destructive and unpromising condition with which to deal,
as it rarely occurs in healthy children, but usually in those with a
constitution already vitiated by heredity or environment. (See p. 75.)
TUMORS OF THE FACE.
The parts described in this chapter may be the site of almost every
tumor which is met with in any other part of the body; in addition
to which there are two which are peculiar to the nose and adjoining
tissues. These are _rhinophyma_ and _rhinoscleroma_. They have both
been described briefly in the chapter on Tumors, and each is to be
differentiated from the other, having a very different etiology.
_Rhinophyma_ consists of vascular engorgement, with hypertrophy,
especially of the glandular and connective-tissue elements of the
skin, which begins about the tip and the alæ of the nose, and produces
disfiguring deformity. It is, however, at first, quite innocent in
its character. It occurs most often in hard drinkers, and is to be
regarded as an overgrowth, coupled with a large amount of secretion,
of the sebaceous glands of that portion of the skin. This secretion
is often so great as to escape and lead to the formation of scabs,
as it dries, until more or less ulceration takes place. The nasal
enlargement is rarely symmetrical, and is nearly always lobular, so
that the overgrowth may consist of a series of nodules whose escaping
secretion becomes offensive. The parts are often discolored, even to a
purplish color, in consequence of venous stasis. Frostbite frequently
predisposes toward it.
[Illustration: FIG. 419
Plexiform angioma of face; cirsoid aneurysm. Not benefited by ligation
of external carotid. (Lexer.)]
[Illustration: FIG. 420
Illustrating ravages of rapidly growing vascular sarcoma of face,
involving all the cranial and facial cavities. (Lexer.)]
Treatment in incipient cases may consist of a sort of massage, by
which the overloaded glands are emptied. In more serious instances the
diseased tissue should be extirpated, and either left to granulate or
be covered by a plastic operation.
_Rhinoscleroma_ is a serious and fatal lesion, consisting of a
parasitic invasion by a peculiar bacillus. It begins as a painless
induration, either at the edge of the nostril or upon the upper lip,
grows slowly, the tissue affected becoming firm and dense. The growth
is usually lobulated, with fissures or excavations between the lobules,
which may crack and give rise to a yellowish discharge that dries
into crusts. While the affection may begin in the deeper parts of the
nasopharynx its occurrence there is usually the result of extension
from the anterior growth. The disease may occur either in the young or
in the adult. A case illustrated elsewhere (see p. 55), for which I
am indebted to Dr. G. W. Wende, proved fatal after a couple of years.
In this country it is rare, but occurs frequently in some portions of
Russia.
For treatment there is but little encouragement, least of all for
operative intervention. Growths nearly always recur after removal.
In the cheek _cysts of Stenson’s duct_ and _dermoid_ tumors and cysts
have often been observed near the parotid region. The so-called “fatty
ball of Bichat” is occasionally the site of an angioma, which may
press upon Stenson’s duct and be accompanied by calculus in the parotid
gland, the superficial veins being much dilated. (Souchon.)
Fatty tumors, as well as sarcoma in this same tissue, are prominent.
The most frequent tumors of the face are the _epitheliomas_ of the lip,
nearly always of the lower lip, occurring oftener in men than in women.
A growth of this character at this site is regarded as an expression
of the result of irritation, which may be produced by a carious tooth
or by constant friction of a pipe-stem, or from many other causes.
It frequently develops at the site of an old chronic fissure. These
growths spread from small beginnings, and if, when small, they were
extirpated there would be fewer cases of cancer of the lip spreading
to and involving the face and neck. Every ulcer of the lip whose
base becomes indurated, and from which the syphilitic element can be
excluded, should be excised, the ensuing defect being repaired by a
plastic operation. (See above.)
[Illustration: FIG. 421
FIG. 422
FIG. 423
FIG. 424
FIG. 425
FIG. 426
FIG. 427
FIG. 428
FIG. 429
FIG. 430
FIG. 431
Utilization of rectangular flaps.]
OPERATIONS UPON THE FACE AS A WHOLE.
The tissues composing the face are extremely vascular, hence hemorrhage
is profuse and hemostasis should be exact. By virtue of this same
rich blood supply the process of repair is prompt and satisfactory,
if sources of infection be avoided. Patients here, more than anywhere
else, desire a minimum of scar. Incisions, then, should be so planned
as to permit the utilization of the natural folds or grooves of the
face. They should also be so made as to avoid injury to main trunks
of vessels and nerves, as well as to Stenson’s duet. Sharp knives and
the least possible bruising of the tissues help to ensure the desired
result. When possible a subcutaneous suture should be employed. When
this is not sufficient fine needles and fine suture material should be
used. A reasonably short, clean wound upon the face, especially in
the neighborhood of the mouth, should be protected from the air until
it is dry, using a dusting powder and then covering with collodion. In
extensive operations provisional or permanent ligation of the carotid
may be necessary; usually the external branch will suffice. In every
instance plastic repair should be made, as it will always be required
after the excision of growths involving the surface.
Space does not permit of detailed or specific directions for all
possible methods of plastic repair of facial defects, but Figs. 421 to
441 illustrate the principal methods which may be utilized in planning
and sliding flaps which shall serve this purpose. These may be modified
or combined to meet special indications.
[Illustration: FIG. 432
FIG. 433
FIG. 434
FIG. 435
FIG. 436
FIG. 437
FIG. 438
FIG. 439
FIG. 440
FIG. 441
Sliding rectangular flaps into desired position.]
It is often necessary to intermit the anesthetic because the operator
must displace the mask in order to do his work. Souchon advises an
apparatus by which most of this delay can be avoided. By means of a
rubber bulb a current of air is passed through the bottle containing
the anesthetic and then directed through a tip which is passed down in
the pharynx through a nostril. This may be connected, if so desired,
with a bag of nitrous oxide gas, which is illustrated in Fig. 442, and
its use in Fig. 443.
Ligation with excision of a section of the external carotid has been
suggested by Dawbarn as a means of cutting off the blood supply in
_cases of inoperable malignant tumors of the face_, thus reducing their
rate of growth. In tumors of the jaw, for instance, he would also tie
the inferior dental artery, with its mylohyoid branch, just before it
enters the inferior dental canal. He advises, also, the removal of one
inch of the inferior dental nerve, thus avoiding pain and distress,
occluding the artery on the less diseased side first, waiting for two
or three weeks before attacking the more diseased side, for should
there be noticeable benefit after operation on the more affected side
many patients would be unwilling to be again subjected to the other
operation. Other operations include those made upon the various nerves
for relief of neuralgia or for nerve suture of divided trunks. These
have been described in a previous chapter.
[Illustration: FIG. 442
FIG. 443
Souchon’s intranasal inhaler.]
OPERATIONS ON THE NOSE.
Plastic operations upon the nose appear to have been practised early
in the history of surgery. The East Indians had a method by which the
skin of the forehead was made to furnish a flap from which a new nose
was created. This was known as the Indian method. It has been somewhat
modified of late years by raising with the skin flap the periosteum,
or, as suggested by König, the outer table of the frontal bone, with
the intent and hope that something resembling the nasal bone might
be secured. The so-called Italian method (named the Tagliacotian
operation, after Tagliacozzi) consists in utilizing the skin of the
arm, which is loosened according to a pattern previously made, leaving
it connected only by a pedicle through which its blood supply is to be
afforded. This flap is usually cut out and perfectly formed, then left
loose upon the arm for about fifteen days until its viability has been
thoroughly proved and its under surface is granulating. Then the edges
of the defect in the nose are pared, as well as those of the flap, and
the arm is brought into such position as to allow fitting the latter
to the former, where it is held by stitches. The arm is held in proper
position by cushions and by bandages of plaster of Paris until union
has taken place, after which the pedicle is severed and the arm then
released.
[Illustration: FIG. 444
“Saddle-nose” due to syphilitic destruction of bone. (Lexer.)]
Lesser deformities of the nose may be remedied or repaired in various
ways. Angular deformities may be excised, while a sunken bridge may
be raised, as Weir has suggested, through a bevelled incision at the
junction of the nasal and maxillary bones, they being held in place by
a transfixion pin. One of the most common and objectionable deformities
is the so-called _saddle-nose_, which may be treated by Weir’s method,
or which has afforded satisfactory results after the injection of
paraffin. Roe, of Rochester, New York, has succeeded in remedying many
of the more trifling nasal deformities by operation from within the
nose, as, for instance, in case of _pug-nose_, where he dissects from
within superfluous fat and connective tissue (Fig. 444).
HARE-LIP AND OPERATIONS UPON THE LIPS.
