Part 32

Nothing has as yet been said of the columna. In the Indian operation it is provided for by a slip purposely brought down from the forehead, and attached to the point which the root of the original columna occupied. Their flap is shaded as in the following figure. In the greater number of foreheads, an encroachment must be made on the hairy scalp, in order to obtain this part of the flap; and after bringing it down and ingrafting it into the lip, there is a risk of its not adhering, as happened in a case on which I operated now many years ago. Besides, during the healing of the internal surface, it will be difficult to prevent it from shortening, and turning inwards upon itself, and thus pulling down the apex of the nose. In the case to which I alluded, a columna was made, after consolidation of the rest of the organ, from the upper lip, as will be immediately explained; and in again performing the operation for restoration of the whole nose, I should proceed on the plan of taking only a flap sufficient for the apex and alæ from the forehead, and should borrow the columna from the lip. In this way the risk of failure will be diminished, and the form of the lip materially improved. The columna might be provided at the same time with the other parts; but it would be more advisable to delay this part of the operation till a few weeks after adhesion of the other flap has been perfected.

Since writing the preceding observation, I have in a very great many instances performed the operation according to the plan here proposed, and with the most perfect success. The form of the nasal flap was this. The little projection was made in order to be turned down, so as to form the tip of the nose; as well as to constitute a convenient attachment for the columna, which was subsequently to be made.

In separating the connexion with the forehead, a thin wedge-like portion is removed, and the raw surfaces, after the cessation of bleeding, are laid in apposition, and retained by gentle compression. But this should not be done till the new nose is consolidated and perfect.

Restoration of the columna is an operation which, in this, and other civilized countries, must be even more frequently required than the restoration of the whole nose. This latter operation came to be practised in consequence of the frequency of mutilations as a punishment; the punishment for some of our sins is left to nature, and she generally relents before the whole of the organ disappears. The columna is very frequently destroyed by ulceration, a consequence, as before stated, of injury or of constitutional derangement. The deformity produced by its loss is not far short of that caused by destruction of the whole nose. Happily, after the ulceration has been checked, the part can be renewed neatly, safely, and without much suffering to the patient. The operation which I have for some years practised successfully, and in a great many instances, is thus performed:—The inner surface of the apex is first pared. A sharp-pointed bistoury is then passed through the upper lip, previously stretched and raised by an assistant, close to the ruins of the former columna, and about an eighth of an inch on one side of the mesial line. The incision is continued down, in a straight direction, to the free margin of the lip; and a similar one, parallel to the former, is made on the opposite side of the mesial line, so as to insulate a flap composed of skin, mucous membrane, and interposed substance, about a quarter of an inch in breadth. The frænulum is then divided, and the prolabium of the flap removed. In order to fix the new columna firmly and with accuracy in its proper place, a sewing-needle—its head being covered with sealing-wax to facilitate its introduction—is passed from without through the apex of the nose, and obliquely through the extremity of the elevated flap; the small spear-pointed harelip needle answers even better: a few turns of the thread suffice to approximate and retain the surfaces. It is to be observed, that the flap is not twisted round as in the operation already detailed, but simply elevated, so as to do away with the risk of failure. Twisting is here unnecessary, for the mucous lining of the lip, forming the outer surface of the columna, readily assumes the colour and appearance of integument, after exposure for some time, as is well known. The fixing of the columna being accomplished, the edges of the lip must be neatly brought together by the twisted suture. Two needles will be found sufficient, one being passed close to the edge of the lip; and they should be introduced deeply through its substance; two-thirds, at least, of its thickness must be superficial to them. Should troublesome bleeding take place from the coronary arteries, a needle is to be passed so as to transfix their extremities. The whole cut surface is thus approximated; the vessels being compressed, bleeding is prevented; and firm union of the whole wound is secured. The ligature of silk, which is twisted round the needles, should be pretty thick and waxed; and care must be taken that it is applied smoothly. After some turns are made round the lower needle, the ends should be secured by a double knot; a second thread is then to be used for the other needle, and also secured. With a view of compressing and coaptating the edges of the interposed part of the wound, the thread may be carried from one needle to the other, and twisted round them several times; but in doing this, care must be taken not to pull them towards each other, else the object of their application will be frustrated, and the wound rendered puckered and unequal. Last of all, the points of the needles are to be cut off with pliers. No farther dressing is required; as previously remarked, no good end can be answered by any application, and the separation of dressing may afterwards be troublesome; discharges from the neighbouring passages are retained by it, fetor is produced, and union interrupted. The needles may be removed on the second or third day; their ends are cleared of coagulated blood, and, after being turned gently round on their axes, they are to be cautiously withdrawn, without disturbing the thread or the crust which has been formed about them by the serous and bloody discharge. This often remains attached for some days after removal of the needles, and forms a good protection and bond of union to the tender parts. Some care is afterwards required from the surgeon and patient in raising up the alæ, by filling them with lint, and thus compressing the pillar, so as to diminish the œdematous swelling which takes place to a greater or less degree in it, and to repress the granulations. It is besides necessary to push upwards the lower part of the columna, so that it may come into its proper situation; and this is done by the application of a small round roll of linen, supported by a narrow bandage passed over it and secured behind the vertex.

