prevent the access of cold air; and, if the hemorrhage be profuse,
long pieces of lint pushed well back will generally be sufficient to
arrest it: if not, the posterior cavity must be plugged from behind.
It is prudent to prepare for the stuffing posteriorly in bad cases in
which violent hemorrhage may be expected. Instruments with springs,
&c., have been contrived for the purpose, but are useless, and cannot
always be had. A loop of thin flexible wire, or of thick catgut, is
passed along the floor of the nostril, and on reaching the throat
is caught by the finger, or by a hook or forceps, and brought into
the mouth. A piece of strong thread is then attached to the wire or
catgut, and the latter is withdrawn; one extremity of the thread
hanging from the nostril, the other from the mouth. To the middle
of the thread a piece of lint rolled up to the size of the point of
the thumb is affixed, and this is pulled back into the mouth, and
directed into the posterior nares with the fingers; by the pressure
of these, and by pulling at the thread, the dossil is firmly wedged
into the aperture. Lint is preferable to sponge, as being more easily
removed; sponge swells, and is apt to produce inconvenience. The plug
must be well proportioned to the opening: if too large, it cannot be
lodged in its situation; if too small, it does not fill it, and may be
pulled through altogether. It should be smaller, of course, for young
subjects and females than in adult males. It may be necessary to close
both nostrils in this manner, when both are bleeding profusely, or
when they communicate through an aperture in the septum. The anterior
cavity is then closed with lint, and the hemorrhage, however violent,
is completely commanded. The posterior plug is removed on the second
or third day by pulling the oral extremity of the thread, and, if need
be, by pressing through the nostril with a strong probe. Plugging may
be required in epistaxis from other causes, when other means, as cold
applied to the surface of the body, and astringent injections to the
part, have failed. The latter remedy is not much to be depended upon.
The operation for polypus may be repeated when the parts have
recovered, and the pain and discharge ceased. Ere then the patient
again finds himself unable to propel air easily through the nostril,
and, on examination, greyish, shining tumours are again visible. The
same process of extraction is repeated until all are eradicated.
Escharotics may be then applied with some advantage, but must be
used with caution, and not of too active a nature: nitrate of silver
and the red oxide of mercury are those commonly employed. But it is
questionable whether these applications have any effect in preventing
the future growth of the tumours.
The malignant form of the disease, even in a very early stage, is
unmanageable: the tumours, if removed, are speedily reproduced, and
the fatal termination may be accelerated by the interference. I have
removed tumours from the antrum maxillare, and from the frontal
sinus; but the parts became soon occupied by morbid growths of a more
formidable character than the preceding: the membrane and bone appear
to assume a disposition to generate such, and the fungous protrusions
cannot be kept down with escharotics, nor with the actual cautery: nor,
after free removal with cutting instruments, have escharotics, however
freely applied, any effect in counteracting the inherent disposition to
the disease, and preventing its recurrence.
The antrum, when filled with such tumours, is easily laid open. The
cheek is divided perpendicularly from over the inferior orbitary
foramen to the mouth, and the soft parts are dissected from off the
bone. The cavity may then be exposed by means of a small trephine:
but this instrument is scarcely ever required, the parietes being so
softened as to yield easily to the knife: pliers or cutting forceps may
be useful in enlarging the cavity. By the guidance of the finger, the
attachments of the morbid growth are separated with a blunt-pointed
bistoury; and a scoop is used to turn out the diseased mass. The
root of the tumour is then touched with a red-hot iron, and by this
implement, or by dossils of lint, the hemorrhage is easily arrested.
But such operations, considering the result of those which have been
practised, are scarcely justifiable.
It has been proposed for this disease to remove the tumour, along with
its investment—to separate and dissect out the superior maxillary
bone. It is a very severe operation, and one which puts the patient’s
life in imminent jeopardy, from profuse hemorrhage or constitutional
disturbance. In one case, the surgeon began the operation after having
tied the common carotid of the affected side; but, having made the
incisions of the cheek and palate, was obliged to desist, on account
of the violent bleeding: eight days after, the common trunk of the
temporal and internal maxillary was tied on the opposite side, and
the incisions repeated, but the result was the same; the growth
increased, and the patient perished. The disease is very insidious in
its progress, and has gained much ground before the patient becomes
alarmed and applies for surgical aid. The parietes of the antrum are
expanded and softened; the tumour has projected behind through the
tuberous process, upwards through the plate of the orbit, or inwards
to the nostril; and has contaminated by its presence and contact all
the neighbouring parts. Then removal of the maxillary bone, or of all
the bones in that side of the face, can be of no service. The disease
is seldom if ever seen by the surgeon early enough to admit of any
operation being practised with the least chance of ultimate success. At
a sufficiently early period, the removal of the bone—of the parietes
of the cavity containing, and from which the tumour has grown, must
without doubt afford a better chance, and is, in every point of view,
to be preferred to the old operation described above of what was called
trephining the antrum. In one case of soft and brain-like tumour
filling the antrum, and evidently commencing there, I succeeded in
removing the entire disease. The patient remained sound. I have more
than once seen the operation performed for this soft and malignant
growth of only some months standing; portions of the bone and tumour
crumbled under the fingers of the operator—the operation was harsh,
painful, and appalling—the cases hopeless. Execution of the manual
part is not attended with serious difficulty, and it can seldom be
necessary to tie arteries previously. To expose the bone, the cheek is
divided from the angle of the mouth, to the origin of the masseter,
and a second incision made from the inner canthus to the edge of the
upper lip near the mesial line, detaching the alæ of the nose from the
maxillary bone.
