Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 102

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189

USA > Ohio > Hancock County > Findlay > Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens > Part 102

Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).

Until 1899 the method had not been extensively used as is videnced by Victor Lange's statement in Heymann's Hand- uch that there was no good operative method for the correc- on of septal deformities. In this year Bonninghaus reported 9 cases and stated that he had been using this method for e last four years. He lays emphasis on the importance and ecessity of also removing the bony parts of the deviation. he discovery of the properties of an aqueous extract of the prarenal capsule on the vascular system by Schaefer and liver and others and further work along this line by Abel as quickly followed by the clinical use of this substance. his discovery materially aided the development of this eration as it did of all other operative nasal work.

In America, Otto T. Freer developed this operation along iginal lines. His first publication in the Journal of the nerican Medical Association gives E. F. Ingals (1882) dit for originating the type of operation designated by ;jeg as the window resection. Freer's work was started in 01 and he was ignorant of the previous work of Krieg and nninghaus. Freer's original method consisted in the mak- [ of flaps, the anterior one being held forward so as to roughly expose the deviation, and after dissection of the

Paper read before The Southern Section of the American yngological, Rhinological and Otological Society, Jan. 21, 1911.

mucosa, in removing the cartilage. He then fractured the cartilage and placed it in a straightened position. In his later publications he states that he has given up the practice of fracturing the bony septum, and instead cuts it away with Griinwald's forceps. For this work he has devised 12 knives which are found to be most useful and necessary. In speaking of making the flaps he speaks of dissecting the mucosa but he probably includes the perichondrium and periosteum in this flap. Comparing this operation with the Asch method, he says "the latter will always be resorted to by the general surgeon who enters special fields without special skill, for the surgeon sins against us far more than the cautious general practitioner anxious for his patient's welfare."

Killian in 1904 published his most exhaustive paper giving the whole detail of the operation in his hands and the results of his cases. His paper marks an important milestone in the development of the operation, inasmuch as most operators at the present time use essentially his method. In a previous paper (1899) he had pointed out that the making of a flap and the use of his long speculum for "rhinoscopia media " materially helped in the operation and lessened the after treatment. He lays great stress in a strict aseptic technique and draws attention to the various contra-indications to the operation. Killian makes a vertical incision about one-half a centimeter behind the movable septum. This incision goes to the cartilage. He next elevates, laying stress on the import- ance of including the perichondrium in the part elevated. He next perforates the cartilage, using a finger in the other side of the nose to prevent going all the way through to the other side. After elevating the muco-perichondrium of the other side he removes the cartilage with his own cartilage knife or with Hartman's biting forceps. A picture of his cartilage knife readily demonstrates that Ballenger's swivel knife is practically the same with the exception that the knife revolves. Posteriorly the bone is removed with Hart- man's biting forceps, anteriorly with Killian's chisel. If necessary the flap is sutured.

About the same time Hajek, Menzel and others published the results of their work and their methods, but they added nothing to that of Killian, in fact they hardly seemed to realize the beauty and the superiority of his work.

From this time on these methods of operating on deformed nasal septa increased in popularity. They were rather late in getting to England notwithstanding its proximity to the country where it originated and was rather extensively used. For instance, in 1901 Mayo Collier remarked that he had seldom or never attempted to straighten the septum; the results were most unsatisfactory, and he preferred to remove a piece with knife, chisel or saw. In 1904, St. Clair Thomson described his results in a number of cases.

There have been various improvements in technique in the

Digitized by Google

122

JOHNS HOPKINS HOSPITAL BULLETIN.

[No. 84

last few years. Ballenger's swivel knife, a modification of Killian's cartilage knife, has simplified the removal of the cartilaginous septum. Hurd, Beck, Carter, Bruning and others have devised various instruments that assist in the operation. To prevent perforations, Gulliver transplants a piece of muco-perichondrium from the redundant side in the perforated spot and holds it there with packs. Ballenger describes another method of avoiding a permanent perfora- tion, which he says he learned from Dr. Goldsmith of Toronto. After resecting the cartilage it is placed in normal salt solution and if there is a perforation produced during the operation, a piece of this cartilage is placed and held there by packs. Yankauer's suggestion to extend the vertical incision across the base of the nose, aids considerably in enlarging the field of operation.

WRITER'S METHOD OF SUBMUCOUS RESECTION OF THE DEVIATED NASAL SEPTUM.

