Lastly, when the lower lip has been entirely removed, it is still possible to supply its place in the following manner, which was devised by Mr. Syme: The tumour being fairly isolated by a V-shaped incision (Fig. XXI.) C A C including the whole thickness of the lip, each of the incisions should be prolonged downwards and outwards, as shown by the dotted lines A D, A D. The flaps thus marked out must be separated from the bone, brought upwards, and approximated in the middle line. Possibly it may be necessary still further to enlarge the buccal orifice by short lateral incisions, C C. Whether these are required or not, silk st.i.tches are to be introduced to unite the skin and mucous membrane along the lines A C. The gap left between D B D must be left to granulate, but in most cases may be very much diminished in size by additional sutures at its outer corners, near D. The granulating surface E E very rapidly heals up, leaving a dimple on each side, which rather improves the appearance, by adding to the prominence of the chin, B.

[Ill.u.s.tration: FIG. XXI.[101]]

[Ill.u.s.tration: FIG. XXII.[102]]

THE OPERATIONS FOR HARELIP, though all conducted on the same general principles, vary considerably in extent required according to the position and size of the fissure or fissures to be remedied.

1. _For Single Harelip._--Where the fissure extends only from the prolabium up to the attachment of the lip to the gums: this is very easily remedied, the chief risk being lest the surgeon should not remove enough of the edges of the fissure.

_Operation._--Bleeding being controlled by an a.s.sistant, the surgeon fixes a pair of spring artery forceps into the mucous membrane and skin at the salient angle at each side of the fissure. Taking one of these in his left hand, he puts the edge to be pared on the stretch, and then with a sharp narrow straight bistoury he transfixes the lip at the point just beyond the upper angle of the fissure, and cuts outwards, being careful to remove the whole thinner part of the lip, and to leave the edge rather concave than convex. If left convex, or even quite straight, there is a risk that, after union has taken place, an angle remain showing the position of the cleft. The same is then to be done on the other side. The bleeding is then to be controlled by twisting the larger vessels, and if oozing still continues from the smaller ones, a pad of lint should be placed in the wound, and a few minutes' delay given, as, to facilitate immediate union, it is of the greatest importance that all haemorrhage should have ceased before the edges are brought together.

When the bleeding has ceased, the edges should be approximated by two or more points of interrupted metallic suture inserted very deeply through the tissues, and taking a good hold of the edges of the wound. If the edges do not fit accurately, one or two horse-hair sutures will help.

Some surgeons still prefer the old harelip needles secured by a figure-of-eight suture. A silk suture inserted through the prolabium is of great advantage, as it keeps the inner surface of the wound closed, which without it is very apt to be kept open by the pressure of the teeth or gums, and in infants by the movements of the tip of the tongue.

Various methods have been devised to utilise, if possible, the portion of the edge of the lip which is separated during the operation of refreshing the edges, for the purpose of filling up the sort of cleft or gap which is apt to be noticed at the edge of the prolabium. The most ingenious and simplest of these is that proposed by M. Nelaton, for use in cases where the fissure does not extend so far up as the nose. It consists in leaving the two portions which are pared off (Fig. XXIII.) the sides of the cleft attached to each other as well as to the free edge of the lip, then pulling them down, so as to bring their bleeding surfaces into apposition, and make a diamond-shaped wound instead of a triangular cleft (Fig. XXIV.) When brought together by sutures a projection is left at the edge of the lip; this, in most cases, disappears; if it does not, it can easily be pared down.

[Ill.u.s.tration: FIG. XXIII.[103]]

[Ill.u.s.tration: FIG. XXIV.[104]]

2. When the fissure, though single, extends upwards into the nose, the operation is more difficult, and the result frequently less satisfactory. The first thing to be done is to separate the lips from the gums, so as to make them more freely mobile. The whole edges of the cleft require refreshing.