_Hare-lip_, or _coloboma of the upper lip_, is due to a failure in
coalescence of the developing maxillary processes, which should unite
early in fetal life to form the lip, alveolar process and roof of the
mouth. This failure may involve but a trifling part of this line of
normal junction or may be complete. Thus anywhere along it defects may
be noted, such, for instance, as a little notch in the lip, a small
opening in the hard or soft palate, or a bifid uvula. The defect in the
lip alone is known as hare-lip because of its normal occurrence in the
hare, and occurs on either side of the median line, absolute median
fissure being extremely rare. It may occur alone or in combination with
deeper fissures which involve the gum or the alveolar process alone or
the entire palate. In extensive fissures of this character development
is rarely symmetrical, and one side is usually not developed
sufficiently to match the other. This makes operative treatment the
more difficult. The more complete and extensive fissures are often
complicated by excessive development of the intermaxillary bone,
apparently from lack of pressure. This permits a projection of the
septum, and especially of the central portion of the alveolar process,
with a small part of the skin and connective tissue, which should
have been blended into the lip proper. It represents the original
intermaxillary bone with the portion which should have been developed
downward from the nasal process of the midfrontal region. This gives a
snout-like appearance to the face, and nearly always necessitates doing
an operation for closure of the lip in two sittings. In Figs. 445 and
446 will be seen wide clefts with projecting intermaxillaries, while
Fig. 447 illustrates a much more complete coloboma of the face, with
complete bilateral fissures. Figs. 448 and 449 show the double form
with philtrum or snout. Figs. 450 and 451 give the palatal conditions
of irregularity and projection of the intermaxillary bone. (See Cleft
Palate.)
[Illustration: FIG. 445
Incomplete hare-lip.]
[Illustration: FIG. 446
Complete fissure in double hare-lip.]
[Illustration: FIG. 447
Complete bilateral fissures (coloboma) of face. (Guersant.)]
All forms of hare-lip call for operation not alone for cosmetic
purposes, but so that patients can nurse, drink, eat, and talk to
better advantage. Obviously the earlier such operations are done,
other things being equal, the better the results. When the cleft does
not include the deeper tissues it may be closed within the first week
or two of infancy. When the roof of the mouth is involved the surgeon
is perplexed in deciding which is the better of two courses--to operate
or to wait. Unquestionably by early closure of a fissured lip a gentle
but constant influence is maintained to press the divided upper edges
together, or at least to influence their more rapid growth toward each
other. For this reason it would be desirable to operate early. On the
other hand with a bad palatal defect it is a difficult thing to operate
until, with the increasing age of the child, the mouth has attained
a size which will permit the manipulations required for the purpose.
Nevertheless, unless there be some special reason for delay it would
appear wise, at least as a general rule, to operate early. (See Cleft
Palate.)
[Illustration: FIG. 448
Double hare-lip with philtrum or snout.]
[Illustration: FIG. 449
Complete fissure, with labial defect and projecting intermaxillary.
(Bruns.)]
[Illustration: FIG. 450
Illustrating the osseous (palatal) defect in complete fissures.
(Bruns.)]
[Illustration: FIG. 451
Projecting intermaxillary bone. (Bruns.)]
The underlying principle of these operations is easily and briefly
stated. The edges of the defect should be freshened and brought
together by sutures. Extreme care should be taken that the vermilion
border of the lip be maintained. A little particle of mucous membrane
in the lip of an infant, dislocated to a level higher than that where
it belongs, will appear later in life as a reddish patch upon the skin,
which will prove quite a disfigurement. Simple fissure of the lip is
easily managed by Nélaton’s procedure (Figs. 452 to 457). The deeper
and more extensive the fissure the more plastic reconstruction is
required.
[Illustration: FIG. 452
Malgaigne’s operation: the incision.]
[Illustration: FIG. 453
Malgaigne’s operation: the sutures in position; the lower sutures tied.]
[Illustration: FIG. 454
Nélaton’s operation: the incision.]
[Illustration: FIG. 455
Nélaton’s operation: the sutures.]
Incision, when necessary, may be extended around the angle of the nose
on one side or both, and the lip should be dissected away from the
bone sufficiently to make it movable. Operations by which a certain
dovetailing of the little flaps is performed afford more security than
a perfectly straight incision, but the resulting scar is rather more
marked. The more perfectly the mucous membrane can be preserved upon
the under side of the lip the better will be the result.
[Illustration: FIG. 456
The operation for double hare-lip.]
[Illustration: FIG. 457
Operation for double hare-lip: the sutures in position.]
Hare-lip pins have been abandoned. Sutures only are used, which may be
of thread or horse-hair, catgut absorbing too rapidly. It is my custom
to pass a retaining suture of stout silk through the cheek on either
side, at a distance of one inch or so from the wound margin, to bring
this forward in front of the alveolar process, and, by using a plate
and shot on either end, to prevent tension upon the line of junction.
This is very important, for children will fret and cry in a manner
to tear out many a stitch not thus fortified. After operation young
children should be snugly enclosed in a protective bandage around the
chest, by which it shall be made impossible for them to get their hands
to their mouths. It is vitally necessary to maintain absolute rest of
the face and protection from any possible source of harm.
[Illustration: FIG. 458
FIG. 459
Line of incision, according to König.]
_Fissures of the lower lip_ are surgical curiosities. Should one be met
it may be treated on the same general principles.
[Illustration: FIG. 460
Cheiloplastic operation on lower lip. (Tillmanns.)]
The other _cheiloplastic operations_ upon the lips are those made
necessary by excisions of malignant growths, or by deforming cicatrices
such as follow burns, syphilitic lesions, and the like.
[Illustration: FIG. 461
FIG. 462
Estlander’s cheiloplastic operation.]
Fig. 460 illustrates one method of filling a defect of the lower lip,
while Figs. 461 and 462 indicate a method of bringing down a flap from
the upper lip for the same purpose.
THE SALIVARY APPARATUS.
FOREIGN BODIES IN THE SALIVARY DUCTS.
Foreign bodies occasionally enter the salivary ducts, especially
Stenson’s and Wharton’s, where they may set up an inflammation known as
_sialoductilitis_. These may consist of bristles, fish-bones, and the
like. Abscess, in consequence, may form in the gland or between it and
the foreign body. Calculi also lodge in the ducts, where they remain
as foreign bodies, producing sometimes a disproportionate amount of
irritation.
FISTULAS OF THE SALIVARY DUCTS.
Fistulas of the salivary ducts involve Stenson’s duct. They open on the
inside of the buccinator muscle, back of the orifice of the duct, which
is opposite the second upper molar tooth. These fistulas of the parotid
gland may be recognized by the passage of a probe from within the
mouth. When they open externally they result nearly always from injury,
and it is only the external forms which are troublesome. One may resort
to the mildest measures first, and experiment with cauterization of the
orifice or compression by occlusion. These measures will be ineffective
if there be no opening upon the inside of the mouth, in which case
one must be made by reëstablishing the original canal or forming a
substitute. For this purpose a suture may be passed around the duct,
back of the fistula, using a curved needle, and making it come out near
the point of entrance. It should hold the duct in its loop. This suture
may then be tightened and the distended duct punctured on the inside
of the cheek. When once the flow of saliva is diverted to the mouth
the edges of an external fistula may be pared and closed. In obstinate
cases which have resisted all other methods it has been suggested to
remove or destroy the gland which connects with the duct at fault.
Even this is not an easy matter, but it can be done in the case of the
parotid by careful dissection, with separation of the branches of the
facial nerve and removal of the greater portion of the gland itself.
Congenital anomalies of the salivary glands are rare and of small
import. Any one of them may be displaced, or either of them may connect
with an accessory gland separated from it by an appreciable interval.
Abnormal duct openings have also been noted.
INFLAMMATION OF THE SALIVARY GLANDS.
Inflammatory affections of the salivary glands give rise to
_sialoadenitis_. Among these by all means the most common is
_parotitis_ (_mumps_), which often occurs in epidemic form. It is an
infectious and probably contagious disease, usually attacking the
young, though no age is exempt. The period of incubation is about
fourteen days. The condition begins with a stomatitis and with swelling
of the affected parotid, with edema of the overlying tissues. It is
accompanied by moderate fever. Swelling may be extensive and involve
the entire neck region. The parotid on the other side becomes affected
within a few days, although usually not to a similar extent. The other
salivary glands occasionally participate. The febrile stage lasts for
about a week, after which the swelling recedes and is gone within from
two to four weeks. Occasionally the affected glands suppurate, in which
case the condition may be very serious, since it may simulate Ludwig’s
angina, or may be followed by sloughing and gangrene.
Save when abscess threatens the treatment should consist of
warm antiseptic mouth-washes and the external application of an
ichthyol-mercurial ointment or of Credé’s silver ointment. When
suppuration threatens early incision should be made for the relief of
tension and prevention of destruction.
