Chapter 20

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 passed 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the fistula, and then as far backwards as convenient through the cheek into the mouth; the needle should then be withdrawn, the thread being left in.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at the fistula, and carried forwards in a similar manner; the needle should be again unthreaded in the mouth and withdrawn; the two ends should then be tied pretty tightly inside, and allowed to make their way by ulceration into the cavity of the mouth.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 passage will thus be obtained for the saliva into the mouth, and every possible precaution should be taken to enable the external wound to close.

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 pass 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 Écraseur._--Nunneley of Leeds has recorded cases in which he made a small incision through the skin, and mylohyoid and geniohyoid muscles, and through this passed a curved needle bearing the chain of the écraseur 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 écraseur is then passed 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 écraseur.

Mr. Furneaux Jordan has removed the whole tongue with success by means of two écraseurs 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 hæmorrhage, 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 écraseurs.

Mr. Walter Whitehead,[118] of Manchester, has had a very large experience of an operation devised by himself, in which, after pulling the tongue well forward by a string previously introduced near its apex, and the mouth being held open by a gag, he detaches the organ from jaw and fauces by successive short snips with scissors, and then in same manner divides the muscles, tying or twisting the vessels as they bleed. His success has been very great by this method, though others who have tried it have sometimes found bleeding troublesome.

It is comparatively seldom now necessary to split the jaw and perform Syme's operation, and in all operations on the tongue the thermocautory (Paquelin's) is of great use.

Regnoli's method[119] may deserve a brief notice. A semilunar incision along the base of the jaw, from one angle to the other, detaches the muscles and soft structures, and is thrown down; the tongue is then drawn through the opening, and can be freely dealt with either by knife or ligature. After removal the flap is replaced.

FISSURES IN THE PALATE.--The operations requisite for the cure of fissures in the soft and hard palates are so complicated in their details, that a small treatise would be required thoroughly to describe the various procedures.

Different cases vary so much in the nature and amount of their deformity, that at least five different sets of cases have been described. It is sufficient here merely to describe the absolutely essential principles of the operations for the cure of fissures of the hard and soft palate respectively.

In all operations on the palate, two conditions used to be considered requisite for success:--1. That the patient should have arrived at years of discretion, at twelve or fourteen years at least; that he be possessed of considerable firmness, and be extremely anxious for a cure, so as to give full and intelligent co-operation. 2. That for some days or weeks prior to the operation the mouth and palate should have been trained to open widely and to bear manipulation, without reflex action being excited. Professor Billroth of Vienna,[120] and Mr. Thomas Smith[121] of London, have had cases which prove the possibility of performing this operation in childhood, under chloroform, with the assistance, in the English cases, of a suitable gag, invented by Mr. Smith. The effect of the operation on the voice of the child has been very encouraging, as much more improvement takes place than in cases where the operation is performed late in life.

_Fissure in the soft palate only_ appears as a triangular cleft, the apex of which is above, the base being a line between the points of the bifid uvula, which are widely separated. To cure this it is required--

1. That the edges of the fissure should be brought together without strain or tightness. In small fissures this can generally be done easily enough; but where the fissure is extensive, some means must be used to relieve tension. For this, Sir William Fergusson long ago proposed the division of the palatal muscles, the levator, tensor, and palato-pharyngeus muscle of each side. The incisions in the palate for this purpose certainly aid apposition, but many surgeons entertain doubts whether the division of the muscles has much to do with the good result, and believe that the simple incisions in the mucous membrane, in a proper direction, are all that is required (see Fig. XXIX.).

2. That the edges of the fissure be made raw, so as to afford surfaces which will readily unite. Complicated instruments, such as knives of various strange shapes, have been devised for this purpose; an ordinary cataract knife, very sharp, and set on a long handle is perhaps the best. It greatly facilitates the section if the parts are tense, so the point of the uvula should be seized by an ordinary pair of spring forceps, and drawn across the roof of the mouth, while the knife should enter in the middle line, a little above the apex of the fissure, and make the cut downwards as in harelip.

3. That sutures should be inserted to keep the edges in apposition, yet not so tightly as to cause ulceration. They may be either of metal, silver being preferable, or of fine silk well waxed. The metallic sutures are now generally preferred. Some dexterity is required in their introduction, and various instruments have been devised; the best seems to be a needle with a short curve fixed on a long handle, which should be entered on the (patient's) left side of the fissure in front, and brought out on the right side.

If silk sutures be used, the chief difficulty, that of passing the thread through the second side from behind forwards, can be avoided in the following manner.[123] A curved needle is passed through one side of the fissure, and then towards the middle line, till its point is seen through the cleft. One of the ends of the thread is then seized by a long pair of forceps, and drawn through the cleft; the needle is then withdrawn, leaving the thread through the palate, and both ends are brought outside at the angle of the mouth. Another needle is then passed through a corresponding point at the opposite side of the palate, till its point again appears at the cleft; this time a double loop of the thread is also brought out through the cleft by the forceps into the mouth. If then the single thread of the first ligature which is in the cleft be passed through the loop of the second one also in the cleft, it is easy, by withdrawing the loop through the palate, to finish the stitch (see Fig. XXIX.). All the stitches should be passed and their position approved before any one be tied, and it is most convenient to secure them from above downwards. To prevent confusion, each pair of threads after being inserted should be left very long, and brought up to a coronet fixed on the brow, which is fitted with several pairs of hooks numbered for easy reference. This will prevent twisting of the threads or any mistake in tying.