The flap of the cheek thus formed is dissected up, and the nasal
process of the maxillary bone and the body of the os malæ are divided
with a saw, or with strong cutting pliers. An incision having been
made through the covering of the hard palate, near the mesial line,
a small convex-edged saw is applied to the bone; and the alveolar
process is cut through by the pliers, after extraction of the middle
and lateral incisors. The bone is then pulled downwards and forwards,
and its remaining adhesions separated by means of the knife or
pliers. This last part must be accomplished rapidly, so as to reach
the vessels, and arrest the hemorrhage. During the progress of the
operation, cut branches of the facial and temporal are commanded by
ligature or pressure, and the violence of the hemorrhage is moderated
by compression of the carotids. After removal of the bone, the deep
vessels, branches of the internal maxillary, are secured either by
ligature, or by firm pressure with charpie or dossils of lint. The
facial flap is replaced, brought together over the charpie by which
the cavity is filled, and united by interrupted or convoluted suture.
Cures by such proceedings, in such cases, are reported; the patients do
not always die immediately after the operation; but there is reason to
complain of want of candour as regards the ultimate result.
The disease, it is said, has been arrested by ligature of the common
carotid; the allegation is not borne out by facts, nor is it easy to
discover on what principle the practice was adopted. Such a result
is not to be expected _à priori_, nor to be believed without farther
trial; and these trials are not likely to be made.
The superior maxilla is liable to become the seat of other tumours
beside the preceding. It may be occupied by fibrous tumour, commencing
in the bone, or in the alveoli. The tumour feels hard, and very often
not encroaching upon the antrum, is evidently circumscribed, and
presents a smooth and botryoidal surface. It has not that disposition
to involve neighbouring parts, hard as well as soft, but may remain
long without extending farther than the superior maxillary bone, and
occupying only a part of it. In such a case, excision of the maxillary
bone is warrantable, and ought certainly to be performed; for there
is no risk of the parts being extensively contaminated. I met with
one instance of it in the latter situation a good many years ago. The
patient was a female, about twenty-five years of age. The tumour was
of four years’ duration, and its origin was attributed to a severe
bruise of the cheek upon the corner of a table. The teeth had loosened
soon after the injury, and the disease commenced in the gums. When
she applied, there was a hard prominent swelling in the forepart
of the maxillary bone, and a firm tumour involved the gums on the
same side, and a part of the hard palate: the disease had made much
progress during the previous six months, but had evidently none of the
malignancy of the soft tumours which originate in, or early involve,
the cavity of the antrum: at first it had possibly been of the nature
of epulis. I removed the bone in the same way as already described,
and had the satisfaction to find the disease completely taken away.
The hemorrhage was restrained by compression behind the angle of the
jaw during the incisions, and not more than ℥iii. of blood were
lost. The tumour, when cut into, presented a homogeneous and fibrous
appearance; at one or two points, softening had begun, and a small
quantity of pus had been deposited. The external wound healed by the
first intention, and the internal cavity granulated kindly. The patient
remains perfectly free of disease, and bears little mark of so serious
a disease or of so severe an operation. Within the last four or five
years I have repeated the operation for this disease very often, and
with uniform success. The cases are recorded in the _Medico-Chirurgical
Transactions_, vol. xx., in the _Lancet_, and _Practical Surgery_, to
which the reader is referred for further information on the subject.
One of the tumours had attained an enormous size, and weighed nearly
four pounds.
[Illustration]
_Of Inflammation, Abscess and Ulceration of the Nose, and Cavities
connected with it._—Inflammation may be excited in the nose by external
injury, as a bruise, or fracture, or displacement of the bones. The
acute symptoms are swelling and discoloration of the integuments,
turgescence of the Schneiderian membrane, which covers the septum
narium and the turbinated bones, and consequent obstruction to the
passage of air. Unless active measures are pursued, abscess follows,
with great swelling and obstruction; and extensive loss of substance,
with deformity, may ensue. Unless the acute symptoms, the short
duration of them, and the rapid supervention of tumour be considered,
the swelling may be mistaken for polypus.
