The principles and practice of modern surgery

CONGENITAL DEFECTS.

Aside from anomalies due to incomplete closure or erratic development from the branchial clefts, the principal congenital defects of the regions included in this chapter are as follows: The mouth is essentially a coalescence of the upper end of the foregut and a recess known as the stomodeum, which are at first separated by membrane, the latter disappearing early in fetal life. Some remains of it, however, may produce a narrowing of the oral fissure and cause one form of microstoma. Some of these facial defects are due to formation of amniotic bands and adhesions, which restrain or interfere with the normal development from the branchial fissures. Malformations of the tongue may accompany other anomalies. A median cleft, called also a bifid tongue, and defective development and undue adhesions to the floor of the mouth, are known, whose most trifling expression may be seen in the so-called tongue-tie, where the frenum is too short and needs to be divided in order to release the tip and more movable part of the organ. Adhesive bands may also attach the tongue laterally to the cheek, bands between the cheek and the gums being also occasionally seen. An extreme type of tongue-tie is known as ankyloglossum. Abnormally long tongues are also met, and cause an actual menace from danger of the tip being swallowed, as children have suffocated from this cause. Congenital macroglossia has been described; it is usually due to lymphangioma of the tongue. A condition known as lingua plicata is characterized by moderate enlargement of a number of either longitudinal or transverse folds or rugæ. The covering mucosa, however, is normal. Complete absence of the tongue has been noted.

Aside from malformation of the upper jaw, cleft palate, there are arrest of development in one or both sides of either jaw and a failure of union in the two halves of the lower jaw. Anomalies about the temporomaxillary joint interfere with its function and may prevent separation of the jaws.

Malformation and misplacement of the teeth are extremely common. Thus a tooth may develop in an abnormal position by displacement of its body, or it may project in an abnormal direction; while teeth may be lacking in number or in eruption, so that a given tooth, usually a molar, completely fails to appear. Absence of a number of teeth is more rarely noted. Numerous cases are on record where a third set of teeth has succeeded the second instead of the latter remaining permanent. Abnormalities of tooth formation extending to the dignity of tumors of the dental tissues have been referred to in the chapter on Tumors, under the head of Odontomas. Cysts of congenital origin not infrequently develop around unerupted or misplaced teeth, and constitute tumors which at birth are scarcely noted and which may not develop until later in life.

Persistent remains of the thyroglossal or thyrolingual ducts may be seen early in childhood, or not until late in life. Their consequence is occasionally noted in the existence of fistulas, but more often of cysts or dermoid tumors, which, though having their origin in the middle line, may become displaced to one side, and when seen by the surgeon have a lateral position.

CLEFT PALATE.

Cleft palate is a congenital defect due to failure of coalescence between the nasal and maxillary processes, which, proceeding from either side, should meet and unite in the middle line. The defect may be so slight as to produce only a small notch in the alveolar border, or a small opening in the roof of the mouth, or it may be so complete as to constitute a separation with the formation of but a small part of the roof of the mouth, leaving but little tissue serviceable for any possible operation. The relation between the products of lateral growth and the downward projection and formation of the intermaxillary bone by the midfrontal and nasofrontal processes is too complex to be described here (Fig. 465). In some instances there is but little evidence of the formation of such a bone, while at other times it has not only bone formation but is relatively overdeveloped, in such a way as to make the lower anterior angle of the septum and its own part of the alveolar process project far beyond the level of the surrounding tissues, thus producing a snout-like appearance, which not only makes the case more disfiguring, but seriously complicates operative procedure. Usually the lower border of the nasal septum will be found attached to one side of the cleft (Fig. 466). The soft palate presents the same fissure, and the uvula is often neatly separated into halves.

The coincidence of cleft palate with hare-lip has been described. (See p. 645.) While they often are combined, either may occur without the other (Fig. 467).

No matter how incomplete the palatal cleft may be the nose and the mouth are converted into a common cavity. Suction, as from the breast, is impossible. Infants with this defect should be carefully fed by hand; as they develop, food passes readily from the mouth to the nose, while there is corresponding difficulty in swallowing. With lapse of time speech becomes defective or almost unintelligible. There is, therefore, every reason for any possible closure of such defects. Against the mechanical difficulties on one side should be weighed the desirability of such closure on the other. One argument advanced in favor of operation on hare-lip is that the influence of the pressure thus afforded will tend to hasten the natural attempt on the part of the halves of the upper jaw to grow toward each other instead of in the opposite direction. On the other hand, by closure of the labial defect, the space within is materially diminished and manipulation made more difficult. It then becomes a serious problem when to operate upon a given case of cleft palate. The operation itself is usually one of no small mechanical difficulty, the space required for manipulation is most restricted, the procedure relatively a long one because of the anesthetic, and necessity for its frequent suspension in order that the operator may proceed, and, because of these difficulties and delays, the attendant shock to the patient. A puny child, unable because of the defect to take sufficient nourishment, is then in far from a favorable condition for a serious operation. Without a general anesthetic no child will endure it, while local anesthesia in the young is insufficient on account of their timidity and involuntary resistance. When to operate, then, should depend upon the condition of the child, the dexterity of the operator, and the width of the cleft—that is, the amount of work to be done.