FISSURE OF THE HARD PALATE.--This may vary in extent from a very slight cleft in the middle line behind, up to a complete separation of the two halves of the jaw, including even the alveolar process in front, and sometimes complicated with harelip.

To close such fissures by operation is difficult, as the breadth of the cleft is so great as to prevent the apposition of the edges when prepared, without such extreme tension as quite prevents any hope of union. Through the researches of Avery, Warren, Langenbeck, and others, a method has been discovered of closing such fissures by operation, which, though certainly not easy, is, when properly performed, generally successful.

_Operation._--In addition to the usual paring of the edges of the cleft, an incision is made on each side of the palate, extending "from the canine tooth in front to the last molar behind,"[124] along the alveolar ridge (Fig. XXX.). The whole flap between the cleft and this incision on each side is then to be raised from the bone by a blunt rounded instrument slightly curved. With this the whole mucous membrane and as much of the periosteum as possible should be completely raised from the bone, attachments for nourishment of the flap being left in front and behind where the vessels enter.

The flaps thus raised will be found to come together in the middle line, sometimes even to overlap, and, when united by suture, form a new palate at a lower level than the fissure, experience having shown that in cases of fissure the arch of the palate is always much higher than usual. The flaps do not slough, being well supplied with blood, unless they have been injured in their separation.

The edges must be carefully united by various points of metallic suture, and the fissure of the soft palate closed at the same sitting, unless the patient has lost much blood, or is very much exhausted with the pain. The stitches may be left in for a week, or even ten days, unless they are exciting much irritation. The patient must exercise great self-control and caution in the character of his food and his manner of eating for ten days or a fortnight after the operation.

EXCISION OF TONSILS.--To remove the whole tonsil is of course impossible in the living body, the operation to which the name of excision is given being only the shaving off of a redundant and projecting portion. When properly performed it is a very safe, and in adults a very easy operation, but in children it is sometimes rendered exceedingly difficult by their struggles, combined with the movements of the tongue and the insufficient access through the small mouth. Many instruments have been devised for the purpose of at once transfixing and excising the projecting portion; some of them are very ingenious and complicated. By far the best and safest method of removing the redundant portion is to seize it with a volsellum, and then cut it off by a single stroke of a probe-pointed curved bistoury; cutting from above downwards, and being careful to cut parallel with the great vessels.

The ordinary volsellum is much improved for this purpose by the addition of a third hook in each tonsil placed between the others, with a shorter curve, and slightly shorter; this ensures the safe holding of the fragment removed, and prevents the risk of its falling down the throat of the patient.

If both tonsils are enlarged they should both be operated on at the same sitting, and the pain is so slight that even children frequently make little objection to the second operation. Bleeding is rarely troublesome if the portion be at once fairly removed, but if in the patient's struggles the hook should slip before the cut is complete, the partially detached portion will irritate the fauces, cause coughing and attempts to vomit, and sometimes a troublesome hæmorrhage.

The plentiful use of cold water will generally be sufficient to stop the bleeding, though cases are on record in which the use of styptics, or even the temporary closure of a bleeding point by pressure, has been necessary.

M. Guersant has operated on more than one thousand children, with only three cases of any trouble from hæmorrhage, while four or five out of fifteen adults required either the actual cautery or the sesqui-chloride of iron.[126]

FOOTNOTES:

[114] Rough diagram of operation for salivary fistula:--A, section of cheek close to buccal orifice; B, section of zygoma, muscles, etc.; C, the duct of the parotid; D, the fistulous opening of the cheek; E E, the thread knotted inside the mouth; F, the palate.

[115] _Lancet_, Feb. 4, 1865.

[116] _Med. Times and Gazette_ for Feb. 10, 1866.

[117] _Lancet_, April 20, 1872.

[118] _Transactions International Medical Congress_, 1881, vol. ii. p. 460.

[119] Gross's _Surgery_, vol. ii. p. 472.

[120] Langenbeck, _Archiv_, ii. p. 657.

[121] _Med. Chir. Trans._ for 1867-8.

[122] Diagram of staphyloraphy, chiefly to illustrate the passing of the threads:--_a_, the first thread; _b_, the second. The dotted line at edge of fissure shows amount to be removed; the other dotted lines showing size and position of the incision through the mucous membrane above.

[123] Holmes's _Surgery_, vol. ii. pp. 504-513.

[124] _Edinburgh Medical Journal_ for Jan. 1865, Mr. Annandale's instructive paper on "Cleft Palate."

[125] Diagram of fissure of hard palate:--_a_, anterior palatine foramina; _b_, posterior palatine foramina with groove for artery; _c_, incisions requisite to free the soft structures.

[126] Holmes's _Diseases of Children_, p. 555.