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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.

OTTO GLOGAU, M. D., Otologist, German Odd Fellow Home and Infant Asylum"; Oto-Laryngologist, Y. W. H. Association; Chief, Ear, Nose and Throat Dept., Sydenham Hospital, 0. P. D., Oto-Rhinological Surgeon, Ophthalmic

and Aural Institute and Mt. Sinai Hospital,

0. 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

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structions were attended to whose causes causing an approximation and eventual could be recognized with the naked eye. union of the edges. Immense polypi or very large hypertrophies The next popular method of straightenof the inferior turbinates, when protruding ing the cartilaginous deviation consisted in from the nostrils, were operated upon, making a horizontal or vertical incision inwhereas the pathological changes of the to the cartilage and forcing one part to inner nasal structures


totally overlap the other. A similar idea is the neglected, not only from a diagnostic but principle of the ingenious Asch operation, also from a therapeutic standpoint.

in which longitudinal and horizontal inAn old physician of the pre-rhinological cisions were made into the cartilage by era, told me how he at that time treated means of very strong cutting forceps; the a “stuffed up nose.” He simply pushed his overlapping parts were expected to unite sharp spoon into each nostril and curetted in a straight line by the pressure of nasal the nasal cavities to such an extent as to splints which the patient had to carry in be able to freely bring his instrument back- his nose for several weeks. Except wards to the pharyngeal wall.

When we

for the sawing or chiseling away of take into consideration that anesthesia, bony spurs, the deformities of the bony both local and general, was not yet re

septum have been perfectly neglected sorted to, we must look upon this "treat- until recently when the submucous resecment" as a rather brutal and unscientific tion of both the cartilaginous and bony method to relieve nasal obstruction, es- septum proved to be a rational treatment, pecially when the latter happened to be not only for the former but also for the caused by a deviation of the septum. Hereto- latter. fore the deviation of the cartilaginous sep

While the number of instruments on the tum-(that of the bony septum not yet market for operation on the nasal septum having been known) was regarded as are very numerous, yet in the large maa noli me tangere, until there was invented jority of cases a very small armamentarium a very ingenious instrument, by which a will answer all purposes. The instruments considerable part of the deviated portion ordinarily employed by the writer are a was punched out, leaving a large perfora- nasal speculum, a scalpel, a dull and a semition with all its accompanying ill effects. sharp (Hajek) periosteal elevator, the

When the use of reflected light gave swivel knife, a stout forceps and the two a better view of the interior of the nose, bone sawing instruments, to be later dethe methods of dealing with the deviations scribed. of the cartilaginous septum became more The submucous resection is performed rational. The above method was soon suc- in the following way: ceeded by a modification, in which a more An incision is made anteriorly on the or less rectangular piece of the cartilage convexity of the deviation, the scalpel diwas removed together with its mucous lin- rected parallel to the cartilage. The ing, with the idea of correcting the devia- mucous membrane with its underlying tion by having the gap thus formed filled perichondrium is incised until the carup by pressure through bilateral packing, tilage is reached. The latter is then sep

arated from its muco-perichondral lining be to precisely remove a measured portion along its entire length, the dull periosteal of the bony deviation. elevator working backwards towards the After many months of experimentation vomer, till the whole cartilaginous bony de- the writer designed the following two inviation is exposed on its convexity. Then struments, which have given him the greatthe cartilage is cut through at the place of est satisfaction during the last year.

Both the primary incision, which is the most deli- instruments are of bayonet shape, consistcate part of the operation. If the finger is ing of a four-inch long handle and a shank pushed into the nostril on the concave side, whose fork-like end is raised three-quarters the sense of touch distinctly indicates when of an inch above the former. The fork the point of the knife reaches the soft peri- is two inches long and contains at its end chondrium after having left the rather "Glogau's submucous saw,” in the one inhard cartilage. In this way perforation strument of a horizontal, in the other of a is avoided. With the dull periosteal elevator

vertical direction. There are two saws on the concave side of the deviation is now each of the instruments, one

on each separated. Then the whole deviated part blade of the fork, facing each other and contained in its perichondro-periosteal cul- fitting into one another. As the saw blacles de-sac is easily accessible to operative inter- are bent concavely to each other at their ference. The swivel knife is then slipped proximal end, the saws are closed pretty over the free border of the cartilaginous de- tightly by their own elasticity. While useri viation and the latter removed by a back- they can be kept in close touch with the ward, downward and forward movement. bony deviation by means of a ferrule The now accessible bony structure can be at- forced over the bent part of the blades. The tacked by two distinct groups of instru- sawing surface of the horizontal instruments, either of the punching or the break

ment is one inch. The end of the vertical ing kind. The first are safer than the sec

instrument is bent at a right angle, and the ond, but prolong the operation unnecessa- vertical portion of the fork, one-half inch rily by allowing only tiresome piece-meal

d work; and besides, in the presence of very thick bone, especially when combined with

b a very big spur, or when an obstructing broad maxillary spine has to be removed,

d only the group of breaking instruments by GLOGAU's HORIZONTAL SUBMUCOUS Saw. virtue of their strength can be relied a, handle; b, shank; C, fork; d, ferrule; e, upon. But the great disadvantage in the horizontal saws; f, V shaped space. use of the latter is the lack of control.

long, contains within its blades the two Not only may bigger portions of the

vertical saws. non-deviated septum be broken away,

The tip ends of the blades but also a fracture of the upper jaw

when brought together enclose a V shaped or even of the bones of the base of the space, allowing them to slip easily over the

It occurred to the writer margin of the bony deviation. The instruthat an improvement in the operation would ments are made by Meyrowitz, N. Y.




skull may



} ORIGINAL ARTICLES Complete Series, Vol. XVI.

