Elements of Surgery

by Robert Liston

It may be necessary to remove the whole lip, or the greater part of it. Hence arises much inconvenience to the patient; he is much reduced by the profuse secretion and loss of saliva; the surrounding parts are excoriated and irritable; his clothes are wetted; his speech is very indistinct; his teeth become thickly coated with tartar; and he is in short kept in a state of constant annoyance. The part may be supplied from under the chin; but this reparative operation should not be performed at the same time with the removal of the original and carcinomatous lip. By making two operations, with a considerable time intervening, the chance of success is greater, and indeed the difficulty is much diminished. After removal of the disease, allow the parts to fill up by granulation and contract as far as they will, then form a new lip. I have done so in several instances; in one case, the parts had perished by external violence; in another, they had been destroyed by some powerful escharotic. A piece of soft leather, of the size and shape of the under lip, is placed under the chin, and a corresponding portion of the integuments is reflected upwards, an attachment being left at the symphysis menti. The callous margins of the space formerly occupied by the original lip are pared; and the flap, having been twisted round, is adapted to the edges of the wound, and retained by points of interrupted or convoluted suture. To insure adhesion, the attachment at the chin should be left thick and fleshy; the flap should not consist of mere integument, but contain no small share of the subcutaneous cellular and adipose tissues, in order that circulation may be vigorous in the part. The integuments below the chin are naturally lose, and consequently the margins of the wound there are readily approximated. The flap soon becomes œdematous, and remains so for some weeks; it must be supported by a compress and bandage. After adhesion of its upper part is completed, the mental attachment, which prevented the lower portion from uniting, is to be removed; a bistoury is introduced beneath the non-adhering point, and carried down so as to divide the attachment, which is then removed by a second stroke of the knife. The lower part of the flap is now laid flat and close to the chin, and supported by a bandage. In the adult, union may be retarded by the edges of the flap twisting inwards, and interposing the hairs upon them between the opposed surfaces; when such is the case, the offending margins must be pared away. The advantages of such an operation, when successful, are too evident to require detail.

Removal of glands in the neck or beneath the jaw, that have become diseased in consequence of malignant disease in the lip, is attended with danger, and not followed by any benefit. But for this disease I have known most bloody and cruel operations undertaken,—even portions of the jaw to which the glandular tumours adhered have been cut out. Such proceedings cannot be too strongly reprobated.

Congenital Deficiencies of Lips, Palate, &c.—Congenital deficiency of the lip uniformly occurs in the upper one; it is either simple or complicated. Frequently there is only a fissure on one side of the mesial line. This may, though seldom, be combined with division of the soft or of the hard palate; or there may be a fissure on each side of the mesial line, with an intervening flap. The flap may be either of the same length as the rest of the lip, or more or less shortened; and it may be either free, or attached to part of the alveolar process. In such cases as the latter, the central alveolar processes and teeth often project considerably beyond the arch of the hard palate, greatly increasing the deformity. The deficiency of the lip produces a disgusting and horrible deformity of the countenance; and when there is division of the palate, the voice is indistinct, or almost unintelligible.

The simple fissure of the lip, without deficiency of the palate, is easily remediable by operation. As already mentioned, the fissure is to one side of the mesial line; and its edges, covered by a continuation of the prolabium, are rounded off at their lower part. The operation is not attended with much loss of blood, nor is it very painful. It can be performed at any period of life, but in young children it is not advisable to have recourse to more severe operations on these or other parts. Children bear the loss of blood badly, and their nervous system is apt to be shaken; convulsions are induced, and often terminate fatally. The most proper age for removing deformity by operation is from two and a half to four years; there is then no danger incurred, and during the growth of the individual the parts recover more and more their natural and healthy appearance.

The operation for single harelip consists in paring off freely the edges of the fissure, and removing completely the rounded corners

at the free margin, thus. This is most neatly, quickly, and easily accomplished by passing a straight bistoury through, from without inwards, so as to penetrate the membrane of the mouth, above the angle of fissure. The parts are stretched by the fingers of the surgeon or assistant, whilst the instrument is carried downwards, so as to detach a flap composed of the edge and rounded corner. Unless the rounded portions are taken clean away, an unseemly notch is left in the prolabium, where in the natural structure is prominent. A similar proceeding is followed on the opposite side. Hemorrhage is prevented by the assistant making gentle pressure whilst he stretches the lip. Two sewing needles, the heads covered with a small nodule of sealing wax, are introduced as directed after the operation for removal of diseased parts in the lower lip, and the twisted suture completed. For some years I have used pins made purposely; they are spear-pointed and tempered near their points. From their length they can be easily inserted without being fixed in a handle, or provided with a head. One needle should always be passed close to the free margin of the lip. No further dressing is required, for reasons already assigned. The forceps of different kinds for holding the edge during its removal are worse than useless; and paring with scissors is to be reprobated, as an effectual means of preventing immediate union. By the plan above recommended, bruising is avoided, and union takes place rapidly.

Fissures, more or less extensive, of the hard palate, generally attend double harelip. The position and size of the intermediate portion of the lip, and of the superior maxillary bone, are various; and the operator, in forming his plan of procedure, must be guided by the state of the parts. If the fissures are not very wide—if the

intermediate portion of bone, that adhering to the septum narium, is not prominent—and if the soft parts covering this are free and long, the operative procedure is simple. Two such operations as are described for single harelip, the latter performed at an interval of some weeks, are required. Thereby the intervening flap is united first to one side, and then to the other.