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FISTULA OF THE PAROTID:
1360 2. ’Surgical measures, including cases which have become debilitated by overlong expectant treatment, have cured at least 60 per cent., whether by gastrojejunostomy or Ramstedt’s operation (Gray and Pirie). 3. Where the diagnosis is reasonably certain from the finding of a small tumour, presumably the pylorus (with the other signs of pyloric obstruction), operation should be undertaken without delay, and should be regarded as the normal treatment. 4. Where the diagnosis is not absolutely decided medical measures (gastric lavage and small feeds) may be continued for a few days while careful frequent examinations are made for the pyloric tumour. If projectile vomiting persists, faeces remain abnormal, or the weight does not increase, a laparotomy should be done high up in the abdomen and the pylorus hooked up through a small incision and examined. 5. Although there is not much difference between the percentage recovery of the cases in this series treated by gastro-jejunostomy and the Great Ormond-street series treated by Ramstedt’s operation, the latter will probably be the operation of choice in the future on account of its less severe character. If employed early in all cases the results could probably be considerably
Excision of the two huge scars shown in the accompanying photograph, in the centre of each of which was a salivary fistula, would have been inadvisable, even if practicable, as the fistula treated in the anterior (upper} scar healed straight away and that in the posterior-
(lower)
later on, without fresh incisions. test case can be so cured, the method in its improved form may be deemed worthy of more extensive trial before resorting to Mr. Cole’s open operation, suitable as it is, if the simpler method fails. one
If such
a
I
improved. 6. There is a great disturbance of metabolism in these infants, rendering the after-treatment a problem in feeding to be solved in each case individually. ,
I must express my thanks to my house surgeon, Mr. Bettinson, for his care in collecting the notes of the Shadwell cases. Weymouth-street, W.
FISTULA OF THE PAROTID: AN IMPROVED METHOD OF CURE.
BY HENRY
CURTIS, B.S., M.D. LOND., F.R.C.S. ENG.,
SURGEON TO THE METROPOLITAN HOSPITAL ; LATE SURGEON TO THE MILITARY HOSPITAL, ENFIELD-ROAD, E., AND TO THE HOSPITAL FOR FACIAL INJURIES, BROOK-STREET, W.
A
IN THE LANCET of June 7th, 1919, Mr. Percival Cole wholly condemns seton operations for the cure of complete fistula of the parotid duct, as they usually fail, he says, and render more difficult any subsequent reparative procedure. In the two cases on which he performed the operation he advocates " several previous attempts to cure had been made by seton methods, the only result being to diminish plasticity by the increase of scar tissue, and so add new difficulties to those already existing." Starting with the principle that " if the duct will not meet the mouth cavity, the mouth cavity must be made to meet the duct," essentially the procedure recommended by Mr. Cole would appear to be based on the older operation, quoted in my article on " Affections of the Salivary Glands " in the " Index of Treatment," of freeing the portion of the duct proximal to the fistula and bringing it into the mouth through an opening at the level of the anterior border of the masseter. Mr. Cole’s modification consists in leading the freed duct through the slit-up apex of a pouch of buccal mucous membrane, caused to bulge into the wound made by a generally horizontal skin incision through the cheek; the pouch when slit is sutured to the deep structures of the cheek, and the resected end of the duct then anchored to the mucous membrane within the mouth. This operation in the two cases he records has given Mr. Cole excellent results; but, in my opinion, if cure can otherwise be effected it should not at once be resorted to. Though it is true that an ugly scar, if present, can at the same time be excised, Mr. Cole’s operation itself involves a fresh cheek wound, which is not so inevitable as might be assumed. The following case, where there were two 8stulae, and one other case were treated successfully by a modification, devised by me during the war, of an old procedure which Mr. Cole, presumably, would include in the category of the condemned seton operations.
of two salivary fistulae, one in each of the linear scars seen in the left cheek, cured by the method described in the text.
case
Technique of Operation. The
original
method is
as
follows :-
,
.
