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health, while even minor deformities will affect the health to some extent. fore, the role of the surgeon in treating nasal deformities is a supremely important one and I argue that just as it is essential to health to have the nose in a healthy condition, so it is necessary to call in the services of a surgeon to bring about this end. Accordingly, it is well within the sphere and province of the nose and throat surgeon to hold himself up as at least one of the chief agents in preserving the general

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Fig. 1. Vertical Deflection of the SeptumArrow indicates point of contact. health and as by no means an unimportant factor in the scheme of preventative and curative medicine. It will be my object It will be my object in this paper to discuss deflection or deviation of the nasal septum.

Deformity of the nasal septum is one of the most frequent conditions for which rhinologists are consulted. In fact, the majority of adult patients, suffering from this condition who consult the nose and throat specialist, present some degree of septal deformity, moderate or marked; many such cases are not sufficiently pronounced in character to warrant surgical interference, whereas in other cases the

Fig. 2. Horizontal Deflection of SeptumShowing thickening of bone at point of contact "A" and of cartilage at "B."

normal vertical position, it necessarily narrows one fossa and enlarges the other, thereby giving the patient too much air space on one side and too little on the other. Nature requires the nasal passage to be in a perfectly normal condition, as it is through these passages the air is warmed and moistened before entering the lungs. Until the seventh year the nasal septum is, as a rule, in the mesial plane, but after this age is often deflected on one or the other side, the deflection being greatest along the line of junction. It may be said that deflection of the septum is more com

mon in European than in non-European plete until puberty. Many factors enter people. into the cause of deformity of the nasal septum, defective septal development, affections of the septum, affections of other regions in the nose, excessive development of the turbinals. Broadly speaking the principal etiological factors are congenital, traumatic and developmental. The high placed palatal processes of the superior maxilla or so-called gothic arch is a cause of septal deviation and is congenital. The high placed palate crowds the septum upwards displacing it out of its normal vertical position. Deviation also results largely from traumatism. By far the most fre

The nasal septum is composed of cartilage and bone. The cartilage portion of the septum occupies the interval between the vertical plate of the ethnoid bone and vomer, being in contact with the vertical plate of the ethnoid bone at its posterior superior border. It articulates with the anterior nasal spine of the superior maxilla and vomer at the posterior inferior border. The anterior inferior border is attached above to the crest on the under surface of the nasal bones at their junction and is contiguous with the superior

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Fig. 3. Sigmoid Deflection of SeptumArrows indicate points of contact. lateral cartilage below. The anterior inferior border extends downward and backward and attaches to the anterior nasal spine. The bony portion of the nasal septum is formed by the nasal spine of the frontal bone, the crest of the sphenoid bone, the perpendicular plate of the ethnoid bone, the vomer, the palate bones and the palatal processes of the superior maxilla bones. The anterior third of the septum remains cartilaginous throughout life. The perpendicular plate of the ethnoid ossifies between the first and second years, whereas the vomer begins to ossify about the third month of fetal life and is not com

Fig. 4. Deviation of Septum to right side. quent cause of septal deviation, in my opinion, is slight injuries, which bring about but slight displacement of the septum at the time of injury but which set up a low grade of inflammatory action causing hyperplastic changes in the septum some time after resulting in deflection, the septum being deflected in the line of least resistance. I think we too hastily arrive at the conclusion that the cause is congenital simply because we do not obtain a history of injury to septum-obviously the nose is the most prominent organ of the face, it may be termed its outstanding feature and consequently is more liable to injury. Children of a tender age, when

learning to walk, frequently fall striking the nose. At the time little importance is attached to the circumstance, and thus it is quite possible that the septum may be injured more or less seriously without evidence of contusion or any immediate deformity. For infants and young children to fall is a daily happening and in the absence of parents or nurse, it is not surprising we do not obtain more recorded evidence of injury to the septum. In my opinion, the majority of cases of deflected septum in adults are primarily due

Fig. 5. Septum after operation.

to injury or accidents in childhood. Few children escape falls and blows, and unless these are severe, causing marked external injuries, are not noticed. The probability that traumatism is the most common cause of deflected septum is increased by the fact that deviations are much more frequent in males who are more exposed to injuries than females. However, it must be said that such high authorities as Zuckerland, Fletcher, Ingalls and Asch are skeptical as to traumatism

being the main cause of septal deviation.

When the cause is developmental the cartilage and bony septum are both involved, when of traumatic origin in the great majority of cases, the deflection is essentially cartilaginous, as the injury is rarely severe enough to involve the bony

structure.

Hypertrophied turbinates in children, provided the hypertrophy has advanced to the extent of causing pressure on the septum will in the flexible septum of children cause the septum to deflect to the opposite side. Hypertrophied inferior or middle. turbinates in adults are frequently associated with deviations, the hypertrophy in these cases being the result rather than the cause. There are a variety of septal deformities, and it is almost impossible to classify the various forms. The most frequent form is limited to the anterior portion of the cartilage known as the columnar, and presents the deviation at a right. angle in the floor of the nose. This variety of deformity is commonly the result of traumatism. A second variety presents an angular deflection, the long axis of the deformity being anterior posterior. It refers to various deformities of the nasal septum in which definite prominences, spurs, ridges and thickening present upon the septum due to a solution of continuity in the structure of the septum. This variety of septal deformity is usually due to injury, the abnormal condition gradually increasing often accompanied by inflammatory changes in the mucous membrane.

