the septum, may be easily straightened. Careful after-treatment is required to retain the nose in position. The operation is quick and not severe. There may be pain for the first 48 hours. Pegler has reported very favourably on this method, and Mayo Collier has effected great improvement in the shape of the nose itself by a practically identical procedure. Finally, it has been pointed out that it is often easier to overcome the nasal obstruction by removing pieces from the outer wall of the nose so as to make an airway past the obstruction, than to operate successfully upon the septum. When the obstruction is low down inferior turbinectomy has been recommended; when it is high up removal of the middle turbinate. These operations may certainly sometimes have the advantage of being easy to carry out and may overcome the nasal stenosis, but it is bad surgery to remove large pieces of healthy and eminently useful normal structures, such as the turbinates, instead of dealing with the septum, solely because the operation is easier. References. MAYO COLLIER (and discussion). Journ. of Laryngol., 1896, x. p. 117; 1903, xviii. p. 24. Brit. Med. Assoc. Meeting, Birmingham in 1890. Brit. Med. Journal, 1890, ii. p. 617. HARTMANN and PETERSEN. Berlin. klin. Woch., 1883, xx. pp. 329, 782. ASCH. New York Med. Journ., 1890, lii. p. 675; and Proceedings 12th BÖNNINGHAUS. Archiv für Laryngol., 1899, ix. p. 269. BALLENGER. (Electrolysis) Journ. Amer. Med. Assoc., 1896, xxvi. p. 58. KANTHACK. Proc. Laryngol. Soc. Lond., 1894-95, ii. p. 47. BAUMGARTEN. Monatschr. für Ohrenheilk., 1898, xxxii. p. 404. FLATAU. Wiener klin. Rundsch., 1899, 40. HAAG. Archiv für Laryngol., 1899, ix. p. 1. BOSWORTH, ASCH, ROE and GLEASON. Laryngoscope, 1899, vi. pp. 337, 340, 344, 352. MOURE. Journ. of Laryngol., 1901, xvi. p. 163. HAJEK. Archiv für Laryngol., 1903, xv. p. 45. MENZEL. Archiv für Laryngol., 1903, xv. p. 48. VICTOR LANGE. Heymann's Handbuch der Laryngol. u. Rhinol., vol. iii. Wien, 1899, pp. 440-506. OTTO FREER. Journ. Amer. Med. Assoc., 1902, xxxviii. p. 636; and 1903 xli. p. 1391; and Annals of Otol., Rhinol. and Laryngol., 1905, June. MOURE. Journal of Laryngology, 1901, xvi. p. 163. SUCKSTORFF. Archiv für Laryngol., 1904, xvi. p. 362. WEIL. Archiv für Laryngol., 1904, xv. p. 578. KRIEG. Archiv für Laryngol., 1900, x. p. 477. KILLIAN. Archiv für Laryngol., 1904, xvi. p. 362. SYNECHIAE, OR ADHESIONS BETWEEN THE SEPTUM AND OUTER WALL OF THE NOSE. Causation. Adhesions most frequently occur between the inferior turbinate and the septum, but are more rarely seen in the upper part of the vestibule and in the middle meatus. They may result from any condition in which the septum and the outer wall of the nose are simultaneously denuded of epithelium. Thus, they may follow various forms of trauma; ulceration of the nose, such as occurs in syphilis, acquired or congenital; or acute inflammatory affections, such as fibrinous rhinitis or nasal diphtheria. One of the most common causes is the unskilful application of the electric cautery. The possibility of an adhesion emphasises the necessity of avoiding injury to the septum when operating upon the inferior turbinate, and vice versa. Similarly curettement of the upper part of the nose, as for nasal polypi, may result in adhesions between the middle turbinate and upper part of the septum. A web-like band across the nose, at the junction of the vestibule and mucous membrane proper, is often congenital, but may result from trauma or from syphilis, lupus, etc. Symptoms. Synechiae may consist of long narrow bands, or of broad firm adhesions between two closely adjacent structures. The former usually cause no symptoms, or at the most a slight dragging sensation and a feeling of, rather than actual, nasal obstruction. The latter are most common between the inferior turbinate and the septum, and generally give rise to more or less obstruction to nasal breathing, especially to expiration. The adhesion has a tendency to entangle the secretions, which thus collect in the inferior meatus and produce considerable discomfort. Synechiae may also hinder the inspection of the posterior or upper parts of the nose, and may prevent approach to the accessory sinuses or hinder the passage of the Eustachian catheter. The worst adhesions are those which result from imperfect operations on the septum, in which a surface has been bared of epithelium, and the opposing area of the turbinate injured, without the removal of a sufficient amount to leave a free passage. In these cases a broad firm band