Brophy, of Chicago, has taken a radical and advanced position in this matter, and believes that these operations should be performed in early infancy, a fact which his own large experience would appear to demonstrate. Yet this same experience has developed in him a facility possessed by few, and that which such an operator may do with impunity can be duplicated by but few. He finds, however, unanswerable argument in this: that in infancy the bones of the jaws are scarcely developed, are not only friable but very flexible and yielding; that even in the very young the tissues unite kindly, and that very young infants seem to be less liable to extreme shock than those several months old; that the earlier the muscles of the palate are brought into contact and action the better performed are the functions of deglutition and of speech, and that if they are not used they atrophy; that the teeth are more likely to erupt normally, and that the extreme liability to pharyngitis produced by such wide-open fissure is obviated. To all of these statements no objection can be raised, and the only argument which can be adduced against Brophy’s position is the actual danger of the operation.

In the matter of time it may be said that in extremely competent hands operation in infancy is the ideal method, but that when children reach the age of two or three years and still have very small mouths, not much is lost by waiting until they are five or six years of age, while considerable room is gained for ease of manipulation. Much depends also on the temperament and obedience of the child. These children, like most of those born with congenital defects, are usually pampered and spoiled by indulgent parents, so that at a time when implicit obedience is most needed it seems almost impossible to do anything with them. In dealing, therefore, with such a child one should insist upon its being thoroughly disciplined, and, at the same time, accustomed to manipulation within the mouth, as the presence of a finger, tongue depressor, etc., so that when need comes for their use the child shall not be totally unaccustomed thereto. Every case should also be prepared so far as possible by antiseptic and astringent mouth-washes. A nasopharyngeal catarrh which shall compel such a patient to be constantly swallowing and spitting may defeat the object of the operation itself.

The terms usually used in this connection are uranoplasty, which means closure of the hard palate, and staphylorrhaphy, which means the closure of the soft palate.

Operations for cleft Palate.

—The responsibility of the anesthetist in these cases is great. Considering that he has to work through the same cavity as the surgeon it is sometimes very difficult to keep the child in a consistent state of narcosis. The inhaler devised by Dr. Souchon serves an admirable purpose. (See p. 644.) I regard chloroform as the safest of the anesthetics, as it is less irritating and provokes less flow of saliva. It is a good plan to cocainize the parts previous to incision, in order to so benumb them as to make reflex impressions less pronounced.

The theory of these operations, like that for hare-lip, is simple. It consists in freshening the edges of the cleft, bringing them together and holding them in position; this requires clean work and a mouth kept clean—in other words, it calls for efficient antisepsis, for strict asepsis is impossible. All carious teeth should be removed or put in good condition, and large tonsils, with their distended crypts and reservoirs of decomposing material, and all adenoid tissue should be removed.

Owen has shown the benefit in nursing infants of using an old-fashioned “slipper bottle,” having a soft giant teat with a hole on the under surface. As the infant sucks from this the teat fills the cleft, and as the child compresses it in sucking the milk is directed downward. When this does not suffice milk may be given in a warm teaspoon, passed far back over the tongue, or from a medicine dropper.

Owen sustains Brophy in the contention that the most favorable time for operating on a cleft palate is between the age of two weeks and three months, there being at that time less shock, and the bones are extremely flexible. Accepting this statement as authoritative the operation upon young infants will be described.

Previous to the operation a warm, nourishing, and stimulating enema should be given the patient. After the infant is anesthetized the tongue is drawn forward by a long suture and the mouth kept open by a mouth-gag. The edges of the cleft are then pared with a sharp knife, after which effort should be made to press the upper maxillæ together, in order to test their flexibility and the possibility of approximating them in this manner. This will rarely be sufficient, however, and it becomes necessary to raise the cheek, on each side, toward the posterior extremity of the hard palate just behind the malar process, and pass a knife through the outer bony surface, making a sufficient division of the antral wall through a minimum of opening. Rather than cut too much bone at first the knife may be re-introduced. The actual approximation of the maxillæ is produced by silver-wire sutures. A firm, stout needle carrying a thick, silk pilot suture is passed through at the point above mentioned and made to appear in the fissure, where the loop may be pulled down, after which it may be again passed through the other side and made to emerge at a point corresponding to that at which it entered. The suture thus passed in one way or the other is made to carry a strong silver wire from one side across to the other, on a level above the hard palate, emerging on each side within the cheeks. Another wire suture is similarly passed more anteriorly. Two small oblong leaden plates, 1.5 Cm. in length and 35 or 40 Cm. in width, drilled with two holes, are then provided, one of them laid along the outside of each maxilla, the wire sutures passing through the holes which they contain. On one side the ends of the wire are then twisted firmly and cut short, thus forming a complete grip upon the plate on its side; then the jaws are pressed firmly together, while the wire sutures on the other side are similarly fastened over the lead plates and twisted tightly to make permanent the effect produced by pressure with the fingers. These sutures should be made sufficiently tight to permit of approximation of the borders of the mucoperiosteal surfaces, already freshened, in such a way that they may be held together with fine wire or horse-hair sutures and without undue tension.

The lead plates are left in situ for three or four weeks. If necessary the wire suture may be tightened to allow for relaxation produced by pressure effect. Some ulceration may occur beneath the plates, but this heals after their removal. Theoretical objection to this method may be made because of the tendency to narrowing of the upper jaw. In fact, however, it is only restored to its proper dimensions, as that part of the face has been previously widened by the width of the cleft. Irregular eruption of teeth or irregularity of development may be treated by a dentist.

When the vomer affixed to the intermaxillary bone projects in a snout-like manner it is necessary to remove a V-shaped section from it, the base of the triangle being along the margin of the cleft, in order that the projection may drop backward and the corresponding part fall into line with the rest of the alveolar process. This is best done as a preliminary and distinct operation.