The septum suffers more than other parts of the nose, from the
concussion produced by a blow, and is in general more seriously
affected by the morbid action which is induced. Matter is effused
beneath the membrane, in one or both sides, usually in both, and
tumours are thereby formed, which project into the cavities of the
nostrils; when attentively examined, fluctuation is felt, and, if the
affection has existed for a considerable time, the abscesses are found
to communicate with each other, the septum having been absorbed or
necrosed at one or more points. An individual received a severe blow
over the extremity of the ossa nasi, and a slight wound was produced.
The breathing soon became obstructed, by swelling in the nostrils, and
great pain in the part was complained of. A large tumour formed on the
septum, and completely filled the cavities; it was opened, and a great
quantity of matter evacuated. The septum was destroyed by ulceration to
a considerable extent, and a slight falling down of the middle of the
nose followed. Such cases are of common occurrence.
Independently of any vice in the constitution, ulceration of the
nostrils may be induced by injury, and proceed until great ravages
are effected, if the treatment be not properly conducted. A young
gentleman, playing at ball, was struck accidentally on the nose with
the flat part of his companion’s hand. Inflammation took place,
externally and internally, and the passage of air was obstructed,
abscess formed, and the matter was evacuated spontaneously; extensive
ulceration ensued; the cartilage and bone became affected, portions of
them separated, and a bloody fetid sanies flowed from the nostrils.
All the cartilaginous and part of the bony septum were destroyed; the
morbid action ceased after having continued for a long time; but the
organ was curtailed, sunk on the face, and altogether much deformed. In
this case I first proposed, and some time afterwards performed for the
first time, the operation for the formation of a new columna nasi from
the lip.
The alæ, as well as the septum, may suffer from external injury, indeed
the whole cartilaginous part of the nose may be destroyed.
Incited action must be subdued by abstraction of blood from the
external parts, or from the Schneiderian membrane, leeches being
applied in sufficient numbers, and repeated. Should suppuration not
be prevented, the abscess, particularly when internal, must be early
opened; the surgeon is, perhaps, somewhat to blame, if the patient,
having been under his care from the first, sustains any deformity. If
abscess has formed on both sides of the septum, each must be opened
freely; afterwards hot fomentations are to be used, and the cavity
should be frequently cleansed by the injection of a bland and tepid
fluid.
Intractable ulceration of the nostrils is often induced by trifling
irritations or injuries in constitution, either originally unsound, or
rendered so by imprudent conduct; slight blows on the prominent part
of the organ produce swelling with discoloration, and that is followed
by abscess and ulceration. Internal ulceration is frequently caused
by the continued use of snuff, or the presence of other irritating
matters,—by irritation communicated from diseased gums or alveoli, or
from decayed or crowded teeth, particularly the incisors of the upper
jaw—by stumps in any part of the mouth, or the pivoting of artificial
teeth on them—or by introducing the dentist’s perforator, with a view
of destroying the nerve of a tooth. I have seen ulceration, and loss of
substance in the skin, membranes, and bones of the face, arising from
each and all of these causes.
The ulceration occasionally commences, even in young subjects, in a
wart or fissure on the integuments of the nose or upper lip; it thence
extends to the alæ and floor of the nostrils; the cartilages, and
even the bones, are destroyed; the discharge is thin, acrid, bloody,
and fetid, and the action is with much difficulty controlled. The
disease is met with of various degrees of severity and malignancy; it
may cease spontaneously, may appear to be arrested by constitutional
and local treatment, or, resisting all means employed against it,
may go on consuming portions of the face, both hard and soft;
destroying the nose, lips, and eyelids, and ultimately the bones
in their neighbourhood. Horrid cases are occasionally met with, in
which scarcely the vestige of a feature is discernible—the patient is
nourished, and life is often protracted for a long period, by food
conveyed over the root of the tongue, through funnels or tubes. _Noli
me tangere_, and _lupus_, are names applied to the advanced stages of
the disease.
_Ozœna_, which denotes the internal ulceration of the nose, or rather
the discharge indicating such, is generally of long continuance.
The discharge is at one time profuse, at another scanty; sometimes
it ceases almost entirely, but the accompanying fetor, of a most
disgusting nature, is still perceptible on approaching the patient,
or coming within the influence of the air expired over the diseased
surface; the stench is particularly offensive when portions of bone
are separating. The bones may die either from inflammatory action in
them running high, or from being uncovered and deprived of support by
ulceration of the investing membrane. In many cases, the disease is not
arrested till the cartilaginous and bony septum, the turbinated bones,
the hard and soft palate, and frequently the alveoli, are completely
destroyed. The patient, if he live, is in a miserable plight;—his
countenance is deformed and ghastly; the situation of the nose is
occupied by a large dark and foul sore; the discharge is profuse and
weakening; the expired air is as a pestilence to himself and those
around; speech is almost unintelligible; breathing is difficult;
the strength is gradually exhausted; and the spirits sink under the
harrowing impression of misery. All these ills result more frequently
from the injudicious employment of mercurial preparations than from
any other cause. In almost every instance, the predisposition to such
frightful ulcerations has been induced by the use of mercury, and can
readily be traced to it. Exposure to atmospheric changes, during or
after the exhibition of mercury, may render the mucous surface and the
coverings of the bones more susceptible of the disease; that medicine
may be given with the utmost precaution, but for long after the
constitution cannot shake off its influence; and too frequently more of
the poison is administered for disease produced by it. Ulceration of
the tonsils, and other parts in the fauces, often coexist with disease
of the nostrils.