The patient enters the hospital on the morning of the operation, undergoing a thorough physical examination. The urine is examined for albumin and sugar. One-half hour before the operation there is administered a hypodermic of one-quarter grain of morphia.

Instruments .- The following instruments are used : Beck- man's nasal speculum, probe, applicators, Freer's right and left angular and straight knives, Freer's sharp and dull elevator, Jansen's dull elevator, the writer's specula, Ballen- ger's swivel knife, Grünwald's and Jansen's biting forceps, Killian's chisel and hammer, dressing forceps, and Worth- ington's membrane holder.

Technique .-- Two nurses are used, and the instruments are sterilized by boiling, the head mirror by the use of formalin vapor. [Photographs show the arrangement of the room and table.] The patient's face is washed with soap and water, alcohol, and bichloride solution. A sterile towel is placed around the head and a sterile sheet covers the body.

Operation .- The septum is cocainized with swabs placed first in adrenalin chloride solution 1-1000, wrung dry and then dipped in powdered cocaine. This is rubbed on both sides and also on the turbinates if these are to be removed at the same time, and in the antral, ethmoid and sphenoid regions, if a sinus operation is also to be performed. Cocaini- zation is very rapid and the writer has not seen a single case of cocaine intoxication by this method in over five years' use of cocaine, whereas such was not infrequent by the pledget method of using cocaine. Also the anesthesia is much more profound especially where sinus work has also to be done. Rarely general anesthesia is necessary, ether being used. After cocainization, long pledgets soaked in a 1-1000 solution of adrenalin and wrung out almost dry, are packed against the septum of both sides and allowed to remain there from five to ten minutes.

The initial incision of Killian is made just in front of the deflected portion and continued outwards across the floor of the nose as suggested by Yankauer. This incision goes down to the cartilage and the muco-perichondrium and muco-peri-

osteum of the convex side is then elevated with the various elevators described. The cartilage is next incised to the peri- chondrium of the opposite concave side. One soon learns to recognize when the perichondrium is reached and no special instrument or technique is necessary to prevent perforation at this point. If it occurs the method described by Ballenge: of inserting a portion of the resected cartilage here can be used, although the author has had no occasion to try this procedure. Next the muco-perichondrium and muco-perio- teum of the concave side are elevated. This is often much so- celerated and rendered easier by the employment of the author's speculum which is next inserted, one blade on each side of the cartilage, and then opened up as far as possible. By the use d' his speculum the field of the following steps is made me plain and visible and any injury of the membrane of either side is prevented (see cuts). The cartilage and bony deflected parts are then removed with Ballenger's swivel knife, Grünwald's and Jansen's biting forceps. The maxillary crest is removed with Killian's chisel. Where the deflection is very acute this method is slightly modified in that the cartilage up to the point of the deflection is first removed, and then the remain- ing part can be manipulated into a better position for con- tinuing the dissection of the membranes. After all the deflected parts of cartilage and bone are removed the wound is thoroughly cleaned of debris with cotton sponges soaked in normal salt solution. The membranes are then smoothed down after removal of the speculum and the septum examined to find if straight or not. If it is not straight, it is due to insufficient removal of cartilage, bone or bony crest of the superior maxilla, which is removed until the septum assumes a vertical position. The membranes are held in position br Worthington's holder and a pack placed in each nostril, when the membrane holder is withdrawn. These packs are made of strips of iodoform gauze, surrounded with gutta perche protective and are greased with vaseline before insertion inte the nose. A number of various degrees of thickness are made for each case and one that fits into the nares snugly is used on each side. They make most excellent packs, are withdrawn without any pain to the patient and without that bleeding which is so annoying after withdrawal of the ordinary gauze dressing. In case sinus work has been done, the protective covering of the pack is perforated in a number of places. If the ethmoid cells have been opened also, a small perforated pack is placed in this region superimposed on the other pack.

After his return to bed, the patient is given a glass of water. containing thirty grains of urotropin to the quart, every hour. He is put on full diet. If there is any headache he is given either migraine tablets, or a powder of acetanilid five grains. codeia sulphate half a grain, and one grain of caffeine citrate. If these are not efficient he is given a hypodermic of one-quarter grain of morphia. The next morning he is given a bottle of citrate of magnesia. The pack on the side opposite the incision is removed at the expiration of 24 hours, and on the side of the operation at the expiration of 48 hours. He is discharged from the hospital on the second day and after the packs are withdrawn is given a spray of Dobell's solution with

Digitized by Google

LV,VVV VI 1-10, VVV solu-

ion for home use. Usually but little after treatment is re- quired in the simple cases. Where an inferior turbinectomy or a sinus operation is performed at the same time, it is neces- ary to irrigate the nose for some time afterwards.