Independently of the great improvement produced on the patient’s appearance by the restoration of the lost part of so important a feature, it may be observed, that, when the columna has been destroyed, the lip falls down, is elongated, and becomes tumid, particularly at its middle, so that borrowing a portion from it materially ameliorates the condition of the part; the cicatrix being in the situation of the natural fossa, is scarcely observable.

The alæ of the nose, deficiencies in the upper, anterior, or lateral parts of the organ, in the forehead, &c., may be supplied from the neighbouring integument, on the same principle as the preceding repairs. In many of these operations the flap can be so contrived and cut out, as that it can be applied without its attachment being twisted. The form of such flaps is here given.

It is merely necessary to bring the portion which has been dissected from the subjacent parts of the forehead, cheek, or lip, to the part prepared for its reception, by effacing the angle betwixt it and the connecting slip. A flap to supply the greater part or even the whole of the organ may thus be transplanted.

The integuments covering the apex and alæ of the nose are sometimes opened out in texture by interstitial deposit, forming a lipomatous tumour, lobulated, discoloured, and intersected by fissures. The sebaceous follicles are enormously enlarged, so as sometimes to admit the point of a small quill. On making a section of the parts, accumulations of sebaceous or atheromatous matter are found inclosed in cysts of considerable capacity. Turgid veins ramify superficially; and the surface is of a reddish blue or a purple colour, varying its hue from time to time, according to the state of the health, and the changes in the circulation. The enlargement often attains great magnitude, producing much deformity. Vision is obstructed, and the introduction of food, both solid and liquid, interfered with: the lobes tumble into the wineglass, spoon, and cup, and sometimes they are so elongated as to require being pulled aside in order to uncover the mouth. Breathing is also impeded more or less, by encroachment on the nasal orifices. The disease may be often attributable to hard living; but many, not intemperate, labour under it.

It is desirable to have the tumour removed, even before it has become large; and it can readily be conceived that local applications must fail in bringing the skin and cellular tissue into a healthy condition. Incision is required. If both sides of the nose are affected, a small scalpel is carried down in the mesial line through the altered structure, and, whilst an assistant places his finger in the nostril, the surgeon lays hold of the integument with a sharp hook, and carefully dissects away the diseased parts, first on one side, and then on the other, so that they may correspond exactly, or present the same uniform appearance. The vessels are then tied, and sometimes a considerable number bleed smartly; oozing may continue, but is readily suppressed by continued pressure, the nostrils being well stuffed. Afterwards such dressings are to be employed as agree with the stages of the sore. After cicatrization, the comfort and appearance of the patient are much enhanced; and there is no risk of reproduction—the disease is one of the skin, and all that is affected has been removed. Sketches taken from one, of very many patients, on whom I have operated for the removal of this shocking deformity, are given in the Practical Surgery, p. 306-8.

