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AN ANALYSIS OF THE VALUE OF THE GALVANO
CAUTERY IN THE TREATMENT OF DISEASES AND GROWTHS OF THE NASO-PHARYNX.
By W. H. DALY, M.D.,
the Throat and Chest to the Pittsburgh Dispensary.
Much has been said and written laudatory of this method of treating diseases and growths in the naso-pharynx. Indeed, so favorable have been the records of experience, and so little has been said about accidents that are liable to attend its employment, that the danger might naturally be considered nil. Such impressions in the beginner might tend to indifference in precautionary measures, and lead unexpectedly to consequences unfortunate to both the patient and operator.
The few succeeding remarks, based chiefly upon practical experience, may serve to show that it is a remedy that requires much discrimination and care, and, while very valuable and to a great extent indispensable to the specialist in rhinal and pharyngeal surgery, yet it is one whose employment is followed by both local and constitutional symptoms, even when used with care, and, should accident or carelessness happen, may be attended with more serious consequences.
An experienced and able advocate of the cautery electrode, Dr. E. L. Shurley, of Detroit, Michigan, has recorded, in a paper read before the American Laryngological Association at its meeting in New York, in 1879, and published in the St. Louis Medical and Surgical Journal, January 5, 1880, “that in destroying a growth upon one of the turbinated bones with the cautery, he also by accident burned the opposite part of the septum nasi, which nearly resulted in permanent agglutination of the nasal passage.
Once in the writer's experience the accidental burning of the rim of the Eustachian orifice with the cautery electrode, while
removing a growth from the vault of the pharynx, caused otitis media of a serious character. And in another case otitis media purulentia was caused in the ear opposite from the nostril in which an operation was performed, and was attended with symptoms of so serious a character as to threaten the life of the patient. The severity of this accident has since served to make the writer watchful of any possibly unfavorable consequences following the use of the galvano-cautery. In the occurrence of this accident there was a wavering of opinion as to whether the inflammation had been conducted to the middle ear by a nerve or line of lymphatics, or whether the superheated air in the pharyngeal vault had entered the middle ear of the opposite side. The latter is the more probable. In another instance a slight cauterization of hypertrophied mucous tissue upon a turbinated bone caused facial erysipelas that nearly proved fatal.
Carl Michel, of Cologne-on-the-Rhine, a most enthusiastic advocate of the galvano-cautery, admits that some of his patients had a strong vertigo and fever the day after the operation, and that some of them had to go to bed. Ile notes, apologetically, for this method, that “ Meyer and Wenelt had inflammations of the middle ear, followed by suppuration in the patients operated on by them with the modified tonsillitome or ringmesser.”
It is not improbable that Carl Michel was induced to make the sittings of his patients shorter, viz., “ from ten introductions of the cautery electrode to four or five," by the events which he records on page 95 of his most valuable pamphlet, entitled Diseases of the Nasal Cavity and Vault of Pharynx, translated by Drs. Shurley and Yemans, viz.: A strong young man, upon whom he had operated with the galvano-cautery, had within two hours violent earache and headache, and in a few days perforation of the tympanic membrane and purulent discharge. In another case there was hard hearing upon the third day after the operation, with perforation and discharge from the ears.
Michel, with pardonable consideration for his favorite method, remarks, concerning the first case, that it was very doubtful whether the operation was the cause of these phenomena, since the patient had in an overheated condition entered the coupé of a railroad wagon, and sat beside an open window where a strong drauglit was blowing upon his ears. And, remarking upon the second case, he says during the same winter the patient under
went two more attacks of otitis media purulentia without any operation having preceded them.
If these accidents admittedly occur in the hands of the experienced and skilful advocates of the galvano-ciutery, then it is fair to presume they will occur no less often in the bands of the inexperienced; and the conclusion must be that it is a remedy fraught with more or less danger to important adjacent organs, and should be used with caution and a full knowledge of the possibility of accidents following its use.
