Elements of Surgery

by Robert Liston

Deafness is attributable to various causes besides those already mentioned. Accumulation of cerumen in the external meatus is the most common. The cerumen is often mixed with wool, and other extraneous substances, which the patient may have been in the habit of introducing as preservatives from cold, and thus a large and firm plug is formed, completely blocking the meatus. It is removable by the assiduous injection of tepid water, the best solvent of cerumen. The whole may not be brought away at the first sitting; but the injection must be repeated again and again, till the membrane of the tympanum is free. A powerful syringe is required. By the use of a speculum, the condition of the external tube and membrane of the tympanum can be ascertained. But it is perhaps unnecessary to enlarge farther here on this subject, for such is the division of labour in these days, that a distinct profession is founded on the operation of squirting water into the external ear; it is true that other operations are talked of by these Aurists, as they style themselves, but the advantage to be derived from any of them is often very doubtful. They talk of deafness as arising from a deficient secretion of cerumen, from dryness, or from eruptions in the meatus; and heating stimulant applications are poured in—oils, ointments, mercurial salts, acetic acid, garlic, &c., all combined. They even go so far as to recommend mercurials to correct the state of the general health, to improve or rectify the functions of the chylopoietic viscera, the assistant chylopoietic, and the whole of the digestive organs, upon derangement of which, say they, many cases of deafness depend. The fools who apply to such charlatans certainly deserve to have their pockets well drained, but ought scarcely to be poisoned by them.

It has been proposed to pass probes and tubes into the eustachian tubes, to reëstablish their continuity if obliterated, or dilate them if partially closed. No doubt deafness often depends on obstruction of this outlet from the tympanum, the requisite reverberation being perhaps thereby impeded. It may be closed by swelling of the lining membrane, by inspissated mucus, by destruction of its extremity from ulceration, by the cicatrisation of ulcers in the immediate neighbourhood, by congenital deficiency, or by pressure of neighbouring swellings, or of morbid growths, producing temporary or permanent obstruction. None but the first two causes could possibly admit of the use of the probe, and even then it can scarcely be required. By removal of the cause of such turgescence at the end of the tube, or in the neighbouring parts,—which can often be detected, being local,—by counter-irritation, &c., a cure is much more likely to be effected than by the introduction of probes. Not that the operation is exceedingly difficult; for, after practice on the dead body, a probe can readily be passed into the eustachian tube of the living from the nostril. The instrument is fixed in a handle, with its point slightly bent, and on the handle there should be a mark to show the direction of the point; the distance of the termination of the tube from the nasal orifice ought also to be marked. The instrument is passed along the floor of the nostril, and then its point is directed upwards and outwards, whilst the handle is pressed towards the septum narium. It has been proposed, moreover, to force a stream of cold and condensed air into the internal ear, and to apply ætherial vapours to the cavity of the tympanum. The attempts have been made on an extensive scale in all sorts of cases, and quite indiscriminately. This plan of curing deafness has been well advertised, and unblushingly puffed in scientific and other journals. Not one case of deafness in a hundred probably depends upon any affection of the eustachian tube: vitiated mucus cannot even be displaced by injection of air or other fluid, unless the membrane of the tympanum be ruptured; this has indeed been accomplished by the operation in question, and then the mucosity could only be forced into the cavity of the tympanum, so as, if possible, to make matters worse.

Nervous deafness, like functional amaurosis, may sometimes be relieved or even removed entirely by stimulating frictions, or the application of strychnine to a raw surface behind the auricle, and by attention to the general health.

Puncture of the Tympanum has been recommended as a remedy for deafness arising, or supposed to arise, from obstruction of the eustachian tube; but I believe it has not succeeded in above one out of twenty cases. The puncture is apt to close very soon; and though the hearing may be improved for a short time, the advantage gained soon disappears. The means of keeping the puncture open are not easily applicable; perhaps the most effectual is to touch the edges occasionally with pencil-pointed lunar stone. The puncture is generally made with a short-pointed trocar, such as is used for hydrocele. The canula is passed down to the membrane, and placed on one side of its centre, lest the long head of the malleus should be interfered with. The trocar is then pushed on gently, and should penetrate but a very short distance, for fear of injuring the important parts at the bottom of the cavity. By some a sharp-pointed probe is used, passed through a quill; or an instrument about the same size with the probe is made for the purpose, with a canula to fit. But these are by much too small; even the puncture with a trocar closes, notwithstanding the application of nitrate of silver. I have lately used a sort of punch, such as is employed for making holes in leather, of a pretty large size, and neatly made, with the edge very keen, and on a small stalk. This is introduced; and when obstructed, having reached the bottom of the canal, an attempt is made, with a rapid turn of the hand, to cut out a portion of the membrane. I have thus succeeded in improving immensely the hearing of one gentleman, enabling him to hear at four or five times the distance he could formerly. He had repeatedly submitted to punctures before I saw him; and, previously to the operation with the punch, I passed through the membrane a trocar, made large, and well-pointed for the purpose; but notwithstanding this, and the application of the nitrate of silver, I was unable to preserve the advantage gained longer than a very few days. In suitable cases, the operation is worthy of trial, being unattended with pain or any dangerous consequences. M. Fabricci has contrived a very ingenious little instrument for the purpose; by it the piece of membrane is fixed by a small screw, before being punched out.

