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.

There are two substances used in medicine and in the arts which have a proclivity for the tissues of the mouth and jaws. These are phosphorus and mercury, the former usually affecting the bone and the latter the softer tissues. Before legislation had been enacted by which the young were prevented from working in match factories phosphorus necrosis of the lower jaw was not uncommon. Today it is rarely seen. Again, in the older days when mercury was given in large amounts, and its effects were not as well guarded against as now, mercurial stomatitis proceeding to ulceration and even loss of teeth was not an uncommon event. Now it is seen only in those who have an idiosyncrasy which makes them peculiarly liable to its effects. The mechanism of phosphorus necrosis is supposed to be an ossifying periostitis, with formation of small osteophytes in the alveolar periosteum, which lower tissue resistance and permit easier invasion of bacteria from the mouth. (See p. 428.)

The extension of disease from the teeth, especially of the upper jaw, upward into the antrum of Highmore, with its consequent infection, is elsewhere discussed, and the reader will find the treatment of empyema of the antrum considered in Chapter XXXVII.

The teeth are also subjects of certain tumor formations which in general are spoken of as odontomas, and have been mentioned in the chapter on Tumors. (See p. 281.)

Teeth, moreover, show at times excessive development or marked displacement or defects of development. Thus they erupt in abnormal positions, or fail completely in eruption, or they project in abnormal directions or are sometimes amalgamated. The art and science of the dentist permit of wonderful control of abnormal development of those teeth which once appear upon the surface. Children whose teeth are irregularly placed, or which are abnormal in any respect, should be placed under the care of a competent specialist. The most serious tumors of the teeth are those connected with cyst formation, which may assume considerable size. A dentigerous cyst is proper material for the surgeon rather than for the dentist, inasmuch as while the operation can be usually done through the mouth it may require external incision and removal of a considerable shell of bone, perhaps with plastic restoration of tissues.

THE EXTRACTION OF TEETH.

The general practitioner has often to remove diseased teeth as well as the surgeon. The theory of tooth extraction is simple. Its performance, especially when the tooth is diseased, may be exceedingly difficult, for such teeth may be crumbled in consequence of the force needed for their removal.

Forceps of different shapes are required for the various teeth. At least half a dozen different patterns are requisite. A form of elevator is also of use in elevating stumps which may lie beneath the alveolar border.

The tooth to be removed should be seized along the fang and beyond the crown. The blades of the forceps should be pressed firmly down and along the tooth, in order to separate from it the softer tissues of the gum and the firmer tissue of the alveolar socket. This is thinner upon its outer aspect than its inner, save in the location of the wisdom tooth, and it is the outer border which is more easily broken away by force applied toward the cheek rather than toward the interior of the mouth. Using first one blade of the forceps and then the other to split the socket and separate the osteofibrous tissues, the tooth being then firmly grasped between them, the operator makes a series of rocking movements, by which it is itself loosened and its further attachments torn, until by a lifting effort it can be extracted from the socket. In this minor operation the head must be firmly held with the disengaged hand, or better between the forearm and the operator’s body, while with that hand he supports and manipulates the lower jaw, if it be a lower tooth which is to be removed.

The operation is painful for the moment. With timid patients local anesthesia may be produced with cocaine or one of its substitutes, the solutions being sterile, and either locally applied around the socket or injected into the surrounding tissues with the ordinary hypodermic syringe needle. Such attempts are not without their own danger, for I have seen serious infection follow the introduction of unsterile solutions by dentists not familiar with aseptic technique. Again, nitrous oxide gas may be administered, it being usually necessary to employ a mouth-gag. Recovery from anesthesia is prompt and muscle spasm may not be entirely abolished; therefore, the gag should be inserted before the gas is administered. It may be sufficient for the purpose to employ a good-sized piece of cork, to which a cord should be attached in order that it may not disappear down the patient’s throat during a violent effort at inspiration. The horizontal position is the safer for this purpose.

It is especially the removal of fangs or roots which gives the greatest trouble in these cases. For this purpose special forceps are devised, but for their use it is necessary to clear away the gum and periosteum and to cut away a portion of the alveolar process. Such broken fragments of teeth allowed to remain give rise to curious reflexes, such as convulsions, neuralgia, etc., all of which makes it apparent that the extraction of a tooth being undertaken it should be thoroughly performed. After its removal the patient should rinse his mouth with water as hot as can be borne, to check hemorrhage. The removal of the tooth having left an open pathway for infection, antiseptic mouth-washes should be frequently used and the socket packed with antiseptic gauze. Except in rare instances granulation tissue fills the cavity and the process of repair is rapid.