The writer has used the cautery a great deal, and, with the accumulation of experience, has grown to regard it as a valuable remedy, that requires much judgment and care in employment in the naso-pharynx, and to consider its use not always unattended with danger both local and constitutional. He was observed that in about fifty per cent. of the cases in which the galvanocautery is used in the nasal cavities for the reduction or destruction of new growths, there are local and constitutional symptoms following:
The word reduction is used because the writer has observed that the electrode, heated to a cherry-red, and applied to small adenoid growths, will hasten their reduction or absorption, while at the time of application there will apparently be no destruction of growth whatever, or other change than an increased redness of the part, as though it were merely irritated, and for three days following there will be swelling and increased redness in the growth, after which it pales, softens, and absorbs rapidly, leaving no scar or other trace of its former existence.
The immediate local symptoms will depend much upon the locality of the application of the heated electrode; for instance, when applied upon the anterior ends of the middle turbinated bone, a pain will extend into the eye of the same side, and if applied further back the pain will extend into the ear of the opposite side. More than once patients have been observed by the writer to quickly place one hand upon the eye of the same side on which the cautery electrode was being applied, while the other hand was placed upon the ear of the opposite side to deaden the pain produced.
When operations are made further back, the parts are found immediately more insensitive.
Constitutional symptoms may supervene within two hours, or be deferrel for twenty-four, thirty-six, or forty-eight hours after
the operation, such as actual fever, attended with increase of temperature, headache, faceache, soreness in the calves of the legs and muscles generally, creeping chills and loss of appetite, paleness of face and torpidity of the bowels. This condition may last for five or seven days, and then subside.
During this time the patient will insist that he has caught cold; and follicular tonsillitis, with swelling of the posterior pillars of the half arches, may be present to confirm his suspicion. But operations at subsequent times, with every precaution, will be followed by the same chain of symptoms, to convince him that not taking cold, but the operation itself, produced the depressing effect upon the system.
These symptoms do not follow so surely, nor are they usually 60 severe as to make it necessary to warn the patient that they will follow; but they should never be unlooked for by the operator, and every precaution should be taken by him to avert their occurrence, and, should they occur, to meet them promptly to prevent destructive consequences.
In summing up the value of the galvano-cautery, it may be doubted whether it will ever become a popular instrument in the hands of the general practitioner, since its expense is considerable and its behavior often capricious. It has the advantage over other caustics that it can be carried to the part, and the current be closed, and the work done; while other caustics, such as nitrate of silver, caustic potash, etc., are liable to touch other parts, and the pain attending their use often lasts for twentyfour hours or more.
In the greater number of erectile, adenoid, polypoid, hypertrophic growths in the nasal cavities, the mineral caustics, carefully guarded, will do the work as well as the galvanic cautery, and are altogether less liable to be followed by serious local or constitutional symptoms, besides having the merit of readiness at little expense and trouble.
ON THE INTRODUCTION OF LIQUIDS INTO THE
EUSTACHIAN TUBE AND MIDDLE EAR.
By S. J. JONES, A.M., M.D.,
The question of safety in the passage of liquids into the Eustachian tube and middle ear is one that has interested otologists in no small degree. In this, as in other matters, doubtless the test of time decides the value of theories.
About the year 1800, Sir Astley Cooper advised and practised puncture of the membrane of the drum of the ear, in the belief that impaired hearing resulted, in many cases, from complete occlusion of the Eustachian tube, and consequent rarefaction of the air in the tympanum, and that admission of air to the tympanic cavity, through an artificial opening, would restore hearing:
At a later date, Horner, of Philadelphia, practised similar puncture of that membrave; but he went further than Cooper, and forced air, through the external meatus and an artificial opening thus made, into the middle ear, causing it to escape through the Eustachian tube into the fauces, with the double purpose of admitting air to the middle ear and of blowing accumu. lations of mucus from that cavity. Later, he forced in liquids in the same way, washing the abnormal contents of the tympanum through the Eustachian tube, serving to clear the middle ear, and to dilate the Eustachian tube.
Others seem not to have adopted the procedure, and it was lost sight of until about the year 1868 or 1869, when Ilinton, of London, revived it for the same purpose, and claimed for it great advantages in the removal of dried accumulation in the niddle ear, which the investigations of Toynbee had shown to exist more frequently, and to a greater extent than bad been supposed.
To remove such dried secretions, without puncture of the