Fig. 480
Plugging the nares with Bellocq’s cannula. (Fergusson.)
It is, however, by no means necessary to have this special instrument in order to accomplish the purpose. A soft catheter may be passed backward through the nostril until its end appears in the nasopharynx, where it is caught with forceps and drawn into the mouth. Here, by means of a needle or knot, a piece of silk is fastened to this end. When the catheter is drawn out from the nose it pulls up after it and out through the nostril this bit of silk, to whose middle is tied a tampon, made of a sufficient amount of gauze or similar material, folded or rolled into the desired shape. By combined manipulation, as the silk thread is drawn upward and outward through the nostril, it pulls up the tampon into the nasopharynx, where it should be guided into its place by the tip of the index finger of the disengaged hand. If necessary this procedure is then repeated upon the other side, and thus a complete double tamponing can be effected. If the procedure be made difficult by the extreme sensitiveness of the part this can be overcome by local anesthesia. The tampon may be saturated with a weak adrenalin solution if desired. Ordinarily such a tampon can be easily disengaged and removed by again passing the finger up behind the soft palate and dislodging and withdrawing it, using curved forceps for the purpose of securing it. A tampon inserted for the control of hemorrhage should be left in situ for at least forty-eight hours, possibly longer. The case should be watched for a while after its removal, lest it might require re-introduction. This maneuver is made easier by fastening the tampon in the middle of a long piece of silk as described; one end being brought out through the nostril is tied to the other portion, which is allowed to come out of the mouth. The latter will provoke some discomfort, and patients should be cautioned not to disturb it, its purpose being explained to them.
Mulford, of Buffalo, has suggested a method of dealing with cases of epistaxis by injecting two or three drops of reduced adrenalin solution into the tissues at the base of the upper lip, in close proximity to the course of the arteries which pass upward on either side and supply the septum. The injection should be made in the fold of the mucous membrane just beneath the septum of the nose.
RETROPHARYNGEAL ABSCESS.
This has already been referred to as the product of tuberculous disease in the upper cervical vertebræ, or in the neighboring lymph nodes, or as the possible sequel of more acute infections occurring in the upper portions of the neck, proceeding usually from infected tooth sockets or other lesions within the nose and mouth. Collections of pus in this location may be circumscribed or may be extensive and rapidly assume serious phases. A chronic abscess is essentially a tuberculous expression. Acute abscesses, either in the tissue behind the pharynx or to either side of it, may be seen in cachectic children and assume serious phases.
The first evidences in these cases are those of pharyngitis, but swelling and edema occur rapidly, septic indications become unmistakable, and, finally, almost complete nasopharyngeal obstruction may occur. The discovery by the palpating finger of a fluctuating swelling will make the presence of pus practically positive. If the operator be still in doubt he may use the exploring needle. The experienced practitioner will at once plunge the point of a knife into such a swelling, and, at the same time, plan his opening in such a way as to afford the best possible drainage.[48] For the purpose it may be necessary to have the patient in the position of down-hanging head, or, in extreme cases, the patient may be almost inverted in order that pus as it gushes forth may escape through the mouth rather than into the larynx or down the esophagus. The operation should be done without an anesthetic. The mouth may be opened with the O’Dwyer mouth-gag, or it may be forced and held open with the ordinary tongue depressor. When pus has travelled to such an extent as to give the case the importance and aspect of a deep cervical phlegmon, such as described in the chapter on the [Neck], then anesthesia is necessary in order that by external, combined with internal, incision, escape of pus and provision for drainage may be permitted.
[48] Nevertheless in one instance an eminent American practitioner thus hastily incised a fluctuating intrapharyngeal swelling and found, to his dismay, that he had opened a carotid aneurysm, the patient dying within five minutes.
Two dangers attend inexcusable delay in such acute cases—one is of suffocation from pressure or from sudden spontaneous rupture of abscess; the other is of invasion of large blood trunks in the vicinity and possibility of hemorrhage after erosion, either into the abscess cavity or directly into the outer world.