Inflammation of the antrum maxillare is occasionally met with; but the surgeon is more frequently called upon to treat the consequences of this action in it. The symptoms of inflammation of the antrum are violent throbbing pain, referred to the part affected, to the temple, and to the teeth implanted in the alveolar processes that form the lower part of the cavity; the side of the face is swelled from infiltration of the soft parts, and the Schneiderian membrane of the corresponding nostril is generally observed red and swollen. The affection can frequently be traced to exposure to cold; it may be the result of external violence; but is usually an extension of disease in the sockets of decayed teeth. Unless active and early measures are taken to subdue the inflammatory attack, the antrum becomes distended by increased and vitiated discharge from its lining membrane. The swelling of the cheek becomes more apparent, since, to increased infiltration of the soft parts, enlargement of the cavity is superadded. The enlargement of the side of the face, and the bulging into the orbit are seen in the accompanying cut. The membrane covering the small aperture through which the antrum and nostril communicate partakes of the general thickening, and thus no outlet is left for the accumulating fluid. The escape of matter from the nostril, on the head being turned to the opposite side, has been laid down as an indication of accumulation or abscess in the antrum; the statement is incorrect, and is a result of surgery being professed by those who have not practised it, but judge of morbid states and their signs and symptoms by the healthy condition of parts only. In the skeleton, fluid no doubt will run over from the osseous shell, in some positions of the skull; but it cannot escape from the cavity when covered with membrane, and that membrane subject to vital actions. In short, the symptom is not observable in the disease in question. Extensive ulceration of the parietes of the antrum towards the nose may, perhaps, take place, as a consequence of the accumulation, and the matter may then escape by the nostril, if not allowed an exit otherwise; but such is not a common occurrence.

In general, the cavity is considerably enlarged before the matter comes to the surface. If not interfered with, it usually escapes through the sockets of decayed teeth, or, the anterior thin parietes being absorbed, it comes down by the side of the canine or small molar teeth, and is discharged slowly, so as to annoy the patient by its flavour and fetor, without the abscess being emptied, or a chance of cure afforded.

Accumulations of fluid sometimes takes place in this cavity, give rise to great enlargement of the sinus, and continue for many months, without pain or much inconvenience, and without any matter escaping. The bony parietes are attenuated, yield to slight pressure, and return to their original level with a crackling noise, such as is produced by parchment. The contained fluid is thin, greyish, and contains flocculent solid particles. In short, the antrum maxillare is occasionally the seat of chronic, as well as of acute abscess.

Cancerous ulceration sometimes takes place in the cavity; the matter is not long confined, the parietes soon soften, the teeth drop out, the alveolar processes disappear, and a large opening is formed, which furnishes a fetid, sanious discharge.

In inflammation of the antrum, carious teeth must be removed, blood must be abstracted from the neighbourhood of the affected part—leeches being applied to the gums, the Schneiderian membrane, and the integuments—and fomentations to the cheek should be frequently and assiduously employed. When the cavity has become distended with fluid—mucous, muco-purulent, or purulent—such must be evacuated without delay; and the opening must be of such size, and so situated, that the fluid may escape as soon as secreted. In removing diseased or crowded teeth opposite the part, an opening may be made from the extremities of the fangs having projected into the cavity; it is in a good situation, but cannot easily be made of sufficient size; an aperture of but small extent may be sufficient for the draining of an abscess in soft parts, but here the divided texture is unyielding, and the perforation must be free. Bad teeth are taken away with the view of abstracting a source of irritation which may give rise to, keep up, or induce a return of collection in the antrum; but extraction of sound teeth, to obtain an exit for the matter, is not warrantable. Even when they are extracted for a different reason, and discharge of matter follows, the surgeon must not be contented, but must make another and more efficient opening. The membrane of the mouth is to be divided on the forepart of the maxillary bone, immediately above the first small grinder, and a large perforator then pushed into the antral cavity; little force is required, for the parietes are soft and partially absorbed. The perforation should be of a size sufficient to admit the little finger; thereby a free and dependent exit is allowed for the concrete as well as the fluid matter. Curdy and very offensive stuff is sometimes found in great abundance in this cavity. If the discharge is very fetid, and long of drying up, and if there is an appearance of disease in the osseous parietes, injections into the cavity may be required, though seldom. They are occasionally useful in dislodging the atheromatous matter. In general the discharge gradually diminishes, the membrane of the antrum resumes its healthy condition and functions, and the aperture in its parietes is shut by a fine ligamentous substance.