Among the accidents which may follow extraction of teeth are hemorrhage, which may be checked by plugging and the use of adrenalin. Adjoining teeth are occasionally injured in clumsy efforts at extraction, while not infrequently a patient who has not sufficiently described his symptoms has indicated to the dentist the wrong tooth, whose consequent extraction has, therefore, not relieved him of his difficulty. Some teeth have such spreading roots as to make their removal extremely difficult, and even careful operators have occasionally inflicted fractures, especially of the lower jaw. The treatment of such an accidental fracture will not be different from that of fractures otherwise produced. Such an accident as forcing a tooth upward into the antrum of Highmore should be followed by its removal, even at the expense of further operation, while excessive tearing of the alveolar border, or especially of the gum, may be treated by suitable packing or by suturing. The accident of aspiration into the larynx of part or all of a tooth just removed has been known to be followed by suffocation. The operator, therefore, should not release the tooth from the grasp of the forceps until the latter are entirely out of the mouth.

By accident or from indifference it may happen that a healthy tooth has been removed instead of one diseased. Should this happen the tooth may often be re-implanted after being cleansed, and will usually resume its previous position and function. So feasible is such re-implantation of teeth that they have been frequently removed or transplanted from one mouth to another, for a compensation, a new socket being made for the reception of the healthy tooth just removed from the mouth of the individual willing to part with it.

THE JAWS.

While the jaws are not subject to affections peculiar to these parts, there may be seen in them peculiar expressions of general conditions, made so by virtue of environment or complexity of tissues. Most of the acute infections of the jaw bones are propagated from the teeth or the tooth sockets. There may be periostitis and osteomyelitis, and these may be followed by a sclerosing process or acute suppuration. The jaws are prone to be thus affected in consequence of the acute exanthems and the infectious fevers, while the effects of mercury and phosphorus have been mentioned. The treatment of the inflammatory affections here is the same as elsewhere, i. e., early incision and complete evacuation of pus, with removal of necrotic bone or other tissue. Many sequestra may be removed from within the mouth in such a manner as to avoid disfiguring scars. When external sinuses complicate the case, incisions through the skin should be made. These may be so planned as to coincide with the natural wrinkles or folds of the face.

The temporomaxillary joint is a locality of considerable interest. Dislocations take place here in consequence of blows or of violent muscular effort, and are easily recognized because of the fixation and displacement which they produce. Ordinarily they are easy of replacement. These luxations may be unilateral or bilateral. As the result of violence the condyle has been driven upward through the base of the skull, the violence producing such injury usually being fatal. Aside from these injuries to the grosser structures the temporomaxillary joint is not infrequently the site of acute synovitis, or more extensive inflammation, usually propagated from surrounding tissues, but sometimes the result of distant infection. In phlegmons of this region the structures of the joint rarely escape a sympathetic participation, while parotid abscess and similar collections of pus may penetrate the joint and destroy it. Again it is occasionally the site of a postgonorrheal arthritis, or it may suffer as do other joints after the exanthems and acute fevers. It also occasionally becomes involved in the disturbances accompanying irregular eruption of the last molar, i. e., the wisdom tooth; in other words, it may suffer just as may any other joint in the body, and from similar causes.

Ankylosis of the temporomaxillary joint is an infrequent result of its involvement in serious disease, or may result from lesions of the adjoining tissues, as from the cicatricial deformity following noma, burns, and the like. Thus we may have either a true or a spurious ankylosis of this joint, in either case the resulting condition being intractable and exceedingly difficult to manage. When it can be foreseen as a consequence of extrinsic disease it may be prevented by the insertion of a mouth-gag, and more or less frequent and forcible stretching, or by wearing some suitable apparatus between the teeth which shall keep the jaws apart, and which may be used at night. A pseudo-ankylosis produced by cicatricial bands, and long neglected, will become genuine, and require as radical an operation as though it had been interosseous from the outset.

For the relief of such conditions various operations have been devised, in each of which the formation of a false joint is contemplated, it depending upon the exigencies of the case whether this shall be produced by the division of the horizontal ramus in front of the masseter, or of the ascending ramus behind the masseter, or whether there shall be actual resection of the temporomaxillary joint, with division of the neck and removal of the condyle. The latter procedure is the more ideal, at the same time the more difficult, and the more likely to permit injury to the branches of the facial nerve, with consequent paralysis of the orbicularis and the facial muscles.

