Elements of Surgery

by Robert Liston

No satisfactory cause can be assigned for the appearance of either the benign or malignant form of polypus.

The nostrils can be readily cleared of benign polypi, but seldom completely, as already stated, by one operation: in several cases, wherein only one or two tumours obstructed the cavities, I have had no occasion to repeat my interference. If the attachments are broad and extensive, a small curved blunt-pointed bistoury, or probe-scissors, may be employed for their separation. Sometimes the tumours can be pushed off by the finger, or by a probe with a blunt and forked extremity: then they either are blown out by the patient, or fall into the posterior cavity, thence into the pharynx, and are coughed up or swallowed. In cases such as are usually met with, forceps and a small vulsellum are the best instruments. The forceps should be about half the size of those generally used or sold by cutlers as polypus forceps. The patient is seated facing a good light and the body of the prominent tumour is laid hold of by the vulsellum; the forceps are then introduced, with the blades expanded, and carried backwards so as to reach its neck, which is then to be firmly grasped by the instrument, and gently twisted, so as to separate its connexions with the membrane. No force, no jerking or pulling, is allowable. It may happen, even with the gentlest and most careful management, that a small fragment of bone comes away along with the tumour; but this generally can or should be avoided: the cure is not rendered more certain by such an occurrence, as has been supposed. One tumour being thus detached, the same process is repeated with the others, till the cavity is cleared so far as hemorrhage or the patient’s fortitude will admit. Both nostrils, if, as is usually the case, both are stuffed, may be emptied at the first sitting, so as to enable the patient to blow through them. When the tumours filling the passage to the throat have been removed, so as to allow the ready egress and ingress of air, and when the forceps can be passed along the floor of the cavity, and are expanded and shut without meeting any obstruction, examination is to be made with the finger. In those who have long laboured under the disease, the fissure between the cavities is so much expanded as to admit the little finger easily, and by it the situation of the remaining tumours is ascertained, and instruments guided to them.

After the operation the nostrils are stuffed gently with lint, to 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.