Ulcers of Lips.—The prolabium is liable to ulceration from various causes; from long-continued irritations, as sharp corners of teeth, rugged tartar on the external surfaces of the teeth, the habitual use of a short tobacco-pipe; from external violence; from the application of acrid matter; or from an ulcerative disposition unconnected with external circumstances. The constant and free motion of the parts is prejudicial to healing, and consequently the sores often remain long open. Though ulcers on the lips are generally of a bad character, it does not follow that all are so. Many are simple; but these, after remaining long, are apt to degenerate. Others from the first assume malignant action, and unfortunately they are more frequently met with than simple and well-disposed sores. The malignant sore often commences in a warty excrescence which ulcerates at the base; the ulceration extends, the warty appearance is succeeded by ragged and angry fleshy points, the surrounding parts become indurated, and the stony hardness spreads. The appearance which the sore presents is that of open cancer, described at page 147, and represented on preceding page. The ulceration may either be limited in depth and extent to a small part of the lip, or may involve the greater part of the prolabium, and that without much induration. It is generally situated on the right side of the lower lip; sometimes in the angle of the mouth; the upper lip is rarely affected. I have removed a few malignant ulcers from this last situation. Sooner or later the lymphatic glands participate in the disease; a chord of indurated lymphatic vessels is felt passing over the jaw in the course of the facial artery, and the glands with which these are more immediately connected, soon enlarge and become hard. This disease, though by some pathologists said to be “improperly called cancer,” differs apparently in no respect in its progress, and is in all respects as malignant as the disease commencing in any other structure and in any other way. Indurated swellings over the jaw, lymphatic or not, usually depend on the labial disease; they in some instances increase very slowly, in others acquire such volume as to induce by their pressure on neighbouring parts alarming and dangerous symptoms at an early period. Without much increase of size they sometimes attach themselves firmly to the bone, and involve it in the disease. The malignancy seems to acquire fresh virus, the skin ulcerates with fetid discharge, all the neighbourhood is speedily infected, and the patient sinks slowly under the evil.

Simple ulcers of the lips may be made to heal readily,—by abstracting the exciting cause, preventing the motion of the lip by the restraint of a bandage, disusing the part as much as possible, and by employing such applications to the sore as are best suited to the character and appearance which it may present; but it must be borne in mind that all remedies can be of little service unless motion of the lip be prevented. Sores of a bad kind must be attacked early, otherwise no hope of success can be entertained. Escharotics are not to be trusted to; the knife is the only effectual means of removing the disease. When the sore does not involve much of the lip, the molar teeth having been lost, and the alveolar processes absorbed, the cheeks are thus rendered flabby and relaxed: in such circumstances, all the diseased part is taken away with facility, and the features are not thereby deformed, but rather improved. The part cut away resembles the letter V, the angle being towards the chin: this form of incision is preferable, on account of the diseased portion being chiefly in the prolabium, and the parts afterwards coming together very neatly and readily. The lip is stretched by the operator and his assistant laying hold of the prolabium on each side of the portion destined to be taken away; a narrow straight bistoury is passed through the lip, at the angle of the form of incision; and the operator, standing in front of the patient, makes the first incision towards himself, by bringing the knife up to the prolabium. He then takes hold of the part to be removed, and laying the edge of the knife on the prolabium at the other side of the induration, cuts down to the point where the instrument originally entered. The incisions must always be made far from the indurated parts. The edges of the wound are retained in apposition by means of convoluted suture, as formerly described. When the wound is extensive, as when a considerable part of the cheek is involved, approximation may be accomplished by a few points of interrupted suture, and afterwards the parts may be more securely and accurately fixed by convoluted sutures placed between the interrupted. When a large portion of the cheek is removed, as for disease which had commenced at the angle of the mouth and extended around, all the parts cannot be brought into contact, and some of the deficiency remains to be filled up by granulation. The neighbouring parts stretch, and the deformity that may be the immediate result of the operation in a great measure disappears after some time. In cases of superficial and malignant ulceration of great extent, no attempt can be made to bring the parts together after excision: great deformity, and almost total closure of the mouth, would be the consequence. The diseased parts must be freely removed (for this is the primary and essential part of the operation, all other considerations yielding to it), and the deformity will prove much slighter than might be supposed: granulations arise, and considerable reparation of the lost parts thence ensues. Still there is a risk of the sore, at first healthy and active, gradually assuming the nature of that for which the incisions were made.