A frequent and important _complication of parotitis is orchitis_, or
swelling of the testicle. This is an unexplained feature of these
cases, and occurs mainly in sexually mature individuals. It is the
testis proper which suffers and not the epididymis. Suppuration here
is rare. More or less atrophy is a remote consequence in many cases,
estimated at about one-third. When both testicles are affected to
a marked degree impotency may follow. Treatment of this orchitis
consists in absolute rest in bed, with elevation of the parts affected,
often with the application of an ice-bag. Painting the scrotal skin
with guaiacol in small amount will often relieve pain. A similar
complication occurs in the female, the _ovary_ being involved.
Aside from this, other complications may occur in the breast, the
vulvovaginal glands, the prostate, the heart, the eye, and the ear.
Apart from this somewhat specific affection the parotid and the other
salivary glands may become involved in swelling and inflammation on
account of surrounding local infections, or the presence of foreign
bodies, stones in the ducts, etc. Metastatic abscesses, especially in
the parotid, are not uncommon. Considering the open pathways offered
it is surprising that these glands are not oftener involved in septic
conditions of the mouth.
MIKULICZ’S DISEASE.
Mikulicz has described a not very infrequent simultaneous affection
of two or more of the salivary glands, occurring in middle age,
characterized by uniform swelling which may involve even the palatine,
labial, and buccal glands. It is spoken of in German literature
as _Mikulicz’s disease_. The swelling progresses slowly, so that
the glands reach a varying size in the course of years. Thus the
parotid glands may attain the size of the fist, and other glands a
corresponding increase. Sometimes the adjoining lymphatics are also
involved. The enlargements are not tender, but may interfere with
movements of the tongue and jaw. These tumors have been known to
recede after an intercurrent acute disease. Nothing is as yet known
of the cause or nature of the affection. In its treatment arsenic and
potassium iodide have given perhaps the most favorable results.
The salivary glands, especially the parotid, are as likely to be
involved in the manifestations of tuberculosis, actinomycosis, and
syphilis as are the other structures of the body. Lesions of these
various natures will be appreciated without further description.
TUMORS OF THE SALIVARY GLANDS.
Tumors of the salivary glands are not uncommon. The parotid is more
frequently affected than either of the others. These tumors may be of
cystic character, either large from obstruction of the excretory duct,
or small and numerous. Almost all the tumors described in Chapter
XXVI may be found in this region. Simple adenomas are common and the
parotid especially is often the site of tumors of mixed character, in
which the various mesoblastic elements mingle in a confusing manner.
Cartilaginous tumors here are frequent. The presence of cartilage is
to be explained on Cohnheim’s hypothesis. Endothelioma, sarcoma, and
carcinoma are also common, especially as primary tumors in the parotid.
Any or all of the glands may also suffer by extension of malignant
disease from primary foci in their neighborhood (Figs. 463 and 464).
[Illustration: FIG. 463
Mixed tumor of the parotid. (v. Bruns.)]
[Illustration: FIG. 464
Mixed tumor of the submaxillary gland. (v. Bruns.)]
Cancer of the parotid is especially serious and discouraging, because,
while radical removal is necessary, it is impossible to effect this
without destroying the facial nerve and producing consequent paralysis
of the face on that side. Such an operation should not be made without
explaining to the patient beforehand its inevitable result. Only when
seen in their very early stages can these tumors be so effectually
removed as to not leave the patient liable to secondary or metastatic
affections. This also should be explained to them in order that the
surgeon may protect himself from blame.
SALIVARY CALCULI.
Calculi which form either in the substance of the glands, or much
more commonly in their ducts, by precipitation of those salts held in
solution by the saliva, are of the same character as the accumulations
of the so-called tartar upon the teeth. They are met with frequently in
Wharton’s duct and occur more often in men than in women. They may vary
in size from that of a rice-grain to a stone more than one inch long.
They are always ovoid in shape and with a rough exterior. They are
believed to grow much as do gallstones, as the result of some previous
infection, a clump of bacteria perhaps affording the nidus on which
calcareous material is deposited. The affection may be spoken of as
_sialolithiasis_.
They usually give rise to pain and swelling, and lead occasionally to
the formation of abscess and fistulous openings. They may be revealed
by the _x_-rays, or the operator may search for them as for stone in
the bladder, with a small probe passed through the duct opening. The
discharge of mucopus or blood into the mouth would suggest infection of
this kind. They may also be recognized by thrusting a needle through
the overlying tissues in the direction of the swelling which they
produce. Their removal through the smallest incision on the interior of
the mouth which will suffice for the purpose is indicated. No attempt
need be made to close the opening.
Operations on the parotid region are difficult and severe. In case
of large tumors the external carotid and the common carotid may
be ligated. By separating the patient’s jaws the parotid space is
increased and deep dissection is more easily made. Caution should be
taken not to open the maxillary joint. Souchon has called attention to
the fact that the safest plan is to proceed so long as the surrounding
tissues are easily removed _en masse_, and to stop when they become too
resistant as the deep surface is approached. Then the portion of the
tumor which has been cleared should be cut off. The stump thus left
will, in growing again, become more superficial, and it is sometimes
possible to effect a radical removal by a second operation.
CHAPTER XL.
THE MOUTH, THE TONGUE, THE TEETH, AND THE JAWS.
CONGENITAL DEFECTS.
Aside from anomalies due to incomplete closure or erratic development
from the branchial clefts, the principal congenital defects of
the regions included in this chapter are as follows: The mouth is
essentially a coalescence of the upper end of the foregut and a recess
known as the stomodeum, which are at first separated by membrane, the
latter disappearing early in fetal life. Some remains of it, however,
may produce a narrowing of the oral fissure and cause one form of
_microstoma_. Some of these facial defects are due to formation of
amniotic bands and adhesions, which restrain or interfere with the
normal development from the branchial fissures. Malformations of the
_tongue_ may accompany other anomalies. A _median cleft_, called also
a _bifid tongue_, and defective development and undue adhesions to the
floor of the mouth, are known, whose most trifling expression may be
seen in the so-called _tongue-tie_, where the frenum is too short and
needs to be divided in order to release the tip and more movable part
of the organ. Adhesive bands may also attach the tongue laterally to
the cheek, bands between the cheek and the gums being also occasionally
seen. An extreme type of tongue-tie is known as _ankyloglossum_.
Abnormally long tongues are also met, and cause an actual menace
from danger of the tip being swallowed, as children have suffocated
from this cause. _Congenital macroglossia_ has been described; it is
usually due to lymphangioma of the tongue. A condition known as _lingua
plicata_ is characterized by moderate enlargement of a number of either
longitudinal or transverse folds or rugæ. The covering mucosa, however,
is normal. _Complete absence of the tongue has been noted._
Aside from malformation of the upper jaw, _cleft palate_, there are
arrest of development in one or both sides of either jaw and a failure
of union in the two halves of the lower jaw. Anomalies about the
temporomaxillary joint interfere with its function and may prevent
separation of the jaws.
_Malformation and misplacement of the teeth_ are extremely common.
Thus a tooth may develop in an abnormal position by displacement of
its body, or it may project in an abnormal direction; while teeth may
be lacking in number or in eruption, so that a given tooth, usually
a molar, completely fails to appear. Absence of a number of teeth is
more rarely noted. Numerous cases are on record where a third set
of teeth has succeeded the second instead of the latter remaining
permanent. Abnormalities of tooth formation extending to the dignity
of tumors of the dental tissues have been referred to in the chapter
on Tumors, under the head of _Odontomas_. Cysts of congenital origin
not infrequently develop around unerupted or misplaced teeth, and
constitute tumors which at birth are scarcely noted and which may not
develop until later in life.
Persistent remains of the _thyroglossal or thyrolingual ducts_ may be
seen early in childhood, or not until late in life. Their consequence
is occasionally noted in the existence of _fistulas_, but more often
of _cysts_ or _dermoid tumors_, which, though having their origin in
the middle line, may become displaced to one side, and when seen by the
surgeon have a lateral position.
CLEFT PALATE.
Cleft palate is a congenital defect due to failure of coalescence
between the nasal and maxillary processes, which, proceeding from
either side, should meet and unite in the middle line. The defect may
be so slight as to produce only a small notch in the alveolar border,
or a small opening in the roof of the mouth, or it may be so complete
as to constitute a separation with the formation of but a small part
of the roof of the mouth, leaving but little tissue serviceable for
any possible operation. The relation between the products of lateral
growth and the downward projection and formation of the _intermaxillary
bone_ by the midfrontal and nasofrontal processes is too complex to
be described here (Fig. 465). In some instances there is but little
evidence of the formation of such a bone, while at other times it has
not only bone formation but is relatively overdeveloped, in such a way
as to make the lower anterior angle of the septum and its own part of
the alveolar process project far beyond the level of the surrounding
tissues, thus producing a snout-like appearance, which not only
makes the case more disfiguring, but seriously complicates operative
procedure. Usually the lower border of the nasal septum will be found
attached to one side of the cleft (Fig. 466). The soft palate presents
the same fissure, and the uvula is often neatly separated into halves.