I have elsewhere described a peculiar condition of relaxation of the temporomaxillary ligaments, by which there is a recurring subluxation of the joint, noticed most often during eating and accompanied by a snapping sound. This is usually unnoticed by the patient, but is often observed by others. It is painless, harmless, and not ordinarily amenable to treatment. (See p. 528.)

Tumors of the jaws proper include mainly cysts, which are often connected with odontomas, benign tumors, such as fibroma, chondroma, and osteoma, most often of mixed type, and the malignant tumors, i. e., sarcoma, carcinoma, and endothelioma. Malignant tumors primary to the bone are usually of sarcomatous type, though these may include the endotheliomas. Carcinoma and epithelioma do not originate in bone texture, but may easily spread to and involve it. Thus many cases of advanced epithelioma of the lip involve the bone as well as the other neighboring tissues.

Epulis is a somewhat vague term, which has been applied to tumors which spring from and mainly involve the fibrous texture of the gum and the periosteum covering the alveolar process. The term itself simply implies a tumor upon the gum. Microscopically these tumors are usually of the giant-cell type of fibrosarcoma, and are among its least malignant varieties. They pursue a slow course, gradually loosening one tooth after another as they invade the tooth sockets, show very little tendency to spread rapidly, and are usually sharply circumscribed growths, tending to ulceration. They seem to be products of irritation. When removed they rarely recur. The surgeon should excise involved tissue in order to be on the safe side, sacrificing teeth, gum, and alveolar process as widely as necessary for the purpose. Formerly the epulides were made to include different expressions of fibroma and sarcoma involving the gum, but the name is so vague that it would be better to speak of each of these cases as its histological characteristics may indicate.

Benign tumors involving the entire bone may necessitate its removal, but most of the dentigerous bone cysts may be laid open, their contents evacuated, their size reduced, and the remaining cavity allowed to fill with granulation tissue; while malignant tumors call for sacrifice of every portion of tissue involved, often including the skin, and in the upper jaw much of the complicated structure of the nasal cavity, or in the lower jaw the loss of the tongue or a large portion of the floor of the mouth. A cancer of the lower jaw may be removed, with permanent good result, but a true cancer of the upper jaw should be seen early and mercilessly extirpated if the result is to be more than temporary.

OPERATIONS UPON THE JAWS.

Aside from those already mentioned the principal operations upon the jaws consist of partial or complete excision.

Removal of the upper jaw is a rather formidable procedure, frequently made so by extent of the disease which requires its performance. The presence of an extensive and ulcerating tumor, by which normal anatomical outlines are obliterated, will cause mechanical difficulties as well as unusual liability to hemorrhage. During some portion of its performance a temporary control of the vessels of the neck may be of assistance. This can be usually afforded by external digital pressure. In serious cases a ligation of the external or the common carotid may be of assistance. If soft, vascular tumors protrude into the nasopharynx a preliminary tracheotomy should be performed, tamponing the pharynx in order to prevent escape of blood down the throat. The position of the patient with the down-hanging head may be also of assistance in these cases. Of the various incisions employed one should be selected according to the nature of the case. Most of the operations include a splitting of the upper lip near the middle, with continuation of the incision along the margin of the nose, upward toward the orbit and outward along the orbital border, as originally suggested by Fergusson. This permits of completely raising the cheek from the underlying bone in one extensive flap and turning it backward, with complete exposure of the anterior surface of the superior maxillary. The operator next proceeds according to the desired extent of removal. If the roof of the mouth is to be sacrificed the osteoperiosteal and soft tissues composing the palate should be divided as far from the middle line as may be permitted, then reflected, and the bone divided with chisel or with cutting forceps. It may be necessary to remove one of the incisor teeth to permit the insertion of the chisel for division of the anterior part of the jaw. Bone forceps or a chain or wire saw will serve for division of the zygoma and the external or lower wall of the orbit, while with chisel or forceps the nasomaxillary region is divided. The loosened bone can now be seized with strong lion-jaw forceps and wrenched from its attachments, which may then be divided with scissors or knife as they are encountered (Fig. 474).

Resection of superior maxilla. (Farabeuf.)]

