Elements of Surgery

by Robert Liston

It is unnecessary here to treat of the emetics which act most quickly, or which are most proper in different cases, nor of antidotes for various poisons. Many stomach-pumps have been contrived, and their merits have caused much rivalry; but they are all constructed on much the same principle. People, too, seem to indulge the inventors by swallowing deleterious substances much more frequently than before. There has been a demand for cases of poisoning, and the supply has kept pace pretty well with the demand. Now-a-days twenty seem to attempt suicide by poison for one that did so long ago.

Most vegetable narcotics—those which do not act with great rapidity, can be removed mechanically; but some of the mineral poisons are heavy and difficult of solution, and are not so readily extracted. Read’s apparatus appears to me the simplest and the best, for this and various other purposes. Ample directions for its use are given along with the instrument.

Inflammation and Abscess of the Ear are either deep-seated, or confined to the external meatus. Suppurations in the internal parts—in the cavity of the tympanum, or in the mastoid cells—are often attended with the most violent symptoms, excruciating pain, fever, delirium. Such are highly dangerous in their consequences. Collections nearer the surface, under the membrane lining the meatus, are, though not so dangerous, also attended with great suffering and severe constitutional symptoms. The disease may occur at all ages, but is most common in children during dentition; in them it is often accompanied with convulsions and head symptoms, leading to a suspicion of hydrocephalus being established. The symptoms are all much relieved on the occurrence of copious purulent discharge.

Suppuration in the organ of hearing often follows eruptive diseases; and both ears, or one, may continue to discharge for a long time. There is always more or less derangement of the functions of the parts. When the disease is external, perhaps hearing may not be much affected; but when, as often happens, the ossicula, nervous expansions, membrane, parietes, are all destroyed or injured, hearing is lost, or rendered at least very obtuse. Purulent discharge often continues for the rest of the patient’s life, at one time scanty, at another profuse, and preceded or accompanied by inflammatory symptoms. Openings form over the mastoid process, communicating with the cells; and these are often connected with abscess betwixt the dura mater and pars petrosa of the temporal bone. Abscesses, too, of the middle lobe of the cerebrum, or in the cerebellum, are sometimes evacuated through the meatus auditorius. In all cases, but in the last more particularly, the patient suffers extremely on the discharge being suppressed, and is again relieved on its recurrence. At length, fever and delirium may supervene, terminating in coma and death; I have dissected many who have perished in this manner. Or, after long-continued discharge from the meatus, perhaps with paralysis of one side of the face, a soft tumour of the dura mater will be found lying over the pars petrosa, having caused extensive absorption of the bone, and exposed the semicircular canals, cochlea, tympanum, &c., filled with purulent matter. Abscess of the tympanum itself discharges long; and large, flabby, soft granulations fill up the meatus, very different in appearance from the solid tumours which sometimes occupy that situation.

Ordinary earache—inflammation extending along the meatus externus, and confined to the lining membrane—will be relieved by leeching behind the auricle, and by assiduous and regular fomentation afterwards. But suppuration is seldom prevented. The abscess may sometimes be opened, with great relief. If deeply seated, the parts are soothed by fomentation and poultice, till spontaneous evacuation of the matter occurs; this is then to be washed away, from time to time, by the injection of a warm and bland fluid; the abscess gradually closes, and the discharge slowly disappears. In cases of long-continued discharge, it is generally impossible to ascertain from what depth the matter comes, and there is always great risk in using means to arrest its flow. The patient must submit to the annoyance. The discharge can be moderated, or altogether suppressed, by injections of astringent salts, but the practice is unsafe, and in most cases unwarrantable. The parts are to be kept clean by frequent ablution with tepid water, lime water, or other bland fluids; and cotton or wool may be worn in the meatus to take up the discharge, and prevent bad effects from cold. Discharge from the external meatus, and about the auricle, is often kept up by irritation in the mouth, in both children and adults; this should be looked to, and the offending cause removed, if possible.

Foreign bodies are frequently lodged by children in the meatus auditorius externus—peas, beads, shells, shot, pins, &c. By awkward attempts at removal they are pushed deep into the cavity; and the membrane of the tympanum is sometimes broken, as indicated by effusion of blood, and swelling of the parts. Violent inflammatory symptoms may be caused by such substances, and will be seriously aggravated by unsuccessful attempts at extraction. Sometimes they are allowed to remain for days or weeks; in such circumstances seeds swell, separate, and begin to throw out a germ, thus fixing themselves more firmly in the passage. They are easily removed at first, by a small silver scoop, of convenient size and form; and even at a later period, a determined, though not forcible, attempt with the instrument will be followed with success. The scoop is gently and gradually insinuated betwixt the membrane and foreign body; and on its handle being then raised the body is extruded. It is seldom that any excitement follows extraction by this method: but if large and powerful instruments be introduced, and force applied, the parts may sustain severe injury, and troublesome consequences ensue: indeed such proceedings have proved fatal.

Foreign bodies are also occasionally impacted in the nostrils: the procedure above described is to be adopted. Sometimes they are discharged by the posterior nares during attempts at extraction.

Polypus of the meatus auditorius externus is generally of pretty firm consistence, pyriform, sometimes slightly lobulated and warty-looking; it adheres by a narrow neck to the parietes of the tube near the margin of the membrana tympani, is attended with slight discharge, and with deafness to a greater or less extent.

Extraction is the only means of cure. The body of the tumour is depressed and pulled outwards by the flat end of a probe slightly bent; delicate forceps are introduced gently, and passed up to the neck of the polypus, which is then firmly grasped; by combining slight twisting with gentle extractive force, it is readily removed. Or a flat scoop, with a sharp round edge, is passed along till obstructed, and by slight rotatory motion of the edge, the neck of the tumour is divided. After a day or two, a mild escharotic may be applied with the view of preventing reproduction; a bit of charpie sprinkled with the oxidum hydrargyri rubrum may be pushed up to where the tumour was attached, and the application may be repeated several times, one or two days intervening. Even after this the tumour sometimes returns, again rendering extraction necessary.