Ulceration of the nostrils is arrested with difficulty. It cannot
be expected to cease till dead parts have separated, become loose,
and fall out, or are removed by art. Portions of the bones, forming
the floor of the nostril, can often be removed, when dead, through
ulcerated apertures in the palate; whilst others are brought away
through the nostrils, there being generally sufficient space
allowed for their discharge—the nasal cavities being laid into one
by destruction of the columna, and more or less of the septum.
Occasionally the ossa nasi, or parts of them, escape through an opening
in the superimposed integuments; sometimes they cannot be discharged
otherwise, as in the following case:—Matter had come to the surface
over the nasal process of the frontal bone, an incision was made for
its evacuation, sequestra were found loose, and some extracted; one was
pushed down with the view of pulling it through the nostril, but this
was found closed from the effects of small-pox.
Various applications to the ulcerated cavities are employed. Injections
of spirituous and aromatic lotions are used to wash away the discharge
and correct the fetor, as diluted tincture of myrrh, or of aloes,
a lotion containing a proportion of kréosote the sulphate of zinc,
solutions of the chlorides of lime or soda, &c. Applications, soothing
or stimulant, are made to the exposed sores according to their
appearance and disposition. When the ulcer is of an angry and irritable
aspect, it is to be touched lightly with the nitrate of silver,
in substance or solution, and then covered with a bread and water
poultice. Fowler’s solution of arsenic is useful in some cases, when
the object is to clean or destroy the surface; this is also effected
by a slight application of the potass. A very manageable and efficient
escharotic is the chloride of zinc. It is mixed with an equal quantity
of dried plaster of Paris or flour, and made into a paste, with a few
drops of water for application. Black wash sometimes agrees well, as
also a liniment of olive oil and lime-water, with citrine ointment
(three parts of the former ingredients to one of the latter), or the
sulphate of zinc lotion. When the sore is very indolent, showing no
signs of granulation, it may be touched occasionally with spirit of
turpentine, either pure or combined with alcohol, and afterwards
covered with an ointment composed of ung. ceræ and spir. terebinthinæ;
under this application ulcers often heal, after having resisted all
others. But nitrate of silver applied gently, and repeated at the
interval of two or three days, will, in the majority of cases, be found
the most efficient remedy, combined with the simple dressing of tepid
water. Constitutional treatment must not be neglected. When the disease
cannot be traced to mercurial action, small doses of the bichloride
of mercury are allowable when excitement is required. The arsenical
solution given internally sometimes produces good effects. In foul
internal disease of the nostrils with cachexia, no medicine exerts so
beneficial an influence on the general health and local disease, as
sarsaparilla, exhibited either in decoction, in extract, or in powder.
Loss of substance, from ulceration or injury, is repaired by surgical
operation. A portion of integument is borrowed from some other part,
and by the adhesive process is made to cover and supply the deficiency.
Such operations were contrived and practised by Sicilian and Italian
surgeons some centuries ago, and were revived in our day in Germany.
The integument was borrowed from the upper part of the arm; it has
sometimes not been applied immediately, but detached gradually, and
allowed to thicken, to change its consistence, and to become more
vascular, previously to its adaptation to the mutilated organ. When
considered sufficiently prepared, it has been shaped so as to fit
accurately, though still remaining attached at one point to the arm;
the cicatrized edges of the deficient parts should then be made raw,
and the new substance affixed by suture; the original attachment is
preserved entire, and the patient kept in a constrained position—the
arm and head being approximated and bound together by apparatus—for
many days, till union occurred. Then the flap is separated entirely,
and the new nose moulded into its proper form, by subsequent paring and
compression.
The Rhinoplastic operation, introduced from India—where from time
immemorial it has been practised by one of the castes—has superseded
the preceding, and is variously modified. It is less difficult in
execution, not so liable to failure, and more easily undergone by the
patient. The same preparation of the flap is not required, though
it is said that the Indian operators are in the habit of previously
pummelling, with the heel of their slipper, the integument to be
used for the new nose, so as to excite the circulation, and produce
thickening; from the similarity of texture in the integument of the
face, its application to the new situation is not much observed.