1 
ABSTRACT OF A PAPER ON DE- 
FLECTION OF THE NASAL 
SEPTUM. 
. BY JOHN N. MACKENZIE, M. D., 
of 
Surgeon to the Baltimore Eye, Ear and Throat 
Charity Hospital. 
[Read by invitation before the State Medi- 
cal Society of Virginia, Sept. 6, 1883.] 
{Reprint from Maryland Med. Journal of Oct. 20, 1883). 
accompany or follow irregularities in the 
embryological evolution of the nasal 
chambers and their dividing partition. 
Morgagni thought that the more rapid 
growth of the septum itself, as compared 
with "the other bones of the upper jaw," 
must be reckoned among the causes of the 
malformation, and elongation in its vertical 
diameter has been insisted on by subse- 
quent observers as provocative of the same 
result. Undue arching of the palatine pro- 
cess of the superior maxilla and a diminu- 
tion, therefore, of the vertical diameter of 
the corresponding nasal fossa, as well as 
other asymmetrical conditions of the nasal 
chambers, furnish the explanation of the 
malformation in a certain number of cases. 
These asymmetrical states are usually asso- 
ciated with imperfect development of the 
corresponding side of the skull, and are 
either the result of a teratological process 
or are due to the operation of accidental 
influences. They have been found, for ex- 
ample, in the embryo and foetus, and occur 
in connection with the imperfect cerebral 
development of idiots, and Ziem has shown 
that nasal disease itself may be an impor- 
tant factor in their production. Among 
the causes of acquired deflection, the most 
common is traumatism. Dislocation of in- 
dividual parts of the septum, fracture of 
the cartilage or bone, or both, occur in de- 
pressed fractures of the nasal bones, the 
accident generally involving the cartilagi- 
nous septum, fracture of the vomer being 
rare. It is possible that injury to the nose 
and consequent deflection of the septum 
may occur during difficult parturition, and 
it is also conceivable that the introduction 
of the finger into the nose, as suggested by 
Quelmalzius, Cloquet and others, may lead 
to displacement, but this, as well as the use 
of the hand in cleansing the organ, must 
be looked upon as an infrequent cause of the 
deformity. Deflection may also be pro- 
duced mechanically by tumors of the nasal 
and accessory cavities, excessive hypertro- 
phic states of the turbinated bodies and 
bones, and other irregularities in the con- 
formation of the outer nasal wall. Dia- 
thetic diseases (rickets, syphilis, osteo-ma- 
lacia, etc.), by involving the nose, lead to 
malformation of the septum. Quelmalzius 
thought that the prolonged use of sternu- 
tatories and astringents brought about de- 
flection, by contracting the pores of the 
vessels - a process which he compared 
to incurvation of the written side of a 
sheet of paper when held before the stove 
to dry. 
The deformity may consist either in 
simple deflection to right or left, in which 
case the inclination is usually confined to 
the cartilaginous portion and anterior part 
After some introductory remarks on the 
influence of nasal obstruction in the evolu- 
tion of morbid conditions of the lower 
organs of respiration and middle ear, Dr. 
Mackenzie proceeded to comment on the 
frequency of the deformity and the unsat- 
isfactory manner in which the subject is 
treated in surgical works. Differences in 
the direction and form of the external nose 
depend to a great extent upon correspond- 
ing peculiarities in the septum, so that 
when Tennyson sings of the " nose, tip- 
tilted like the petal of a flower," it is only 
the poetical expression of the fact that the 
septum narium of his heroine was deflected. 
Adherence t> national custom was given as 
the probable explanation of the relative in- 
frequency with which asymmetrical posi- 
tion of the septum is encountered among 
different races. The elegant aquilinity of 
the Caucasian nose is attributed to the care- 
ful manipulation of nurses, and we are told, 
that, among the Persians, the eunuchs who 
had charge of the royal offspring, were ac- 
customed to introduce tubules into the nos- 
trils to preserve that symmetry of the 
organ, which was essential to him who as- 
pired to the throne. Acquired malposi- 
tion is most commonly met with in youth 
and manhood, and more frequently in men 
than in women, as the former are more 
exposed to the agencies by which it is 
produced. 
