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tion 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.

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. Others again show only a displacement of the cartilage of the septum at its lowermost point, the sharp border of the cartilage projecting into

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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 various forms of septal spurs, ridges, etc., it is not the purpose of the present paper to deal.

A well defined deflection of the septum sufficient to occlude one or both of the nostrils even a portion of the time, is fraught in the vast majority of cases with a long trail of evils, which it is our purpose briefly to notice. A septum

may be forced to one side and in contact with the turbinate bodies of one of the nostrils. This, while it occludes the one nostril, leaves an excess of space on the other side. Nature abhors a vacuum. She attempts to fill up the vacant space. The turbinates undergo a compensatory hypertrophy on that side, and, in a 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 inter-dependence 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 causewhen 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.

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

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FIG. 3.

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 straight-cutting 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. Should this cause pain, a ten 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 galvano-cautery 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 Ave.

The Indications and Modes of Drainage After Abdominal and Vaginal Section.

The following from the pen of Nicholas Senn, M. D., of Chicago, is interesting and valuable:

Drainage of the abdominal cavity is an expression of the present imperfect state of surgery. It is often an unavoidable evil. It should be limited to appropriate cases, and it is, therefore, well that the indications for it should be laid down clearly, so that we may have eventually some definite rules that will guide the surgeon in his abdominal work. There are now no fixed rules. Some surgeons avoid drainage wherever possible; others drain as a rule. If I were permitted to pass my judgment on this question as a whole, I would say that the surgeon who has the ambition to operate quickly, to make an impression on the bystanders, should drain frequently; while, on the other hand, the surgeon who proceeds with his work carefully, step by step, with plans well laid out, with his practical knowledge resting on a firm pathological basis, will only drain in exceptional cases. After opening the abdomen the surgeon has frequently to deal with affections that absolutely call for drainage. There is no other course to pursue. He meets with pathological conditions that cannot be successfully removed; he meets with cavities, the walls of which it is impossible to extirpate, and consequently he proceeds to establish an abdominal fistula, a great consolation to the operator, because it enables him to do something, so that probably during the course of time Nature will come to his rescue, taking advantage of the temporary drainage, and eventually closing the cavity where drainage was established. One of these conditions is met with in a distended or diseased gall bladder. It is my firm conviction that the best success obtained in cases of disease of the gall bladder requiring opening of the organ, in the absence of a permanent occlusion of the common duct, is the establishment of an external fistula. This operation shows the greatest success, is attended by the least danger-in fact, it is almost devoid of danger if the sur

geon is careful to prevent infection of the peritoneal cavity during the operation.

The next condition-one that is not so frequently met with (but there are now forty or sixty cases on record)—is cyst of the pancreas. A few bold surgeons have made the attempt and in a few isolated cases have succeeded in extirpating pancreatic cysts with Statisa mortality of more than 50 per cent. tics show that the formation of a fistula usually results in a permanent cure in the course of a few weeks, and that a permanent fistula is the exception.

Very often the surgeon makes a mistake in diagnosis, opens the abdomen for a supposed ovarian cyst or an ovarian tumor of some kind, and is astonished, when he has exposed the abdominal organs, to find a retroperitoneal cyst, a hydronephrotic kidney. Many surgeons under such circumstances have resorted to the formation of an abdominal fistula, thus draining the distended pelvis of the kidney-a very unwise procedure, because a lumbar fistula will accomplish the same object, the formation of which is attended by less danger, and eventually, if it should become necessary, a nephrectomy is attended by a great deal of difficulty if previously the organ has been attached to the abdominal wall. So that I should lay down the rule that in hydronephrosis, whether diagnosticated before or during the operation, the surgeon should make a lumbar nephrotomy.

Then comes that large class of pelvic abscesses without removable walls; abscesses which have had their origin in the pelvic removable walls; abscesses which have had their origin in the pelvic connective tissue, perimetritic abscesses; abscesses originating within the fallopian tubes, and abscesses within or around the ovary, but in which the careful surgeon will make the most scrutinizing examination before he attempts the work of enucleation. If he finds enucleation impossible it would have been vastly better if he had dealt in a more conservative manner with his patient, and had resorted to abdominal drainage as taught us by Mr. Tait.-Am. Gyn. and Obstet. Jour., March, 1896.

Novel Method of Disposing of Neuromata.

It has been found that neuromata after amputation almost always appear in scar tissue, and are especially fixed against the sawn end of the bone. Senn endeavors to obviate this by amputating the nerve high up in the tissue, and then cutting a V-shaped wedge out of the distal end, uniting the two flaps with sutures so that none of the interior of the nerve-trunk is exposed-all nerve tissue is covered in by the endothelial sheath.-The Medical Age.

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We publish in other columns a good paper by Dr. Chaffee of Brooklyn, in which he discusses at length the Railway Employes' Hospital Association and its benefits, especially to the injured and sick employes. We hardly conceive the possibility of a difference of opinion among surgeons as to the desirability of the railway hospital system, and it seems to us that this paper of Dr. Chaffee's should be enough in itself to convince the most prejudiced railway man of the advantage both to the employe and to the management of such a scheme.

As Doctor Chaffee says, accidents upon the railway are inevitable, and we must have railway surgeons, and while we are all prepared to prove that good surgery can be done at the cross roads, there is no necessity for proof that railway surgery can be best done in well ordered hospitals, and if a road can own and manage its own hospital, or have a system of hospitals distributed along the line, all under one chief surgeon, and arranged and conducted after the same general plan, it must of necessity be productive of the very best work in the care of the sick and injured.

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As to the economical side to the question, we believe it has been quite sufficiently demonstrated that, all things considered, this method of caring for those injured on the track is by far the best and cheapest.