The finest of drainage-tubes, threaded with silk at both ends, is attached to the eye of a probe, the fine point of which is insinuated into the mouth of Stenson’s duct and brought out on to the cheek, leaving the tube in the duct. The silk threads are tied over the cheek; after four days they are untied, the tube is dragged some way on to the cheek, and about4 in. is removed from the outer end. To the outer end of what remains a fresh thread is attached, and the tube dragged back into place, thread, however, now replacing in the track the removed portion of tube. In the same way, art intervals of four days, the rest of the tube is gradually shortened, until by the time it has been completely removed leaking from the fistula has almost ceased. If there is recurrence of leaking the procedure is repeated. By dragging the tube across from the distal into the proximal portion of the duct, thus establishing direct continuity and correct alignment of these two portions, the results can be much improved upon. It is quite easy to insert a fairly large ophthalmic probe through the fistulous opening on the cheek into the proximal portion of the duct. The opening in the duct itself naturally lies in the fioor of the fistulous opening at a varying depth from the surface. In the cases recorded by Mr. Cole there was a slit in the outer wall of the duct proximal to the stenosed end, this slit being the remains of either the original wound or of the lumen of the completely divided duct, kept open by the constant flow of saliva. In other cases, as the present writer has observed, the completely divided end of the proximal portion of the duct, as the result of scarring, is directed
outwards,
so as
to lie sometimes
immediately beneath
the
orifice in the skin, and a probe can be at once passed obliquely inwards and backwards along the duct. This displacement, in relation with the upper end of the distal portion of the duct, must be remedied for cure of the fistula, and the procedure now recommended is persistent directed to restoring the continuity of the divided ends. Leaving the probe in situ, or reintroducing it later, the finest drainage-tube, threaded at both ends with " black ophthalmic Dfishing-gut, is inserted into Stenson’s duct from the mouth, and its outer end dragged on to the cheek in the manner already described. A non-cutting round
1361 intestinal needle is now threaded on to the suture attached to the outer end of the tube, and removing the probe left in the proximal end of the duct, the needle is carefully introduced into the duct for about 1 inch, and its point then made to puncture the duct and emerge through the cheek, ’dragging with it the suture. The tube is thus brought across from the distal to the proximal portion of the duct, and the divided ends are placed in continuity. The suture is fastened by a loop around the ear, and to the loop is .attached the other suture fixed to the inner end of the tube .and brought out of the mouth. A collodion dressing, repeated daily, seals the fistulous opening and seems decidedly to facilitate healing. The inner or oral end of the tube is dragged down and - shortened by about4 inch every fourth day, until it has been completely cut away. The suture may be allowed to remain
experience differ over which were the knuckle-joints of the hand. Whether the first metacarpal bone is a bone of the thumb is another point often in dispute. Al-ilitai-V Assessments. The assessment of hand injuries under the Workmen’s Compensation Act is a very much more difficult and complicated matter than assessing in accordance with the Royal Warrant under the Ministry of Pensions. Civilian and
Under the Workmen’s occupation has to be taken into consideration, and there is no schedule of fixed amounts for definite injuries to guide one. There are geographical limitations to one’s knowledge, whilst one is supposed to be well acquainted with the decisions of the courts. Both sides know by this time the relative values of different hand injuries, and where common sense prevails needless expense over useless litigation can be easily avoided. As a result of a Home Office inquiry, now being carried out in connexion with definite injuries under the Workmen’s Compensation Act, it may be expected that this Act of Parliament will be improved by containing a schedule of fixed amounts on the same principle as the Ministry of Pensions.
’, This arises from two factors.