Malposition also occurs as the natural 
result of the changes in the skeleton of 
the face which accompany the pro- 
cesses of old age. The occasional ap- 
pearance of the same deformity in a 
number of individuals of the same family 
would lead to the belief in an inheri- 
ted proclivity to deflection, and, according 
to the author's observation, the same is 
true in regard to certain deformities of the 
turbinated bones. The anomaly may be 
congenital or acquired. In the latter case 
it is either the result of traumatism, or oc- 
curs as the sequel of a pathological pro- 
cess. Under the first head may be in- 
cluded asymmetrical conditions of the 
bony and cartilaginous framework which 2 
of the bony septum, deflection of the pos- 
terior third of the vomer being exceedingly 
rare, or the septum may be bent in a more 
or less sigmoid curve, or flexed in an angu- 
lar manner. Not infrequently it is inclined 
neither to one side nor to the other, but 
presents, usually in its bony portion (but 
sometimes at the junction of the cartilage 
with the vomer and ethmoid), an oblique, 
rounded, bony ridge, which produces more 
or less occlusion of the nostril into which 
it projects. The opposite surface of the 
septum, corresponding to that of the anom- 
aly, is usually concave. This form of de- 
flected septum, which has been recently 
carefully studied by Zuckerkandl, did not 
escape the observation of Morgagni, who 
was the first to describe it. The deflection 
may affect the septum as a whole or be 
limited to the cartilage, the perpendicular 
plate of the ethmoid, or the vomer. In 
the latter case it usually takes place at the 
juncture of the latter with the perpendicu- 
lar plate, or the articulation of the latter 
with the cartilaginous septum, the condi- 
tion here being, according to Harrison 
Allen, one of hyperostosis of the sutural 
line. A very common point of irregularity 
in the vomer is along its inferior edge, in 
the neighborhood of the nasal spine, where 
it is associated with a similar projection of 
the cartilage, the two together forming a 
more or less wedge-shaped process, whose 
apex lies across the floor of the nostril. 
Occasionally an 5-shaped incurvation, from 
above downwards, of the bony septum is 
seen, in which both the vomer and perpen- 
dicular plate participate. By far the most 
common seat of deflection is, however, the 
cartilaginous septum, which presents a 
great variety of irregularities and abnormal 
positions. The principal are: I. Simple 
bulging on one side and concavity on the 
other, the smooth, rounded dome of the 
deflected portion occluding the nostril of 
that side and giving to the eye the impres- 
sion of a polypus. 2. Wedge-shaped pro- 
jections, the apex of the wedge projecting 
into the obstructed nostril, and running 
either in an antero-posterior or vertical di- 
rection. The opposite side of the cartilage 
may or may not show a corresponding de- 
pression. 3. Spurs of the inferior border, 
either confined to the anterior portion or 
running the whole length of the cartilagi- 
nous septum. These are often associ ited 
with a depression of the septum above 
them, which t ulges into the fossa of the 
opposite side. 4. Irregular nodular growths 
of the cartilage of varying size and appear- 
ance, often extremely vascular, and giving 
rise to deformity, which may be looked 
upon rather as cartilaginous outgrowths 
than true deflections. 6. S-shaped incurv- 
ation, producing obstruction of one nostril 
anteriorly and the other posteriorly. 6. 
Lateral dislocation of the inferior border. 
7. Two or more of the above combined. 
Dr M. next dwelt upon the evils 
which follow as the natural results of the 
deflection, and its importance as an etiologi- 
cal factor in the production of throat and 
middle ear disease, and, in connection with 
this part of his subject, called attention to 
the development of laryngeal and aural 
disease through the reflex agency of the 
vaso-motor and trophic nerves as the result 
of pathological conditions of the turbinated 
tissues of the nose. Passing, then, from 
diagnosis and treatment, the operations 
with the galvano-cautery, knife and snare 
were mentioned, and resection, as practised 
by Dieffenbach, Heylen, Chassai nac, De- 
marquay, Ingals and others was com- 
mented upon. Adams' operation, with the 
modification practised by Jurasz, were de- 
scribed, and theprocedure known asSteeles, 
viz: triangular division ot the cartilage 
and subsequent replacement, was shown to 
have originated with Dr. Bolton, of Rich- 
mond. Of the various forms of plug used 
to retain the septum in its po ition, gutta 
percha was specially recommended, and the 
use of rubber bags, introduced into the 
nostril and inflated, were suggested.as pro- 
ducing less irritation and securing more 
equable pressure than the other forms of 
plug in common use. In reference to the 
operation of perforating the cartilage, as 
practiced by Blandin and others, Dr. M. 
said: "Apart from the creation of a condi- 
tion which disturbs the physiological rela- 
tions of the air-current, the tendency to 
scabbing and the difficulty of thoroughly 
cleansing the nostril after the perforation, 
this operative procedure must be regarded 
at the best only as a palliative measure, the 
anatomical relations, and, therefore, the 
most disagreeable feature of the case, re- 
maining the same, and the nostril deprived 
of its natural functions. It is only, there- 
fore, in exceptional cases, where other ope- 
rative procedures are contra-indicated or 
impossible, that the operation will be called 
for." After referring to the operations on 
the bony septum with the dental engine 
and saw, and the suggestion of Dr. Dela- 
van to remove the turbinated bone of the 
unobstructed nostril in cases where it was 
hypertrophied before resorting to straight- 
ening the septum, Dr. M. called attention 
to certain cases of deflection of the bony 
septum where operative procedures are 
difficult of execution,and recommended as 
a substitute for operation on the septum it- 
self removal of the turbinated bone of the 
obstructed nostril, relating a case where he 
had successfully performed the operation.