It may be necessary to remove the whole lip, or the greater part of it. Hence arises much inconvenience to the patient; he is much reduced by the profuse secretion and loss of saliva; the surrounding parts are excoriated and irritable; his clothes are wetted; his speech is very indistinct; his teeth become thickly coated with tartar; and he is in short kept in a state of constant annoyance. The part may be supplied from under the chin; but this reparative operation should not be performed at the same time with the removal of the original and carcinomatous lip. By making two operations, with a considerable time intervening, the chance of success is greater, and indeed the difficulty is much diminished. After removal of the disease, allow the parts to fill up by granulation and contract as far as they will, then form a new lip. I have done so in several instances; in one case, the parts had perished by external violence; in another, they had been destroyed by some powerful escharotic. A piece of soft leather, of the size and shape of the under lip, is placed under the chin, and a corresponding portion of the integuments is reflected upwards, an attachment being left at the symphysis menti. The callous margins of the space formerly occupied by the original lip are pared; and the flap, having been twisted round, is adapted to the edges of the wound, and retained by points of interrupted or convoluted suture. To insure adhesion, the attachment at the chin should be left thick and fleshy; the flap should not consist of mere integument, but contain no small share of the subcutaneous cellular and adipose tissues, in order that circulation may be vigorous in the part. The integuments below the chin are naturally lose, and consequently the margins of the wound there are readily approximated. The flap soon becomes œdematous, and remains so for some weeks; it must be supported by a compress and bandage. After adhesion of its upper part is completed, the mental attachment, which prevented the lower portion from uniting, is to be removed; a bistoury is introduced beneath the non-adhering point, and carried down so as to divide the attachment, which is then removed by a second stroke of the knife. The lower part of the flap is now laid flat and close to the chin, and supported by a bandage. In the adult, union may be retarded by the edges of the flap twisting inwards, and interposing the hairs upon them between the opposed surfaces; when such is the case, the offending margins must be pared away. The advantages of such an operation, when successful, are too evident to require detail.

Removal of glands in the neck or beneath the jaw, that have become diseased in consequence of malignant disease in the lip, is attended with danger, and not followed by any benefit. But for this disease I have known most bloody and cruel operations undertaken,—even portions of the jaw to which the glandular tumours adhered have been cut out. Such proceedings cannot be too strongly reprobated.

Congenital Deficiencies of Lips, Palate, &c.—Congenital deficiency of the lip uniformly occurs in the upper one; it is either simple or complicated. Frequently there is only a fissure on one side of the mesial line. This may, though seldom, be combined with division of the soft or of the hard palate; or there may be a fissure on each side of the mesial line, with an intervening flap. The flap may be either of the same length as the rest of the lip, or more or less shortened; and it may be either free, or attached to part of the alveolar process. In such cases as the latter, the central alveolar processes and teeth often project considerably beyond the arch of the hard palate, greatly increasing the deformity. The deficiency of the lip produces a disgusting and horrible deformity of the countenance; and when there is division of the palate, the voice is indistinct, or almost unintelligible.

The simple fissure of the lip, without deficiency of the palate, is easily remediable by operation. As already mentioned, the fissure is to one side of the mesial line; and its edges, covered by a continuation of the prolabium, are rounded off at their lower part. The operation is not attended with much loss of blood, nor is it very painful. It can be performed at any period of life, but in young children it is not advisable to have recourse to more severe operations on these or other parts. Children bear the loss of blood badly, and their nervous system is apt to be shaken; convulsions are induced, and often terminate fatally. The most proper age for removing deformity by operation is from two and a half to four years; there is then no danger incurred, and during the growth of the individual the parts recover more and more their natural and healthy appearance.

