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degree this defect, and I am happy to say the young man now has a very presentable nose.
Another case of very marked deformity came to me last summer. Some two years previous, while swinging on the backs of two seats in school, one gave way and he fell, striking a direct blow upon the nose. I have a photograph of him (Photo 3) showing marked external deformity. This was accompanied by such a shattering of his septum that no air could pass through either side. The triangular cartilage had been completely absorbed, probably as result of hematoma and later abscess of the septum. First, we remedied his stenosis by submucous resection, but when we came to look for inserts, we could not find a respectable sized or shaped piece of bone or cartilage to use. Meanwhile he had a very much hypertrophied right inferior turbinate, so with scissors I removed pretty much the entire turbinate, dipped it into tr. iodine, then alcohol, and then into sterile saline solution, went ahead with my dissection, and used it for insert, the result being shown by photograph (Photo 4).
In four cases I have implanted tissue from one individual into another, and in three they were perfectly successful. The fourth proved my only failure, indeed the only insert that did not take kindly to its new surroundings in my entire series. An explanation of this occurs to me in that the insert came from an Irishman and the matrix was on a Hebrew. You can't mix 'em. Another interesting case is that of a young woman who needed raising of the tip of her nose. Her fiancé needed a submucous, so we decided to take the tissues from his septum. We did this and implanted it with perfect success. Later, the young lady, who has a beautiful voice, went abroad as an entertainer with the Y. M. C. A., and found a man still more to her liking. On her return the engagement was broken, all presents were returned, and with his, he wrote a note telling her there was still one present she failed to return, viz., the piece of bone in her nose.
Patients come to us with these irregularities and deformities, many of them slight, and scarcely noticeable, but of which the individual is very conscious, and frequently rendered most unhappy thereby. However, sometimes they are marked and
affect the entire facial aspect, even the appearance of intelligence, and, in these days of competition, the earning capacity of the individual. Inasmuch as many of them can be entirely relieved, and others greatly improved by these comparatively simple measures, and as there need be no external scar, it seems to me to offer a field of valuable effort, certainly one greatly appreciated by the patient.
DR. FREDERICK N. SPERRY (New Haven): I am very glad to have heard Dr. Hammond's paper and to have seen his pictures. He is certainly to be congratulated on his success. It would be a mistake, however, to believe that the problems are as simple as he has presented. They are very difficult and the results are not always as successful as they have been in Dr. Hammond's hands.
There are two problems: one, the restoration of function of nasal breathing, and the other one of cosmetic effect. My efforts have been mainly directed to restoring nasal breathing, and for that nothing can compare with the operation of submucous resection. While it does not meet every situation, in most cases it is the operation par excellence. The work that Dr. Hammond has shown brings to mind an important question. It has been considered necessary to unite the bone implant with the bone of the patient, and, if possible, also the periosteum with the periosteum of the patient. This would require the hollowing out of a place for the insert. I am glad to know that Dr. Hammond has done without this procedure. If the grafting is unsuccessful we have a worse condition than before the operation,—you have the defect plus the hollowing out for the implant. I have no doubt that many of these cases will remain in the tissues without being absorbed. I should like to know, however, what an X-ray picture of the bone would show two or three years from now,-whether the bone will remain in the tissues or be absorbed, after months or years. The pioneer of this work in this country was John O. Roe of Rochester, N. Y. From all over the country patients went to him for the correction of nasal deformities. There are comparatively few men doing this work now, and I presume that Hartford, with its Dr. Hammond, will become a Mecca where men will go to have their noses straightened.
DR. MARK S. BRADLEY (Hartford): We have all seen cases of nasal deformity produced by syphilis. With the exception of trauma it is perhaps the most common cause of nasal deformity. These cases of syphilitic nasal deformity may be divided into two classes; the first being where there is extreme destruction of tissue, where there are extensive perforations in the triangular cartilage, cases of complete septal
perforation extending through the vomer, the ethmoid, and even the ethmoid cells. The second class is formed by those where the evidence of syphilitic destruction is not so prominent, where there is not such marked ssue destruction, and where we may not be so positive that it has been produced by syphilitic infection. In these cases in order that we may be safer from the possibility of sloughing away of tissue from syphilitic infection, it would seem wise to test the condition by the Wassermann reaction before operating.
There is very little to discuss in the paper presented by Dr. Hammond; his results are as plain as the nose on your face, as he so aptly expresses it, and the paper itself is one of the most valuable additions on the subject of cosmetic surgery of the nose that has been submitted in recent years.