[Illustration: FIG. 465
Double cleft palate.]
[Illustration: FIG. 466
Left-sided cleft palate.]
The _coincidence of cleft palate with hare-lip_ has been described.
(See p. 645.) While they often are combined, either may occur without
the other (Fig. 467).
[Illustration: FIG. 467
Left-sided hare-lip and cleft palate. Marked displacement of
intermaxillary bone. Boy, aged six years. (Bevan.)]
No matter how incomplete the palatal cleft may be the nose and the
mouth are converted into a common cavity. Suction, as from the breast,
is impossible. Infants with this defect should be carefully fed by
hand; as they develop, food passes readily from the mouth to the nose,
while there is corresponding difficulty in swallowing. With lapse of
time speech becomes defective or almost unintelligible. There is,
therefore, every reason for any possible closure of such defects.
Against the mechanical difficulties on one side should be weighed the
desirability of such closure on the other. One argument advanced in
favor of operation on hare-lip is that the influence of the pressure
thus afforded will tend to hasten the natural attempt on the part of
the halves of the upper jaw to grow toward each other instead of in the
opposite direction. On the other hand, by closure of the labial defect,
the space within is materially diminished and manipulation made more
difficult. It then becomes a serious problem _when to operate upon a
given case of cleft palate_. The operation itself is usually one of no
small mechanical difficulty, the space required for manipulation is
most restricted, the procedure relatively a long one because of the
anesthetic, and necessity for its frequent suspension in order that the
operator may proceed, and, because of these difficulties and delays,
the attendant shock to the patient. A puny child, unable because of the
defect to take sufficient nourishment, is then in far from a favorable
condition for a serious operation. Without a general anesthetic
no child will endure it, while local anesthesia in the young is
insufficient on account of their timidity and involuntary resistance.
When to operate, then, should depend upon the condition of the child,
the dexterity of the operator, and the width of the cleft--that is, the
amount of work to be done.
Brophy, of Chicago, has taken a radical and advanced position in this
matter, and believes that these operations should be performed in
early infancy, a fact which his own large experience would appear to
demonstrate. Yet this same experience has developed in him a facility
possessed by few, and that which such an operator may do with impunity
can be duplicated by but few. He finds, however, unanswerable argument
in this: that in infancy the bones of the jaws are scarcely developed,
are not only friable but very flexible and yielding; that even in the
very young the tissues unite kindly, and that very young infants seem
to be less liable to extreme shock than those several months old;
that the earlier the muscles of the palate are brought into contact
and action the better performed are the functions of deglutition and
of speech, and that if they are not used they atrophy; that the teeth
are more likely to erupt normally, and that the extreme liability to
pharyngitis produced by such wide-open fissure is obviated. To all of
these statements no objection can be raised, and the only argument
which can be adduced against Brophy’s position is the actual danger of
the operation.
In the matter of time it may be said that in extremely competent hands
operation in infancy is the ideal method, but that when children reach
the age of two or three years and still have very small mouths, not
much is lost by waiting until they are five or six years of age, while
considerable room is gained for ease of manipulation. Much depends
also on the temperament and obedience of the child. These children,
like most of those born with congenital defects, are usually pampered
and spoiled by indulgent parents, so that at a time when implicit
obedience is most needed it seems almost impossible to do anything with
them. In dealing, therefore, with such a child one should insist upon
its being thoroughly disciplined, and, at the same time, accustomed
to manipulation within the mouth, as the presence of a finger, tongue
depressor, etc., so that when need comes for their use the child
shall not be totally unaccustomed thereto. Every case should also be
prepared so far as possible by antiseptic and astringent mouth-washes.
A nasopharyngeal catarrh which shall compel such a patient to be
constantly swallowing and spitting may defeat the object of the
operation itself.
The terms usually used in this connection are _uranoplasty_, which
means closure of the hard palate, and _staphylorrhaphy_, which means
the closure of the soft palate.
=Operations for cleft Palate.=--The responsibility of the anesthetist
in these cases is great. Considering that he has to work through the
same cavity as the surgeon it is sometimes very difficult to keep the
child in a consistent state of narcosis. The inhaler devised by Dr.
Souchon serves an admirable purpose. (See p. 644.) I regard chloroform
as the safest of the anesthetics, as it is less irritating and provokes
less flow of saliva. It is a good plan to cocainize the parts previous
to incision, in order to so benumb them as to make reflex impressions
less pronounced.
The theory of these operations, like that for hare-lip, is simple. It
consists in freshening the edges of the cleft, bringing them together
and holding them in position; this requires clean work and a mouth kept
clean--in other words, it calls for efficient antisepsis, for strict
asepsis is impossible. All carious teeth should be removed or put in
good condition, and large tonsils, with their distended crypts and
reservoirs of decomposing material, and all adenoid tissue should be
removed.
Owen has shown the benefit in nursing infants of using an old-fashioned
“slipper bottle,” having a soft giant teat with a hole on the under
surface. As the infant sucks from this the teat fills the cleft, and as
the child compresses it in sucking the milk is directed downward. When
this does not suffice milk may be given in a warm teaspoon, passed far
back over the tongue, or from a medicine dropper.
Owen sustains Brophy in the contention that the most favorable time
for operating on a cleft palate is between the age of two weeks and
three months, there being at that time less shock, and the bones are
extremely flexible. Accepting this statement as authoritative the
operation upon young infants will be described.
Previous to the operation a warm, nourishing, and stimulating enema
should be given the patient. After the infant is anesthetized the
tongue is drawn forward by a long suture and the mouth kept open by a
mouth-gag. The edges of the cleft are then pared with a sharp knife,
after which effort should be made to press the upper maxillæ together,
in order to test their flexibility and the possibility of approximating
them in this manner. This will rarely be sufficient, however, and
it becomes necessary to raise the cheek, on each side, toward the
posterior extremity of the hard palate just behind the malar process,
and pass a knife through the outer bony surface, making a sufficient
division of the antral wall through a minimum of opening. Rather than
cut too much bone at first the knife may be re-introduced. The actual
approximation of the maxillæ is produced by silver-wire sutures. A
firm, stout needle carrying a thick, silk pilot suture is passed
through at the point above mentioned and made to appear in the fissure,
where the loop may be pulled down, after which it may be again passed
through the other side and made to emerge at a point corresponding to
that at which it entered. The suture thus passed in one way or the
other is made to carry a strong silver wire from one side across to the
other, on a level above the hard palate, emerging on each side within
the cheeks. Another wire suture is similarly passed more anteriorly.
Two small oblong leaden plates, 1.5 Cm. in length and 35 or 40 Cm. in
width, drilled with two holes, are then provided, one of them laid
along the outside of each maxilla, the wire sutures passing through the
holes which they contain. On one side the ends of the wire are then
twisted firmly and cut short, thus forming a complete grip upon the
plate on its side; then the jaws are pressed firmly together, while the
wire sutures on the other side are similarly fastened over the lead
plates and twisted tightly to make permanent the effect produced by
pressure with the fingers. These sutures should be made sufficiently
tight to permit of approximation of the borders of the mucoperiosteal
surfaces, already freshened, in such a way that they may be held
together with fine wire or horse-hair sutures and without undue tension.
The lead plates are left _in situ_ for three or four weeks. If
necessary the wire suture may be tightened to allow for relaxation
produced by pressure effect. Some ulceration may occur beneath the
plates, but this heals after their removal. Theoretical objection
to this method may be made because of the tendency to narrowing of
the upper jaw. In fact, however, it is only restored to its proper
dimensions, as that part of the face has been previously widened by
the width of the cleft. Irregular eruption of teeth or irregularity of
development may be treated by a dentist.
When the vomer affixed to the intermaxillary bone projects in a
snout-like manner it is necessary to remove a V-shaped section from it,
the base of the triangle being along the margin of the cleft, in order
that the projection may drop backward and the corresponding part fall
into line with the rest of the alveolar process. This is best done as a
preliminary and distinct operation.
_Uranoplasty in older patients_ consists essentially of forming two
anteroposterior mucoperiosteal flaps, from the hard and soft palates,
on either side of the cleft, with their inner edges neatly pared,
which should be separated from the bony roof of the mouth, and slid
toward each other until they can be held together by sutures. These
operations are best performed with the patient’s head hanging over the
end of a table, so that blood may not find its way into the trachea or
stomach, but be sponged away. This is the position of the so-called
“down-hanging head” described by Rose. In fat-necked individuals it
may be impracticable. After paring the borders adjoining the fissure
an incision is made just within the alveolar border, close up to the
teeth, parallel to the former, of sufficient length to permit of
the formation of the flap above mentioned; then with raspatories or
elevators it is detached from the hard palate. In a mouth with a gothic
arch or roof it is often easier to form these flaps and to bring them
together than in others. It may be possible in such cases to not only
suture the edges, but also some portion of their raw surfaces, thus
ensuring better union. (See Fig. 468.)
