COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00035645 "^"^.st^ Colmnbta ©nibmiftpj^ mtlicCilp»t»ttoJ9(irk ^°V^ &ff«n« IGibrarg \ Digitized by the Internet Arciiive in 2010 with funding from Open Knowledge Commons (for the Medical Heritage Library project) http://www.archive.org/details/surgerydiseasesoOOblai SURGERY AND DISEASES OF THE MOUTH AND JAWS SUMGERY AND DISEASES OP THE MOUTH AND JAWS A PRACTICAL TREATISE ON THE SURGERY AND DISEASES OF THE MOUTH AND ALLIED STRUCTURES VILRAY PAPIN BLAIR, A M., M. P., P. A. C. S. PROFESSOR OF ORAX SURGERY IN THE WASHINGTON UNIVERSITY DENTAL SCHOOL, AND ASSOCIATE IN SURGERY IN THE WASHINGTON UNIVERSITY MEDICAL SCHOOL THIRD EDITION REVISED SO AS TO INCORPORATE THE LATEST WAR DATA CONCERNING GUNSHOT INJURIES OP THE PACE AND JAWS Compiled by the Section of Surgery of the Head, Subsection of Plastic and Oral Surgery, Office of the Surgeon-General of the Army, Washington, D. C. With 4-60 Illustrations ST. LOUIS C. V. MOSBY COMPANY 1917 / Copyright, 1912, 1917, by C. V. Mosby Company d-'^'l'^ Press of C. v. Mosby Company St. Louis TO THE FEIENDS WHOM I HAVE NEGLECTED WHILE PURSUING THESE STUDIES THIS VOLUME IS IN ALL SINCERITY DEDICATED PREFACE TO THIRD EDITIOX No surgical truth has received greater emphasis in this war than the necessity of correlating the skill and the knowledge of the general and the dental surgeons in the treatment of the combined injuries of the face and the jaw bones. An eminent authority on military surgery said, after the war of 1870-71: "I should not care to go through another campaign without having obtained competent technical assistance for those who have sus- tained injury of the face and fractured jaw.'' The present revision is mostly confined to the parts related to injury and sepsis and their treatment, and was done by the Section of Surgery of the Head, Subsection of Plastic and Oral Surgery, as an expeditious method of giving, in a correlated form, the sum of the observations of the many workers abroad, to whose reports and recom- mendations, published, written and verbal, this section had access. These were put forth in this form because, on the one hand, time did not permit of a full exposition of the subject in a special manual; while on the other, it would be of less utility and somewhat awkward to attempt to present these observations while disregarding the well- established principles upon which they are based. The subject of peridental infections has been rewritten by Dr. Arthur D. Black, of Chicago, and read by Dr. Thomas L. Gilmer, ]\Iost of the illustrations were furnished by Dr. Black. The chapter on local anesthesia has been revised by the original author, and that on general anesthesia by Dr. Ellis Fischel. Because of insufficient time, the other chapters, not referred to in this preface, were not revised. The abstracting of the war literature and much of the assembling was done by Captain Robert H. Ivy, ^Medical Reserve Corps, of }^Iil- waukee ; while further reassembling and the reading of proof was IX X PREFACE. intrusted to Captain Virgil Loeb, Medical Reserve Corps, of St. Louis. The author has been collecting material for years for a general revision of this book, and certain matters referring to the repair of defects have been included in this revision, to which have been added some recent observations on cancer of the mouth. Office of the Surgeon-General of the VILRAY PAPIN BLAIR, Army, Washington, D. C. Major, M. R. C, U. S. A. In charge October 20, 1917. of the Subsection of Plastic and Oral Surgery, Section of Surgery of the Head. PREFACE TO SECOND EDITION Advantage has been taken of the opportunity afforded by the issuing of the second edition to eliminate certain typographical errors and in a few places to reconstruct the text. The author wishes also to avail himself of this opportunity to thank the pro- fession for their kind reception of this book. VILRAY PAPIN BLAIR. August 1st, 1913. PREFACE TO FIRST EDITION In spite of all of the special work that has been done in the study of the teeth and allied structures, the ordinary standard of surgical treat- ment given to diseases and deformities of the mouth does not equal that attained in other regions. This is due largely to a rather general lack of reciprocity of ideas and observations between constructive workers in the medical, with those of the dental professions. It was with the hope of presenting their more pertinent observations and deductions in a coordinated scheme that the present work was undertaken. This attempt has been made possible by the untiring efforts that the author's many associates in the dental profession have always made to help him solve cases that contained dental problems. For the benefit of his dental students certain chapters on surgical pathology and surgical principles have been included. As hemorrhage is often a serious matter in mouth operations, this has been considered at some length. Throughout, the attempt has been made to give proper credit to the originators of ideas presented, but this is not always possible. Most procedures are common property, their origin having been lost. Fur- ther, similar problems often evoke similar answers, and the same pro- cedure is often reinvented many times. Even when a unique condition demands a somewhat radically new procedure, the deductions that seem to warrant it are often largely adapted from the observations and pro- cedures of others, though these may have been made and executed under different circumstances and in other regions. The author is deeply indebted to Dr. William Krenning for a thor- ough sifting of the English, German, and French literature of the subject. Among others, he is also indebted to Drs. Thomas Gilmer, Hermann Prinz, Willard Bartlett, John Kennerly, B. E. Lischer, Greenfield Shider, William Coughlin, William Mook, James Clemens, M. A. Bliss, and Charles Klenk for reading certain chap- XI XII PREFACE. ters, or for other help extended, and to many other physicians and dentists for the opportunity of studying interesting cases. The illustrations have, with the exception of bone lesions, been almost entirely confined to special anatomy, deformities, and technique. These have been made directly from bones, dissections, or from patients. For permission to reproduce certain anatomical plates from Spalteholz, Hand Atlas of Anatomy, the author is indebted to J. B. Lippincott and Company. Most of the skiagrams presented were made by Dr. R. D. Carman or by Dr. F. B. Hall. VILRAY PAPIN BLAIR. St. Louis, October, 1912. CONTENTS. CHAPTER I. PAGE Physical Examination — Anatomical Consideration 1-27 Examination — Mouth Cavity — Floor of the Mouth — Tongue — Palate — Fauces and Pharynx — Teeth — Gums — Vestibule of the Mouth — Lips — Temporomandibular Joint — Jaws — Muscles of Mastication — Salivary Glands — Lymph Nodes. CHAPTER IL Inflammations, Infections, Tumors, Cysts 28-41 Inflammation — Infections — Suppuration — Treatment of Infections and Inflammations — Method of Preparing and Administering Auto- genous Vaccines — Tumors and Cysts. CHAPTER III. Preparation of the Hands, Operative Field, Instruments, and Dress- ings 42-45 Preparation of the Surgeon's Hands — Preparation of the Operative Field — Sterilization of Instruments — Sterilization of Rubber Gloves — Sterilization of Cloths, Dressings, Etc. — Sterilization of Sutures. CHAPTER IV. Hemorrhage. Shock, and Allied Complications 46-64 Hemorrhage — Saline Transfusion — Blood Transfusion — Shock — Air Embolism — Postoperative Pneumonia — Edema of the Lungs — Sup- pression of Urine — Acetonuria. CHAPTER V. Wounds and In.turies of the Soft Parts 65-82 Wounds — Burns — Sutures — Dressings. CHAPTER VI. Injuries of the Teeth and Alveolar Process 83-85 Mechanical Abrasion of the Teeth — Loosening or Avulsion of the Teeth — Fracture of the Teeth — Fracture of the Alveolar Process. XIII XIV CONTENTS. CHAPTER VII. PAGE Fractures of the Upper Jaw 86-92 Character of the Injury — Treatment. CHAPTER VIII. Fractures of the Lo^\'^R Jaw 93-130 Character of the Injury — Treatment — Feeding During the Treat- ment of a Fracture of the Jaw. CHAPTER IX. Treatment of Individual Fractures 131-145 Fractures Without Loss of Substance — Time Required for Union — Delayed Union — Malunion — Gunshot Fractures of the Jaw-Bones. CHAPTER X. Dislocation of the Lower Jaw 146-152 Kinds of Dislocations — Treatment — Unreduced Dislocations — Chronic Dislocations — Subluxation. CHAPTER XI. Congenital Facial Clefts 153-169 Morphology — Relation of the Alveolar Cleft to the Teeth — Clinical Types of Congenital Clefts — Theories of Failure of Cleft Closure — Congenital Lip Pits. CHAPTER XII. Concenital Palate Clefts — Principles of Repair by Plastic Flaps . 170-178 Anatomical Considerations — Flaps made from Palate Tissues — Flaps made from other than Palate Tissues. CHAPTER XIII. Congenital Clefts of the Palate and Lip — Preferable Age at which to Operaje 179-181 Consideration of Various Ages — Advantages of Very Early Operation. CONTENTS. XV CHAPTER XIV. PAGE Congenital Palate and Lip Clefts — Operations in Early Infancy . 182-197 Preparation for Operation — Brophy Operation — Lane Operation — Choice of Operation — After-treatment — Mortality. CHAPTER XV. Congenital Palate Clefts — Plastic Operations in Ordinary Cases After Early Infancy 198-216 Preparation for Operation — Position and Light — Instruments and Materials — Flap Sliding Operation — Retention Devices — After-treat- ment — Postoperative Hemorrhage — Non-union — Reoperation — Mortal- ity — Results. CHAPTER XVI. Congenital Palate Clefts — Operations for Extraordinary Cases . 217-226 Kiister's Operation — Two-step Operations — Approximation of the Maxillae — Repair by Flaps from Other than Palate Sources. CHAPTER XVII. Congenital Clefts of the Lip and Alveolar Process — Operative Cor- rection 227-241 Correction of Alveolar Clefts in Infants — Correction of Single Alve- olar Clefts at Later Periods — Correction of Double Alveolar Clefts at Later Periods — Correction of Harelip — ^Rose Operation — Owen Operation — Operation for Double Harelip — Correction of Deformity of the Nostril and Nose — DifBcult Respiration After a Lip Operation — After-treatment — Results. CHAPTER XVIII. Obturators, Artificial Vela, and Speech Training 242-247 Physiological Action of the Muscle Concerned — Obturators and Arti- ficial Vela — "Cleft Palate" Speech — Speech Training — Postpharyngeal Injection of Paraffin — Obturators Versus Operation. CHAPTER XIX. Repair of Acquired Defects in the Lips, Cheeks, and Palate . . 248-278 Varieties of Grafts— Transplantation of Skin- or Mucus-covered Flaps — Closure of Defects at the Angle of the Mouth and Cheek — Restoration of the Lower Lip — Bone Grafts — Deep Scars on the Face — Restoration of the Upper Lip — Perforations of the Palate — After-treatment. XVI CONTENTS. CHAPTER XX. PAGE Ideal Occlusion and Malocclusion of the Teeth — Irregularities in THE Growth and Relation of the Jaws . . . . . . . 279-287 Ideal Occlusion — Malocclusion — Causes of Irregular -Setting of Teeth — Malrelation of the Dental Arches and of the Jaws — Orthodontia in the Treatment of Malrelations of the Jaws — Indications for Surgical Operation. CHAPTER XXL ? Treatment of Deformities and Malrelations of the Jaws . . . 288-312 Deformities of the Maxillae: Osseous Obstruction of the Nares — Re- traction of the Lower Jaw — Operation for Retraction of the I^ower Jaw — Obliquity of the Chin — Protrusion of the Lower Jaw — Irans- mucoperiosteal Operation for Protrusion of the Lower Jaw — Submu- coperiosteal Operation for Protrusion of the Lower Jaw — Babcock's Operation for Protrusion of the Lower Jaw — Open Bite— Operation for Open Bite — Atypical Deformities — Preoperative Considerations — After-treatment. CHAPTER XXII. Diseases of the Temporomandibular Joint — Limited Movement of the Jaw 313-327 Diseases of the Temporomandibular Joint — Hysterical Closure of the Jaws — Limitation Due to Reflex Irritation — Limitation of Move- ments Following War Injuries — Limitations Due to Scar Bands or Ankylosis — Operative Treatment of Oral Scar Bands — Operation by Flap Transplantation — Operations for Ankylosis of the Jaw CHAPTER XXIII. Fkactukks and Deformities of the External Nose . . . . . . 328-339 Treatment of Fractures of the Nose. CHAPTER XXIV. Extraction of Teeth 340-347 Removal of the Individual Teeth — Impacted Teeth. CHAPTER XXV. I.\FECTio.\s A.\D Inflammations of tiif Moittii 348-370 Stomatitis — Gangrene (Slough) — Noma (Cancrum Oris) — Specific Infections — Parasites of the Mouth. CONTENTS. XVII CHAPTER XXVI. PAGE Infections of the Teeth, Peridental Tissues and Maxillary Bones . 371-391 Alveolar Abscess — Diseases of the Gingivae and Peridental Mem- brane — Osteitis or Inflammation of the Bone — Necrosis — Specific In- fections of Bone — Atrophy — Hypertrophy — Tumors of Bone — Leon- tiasis Ossea. CHAPTER XXVII. Treatment of Infections of the Teeth, Peridental Membranes, and Maxillary Bones 392-408 Acute Alveolar Abscess — Chronic Alveolar Abscess — Necrosis — Chronic Bone Abscess — Acute Ulcerous Gingivitis — Gingivitis Caused by Deposits of Salivary Calculus — Gingivitis Caused by De- posits of Serumal Calculus — Gingivitis Due to Injuries — Chronic Suppurative Pericementitis — Specific Infections. CHAPTER XXVIIL Septic Infections of the Floor of the Mouth and Neck .... 409-417 Acute Adenitis — Acute Cellulitis— Chronic Adenitis — Chronic Cellu- litis — Treatment of Acute Adenitis — Treatment of Acute Cellulitis — Treatment of Chronic Adenitis — Treatment of Chronic Cellulitis — Phlegmonous Stomatitis — Abscess of the Tongue. CHAPTER XXIX. Diseases of the Maxillary Sinus 418-426 Antral Infection — Cysts of the Antrum^ — Tumors of the Antrum. CHAPTER XXX. Tumors of the Mouth and Jaw-Bones 427-453 Hypertrophy of the Gums — Mucous Cysts — Epulis — Lipoma — Fibroma — Chondroma — Osteoma — Myxoma — Odontoma — Supernum- erary Teeth — Dental Cysts — Sarcoma — Myeloma — Endothelioma — Multilocular Cystic Tumors — Carcinoma — Retromaxillary Tumors. CHAPTER XXXI. Excisions and Temporary Resections of the Jaw-Bones .... 454-467 Resections and Excisions of the Maxilla — Osteoplastic Resections — Resection and Excision of the Mandible — Prevention of Deformity. XVIII CONTENTS. CHAPTER XXXIT. PAGE Diseases ajs^d Tumors of the Lip 468-473 Injuries — Scars — Lip Cracks or Cliaps— Simple Hypertrophy— Macro- clieilia — Furuncle — Phlegmon — Gangrene — Herpes — Perleche — Tuber- culosis of the Lips— Syphilis — Cysts— Hemangioma — Endothelioma— Warts and Papillomata. CHAPTER XXXIII. Cancer of the Lip 474-483 Diagnosis — Treatment — Prognosis. CHAPTER XXXIV. Tumors and Cysts of the Floor of the Mouth 484-491 Obstruction Cysts of the Mucous Glands — Ranula — Dermoid Cysts — Benign Tumors — Malignant Tumors. CHAPTER XXXV. Affections of the Salivary Glands and Their Ducts 492-523 Inflammation of the Larger Ducts — Epidemic Parotitis — Acute Sup- purative Inflammation of the Submaxillary and Sublingual Glands in Young Infants — Secondary Infections and Septic Parotitis — Chronic Inflammation — Hypertrophy (Mikulicz's Disease) — Speciflc Infection of the Salivary Glands — Obstruction of the Ducts of the Salivary Glands — Cysts — Foreign Bodies and Stones in the Ducts and Glands — Wounds of the Salivary Glands and Ducts — Salivary Fis- tula — Tumors of the Salivary Glands. CHAPTER XXXVI. Congenital Affections and Inflammations of the Tongue . . . 524-536 Congenital Deformities — Nodules — Indentations — Fissures — Ulcers — Inflammations — Raw Tongue — Erythema Migrans Linguae — Chronic Superficial Glossitis— Glossodynia Exfoliativa — Tuberculosis of the Tongue — Syphilis of the Tongue. CHAPTER XXXVII. Tumors of the Tongue 537-550 Lymphangiomatous Macroglossia— Simple Muscular Macroglossia — Tumors of the Blood Vessels— Cartilaginous Tumors— Lipoma — Fibroma— Keloid— Tumors and Cysts of the Thyroglossal Tract— Papillomata, Warts— Sarcoma. CONTENTS. XIX CHAPTER XXXVIII. PAGE Cancer of the Tongue 551-592 Position — Etiology and Predisposition — Early Diagnosis — Responsi- bility of Medical Practitioners and Dentists in Regard to the Recog- nition of the Early Manifestations of Cancer — Early Types of Cancer — Early Clinical Characteristics — Clinical Stages of Carcinoma of the Tongue — Mid-period of Carcinoma of the Tongue — Pinal Stage of Carcinoma of the Tongue — Diagnosis — Differentiation between Oper- able and Non-operable Carcinomata — Prognosis of Carcinoma of the Tongue — Treatment of Carcinoma of the Tongue — Operation for the Removal of the Tongue — -Intraoral Operation — V-shaped Operation — Excision of One Half of the Body — Bilateral Excision — Resection of the Tongue at the Root — Kocher's Operation- — After-treatment. CHAPTER XXXIX. Tuberculous and Malignant Diseases of the Cervical Lymphatics . 593-605 Tuberculous Adentis — Secondary Carcinoma of the Cervical Lym- phatics. CHAPTER XL. Congenital Malformations, Injuries, and Diseases of the Pharynx . 606-618 Anatomical Considerations — Congenital Malformations of the Pharynx — Injuries of the Pharynx — Acute Infections — Adhesions of the Velum and Fauces and Pharyngeal Wall — Stricture of the Pharynx. CHAPTER XLI. Tumors of the Velum, Tonsils, and Pharynx 619-628 Teratomata — Benign Tumors — Palate Adenoma — Nasopharyngeal Polypus or Nasopharyngeal Fibroma — Retropharyngeal Goiter — Malignant Tumors of the Pharynx — Pharyngotomy. CHAPTER XLII. Ligation and Temporary Constriction of the Arteries 629-634 Coronary Arteries — Temporal Artery — Facial Artery — Lingual Artery — External Carotid Artery^ — Common Carotid Artery. CHAPTER XLIII. Motor Derangement 634-643 Paralytic Affections — Spasmodic Affections. XX • CONTENTS. CHAPTER XLIV. PAGE Tic Douloureux and Sphenopalatine Neuralgia 644-674 Fifth Cranial Nerve — Tic Douloureux: Major Neuralgia of the Fifth Cranial Nerve — Sphenopalatine Neuralgia — Treatment. CHAPTER XLV. Local Anesthesia 675-690 Means of Producing Local Anesthesia — Hypodermic Armamentarium — Technique of Injection — Local Anesthesia for Operations About the Mouth, CHAPTER XLVI. General Anesthesia 691-696 Chloroform — Ether — Intratracheal or Insufflation Anesthesia — Nitrous Oxid — Infiltration Anesthesia. APPENDIX. Appendix 697 ILLUSTRATIONS. FIGURE PAGE 1. Coronal section through the face 3 2. Muscular floor of the mouth 4 3. Sublingual mucous surface ... 5 4. Sublingual structures 6 5. Sagittal section through the face 8 6. Dorsum of the tongue 9 7. Submucous palate structures 13 8. Position of the teeth 15 9. Myocardiogram in air embolism 59 10. Blood pressure tracings in air embolism 60 11. Blood pressure tracings in air embolism 61 12. Blood pressure tracings in air embolism 61 13. Injury from shell fragment 67 14. Interrupted suture, defective 79 15. Interrupted suture, defective 79 16. Interrupted suture, effective 79 17. Eelation of suture to wound 79 18. Deep suture 79 19. Modified Lane suture 79 20. Figure-of-eight suture 79 21. Fracture of the maxilla 89 22. Fracture of the maxillae 91 23. Splint for comminuted fracture of the upper jaw 92 24. Direction of pull of the floor muscles 94 25. Diagram of horizontal displacement in fracture at first molar . 94 26. Diagram of horizontal displacement in double fracture at the cuspids 94 27. Diagram of horizontal displacement in fi-acture near the angle . 94 28. Diagram of the pull of the floor muscles 95 29. Diagram of vertical displacement in fracture in front of the canine 95 30. Diagram of vertical displacement in double fracture at the canine 95 31. Diagram of lack of vertical displacement in double fracture at the bicuspids 95 32. Diagram of the pull of the muscles of mastication 96 33. Diagram of vertical displacement in fracture behind the molars . 97 34. X-ray of fracture of the ramus 98 35. Angle fracture bands 100 36. Gilmer's method of wiring the teeth 100 37. Gilmer's wires in position 101 38. X-ray of silver wire passed around symphysis 103 39. Gilmer's wires protected by gum 104 XXI XXII ILLUSTRATIONS. FIGURE PAGE 40. Diagram of method of wiring the body of the jaw 105 41. X-ray of a wired fracture 106 42. Hammond splint 107 43. Splint for fracture and loss of bone in incisor region 108 44. Inclined plane of splint 108 45. Plaster cast in fracture of the jaw 109 46. Sawed plaster cast of the fractured jaw 109 47. Plaster cast reconstructed, in fracture of the jaw 109 48. 49. Two views of fractured mandible in malposition Ill 50. Guilford's articulator Ill 51. Face-bow in position in articulator 112 52. Model placed in articulator 112 53. Finished splint in place on model 113 54. Gunning splint 114 55. Metal gunning splint (Kelly-Supplee) for emergency fixation of fractures of the jaw bones 115 56. Impression tray converted into a Kingsley splint 115 57. Hullihan splint 116 58. Gilmer posterior band splint 116 59. Modified Gunning splint 117 60. Band and wire splint 118 61. Metallic band splint to bridge defect 119 62. Sectional metal jacket and wire splint 120 63. 64. Sectional vulcanite splints with jack-screws for slow separation of fragments 121 65. Swaged metal jacket splint with hooks and ligature wire . . . 121 66. Metal jacket splints with inclined planes 122 67. Sectional removable vulcanite prosthesis / . . . . 123 68. Permanent chin prosthesis 124 69. 70. Illustrations emphasizing the danger of dressing the mouth open 125 71. Induration surrounding fracture 127 72, 73. Improperly set fracture 132 74. X-ray of displacement of the ramus 133 75. Lower bar and saddle splint 133 76. X-ray of displacement of the ramus 134 77. Facial support 140 78. Facial support 141 79. Modified Barton bandage 144 80. Ligaments of the temporomandibular joint 147 81. Section through the temporomandibular joint 148 82. Head of a fetus in the fifth week 153 83. Head of a fetus in the seventh week 153 84. Schematic diagram of facial clefts 154 85. Diagram of oblique facial cleft 155 86. Oblique facial cleft 155 87. Diagram of ordinary harelip 156 88. Single harelip 156 89. Median harelip 156 90. Absence of the intermaxillary process 157 ILLUSTRATIONS. xxiil FIGUKE PAGE 91. Absence of the intermaxillary process 157 92. Diagram of macrostomia 158 93. Partial macrostomia 158 94. Macrostomia 158 95. Diagram of cleft of lower lip 159 96. Diagram of the palate in the sixth fetal week 159 97. Diagram of complete cleft palate 160 98a. Pendulous tooth in alveolar cleft 161 98b. Protruding tooth buds in alveolar cleft 161 99. Midline cleft 161 100. Incomplete double harelip "^ . . . 163 101. Complete double harelip 163 102. Skull with complete single palate cleft 164 103. Skull with incomplete double palate cleft 165 104. Incomplete harelip 168 105. Lip pits 169 106. Essential palate muscles 171 107. Diagram of double cleft of the palate 172 108. Diagram of single cleft of the palate 172 109. Diagram showing the velum detached from the palate .... 173 110. Intranasal palate flaps 174 111. Diagram of the efficiency of palate flaps 175 112. Diagram of cleft closed with the flap from the neck 177 113. Single complete cleft in an infant 180 114. Single complete cleft in an infant, repaired 180 115. Closure of the bony cleft in early infancy, first step 183 116. Closure of the bony cleft in early infancy, second step .... 184 117. Closure of the bony cleft in early infancy, third step 185 118. Closure of the bony cleft in early infancy, wires traversing the maxillae 186 119. Closure of the bony cleft in early infancy, completed operation . . 186 120. %-circle needle 186 121. Coronal section of an infant's face 187 122. Relation of an infant's jaws in cleft of the palate 188 123. Growth of the palate 188 124. Diagram of needle traversing the maxilla 189 125. Brophy palate needle 189 126. Diagram of crushing forceps applied to maxillae 190 127. Knife for cutting the maxilla 190 128. Cast of single cleft of the palate in an infant 191 129. Cast of single cleft of the palate in an infant, repaired .... 192 130. Diagram of mucoperiosteal flaps 192 131. Incision for Lane operation for a single palate cleft 192 132. Lane operation for a single palate cleft, completed 192 133. Lane operation for a velum cleft 193 134. Incisions for Lane operation for a cleft in the posterior part of the hard palate 193 135. Lane operation for a cleft in the posterior part of a hard palate, completed 193 136. Incision for Lane operation for a complete double palate cleft . . 194 XXIV ILLUSTRATIONS. FIGUEE PAGE 137. Lane operation for a complete double palate cleft, completed . . 194 138. Robert's modification of Hammond palate clamp 197 139. Diagram of the amount of tissue available for a palate flap . . 198 140. Lane gag 200 141. Owen's modification of Smith gag 201 142. Palate tenaculum constructed from artery forceps 202 143. Tonsil scissors 202 144. Brophy elevators 204 145. Bartlett elevator 204 146. Application of Bartlett elevator 205 147. Shepherd's crook needle 206 148. Insertion of the shepherd's crook needle 206 149. McCurdy's method of using the shepherd's crook needle, first step . 206 150. McCurdy's method of using the shepherd's crook needle, third step 207 151. Vertical mattress suture 207 152. Freeing the velum from hard palate 207 153. Paring the left border of a palate cleft 209 154. Paring the right border of a palate cleft 209 155. First insertion of the needle 211 156. Last insertion of the needle of the first suture of the palate cleft . 211 157. Vertical mattress suture in the mucoperiosteal flap 212 158. Vertical mattress suture in the velum 212 159. Suturing the velum ' 212 160. Suturing the mucoperiosteal flaps 212 161. Stay sutures in position 213 162. Lead plates in position 214 163. Incisions for modified Kiister operation 218 164. Modified Kiister operation, completed 218 165. Palate cleft of extraordinary width 219 166. Cleft narrowed by packing under flaps 219 167. Cast showing the lateral incisions in a wide cleft 220 168. Cast showing the lateral incisions in a wide cleft 220 169. Cast showing the result of operation on a wide cleft 220 170. Cast showing the defect resulting from sloughing at previous operations 221 171. Cast showing the operative results 221 172. Cast showing wide cleft with protruding intermaxillary process . . 222 173. Cast showing cleft narrowed, and intermaxillary process brought back by orthodontic apparatus 222 174. Cast showing final operative results 222 175. Incisions for repairing cleft with buccal fiaps 223 176. Cleft repaired with buccal flaps 223 177. Cast showing wide defect resulting from sloughing at previous operations 225 178. Cast showing wide defect repaired with neck flap 225 179. Permanent gag protecting the neck flap from the teeth .... 226 180. Scar resulting from turning a neck flap into the mouth .... 226 181. Displacement of alveolar process in a case of alveolar cleft . . . 227 182. Method of closing a wide alveolar cleft 228 183. Alveolar cleft closed by operation 228 ILLUSTRATIONS. xxv I'lGURE , PAGE 184. Line of incision for replacing intermaxillary process 229 185. Protruding intermaxillary process in a double harelip, with single alveolar cleft 230 186. Protrudng intermaxillary process in a double harelip, with com- plete double cleft at the palate 230 187. Retraction of the tip of the nose after the repair of the double harelip 230 188. Constriction of nostril after a harelip . 231 189. Temporary compression of blood vessels, while repairing a harelip 232 190. Incisions for a Rose operation for an incomplete lip cleft . . . 233 191. Incisions for a Rose operation for a complete single cleft . . . 233 192. Method of approximating the cleft borders for a suture, after a Rose operation 233 193. Incision for a Rose operation for incomplete double harelip . . . 233 194. Completed Rose operation for double harelip 233 195. Cast showing result of an unsuccessful harelip operation .... 234 196. Cast showing the result of operation after an unsuccessful harelip operation 234 197. Incisions for the Owen operation for single harelip 235 198. Suturing of the vertical cut in an Owen operation ...... 235 199. Suturing of the transverse cut in an Owen operation 235 200. Incisions for an operation for a complete double harelip .... 235 201. Completed operation for double harelip 235 202. Stay suture and lead plates, after a harelip operation .... 237 203. The cutting of a displaced nasal septum 238 204. Replaced nasal septum anchored to a bicuspid tooth 238 205. Replaced nasal bones anchored to a molar tooth 239 206. Breathing tube 240 207. Diagram showing closure of nasopharynx by the velum and superior pharyngeal constrictor 243 208. Nasopharynx open 243 209. Constrictor action of the superior pharyngeal constrictor . . . 244 210. Obturator for cleft of the velum 244 211. Obturator for cleft of the velum . 245 212. Nasal pharyngeal obturator to supplement a short velum . . . 245 213. Diagram of the seventh nerve 251 214. Transplantation of forehead flap with anterior temporal artery to fill defect of cheek 253 215. Showing defect with skin borders drawn by scar contraction . . 254 216. Transplantation of forehead flap to fill defect in cheek 254 217. Transplantation of forehead flap to fill defect in cheek 254 218. Neck flap sloughing 255 219. Incision for repaii'ing a cheek defect by sliding flaps 256 220. Repair of a cheek defect with a neck flap 257 221. Repair of a cheek defect with a neck flap, second step 257 222. Repair of a cheek defect with a neck flap 258 223. Serre operation for replacing the angle of the mouth 258 224. Result of a Burow-Stewart operation 259 225. Ability to elevate the upper lip after a Burow-Stewart operation . 260 226. Repair of defect of cheek with flap from neck 261 XXVI ILLUSTRyVTIONS. FIGURE PAGE 227. Burow-Stewart operation for restoring the lower lip 262 228. The V-shaped excision of a small lip tumor 262 229. Eesult of a V-shaped excision from the lip 262 230. Excision of half the lower lip in the corner of the month .... 262 231. Result of excision shown in the preceding figure 262 232. Excision of the corner of the month 263 233. Eesult after the excision shown in the preceding figure .... 263 234. Excision of the lower lip and chin to be repaired with neck flaps . 263 235. Result of the excision shown in the preceding figure 263 236. Diagrammatic representation of the right costal cartilage from which cartilaginous grafts may be obtained 265 237. Transplantation of bone to repair bony defect of jaw at chin, implanted piece of rib in position 268 238. Same as Fig. 237. Raising the flap at second operation .... 268 239. Same as Fig. 237. Flap is turned into place and the implanted bone ends are fastened to the freshened end of the jaw fragments 269 240. Lateral implantation of osteoplastic flap from clavicle 27 241. Lateral implantation of osteoplastic flap from the neck and clavicle 271 242. Method of grasping the jaw through the intact skin to draw it forward 272 243. Author's method of repairing defect due to scar tissue .... 275 244. Esser's method of repairing defect due to scar tissue 275 245. Restoration of the upper lip 276 246. An acquired defect of the palate 277 247. Repair of an acquired palate defect 277 248. X-ray of undeveloped lower jaw 279 249. Occlusion of the teeth, viewed from behind 280 250. Jaw deformity resulting from premature loss of the first molar tooth 281 251. Greek profile 282 252 Negro profile 282 253. Cast showing protrusion of the lower jaw 283 254. Skull showing retraction of the lower jaw 283 255. Diagram after Hunter, illustrating growth of the lower jaw . . 284 256. Casts of a case of an open bite 285 257. Photograph of a case of an open bite 285 258. Correction of retraction of the mandible by orthodontic appliance, Lischer 289 259. Correction of retraction of the mandible by orthodontic appliance, Lischer 290 260. Transverse section of the face, diagrammatic 291 261. Subcut&neous section of the ramus of the mandible 292 262. Needle for passing a wire saw around the ramus 292 263. Dilator for forceful opening of the mouth 292 264. X-ray showing the ramus cut and the body of the jaw moved for- ward 293 265. Lateral deviation of the chin 293 266. Lateral deviation of the chin, corrected 293 267. Jaw wired in position after section of the ramus 295 268. Obliquity of the chin 296 ILLUSTRATIONS. xxvil FIGURE , PAGE 269. Retracted mandible brought forward by operation 296 270. Retraction of the mandible, full face 297 271. Operative correction of retraction of the mandible, full face . . . 298 272. Retraction of the mandible, profile 299 273. Operative correction of retraction of the mandible, profile . . . 300 274. Cast showing protrusion of the lower jaw 301 275. Cast showing protrusion of the lower jaw 301 276. Cast showing protrusion of the lower jaw, corrected by operation 301 277. Protrusion of the lower jaw, correction by orthodontic appliance, Lischer 302 278. Protrusion of the lower jaw, correction by orthodontic appliance, Lischer 303 279. Bone cuts for resection of the lower jaw for the correction of protrusion 304 280. Reconstruction of the lower jaw after resection 304 281. Double-bladed saw 305 282. Submucous resection of the lower jaw 307 283. Modified Angle splint for resected lower jaw 308 284. Modified Angle splint, adjusted after resection of the jaw . . ,. 308 285. Fixation of the jaw by wires, after resection 309 286. Correction of open bite by simple section of the body of the jaw . 309 287. Open bite corrected by V-shaped excision of the body of the jaw . 311 288. Open bite corrected by an S-shaped section in the body of the jaw 311 289. Wooden dilator for stretching scar bands 316 290. Apparatus for gradual separation of jaws in trismus . . ... . 316 291. Ankylosis with retraction of the chin 317 292. Pneumatic dilator for fibrous ankylosis 318 393. Showing inability to open mouth after extensive removal of car- cinoma, and correction of defect 319 294. X-ray showing normal mandibular joints 320 295. X-ray showing ankylosis of the temporomandibular joints . . . 321 296. Skin incision for resection of the joint 323 297. X-ray showing resection of the joint 323 298. Natural limit of opening in a case of ankylosis 321 299. Limit of opening immediately after reconstruction of the joint . . 324 300. Mouth blocked open after reconstruction of the joint 324 301. Final opening obtained after reconstruction of the joint .... 324 302. Opening temporarily obtained after section of the ramus .... 324 303. Ankylosis with retraction of the chin 325 304. Operative result in a case of ankylosis 326 305. Reconstruction of the temporomandibular joint 327 306. Nasal bridge supported from the teeth 329 307. Showing deformity of nose from blow received, and result of correction 330 308a. Diagrammatic representation of the right costal cartilage from which cartilaginous grafts are obtained 331 308b. Depressed bridge elevated by cartilage transplant 331 309. Deformity of the nose from injury, showing result of correction . 332 310. Too prominent bridge, showing the result of correction .... 333 311-313. Technique of constructing nose when totally absent . . . 336 xxviil ILLUSTRATIONS. FIGURE PAGE 314. Upper incisor and bicuspid forceps 341 315. Right and left upper molar forceps 341 316. Bayonet root forceps 341 317. Hawk-bill forceps for lower anterior teeth 841 318. Hawk-bill lower molar forceps 341 319. Universal forceps • • • 341 320. Slender root forceps 341 321. Root elevators 341 322. Root elevator 342 323. Elevator for removing impacted lower third molars 342 324. Impacted upper third molar 346 325. Noma 356 326. Route for infection at apex of root via pulp canal 374 327. Route for infection and detachment of peridental membrane along side of root 374 328. Acute abscess penetrating periosteum 375 329. Acute abscess lifting periosteum 375 330. 331. Plaster models of case of chronic abscess with a sinus . . . 377 332. Radiograph showing a chronic alveolar abscess at the root of upper lateral incisor 378 333. Radiograph showing two blind alveolar abscesses 378 334. Showing destruction of lower jaw-bone by chronic alveolar abscess 379 335. Gum and bone destruction due to tartar deposit without pocket formation 380 336. Deposit of serumal calculus under the free gingiva 380 337. Bone absorption resulting from pyorrhea alveolaris 381 338. Radiogi'aph showing extensive destruction of the bone and alveolar process in a case of chronic suppurative pericementitis .... 382 339. Explorers for measuring the depth of pus pockets 383 340. Infection around unerupted teeth 384 341. X-ray of chronic bone abscess 385 342. Inflammatory destruction of bone 387 343. Necrosis of the jaw-bone 387 344. Acquired perforation of the palate 389 345. Leontiasis ossea 390 346. Rubber drain 393 347. Steel probe 395 348. Unerupted third molar 396 349. Diagram of bone abscess 400 350. Diagram of the treatment of bone abscess 400 351. Result of gum amputation for the cure of a pocket on buccal surface of the anterior root of first lower molar 405 352. Amputation of the distal root of a lower first molar 405 353. Operation for elimination of pus pockets 406 354. Submaxillary incision for induration of the floor of the mouth . . 413 355. Submaxillary incision completed 414 356. Submaxillary incision completed 415 357. Result' of operation 416 358. Drilling the antrum 421 359. Self-retaining temporary drain in antrum 421 ILLUSTRATIONS. xxix FIGURE PAGE 360. Denker operation 424 361. Denker operation 425 362. Calcified antral cyst 426 363. Hypertrophy of the gums 427 364. Epulis 428 365. Osteoma 430 366. Ossicles from jaw tumor 431 367. Follicular odontoma 432 368. Cementoma 432 369. Cementoma . 432 370. Composite odontoma 432 371. Inflammatory cyst of the jaw 433 372. Bone cyst 433 373. Supernumerary teeth 434 374. Cystic adamantinoma 440 375. Cystic adamantinoma 440 376. Excision of the upper alveolar process 455 377. Kocher incision for excision of the maxilla 458 378. Total excision of the maxilla . 458 379. Ostoplastic resection of the maxilla 458 380. Excision of the lower alveolar process 462 381. Occlusion, after excision of one half of the mandible 464 382. Scar band limiting the opening of the mouth 464 383. Result obtained by releasing the scar band 464 384. Marten splint 464 385. Buried silver splint 465 386. Scar resulting from noma 469 387. Lymphangioma of the face 473 388. Lymphangioma of the face, result of the treatment 473 389. Inoperable cancer of the mouth 477 390. Submental incision for cancer of the lip 479 391. Lymphatic excision in the upper part of the neck 480 392. Diagram of location of sublingual dermoids 488 393. Operation for sublingual cyst 489 394. Exposure of the parotid gland 495 395. Bilateral parotid abscess following operation for suppurative ap- pendicitis 495 396. Packing in place after exposure of parotid gland 496 397. Showing extent of wound after removal of first packing .... 496 398. Symmetrical action of the facial muscles 496 399. Inconspicuous scar one year after exposure of parotid gland . . 496 400. Congenital fistula of the parotid duct restored by construction of a new duct from the skin and mucous lining of the cheek . . . 498 401. Relations of the parotid duct 512 402. Excision of the parotid gland, first step 519 403. Excision of the parotid gland, second step 520 404. Excision of the parotid gland, completed 521 405. Scar from suppurating thyroglossal fistula 546 406. Thyroglossal fistula 547 407. Operation for invading the retrohyoid region 548 XXX ILLUSTRATIONS. FIGURE PAGE 408. Lymphatics of the tongue 561 409. V-shaped excision from the tongue 582 410. Excision of one half of the tongue from within the mouth, third step 583 411. Excision of one half of the tongue from within the mouth, fourth step 584 412. Diagrammatic coronal section of the tongue 585 413. Excision of one half of the tongue within the mouth, completed . 586 414. Excision of the deep cervical lymphatics 599 415. Paralysis of the lower lip following the submaxillary operation . 602 416. Branchial fistula of first cleft 608 417. Branchial fistula of the second cleft 608 418. Incision into the anterior faucial pillar 617 419. Anastomosis of the facial nerves 640 420. Injection of the facial nerve 642 421. Anomalous distribution of the first division of the fifth nerve . . 646 422. Anomalous distribution of the first division of the fifth nerve . . 646 428. Pain spots in tic douloureux 646 424. Pain spots in tic douloureux 646 425. Pain spots in tic douloureux 647 426. Radiation of pain in tic douloureux 647 427. Needle for deep injections 653 428. Injection of the mandibular nerve 655 429. Position of the patient during injection 656 430. Course of the needle during injection of the second and third division 657 431. Osteoporosis of the skull 658 432. Osteoporosis of the orbit 661 433. Injection of the first division of the fifth nerve 662 434. Anesthesia after injecting the second division of the fifth nerve . 663 435. Anesthesia after injecting the second division of the fifth nerve . 663 436. Anesthesia after injecting the first and second divisions of the fifth nerve 664 437. Anesthesia after injecting the first and second divisions of the fifth nerve 664 438. Anesthesia after injecting the second and third divisions of the fifth nerve 665 439. Incision for approaching the posterior root of the Gasserian ganglion 665 440. Rubber head apron on standard 667 441. Rubber head apron in position 668 442. Incision for approaching the posterior root of the Gasserian ganglion 669 443. Avulsion of the posterior root of the Gasserian ganglion — Ex- posure of the dura 670 444. Avulsion of the posterior root of the Gasserian ganglion — Path traversed along the floor of the middle cerebral fossa .... 671 445. Avulsion of the posterior root of the Gasserian ganglion — Display of the middle meningeal artery 672 446. Avulsion of the posterior root of the Gasserian ganglion — Ligation of the middle meningeal artery 673 ILLUSTRATIONS. XXXI FIGURE • PAGE 447. Avulsion of the posterior root of the Gasserian ganglion — Display of the root and the ganglion 674 448. Porcelain dissolving cups 679 449. Glass measure for local anesthetics 680 450. Hermetically sealed glass ampuls 681 451. Thoma sterilizer 682 452. Novocain armamentarium 683 453. Subperiosteal injection of a canine tooth — Prinz 685 454. Subperiosteal injection of a molar tooth — Prinz 685 455. Subperiosteal, peridental, and intraosseous injection of a canine tooth — Prinz 685 456. Peridental injection of a premolar tooth — Prinz 685 457. Perineurial injection of the upper teeth — Prinz 687 458. Rupert apparatus for administration of ether vapor spray . . . 692 459. Richardson apparatus for intratracheal anesthesia 693 460. Armamentarium for infiltration anesthesia 694 CHAPTER I. PHYSICAL EXAMINATION— ANATOMICAL CONSIDERATIONS. During the physical examination, at least mental note must be made of the condition of all the essential and correlated structures of the mouth. EXAMINATION. The adult to be examined should, if possible, be placed in a sitting posture. The light, which may be direct or reflected from a head mirror, should be good. To inspect the posterior part of the tongue or the nasopharynx, a head mirror and laryngoscopic or rhinoscopic mirror are necessary. One of the latter may also be used in place of a dental mirror. A comfortably fitting, broad tongue depressor is pref- erable to the handle of a spoon. Cocain^ may be necessary to satis- factorily conduct certain details. If there is an overhanging mustache, it should be brushed or held well out of the way. The. hands of the surgeon should be well washed, either in the presence of the patient or in an adjoining room, and the odor of tobacco, especially in examining women, should be entirely eliminated. It is sometimes almost impossible to make a satisfactory examina- tion of a struggling child, but patience and kindness will be successful in nearly every case. As a rule, children resist because they are fright- ened, and it is better to spend a little time in making friends than to risk prolonging strained relations by a forced examination. If the examination or treatment must be done forcibly^ it is best accomplished by seating the child upon the nurse's lap, with its body well against her. With one hand pressed on the, forehead,, she holds the child's head against her shoulder or forehead; withtlje other arm she controls its arms and body. Infants are best examined lying on the back on the nurse's lap, with the feet toward her body and the head hanging between her knees, with the face toward the surgeon and the light. The arms may be swathed to the body by a large towel or sheet, but if this is done, it should be done effectually. A history should be obtained, not only of the affection for which relief is sought, but also the hereditary and personal history of any and '^The word cocain Is used here as the generic term for local anesthetics of this class. 2 SURGERY OF THE MOUTH AND JAWS. all conditions that may bear upon it. It should always be borne in mind that the mouth is an integral part of the body, that it may show local expressions of general diseases, and that local diseases are apt to have more or less effect on the whole organism. If a rash is present, its character and distribution should be studied, and its possible relationship to a local irritation or a general disease considered. A sinus should be recognized and its cause determined. In examining an ulcer, the surgeon should determine the character of its base, its edge and its discharge, the presence or absence of pain, the condition of the surrounding tissue, local and distant ; their number and position should be noted, and their cause sought. An ulcer is a process of disintegration which is more intelligible to us than are formative changes. Sometimes the cause of the ulceration is as evi- dent as the ulcer itself. With ulcers of uncertain character, a diag- nosis is often facilitated by a microscopic examination of the discharge or scrapings made from the ulcer, or preferably from a piece removed from the edge and base. The character of a tumor or a swelling can usually be more or less accurately diagnosed by following the scheme planned by Pierce Gould, which includes attention to the following points : its position, the de- termination of the structure in which located, its manner of onset, its physical characteristics, its life history, its mode of growth, presence or absence of pain, its evidence of infectivity — local and distant, the effect of the growth on the general condition of the patient, and when necessary, a laboratory examination of its tissues or its aspirated contents. Microscopic and macroscopic examination should be made of patho- logic discharges, while bacteriologic cultures will often shed further light. Pain may result from local or distant causes. A carious tooth may cause pain at its site, or a neuralgia in the ear or in some distant point. Tenderness on pressure is always due to a local lesion. Referred pain, induced by pressure, may be due to impulses transmitted through nerves. Touching the cheek may start a paroxysm of tic douloureux at some other point. The pressure itself may be transmitted to a dis- tant site. Pressing on the angles of the jaw will cause pain at the site of a fractured symphysis. MOUTH CAVITY. The mouth is a part of the face. The latter consists of a series of bony partitions, covered with soft structures, attached to the fore part of the under surface of the brain case. These partitions inclose spaces that contain either air or special organs. The mouth is most inferiorly ANATOMICAL CONSIDERATIONS. 