3. _Double Harelip_, without bony deformity, and where the intervening portion of the skin is vertical, does not project, and can be made useful for the new lip. Such cases are not very common, but when they do occur the question arises, How are they to be managed--in two separate operations or at once? I believe, in every case, at once. The central wedge-shaped portion is not large enough to extend downwards as far as the prolabium, but still should not be removed altogether, as it may be of great use, especially in bearing the columna nasi, and allowing its full development. The edges should be pared in the same way, and to the same extent as in single harelip, with the addition that the intervening portion should have its edges completely removed, and be left in the form of a wedge, with its apex downwards. The highest suture should be pa.s.sed through first one side, then the base of the wedge, and then the other side; the second one through both, and the apex of the wedge; and a third should unite the prolabium, not including the wedge.

[Ill.u.s.tration: FIG. XXV.[105]]

4. _Double Harelip_ combined with fissures of the hard palate, and projection of a central bone. This is the a.n.a.logue of the inter-maxillary bone in the lower animals, and bears the two middle incisor teeth, and projects very variously in different cases. In some it projects horizontally forwards in the most hideous manner, in others it lies at an angle more or less oblique; in very few does it maintain its proper position; when projecting forwards, and as the teeth also share in its projection, it entirely prevents approximation of the edges of the fissures by operation, so it must first be dealt with in one of two ways, either--

[Ill.u.s.tration: FIG. XXVI.[106]]

(1.) It may be at once removed with bone-pliers, the piece of skin over it being saved. This is the best that can be done in cases of old standing after the first year or two, though attempts have been made to break the neck of the projecting portion, and thus permit of its being shoved back.

(2.) By gradual pressure by a spring truss, strapping, or a bandage, it may be forced back. This is possible only in cases where the deformity has been comparatively slight, and the patient has been seen early. The edges must then be pared and approximated as directed above.

One or two points about the operation for harelip require a special notice:--

1. _When to operate._--Great differences in opinion exist. Some say not before two or three years, others within two or three days, or even _hours_, after birth.

Probably the safest time is not much earlier than the second month in very strong children, the fifth in weakly ones, up to the commencement of the first dent.i.tion; and when once dent.i.tion has commenced it is not so safe to operate till it is over.

Prior to dent.i.tion the operation is attended with rather more risk, but again, if delayed, there is great risk that the teeth do not come in properly.

2. With regard to the most delicate part of the operation, _the management of the prolabium_.--Some are satisfied, and I believe rightly, with careful apposition by a silk suture after a _sufficient_ amount of the edges has been removed; others have proposed various plans to obviate any risk of an angle remaining.

Malgaigne proposes to retain a small portion of the parings of the edge to make small flap at each side; Lloyd a single one from the long half of the lip, and brings it up under the opposite one, securing it with a st.i.tch.

FOOTNOTES:

[95] Operation for formation of a new nose from the cheeks; A A, flaps approximated in middle line; B B, outer part of bed of flaps st.i.tched up; C C, triangle at each side left to granulate.

[96] _The Restoration of a Lost Nose by Operation_, p. 57; an excellent monograph on the subject.

[97] Operation for formation of a new nose from the forehead:--_a_, prominence of flap which is to be used as septum; _b_, left-hand corner of flap, which is twisted and fastened at _c_; _d_, one of the tubes or quills over which the nose is moulded.--(_Modified from Bernard and Huette._)

[98] Syme's _Observations in Clinical Surgery_, p. 132.

[99] Diagram of V-shaped incision; A B A, dots showing points for sutures.

[100] Diagram of incision for scooping out a shallow tumour by scissors.

[101] Diagram of incisions:--C A C, outline of incision for removal; C A D, outline of flap on each side; B, prominence of chin; C C, dotted lines, showing incisions to enlarge mouth, if required.

[102] Diagram of flaps in position:--A A, corners of flaps brought up and approximated by _silver_ sutures; C C, new lip got by lateral incisions, skin and mucous membrane being united by _silk_ threads; E E, gap left to granulate.

