EXTIRPATION 
OF THE 
BONES OF THE NOSE AND MOUTH 
BY THE USE OF 
THE SURGICAL ENGINE. 
RY 
I). H. GOODWILLIE, M.D., D.D.S., 
NEW YORK CITY; 
n CLINICAL ASSISTANT TO THE METROPOLITAN THROAT HOSPITAL; PERMANENT MEMBER 
OF THE AMERICAN MEDICAL ASSOCIATION; MEMBER OF N. Y. NEUROLOGICAL 
society; of the medical society of the covyTYjM*/S'++m 
THE MEDICAL LIBRARY AND JOURNAL A^SOCI 
Reprinted from The Medical Record, July, 1879. 
NEW YORK: 
WILLIAM WOOD & COMPANY. 
1879. With compliments of 
DR. D. H. GOODWILLIE, 
160 West 34th Street, 
New York. EXTIRPATION 
OF THE 
BONES OF THE NOSE AND MOUTH 
BY THE USE OF 
The Surgical Engine. 
BY 
D. H. GOODWILLIE, M.D., D.D.S. 
(Read before the Medical Society of the County of New York, 
April 28, 1879.) 
Reprinted from The Medical Record, July 12. 1879. 
NEW YORK: 
WILLIAM WOOD & COMPANY. 
1879. EXTIRPATION OF THE BONES OF THE 
NOSE AND MOUTH BY THE USE OF 
THE SURGICAL ENGINE. 
The deep seated bones of tne nasal fossae become 
necrosed from numerous causes. The diagnosis is in 
many cases quite difficult, as in all cases there is 
stenosis of the nostrils from thickening of the soft 
tissue. But, by the aid of the rliinoseope under a 
very strong light, and by properly constructed nasal 
speculum and probe, together witli the general physi- 
cal condition and history in each case, it can be made 
out. 
If necrosis is present to any great amount, it will 
generally be observed that the necrosed •material will 
have made excoriated tracks on the pharynx on either 
side of the vertebral ridge. 
Sometimes one, and again both sides, may be so 
seen. On the side on which the greater amount of dis- 
organized tissue flows will be found the openings to 
the necrosed bone. If the vomer is the only bone ne- 
crosed, fistulous openings may be discovered—often 
near the junction of that bone with the palate posteri- 
orly. 
In many cases, owing to extensive swelling of the 
parts, rhinoscopy is impossible. 
Necrosed bone cannot always be felt with a probe 
from the anterior nares, as the fistulous openings are 
in the posterior nares, and open toward the pharynx. 
But, should there be necrosis of the soft parts, or if 
the bone necrosis extends to the maxillary bones, then 
it may be discovered by the probe. 
The causes, in the writer’s experience, have been in 
about the following order: 
1. From a morbid virus in the system, in which 6 
syphilis stands most prominent, struma, diphtheria, 
etc. 
2. From mechanical and traumatic causes; polypi, 
causing by their growth pressure and consequent ne- 
crosis ; foreign substances, deviated nasal septum, 
blows upon the nose, etc. 
In the nasal lesions in tertiary syphilis, the necrosis 
nearly always commences in the vomer, then extends 
to the other bones of the nasal fossse. The first symp- 
toms are an intense pain in the frontal sinuses, extend- 
ing down the bridge of the nose, and, when the disease 
has extended to the hard palate, pain in the mouth, 
in the centre line of the palate. 
Treatment.—When necrosis has been recognized, no 
time should be lost in removing it. The dissolution 
and discharge of a necrosed bone may cause the loss 
of the surrounding hard and soft parts. It will be 
necessary to give constitutional treatment suitable to 
each case. In December, 1872, the writer devised and 
made use of single and multiple revolving knives, 
saws, and trocars for operations upon the hard and 
soft tissues of the mouth and nose, the revolving 
power being .supplied by the surgical engine. This 
consists of a fly-wheel, set in motion by the foot, a 
driving-pulley, and a communicating cord. On the 
top of the upright movable shaft the pulley is con- 
nected to a flexible wire cable inclosed in a flexible 
sheath. This cable is connected to the hand-piece, in 
which can be put any revolving instruments. The 
flexibility of the wire cable allows the instrument in 
the hand-piece to be freely used at any angle. The 
hand-piece, held in hand as you hold a pen, is under 
perfect control. The instruments are securely fast- 
ened in the hand-piece by means of a spring-catch. 