3 situated of these facial spaces, is the beginning of the ahmentary canal, and an accessory air passage. With its contents, it is the organ of mastication, taste, and articulate speech (Fig. 1). The teeth and gums separate the mouth cavity proper from an outer space, which is called the vestibule. The palate, which is bony in its anterior five eighths, forms the roof of the mouth, from which it separates the nasal fossae and the nasal Obliquus superior muscle Levator palpebrse superioris muse Rectus superior muscle ... Eyeball Superior lacrymal gland. Rectus Internus muscle Rectus externus muscle Rectus inferior muscle, Obliquus inferior muscle Buccal fat Masseter muscle... . Palatina major artery. . Palatine gland . Buccinator muscle Gingiva Platysma muscle Geniohyoglossus mu&tle Mandible.. . Geniohyoid muscle Mylohyoid muscle Digastric muscle Frontal sinus. Probe in the infundibulum. Middle turbinated bone. Uncinate process. Middle nasal meatus. Mouth of the maxil- lary antrum. Nasal septum. .Inferior nasal meatus. Inferior turbinated bona Maxillary antrum. ...Palatine process of the maxilla. Alveolar process. Cavity of the mouth. Vestibule of the mouth. Tongue. Ranine artery. Plica sublingualis. .Submaxillary duct. . ..Lingual nerve. Sublingual gland. "_ Platysma muscle. Fig. 1. Coronal section through the face. — From Spalteholz. pharynx, and in some instances, from one or both of the maxillary sinuses. Anteriorly and laterally the cavity is bounded by the alveolar pro- cesses and teeth of the upper jaw, and by the teeth, alveolar processes, and body of the lower jaw. Posteriorly it communicates, by the wide space between the fauces, with the shallow oral pharynx, which pos- teriorly rests on the bodies of the cervical vertebrae. 4 SURGERY OF THE MOUTH AND JAWS. FLOOR OF THE MOUTH. The floor of the mouth consists really of a muscular plane, which separates the mouth and its contained structures from the neck below. For convenience, however, the structures lying along its upper surface are spoken of as being in the floor of the mouth, and all of these, with their intraoral mucous covering, are referred to as the floor of the mouth. The muscular floor is formed by geniohyoid muscles and the un- paired mylohyoid muscle, which stretches between two concentric bony arches from the concavity of the body of the mandible to the convexity of the body of the hyoid bone. Behind this, within the concavity of the hyoid bone, the air and food passages proceed downward from the oral .Coronoid process Ramus of tbe lower jaw ( small cornu Hyoid bone -, , I large cornu. Mylohyoid muscle. Geniohyoid muscle. Fig. 2. Muscles that form the floor of the mouth stretching between the concavity of the body of the mandible and the convexity of the hyoid bone. — From Spalteholz. pharynx into the neck. The lateral walls and most of the roof of the mouth are of unyielding tissue, and when closed, it is through the muscular floor that adjustment of capacity is accomplished (Fig. 3). Except through a central vertical septum composed of the genio- hyoglossi muscles, nowhere is the tongue in contact with the muscular floor. This is best illustrated by referring to coronal and sagittal sec- tions of the mouth (Fig. 1). The space between the body of the tongue and the muscular floor is divided into two lateral compartments by this muscular septum. Each of these subspaces is bounded below by the muscular floor, externally by the body of the mandible, medially by the geniohyoglossi and geniohyoid muscles, and above by the reflec- tion of the mucous membrane upon which the body of the tongue rests. In these compartments are the structures that are spoken of as being in the floor. Anteriorly these spaces are limited by the mental portion of ANATOMICAL CONSIDERATIONS. 5 the mandible, while posteriorly, between the root of the tongue and the angle of the jaw, they open freely into the intermuscular connective tissue spaces of the neck. It is these posterior intermuscular spaces that afford entrance and exit to the vessels, nerves, and ducts that are found in the floor. Within the floor of the mouth are contained the lingual vein, lingual nerve, and submaxillary duct. The lingual artery lies buried in the under surface of the tongue. Within the floor of the mouth and in the under surface of the tongue are several excretory glands, mucous and salivary. Labial commis- sure Fig. 3. Mucous reflections under the anterior of the tongue. — Prom Spalteholz. Glands of Nuhn and Blandin. — Blandin first described a gland lying on the under surface of the tongue, near the tip, on either side of the midline, about the size of an ordinary almond. Each gland has one or two excretory ducts opening on the under surface of the tongue. Cysts, stones, and tumors occur in connection with these glands. Incisive Glands. — Besides the glands of Nuhn and Blandin, Suzanne and Merkel have described a group of glands on either side, lying in front of the salivary caruncle and just behind the periosteum of the jaw. Tillau and Fleischniann describe an inconstant sublingual bursa on either side between the geniohyoglossi muscles and the mucous mem- brane lying between the frenum and the sublingual gland. This has 6 SURGERY OF THE MOUTH AND JAWS. been credited as the cause of acute ranula. Merkel and others have denied the existence of this bursa. Bochdalek's Glands. — Bochdalek's glands are certain remnants containing ciliated epithelium supposed to be derived from the thyro- glossal tract, which is often called the thyroglossal duct. Chronic ob- struction of the excretory duct of an incisive, a Bochdalek, or a sub- lingual salivary gland causes a cyst known as ranula. The sublingual salivary glands consist of lobules lying on the floor of the mouth beneath the submaxillary duct. The submaxillary sali- vary gland lies mostly outside of the mouth, beneath the mylohyoid muscle. Part of the gland, however, containing the common excre- tory duct, bends around the posterior border of this muscle, and comes Apex of the tongue Gland of Nuhn and Blandin Styloglossus muscle Geniohyoglossus muscle Sublingualis muscle Gland of Nuhn and Blandin. -J^-i- Lingual vein. 4^ _y_ Lingual nerve. Ranine artery. Sublingual gland — Submaxillary duct Great sublingual duct- Sublingual caruncle Fig. 4. Structures lying beneath and within the anterior part of the tongue. — After Spalteholz. to lie above the muscle within the floor. The duct is continued along the upper surface of the mylohyoid muscle and sublingual gland. On either side of the junction of the frenum of the tongue with the floor is a small papilla, on which may be seen the openings of the sub- maxillary ducts. Running backward from this, at the bottom of the sulcus, are two elevated ridges of mucous membrane, under which lie the sublingual glands, and through the crest of which the sublingual ducts open (Figs. 3 and 4). These ridges, the plicje sublingualis, also mark the course of the ducts of the submaxillary glands, the lingual nerve, and the lingual vein, which lie along the floor of the mouth to the median side of the sublingual gland. The lingual nerve enters the floor of the mouth from above, just to the inner side of the body of the mandible, and can be felt by pressing the tip of the finger against the bone below the last molar tooth. ANATOMICAL CONSIDERATIONS. 7 With one finger in the sulcus and two fingers of the other hand thrust under the jaw from without, the sublingual gland in front, and the submaxillary gland, posteriorly, can be distinctly outlined, unless there is too much fat. In the normal condition the submaxillary duct cannot be felt, but a stone in the duct, or the thickening around it, can always be detected. In carrying on this examination of the floor, the mouth should be moderately open, with the head bent slightly forward, to re- lax the muscles of the floor and the platysma. The fingers of one hand should steady the structures while they are being palpated by the other. In examining for stone in the duct, it is possible to pass a probe into the duct from the opening in the papilla. The connective tissue in the floor of the mouth is very lax. In certain inflammatory conditions it may become rapidly infiltrated with serum until the mucous membrane is raised up in a roll above the level of the gums, and the tongue is pushed before it. TONGUE. The tongue in the normal state of rest is entirely within the mouth. The body occupies the upper portion of the cavity, and the dorsal sur- face presents an antero-posterior convexity that approximates a half circle. When the mouth is opened, the body follows the movements of the lower jaw (Fig. 5). It is anchored, by relatively small mus- cular attachments, posteriorly to the body of the hyoid bone and an- teriorly to the symphysis of the mandible. Its mucous reflections and some extrinsic muscles further limit its excursion and determine its shape. Nowhere is it attached or supported by ligaments. The mobil- ity of the tongue is further augmented by the fact that the hyoid bone is, in turn, dependent for its position entirely on the muscles to which it furnishes attachment. Far back on the tongue, and best seen with a mouth mirror, is the sulcus terminalis, a scarcely visible V-shaped furrow on the dorsal sur- face. It runs from the attachment of the anterior faucial pillar, on either side, backward and toward the median line to the foramen cecum, which latter marks the upper termination of the thyroglossal duct or tract. Slightly in front of and parallel with the sulcus termi- nalis is a V-shaped row of large taste papillae, known as the circum- vallate. These, by their supply through the glossopharyngeal nerve, are related to the pharyngeal portion of the organ. That portion of the tongue behind the sulcus is called the root, and is- morphologically related to the pharynx ; while that in front is the body, and is derived from the primitive buccal cavity. The root of the tongue forms most of the anterior wall of the oral pharynx. The mucous covering of the pharyngeal surface continues on to the 8 SURGERY OF THE MOUTH AND JAWS. fauces and the lateral pharyngeal walls. Below it is reflected on to the front of the epiglottis and forms the middle glossoepiglottic fold. This part of the mucous membrane is much more sensitive to pain than that over the dorsum, and in examination, unless cocainized, should not be touched by the tongue depressor. The submucous tissue of this Upper lip Tongue...., Lower lip... Septum linguEe... _ Mandible... Genibliyoglossus muscle Geniohyoid muscle...' Mylohoid muscle Hyoid bone Laryngeal prominence. Thyroid cartilage.. Cricoid cartilage.. Sternohyoid muscle.. Isthmus of the thyroid. I !l< sternothyroid muscle i - ll\ Spprasternal space ^ Innominate vein _ I Body of the sternum --f^l Septum nasi. , Hard palate. -t- Sphenoidal sinus. • ' - Vault of the pharynx. ■■- Nasopharynx. . Pharyngeal opening t ^ of Eustachian tube. -.^-'■^V Palatine gland. ' "^^yt Soft palate. ^•-i - ...2d cervical vertebra. ... Foramen cecum. ..- ....Root of the tongue. +— ^B - —^ i^"-^ Thyroglossal duct. Oropharynx. 'f>~''t~' Epiglottis. ^l^ti- Laryngopharynx. .Upper aperture of '"'^SS *^® larynx. -. x-j! ..Vestibule of the larynx. .. Cricoid cartilage. ..Laryngeal cavity. .7th cervical vertebra. - 1st thoracic vertebra. Trachea. . _ ...Esophagus. ^ ■ - Innominate artery. m Fig. 5. Sagittal section through the midplane of the face. — After Spalteholz. part contains mucous glands and heaped-up lymph follicles, the latter constituting the lingual tonsil (Fig. 6). This, with the faucial and pharyngeal tonsils, makes a complete ring of adenoid tissue surround- ing the entrance of the pharynx. There are also mucous glands on the dorsal surface, and lateral borders in the neighborhood of the sulcus terminalis and circumvallate papillse, and any of them may give rise to a mucous cvst. Over the dorsum the mucous membrane is beset ANATOMICAL CONSIDERATIONS. 9 with taste papiHse. These give the tongue a rough appearance, which varies greatly under certain conditions. The mucous covering is reflected from the dorsum around the bor- ders to the inferior surface of the body, which latter it invests over the greater part of its extent. Thence the mucus passes to and across the floor to the gum and fauces, and while it forms part of the anchorage of the organ, this distribution permits of great freedom of movement and also of digital examination of the body and of the floor separately. Middle glossoepiglottlc fold .1 Vallecula Lateral glossoepiglot- tlc fold , Posterior pillar of f^B^W,& the fauces -y-lHHtM Tonsil -.Mam^'ryAf ,> 'fj *; Tonsillar sinus .iSM? '•M.'^ fl -/^. - ^b Plica triangularis ^..+ %. .l^-'i Anterior pillar of the ^^B ^''' fauces '^^^X<' Papillae lenticulares Papillae conicae.... - '^_ '/'- PapillEB fungiformes ' ' Papillae filiformes ; .Epiglottis Root of the tongue. ^ Lingual tonsil. Lingual follicles. *' ^ -^^ Foramen cecum. ...Sulcus terminalis. Papillae circumvallatae. ~ Papillae foliatae. Body of the tongue. - ...Upper surface of tongue. Raphe linguae. , Lateral margin of the tongue. Tip of the tongue. Fig. 6. Dorsum of the tongue. — After Spalteholz. On raising the tongue, it will be seen that the mucous membrane on the under surface is smooth in character, and that it is reflected to the bottom' of the glosso-alveolar sulcus in a double fold, with a free border anteriorly (Fig. 3). At the posterior limit of this fold the membrane forms the posterior limit of the glosso-alveolar sulcus by becoming continuous with the lower gum and anterior faucial pillar behind the last molar tooth. In the anterior portion of this fold the two layers of mucous membrane inclose but little connective tissue, while posteriorly they are separated by the interposition of the genio- hyoglossi muscles. Grasping this septum with the thumb and finger, 10 SURGERY OF THE MOUTH AND JAWS. the anterior border of the muscles car be felt. The anterior non- muscular portion of the septum is called the frenum. ' It may be ab- normally short from above downward, and its upper attachment may extend sufficiently forward to bind the tongue down in the sulcus. This condition is known as tongue-tie, and is rather rare. The oppo- site condition of too great laxity of the frenum has been reported to have caused death by suffocation by the tongue turning back into the pharynx. Two elevated fringes may be seen on the under surface of the tongue, converging at its tip. These indicate the positions of ranine arteries. About 12 millimeters on either side of the frenum may usually be seen the terminations of the ranine veins. These, with other veins in the sulcus, may become varicose, in which case a mass of large dark veins are seen under the mucous membrane, almost oblit- erating the fore part of the sulcus. They are soft and yielding to touch, but fill as soon as the pressure is removed. A dermoid cyst may be met with on the under surface of the tongue, usually in the midline between the two geniohyglossi muscles, and is probably due to an infolding of integument during development. Ac- cessory thyroids may occur above the mylohyoid muscle, and may be- come, the seat of a goiter. The surface in front of the circumvallate papillae is the least movable part of the body of the tongue, and is therefore more apt to be coated. Unilateral furring has been noted in connection with irritations of the fifth cranial nerve of the same side, but as Mr. Hutchinson states, unilateral furring in the presence of toothache may be due partly to the instinctive immobilization of the tongue on that side. We have repeatedly observed unilateral furring in tic douloureux. The mucous membrane of the tongue, like that of the mouth, is liable to a variety of superficial lesions. Aphthse may form upon the tip and edges, thrush may occur in infants and adults whose health is broken down, herpes is occasionally seen, and the ulcerative stomatitis may extend to it from the cheek or palate. In addition to these, how- ever, and to various kinds of specific diseases — such as syphilis and tuberculosis — the tongue is especially subject to certain forms of chronic inflammation. Some are superficial, and spread over the greater portion ; others are local, and end in deep ulceration. On the mucous surface of this part — or, in fact, over any part of the mouth — may develop one or more white sodden i)atclies of leucoplakia. or a ])a])i]l()ma or nevus may be present. The body of the tongue is composed almost entirely of intrinsic muscles. Between the two halves of the body is an incomplete fibrous septum corresponding to the median raphe. Butlin is inclined to re- ANATOMICAL CONSIDERATIONS. ' 11 gard this as analogous to certain fibrous or bony processes found in connection with the midplane of the tongue or body of the hyoid bone in certain lower animals. Occasionally fatty and cartilaginous masses have been found in connection with the median septum of the human tongue. It is a matter of clinical observation that cancer of one side of the body of the tongue is very slow to cross the median septum. Foreign bodies may become imbedded in the body of the tongue. It may be the seat of gummata and many other infections. Dermoid cysts, lipomata, and fibromata occur in its substance, but these benign growths are rare. It is a favorite seat of cancer, which often develops from a papilloma, leucoplakia, or any chronic irritation, but sarcoma of the tongue is very rare. Abscess of the tongue is not common, but it contains sufficient connective tissue to allow great swelling; and it is sometimes subject to a congenital enlargement known as macroglossia. Congenital deformities of the tongue are very rare, the commonest be- ing tongue-tie, or a median cleft of the body. The latter resembles that of some lower animal. The tongue is plentifully supplied with blood, chiefly from the lingual arteries, which run near its inferior surface and which have but scanty intercommunication. The lymphatics are especially large and numerous, and rapidly disseminate cancer cells. They drain from different areas into the submental, submaxillary, and superior and inferior deep cervical nodes. Special importance is attached to one superior deep cervical node sit- uated a little above the bifurcation of the common carotid artery, which, on account of the numerous streams that reach it, has been called the principal node of the tongue. The motor nerve supply of the tongue is mostly from the hypo- glossal. Injury to this nerve or its center, or pressure on the nerve at its foramen of exit or any other point, will cause paralysis and atrophy on the affected side. When protruded, the tongue deviates toward the paralyzed side. The tongue is well supplied with sensory nerves for both taste and common sensation. Tactile sensation is more acute on the tip than on any other part of the body. The sensory supply of the pharyngeal sur- face and the circumvallate papillje is through the glossopharyngeal nerve from fibers originally derived from the trifacial. This latter nerve supplies also the oral part of the organ directly through the lingual. The taste papillze on the tip, sides, and dorsum probably send their afferent fibers through the lingual and chorda tympani nerves. Painful affections of the tongue in the area supplied by the lingual nerve may be accompanied by severe neuralgia deep in the meatus of the ear through the connection of the fifth nerve with the seventh, or 12 SURGERY OF THE MOUTH AND JAWS. it may be over the terminal branches of the fifth. Spasmodic contrac- tures of the muscles of mastication may result from the same reflex irritation of the fifth. According to Dr. Head, irritation on the pharyn- geal surface may be associated with tender areas in the skin of the larynx. PALATE. The palate presents a median raphe, which ends anteriorly in the incisive papilla, which marks the opening of the anterior palatine fossa. In infants this papilla is connected with the frenulum of the lip. The raphe may be raised by a ridge of bone in the midline, the torus pala- tinus. Sometimes a small pit that will admit the point of a pin is seen on each side immediately behind the incisive papilla about 2 millimeters from the midline. These correspond to the lower openings of Stenson's canals. In the region of the junction of the hard and soft palates is usually seen on each side of the raphe a small pit, the foveola palatina, which contains the excretory ducts of several palate glands. The palate ridges are confined to the anterior part of the hard palate. The mucous membrane and periosteum of the hard palate are fused into a single layer, which is thickest at the edges and is rather insensi- tive. The vessels of the palate lie in its deeper portion, and the de- scending palatine arteries may be felt pulsating in the posterior part, close to the junction of the palate with the alveolus (Fig. 7). In the submucous tissue is a layer of mucous glands, which is thickest at the lateral border and at the junction of the hard and soft palates. Large mucous glands are found on both surfaces of the uvula. The soft palate, or velum, is composed of muscle and the palate aponeurosis. It is attached to the posterior border of the hard palate, and covered with mucous membrane on both surfaces. From the mid- dle of its posterior border hangs a fleshy mass, the uvula, which helps to close the space between the posterior faucial pillars during the act of swallowing, etc. It may be absent, bifurcated, or abnormally large. The anterior faucial pillars, arching from the under surface of the velum 1 centimeter in front of its free edge, near the base of the uvula, pass downward and slightly forward to join the tongue a little in front of the n-^iddle of its lateral border. These are made up of the palato- glossi muscles, covered by mucous membrane. The posterior pillars spring from the posterior border of the palate, and pass downward and slightly backward, to be lost in the lateral wall of the oral pharynx. They contain the palatopharyngei muscles. Be- tween the anterior and posterior pillars lie the faucial, or oral, tonsils. Just behind the last upper molar tooth is the prominence of the max- ANATOMICAL CONSIDERATIONS. 13 illary tubercle, and behind that may be felt the hamular process which surmounts the internal plate of the pterygoid process of the sphenoid bone. Over this hamular process plays the tendon of the tensor palati muscle. The upper surface of the hard palate can be partially examined through the nose with a sound or by inspection. As suggested by Kocher, after division of the columella and the nasal septum, this ex- amination may be made with the finger. The upper surface of the soft palate can be palpated from behind through the oral pharynx. Upper dental arch Hard palate. Palatine spine. Palatina major artery. Mouth of parotid duct. Tensor palati muscle. Hamular process. Mucous membrane of the mouth. ....Levator palati muscle. -f -.Buccopharyngeus muscle. Palatopharyngeus muscle. ..Azygos uvulae muscle. Palatoglossus muscle. ...Upper surface of tongue. Gingiva '' / Palatine glands.. »-- Buccinator muscle -V- Pterygomandibular ligament Tonsil _ Fauces ' f^ ' Lower dental arch... Fig. 7. Submucous structures of the palate and faucial pillars. — After Spalteholz. The arch of the palate varies in height, width, and shape. Marked variations are usually credited to, or associated with, early mouth breathing. The palate may show a congenital longitudinal cleft in a part or the whole of its length. It may show the scars resulting from the surgical repair of such a deformity, or defects due to injuries or distinctive ulceration. The velum or the fauces may be deformed by cicatricial contrac- tion and adhesions resulting from destructive inflammations. The palate is a favorite site for gummata and resulting syphilitic perfora- tions, and in some countries lupus and tuberculosis are not uncom- mon. Cysts and benign and malignant tumors are also found in the palate, and teratomata may be connected with it. 14 SURGERY OF THE MOUTH AND JAWS. FAUCES AND PHARYNX. When the patient breathes deeply through the mouth with the head thrown back, the soft palate is raised, the pillars are separated, and the uvula, tonsils, fauces, and walls of the oral pharynx are exposed. The arch of the atlas corresponds to the hard palate, and the body of the axis to the soft palate (Fig. 5). JDie upper four, in children the upper six, vertebral bodies can be e^^^^K with the finger. The pos- terior pharyngeal wall should rest fi^^^f ainst the bodies of the ver- tebrae, but may be separated from them by a postpharyngeal collection of pus. The examining finger can feel the circumvallate papillse, lingual tonsil, epiglottis,^^ytenoepiglottic folds, and smaller laryngeal car- tilages. Passi^^^K finger upward behind the velum, the vault of the nasophary^^^^Rterior part of the nasal septum and Eustachian cushions, and nWRlarged, the pharyngeal tonsil may be felt. In ex- amining a hypertrophied pharyngeal tonsil, the amount of enlargement may be gauged by observing the height to which it rises on the posterior border of the septum. This may be done with the finger or with the posterior nasal mirror. Cocain may be necessary to make such an ex- amination in the adult, but here the laryngoscope and posterior rhino- scopic mirror will reveal what is more readily felt in children. The palate, fauces, and oral pharynx in children are especially liable to injury from falling on sharp sticks. This may be followed by a con- dition of trismus, not necessarily tetanus, and requires an anesthetic to make a satisfactory examination. The lymphatics from the palate and upper part of the pharynx pass to the lateral pharyngeal and retro- pharyngeal and to the superior cervical nodes. Besides the acute and chronic catarrhs, the pharynx is subject to secondary tuberculous ulcers, mucous patches, snail-tracked ulcers of secondary syphilis, diffuse gummatous infiltration, and localized submucous gummata. Benign tumors and both primary and secondary malignant tumors are also found in the pharynx. The oral tonsils are situated between the anterior and posterior faucial pillars, and rest on the superior constrictor muscle of the pharynx. When enlarged, the tonsil may stand out freely from the pillars, or it may push the anterior pillar inward, in which case it is known as a buried tonsil. Often as much or more can be gained by palpating the tonsil as by inspection (Fig. 7). Besides the enlargement of the tonsil itself from acute or chronic inflammation, there may be infection and suppuration of the periton- sillar tissue, with diffuse swelling and induration of the surrounding parts. If such a collection of pus bursts through the pharyngeal ANATOMICAL CONSIDERATIONS. 15 wall, postpharyngeal suppuration will result. Chancre, secondary snail- tracked ulcers, and diffuse gummata are the syphilitic lesions most com- monly found. Fibroma, epithelioma, lymphosarcoma, and round-celled sarcoma are the tumors common to the tonsils. The lymphatics from the tonsils drain into the superior deep cervical nodes. An enlargement of one of these, situated just behind the angle of the jaw, is so constant in tonsillar infections that it has been called the tonsillar node. TEETH. The crowns of the teeth rise free in the mouth above the gum mar- gin. The anterior teeth have incisive edges, and are for biting off the food; while the posterior, the molars, are broad and have grinding surfaces. The teeth between these, the cuspids and bicuspids, are in- Ist, 2d and 3d upper molar Maxillary antrum. 1st and 2d upper bicuspid. Upper canine. ....Incisors. 1st and 2d lower bicuspid. Inferior dental canal 1st, 2d and 3d lower molar Mental foramen. Fig. 8. The occlusion of the teeth and their position in the jaw-bones. — After Spalteholz. termediate in character and function. Later in life, when the teeth are worn down, fairly good grinding surfaces are formed on the anterior teeth, which are very useful when the bicuspids and molars are lost. In most individuals the edges of the lower incisors are slightly over- lapped by those of the upper, which gives them a scissors action. The crowns of the upper central incisors are wider than the lower, with the result that every tooth in the lower jaw, with the exception of the cen- tral incisors, is in relation with two teeth in the upper, and every tooth in the upper jaw, except the last molar, is in relation with two in the lower. This relation is in such a way that any cusp of any tooth in the lower jaw is slightly in advance of the corresponding cusp of the same tooth above (Fig. 8). In the molar region the buccal cusps of 16 SURGERY OF THE MOUTH AND JAWS. the lower teeth rest in the grooves formed between the buccal and lingual cusps of the upper. Any variation from this arrangement in the child, especially if the variation is in the occlusion of the first molars, should be referred to the orthodontist for examination. The crowns of the teeth may be perfectly formed, or show the mal- formations resulting from early nutritional disturbances. Common among these is the Hutchinson tooth, which is best marked in the upper central incisors, and consists in a notching of the incisal edge and a globular shape to the crown. This has been supposed to be almost always caused by congenital syphilis. The crowns of the teeth may be of various sizes and shades of color, and the teeth may vary in form and number. They may be abnormally soft, and as a result of this in young people, or from continued use in older ones, the crowns may be worn away almost to their necks. The teeth may present all stages of caries from slight pits in the enamel to total destruction of the crowns and parts of the roots. In most instances the caries is evi- dent on ordinary inspection. A cavity may, however, be hidden on the interdental surface, or a very slight crack in the enamel may lead down to an extensive destruction of the dentin or to an open pulp cavity. Unless the patient is scrupulous in the care of his teeth, and even then in certain individuals, the teeth will show deposits of tartar. This consists mostly of the precipitated calcium salts of the saliva, and therefore the deposits will be greatest on the lingual surfaces of the lower incisors and canines and on the buccal surfaces of the upper molars, these being exposed to the salivary streams from the submax- illary, sublingual, and parotid glands. The nerves supplying the teeth are derived from the second and third divisions of the fifth nerve, the dental branches from which pass through bony canals in the substance of the maxilla and the mandible. They also receive fibers from the palatal, lingual, and buccal nerves. Caries or other irritations of the teeth, or direct irritation of the nerves in the bony canals, may cause reflex neuralgia along other distributions of the fifth nerve. It may also cause spasm of the muscles of mastica- tion. Spasm seems to be more commonly associated with irritation of the third division than of the second. In this regard, the condition of the tooth pulp — whether healthy, in- flamed, or dead — and the condition of the peridental membrane is often a matter of importance. The diagnosis of the conditions of a tooth depends on changes of color, sensitiveness or lack of sensitiveness to certain stimuli, includ- ing the electric current, heat and cold, variations in translucency, and percussion note produced when struck with a metal instrument. To interpret these accurately requires the experience and training that be- ANATOMICAL CONSIDERATIONS. it long essentially to the dentist. The most accurate' method of diagno- sing the condition of the pulp is by the use of the electric current as developed by Prinz.^ GUMS. The gums may be inspected and palpated throughout their entire extent. They are composed of a mucoperiosteum, which surmounts the alveolar processes of the jaws. This covering resembles the soft tissue of the hard palate, and contains large mucous glands. These are especially numerous near the necks of the teeth, and any of them may give origin to mucous cysts. It is continuous with the mucous covering of the lips and cheeks on the outer surface, and with that of the palate and floor of the mouth on the inner. Around each tooth the muco- fibrous tissue rises on the base of the crown, forming a collar which constitutes the gingival margin. P'or some distance from its occlusal edges, each tooth is in contact with the tooth on either side of it. Toward the neck the crown decreases in size, leaving the inter- dental spaces into which the gingiva extends, forming the interdental papilla. The periosteum descends into the alveolus as the peridental membrane, which performs its double role of covering the root and lin- ing the socket. The peridental membrane is of such consistency that, while it holds the teeth sufficiently firm for function, they are not perfectly rigid in their sockets, and an inflammation of this membrane will cause the teeth to rise and become abnormally loose. Salivary calculus, which collects around the necks of the teeth, is one of the causes of chronic irritation of the gingiva, and brings about the recession of the gums so commonly seen. This irritation may open an avenue of infection to the peridental membrane, in which case pus may be seen exuding from between the socket and root, and the teeth may become permanently loosened and lost. When advanced, this con- dition is called pyorrhea alveolaris, and is to be distinguished from an abscess in connection with the root, which discharges between the tooth and the soft tissue. Certain mineral poisons also predispose the gingiva to ulcerative inflammation, among which are mercury, phosphorus, and bismuth, while lead produces the characteristic blue line running along the gingival edge. After an unchecked caries has attacked the dentin of the crown, it is apt to open into the pulp chamber, which is continuous with the root canal. This later opens through the apical foramen into the apical con- nective tissue space of the alveolus, creating an open avenue of infec- tion from the pulp chamber to the peridental tissue, which may result in any degree of inflammation or suppuration. 2 Prinz, Dental Materia Medica, page 585. 18 SURGERY OF THE MOUTH AND JAWS. If properly treated by the dentist, such an abscess may sometimes be made to discharge through the root canal, but if neglected, it seeks the surface by one or two routes. In the incisor region it may occa- sionally discharge at the side of the root, so that the pus will be seen welling up around the neck. In all cases it will most likely perforate the alveolar process, and give rise to a subperiosteal abscess, which occasionally points toward the mouth, but generally toward the buccal cavity. In the upper jaw such an abscess, having perforated the bone, may burrow under the mucous membrane of or perforate into the max- illary sinus. Such abscesses are generally accompanied by consider- able swelling of the face and marked constitutional disturbance. The acute pain is, for a time at least, relieved when the pus finds egress from the alveolus. If the perforation is from the abscess surrounding the root of a tooth that has but a single root, as an incisor, it will almost always be on the labial surface of the alveolar process. In the case of a lower molar — which has two roots, one in front of the other — the perforation may be on either surface, usually the buccal. The first and second upper molars, however, have each three roots, one large one on the palate side and two smaller ones situated buccally. Infection from the tooth may travel through any of these roots, and therefore the perfora- tion of such an abscess may be into the antrum or on the palate, or the buccal surface. In any event, the resulting abscess may be present at the time of the examination, or a sinus may lead down to a piece of dead bone or root, or to a chronic bone abscess. In the lower jaw the dissecting up of the periosteum by pus is apt to be followed by extensive necrosis of the bone, but in the upper jaw caries or absorption abscess is more common. The presence of areas of necrotic bone may be verified by feeling with an ordinary probe, but caries is best detected by thrusting a sharp steel Gilmer probe through the gum tissue into the soft insensitive bone, or by use of the x-ray. Though the mucous covering of the gum is relatively rather insensi- tive, it is better to cocainize it before making the punctures. A local tenderness, a submucous thickening, or an abnormally soft spot will generally be the guide for making such a puncture. In any of these conditions a radiogram is very helpful. The gums may be the seat of leucoplakia, acute or chronic abscess, or mucous cysts. Very rarely in young people there is a chronic hyper- trophy of the gums that may hide the teeth and greatly encroach upon the vestibule and mouth cavity (Fig. 363). Epulis may be present on the gums in the form of a small peduncu- lated or sessile tumor arising from the peridental membrane or perios- teum ; or a sarcoma, osteoma, or fibroma may involve a large section of ANATOMICAL CONSIDERATIONS. 19 the gum and jaw-bone. Carcinoma, often secondary to carcinoma of the Hp, cheek, or tongue, is common in old people, especially men. VESTIBULE OF THE MOUTH. The vestibule of the mouth is the space bounded by the lips and cheeks externally, and the teeth and gums internally. The muscular layer of the cheeks and lips is more or less closely attached to the outer surface of the jaws. The mucous lining is reflected on the alveolar processes, and is continuous with the gums. In the midline above, this reflection is drawn down in a fold which connects the upper lip with the gum. This fold, which is called the frenum or frenulum of the lip, may contain a nodule or may preserve the infantile arrangement of reaching to the incisive papilla. In the latter case it will cause a sepa- ration of the two central incisors. The frenum of the lower lip is not so marked as the upper. Posteriorly, when the mouth is closed, there is a space behind the third molars and the maxillary tubercle, that will admit a 5-millimeter tube, through which the vestibule communicates with the cavity. When the mouth is widely open, the pterygomaxillary ligament can be felt stretching from the hamular process of the sphenoid bone to the inner side of the ramus of the mandible. Posteriorly the superior constrictor of the pharynx is attached to the full length of the ligament, while an- teriorly it gives attachment to the buccinator muscle, and through it these muscles are continuous with each other. The orbicularis oris muscle in front, the buccinators laterally, and the superior pharyngeal constrictor behind form a continuous muscular band which surrounds the vestibule and the oral pharynx. To the outer side of this ligament may be felt, in the order named, the anterior border of the internal pterygoid muscle, the whole of the anterior of the border of the ramus of the mandible and its coronoid process, and the anterior border of the masseter muscle (Fig. 260). Temporal abscess may point into the upper fornix of the vestibule, between the coronoid process and the maxillary tubercle. In the upper fornix above the first molar may be felt the prominence of the malar process of the maxilla. In front of this prominence is the canine fossa, through which the antrum may be opened. 'Opposite the second molar tooth will be seen the papilla through which the duct of the parotid gland discharges. It admits a probe with difficulty. The cheeks and lips are everywhere closely applied to the gums and teeth by the tone of the buccinator muscle, which, in chewing, prevents the food from falling into the lower fornix. In palsy of the seventh nerve this power is lost. The mucous membrane is everywhere closely adherent to the mus- 20 SURGERY OF THE MOUTH AND JAWS. cles of the cheeks, with but httle submucous tissue. This accounts for the fact that in heaUh it is seldom caught between the teeth. There are a number of mucous glands lining the cheek, especially in the neighborhood of the last molar teeth, which are called the buccal glands. These may become cystic. Over the lips the submucous tissue contains a number of large mucous glands, which may be felt with the tongue, and which may be congenitally cystic or may become distended later. The cheek may present an acute or chronic traumatic ulcer, a papilloma, a patch of leucoplakia, or a carcinoma. Sarcoma of the cheek may be secondary to sarcoma of the jaw. The gums, lips, and cheeks may show recent noma or its resulting scars. Dense scars from this or other causes, situated in the oral surface of the cheek, may materially limit the separation of the jaws. LIPS. The lips surround the entrance to the vestibule, which is the rima oris. Here they are covered with a modified mucous membrane, which begins where the integument changes color at the outer margin. This membrane ends posteriorly just behind the line along which they meet when closed, where it merges into the ordinary mucous membrane of the vestibule. It contains numerous simple vascular papillae, in which its nerves terminate, and which renders this part of the lip exquisitely sensitive to pain. It contains no hair follicles, but especially near the skin line are numerous sebaceous follicles, which may become the seat of minute retention cysts, or the starting point of rodent ulcer. The lips themselves are made up of skin, fatty superficial fascia, the orbicularis oris muscle, submucous tissue, and mucous membrane. The two lips converge at the angles of the mouth, which are situated opposite the first bicuspid teeth. The line of closure of the lips is slightly curved, and iis just below the middle of the upper incisor crowns. The size of the rima oris varies in individuals, and seems to be related to the size and prominence of the teeth. The orbicularis oris, which surrounds the aperture, is a circular muscle, which has very slight bony connections, but is closely attached to both the mucous membrane and the skin. It receives fibers from and constitutes the insertion of every muscle of the face that converges to the mouth, including the buccinators, and accounts for the infinite variety of expressions and contortions of which the lips are capable. The laxity of the lips favors plastic operations, but is also partly re- sponsible for the distortion caused by scars that follow destructive in- flammations. The lips contain a large amount of connective tissue, and are capable of immense swelling that may be dependent on injury, in- fection, or angioneurotic edema. ANATOMICAL CONSIDERATIONS. 21 The blood swpply of the Hps is mostly from the coronary arteries, which form an elliptical anastomosis around the mouth near the deep surface, and which can usually be felt pulsating under the mucous membrane. In falls on the lips, they are easily cut by the teeth, and the blood may be swallowed, thus giving rise to the surmise of some internal injury. The facial vein continues above with the ophthalmic, and neither contain valves, which accounts for the comparative fre- quency with which facial infections cause septic thrombosis of the cavernous sinuses. The cutaneous surface of the lips in both sexes is closely beset with hair follicles, that may become the starting point of carbuncle. The lymphatics of the lip drain into the submental and sub- maxillary nodes. The sensory supply is of the fifth nerve — the upper lip through the infraorbital, the lower through the long buccal and in- ferior dental. The motor supply of all the muscles of the face is from the seventh cranial nerve. Complete unilateral paralysis causes a char- acteristic drawing of the mouth to the opposite side and inability to close the eye. The lips and oral slit are subject to a variety of malformations. The lower lip especially may be subject to congenital enlargement due to lymphatic hypertrophy. There may be enlargement of the upper lip in children, associated with labial fissures. In both children and adults enlargement of the lower lip may be due to syphilis. The skin of the lips immediately surrounding the mouth may be covered with fine radi- ating scars of syphilitic origin. The lips are the common seat of nevi of various sizes, and the mucocutaneous edge of the lip is the most com- mon site of herpes, fissure, extragenital chancre, and epithelioma. Papillomata of the lip have been known to become cornified, and even to develop true protruding horn. Either lip may be congenitally cleft. TEMPOROMANDIBULAR JOINT. Passing the finger backward along the lower border of the zygoma, the condyle of the mandible is distinctly palpable just in front of the ear. Pressing gently on this point with two fingers while the mouth is being opened, the condyle is felt to travel first downward and for- ward, and then straight forward as it travels on and then across the articular eminence. As the limit of excursion is approached, there may be a slight click, a loud cracking, or even a locking of the condyle on the eminence. The latter is a subluxation. The condyle may be dislocated into the pterygoid fossa, in which event the mouth is held rigidly open. When the mouth is wide open, a deep hollow can be felt in "the position that is occupied by the condyle when the mouth is closed. Ey violent force transmitted through the jaw, such as a fall on the chin, the condyle may be driven through the tympanic plate of 22 SURGERY OF THE MOUTH AND JAWS. the temporal bone into the middle ear or upward into the middle fossa of the skull, constituting the backward or upward dislocations. This joint, on one or both sides, may be replaced by a true ankylosis, or the movement may be limited by fibrous tissue. If ankylosis has ex- isted during the period of growth, it will interfere with the develop- ment of the mandible and cause retraction of the chin. The joint may be the seat of any of the affections to which true joints are subject. Suppuration in the joint is more apt to spread anteriorly or posteriorly than externally or medially on account of the relative thickness of the capsule in these various surfaces. On account of its proximity to the middle ear, the pus may invade that cavity, or vice versa. There may be mechanical interference with normal action of the jaw, or there may be paralysis or spasticity of one muscle or a group of muscles, or certain members of several groups. The former condition may be due to one or more of several causes. A tumor may mechanic- ally interfere, or the joint may be the seat of true or fibrous ankylosis, or of exostosis. The condyle or interarticular cartilage may be dislo- cated, or scars may bind the bone in any part. In certain fractures the jaws cannot close voluntarily. The limitation may be voluntary, to avoid the pain it would induce as the result of inflammation or an in- jury. Muscle spasm may be caused by central irritation or peripheral irritation along the distribution of its own or associated nerves ; almost never by disease within the muscle. Paralysis is always caused either by a central lesion or some interference in the course of the motor-con- ducting paths to that muscle. JAWS. The jaws should be examined on all exposed surfaces. With the exception of the sigmoid notch, all of the borders and most of the sur faces of the mandible may be palpated. The maxillae, with the malar bones, are almost equally accessible to the examining fingers. In seek- ing for obscure fractures, care should be taken not to increase the original damage in the effort to obtain crepitation. Gentle manipula- tion is all that is ever permissible, and is usually sufficient. Pressure applied at the angles will cause pain at a fracture, and such a hint should be sufficient. The portion of the alveolar process may be broken from either jaw. Fractures of the maxillae are usually impacted, and crepitus is rarely present. One maxilla may be broken loose, or there may be a complete transverse fracture through both bones, so that the upper jaw hangs from the cranial base only by the soft tissues. Fractures of the maxillae may extend into the oral, orbital, or nasal cavities, or into the maxillary antrum, or may injure the superior maxillary nerve, the nasal duct, or ANATOMICAL CONSIDERATIONS. 