of union is apt to occur. Treatment. In recent cases. If a case be seen when an adhesion is in process of formation, an attempt may be made to prevent its occurrence. Having thoroughly anaesthetised the nose, a probe may be gently inserted between the raw adhering surfaces, and then a narrow strip of gauze soaked in oil is introduced. Many other substances have been recommended in place of gauze, such as thin strips of rubber, metal or ivory plates, and celluloid films. These are non-absorbent and easily changed, but more uncomfortable than gauze, which in my experience is the best material to use. The gauze packing must be changed daily, and the nose irrigated with a mild antiseptic solution. In these cases, however, the mucous membrane is often inflamed, and any attempt to keep the parts separate causes so much local irritation and swelling that it soon becomes intolerable. Occasionally a good result is obtained, but more often, after weeks of treatment, the raw surfaces refuse to heal until all packing or splints have been removed. If, therefore, after a reasonable time failure seems certain, it is better to stop the treatment and allow the adhesion to form.1 In Chronic Cases. Synechiae may require to be removed if they produce symptoms, such as nasal obstruction, expiratory or inspiratory, or a sense of dragging pain in the nose, or if they prevent the carrying out of other necessary operations, such as the passage of the Eustachian catheter, or if they are a source of reflex symptoms. When the synechiae are small and elongated, they may be simply divided, as there is no tendency for re-adhesion to take place. After the application of cocaine the adhesion may be cut through with the galvano-cautery, or with a hook-shaped knife, which is passed behind the adhesion and forcibly drawn forwards. In more extensive adhesions, it is better to use the galvano-cautery, as the charred surfaces have little tendency to reunite at any rate for a few days. The only after-treatment necessary is to see the patient every second or third day for a fortnight, and, after applying cocaine, to pass a probe between the raw surfaces and see that the adhesion does not re-form. An ordinary cleansing lotion or better still an oily application such as the Pigment. Hydrarg. Nit. may be ordered. If an extensive adhesion be present, such as may form between a large spur on the septum and the inferior turbinate, the best plan is to saw through the spur, completely detaching it from the septum, and then to remove with the spoke-shave the spur, the adhesion, and a considerable piece of the adjoining turbinate. In this way a large gap is left between the raw surfaces, and healing will take place without any tendency to re-formation of the adhesion. No special after-treatment is required, beyond the use of an ordinary nasal wash, but the patient should be seen every second or third day until healing is complete, so that any exuberant granulations can be snipped off or cauterised. Reference. Discussion Laryngological Society of London, March, 1899. Reported in case has CONGENITAL ATRESIA OF THE POSTERIOR CHOANAE. Complete atresia of the nostrils is extremely rare: only one been shown and four others mentioned in discussion in the Laryngological Society of London during the last twelve years. The occlusion may 1 Vide Proceedings Laryngological Society of London, 1904, March. be unilateral or bilateral, membranous or bony. It is usually situated at or close to the posterior choana, and is congenital, although a membranous obstruction may possibly be acquired. Haag gives details of 44 cases which he has collected from medical literature. Of these 20 were bilateral and in all but one the obstruction was bony: 24 were unilateral. It is interesting to note that of the 20 cases which were bilateral, in only one was the upper jaw normally developed; all the others and 75 per cent. of the unilateral cases had a high narrow-arched palate. The deformity was equal on both sides even when the nasal obstruction was unilateral. The nasal passages were often otherwise well-developed. These observations go far to confirm the views that have already been expressed upon the aetiology of the high palate, and upon its association with nasal obstruction (see p. 63). Diagnosis. The symptoms are those of unilateral or bilateral nasal obstruction. On examination with the post-nasal mirror or with the finger the complete obstruction of the posterior choana on one or both sides is readily made out. Cocaine and supra-renal extract should be applied