Uranoplasty in older patients consists essentially of forming two anteroposterior mucoperiosteal flaps, from the hard and soft palates, on either side of the cleft, with their inner edges neatly pared, which should be separated from the bony roof of the mouth, and slid toward each other until they can be held together by sutures. These operations are best performed with the patient’s head hanging over the end of a table, so that blood may not find its way into the trachea or stomach, but be sponged away. This is the position of the so-called “down-hanging head” described by Rose. In fat-necked individuals it may be impracticable. After paring the borders adjoining the fissure an incision is made just within the alveolar border, close up to the teeth, parallel to the former, of sufficient length to permit of the formation of the flap above mentioned; then with raspatories or elevators it is detached from the hard palate. In a mouth with a gothic arch or roof it is often easier to form these flaps and to bring them together than in others. It may be possible in such cases to not only suture the edges, but also some portion of their raw surfaces, thus ensuring better union. (See Fig. 468.)

Branches of the anterior palatine artery will bleed freely during this part of the performance. Firm pressure and the use locally of adrenalin solution will usually overcome this difficulty. As the incision is extended backward the posterior arteries will cause the same difficulty. The wider the defect the farther backward should the lateral incisions be extended. Here the principal obstacle to easy approximation of edges is the activity of the levator and tensor palati muscles. Formerly it was a part of operations to divide the tendon of the latter as it passes around the hamular process. It has been found, however, that this is often unnecessary. A tenotomy of this tendon, however, may be made just as that of any other tendon with the expectation that the gap thus made will be filled with fibrous tissue. While, on one hand, it is of great advantage to spare this tendon, on the other hand its muscle may be the principal factor operating to pull apart those surfaces which have been neatly brought together.

Fergusson and Langenbeck have not hesitated to make osteoplastic flaps when necessary, dividing the hard palate along the line of the lateral incisions with a fine chisel. This is not often required, and complicates the case to an undesirable extent, although it may be necessary in wide fissures with a minimum of tissue (Fig. 469).

Sutures are best made of fine silver wire or of black silk, as the ordinary silk is usually too absorbent, and permits infection of the stitch holes. These sutures are introduced with any one of a variety of needles devised for the purpose. A complicated needle is not necessary for this purpose, for with an adequate needle holder even the ordinary needles can be used. Silver wire may be fed directly into the needle or through a hollow needle devised for the purpose, or sutures of silk may be passed, by which a wire suture is pulled after them.

Great assistance can be obtained from packing strips of gauze between the flaps and the bone from which they have been detached. These may be inserted for pressure effect and prevention of hemorrhage during the operation, and later may be substituted by smaller packing of antiseptic gauze left for the purpose of helping to minimize tension, flaps being crowded toward each other by their use.

The parts being approximated and the wound suitably tamponed it is necessary to keep the patient as quiet as possible. Young infants tend to keep up a constant sucking motion with the tongue, which may interfere with the quietude of the palate. Small doses of bromide or chloral may be administered either by the mouth or rectum, for every effort at crying, coughing, or vomiting tends to make a stress upon the line of sutures. Vomiting immediately after the operation is not necessarily serious, and yet should be avoided. Patients sufficiently old to talk should be cautioned not to converse. Water is better for the patient than milk, as the latter does not allay thirst so well and may form curds. Most of the nourishment for the next few days should be administered by the rectum, giving only water through the mouth. Children should be watched continuously lest they get fingers or toys into their mouths, and fretfulness should be guarded against. Thread sutures should only be removed with scissors and forceps after the expiration of five or six days. A useless suture is a foreign body which does more harm than good. When lead plates are used with strong wire sutures they should remain from two to four weeks. In young or undisciplined children it may be necessary to give an anesthetic for removal of the sutures. The tampons or pledgets of gauze should be removed from day to day. An antiseptic mouth-wash or spray should be frequently used.

The two results most desired are prevention of passage of food from the mouth to the nose, which is always commensurate with the success of the operation itself, and improvement in speech and voice. The earlier the closure the more natural the voice. Patients in adolescence or adult life rarely note much gain in this respect, while those operated in early childhood may learn to talk almost perfectly.

There are cases, especially those which have gone for years unattended, where the arch of the mouth is of such gothic shape and the defect so wide that disappointment is sure to follow in at least one of the above respects. The art of the dentist has now reached a point where plates or obturators may be constructed for unsuitable cases, which will give better functional and vocal results than any which the surgeon can produce.

Another form of palatal defect is the result of the late manifestations of syphilis, and small and large perforations may occur, usually in the hard rather than in the soft palate. They are to be dealt with surgically, but not until after the patient has been subjected to a course of antisyphilitic treatment.

THE MOUTH IN GENERAL.

The mouth more than any other part of the body is the habitat of a large fauna and flora of minute organisms. Over one hundred different kinds of bacteria from this region have been identified by Miller, and it will be easily seen how prone fresh wounds or old lesions may be to infection from these sources. Fortunately but few of these microörganisms have decided pathogenic propensities. They lurk especially in two localities—the crypts of the tonsils and along the gingival borders and alveolar processes. Along the gingival border of the teeth tartar accumulates, by a precipitation of mineral salts from the saliva, where by irritation, coupled with germ activity, the gum is loosened from the teeth beyond the level of the enamel, and the sockets thus exposed to various kinds of infection. In consequence the teeth thus undergo dental caries, become loosened in their sockets, while, at the same time, infection travels along lymph paths until the germs are filtered out in the adjoining cervical lymph nodes, which thus suffer enlargement and often suppurative destruction. An interstitial gingivitis, therefore, is always a serious menace to the integrity of the teeth. This will furnish another argument for a semi-annual inspection of the mouth by a competent dentist, that he may clean away all tartar accumulations and treat the gums in such a way as to prevent disintegration. In elderly people, especially, there is a marked tendency toward retrocession of the gums. In young or old, when this condition is noted, it may be treated by applications of zinc iodide, either of the dry, minute crystals or of a saturated solution, which may be used daily or weekly. By such precautions the teeth may be preserved to old age, the importance of which is not generally appreciated, since the teeth are necessary for suitable mastication of food which the enfeebled stomach of an aged person can more easily digest.