WRITER'S RESULTS.

The object of this paper is to give the results up to date n a series of cases in which he has performed this operation. His conclusions are based on his records of over fifty cases. "Some earlier cases were dispensary cases of which he has no histories. Some of this small series were also dispensary cases out inasmuch as these received the same attention as the private cases, they are of equal value as statistics. Letters

FIG. 1 .- Speculum in place, before removal of cartilage and bone.

were written to all of the patients to return for examination o determine whether there had been any difference in the 'esult as considered for a short time after the operation. Unfortunately only a small percentage have seen fit to appear twenty-three). Letters have been received from seven which re of some value.

I shall first enumerate the results in these cases at the ime of their discharge and then give the further observa- ons based on those patients who have returned for examina- on or who have written.

Regarding the ages of these patients, all but four of the irly cases are over fifteen years of age. One patient was n, another twelve, and two were thirteen years old. Owing the fact that we do not know what effect this operation ill have on the development of the nose, I have thought isest not to operate on young children unless the breathing absolutely cut off. In such cases it might be well to en-

deavor to improve the septal position by widening the palatal arch as suggested by Black, Brown, and others. So far I have seen but one of these young patients after the lapse of any time. This patient was a boy aged 13 years, on whom a submucous resection of the septum and later a double in- ferior turbinectomy was performed. Now, over three years later, the good result obtained at the time of the operation still continues; the breathing space is good, and the nose, he thinks, has rather improved in shape.

In about half of my cases a simple submucous resection was performed and in nearly all the rest either the inferior tur- binate of one or both sides was removed in part. In one case, the anterior ends of the middle turbinates were resected. In three cases extensive sinus work was performed at the same

FIG. 2 .- Deflected bone and cartilage removed. Posterior part of vomer and perpendicular plate of ethmoid visible.

time. In one case a hump on the dorsum of the nose was also removed by an external incision.

Reaction Following Operation. Infection .- I had always considered the submucous resection of the septum, an opera- tion with no risk of mortality until I received a report from H. Hays, in which he described two cases of infection, re- sulting in one case in meningitis and death. Purcell also mentions one death following infection. As practically all these cases were done in the hospital the temperature charts have been at my disposal for accurate observation; also I have seen all of the cases for long enough times after the operation to make my following remarks absolutely accurate.

The temperature charts of my cases, to all but a few of which I have had access, show in most either a normal tem- perature or a rise of about one degree on the following day which quickly subsides after removal of the packs and clear- ing of the bowels. In one case the rectal temperature rose

-- 1

- 1.

Digitized by

Google

124

JOHNS HOPKINS HOSPITAL BULLETIN.

to 102.5º F. and in another 103.4º F. but in these cases the temperature subsided in about 24 hours to normal after re- moval of the packs and calomel purgation. I have two cases of slight infection to report. In one case, an incomplete submucous resection was done by one of the house surgeons- his first case. Four days later the patient was readmitted to the hospital with a red swelling on the side of the nose which proved to be erysipelas, a mild attack, which quickly subsided. Examination of the nose revealed an incomplete removal of the cartilage and a small perforation of the septum and the septum somewhat swollen. One month later a more complete submucous resection was performed with excellent result. The day following the operation, the temperature went up to 102.6º F. (rectal) but fell to normal in 24 hours. In another case there was a slight infection between the mem- branes with slight swelling and slight elevation of tempera- ture. A small amount of grumous material was scraped out through the original incision and a counter incision made in

FIG. 3 .- Worthington's flap holder, and author's speculum (two sizes).

the septum, a little posteriorly. This discharged pus for about a week and then closed, leaving a clean septum, with no perforation. This case has been attended by no other bad result-such as sinking of the bridge of the nose.

