VOL. IX.

No. 11.

IN

N CHOOSING a subject for a paper before your association, I have been guided by the knowledge that it was to be read before an assembly of practical surgeons before a body of men whose daily work lay in the performance of formidable and serious operations. I feel that it is largely due to the influence of the general surgeon that the treatment of the obstructive diseases of the upper respiratory tract has been rescued from its former thraldom in the hands of specialists whose endeavors were limited to ringing long and wearying changes upon various sprays and other local applications, which left the patient at the end of his treatment

* Read at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, Mo., May, 1896.

exactly where he was at the beginning. We have come to realize that upon active surgical intervention depend most of the successful results of treatment in this special field of work. This fact has been particularly apparent in the matter of deformities of the nasal septum, and it is to this purely surgical matter that I invite your attention this afternoon.

If we inquire into the causes of deflection of the septum, we are struck by the number and variety of agencies asserted to cause the deformity. Among these are many utterly unworthy of serious consideration. Indeed, when one studies his cases, he is soon convinced by an almost unvarying history of an injury to the nose that the cause of the deflected septum

may be said to be almost always purely traumatic. In the majority of cases the history is a clear one. In others it is not. Yet these latter are easily accounted for when we consider the number of bumps and falls that attend our early attempts at walking. An injury too slight to injure an adult nose may easily produce a slight deflection in that of a child, which, increasing with time, becomes a marked deformity as manhood is reached. Indeed, so common are these deformities that it is extremely rare to find an adult male with an entirely normal septum; and a close inspection of the half-dozen noses nearest us will show that perhaps not a single one of them occupies the exact median line of the face.

Others

Just what deformity of the septum will result as the effect of the injury inflicted must depend upon the character and point of application of the blow. We see those cases wherein, as the result of a powerful blow, not only the cartilaginous, but the bony, portion of the septum has been forced to one side. again show only a displacement of the cartilage of the septum at its lowermost point, the sharp border of the cartilage projecting into the lumen of one of the nostrils, producing more or less occlusion on that side. In the majority of cases, however, of true deflection, we are concerned with the deformity which involves the entire cartilaginous part of the septum, the deviation involving but slightly the upper and bony portion. With the vari

varying length of time, both nostrils are partially or completely obstructed. Let us study some of the effects of this interference with nasal respiration. We are likely, from our long continued habit of regarding the nose mainly as an organ of smell, to forget its far more important and necessary functions, namely, those of moistening and warming the inspired air, and of assisting in voice formation. We find, then, depending upon the degree of nasal obstruction a more or less completely enforced habit of mouth-breathing, both when asleep and awake. The inspired air, not properly moistened, passes over the mucous surfaces of the fauces, larynx and bronchii, drying them and rendering them irritable and inflamed. Meanwhile, the natural drainage being interfered with, the patient finds himself annoyed by the presence of an excess of mucus. The usual attempt to dislodge this is by a vigorous blowing. To blow an obstructed nose with all the force of a powerful pair of lungs is to force the air somewhere; and the eustachian tube feels the force of a strong blast of air as often as the obstructed nose is vigorously blown. Conversely, at each effort to swallow, as all of us may feel by pinching our nostrils together and swallowing, there is a rarefaction of the air in the eustachian tube and the tympanic cavity; in other words, a continued performance of the so-called Toynbee's experiment, broken at intervals by a Valsalvan inflation when the patient

blows his nose. The interdependence of nasal obstruction and middle-ear disease is too well known to be further referred to. When we add to the above results of nasal stenosis the frequent existence of severe headaches of clearly demonstrated nasal origin, the loss of purity of certain tones of the voice from the same cause-when we consider at once the discomfort of the individual and the harmful results that accrue from a neglect of this condition-we cast about us for the best means for relief from the trouble.

GTIEMANN&Co. FIG. 3.