23 branches of the internal maxillary artery. Through its intimate asso- ciations with the nasal passage and accessory cavities, fractures of the maxilla may be followed by emphysema of the cellular tissues of the face. With advancing age, as the teeth are lost, the alveolar processes are absorbed; when entirely gone, plates for artificial teeth are worn with difficulty. As their function is lost, the muscles of mastication atrophy, and with them the bone that serves for their attachment, so that the angle of the jaw appears to gradually open out and the body to lengthen. Loss of teeth and alveolar processes gives the peculiar shortening of the lower part of the face and the prominence of the chin often seen in old people. The jaws may present deformity resulting from maldevelopment, necrosis, or malunion of fracture, and are subject to a variety of cysts and tumors. Among the tumors of the upper jaw are fibroma, enchondroma, osteoma, myeloid sarcoma, round- or spindle-celled sarcoma, and can- cer. The last is secondary, usually to cancer of the mucous mem- brane of the mouth or antrum. In the upper jaw, mucous cysis of the antrum and dental cysts are the varieties usually found. The lower jaw is subject to the same tumors as the upper, but myeloid sarcoma is much more common. The common cyst of the lower jaw is a dentiger- ous cyst, while fibrocystic tumors also hold this as their site of election. Actinomycosis is commonest in the neighborhood of the lower jaw, and both jaws may be involved in leontiasis ossea. Fractures of the mandible are not impacted, and those of the body are usually compound, owing to the inelastic character of the muco- periosteum covering the gums. We have seen one impacted fracture of the mandible, but regard it as a surgical curiosity. Maxillary Antrum. — The maxillary antrum is situated in the body of the maxilla. The upper wall of the antrum is the floor of the orbit, the inner wall is part of the outer wall of the nasal fossa, the outer wall is the facial surface of the maxillary bone, and the inferior wall is the base of the alveolar process. It communicates through a small opening in the hiatus semilunaris with the middle meatus of the nose. This opening is at the upper part of the antral cavity, and free fluid, usually pus, can drain through this opening only when the head is held downward or to the opposite side. The infraorbital nerve runs in the upper wall of the antrum, and its anterior and middle dental branches course downward in canals in the outer wall. The nasal duct, which conducts the tears from the lacrymal sack to the inferior meatus of the nose, runs through its inner wall. The apices of the roots of the molar teeth, of one or both of the bicuspid teeth, and sometimes of S4 -SURGERY OF THE MOUTH AND JAWS. the cuspid tooth, are in close relation with its floor and may extend up into the cavity. Malignant growths tend to infiltrate through the wall, while cysts and benign tumors may thin the wall and push it outward. Cysts may arise from the mucous glands of the interior, or may be the extension upward of dental cysts — rarely dentigerous cysts. The outer wall may become so thinned that digital pressure will cause a crackling, or fluctuation may be felt. Aspiration or puncture of the antrum is done through the inferior meatus of the nose, the canine fossa, or, when a suitable tooth has been recently extracted, through the alveolus. The antrum may be examined by palpation, transmitted light, x-ray, aspiration, and exploration. Infection from the roots of the teeth in relation to it may cause suppuration between the mucoperiosteal lining and the bony wall, may infect the mucous cavity directly, or may even cause infection of the orbit (Figs. 290, 300). Tumors that arise in the antrum may grow in any direction. When inward, they obstruct the nose and the nasal duct; inward and back- ward, they obstruct the nasopharynx; upward, they infringe on the orbit, causing exophthalmus and neuralgia ; outward, they cause swell- ing of the face, with neuralgia ; and downward, cause downward arch- ing of the palate, loosening of the teeth, and toothache. MUSCLES OF MASTICATION. When tense, the masseter muscle can be distinctly felt, and often seen, on the outer surface of the ramus. The temporal muscle can be felt while chewing, and by pressing with the finger just above and in front of the ear. As mentioned, the anterior border of the internal pterygoid can be felt in the mouth, but the external pterygoid muscle cannot be palpated. In tetanus the masticatory muscles are usually the first and most constantly involved, but spasm of these muscles may result from intra- oral irritations, especially those located over the distribution of the third division of the fifth nerve. The spasm may be clonic or tonic. Paralysis of the muscles of mastication will follow any injury of the motor root of the fifth nerve, and commonly an operation on Gas- serian ganglion or its root for facial neuralgia. SALIVARY GLANDS. Sublingual Gland. — The sublingual gland, lying between the mylohyoid and the geniohyoglossus muscles, and covered by the mucous floor of the mouth, has already been noted. It has a number of ducts, and contains no lymph nodes. Parotid Gland. — The parotid, the largest of the salivary glands, lies just in front of the ear, behind and overlapping the ramus of the ANATOMICAL CONSIDERATIONS. 25 jaw and masseter muscle. When inflamed, it causes the swelling that is characteristic of mumps. The space in which the gland lies is in- creased when the head is held erect, with the mouth closed and the jaw thrust forward, and advantage should be taken of this while making an examination. It is impossible to feel the substance of the gland in the normal condition. It seems to be peculiarly liable to infection in some epidemic of typhoid fever, and may also become infected by local injury, or through its duct. The gland is incased in a dense fascia externally and below; but internally, at the upper part, the sheath is lacking, and the parotid space communicates with the deep connective tissue spaces of the pharynx. Retropharyngeal abscess may infect the gland, or pus from the gland may burrow into the space, into the tem- poral fossa, down into the neck, or into the external auditory canal ; but it rarely points superficially. Virchow has reported cases of intra- cranial infection from parotid abscess along the branches of the fifth nerve. The duct of the parotid gland, Stenson's duct, runs through the cheek a finger breadth below the zygoma to turn toward the mouth at the anterior border of the masseter muscle, where it can be distinctly felt when the muscle is made tense. Besides the external carotid artery and external jugular vein, it contains the seventh nerve, the auriculotemporal branch of the fifth nerve, and filaments from the great auricular nerve of the cervical plexus. Facial paralysis or neuralgia of the temple or upper part of the anterior surface of the pinna may result from infection or tumors of the parotid gland. It also contains a number of lymphatic nodules, which receive their efferent vessels from the eyelids, eyebrows, root of the nose, upper part of the cheek, the frontal and temporal part of the scalp, the outer surface of the ear, the tympanum, and possibly from the mucous membrane of the nose, the posterior alveolar region of the superior maxilla, and the soft palate. Its afferent vessels pass into deep cervical nodes. Tumors of the parotid are usually of a peculiar variety known as salivary gland tumors. They arise from the body of the gland or detached nodules, most commonly in young adults, grow slowly or remain stationary for years, and then may take on rapid infil- trating growth. Some sarcomata of the parotid grow rapidly from the first. Submaxillary Gland. — The submaxillary gland lies under the side of the jaw, in front of the angle, and is inclosed in a complete capsule. Part of the posterior end of the gland turns around the pos- terior border of the mylohyoid muscle and lies in the floor of the mouth, and it is from this part that the duct is given off. Unless there is too much subcutaneous fat, the normal gland can usually be palpated 26 SURGERY OF THE MOUTH AND JAWS. by feeling in the floor of the mouth with one finger while the gland is pressed up from below with the other hand. The facial artery grooves its deep surface. While the vein crosses superficially, its sheath con- tains lymph nodes — usually only the superficial layer. These receive lymphatics from the lips, middle of the dorsum of the tongue, and the floor of the mouth, and are sometimes the secondary starting point of a fulminating infection in the neck — Ludwig's angina. Primary growths of the submaxillary are rarer than in the parotid, but stone in its duct, with secondary inflammation of the gland, is very much more common. LYMPH NODES. The lymph nodes are always of interest. It is comparatively seldom that they are the seat of primary disease. Secondary enlarge- ment, however, almost constantly follows infections of the areas which they guard, and they form the first barrier to infectious material that has escaped into their lymph streams. The lymph nodes that concern the mouth and upper part of the pharynx are grouped as follows : The lingual nodes lie between the geniohyoglossi muscles above the mylohyoid. They are small and rarely palpable. The suprahyoid or submental lymph nodes are situated in the an- terior part of the digastric triangle, below the chin and above the hyoid bone. They are apt to become enlarged in disease of the tip of the tongue, the midpart of the gums or floor of the mouth, the midpart of the lower lip or chin. They send their lymph partly into the submax- illary nodes and partly into a node situated on the anterior surface of the internal jugular vein, at the level of the cricoid cartilage. The in- frahyoid nodes lie in front of the internal jugular vein, between it and the omohyoid muscle, just above the point where this muscle crosses the carotid sheath. They are supposed to drain the neighborhood of the frenum of the tongue. The submaxillary group lies under the deep cervical fascia, just be- low the border of the mandible on each side. They are usually super- ficial to the submaxillary gland, but rarely one may lie beneath it. A large node is usually situated near the fascial artery. They receive streams from the side of the nose, the upper lip, the outer border of the lower lip, the anterior third of the lateral border of the tongue, the gums, the submaxillary and sublingual glands, and the adjacent parts of the floor of the mouth. They discharge into the upper deep cervical nodes, mostly into those in the neighborhood of the bifurcation of the common carotid artery. The retropharyngeal glands lie behind the nasopharynx, and re- ceive lymph from the nasal cavities and the accessory air sinuses, the ANATOMICAL CONSIDERATIONS. 27 nasopharynx, Eijstachian tube, and adjacent structures. Their efferent vessels run to the upper deep cervical glands. From their position they are rarely palpable. There are a variable number of nodes situated along the course of the internal maxillary artery. These rarely, if ever, are palpable, and receive streams from the orbit, the zygomatic and temporal fossse, the cerebral meninges, the nose and palate, and discharge into the upper deep cervical nodes. There are a few nodes in the superficial fascia of the cheek, and also superficial to the parotid gland. They drain the superficial structures of the upper part of the face and ear, and empty into the superficial and deep cervical nodes. According to Cunningham, there may be present a lateral nasal node situated between the ala of the nose and the cheek. The deep parotid nodes were described with the parotid gland. The superficial cervical nodes are upon or imbedded in the deep cervical fascia along the course of the external jugular vein. They drain from the superficial tissues of the neck and the superficial parotid and submaxillary nodes. The lymph streams from all of these are emptied into the deep cervical nodes, which are arranged in two groups. Those along the common carotid artery and internal jugular vein, which constitute the deep cervical group, lie under the sternomastoid muscle. The others, which are disposed in the posterior triangle of the neck behind the sternomastoid muscle, are called the supraclavicular group. They all finally empty their lymph streams into the general blood stream at the junction of the internal jugular and subclavicular veins. While the above indicates the normal course of the lymph streams, all the vessels are connected, and when any group of glands and vessels becomes blocked with pathological material, the lymph will seek other and more roundabout courses, so that finally all the neighboring groups of nodes may become involved from a single primary lesion. CHAPTER II. INFLAMMATIONS, INFECTIONS, TUMORS, CYSTS. We are more resistant to some infections than to others — as a rule to those that we are constantly carrying around with us. Our preser- vation from infection depends : first, on the fact that we are entirely enveloped in a resisting capsule composed of skin and mucous mem- brane ; secondly, on a more or less perfectly acquired or inherited immunity, which, when efficient, will prevent the development of bacteria after they have gained access to our tissues. Sometimes infectious agents penetrate the skin or the mucous membrane by some inherent power they possess, and at other times they enter through open wounds. One kind of infection having gained a foothold often serves to pave the way for the entrance of an infection of another variety. The opportunities for invasion are so numerous that, were it not for our natural or acquired immunities, and for the power that the tissues have for overcoming infections after they have gained a foothold, none of us would long survive. Both the immunity acquired or inherited, which prevents infection, and the resistance that overcomes infection after it has occurred are developed by a process that may be broadly termed inflammation. INFLAMMATION. Inflammation is the reaction exhibited by live tissues to irritation. The irritation may be mechanical, thermal, toxic, chemical, electric, etc., but to produce inflammation, the irritant must be directly or indirectly continuous in its action. After an irritation ceases to act, the process is simply one of repair. The inflammatory process and repair are very similar in many respects. We will consider that phase of inflammation that accompanies an infection. The changes that accompany and con- stitute inflammation are briefly as follows : There is, first, a local dilatation of the blood vessels, with an in- creased supply of blood. Next follows a slowing of the blood current, with agglutination of the white cells to the walls of the vessels. There may be for a time an absolute stoppage of the blood current in some of the smaller vessels ; accompanying this, there is a pouring out of plasma and white cells into the surrounding tissues. In very severe inflamma- tions even the red cells may leave the vessels without an apparent rupture of the wall. At some time during this process there is a pro- 28 INFLAMMATIONS, INFECTIONS, TUMORS, CYSTS. 29 liferation of certain of the fixed tissue cells. If the process advances sufficiently far, there is an increase in the number of blood vessels. By this process, it will be understood, the tissues involved in the inflamma- tion have increased blood supply and become crowded with plasma and wandering fixed cells, which form a resisting wall that mechanically helps to keep the invading infection localized. Certain of the white cells that are poured out into the tissues in an inflammation have the power of devouring invading bacteria. This is another factor in overcoming infection, but the multiplying connective tissue cells are much more resistant to irritants than are the leucocytes derived from the blood. Blood plasma poured out in the presence of an inflammation has a much higher bactericidal power than has the normal blood. Even beyond all this, the effort to overcome an invading in- fection is seldom limited to a local inflammatory reaction. In the. first place, in the presence of a septic infection, there is an increase in the absolute number and relative proportion of the polymorphonuclear white cells of the blood. Seqondly, when bacteria or bacterial poisons are absorbed into the general circulation, there is a reaction on the part of certain widely distributed cells, by which is produced a specific anti- body, which directly or indirectly, when effective, destroys infection and neutralizes the toxins. From this it will be seen that an inflamma- tion, both in its local and general manifestation, is a process that has for its object the overcoming of infection. The resistance to a specific infection is not immediately lost with the subsidence of the disease, but in many cases is permanently re- tained. Thus it is that such diseases as measles, whooping-cough, scar- let fever, and many others are seldom acquired more than once by the same individual. This acquired immunity may even be handed down as an inherited immunity. It is in this way that certain individuals are immune to certain diseases which they have never had. In other in- stances, and especially with certain diseases, the immunity is but short- lived. We see individuals who are subject to recurrent attacks of pneumonia, pus infections, erysipelas, etc. Symptoms of Inflammation. — -The classic symptoms of inflam- mation, handed down from the time of Hippocrates, are redness, heat, swelling, and pain. The redness and heat are due to the increased blood supply; the swelling, to the dilatation of the vessels and infiltration of the tissues with plasma and blood cells, and in some instances to the increase in the number of fixed tissue cells. Pain is not an essential symptom of all inflammations, but is rather constant in the acute stages. There are many subacute and chronic inflammations in which no pain occurs. Pain seems to be due, at least partially, to pressure; but it is well recognized that the passive congestion and edema that accompany 30 SURGERY OF THE MOUTH AND JAWS. an inflammation, to a certain extent, allay pain. It is safe to state that the pain is in part caused by the irritant, and not wholly by the inflam- mation. Kinds of Inflammations. — An inflammation may be acute, chronic, or subacute, but in all of its stages a rigid distinction should be made between the inflammation and the irritant that causes it. Until this is done, only confusion can result. Inflammation is essentially a protective process, closely allied to repair and body growth. A sub- acute or chronic inflammation means a continuously acting irritant, for, when the irritant is withdrawn and the resulting damage repaired, the inflammation subsides. Inflammation is essentially not an evil, but an evidence of vital resistance. It does not occur in dead tissue, and we occasionally see instances where inflammation fails to occur in tissues of very low vitality. Pus formation is but a way of ridding the body of the poisons it cannot neutralize. An inflammation of any particular organ or structure is designated by the suflix "itis" or "ia," as gingivitis, peritonitis, glossitis, ophthal- mia, and pneumonia. Cellulitis is a term used to express a more or less diffused inflamma- tion, dependent on bacterial infection, which travels along the cellular tissue planes, particularly those under the skin, though it may occur between muscles or in any part of the body. It may stop short of or extend to suppuration. Local cellulitis is a common phenomenon around any suppurating focus, and is often seen around a suppurating focus in the mouth. Lymphangitis and adenitis refer to infections spreading in the lymph channels, and are evidenced by an inflammation along the course of the lymphatics and a swelling of the lymph nodes. An adenitis may attain any stage of inflammation from acute or chronic hyperplasia to suppuration. With certain infections, as the tubercle, the chronic hyperplasia may be followed by a kind of tissue necrosis known as caseation. Results of Inflammation. — Besides the overcoming of the in- fection, certain more or less permanent results may accompany or fol- low an inflammation. As an inflammation subsides, the blood vessels contract, the normal circulation is restored, and the plasma and cells that have left the blood vessels are carried off in the lymph streams. If the inflammation goes to suppuration, quantities of serum, of white cells, and of fixed tissue cells are thrown off in the pus. Any excess of connective tissue that has formed usually turns into scar. As scar tissue ages, it contracts, and it is this contraction of the interstitial scar tissue that impairs the function of the vital organs after they have been the site of a chronic inflammation. INFLAMMATIONS, INFECTIONS, TUMORS, CYSTS. 31 In an interstkial nephritis, a cirrhosis of the Hver, and a tabes dorsahs the parenchymatous cells of the kidney, or of the liver, or the axis cylinders of certain nerve tracts in the spinal column are squeezed until they can no longer perform their function. Scar formation may be long delayed, due possibly to the persistence of the inflammation in a subacute state. The surface epithelium may remain thickened or changed. In some instances masses of new connective cells will re- main unchanged for indefinite periods. As an instance of this, we have the simple hyperplasia. The new tissue may become necrotic, and either liquefy or caseate, and it sometimes becomes impregnated with lime salts. We have examples of this in ulcerating gummata, or break- ing-down or calcification of the tubercle. This fixed tissue cell prolif- eration is somewhat analogous to tumor formation, which consists chiefly in the localized growth of the cells of a certain tissue. Some of these localized growths we know to be caused by an infection, as, for example, granuloma resulting from infection with actinomycosis. These granulomata, tubercles, gummata, etc., which are known to be caused by an infection, are no longer classed as tumors. Just how many of the new growths that we now consider to be true tumors will be ultimately classed under inflammatory processes, it is impossible to foretell It might be argued that the interstitial scar deposits that follow some inflammations are positive evils, and that therefore the inflammation that caused this scar deposit is also an evil. It is, however, safer to con- clude that the inflammation was a conservative process, and that the in- terstitial scar formation is a lesser evil than the condition that would have resulted if there had been no inflammatory reaction. An inflam- matory granuloma is to be regarded as an effort to hold in check an infection which the tissues are unable to destroy. Whether the true tumors as we now regard them will eventually be placed in the same category, we do not know. It may be possible that even the malignant tumors, such as cancer, are but a vain inflammatory effort to over- come an infection. Even the fever that accompanies most infections is not to be regarded as an evil per se,. but as a necessary part of the effort to overcome infection. Without negativing this view of inflammation, it is, however, prob- able in many instances that the inflammatory process is carried beyond the point where it accomplishes unmixed good. Just as a fireman may distribute more water than is needed to extinguish a fire, and thereby sometimes does more harm than the blaze, so there is no question that stagnation of blood and lymph in an inflamed area can be so great as to cause gangrene by pressure, and that the inflammation, and not the toxins, is often the immediate cause of the localized tissue death. If we grant that inflammation can cause tissue necrosis by pressure, we 32 SURGERY OF THE MOUTH ANlD jAWS... .1 will have also to grant that by a less degree of pressure the vitality of the tissues can be damaged to a less extent. It would seem, tlierefore, that an excessively active inflammation can produce evil results, and this idea is borne out by the extreme contradictions that are met with in clinical observations. Gangrene is the death of tissue, with putrefaction. Necrosis is the simple death of tissue.- It is for the reason that, bone being little changed by the- organisms of putrefaction, the death of bone, even when due to sepsis, is spoken of as necrosis. Ulcer is the defect that remains after a local surface destruction of tissue from bacterial invasion, from the breaking down of a tumor, or following a number of different inflammatory processes the cause of which we may not understand. Any open sore, whether it be the result of the bursting of a herpetic bleb ; the breaking down of a carcinoma, of a gumma, or a tubercle; whether it be the granulating surface left after the separation of a superficial slough; an open sore due to the melting away of any of the surface tissues ; or an open sore of almost any kind, excepting the acute stages following an injury — any of these may be spoken of as an ulcer. Naturally the varieties of ulcer are very numerous. INFECTIONS. An infection is the invasion and growth of some kind of a minute organism, that feeds upon and poisons the living tissues. Agencies of infection, as we recognize them, are various, and include certain very low forms of life called bacteria, to which class belong: the pus-pro- ducing organisms, pneumococci, typhoid bacilli, etc. ; certain plant cells, as yeast fungi and mycoses ; and also some of the lower forms of animal life. These agencies of infection are widely distributed. With some of them we are in constant touch — for instance, those that are normally found in the mouth and in the intestines. With some other infections we rarely come in contact. As examples of the latter, we might men- tion the cholera bacillus, Bacillus mallei (which causes glanders), the leprosy bacillus, and Bacillus pestis (the cause of plague). Spread of Infections. — If an infection fails to remain localized, it may spread in a number of ways. If there is not sufficient local re- sistance, infection may be disseminated along the neighboring cellular planes, or it may spread through the lymphatics, giving rise to lym- phangitis. If septic inflammation spreads along the blood stream, the condition is known as pyemia or septicemia, according to its mode of transfer. If it is carried to distant parts of the body by means of small infected blood clots — septic emboli floating in the blood streams — the condition is known as pyemia. When such a clot lodges in a capillary, a new focus of infection may occur. At first this is most likely to hap- INFLAMMATIONS, INFECTIONS, TUMORS, CYSTS. 33 pen in the capiUaries of the lungs or hver, and it is for this reason that pneumonia may follow an infection of any part of the body, or liver abscess may follow an infection of the area of the portal circulation. Ultimately a pyemia may cause numerous localized infections in many parts of the body. If bacteria, or any other agencies of infection, float free in the blood stream in any quantity, not bound up in blood clots, the condition is known as a septicemia. The chief difference between this condition and that of a pyemia is that in the latter the clots con- taining the bacteria are bound to lodge in some small vessel, where a secondary focus is very likely to arise. Bacteria floating free in the blood have no protection from the germicidal actien of the blood, and are more apt to be destroyed. SUPPURATION. When the tissues are invaded by certain organisms, under certain conditions, suppuration results. Suppuration is characterized by the formation of fluid containing waste material, that has been sacrificed in the struggle against the invading organisms, together with dead and living microbes and their products. It is preceded by changes in the circulation and fixed tissues, already described as being essential parts of inflammatory process, and is one of the ultimate manifestations of the struggle between the germs and the resisting power of the body. In dead tissue there is no inflamma- tory action, and in tissue of low resistance there may be no suppura- tion. It was because, in the formation of certain kinds of pus, the older surgeons recognized a strong resistance on the part of the body which foretold ultimate recovery, that this pus was referred to as laudable pus. Practically, from a surgical standpoint, there can be no pus formation without the presence of bacteria of certain species. Still, pus can be produced experimentally by injecting certain irritating chemical sub- stances. Certain organisms that do not really produce pus can cause a tissue necrosis that may liquefy or become semiliquid, but this is not true pus. The most common example of this is the caseation that may take place in the granulations that result from the presence of tubercle bacillus. Microorganisms of Suppuration. — Some pus-forming organisms, such as the staphylococcus and Streptococcus pyogenes, will always tend to form pus. Often, however, owing to the lack of virulence ot lack of sufficient numbers in proportion to the tissue resistance, the in- flammatory process may be cut short before it reaches the stage of sup- puration. Thus there may be a swelling of the gum and face around an infected tooth, but this may subside without the formation of pus. 34 SURGERY OF THE MOUTH AND JAWS. Certain infectious organisms, such as tlie typhoid bacilhis, will cause suppuration only under extraordinary circumstances. The principal microorganisms of suppuration are Staphylococcus pyogenes aureus and alhus. Streptococcus pyogenes, Micrococcus gon- orrhooa. Bacillus pyocyaneus, and the pneumococcus. Among the or- ganisms that less commonly cause suppuration are the typhoid bacillus, influenza bacillus, diphtheria bacillus, actinomyces, and various forms of the yeast fungi. Of the two more commonly present pyogenic bac- teria, Staphylococcus pyogenes and Streptococcus pyogenes, the former is usually less virulent, and is more easily limited by the inflammatory reaction to the neighborhood in which the infection occurs. Therefore Staphylococcus aureus or alhus is more commonly found in localized abscesses. The streptococcus seems to be less easily resisted by the inflammatory reaction, and has a greater faculty of becoming diffused. It is therefore more often the cause of rapidly spreading extensive in- fection, and as a rule, is much more destructive. Tissue Changes in Suppuration. — The changes in the tissues that occur in suppuration are briefly as follows : The changes already described as constituting the active stage of an inflammation always occur. The bacteria of suppuration seem to have the power of attracting from the blood vessels the polymorphonuclear white cells in great numbers, the greater demand for them being met by a greater production of them in the bone marrow. The fixed tissue cells are excited to greater proliferation, and there is a wall of cells thrown around and throughout the inflamed area, derived from the fixed tissue cells and from the leucocytes, that tends to localize the in- fection. It would appear that around the staphylococcus this wall is produced with comparative ease ; but around the streptococcus it is not easily accomplished, and it is for this reason that one remains localized and the other so commonly becomes diffused. Owing to the peptonizing power of certain bacteria, the tissues in the central part of the inflamed area become liquefied. As a result, there is a mixture of blood plasma, dissolved fixed tissues, leucocytes, newly formed cells, bacteria, and poisons, that is termed pus. An abscess is a circumscribed cavity of pathological origin containing pus. A collection of pus in a closed anatomical cavity, such as the pleural cavity, is often spoken of as an empyema. If the infection becomes localized, the abscess which contains the pus is surrounded by a limiting wall of granulations. This wall confines the pus until it is either lib- erated spontaneously by some tract of exit formed by the action of the phagocytes, or it is liberated artificially by an incision. Less com- monly the abscess remains permanently buried, or may even be absorbed after the death of the bacteria it contained. INFLAMMATIONS. INFECTIONS, TUMORS, CYSTS. 35 TREATMENT OF INFECTIONS AND INFLAMMATIONS. After an infection has once gained a foothold in the living tissues, we must in our treatment regard not only the infection but the inflam- matory processes that it has excited. We are not certain that the in- flammatory process itself ever needs treatment, and v^e do know that there are very few, if any, infections that could ever be overcome with- out inflammation. Inflammation is nature's way of fighting infections, and we must work with it, not against it; for otherwise our efforts will be in vain. There are a few infections that we can overcome by saturating the body with a poison that will not destroy the tissues. Among these may be mentioned malaria, which may be killed by quinin, and syphilis, which may be killed by mercury or salvarsan. When an infection is superficial, it may be influenced by locally applied antiseptics, such as alcohol, essential oils, iodoform, silver salts, etc. With a few isolated exceptions, however, treatment consists, at least in part, in promoting or regulating the inflammatory process. One of the first requisites is the regulation of the body functions, especially the excretory organs. In the presence of an infection, the parenchymatous cells of various organs may become sluggish in their action and may require stimulation. The most common instance of this treatment is the administration of a purge and a stimulation of the skin by bathing. Next comes the establishment, as far as possible, of physiological rest of the affected part. Nature gives a strong hint in this regard in the pain that results from exercising an inflamed part. This rest should include the proper quota of sleep, and it may be nec- essary to administer an analgesic or a soporific. If the disease is at all prolonged, careful attention must be given to the nourishment of the* patient. During this time the tissue waste is often greater than ordi- nary, and the ability to assimilate food is lessened ; therefore food should be given in an easily digested form. Prolonged high fever is very detrimental, but it is not proper to continuously give antipyretics to reduce it. Bathing reduces the fever, stimulates the secretions, and tends to quiet nervous irritation. It has been a routine custom to give alcoholic stimulants in septic infections, but except when the vital functions need stimulating, this practice is falling into disuse. Another well-established therapeutic procedure is, where anatom- ically possible, to remove the infection by a surgical operation. If the infected part is no longer functional, this can be done by an excision — as the surgeon removes an inflamed appendix, and a dentist removes a tooth whose utility cannot be reestablished. In the presence of certain virulent infections, even more important organs may be sacrificed. The 36 SURGERY OF THE MOUTH AND JAWS. tongue or the cervical lymph nodes may be removed on account of a tubercular infection, and an arm may be removed on account of a pus, gas bacillus, or other virulent infection that threatens life. A carbuncle may be totally excised, and any but the absolutely vital organs are sac- rificed when carcinomatous. However, in many of our surgical opera- tions for infection we are content with a less radical measure, which consists in draining the affected tissues by making one or several in- cisions. The tissue fluids are allowed to flow out of the wound, and with them great quantities of the infecting organisms and their toxins. This free drainage often gives the fighting tissues just the help they need, and enables them to overcome the infection that remains. There are three therapeutic agencies, all of established value, and each contradictory to one of the others, which have to be mentioned, but the rationale of which we do not fully understand. These are heat, cold, and passive hyperemia. One of the oldest treatments for local- ized infection is heat. In general, it seems to promote comfort, allay pain, and promote the circulation. With septic infections it probably predisposes to suppuration, but in the presence of a septic infection of a certain virulency, local suppuration cannot be regarded as an evil. Local irritants — counterirritants, as they are sometimes called — act like heat, as they cause a deep as well as superficial dilatation of the blood vessels, with increased circulation. According to our ideas, an in- creased blood supply means increased resistance. According to our present ideas, it is rather diflicult to explain the good that undoubtedly results in many instances from the application of cold to an inflamed part. It cannot be from the direct action of the cold on the infecting organisms, for they are generally much too deep in the tissues to be influenced by a direct cooling effect. Cold, un- doubtedly, causes a contraction of the blood vessels, a lessening of the inflammatory reaction, and tends to prevent suppuration and allay pain. There are certain animal experiments that demonstrate the fact that re- ducing the temperature of the tissues reduces their resistance. We might conclude that in all instances the inflammatory reaction is exces- sive, and that cold is beneficial by regulating it. Blood-letting was once popular, and in certain cases it undoubtedly accomplishes good. Whether this is by reducing the inflammation or by stimulating it, or by drain- ing off poisons, or by a combined effort, is difficult to say. In apparent contradiction to this is the fact that induced hyperemia, commonly known as Bier's treatment, increases the inflammatory reaction, and is a strong agency in overcoming infections. Bier's hyperemia consists in the establishment of a temporary venous stasis, either by suction or by constricting the veins above the inflamed part. This is an augmenta- tion of an essential part of the inflammatory process. INFLAMMATIONS, INFECTIONS, TUMORS, CYSTS. 37 There are two other plans of treatment which have lately demanded considerable attention, and which in certain cases are giving great re- sults. The first of these is the use of artificially produced antitoxins. When an animal overcomes a disease, it has circulating in its blood antibodies which give it an immunity to that disease. With some dis- eases this immunity is permanent. By the injection of gradually in- creased doses of toxins into a susceptible animal, it is immunized. When the blood of such an immunized animal is withdrawn and in- jected into a similarly infected individual, his resistance is immediately increased. The most brilliant example of this is the use of the diph- theria antitoxin. Unfortunately there are at present very few infec- tions that can be treated in this way. Another form of treatment, and one that promises to have a wider range of application, is the artificial stimulation of the production of antibodies within the infected individual. A localized infection may persist, or a person is overcome by an infection, not because the body cannot produce antitoxin, but because it does not do so, or because it does not do so until the infection has gained too great a headway be- fore the antitoxin-producing reaction has taken place. As stated earlier in this chapter, the production of antitoxin is stimulated by the presence of toxins in the general circulation. As long as the infection remains localized, there may not be sufficient toxin in the general circulation to call up this reserve power, and when the infection becomes general- ized, this may happen so rapidly that the cells have not time to form the antibodies before they are overcome and destroyed by the invading host. It has been found that, by injecting measured doses of killed bacteria of the same strain as the infection, all the antitoxin-producing cells of the body can be safely stimulated, so that they will evolve suffi- cient antitoxin to overcome an infection while it still remains localized. METHOD OF PREPARING AND ADMINISTERING AUTO- GENOUS VACCINES. By Dr. Charles L. Kxenk. In order to produce an immunity against certain conditions pro- duced by certain bacteria, one method is the use of a substance com- monly called a vaccine. These so-called vaccines are supplied in stock form by various biological laboratories. Preparations are made from a given organism of a certain strain or species, and used against all conditions, irrespective of the strain to which the organism belongs. These "stock" vaccines are in most instances of no value, because it has been definitely determined that, with perhaps the exception of cer- tain strains of staphylococcus, in order to immunize an individual against a certain organism it is necessary to use one of the same strain. 38 SURGERY OF THE MOUTH AND JAWS. This form of vaccine is called an autogenous vaccine. The autogenous vaccines commonly used are composed of dead bacteria obtained from cultures, taken from the individual to be immunized. Immunity has also been produced by the injection of very small doses of living bacteria of full virulence, or those attenuated by pro- longed cultivation in vitro, or those modified by heat. The method of using dead bacteria has many advantages that the others do not possess. The dose is under accurate control — there is no danger of the spread of the infection, as might be the case if living bacteria were used — and the vaccine is easily kept for use without the danger of multiplication. The method of preparing a vaccine is usually a simple matter. The chief difficulty is to insure the purity of the organism used and the ab- sence of all other bacteria, especially the pathogenic varieties. If possi- ble, a lesion should be selected that is recent and uncontaminated. For example, in case of an abscess the following is the procedure : The skin should be carefully cleansed, and possibly seared with a hot instrument, to insure the destruction of all surface bacteria. With an absolutely sterile knife or needle an opening is made, and the exuding pus or fluid is immediately transferred to a suitable culture medium and incubated for at least twenty-four hours. The resulting growth is ex- amined, and the organism identified. If a good culture is secured, the growth can be washed off the medium with sterile salt solution and put into a sterile tube. The number of bacteria to the cubic centimeter are determined preferably by Wright's method. A certain amount of the bacterial emulsion in salt solution is mixed with human blood in definite proportions, and smears are prepared over a strainer. The red cells and bacteria are counted, and the proportion of the two will permit of the calculation of the number of bacteria. In conditions in which the organism is known, but other bacteria are present, it is necessary to get rid of this contamination. Cultures are usually made on Petri dishes, or other containers giving a large culture surface. The writer has used a form of container which has been very useful — an ordinary 4- or 6-ounce bottle, the so-called flat Philadelphia oval form. A small amount, about 10 cubic centimeters, of medium is put into the bottle, which is placed flat on its broad side. The medium is allowed to solidify, and a large, smooth, transparent surface is obtained. After these cultures are made, the entire growth is worked off with sterile salt solution. In some instances the exact organism is not known, several species being present which produce similar conditions. If such is the case, a vaccine may be prepared con- taining all these forms. This vaccine is known as "combined vaccine." After the growths have been examined and found to be pure, the dose INFLAMMATIONS, INFECTIONS, TUMORS, CYSTS. 39 for injection As determined. The usual dose for adults is from 25,- 000,000 to 50,000,000 bacteria as an initial dose. The kind of organism,, if a bacillus or a coccus, should be taken into consideration. The writer usually begins with 25,000,000 when bacilli are used, and 50,000,000 when cocci are used, Wright's method of counting may be used for this purpose. The injection of these dead bacteria usually produces a reaction, both local and general — in most instances very mild in character. The local reaction is recognized by redness, slight swelling, and some pain; the general reaction, by some nausea, pains in the joint, a slight eleva- tion of temperature, and perhaps a slight headache, all of which usually disappear in three to five days. This reaction usually occurs twelve to twenty-four hours after the injection. After this reaction subsides, about four or five days after the injection, a second dose is given. This dose is usually twice as large as the first, and is continued until the desired amount is obtained. A much simpler method, and one which the writer recommends, is the determination of the dose by the injection of a very small amount of the vaccine, perhaps two or three drops, and if no reaction occurs, the dose is doubled for the next injection, and so on until a proper re- action is obtained. This is then used as a basis for determining the subsequent injections. The form of vaccine in which the number of bacteria are known is called "standardized," while that in which the dosage is determined by the reaction is called "unstandardized." The writer secures a rich growth on a large surface in a 4-ounce flat medicine bottle, previously described, and washes ofif the bacteria, if cocci, in 10 cubic centi- meters of sterile salt solution ; if bacilli, in 20 cubic centimeters. The emulsion is transferred to a sterile bottle, and heated to a certain tem- perature in the water bath to insure the death of the bacteria. The tem- perature must not be too high, so as to injure their antibactericidal properties. The usual temperature is 60 to 80° C. The streptococcus, pneumococcus, gonococcus, and colon bacillus can be killed at 60 to 65° C. in one hour. Some strains of staphylo- coccus will also be killed at this temperature. The writer has found cer- tain strains of staphylococcus that require 80° C. for several hours to kill them. The best results have been with the staphylococcus, strepto- coccus, and pneumococcus. The colon has not given quite as good results for the reason that, as the writer believes, the colon bacillus does not commonly produce infections, being a normal inhabitant of the body, and accordingly the body establishes a natural immunity against it. It has been found in many instances that, in conditions in which colon 40 SURGERY OF THE MOUTH AND JAWS. bacilli were found, the symptoms were not due to them, but to other organisms also present, and vaccine made from these bacteria produce the desired immunity. TUMORS AND CYSTS. The original meaning of the word tumor was swelling, but as it became known that many swellings were due to an inflammatory re- action or to some infection or injury, the word tumor was restricted to growths that were not known to be due purely to injury or to a recognized parasitic infection. As knowledge of pathology increased, certain enlargements that were formerly called tumors have, as their specific cause was discovered, from time to time been withdrawn from this classification and placed among the infectious diseases. It is probable that this process of elimination will continue indefinitely. The unmistakably inflammatory processes, such as pus infections, were early differentiated from tumors, but certain of the more chronic in- fections — among which are tubercle, actinomycosis, and syphilis — cause swellings that were often confounded wtih tumors. Even now it is sometimes difficult, clinically, to distinguish between them. Tumors that contain fluid are called cysts. A cyst always possesses a definite wall of special tissue that has grown to accommodate its contents — not simply stretched. This eliminates from the class of cysts such accidental accumulations as pus or blood, and also the simple distention of the normal duct with fluid. For example, an abscess, hematoma, or a recent obstruction of Wharton's duct does not con- stitute a cyst; but a permanent obstruction of a sublingual duct, which is one form of ranula, is a true cyst. Fluid areas in a solid tumor may sometimes be spoken of as a cystic degeneration. Tumors are often classified according to the tissue that predomi- nates. Thus we have lipomata, that are composed mostly of fat; fibromata, composed of fibrous tissue; osteomata, composed of bone. An important clinical distinction is that between the malignant and non-malignant tumors. Benign Tumors. — A non-malignant tumor is one that grows within a definite limiting capsule and does not invade the neighboring struc- tures, though it may grow between them, pushing them before it, or cause them to atrophy by pressure. A benign tumor never spreads to some distant part of the body by something transmitted through the blood or lymph streams, as do malignant tumors. Malignant Tumors. — Malignant tumors have no definite limiting capsule. As they grow, they tend to infiltrate neighboring tissues, the essential cells of the tumor growing directly into the neighboring tissues. Furthermore, malignant tumors disseminate to distant parts INFLAMMATIONS, INFECTIONS, TUMORS, CYSTS. 