Elements of Surgery

by Robert Liston

Inflammation of the antrum maxillare is occasionally met with; but the surgeon is more frequently called upon to treat the consequences of this action in it. The symptoms of inflammation of the antrum are violent throbbing pain, referred to the part affected, to the temple, and to the teeth implanted in the alveolar processes that form the lower part of the cavity; the side of the face is swelled from infiltration of the soft parts, and the Schneiderian membrane of the corresponding nostril is generally observed red and swollen. The affection can frequently be traced to exposure to cold; it may be the result of external violence; but is usually an extension of disease in the sockets of decayed teeth. Unless active and early measures are taken to subdue the inflammatory attack, the antrum becomes distended by increased and vitiated discharge from its lining membrane. The swelling of the cheek becomes more apparent, since, to increased infiltration of the soft parts, enlargement of the cavity is

superadded. The enlargement of the side of the face, and the bulging into the orbit are seen in the accompanying cut. The membrane covering the small aperture through which the antrum and nostril communicate partakes of the general thickening, and thus no outlet is left for the accumulating fluid. The escape of matter from the nostril, on the head being turned to the opposite side, has been laid down as an indication of accumulation or abscess in the antrum; the statement is incorrect, and is a result of surgery being professed by those who have not practised it, but judge of morbid states and their signs and symptoms by the healthy condition of parts only. In the skeleton, fluid no doubt will run over from the osseous shell, in some positions of the skull; but it cannot escape from the cavity when covered with membrane, and that membrane subject to vital actions. In short, the symptom is not observable in the disease in question.[35] Extensive ulceration of the parietes of the antrum towards the nose may, perhaps, take place, as a consequence of the accumulation, and the matter may then escape by the nostril, if not allowed an exit otherwise; but such is not a common occurrence.

In general, the cavity is considerably enlarged before the matter comes to the surface. If not interfered with, it usually escapes through the sockets of decayed teeth, or, the anterior thin parietes being absorbed, it comes down by the side of the canine or small molar teeth, and is discharged slowly, so as to annoy the patient by its flavour and fetor, without the abscess being emptied, or a chance of cure afforded.

Accumulations of fluid sometimes takes place in this cavity, give rise to great enlargement of the sinus, and continue for many months, without pain or much inconvenience, and without any matter escaping. The bony parietes are attenuated, yield to slight pressure, and return to their original level with a crackling noise, such as is produced by parchment. The contained fluid is thin, greyish, and contains flocculent solid particles. In short, the antrum maxillare is occasionally the seat of chronic, as well as of acute abscess.

Cancerous ulceration sometimes takes place in the cavity; the matter is not long confined, the parietes soon soften, the teeth drop out, the alveolar processes disappear, and a large opening is formed, which furnishes a fetid, sanious discharge.

In inflammation of the antrum, carious teeth must be removed, blood must be abstracted from the neighbourhood of the affected part—leeches being applied to the gums, the Schneiderian membrane, and the integuments—and fomentations to the cheek should be frequently and assiduously employed. When the cavity has become distended with fluid—mucous, muco-purulent, or purulent—such must be evacuated without delay; and the opening must be of such size, and so situated, that the fluid may escape as soon as secreted. In removing diseased or crowded teeth opposite the part, an opening may be made from the extremities of the fangs having projected into the cavity; it is in a good situation, but cannot easily be made of sufficient size; an aperture of but small extent may be sufficient for the draining of an abscess in soft parts, but here the divided texture is unyielding, and the perforation must be free. Bad teeth are taken away with the view of abstracting a source of irritation which may give rise to, keep up, or induce a return of collection in the antrum; but extraction of sound teeth, to obtain an exit for the matter, is not warrantable. Even when they are extracted for a different reason, and discharge of matter follows, the surgeon must not be contented, but must make another and more efficient opening. The membrane of the mouth is to be divided on the forepart of the maxillary bone, immediately above the first small grinder, and a large perforator then pushed into the antral cavity; little force is required, for the parietes are soft and partially absorbed. The perforation should be of a size sufficient to admit the little finger; thereby a free and dependent exit is allowed for the concrete as well as the fluid matter. Curdy and very offensive stuff is sometimes found in great abundance in this cavity. If the discharge is very fetid, and long of drying up, and if there is an appearance of disease in the osseous parietes, injections into the cavity may be required, though seldom. They are occasionally useful in dislodging the atheromatous matter. In general the discharge gradually diminishes, the membrane of the antrum resumes its healthy condition and functions, and the aperture in its parietes is shut by a fine ligamentous substance.

