Disarticulation of the entire bone has been very rarely performed.112 If necessary, it can be performed without any incision into the mouth, by one semilunar sweep from one articulation to the other, passing 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 masseter 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 masseter and pterygoid muscles were not completely divided, and the facial artery was intact."113
Fergusson114 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 hæmorrhage and deformity, as the labial 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.
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 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the fistula, and then as far backwards as convenient through the cheek into the mouth; the needle should then be withdrawn, the thread being left in.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.
Fig. xxviii. 115
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:116—
"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.117
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.118
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,119 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 method120 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,121 and Mr. Thomas Smith122 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.).
Fig. xxix. 123
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.124 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,"125 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.
Fig. xxx. 126
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.127
CHAPTER IX.
OPERATIONS ON AIR PASSAGES
Operations on the Larynx and Trachea.—The great air passage may be opened at three different situations, and to the operations at these different places the following names have been given:—
Laryngotomy, when the opening is made in the interval between the cricoid and thyroid cartilages, through the crico-thyroid membrane.
Laryngo-tracheotomy, when the cricoid cartilage and the upper ring of the trachea are divided.
Tracheotomy, when the trachea itself is opened by the division of two, three, or more rings.
Of these the last, tracheotomy, is by far the most frequent, important, difficult, and dangerous, and requires a very detailed description. Chassaignac128 says "the only really rational operation for the opening of the air passages by the surgeon is tracheotomy."
Tracheotomy.—Anatomy.—Between the cricoid cartilage and the level of the upper border of the sternum, the middle line of the neck is occupied by the upper portion of the trachea. Its depth from the surface varies, gradually increasing as the trachea descends, and varying very much according to the fatness, muscularity, and length of the neck. It is, however, almost subcutaneous at the commencement below the cricoid, and on the level of the sternum it is in most cases at least an inch from the surface, in many much deeper. Again, its length varies, even in the adult, from two and a half to three, or even four inches. This is important, as affecting the simplicity of the operation, which, as a rule, is easier the longer the neck is.
The trachea has most important and complicated anatomical relations—some constant, others irregular.
1. The carotid arteries and jugular veins lie at either side, but, where these are regular in their distribution, do not practically interfere in a well-conducted operation.
2. The thyroid gland lies in close relation to the trachea, one lobe being at each side (Fig. xxxi. B B), and the isthmus of the thyroid crosses the trachea just over the second and third cartilaginous rings. In fat vascular necks, or where the thyroid is enlarged it may occupy a much larger portion of the trachea. The position of the isthmus practically divides the trachea into two portions in which it is possible to perform tracheotomy. Both have their advocates, but the balance of authority tends to support the operation below the thyroid. A separate notice of each will be required immediately.
Fig. xxxi. 129
3. The muscles in relation to the trachea are the sterno-hyoid and sterno-thyroid of each side. The latter are the broadest, are in close contact across the trachea by the inner edges below, but gradually diverge as they ascend the neck. In thick-set, muscular necks, however, they are in close contact for a considerable distance, and require to be separated to give access to the trachea.
The arteries are in most cases unimportant; no named branch of any size ought to be divided in the operation. However, occasionally very free bleeding may result from the division of an abnormal thyroidea ima running up the trachea to the thyroid body from the innominate, or even from the aorta itself.
The veins are very numerous and irregularly distributed. There is generally a large transverse communicating branch between the superior thyroid veins just above the isthmus. The isthmus itself has a large venous plexus over it. Below the isthmus the veins converge into one trunk (or sometimes two parallel ones) lying right in front of the trachea.
4. The last anatomical point which may give trouble in normal necks is the thymus, which is present in children below the age of two, and covers the lower end of the trachea just above the level of the sternum. Where this is not only not diminished, but enlarged, as it sometimes is in unhealthy children, it may give a very great deal of trouble, rolling out at the wound and greatly embarrassing proceedings.
Abnormalities are very various and sometimes very dangerous: vessels crossing the trachea, as the innominate did in Macilwain's case,130 or where two brachiocephalic trunks are present, as recorded by Chassaignac.131 One of the most frequent dangers to be guarded against is a possible dilatation of the aorta or aneurism of the arch. This may very possibly, as happened in one case to the author, give rise to suffocative paroxysms from its pressure on the recurrent laryngeal nerves. Tracheotomy may be deemed necessary, and there is a great risk, unless proper precautions be taken, of wounding the aorta, where it passes upwards in the jugular fossa. In the author's case the vessel had actually to be pushed downwards by the pulp of the forefinger while the trachea was opened, the knife being guided on the back of the nail of the same finger.
The Operation.—In a work of this kind it would be utterly impossible to go at all into the subject of what diseases, injuries, etc., warrant or require the operation. It is enough to describe the various methods of operating, their dangers and difficulties.
1. The operation above the isthmus of the thyroid.—A spot about a quarter or half of an inch in vertical diameter between the cricoid cartilage (Fig. xxxi.) and thyroid isthmus.
Advantages.—It is near the surface, the vessels are few and comparatively small. It is most suitable in cases of aneurism.
Professor Spence132 gives his sanction to the high operation in adults with thick short necks when the operation is performed for ulceration or papilloma of larynx or for spasm from aneurism, the low operation being still best in cases of croup or diphtheria.