Compensation
’
Act the man’s
Assessing hand injuries in accordance with the Royal Warrant of the Ministry of Pensions, the schedule for definite injuries has to be strictly adhered to. The right hand is assessed at 60 per cent.; right thumb or four fingers at 40 per cent. ; two fingers 20 per cent. There is a scale for minor injuries for individual fingers and parts thereof. As stated above, there is no corresponding Symes, Chopart, or Lisfranc operation in dealing with the hand, so that injuries involving the carpal and metacarpal bones have to be assessed on general considerations. No matter how great the mutilation of the right hand, the assessment cannot be over 60 per cent., the value of the entire hand. Injury involving loss of the carpal bones nearly invariably implies loss of the corresponding metacarpal bones and phalanges. We know the assessment for the loss of the whole hand and also the assessment for the THE ASSESSMENT OF HAND INJURIES. fingers, so that there should not be any great difficulty in dealing with conditions existing between these two BY J. J. SCANLAN, L.R.C.P. & S. EDIN., D.P.H. points. The thumb is the most important factor, and its presence or absence will seriously affect the THE introduction of the Workmen’sCompensation assessment. The assessments under the Ministry of Pensions Act, 1906, called for the assessment of a large number of cases of hand injuries. The war has increased the must not be taken as any guide for assessing under number tenfold. All over the country medical men, the Workmen’s Compensation Act. At best they show either on military or pensions boards, are engaged in how the Act would be improved by containing a examining and assessing mem with damaged and schedule of fixed amounts for definite injuries. mutilated hands, and it is very desirable that In assessing hand injuries it will be remembered that the function of the hand is manipulation, whilst that of uniformity should be aimed at. Anatomically, the hand resembles the foot; surgi- the foot is locomotion. Deprived of all five digits the cally, they differ. At the wrist and ankle respectively hand is practically useless. Loss of all toes interferes we have the well-known Colles’ and Pott’s fractures. only in a minor degree with the utility of the foot. ’Below the ankle we have the equally well-known In reporting on hand injuries, whether under the operations of Symes, Ohopart, and Lisfranc. In the Workmen’s Compensation Act or for the Ministry of ’hand we have no such well-known operations, and this Pensions, the medical examiner will remember that his makes the assessment of hand injuries so difficult as report will be perused and criticised and an assessment - compared with the foot. The Royal Warrant containing made from it by a colleague who devotes his whole time the schedule of fixed amounts for different injuries to this class of medical work. To paraphrase an old under the Ministry of Pensions can be bought over the saying, " An inch of diagram is worth a yard of counter, so that both sides know exactly where they description." Failing a radiograph or photograph of the are. A Symes and a Chopart are both assessed at damaged hand, the simplest and most satisfactory 60 per cent. of the amount due for a total disablement, adjunct to a medical report is an outline of the hand and a Lisfranc at 40 per cent. No such schedule exists taken by running a pencil round the hand laid flat on a for injuries involving the carpal and metacarpal bones. sheet of white paper. For completion sake an outline It is not only the absence of a fixed schedule for of the other hand is desirable. When these are supplied injuries of the carpal and metacarpal bones which written description can be reduced to a minimum and causes trouble in assessment. Difficulties arise from common mistakes easily avoided. To cite a common faulty nomenclature and the use of expressions which example: a medical report states that " the third are not strictly anatomical. One has only to peruse finger of the right hand has been amputated at the three or four reports dealing with the same hand injury first joint." To begin with, you cannot be sure which to appreciate this. I have seen scores of medical finger is referred to as long as medical examiners conreports rendered useless by the fact that the elementary tinue describing fourth and fifth fingers. The actual division of the skeleton of the hand into carpal, meta- site of amputation cannot be determined till it has carpal, and phalangeal bones has often not been kept in been ascertained whether the examiner means the mind. The anatomy of the hand might well be taught metacarpal-phalangeal joint or the first interphalangeal with a little more clearness in some of the medical joint. With an outline of the hand such ambiguity schools and text-books. I have seen medical men of would be impossible.
Excision of the two huge scars shown in the accompanying photograph, in the centre of each of which was a salivary fistula, would have been inadvisable, even if practicable, as the fistula treated in the anterior (upper} scar healed straight away and that in the posterior-
(lower)
later on, without fresh incisions. test case can be so cured, the method in its improved form may be deemed worthy of more extensive trial before resorting to Mr. Cole’s open operation, suitable as it is, if the simpler method fails. one
If such
a
I
improved. 6. There is a great disturbance of metabolism in these infants, rendering the after-treatment a problem in feeding to be solved in each case individually. ,
I must express my thanks to my house surgeon, Mr. Bettinson, for his care in collecting the notes of the Shadwell cases. Weymouth-street, W.
FISTULA OF THE PAROTID: AN IMPROVED METHOD OF CURE.
BY HENRY
CURTIS, B.S., M.D. LOND., F.R.C.S. ENG.,
SURGEON TO THE METROPOLITAN HOSPITAL ; LATE SURGEON TO THE MILITARY HOSPITAL, ENFIELD-ROAD, E., AND TO THE HOSPITAL FOR FACIAL INJURIES, BROOK-STREET, W.