While we are aware that on some roads the proposition to establish such a system and to assess employes for its support has met with opposition among the men, we believe it has always been due to a misunderstanding, because of faulty presentation of the plan and a misconception on the part of the employes of what was desired of them and what the benefits were to be.

Referring again to the paper of Dr. Chaffee, there is abundant proof such as he furnishes in the form of letters from railway men who have been patients in the hospitals, that when the system is fully comprehended and its bene-. fits experienced by the men, all opposition on their part ceases and they are loud in their praises of the method.

We can conceive of nothing more desirable or more humane than the transfer system which Doctor Chaffee suggests, looking to the exchange of patients by various railway hospitals situated in the different parts of the country, and trust that the subject will be agitated until such a system is established. It is certainly a perfectly feasible thing, and, we believe, would so shorten the term of hospital life in many cases as to make it a reai economy, as well as a true beneficence.

We have just received a reprint of an article by Dr. Frank H. Caldwell, chief surgeon. of the Plant System, entitled "Transportation of Injured Employes," in which he gives a very good description of the hospital car used upon the Plant System for transporting patients from one hospital to another, and also from the scene of an accident to the nearest hospital. This seems to leave almost nothing to be desired for the immediate and continuous care of persons injured upon the railway. He says:

"It has been conclusively demonstrated that injured persons, except when suffering from severe and extensive injuries to the head, spine, thoracic and abdominal cavities, or in a state of profound shock, may, when properly handled, be transported almost an indefinite distance without endangering life or increasing the extent of injury. And it has been further shown by actual experience that a large percentage of the exceptional injuries above men

tioned can be safely handled if proper transportation facilities are provided. In cases of lighter forms of injury, as a crushed limb, how should they be transported to the hospital in order that shock may not be induced or increased, or the already mangled parts be further injured?

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"The nearest surgeon is sent for, and under no circumstances should the patient be carried to him. The messenger informs the surgeon as nearly as possible of the nature and extent of the injury, so that he may come prepared, for not all surgeons have emergency cases, ready for every kind of accident. surgeon, upon his arrival, controls hemorrhage, anticipates or combats existing shock, and adjusts a temporary dressing. Briefly, he prepares the patient for his journey, whether it be long or short. After due preparation, the patient is lifted gently a few mches from the ground or floor, and a stretcher slipped under him, and he is lowered into it and made comfortable. He is then carried into a coach or baggage car of the first passenger train going in the desired direction. An injured man should never be transported by a freight train. If no passenger train is available in a reasonable time, a "special" should be provided. If the surgeon in attendance fears for the safety of his patient, the chief surgeon should be notified of the fact, and he should instruct the surgeons along the line to visit the patient as the train passes their stations and renders any assistance necessary.

"As a rule, upon arrival at the hospital, you will find your patient in condition to submit to any operation required for his relief. The plan above outlined in this class of cases, is the one practiced on the system which the writer represents, and furnishes the patient almost constant attention from the receipt of injury until he arrives at the hospital; the greatest distance between surgeons being forty miles, and usually but twenty.

"The comfort and safety of the patient will depend very much upon the stretcher in transporting him. The writer spent several years experimenting before one was secured which answered the purpose to the satisfaction of himself and patients. Photographs of the ones that have been in use upon our system for the past eight years are submitted for your inspection. It is made of cypress; a light, springy, yet strong, native wood. The stretcher will pass easily through a car door, and two standard car cushions placed end to end, fit it exactly, and can be used as additional protection when required. The bottom of the stretcher is of wire netting, two-inch mesh, and is covered with eight-ounce duck. The netting and duck are fastened to the frame with strips of wood which are screwed on, and enabling us to easily clean or repair the wire

and duck. The legs fold under, and have heavy, corrugated rubber tips. This stretcher is light, strong, durable, and easily kept clean. It has sufficient elasticity to prevent undue jolting, but not enough to give pain. The writer has personally tested it, and can certify to its comfort.

"There have been several plans of ambulance cars proposed from time to time, but they have, in the writer's opinion, been too elaborate, entailing a large expense upon the company, the officials of which could not see a proportionate benefit; and in my judgment they have taken the correct view of the case. What we need is a strong, stiff car, with firstclass trucks, furnished in the simplest style, without upholstery of any kind. We need a transportation room, an operating room, and a small consultation room.

"The transportation room is furnished with wrought-iron beds, with woven wire springs. Heavy, corrugated rubber tips are on the legs, which prevents slipping, and breaks the jar to a great extent. When not in use, these beds are fastened against the walls of the car, and are entirely out of the way. In addition to these, we have an air bed, which, when not in use, is folded into a very small compass, and packed into a closet. It takes but a moment to inflate it with air. Lastly, there is a hammock arrangement made to suspend from the roof of the car by strong straps. This hammock has a device of short, strong, spiral springs, which absolutely prevents any jolt cr jar being communicated to the patient.

The operating room is supplied with an iron, glass-top table, and all necessary appliances for the treatment of shock, and for the performance of perfectly aseptic operations. Sterilizers, etc., are stored beneath the water tank, which is kept filled with sterilized water. All bedding, etc., are packed in the corner cupboard. Bandages, bottles containing chloroform, ether, etc., are in the center cup

board.

The car is painted with a specially prepared paint, which may be scalded without injury, and will stand disinfection by means of superheated steam or air."

Physic is of little use to a temperate person, for a man's own observation on what he finds does him good, and what hurts him is the best physic to preserve health.-Bacon.

A doctor is a man whom we hire for the purpose of telling stories in the chamber of a sick person till nature effects a cure or his medicine kills the patient.-Seward.

Some persons will tell you, with an air of the miraculous, that they recovered, although they were given over, whereas they might, with more reason, have said, they recovered because they were given over.--Colton.

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