Elements of Surgery

by Robert Liston

Removal of the local cause, and mild antiphlogistic measures, are usually sufficient to effect resolution, and put a stop to the disease. General bleeding will seldom be required; blood is abstracted locally, either by scarifying the internal surface, or by applying leeches at the angle of the jaw. Fomentations afford much relief, and may be applied either externally, or internally by inhalation of the steam of water, or of water and vinegar. The greatest benefit is experienced from this remedy during the early stage, it being then employed either to promote salutary effusion and effect resolution, or at a later period to forward the secretion of purulent matter. At the same time, antimonials, purgatives, warm drinks, diaphoretics, and the pediluvium, are not to be neglected. In the relaxed state of the parts, after subsidence of the violent symptoms, stimulating and astringent gargles may be used with advantage.

But in neglected cases, or those originally violent, suppuration, sometimes extensive and dangerous, occurs in the cellular tissue, betwixt the pillars of the soft palate, or betwixt the layers of the velum. The swelling thereby formed may be so large as to impede the passage of air by both the mouth and nostrils. The mouth is opened with difficulty and pain; deglutition is seriously impeded, or altogether impracticable; the voice is weak and indistinct; and the countenance is swollen and discoloured. Life is endangered by the risk of the purulent matter bursting out suddenly during the painful and laborious efforts at respiration, and escaping into the air passages; fatal results have thus taken place, and to prevent such the abscess should be opened early. When the swelling is large, and attended with alarming symptoms, the matter is most conveniently evacuated by a flat and long trocar and canula. If the abscess be small, and the breathing not affected, there will be no danger in allowing the collection to burst spontaneously. Suppuration may also occur in the external glandular tumour, or in the surrounding cellular tissue. When sloughing to any extent takes place, it is in patients of an extremely debilitated habit of body, or when the affection is attendant on disease of a malignant character. Metastasis may take place to the larynx, to the trachea, or to the lungs, either spontaneously, or in consequence of repellent applications.

Chronic abscesses are occasionally met with in these parts, or behind the upper part of the pharynx, unconnected with disease of the subjacent bones. The matter must be evacuated as soon as its existence is ascertained. No great accumulation should be allowed to take place in any situation, far less in the immediate neighbourhood of important parts.[36]

Scarification of the tonsils and surrounding membrane is seldom required. A lancet concealed in a canula, with a spiral spring to withdraw its point, is used for this purpose, and for opening abscesses; but dangerous and fatal results may ensue, and have actually followed such incisions of these parts. A sharp instrument directed outwards, made to penetrate either by the rash thrust of an ignorant and careless practitioner, or by a hurried movement of an unsteady patient, may reach the common trunk of the temporal and internal maxillary arteries, or even the internal carotid. The sheathed lancet may be useful in the hands of such as are not habituated to the use of instruments; but scarification of the parts and puncturing of abscesses can be effected safely by a straight, sharp-pointed bistoury, covered with a slip of lint to within three-quarters of an inch of its point. The patient’s head is steadied by an assistant, the point of the instrument directed backwards, not at all outwards, and its edge upwards so as to avoid wounding the tongue, which is also to be kept out of the way by the forefinger of the left hand.

New formations about the isthmus faucium are rarely met with. Small warty excrescences, and small pendulous, fatty, or polypous tumours, are occasionally seen. These, if productive of inconvenience, can be easily removed by cutting instruments.

Enlargements of the uvula and tonsils are common, impeding deglutition, and producing indistinct and burring articulation. If large, respiration is interfered with.

Elongation and Enlargement of the Uvula attends inflammatory attacks in the fauces, but may continue for a long time afterwards. The organ is increased in volume, both in length and in breadth, from interstitial deposition of new organised substance, and from unusual vascularity. The inconvenient size produces nausea and cough; it is even said that the tumour has, in some instances, got entangled in the rima glottidis, suffocating the patient, or at least giving rise to the most alarming symptoms. In some cases the elongation appears to have kept up cough and expectoration for months or years.

The parts may be touched with a bit of sponge, dipped in the tinct. muriatis ferri; but a more useful remedy is the powder of alum, applied either on a spatula, or by insufflation. Astringent decoctions, or solutions, are of little use. But in cases of large and long continued enlargements, the swelling cannot be expected to subside under such treatment, and recourse must be had to curtailment by cutting instruments, of which the best for this purpose are long blunt-pointed scissors and forceps, with hooked points. The patient is made to open his mouth wide; the surgeon then introduces the instruments into the month, and watching an opportunity when the uvula is nearly stationary, suddenly seizes and clips off a sufficient portion. This is followed by instant relief.

Frequently an œdematous swelling of the uvula, of a crystalline appearance, resembling a large grape, accompanies ulceration in the neighbourhood; puncturing of the part, and attention to the cause of the affection, are sufficient for the cure. When the bloodvessels of the uvula are in a state of chronic enlargement, scarification is also employed with advantage.