41 of the body through the blood or the lymph streams. When wandering cells lodge at some distant site, they begin to grow, and there is a secondary tumor of the same character at this site. This process of distant infection is called metastasis, and by it the whole body may become permeated with the tumor. Tumors that tend to infiltrate neighboring tissues, but do not cause metastasis, are spoken of as being locally malignant. Myeloma is an example of this. At present ma- lignant tumors are divided into three primary classes — sarcomata, endotheliomata, and carcinomata, or cancer. Sarcoma. — Sarcoma is a term applied to all malignant tumors that arise from connective tissues — such as bone, muscle, or fascia — in contradistinction to those that arise from endothelial or epithelial cells. The metastasis of a sarcoma is usually through the blood stream and rarely through the lymphatics. Sarcomata are often classified according to the structures they represent. Thus we have osteo-, fibro-, and chondro-sarcomata, etc., when bone, fibrous tissue, and cartilage can be respectively recognized in the growth. When the cells fail to develop sufficiently to recognize the tissue from which they form, they are classified according to size and shape of the component cells, as round cell, spindle cell, and giant cell sarcomata. EndCThElioma. — Endotheliomata arise from the endothelial cells of the blood vessels or serous cavities. The blood vessels and lym- phatic tissues arise originally from the same germinal layer as does the connective tissue : the mesoblast. Endotheliomata somewhat closely resemble sarcomata, from which they have more recently been differ- entiated. " Carcinoma. — Carcinoma, or cancer, is a growth of epithelium that breaks through the normal, limiting, basement membranes and invades the subepithelial tissues. This is the chief distinguishing feature between cancer and a benign papilloma or wart. The cells of the latter grow toward the surface, and never break through the limiting base- ment membrane. The metastasis of cancer takes place through the lymphatics, and it is for this reason that the regional lymph nodes always become infected with the growth. Carcinomata are classified mainly by the kind of epithelium from which they grow, those arising from the surface being squamous carcinomata, and those from glandu- lar epithelium being adenocarcinomata. In the nose and accessory sinuses the normal ciliated epithelium may be replaced by squamous epithelium at the site of a developing carcinoma. Carcinomata are also classified as medullary and scirrhous, according to the softness or hard- ness of the growth. The exact classification of some tumors is still a matter of question. CHAPTER III. PREPARATION OF THE HANDS, OPERATIVE FIELD, INSTRUMENTS, AND DRESSINGS. The object of these preparations is to reduce to a minimum the amount of septic material that may be introduced into a wound. Sur- gery cannot be done under the circumstances that test tube experiments in the bacteriologic laboratory might lead one to deem essential, but fortunately for the practicability of our art and for the preservation of the race, there is a natural resistance on the part of the tissues that will usually overcome any moderate bacterial invasion. We are often somewhat prone to forget what we owe to tissue re- sistance, crediting good results to some particular agent, when, as a matter of fact, we frequently do more harm than good by our activities. In observing the technic in vogue in any large clinic, where the opera- tors have the best opportunities for clinical observations and laboratory diagnosis, one must be impressed with the simple methods and the tendency to discard antiseptics. Complicated methods are apt to mis- carry, and to do more harm than good. PREPARATION OF THE SURGEON'S HANDS. All that is demanded for dental work and mouth examination is ordinary personal cleanliness, but the hands should be cleansed in the presence of the patient before each examination or operation. When bone or soft tissues are to be invaded, then what is regarded as surgical cleanliness is to be adopted. This differs from the former in degree — not kind. It is absolutely impossible to free the skin from all bacteria, but their number can be greatly reduced. To clean the hands for an operation, the nails should be trimmed and cleaned, and dead cuticle and "hang nails" should be removed from the edges of the nails. A surgeon's nails should be kept cleaned with a brush, and not require the use of a scraper or "nail cleaner." The hands and forearms to above the elbows are scrubbed with a brush or wash cloth in hot water and soap for five minutes. It is customary to subsequently immerse them for a few minutes in some antiseptic solution. In the way this is ordinarily done, it makes little difference what is used if it causes no irritation of the skin. Ninety-five per cent alcohol used for five minutes will destroy most of the surface bacteria, and has sev- eral advantages over the aqueous antiseptic solutions. It is usually 42 PREPARATION OF HANDS AND INSTRUMENTS. 43 non-irritating, and is a much more powerful germicide than are any of the solutions that can be habitually borne by the hands. It is very deliquescent, and quickly penetrates into wet crevices and pores. Various strengths have been advocated as being most efficient, but we use 95 per cent. To remove all danger of transferring bacteria by the hands, the latter must be covered by rubber gloves, and the arms with sterile sleeves. If gloves are worn, they should be free from minute holes, and should be changed if punctured. The perspiration that collects within a glove is usually germ-laden. One of the most important points in the care of a surgeon's hands is to avoid irritation of the skin and exposing them to infectious material, such as pus. PREPARATION OF THE OPERATIVE FIELD. Within the mouth little more can be done than the removal of gross sources of sepsis and repeated washing with a non-irritating fluid. Weak solutions of essential oils, iodin, permanganate of potassium, or certain other chemicals help to reduce the number of bacteria present, but their strength should not be sufficient to cause irritation. One of the most efficient antiseptic washes is a 50 per cent solution of alcohol. In the preparation of the skin of an operative field, it was formerly the custom^ to wash the skin several times with soap and water and alcohol or ether. This might be followed with various other anti- septics. Of late the simple method of painting the skin with a solution of iodin in alcohol has become rather popular. The rationale of the latter method is not supported by laboratory experiments, but in prac- tice it has been found eminently satisfactory, and is less annoying to the patient than repeated prolonged scrubbings. Our custom is as fol- lows : If hair is present, it is removed several hours before with soap and water and a sharp razor, or immediately before the operation with benzin and a razor. Dirt and scales of skin are removed with benzin. When the iodin preparation is used, the skin should be dry before being painted. Just before the operation, a 2^/2 per cent solution of iodin in alcohol is applied to the skin three times at ten-minute intervals. If the skin is dirty or scaly, it is first cleansed. If it is not convenient to make the three separate applications of the weaker solution, then U. S. P. tincture of 7 per cent iodin in alcohol is applied once freely, and as soon as dry, is removed with alcohol. If the full strength tincture is left on the skin, it is apt to blister. We are still uncertain whether the value of this mode of preparation is by virtue of the iodin, alcohol, or both. During "clean" operations, all skin is covered with sterile towels as soon as the incision is made. 44 SURGERY OF THE MOUTH AND JAWS. STERILIZATION OF INSTRUMENTS. It is an almost universal custom to sterilize instruments by boiling them from ten to twenty minutes in plain water. At sea level, water boils at 100°C. or 212° F. This will kill nearly all pathogenic bacteria, but will not always kill spores. Certain staphylococci and the spores of anthrax and tetanus will resist boiling water for long periods, but it is probably very seldom that these are present. It is possible that some of the bacteria that we now consider harmless are not so, and that certain of the little understood chronic diseases are due to infections with organisms that we now consider non-pathogenic. It may there- fore occur that the practice of partial sterilization will be discarded, and that some time in the future all instruments, dressings, etc., will be sterilized by steam or water at a higher temperature than 212° F. Boiling for twenty minutes is injurious to the edges of fine-cutting instruments, and these should always be sharp. It is therefore usually customary to resort to some form of chemical sterilization. One plan is to dip them in 95 per cent carbolic acid and then boil them for a minute. Another good plan is, after thoroughly cleansing them, to place the knives for fifteen minutes in 95 per cent alcohol. For chem.- ical sterilization to be successful, the knives must be absolutely clean and free from finger marks. It is a good plan for dentists to sterilize their burs, forceps, etc., in the presence of the patients. This can be conveniently done immediately after using them, and it removes a doubt that is often present in the patient's mind. Brushes, wooden-handled instruments, etc., may be sterilized in formaldehyde vapor, and cabinets for this purpose may be improvised or bought from supply houses. This sort of sterilization requires a number of hours, and is more often a matter of show than result. STERILIZATION OF RUBBER GLOVES. These are boiled with the instruments, and should be thoroughly wet inside. Dry sterilization of gloves is not practical, as dry heat drives off the sulphur, and a glove will stand only three sterilizations in a steam chamber. STERILIZATION OF CLOTHS, DRESSINGS, ETC. These may be boiled, but this is not convenient. They may be par- tially sterilized in steam under normal atmospheric pressure at sea level in twenty minutes. It is usually customary in hospitals to subject them to steam under fifteen pounds pressure for ten to fifteen minutes. This will give absolute sterilization. In sterilizing dressings, cloths, etc., it is essential that the steam penetrates, and for this reason they must not PREPARATION OF HANDS AND INSTRUMENTS. 45 be packed tighriy. Steam, even under fifteen pounds pressure, will not easily sterilize tightly packed cloths. Dry heat, such as a hot oven, will kill bacteria in from fifteen min- utes to one hour, depending on the temperature, but dry heat does not penetrate as well as steam. Outside of hospitals it is usually more practical to buy dressings already prepared by reliable manufacturers. STERILIZATION OF SUTURES. Silk, horsehair, silkworm gut, wire, etc., may be boiled or put in a pressure sterilizer. Catgut may be boiled in oil, ether, or alcohol, after all of the water has been removed in a dry oven. It is customary to buy catgut already prepared, but it can be done by anyone who will give it proper care. CHAPTER IV. HEMORRHAGE, SHOCK, AND ALLIED COMPLICATIONS. While most of the compHcations that may follow surgical opera- tions are preventable, they will nevertheless occasionally arise. When conditions are present that predispose to any of these complications, such conditions may usually be recognized in a careful preoperative exam- ination, and be corrected by proper treatment. HEMORRHAGE. Prevention of Hemorrhage. — In surgical operations the unnec- essary loss of blood is to be rigidly avoided, and the control of hemor- rhage should always be considered in planning the technic. Wherever possible, vessels should be isolated and temporarily or permanently ligated before being cut, and every cut vessel that continues to give a flow sufficiently large to be recognized as an individual source of hem- orrhage should be controlled. The proper planning of incisions, and the controlling of the larger vessels before cutting them, constitute our most potent prophylactic measures. For operations on the face the control of one external carotid is not always sufficient, on account of the number and size of the anastomoses, especially if there is any arterial sclerosis. We have found that the plan of temporarily clamping both external carotids, or one external and the other common carotid, serves the purpose well. We believe that the common carotid should never be tied without abso- lute necessity, and both common carotids should not be clamped at the same time. The position of the patient especially influences venous bleeding, which is greatest when the head is low, by sheer weight of the column of blood in the veins. If, to avoid aspiration of blood, the head is al- lowed to hang downward during an operation, this objectionable fea- ture may be somewhat ameliorated by having the table in such a posi- tion that the trunk and limbs slope slightly downward^the reverse Trendelenburg position. The sequestration of blood, after the manner proposed by Dawbarn, holds a certain amount in reserve, and we have resorted to it when free hemorrhage is anticipated. It is accomplished by fastening elastic bands around the extremities, close to the trunk, at such tension that the venous, but not the arterial, flow is retarded. This causes the 46 HEMORRHAGE AND SHOCK. 47 veins and capiiraries to become engorged. Later, when the bleeding is controlled, this reserve is liberated. If, for any reason, it is suspected that the clotting power of the blood is below normal, the clotting time should be ascertained, and if sluggish, an attempt should be made to remedy the defect. It is our practice to obtain some idea of the clotting time in all cases of elective operations. One very simple, yet practical, way of doing this is to obtain a drop of blood, about 8 or 10 millimeters in diameter, on a clean glass slide. In obtaining the blood, the end of a finger or the lobe of an ear is stuck with a cutting needle. The blood must flow- without squeezing the part, as squeezing lessens the clotting time. The point of a clean needle is passed through a new place on the edge of the drop every minute until a distinct string of fibrin can be made to adhere to the needle, which occurs just a little before the true clot is formed. This method is sufificiently accurate for practical purposes. A more exact way is to draw the blood up into a freshly made capillary tube 1 or ^ millimeters on its inside diameter. A short section of the tube is broken off each minute, or a part of the blood is blown out of the tube at minute intervals. As soon as the clot forms, the fibrin is seen stretching between the separate tube ends, or it can no longer be expelled by blowing. Still more exact methods are employed in physiological laboratories. A deficiency in clotting power may be natural or acquired. The formation of the clot depends on the presence of three elements — thrombogen, thrombokinase (both supplied by the blood or the tissues with which the blood comes in contact), and cal- cium ions (also normally present in sufficient quantity). Were calcium the element lacking, it could be easily supplied. It has been our experience and that of Dr. Sluder, who uses calcium lactate as a routine practice before tonsil and adenoid operations in children, that calcium lactate will lessen the clotting time in almost all cases. Between 1 and 4 grams are given daily for several days before the operation when the natural clotting time is over four minutes. It is not unusual for the clotting time to be reduced by this from as high as seven down to three minutes or less. We have seen even more striking reductions. Judging from the general tone of the literature, our experience with calcium lactate has been more fortunate than has been that of some others. Lack of calcium is not always where the fault lies, and for this reason various other therapeutic agents have been proposed. The repeated intravenous injection of a 2 per cent solution of gelatin, in normal saline, has been supposed to be helpful, but our personal experience with this method does not support this. In the review of all the literature, Wirth states that gelatin, calcium, and ovarian and other organotherapy have been disappointing, but that 48 SURGERY OF THE MOUTH AND JAWS. Weil's method of subcutaneous or intravenous injection of fresh animal serum is far better. Thirty cubic centimeters of a freshly made serum from an animal should be injected subcutaneously. Where conven- iences for preparing fresh serum are not at hand, an antitoxic serum has been used, but it is not as good as the fresh serum. Good results have sometimes been obtained from the local application of a foreign serum; or blood to the wound. Morawitz has proposed defibrinated blood transfusion as a styptic and reports good results. But in these cases improvement did not shov^ until after forty-eight hours. Holt recommends this highly. We have had excellent results from direct blood transfusion. General hygiene, tonic medication, and feeding should not be overlooked. The lack of clotting may be due to an increased percentage of salts in solution, as the presence of bile salts, or to certain diseases or pois- ons, as sepsis, scurvy, hemophilia, or purpura. When possible, the causes of these conditions should be treated; or, by serum injections or by direct transfusion, a blood that will clot should be obtained before an operation is undertaken. The clotting time in the individual may vary from time to time. When reduced by the administration of cal- cium, we have noticed that it begins to rise again within a few days after the drug is withdrawn. As hemorrhage continues, the clotting time decreases. We have learned from clinical observations that in the same patients the clotting time may change from time to time without apparent cause. Control of Hemorrhage. — Hemorrhage is designated as arterial, venous, or capillary, according to its source, but as a matter of fact in almost every instance it is a combination of all three, with one pre- dominating. To intelligently treat bleeding, one must understand and work in harmony with the natural hemostatics, without the existence of which all the surgeon's efforts would be futile. These are the re- traction and contraction of the cut vessel, the lowering of the blood pressure by diminution of the strength of the heart's action and of the arterial tone, and most important of all, the clotting of the blood. The clotting is facilitated by the retraction and contraction of the ves- sels and by the lowered blood pressure. Arterial bleeding is usually controlled by digital pressure, forceps pressure, torsion or ligation of the bleeding ends, or by ligation of the vessel and tissues en masse by means of deep sutures. Bleeding from the vessels situated in bony canals, such as the inferior dental or pos- terior palatine, may be controlled by inserting a peg, or pieces of mus- cle, or connective tissue, into the canal, or by occluding it by pressing in a soft piece of wax. The formula of Horsley, carbolic acid, 1 part ; olive oil, 2 parts; white wax, 7 parts, is very serviceable. The wax is HEMORRHAGE AND SHOCK. 49 sterilized by heat, and while still liquid is floated out on cold sterile water. Pieces of the congealed wax may be forced into the bone spaces and canals. When the bleeding point cannot be attacked directly, the outflow can be lessened and clotting favored by tying the artery any place proximal to the bleeding point. Where an artery has few and small anastomoses, such as the lingual, this plan is very effectual. Ligatures, whether of silk or catgut, should be drawn just tight enough to close the lumen of the vessel and to prevent slipping. They should not cut any of the coats, which would predispose to secondary hemorrhage. If there is not a sufficient amount of the vessel exposed to insure the ligature against slipping, the strand should be engaged in the tissues by means of a needle. The vessels should be tied with a square knot, and the forceps should be released just as the first tie of the knot is drawn tight. Except on large vessels, as a cut lingual, only catgut ties should be used in closed wounds of doubtful asepsis. Silk may be used in open wounds and in aseptic closed wounds. In wounds of any depth, especially if the vessels cut are not too large, the bleeding may be controlled by a temporary packing with gauze. If this is done aseptically, the wound may on the second, third, or fourth day be closed by secondary sutures, which might have been put in at the time the packing was placed. If the wound is not suffi- ciently deep to maintain the packing, it may be fixed in place with sutures, the pressure of a bandage, or, in some parts of the mouth, by fastening the lower to the upper jaw by ligating the teeth, or less effectually by a Barton bandage. One of the most effectual and convenient ways of controlling the bleeding in most wounds in the face, mouth, and scalp is by the use of deep approximation sutures, which should be drawn just sufficiently tight to accurately approximate the cut surfaces. Unless there is a grave fault in the clotting power, this will be sufficient. Greater ten- sion will cause necrosis and risk of sepsis along the suture tracts. Bleeding veins had best be tied, but a light pressure will control the flow. When there is any question of the collateral circulation, a longi- tudinal wound in a large vein, such as the internal jugular, may be stitched with a fine catgut or silk, or even patched by slitting a tribu- tary or neighboring vein and sewing it in to the defect. Torsion, tying, packing, and plugging replace or supplement the natural contraction of the vessels and clotting of the blood, while the ligation of an artery at a distance lessens the local blood pressure. In average individuals the bleeding from capillaries and small ves- sels needs no treatment. Continued capillary oozing is almost always due to slow clot formation, and may be treated by lowering the blood 50 SURGERY OF THE MOUTH AND JAWS. pressure and increasing the clotting time, and also by the local appli- cation of styptics, pressure, and means that stimulate the contraction of the local vessels. The direct application of the extract or powder of suprarenal bodies, preferably in the form of the alkaloid — as the 1 :1000 solution of adrenalin chlorid, for example — causes a contrac- tion that will often control the bleeding from small vessels until the clot has had time to form. The application of cold, usually in the form of ice or cold water — either directly to the bleeding area or, where this is not practical, to some related area — also lessens the caliber of the vessels, and is therefore helpful. Hot water will cause a contrac- tion and also hastens clotting. On account of the association of vasomotor reflexes, the application of cold to certain regions will cause a contraction in other anatom- ically remote areas. The immersion of one hand in cold water will in this way lessen the temperature of the other hand. The application of an ice bag over an inflamed appendix will lessen the hyperemia of the organ, and, what is more applicable to our subject, the application of ice to the back of the neck will cause a contraction of all of the vessels of the head, including those of the nose and mouth. Cold is very efficient in moderating and controlling the bleeding from subcu- taneous injuries, thus limiting the size and extent of ecchymosis and hematoma. For persistent bleeding following the extraction of one or more teeth, the sockets should be packed with antiseptic gauze or cotton. The selvage of the gauze is convenient for this purpose. If this does not control the bleeding, two to four thicknesses of the gauze are laid smoothly over the surface of the packing and the adjacent gums, and the whole is covered with soft modeling compound or quick-setting plaster of Paris. The modeling compound (a hard wax that softens in hot water and is used by dentists for taking impressions in the mouth), or impression plaster, should embrace the gauze-covered gum, and be of sufficient bulk to be in contact with the opposing gums or the teeth when the jaws are in contact. Before the wax or plaster is quite hard, the jaws are closed firmly and held in this position. The en- veloping wax or plaster now holds the gauze in a position under slight pressure. If there are any occluding teeth in the upper and lower jaws, the fixation is best done by wiring the lower to the upper jaw, with or without bands (page 100). If there are no teeth to which to wire, then a chin bandage must be depended upon, or resort may be had to a modified Kingsley splint (page 01) to hold the gauze in place. Measures should also be instituted to increase the clotting of the blood. Delayed clotting may be locally treated by applying foreign serum or blood (Prevention of Hemorrhage, page 46), or certain coagulents. HEMORRHAGE AND SHOCK. 51 such as alcohol, boiling water, chemical styptics, or the actual cautery. But any application that produces a slough or favors sepsis may be only temporarily effective ; for, as the slough separates, or the extra- vascular clots are liquefied, unless there is an intravascular clot in the intact part of the vessels, the bleeding will start again. Boiling water, instantaneously applied, alcohol, or a saturated solution of anti- pyrin, or an antiseptic gauze pack, are probably the best local styptics. The actual cautery is useful to touch a bleeding point, but it is hardly applicable to the surface. Gauze packing may be impregnated with a 5 per cent solution of collargolum, or colloidal silver in water. We have found that this is non-irritating and antiseptic. The presence of a large extravascular clot may favor the persistence of bleeding. One is sometimes surprised, on cleaning the clots out of a bleeding wound, to find that the flow rapidly diminishes and ceases. After hemorrhage has persisted for a certain time, the blood pres- sure continuously falls. The general, and with it the local, blood pres- sure is lowered by laying the patient in the recumbent position, in- suring quiet with sedatives, and not resorting to stimulants. This is an imitation of the faint that often accompanies severe hemorrhage. To raise up or stimulate a patient who has fainted from the loss of blood is but to invite an increase of the bleeding. Certain drugs, such as the nitrates, will lower the blood pressure, but their employment has seldom been advocated. Morphin, though a stimulant, is most valuable in quieting both the mind and body. The use of vasoconstrictor drugs as styptic, that cause a general contraction of the blood vessels, is on physiological grounds to be unqualifiedly condemned. Vasoconstrictors cause an elevation of blood pressure, which will outweigh the benefit derived from the relatively slight contraction of the blood vessels that occur at one point. The value of ergot in uterine hemorrhage is not due to its general action, but to its selective action on the uterine muscle. In bleeding of moderate severity, resort may be had to an expe- dient proposed in a German clinic. This consists in keeping the pa- tient in the erect or sitting posture until he faints and then laying him flat. By this means syncope must come earlier, and with less loss of blood than in the prone position. As bleeding continues, the clot- ting time continually decreases until one half the total quantity of the blood is lost. This is possibly the reason why, in many instances, apparently hopeless bleeding finally ceases before causing death. Postoperative Hemorrhage. — Primary hemorrhage should be controlled at the time of the operation or injury. If this has been properly done, postoperative bleeding, which is due to the slipping of ligatures or the expulsion of intravascular clots on restoration of normal blood pressure, will seldom occur. If it is due to the slipping 52 SURGERY OF THE MOUTH AND JAWS. of a ligature or the expulsion of a clot from a larger vessel, it is usually best to catch, and either re-tie it, or simply leave the forceps in place. Often the bleeding can be controlled by removing clots, readjusting the packing, maintaining the recumbent position, quieting the patient with a little morphin, and the avoidance of any pernicious surgical activity. As stated before, the patient may be made to sit up until he faints and then laid flat. Secondary Hemorrhage.- — ^This usually occurs some days after the operation or injury. It may follow suppuration or the separation of the sloughs, and presents a special difficulty, inasmuch as the vessels involved may be very friable or held in a dense inflammatory mass. It is best treated by cleaning out the wound with antiseptics, cutting in- struments, or a cautery at a dull red heat, and the use of any other previously mentioned means that circumstances dictate. If a pack is applied, it must retard, not favor, sepsis. The actual cautery is dan- gerous in the neighborhood of large vessels. An artery can be ligated at a distance to control bleeding from its trunk or any of its branches. The efficiency of this latter procedure varies inversely with the size and number of the anastomoses distal to the ligature, because the col- lateral circulation will be proportionally active. Ligation of the lingual artery will effectually control bleeding from one half of the tongue, ligation of one external carotid has little effect, and ligation of the in- dividual branches will vary in efficiency according to the size and number of their communications. The ligation of the internal max- illary artery is too difficult to be practicable, but after tying the ex- ternal carotid above the occipital artery, the temporal can be tied above the origin of the internal maxillary, which will leave only the transverse facial, the posterior auricular, and some parotid branches uncontrolled. A patient suffering from loss of blood first feels faint, and possibly nauseated ; if the erect position is maintained, he may fall. With mod- erately slow progressive hemorrhage there is thirst and restlessness ; there is an increasingly rapid and weak pulse, with a continuous fall of blood pressure; the skin is often moist and clammy, and both the skin and mucous membrane become pale. Eventually there is air hunger. The condition closely resembles the restless form of shock, from which it is often difficult to distinguish when the bleeding does not show on the surface. Treatment of the Effects of Hemorrhage. — With rare excep- tions, according to our experience and opinion, neither stimulants nor transfusion, nor any other method of raising blood pressure, should be employed before the bleeding is at least temporarily controlled. If the condition of the patient seems critical, quiet should be insured, if nee- HEMORRHAGE AND SHOCK. 53 essary, with a 'little morphin given hypodermatically. The head should be on or below the level of the body ; the limbs may be elevated, or even bandaged, to keep as much of the blood as possible circulating between the heart, the lungs, and the vital centers ; the body should be kept warm by blankets and artificial heat. Hot-water bottles placed around an unconscious or semiconscious person should be at a temperature of 115° F., and no higher, for otherwise the patient may be seriously burned. Once the loss of blood is controlled after a severe hemorrhage, the vessels should be filled with normal saline solution at a temperature of 104° F. to 110° F. Fatal hemorrhages can occur through loss of fluid when there are still enough blood cells and plasma in the vessels and tissues to comfortably carry on function, if they could but circulate. A level teaspoonful of salt to a pint of water, boiled and cooled to 110° F., by setting the vessel in a pan of cool water, is a practical way of preparing the saline solution. It should be introduced either directly into a vein, under the skin, or into the rectum at a temperature of 100° F. For want of a special reservoir, a sterilized fountain douche bag is usually accessible and is very effective. It is difficult to accurately gauge the amount of fluid that is slowly running from a rubber douche bag, but if the bag is hung on the ordinary spring balance scale that is usually found in every house, the flow can be gauged with some accuracy. SALINE TRANSFUSION. Intravenous Transfusion. — To introduce saline directly into a vein, the cephalic, median cephalic, or median basilic are the veins usually selected, but any vein of sufficient size in either extremity will answer. Sometimes the long saphenous vein in front of the internal malleus is more accessible than are those of the upper extremity. The vein may be tied after being exposed under a local anesthetic, the ends of the ligature remaining long. A V-shaped or longitudinal slit is made in the vein, just proximal to the ligature, and the point of a glass eye-dropper attached to the douche tube is slipped into the vein. A simpler method is to attach a fair-sized hypodermic needle to the douche tube and insert the point directly in the vein without incising the skin. This is sometimes very difficult to do. It is needless to state that these operations should be done asep- tically. If necessary, a vein can be made prominent by throwing a bandage around the upper part of the limb. The compression bandage must be removed before allowing the saline to flow. Fluid should not be put directly into the vein at a greater rapidity than 500 cubic centi- meters in ten minutes, and the flow should be withheld on any signs 54 SURGERY OF THE MOUTH AND JAWS. of cardiac embarrassment. In either method, the second sound is a good index to the heart's condition. The air and cold water should be expressed from the tube and needle just before inserting by holding the needle with a little less than one half of the tubing pointing toward the ceiling, and allowing the water to flow until it comes warm from the needle unmixed with air. Air that remains in the tube after this will not be carried into the vein. Hypodermoclysis. — Saline may be put into the subcutaneous tissue of the chest, abdomen, or thighs by means of a hollow needle and gravity. This method is more painful than intravenous transfusion, but it is safer and usually sufficiently rapid. Absorption from the sub- cutaneous tissues is hastened by massage and kneading of the indu- ration. Proctoclysis. — If the rectum is loaded with feces, this may have to be removed with an enema. If a large quantity of water is thrown into the rectum, it may start peristalsis and be expelled. If the saline solution is allowed to trickle in, its absorption is more certain. Ordinarily it should not be allowed to flow much more rapidly than it can be absorbed — one or two drops a second. This latter method was first proposed by J. B. Murphy. Of the various methods of in- troducing saline into the circulation, proctoclysis is the freest from danger, and the one most commonly employed. Water flowing slowly into the rectum, or into the subcutaneous connective tissue, cools rapidly in the tube. There are special devices for maintaining the proper temperature, a very efficient one having been devised by O. Elbrecht, but these are not always at hand. For intrave- nous and subcutaneous transfusions, if it is found necessary, several coils of the douche tube may rest in a basin of water, or be wound around a hot-water bottle maintained at the proper temperature, and held very close to the patient. For slow rectal injections, the douche bag is held very little above the level of the bed, and all of the tube can be under the bed clothes and thus kept warm. If, after transfusion, or any other method of introducing fluid into the circulation, there is profuse sweating, it should be controlled with moderate doses of atropin. Even where this is due to shock, the atropin often seems helpful. It is a serious question to our mind as to whether other internal stimulants than filling the vessels and the use of a little morphin are ever indicated in the treatment of hemorrhage. When a transfusion is done with saline, the blood is diluted, which may increase the clotting time. If it has not already been controlled, it will be more difficult to accomplish this after than before the saline transfusion, on account of both increased blood pressure and decreased clotting power. If repeated hemorrhage and saline transfusions alter- HEMORRHAGE AND SHOCK. 55 nate several times, a blood of very poor clotting power will result. When not satisfied that the source of the bleeding is permanently con- trolled, the transfusion should be with blood. BLOOD TRANSFUSION. Direct blood transfusion is done by connecting a blood vessel of a donor, who is free from transmissible taint, to a vein of the patient in such a way that the blood passes from the donor to the patient. One method of doing this is to unite the radial artery of the donor to the cephalic vein of the recipient in such a way that the blood in its passage comes in contact only with the endothelial lining of the vessels. The ra- dial artery and cephalic vein are selected simply for convenience. This is usually done by means of a cannula, first devised by Payr, and of which various modifications have been made. The operation is done under a local anesthetic. The clinical symptoms evinced by the donor and donee should determine the length of the operation. A strong, full-blooded donor in the recumbent position will probably lose 500 to 800 cubic centimeters of blood before showing marked symptoms. A dog may bleed to the last drop and be perfectly restored by this method. This operation, while apparently simple, is not apt to be conducted smoothly by one who has never performed it. Even in the hands of one more or less expert, it is not always successful. The two people to be operated upon should be placed in the proper juxtaposition, and sufficient of each vessel should be freed. The arteriovenous operation has two serious difficulties inherent to it — one, the lesser, is that an artery has to be freed, and the other is that the cannulae are very min- ute, somewhat difficult to handle, and give very little room for the blood stream. It is for these reasons that we look on the method de- vised by Dorrance and Ginsburg as superior, which consists in uniting the distal end of a vein of the donor to the proximal end of the recip- ient's vein. Lewisohn's Method of Sodium Citrate Blood Transfusion. — Lewisohn's experiments^ have shown that 0.2 per cent of sodium citrate in blood is sufficient to prevent coagulation outside the body for 2 or 3 days. Five grams of sodium citrate represents the largest amount that can be safely introduced into an adult. 1000 c.c. of blood containing 0.2 per cent citrate only represents 2 grams of sodium citrate. The technique employed by Lewisohn is most simple. 1. Obtaining the Blood from the Donor. — A tourniquet is applied to the donor's arm and one of the veins at the bend of the elbow punctured. A large cannula is used so the blood will flow rapidly. The blood is allowed to fall into a graduated glass jar which con- iJournal of the A. M. A.. March 17. 1917, 826. 56 SURGERY OF THE MOUTH AND JAWS. tains 2 per cent sodium citrate solution in quantity necessary to make a 0.2 per cent solution in the amount of blood to be given. For example, if we want to give 450 c.c. of blood, we add this to 50 c.c. of the 2 per cent citrate solution. The blood is well stirred as it falls into the jar. Care must be taken never to have less than 0.2 per cent of sodium citrate, or the blood will coagulate. A slight surplus of citrate solution will prevent this and can be added with perfect safety. 2. Infusion of Blood into the Recipient. — The citrated blood is either administered through a funnel or transferred to a glass in- fusion jar. The patient's ivein usually has to be exposed through a small incision. The cannula is inserted and attached to a funnel or infusion jar which contains 20 or 30 c.c. of physiologic saline solution. The citrated blood is then poured into this receptacle and allowed to flow into the vein by gravitation. Before resorting to transfusion in any case, whenever possible a Wassermann test must be made on the donor, and the blood of the donor and recipient must be tested for agglutination and hemolysis. Neglect of these precautions may bring disastrous re- sults. The simplicity of Lewisohn's technique renders it available to all, and makes it superior to all other methods of transfusion, either direct or indirect. SHOCK. It is easier to prevent than to efifectually treat shock. Fear, loss of blood, rough handling of richly innervated tissues and nerve trunks, chilling of the surface, and prolonged operations are all conducive to shock. It is difficult to estimate the resistance of the individual, and therefore the energies should always be conserved. Old people, with high blood pressure, stand the loss of blood poorly, and the supervening shock comes suddenly. Shock is accompanied by a fall of blood pres- sure ; in fact, the latter may be taken as an indication of the degree of the shock. Except in cases of advanced arteriosclerosis, in cases of increased intracranial pressure, and in cases where the shock is pro- duced by a sudden injury — as cutting large nerve trunks or chiseling on the skull — the stage of severe shock is usually preceded by a some- what gradual loss of pressure. Therefore, in all operations in which shock might develop, it is a wise precaution to keep track of the blood pressure by palpation of an artery, or, more accurately, by frequent readings from a sphygmomanometer. One of the most concise descriptions of shock has been given by Moullin : HEMORRHAGE AND SHOCK. 57 Two varielies of shock are described — the one characterized by ex- treme depression ; the other, which is much more rare, by great excite- ment. Upon what the difference depends, why one form should occur and not the other, is not known. In the ordinary form the patient lies perfectly quiet, with the eye- lids half closed and the limbs in the position that chance may have placed them ; conscious, but paying no attention to anything around ; able to speak feebly and slowly, but entirely incapable of any mental effort. The face has lost all expression ; the skin is cold, pale, and clammy, that on the forehead often being covered with perspiration ; the pulse is frequent, generally more or less irregular, the artery seem- ing to collapse and empty itself with each beat ; the respiration is shallow, and the temperature far below normal — sometimes as much as three or four degrees. The sphincter ani is usually relaxed; urine, if the bladder is full at the time of the accident, is retained, but afterward for many hours the secretion stops almost altogether. In the worst cases, such as are almost certain to prove fatal, there is complete absence of the sense of pain. The writer has many times seen patients dreamily looking on, without a sign of intelligence, while broken fragments of bone were being removed and search made for bleeding arteries in limbs that had been crushed in a railway accident. Vomiting is of frequent occurrence; in head injuries it not uncom- monly marks the onset of reaction. In a few moments the face be- comes flushed, and the pulse regains its vigor and fullness. In other cases it may either occur at the commencement, when it is compara- tively of little significance, or later, after a few hours, and then it not uncommonly marks the beginning of the end. Shock may be almost instantaneously fatal. The author has known death to occur within five minutes from puncturing a small hydatid cyst in the liver, or it may begin more gradually and slowly become worse and worse until death ends the scene. The other variety, that which is characterized by furious excitement, is more uncommon. Its onset is nearly always gradual ; at the first there is some ground for hope, and the general condition appears not altogether unsatisfactory, although the pulse is very rapid and devoid of power ; very soon, however, the patient becomes restless and begins to talk volubly and incoherently ; delirium sets in ; the limbs are thrown wildly, utterly regardless of pain, and in a short time this is followed by a condition resembling furious mania. The result is invariably fatal from collapse. Diagnosis.— Syncope due to failure of the blood supply to the brain rarely causes any difficulty; with hemorrhage, especially when it is internal, it is different. In many cases of injury to the abdominal 58 SURGERY OF THE MOUTH AND JAWS. viscera it is practically impossible to make a diagnosis — the two are so often associated. Given a case of severe contusion followed by col- lapse, it may be due to shock alone or to shock complicated by hemor- rhage from rupture of the viscera or tearing of a mesenteric artery or vein, and there is no certain method of separating one condition from the other. Failure of sight due to anemia of the retina, constant yawning or deep sighing inspirations, and throwing the arms over the head are very suggestive of hemorrhage, but nothing more; and a great deal of blood may collect in the abdominal cavity without causing any marked degree of dullness. Treatment. — The expeditious operator, who uses ordinary judg- ment, will seldom have to deal with severe shock of his own produc- tion. Operations should be carefully planned and nicely executed. They should never be begun without a definite plan of technique and of cooperation on the part of the assistants and anesthetist. Many opera- tions can advantageously be done in two stages. The patient should have his fears allayed before the operation. During the operation the patient should be kept dry and enveloped in woolen blankets or rubber dam. Excessive loss of blood should be immediately followed by rectal, subcutaneous, or intravenous infusions of salt solution. Where practical, large nerve trunks should be blocked by the injection of a 1 per cent solution of cocain or novocain directly into the sheath before they are cut. The same holds true for the superior laryngeal nerve. Until we learn the true pathology of shock, all treatment must re- main empirical. Varied as are the views as to the precise nature of this condition, there is a unanimity of opinion that the prime essentials in the treatment are bodily warmth and mental and physical rest. Warm blankets and hot-water bags, or bottles, will insure the former ; while for the latter we are much dependent on the behavior of those around the patient. Morphin in small doses hypodermatically is often very useful. The value of stimulants in shock is a mooted question, but it is probable they are given, as a rule, rather from the desire to be doing something than from any warranted conviction as to their utility. If a stimulant is to be administered, it is possible that an ordi- nary hypodermic syringeful of neutral camphorated oil injected every half hour will be found to be as useful as any and open to fewer objec- tions. If intravenous or subcutaneous infusion of saline is resorted to, it should be supported and sustained by adrenalin and atropin. Because of the supposed loss of vasomotor control and consequent sequestration of blood in the abdominal veins, bandaging of the limbs in severe shock has been a common practice, and Crile elaborated a pneumatic suit for maintaining the blood pressure. Even if effective, the latter is at Ibe disposal of but few, Init it can l)e imitated by bandag- HEMORRHAGE AND SHOCK. 