The incisions recommended for this operation have been very various, and a knowledge of some of them may occasionally be useful, on account of specialities in the shape and size of the tumour. Liston "entered the bistoury over the external angular process of the frontal bone, and carried it down through the cheek to the corner of the mouth. Then the knife is to be pushed through the integument to the nasal process of the maxilla, the cartilage of the ala is detached from the bone, and lip cut through in the mesial line; the flap thus formed is to be dissected up and the bones divided."[108] Dieffenbach made an incision through the upper lip and along the back or prominent part of the nose, up towards the inner canthus, from whence he carried the knife along the lower eyelid, at a right angle to the first incision as far as the malar bone.

In cases where the tumour is of moderate size, Sir W. Fergusson found[109] it sufficient to divide the upper lip by a single incision exactly in the middle line, this incision to be continued into one or both nostrils, if required. The ala of the nose is so easily raised, and the tip so moveable as to give great facilities to the operator for clearing the bone even to the floor of the orbit.

In cases where the tumour is larger, or the bones more extensively affected, Sir W. Fergusson preferred an extension of the foregoing incision (Fig. XXVII. B) upwards along the edge of the nose almost to the angle of the eye, and thence at a right angle along the lower eyelid, as far as may be necessary, even to the zygoma. The advantages claimed for such procedures are that the deformity is less and the vessels are divided at their terminal extremities.

2. EXCISION OF THE LOWER JAW.--Removal of portions, greater or smaller, of the lower jaw, for tumours, simple or malignant, are now operations of very frequent occurrence, while in some few cases the whole bone has been removed at both its articulations.

The operative procedures vary much, according to the amount of bone requiring removal, and also the position of the portion to be excised.

(1.) _Of a portion only of one side of the body of the bone._--This is perhaps the simplest form of operation, and is frequently required for tumours, specially for epulis.

_Incision._--If the parts are tolerably lax and the tumour small, a single incision just at the lower edge of the bone, of a length rather greater than the piece of bone to be removed, will suffice; this will divide the facial artery, which must be tied or compressed,[110] while the surgeon, dissecting on the tumour, separates the flaps in front, cutting upwards into the mouth, and then detaches the mylohyoid below, and clears the bone freely from mucous membrane. He then, with a narrow saw, notches the bone beyond the tumour at each side, and, introducing strong bone-pliers into the notches, is enabled to separate the required portion. The wound is then st.i.tched up, and a very rapid cure generally results with very little deformity, as the cicatrix is in shadow. If from the size of the tumour more room is needed, it can easily be got by an additional incision from the angle of the mouth joining the former.

To prevent deformity, which is apt to result from the centre of the chin crossing the middle line, it is often a wise precaution to have a silver plate prepared fitting the molar teeth of both jaws on the sound side, and thus acting as a splint. Such a precaution may be required in any operation in which the lower jaw is sawn through.

_N.B._--There are certain cases in which the epulis is small and confined to the alveolar margin, in which an attempt may be made to retain the base of the jaw entire, and remove the tumour without any incision of the skin. The mucous membrane on both sides being carefully dissected from the affected part, the bone may be sawn as before, but only through the alveolar portion, the groves of the saw converging as they penetrate, then by a pair of strong curved bone-pliers, the affected alveolar portion is to be scooped out without injuring the base. This proceeding, which has been practised by Syme, Fergusson, Pollock, the author in many cases, and others, leaves no deformity, but, it must be owned, is much more liable to the risk of recurrence of the disease, and for this reason is strongly condemned by Gross.

_Note._--In this, as in all other operations on the jaws, the very first thing to be done is to draw the teeth at the spots at which the saw is to be applied.

(2.) _Excision of a portion involving the Symphysis._--Free access is of importance. The best incision is probably one which (Fig. XXVII. C) commences at the angle of the mouth opposite the healthy portion of jaw, extends down to the place at which the saw is to be applied and then along the base of the jaw past the middle line to the other point of section. The flap is to be thrown up and the bone cleared. The next point to be noticed is, that when, in clearing the bone behind, the muscles attached to the symphysis are divided, the tongue loses its support, and unless watched may tend to fall backwards, embarra.s.sing respiration and even perhaps choking the patient. The tongue, being confided to a special a.s.sistant, must be drawn well forwards. Various plans have been devised for keeping it in position, as st.i.tching it to the point of the patient's nose; putting a ligature into its apex, and fastening it to the cheek by a piece of strapping, and transfixing its roots with a harelip needle, used to st.i.tch up a central incision in the chin. The tendency to retraction very soon ceases, new attachments are formed by the muscles, and after the first five or six days there is very little risk of the tongue giving rise to any untoward consequences by its displacement.

