certain of having removed the whole of the disease, that less sloughing occurs, and that the operation is more quickly performed. Where, however, the tongue is adherent to the floor of the mouth, and hence cannot be drawn forward, or the mouth cannot be opened sufficiently wide, or the light is bad, removal with the scissors is attended with considerable difficulty, and under these circumstances removal with the écraseur will be found safer. As regards the amount of sloughing I am not convinced that more attends the use of the écraseur than the scissors, and if care is taken to pass the cord of the écraseur well beyond the disease, as complete a removal can be ensured.

4. Excision with the galvano-cautery is strongly recommended by some surgeons, but is open to the serious objection that it is liable to be followed by secondary hemorrhage on the removal of the sloughs.

Whatever operation is undertaken, it will be facilitated when the disease is far back by splitting the cheek from the angle of the mouth to the masseter muscle; while, if the disease has invaded the bone, the lower lip may be vertically divided in the middle line, the incision continued on each side for a short distance along the lower border of the ramus of the jaw, the soft parts dissected up, and the infiltrated bone removed by the saw or bone-pliers. When the glands in the neck are much affected, and the disease extends far back, Kocher removes the tongue by an incision from the mastoid process to the hyoid bone, and thence to the jaw, extirpating the glands and tying the lingual artery in the course of the operation. During the removal of the tongue chloroform should be administered by a tube passed through the nose (Junker's method), or if tracheotomy is performed, and the trachea plugged, through the cannula.

The after-treatment consists in dusting the stump with iodoform, or packing the mouth with iodoform gauze, and frequently syringing the mouth with Condy's or other antiseptic fluid. Some surgeons recommend feeding with a tube for the first few days, or by the rectum. It is well to leave a ligature through the stump of the tongue, so that, should recurrent hemorrhage occur, it may be drawn forward, and the bleeding vessel more easily secured. Here it may be said that bleeding can always be arrested temporarily either by passing the finger into the pharynx, and pressing the remains of the tongue against the inner surface of the jaw, or by Lockwood's clamp, which compresses the lingual artery.

DISEASES OF THE UVULA, PALATE, FAUCES, AND TONSILS. UVULITIS, or inflammation of the uvula, is a frequent accompaniment of pharyngeal catarrh. The uvula appears red, swollen, and oedematous, and often considerably elongated. If the inflammation does not yield to the remedies employed for the catarrh, scarification should be practiced.

ELONGATION OF THE UVULA may depend upon chronic catarrh of the pharynx, or upon conditions similar to those leading to chronic enlargement of the tonsils. The elongated uvula may come into contact with the back of the tongue, or even with the mucous membrane of the larynx, and in either case is productive of a troublesome tickling cough. If astringents fail, the end of the uvula may be amputated.

CLEFT PALATE is a congenital defect due to an arrest of development of the processes which normally grow inward from

FIG. 145.

the superior maxillary and palate bones, and meeting each other and the vomer in the middle line, and the premaxillary bone in front, form the hard and soft palate. This arrest of development may be complete, the fissure extending in the middle line through the uvula and the soft and hard palate, and thence through the alveolar process in the line of suture either on one or both sides of the premaxillary bone (Fig. 145). It will in this case be generally combined with double or single hare-lip respectively. When the arrest is only partial, the cleft may extend through the uvula alone, or through the soft palate as well, or the soft and part of the hard palate; while, in other instances, the alveolar process only on one or both sides of the middle line may be notched, as occurs so often in hare-lip. The vomer, which is continuous in front with the premaxillary bone, either presents a free border in the middle of the cleft, or is attached to one or other margins of the cleft. The consequences of cleft palate vary with the age of the patient and extent of the cleft. In infancy, suction and deglutition are seriously interfered with; while later, the voice, articulation, taste, smell, and hearing may all be impaired.

Treatment. The infant, if unable to take the breast in an erect or semi-recumbent posture, must be fed with the mother's milk by a spoon passed well to the back of the mouth, or by a feeding-bottle with a large teat to act as a plug to the cleft. The operation for the cure of the deformity should be undertaken before the child begins to speak, which is generally about a year

later than usual; but not in infancy, as bleeding is then badly borne, and the cleft of the bony palate diminishes in width during the first three years of life. Infants, moreover, are very liable to such ailments as catarrh of the pharynx and lungs, and coughing and sneezing tend to tear the parts asunder. The cleft in the hard and soft palate should be closed at the same time. Hare-lip, if present, should be operated on in infancy.

Staphyloraphy or closure of the soft palate. Chloroform having been given by Junker's apparatus with the tube passed through the nose, and the mouth widely opened by a Smith's gag, which depresses the tongue at the same time (Fig. 146), one end of the bifid uvula is seized with long forceps, and the edge of the cleft pared from below upward, and the paring repeated on the opposite side. The uvula and

FIG. 146.

gmai

the lower part of the palate are then united by horsehair, the upper part by silver wire. The wire-sutures are best passed by Smith's needle, by which they can be carried through both sides of the cleft by one transit of the needle. The needle, shown in Fig. 147, has "a small reel attached behind the handle to hold the wire, and a small serrated wheel halfway up the handle to protrude the wire from its tubular point." The horsehair may be passed across the cleft

FIG. 147.

