—Local applications being of small avail in producing either condensation or resorption, the treatment of this condition is essentially surgical. With children an anesthetic is always necessary. With adults cocaine may be sufficient. The best position for the patient is that with the down-hanging head (Rose’s), as blood is not swallowed nor passed into the lungs, but may be removed as fast as it collects. The hemorrhage in these operations is generally profuse but of short duration.
Adenoids are removed either with a snare, the curette, or by special instruments constructed on the type of a tonsillotome, and having a concealed blade. The curette is also used as forceps. Two or three curettes and forceps are sufficient for nearly all purposes. In operating the instruments are guided entirely by the sense of touch and the operator’s knowledge of anatomy, for he relies upon his finger-tip for information as to whether the tissue has been completely removed or needs further attention. These instruments are used until the entire vault of the pharynx and its openings into the nasal cavities (choanæ) are freed from all hypertrophied tissue or excrescence. The posterior wall of the pharynx should be scraped until it is smooth. In addition the tonsils should be removed if it be necessary, while the lingual tonsil may be also removed with curette or forceps if it be involved. For a few moments there will be a free flow of blood through both nose and mouth. In some instances there will be indications for cutting away hypertrophied turbinates and removing nasal polypi. Hemorrhage, at first profuse, quickly subsides. A mixture of 1 per cent. cocaine solution with a little adrenalin is the best hemostatic for local use. The nostrils may be packed if the turbinate has been cut away, or the entire passage-way may be left open for the purpose of permitting the later use of an irrigating stream, by which blood clot may be washed away and antiseptics applied. While using and relying upon instruments for the greater part of this work there is no better curette for concluding the work than the finger-nail of the index finger. The finger being introduced recognizes the degree of relief afforded, and the finger-nail may be used to scrape away any remaining projecting tissue.
Various operators have devised formidable operations, varying from the temporary resection of one upper jaw to Cheever’s ingenious method of dividing and separating both upper jaws in one piece from the cranium, and thus exposing the nasopharynx from in front and above. Such operations are rarely performed.
Other neoplasms in this region are cysts and dermoids of congenital origin—those involving the original craniopharyngeal canal, and those produced from pharyngeal diverticula. These produce only the ordinary manifestations of tumor and are of pathological rather than surgical interest.
EPISTAXIS (NOSE-BLEED).
The escape of a small amount of blood from the nose, especially in childhood, is a common occurrence, and may occur in consequence of slight traumatisms or even spontaneously. The so-called nose-bleeding of children, then, is scarcely of sufficient importance to justify consideration here, nor would it were it not for the fact that it may become severe and even dangerous. Children in whom it frequently recurs will lose sufficient blood to become anemic, while the effect of its frequent occurrence may bespeak a depraved condition of the blood as well as of the tissues which permit of its escape. A history of repeated nose-bleed should prompt an investigation into the general condition of the patient as well as a local examination of the nasal passages, where some explanation may be afforded. For instance, a polypus may be found whose removal will then be indicated, or an exceedingly spongy and vascular area may be revealed, which will call for a touch of the actual cautery or the use of the curette.
Besides the frequent expressions of this kind in childhood, some of which may occur during sleep, there are other forms of nasal hemorrhage. A vicarious menstruation is known to assume this type, individuals thus losing blood every month. This is a rare but well-known phenomenon. A plethoric individual may suffer serious epistaxis at any time, and this may be beneficial unless it be too extensive. Nasal hemorrhages may occur with certain fevers. Individuals with a hemorrhagic diathesis are peculiarly liable to it, and it is seen in connection with purpura hæmorrhagica. When this occurs in the debilitated or dissipated it may be fatal. Thus epistaxis may terminate fatally in spite of all that can be done. This statement requires some explanation. The nasal cavity may be tightly plugged, but such plugging cannot be made permanent because of decomposition of products thus retained and their absorption, with consequent septic infection. Nasal tampons should be removed every day or two, for the purpose of cleanliness, although their removal is contra-indicated when the necessity for physiological rest of the part is realized. The treatment, then, of epistaxis may be trying, at least, and in rare cases will prove absolutely disappointing and ineffectual. I have even been compelled to tie the common carotid to save life.
Treatment.
—The ordinary nose-bleed of a young child will usually subside with the application of cold to the nose, elevation of the arms, or firm pressure upon the upper lip just below the nasal septum. It may be also checked by an irrigating stream of cold water, or by a spray of cocaine or weak adrenalin solution. A 5 per cent. antipyrine solution also makes an excellent styptic for the purpose. Within a day or two after a serious hemorrhage, after the remaining clots have been cleaned away, a thorough inspection of the nasal cavity should be made in order to reveal the source of the hemorrhage and permit local treatment.
Nasal hemorrhage may be subdued by plugging the anterior nares with strips of gauze, or, better still, after the introduction of a tube through which air may pass freely, and around which packing may be firmly inserted. The ordinary dry styptics should not be used, for they may produce such a crusting of tampons as to make it difficult to remove them. More efficient materials can be used in solution. No tampon should be introduced into the nostrils which is not tied with a ligature of silk in such a way that it may be by it more easily withdrawn, and, at the same time, prevented from going too far. If the source of the bleeding be in the anterior part of the nasal cavity anterior packing may be sufficient. The surgeon should not, however, be deceived by the apparent cessation of bleeding, which cannot escape through the nostrils under these circumstances, but may continue into the nasopharynx, the patient swallowing the blood as it trickles down. Inspection of the pharynx should be made after the use of tampons. A much greater degree of safety is afforded by posterior tamponing of each side of the nasal cavity, which is most easily effected by means of the little instrument known as Bellocq’s cannula, whose use is illustrated in [Fig. 480].