A Manual of the Operations of Surgery Part 22

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

His success has been very great by this method, though others who have tried it have sometimes found bleeding troublesome.

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

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

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

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

In all operations on the palate, two conditions used to be considered requisite for success:--1. That the patient should have arrived at years of discretion, at twelve or fourteen years at least; that he be possessed of considerable firmness, and be extremely anxious for a cure, so as to give full and intelligent co-operation. 2. That for some days or weeks prior to the operation the mouth and palate should have been trained to open widely and to bear manipulation, without reflex action being excited. Professor Billroth of Vienna,[120] and Mr. Thomas Smith[121] of London, have had cases which prove the possibility of performing this operation in childhood, under chloroform, with the a.s.sistance, 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.).

[Ill.u.s.tration: FIG. XXIX.[122]]

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 pa.s.sing the thread through the second side from behind forwards, can be avoided in the following manner.[123] A curved needle is pa.s.sed 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 pa.s.sed 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 pa.s.sed through the loop of the second one also in the cleft, it is easy, by withdrawing the loop through the palate, to finish the st.i.tch (see Fig. XXIX.). All the st.i.tches should be pa.s.sed and their position approved before any one be tied, and it is most convenient to secure them from above downwards. To prevent confusion, each pair of threads after being inserted should be left very long, and brought up to a coronet fixed on the brow, which is fitted with several pairs of hooks numbered for easy reference. This will prevent twisting of the threads or any mistake in tying.

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

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

_Operation._--In addition to the usual paring of the edges of the cleft, an incision is made on each side of the palate, extending "from the canine tooth in front to the last molar behind,"[124] along the alveolar ridge (Fig. x.x.x.). 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.

[Ill.u.s.tration: FIG. x.x.x.[125]]

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 st.i.tches 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 haemorrhage.

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 haemorrhage, while four or five out of fifteen adults required either the actual cautery or the sesqui-chloride of iron.[126]

FOOTNOTES:

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

[115] _Lancet_, Feb. 4, 1865.

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

[117] _Lancet_, April 20, 1872.

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

460.

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

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

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

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

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

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

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

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

CHAPTER IX.

OPERATIONS ON AIR Pa.s.sAGES.

OPERATIONS ON THE LARYNX AND TRACHEA.--The great air pa.s.sage 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. Cha.s.saignac[127] says "the only really rational operation for the opening of the air pa.s.sages by the surgeon is tracheotomy."