, Vol. V., No. 12. The modus operandi with Glogau's sub- spine, which may either be removed with mucous saws is the following:

the bony deviation, its basis being conAfter having made accessible the entire sidered to be the lower margin of the deviation by separating it from both peri- latter, or may be sawn out separately, chondrium and periosteum in the above after the remaining part of the bony dementioned way, the cartilaginous deviation viation has been removed. In both inis removed with the swivel knife. The stances this method is far superior to the horizontal submucous saw is then slipped method of breaking, as well for the pa

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d GLOGAU'S VERTICAL SUBMUCOUS Saw. a, handle; b, shank; C, fork; d, ferrule; e, vertical portion of the fork containing on

its two blades the saws f; g, V shaped space. over the bony structure along the upper tient's safety as also his subjective sensamargin of the deviation, whereafter by tions. The slipping off from a big bony spur horizontal sawing movements the bone, of both punching and breaking instruments in the grasp of the two blades. is is avoided by Glogau's submucous saws, the sawn through with perfect safety to the spur itseif being removed with the deviated “cul-de-sac," the latter being only in con- portion it springs from, tact with the dull outer surfaces of the With the submucous saws it is possible blades. The instrument is then slipped to remove, without resorting to the swivel over the lower margin of the bony devia- knife, both cartilaginous and bony deviation, which is sawn through in the same tion in one piece. way.

Now the vertical submucous saw In a paper read before this society is slipped over the bony deviation, back- December, 1908,' I called special attention ward to its posterior margin, where by to the frequency of septal deviation in both vertical movements the bone is

adults and children. Among 4,400 cases through and removed in one piece.

examined in one year at Mt. Sinai Hospital To make the operation more rapid, the Dispensary in the service of Dr. Oppensaws applied on the bony structure in the heimer, there were 3,823 septal deformities, above mentioned way, need not go through most of them being deviations. As this the bone, it being sufficient to make a pathological nasal condition is able to more or less marked indentation on its cause serious complications of the accestwo surfaces. Now the entire bony devia- sory sinuses, the naso-pharynx and the tion may safely be removed by some middle ear, any improvement of the methbreaking instrument, the same as a glazier od of "straightening” the septum and thus breaks off the amount of glass wanted, by restoring the normal äeration of the nasal grooving the surface with his diamond. "adnexa” may be at least worthy of The horizontal saw is of great advan

"Nasal obstruction in children, "American tage in dealing with a broad maxillary Medicine," April, 1909.



a fair trial by the profession, before which by effusion. In the dry form the condition the writer's submucous saws are brought terminates nearly always in adhesion of for the purpose of increasing the safety and the pericardial surfaces. In the form with efficiency of submucous resection of the effusion, adhesion may also occur after the bony septum.

absorption of the exudate has taken place. 1184 Lexington Ave.

The effusion may be serous, sero-sanguin

olent or hemorrhagic but rarely purulent. TUBERCULAR PERICARDITIS AND

The quantity may be variable.

Myocarditis in some degree is present MYOCARDITIS.1

in all cases of pericarditis, and to it are

chiefly due the symptoms of dyspnoea and FRANK 0. MANNING, M. D.,

disturbances of the circulation especially New York City. Pericarditis occurring in tubercular

in the absence of effusion. If the infection subjects is not a very rare affection, but of the myocardium is extensive there will tubercular pericarditis in which the peri- be granular and fatty degeneration of the cardium is infected by the tubercle bacillus

muscle which will be most marked in the is comparatively rare. The increasing at

superficial layers next to the pericardium. tention attracted by tuberculosis has led Tubercular deposits occur most frequently to its being recognized more frequently. It about the base of the heart especially that has been observed in all ages and probably

of the auricle. occurs most often in young adult life, and

In the majority of the cases there is a in males more frequently than females.

fibrinous exudate of variable degrees of The view is becoming more and more

thickness deposited chiefly on walls of widely accepted that the lymphatic glands pericardium. There may be excessive forare always the first seat of tubercular in

mation of new fibrinous tissue, at first fection and that the various organs and grayish and translucent but later becomtissues subsequently infected are invaded ing white and firm as it is converted later by way of their lymphatic vessels. Most

into dense cicatricial tissue which firmly cases of tubercular pericarditis develop

unite the pericardial surfaces. If the exsecondarily to infection of other organs

udate is purulent it may become insuch as the lungs, pleura, vertebrae, peri- spissated and this may in time be contoneum or even the intestines.

verted into a calcareous mass. The reason for the rare and usually late

Symptoms:-As a rule the infection is invasion of the pericardium probably lies latent throughout its whole course and in its relatively scanty vascular supply. In is only discovered at a post-mortem extubercular pericarditis are found many of

amination. This is accounted for in the the lesions common to the other forms of first place by the fact that the disease of pericarditis, as well as some of the lesions the pericardium usually begins insidiously of tuberculosis. The pericarditis may be

a subacute or chronic course, of the dry form, or it may be accompanied and in the second place that the pericardial

and runs

symptoms are overshadowed by the sympRead before the Lenox Medical and Surgical Soc. Mar. 26th, '10.

toms of lesions in other organs.

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