(3.) _Disarticulation of one, or both Joints._--When the portion of bone implicated involves disarticulation for its complete removal, the difficulty of the operation is much increased. The remarkably strong attachments of the joint, especially the relation of the temporal muscle to the coronoid process, and the close proximity of large arteries and nerves, especially the internal maxillary artery and the lingual nerve, render this disarticulation very difficult.

The chief points to be attended to seem to be (1.) that the incision through the skin should extend quite up to the level of the articulation; (2.) that the bone should be sawn through at the other side of the tumour, and freely cleared from all its attachments, before any attempt be made at disarticulation, for by means of the tumour great leverage can be attained, so as to put the muscles on the stretch, and allow them to be safely divided; (3.) that the articulation should always be entered from the front, not from behind, and the inner side of the condyle should be very carefully cleaned, the surgeon cutting on the bone so as to avoid, if possible, the internal maxillary artery; (4.) free and early division of the attachment of the temporal muscle to the coronoid process.

Disarticulation of the entire bone has been very rarely performed.[111]

If necessary, it can be performed without any incision into the mouth, by one semilunar sweep from one articulation to the other, pa.s.sing along the lower margin of each side of the body, and just below the symphysis of the chin.

_Disarticulation of the Ramus without opening into the cavity of the Mouth._--That this operation is possible, though it may not be often required, is shown by the following case by Mr. Syme. It was a tumour of the ramus, extending only as far forwards as the wisdom-tooth:--

"An incision was made from the zygomatic arch down along the posterior margin of the ramus, slightly curved with its convexity towards the ear, to a little way beyond the base of the jaw. The parotid gland and ma.s.seter muscle being dissected off the jaw, it was divided by cutting-pliers immediately behind the wisdom-tooth, after being notched with a saw. The ramus was then seized by a strong pair of tooth-forceps, and notwithstanding strong posterior attachments, was drawn outwards, its muscular connections divided and turned out entire. There was thus no wound of the mucous membrane of the mouth, the ma.s.seter and pterygoid muscles were not completely divided, and the facial artery was intact."[112]

Fergusson[113] holds that even the very largest tumours of the lower jaw may be successfully removed without opening into the orifice of the mouth at all by division of the lips. A large lunated incision below the lower margin of the bone, with its ends extending upwards to within half an inch of the lips, will give free access, and yet avoid both haemorrhage and deformity, as the l.a.b.i.al artery and vein are not cut, and there is no trouble in readjusting the lips. Some tumours of lower jaw can be removed without any wound of skin.

FOOTNOTES:

[107] Diagram of operations on the jaws:--A, incision for removal of the whole upper jaw; B, incision for removal of alveolar portion and antrum; C, incision for removing the larger half of lower jaw; the opposite side is the one supposed to be operated on, and the incision is crossing the symphysis and turning up at a right angle.

[108] _Operative Surgery_, p. 265.

[109] _Lancet_, July 1, 1865.

[110] Temporary compression of the facial can be easily managed, in cases where it is of much importance to avoid loss of blood, by pa.s.sing a needle from the outside through the skin above the vessel, then under the vessel, and out again through the skin below. A figure-of-eight suture can then be thrown round both ends of the needle, and the artery thus thoroughly compressed.

[111] Syme, _Contributions to the Path. and Practice of Surgery_, p. 21; Carnochan of New York, _Cases in Surgery_.

[112] _Contributions to the Path. and Prac. of Surgery_, pp. 23, 24.

[113] _Lancet_, July 1, 1865.

CHAPTER VIII.

OPERATIONS ON MOUTH AND THROAT.

SALIVARY FISTULA, _Operation for._--After a wound or abscess of the cheek, in which the parotid duct is implicated, a salivary fistula is very apt to remain. The saliva thus discharges in the cheek, giving rise to considerable annoyance, as well as injury to the digestion. It is by no means easy to cure this. Perhaps the best operation is the one of which a rude diagram is given (Fig. XXVIII.). The duct (C) communicates with the fistula (D). One end of a thread, either silken or metallic, should be pa.s.sed through the fistula, and then as far backwards as convenient through the cheek into the mouth; the needle should then be withdrawn, the thread being left in. The other end being threaded should then be re-inserted at the fistula, and carried forwards in a similar manner; the needle should be again unthreaded in the mouth and withdrawn; the two ends should then be tied pretty tightly inside, and allowed to make their way by ulceration into the cavity of the mouth. A pa.s.sage will thus be obtained for the saliva into the mouth, and every possible precaution should be taken to enable the external wound to close.