Bronchocele is not rare in some districts of Great Britain, but unattended with the same peculiarities of countenance and mind as in some other countries.[39] The majority of those affected come from mountainous districts. The disease generally commences early in life, and females are more subject to it than males; indeed almost all who present themselves are females. The tumours are of various sizes, involving either the whole gland, or only a part. One lobe is usually in a state of greater advancement than the other. The swelling is for the most part soft and yielding, the integuments are thin and moveable, and large veins shine through them. It is unattended with pain, or any great inconvenience, though sometimes it equals in size the patient’s head, or nearly so, and then it is troublesome from bulk alone. In general, there is little or no obstruction to deglutition or respiration, and the health is not impaired. The tumour is always of slow growth, at length becomes stationary, and the patient gets reconciled to the deformity. Its structure is that of the simplest form of tumour, a genuine hypertrophy, and it is seldom that its action degenerates. It is often made up also partly of cysts containing serosity, or glairy albuminous fluid.

Internal remedies have been prescribed, with the view of arresting the growth, and promoting absorption of the enlarged thyroid—burnt sponge—muriate of lime—muriate of baryta, &c. The use of iodine, externally and internally, has in many cases been attended with beneficial effects. Tumours have diminished, and even disappeared entirely, during the employment of this medicine; but in others, the diminution has been either trifling or none. The insertion of setons has been strongly recommended; and many patients are said to have been thus cured. I have tried this plan in one case only; it certainly had the effect of diminishing the swelling; but for some time great trouble was experienced from bleeding, whenever the cord was drawn, and the patient afterwards became much weakened by the profuse discharge. The proposal to tie the thyroid arteries, for the cure of bronchocele, has been put in practice, but without a favourable result.[40]

Extirpation of such growths has been repeatedly attempted; but the patients, almost without exception, have perished from hemorrhage, under the hands of the knivesmen. The immense supply of blood afforded to the gland in the healthy state must be kept in mind, as also the enlargement of the vessels proportional to the increase of the part. Not arteries alone, but enormous veins, are to be encountered. The tumour is in the vicinity of important organs, and of the trunks of large vessels and nerves, and probably has become attached to them. In short, the operation is attended with such risks, with so absolute a certainty almost of fatal result, as not to be warranted under any circumstances, far less for removal of deformity only.

Enlargement of the isthmus alone gives rise to more severe symptoms apparently, and may warrant an attempt at removal; but this can scarcely be accomplished altogether by incision. Such is my impression, and under this impression I proceeded very cautiously in a case of this nature with which I had to deal.—J. R., a rat-catcher, aged forty-seven, from the Highlands, was admitted into the Royal Infirmary. The isthmus of the thyroid gland was enlarged to the size of a goose’s egg. The tumour was extremely hard and irregular on its surface, but not painful when touched; it appeared to be adherent to the trachea, and did not admit of much motion. The voice was considerably impaired, and breathing much impeded, inspiration being difficult and attended with a loud wheezing noise. On making unusual exertion, even though inconsiderable, the dyspnœa was much increased; and on ascending a height, or even remaining for some time in a stooping posture, it amounted almost to suffocation. There was no pain or uneasiness in the larynx or trachea. The disease was of three years’ duration. A seton had been introduced, but effected no diminution, and rendered the tumour more dense and less moveable than formerly. I surrounded the lower part of the tumour by two semicircular incisions, and, dissecting cautiously beneath its base, detached it from its more loose connections, not interfering with the central portion and its connection to the trachea. During the progress of the dissection, the blood flowed most profusely from both arteries and veins, but was restrained by securing the former with a ligature, and compressing the latter with sponge. An armed needle was then passed through the centre of the tumour, as close to the trachea as possible, and its remaining attachment enclosed by the separate portions of the ligature firmly applied. Everything proceeded favourably. The tumour soon came away; the wound healed with a firm cicatrix, and in about a month the patient went home well. I met him by chance, in Aberdeen, twelve months afterwards, free of complaint, and breathing easily under all circumstances, his neck presenting no vestige of the tumour.

Glandular Tumours of the Neck, as formerly noticed, arise from various irritations; and some constitutions are more subject to them than others. The nature of the enlargement is dependent on the cause; it may be simple or malignant. Simple swellings often attain a large size; the lymphatic glands in both spaces of the neck, and on one or both sides, get immensely enlarged, the cellular tissue around is infiltrated with solid matter, and all matted together. Great deformity is produced; the head is turned with difficulty, and twisted to one side; often there is not much pain. After some time, the swelling becomes looser than before; its various portions separate, and gradually disappear; or the centre becomes soft, suppuration spreads extensively, and the surrounding hardness either goes off, or becomes partial.

Discussion of the swelling is to be promoted, and, if possible, the cause removed; and fomentation, friction, pressure, internal stimulants are to be employed, according to the state of the parts, along with what are called deobstruents, in the first instance. When suppuration cannot be arrested, the attention must be directed to prevent the integuments from being destroyed. With this view, the abscess should not be permitted to give way spontaneously, lest an opening be formed whose cicatrisation would cause deformity, and leave a stain on the race and generation. An artificial aperture must be made early; and in the upper and most exposed parts of the neck this should be in the direction of the folds, and small.