OBSERVATION concerning a fungus in the maxillary sinus by M. PLAIGNAUD, surgeon at the Hotel Dieu |
Jacques Thibault, born at St Aubin, in Normandy, aged 22, with a strong constitution, soldier of the Viernnois regiment, felt in 1785 deep pains in the maxillary sinus, following a strong contusion on the right side of the nasal spine; pains, which had been present for a long time, without, apparently any external changes on his cheek. In September 1789, the cheek bone began to rise, the eye became prominent, the eyesight became weaker from day to day, the nasal canal became narrowed and the epiphora [excessive flow of tears] followed. This soldier unable to continue with his duties, went to the hospital in Lille, Flanders; from what he said, the disease was considered as an ozena [atrophic rhinitis] of the maxillary sinus. After having extracted all the molar teeth on the same side, the alveolar process was perforated: instead of pus, only a fungal tumor was found, the extraction of which was tried; but the attempt to remove the tumour was halted by heavy bleeding. This was controlled by rolls of linen lint sprinkled with collophane. The opening wound that had been made speeded the growth of the fungus, which soon extended in the mouth, where it no longer met resistance. Six days after this first attempt cautery was applied which slowed down the progress of the tumour, without stopping it. It continued to grow and the 22nd day after cauterization its volume was so considerable that it filled part of the mouth and the entire right nostril. It seemed best to deal with the part of the fungus which extended into the nose. The ligature was made with a brass wire tightened several times by twisting with pliers. These torsions were very painful, the sick man lost patience, he did not accept them any longer, and left the hospital to go to the Hotel-Dieu in Paris where he was admitted on December 12, 1789. At this stage, he could only open his mouth with difficulty; the right eye ball was prominent, the eyesight was weak; tears dropped continually on to his cheek; the nostril was dry; and the cheek, together with the nasal spine, very high. As regards the fungus, it pushed down the soft palate and the alveolar process, and occupied such a great part of the mouth and the nasal fossae, that swallowing and breathing were considerably reduced. The ligature that had been passed through the nose, was still there, and produced excessive pain each time it was touched. The length of this disease, its complication, the lack of success following the means used, the spread and hardness of the fungus, left much doubt as to the success of a new operation. However, the heartfelt and frequent request of the patient, the courage and resolve he showed, determined the course of action. The patient, sitting on a chair was operated on in the following manner. An assistant, forced open the mouth with a key, the surgeon made a semicircular incision with a one sided cutting lancet from back to front, starting from the soft palate and reaching the under part of the hard palate. He made a second incision on the outer side of the tumor between the buccinator muscle and the alveolar process, of the same extent as the previous one. Then grasping the tumor with his thumb and forefinger, he pulled it away and then continued the dissection from inside outwards and from back to front. Blood came out as expected, in such quantity that the patient emitted mouthfuls. It was stopped by rolled linen lint that was taken out soon after the actual cautery, under white heat. Cautery was applied several times, not only to control blood bleeding but also to destroy what was left of the fungus. The cavity, left by the extrication of the tumor, was followed by narrow epiphora which was then filled with rolled linen lint sprinkled with collophane and bound together by using a frond. The whole cheek was covered by a poultice to prevent swelling and reduce irritation due to the cautery. The patient suffered little for the rest of the day; but in the evening, a light fever appeared, increasing during the night. The next day, swelling appeared and the fever was intense. On the third day, part of the rolled linen was taken out and replaced by soft linen. Swelling had increased a little, inflammation and thirst were reduced. The fourth day, only the soft linen lint that had been introduced the previous day was taken out; but in fear of a new hemorrhage, the linen lint that still remained below, was left. The fifth day, the fever disappeared. The sixth day, the swelling was slightly reduced; the patient had no more fever: to help him recover strength he was given creamed rice that he swallowed with difficulty. The seventh day, suppuration detached the shredded linen and the scabs which had been produced by the cautery: their loss was followed by a new hemorrhage that was stopped as before, with shredded linen lint sprinkled with collophane and supported by binding the jaw. The next day, all the lint fell off by suppuration, but without bleeding. The eleventh day, suppuration had reduced; the patient suffered little: he frequently gargled with rose petal honey. The fifteenth day, tears began to return to their natural path the eye went back into the orbit. Suppuration had totally stopped: gargles were discontinued. At that time, M. Desault was convinced that the ligature, which had been placed in the nose one month before, was useless and therefore tried to get it out. But the pain involved made him give up. But having noticed that the patient felt better when this ligature was been pulled forward and being assured that following a continuous long traction, could achieve the same effect as tightening the ligature, he supported the extension of the ligature on the cheek by using a sticking plaster. This expedient proved a success after fourteen days. The brass thread came off. A portion of fungus reappeared the 30th day, and after six days reached the size of a pigeon egg; it was then was treated with a branding iron: the scab fell off three days after. As the swelling of the cheek decreased slightly the patient suffered less, and was on the way to recovery. Nevertheless on the 25th day of this second application of the cautery, new fungus reappeared in the back of the sinus, towards the bottom of the orbit. This was cauterised like the others using several cauteries. The 18th day of this third cauterization, the cheek was practically back to normal; tears could flow normally through the nasal canal and the sight was as good on one side as the other. The 29th day, the patient said that he felt discomfort in his right nostril, and in fact a small fungus seemed to be growing from the soft palate. It was burnt with the branding iron introduced through the nose by means of a cannula. This fourth application of the cautery was the last. The fungal growths, burnt to their root, never reappeared. The walls of the maxillary sinus, where these vegetations had seemed to be implanted, were brought near one another; in place of this cavity, there was just a depression corresponding to the alveolar process. The patient was kept under observation for another month so as to make sure that no new fungus reappeared and until complete recovery: he left the Hotel-Dieu hospital 134 days after his entry. This soldier had borne the various cauterization with notable bravery; and one can say he owes his recovery as much his courage and readiness to cooperate as to the contribution of medical art. Translated by Dr CatherineKauffmann-Lacroix, of Poitiers and her father, with contributions from Professor John Pickstone, Wellcome Professor of the History of Medicine, University of Manchester The article from the book can be found on this website; |