Branches of the anterior palatine artery will bleed freely during
this part of the performance. Firm pressure and the use locally of
adrenalin solution will usually overcome this difficulty. As the
incision is extended backward the posterior arteries will cause the
same difficulty. The wider the defect the farther backward should the
lateral incisions be extended. Here the principal obstacle to easy
approximation of edges is the activity of the levator and tensor palati
muscles. Formerly it was a part of operations to divide the tendon
of the latter as it passes around the hamular process. It has been
found, however, that this is often unnecessary. A tenotomy of this
tendon, however, may be made just as that of any other tendon with the
expectation that the gap thus made will be filled with fibrous tissue.
While, on one hand, it is of great advantage to spare this tendon, on
the other hand its muscle may be the principal factor operating to pull
apart those surfaces which have been neatly brought together.
Fergusson and Langenbeck have not hesitated to make _osteoplastic
flaps_ when necessary, dividing the hard palate along the line of the
lateral incisions with a fine chisel. This is not often required, and
complicates the case to an undesirable extent, although it may be
necessary in wide fissures with a minimum of tissue (Fig. 469).
Sutures are best made of fine silver wire or of black silk, as the
ordinary silk is usually too absorbent, and permits infection of the
stitch holes. These sutures are introduced with any one of a variety of
needles devised for the purpose. A complicated needle is not necessary
for this purpose, for with an adequate needle holder even the ordinary
needles can be used. Silver wire may be fed directly into the needle or
through a hollow needle devised for the purpose, or sutures of silk may
be passed, by which a wire suture is pulled after them.
Great assistance can be obtained from packing strips of gauze between
the flaps and the bone from which they have been detached. These may
be inserted for pressure effect and prevention of hemorrhage during
the operation, and later may be substituted by smaller packing of
antiseptic gauze left for the purpose of helping to minimize tension,
flaps being crowded toward each other by their use.
[Illustration: FIG. 468
Uranoplasty, showing incisions. (Tillmanns).]
[Illustration: FIG. 469
Staphylorrhaphy, sutures placed. (König.)]
The parts being approximated and the wound suitably tamponed it is
necessary to keep the patient as quiet as possible. Young infants
tend to keep up a constant sucking motion with the tongue, which may
interfere with the quietude of the palate. Small doses of bromide or
chloral may be administered either by the mouth or rectum, for every
effort at crying, coughing, or vomiting tends to make a stress upon
the line of sutures. Vomiting immediately after the operation is not
necessarily serious, and yet should be avoided. Patients sufficiently
old to talk should be cautioned not to converse. Water is better for
the patient than milk, as the latter does not allay thirst so well and
may form curds. Most of the nourishment for the next few days should
be administered by the rectum, giving only water through the mouth.
Children should be watched continuously lest they get fingers or toys
into their mouths, and fretfulness should be guarded against. Thread
sutures should only be removed with scissors and forceps after the
expiration of five or six days. A useless suture is a foreign body
which does more harm than good. When lead plates are used with strong
wire sutures they should remain from two to four weeks. In young or
undisciplined children it may be necessary to give an anesthetic for
removal of the sutures. The tampons or pledgets of gauze should be
removed from day to day. An antiseptic mouth-wash or spray should be
frequently used.
The two results most desired are prevention of passage of food from the
mouth to the nose, which is always commensurate with the success of the
operation itself, and improvement in speech and voice. The earlier the
closure the more natural the voice. Patients in adolescence or adult
life rarely note much gain in this respect, while those operated in
early childhood may learn to talk almost perfectly.
There are cases, especially those which have gone for years unattended,
where the arch of the mouth is of such gothic shape and the defect so
wide that disappointment is sure to follow in at least one of the above
respects. The art of the dentist has now reached a point where plates
or obturators may be constructed for unsuitable cases, which will give
better functional and vocal results than any which the surgeon can
produce.
Another form of palatal defect is the result of the late manifestations
of _syphilis_, and small and large perforations may occur, usually in
the hard rather than in the soft palate. They are to be dealt with
surgically, but not until after the patient has been subjected to a
course of antisyphilitic treatment.
THE MOUTH IN GENERAL.
The mouth more than any other part of the body is the habitat of a
large fauna and flora of minute organisms. Over one hundred different
kinds of bacteria from this region have been identified by Miller,
and it will be easily seen how prone fresh wounds or old lesions may
be to infection from these sources. Fortunately but few of these
microörganisms have decided pathogenic propensities. They lurk
especially in two localities--the crypts of the tonsils and along the
gingival borders and alveolar processes. Along the gingival border of
the teeth _tartar_ accumulates, by a precipitation of mineral salts
from the saliva, where by irritation, coupled with germ activity, the
gum is loosened from the teeth beyond the level of the enamel, and the
sockets thus exposed to various kinds of infection. In consequence the
teeth thus undergo _dental caries_, become loosened in their sockets,
while, at the same time, infection travels along lymph paths until
the germs are filtered out in the adjoining cervical lymph nodes,
which thus suffer enlargement and often suppurative destruction. An
_interstitial gingivitis_, therefore, is always a serious menace to
the integrity of the teeth. This will furnish another argument for a
semi-annual inspection of the mouth by a competent dentist, that he may
clean away all tartar accumulations and treat the gums in such a way
as to prevent disintegration. In elderly people, especially, there is
a marked tendency toward _retrocession of the gums_. In young or old,
when this condition is noted, it may be treated by applications of zinc
iodide, either of the dry, minute crystals or of a saturated solution,
which may be used daily or weekly. By such precautions the teeth may
be preserved to old age, the importance of which is not generally
appreciated, since the teeth are necessary for suitable mastication
of food which the enfeebled stomach of an aged person can more easily
digest.
Infection may also occur during the period of eruption of teeth in
young people, and serious trouble sometimes accompanies the appearance
of temporary or permanent teeth. Gingivitis of toxic origin is not
uncommon, as among the possible effects of overdosage of _mercury_ and
_phosphorus_.
All that has been said of the teeth and their sockets is in the main
true of the tonsils, which afford numerous crypts or lacunæ in which
germs may be harbored for a long time. The explanation of probably
75 per cent. of enlarged and tuberculous lymph nodes is afforded
by infection spreading from the tonsils and teeth. It may not be
tuberculous at first, but it becomes so later.
In the mouth may be seen expressions of _actinomycosis_,
_tuberculosis_, and especially of _syphilis_, among the more chronic
lesions, as well as of diphtheria, erysipelas, and the result of the
_oidium albicans_ of _thrush_. Tuberculosis is more common in the
pharynx, while the syphilitic infections may appear anywhere and in
any form, as chancre on the tonsil or the lip, mucous patches of the
tongue, destructive lesions of bone, all of the earlier and most of the
later expressions of the disease offering serious dangers of contagion.
_Stomatitis_ is a term generally applied to the lining membrane of the
mouth and indicates little regarding its nature or seriousness. It may
be of traumatic origin, as when strong caustics have come in contact
with the mucosa. _Ulcerative stomatitis_ is a disease of childhood, due
to the activity of the _oidium albicans_ or some kindred microörganism,
it being usually a more serious expression of the condition known
as “thrush.” Washing the mouth frequently with dilute solutions of
hydrogen peroxide or of tincture of iodine will usually be all that
is necessary. Resistant ulcerations may be treated with 10 per cent.
solution of silver nitrate. _Stomatitis gangrænosa_ is another name
for _noma_, or _cancrum oris_, which was described in the chapter
on Gangrene. In these cases the surgeon should hasten the tedious
separation of sloughs by use of scissors, curette, or the actual
cautery (Fig. 471).
_Blastomycetic lesions_ of the mouth, and especially of the lips, have
been recognized. Bevan has reported extirpation of granulomas provoked
by the blastomycetes, or yeast fungi, which are known to produce
similar effects elsewhere (Fig. 471).
[Illustration: FIG. 470
Misplaced and imprisoned tooth. (Forget.)]
[Illustration: FIG. 471
Destruction of cheek the result of cancrum oris. (Tiffany.)]
Severe infections of the mouth may also involve the tongue and thus
produce acute glossitis or may spread to the connective tissue, or the
submaxillary region, and there produce that type of phlegmon called
_Ludwig’s angina_, described in the chapter on the Neck. The source of
infection in most of these cases is a tooth or tooth-socket.
_Injuries and wounds of the mouth_ are _liable to septic infection_,
whether they occur from mechanical, chemical, or traumatic causes.