A
IN THE LANCET of June 7th, 1919, Mr. Percival Cole wholly condemns seton operations for the cure of complete fistula of the parotid duct, as they usually fail, he says, and render more difficult any subsequent reparative procedure. In the two cases on which he performed the operation he advocates " several previous attempts to cure had been made by seton methods, the only result being to diminish plasticity by the increase of scar tissue, and so add new difficulties to those already existing." Starting with the principle that " if the duct will not meet the mouth cavity, the mouth cavity must be made to meet the duct," essentially the procedure recommended by Mr. Cole would appear to be based on the older operation, quoted in my article on " Affections of the Salivary Glands " in the " Index of Treatment," of freeing the portion of the duct proximal to the fistula and bringing it into the mouth through an opening at the level of the anterior border of the masseter. Mr. Cole’s modification consists in leading the freed duct through the slit-up apex of a pouch of buccal mucous membrane, caused to bulge into the wound made by a generally horizontal skin incision through the cheek; the pouch when slit is sutured to the deep structures of the cheek, and the resected end of the duct then anchored to the mucous membrane within the mouth. This operation in the two cases he records has given Mr. Cole excellent results; but, in my opinion, if cure can otherwise be effected it should not at once be resorted to. Though it is true that an ugly scar, if present, can at the same time be excised, Mr. Cole’s operation itself involves a fresh cheek wound, which is not so inevitable as might be assumed. The following case, where there were two 8stulae, and one other case were treated successfully by a modification, devised by me during the war, of an old procedure which Mr. Cole, presumably, would include in the category of the condemned seton operations.
of two salivary fistulae, one in each of the linear scars seen in the left cheek, cured by the method described in the text.
case
Technique of Operation. The
original
method is
as
follows :-
,
.
The finest of drainage-tubes, threaded with silk at both ends, is attached to the eye of a probe, the fine point of which is insinuated into the mouth of Stenson’s duct and brought out on to the cheek, leaving the tube in the duct. The silk threads are tied over the cheek; after four days they are untied, the tube is dragged some way on to the cheek, and about4 in. is removed from the outer end. To the outer end of what remains a fresh thread is attached, and the tube dragged back into place, thread, however, now replacing in the track the removed portion of tube. In the same way, art intervals of four days, the rest of the tube is gradually shortened, until by the time it has been completely removed leaking from the fistula has almost ceased. If there is recurrence of leaking the procedure is repeated. By dragging the tube across from the distal into the proximal portion of the duct, thus establishing direct continuity and correct alignment of these two portions, the results can be much improved upon. It is quite easy to insert a fairly large ophthalmic probe through the fistulous opening on the cheek into the proximal portion of the duct. The opening in the duct itself naturally lies in the fioor of the fistulous opening at a varying depth from the surface. In the cases recorded by Mr. Cole there was a slit in the outer wall of the duct proximal to the stenosed end, this slit being the remains of either the original wound or of the lumen of the completely divided duct, kept open by the constant flow of saliva. In other cases, as the present writer has observed, the completely divided end of the proximal portion of the duct, as the result of scarring, is directed
outwards,
so as
to lie sometimes
immediately beneath
the
orifice in the skin, and a probe can be at once passed obliquely inwards and backwards along the duct. This displacement, in relation with the upper end of the distal portion of the duct, must be remedied for cure of the fistula, and the procedure now recommended is persistent directed to restoring the continuity of the divided ends. Leaving the probe in situ, or reintroducing it later, the finest drainage-tube, threaded at both ends with " black ophthalmic Dfishing-gut, is inserted into Stenson’s duct from the mouth, and its outer end dragged on to the cheek in the manner already described. A non-cutting round
1361 intestinal needle is now threaded on to the suture attached to the outer end of the tube, and removing the probe left in the proximal end of the duct, the needle is carefully introduced into the duct for about 1 inch, and its point then made to puncture the duct and emerge through the cheek, ’dragging with it the suture. The tube is thus brought across from the distal to the proximal portion of the duct, and the divided ends are placed in continuity. The suture is fastened by a loop around the ear, and to the loop is .attached the other suture fixed to the inner end of the tube .and brought out of the mouth. A collodion dressing, repeated daily, seals the fistulous opening and seems decidedly to facilitate healing. The inner or oral end of the tube is dragged down and - shortened by about4 inch every fourth day, until it has been completely cut away. The suture may be allowed to remain
experience differ over which were the knuckle-joints of the hand. Whether the first metacarpal bone is a bone of the thumb is another point often in dispute. Al-ilitai-V Assessments. The assessment of hand injuries under the Workmen’s Compensation Act is a very much more difficult and complicated matter than assessing in accordance with the Royal Warrant under the Ministry of Pensions. Civilian and
Under the Workmen’s occupation has to be taken into consideration, and there is no schedule of fixed amounts for definite injuries to guide one. There are geographical limitations to one’s knowledge, whilst one is supposed to be well acquainted with the decisions of the courts. Both sides know by this time the relative values of different hand injuries, and where common sense prevails needless expense over useless litigation can be easily avoided. As a result of a Home Office inquiry, now being carried out in connexion with definite injuries under the Workmen’s Compensation Act, it may be expected that this Act of Parliament will be improved by containing a schedule of fixed amounts on the same principle as the Ministry of Pensions.