DR. H. F. STOLL (Hartford): One point has occurred to me in explanation of the statement of Dr. Hammond's that the graft did not "take" when taken from another person. The iso-agglutinins of blood may have been incompatible. It has been found in skin grafting that blood grouping should be done, as it is in all transfusions, and it is quite likely that a bone graft would take better if compatible donors were selected.
DR. H. E. SMYTH (Bridgeport): I have not much to say on Dr. Hammond's paper, although I was much interested in hearing it. I know that the operation has been done in New York, and also that splints have been taken from the rib and tibia. Ten or twelve years ago paraffin was much used, and in many cases was very satisfactory, but has come into disrepute, and at present is not much used. Resection of the septum has come to be a recognized operation, and is required in many cases of nasal deformity, and if material can be obtained in this way, and be applied as a splint with Dr. Hammond's skill, it seems ideal.
DR. W. H. CARMALT (New Haven): I have known of cases of suits for malpractice in using paraffin having been brought and substantial damages obtained.
DR. HAMMOND: Dr. Sperry spoke of using X-ray findings to note the result of these inserts. Within a month Dr. Carter has sent out reprints stating the results of examination by the X-ray of several cases where practically all of them showed true growth. Furthermore, he has abandoned the use of a section from the rib, and is now using the submucous method, as I described to-day. As to the use of paraffin, I am glad to find so many backers in considering that an unfortunate procedure. I have seen noses that were a mass of slough and where even the cheeks were involved, with horrible results. I believe the consensus of opinion to-day is that it is not a surgical procedure and should no longer be used.
EMANUEL A. HENKLE, M.D., New London.
There are few diseases which are more thoroughly discussed and more extensively disputed than that of visceroptosis. It seems to be a topic for constant disagreement and self-contradiction among the clinicians.
In scanning the literature on visceroptosia, I find that prior to Glénard very little attention had been given to this extremely important subject. It had been recognized by earlier writers, but to Glénard undoubtedly belongs the credit for fully describing and emphasizing the importance of this condition.
With the advent of the Roentgen ray, the entire subject of gastro-enterology has been completely revolutionized. The anatomist was compelled to change his former rigid landmarks and allow for considerable variation in the normal location and habitus of the alimentary canal. Previous methods of examination for the position of viscera by palpation and gas inflation in the recumbent position were inadequate. The stomach was supposed to be in a normal position when its lower border was on a level with the umbilicus and when the colon was on a line crossing the iliac crests. There may be great variation between the erect and the horizontal positions in the location of the stomach and the intestines-therefore, roentgenologically, the position of the viscera must be determined with the patient erect. The weight of the barium or bismuth salts does not affect the position, since it is not heavier than an ordinary meal.
The etiology of splanchnoptosis has received the maximum of controversy. The two types of this condition, which are generally recognized, are the congenital and the acquired. It is thought by some that the congenital type predominates. In 1895 Stiller advanced the original theory that enteroptosis results from a congenital predisposition. Glénard, at first, laid stress on the normal kinks of the intestines, retaining the intestinal contents which drag on the peritoneum which, in turn, eventually
yields, and thus results in ptosis. He later abandoned this idea. and ascribed viseroptosis to a constitutional diathesis which he called "diathèse hépatique."
It is R. H. Smith's opinion that there is a predisposition to prolapse in childhood and that slender physique, frail health, and neurosis may contribute toward visceroptosis. He examined over one hundred children, ranging from birth to thirteen years, and states that actual prolapse of viscera rarely occurs in childhood; there are, however, muscular insufficiencies which in later life may result in ptosis. He recognizes an acquired type in women who are suffering from nervous strain, childbirth, and over-exertion. He states that in such cases the prolapse is never excessive.
Rovsing does not agree with Stiller's hypothesis and believes that visceroptosis in women is of two types-first, what he calls the virginal type, which is caused by corsets and tight bands, and which begins at puberty, and secondly, the maternal type which is caused by childbirth.
Kaufman states that the majority of cases of gastroenteroptosis find their origin in fatigue neurosis. He gives the reason for this view as follows:
1. Many persons who have prolapsed organs have no symptoms of any kind.
2. These persons may acquire gastrointestinal symptoms when subjected to nervous strain.
3. The symptoms may be made to disappear in many instances, without paying attention to the visceroptosis.
We may argue :—
1. That persons with prolapsed organs have no symptoms unless the prolapse is complicated.
2. That the gastrointestinal symptoms may be due to the nervous strain and not to the enteroptosis.
3. That the symptoms may disappear with the abatement of the nervous condition, but the ptosis may still remain.
Farther on, under the discussion of treatment, Kaufman modifies this view by stating that in many cases the symptoms of gastroptosis cannot be overcome until some support is offered