Results in General .- In general, the results may be termed excellent. The main cause for this operation, difficulty in breathing through the nose, has been relieved in all cases but one, and in that case failure was due to a projection of the end of the quadrangular cartilage outside the nose on the side opposite the side of the deflection. This was not removed at the operation and on removal of the packs the cartilage reassumed a deflected position. Unfortunately this was an out of town patient and I have had no further opportunity to correct the work. The lesson from such a case is to operate from both sides, dissecting out the anteriorly placed deflection through an incision made in the cutaneous septum. Although no particular attempt was made in any of the cases to remedy external deformities, these were in many cases much improved as is shown by the rough casts of one case. These plaster casts are not difficult to make and once made, constitute an

excellent method of gauging the result in this particular In one case headaches were entirely relieved. A severe netes- gia of the side of the face to which the septum was deriace! has been entirely relieved for three and a half years foloz. ing the operation in another case. A general improvemec: in health was noted by many.

Perforation of the Septum .- I have notes of perforatic: in four cases; three of which were very small and one being fairly large. In the last case, done some years ago, deviation, as shown by the plaster cast, was very extreme forcing outward the nasal bone of that side. I take it, bri- ever, that a perforation in this case could either have been avoided or would have been much smaller by using the meth .! described earlier, namely, first removing the cartilage up : the point of deflection before attempting to dissect the men- branes beyond this point. As has been the experience .. others, I have observed no scabbing about these perforatiec- nor have they given a patient, who is unaware of them. an: discomfort.

Special Results .- One of the objects in reviewing the- cases was to determine whether there occurred after the la ?- of some time any bad after effects, such as sinking of tr bridge of the nose. I also wished to get some evidence regard- ing the reformation of the cartilage and bone removed.

Depression of the Bridge of the Nose .- An early report : Shecdy of a number of cases of a sinking in of the nose fl- lowing this operation made me particularly apprehensive ! this regard. A later report by him is to the effect that now i seldom sees this deformity and thinks the former bad resul- were due to too extensive removal of cartilage. As the inu- mediate result of the operation, I have not seen such a result. I have seen or heard from twenty-nine patients on whora ! have operated from over four years ago to the present time. In not a single case was there a trace of any secondar: sinking of the bridge of the nose. Several of these patien: had syphilis which had been thoroughly treated and tives did as well as any of the cases.

Reformation of the Septal Cartilage and Bone .- At t. present time I can report on but eighteen cases in regard t- this point. In all, the septum had regained firmness but in none could one say that there was complete reformation of til- cartilage and bone. In some there was a large area, quite soft and movable to the probe; in others this area corn- sponded only to the center of the place from which the car- tilage had been removed. Some of the more recent cases wer firmer than the earlier cases. It is possible that this is du- to not having included all of the perichondrium and perins- teum in the early cases.

CONCLUSIONS.

1. The submucous resection of the nasal septum is a methe by which all varieties of deflections of the septum can lx corrected.

2. It is probably better for us to be cautious in the case if young children and do the operation only when it is urgently demanded.

Digitized by Google

"is often a necessary accompaniment in order to complete the sinus work and obtain free drainage. Such operations as well as inferior or middle turbinectomies are best done at the same time.

4. Luetic individuals who have been well treated and show no signs of the disease, yield as satisfactory results as others.

5. It is absolutely essential to have strict asepsis in all the details of the work.

6. Infections following this procedure should be as infre- quent as in any other operation carried out with aseptic technique, and the operation considered both safe and satis- factory.

7. Perforations of the septum may be caused infrequently but they are of no consequence and cause the patient no discomfort.

8. There is no reason to fear sinking of the bridge of the nose, following at any time after the operation. On the other hand, external deformities which may be present are frequently relieved.

9. While it is possible that there may be, to a slight extent, new cartilage or bone formed after the operation, this is never complete.

BIBLIOGRAPHY.

Abel, John J .: On the Blood-Pressure-Raising Constituent of the Suprarenal Capsule. Johns Hopkins Hosp. Bull., July, 1897.

Abel, John J .: On Epinephrinend Its Compounds, etc. Am. J. Pharmacy, July, 1903.

Black, W. M .: Septal Deviations. J. Am. M. Ass., March, 1909. Ballenger, W. L .: A New Technique for the Submucous Re -. section of the Cartilaginous Septum. The Laryngoscope, June, 1905.

Ballenger, W. L .: The Submucous Resection of the Septum, Illustrated. The Laryngoscope, 1907.

Barnhill, J. F .: J. Laryngol., July, 1906.

Beck, J. C .: J. Laryngol., 1906.

Bönninghaus, George: Ueber die Beseitigung schwerer Ver- biegungen der knorpeligen und knochernen Nasenscheidewand durch die Resection. Arch. f. Laryngol. u. Rhinol., 1899, IX.