Infection may also occur during the period of eruption of teeth in young people, and serious trouble sometimes accompanies the appearance of temporary or permanent teeth. Gingivitis of toxic origin is not uncommon, as among the possible effects of overdosage of mercury and phosphorus.

All that has been said of the teeth and their sockets is in the main true of the tonsils, which afford numerous crypts or lacunæ in which germs may be harbored for a long time. The explanation of probably 75 per cent. of enlarged and tuberculous lymph nodes is afforded by infection spreading from the tonsils and teeth. It may not be tuberculous at first, but it becomes so later.

In the mouth may be seen expressions of actinomycosis, tuberculosis, and especially of syphilis, among the more chronic lesions, as well as of diphtheria, erysipelas, and the result of the oidium albicans of thrush. Tuberculosis is more common in the pharynx, while the syphilitic infections may appear anywhere and in any form, as chancre on the tonsil or the lip, mucous patches of the tongue, destructive lesions of bone, all of the earlier and most of the later expressions of the disease offering serious dangers of contagion.

Stomatitis is a term generally applied to the lining membrane of the mouth and indicates little regarding its nature or seriousness. It may be of traumatic origin, as when strong caustics have come in contact with the mucosa. Ulcerative stomatitis is a disease of childhood, due to the activity of the oidium albicans or some kindred microörganism, it being usually a more serious expression of the condition known as “thrush.” Washing the mouth frequently with dilute solutions of hydrogen peroxide or of tincture of iodine will usually be all that is necessary. Resistant ulcerations may be treated with 10 per cent. solution of silver nitrate. Stomatitis gangrænosa is another name for noma, or cancrum oris, which was described in the chapter on Gangrene. In these cases the surgeon should hasten the tedious separation of sloughs by use of scissors, curette, or the actual cautery (Fig. 471).

Blastomycetic lesions of the mouth, and especially of the lips, have been recognized. Bevan has reported extirpation of granulomas provoked by the blastomycetes, or yeast fungi, which are known to produce similar effects elsewhere (Fig. 471).

Severe infections of the mouth may also involve the tongue and thus produce acute glossitis or may spread to the connective tissue, or the submaxillary region, and there produce that type of phlegmon called Ludwig’s angina, described in the chapter on the Neck. The source of infection in most of these cases is a tooth or tooth-socket.

Injuries and wounds of the mouth are liable to septic infection, whether they occur from mechanical, chemical, or traumatic causes. Injuries inflicted by the mouth, or rather by the teeth, upon others constitute infected wounds of a serious type. Burns, scalds, and similar lesions inflicted by violent caustics, such as carbolic or nitric acids, may be followed by cicatricial contraction and produce serious consequences. So far as the latter can be foreseen they should be prevented, while for their more extreme results various plastic operations may be performed.

THE TONGUE.

What has been said above with regard to the possibility of infected wounds in the mouth applies also to the tongue and other parts. It is often lacerated by being caught between the teeth in falls and blows and is sometimes bitten by epileptic patients during their convulsions. Free hemorrhage from such wounds may occur and may require ligation of vessels at the site of the wound, or of suture of tissues en masse with catgut, or ligation of the lingual artery just above the hyoid bone. Lacerated wounds should be closed with sutures, and antiseptic mouth-washes should be frequently used.

Glossitis, or inflammation of the structures of the tongue, may appear in either acute or more chronic form. To some extent it is a part of a general stomatitis, but no matter in what form occurring it is an expression of infection from a source easily recognized, and may be limited to one side of the tongue. Its principal features are swelling, which may be so extensive as to prevent movement of the tongue, infiltration of the floor of the mouth, and extension of a phlegmonous type down the structures of the neck. The swelling may also involve the epiglottis and larynx, causing edema and even suffocation unless tracheotomy be performed. Thus acute glossitis may frequently lead to abscess formation either in the tongue or the adjoining tissues. When swelling is extreme its formation may be anticipated, and free incision should be promptly made to permit of its evacuation. Naturally the region of the large vessels should be avoided, and, after external incision the focus should be reached by blunt dissection. Some of these cases are due to extension of an erysipelatous process commencing externally. Even hemiglossitis may be accompanied by serious swelling and high fever. One form of this affection is supposed to be analogous to herpes zoster. The relation of phlegmonous glossitis to Ludwig’s angina, the latter being described in Chapter XLI, may be readily appreciated. Sometimes it is due to the entrance of foreign bodies, as fish-bones, bone-splinters, and the like.

Most urgent danger is that of asphyxia from pressure, and of inspiration pneumonia, for the infected saliva in these cases will trickle down within the larynx and trachea. Even gangrene of the tongue has been observed as the result of pressure, while the teeth will leave their impress upon the sides of a swollen tongue.

The more chronic infections of the tongue are syphilis, tuberculosis, and actinomycosis. Syphilis may assume a primary type and occasionally typical chancres may be seen on the tongue. It is frequently the site of mucous patches and of other ulcerative lesions. Tuberculous ulcerations of the tongue assume less indurated and irregular borders, and may be suspected in connection with well-marked tuberculous lesions of other parts of the respiratory tract, being particularly common in consumptives. These ulcers yield best to cauterization and antiseptic mouth-washes, whereas syphilitic lesions rarely disappear without active antispecific medication. Both syphilis and tuberculosis produce gummatous tumors, the former more frequently than the latter. The former will disappear equally readily under suitable treatment.