59 ing the inner tube of a bicycle tire to the extremities and trunk, and then inflating the tubes. After all, however, aside from rest, the restoration of the normal bulk of fluid in the vessels, the maintenance of bodily warmth and of mental and physical rest, and the elimination of pain, shock is best treated in a negative way. AIR EMBOLISM. If air enters a vein in sufficient quantity to reach the right auricle, grave depression or death may follow. If any conclusion can be drawn from animal experimentation, it must be that the danger result- ing from air in the right heart is considerably exaggerated in most textbooks, although there are a number of apparently authentic cases Fig. 9. Experiment IIB. Tracing made from ventricle of a cat while repeated injections of air were made into the jugular vein. The interruptions in the contrac- tions are plainly shown. of death from this cause. In 1885, Senn collected about twenty such instances. In a carefully conducted series of experiments on cats and dogs, which were made for the purpose of obtaining accurate data for this subject, during which blood pressure tracings were taken while and after measured quantities of air were let or forced into the jugular vein, it was observed that there was both a mechanical and a vital dis- turbance on the entrance of the air into the right heart. The air de- stroyed the action of the valves, and at the same time the heart's effort was decreased (Fig. 9). As a result the blood pressure would fall dangerously low— sometimes almost to zero. The amount of air required to kill different animals of the same species varied enormously, which possibly explains the lack of uniform- ity in the published clinical reports on the subject (Figs. 10 and 11). Based on the observations made during these experiments, the treat- ment we propose for air embolism accompanied by serious symptoms is the introduction of adrenalin chlorid in a fairly concentrated solution, 60 SURGERY OF THE MOUTH AND JAWS. 1:10,000 to 1:1000, directly into the right ventricle, and this should be accompanied by a small amount of normal saline solution. In our experiments on dogs we used 40 cubic centimeters or more of saline solution ; but in most cases a large quantity of air had been put in under pressure, and it required a pressure of 60 centimeters of water to force the fluid into the vein (Fig. 12). For clinical application, a fine hypodermic needle might be pushed through the chest wall directly into the right heart. This could be done by inserting the needle through the chest wall and lung at the anterior extremity of the third or fourth right intercostal spaces. We observed no evil effects in dogs from perforating the heart wall with a fine needle, but to attempt to do it through the chest wall would be a very uncertain procedure. •'if:iis&6t23ssx-sA^:&'t m,^ cu, ^oj. lj.n (fi crM-«4«'w^, , - \i,'^l ""^^rils and palatal supports. It is controlled and held in place by a hook or wire near its socket "" ^^^MoVabl'^" extensions are made of wire (German silver No. 14 American gauge) with vulcanite rubber pads, which can be bent according to the direction of P':^^^.^^,.'^^^^ [^f; to relieve the tension of sutures. Thoy arc hHd In place by ligatures.— Alter Ka/an,iian. suture, httle or no consideration being given to early correction of the bony displacement. As a consequence, the cases finally came into the hands of the oral and dental surgeon with the soft tissues TREATMENT OF INDIVIDUAL FRACTURES. 141 tensely united .over the deformed bones, and the difficulties to be overcome in correction were enormously increased. It has now be- come a well recognized principle that "no attempt should be made to suture the soft parts with the idea of closing a gap until such time as union of the fractured parts in correct relation is well under way and permanent splints are adjusted" (Kazanjian). By keep- ing the mouth cleaned and reducing displacement, there will be less disfigurement to rectify. It is not desirable to wait until scar tis- .sue has formed. We would amplify this to the extent of saying that repair may be made over a defect if the bony gap is filled by a properly fitting lug (Marten's splint) affixed to the retaining splint. As soon as the splints are adjusted and healthy granulation of the wounds has begun, the parts may be sutured. Kazanjian de- Fig. 78. Illustrating method of support by means of revised Kingsley splint with wires and vulcanite plate. Patient had an extensive clean wound due to a shell fragment, severing the nose and cheeks, which were turned downward. (See Fig. 13.) Parts were also supported in approximately normal position by means of the vulcanite pad. — After Hayes. scribes the use of facial supports in these cases as follows : "Facial supports are of great assistance in moulding the parts and support- ing the sutures. A simple support is made in the following manner : ordinary hooks are sewed close together to the edge of strong band- age material. A piece of this is stuck to the face, with collodion on either side of the sutured portion of the soft tissue and the two laced together with silk. Hooks may also be sewed to adhesive tape. Another form of facial support is one in which a series of plates of vulcanized rubber held in place about the face and cheeks by head gear serves as a base. To this are attached heavy wires, with vul- 142 SURGERY OF THE MOUTH AND JAWS. canite fingers on the ends to press the tissues at certain places and offset muscular tension. There are many possibilities for additions and variations such as tubes to serve as nostrils, etc." (See Figs. 77 and 78.) Methods of Fixation. — Immobilization of the bones can usually be carried out within a few days at a time when the fractured parts can still be moved freely. The former occlusion of the lower teeth with the upper should always be the guide in fixation of the frag- ments, even though this entails considerable separation between the fractured ends. The form of fixation to be appHed depends upon the location of the fracture, the amount of substance lost, the amount of displace- ment, the number, condition, and position of teeth present. Below is given a rational classification of gunshot fractures of the jaws, with an indication of the form of apparatus best adapted to each form. The selection and adaptation of the best method of fixation for individual cases must be left to the ingenuity of the surgeon and his assistants. In a general way, any method of fixation that is effective and allows the mouth to be open, is better than one in which the jaws must be kept closed. The latter interferes with mastication, leading to ankylosis, and hinders drainage. A. Recent Fractures. — 1. Fracture; oi? the; Bodiy of the; Mandibi.^ Anterior to the Last Existing Tooth Without Loss of Substance. — Fractures of this type frequently occur from concussion, where the projectile does not strike the jaw itself. They may be treated by methods of fixa- tion employed in civil practice, among the best of which are the vulcanite or metal jacket splint described on page 116 (Hullihan's splint, Fig. 57.) Gilmer's lingual band splint described on page IIG (Fig. 58) may also be found useful. 2. Fractures of the Body of the Mandibee Anterior to the Last Existing Tooth With Few Teeth, Considerabee DispeacEp MENT, or Loss of Substance. — In this class are found the major- ity of gunshot fractures. When there is loss of substance at the symphysis, the fragments tend to be drawn together in front with the occlusal surfaces of the teeth facing inwards toward each other. In the lateral portion of the bone, the loss of substance causes the fragment on the sound side to be drawn over to the affected side. The best method of maintaining separation and fixing the fragments in their normal positions in relation to the upper teeth in these cases is by the metal band and wire splint described on page 120 either TREATMENT OF INDIVIDUAL FRACTURES. 143 made in one aolid piece or applied in sections, afterwards fastened together. In cases with considerable loss of substance, where there is a tendency for the lower jaw to swing over to one side, the outer sur- face of the spHnt on the opposite side may be provided with a metal- lic flange to engage the teeth of the upper jaw, thus acting as an inclined plane to bring the teeth into proper occlusion when the jaws are closed (see page 123). 3. Fracture oi^ thk Mandibli: Behind the L'ast Existing Tooth. — The form of apparatus is selected to best suit the individual case. These cases comprise fractures of the body of the bone, ramus, or condyle, with or without loss of substance. Where there is no tendency to displacement and no loss of substance, the simplest form of treatment is by fixation of the lower jaw to the upper by means of ligature wires directly applied to the teeth (see page 101) or through the intervention of Gilmer's arch (page 116). In fracture of the angle and ramus with loss of substance, if the ramus stays in good position this form of wiring may be sufficient, but if the ramus displaces forward or laterally, after fixing the anterior fragment by wiring the teeth to those of the upper jaw, the ramus may be steadied in position by drawing it back with a hook passed around it through the cheek, or a lion-jaw forcep catch- ing it through the skin, and then placing modeling composition be- tween the ramus and the last molars above and extending down be- hind the molars below. In case the upper and lower teeth are not available for ligating with wire, intermaxillary fixation with ligature wire may be carried out' as follows :^ Holes are drilled through the jaws at the level of the roots of the teeth about three-fourths of an inch away from each fracture line. Stout silver wire is then passed through the holes, and the fragments approximated if possible. Further holes are drilled in the region of the lateral incisors in both upper and lower jaws, or in other suitable positions, according to the site of the frac- ture, and silver wire passed through both. The mandible is brought into the desired position, and the wire tightened by twisting. Fractures in this region may also be treated through the medium of the upper and lower swaged metal jackets described on page 121. Occasionally, also in cases where there is tendency of displace- ment of the jaw to one side, the hooks on the splint afiford attach- ment for intermaxillary elastics, this force being used to overcome the deviation. Where it is desirable to dress the jaw with the mouth open, and iPickerill, Dominion Dental Journal, 1917, xxix, 217. 144 SURGERY OF THE MOUTH AND JAWS. prevent forward displacement of the ramus, the splint described by Herpin (Fig. 75) is applicable. 4. Gunshot Fractures of thij. Upper Jaw. — (a) Partial fractures as a rule are easily maintained in position by some form of appliance such as a band and wire splint, or a swaged metal jacket attached to the upper teeth. In unilateral frac- tures, ligation of the teeth of the sound side to those of the lower jaw is often efficient. (b) In transz'erse fracture of the entire maxilla, the reversed Kingsley bar splint combined with a head cap as described by Mar- shall (see page 90) is suitable. (c) In comminuted fractures or those associated with much loss of bone, the modification of the Kingsley splint is not applicable as Fig. 79. Modified Barton bandage for fracture of mandible and supporting sub- maxillary dressings, which avoids backward pull on chin. Turns are as follows: Vertex to chin, under chin to occiput, to vertex, to chin, under chin, to occiput, to vertex, etc. pointed out on page 91, and the apparatus described and illustrated on page 92 should be employed. B. Old Fractures of the Mandible with Partial or Non-union, and the Fragments in Bad Position. — 1. Operative Treatment. — The method of choice in these cases is, under local or general anesthesia, to divide adhesions, fibrous bands or callus, bringing the fragments into their correct relations, and fixing them there by means of any of the appliances described in the previous section suitable for the given case in hand. Consider- able gaps in the bone, even amounting to several centimeters in width, produced by this readjustment of the fragments, may be in time solidly filled with new bone. If non-union persists after sev- TREATMENT OF INDIVIDUAL FRACTURES. 145 eral months' trial, the case may be considered suitable for replace- ment of the lost tissue by bone or cartilage grafting. It is in these late cases especially that the inclined planes made by flanges of suit- able shape to engage the teeth of the opposite jaw, are of especial value in overcoming the tendency to return of the fragments to their old incorrect position. In operating upon these cases, after dividing cicatrices, the separated tissues may be kept apart by means of softened modeling composition pressed into the wound. 2. Orthopedic Splints. — In. cases of displacement of lesser de- gree, or where for some reason operative measures are not to be considered, orthopedic splints for the gradual restoration of the frag- ments to their normal position may be employed. Great ingenuity is manifested in the adaptation of these principles to individual cases. The forms of apparatus most commonly used for this purpose are : the sectional band and wire splint, the jackscrew, and lugs and in- clined planes, described on pages 121 and 122. Bandaging. — Bandaging in connection with fractures is of im- portance. The most useful bandage is a modification of the Barton, which avoids the disadvantage of the latter in making backward pressure on the chin (Fig. 79). An elastic bandage, preferably a piece of rubber dam 15 or 17 cm. broad, if not put on too tightly, is more comfortable and more effective than a non-elastic bandage. CHAPTER X. DISLOCATION OF THE LOWER JAW. The mandibular joint is made up of the condyle of the mandible below, and the glenoid fossa and articular eminence on the under sur- face of the temporal bone above. Posteriorly, the glenoid fossa is bounded by the delicate tympanic plate, which separates it from the external auditory canal. The roof between the glenoid fossa and the middle cerebral fossa is very thin. Between the condyle and the tem- poral bone there is an intraarticular fibrocartilage that divides the joint into two compartments. It is surrounded by a capsular ligament, while three other ligaments, which are described later, add to its strength (Figs. 80 and 81). KINDS OF DISLOCATIONS. There are four varieties of dislocation at this joint that have been described: forward, which is the ordinary form, and usually uncom- plicated by any fracture ; and an upward, a backward, and an outward dislocation. Instances of the occurrence of any of the latter three varieties are extremely rare, and each of them is, of necessity, accom- panied by a fracture. Albert states that the condyle may be dislocated backward below the external auditory canal, which could occur with- out a fracture. For convenience, the latter three will be considered first. Upward Dislocation. — A severe upward blow on the chin while the mouth is open, or an upward blow under the angle, if the upper or lower posterior teeth are missing, might drive one or both condyles through the roof of the glenoid fossae into the skull. In such an in- jury the movement of the jaw would be limited, and the ramus would be apparently shortened. Le Fevre reports such a case. Treatment would consist in trephining above the glenoid fossa, ex- tracting the condyle, and possibly draining the middle cerebral fossa. The mandible could be retained in position by appropriate dental fixa- tion. In one case of partial upward dislocation we simply wired the jaws together for five weeks. Backward Dislocation. — A backward blow on the chin while the mouth is closed might drive the condyle against the tympanic plate with such force as to crush it into the external auditory canals. The chin would recede, and there would probably be bleeding from the ca- nals ; and an examination with an aural speculum would show obstruc- 146 DISLOCATION OF THE LOWER JAW. 147 tion of the canal. The condyle would be felt, or, with an x-ray exami- nation, would be seen to be in an abnormal position. If the backward dislocation is unilateral, the chin will deviate to that side. Treatment will consist in drawing the jaw forward and retaining it by dental fixation. (See methods under Fracture of the Mandible, Chapter VIII.) An attempt should be made to restore the auditory canal. Fig. 80. Ligaments of the temporomandibular joint viewed from tlae external sur- face. A, capsular ligament ; B, stylomandibular ligament. Outward Dislocation. — Robert has reported a case of outward dislocation. The body was fractured in front of the angle, and the condyle was to the outer side of and above the zygoma. To reduce the dislocation, the ramus was pushed outward until the condyle was freed from the zygoma, and the condyle was pushed down and into place. The jaw should then be treated as in a fracture in front of the angle. Forward Dislocation. — Even this form of dislocation is com- paratively rare, and is more frequent in females than in males. It has occurred as the result of drawing on the jaw in an attempt to deliver 148 SURGERY OF THE MOUTH AND JAWS. the head in difficult labor, but it is much more rare in children and in elderly people than in the prime of life. When the jaws are closed, the condyle rests in the glenoid fossa ; but as the mouth opens, the axis of motion being in the neighborhood of the inferior dental foramen, the condyle travels forward on the articular eminence. If from any cause the condyle is forced but a little past the crest of the eminence, usually without a rupture in the capsular ligament, it may become locked in that position. This constitutes an anterior or the common dislocation of the jaw. The determining cause is usually an over- activity of the external pterygoid muscle, assisted possibly by the pos- terior fibers of the masseter, when the mouth is fully open. More rarely it is due to a backward blow on the chin when the mouth is Fig. 81. Temporomandibular joint. A, capsular ligament ; B, external auditory canal; C, ma.stoid processes: D, upper joint compartment; B, intraarticular cartilage; F, articular eminence ; G, zygoma ; H, mandible. open, which, by forcing the body and lower part of the ramus back- ward, at the same time throws the condyle forward. The jaw has been dislocated in the act of drawing a tooth, but in this case the dislocation is more probably due to muscular action, or from opening the mouth too widely, than from the force used in the extraction. A unilateral dislocation has been produced by a blow on the posterior border of the ramus. The amount of displacement varies greatly in different cases. In a few the coronoid process has become engaged under the malar bone, and this has been regarded by some as the factor that prevents reduc- tion in all instances, which is true probably in but a very small per- centage of cases. The condition in most anterior dislocations of the jaw does not differ materially from that in a dislocation of the hip or shoulder. In each of these joints the head of the bone is held in a socket by the tension of the muscles and ligaments. If the head DISLOCATION OF THE LOWER JAW. 149 once crosses the raised border that surrounds the socket, the same mus- cular and ligamentous pull holds the head in its new position, and it is only by some manipulation that either relaxes or overcomes this mus- cular ligamentous pull that the head can be returned to its socket. This view with reference to anterior dislocation of the jaw has been ex- pounded at various times, but it is most clearly presented by Dr. Lewis A. Stimson in his classic chapter on dislocations of the lower jaw; and we are in such full agreement with the views which he holds that we cannot help following his text rather closely. Perthes and Albert ex- press no opinions radically different from those of Stimson, and in the main corroborate his views. Besides the capsular, the joint is protected by three other strong ligaments : the stylomandibular, extending from the styloid process to the posterior border of the ramus ; the external lateral, closely incor- porated with the capsular ligament ; and the internal lateral, which is attached above to the spine of the sphenoid and below to the spine of the mandible. Of these the external is the shortest and strongest, and is most closely concerned in maintaining the head in its false posi- tion when it becomes dislocated anteriorly, the other ligaments con- tributing. When the condyle occupies the glenoid fossa, the direction of the external ligament is downward and backward. As the condyle travels forward, the point of attachment of the ligament on the neck assumes a position directly inferior to its upper attachment. This would allow the ligament to become slack if the plane of the posterior surface of the eminence were not downward and forward. When the head reaches the crest of the eminence, the neck of the jaw and the ligaments are in the same plane, and the latter is tense (Fig. 80). For the head to travel farther forward without rupture of the ligaments, the axis of motion must, for the moment, change from near the en- trance of the dental canal to the point of insertion of the external lateral ligament. The head first tilts forward on this new axis, and then by the continuance of the force slides onward, carrying the inferior attachment of the ligament with it until the ligament is again taut. Where an anterior dislocation has occurred, the direc- tion of the combined pull of the muscles of mastication is such as to hold the lower attachment of the ligament forward. The muscles of mastication can no longer tilt the head backward, as they do under normal conditions, for now, with the ligament serving as a fulcrum, the posterior surface of the head is jammed against the eminence by the temporals, the internal pterygoid, and the anterior part of the mas- seter, thus pulling forward and upward on the long end of the lever. It is probable that in most anterior dislocations the ligaments are not ruptured. Perthes holds this view, and Albert quotes Schnitz- 150 SURGERY OF THE MOUTH AND JAWS. ler as being unable to tear the ligaments in producing a disloca- tion on the cadaver. There are, however, undoubted instances where the capsule has been torn, and it is likely that this occurs in all cases of primary dislocation where the head travels well forward of the eminence. In these instances the head is held in its new position by the muscles and the stylomandibular and internal ligaments. The position of the meniscus in an anterior dislocation is a matter of some uncertainty. It is probable that it usually remains in place, the con- dyle slipping in front of it, but in some recorded instances this has not been the case. It is a very old idea held by Hippocrates, and many others since his time, that reduction is prevented by the coronoid be- coming engaged under the malar bone. While there is on record one undoubted instance of this occurrence, it is rare. According to Per- thes, however, in 50 per cent of the cases the coronoid coming in contact with the zygoma helps to prevent the closure of the jaws. Symptoms of Anterior Dislocation. — The mouth is at first held open, and chewing is impossible. The chin is slightly forward, swal- lowing and talking are difficult, and the muscles are usually tense. Most important of all, the absolute sign, the condyle may be felt, or seen by means of the x-ray, to be in advance of its natural position. In a unilateral dislocation, the chin deviates to the opposite side. TREATMENT. The treatment consists in reducing the dislocation and holding the head in the socket by artificial means until the stretched or torn liga- ments have time to unite or recover their normal tone. Reduction may be accomplished in one of two ways: (1) by traction that forces the ligaments and muscles to yield sufficiently to allow the head to pass the obstruction and slip into the socket, or (2) by manipulations that bring the head, in reverse order, into the various positions which it assumed while leaving the fossa. The latter course is the preferable way, requiring less force and inflicting less pain ; while the former, by stretching the lateral ligaments, might inflict more damage to the joint than was sustained at the original injury. Reduction by Traction.- — This is accomplished by grasping the body of the jaw on each side, with the thumbs on the occlusal surfaces of the molars, and, while making downward traction on the rami, mak- ing an. attempt to raise the chin and push the condyles backward into the sockets. The attempt may be made on one side at a time. In doing this, the thumbs must be protected by a thick wrapping of gauze, or otherwise they may sustain injury when the jaws snap together. If the reduction cannot be done with the unaided hands, as suggested by Gilmer, a stout stick may be placed in the mouth, one end of which DISLOCATION OF THE LOWER JAW. 151 rests on the inferior molars of one side, while the upper molars on the other side are used as a fulcrum, and in this way the ramus may be pried downward. The teeth should be protected by rubber tubing or gauze while this is being done. The reduction is facilitated by an an- esthetic. Reduction by Manipulation. — It is not an uncommon occurrence for an anterior dislocation to become reduced spontaneously, and as Stimson points out, the most gentle methods that have been found suc- cessful are those which carry the condyle back through the positions it assumed while leaving the socket. In many instances, however, these manipulations were carried on without a true understanding of the mechanism that hindered reduction. Hippocrates supposed that reduc- tion was prevented by the coronoid being engaged on the malar bone; and in order to free it, he depressed the chin and pushed the jaw back- ward, at the same time encouraging the patient to voluntarily relax the muscles. Galen and others have followed this method. For the most part, however, it was lost sight of, and the practice of using force to overcome the muscular and ligamentous resistance, as described above, has for a long time been the one now widely adopted. Maisonneuve, in 1862, after a careful study concluded that muscular spasm and the resistance of the ligaments prevented the reduction, and that these could best be overcome by direct backward propulsion after opening the mouth more widely. The spasm of the muscles should be overcome, either with the assistance of the patient or by aid of an anesthetic ; and the ligaments are relaxed by depressing the chin and pushing backward on the rami. The theory of this is : that as the chin is depressed the lower end of the rami travels upward and backward, which relaxes the ligaments and disengages the condyle from the eminence. As the back- ward pressure on the rami is continued, the head glides over the crest of the eminence, and the reduction is complete. In some cases all methods short of cutting down upon the joint will fail. In one case reported by Stimson, the meniscus had become detached and was folded up in the glenoid fossa, preventing the head from entering. (For the technic of exposing this joint, see Chapter XXII.) Retention. — When the dislocation is reduced, means must be taken to prevent its recurrence. The head cannot become dislocated until it rises up on the eminence, which does not begin until the mouth is opened at least 1 centimeter. This can be done, as suggested by Stimson, by the use of a head-to-chin bandage for three weeks. A very much neater way is to band an upper and lower tooth, a canine or first bicuspid, and unite them with a strand of braided silk that will allow the jaws to separate 1 centimeter. For an acute dislo- cation this must be worn for three weeks. The silk or silkworm gut 152 SURGERY OF THE MOUTH AND JAWS. strand may have to be removed every few days, but if necessary, the patient can be taught to do this himself. UNREDUCED DISLOCATIONS. According- to Stimson, the prognosis of an unreduced anterior dislo- cation is not bad. The condyle and ligaments adopt themselves to the new position. Reduction should even be attempted some time after the dislocation has occurred. If function is poor, the joint should be opened, the fossa cleared, and the condyles replaced. If this cannot be done, both condyles may be excised. Mazzoni excised both condyles in one case eight months after the injury with good functional results. (For technique, see Chap. XXII.) CHRONIC DISLOCATIONS. If proper means are not taken to prevent its recurrence, a disloca- tion may become chronic, the condyles slipping forward at any time when the mouth is widely opened. For such a condition Annandale opened the joint and stitched the meniscus to the periosteum in two cases. We think a simpler method of treating such a condition is to limit the motion of the jaw, as described above. We once had a patient wear this appliance for three months with good results. SUBLUXATION. It is not an uncommon condition for the condyle to catch every time the mouth is widely opened and to recede with a cracking sound. In older persons it may be due to an anthritis, but in young persons, with lax ligaments, it is in most cases either a subluxation or a catch- ing of the meniscus. Besides general tonic treatment, the movement of the jaw may be limited until the ligaments regain a healthful tone. CHAPTER XL CONGENITAL FACIAL CLEFTS. The general relation of open facial clefts to the embryonal fissures has long been established ; but there are certain points that are still the subject of discussion, and the cause or causes of their partial non- closure are still to be determined. MORPHOLOGY. After the fifteenth day from conception, the cavity, from which will be formed the future mouth and nose, is bounded above by a tubercle Fii 82. Pig. 83. Pig. 82. Head of fetus at end of fiftli week (after His). C, frontonasal process; B, maxillary process ; A, mandibular processes. Pig. S3. Head of fetus in the seventh weelv (after His). A, the now united man- dibular processes ; B, the maxillary process ; C, frontonasal process ; D, lateral nasal process ; E, globular processes attached to the nasal part of the frontonasal process. The central nasal processes are separated from the lateral on each side by the lateral nasal grooves, which represent the anterior cares. projecting from the anterior part of the head, called the fronto- nasal process, and on each side by maxillary processes (Fig. 82). The 153 154 SURGERY OF THE MOUTH AND JAWS. mandibular processes join in the midline about the fifth fetal week, and they together form the lower jaw, which represents the first pair of visceral arches. The maxillary processes do not meet in the midline, but remain wedged between the frontal and the mandibular parts. The cavity is now bounded below by the mandible, laterally by the max- illary, and above by the frontal processes. About this time there ap- pear on the lower end of the developing frontal process three tubercles, which are in turn called the central and two lateral processes. Each lateral tubercle is separated from the central by a short fissure called the lateral nasal groove, or olfactory pit (Fig. 83). Farther on the lower border of the central processes are developed two other tubercles Fig. 84. Schematic diagram, modified from Merkel, showing plan of facial clefts. which are called the globular processes, and these are separated from each other by a single central groove. From the frontonasal process with the nasal processes will be formed the forehead, external nose, and central part of the lip. The maxillary processes are separated from the frontal, which now include the lateral nasal and globular processes, by the orbital fissure which extends to the mouth, in the upper part of which the eye is developed. Somewhere below its middle the orbital fissure is joined by the lateral nasal groove, and together they have been described by Merkel as a Y-shaped cleft. The lower single limb of the Y opens into the mouth ; while the ex- ternal upper limb extends to the eye, and the upper median limb is the CONGENITAL FACIAL CLEFTS. 155 lateral nasal gfoove which separates the lateral nasal from the central nasal process. The frontonasal and maxillary processes are separated from the lower jaw by a transverse fissure, the median part of which will be the future external mouth slit. By the non-closure of any part of the Y-shaped fissures, the trans- verse mouth fissures, or the cleft that existed in the midline between the mandibular processes, or the median groove between the globular processes are produced any and all of the typical face clefts which are here schematically illustrated by a slightly modified diagram from Mer- kel (Fig. 84). Fig. 85. Fig. 86. Fig. 85. Diagram of oblique facial cleft. The cleft shown in this diagram corre- sponds to the cleft 5-4-6 in Merkel's diagram (Fig. 84). Fig. 86. Oblique facial cleft, complete into palpebral fissure on subject's left side. — From specimen in the London Hospital Museum, photographed for this book, by cour- tesy of the curator. Types of Clefts. — If the maxillary fails to unite with the frontal process throughout the entire extent of the fissure, there will be a cleft extending from the mouth through the lateral part of the upper lip to the eye and possibly beyond : obliquely facial cleft (Figs. 85 and 86). If the maxillary fails to unite to the globular process, there will be a cleft extending through the lateral part of the lip toward or into the nostril: ordinary harelip (Figs. 87 and 88). If the two globular proc- esses fail to unite with each other, there will be a median harelip which is usually only a notch (Figs. 89, 90, and 91). From failure of closure 156 SURGERY OF THE MOUTH AND JAWS. of the lateral parts of the transverse mouth cleft, an abnormally large moutli slit results: macrostomia (Figs. 92, 93, and 94). Finally, if the two mandibular processes fail to unite in the midline, a median cleft of the lower lip and possibly the jaw and tongue is the result (Fig. 95). The failure of closure of any or all of the clefts may be so slight as to leave only a lip notch, or so complete as to involve the whole of the fissure, extending even into the base of the skull and brain, or to the ears or down to the sternum. In presenting the above, the writer has followed the rather generally accepted theory that the lateral nasal process does not extend down to Fig. 87. Diagram of ordinary harelip. Fig. 88. Almost complete single harelip. Fig. 89. Diagram of median harelip. Pig. 89. the mouth, that it takes no part in the formation of the lip, and that all lip clefts lie between the globular and the median nasal, and the maxillary processes, but this is one of the points that is disputed by Albrecht and his followers. They maintain that the lateral nasal process extends normally to the transverse mouth slit, that it forms part of the upper lip and the palate, and that a lateral lip cleft runs between it and the globular process. This cannot be absolutely disproved, but it is denied by the majority of embryologists ; and Merkel asserts that the lateral nasal process under abnormal conditions remains entirely shut out from the formation of the lip and intermaxillary process. What CONGENITAL FACIAL CLEFTS. 157 happens under normal conditions is not so plain, and the study of cases of oblique facial cleft does not solve the question. In these cases the cleft may extend through the lip directly to the eye, in which event it could be skirting a lateral nasal process throughout its entire extent ; Fig. 90. Median fissure of upper lip due to absence of tlie intermaxillary procesess. — From specimen in the Royal College of Surgeons Museum, London, photographed for this boob, by courtesy of the curator. Fig. 91. Skull from specimen shown in Fig. 90. — From a specimen in the Royal College of Surgeons Museum, London, photographed for this book, by courtesy of the curator. or it may extend through the lip into the nostril, and then around the ala to the eye, which would be utter disregard of any part of the lateral nasal process below the ala. These two varieties of facial cleft are de- picted in Merkel's diagram (Fig. 84). The relation of the lateral 158 SURGERY OF THE MOUTH AND JAWS. process to the lip and palate will be again considered with clefts of the latter. The palate is a part of the face. Its anterior portion as far back as the incisive fossa is formed by the frontonasal process. The max- illary processes through their palate ridges extend to the midline be- Fig. 94. Fig. 92. Fig. 93. Fig. 94. Diagram of macrostomia. Macrostomia. Less degree than in the preceding. Macrostomia. The oblong opening behind the mouth slit is from the re- moval of a piece of tissue for examination. — From specimen in the Royal College Mu- seum, London, photographed for this book, by courtesy of the curator. hind the frontonasal process and form the remainder (Fig. 96). The palate, therefore, is made up of three parts which were originally sep- arated from each other by another Y-shaped fissure. The vertical stem of this Y was posterior and lay between the two maxillary parts, while the two short oblique arms were anterior and separated the palate sur- face of the frontonasal process from the palate surface of the maxillary CONGENITAL FACIAL CLEFTS. 159 processes (Fig; 97). These and face fissures are but different views of the same through-and-through clefts. If the whole of the Y-shaped palate fissure fails to close, there re- sults a complete cleft which is double anteriorly, while partial failures cause lesser clefts in various parts. These clefts will always be median behind the anterior palatine fossa and will be lateral in front of it, un- — Tlae lack off an incisor at i was expl aie ir^oirted wlsidi ttiip cle& the site oi the ssHpposHtiGn that i ^ cjfeft iin wMafii atr BiinlrBB a lioiiafi&i Bannsig iri nininiii tke latft'Effilj nmaurgSm cuff t£B» aLthreGBllaur idtetfi JFbe. *>£!.. (Case nif .tiiinmfjBfaii eil^t, iffl ■wftatfti mraEttBa Ibimfls jBinuHji'iuSeS fenna "^^K. "«i wk ^^1 L*' |3p^^ k 'i l^m- Fig. 9®. iraife (ieffoBinnifiiiy fe ssnniffwfnatt irfflme aimfl ftiais, inm ttBae (SensftoHiKffl : ai nniiffllSm)® a'Bsfflr lEffltt teeiiiaig inn (tsBmfflwnntiilij' wfittBa IkuMaswim tfifftaDaur fioisttainxfe' uflne (ffleffcniniffluiitjr 'wsbs ebsas- Hbb BIDS' ^at ttlmtr ttflup nm iDaagsr. Im aflofe pair- mnMIlniDe aaxS tiftie sarenmaisSlIIla ajsKi pirsBllaBBiinniiffli ((ttSas' toTsrsir ssiafl off ttBog' 'VK^re aiScQiwe >Lte iraaxSIIMe attttaidteri ten tLBoe- sDasaill septnmm -nriittMm it&e ifmmnnlti mmiaisaill JsniBatesSJ) it had heen lost mm the deft ; and in this he is simpported hj Wamraekros, and oar observaticms denoonstirate the possibility^ of socfa an occurrence. We faaTe seen a nnnDber of cases where the tooth bads protrnded into the deft or were sraspemded by a slosder pedide (Figs. StiSA and @8B}. 'Wamekrosf Theory. — ^Whem am incisoir is missing" in a case of defit of 1^ or palate ^^f ^iparentlj does not invidine the ahnedar 162 SURGERY OF THE MOUTH AND JAWS. process, according to Warnekros, it lies hidden in an occult bony cleft that does not involve the gum tissue. KoUiker's Theory.— From Goethe to Kolliker all surgeons adopted the simple view that the cleft ran between the part of the max- illa that is derived from the original maxillary process, and the inter- maxillary bone which is part of the original frontal process. Albrecht's Theory. — Later Albrecht advanced the theory that the intermaxillary bone in development consists of not one part on each side, but two distinct pieces, each carrying an incisor, and that the cleft runs between these two pieces. Albrecht's theory is a pure hypothesis, and no direct evidence of each half of the intermaxillary bone developing from two centers has been discovered. However, as Sir William Turner, after discussing the question, has pointed out: "It should not be forgotten that it is quite recently that the embryolog- ical evidence of the origin of the intermaxillary part of the human up- per jaw from a center distinct from that of the maxilla has been com- pleted, and yet for nearly a century, on such minor evidence as was advanced by Goethe — namely, the suture on the hard palate extending through the nasal surface — anatomists have believed and taught that the upper human jaw represented both the maxillary and intermaxillary bones in any mammal. Where a question of human embryology hinges upon an examination of parts in a very early stage of development, we often have to wait for many years before an appropriate specimen falls into the hands of a competent observer." Albrecht accounts for the occasional condition of two incisors in front of the cleft as an atavistic development of a third incisor; it is the central incisor that we are supposed to have lost, but a cleft behind the canine finds no place in his hypothesis. The latter condition must be explained on one of two suppositions : either a band has cut into the maxilla behind the canine, or the canine has developed from that part of the dental ledge that attached itself to the premaxilla. The majority of embryologists support the view championed by Kolliker. Although this varying relation of the incisor teeth to the cleft has, in different instances, been advanced as an argument to support one or the other theory, it is probable that it is not pertinent to the dis- puted question as to whether each half of the intermaxillary consisted originally of one or two pieces. It seems likely that the original posi- tion of the tooth sacs of the incisors is not fixed in regard to the max- illary and intermaxillary processes, and that the papilla, from which the lateral incisor will develop, may spring from either border of the cleft. The dental ledges from which the teeth develop are formed by an infolding of the mucous membrane of the mouth, which occurs in the seventh fetal week. The relationship which it acquires to the CONGENITAL FACIAL CLEFTS. 163 mesodermic tissue of the jaws is a secondary one. In the ninth week distinct evidence of the future separation into individual teeth can be made out. This latter occurs very shortly after the ossific centers of the maxillae first appear, and a reasonable supposition is that, as the re- lation of the teeth to the bones is an acquired one, the relation of indi- vidual teeth to the cleft is somewhat accidental. CLINICAL TYPES OF CONGENITAL CLEFTS. The deformity that is most commonly brought to the surgeon is complete single cleft of the lip and palate. If the cleft in the lip is /' ^ J Fig. 100. Double cleft of the lip, incomplete on one side. In this case the alveolar process was cleft only on one side, but posteriorly there was a double cleft of the hard palate. This is a not infrequent occurrence. Fig. 101. Complete double cleft of the lip. This is here accompanied by a double cleft of the palate. The intermaxillary bone carries three incisors. double, it may be incomplete on one side (Fig. 100). If it is a complete double cleft of the lip, there will also almost always be a complete dou- ble cleft of the palate (Figs, 101, 84, and 86). Cleft palate may occur without a harelip, or more rarely a harelip occurs without any bony cleft ; but it often accompanies a cleft limited to one side of the alveolus. 164 SURGERY OF THE MOUTH AND JAWS. Cleft of the velum alone is common enough, but cleft of the midpart of the palate with intact velum is very rare. Oblique facial clefts. Pig. 102. Skull of an adult who had a complete single cleft of the lip and palate. TTiis deformity had never been corrected as shown by the lack of approximation of the alveoli at the anterior part of the cleft. — From a specimen in the Royal College of Sur- geons Museum, London, photographed for this book, by courtesy of the curator. Fig. 103. Skull of an adult who had a double cleft of the palate behind the Incisive fossa.^ — From a specimen in the Royal College of Surgeons Museum, London, photo- graphed for this book, by courtesy of the curator. macrostomia, and central clefts of the upper and lower lips or jaws are among the rare surgical curiosities. (See Fig. 99.) THEORIES OF FAILURE OF CLEFT CLOSURE. The exact reason for the failure of closure of the cleft has ever been a source of speculation. Heredity. — The influence of heredity is very striking^ but it has been difficult for us to compute its bearing with any exactitude in CONGENITAL FACIAL CLEFTS. 165 our cases. In a large number of the cases the lack of knowledge on the part of the parents precluded the possibility of getting data on the subject. In spite of this, the proportion of cases in which the defect can be traced through the immediate or collateral branches of the fam- ily is very large, and the instances are often very striking. It is not at all uncommon to find patent facial clefts in two children of the same family, and in one instance, we saw a mother and child both with cleft palate ; and she informed us her father also had one, but she knew noth- ing of his progenitors. Mr. Owen cites a family in which a number of cases had occurred during several generations, both in the immediate and collateral branches. We have seen a number of families who were so afiflicted, and in such cases the defect is often manifested in various degrees. A mother may have a defective or absent lateral incisor, and the child show a complete cleft palate ; one may have simply a peculiar enunciation, where others in the family may have harelip, etc. Hered- ity cannot be advanced as a cause, but simply as a transmission of a cause, and however interesting these observations may be, they shed little light on the etiology. Mechanical Cause. — In speculating upon this subject, it seems fair to assume that the failure of closure of the clefts may be due to more than one determining factor, and in a study of the data at our disposal two possible causes stand out very prominently: (1) that some mechanical obstruction prevents the approximation of the cleft borders; (2) that some influence on the vital forces interferes with union after the borders are approximated. Of the mechanical influ- ences that have been put forward as the possible cause of the defect, some could be sufficiently broad in their action to account for all in- stances of patent clefts ; some could account for only certain limited clefts; while others could have no bearing on the subject. To the lat- ter class belongs the explanation of Fein, who ascribes clefts of the palate to hypertrophy of the pharyngeal tonsil. This view is opposed by Tandler, who shows that between closure of the palate clefts and the first appearance of adenoid tissue two fetal months elapse. The following may be included among the possible mechanical in- fluences : Before the development of the palate ridges the tongue fills the whole mouth and nose cavity, and its failure to recede from the nasal part has been ascribed by Tandler, Dursy. and others as a cause. One specimen of pig embryo has been observed that seems to support this view. In conjunction with this theory Friedrich states that the tongue is still above the level of the palate in the second half of the second fetal month and that the cleft could be caused mechanically by the pressure of some underlying structure pressing upward on the mandible. In one case a left hand was tucked under the chin. In one 166 SURGERY OF THE MOUTH AND JAWS. case preserved in the Hunterian Museum of London, the tongue is ad- herent by a bond of tissue to the anterior end of a palate cleft. Tumors. — Tumors must undoubtedly be the cause in some in- stances. Broca found a tumor of the base of the skull the cause of a complicated harelip, and Lannelongue found a tumor of the tongue accompanying a cleft of the palate. Reasoning from the researches of Bland-Sutton, basicranial teratomata must also be occasional factors. When of sufficient size and appearing early, tumors might cause very extensive clefts. Amniotic bands and adhesions are so often associated with clefts and deformities as to leave little doubt as to their causative influence. H. Fronhofer and others have collected evidence which shows that amniotic bands and adhesions may be related to patent clefts, intra- uterine amputations, skin appendages, and other deformities. Broad adhesions of the amnion are present in most severe facial malforma- tions. It is possible that amniotic bands and lack of liquor amnii are but the result of some vital defect. Supernumerary Teeth. — Warnekros has made a valuable study of the teeth in individuals with palate cleft, and because in almost every instance he was able to demonstrate supernumerary teeth either show- ing in the mouth or buried in occult bone clefts, he concludes that su- pernumerary teeth, by requiring more room than is normally furnished, are always the cause of clefts of the palate. One would hesitate to question the deductions from such careful and extensive observations if there was not such overwhelming contra- evidence. Warnekros does not seem to take into consideration the re- lation of palate clefts to extensive cranial clefts, defects of the brain, facial clefts, and other deformities that can have no connection with the teeth, nor does he seem to offer evidence that the formation of the teeth antedates the normal closure of the palate clefts. The labiodental strand, or dental ledge, from which the teeth are formed, appears about the beginning of the seventh week. About the ninth fetal week, according to Rose, elevations appear on the free bor- der of this ledge which mark the enamel organs of the milk teeth. Whatever influence supernumerary teeth might have must be ex- erted before the time for closure of the alveolar part of the fissure, which, according to Zukerkandl, takes place at a period considerably earlier than the ninth week, and the ninth week is the time when the dental ledge first shows indications of separate tooth papillae. That supernumerary teeth can be present in the absence of patent facial clefts is well known. Dr. Warnekros himself quotes from G. Kohne's treatise as follows : "Through tooth germs remaining latent, but which are always pres- CONGENITAL FACIAL CLEFTS. 