CASE 9. Chart 12. H. R. 64. Gastric neurosis, moderate arteriosclerosis. This patient is markedly subject to nervous influences. I have taken his pulse for months without finding it below 90, often much higher. Taken by himself at home 72-75. He has a marked hypertonia, fluctuations in his blood pressure are very great as will be seen by referring to the chart. There are no cardiac signs and no urinary changes. The nitrites have a marked effect in lowering his pressure as will be seen from his chart.

I should like to remark again that these cases are shown simply to illustrate hypertonia and the effect of the nitrites on this condition.

A NEW AND SAFE METHOD FOR THE SUBMUCOUS REMOVAL OF THE DEFLECTED BONY SEPTUM.

BY

OTTO GLOGAU, M. D.,

Otologist, German Odd Fellow Home and In-
fant Asylum; Oto-Laryngologist, Y. W. H.
Association; Chief, Ear, Nose and
Throat Dept., Sydenham Hospital,
O. P. D., Oto-Rhinological Sur-
geon, Ophthalmic and
Aural Institute and
Mt. Sinai Hospital,
O. P. D.

New York City.

In the infancy of rhinology, when the head mirror was not yet used for diagnostic purposes, only those forms of nasal ob

structions were attended to whose causes could be recognized with the naked eye. Immense polypi or very large hypertrophies of the inferior turbinates, when protruding from the nostrils, were operated upon, whereas the pathological changes of the inner nasal structures were totally neglected, not only from a diagnostic but also from a therapeutic standpoint.

An old physician of the pre-rhinological era, told me how he at that time treated a "stuffed up nose." He simply pushed his sharp spoon into each nostril and curetted the nasal cavities to such an extent as to be able to freely bring his instrument backwards to the pharyngeal wall. When we take into consideration that anesthesia, both local and general, was not yet resorted to, we must look upon this "treatment" as a rather brutal and unscientific method to relieve nasal obstruction, especially when the latter happened to be caused by a deviation of the septum. Heretofore the deviation of the cartilaginous septum-(that of the bony septum not yet having been known) was regarded as a noli me tangere, until there was invented a very ingenious instrument, by which a considerable part of the deviated portion was punched out, leaving a large perforation with all its accompanying ill effects.

When the use of reflected light gave a better view of the interior of the nose, the methods of dealing with the deviations of the cartilaginous septum became more rational. The above method was soon succeeded by a modification, in which a more or less rectangular piece of the cartilage was removed together with its mucous lining, with the idea of correcting the deviation by having the gap thus formed filled up by pressure through bilateral packing,

causing an approximation and eventual union of the edges.

The next popular method of straightening the cartilaginous deviation consisted in making a horizontal or vertical incision into the cartilage and forcing one part to overlap the other. A similar idea is the principle of the ingenious Asch operation, in which longitudinal and horizontal incisions were made into the cartilage by means of very strong cutting forceps; the overlapping parts were expected to unite in a straight line by the pressure of nasal splints which the patient had to carry in his nose for several weeks. Except for the sawing or chiseling away of bony spurs, the deformities of the bony septum have been perfectly neglected until recently when the submucous resection of both the cartilaginous and bony septum proved to be a rational treatment, not only for the former but also for the latter.

While the number of instruments on the market for operation on the nasal septum. are very numerous, yet in the large majority of cases a very small armamentarium will answer all purposes. The instruments ordinarily employed by the writer are a nasal speculum, a scalpel, a dull and a semisharp (Hajek) periosteal elevator, the swivel knife, a stout forceps and the two bone sawing instruments, to be later described.

The submucous resection is performed in the following way:

An incision is made anteriorly on the convexity of the deviation, the scalpel directed parallel to the cartilage. The mucous membrane with its underlying perichondrium is incised until the cartilage is reached. The latter is then sep