Disadvantages.—The space is too small, requires very considerable disturbance of the thyroid isthmus, or actual division of it. It is too near the point where the disease is; so much so, that in most cases of croup or diphtheria it would be perfectly useless. However, if required, or if the operation lower down be contra-indicated, this may be performed easily enough. A straight incision being made in the middle line about one inch and a half in length, expose the upper ring by careful dissection, if possible draw aside the veins, and depress the thyroid isthmus, divide the rings thus exposed, and introduce the tube.
The operation below the isthmus.—This, though more difficult in its performance, is a much more scientific and satisfactory operation. Considerable coolness and a thorough knowledge of the anatomy of the part are absolutely required.
The patient being in the recumbent posture, the shoulders should be well raised, and the head held back so as to extend the windpipe, and thus bring it as near as possible to the surface. A pillow, or the arm of an assistant, behind the neck will be of service.
N.B.—Be careful lest too great extension by an anxious assistant, accompanied by closure of the mouth, should choke the patient (whose breathing is of course already much embarrassed) before the operation be begun.
Chloroform may occasionally be given, and, if well borne, renders the operation very much easier than it would otherwise be. An incision must then be made exactly in the median line of the neck, from a little below the cricoid cartilage, almost to the upper edge of the sternum; at first it should be through skin only, then the veins will be seen, probably turgid with dark blood; the larger ones should be drawn aside, if necessary divided, the bleeding stopped by gentle pressure. The deep fascia must then be cautiously divided, great care being taken to keep exactly in the middle line, and the contiguous edges of sterno-thyroid muscles separated from each other by the handle of the knife. A quantity of loose connective tissue, containing numerous small veins, must now be pushed aside, the thyroid isthmus pressed upwards, still with the handle of the knife. The forefinger must then be used to distinguish the rings of the trachea. If there is much convulsive movement of the larynx and trachea, they should be fixed by the insertion of a small sharp hook with a short curve, just below the cricoid cartilage, and this should be confided to an assistant. The surgeon should then, with the forefinger of his left hand, fix the trachea, and open it by a straight sharp-pointed scalpel, boldly thrusting it through the rings with a jerk or stab, the back of the knife being below, and divide two or three of the rings from below upwards. Any attempt to enter the trachea slowly with a blunt knife or trocar will probably be unsuccessful, as the rings, especially in children, give way before the knife, which merely approximates the sides of the trachea without opening it.
Question of Hæmorrhage.—It is often a question of some importance, and one which sometimes it is not easy to settle, how far attempts should be made completely to arrest the venous hæmorrhage before opening the trachea.
On the one hand, if not arrested, besides the risk of weakening the patient, we have to dread the much more serious complication of the admission of blood into the wound. And this is very serious in a patient whose respiration has already been much impeded, whose lungs are probably engorged, and who has certainly, by the mere existence of a wound in his trachea, lost the power of coughing properly; it must never be forgotten that a quantity of blood so trifling as to be at once ejected by a single cough in the case of a healthy chest, may be a fatal obstacle to respiration in one already weakened by disease. Thus any well-marked arterial hæmorrhage from cut branches, or from the isthmus of the thyroid, must certainly be arrested prior to opening the trachea. Besides this, blood once having entered the bronchi is apt to extend into their smaller ramifications and prove a cause of death, by acting as a local irritation, and setting up intra-lobular suppurative pneumonia. The author has found this to be the case both after tracheotomy and still more frequently in suicide by cut throat.
But, on the other hand, it is equally true that there is almost always a considerable amount of oozing from small venous radicles divided during the operation, which depends simply on the great venous engorgement resulting from the obstruction to the respiration, so that while to attempt to tie every point would be simply endless, we may be almost certain that the oozing will cease whenever the trachea is opened, and respiration fairly improved. Slight pressure on the wound is generally sufficient to stop the bleeding till the venous engorgement has disappeared.
Of late years many tracheotomies have been done bloodlessly by use of the thermo-cautery, for division of the soft parts, but the subsequent sloughing of the wound is a great objection to this method.
In cases of extreme urgency, all such minor considerations as suppression of venous oozing must be ignored, and the trachea simply opened as rapidly as possible. I had once to perform the operation after respiration had entirely ceased, and no pulse could be felt at the wrist, with no assistance except that of a female attendant. Merely feeling that no large arterial branch was in the way, I cut straight through all the tissues, opened the trachea, and commenced artificial respiration. The patient eventually recovered.
Question of Tubes, etc.—Once the trachea is opened, the next question is, How is the opening to be kept pervious? For the moment the handle of the scalpel is to be inserted in the wound, so as to stretch it transversely; this will probably suffice to allow of the escape of any foreign body. But where, to admit air, the wound is to be kept open, how is this to be done? It used to be advised that an elliptical portion of the wall of the trachea be removed; this, though succeeding well enough for a time, was unscientific, as the wound always tended to cicatrise, and ended of course in permanent narrowing of the canal of the trachea. It may be necessary thus to excise a portion of the trachea, in cases where it is very intolerant of the presence of a tube. Such a case is recorded by Sir J. Fayrer of Calcutta.133 Not much better is the proposal to insert a silk ligature in each side of the wound, and by pulling these apart thus mechanically to open the wound. This also is evidently a merely temporary expedient.