[103] Fig. XXIII. shows the incision bounding the cleft.

[104] Fig. XXIV. shows the diamond-shaped wound before the sutures are applied.

[105] Diagram of operation for double harelip:--_a_, st.i.tch through both sides and wedge-shaped portion, which also aids the septum; _b_, other st.i.tches approximating edges.

[106] Diagram of double harelip, with projecting bone:--_a_, central piece of lip, dotted lines showing incision; _b_, projecting bone bearing teeth, which are generally small and stunted.

CHAPTER VII.

OPERATIONS ON THE JAWS.

1. EXCISION OF THE UPPER JAW.--With regard to the morbid conditions for which this operation is undertaken, it may be sufficient here to observe, that in no case can the operation be called justifiable in which the disease extends beyond the upper jaw-bone and the corresponding palate-bone, for unless the morbid growth be entirely removed, recurrence is inevitable, and no advantage is gained by the operation. It is undertaken for the removal of tumours of the antrum and of the alveolar margins, in all which cases the section for its removal must be made through healthy bone, and wide of the disease, so as to insure that the whole is removed. There are other cases in which the whole or part of the upper jaw has been removed for the purpose of giving access to disease behind, for example, to naso-pharyngeal polypi with extensive attachments.

In describing the operation for the excision of the entire upper jaw, we have to consider--(1.) what incisions through the soft parts will expose the tumour best, and with least deformity; (2.) what bony processes require to be divided, and where. Very various incisions have been recommended by various authors; some describing three, in various directions, forming flaps of different sizes, while others, again, are satisfied with a very small division of the upper lip into the nose, or even attempt removal of the bone without any incision through the skin at all. These discrepancies depend in great measure on different views of what const.i.tutes excision of the upper jaw, the more complicated ones contemplating removal of the whole bone anatomically so called, including the floor of the orbit, while the less complicated ones are suitable for cases in which a much less extensive removal is required.

To remove the whole bone, an incision (Fig. XXVII. A) of the skin must extend from the angle of the mouth upwards and outwards in a slightly curved direction with its convexity downwards, as far on the malar bone as half an inch outside of the outer angle of the eye. The flaps must then be raised in both directions, the inner one specially dissected off the bones, so as to expose thoroughly the nasal cavity. It is of great importance thoroughly to display the floor of the orbit, so that the attachment of the orbital fascia may be accurately cut through, the inferior oblique muscle divided at its origin, and the eye and the fat of the orbit cautiously raised from its floor.

[Ill.u.s.tration: FIG. XXVII.[107]]

Three processes of bone then require attention and division.

(1.) The articulation with the opposite bone in the hard palate. To divide this, one incisor tooth at least must be drawn, the soft palate divided by a knife to prevent laceration, and the thick alveolar portion sawn through in a longitudinal direction from before backwards.

(2.) The articulation with the malar bone at the upper angle of the incision through the skin. This must be notched with a small saw in a direction corresponding to the articulation, and then wrenched asunder by a pair of strong bone-pliers.

(3.) The nasal process of the upper jaw must now be divided by the pliers, one limb of which is cautiously inserted into the orbit, the other into the nose. If the disease extends high up in this process, it may be necessary partially to separate the corresponding nasal bone, and thus reach the suture between the nasal process and the frontal bone.

The pliers must now be inserted into the groove already made by the saw on the hard palate, and the separation continued to the full extent backwards. A comparatively slight force exerted on the tumour either by the hand, or (when the tumour is small) by a pair of strong claw forceps, will suffice to break down the posterior attachments of the bone and remove it entire. The necessary laceration of the soft parts behind is so far an advantage, as it lessens the risk of haemorrhage from the posterior palatine vessels.

The haemorrhage from this operation was at one time much dreaded, but is rarely excessive; very few vessels require ligature, except those divided in the early stages in making the skin flaps; the hollow left should be stuffed with lint, which may be soaked in the perchloride of iron should there be any oozing.