167 ent, there are developed in individual cases, ovi^ing to atavism, enamel- less tooth peglets, peg teeth, and also quite normally formed teeth which remain hidden in the maxilla." Zukerkandl found enamelless tooth rudiments in the region of the incisor teeth in 20 out of 630 crania. Maternal Impressions. — The possible influences on the vital processes that could cause failure of cohesion of the cleft borders are probably numerous, but to be effective they must act before the time when the clefts normally close. One of the oldest theories in this re- gard is that of relation to rnaternal impressions. While it is unwise to absolutely deny the possibility of such a cause, still there is little ma- terial evidence to support this view. Our experience, like that of most other observers, has been that in every instance the supposed maternal impression occurred after the time of normal closure of the clefts. Malnutrition. — Another supposedly possible influence, and one that cannot be so quickly disposed of, is malnutrition. It is a matter of common observation that cleft palate and lip occur much more fre- quently among the lower and more ignorant classes, and apparently among those whose hygienic surroundings are poor. Among our cases, especially those occurring in families of the better classes, it has been a frequent observation that the mother, early in pregnancy, suffered ex- cessively from nausea, or was in poor nervous condition. It has been our observation that the occurrence of cleft palate in the negro is infrequent, but one such case having come to our notice. It is supposed that it is almost unknown among the aborigines of the Pa- cific islands. But Mr. Henry George, late technician of the Hunterian Museum, showed me a skull with a cleft palate that is supposed to be of a Polynesian. The observations cited above can be considered as but little more than suggestive, and we do not believe that we are in a position to state that cleft palate is dependent upon poor hygiene. There is one sup- posed occurrence which, if true, would have been of definite value. It has been repeatedly stated that in the London Zoo, when pregnant lionesses were fed on meat containing bones too large to be chewed, the cubs often appeared with palate clefts, but when the mothers were fed on meat containing small or soft bones, the cubs were normal. This was advanced to support the theory that clefts might be dependent upon lack of proper nourishment. In discussing the subject, Mr. Ar- thur Keith, who is an officer of the London Zoological Gardens, in- formed the author that it was true that lion cubs born in the gardens frequently had cleft palate, but that careful experimentation both with the food and water failed to show any relation between the mother's food and the occurrence of the defect. 168 SURGERY OF THE MOUTH AND JAWS. Injury and Infection. — It is probable that both injury and dis- ease may influence the closure of these clefts. While we are not as yet prepared to furnish anything like exact percentages, we have been impressed with the proportion of cleft palate patients that have shown signs suggestive of syphilis. In the majority of infants in whom we have had the conjunctiva examined with the Gzapski-Luedde pattern of the Zeiss Binocular Corneal Microscope, there have been observed aneurysmal dilatation and thickening of the blood vessels. The technique of the examination requires an anesthetic, and we have not as yet made a sufficient number of them to be of value. Many children thus af- flicted show the Graves scaphoid scapula, which we believe bears a relation to congenital syphilis. So far, Wassermann tests have not been satisfactory in settling the question, for they have almost invariably Fig. 104. Incomplete cleft of the lip with a depressed groove running up to spread nostril on that side. proved negative, even in patients who showed facial contour and other signs that are considered typical of congenital syphilis. One child, in whom the Wassermann was repeatedly negative, later developed active tertiary syphilis with positive Wassermann. Biondi suggested that atrophy of the edges of the cleft, due to inflammation, might prevent closure, and we are inclined to accept syphilis as one of the possible causes of such an inflammation. In reference to injuries and ordinary infections, Moll has made a careful study of a large number of products of early abortions. He found in many cases evidences of infection and of faulty development. It is his conclusion that monsters and deformed infants may result from intrauterine injuries and infections that were not sufficiently severe to cause the immediate death of the fetus. Mr. Keith has shown, from au examination of the material in the CONGENITAL FACIAL CLEFTS. 169 various London medical museums, that cleft of the palate is rather com- mon in monsters. No explanation has ever been offered for the fact that palate and lip clefts appear on the left side twice as often as on the right. It is a common observation that lips and palates which are not actually cleft or which may be cleft in only a part of their extent may show a dis- tinct line of irregular union that resembles a scar (Fig. 104). It may be accompanied by the broadening of the nostril and flattening of the ala that are t3'pical of complete harelip. These are not true scars, for they show no scar tissue ; nor do they ever contain mucous membrane with which all true lip clefts are edged. Trendelenburg regards them as an incomplete union, and they are to be compared with the median raphe of the scrotum and perineum. CONGENITAL LIP PITS. A peculiar and rare facial deformity, which is, as far as we know, not directly related to the embryonal clefts, but which, when it has oc- Fig. 105. Congenital lip pits in a girl who had a clclt i)alat(\ There were several instances of open clefts in her family, and her brother had a cleft palate with similar lip pits. In both instances the pits were dry, but cases have occurred in which the pits gave forth a mucous secretion. curred, has usually been in conjunction with patent clefts, is lateral pits in the lower lip (Fig. 105). There may be slight depressions or deep pits, situated in fleshy teats from which fluid exudes. The fact that they are observed to occur in connection with double harelip gave rise to the idea that the lip cleft was in some way responsible for the pit and teat ; but in the specimen shown there was no harelip, but there was a cleft palate. Mr. Arthur Keith, who has studied the subject, finds that the nearest explanation he can give for the occurrence of lip pits in the human is : a possible reversion to the mucous glands which are normally found in the lip of the shark. CHAPTER XII. CONGENITAL PALATE CLEFTS— PRINCIPLES OF REPAIR BY PLASTIC FLAPS. In every case of congenital cleft of the palate situated behind the incisive foramen, regardless of whatever auxiliary means may be adopted, the final closure is done by bridging the deficit with flaps made from the soft tissue. Further, whether the operation is done on a young infant, a child, or an adult, except in certain extraordinary cases, the same general plan of operation is applicable in all cases. This chapter will deal with : first, the general consideration of the construction of flaps from the palate tissues ; and second, of flaps from extrapalatal sources. The success of any operation or mechanical appliance for the res- toration of the palate is mainly in proportion to its success in restoring or taking on the function of the velum. A velum that is too short is but a poor substitute for the normal condition. ANATOMICAL CONSIDERATIONS. The hard and soft palate together are collectively termed the palate, which is covered on both surfaces by mucous membrane and submucous tissue, etc. At the outer border of the hard palate, close to the alveolar process, and at the level of the posterior border of the last molar tooth is the opening of the posterior palatine canal, through which the de- scending palatine artery and large posterior palatine nerve emerge to enter the palate tissues. Other smaller palate nerves emerge from accessory foramina situated behind the opening of the posterior palatine canal (Fig. 7). Anteriorily, at the incisive foramen the nasopalatine nerve emerges with some terminal branches of the vessels of the nasal septum. In cases of double cleft palate, the distribution of these latter is confined to the intermaxillary bone. The maxillary tubercle is the prominence at the posterior end of the superior alveolar process. Be- hind and slightly internal to this tubercle can be felt the tip of the hamular process of the internal plate of the pterygoid process of the sphenoid bone. About 1 centimeter behind the hamular process the ascending palatine artery enters the velum subjacent to its oral mucous membrane. The velum is intimately attached to the hard palate, not only by the palate aponeurosis, but by the continuity of its mucous coverings. 170 CONGENITAL PALATE CLEFTS. 171 Besides the azygos uvulae muscle, which occupies a median position, and portions of the palatoglossi and palatopharyngei, which form the anterior and posterior faucial pillars, the soft palate contains the termi- nations of the levator palati and tensor palati muscles. These latter, after arising from the base of the skull and skirting the lateral wall of the nasopharynx, enter the velum above the upper border of the su- perior constrictor muscle (Fig. 106). In the velum the contained mus- cles are intimately connected with the palate aponeurosis. The tensor palati descends between the external and internal pterygoid plates and is separated by the latter from the mucous lining of the nasopharynx. At the apex of the internal pterygoid plate its tendon turns at a right angle over the hamular process, which serves it as a pulley, and then Fig. 106. Palate muscles. Essential palate niuscles viewed from behiud. A, leva- tor palati muscle ; B, tensor palati muscle ; C, palatoglossus muscle ; D, tendon of the tensor palati muscle ; E, hamular processes ; F, bursa ; G, tensor palati muscle. spreads out in the substance of the velum. Its motor nerve supply, which is from the fifth cranial, enters its posterior border and is well out of danger from cutting during a palate operation. The levator palati muscle is situated behind the tensor, separated from the latter at its origin by the pharyngeal end of the Eustachian tube. As this muscle descends to enter the velum, it approaches the mesial plane and lies directly subjacent to the submucous tissue of the nasopharynx. Strange as it may seem, the motor nerve supply of the levator palati muscle is a matter of uncertainty. Most anatomists be- lieve that it is innervated by the eleventh cranial through the pharyngeal plexus, while Spalteholz, Merkel, and some others maintain that it comes from the fifth cranial through a branch that passes back from the large posterior palatine nerve just after it enters the palate from 172 SURGERY OF THE MOUTH AND JAWS. the posterior palatine canal. This lack of exact knowledge is unfor- tunate, since the preservation of the nerve supply of these muscles con- serves good functional success of the operation. Our own dissections and observations, made after various complicated palate operations, lead us to the belief that, with but few possible exceptions, operations for all cases can be so planned as to avoid injury to the nerve of this mus- cle, regardless of which course it really pursues. The soft tissues covering the hard palate consist of the mucous membrane, the submucous tissue containing lymph follicles, blood ves- sels, and nerves, and the periosteum. These are all fused together into a rather inseparable layer, but the whole is easily detached from the bone. In front and laterally as far back as the maxillary tubercle, in the edentulous mouth, the soft tissues of the palate are continuous through Fig. 107. Fig. 108. Fig. 107. Diagram of coronal section through a double cleft of the palate. Fig. 108. 'Diagram of a coronal section through a single cleft of the palate. the gums with the mucous lining of the vestibule. Where the teeth are in place, this continuity is carried on through the interdental por- tion of the gingivae. In a double cleft, the mucous tissues of the roof of the mouth are continuous with those of the floor of the nose and nasopharynx on both sides, while the nasal septum, attached anteriorly to the intermaxillary process, stands free in the cleft (Fig. 107). The nasal and oral blood vessels anastomose freely around the borders of the cleft. In a single complete cleft, the mucous membrane and submucous tissues lining the roof of the mouth are continuous around one cleft border with the mucous membrane and submucous tissues on the upper surface of the palate process and velum, and at the other border with the mucous membrane and submucous tissues of the upper surface of the velum posteriorly, and of the lateral surface of the nasal septum anteriorly (Fig. lOS). CONGENITAL PALATE CLEFTS. 173 FLAPS MADE FROM PALATE TISSUES. From the anatomical points just considered, it will be seen that flaps of soft tissue for the repair of congenital palate defects may, broadly speaking, be made in three different ways : (a) The border of the cleft may be taken as the base of the flap, with the blood supply coming through the anastomosis with the nasal vessels (Figs. 130 and 131). If there are no intervening teeth in the alveolar arch to interfere, such a flap may include the palate tissues, the gum, and even part of the cheek. Such a flap can be rotated until the raw surface is toward the mouth and the mucous surface is toward the nasal fossa. With care this flap can often be raised sufficiently without cutting either the posterior palatine nerve or the descending palatine artery, which latter will absolutely insure its blood supply. Such a flap can be turned from the upper surface of the velum (Fig. 133). Pig. 109. Diagram illustrating a palate flap in which the velum has been detached from the palate process by cutting through the palate aponeurosis and mucous mem- brane at a. (b) A flap can be raised with a narrow pedicle directed toward the termination of the posterior palatine canal, to be nourished by branches from the descending palatine artery (Fig. 134 and 135). This flap may be cut to include the tissues covering the hard palate, or may be taken from the velum, or even from the cheek and gum. Flaps of the (a) and (b) varieties were first popularized in the Davies-Colley operation. The (a) flaps are used in conjunction with both (b) and (c) by Lane in his operations. (c) A flap may be formed by incising the mucoperiosteum at the border of the cleft and raising the soft tissues from the under surface of the bone as far laterally as the alveolar process. If there are no teeth intervening, the gum and even a part of the cheek may be in- cluded (Figs. 130 and 131). When this has been done, the flap will be still bound to the bone at the posterior border of the palate process, and to free it here, it is necessary to cut the nasal mucous membrane and palate aponeurosis along this line (Fig. 152). When these are sev- 174 SURGERY OF THE MOUTH AND JAWS. ered, the velum and the mucoperiosteum of the palate are converted into one continuous flap (Fig. 109). The fashioning of the last-described flap may be modified in sev- . eral ways. An incision may be made along the nasal surface of the palate process, and part of the mucous and submucous tissues of this surface included in the flap that is raised from the oral surface of the palate process. On one side of a single cleft a large piece of muco- periosteum may be loosened from the nasal septum and included in the flap (Fig. 110). The former method is to be utilized in cases of wide double cleft, and the latter in cases of wide single cleft. Flaps fashioned after the manner described under (c) are those most commonly used, and are the ones employed in the classic opera- tion, which for convenience may be termed the von Langenbeck op- eration. Such flaps are in many ways superior to those described as Fig. 110. Diagrammatic coronal section through a single cleft of the palate. Illus- trating : a, how part of the coverings of the nasal septum may be included with a palate flap ; b, how part of the covering of the floor of the nose may be included with a palate flap. (a) and (b). If properly made, the blood supply is nearly always good, and sloughing of the flap eii masse is extremely rare. If there is failure of union, in part or throughout the suture line, the flaps simply drop back to their bed and adhere in their original positions and shape. On the other hand, sloughing, in part or in toto, of flaps made as de- scribed under (a) and (b) is not at all rare, and when a slough occurs in a large part of a flap, it may be very difficult to find tissues to replace it at a second operation. With (a) and (b) flaps, even failure of union of the suture line is disastrous; for the flap rotated from its original bed is, in case of failure of union, left without sufficient support, and ii shrinks and becomes distorted by the contraction of the granulations on its raw surface. If a (b) or a (c) flap on one side is used in combination with an (a) flap on the other side of the cleft, broad raw surfaces may be brought into apposition (Figs. 130 and 132). The apparant advantage CONGENITAL PALATE CLEFTS. 175 of this is more than outweighed by certain disadvantages that are inher- ent to this method. It requires more handhng of the tissues, which, with the double row of sutures, predisposes to suppuration and even throm- bosis. Failure of union or loss of tissue renders second operation very difficult, and not the least consideration is the fact that it requires more time and is more difficult to make the (a) or (b) flaps. Warren, of Boston, and von Langenbeck, the great Berlin surgeon, proposed operations for the correction of congenital clefts of the pal- ate, which consisted essentially of loosening mucoperiosteal flaps from the hard palate and liberating the velum, and then suturing the denuded median borders of the flaps across the defect. Their ideas are crystallized in what has come down to us as the von Langenbeck operation, which employs only the (c) flaps. On ac- count of the conformation of the bony palate, the (c) flaps usually fur- nish sufficient tissue to close even wide defects. Fig. 111. Diagram illustrating how the flaps taken from an incomplete palate arch together may be of sufficient width to reach across from one side of the base of the arch to the other. The cleft palate is an incomplete Gothic arch. When the muco- periosteum of each side is incised at the borders of the cleft and the flap freed from the bone, which forms the sides of the incomplete arch, they can be brought straight across from one side of the base of the arch to the other (Fig. 111). If there is any deficiency opposite the junction of the hard palate and velum, this is usually compensated for by the lateral incisions (Fig. 159), which do not interfere with the blood supply and allow considerable relaxation of the flap. The reconstructed palate, made with von Langenbeck flaps, is flat from side to side and may present wide gaps at the site of the lateral incisions. As healing progresses, however, the flap is drawn snugly up to the bone, and the edges of the lateral incisions are gradually ap- proximated until, in time, the only abnormality that may be observed on inspection is the longitudinal scar in the midline. If, as should be the case, the periosteum is included in the flap, true bone is commonly reproduced at the site of the cleft, so that ultimately the bony arch may be completely restored. 176 SURGERY OF THE MOUTH AND JAWS. FLAPS MADE FROM OTHER THAN PALATE TISSUES. Flaps made from the nasal septum and from the floor of the nose are, strictly speaking, extrapalatal flaps, but for convenience these were included with flaps made from the palate tissues. Extrapalatal flaps may be derived from intraoral and extraoral sources. Intraoral flaps are covered with mucous membrane, while the extraoral flaps include the skin. The former are usually derived from the inner surface of the cheek or the gums, though sometimes the tongue or pharyngeal wall has been pressed into service. The latter plan was first devised by Passavant. Von Mosetig-Moorhof went to the trouble of supplementing the velum with a flap turned from the posterior wall of the oral pharynx, and then cut a hole in the hard pal- ate to allow of nasal respiration. In the edentulous mouth varying amounts of gum and cheek may be included with the palate flaps. When teeth are present, a buccal flap can advantageously be turned on to the palate, only behind the molar teeth or in front at the site of an alveolar cleft. When the normal mouth is opened to its widest extent, the limit to further excursion of the mandible is in the joint and not in the cheek, which can still be felt to be flaccid. Fairly generous flaps can be constructed from the mucous lining and buccinator muscle with- out inconveniencing the patient. The motor nerve supply of the mus- cle is from the seventh cranial, which comes from behind and around the outer surface of the masseter muscle (Fig. 213). The opening of the parotid duct is opposite the second upper molar tooth, and the blood supply of the cheek is everywhere good. A flap that has its base at the upper lip can be taken from above and in front of the opening of the duct and utilized in closing an alveolar cleft or a defect in the anterior part of the hard palate. The posterior end of the buccinator muscle is attached to almost the full length of the pterygomaxillary ligament, while posteriorly the ligament gives origin to a like amount of the superior constrictor mus- cle of the pharynx (Fig. 7). The ligament itself extends from the tip of the pterygoid process of the sphenoid to the inner surface of the body of the mandible and rests on the anterior part of the in- ternal pterygoid muscle. The adjacent portion of the buccinator mus- cle rests on the inner surface of the masseter muscle, while the adja- cent part of the superior constrictor muscle of the pharynx bears a sim- ilar relation to the internal pterygoid muscle. Flaps which include the pterygomaxillary ligament, the anterior part of the superior constrictor of the pharynx, and the posterior part of the buccinator with their mucous coverings, may be satisfactoril) and safely made according to either of the plans shown in Figs. 163 and 164, or 175 and 176. CONGENITAL PALATE CLEFTS. 177 The cutting of the pterygomaxillary Hgament cannot interfere with the action of tl'ie upper part of the superior constrictor muscle of the pharynx in the formation of Passavant's pad, because the fibers that, by their contraction, produce this eminence are the pterygopharyngeus, and the part of the superior constrictor that arises directly from the pterygoid process. The lower fibers of the muscle are but temporarily crippled by cutting the pterygomaxillary ligament. A piece has been stripped from the edge of the tongue and stitched into a palate defect. The tongue has been split longitudinally at its lateral border and incorporated into the palate. In both of these in- stances the mass of the tongue is later cut free from the palate. Marshall illustrates a case of Rotter's, in which he turned a vertical flap from the middle of the forehead and bridge of the nose and, after Fig. 112. Diagram illustrating a flap (AAA), which has been i-aised from the side of the neck and still attached to the cheek (B), can be brought through an incision in the lower buccal fornix and laid in a palate defect. It can be seen that this flap could be used for lining a cheek, instead of a palate defect. grafting its raw surface with Thiersch grafts, left it in its original po- sition until the grafts had taken. Later he turned the flap into the pal- ate cleft through an incision made at the side of the nose and sutured it into the cleft, the tissues of the face being drawn together with su- tures to efface the defect. He mentions that Blasius was the first to use extrapalatal flaps, and that Thiersch had done so in a second case. We believe that the most available extraoral tissue is to be obtained from the neck. A long narrow flap of tissue can be raised from the side of the neck with its base at the lower border of the mandible. It should include the skin, superficial fascia, and platysma myoides mus- cle. As soon as the flap is liberated, the neck defect can be immedi- ately effaced by drawing the edges of the wound together with sutures. The superficial tissues of the neck are usually very redundant, and the approximation can be further facilitated by undermining between the 178 SURGERY OF THE MOUTH AND JAWS. platysma muscle and the deep fascia. Still further relaxation can be obtained by making an incision at the base of the neck parallel to the original wound and well to its outer side; this wound also serves for drainage. This flap is made 5 centimeters wide, and its length will depend on the sex of the patient. In a girl the tissue from the neck may be used, but in a boy or a man the flap must include the tissue of the upper part of the neck to well below the clavicle, as only the lower end of the flap will be free from hair. Through an incision in the bot- tom of the buccoalveolar cul-de-sac the flap is turned into the mouth and sutured into the palate, the jaws being temporarily held apart with an intraoral gag. Later the pedicle of the flap is cut, and the upper end of the neck wound repaired (Fig. 112). (For further details of turning flaps from the neck see Chap. XVI, Figs. 177, 178, 179, and ISO, and Chap. XIX, Figs. 218, 220, 221, and 222.) CHAPTER XIII. CONGENITAL CLEFTS OF THE PALATE AND LIP- PREFERABLE AGE AT WHICH TO OPERATE. In the determination of the time at which operations for closure of clefts of the hard palate ought best to be done, two considerations con- front us : the ideal, and the surgically probable. CONSIDERATION OF VARIOUS AGES. It was the belief of the older surgeons, the pioneers in this work, that the probability of surgical success is greatest when the cleft is rela- tively small and the soft tissues, from which the obturator is to be made, are comparatively well developed. At Twelve Years. — At the age of twelve or fifteen we still have the excessive nutrition of growing tissue, the alveolus is well devel- oped, the arch of the palate is high, and there is, relatively, a large amount of tissue in proportion to the cleft to be bridged. Further, it was supposed that by this time the intelligence of the patient and the desire for relief from the deformity would materially aid in obtaining the desired result. It was for these reasons that the older surgeons chose this age as the time of election. Unfortunately, though the probability of obtaining a surgical result at this age be great, the result obtained is at best relative. The naso- pharynx, nasal cavities, and the tongue of one so afflicted develop ab- normally, and where speech has been attempted with a cleft palate, the imperfect enunciation that results is but partially corrected by a later restoration of the roof of the mouth and the velum. At Two Years. — The "cleft palate speech" is a stigma that usually outlasts the most perfect late operation. This has caused more recent operators to seek an earlier period for repair, and by a number the age of two has been pronounced as ideal, because there is at this time a fair development of the mucoperiosteal covering of the bone with considerable arching of the palate due to the alveolar process, and because it is possible to narrow the cleft by orthodontic apparatus. Further, at this age the child's speech is but imperfectly developed; therefore the cleft palate habit is not fully formed, and successful opera- tions at this age give excellent voice results. In Early Infancy. — Still other operators, impressed with the fact that at birth there was simply the cleft, though relatively wide, and 179 180 SURGERY OF THE MOUTH AND JAWS. that all the structures were normally developed, and that the longer growth went on with an open palate the farther these structures re- ceded from the normal, sought a still earlier age for surgical interfer- ence. Close study of the subject showed that, besides better after re- sults, the very early ages presented surgical advantages that had been at first overlooked. Certain of these advantages refer to the local con- ditions, while others concern the general condition of the patient. ADVANTAGES OF VERY EARLY OPERATION. Of the local conditions that lend themselves in early operations, there are two : First, the absence of teeth and the lack of pronounced development of the alveolar processes — these make it very easy to go any distance in obtaining flaps of any size for the closure. Secondly, the bones are soft and pliable and exceedingly well nourished, which makes it possible to shift bodily the separated maxillae and approximate Fig. 113. Fig. 114. Fig. 11.3. Single complete cleft in an infant twenty hours old. Fig. 11-4. Same infant eight days later. the normal position. The first of these has been taken advantage of by an English school, led by Lane; and the second operation is an American development, long championed by Brophy. Without going into a discussion of the relative advantages of the two methods, we want to call attention to the fact that, either of these operations being possible and both presenting high probabilities of sur- gical success, there are advantages in the early operation that decrease in direct proportion as the age of the unoperated child increases. Based on our own observation, these advantages are : L That the infant of twelve or twenty-four hours stands the shock of operations as well as it does the violence to which it is subjected during parturition, and that this resistance to shock decreases as the age of the infant increases. IL If the cleft is confined to the lip and alveolus, the child will be in a condition to be nursed by its mother when it is five days' old. It is possible in most cases to preserve the flow of the mother's milk that CONGENITAL CLEFTS OF PALATE AND LIP. 181 long by artificial means — not a breast pump — which gives the child all the immediate and late advantages that are derived from breast milk. III. This very early repair of palate and lip saves the parents an immense amount of heartache and chagrin (Figs. 113 and 111). IV. The health of infants is always better after than before the repair of the cleft. We have seen a number of impressive instances of this fact, but the old observation — that cleft palate infants were apt to die through lack of development in other parts — is correct. The in- fants coming under our observation are on an average as healthy after early operations as are normal infants. V. A normal nasopharynx and a normal voice are assured by early operation. In the very early operations the ideal and the surgically possible meet, except that we must exercise some discretion about avoiding op- eration during the process of teething. We are convinced that the longer the operation is deferred the less advantage is to be gained from it, but also that there is no age at which, with appropriate tech- nique, we cannot operate with advantage. CHAPTER XIV. CONGENITAL PALATE AND LIP CLEFTS— OPERATIONS IN EARLY INFANCY. At twenty-four hours is the earliest we have operated for this de- fect, but judging from the fact that young animals, upon which the experiment has been made, show greater resistance to shock and less susceptibility to pain during the first twenty-four hours of life than they do during the second, we believe that the operation should be per- formed as soon after birth as possible. PREPARATION FOR OPERATION. The healthy infant requires no preparation, and if old enough to take nourishment, should be fed within two hours of the operation. Starved infants with a subnormal temperature should, by proper feeding, oil rubs, etc., be brought into relatively good condition. In dispensary practice it is a good custom to take such debilitated infants into the hospital for a few days until the child shows signs of mending, and then to send it home, keeping close supervision of its food and care. Usually ten days or two weeks is sufficient to bring the child to an operable condition. At least in summer, it is not wise to keep an infant in the hospital any longer than is necessary. Special nipples, carrying broad obturators, have been devised to enable such infants to suck from a bottle, but when it is intended to do an early operation, these are unnecessary, as the infant can be more quickly and more accurately fed by means of an eye dropper. Some of them, with complete clefts of the lip and palate, can do very well with an ordinary nipple and bottle.^ In the presence of any acute contagious disease, the operation should be postponed, but pus infections should be treated by appro- priate surgical measures, general hygiene, and possibly by appropriate vaccines. At the time of operation the child should be swathed in a light wool covering, which is enveloped in a sterile towel. The eyes and head should also be covered with a sterile towel that is held in place with an artery forceps or a safety pin. The child should be given only suf- *The normal process of procuring milk from the mother's breast Is not one purely of sucking. The infant takes the nipple and most of the areola Into Its mouth, and while it sucks, it also squeezes the breast with its Jaws. It Is only the latter part of the Drocess that can be utilized by the cleft palate baby. 182 CONGENITAL PALATE AND LIP CLEFTS. 183 ficient anesthetic to prevent him from crying out, and that by an extremely careful anesthetist. Some form of a Junker apparatus is most convenient for this purpose. The author uses ether in all cases. The light should be good and preferably daylight, but usually arti- ficial light and head mirror are more available. The operation may be done w^ith the child lying flat upon its back, but v^e prefer to have the head hanging over the end of the table, resting in the hands of an assistant, or to have the patient on the side with the head of the table Fig. 115. Approximating tlie maxillae by througli-and-through wires, placing a heavy sillc loop through one maxilla posteriorly. First step. somewhat lowered. In either of the positions, the blood tends to flow away from the larynx. There are two popular methods of operating on the cleft in early infancy, which are radically different in principle and execution. They can be very properly designated as the Brophy and the Lane operations respectively. In the case of a single cleft, it should be determined at the time of operation that the nostril on the cleft side is patent posteriorly; this may be done by inserting a probe. 184 SURGERY OF THE MOUTH AND JAWS. BROPHY OPERATION. According to Heitmiiller, Velpeau probably first suggested the early operation for cleft palate. Julius Wolfif recommended that the operation be done as early as possible. In 1861, Dr. Reeves, on examining a dead infant that had a cleft palate, observed that most of the tissue that goes to make up the normal palate was present and the width of the cleft depended upon the fact that the maxillary bones were spread apart. He suggested the pos- --a Fig. 116. Approximating the maxillae by througli-and-tlirough wires, placing a heavy silk loop through the other maxilla posteriorly. Second step, sibility of treating the deformity by approximating the separated max- illae (Fig. 122). Dr. Brophy, of Chicago, later devised the operation that made this practical. The technique that we have evolved differs somewhat from that used by Dr. Brophy but, in principle, is the same. The operation consists of passing silver wires through the maxillary bones from one buccoalveolar cul-de-sac to the other. By twisting the wires over two lead plates and by lateral pressure on the bones and, when needed, by cutting the outer wall of the orbit through a very small mucous incision, the anterior end of the cleft is obliterated, and CONGENITAL PALATE AND LIP CLEFTS. 185 the posterior, part is narrowed. The parts of the maxillae that are brought in contact should be denuded to the bone. If it is thought ex- pedient, a mucoperiosteal flap can be raised from the hard palate on both sides and united over the anterior third of the cleft. If this is to be done, the mucoperiosteal flap should be freed, and the sutures in this flap inserted, before the anterior parts of the maxillae are com- C~- — a C-- Fig. 117. Approximating the maxillae by through-aiid-througli wires. Anteriorly is shown how one loop (a') is passed over the ends of the second loop (b')- By drawing on the (a') loop, the (b') loop is made to traverse both maxillae, (b) shows loop in position with wire; (C) ready to be drawn in place. pletely approximated. The various steps of this operation are illus- trated in Figs. 115 to 119. The needle shown in Fig. 120 is held in a strong needle holder and inserted high up in the cul-de-sac, and with a little twisting mo- tion it enters the bone without difficulty. As shown in Fig. 121. in young infants there is no space between the tooth and the orbit, and the needle either penetrates the upper part of the tooth sac or passes 186 SURGERY OF THE MOUTH AND JAWS. along- the upper surface of the floor of the orbit (Figs. 121 and 124). The latter course is often evidenced by the appearance of a subcutane- ous orbital hemorrhage. We have never seen any evil effect follow from Pig. 119. Fig. 120. * f '^'i,, • Approximation of the maxillae by through- and-through wires Showing two double wires in position threaded at each end on a lead plate (d). If single wires are used, No. 20 is the proper size, while No. 22 or 24 is used double. *u ^'S-.,ll'^- Approximation of the maxillapj by through-and-through wires This shows the maxillae approximated. This is done by pressing the bones together and talking up the slack by twisting appropriate wires. The approximation of the alveolar part of the cleft IS made more sure by bringing two of the wires around the intermaxillary bone and twisting them at (g-g). a naij^ uuue. Pig. 120. The needle we use in piercing the maxillae is what is known as a %-ciT- cle. reverse-eyed Hagedorn. We use two sizes : one of a circle the size of a nickel and thf f". ^ ^ ^'^® °' ^ quarter. Usually we grind off some of the broad cut CONGENITAL PALATE AND LIP CLEFTS. 187 this. The height at which the needle may be entered can be judged by noting the lower border of the orbit on the face (Fig. 134). Dr. Brophy uses the needle illustrated in Fig. 125, and passes it through the gum, at a lower level than described above. Though this must do some damage to the developing deciduous teeth, it cannot di- rectly injure the buds of the permanent teeth, which at this time are very small and lie to the median side of the large crowns of the teeth of the first dentition. The wire we use is a very soft No. 20 virgin-silver wire. A strong braided silk, or silkworm gut, should be used as carriers for drawing c^ Ocular muscles .^ Orbital fat Bony floor . .- Molar tooth Buccal fat Upper gum .... Fig. 121. Coronal section through frozen head of an infant at term, through the antrum. It will be seen that there is only a thin plate of bone between the tooth sac and the orbit, and that, in transfixing the maxilla, the needle must penetrate one of them. The antrum is still very small and lies mesial of the tooth sac of the second molar tooth. By the arrow points it will be seen that the upper jaw is narrower than the lower. the wires through the bone. We believe that placing the wires above the floor of the orbit and the lead plates high up on the alveolar process has several substantial advantages. The orbit is relatively large for its contained structures, and there is plenty of room to pass the needle above the floor through the orbital fat without injuring the ocular muscles. The body of the maxillary bone is rather compact and less lacerated by the passage of the needle and wires than is the alveolar border. Where it is desired to narrow the posterior part of the cleft, the high position of the wires and plates gives a better hold for reten- tion. It is a surgical impossibility to bring the borders of the palate 188 SURGERY OF THE MOUTH AND JAWS. processes in contact with each other by this operation, and even in very young infants the posterior part of the cleft cannot be narrowed to anv considerable degree without employing a crushing force. This Fig. 122. Coronal section tlirougli plaster casts of the upper and lower jaws of a case of single cleft palate. By comparing the relative positions of the arrow points in this figure with those in the preceding, it will be seen that, while in the normal state the upper jaw is narrower than the lower, when there is a complete palate cleft present the maxillae are spread apart until the upper jaw is wider than the lower. It is for this reason that it is perfectly proper to approximate the maxillae artificially in operat- ing on a cleft. Fig. 123. A study of the growth of the palate from infant to adolescence. The cross on both palates is the same size, 18 mm. in length and 20 mm. in width, which are the full dimensions of the infantile palate. The measurements on the infantile palate were taken from the anterior palatine canal to the posterior nasal spine, and be- tween the posterior palatine canals. When the cross of the same dimensions is laid on the adult palate, taking the anterior palatine canal as the fixed point, it will be seen that the cross piece is at the level of the posterior borders of the second bicuspids, which is the original position of the posterior palatine canals, and that while there is a slight lateral and forward growth of the palate, the great part has been backward ; which was to be expected because it corresponds to the direction of growth of the alveoli of the upper and lower jaws. can be done by covering the jaws of a pair of long sequestrum forceps, inserting them through the mucous membrane at the upper fornix of the vestibule on each side, and getting a grasp on the bodies of the maxillary bones (Fig. 126), If any pressure is exerted on the CONGENITAL PALATE AND LIP CLEFTS. 180 alveoli, they will fracture into the tooth sacs, and the teeth will be ex- pelled. The borders of the anterior part of the cleft can be closed by simply pressing open the alveoli with the fingers or with the handle of a knife, and taking up the slack in the wires by twisting them on each side alternately. No attempt should be made to draw the bones to- o-ether by simply twisting the wires, and both wires must share equally in the twist, otherwise one of them is apt to snap at the plate. With increasing observation, we are more and more inclined to sim- ply obliterate the anterior part of the cleft and allow the posterior por- tion to take care of itself until the flap operation is performed. At Fig. 125. Fig. 124. An accurate diagrammatic reproduction of a section of a frozen head of an infant with a single cleft of the palate. This illustrates how a % -circle needle can be made to pass from the upper buccal fornix, through the jawbone, along the floor of the orbit and into the cleft. Fig. 125. Brophy needle. Dr. Brophy has two of these made, right and left. The shank of this needle is shorter than the original instrument. the age of ten months or two years, it is usually easy to close the pos- terior part of the cleft by a von Langenbeck operation. In the Brophy operation there is little hemorrhage, and unless too energetic efforts have been made to close the posterior part of the cleft, there is no shock. The objection that has been argued against this operation, that it unduly narrows the palate and the nasal passages, is not necessarily true; for the maxillary bones are already spread apart, and the operation attempts simply to restore them to the natural position. However, it is very easy in some cases to carry the operation to the extent of ob- structing the anterior part of the nasal fossa and cause nasal obstruc- 190 SURGERY OF THE MOUTH AND JAWS. tion on one or both sides. This point should be carefully watched, and each nasal fossa should, in a young infant, admit a probe with a head 2 or 3 millimeters in diameter. G. V. I. Brown cites experiments car- ried on in the Parke-Davis Laboratories, which demonstrated that pup- pies, in which the nasal fossa had been obstructed in this manner, de- veloped very poorly. We feel sure that the infant has suffered in a similar manner. The deciduous teeth are usually lost soon after the operation; but this often happens in cleft palate cases where no oper- ating has been done, and is a minor consideration. In doing the op- Pig. 127. Fig. 126. Showing pcsition of the jaws of the forceps in forceful approximation of the maxillae. Fig. 127. Double-edged knife we. occasionally use in cutting the maxilla. The knife is thrust high into the body of the bone through a small mucous opening, and moved forward and backward In the bone. eration. Dr. Brophy draws two wires through each hole in the bones, principally to have a reserve in case one wire breaks. If a soft No. 20 wire is used, and the wires are twisted only to take up the slack that is gained by pushing the maxillae together, there will be no danger of their breaking short. The prominent intermaxillary part of the alveolus can be held back, either by twisting two of the long ends of the wires around the front of the gum (Kig. 119), or by passing a sep- arate finer wire through the alveolus on each side of the cleft. If the needle pierces the alveolar process of the intermaxillary bone, it should be in the midline. By doing this, injury to the buds of the CONGENITAL PALATE AND LIP CLEFTS. 191 permanent central incisors will be avoided. In either case it is better to pass the wire through the frenum and make the twist at one side, as this places the wire higher on the bone. The twisted ends should be cut short and bent so as not to stick into the cheeks. The operation illustrated above is the one we performed for a num- ber of years on every wide complete cleft in an infant under three months (Figs. 128 and 129). Of late we have been satisfied, in very young infants with single clefts, to forcefully approximate the maxillae and pass one wire through the anterior part of the jaws, bringing it around in front of the intermaxillary bone without the lead plates. This is a simpler operation, and we believe here that the results are equally satisfactory. Fig. 128. Fig. 129.