Actinomycosis of the tongue is rare in man. It constitutes a granuloma which may soften and present a ragged, ulcerated surface. (See Actinomycosis, Chapter VIII.)

Leukoplakia implies the appearance of opaque, white patches upon the mucous surfaces of the tongue as well as on the lining membrane of the mouth, lips, and palate. They are far more frequent, however, on the tongue and generally appear there first. Here they appear almost as if thin scales could be separated from the surface upon which they lie, but this will not be found possible when the effort is made. The patches are irregular, but sharply outlined, occasionally confluent, involving the entire upper lingual surface; while the plates become harder and more roughened as they grow older, and furrows, subsequently ulcerating, may appear between them. The affection is chronic and intractable. It occurs often in the mouths of smokers during middle and advanced life. While its etiology is unknown it may be due to chronic irritation.

Between leukoplakia and epithelioma of the part involved there seems to be a strong relation, and the former is often regarded as a precancerous stage of the latter. Epithelioma is a frequent terminal feature of leukoplakia. There often seems, moreover, a predisposition to it in syphilitic individuals. It is mainly to be distinguished from secondary syphilitic lesions, which may be done by recalling its chronicity and its obstinacy to the treatment which would disperse the latter.

In the way of treatment smoking must be prohibited, antiseptic mouth-washes often used, with cauterization to a mild degree. These methods, however, suffice only for the milder cases. If any caustic be used it may be either 10 per cent. chromic acid, chemically pure lactic acid, or nitric acid, caution being used in their application. The more serious forms of leukoplakia will usually yield to local anesthesia, followed by curetting of each patch until the raw surface beneath is exposed, and then the application of the actual cautery. Rigorous treatment is necessary when ulcerated and fissured patches are present.

The benign tumors of the tongue include nevi, often in connection with single or multiple papilloma, or which may assume the type of multiple papillomas, each of which is extremely vascular. Occasionally the tongue will be seen almost covered with these small growths. This condition is noted usually in young children, and is practically of congenital origin. It frequently subsides spontaneously, but may require the actual cautery or something equally radical. The other benign tumors are of occasional occurrence, even an enchondroma having been occasionally seen. Much more common are the retention cysts, especially that particular form of cyst occurring beneath the tongue or at its base, known as ranula. This term is vaguely applied to cysts produced by obstruction of one of the salivary ducts or by cysts of congenital origin. It is caused mainly by incomplete obliteration of the thyroglossal duct. A so-called ranula may contain colorless fluid, more or less thick, and mixed with epithelial or dermoid products.

It is possible to extirpate nearly all of these growths through the mouth, with aseptic precautions.

Macroglossia is a condition of congenital enlargement of the tongue, due mainly to a form of lymphangioma, which may be accompanied by vascular papillomas or alteration of the mucous covering. Such a growth will produce enlargement of the tongue to an extent that does not permit of its retention within the mouth. Excision of a V-shaped portion sufficiently large to reduce the tongue to proper dimensions is usually requisite in these cases (Fig. 472).

Of the malignant tumors of the tongue epithelioma is by far the most common. It is rarely seen in women, and not often before middle life. Here more than in almost any other part of the body the possible causative factors of irritation and trauma are present, jagged teeth furnishing the usual source of each. It is known also to be a frequent sequel of leukoplakia and of various chronic ulcerations and other lesions. Other benign growths occasionally alter their type and become epitheliomatous. It occurs usually on the exposed surface, and tends quickly to an ulceration whose border is indurated and often fissured. It is ordinarily distinctive in its appearance, but occasionally needs to be differentiated from lesions of syphilis, tuberculosis, and actinomycosis. Lymphatic involvement occurs early in each of these conditions and may be confusing. A suspicious ulcer which tends constantly to deepen and increase in dimensions, accompanied by marked induration and lymphatic involvement, and not benefited by antisyphilitic treatment, will generally prove to be epitheliomatous. As the lesion extends there is involvement of all the surrounding structures—the floor of the mouth as well as the pharynx, the salivary glands, and even the lower jaw itself. When pain is felt it is usually referred to the region of the ear. There will be, naturally, interference with all the functions of the mouth, as well as with speech, while starvation, septic infection, and hemorrhage may terminate the case.

In no part of the body is prognosis more unfavorable. Recurrence, even after early and radical operations, is usually unavoidable, and it is doubtful if 10 per cent. of cases of epithelioma of the tongue are free from disease at the expiration of three years after removal.

Treatment should be prompt and radical. It consists of extirpation, which must be extensive to be effectual. A small cancerous ulcer on one side of the tongue may justify removal of one-half of the organ, but, under nearly all circumstances, it is best to make a complete removal of the tongue. This may necessitate a formidable operation, and may be expected to materially interfere with speech; but that it does not prevent it is shown by the fact that in medieval days, when tearing out the tongue was a means of punishment or torture, men were often still able to speak intelligibly.

Inoperable cases should be made comfortable with cleansing mouth-washes and applications of local anesthetics, coupled with such anodynes as it may be necessary to administer. Resection of the lingual nerve will sometimes relieve the intense pain, while proximal ligation of the lingual artery may arrest rapidity of growth. It is in these inoperable cases that Dawbarn’s suggestion of the extirpation of the external carotid artery, first on one side and then on the other, may be put into practice, the intent being to so completely shut off circulation as to check growth. In some forty cases or more it has given results as satisfactory as could be expected.

OPERATIONS UPON THE TONGUE.

