The lips, particularly the lower, are very subject to cancerous excrescence and ulceration, which if not early removed, soon contaminate the contiguous lymphatic glands, rendering au operation hopeless. When the lower lip is the seat of disease, the can cerous portion, with some of the healthy structure on each side, requires removal, and is done by making two incisions of the figure of the letter V, the apex pointing towards the chin, and approxi mating the raw surfaces as described above.
The nerves of the face, viz. the supra-orbitary, infraorbitary, mental and facial, arc all liable to be affected with neuralgia, or tie douloureux, which is a peculiar excited state of the nerves, being either an inflamed condition of the neurilema, or a spasmodic condition of the medullary structure, and often results from a deranged state of the stomach, or rest of the alimentary canal or liver. The treatment therefore depends on the cause; if not constitutional, the best local application is the moxa, the next the knife. For an account of the various operations, see Lizars' Ault. Plates, Part. II.
The face, from its glandular structure, is very subject to tumours, warty excrescences, and can cerous ulceration, all of which should be early ex cised; and in performing operations in this region, we must be careful to avoid the parotid duct, and disfiguring the face. When the parotid duct is wounded, the saliva discharges itself over the cheek, constituting salivary fistula, and is to be treated by establishing a fistulous aperture into the mouth by means of a seton, then closing the ex ternal wound towards the cheek by caustic, actual cautery, compress and bandage. The parotid gland, and particularly the lymphatic ones super ficial to it, are frequently scirrhous, and require extirpation. Some we have known remain dor mant for thirty years, while others have advanced to ulceration, and produced a most painful and loathsome existence. In removing the parotid gland with the knife, the common carotid of the af fected side ought to be first compressed or secured, then an incision over the gland, from the zygoma downwards to the sternomastoid muscle, or two semi-elliptical ones, according to the magnitude of the tumour. The skin dissected, first forwards to wards the face, and next backwards towards the ear; and the gland carefully insulated by lateraliz ing the knife with its cutting edge towards the chin, and preserving the nervus vagus and internal jugular vein, both of which may be so embedded in the tumour, as to require a portion of the disease to be left. It has been removed repeatedly with success.
The submaxillary gland, or its contiguous lym phatic glands, are subject to the same diseased condition as the parotid, and also require removal with the knife; but as there is only the facial em bedded in the tumour, there is no necessity for se curing the carotid. The lingual, however, may be wounded in the operation. The knife should be lateralized in the same manner as recommended for the parotid. The different lymphatic glands in the region of the carotid artery, are very subject to the various sarcomatous enlargements, particu larly the carcinomatous, and require extirpation.
Those at the angle of the inferior maxilla, are fre quently so braced down by the sterno-mastoid, and the platysma myoides muscles, together with the cellular fascix, that they are in close contact with all the important blood-vessels and nerves in this region, while they appear to be immediately under the skin. In removing them, the knife is to be lateralized as mentioned above. In the lower re gion of the neck, and near the axillary plexus, tu mours arc generally softer, occasionally encysted and cartilaginous.
The enlargement of the thyroid gland, which depends on the water drunk by the individual, is now found curable by iodine, and a removal to a distance from the water which produced it, avoid ing, however, every danger of falling into Charyb dis. Wry-neck is a contraction of the sterno-mas toid muscle, which then requires to be divided. Sometimes only the clavicular attachment need be separated; but if the whole muscle, either its origin or insertion should be selected, and the latter is less dangerous; and if the operator proceed cau tiously, he will injure no important objects. Alter the operation, the chin-stay, Fig. 22 of Plate DXVI. should he worn.
While in the act of eating various substances, especially fruits, the stones are liable to be swal lowed and enter the larynx, and unless removed, immediately produce suffocation, by entering the glottis, or sacculus laryngis; or they descend into the trachea, and produce difficult respiration, in flammation, effusion, and occasionally emphysema. They even sometimes descend into the minute di visions of the bronchii, and produce abscess of the lungs, or phthysis pulmonalis. As suffocation may be produced by bodies arrested in the pha rynx, a prohang should be first inserted into it, but if the suffocating symptoms continue, laryngotomy ought immediately to be performed, which consists in making a longitudinal incision over the thyro cricoid membrane, and securing any small arteries, if necessary; then making an incision in this liga mentous membrane, and searching for the foreign body. If it be below the incision in the trachea, the efforts of coughing will bring it up; and if in the ventricles of the glottis, a probe scoop, or for ceps will dislodge it. Any incision of the thyroid, or even cricoid cartilage, is to be as much as pos sible avoided, especially the former. Laryngotomy is also performed when foreign bodies have been arrested in the (esophagus, threatening instant suffo cation, and the operator unable to dislodge them by the probang; it is also adopted to inflate the lungs in suspended animation, likewise in la ryngitis. See Article MEDICINE, vol. XII. p. 807. And when the glottis is ulcerated in syphilis, or too much mercury has been taken, and when tu mours in the vicinity oppress the breathing. With the exception of the first of these cases, laryngo tomy appears unnecessary; and when performed, a trocar and canula, as delineated in Fig. 18, Plate DXVI., should be plunged obliquely downwards into the trachea, after the oblong square space is brought into view, the canula left and the trocar withdrawn.