Injuries inflicted by the mouth, or rather by the teeth, _upon others_
constitute infected wounds of a serious type. Burns, scalds, and
similar lesions inflicted by violent caustics, such as carbolic or
nitric acids, may be followed by cicatricial contraction and produce
serious consequences. So far as the latter can be foreseen they should
be prevented, while for their more extreme results various plastic
operations may be performed.
THE TONGUE.
What has been said above with regard to the possibility of infected
wounds in the mouth applies also to the _tongue and other parts_. It is
often lacerated by being caught between the teeth in falls and blows
and is sometimes bitten by epileptic patients during their convulsions.
Free hemorrhage from such wounds may occur and may require ligation of
vessels at the site of the wound, or of suture of tissues _en masse_
with catgut, or ligation of the lingual artery just above the hyoid
bone. Lacerated wounds should be closed with sutures, and antiseptic
mouth-washes should be frequently used.
_Glossitis_, or inflammation of the structures of the tongue, may
appear in either acute or more chronic form. To some extent it is a
part of a general stomatitis, but no matter in what form occurring
it is an expression of infection from a source easily recognized,
and may be limited to one side of the tongue. Its principal features
are swelling, which may be so extensive as to prevent movement of
the tongue, infiltration of the floor of the mouth, and extension of
a phlegmonous type down the structures of the neck. The swelling
may also involve the epiglottis and larynx, causing edema and even
suffocation unless tracheotomy be performed. Thus acute glossitis
may frequently lead to _abscess_ formation either in the tongue or
the adjoining tissues. When swelling is extreme its formation may be
anticipated, and free incision should be promptly made to permit of
its evacuation. Naturally the region of the large vessels should be
avoided, and, after external incision the focus should be reached
by blunt dissection. Some of these cases are due to extension of an
erysipelatous process commencing externally. Even _hemiglossitis_ may
be accompanied by serious swelling and high fever. One form of this
affection is supposed to be analogous to herpes zoster. The relation of
phlegmonous glossitis to _Ludwig’s angina_, the latter being described
in Chapter XLI, may be readily appreciated. Sometimes it is due to the
entrance of foreign bodies, as fish-bones, bone-splinters, and the like.
Most urgent danger is that of asphyxia from pressure, and of
inspiration pneumonia, for the infected saliva in these cases will
trickle down within the larynx and trachea. Even _gangrene of the
tongue_ has been observed as the result of pressure, while the teeth
will leave their impress upon the sides of a swollen tongue.
The more _chronic infections of the tongue_ are _syphilis_,
_tuberculosis_, and _actinomycosis_. Syphilis may assume a primary type
and occasionally typical chancres may be seen on the tongue. It is
frequently the site of mucous patches and of other ulcerative lesions.
Tuberculous ulcerations of the tongue assume less indurated and
irregular borders, and may be suspected in connection with well-marked
tuberculous lesions of other parts of the respiratory tract, being
particularly common in consumptives. These ulcers yield best to
cauterization and antiseptic mouth-washes, whereas syphilitic lesions
rarely disappear without active antispecific medication. Both syphilis
and tuberculosis produce gummatous tumors, the former more frequently
than the latter. The former will disappear equally readily under
suitable treatment.
Actinomycosis of the tongue is rare in man. It constitutes a granuloma
which may soften and present a ragged, ulcerated surface. (See
Actinomycosis, Chapter VIII.)
_Leukoplakia_ implies the appearance of opaque, white patches upon the
mucous surfaces of the tongue as well as on the lining membrane of
the mouth, lips, and palate. They are far more frequent, however, on
the tongue and generally appear there first. Here they appear almost
as if thin scales could be separated from the surface upon which they
lie, but this will not be found possible when the effort is made. The
patches are irregular, but sharply outlined, occasionally confluent,
involving the entire upper lingual surface; while the plates become
harder and more roughened as they grow older, and furrows, subsequently
ulcerating, may appear between them. The affection is chronic and
intractable. It occurs often in the mouths of smokers during middle and
advanced life. While its etiology is unknown it may be due to chronic
irritation.
_Between leukoplakia and epithelioma_ of the part involved there
seems to be a strong relation, and the former is often regarded as a
precancerous stage of the latter. Epithelioma is a frequent terminal
feature of leukoplakia. There often seems, moreover, a predisposition
to it in syphilitic individuals. It is mainly to be distinguished
from secondary syphilitic lesions, which may be done by recalling its
chronicity and its obstinacy to the treatment which would disperse the
latter.
In the way of _treatment_ smoking must be prohibited, antiseptic
mouth-washes often used, with cauterization to a mild degree. These
methods, however, suffice only for the milder cases. If any caustic be
used it may be either 10 per cent. chromic acid, chemically pure lactic
acid, or nitric acid, caution being used in their application. The more
serious forms of leukoplakia will usually yield to local anesthesia,
followed by curetting of each patch until the raw surface beneath is
exposed, and then the application of the actual cautery. Rigorous
treatment is necessary when ulcerated and fissured patches are present.
The _benign tumors of the tongue_ include nevi, often in connection
with single or multiple papilloma, or which may assume the type of
multiple papillomas, each of which is extremely vascular. Occasionally
the tongue will be seen almost covered with these small growths. This
condition is noted usually in young children, and is practically of
congenital origin. It frequently subsides spontaneously, but may
require the actual cautery or something equally radical. The other
benign tumors are of occasional occurrence, even an enchondroma having
been occasionally seen. Much more common are the _retention cysts_,
especially that particular form of cyst occurring beneath the tongue
or at its base, known as _ranula_. This term is vaguely applied to
cysts produced by obstruction of one of the salivary ducts or by cysts
of congenital origin. It is caused mainly by incomplete obliteration of
the thyroglossal duct. A so-called ranula may contain colorless fluid,
more or less thick, and mixed with epithelial or dermoid products.
[Illustration: FIG. 472
Macroglossia. (Tillmanns.)]
It is possible to extirpate nearly all of these growths through the
mouth, with aseptic precautions.
_Macroglossia_ is a condition of congenital enlargement of the tongue,
due mainly to a form of lymphangioma, which may be accompanied by
vascular papillomas or alteration of the mucous covering. Such a
growth will produce enlargement of the tongue to an extent that does
not permit of its retention within the mouth. Excision of a V-shaped
portion sufficiently large to reduce the tongue to proper dimensions is
usually requisite in these cases (Fig. 472).
Of the _malignant tumors of the tongue epithelioma_ is by far the
most common. It is rarely seen in women, and not often before middle
life. Here more than in almost any other part of the body the possible
causative factors of irritation and trauma are present, jagged teeth
furnishing the usual source of each. It is known also to be a frequent
sequel of _leukoplakia_ and of various chronic ulcerations and other
lesions. Other benign growths occasionally alter their type and
become epitheliomatous. It occurs usually on the exposed surface,
and tends quickly to an ulceration whose border is indurated and
often fissured. It is ordinarily distinctive in its appearance, but
occasionally needs to be differentiated from lesions of syphilis,
tuberculosis, and actinomycosis. Lymphatic involvement occurs early
in each of these conditions and may be confusing. A suspicious
ulcer which tends constantly to deepen and increase in dimensions,
accompanied by marked induration and lymphatic involvement, and not
benefited by antisyphilitic treatment, will generally prove to be
epitheliomatous. As the lesion extends there is involvement of all the
surrounding structures--the floor of the mouth as well as the pharynx,
the salivary glands, and even the lower jaw itself. When pain is
felt it is usually referred to the region of the ear. There will be,
naturally, interference with all the functions of the mouth, as well
as with speech, while starvation, septic infection, and hemorrhage may
terminate the case.
In no part of the body is prognosis more unfavorable. Recurrence, even
after early and radical operations, is usually unavoidable, and it is
doubtful if 10 per cent. of cases of epithelioma of the tongue are free
from disease at the expiration of three years after removal.
Treatment should be prompt and radical. It consists of _extirpation_,
which must be extensive to be effectual. A small cancerous ulcer on one
side of the tongue may justify removal of one-half of the organ, but,
under nearly all circumstances, it is best to make a complete removal
of the tongue. This may necessitate a formidable operation, and may
be expected to materially interfere with speech; but that it does not
prevent it is shown by the fact that in medieval days, when tearing out
the tongue was a means of punishment or torture, men were often still
able to speak intelligibly.
Inoperable cases should be made comfortable with cleansing mouth-washes
and applications of local anesthetics, coupled with such anodynes as
it may be necessary to administer. Resection of the lingual nerve will
sometimes relieve the intense pain, while proximal ligation of the
lingual artery may arrest rapidity of growth. It is in these inoperable
cases that Dawbarn’s suggestion of the extirpation of the external
carotid artery, first on one side and then on the other, may be put
into practice, the intent being to so completely shut off circulation
as to check growth. In some forty cases or more it has given results as
satisfactory as could be expected.
OPERATIONS UPON THE TONGUE.