These changes in the course of time will develop a deviation of the septum. Another class embraces the kind of deflection where the septum bulges into one side. above and into the opposite side below, forming an S shaped deflection

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Septal deformities are amenable to treatment by operative procedure and this is the point that I especially wish to insist

upon.

For surgical treatment of deviation of the septum, the method most frequently followed by the majority of rhinologists is submucous resection of the septum. Submucous resection of the septum is one of the greatest achievements of modern rhinology. Several methods are practiced by nose and throat specialists and have been described by various authors. That most generally followed is the one initiated by Prof. Killian of Frieburg. The other methods differ in technical points and may be denominated as modifications. Freer of Chicago employs and advocates what is termed the open method with which he has had considerable success. Ballenger of Chicago has introduced technical improvements of the original method. would be superfluous to describe at length the technic of so well known an operation. The operation consists in removing the cartilage or cartilage and bones of the septum submucously by leaving the mucous membrane and perichondrium intact. Spurs, ridges and thickening can be removed submucously in most cases but I see no objec

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tion to the use of the saw or other means so long in use. As stated before there are septal deflections which do not call for operation, but only those cases in which the abnormal condition of the septum interferes with the proper functions of the nose. The degree of obstruction to respiration is in proportion to the degree of deflection. If the septum is deflected very much to one side, complete occlusion may result. In most cases a nasopharyngeal catarrh is due principally to the interference with the flow of the secretions an

teriorly, causing them to flow posteriorly down the pharynx and these are swallowed or expectorated. Frequent attacks of epistaxis are caused by the prominence on the septum pressing against the turbinal body causing erosion. In order to relieve such cases, attention to the septum is needed and operative measures should be resorted to when such a condition is found as is prejudicial to the health. My aim in writing this paper has been to show that it is part of the role of the surgeon to treat nose affections so as to not only relieve the local trouble but to prevent the infection from spreading throughout the system. Thus the rhinologist is a factor of considerable importance in the practice as well as of remedial medicine. 159 West 105th Street.

THE ANNOTATOR.

Schools. An editorial tells us that there The Rapid Growth of Open Air are now more than 200 open-air schools and fresh air classes for tuberculous and anemic. children, as well as for healthy children in certain rooms and grades. These schools are distributed over various portions of the country, all of them having been established since January, 1907, when the first one was opened at Providence, R. I. On January

1, 1910, there were only thirteen in the entire country, but a year later they had increased to twenty-nine.

Their major development is therefore confined to the past two years.

Massachusetts has 86 fresh air schools. Boston alone having 80, New York follows with 29, and Ohio is third with 21.

These schools are now distributed among 50 cities in 19 states. From the statistics of population and mortality which have. been prepared by the Census Bureau it has been estimated that 100,000 children who are now in school in the United States will die of tuberculosis before they have reached their eighteenth year.

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2. In each city there should be a psychological clinic connected, if possible, with the city hospital and controlled by the board of education. This clinic should determine scientifically the degree of mental dulness of sub-normal children. Full clin

ical records of the patients should be kept and these patients should be assigned to a particular school or a particular task, or else to a state institution.

3. There should be suitably equipped

class rooms for such children in school buildings. They should be large, sunny, and accessible to the street, the play ground and the toilet rooms.

4. The number in the classes should not exceed twelve to fifteen, in order that individual or group attention may be given, as may be indicated.

5. Specially qualified teachers must be chosen for this work, for it requires patience, tact, sympathy, and resourcefulness. Such teachers must keep abreast with the progress which is being made in this line of work.

6. There must be love and sympathy in the management, and no nagging, threatening, or punishments.

7. The course of study must emphasize the essentials; it must be flexible and lead

1 Dr. A. W. Edson, New York Medical Journal, December 7, 1912.

directly to a vocation. Teachers must have. a free hand in adapting the course of study to the needs of the classes.

8. The instruction must be personal and emphasizing physical and manual training, nature study, and illustrative material.

The skilled teacher and the skilled physician must labor, side by side, in this work. Physical defects must be remedied as speedily as possible, the training must be corrective and curative, both along physical and intellectual lines.

IO. If school authorities fail in their duty to these unfortunates, if there is lack of funds or of interest, private individuals should be appealed to for the performance of the work, a leader with a well-matured and workable plan is indispensable. This is an interesting problem which cannot be dodged, it must be worked out. These chil

dren are with us whether we desire them or not, and it is certainly better economy to fit them for usefulness than to let them grow up a helpless burden to the community for their entire life.

Disinfection and Contagion Carriers.1An editorial notes that in the city of Provi

dence disinfection following communicable diseases is no longer compulsory but is done only when it is desired by the family in which the disease has prevailed. Since 1905 disinfection following diphtheria has been discontinued, as a routine measure when two successive negative cultures have been secured from each member of the family concerned. During the years 1901-5 this disease prevailed in 1,457 families in Providence and there were 1.71 per cent of recurrences after disinfection. Since 1905, with no compulsory disinfection, the recurrences have been 1.80 per cent which suggests that recurrence may be independent of disinfection.

It is suggestive that recurrences are not due to germs lurking in the house, but to those which are carried in the throats and nasal passages of various members of the family. Notwithstanding compulsory terfamily. minal disinfection .88 per cent of those who afterward had the disease were away from home while diphtheria was in the home and until after the disinfecting meas

1 Medical Review of Reviews, December, 1912.

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