Hemorrhage will be profuse at this juncture, when the internal maxillary artery is, with many of its branches, thus torn across or severed. The surgeon should be ready with tampons and forceps to check the bleeding and secure the vessels. The complete Fergusson operation includes removal of the entire upper maxilla, but oftentimes much less than this will suffice. On the other hand it is necessary sometimes to go still farther and remove more bone from the orbit or the nasal cavity, or perhaps to clean out the orbit entirely. A case which necessitates one of the more formidable operations is too unpromising to make it often judicious to perform it.

When the tumor involves the overlying skin this should also be sacrificed, and a plastic operation should be made to cover the defect. The skin flaps required for this purpose may be taken from the temple, the forehead, the neck, or adjoining parts of the face.

Bardenheuer has suggested the raising of osteoplastic flaps for removal of tumors lying within the jaw, and their replacement at the conclusion of the operation. He has also devised ingenious methods of making immediate plastic repair which are worthy of study, but which are so seldom required as to not justify description in this place.

After operation the bleeding should be checked by torsion, by ligation, by sutures en masse, by application of hot water, and by securely tamponing with antiseptic gauze, by whose pressure oozing is checked and protection from infection afforded. The patient is allowed to sit up as early as possible, meanwhile being made to lie upon the affected side in order to avoid danger of aspiration pneumonia, and using an antiseptic mouth-wash with relative frequency.

It is sometimes possible to perfect an artificial substitute for tissues removed, which can be inserted after the operation. The loss of tissue will cause more or less disfigurement by sinking in of the cheek and side of the face. After the parts are healed an apparatus made of gutta-percha or metal, and adapted to each case, by which most of the lost symmetry may be restored, should be worn, in the same manner as an artificial denture.

The lower jaw seldom requires complete removal. It is rarely necessary to go so high as the joint or the coronoid process, although occasionally the condyle must be avulsed and the coronoid either cut away or its temporal tendon detached. Most of the exsections in this location are confined to some portion of the horizontal ramus. Except in rare instances it is not possible to make a complete excision of the lower jaw through the mouth, and nearly all operations are practised through external incision, carried along the lower border for a sufficient length, and extended upward along the posterior border beyond the angle, if necessary. In most instances the facial vessels are directly exposed and should be secured before division. Masseteric attachments are separated and the instruments are kept as near to the bone as the circumstances of the case will justify. In well-marked ulcerating cancer, however, the surgeon should go nearly an inch beyond its apparent border and remove still more if it be visible, taking everything which seems involved. Here the bone is usually divided with a chain saw, although stout cutting forceps may suffice. It may be necessary to remove a tooth in order to clear a place for the action of the chain saw. Growths involving the skin necessitate not merely linear incisions, but extensive oval excisions of the overlying tissues. All the involved structures should be removed in one mass; if it be necessary to remove the floor of the mouth the divided bone section is seldom cut away until it can be removed with the rest of the tumor. The healthy mucous membrane should be preserved and brought together with catgut sutures at the conclusion of the operation, as the more carefully the cavity of the mouth can be shut off from the balance of the wound the more prompt and satisfactory the healing (Fig. 475).

Resection of inferior maxilla. (Farabeuf.)]

In a few cases it may be possible by the use of stout silver wire, or some other substitute, inserted between bone ends to keep them apart and thus nearly preserve the contour of the lower part of the face; but this can be expected to succeed only when the cavity of the mouth can be completely closed, so that the wire or other material may be quickly incorporated in granulation tissue, where it is expected to remain.

When it is necessary to remove the joint end of the bone the operator should work carefully along the bone toward the joint in such a way as not to injure the facial nerve, the external maxillary artery, or Stenson’s duct. With a sharp separator it is possible to thus expose the joint, and after opening it to avulse the articular surface. In operating for necrosis the healthy periosteum should be preserved, while in the removal of cancer it should be sacrificed to the same extent as the bone itself.

The same rules apply here as above with reference to the closure of the wound and the construction of flaps; an extensive plastic operation being sometimes necessitated, as when a large portion of the lower lip, the chin and the bone are removed for extensive epithelioma. Dead spaces should be avoided, any cavity should be packed sufficiently, opportunity for drainage afforded, and the mouth cavity closed. Mouth-washes should be frequently used.

These cases should be prepared for operation by a careful cleansing of the mouth and the local use of antiseptics. During any of these operations, diseased teeth which may require it should be removed, whether they occupy the site of the operation or some other portion of the jaws. The cleaner the mouth the more prompt will be the healing process.