[Ill.u.s.tration: FIG. XXVIII.[114]]

EXCISION OF THE TONGUE, for malignant disease of the organ, may be either complete or partial. Complete excision affords a hope of permanent and complete relief from the disease, but it is an operation of extreme difficulty and danger. It may be performed in either of the following methods. The first is the only one in which absolute completeness of removal is insured.

1. _Syme's method of excision._--The patient being seated on a chair, chloroform was not administered, so that the blood might escape forwards, and not pa.s.s into the pharynx. The operation is thus described:[115]--

"Having extracted one of the front incisors, I cut through the middle of the lip and continued the incision down to the os hyoides, then sawed through the jaw in the same line, and insinuating my finger under the tongue as a guide to the knife, divided the mucous lining of the mouth, together with the attachment of the genio-hyoglossi. While the two halves of the bone were held apart, I dissected backwards, and cut through the hyoglossi, along with the mucous membrane covering them, so as to allow the tongue to be pulled forward, and bring into view the situation of the lingual arteries, which were cut and tied, first on one side, and then on the other. The process might now have been at once completed, had I not feared that the epiglottis might be implicated in the disease, which extended beyond the reach of my finger, and thus suffer injury from the knife if used without a guide. I therefore cut away about two-thirds of the tongue, and then being able to reach the os hyoides with my finger, retained it there while the remaining attachments were divided by the knife in my other hand close to the bone. Some small arterial branches having been tied, the edges of the wound were brought together and retained by silver sutures, except at the lowest part, where the ligatures were allowed to maintain a drain for the discharge of fluids from the cavity." The patient was able to swallow from a drinking-cup with a spout on the day following the operation, and was able to travel upwards of 200 miles within four weeks of the operation.

2. _By the ecraseur._--Nunneley of Leeds has recorded cases in which he made a small incision through the skin, and mylohyoid and geniohyoid muscles, and through this pa.s.sed a curved needle bearing the chain of the ecraseur completely round the base of the tongue. In one case the chain was unsatisfactory, but strong whipcord was introduced as it was withdrawn, and tied with all possible force. The organ eventually sloughed away, with a cure which lasted at least for some months.

Sir James Paget operates as follows:--

The patient is placed under the influence of chloroform, and the mouth held widely open. The tongue is then drawn forwards, the mucous membrane and soft parts of the floor of the mouth, including the attachment of the genio-hyoglossi to the symphysis being divided close to the bone.

The steel wire of an ecraseur is then pa.s.sed round its root as low down as possible, slowly tightened, and the tongue thus divided through its whole thickness in a very few minutes. The bleeding is slight, being almost entirely from the parts cut with the knife. Recovery has been rapid in the recorded cases.[116]

To Dr. George Buchanan of Glasgow the credit is due of the invention of the operation of removal of the half of the tongue in the median line.

In at least one instance the cure after five years is still permanent.

Partial excisions of the tongue are as unsatisfactory in their results as they are unsound in principle, yet many cases present themselves, in which, while the patient urges some operative measure for his relief, the tumour is so limited as not to warrant the exceedingly dangerous operation of complete excision.

Portions may be removed in various ways:--

1. By the knife. If in the apex, by a V-shaped incision; if in the lateral regions, by a bold free incision with a probe-pointed bistoury round the tumour.

2. By ligature, drawn as tightly as possible, and, if the portion included be large, in successive portions.

3. By the ecraseur.

Mr. Furneaux Jordan has removed the whole tongue with success by means of two ecraseurs worked at the same time.[117]

4. By the galvano-caustic wire.

5. The author has in nine cases removed the affected half of the tongue by means of the thermo-cautery, first splitting it in the middle line and then cutting through the base with a curved platinum knife at a low red heat. In one only was there any trouble from haemorrhage, and all made good recoveries.

Mr. Barwell has recorded (_Lancet_, 1879, vol. i.) an easy, safe, and comparatively painless mode of removing the tongue by ecraseurs.