Operations upon the tongue include _partial excision_ and _complete
extirpation_, perhaps with much of the adjoining tissues. Here, as
in every operation, the mouth should be thoroughly cleansed. Before
extensive operations a preliminary ligation of the lingual artery
should be made on both sides, just above the hyoid bone. (See p. 352.)
A small lesion at the tip of the tongue may be excised by a wide
V-shaped removal of the anterior part of the tongue, under cocaine
anesthesia, the edges of the opening being brought together with
sutures of silk or of chromic catgut, for ordinary catgut would be too
quickly macerated when thus soaked in the mouth. The lesion may be so
placed as to not permit of this V-shaped opening being symmetrically
placed. The same rules, however, will apply, the operation being
performed with a sharp-bladed bistoury or with sharp scissors, bleeding
vessels being seized with forceps as they are cut. These clean removals
give more satisfactory results than the old operations performed with
the écraseur or cautery. A _complete excision of the lateral half_ of
the tongue is easily made through the mouth, the organ being controlled
by a stout suture passed through the other portion. The vessels
and lymphatics of the tongue do not cross its septum, and all the
hemorrhage that need be anticipated will come from the side attacked;
but when it is necessary to remove an entire half of the tongue the
case has usually progressed to such an extent that its complete removal
will be usually indicated and will be more effectual.
Of the various complete operations upon the tongue but three will be
described here.
_Whitehead’s_ operation comprises an almost total extirpation made
through the mouth, without division of cheeks or lips. The patient
is placed in a semi-upright or upright position. The mouth is held
open with a mouth-gag, for which purpose none serves better than the
O’Dwyer gag used for intubation. The operation is begun under brief but
complete anesthesia, and is usually completed before the patient has
recovered from it.
The tongue being secured with a stout suture passed through it, its
frenum and its attachment to the fauces are divided, along with
all other reflections of the mucosa. Vessels which spurt should be
caught at once. General oozing may be disregarded. After being thus
freed the tongue is pulled forward, a strong suture passed through
the glosso-epiglottidean fold, and then with sharp, slightly curved
scissors the entire organ is cut away from its base, the lingual
arteries being seized the instant they are divided. The operation
is bloody for the few minutes required for its performance, but is
quickly done and with a minimum of disfigurement. By the last-mentioned
suture the stump can be pulled forward, should the epiglottis tend to
drop backward and disturb respiration, or should hemorrhage require.
After its conclusion, and during the after-treatment, frequent warm,
antiseptic solutions should be used for washing the mouth, and it is
the practice of some to paint the raw surfaces with a styptic varnish,
made of balsam and saturated solution of iodoform in ether. In order to
avoid the passage of saliva downward the patient is encouraged to sit
up and to expectorate freely rather than swallow infected saliva.
The _Regnoli-Billroth operation_ is performed by turning down a
horseshoe-shaped flap, its convexity being taken from the symphysis of
the jaw, and thus opening into the mouth from below. After making the
opening sufficiently wide, the tongue, through which a traction suture
has been passed, is pulled through the submental wound and its base
divided with scissors. Should it be difficult to locate bleeding points
in the stump a finger may be hooked in the pharynx and the latter
pulled forward. The submaxillary wound is then closed with sutures,
with one drain.
[Illustration: FIG. 473
Lines of incision for total excision of the tongue. (Chalot.)]
The most complete of these operations is that described by Kocher.
It permits of removal of the tongue, of the floor of the mouth, of
all infected lymphatics, and even of a portion of the jaw if this be
necessary. A line _A-B_, Fig. 473, may offer sufficient exposure by
incision, but the line _C-D-E-F_ will permit more complete attack.
Through this incision a flap is raised, the facial vessels being
ligated. All lymph nodes are extirpated, as well as the salivary
glands, if necessary. After separating the mylohyoid from its insertion
in the inferior maxilla the mouth is opened and the tongue drawn out
through the incision, where it may then be kept under perfect control.
It will facilitate matters if the lingual arteries be secured before
the entire tongue is cut away. In some cases a preliminary tracheotomy
is considered advisable, largely because the performance of the
operation interferes with the administration of the anesthetic in the
ordinary way. Should it be done the pharynx should be tamponed until
the conclusion of the operation. The trachea tube may be immediately
removed or left, as seems advisable, while the patient is fed for
several days with a stomach tube.
Operations suggested by Sédillot and Langenbeck include division of
the lower jaw in such a way that by separation of its portions a more
complete exposure of the floor of the mouth is afforded. They are at
present rarely adopted, unless extension of the disease to the bone
should necessitate excision of some portion of the jaw itself.
THE TONSILS.
The tonsils are the most conspicuous portion of the ring of lymphoid
tissue which extends completely around the original opening connecting
the exterior of the face with the upper end of the neurenteric canal.
This tissue is particularly inflammable, and this may account for the
frequency with which severe infections of the tonsils occur, and the
marked toxemia which complicates even mild degrees of the same. In this
lymphoid, or, as it is usually called, “_adenoid_” tissue, crypts and
follicles abound, and in these latter all sorts of infectious materials
accumulate. Thus acute infections, as well as chronic hypertrophies due
to pressure and irritation, are extremely common.
The various forms of _angina_, _i. e._, _sore throat_, have to do
largely with expressions of these infections in varying degrees
of severity. The adjoining mucosa and other tissues frequently
participate, and it is possible to produce a painful degree of
chemosis of the membranes involved in a short time. Adjoining lymph
involvement, with discomfort or even distress in the region of the
throat, and sometimes pronounced general malaise, are extremely common
accompaniments.
The “cynanche tonsillaris” of the older writers implied an acute
expression of this kind, often with more or less exudation, which,
accumulating upon the exposed surfaces, produces there a membrane, the
condition being most noticeable in the pronounced types of diphtheria.
At other times activity is manifested rather in the peritonsillar
structures, and acute and suppurative types of cellulitis, leading
either to abscess in the tonsil or deep in the neck, are the result. A
surprising degree of toxemia accompanies these lesions and sometimes
severe and fatal general septic infection, perhaps with endocarditis.
_Abscess of the tonsil_ may produce so much occlusion of the pharynx as
to make breathing difficult and even almost impossible, perhaps even
to a point requiring tracheotomy. Tonsillar abscesses usually evacuate
themselves in time; if they are opened by the surgeon relief comes
promptly, with evacuation of pus, no matter how brought about.
Many such abscesses could be easily recognized and incised were it
not for the surrounding inflammation, which prevents the patient from
opening the mouth sufficiently wide to expose the pharynx. Suffering in
these cases is acute.
A swollen and fluctuating tonsil, if it can reached, is easily
perforated by a sharp, straight knife. Erasion and fatal perforation
of the carotid artery has been known to be a sequel of such a case
unrelieved. Again, pus having its source within the tonsil may burrow
in such a direction as to produce a retropharyngeal abscess.
The tonsil is rarely the site of primary _syphilitic_ lesions, more
often of the secondary, and occasionally of _tuberculous_ lesions.
The most common chronic affections of the tonsils result from failure
of absorption of inflammatory products after acute inflammations, which
leaves a permanent enlargement, and which is constantly irritated and
provoked into further growth by the retained contents of the tonsillar
crypts. It is in this way that _chronic hypertrophy_, or the so-called
_enlarged tonsils_, result. These conditions are especially common in
children, presenting the milder forms of the status lymphaticus. (See
Chapter XIV.) These enlargements are seldom seen alone in the tonsils.
Similar involvement of the lymphoid or adenoid tissue in the vault of
the pharynx, and even at the base of the tongue, is quite common, the
entire original lymphoid ring being more or less involved.
The consequences of chronic enlargement of the tonsils have much to do
with the subsequent welfare of patients. Not only is speech interfered
with and made peculiarly “throaty,” but, owing to encroachment upon
the natural breathing space, children suffering in this way contract a
habit of carrying the head forward and stooping the shoulders, in order
thereby to increase the dimensions of the nasopharynx; thus they become
“mouth-breathers” and hard of hearing, which is deleterious to their
intelligence as well as to their physical well-being. Such children, in
time, become stupid, unintelligent, and defective in many ways. There
is, then, every reason for removing these obstructions to respiration
and for doing it early.
Children thus suffering will present such peculiarity of voice as to
suggest immediate examination of the oropharynx, while the posture
above described and the existence of the mouth-breathing habit should
also prompt investigation. An instant inspection through the widely
open mouth should permit the detection of this condition. Should it
be desired to estimate it more thoroughly it may be done with the
finger, although it will provoke the act of coughing or vomiting and be
resisted by most children. Frequently the enlargements can be felt from
the outside. There is but one suitable treatment for such a case, _i.
e._, _tonsillotomy_.
Tonsillotomy may be effected with any one of several different patterns
of tonsillotomes on sale in the instrument stores, most of which are
neat and speedy in their work, but the surgeon need not refrain from
the purpose of removal because of the lack of such an instrument, as
it may be easily accomplished without one. Young and timid children
are probably best anesthetized, although if one can establish perfect
confidence it may be possible to do it by the aid of local anesthesia.
