I-7 When to operate in the Nasal Passages. AND A Nasal Cutting-Forceps. BY A. B. FARNHAM, M. D., LARYNGOLOGIST TO THE MILWAUKEE HOSPITAL, MILWAUKEE, WIS. REPRINTED FROM <E!;r Neto York .ftrteto'cal JJourrcal for July 3, 1886, and May 21, 1887. Reprinted from the New York Medical Journal for July 3, 1886, and May 21, 1887. TWO PRINCIPLES WHICH SHOULD DETERMINE WHEN TO OPERATE IN THE NASAL PASSAGES.* By A. B. FARNHAM, M. D., LARYNGOLOGIST TO THE MILWAUKEE* WOSPITAL, MILWAUKEE, WIS. It is the opinion among many of the medical profession that throat and nose specialists frequently operate unneces- sarily. Many recall frenzies which have seized the profes- sion to perform certain operations on different parts of the body, and it is but natural they should suspect the innocent rhinologist and laryngologist of similar madness. I wish to make clear two principles, the proper applica- tion of which will guide us unerringly to the performance or non-performance of any given operation. The first prin- ciple is, that all causes of irritation must be removed. The primary application of this principle takes out of the discus- sion the larger growths and limits it to the smaller hyper- trophies of the mucous membranes and to the exostoses and deviations of the septum. These latter play by all means the leading role in the mucous hypertrophies and degenera- tions under consideration. From congenital and accidental causes, the growths upon and deviations of this partition * Read before the Wisconsin State Medical Society, June 1, 1886. 2 WHEN TO OPERATE IN THE NASAL PASSAGES. are numerous and of exceeding variety and complexity. No matter how numerous or how varied, let them alone unless they are causing irritation, and even then take away only sufficient to fully relieve the pressure and chafing of the op- posing membrane. By one or more observations determine the most offending growth or portion of a growth and re- move that, and wait, when possible, and see the full result of what has been done. Growths of considerable size projecting into the middle meatus, or elsewhere, where no irritation is caused, can be let alone. If the mucous membrane, when distended, touches a growth, you will almost surely find in- dications of its doing so by inspection of the membrane in question. Growths or deflections which we would remove or correct in the young we can often let alone in the older, because they have done all the injury they can do and no direct gain will come from surgical interference. The abnormities of the septum may cause deviations of the turbinated bones and irregularities in the develop- ment of the mucous membrane covering them, consequent pressure, irritation, and probably hypertrophy. Note the point of pressure and irritation and remove just enough turbinated bone or hypertrophied tissue to relieve this irri- tation. Nature may do something for what we leave. The second principle governing our action is the secur- ing of proper drainage and ventilation. Interference with these functions is caused by anterior or posterior stenosis. In my experience the former is more frequently produced by septum growths or deflections, while the latter is more usually caused by growths upon the turbinated bones. Com- paratively less frequently is the vomer at fault. Lack of proper drainage causes retention and consequent alteration in the character of the nasal discharges, producing irrita- tion and its train of evils. The backward drainage of the secretions hardly causes the damage alleged for it, as they WHEN TO OPERATE IN THE NASAL PASSAGES. 3 flow back during our sleep, and in our waking hours a portion of the time, from the position in which the head is held. Anterior stenosis may cause among its evils a rarefac- tion of the air in the naso-pharyngeal space from the great current being taken in through the mouth and consequent suction upon the membrana tyinpani, and partial deafness. The original stenosis is also increased owing to the weaken- ing or atrophy of the dilators and consequent falling of the cartilages of the alae nasi against the septum. Whatever may be the cause of interference with proper drainage and ventilation, remove it in the careful conservative way hinted at above. As this involves operating on the septum, I should like briefly to put on record the method of moving over this par- tition which my experience has led me at present to think the most desirable. Do not use punches. With the small burr of the dental engine the wall can be weakened exactly where one wishes; there will be less haemorrhage, and the membrane on one side will be absolutely uninjured, a mat- ter of great importance. If an angle is attacked, the burr can be supplemented by the nippers or forceps and any desired portion of bone or cartilage removed, leaving the membrane on one side absolutely intact. Generally the convex surface is attacked, but in broad curves the concave surface may be operated on and the desired pressure applied on the uninjured side. The work can be finished, if need be, under ether by the use of Smith's forceps, though my fingers almost invariably serve me best. The attractiveness of this method is its absolute exactness. An appreciation of the exact require- ments of each case and a more or less delicate touch are required. The after-treatment should include cotton plugs, digital pressure, and care and patience ad libitum. A NASAL CUTTING-FORCEPS AND BLOODLESS NASAL OPERATING. The instrument shown below has been of service to the writer, and is presented in the thought that it may help others.