to the anterior nares and examination made from the front with the aid of the probe. In this way the nature of the obstruction, whether fibrous or bony, can be recognised. Treatment. Under general anaesthesia and with the finger passed up into the post-nasal space to serve as a guide and to prevent injury to other parts, an opening is broken through the occlusion with a burr or gouge. Subsequently as much of the obstructing tissues as possible is broken up or cut away with forceps. A thin rubber tube should be passed through the opening to counteract the tendency to contraction. Apparently this operation has usually been successful. Should there be a tendency to contraction in spite of these precautions, Symonds' suggestion of the removal of the posterior part of the septum seems worthy of consideration. It can be easily accomplished with strong post-nasal forceps such as Loewenberg's.1 Reference. IWANOFF. Archiv für Laryngol., 1904, xvi. p. 332. ABSCESS OF THE SEPTUM. Acute abscess of the nasal septum is a rare affection, being met with not oftener than once in 1500 to 2000 of the patients attending a special clinique in London. It is most common in children, and usually results from trauma. Thus, of 12 cases seen in the last seven years, amongst approximately 17,000 patients, all were due to trauma, and only two occurred in adults. 1 A case of this kind, in a girl aged 16, has just come under my care. The palate was markedly deformed. The obstruction was bilateral and bony. It was broken down with burrs and the posterior end of the septum was removed with Loewenberg's forceps. The symptoms are very characteristic. On examination the nasal fossae are found to be blocked by a symmetrical, bright red, tender, fluctuating swelling, situated on the anterior part of the septum. The end of the nose is frequently hot, red, swollen, and tender. The usual history is that the child has received a severe blow or has fallen heavily on the 'nose, and that this was followed by bleeding and nasal obstruction. These symptoms soon subsided, but a few days later the nose became swollen, painful, and completely obstructed. In other cases the development has been more insidious, and the subjective symptoms by no means well marked. Septal abscesses due to other causes, for example, to erysipelas, typhoid fever,1 small pox, tubercle, influenza, and sinus suppuration, have been described. Kuttner3 has recorded three cases, and Wroblewski1 has recorded five as idiopathic. Killian has recorded a case due to a dental abscess, and states that two other similar cases are known to him. 5 The abscess usually contains pyogenic staphylococci. Carrière reports a case in which living larvae were found: the abscesses due to typhoid fever, tubercle, etc., would probably have the specific organisms present. Pathology. The history indicates that in all probability a haematoma of the septum has followed the injury to the nose, and that pyogenic organisms have subsequently gained admission through an abrasion in the mucous membrane. This hypothesis is often demonstrated by finding large pieces of degenerated blood-clot in the pus on evacuating the abscess. Sometimes the blood is extensively effused beneath the perichondrium, stripping it up, and the abscess is apt to result in necrosis of the cartilage. This is especially liable to occur when the cartilage has been extensively broken up, and then a perforation or deformity of the septum and falling in of the bridge of the nose may occur as a late result. The deformity of the nose is probably due as much to the original trauma as to the abscess, though little may be noticeable till some time after the injury. Then a steadily progressive sinking in of the bridge of the nose may ensue and may continue to increase for years, partly perhaps as a result of slow contraction of the fibrous tissue, and partly because the injury has stopped the further natural growths of the parts.6 Diagnosis. The diagnosis is simple, depending upon the evidences of acute inflammation and the presence of a bilateral fluid swelling on the anterior part of the septum. The abscess is invariably symmetrical, 1 Wroblewski, Archiv f. Laryngol., 1895, ii. 287. 2 Hunter Tod, Journ. of Laryngol., 1903, xviii. p. 35. Wertheim, Archiv für Laryngol., 1900, xi. p. 209, and StC. Thomson, Journ. of Laryngol., 1901, xvi. p. 38. 3 Archiv für Laryngol., 1895, ii. p. 72. 5 Münch. med. Woch., 1900, xlvii. p. 155. Archiv für Laryngol., 1895, ii. p. 287. 6 Vide Spencer, Proc. Laryngol. Soc. Lond., 1900-01, viii. p. 3. |