’, This arises from two factors.
Compensation
’
Act the man’s
Assessing hand injuries in accordance with the Royal Warrant of the Ministry of Pensions, the schedule for definite injuries has to be strictly adhered to. The right hand is assessed at 60 per cent.; right thumb or four fingers at 40 per cent. ; two fingers 20 per cent. There is a scale for minor injuries for individual fingers and parts thereof. As stated above, there is no corresponding Symes, Chopart, or Lisfranc operation in dealing with the hand, so that injuries involving the carpal and metacarpal bones have to be assessed on general considerations. No matter how great the mutilation of the right hand, the assessment cannot be over 60 per cent., the value of the entire hand. Injury involving loss of the carpal bones nearly invariably implies loss of the corresponding metacarpal bones and phalanges. We know the assessment for the loss of the whole hand and also the assessment for the THE ASSESSMENT OF HAND INJURIES. fingers, so that there should not be any great difficulty in dealing with conditions existing between these two BY J. J. SCANLAN, L.R.C.P. & S. EDIN., D.P.H. points. The thumb is the most important factor, and its presence or absence will seriously affect the THE introduction of the Workmen’sCompensation assessment. The assessments under the Ministry of Pensions Act, 1906, called for the assessment of a large number of cases of hand injuries. The war has increased the must not be taken as any guide for assessing under number tenfold. All over the country medical men, the Workmen’s Compensation Act. At best they show either on military or pensions boards, are engaged in how the Act would be improved by containing a examining and assessing mem with damaged and schedule of fixed amounts for definite injuries. mutilated hands, and it is very desirable that In assessing hand injuries it will be remembered that the function of the hand is manipulation, whilst that of uniformity should be aimed at. Anatomically, the hand resembles the foot; surgi- the foot is locomotion. Deprived of all five digits the cally, they differ. At the wrist and ankle respectively hand is practically useless. Loss of all toes interferes we have the well-known Colles’ and Pott’s fractures. only in a minor degree with the utility of the foot. ’Below the ankle we have the equally well-known In reporting on hand injuries, whether under the operations of Symes, Ohopart, and Lisfranc. In the Workmen’s Compensation Act or for the Ministry of ’hand we have no such well-known operations, and this Pensions, the medical examiner will remember that his makes the assessment of hand injuries so difficult as report will be perused and criticised and an assessment - compared with the foot. The Royal Warrant containing made from it by a colleague who devotes his whole time the schedule of fixed amounts for different injuries to this class of medical work. To paraphrase an old under the Ministry of Pensions can be bought over the saying, " An inch of diagram is worth a yard of counter, so that both sides know exactly where they description." Failing a radiograph or photograph of the are. A Symes and a Chopart are both assessed at damaged hand, the simplest and most satisfactory 60 per cent. of the amount due for a total disablement, adjunct to a medical report is an outline of the hand and a Lisfranc at 40 per cent. No such schedule exists taken by running a pencil round the hand laid flat on a for injuries involving the carpal and metacarpal bones. sheet of white paper. For completion sake an outline It is not only the absence of a fixed schedule for of the other hand is desirable. When these are supplied injuries of the carpal and metacarpal bones which written description can be reduced to a minimum and causes trouble in assessment. Difficulties arise from common mistakes easily avoided. To cite a common faulty nomenclature and the use of expressions which example: a medical report states that " the third are not strictly anatomical. One has only to peruse finger of the right hand has been amputated at the three or four reports dealing with the same hand injury first joint." To begin with, you cannot be sure which to appreciate this. I have seen scores of medical finger is referred to as long as medical examiners conreports rendered useless by the fact that the elementary tinue describing fourth and fifth fingers. The actual division of the skeleton of the hand into carpal, meta- site of amputation cannot be determined till it has carpal, and phalangeal bones has often not been kept in been ascertained whether the examiner means the mind. The anatomy of the hand might well be taught metacarpal-phalangeal joint or the first interphalangeal with a little more clearness in some of the medical joint. With an outline of the hand such ambiguity schools and text-books. I have seen medical men of would be impossible.