* One great need in nasal work is that the operator should see what he is doing, and, other things being equal, that is the best instrument which least obstructs the vision. A set of special burrs made for the dental engine gave me vision, but a trained assistant was needed and the work had to be finished by other aids, and the personal equation remained unsatisfied till I had these instruments made. Have been using them nearly a year, and, in addition to giv- ing perfect vision, they enable one to operate with great ra- pidity. Have attempted no operations against time, but can and have repeatedly removed within a minute the ordi- nary ridge on the septum of an inch or an inch and a half in length. Over the saw it has the advantage of causing far less shock, of injuring in the operation no other tissues than the ones attacked, of going around a corner and finishing at once what may require a second or third operation, and, on the other hand, the disadvantage of not being able to take off a growth of broad base. But then they were never de- signed for this work. For them I have used and still use the burr, or the saws, of Dr. Harrison Allen, and since their publication those of Dr. Francke Bosworth. * A gnawing forceps is not represented. A NASAL CUTTING-FORCEPS. 5 Over Dr. Jarvis's set of instruments they have the ad- vantage of giving better vision, and are of easier introduc- tion and removal. They do not catch, and are preferable for trimming after the use of the burr. The smaller ones are so delicate that one can reach any portion of the septum, however high, and sufficiently strong to remove any growth suitable for the instrument with greater accuracy and rapid- ity than by means of burrs. A very great practical point is that with these smaller ones one can probe as well as crush. A competent experience of two years with burrs made for me of special length and fineness led me to dis- 6 A NASAL CUTTING-FORCEPS. card them in favor of these instruments. Again, one can control their action better than that of the burr. With the burr, too, one can not probe. They are useful for removing portions of the turbinates. The one with the broader end was designed for work upon the middle turbinates. After destroying the overlying tissues, one nips off just the desired portion. Twice within three days I have found them useful in re- moving a portion of the cartilage for stenosis at the orifice. Pulling the tissues well down that the cut might be made through the mucous membrane under cocaine, and then cut- ting down with the galvano-cautery knife, I have removed what cartilage was deemed necessary, the blades of the forceps acting very well as spuds as well. Both operations were bloodless. Most of the operations within the nasal cavity should be bloodless. Many women and children are shocked at the sight of blood, and. no one really enjoys bleeding, and, be- sides obstructing the view, haemorrhage renders our work more tedious and less exact. Cocaine enables us to do al- most everything without ether, and therefore makes- more demands in other directions than were formerly made. Let the su-geon save himself, too, all he can. The more he works at ease the less the nervous output. By treating the growth on the septum, or portion of tur- binated tissue, to be removed first with chromic or other acid and then with the galvano-cautery as an additional pre- caution, most of the ordinary work can be done without haemorrhage. If not practicable to treat all the surface, touch the presenting portions, and better vision is gained, even i there is slight haemorrhage. While presenting a nasal instrument, I would vet again * protest against removing all abnormities on the septum. * See."N. Y. Med. Journal," July 7, 1886. A NASAL CUTTING-FORCEPS. 7 Very many of them are harmless and should be let alone, and others need not be removed wholly but only in part. The abnormalities have often so modified the adjacent structures that no good can come from surgical interference, but positive harm by making the passages too patent. We have had enough of anatomical surgery. My thanks are due to J. II. Gemrig & Son, of Philadel- phia, who have carried out my ideas much to my satisfac- tion.