- Pig. 128. Wide single cleft in a very young infant. Result of the Brophy opera- tion shown in next figure. Fig. 129. Shows the result that may be obtained by the Brophy operation, in a very young infant. In doing this, the nasal passages should not be obstructed. Although this infant did well in every way, still drawing together the maxillae to the extent here shown may produce nasal obstruction. The closure of the posterior part of the palate and velum is done later by the ordinary flap-sliding operation at any time between the sixth and eighteenth month, or even later. It is easier to do it at a year or eighteen months than at an early period. It should be done before the end of the second year. The health of the child, the season, and the state of dentition are all to be considered. It is our custom to repair the lip at the first operation for the fol- lowing reasons : Nasal breathing, which is the most important result of the operation, is thus established earlier. While these young infants stand one operation remarkably well, they are apt to do very badly if a second operation is undertaken within a few weeks after the first. 192 SURGERY OF THE MOUTH AND JAWS. Lane, who we believe does many more early cleft operations than any one else, always closes the lip when he closes the anterior part of the palate, and maintains that the healing, the cosmetic, and the vital re- sults are superior. LANE OPERATION. In this operation no attempt is made to narrow the bone cleft, but the defect is closed entirely by flaps formed of the soft tissue. Advan- Pig. 133. Pig. 130. Illusti'ating what we have for convenience designated as (a) and (c) flaps. In an (a) flap the palate is incised at the alveolar border, and the flap remains attached at the cleft border. In a (c) flap the palate is incised at the cleft border, and the flap remains attached at the alveolar border. Pig. 131. Diagram showing the Lane method of closing ,a single cleft of the palate. An (a) flap is outlined on the same side as the cleft by the incision (d-e-f-g), and un- dermined as far as the border of the cleft in the hard palate. A (e) flap is outlined on the side opposite the cleft by the incision (a-b-c). This is undermined to the alveolar border. The (a) flap is swung under the (c) flap, as shown in the next figure, and broad raw surfaces are sutured together. The alveolar part of the cleft is filled with tissue turned from the tip. Pig. 132. Lane's method of closing a single cleft. This shows the (a) flap swung into position under the (c) flap, closing the anterior part of the cleft. At a subsequent operation he makes the incision (g-h) through the mucous and submucous tissue, and loosens the posterior part of the (a) flap as far as the cleft border in the velum. At the same time another (a) flap is turned from the upper surface of the velum on the opposite side as outlined by (c-f-j). This second (a) flap, being turned from the upper or nasal surface of the velum, allows its raw surface to lie in contact with that of the (a) flap of the opposite side. By this means the cleft in the velum is closed. Pig. 133. Lane's operation. Illustrating how the (a) flap is turned from the upper or nasal surface of the velum. V, V, cleft velum ; a, flap. CONGENITAL PALATE AND LIP CLEFTS. 193 tage is taken of the fact that, there being no teeth to interfere, the sur- geon can go past the gums and on to the cheeks to obtain extensive flaps. These flaps are made in several different ways. (See Chap. XII for the general principles of the making of plastic flaps.) The writer has seen Mr. Lane operate as follows : For a through-and-through single cleft, to close the anterior part, he makes an (a) flap with its base at the cleft and a (c) flap (Fig. 130) ; the (a) flap is rotated under the (c) flap and sutured (Figs. 131, 132, and 133). This is a modification of the Davies-Colley opera- tion. For a cleft behind the alveolus, he makes two (b) flaps attached posteriorly with the blood supply from the descending palatine arteries. Fig. 135. Fig. 134. Lane's metliod of closing a cleft behind the incisive foramen. The two (b) flaps are outlined by (g-f-b-a) and (h-e-c-d). These are freed from the alveolar and palate processes as far back as the descending palatine artery. An (a) flap is out- lined by (f-b-c-c), with its base at the anterior end of the cleft. To close the cleft in the hard palate, the (a) flap is turned back until its mucous surface is toward the nasal fossa, and the two (b) flaps are drawn to the midline until their raw surfaces rest on that of the (a) flap. Fig. 135. Flaps in place, as described under the preceding illustration. At a sub- sequent operation the cleft in the velum is closed, as described under Fig. 132. and an (a) flap which includes the covering of the anterior part of the gum (Fig. 134). The anterior flap is turned backward until it lies on the anterior part of the cleft with its raw surface toward the mouth; and then the two lateral (b) flaps are brought toward the median line, their raw surfaces partly overlying the rotated anterior flap, and all are sutured in place (Fig. 135). For a wide double cleft, he makes an (a) flap on one side and a (b) flap on the other, rotating the (a) flap until its raw surface is toward the mouth; the (b) flap is drawn to the median line, and they are sutured, raw surface to raw surface (Figs. 136 and 137). He fills the anterior part of the alveolar cleft with flaps turned from the edge of the lip cleft. 194 SURGERY OF THE MOUTH AND JAWS. The cleft in the vehim is repaired at a later date hy two flaps made as described under Fig. 132. When the molars have erupted, the operation will differ but little from the Davies-Colley operation. . Mr. Lane uses fine silk and small curved needles, with flat shanks, for fixing the flaps. It will be seen from the above description that, in constructing the new palate, the nasal, as well as the oral, surface is covered with mu- cous membrane and that everywhere broad denuded surfaces are ap- proximated. The making of these flaps is accompanied by compara- tively little bleeding. When the posterior palatine artery is to be cut, Pig. 136. Fig. 136. Lane operation for complete double cleft. The operation is similar to that for single cleft except that one side in the latter (a-b) flap is substituted for the (c) flap used in the former. Fig. 137. Lane's method of closing a double cleft. Flaps in place for closure of the hard palate portion of a complete double cleft. As with the single cleft, the alveolar part of the cleft is closed with flaps, obtained in freshening the edges of the lip cleft. it is first freed and caught with an artery forceps, which is easily done, as it runs for a space in a groove in the palate process. The above descriptions are less complete than those given in his brochure on the subject, but they are sufficient to illustrate the princi- ples involved. The description of the technique we have given dififers from that given by Mr. Lane, in the paper referred to, in that the operations here described are performed in two stages. This was the manner in which he was doing it at a later date, when we made a special trip to his clinic for the purpose of getting his technique at first hand. We are convinced of the wisdom of the two-stage operation, for, in the few cases we had attempted to do the operation at one sitting, we invariably had failure of union in the posterior part due to a slough- ing of one flap. CONGENITAL PALATE AND LIP CLEFTS. 195 CHOICE OF OPERATION. Granting that the Lane operation is to be performed in two stages, we are sure that, at least in ordinary hands, when the lip is repaired at the same time as the maxillae are approximated, the Brophy operation is superior for the following reasons : It requires less technical skill, aims at the restoration of a more natural anatomical condition, and, we believe, is less of a strain on the vital powers of the patient. If, in the Lane operation, a failure does occur, it is due to slough- ing and a loss of a part of a flap, and the damage is extremely difficult to repair. A bone slough following a Brophy operation is very rare, but when it does occur, the damage is irreparable. AFTER-TREATMENT. As a general proposition, with the exception of the special care of the mouth, these babies are to be treated as if no operation had been done. Very often after doing the early operation on the lip, it will be found that there is a nasal obstruction either from mucus in the nose or, in the case of double harelip, from the temporary closure of the alae of both nostrils. These babies will not, when asleep, breathe through the mouth, even if the lower lip is held to the chin with a suture, as has been recommended ; the tongue will fit up against the new alveolar arch and absolutely preclude inspiration. If this condition is allowed to continue, they are restless and do badly. We were often greatly annoyed by this and on two occasions went so far as to cut the sutures that held the ala in place. Attempts to hold the nostril patent with a bent wire were unsatisfactory, because it was not very efficient, and also because it caused the nostril to spread and injured the cosmetic result. It was not until we hit upon the use of the breathing tube (Fig. 206) that we are able to overcome the diffifculty. This breathing tube is worn almost constantly for the first few days, being removed only for feeding. Usually after the first two or three days, it is not necessary to have it in place constantly, but it is returned to the mouth, whenever it is noticed that the lower lip sucks in on inspiration. After five days, the nostrils usually open sufficiently to allow the tube to be dispensed with. For depression due to loss of blood, saline solution can be given hypodermatically. We seldom resorted to this, but as a routine practice have saline solution placed in the rectum. At the operation the child, almost invariably, swallows blood. An attempt may be made to remove this with a stomach-tube, but we pre- 196 SURGERY OF THE MOUTH AND JAWS. fer to give 4 cubic centimeters of castor oil with .00 cubic centimeter (gtt. 1) of paregoric within a few hours after the operation. As soon as the infant cries, water is given, and when this no longer satisfies, the child of forty-eight hours or more is fed. Usually feeding is com- menced within four or six hours after the operation. If human milk is available, it can be given. After a rather extensive trial we have come to the conclusion that, for the time being, most of these babies do better and lose less weight if fed on "Eagle Condensed Milk" than with modifications of fresh milk. After two days the child should be encouraged to take the breast, if the flow of milk has been preserved. However, it will never be able to gain sufficient nourishment in this way, and the nursing should be immediately supplemented with milk removed with a breast pump or with condensed milk from a spoon, bottle, or dropper. Older infants may require an anodyne during the first forty-eight hours after operation. This is rarely the case and should not be resorted to until it is certain that it is not food, water, or other ordinary attention that the child wants and that a little com- forting in the nurse's arms will not quiet it. Then and then only may a small dose of paregoric or morphin be given. When avoidable, such a child should not be petted or handled. The mouth and nose are gently irrigated with saline each two hours during the day and at feeding times at night. The irrigation is done with a douche can and with the child held on its side over a bucket. If it does not cause the child to vomit, the irrigation is made after the feeding. If it causes vomiting, it is done before feeding. If in older babies the irrigation causes the child to be afraid and to cry afterward, it is omitted. If there is any local evidence of infection, the part is painted after each irrigation with a 10 per cent colloidal silver solution. The line of sutures on the lip is painted with the colloidal silver as a routine practice. Everything that is. used about the child's mouth is to be sterile. The temperature after the operation may rise anywhere from 99° to 103° F., or even more, but usually subsides to about 100° and re- mains there for a few days. As a rule the elevation of temperature needs no treatment. In good weather, older babies, those two weeks old or more, are taken out of doors in a perambulator within a few days after the operation. In dispensary practice it sometimes takes nice judgment to deter- mine whether the danger of hospitalism or of improper care at home is more to be feared. Such babies are usually kept at the hospital ten days or two weeks, but where the child will receive intelligent care at home, after the operation has been done at the hospital, jt may be sent home within a day or two. CONGENITAL PALATE AND LIP CLEFTS. 197 MORTALITY. The immediate m.ortality of the Brophy operation is very low. We have twice lost three months' children within twelve hours after opera- tion. We have seen a few infants die some weeks or months after operation ; but this has occurred only among cases in which the nutri- tion of the infant was persistently bad beforehand, and the operation was undertaken in the hope of improving the condition. In these latter cases death could not be attributed directly to the operation, although no doubt it had been a contributing factor. We think it fair to state that we have seen a much larger percentage of deaths among infants that we were trying to get in shape for operation, than in the first few postoperative months. Fig. 138. Roberts' modification of Hammoud palate clamp. Roberts has made a modification of the Hammond clamp for grad- ually approximating a bony cleft. In this clamp (Fig. 138), the teeth project like hooks above the upper edge of the jaws. The clamp can be applied under anesthesia, the mucosa of the upper fornix being first incised to allow the clamp to fit snugly high up on the body of the jaw. The clamp is tightened a little each day or so, as the segments of the jaw come together. We have never used this clamp, but Dr. Brown once constructed one for us with hard rubber jaws, which were pressed together with a rubber band. We gained something by its use, but not much. The Hammond-Roberts instrument is much more power- ful. Roberts remarks, "Theoretically the method is valuable; but its practical usefulness has not yet been established." It seems to us that the two points to consider in its use are : how much will its continued use fret the baby, and how much will the instrument irritate the soft tissue. CHAPTER XV. CONGENITAL PALATE CLEFTS— PLASTIC OPERATIONS IN ORDINARY CASES AFTER EARLY INFANCY. Aside from the general condition of the patient, the first thing to be determined is the plan of operation that is applicable to the given case; and the conclusion is to be reached by a comparison of the amount of available tissue with the width of the base of the posterior part of the palate arch. The width of the cleft bears only indirectly upon the question. The width of the arch is to be measured from the proposed site of one lateral incision to the other — from a to a (Fig. 139). The amount of the palate tissue available is determined by meas- uring from the site of the lateral incision to the edge of the cleft on both sides. If in a healthy individual the sum of the available palate tissue is equal to five sevenths or more of the width of the arch between Fig. 139. Diagram of a section through a cleft palate. The distance between a and a' is the width of the palate ; a and a' mark the sites of the lateral Incisions. The distances between a and & and between a' and b' give the amount of available palate tissue. the two lateral incisors, the case is a proper one for the simple von Langenbeck operation. That is, if the direct distance from one lateral incision to the other is, for example, 35 millimeters and the sum of the widths of the available tissue for flaps is 25 millimeters, then the pro- portion is 25 millimeters of palate tissue to 35 millimeters of palate width. Here the 10 millimeters of missing palate tissue, plus the 5 millimeters that will be lost by paring the edges, will be compensated for by the spreading at the site of the lateral incisions. If the propor- tion of tissue is smaller, the chances of success will be greatly in- creased, if it be treated by one of the operations given under "Difficult Cases," Cha]). XVI. We have seen a few cases that were difficult to close when the proportion of palate tissue to palate width was greater than 5 to 7. 198 CONGENITAL PALATE CLEFTS. 199 PREPARATION FOR OPERATION. Before the operation is undertaken, it should be determined whether the patient is in a good physical condition, is at the time free from a cough or "cold," is not cutting teeth, and is not likely to break out with some eruption or contagious disease. Children that are known to have been exposed to one of the last should not be subjected to the operation until after the time of incubation has passed. The subjects of active syphilis should, for the time being, be excluded from opera- tion. Phthisical persons should not be subjected to the depressing effects of any surgical procedure, unless there is some special indication for doing so. In one of the latter, a middle-aged woman, we repaired the palate, for the reason that, having no upper teeth and on account of the cleft, she was not able to wear a plate, and her depressed physi- cal condition was partly due to faulty nutrition. If there are decayed teeth in the mouth, they should usually be treated or removed, and if the teeth are not free from tartar, they should be cleaned by a dentist before the operation. If there is any persistent source of pus in the mouth, it should be treated, if necessary, by ap- propriate vaccines. This refers also to suppuration of the accessory sinuses of the nose. Having eliminated all acute diseases and all evident possible sources of irritation and infection, the mouth of the older child or adult may be rinsed frequently for twenty-four hours before the operation with a mild antiseptic wash. Food and water should be withheld for a suf- ficient time before the operation to be certain that the stomach will be empty, and if indicated — not as a routine practice — a laxative may be given. It is our practice to give water in reasonable amounts up to an hour before, and some form of liquid food exclusive of fresh milk about four hours before the operation. POSITION AND LIGHT. During the operation the patient may be sitting erect, lying flat on the back, lying on one side, or lying on the back with the head hanging over the end of the table. The latter is known as the Rose position, and this, or the lateral position, is the one we prefer. Both of these' positions have one great advantage : the blood drains away from the larynx. The Rose position may be modified to this extent : the head rests on a pillow on the surgeon's knees or in the hands of an assistant, which lessens the strain on the unconscious patient's neck. To support the head on the lap comfortably, there must be a proportion between the stature of the operator, the height of the operator's stool, and the height of the table. It is well to have arranged this detail before the operation is undertaken. The pad upon which the patient lies should 200 SURGERY OF THE MOUTH AND JAWS. extend beyond the table so that the neck will be protected. This pad may, very satisfactorily, be made of folded blankets covered with rub- ber, A pillow placed under the shoulders is unsatisfactory as it does not stay in place. With the patient in the lateral or in the Rose posi- tion, the instrument table is to be placed to the right of a right-handed operator. The anesthetist stands behind or to the patient's left, and the assistant to the right, both facing the surgeon. If the head is to be supported in the hands of a second assistant, he sits to the left be- tween the surgeon and the anesthetist. The light should be good — daylight from a side window. This is preferable to artificial light, but as a rule in cities, in winter, electricity is more dependable. If the light is from a cluster, the patient should be placed in such a relation to it that the light will fall directly into the mouth. Unless the operator is very accustomed to its use, a head mirror is not satisfactory, as it destroys the sense of perspective, but an electric headlight is not open Fig. 140. Lane gag. to this objection. A hand light is not as good for this purpose. It is absolutely essential to good work that the light be excellent, INSTRUMENTS AND MATERIALS. Next in importance to the light is the mouth gag. The profusion of varieties presented in any instrument catalogue should by their num- ber suggest caution to the surgeon in selecting one. Rather than waste time with a poorly adapted gag, it is better to place a block of wood or cork between the molars on one side and then firmly wire a tooth in the lower jaw to a tooth in the upper jaw, just in front of the block. Roughly, gags may be divided into two classes : those that are de- signed solely for the purpose of separating the jaws, and others that, besides holding open the mouth, are supposed to depress the tongue. Of the former variety there are two general types : the kind which rests on the incisor teeth, and those which are inserted between the molars. As a rule the former is more satisfactory where it can be CONGENITAL PALATE CLEFTS. 201 used, but it is hardly applicable to clefts that involve the alveolar process. If a posterior gag is used, the Lane type (Fig. 140) is prefer- able to the ordinary kind. Whatever kind is selected, see that it is strong enough and has a reasonable inclination to stay in place. Of the gags that are intended to depress the tongue, we are familiar v^ith three varieties that are useful if the size and shape of the particular model at hand corresponds to the patient's mouth. One is the White- head gag (Fig. 165), which comes in two sizes, but which, taking its bearing at the incisor teeth, is not suitable to cases of through-and- through cleft. The same holds true of the Murdock gag, which has lately appeared with a tongue depressor attached. Mr. Owen's modifi- cation of the Smith gag, which is made by Weiss of London, and comes Fig. 141. Owen's iiiodiflcation of Smith gag. in three sizes, is shown in Fig. 111. The spiked rests are applied to the gums behind the molars, and if the gag fits properly, they will not slip. The simplest of all is Dr. Brophy's oral speculum. While its very sim- plicity recommends it, it does not give as much working room as do the other two, and to assure having one to exactly fit a given case, it is necessary that quite a variety of sizes and shapes be at hand. Having provided for a satisfactory light and gag, the rest of the necessary armamentarium is rather simple, and should consist of a small pointed knife that is sharp enough to cut a suspended hair as freely as a razor. This knife must be resharpened for each operation. It is very rare that a new knife, as it comes from the dealer, is sharp enough to be perfectly satisfactory. It saves the edge of the sharp knife to have a second for making the lateral incisions. 202 SURGERY OF THE MOUTH AND JAWS. There should be at least one dozen artery forceps for sponging and clamping ligatures to the head cloth. One or two of the forceps should be pointed. For a needle holder we use an ordinary Halsted artery forceps, but with it use a needle that has a flat shank. An artery forceps will hold a flat-shanked needle a little obliquely, which is an advantage. The artery forceps will not prevent a round needle from turning. One pair of plain dissecting forceps is needed for manipulating the needles, and a pair with long mouse teeth is useful for catching small pieces of tissue that are to be removed. There is a forceps that combines these two LU a Lr B Fig. 142. An easily constructed tenaculum for handling palate flaps. The one shown above (A) is made to both push and to pull on the flaps, but this double-ended needle is liable to catch in the tissues. We prefer to use two, one to push and the other to pull (C and D). They are made by filing a groove in the end of the blade of a Halsted forceps (B) and setting in the point of a fine cambric needle. features. The flaps themselves should never be grasped with any kind of pressure forceps. Several varieties of hooks and tenacula have been devised for this purpose, but the scheme shown in Fig. 142 can be prepared by anyone and is extremely satisfactory. For cutting the palate aponeurosis and nasal mucous membrane from the posterior border of the hard palate, the straight knife is ef- ficient only when the cleft extends well forward into the bony palate. Nevertheless, in all cases, a pair of thin-bladed sharply curved scissors are more satisfactory. The curved knives made for this purpose are difficult to sharpen, and the angle knives tend to split the velum longitu- dinally. The scissors shown in Fig. 143 are tonsil scissors, one pair of which were especially ground for infants' mouths. Any pair of small CONGENITAL PALATE CLEFTS. 203 scissors that ape curved on the flat or side will do, provided the curve is sufficiently sharp. Unless the tongue-depressing device on the gag is absolutely satis- factory, a narrow-curved spatula is required for controlling the tongue. The kind of elevator used will depend somewhat upon whether the operator chooses to begin freeing the mucoperiosteal flap from the cleft border or from lateral incisions made at the outer border of the palate. For the latter procedure, the most satisfactory are those devised by Dr. Brophy (Fig. 144). The acute angle of the second one is very useful in freeing the anterior part of the flap in a highly vaulted arch. Freeing the flap from a lateral incision is the more rational and satis- I Fig. 143. Tonsil scissors that may be used for cutting the palate aponeurosis, smaller pair have been ground for an infant's mouth. The factory procedure, and a very good instrument for this purpose is the one devised by Dr. Willard Bartlett (Fig. 145). With ordinary care it will not cut the descending palatine artery and will' work both an- teriorly and posteriorly through a small incision (Fig. 146). It will be noted that all of the instruments mentioned are unpaired and can be used at either side of the palate. Sutures. — In the selection of suture material, we have traveled somewhat in a circle. It is well recognized that silver wire is tolerated better in tissues exposed to sepsis than any other suture material. However, the ordinary way of inserting it with silk carriers is cumber- some and time consuming, and it is not always convenient to be de- pendent upon a special instrument, such as the OAven needle. We 204 SURGERY OF THE MOUTH AND JAWS. used horsehair for some time, but abandoned it on account of the fear of tetanus. Its elasticity, the ease with which it is handled, and its non-irritating character all unite to make horsehair an excellent suture. Later we used a fine silkworm gut, but noticed that not infrequently sepsis apparently had its origin at a suture hole. We are now using a No. 30 soft-silver wire, threaded directly on a Ferguson needle. With a little care it can be made to follow the needle without tearing the tissues, and in using it in this way, we believe we have overcome the only objection to its use. To use silk and linen seems objectionable because by their capillarity they promote sepsis. There is little unan- Fig. 144. Brophy palate elevators. Fig. 145. Bartlett elevator. imity of opinion about palate suture material. Among the operators of large experience: Lane uses silk, Judd, of Rochester, uses linen, Brophy uses horsehair, while Gilmer and Owen both use silver wire. In using silver wire, the sutures are at first twisted but loosely, or held to one side with forceps. After all are in place, they are twisted to the proper tension. In most instances we use a small Ferguson needle which has a flat shank. The needle shown in Fig. 147 is extremely useful and some- times almost indispensable in repairing a partial union after a primary operation, when the defect is situated in the hard palate and the edges of the flaps are thick and inverted in the nasal fossa (Figs. 148 to 151). The variety of right and left-curved needles on handles that are offered CONGENITAL PALATE CLEFTS. 205 by instrument makers for palate suturing are absolutely unnecessary, and many of them, on account of their bad lines, are impossible. If retention sutures and lateral plates are to be used, small pierced shot are the most convenient means of fixing the retention sutures in the lead plates. The lead from which the plates are cut is about 1 millimeter thick. The lead plate can be obtained from a plumber and rolled or beaten out to the desired thickness. The shot can be bought from an instrument dealer, or ordinary shot can be drilled out by hand. Sponges.— Though very satisfactory, marine sponges are no longer popular. For sponging ofif the flaps, small wads of absorbent cotton, that have been wet and wrung out very thoroughly by squeez- ing, are very satisfactory. For removing the blood from the naso- pharynx, loosely folded squares of dry gauze, 5 centimeters wide, and four thicknesses of gauze, are better adapted. . Unless the sponges are Fig. 146. .Method of use of Bartlett elevator. rewashed during the operation, there should be a large supply to pro- vide for excessive bleeding and emergencies. We find it convenient to have on hand some folded strips of gauze to temporarily pack the lateral incisions, when bleeding is free. These are to be removed be- fore inserting the sutures. The instruments, sponges, and sutures should be laid out in an or- derly way on a table to the right of a right-handed operator and should be well within his reach and view. FLAP-SLIDING OPERATION. The patient, being anesthetized, is placed in the desired position, and the hair is covered with a rubber cap ; over this is placed a sterile pro- tective cloth that covers the nape of the neck behind and the eyes in front, enveloping the whole head. This is put on firmly so that it will not slip and is pinned, or is clamped with artery forceps. Whether or 206 SURGERY OF THE MOUTH AND JAWS. not there is a tongue depressor on the gag, a traction suture is passed through the tongue, the two ends being knotted together so that it will not slip out. This suture should transfix the tongue at least 1.5 centimeters from the tip and be of soft silk that will not cut through. Being satisfied with the view that can be obtained of the palate, in- cluding the uvula, and that the tongue depressor is not interfering Fig. 147. Pig. 149. Fig. 147. Shepherd's crook needle. Fig. 148. The palate flap may be steadied with a prod while the shepherd's crook needle is inserted. Fig. 149. McCurdy'm method of using shepherd's crook needle. First step : The threaded needle is passed through the cleft, and the palate flap is transfixed from its upper surface. Second step: The loop (a-a) is caught, and the suture end (a) of (a-a) is withdrawn through the palate, so that it hangs in the mouth but is not withdrawn from the eye of the needle. with respiration, the mucus is sponged from the nasopharynx, and the operation proceeds somewhat as follows : A lateral incision is made on either side opposite the position of the last molar tooth. If the patient is lying on the side, the lateral in- cision is made on the side of the palate that is next to the table. If CONGENITAL PALATE CLEFTS. 207 the molar tooth has erupted, the incision is made 4 milHmeters from the gingival border. If the tooth has not erupted, the incision is car- ried along the line of junction of the palate surface with the most prominent part of the gums. The incision is made just median of the last two molar teeth, extends directly to the bone, and is made as close as possible to, without absolutely denuding, the necks of the teeth. Behind the last molar tooth the incision is carried along the crest of the alveolar process. As Mr. Owen tersely puts it: "The closer these incisions are made to the teeth, the less chance of wounding the de- Fig 151. Fig. 150. Fig. 152. Fig. 150. McCurdy's method of using sliepherd's crook needle. Third step : The needle still threaded is withdrawn from the first flap, turned 180 degrees in the axis of its handle, and inserted into the second flap from its upper surface. Fourth step : The loop (b-b) is caught, and the suture end (b) of (b-b) is withdrawn from the eye of the needle. Fifth step : The unthreaded needle is removed. Fig. 151. After placing a suture with the shepherd's crook needle, it can be con- verted into a vertical mattress suture by the use of a small needle. Fig. 152. The blades (S, S) of a pair of eurved-ou-the-flat scissors In position to cut the palate aponeurosis and nasal mucous membrane from the posterior border of the bony palate; (mp) is the mucoperiosteum separated from the bony palate; (p) is the bony palate ; (v) is the velum. scending palatine arteries, the broader will be the flaps, and the less likelihood of their blood supply being seriously interfered with." In the original von Langenbeck operation, which with us is the method of choice, the elevator that dissects the palate flaps is inserted through the lateral incision. In raising the flap, the point of the ele- vator, which should not be sharp, is kept close to the bone so that the artery and nerves will be lifted with the flap. Just in front of the opening of the posterior palatine canal they lie in a distinct bony groove. While these are to be lifted from the groove, the point of the elevator should not dig into the opening of the canal. The vessels will 208 SURGERY OF THE MOUTH AND JAWS. stretch, and the nerves yield until the flap can be moved toward the median line for an astonishing distance. It is usually practical to break through into the cleft with the elevator at the junction of the nasal and palate mucous membranes, thus doing away with the necessity of paring the borders of the cleft in the hard palate. If it is considered desirable to pare the borders of the cleft in the hard palate, it is done as follows: In the case of a double cleft, a strip of tissue may be removed down to the bone, from the mucoperiosteal edge, on both sides, by reversing the position of the knife and cutting anteriorly as far as the limit of the cleft (Figs. 153 and 154). In a single cleft, part of the mucous covering of the nasal septum may be utilized with the palate flap on the side to which the nasal septum is attached. An incision is carried through the mucous cov- ering along the surface of the septum parallel with the palate (Fig. 110). The height above the palate, at which this incision is made, will depend upon the amount of flap that is needed. If this incision on the septum is to be made at a considerable height above the palate, unless one has an especially constructed knife, it is best made by pass- ing a small tenotome through the opening of the nostril on the cleft side and incising the mucous covering of the septum from behind for- ward, and then connecting the anterior and posterior ends of this in- cision with those at the palate border. In clefts that extend well forward into the hard palate, it is often convenient to free the extreme anterior part of each flap by working from the cleft border. For this purpose, the Brophy elevator, that has the blade bent at an acute angle (Fig. 144), is especially useful. The mucoperiosteal flap having been dissected from the surface of the bone on one side, the next and absolutely essential step is to free the velum from the hard palate by cutting the palate aponeurosis and the nasal mucous membrane at the posterior border of the palate pro- cess. This may be accomplished in clefts that involve both the hard and soft palates by passing a knife between the palate process and the mucoperiosteal flap and cutting upward and backward. In all cases, however, it is more conveniently done by passing one blade of a pair of sharply curved scissors between the bone and the flap and the other blade into the nasopharynx (Fig. 152). The mucoaponeurotic layer should be severed from the hard palate as far as the lateral incision. When the velum is freed, it should be possible to carry the median edge of the half palate well past the median line without tension. If it is not sufficiently movable, the fault will probably be that the aponeurosis has not been entirely severed. If the tension is due to contraction of the tensor palati muscles, it can be relieved by Billroth's plan of in- CONGENITAL PALATE CLEFTS. 209 serting a small chisel guided by the finger into the lateral incision, and fracturing the hamular process at its base. This will not permanently cripple the action of the muscle. The lateral incision is not to be ex- Fig. 153. Fig. 154. Fig. 153. Prod and knife in position for denuding the left cleft border, in ele- vating the mucoperiosteal flaps from the hard palate, they are at the same time freed from their continuity with the nasal mucosa. Therefore it is unnecessary to extend the cuts anterior of the junction of the velum with the hard palate. Fig. 154. Knife and prod in position for paring the right cleft border. Ribbon of tissue is shown hanging from the left border of the cleft. If the border of the cleft in the hard palate has been freed with the elevator, the paring is done only in the velum. tended straight backward indefinitely. At a point 1 centimeter behind the hamular process the ascending palatine arteries may be cut, and with them possibly the nerve supply of the levator palati muscles. If 210 SURGERY OF THE MOUTH AND JAWS. further freeing is necessary, it is better to carry the incision backward and outward to the outer side of the anterior border of the ramus of the mandible. This may later cause some stiffness in opening the mouth, but this can be later overcome by a soft rubber dilator. If par- tial failure occurs after operation, it is usually at the junction of the hard palate and velum, and therefore, the flaps should be sufficiently free in this part. The distance to which the lateral incision may be carried anteriorly will depend upon whether the trunk of the descend- ing artery has been injured in loosening the flap. If the artery has not been cut, the incision may be prolonged forward any distance without endangering the blood supply, but unless it is certain that the vessel is intact, the incision should not be extended in this direction. If for lack of this incision it is found impossible to coapt the edges of the flap in front, it is better to unite the posterior part, and postpone the anterior part to a later operation, than risk the misfortune of a slough- ing of this part of the flap. The freeing of the flaps should be com- pleted at this time. To extend the lateral incisions after completing the suturing is to court hemorrhage that may require repacking. Hav- ing ascertained that the palate flap is sufficiently freed, bleeding is con- trolled by temporarily packing the lateral incision with a strip of gauze. The freeing of the flap having been completed on one side, and hemor- rhage controlled, it is repeated on the other. When methodically and properly done, this part of the operation takes but a few minutes. Whether the performing of the whole operation will require thirty-five minutes, or an hour or more, will usually depend entirely upon the care which has been given to each detail at the proper time. Very oc- casionally anesthetic difficulties or hemorrhage will be an unavoidable cause of delay. There are a few operators of considerable experience who free the flaps by inserting the elevator from the cleft border, with- out making lateral incisions, but this is not the practice of the majority. During the whole course of the operation, bleeding is to be con- trolled mostly by temporary pressure ; occasionally an artery can be caught with toothed forceps, but rarely can a ligature be applied. Sometimes a bleeding vessel can be included in a suture, but this pro- cedure is not to be recommended where there is any danger of limiting the blood supply of the flap. Although several writers have stated that it is of little consequence, the cutting of the descending palatine arter- ies is to be dreaded more on account of the danger of ischemia than from hemorrhage, which is usually controlled by temporary pressure or packing under the flap. Plugging the canal has been recommended to control bleeding from this artery, but we have never found it neces- sary. During the operation, the nasopharynx is to be kept free from CONGENITAL PALATE CLEFTS. 211 blood. If one can satisfy himself that he can sterilize marine sponges, they are more efficient than any of the newer substitutes. The flaps having been properly loosened on both sides, the next step is paring the borders of the cleft in the velum. The prod (Fig. 143) is held in the left hand, and is inserted into the uvula near its tip, taking a good hold (Fig. 153). By pushing downward and backward, the cleft edge of the velum is made tense. The point of the knife, with its cutting edge toward the uvula, transfixes the velum at its base about 2 millimeters from the cleft edge and cuts a ribbon of tissue from the Pig. 155. Fig. 156. Fig. 155. Shows first insertion of the needle at the junction of the hard and soft palatBr Fig. 156. Showing the last insertion of the needle for the superficial part of the vertical mattress suture. This suture has the advantage of approximating broad ravr surfaces. free border, as far as the base of the uvula, that leaves a raw surface 5 to 8 millimeters wide. The median border of the cleft velum is one edge of a prism, and a slight variation of the angle at which the knife is held will make a considerable difference in the width of the result- ing raw surface. We have for some time ceased to pare and unite the two halves of the uvula, for the reason that, when this is done, the latter shrinks to a small nodule, while the two halves of the uvula, if not molested, help to fill in the space to an appreciable extent. We advocate postponing the denuding of the cleft border until after the flaps are freed from the bone, for the reason that, by doing 212 SURGERY OF THE MOUTH AND JAWS. so, the raw surfaces are exposed for a shorter time before being coapted by sutures. In actual practice it will be found that, after the palate flaps and velum have been freed from the bone, they become much elongated, and it is now difficult to hold them tense while the denuda- tion is made. It is of the utmost importance that the sutures be not drawn too tight. This is apt to cause sloughing and non-union. The Pig. 15S. Fig. 159. Fig. 160. Fig. 1.57. Showing detail of vertical mattress suture in place, in the mucoperiosteal flap from the hard palate. Fig. 158. Showing detail of vertical mattress suture in place in the velum, a, mucosa of nasopharynx ; b, velum tissue ; c, oral mucosa. Fig. 159. Each suture is used to make the velum tense while putting in the next suture. Fig. 160. The velum sutures are tightened before the sutures are placed in the mucoperiosteal flaps. The latter are all placed before any of them are tightened. use of silver wire has the advantage that it can be accurately twisted to exactly the desired tension. After the operation the tissues will swell, and allowance must be made for this. If the lead plates are used in connection with retention sutures, the packing should not be left in place after the operation is completed, as the palate flap is apt to be constricted between the packing and the CONGENITAL PALATE CLEFTS. 