Smith's Gag for Cleft Palate.

ARNOLD

Smith's Needle for Passing Wire-sutures in Cleft Palate.

FIG. 148.

ARNOLD & SONS LONDON

Smith's Palate Needle for Passing Horsehair Sutures in Cleft Palate.

FIG. 149.

Suture-catcher.

by the needle shown in Fig. 148, and, as the point of the needle protrudes from the palate, the end of the horsehair seized and drawn out by the suture-catcher (Fig. 149), and the needle

withdrawn. The silver sutures should be fastened by the wiretwister (Fig. 150) and cut off short, care being taken to hold the edges of the cleft merely in apposition, and not to apply any tension. The horsehair should be tied with a treble surgeon's knot. When the parts have been brought together, any undue tension should be relieved by making lateral incisions through each side of the soft palate parallel to the cleft and just internal to the

FIG. 150.

ARNOLD & SONS LONDON

Wire-twister.

hamular process with a tenotome on a long handle. By these incisions the levator palati muscles are divided. The palatopharyngei may also be divided, if necessary, by notching the posterior pillars of the fauces with scissors.

Uranoplasty, or closure of the hard palate. The soft palate having been previously brought together in the way described, the operation on the hard may be begun at that stage where the

FIG. 151.

tension becomes such that the soft parts can no longer be brought together. The edges of the cleft having been pared, an incision from a quarter to three-quarters of an inch long should be made on either side of, and parallel to, the cleft through the muco-periosteum down to the bone (Fig. 151, E, E). It should fall a little distance from the alveolar process, so as to avoid wounding the anterior palatine artery. Into one of these incisions a raspatory or an aneurism needle with a short curve should be introduced, and the muco-periosteum separated from the bone along the whole length of the cleft in the hard palate, avoiding the neighborhood of the posterior palatine foramen, through which the anterior palatine artery runs. The attachment of the muco-periosteum to the posterior margin of the hard palate should be divided by curved scissors passed through the cleft and behind the soft palate, which should be drawn forward to facilitate this step of the operation. Pressure should be made upon the parts with a small

Position of the lateral incisions in the operation for cleft of hard palate. E, E, the lateral

incisions through the mucoperiosteum; the dotted line

indicates the line of junction of the hard and soft palate.(From Bryant's Surgery.)

sponge by an assistant, while the muco-periosteum is being separated in like manner on the opposite side. Wire-sutures should now be passed in the way described for uniting the soft palate, and any tension relieved by prolonging the cuts made for the introduction of the raspatory forward or backward, as the case may require. Hemorrhage, though often sharp, is seldom, however, severe, and may generally be stopped by pressure or syringing with ice-cold water, the head being turned over to one side to let the blood escape, or, if it becomes serious, by plugging the posterior palatine canal with a small peg of wood.

After-treatment.-The patient should be fed on iced milk for the first day, and then on soft food for a fortnight. The sutures may be left in for three weeks or a month; if the patient is unruly, they should be removed under chloroform. The cleft ought to heal by the first intention, and the lateral cuts for taking off tension by granulation. If a portion of the cleft fails to unite by the first intention, it will often heal up subsequently by granulation; if not, a second operation must be undertaken. somewhat doubtful whether the muco-periosteum ossifies.

It is

ACUTE TONSILLITIS may be the result of taking cold in a person in feeble health, or the subject of the rheumatic diathesis, or who from previous attacks has become predisposed to the disease; sometimes it is due to septic poisoning, as from the inhalations of sewer gas; or it may occur in the course of other diseases, as scarlet fever. Signs.-It generally begins with a slight chill, or even a rigor, followed by a high temperature, furred tongue, offensive breath, salivation, pain darting to the ear and increased on swallowing, and swelling of the glands behind the angle of the jaw. If the mouth can be sufficiently opened, one or both of the tonsils are found to be red and swollen, and often in contact, blocking up the fauces. The neighboring parts are congested and swollen, and, in the variety known as follicular tonsillitis, a secretion is seen oozing from the mouths of the inflamed follicles. The inflammation may now subside, or terminate in suppuration (quinsy), which may be known by the pain becoming of a throbbing character, and a sense of fluctuation or softening on palpation. Treatment.-At the onset a sharp purge should be given, while large doses of perchloride of iron, quinine, or salicylate of soda, with the local insufflations of bicarbonate of soda, may be tried as abortives. Where suppuration threatens, the throat should be steamed, and hot chamomile mattresses or linseed poultices applied externally. As soon as the abscess has formed, an incision should be made with a bistoury, guarded by wrapping it round with sticking-plaster, to within a half an inch from the end, and directing the point toward the middle