The operation for single harelip consists in paring off freely the edges of the fissure, and removing completely the rounded corners at the free margin, thus. This is most neatly, quickly, and easily accomplished by passing a straight bistoury through, from without inwards, so as to penetrate the membrane of the mouth, above the angle of fissure. The parts are stretched by the fingers of the surgeon or assistant, whilst the instrument is carried downwards, so as to detach a flap composed of the edge and rounded corner. Unless the rounded portions are taken clean away, an unseemly notch is left in the prolabium, where in the natural structure is prominent. A similar proceeding is followed on the opposite side. Hemorrhage is prevented by the assistant making gentle pressure whilst he stretches the lip. Two sewing needles, the heads covered with a small nodule of sealing wax, are introduced as directed after the operation for removal of diseased parts in the lower lip, and the twisted suture completed. For some years I have used pins made purposely; they are spear-pointed and tempered near their points. From their length they can be easily inserted without being fixed in a handle, or provided with a head. One needle should always be passed close to the free margin of the lip. No further dressing is required, for reasons already assigned. The forceps of different kinds for holding the edge during its removal are worse than useless; and paring with scissors is to be reprobated, as an effectual means of preventing immediate union. By the plan above recommended, bruising is avoided, and union takes place rapidly.

Fissures, more or less extensive, of the hard palate, generally attend double harelip. The position and size of the intermediate portion of the lip, and of the superior maxillary bone, are various; and the operator, in forming his plan of procedure, must be guided by the state of the parts. If the fissures are not very wide—if the intermediate portion of bone, that adhering to the septum narium, is not prominent—and if the soft parts covering this are free and long, the operative procedure is simple. Two such operations as are described for single harelip, the latter performed at an interval of some weeks, are required. Thereby the intervening flap is united first to one side, and then to the other.

If the flap is short and free, without osseous projection, the operation may be concluded at once, thus:— The edges are pared on both sides, and the parts brought together as in single harelip, the small intervening flap not preventing apposition below. One pin is passed at the prolabium, the other traverses the flap. In all cases, in fact, the operation may be concluded at once.

When the bone projects, and the flap is long, the parts may be rendered favourable for the operation by gentle and continued pressure; the osseous prominence being reduced, so as to restore the natural position of the soft parts.

When, as not unfrequently occurs, there is projection of the bone, and the soft and hard parts seem to be incorporated with the apex of the nose—when, in short, little or no intermediate flap exists, the protruding portion of bone may be removed by cutting forceps down to the level of the palatine arch; and then the soft parts can be brought together by one operation, as for single harelip.

In some cases, when the space between the palatine plates of the superior maxillary bone is wide, it may be necessary, by mechanical contrivance, fitting on metallic apparatus possessing a strong spring, to approximate the bones before attempting to unite the lip. The cases must be very rare, where the soft parts cannot be otherwise brought together: when they can be united, their equable and continued pressure will have the effect of gradually approximating the hard parts.

When the hard palate is deficient, the patient is subjected to great inconvenience from food escaping into the cavities of the nose, and, in later life, horrid wretchedness of articulation occurs. It can readily be understood, that surgery is of very little avail here. Recourse must be had to mechanical contrivance. A plate of metal (gold or platina), or a piece of ivory, or of sea-horse bone, may be fitted to the opening, and retained either by accurate adaptation, having sponge or caoutchouc attached to the upper surface, or by wires, elastic or not, resting on the neighbouring teeth. It may be made of a piece with artificial teeth, if any are required. The sponge is objectionable, as retaining the discharge, and thereby imparting an unpleasant odour to the expired air. But it is no easy matter, and often altogether impracticable, to retain such apparatus when the soft palate is also deficient. The time at which such contrivance is to be adapted may admit of some dispute. If done early in life, the natural tendency of the parts to approximate may be interfered with and subverted; if dispensed with till a later period, the patient gets into a habit of snuffling and speaking so indistinctly, that the closing of the aperture is productive of little or no improvement. Perhaps the period of commencing the child’s education should be delayed till he be seven, eight, nine, or even ten years of age, and then the artificial palate may be applied advantageously in every respect.

Fissure of the soft palate is usually accompanied with separation of the bones from which it is suspended. The size of the fissure is various, and depends very much upon the state of the hard parts. In some cases, the extent of separation is great; in others, the edges are readily approximated by making the patient throw the muscles into action. The latter class admit of operation with a view to permanent union of the edges of the fissure. But it is a proceeding which, to insure success, requires not only great steadiness, coolness, and dexterity on the part of the operator, but the utmost courage, submission and self-denial on the part of the patient. These qualifications can scarcely be expected in patients under twelve or fourteen; and, consequently, the operation should not be attempted till after that time of life.