In adults the latter will always be sufficient.
An anesthetized patient should be placed in a chair or semi-upright,
and the mouth widely opened. The circular loop of the instrument
should be fitted over the tonsil, this, if necessary, being drawn into
its grasp by a small hook or forceps, after which by a quick motion
of the cutting blade the projecting mass is removed. All instruments
are made to be used with either hand and to cut on either side. The
practised operator will, therefore, use his left hand when operating
on the right tonsil of the patient, and _vice versa_, it being best to
adopt this order, for should he be a little clumsy with his left hand
and the patient be thereby somewhat disturbed, the right hand may more
dexterously perform the excision on the other side. The surgeon should
be thoroughly familiar with his tonsillotome before using it. It is
not, however, necessary to employ such an instrument, and it will often
be more satisfactory to grasp the projecting tonsil in the bite of a
suitably constructed tenaculum forceps, or even hold it with a common
tenaculum, while with blunt scissors, long handled and curved upon the
flat, the tonsil itself is cut away.
None of these methods gives promise of complete extirpation of the
tissue, which is often chronically diseased, and it is often well,
therefore, to complete the extirpation with the sharp spoon or even
to use the finger-nail as a curette. Hemorrhage will be active for a
few moments, but is nearly always controlled with either iced water
or water as hot as can be borne. Only rarely does it give rise to
serious trouble. In such cases adrenalin may be used. Cases are on
record where it has been necessary even to tie the carotid, but such
instances are mostly bugbears which need not deter one of good judgment
from a properly devised operation. Antiseptic gargles, and avoidance of
speech and swallowing of hard food, will be all that are needed in the
after-management.
The young and the timid will need complete anesthesia, which should be
complete in order to abolish reflexes, and cocaine locally to ensure
this condition. Many of these subjects are, however, those presenting
minor degrees of the _status lymphaticus, to whom anesthetics should
be administered with caution_. In such children tonsillotomy should be
combined with the erasion and removal of other involved adenoid tissue
in the nasopharynx. Inquiry should be made as to whether the patient
bleeds unduly freely after minor injuries. In a bleeder it would be
well to proceed with caution or abstain from operating.
_Foreign bodies in the tonsil_ are as often fish-bones as any kind;
they all give rise to serious irritation. True _calculous formation_
in the tonsil is known. Every foreign body which can be detected and
exposed should be removed.
_Tumors of the tonsil_ are usually of the malignant type, either
epitheliomatous or sarcomatous. A cancer of the tonsil should be
recognized as such very early if operative or other relief is to be
effectually afforded, and if operation is made it should be done more
thoroughly than can be done through the mouth.
_External pharyngotomy_ is the measure usually required for this
purpose. This is usually performed by making a long incision along the
anterior border of the sternomastoid muscle, and, after retracting
it, making careful and blunt dissection down in the direction of
the tonsil, separating tissues which are evidently not involved,
but excising everything in which infiltration can be recognized.
An extensive operation of this kind would justify preliminary or
provisional ligation of the common or at least the external carotid
artery. Care should be taken to avoid wounding the nerve trunks,
especially the hypoglossal.
_Subhyoid pharyngotomy_ is performed by a transverse incision just
below the hyoid bone, with division of the platysma, the omohyoid,
the sternohyoid, and the thyrohyoid muscles, leaving enough of their
insertion into the bone to permit of subsequent reunion by suture.
The thyrohyoid membrane is then divided in such a way as to also
permit of its reunion by sutures. Then the mucous membrane, which will
probably now protrude into the wound, is caught and divided, retraction
sutures being inserted in the edges of the wound. The epiglottis may
be retracted or a suture may be passed through it, to be used as a
retractor. The lower portion of the pharynx is now exposed and through
this opening the tonsil may be removed. After completion of the deeper
work the different layers of the tissues are reunited with chromic gut
and the deep wound is drained.
_Transhyoid pharyngotomy._ Vallas has suggested a central method
of approach to the pharynx by a median incision, through which the
mylohyoid muscles are separated, the body of the hyoid exposed, and its
division effected with stout scissors or with cutting forceps. When its
two halves are retracted a space over an inch long is made, through
which the mucous membrane of the pharynx may be opened, this being done
by making it protrude with the finger passed into the throat, which
shall thus serve as a guide. In closing the wound it is not necessary
to make suture of the hyoid bone.
THE TEETH, THE ALVEOLAR PROCESS, AND THE GUMS.
The alveolar process, which furnishes the actual sockets for the
teeth, and which carries that peculiar fibrous texture with its mucous
covering known as the gum, is a frequent site of ulcerative disease
and fertile source of infection. While the toilet of the mouth is
much more generally attended to at present than in times past, the
majority of people are extremely inattentive and indifferent to the
condition of the teeth and the gingival borders. As elsewhere stated
the mouth is the habitat of an extensive flora and fauna, and deposits
of tartar along the gingival border afford excellent hot-beds for their
development and growth. This accounts for the marginal ulceration
of the gum, or _ulcerative gingivitis_, seen in so many mouths, and
it may be regarded as the beginning of a disease process, _pyorrhea
alveolaris_ (Rigg’s disease), that will eventually cause the loss
of the teeth and extensive infection of the lymphatics in the neck.
In almost every mouth where such accumulations of tartar have taken
place the expressions of local infection may be traced by a bluish or
purplish line along the gingival border, with some degree of sponginess
and mild ulceration.
The enamel covering the teeth is extremely resistant, but when the
dentine is exposed below the enamel line, as happens in such instances
as those just described, bacteria may easily enter the dental tubules,
and _dental caries_ or _alveolar suppuration_ is the result. In order
to prevent such disease the services of the dentist should be secured
at least as often as every six months, in order that all tartar may be
removed and the gums placed in a healthy and resistant condition.
For the marginal ulcerations thus produced there is no better
treatment, after removing tartar, than the local application of zinc
iodide, either in fine crystalline form or in saturated solution. It is
not so much the visible surfaces which need such application as does
the gingival tissue in concealed locations and between the teeth. Zinc
iodide is not only an excellent antiseptic, but a powerful astringent,
and meets a double indication. It may be applied once a week or
oftener.
The dental enamel is the protective medium which, being once injured,
exposes the dentine beneath to the possibility of infection. Such
injuries are mechanical, but usually minute. The practice of putting
hot food into the mouth and immediately following it with a drink of
iced water is calculated to crack the enamel on a tooth as it would on
any other material. Such a crack, although microscopic in dimensions,
permits the entrance of bacteria into the dentine, in whose tubules
they multiply and produce minute amounts of lactic acid. The enamel
will resist this acid almost indefinitely, but the softer dentine is
dissolved by it, and in this way cavities are formed within the teeth,
and the condition known as _dental caries_ is engendered. While it
requires the special art and training of the dentist to cope with
such conditions, every general practitioner should be familiar with
the circumstances under which these lesions are produced. Congenital
defects of the enamel afford also the same opportunities for infection.
When infection has extended to the delicate pulp cavity and when one
of the terminal fibers becomes exposed the condition is accompanied by
more or less distress, and when the alveolar socket becomes involved
the tooth is loosened, either temporarily or permanently, according as
the condition is treated. Thus a small _alveolar abscess_, referred to
as “gum-boil,” may result. In the former case there is usually a small
sinus which leads down to the root of the tooth, either through the
spongy bone or alongside the tooth itself.
Plate III illustrates the conditions in teeth undergoing various
forms of caries, there being numerous bacterial forms responsible for
different types of the disease.
_Treatment_ here does not differ in principle from that for treatment
of caries in bone. Its essential feature is actual removal of all
infected dental tissue, with a combination of protection against
further infection, and that substitution for lost tissue which is
effected by the use of gold, amalgam, or some of the other fillings
in common use among dentists. American ingenuity has reached its acme
in the discovery of means and methods for atonement of tissue thus
lost by disease, and American dentists certainly lead the world in
the mechanics of their art. They go much beyond the mere filling of
diseased teeth, but have devised substitutes for teeth actually lost,
and much of the plate work of the past is now substituted by what is
known as _crown and bridge work_.
Dentistry as a part of oral surgery has now become a specialty by
itself. A competent dentist, therefore, is a necessary coöperator in
the treatment of all diseases of the teeth.
It is mainly when disease has spread from the teeth to the surrounding
bone and tissues that the surgeon as such intervenes. _Caries and
necrosis_ of a small or large part of either jaw may be the result of
extension of disease processes having their beginnings as above. In the
chapter on the Neck, when dealing with the subject of tuberculosis of
the lymphatics, it is stated that a large proportion of such cases due
to the propagation of infection from the oral cavity and often from the
teeth.