arated from its muco-perichondral lining along its entire length, the dull periosteal elevator working backwards towards the vomer, till the whole cartilaginous bony deviation is exposed on its convexity. Then the cartilage is cut through at the place of the primary incision, which is the most delicate part of the operation. If the finger is pushed into the nostril on the concave side, the sense of touch distinctly indicates when the point of the knife reaches the soft perichondrium after having left the rather hard cartilage. In this way perforation is avoided. With the dull periosteal elevator the concave side of the deviation is now separated. Then the whole deviated part contained in its perichondro-periosteal culde-sac is easily accessible to operative interference. The swivel knife is then slipped over the free border of the cartilaginous deviation and the latter removed by a backward, downward and forward movement. The now accessible bony structure can be attacked by two distinct groups of instruments, either of the punching or the breaking kind. The first are safer than the second, but prolong the operation unnecessarily by allowing only tiresome piece-meal work; and besides, in the presence of very thick bone, especially when combined with a very big spur, or when an obstructing broad maxillary spine has to be removed, only the group of breaking instruments by virtue of their strength can be relied upon. But the great disadvantage in the use of the latter is the lack of control. Not only may bigger portions of the non-deviated septum be broken away, but also a fracture of the upper jaw

or even of the bones of the base of the skull may occur. It occurred to the writer that an improvement in the operation would

be to precisely remove a measured portion of the bony deviation.

After many months of experimentation the writer designed the following two instruments, which have given him the greatest satisfaction during the last year. Both instruments are of bayonet shape, consisting of a four-inch long handle and a shank whose fork-like end is raised three-quarters of an inch above the former. The fork is two inches long and contains at its end "Glogau's submucous saw," in the one instrument of a horizontal, in the other of a vertical direction. There are two saws on each of the instruments, one on each blade of the fork, facing each other and fitting into one another. As the saw blades are bent concavely to each other at their proximal end, the saws are closed pretty tightly by their own elasticity. While used they can be kept in close touch with the bony deviation by means of a ferrule forced over the bent part of the blades. The sawing surface of the horizontal instrument is one inch. The end of the vertical instrument is bent at a right angle, and the vertical portion of the fork, one-half inch

a fair trial by the profession, before which the writer's submucous saws are brought for the purpose of increasing the safety and efficiency of submucous resection of the bony septum.

1184 Lexington Ave.

TUBERCULAR PERICARDITIS AND

MYOCARDITIS.1

BY

FRANK O. MANNING, M. D., New York City.

tubercular

Pericarditis occurring in subjects is not a very rare affection, but tubercular pericarditis in which the pericardium is infected by the tubercle bacillus is comparatively rare. The increasing attention attracted by tuberculosis has led to its being recognized more frequently. It has been observed in all ages and probably occurs most often in young adult life, and in males more frequently than females.

The view is becoming more and more. widely accepted that the lymphatic glands are always the first seat of tubercular infection and that the various organs and tissues subsequently infected are invaded by way of their lymphatic vessels. Most cases of tubercular pericarditis develop secondarily to infection of other organs such as the lungs, pleura, vertebrae, peri

toneum or even the intestines.

The reason for the rare and usually late invasion of the pericardium probably lies in its relatively scanty vascular supply. In tubercular pericarditis are found many of the lesions common to the other forms of pericarditis, as well as some of the lesions of tuberculosis. The pericarditis may be of the dry form, or it may be accompanied

'Read before the Lenox Medical and Surgical Soc. Mar. 26th, '10.

by effusion. In the dry form the condition terminates nearly always in adhesion of the pericardial surfaces. In the form with effusion, adhesion may also occur after the absorption of the exudate has taken place. The effusion may be serous, sero-sanguinolent or hemorrhagic but rarely purulent. The quantity may be variable.

Myocarditis in some degree is present in all cases of pericarditis, and to it are chiefly due the symptoms of dyspnoea and disturbances of the circulation especially in the absence of effusion. If the infection. of the myocardium is extensive there will be granular and fatty degeneration of the

muscle which will be most marked in the superficial layers next to the pericardium. Tubercular deposits occur most frequently about the base of the heart especially that of the auricle.

In the majority of the cases there is a fibrinous exudate of variable degrees of thickness deposited chiefly on walls of pericardium. There may be excessive formation of new fibrinous tissue, at first grayish and translucent but later becoming white and firm as it is converted later into dense cicatricial tissue which firmly unite the pericardial surfaces. If the exudate is purulent it may become inspissated and this may in time be con

verted into a calcareous mass.

Symptoms:-As a rule the infection is latent throughout its whole course and is only discovered at a post-mortem examination. This is accounted for in the first place by the fact that the disease of the pericardium usually begins insidiously and runs a subacute or chronic course, and in the second place that the pericardial symptoms are overshadowed by the symptoms of lesions in other organs.