=Advantages of the operation.= These may be summarized as follows:--

1. A general anaesthetic is not inevitable.

2. Haemorrhage gives no trouble.

3. Absence of pain and shock.

4. No reaction. The post-operative temperature seldom rises above 99 F.

5. Absence of sepsis, with its possible extension to ears, sinuses, or cranial cavity.

6. No splints are required, and no plugs after the first 48 hours.

7. Rapid healing, without crust formation.

8. No risk of troublesome adhesions.

9. Short after-treatment.

10. Speedy establishment of nasal respiration.

11. Suitability for every variety of deformity of cartilage or bone in the septum which may require treatment.

12. No ciliated epithelium is sacrificed.

13. Accuracy of result can be depended on; the prognosis is, therefore, the more definite.

14. If the external appearance of the nose be altered at all it is in the way of improvement.

It will be seen that the above advantages cancel most of the drawbacks which were formerly so annoying in nasal surgery.

=Contra-indications.= 1. Elderly people are so accustomed to their nasal obstruction, and its secondary consequences are generally so fully established, that the benefits would be much less marked than earlier in life.

2. Serious or progressive organic disease. This does not apply to quiescent or arrested tuberculosis.

3. Active syphilis.

4. Lupus.

5. The operation should be postponed if the patient shows any symptoms of influenza, or of acute or infectious catarrh.

=Operation.= Submucous resection can be completely carried out under local anaesthesia, as described on p. 572. Killian and others secure local anaesthesia by submucous injection of cocaine and adrenalin (see p.

572), but I have found this method alarming to the patient, apt to produce disagreeable palpitation, and not superior to the method of superficial application already described, particularly if sufficient time is allowed for the mixture to act, and if a few cocaine crystals are allowed to dissolve over the site of incision some minutes before starting it.

In nervous subjects it is better to administer chloroform, not so much because of any pain they suffer, but because of the mental strain they are apt to feel in watching the various manipulations.

[Ill.u.s.tration: FIG. 299. BAYONET KNIFE.]

_Position._ The operation is best done with the patient horizontal on an operating table, with the head and shoulders well raised. His nose is then almost on a level with the eye of the surgeon, who is armed with a frontal search-light or Clar's mirror (see p. 571), although he can also operate successfully with an ordinary forehead reflector.

[Ill.u.s.tration: FIG. 300. INCISION FOR SUBMUCOUS RESECTION OF THE SEPTUM.

The incision is made, on the convex side, from B to A. If the free end of the quadrilateral cartilage is displaced from behind the septum cutaneum, and presents in one nostril, then the incision is made from _b_ to _a_.]

_The incision._ This can be made with a narrow scalpel, but a much shorter instrument mounted on a bayonet handle cutting all round the point will be found more satisfactory (Fig. 299). The incision is made from the side of the convexity, just anterior to it, and generally about half a centimetre behind the junction of the skin and mucous membrane (Fig. 300). It is started high up in the attic of the nose, and carried downwards to the floor. Sometimes it curves a little backwards below, but it is quite unnecessary to convert it into an L-incision by a second cut backwards. The incision, in its whole extent, divides the mucous membrane and cartilage at one cut, but without puncturing or wounding the mucosa of the opposite (concave) side. In doing this the operator's forefinger in the opposite nostril serves as a useful guide (Fig. 301).

In those cases where the lower free end of the quadrilateral cartilage is displaced from behind the septum cutaneum into one nostril--commonly but erroneously described as 'dislocation of the septum'--the incision is made directly over the exposed extremity (Fig. 300, _b-a_).

_Raising the convex flap._ With a small sharp elevator the muco-perichondrium is raised along the posterior edge of the incision.

Great care must be taken not to pa.s.s the raspatory between the mucous membrane and the closely adhering perichondrium. The dead white, slightly roughened surface of the bare cartilage should be distinctly visible, and should not be coated with any soft, smooth, or pinkish perichondrium. Once the flap is well started a dull-edged detacher (Fig.

302) will readily undermine it by sweeping movements gradually advancing upwards and backwards. If possible the limits of the convexity should be pa.s.sed, but it is well not to attempt to go round sharp projections, as it is there that perforations are apt to take place. It is easier at a later stage to strip the flap off crests or spurs.

[Ill.u.s.tration: FIG. 301. MAKING THE INCISION FROM THE CONVEX SIDE IN SUBMUCOUS RESECTION OF THE SEPTUM. The forefinger of the left hand acts as a guard in the opposite nostril.]

_Incision through the cartilage._ If the cartilage has not already been completely cut through at the first incision it is now divided in the same extent as the cut in the muco-perichondrium, great care being taken not to b.u.t.ton-hole the mucosa of the concavity.

[Ill.u.s.tration: FIG. 302. DULL-EDGED DETACHER.]

_Raising the concave flap._ The sharp elevator, followed by the dull-edged detacher, is introduced from the incision on the convex side.