Ulcers of Lips.—The prolabium is liable to ulceration from various causes; from long-continued irritations, as sharp corners of teeth, rugged tartar on the external surfaces of the teeth, the habitual use of a short tobacco-pipe; from external violence; from the application of acrid matter; or from an ulcerative disposition unconnected with external circumstances. The constant and free motion of the parts is prejudicial to healing, and consequently the sores often remain long open. Though ulcers on the lips are generally of a bad character, it does not follow that all are so. Many are simple; but these, after remaining long, are apt to degenerate. Others from the first assume malignant action, and unfortunately they are more frequently met with than simple and well-disposed sores. The malignant sore often commences in a warty excrescence which ulcerates at the base; the ulceration extends, the warty appearance is succeeded by ragged and angry fleshy points, the surrounding parts become indurated, and the stony hardness spreads. The appearance which the sore presents is that of open cancer, described at page 147, and represented on preceding page. The ulceration may either be limited in depth and extent to a small part of the lip, or may involve the greater part of the prolabium, and that without much induration. It is generally situated on the right side of the lower lip; sometimes in the angle of the mouth; the upper lip is rarely affected. I have removed a few malignant ulcers from this last situation. Sooner or later the lymphatic glands participate in the disease; a chord of indurated lymphatic vessels is felt passing over the jaw in the course of the facial artery, and the glands with which these are more immediately connected, soon enlarge and become hard. This disease, though by some pathologists said to be “improperly called cancer,” differs apparently in no respect in its progress, and is in all respects as malignant as the disease commencing in any other structure and in any other way. Indurated swellings over the jaw, lymphatic or not, usually depend on the labial disease; they in some instances increase very slowly, in others acquire such volume as to induce by their pressure on neighbouring parts alarming and dangerous symptoms at an early period. Without much increase of size they sometimes attach themselves firmly to the bone, and involve it in the disease. The malignancy seems to acquire fresh virus, the skin ulcerates with fetid discharge, all the neighbourhood is speedily infected, and the patient sinks slowly under the evil.

Simple ulcers of the lips may be made to heal readily,—by abstracting the exciting cause, preventing the motion of the lip by the restraint of a bandage, disusing the part as much as possible, and by employing such applications to the sore as are best suited to the character and appearance which it may present; but it must be borne in mind that all remedies can be of little service unless motion of the lip be prevented. Sores of a bad kind must be attacked early, otherwise no hope of success can be entertained. Escharotics are not to be trusted to; the knife is the only effectual means of removing the disease. When the sore does not involve much of the lip, the molar teeth having been lost, and the alveolar processes absorbed, the cheeks are thus rendered flabby and relaxed: in such circumstances, all the diseased part is taken away with facility, and the features are not thereby deformed, but rather improved. The part cut away resembles the letter V, the angle being towards the chin: this form of incision is preferable, on account of the diseased portion being chiefly in the prolabium, and the parts afterwards coming together very neatly and readily. The lip is stretched by the operator and his assistant laying hold of the prolabium on each side of the portion destined to be taken away; a narrow straight bistoury is passed through the lip, at the angle of the form of incision; and the operator, standing in front of the patient, makes the first incision towards himself, by bringing the knife up to the prolabium. He then takes hold of the part to be removed, and laying the edge of the knife on the prolabium at the other side of the induration, cuts down to the point where the instrument originally entered. The incisions must always be made far from the indurated parts. The edges of the wound are retained in apposition by means of convoluted suture, as formerly described. When the wound is extensive, as when a considerable part of the cheek is involved, approximation may be accomplished by a few points of interrupted suture, and afterwards the parts may be more securely and accurately fixed by convoluted sutures placed between the interrupted. When a large portion of the cheek is removed, as for disease which had commenced at the angle of the mouth and extended around, all the parts cannot be brought into contact, and some of the deficiency remains to be filled up by granulation. The neighbouring parts stretch, and the deformity that may be the immediate result of the operation in a great measure disappears after some time. In cases of superficial and malignant ulceration of great extent, no attempt can be made to bring the parts together after excision: great deformity, and almost total closure of the mouth, would be the consequence. The diseased parts must be freely removed (for this is the primary and essential part of the operation, all other considerations yielding to it), and the deformity will prove much slighter than might be supposed: granulations arise, and considerable reparation of the lost parts thence ensues. Still there is a risk of the sore, at first healthy and active, gradually assuming the nature of that for which the incisions were made.