Operations upon the tongue include partial excision and complete extirpation, perhaps with much of the adjoining tissues. Here, as in every operation, the mouth should be thoroughly cleansed. Before extensive operations a preliminary ligation of the lingual artery should be made on both sides, just above the hyoid bone. (See p. 352.)

A small lesion at the tip of the tongue may be excised by a wide V-shaped removal of the anterior part of the tongue, under cocaine anesthesia, the edges of the opening being brought together with sutures of silk or of chromic catgut, for ordinary catgut would be too quickly macerated when thus soaked in the mouth. The lesion may be so placed as to not permit of this V-shaped opening being symmetrically placed. The same rules, however, will apply, the operation being performed with a sharp-bladed bistoury or with sharp scissors, bleeding vessels being seized with forceps as they are cut. These clean removals give more satisfactory results than the old operations performed with the écraseur or cautery. A complete excision of the lateral half of the tongue is easily made through the mouth, the organ being controlled by a stout suture passed through the other portion. The vessels and lymphatics of the tongue do not cross its septum, and all the hemorrhage that need be anticipated will come from the side attacked; but when it is necessary to remove an entire half of the tongue the case has usually progressed to such an extent that its complete removal will be usually indicated and will be more effectual.

Of the various complete operations upon the tongue but three will be described here.

Whitehead’s operation comprises an almost total extirpation made through the mouth, without division of cheeks or lips. The patient is placed in a semi-upright or upright position. The mouth is held open with a mouth-gag, for which purpose none serves better than the O’Dwyer gag used for intubation. The operation is begun under brief but complete anesthesia, and is usually completed before the patient has recovered from it.

The tongue being secured with a stout suture passed through it, its frenum and its attachment to the fauces are divided, along with all other reflections of the mucosa. Vessels which spurt should be caught at once. General oozing may be disregarded. After being thus freed the tongue is pulled forward, a strong suture passed through the glosso-epiglottidean fold, and then with sharp, slightly curved scissors the entire organ is cut away from its base, the lingual arteries being seized the instant they are divided. The operation is bloody for the few minutes required for its performance, but is quickly done and with a minimum of disfigurement. By the last-mentioned suture the stump can be pulled forward, should the epiglottis tend to drop backward and disturb respiration, or should hemorrhage require. After its conclusion, and during the after-treatment, frequent warm, antiseptic solutions should be used for washing the mouth, and it is the practice of some to paint the raw surfaces with a styptic varnish, made of balsam and saturated solution of iodoform in ether. In order to avoid the passage of saliva downward the patient is encouraged to sit up and to expectorate freely rather than swallow infected saliva.

The Regnoli-Billroth operation is performed by turning down a horseshoe-shaped flap, its convexity being taken from the symphysis of the jaw, and thus opening into the mouth from below. After making the opening sufficiently wide, the tongue, through which a traction suture has been passed, is pulled through the submental wound and its base divided with scissors. Should it be difficult to locate bleeding points in the stump a finger may be hooked in the pharynx and the latter pulled forward. The submaxillary wound is then closed with sutures, with one drain.

The most complete of these operations is that described by Kocher. It permits of removal of the tongue, of the floor of the mouth, of all infected lymphatics, and even of a portion of the jaw if this be necessary. A line A-B, Fig. 473, may offer sufficient exposure by incision, but the line C-D-E-F will permit more complete attack. Through this incision a flap is raised, the facial vessels being ligated. All lymph nodes are extirpated, as well as the salivary glands, if necessary. After separating the mylohyoid from its insertion in the inferior maxilla the mouth is opened and the tongue drawn out through the incision, where it may then be kept under perfect control. It will facilitate matters if the lingual arteries be secured before the entire tongue is cut away. In some cases a preliminary tracheotomy is considered advisable, largely because the performance of the operation interferes with the administration of the anesthetic in the ordinary way. Should it be done the pharynx should be tamponed until the conclusion of the operation. The trachea tube may be immediately removed or left, as seems advisable, while the patient is fed for several days with a stomach tube.

Operations suggested by Sédillot and Langenbeck include division of the lower jaw in such a way that by separation of its portions a more complete exposure of the floor of the mouth is afforded. They are at present rarely adopted, unless extension of the disease to the bone should necessitate excision of some portion of the jaw itself.

THE TONSILS.

The tonsils are the most conspicuous portion of the ring of lymphoid tissue which extends completely around the original opening connecting the exterior of the face with the upper end of the neurenteric canal. This tissue is particularly inflammable, and this may account for the frequency with which severe infections of the tonsils occur, and the marked toxemia which complicates even mild degrees of the same. In this lymphoid, or, as it is usually called, “adenoid” tissue, crypts and follicles abound, and in these latter all sorts of infectious materials accumulate. Thus acute infections, as well as chronic hypertrophies due to pressure and irritation, are extremely common.

The various forms of angina, i. e., sore throat, have to do largely with expressions of these infections in varying degrees of severity. The adjoining mucosa and other tissues frequently participate, and it is possible to produce a painful degree of chemosis of the membranes involved in a short time. Adjoining lymph involvement, with discomfort or even distress in the region of the throat, and sometimes pronounced general malaise, are extremely common accompaniments.

The “cynanche tonsillaris” of the older writers implied an acute expression of this kind, often with more or less exudation, which, accumulating upon the exposed surfaces, produces there a membrane, the condition being most noticeable in the pronounced types of diphtheria. At other times activity is manifested rather in the peritonsillar structures, and acute and suppurative types of cellulitis, leading either to abscess in the tonsil or deep in the neck, are the result. A surprising degree of toxemia accompanies these lesions and sometimes severe and fatal general septic infection, perhaps with endocarditis. Abscess of the tonsil may produce so much occlusion of the pharynx as to make breathing difficult and even almost impossible, perhaps even to a point requiring tracheotomy. Tonsillar abscesses usually evacuate themselves in time; if they are opened by the surgeon relief comes promptly, with evacuation of pus, no matter how brought about.