The muco-perichondrium of the concavity is now raised in the same way and with the same precautions already used on the convexity, the sharp elevator and then the dull-edged detacher being introduced through the incision in the obstructed orifice, and manuvred between the cartilage and the concave flap without puncturing the latter (Fig. 303).

[Ill.u.s.tration: FIG. 303. DENUDATION OF THE SEPTUM IN SUBMUCOUS RESECTION. The muco-perichondrium has been raised from the convex side of the septum, and the cartilage has been cut through (from A to B in Fig. 300). The dull-edged detacher is shown separating the mucous membrane from the concavity of the deflexion.]

[Ill.u.s.tration: FIG. 304. COMPLETE DENUDATION OF THE DEVIATED SEPTUM.

Semi-diagrammatic drawing of a transverse section of the nose, viewed from above. The deviated septum has been divided in front, and its muco-perichondrium has been stripped up on each side. The nasal speculum is introduced through the convex nostril, and a blade is inserted on each side of the septum, between it and its mucous covering.]

_Excision of the deviated cartilage._ A long Killian's nasal speculum (Fig. 346), or the long Thudichum's speculum I have had made, is now introduced through the obstructed nostril, one blade being inserted on each side of the now denuded septum (Fig. 304). It is easy to see if the mucous membrane has been sufficiently stripped off. If not, it can be carried further with a few sweeps of the raspatory. Ballenger's swivel septum knife[61] (Fig. 305) is then placed astride the anterior cut surface of the cartilage, pushed upwards and backwards below the roof of the nose until it comes in contact with the ethmoid, then downwards and backwards to the angle between the ethmoid and the vomer, and, finally, pulled forwards along the upper margin of the vomer (Fig. 306). The excised cartilage is thus removed _en bloc_, and may measure an inch by one and a half inches.

[61] _The Laryngoscope_, vol. xv, June, 1905, No. 5, p. 417.

[Ill.u.s.tration: FIG. 305. BALLENGER'S SWIVEL SEPTUM KNIFE.]

The empty pocket between the two separated and flaccid mucous membranes is wiped out and the two fleshy curtains are allowed to fall together.

With a nasal speculum each nasal chamber is next carefully inspected to see that the thoroughfare is completely restored. As a rule deeper obstructions, formerly invisible, will come into view, and the mucosae are again separated with a long nasal speculum and more of the septum is shaved off with Ballenger's knife or clipped away with Grunwald's punch-forceps, which also serve to remove portions of the vomer and of the perpendicular plate of the ethmoid.

_Excision of bony spurs and ledges._ It has been pointed out that it is extremely rare to find a deviation limited entirely to the cartilaginous septum. I have never yet met a case in which it was not desirable to remove some of the bony septum.

[Ill.u.s.tration: FIG. 306. THE METHOD OF EMPLOYING BALLENGER'S SWIVEL SEPTUM KNIFE. The knife is shown cutting out the cartilaginous deviation.]

When the deformity of the septum is princ.i.p.ally composed of bone the operation is started as already described. It is then easier to lay bare any thickening or deviation of the nasal process of the superior maxilla, or of the chondro-vomerine suture--the usual sites of bony obstructions. When the main ma.s.s of deviated cartilage has been cut out with Ballenger's knife free access is obtained from above to these deformities, and the fleshy muco-perichondrium can be peeled off on each side with much less risk of a tear or puncture. Still, much care is required in working round sharp corners, and, when the spurs lie low, the flaps frequently require to be reflected right down to the floor of the nose. Once well exposed, the maxillary spine is attacked with strong punch-forceps or chisel and hammer, and as pieces of it are prised up they are twisted off with forceps. Once the obstructing maxillary spine is cleared away it is easier to deal with any vomerine deformity.

A great deal of the success of an operation depends on the complete removal of these spurs and ledges, and as they may have to be followed back nearly to the posterior choanae this part of the operation may be the most difficult, as it is the most necessary (Figs. 307-9).

The pocket between the two flaps is again carefully wiped free of blood-clot and chips of bone and cartilage, and when the two mucous membranes are allowed to fall together they should hang perfectly plumb in the middle line and allow of an uninterrupted view through each nasal chamber, right back to the post-nasal s.p.a.ce.

_St.i.tches._ With a small Trelat's needle the incision is closed with one or two catgut st.i.tches.

[Ill.u.s.tration: FIG. 307. SUBMUCOUS RESECTION OF THE SEPTUM. The arrows indicate the points where the chisel may be applied when exostosis of the nasal maxillary spine requires removal.]

_Dressing._ Plain sterilized cotton-wool is tightly rolled into pencils about 3 inches long, and well smeared with sterilized vaseline. These are carefully packed into each nostril. The nose should not be tightly plugged, our object being to keep the two mucous membranes in apposition, but at the same time entirely occluding nasal respiration.