213 plate. In any case, the packing should be removed in twenty-four hours, as it promotes sepsis and has been responsible for extensive sloughing. Care should be exercised not to catch the packing gauze in a suture, as this would prevent its removal. It is safer to remove it before inserting the sutures. Packing that is to be left in place may be saturated with a 10 per cent solution of colloidal silver (Crede), or iodoform. The various steps of paring the flaps and suturing and of applying the retention sutures and lead plates are adequately explained by Figs. 154 to 162. Fig. 161. Showing the method we formerly used in placing lead plates for supple- mentary support. For reasons stated in the text, we have abandoned the use of any form of supplementary support to the suture line. When the operation is finished, the pharynx should be sponged out, and a careful inspection made to exclude active bleeding. This is done by lowering the head, with the patient turned well on one side. Then the blood would run into the hollow of the cheek and not collect in the pharynx. RETENTION DEVICES. Before closing, it is proper to review briefly the subject of stay sutures and various other supplementary means of protecting the suture line and of relieving tension. It is an absolute essential of the opera- tion that the flaps be freed so that they can be approximated without tension, and there is no contrivance that will compensate for a failure 214 SURGERY OF THE MOUTH AND JAWS. in this respect. It is possible, however, but is by no means universally conceded, that, after the flaps have been properly freed and sutured, something more can be done by guarding against tongue pressure, the pull of the palate muscles, and the strain of coughing and vomiting. Tongue pressure may be eliminated by using silver-wire sutures, the ends of which are allowed to point downward in such a way as to cause discomfort when the tongue presses on the palate. Another device for guarding against tongue pressure, but which can only be used when molar teeth are present, is to have a vulcanite plate made that is fitted to the dental arch and which itself does not rest against the newly made palate. We have never tried this plan as it protects against tongue pres- Fig. 162. The last shot being crushed on the lead plate stay suture. sure only and it is not conducive to free drainage or cleanliness. Pack- ing of the lateral incisions has been advised by some, but this is ob^ jectionable because, if left in place, the packing becomes foul and is conducive to sepsis and even to sloughing ; the disturbance of changing would outweigh all of its advantages. Charles Mayo has advocated the use of a piece of tape around the new palate through the lateral incisions, which is made into a band by means of a stitch or ligature. In this way the tissues are held to- ward the median line by the pressure of the tape band. We have had opportunities of observing very disastrous sloughing from use in less skillful hands. Judd, who now does much of the palate operating at the Mayo clinic, informs us that he does not use it. CONGENITAL PALATE CLEFTS. ai5 Fillebrown, Brophy, and others have devised modifications of the old quill or lead plate suture, w^hile especially constructed clamps have also been made. We formerly applied lead plates, as illustrated in Figs. 161 and 162, but have discontinued their use, because they occasionally caused sloughing in spite of every care. It is our present belief, after a rather extensive observation, that, although these mechanical adju- vants may be helpful, in some cases they will cause sloughing. We have discarded them all, now depending entirely upon the sufficient freeing of the flaps. AFTER-TREATMENT. The patient is given water as soon after the anesthetic as desired, and a purgative is administered as early as possible to get rid of the blood that has been swallowed. Liquid food or soft jellies and gruels are given for ten days, and for the first few days all food and water should be sterile. The patient is not allowed to talk for ten days or two weeks. He is allowed to get up on the second or third day, unless there is, fever. A mouth wash and a nasal douche are used from the first. In young children, simple saline solution is used, but older chil- dren and adults may use a mild mouth wash after each feeding and fre- quently between times. The alkaline antiseptic solution (N. F.) diluted with three parts water makes an agreeable nasal wash, which is allowed to flow into the nose from a syringe or douche cup, while the head is held erect. Lead plates may be removed at the end of two weeks, and the su- tures at any time later. It is not well to make too frequent inspection of the palate during the first few days following the operation ; and a tongue depressor should not be used, as it might cause gaping or even vomiting, which would be a strain on the line of union. POSTOPERATIVE HEMORRHAGE. Our observations coincide rather closely with Mr. Owens', in that we have but once had serious hemorrhage follow this operation. In this case it was controlled by packing. It seems to us that the use of an anodyne, packing the lateral incisions, and, if necessary, allowing the patient to sit up until syncope comes would control hemorrhage in most any case, except possibly of pronounced bleeders. If necessary, the patient should be anesthetized, the suture line opened, and the bleeding point found ; or the packing could be sutured in place. NON-UNION. Except where tape, packing, plates, or some other means of reten- tion has been used, sloughing at any place, beyond the grasp of the sutures, rarely occurs. A mild grade of sepsis following the operation 216 SURGERY OF THE MOUTH AND JAWS. is not infrequent and is the usual cause of total or partial failure after a well-performed operation. It is evidenced by the persistence of a temperature of 101}^° F., or over, and by a fetid odor. The sloughs fall away in three to four days, and if there is a failure of union, it will usually be evidenced by this time. Besides the use of potassium permanganate solution locally, we think the use of small doses of quinin and calomel, continued for twen- ty-four or forty-eight hours, is helpful in this condition. REOPERATION. After a non-union due to sepsis, Mr. Owen recommends reopera- tion at the end of two weeks ; for at this time the flaps are still soft, and he believes that the patient has developed a resistance to the par- ticular infection. We have followed this plan successfully, but thought there was excessive reaction following the second operation. We cer- tainly would refrain from doing it in infants or young children. Un- less there has been extensive loss of tissue, the flaps can usually be freshened and reapproximated without difficulty. In refreshening the edges of the flaps for a secondary operation, the edges must be de- nuded down to the normal tissue, as there is at the base of every gran- ulating surface a plane of scar tissue that interferes with the rapid union that is necessary for success. Small defects may sometimes be made to close by touching the edges (more than once if necessary) with the actual cautery. MORTALITY. We have had but one fatality from this operation. In this case there was good reason to believe, both from the symptoms and from other cases developing in the ward, that the child died of scarlet fever. RESULTS. The later functional result will depend both upon the length and mobility of the velum and upon the ability of the patient to develop the use of the superior constrictor of the pharynx, and tongue, as aids of the velum, which latter after a late operation is always short. As a general rule, the earlier the operation is performed the better will 1)e the functional results. (See Speech Training. Chap. X\''III.) CHAPTER XVI. CONGENITAL PALATE CLEFTS— OPERATIONS FOR EXTRAORDINARY CASES. With very few exceptions all cases of congenital cleft palate can be closed by the original von Langenbeck operation, described in the preceding chapter, but in some instances certain accessory procedures are advisable and even necessary. In a few cases, usually those in which large parts of the tissues have been lost after previous unsuc- cessful operations, it is necessary to employ radically different meas- ures. While the von Langenbeck operation will close almost every cleft, still, after a child with a cleft palate has passed the tenth or twelfth year, the velum will not have developed to the normal length. If the flaps are simply brought together in the median line, inability to com.- pletely shut off the nasal pharynx usually results, which is accompa- nied by what is recognized as the "cleft palate" speech. As the age of the unoperated case increases, this deficiency is apt to become more marked. KUSTER'S OPERATION. The operation proposed by Kiister, a modification of which is illus- trated in Figs. 163 and 164, to a certain extent overcomes this difficulty and is advisable in all cases of healthy individuals who have passed the age of eight or ten years and in wliom there is sufficient palate tissue to allow its execution. If the sum of the available palate tissue is in a proportion to the width of the palate of less than 5 to 7 (page 19S), or even in this or near this proportion ; if the patient himself, or the palate tissues, are not in the best condition, one of the two following accessory operations will be expedient. TWO-STEP OPERATIONS. The simplest modification of the von Langenbeck operation is to do it in two steps. In the first stage the mucoperiosteal flaps are loosened from the bone through lateral incisions, and the velum is de- tached from the posterior border of the palate process ; but no incision is made at the cleft borders. The space between the flaps and bone is packed with gauze for a few days, when the operation is completed in 217 218 SURGERY OF THE MOUTH AND TAWS Fig. 163. In Figs. 163 and 164 Kiister proposed the plan by means of the incisions (b-b) of lengthening the velum, but there is rarely suflBcient palate tissue to permit of this being done without leaving such wide gaps at the site of the lateral Incision that subsequent scar contraction renders the velum too tense to move freely. The figure shows a modifi- cation which obviates the latter dlfllculty. > (a) shows incision at lateral border of hard palate through the mucoperlosteum (■arried behind the ma.xillary tubercle and straight out on the buccal mucosa for 1 Vj centimeters, then backward to the level of the lower jaw, and then inward ; again cut- ting the pterygomaxillary ligament. The mucus, pterygomaxillary ligament, and buc- cinator muscle are cut through, and the flap is dissected up until the space between the internal pterygoid and tensor palati muscles Is opened. The hamular process is cut across at Its base. The cleft borders of the velum are not freshened in the usual way ; but the incisions (b-b) are made on each side through the whole thickness of the soft palate, and the flaps behind these incisions are rotated backward. In this way the incisions (b-b) are opened, and the raw surfaces thus exposed are sutured to each other at the median line (Fig. 164). As the two halves of the velum are cariied toward the median line, the flaps (a-a) are drawn inward, and there will be no subsequent scar contraction to render the velum tense and comparatively useless. The space between the upper and lower jaw is still covered, and opening of the mouth is but slightly interfered with. This opera- tion gives a longer velum than is obtained by the simple von Langenbeck operation, and therefore a better functional result. It will not permanently cripple the action of the superior constrictor muscle of the pharynx. CONGENITAL PALATE CLEFTS. 219 the usual manner. This procedure causes the tissues to stretch and thicken, and also increases their blood supply. It is our custom to sat- urate the packing gauze with a 10 per cent solution of colloidal silver (Crede) and to stitch it in place. It is applicable in cases in which the cleft is of more than moderate width compared to the available soft tissues of the palate, and also in cases where these tissues are thin and atrophic. The objection to this procedure is that, if for any reason the second operation cannot be performed within four days, the pack- Fig. 165. Figs. 165 and 166. Showing amount that the cleft had been narrowed by packing under the flaps through lateral incision. ing must be withdrawn. If allowed to stay in longer, there will be shrinking of the flaps. Figs. 165 and 166 are of a case of wide cleft in an adult before and after this step and show the amount gained. Figs. 167, 168, and 169 are of casts made of this case before the first and after the final operation. The dotted lines show the exact location of the lateral incisions w;hich, where practical, were carried to the outer side of the gums. The patient was forty odd years of age ; and the operation was done because she was losing her teeth on account of 220 SURGERY OF THE MOUTH AND JAWS. pyorrhea alveolaris, and without a restoration of the palate she would not be able to wear artificial dentures. This case was one of those rare instances in which, although there was complete palate cleft, the patient learned to enunciate almost perfectl}/ by using the base of the tongue against the posterior wall of the pharynx to produce those Fig. 167. Fig. 168. Showing two views of a wide cleft — before operation — that was operated on in two stages. The dotted lines show the outline of the lateral incisions. Fig. 169. Same case as shown in preceding figures nfter vlosure of the cleft. sounds that ordinaril\' rt'(|uire llic closure of the naso[)harynx by the velum. Figs. 170 and 171 are of casts before and after the closure of a wide cleft in an edentulous mouth by this method. The previous attempts by CONGENITAL PALATE CLEFTS. 221 the. ordinary means had been ahnost complete failures. The case was that of a tuberculous adult, whose home surroundings were such that without teeth she could not get proper nourishment. All of the teeth in both jaws had been removed before we first saw her. Fig-. 171 shows the final successful result. Pig. 171. Fig. 170. Sliowing a very wide cleft that was closed by a two-step operation by first packing under the palate flaps. Fig. 171. Showing exposed bone which later became covered with mucosa drawn from the neighborhood by scar contraction. Another plan consists in driving a chisel through the palate process at the ordinary sites of the lateral incision and forcing- the processes toward the midline. These lateral wounds are packed with gauze for a few days, when the palate cleft is closed in the ordinary manner. APPROXIMATION OF THE MAXILLAE. Dt. G. V. I. Brown, of Milwaukee, and Prof. Herman Schroeder, of Berlin, have devised methods of narrowing the cleft in children by 222 SURGERY OF THE MOUTH AND JAWS. means of orthodontic apparatus. Brown recommends this in cases of eighteen months to two years as a substitute for the early Brophy op- eration, while Schroeder uses it up to nine or ten years. Figs. 172 and 173 illustrate a case of a boy of six years with a cleft that was wide in proportion to the available palate tissue. The result in three weeks is shown in Fig. 173. The amount gained at the posterior Fig. 172. Fig. 173. Showing plan of narrowing cleft by traction. This apparatus was constructed and applied at our request by Dr. LeGrand Cox of St. Louis. Fig. 174. Final result in case shown in preceding illustrations. part of the cleft palate is shown in numerals, while it will be seen that the projecting intermaxillary process was pulled back into place and the aveolar part of the cleft approximated. Fig. 174 shows the final result which was obtained without difficulty by the ordinary operation. After removing the clamps, the maxillae later spring back to near their original positions. CONGENITAL PALATE CLEFTS. 223 REPAIR BY FLAPS FROM OTHER THAN PALATE SOURCES. There still remain those cases in which much or most of the soft tissues covering the palate processes have been lost from sloughing after previous unsuccessful operation, and these can only be repaired by Fig. 176. Showing method of gaining tissue from the cheek lining. Fig. 175 shows the in- cision that is made at the side of the hard palate through the mucoperiosteum, carried behind the maxillary tubercle, then skirting the alveolar process forward to the an- terior border of the masseter muscle. It is then carried outward in the buccal mucosa for 1 centimeter, and then backward. It cuts through the mucous membrane and the buccinator muscle, which structures are raised in a flap as far Inward as the tensor palati muscle. The hamular process of the pterygoid process is fractured at its base. As the palate tissues are moved toward the median line, the flaps (a-a) are transferred to the palate, and the defect in the cheek is partially effaced by two sutures. In taking up this cheek flap, the anterior borders of the ramus of the jaw and of the internal pterygoid muscles are exposed, and the space between the internal pterygoid and tensor palati muscles is opened by passing in a blunt instrument and pushing the velum toward the median line. Fig. 176 shows the completed operation. 224 SURGERY OF THE MOUTH AND JAWS. flaps derived from some extrapalatal source. The following pro- cedures are applicable in certain cases where palate tissue has been lost from ulceration or at an operation for the removal of a growth. If the posterior border of the velum has been preserved, — and this is a part we have never observed to suffer from a postoperative slough- ing — the velum and the posterior part of the hard palate can be recon- structed by the procedure illustrated in Figs. 17.5 and 17G. In taking up the flaps in a secondary operation, any tissue that immediately turns to a dark purplish red is to be discarded at once, for it is granulation or scar tissue that will not survive after being raised from its bed. The operation illustrated in Figs. 175 and 17G is possible even after lateral incisions were made at the outer border of the velum at a previous operation, for the nutrition of the flap will come from its attached posterior part. The cleft in the hard palate may be restored by a flap turned from the buccal surface of the cheek or from the neck. If there is a hare- lip the border of the lip cleft makes a convenient base for the pedicle of the buccal flap. In a child a fairly extensive flap may be taken from the inner surface of the cheek without causing any inconvenience or deformity. This flap should include enough submucous tissue to insure the blood supply. The plans of operation illustrated in Figs. 175 and 17G are applicable only in cases in which some of the mucous coverings of the palate has been preserved on each side. If this tissue has been lost through the whole of its transverse extent, then repair can be made only by means of a flap obtained from an extraoral source. If this is the case, the edges of the defect and the scar-covered surfaces of the palate pro- cesses are denuded, and special care is taken to remove all scar bands that draw the velum forward. It is just as easy to fill a large gap as a small one with a flap from the neck, and the longer the palate the better the result. (For general plan of making the neck flap, see page 25:3.) In planning the length of the flap, it is to be remembered that it must reach from the lower border of the cheek to the roof of the mouth and then to the edge of the palate defect without tension while the mouth is partially open. If, after the flap has been fastened, it is found to be too short, it may be lengthened by extending the cuts up- ward on the cheek, but this will leave scars in a conspicuous place. There will be no question about its antero-posterior extent, for the flap should be made nearly 5 centimeters wide to insure the blood supply. The flap is sutured with silkworm gut or silver wire, skin edge to mucous edge, across the anterior border of the velum, the lateral bor- der of the defect of the side opposite to that from which the flap is CONGENITAL PALATE CLEFTS. 225 turned, and across the posterior border of the remaining mucous tissue of the hard palate. These sutures should not be too numerous or drawn tight. Eight or ten days later the flap may be cut across at the palate border, and the pedicle again turned on to the neck for the re- pair of the upper part of the external wound. Before the flap is cut across, it is well to test the local blood sup- ply of the implanted part by gently constricting its base with a pair of forceps. While the flap is in place, until the base is cut, the jaws must be held apart to prevent the teeth from shutting off the blood supply. This may be done by wiring a block of wood or a piece of a rubber stopper between the bicuspid teeth on one side. It is very much safer and more satisfactory, however, to have an accurately fitting piece of Fig. 177. Pig. 178. Showing extension defect resulting from postoperative sloughing, and the result ob- tained by the use of a flap from the neck. metal, made beforehand by a dentist, which is fastened by wires to rings on tooth bands above and below. Fig. 177 shows condition after a second failure with extensive post- operative sloughing, following attempts to close the cleft by the von Langenbeck operation. Fig. 178 shows restoration by the method just described. Fig. 179 shows the neck flap in place in the mouth before being cut loose. Fig. 180 shows the condition of the neck one week after the flap was taken from the neck, but before the pedicle was released from the mouth. Owing to the abundance of tissue obtained, this gives a longer velum and a better functional result than is ordinarily obtained in adults by the von Langenbeck operation. It leaves but a linear scar to show where the tissue has been removed from the neck. In a num- 226 SURGERY OF THE MOUTH AND JAWS. ber of cases where we have resorted to skin flaps from the neck for the repair of mouth and palate defects, no inconvenience has been observed as a result of transplanting skin into the mouth. It soon takes on an appearance which closely resembles normal mucous membrane. In one case we successfully resorted to this method in restoring part of the velum, the fauces of one side, and part of the oral pharynx, Fig. 179. Shows permanent gag in place, and neck flap sutured into the palate defect. Fig. 180. Show.s neck defect almost entirely obliterated by drawing the skin edges together. The upper triangular defect still remaining is closed with the pedicle of the flap, after it is cut and withdrawn from the mouth. . after an excision of a malignant growth. In another we failed to close a palate defect after taking a flap from both sides of the neck in turn, owing to progressive sloughing of the flap. This was in a syphil- itic child. The idea of repairing palate and other intraoral defects with epi- thelial tissue from other sources is not new; Blaisus, Thiersch, Rotter, and other surgeons having reported such cases. CHAPTER XVII. CONGENITAL CLEFTS OF THE LIP AND ALVEOLAR PROCESS— OPERATIVE CORRECTION. Cleft of the lip and cleft of the alveolus are presented together, because the latter seldom occurs in the absence of the former and be- cause, surgically, the closure of the alveolus is related more intimately to closure of the lip cleft than to the palate cleft when the latter is pres- ent. In the presence of cleft palate there is nearly always at least an occult bony cleft in one or both sides of the alveolus. This is some- times evidenced by a simple irregularity of the teeth or a notch. In discussing the treatment of alveolar cleft it is convenient to do so as follows : single or double clefts in young infants ; single cleft at Fig. 181. Showing a condition in which the end of the alveolar process to the outer side of an alveolar cleft is situated behind the intermaxillary bone. To correct this, the end of the alveolar process of the maxilla must be loosened and pushed out- ward, as shown in the second figure, before the intermaxillary bone can be replaced. later periods; and double cleft at a later period. In each the follow- ing rule holds true : The intermaxillary bone is never to be removed but is to be placed in the best attainable position, usually the cleft bor- ders being denuded to the bone so that raw surfaces will be in contact when the gap in the process is closed. When the process is replaced, the attachment of the nasal septum and columella should be in the mid- line. After early infancy some orthodontic procedure may be necessary to draw together the borders of the alveolar cleft. This can usually, 227 228 SURGERY OF THE MOUTH AND JAWS. but not always, be accomplished by repairing the lip over the alveolar cleft; but this gives a difficult lip repair and usually a defined nostril. (See Figs. 182 and 183. ) The alveolar process should never be cut with a chisel to close this cleft in older children. CORRECTION OF ALVEOLAR CLEFTS IN INFANTS. The alveolar cleft, as well as the lip. should be repaired at the same time as the Lane or Brophy operation is performed. The latter opera- tion usually consists in little more than reestablishing the continuity A B a Fig. 182. The first cast (A) shows a wide unrepaired cleft at the age of eighteen months. The cleft is partially filled by a transverse part of the nasal septum that would prevent the maxillary bones from being drawn together. At the first operation this transverse part of the nasal septum was removed and the palate repaired by a .von Langenbeck operation. As a result of the traction of the soft tissues across the bony cleft the palate became narrower, shown in cast (B) made three months later, but there was still a wide alveolar separation. Dr. F. J. Brockman constructed the orthodontic appliance shown on cast (B), with which, by means of an elastic band, the alveolar cleft was clcsed in two weeks, as shown in cast (C). Then the lip repair was made. Fig. 18.3. Showing the obliteration of the alveolar cleft by means of an expansion arch by Brockman. Fig. 18.3C shows the final lip repair over the closed alveolar cleft. of the alveolus, and we doubt whether any more extensive bone shifting is ever necessary or always advisable. In early infancy it is not neces- sary to cut the nasal septum in order to replace the intermaxillary bone. If the cleft is limited to the alveolar process, it may be necessary to remove or incise some of the palate process of the maxilla, just behind the cleft, before the protrusion can be pushed back into line. This is CLEFTS OF LIP AND ALVEOLAR PROCESS. 229 done submucoperiosteally with a small chisel or bone forceps. In some cases the alveolar process to the outer side of the cleft will have traveled toward the median line, and it is necessary to pry it outward in order to make room for the intermaxillary process (Fig. 181). CORRECTION OF SINGLE ALVEOLAR CLEFTS AT LATER PERIODS. Before six months, when there is also a palate cleft, the protruding process can be pushed back by thumb pressure. In older children the protruding- process should be brought back into place by an orthodontic apparatus (Figs. 173 and 173). Many surgeons simply repair the Pig. 184. Complete double cleft in an infant. White line shows where the mucous membrane is incised at the lower border in order to remove a V-shaped piece from the septum. lip, depending upon the pressure of the lip to force the process back into place. We do not believe this is to be recommended because of the difficulty of making a satisfactory lip repair over the protruding process. CORRECTION OF DOUBLE ALVEOLAR CLEFTS AT LATER PERIODS. In double complete cleft, the intermaxillary process travels forward at the expense of the columella ; and to replace it after early infancy, 230 SURGERY OF THE MOUTH AND JAWS. the septum must be incised behind the intermaxillary bone, or a V- shaped section must be removed at this site (Figs. 184, 185, and 186). This shortening of the columella is more apparent than real, and usually, in replacing the intermaxillary bone, it has been inoved too far Fig. 185. Fig. 186. h0^ ^H H^w.> hI^ y JWKm Hi^^' ^^c^ Hjiiiifc,, Fig. 187. Fig. 185. Showing prominence of intermaxillary bone and short columella. In- fant of 9 months. Fig. 186. Showing same condition as the preceding illustration. Child 5 years old. This condition will persist as long as the lip cleft is unrepaired. Fig. 187. Showing the drawing in of the nose after replacing a protruding inter- maxillary process. This condition improves very much in time, and the earlier the op- eration is done the better. back. The result of this is that the end of the nose is drawn in and the intermaxillary is rotated until the contained incisor teeth point some- what backward. Only a very small section should be removed from the nasal septum, and in repairing the lip, the lateral portions should be brought forward to the apparently still prominent prolabium. This will CLEFTS OF LIP AND ALVEOLAR PROCESS. 231 preserve the prominence of the Hp and partially prevent the flat ap- pearance that is so frequently seen after an operation for double cleft of the lip and alveolus (Fig. 187). In young infants this is not diffi- cult to do, but later there are intraoral conditions that may make it im- practicable to get immediate union between intermaxillary and palate parts of the alveolus. As a rule, some of the alveolar tissue is missing, so that in order to obtain firm bony union between the intermaxillary and the maxillary bones it is necessary to place the former farther back than it belongs. In young infants the anterior part of the two halves of the palate can be approximated by a Brophy operation so that the in- termaxillary will sit in front of, rather than between, the maxilla. At later periods it is better simply to set the intermaxillary bone back to its proper position without denuding the cleft borders. After the lip wound has healed, an electric or Paquelin cautery blade may be thrust into the cleft on either side. If the lining mucosa is destroyed, this will be followed by bony, or strong fibrous, union. CORRECTION OF HARELIP. We repair the lip at the same time as the alveolar cleft. There have been so many various operations proposed for the repair of hare- Fig. 188. Showing construction of nostril, that may oicur from an infolding of the upper part of the ala. lip that one seeking help from the surgical textbooks is likely to be confounded by the wealth of ideas suggested. But four will be pre- sented here, for the reason that one of the number will be found ade- quate for almost every case, and that we believe they will not only give the best results, but the plan of each of these is easily carried out. Among others, we have discarded the time honored Nelaton operation because it will seldom give an accurate result. 232 SURGERY OF THE MOUTH AND JAWS. Regardless of the plan of operation chosen, it is a good practice to outline the cuts by scratching on the skin with the point of a knife be- fore actually making the incisions, and the use of some sort of a meas- ure or of a pair of compasses will give greater accuracy. In this way one is not confused by the flow of blood, as may be the case when he attempts to plan and cut at the same time. It is very pretty to watch a skilled operator make his flaps with two or three quick cuts, but the average surgeon will get far better results by the method suggested above. It is usually necessary to undermine the lip in order that it may slide over to its new position without tension. The lateral seg- ment of the lip is often closely attached to the alveolar process by a sort of frenum; this is cut, and the lip and cheek are freed from the maxilla with an elevator that hugs the bone closely. If necessary, the opening in the mucosa at the fornix may be enlarged. The ala should not be freed higher than is necessary as when it is entirely detached it tends to fold inward and to obstruct the nostril (Fig. 188). An almost absolute essential to the making of accurate incisions is a thin narrow-bladed knife that has an edge so sharp and smooth that it will not drag on the lip in cutting. After the flaps have been out- lined, before the cuts are made, at least in infants, hemorrhage should Fig. 189. Showing method of partially controlling hemorrhage while paring the cleft borders. to a certain extent be controlled. This is done by grasping each half of the lip with a pair of straight-sided tenaculum forceps that are held tight enough to constrict the tissues without crushing them; artery forceps may be snljstitiited for these (Fig. 180). The intraoral prong of each pair of forceps is thrust through the mucous membrane at the upper fornix and into the tissues of the face. CLEFTS OF LIP AND ALVEOLAR PROCESS. 233 ROSE OPERATION. This consists of the removal of a semioval-shaped piece from each side of the lip cleft so that when the two concave raw surfaces are pulled straight and approximated the lip notch is obliterated. The originator of this operation used it for all sorts of clefts, but it is espe- cially appropriate for cases of partial cleft, for notches remaining after previous operations, and for cases of complete harelip in which little of the lip tissue is missing. It has the virtue of simplicity and is easily performed (Fig. 190). In making the incisions, the following points are to be borne in mind : 1. The full thickness of the lip is to be incised, no more being taken from the cutaneous than the inner surface, and vice versa. Fig. 193. Fig. 194. Fig. 190. Outlines of incision in a Rose operation for partial lip cleft, in which there is also a spreading of the nostril of that side. By the vertical dotted lines it Is seen that the Incisions extend laterally as far as the widest part of the cleft. It will also be seen that the length of each cut within the vermilion border of the lip is the same. If the lengths of the two curved incisions were measured, it would be found that they were of the same length on each side. These are the three important points in designing the incisions of a Rose operation. Fig. 191. Incisions for Rose operation of a complete single cleft. Fig. 192. After making the incisions for the Rose operation, the ala is replaced with one suture, and the newly pared borders are approximated and put on the stretch by a tension suture placed at the mucocutaneous border. Fig. 193. Rose operation for double harelip, incomplete on one side. Fig. 194. Completed Rose operation for double harelip. 2. The incision must traverse the mucous border of the lip at a place where the latter is of the full normal breadth. Sometimes close to a lip notch the mucous border is narrower than at the other parts. 3. The convexity of the lip incisions on each side of the cleft must extend laterally as far as the widest part of the cleft, which latter is 234 SURGERY OF THE MOUTH AND JAWS. always at the lip border (Figs. 190 to 19 J:). When the new lip is com- pleted, there must be a teat at the lower end of the suture line. This is to allow for scar contraction, In this, as in other operations, the borders to be united are approximated by stay sutures at each end; by drawing upon these, slight inequalities in length between two bor- ders are thus equalized (Fig. 192). The outer surface and red border of the lip are united by a fine continuous running suture that includes only the skin or mucosa. The deep approximation is made with one or two modified Lane sutures (Fig. 19). The Rose operation is par- ticularly adapted to the correction of the result of a poor operation (Figs. 195 and 196). Pig. 195. Pig. 196. Pig. 195. Cast of lip and uose of a girl sixteen years old, who had a very poor operation done at three years. Fig. 196. Same case as shown in preceding figure. Cast made some months after a Rose operation. OWEN OPERATION. This is more appropriate for single clefts with widely diverging borders, and is the one we prefer for most cases of complete single hare- lip. When properly done, this gives a very good lip that is not tight at its lower border, and as the scar crosses the mucous border at the angle of the mouth, it is not very noticeable. The incisions and the manner of suturing are shown in Figs. 197, 198, and 199. The traiis- verse incisions are usually made about midway between the mucocu- taneous border and the nose. As with the Rose operation, it is im- portant that the incision traverses the lip in such a way that it is the same distance from the lip or cleft border, on the cutaneous as on the mucous surface. OPERATION FOR DOUBLE HARELIP. For those cases in which the cleft is complete on one side but par- tial on the other, we use the Rose operation (Fig. 19:]). For complete double harelip where the clefts have a complete mucous border, the plan shown in Figs. 200 and 201, is simple and satisfactory. CLEFTS OF LIP AND ALVEOLAR PROCESS. 235 Fig. 197. Incisions for the Owen operation on a single harelip. The important points are to make the transverse cut parallel with the mouth slit ; to make (a-b) equal to (a'-b') ; so to place the point (b) that the flap will be of the proper width to fill the gap below (b'). Fig. 198. Owen operation. Nostril has been approximated by one deep suture, and the borders of vertical part of the cleft by another, at their lower end. The latter is used as a traction suture to approximate and make even the cleft borders while the superficial sutures are put in place. Fig. 199. Owen operation for single harelip. Suturing of the transverse incision. 200. Fig. 200. Operation we use for complete double harelip. The tissue within the cuts (c, d, a) is discarded on each side, as is the border of the prolabium. Fig. 201. Operation for complete double harelip completed. 236 SURGERY OF THE MOUTH AND JAWS. After operation no dressing but a dusting powder is placed on the suture line, or it is painted with alcohol or colloidal silver. After completing any operation for harelip, some plan should be adopted to take off the pull of the buccinator muscles. Several plans of doing this have been used; one is simply to place a single strip of adhesive plaster across the lip and cheeks from ear to ear. To avoid placing the adhesive plaster across the lip wound, common dress hooks may be sewed on the ends of the two shorter strips, one set of the hooks resting on each side of the lip wound. These are laced to- gether with silk thread. This will not prevent slipping of the ala of the nose, and even silk threads resting over the lip wound are objec- tionable; therefore the transverse straps have been rather generally abandoned. Placing narrow strips of adhesive plaster from under the chin, around the cheek, across the bridge of the nose, and on to the fore- head on both sides will draw the cheeks toward the nose and somewhat relieve the strain. It has the advantage of not covering the lip, but it will not entirely prevent spreading of the nostrils. These straps should be retained and, when they slip, replaced for eight or ten days. Twice we have seen a well-placed nostril spread wide open on the fifth or seventh day when the straps were prematurely removed. On ac- count of the occasional slipping of the ala, even with these straps, we have adopted Gilmer's modification of Garretson's use of lead plates (Fig. 202). CORRECTION OF DEFORMITY OF THE NOSTRIL AND NOSE. In repairing a harelip, the restoration of the nostril and ala is usually the most difificult part of the operation. Even in cases of slight lip notch there is usually some spreading of the nostril with a displace- ment of the columella, septum, and tip of the nose to the opposite side; in complete single cleft the ala of that side may be absolutely flat, with a still greater displacement of the septum and nose. In double hare- lip the nose remains in the midline, but both alae are spread laterally. In planning the incisions, we aim to make the inlet of the nostrils smaller than normal, for it usually happens that, in spite of careful ap- proximation and suturing, the ala slips and the nostrils widen within a week. The incision is made close to the lower border of the ala, but the least possible amount of tissue is removed from within the nos- tril ; for it is easy to block the nostril by an infolding of the upper bor- der of the ala cartilage (Fig. LSS). If this occurs, the impinging part of cartilage may be removed submucously. Often, immediately after suturing the ala in babies, the external opening is reduced to a mere CLEFTS OF LIP AND ALVEOLAR PROCESS. 237 slit or is completely closed ; but this begins to open in a few days, and gradually the proper shape of the nostrils is restored. If, however, the nostril is blocked by an infolding of the upper border of the ala cartilage, it never completely corrects itself. To prevent slipping of the ala, after it has been properly placed, is difficult, some slipping oc- curring in most cases. In addition to careful, deep suturing, so far, the most effective plan we have tried has been the lead plates (Fig. 202). These must be placed a little distance from the ala and are held in place with a shotted silver wire. In reoperating on a case in which the nostrils spread, the ala is dis- sected loose from the cheek and replaced after removing a diamond- Pig. 202. Showing lead plates on cheek. Through these is passed a silver wire that traverses the tissues of the face above the level of the lower border of the alae. These wires are shotted. shaped piece from the floor of the nostril and upper part of the lip. If the ala is much spread in an adult or older child, we have found it expedient not only to free the ala from the maxilla but also to carry an incision outward just below the ala out through the full thickness of the cheek for 15 millimeters ; this usually allows of easier adjustment of the ala. In young infants the columella, the septum, and the nose itself will be drawn to the midline when the intermaxillary bone is restored to its proper position. When the lip cleft has been allowed to persist, 238 SURGERY OF THE MOUTH AND JAWS. unoperated, or only partially obliterated, the external nose and septum become permanently distorted; the columella can be drawn over with the lip, but the lower anterior part of the septum with the external nose will remain in its lateral position. When this distortion is sufficient to Fig. 203. Correction of a deflected septum. Dotted line shows line of incision through septum, made with hooked knife. Chisel in place shows how the bone of the septum is cut from the maxilla. Fig. 204. Correction of a deflected septum. The septum having been freed, as shown in the preceding figure, it is anchored in its new position to a bicuspid tooth with silver wire. be noticeable or causes partial nasal obstruction, it may be corrected as follows : Through the upper fornix, the lip is dissected up as far as the lower part of the anterior nasal spine of the maxilla. A chisel with a CLEFTS OF LIP AND ALVEOLAR PROCESS. 239 blade about 1 centimeter broad is placed against the base of this spine ; it and the lower part of the septum are cut straight backward for about 4 or 5 centimeters. With a small hooked septum knife, the sep- tum is again cut completely through from near the nasal spine of the frontal bone vertically downward to intersect the first cut (Fig. 203). Having freed a triangular flap of septum, a thin, soft-silver wire is passed through the lower part of the septum near the nasal spine, and the septum and spine are held in their proper position by anchoring this wire to a bicuspid tooth (Fig. 204). This will draw the septum and the tip of the nose to the midline. If the nasal bones share in the deviation to a marked extent, they may be brought over by laying a thickly folded towel against one side, fracturing the bones by striking them with a mallet. Fig. 205. Correction of deflection of the nose. Diagram showing a displaced nose held In its new position by a silver wire passing from the nasal bone on one side through the septum, nasal cavities, and soft tissues of the cheek, and anchored to a molar tooth of the opposite side. This plan of replacing a deviated nose was, as far as we know, first practiced by Dr. E, M. Senseny, and we have found it fairly satis- factory. If the nasal bones are not prominent, especially in children, we cut the nasal bones en masse, subcutaneously from the maxillary and frontal bones. This is done by inserting a narrow straight chisel into each nostril, in turn, and applying the edge to the junction of the lower border of the nasal bones with the maxillae. It is driven up- ward on each side, as high as the frontal bone. The chisel is guided by feeling one corner under the soft tissues of the face as it travels upward. The attachment of the nasal bones to the frontal is not cut entirely through. The nose is shifted in its proper position by thumb pressure. To hold the nose in the proper position, two holes are drilled through the skin and nasal bones on the side to which the nose has deviated. The two ends of a No. 24 soft-silver wire are, in turn. 340 SURGERY OF THE ^lOUTH AND JAWS. threaded with a long, straight needle and passed through the two holes in the bone, through the nasal chambers and septum, through the tis- sues of the cheek, into the vestibule of the mouth in front of the last upper molar tooth. Here they are anchored at proper tension to a wire band on the last upper molar (Fig. 205). By incising the skin down to the bone between the two drill holes, the external loop of the wire becomes buried. This is the only satisfactory plan we have ever tried for holding the nose in position. In our hands, external appli- ances have been very unsatisfactory. We also use this plan for read- justing the nose after a malunion from fracture. DIFFICULT RESPIRATION AFTER A LIP OPERATION. It often happens that, after an operation for harelip, especially in an infant, there is difficult respiration, evidenced by restlessness and by sucking in of the lips at each inspiration. If this is not relieved, the child emaciates rapidly, and we believe this has been the cause of Fig. 206. Breathing tube made of soft one-fourth-inch gum tubing, to be used in case of difficult respiration after operation for harelip. The tube is Inserted in the mouth and above the tongue, and the tapes are tied behind the head. postoperative depression in some of our earlier cases. Suturing down the lower lip is seldom satisfactory, and we have resorted to the prac- tice of using a breathing tube (Fig. 206) in every case of harelip opera- tion in an infant. The tube is removed at first only for feeding; but usually after a few days the nostrils become free, and the breathing tube may be dispensed with. AFTER-TREATMENT. The wound is covered with a simple dusting powder, and crusts are not allowed to collect. If retention straps are used, they are read- justed when needed, and retained for nine days. The child must be prevented from picking the lip. The infant's sleeves may be pinned to the diaper at the elbow. With older children, a pasteboard tube may be slipped over the arm from the wrist to the axilla ; this will pre- vent the elbow from bending. The child's arms should not be bound CLEFTS OF LIP AND ALVEOLAR PROCESS. 241 to the side with tight wrapping as it interferes with the respiration and the natural voluntary movements. Infants should be given plenty of fresh air, and in good weather their daily outings should be resumed a day or two after operation. The superficial sutures may be removed on the fifth or sixth day, but the lip should not be turned back to remove the deep stay sutures for ten days or two weeks ; the wire in the alveolus may remain much longer. The lead or silver plates are removed after ten days. RESULTS. We have never seen a complete failure of a harelip operation, al- though they have occasionally been infected. This is more apt to oc- cur where the stay sutures include any part of the skin. The resulting abscesses discharge spontaneously. Gilmer has recently told us of a case in which the lip failed to unite purely on account of inanition, the child's temperature remaining below 95° F. for several days after op- eration. Slight defects are apt to result after operation, especially when it is done in very early infancy. If the defect is a notch at the lip border, it may be corrected by a Rose operation at the time the palate is repaired. CHAPTER XVIII. OBTURATORS, ARTIFICIAL VELA, AND SPEECH TRAINING. In order to treat intelligently a cleft of the velum, either by opera- tion or by the construction of an obturator, it is necessary to have at least a general idea of the physiological action of the muscles con- cerned, both in the normal and in the cleft palate. PHYSIOLOGICAL ACTION OF THE MUSCLE CONCERNED. The velum is a flap valve which, when raised by the levator palati muscles, helps to completely or partially close the nasal from the oral pharynx in order that the sounds emanating from the larynx may be modified in the mouth by the lips, cheeks, tongue, teeth, etc., (Fig. 207). A very few sounds known as nasals, such as m, n, and ng, do not re- quire the closure of the nasopharynx (Fig. 208).^ This closure of the nasopharynx, which also occurs during degluti- tion, is not accomplished entirely by the velum, but partly by the pos- terior pharyngeal wall coming forward to meet the velum in the form of a definite protrusion, known as Passavant's cushion, which was first described by Passavant in 1868. This protrusion is due to the con- traction of the upper part of the superior constrictor muscle of the pharynx, that part which arises from the pterygoid process, and is called the pterygopharyngeus. Rose has denied that the so-called "Passavant's cushion" is due to the action of the superior constrictor of the pharynx. Dr. Warnekros points out that, "such notable anato- mists as Tourtual, Luschka, and Zuckerkandl ; such physiologists as Hermann, Landois, and Munk ; such singers and laryngologists as Volto- lini, Zaifal, Kingsley, Frankel, Wendt, and Myer have in the past tested Passavant's observation very exhaustively and have recognized it as being thoroughly correct." We have seen cases where the action was very plainly visiljle. In Fig. 207, Kingsley illustrates the pad help- ing to close the nasopharynx, while in Fig. 208 the passage is shown to be open. The lower part of the superior constrictor muscle of the pharynx (Fig. 209) also takes part in narrowing the cavity of the oral pharynx. In Fig. 20!) by K. Warnekros, a shows the outline of this 1 For a clearly Illustrated description of the mechanism of speech, see Kings- ley's Oral Deformities. 242 OBTURATORS AND SPEECH TRAINING. 243 part of the constrictor when at rest, while the dotted line d shows the outline of the muscle during contraction. When it is remembered that the palatopharyngei and the palatoglossi muscles lie within the circle of this muscle, it will be understood how it is that the contrac- Fig. 207. Position of the velum and Passevant's cusliion in malting the sounds ah. Tie velum and cushion close the opening also in making the sounds oo, o, a, e, u, i, b, p, t, d, Ic, g, f, V, s, z, sh, zli, ih, ch, j, I, and r. — After Klngsley. Fig. 208. Position of the velum in making the sound m. Tlie opening into the nasopharynx also remains open in making the sounds n, ng.— After Kingsley. tion of this part of the superior constrictor can narrow the width of a cleft in the velum during the effort of speaking. The tensor palati muscles, as their name implies, by their action render the velum tense, but in the presence of a cleft their contraction causes the cleft to become wider. During normal nasal respiration the velum is held against the pharyngeal part of the tongue mainly by the action of the palatoglossi muscles. 244 SURGERY OF THE MOUTH AND JAWS. OBTURATORS AND ARTIFICIAL VELA. From this meager description it must be clear that operations for the correction of velum clefts must aim at producing a velum that is long enough to do its share in closing the nasopharynx ; that in doing this the velum must be left sufficiently pliable to move freely in re- sponse to its various muscles ; and that these muscles must not be crip- pled or their nerve supply cut. It can also be understood how an in- adequate velum can be supplemented by an obturator that closes the 9 Fig. 209. IOm-> - 1 Pig. 210. Fig. 209. Diagram illustrating the contraction of the superior pharyngeal con- strictor in the formation of Passavant's cushion. — After Warnel