Many such abscesses could be easily recognized and incised were it not for the surrounding inflammation, which prevents the patient from opening the mouth sufficiently wide to expose the pharynx. Suffering in these cases is acute.

A swollen and fluctuating tonsil, if it can reached, is easily perforated by a sharp, straight knife. Erasion and fatal perforation of the carotid artery has been known to be a sequel of such a case unrelieved. Again, pus having its source within the tonsil may burrow in such a direction as to produce a retropharyngeal abscess.

The tonsil is rarely the site of primary syphilitic lesions, more often of the secondary, and occasionally of tuberculous lesions.

The most common chronic affections of the tonsils result from failure of absorption of inflammatory products after acute inflammations, which leaves a permanent enlargement, and which is constantly irritated and provoked into further growth by the retained contents of the tonsillar crypts. It is in this way that chronic hypertrophy, or the so-called enlarged tonsils, result. These conditions are especially common in children, presenting the milder forms of the status lymphaticus. (See Chapter XIV.) These enlargements are seldom seen alone in the tonsils. Similar involvement of the lymphoid or adenoid tissue in the vault of the pharynx, and even at the base of the tongue, is quite common, the entire original lymphoid ring being more or less involved.

The consequences of chronic enlargement of the tonsils have much to do with the subsequent welfare of patients. Not only is speech interfered with and made peculiarly “throaty,” but, owing to encroachment upon the natural breathing space, children suffering in this way contract a habit of carrying the head forward and stooping the shoulders, in order thereby to increase the dimensions of the nasopharynx; thus they become “mouth-breathers” and hard of hearing, which is deleterious to their intelligence as well as to their physical well-being. Such children, in time, become stupid, unintelligent, and defective in many ways. There is, then, every reason for removing these obstructions to respiration and for doing it early.

Children thus suffering will present such peculiarity of voice as to suggest immediate examination of the oropharynx, while the posture above described and the existence of the mouth-breathing habit should also prompt investigation. An instant inspection through the widely open mouth should permit the detection of this condition. Should it be desired to estimate it more thoroughly it may be done with the finger, although it will provoke the act of coughing or vomiting and be resisted by most children. Frequently the enlargements can be felt from the outside. There is but one suitable treatment for such a case, i. e., tonsillotomy.

Tonsillotomy may be effected with any one of several different patterns of tonsillotomes on sale in the instrument stores, most of which are neat and speedy in their work, but the surgeon need not refrain from the purpose of removal because of the lack of such an instrument, as it may be easily accomplished without one. Young and timid children are probably best anesthetized, although if one can establish perfect confidence it may be possible to do it by the aid of local anesthesia. In adults the latter will always be sufficient.

An anesthetized patient should be placed in a chair or semi-upright, and the mouth widely opened. The circular loop of the instrument should be fitted over the tonsil, this, if necessary, being drawn into its grasp by a small hook or forceps, after which by a quick motion of the cutting blade the projecting mass is removed. All instruments are made to be used with either hand and to cut on either side. The practised operator will, therefore, use his left hand when operating on the right tonsil of the patient, and vice versa, it being best to adopt this order, for should he be a little clumsy with his left hand and the patient be thereby somewhat disturbed, the right hand may more dexterously perform the excision on the other side. The surgeon should be thoroughly familiar with his tonsillotome before using it. It is not, however, necessary to employ such an instrument, and it will often be more satisfactory to grasp the projecting tonsil in the bite of a suitably constructed tenaculum forceps, or even hold it with a common tenaculum, while with blunt scissors, long handled and curved upon the flat, the tonsil itself is cut away.

None of these methods gives promise of complete extirpation of the tissue, which is often chronically diseased, and it is often well, therefore, to complete the extirpation with the sharp spoon or even to use the finger-nail as a curette. Hemorrhage will be active for a few moments, but is nearly always controlled with either iced water or water as hot as can be borne. Only rarely does it give rise to serious trouble. In such cases adrenalin may be used. Cases are on record where it has been necessary even to tie the carotid, but such instances are mostly bugbears which need not deter one of good judgment from a properly devised operation. Antiseptic gargles, and avoidance of speech and swallowing of hard food, will be all that are needed in the after-management.

The young and the timid will need complete anesthesia, which should be complete in order to abolish reflexes, and cocaine locally to ensure this condition. Many of these subjects are, however, those presenting minor degrees of the status lymphaticus, to whom anesthetics should be administered with caution. In such children tonsillotomy should be combined with the erasion and removal of other involved adenoid tissue in the nasopharynx. Inquiry should be made as to whether the patient bleeds unduly freely after minor injuries. In a bleeder it would be well to proceed with caution or abstain from operating.

Foreign bodies in the tonsil are as often fish-bones as any kind; they all give rise to serious irritation. True calculous formation in the tonsil is known. Every foreign body which can be detected and exposed should be removed.

Tumors of the tonsil are usually of the malignant type, either epitheliomatous or sarcomatous. A cancer of the tonsil should be recognized as such very early if operative or other relief is to be effectually afforded, and if operation is made it should be done more thoroughly than can be done through the mouth.

External pharyngotomy is the measure usually required for this purpose. This is usually performed by making a long incision along the anterior border of the sternomastoid muscle, and, after retracting it, making careful and blunt dissection down in the direction of the tonsil, separating tissues which are evidently not involved, but excising everything in which infiltration can be recognized. An extensive operation of this kind would justify preliminary or provisional ligation of the common or at least the external carotid artery. Care should be taken to avoid wounding the nerve trunks, especially the hypoglossal.