It is not my present purpose to recite to you the various and widely differing operations that have been put forward for the relief of the deflected septum. The very variety of the procedures tells in unmistakably clear language how unsatisfactory they have all proven. I wish to call your attention to an operation which does result in a satisfactory cure of the condition, and a relief from the deformity and inconvenience that arise from the existence of the trouble. This procedure has become known as the Asch operation, having been devised by that well-known operator and modified by his associate, Dr. Emil Mayer. The instruments, which are somewhat elaborate and, for intranasal work, I must admit,

somewhat formidable, are before you, and the steps of the operation are as follows: The patient is given a general anæsthetic and the angular shears (Not illustrated. Like Fig. 1, but bent at right angle.), of which you observe there are two pairs, according as the convexity of the septum is toward the right or left, are introduced and the septum cut entirely through at its point of greatest prominence. The scissors are now turned and another incision made at right angles to the first. The forefinger is now introduced into the obstructed side and an attempt is made to push the softened septum over to the median line. Several prominent angles will be found projecting into the lumen of the nostril. These are reduced by the use of the straightcutting scissors (Fig. 1), of which you observe two sizes, a large and small pair. When the septum has become entirely and completely plastic, it is placed in the median line by the use of the Mayer straightening forceps (Fig. 2), the operator assures himself that the passageway back to the pharynx is clear and free from synechia on both sides, and the drainage tubes (Fig. 3) are inserted. The hemorrhage, which, up to this point, has been very free, is at once entirely controlled by the slight pressure exercised by the tubes. You will observe that the drainage tubes are of red vulcanite, smoothly polished and perforated at numerous points. These tubes are made in varying sizes to

fit nostrils of different capacity. I have had them made by an ingenious dentist friend by furnishing him with plaster of Paris models of the necessary forms and sizes. The reaction following the operation is usually not great, and the after-treatment consists in the frequent removal of the tubes and the flushing or spraying of the nose with some simple detergent solution. The tubes are then reinserted. serted. Should this cause pain, a 10-per-cent. cocaine solution may be sprayed into the nostril before restoring them to place. In a few days the shattered septum will have acquired a fair degree of firmness. The patient continues to wear the tubes, however, until the septum is firm and strong, a time lasting from three to six weeks. This entails but little inconvenience, since their presence is not painful at this stage, nor are they as noticeable as would be supposed.

I have already alluded to a compensatory hypertrophy of the turbinates on the side of the concavity of the septum. Before beginning the operation proper, just described, these hypertrophies should be thoroughly reduced by the galvanocautery or removed by the cold snare, lest, when the septum is restored to the median line, the stenosis be simply transferred from the one side to the other.

If the details of this operation are properly carried out, the result is an eminently satisfactory one. Faulty results are most likely to occur from a too timid use of the

scissors, and a consequent insufficient breaking up of the septum. In such cases the septum resists its reposition in the median line, and the tubes are retained with greater pain and difficulty. The greatest objection that can be urged against the operation is its somewhat formidable and sanguinary character. But this is more apparent than real, and is not a valid objection to the operator accustomed to making serious operations. It is not an operation which requires special knowledge of intranasal work, and since it is successful in its object of relieving nasal stenosis and its consequent train of evils, I urge that

it is the best and the most practical operation we possess for the cure of the deflected septum.

It has happened to me on one occasion that the angular scissors broke in attempting to perforate a septum, the deflection of which was unusually high up and composed largely of bone. I am indebted to Dr. Outten, who was present, for a suggestion of great practical value in such cases, namely, that the scissors be constructed with the Henckel joint, like the powerful pair of plaster scissors I have here, the gliding motion of the blade adding immensely to their strength. 2836 Lafayette avenue.

'N PRESENTING to you this first

IN

case to-day, we have one that is of the greatest interest to surgeons and one of the acute variety in surgical troubles-one that is really an extreme rarity. This case This case has the following history: The patient, is a wandering tramp, who, in trying to beat his way to the city, hid himself in a box-car. discovered on the arrival of the car in East St. Louis, was violently dragged out, thrown upon the ground, kicked and trampled upon. The injuries occurred several days since, and after their inception he walked the entire distance from

He was

East St. Louis, suffering the most excruciating pain in the abdomen. He was picked up by the police and sent to the hospital for treatment. Examining the entire surface of the body, we find no indication of injury to the superficial structures, except slight discoloration and some cuts on the lower extremities. An examination of the superficial markings of the abdomen shows there is considerable tympanitis, and on percussion from above downward we find dulness extending from the ensiform cartilage to the pubis, and in the lumbar region on the side, from above downward, there is a de