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entirely on differences in surgical technique. The whole question seems to depend on how sharp a periosteal elevator is employed; if only the fibrous layer is removed it contains no osteogenetic capacity; the periosseous membrane is the one that has the osteogenetic capacity and it has very much less density; it is partly attached to the fibrous layer of periosteum and dips down into the cortical bone itself, so that it is a question whether it is actually a part of the periosteum or a part of the cortical bone. However, so far as the grafting or transplanting of bone are concerned, we must bear in mind that the periosteum plays a rôle of importance in so far as the nutrition of the transplanted bone is concerned. A larger number of successful transplants can be made if the periosteum is kept intact, and as a practical matter we should bear that in mind when separating the periosteum in the transplantation of bone.
DR. E. H. ARNOLD (New Haven): I also agree with the previous speakers that this is chiefly a matter concerning technique. Two years ago I read before you a paper on bone grafting, and in the discussion was asked about my management of the periosteum. I said that it made little difference whether the periosteum went with the graft or not, that it kept alive either way and that the osteogenetic elements lie in the cortical part of the bone. However, what Dr. Swett says is true, where we want to make doubly sure we had better take the periosteum along. In plastic work where we don't want the graft to proliferate, the periosteum may serve the function of a limiting membrane. I have so used it in bone grafting. In the upper part of the spine and where the size of the spinous processes permit I have followed Albee's method of splitting and putting in the trough so made my graft periosteum upward. That has worked very well. In grafting, however, for fixation of the sacrum such inlay into the spinous processes is practically impossible for they are too shallow on the sacrum. I have, therefore, put my grafts alongside to the left and right of the spinous processes of the lumbar region and sacrum in order to get fusion between graft and sacrum. The periosteum has to be lifted off the spinous processes and laminae. In several cases in a rather large number of such operations I failed to get fusion though the graft lived. On reflection I ascribed such failures to the difference in the technique of lifting up the periosteum. Where I had lifted it up with a blunt lifter I had some failures and upon changing to the use of a sharp periosteum lifter and chiselling a trough into the cortical layer of the sacrum I have had no failures since. This is explained by what Dr. Hyde said in his paper and his advice should be closely followed. When we come to use bone grafting for plastic work the question of whether we wish to get bone regeneration of simply the size of the graft, or proliferation, must determine the method.
Correction of Nasal Deformities by Combined
under Local Anesthesia.
SAMUEL M. HAMMOND, M.D., Hartford.
By its location and anatomical construction, the nose is particularly liable to injury, the results of which are most apparent. "Plain as the nose on your face," is still the ultimate of clearness. Beside those due to trauma, we find deformities due to disease; syphilis, tuberculosis and tumors; occasionally as result of surgical procedure; and finally from faulty development of the
The commoner forms are known as crooked or cork-screw nose, hooked-nose, dropped-nose, saddle-back, the flat and the pinched nose. All are prone to be accompanied by malformations within the nose that militate against proper breathing.
I have long felt that the nose has been more neglected than any other organ of the body in the curriculum of our medical schools. Few realize that this organ secretes two quarts of water in twenty-four hours to moisten the air we breathe, or that air at zero or below, breathed in, is delivered to the throat at normal temperature; that one's intake of oxygen may vary by fifty per cent due to improper functioning of this organ. A good nose is so important to the individual health, comfort, and well-being, that it seems a few hours more time might well be given to its study.
In dealing with these deformities it is of first importance to establish proper breathing channels. This means trimming excessive turbinate tissue, and by sub-mucous resection removing all ridges, spurs, thickened and deflected areas of the septum.
Long ago, I became impressed with the improved appearance of some of these cases, especially the crooked-nose type, as result of sub-mucous resection. Having seen some of the results of paraffin injection-a not too surgical procedure, and so often
unsuccessful, and having read of Dr. Wesley Carter's work in New York, of reconstructing the nasal bridge by use of a resected portion of a rib, some two years ago, it occurred to me that it would be much simpler to avail oneself of the material at hand after submucous resection for a like purpose, and do the work submucously and subcutaneously. At the time I supposed this was original but later learned that at least two other men had been using this method for some time.
Again, eight months ago, I ran across two cases in which the nasal depression was too great to be filled by the products of septal resection, so made use in one case of the larger part of a middle turbinate, and pretty much the entire, very much enlarged, inferior turbinate in the other. Verily "there is nothing new under the sun" for about six weeks later I received a reprint describing a similar proceeding.
We much prefer local to general anaesthesia for these cases: first, because it is simpler; second, the field of operation is much freer from blood; third, because it is absolutely efficient and finally it avoids the danger of vomitus entering the nasal passage as frequently occurs after ether.
For some time we have been using a ten per cent solution of crystals of cocaine in one to one thousand adrenalin solution. This is carefully rubbed into the septum, on cotton wound applicator, covering its entire surface and repeated until the anaesthesia is complete. The adrenalin solution by its effect on the smaller blood vessels apparently prevents any but a local absorption of the cocaine. Certainly we have nothing like the ill results of former days when we used a watery solution of cocaine even in smaller percentage.
We now proceed with our submucous resection, carefully saving such bone and cartilage removed as may prove available, and keeping it in warm sterile saline solution. We sew up our incision these days and use no packing after submucous resection; strangely our cases seem to have less bleeding and certainly much less discomfort than in the old days when six or seven yards of vaselined gauze was packed in either nostril.
After having corrected our internal deformities we are now
ready to work on the external, making use of differing measures according to the type we are dealing with.
Let us consider the crooked or twisted nose first.
Frequently our submucous resection has almost completely cured the deformity, leaving perhaps a little manual work in moulding the soft part into proper place. Sometimes considerable pressure must be used and again we may need to remove a bit of bone or insert a piece of bone or cartilage to fill up some
depression. We then make use of the technique as in the depressed, drop, or saddle-back type.
First we insert a pledget of cotton saturated in solution of cocaine, carbolic acid and menthol, equal parts, into the anterior lower angle of the left nostril, prepare a hypodermic of cocaine 14 of 1% adrenalin, 1/20,000, in sterile saline solution. After five minutes we remove our pledget of cotton and paint the line of our incision with iodine followed by alcohol. This incision. is made from 4 to 1⁄2 inch within the left nostril at the junction