Subhyoid pharyngotomy is performed by a transverse incision just below the hyoid bone, with division of the platysma, the omohyoid, the sternohyoid, and the thyrohyoid muscles, leaving enough of their insertion into the bone to permit of subsequent reunion by suture. The thyrohyoid membrane is then divided in such a way as to also permit of its reunion by sutures. Then the mucous membrane, which will probably now protrude into the wound, is caught and divided, retraction sutures being inserted in the edges of the wound. The epiglottis may be retracted or a suture may be passed through it, to be used as a retractor. The lower portion of the pharynx is now exposed and through this opening the tonsil may be removed. After completion of the deeper work the different layers of the tissues are reunited with chromic gut and the deep wound is drained.

Transhyoid pharyngotomy. Vallas has suggested a central method of approach to the pharynx by a median incision, through which the mylohyoid muscles are separated, the body of the hyoid exposed, and its division effected with stout scissors or with cutting forceps. When its two halves are retracted a space over an inch long is made, through which the mucous membrane of the pharynx may be opened, this being done by making it protrude with the finger passed into the throat, which shall thus serve as a guide. In closing the wound it is not necessary to make suture of the hyoid bone.

THE TEETH, THE ALVEOLAR PROCESS, AND THE GUMS.

The alveolar process, which furnishes the actual sockets for the teeth, and which carries that peculiar fibrous texture with its mucous covering known as the gum, is a frequent site of ulcerative disease and fertile source of infection. While the toilet of the mouth is much more generally attended to at present than in times past, the majority of people are extremely inattentive and indifferent to the condition of the teeth and the gingival borders. As elsewhere stated the mouth is the habitat of an extensive flora and fauna, and deposits of tartar along the gingival border afford excellent hot-beds for their development and growth. This accounts for the marginal ulceration of the gum, or ulcerative gingivitis, seen in so many mouths, and it may be regarded as the beginning of a disease process, pyorrhea alveolaris (Rigg’s disease), that will eventually cause the loss of the teeth and extensive infection of the lymphatics in the neck. In almost every mouth where such accumulations of tartar have taken place the expressions of local infection may be traced by a bluish or purplish line along the gingival border, with some degree of sponginess and mild ulceration.

The enamel covering the teeth is extremely resistant, but when the dentine is exposed below the enamel line, as happens in such instances as those just described, bacteria may easily enter the dental tubules, and dental caries or alveolar suppuration is the result. In order to prevent such disease the services of the dentist should be secured at least as often as every six months, in order that all tartar may be removed and the gums placed in a healthy and resistant condition.

For the marginal ulcerations thus produced there is no better treatment, after removing tartar, than the local application of zinc iodide, either in fine crystalline form or in saturated solution. It is not so much the visible surfaces which need such application as does the gingival tissue in concealed locations and between the teeth. Zinc iodide is not only an excellent antiseptic, but a powerful astringent, and meets a double indication. It may be applied once a week or oftener.

The dental enamel is the protective medium which, being once injured, exposes the dentine beneath to the possibility of infection. Such injuries are mechanical, but usually minute. The practice of putting hot food into the mouth and immediately following it with a drink of iced water is calculated to crack the enamel on a tooth as it would on any other material. Such a crack, although microscopic in dimensions, permits the entrance of bacteria into the dentine, in whose tubules they multiply and produce minute amounts of lactic acid. The enamel will resist this acid almost indefinitely, but the softer dentine is dissolved by it, and in this way cavities are formed within the teeth, and the condition known as dental caries is engendered. While it requires the special art and training of the dentist to cope with such conditions, every general practitioner should be familiar with the circumstances under which these lesions are produced. Congenital defects of the enamel afford also the same opportunities for infection.

When infection has extended to the delicate pulp cavity and when one of the terminal fibers becomes exposed the condition is accompanied by more or less distress, and when the alveolar socket becomes involved the tooth is loosened, either temporarily or permanently, according as the condition is treated. Thus a small alveolar abscess, referred to as “gum-boil,” may result. In the former case there is usually a small sinus which leads down to the root of the tooth, either through the spongy bone or alongside the tooth itself.

Plate III illustrates the conditions in teeth undergoing various forms of caries, there being numerous bacterial forms responsible for different types of the disease.

Treatment here does not differ in principle from that for treatment of caries in bone. Its essential feature is actual removal of all infected dental tissue, with a combination of protection against further infection, and that substitution for lost tissue which is effected by the use of gold, amalgam, or some of the other fillings in common use among dentists. American ingenuity has reached its acme in the discovery of means and methods for atonement of tissue thus lost by disease, and American dentists certainly lead the world in the mechanics of their art. They go much beyond the mere filling of diseased teeth, but have devised substitutes for teeth actually lost, and much of the plate work of the past is now substituted by what is known as crown and bridge work.

Dentistry as a part of oral surgery has now become a specialty by itself. A competent dentist, therefore, is a necessary coöperator in the treatment of all diseases of the teeth.

It is mainly when disease has spread from the teeth to the surrounding bone and tissues that the surgeon as such intervenes. Caries and necrosis of a small or large part of either jaw may be the result of extension of disease processes having their beginnings as above. In the chapter on the Neck, when dealing with the subject of tuberculosis of the lymphatics, it is stated that a large proportion of such cases due to the propagation of infection from the oral cavity and often from the teeth.

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

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

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

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

THE EXTRACTION OF TEETH.

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

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

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

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

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

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

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

THE JAWS.

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

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

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

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

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

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

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