Brunings: A Contribution to the Submucous Resection of the Nasal Septum. J. Laryngol., 1908.

Collier, Mayo: Remarks at Meeting of the British Laryngo- logical, Rhinological and Otological Association, March, 1901. J. Laryngol., 1901.

Carter, W. W .: Instruments for the Submucous Resection of the Septum. The Laryngoscope, April, 1906.

Carter, W. W .: Report of Cases of Submucous Resection of the Septum, with Conclusions Drawn from Same. The Laryn- goscope, 1906.

Douglas, B .: Nose and Throat Surgery, 1906.

Emerson, Francis P .: The Results of the Operation of Sub- mucous Resection of the Septum in Private Practice. J. Am. M. Ass., Oct., 1910, 1449.

Fein, J .: A Note on a Simple Method of Performing Sub- mucous Resection of the Nasal Septum. J. Laryngol., 1909. Original article in Monatschr. f. Ohrenh., No. 8, 43.

Fein, J .: The Simple Window Resection. J. Laryngol., 1910. Abstract.

Freer, Otto T .: The Correction of Deflections of the Nasal Septum, with a Minimum of Traumatism. J. Am. M. Ass., Dec. 5, 1903.

ganzender Nachtrag. Arch. f. Laryngol. u. Rhinol., XX, 361.

Glas, Emil: On the Indications and Operation for Deflection of the Nasal Septum. J. Laryngol., 1910. Abstract.

Gulliver, F. D .: A New Method for the Repair of Perforations Occuring during the Submucous Resection of the Nasal Septum. Lancet, 1909, 166.

Hajek, M .: Bemerkungen zu der Kriegsche Fensterresektion. Arch. f. Laryng. u. Rhinol., 1904, XV, 44.

Hilscher, F. W .: Submucous Resection of Septum. Northwest Med., Nov., 1909.

Hays, H .: Septicemia following Submucous Resection of the Nasal Septum. The Laryngoscope, 1909.

Hurd, L. M .: Elevator, Speculum and Forceps for Use in the Submucous Resection of the Nasal Septum. The Laryngoscope, 1905.

Killian, Gustav: Die submucose Fensterresektion der Nasen- scheidewand. Arch. f. Laryng. u. Rhinol., 1904, XVI, 362.

Klemptner, L .: Die submukosen Resektion der Nasenscheide- wand. Arch. f. Laryng. u. Rhinol., 1910, XXIII, 412.

Krieg: Ueber die Fensterresektion des Septums nariums zur Heilung der Skoliosis Septi. Arch. f. Laryng. u. Rhinol., 1900, X, 477.

Laurens, G .: Chirurgie du Nez.

Levy, R .: Indications for the Submucous Resection of the Nasal Septum. The Laryngoscope, 1906, 200.

Lothrop, O. A .: Some Observations on the Late Results ob- tained by the Submucous Resection of the Nasal Septum. J. Laryngol., 1901. Abstract.

McCaw, J. F .: The Submucous Resection of the Nasal Septum with Ballenger's Swivel Knife. The Laryngoscope, 1906.

McCoy, John: Forceps and Knife for Use in the Submucous Septal Operation. The Laryngoscope, 1906.

Menzel, K. M .: Zur Fensterresektion der verkrummten Nasen- scheidewand. Arch. f. Laryng. u. Rhin., 1904, XV, 48.

Richardson, C. W .: The Operative Treatment of Deflections of the Nasal Septum. J. Laryngol., 1909. Abstract.

Sheedy, B. de Forrest: Deviations and Deformities of the Nasal Septum, with Special Reference to Possible Results Fol- lowing the Submucous Operation. Internat. J. Surg., Dec., 1907.

Sheedy, B. de Forrest: The Saw and Crushing Instruments in Surgery of the Nasal Septum. Med. Rec., Oct., 1910.

Thomson, St. Clair: J. Laryngol., 1904.

Suckstorff: Zur Geschichte der submucosen Fensterresektion der Nasenscheidewand. Arch. f. Laryng. u. Rhinol., 1904, XVI, 355.

Tilley, L .: J. Laryng., 1907.

Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.

Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens, Part 102

Author: Jacob Anthony Kimmell Publication date: 1910 Publisher: Number of Pages: 1189

Author: Jacob Anthony Kimmell
Publication date: 1910
Publisher:
Number of Pages: 1189