The single revolving knife (Fig. 1) is circular and 
sharpened on the edge (a), and has a protecting sheath 
(ft) to cover up the part of the knife left exposed. 
Fig. 1. 7 
Under a velocity of two or three thousand revolu- 
tions per minute, the single revolving knife, in cut- 
ting soft sensitive parts, gives little or no pain. 
The multiple revolving biives (Fig. 2) are arranged 
around the end of a shaft in an acute angle, and cut 
DJi.GQOOmL UE.MQ. 
Fig. 3.—Knife (a) within the sheath. 
Full size. 
Fig. 2. 
as they revolve, and do not scrape as the dental burrs. 
These instruments have a protecting sheath (Fig. 3), 
to be used when necessary. 8 
Saws, like the single knives, are circular, and have 
teeth on the edge. 
The trocars are of different forms and sizes, and 
they are intended to make an opening and then to 
enlarge it. Fig. 4 shows two of the most efficient 
Fig. 4. 
ones: the spiral cutting edge, and the other flat, with 
two straight cutting edges and double edges on the 
point. 
Self-retaining nasal speculum (Fig. 5) represented in 
The Medical Record, July 31, 1875. The writer has 
Fig. 5. 
several modifications of it to more effectually show 
the posterior nares. 
Oral speculum described in the Transactions of State 
Medical Society, 1877, and consists of hard rubber or 
metal splint (6, b), covering upper and lower teeth, at- 
tached at their posterior ends by an adjustable hinge 
(g, g). The splints are separated and the mouth kept 
open by a brace (a, a) on either side. The palate spat- 
ula (d) is attached to lower splint, the other end 
holding the palate against the pharynx. The bead- 
rest fits the back of the head and neck, with side- 
pads, over these, and over the brow of the patient 
passes a leather strap, firmly confining the head. (See 
N. Y. Med. Jour, for July, 1872, page 22. Resections 
of maxillary bones without external incision.) 9 
Operation.—The patient is placed in an operating- 
chair, nitrous oxide is given to produce anaesthesia, and 
then ether is used, and the head securely fixed in the 
head-rest. If the operation is in the nose, now close off 
Fig. 6. 
entirely the nasal pharyngeal opening by pushing 
the uvula and soft palate back against the pharynx 
by means of the palate spatula, which is attached to 
the oral speculum. This will prevent the necrosed 
portions of bone thrown from the revolving knives 
from entering the larynx. Where the operation is 
done without an anaesthetic, this preventive measure is 
not necessary. In the operation for the removal of 
the vomer, the knives are used to remove the anterior 10 
part of the necrosed bone (Fig. 7, shown by dotted 
line), and then the posterior part grasped with the 
forceps through the anterior nares. 
Fig. 7. 
This is pulled out from between the soft walls cover- 
ing this part of the bone. When moved from its bed, 
it is either brought out through the anterior nares, or, 
if too large to pass there, it may be passed through the 
posterior nares. By the careful removal with the 
forceps of this posterior half of the vomer, the soft 
parts remain, and thus the union between the septum 
and palate is not destroyed. Have noticed in some 
cases a partial reproduction of that bone. In the case 
of the turbinated bones, they are entirely removed by 
means of the knives. The hard palate and maxillary 
bones can all be removed without disturbing in the 
least the soft parts. From a sinus big enough to admit 
the instrument can be successfully removed any amount 
of necrosed bone. 
Before the patient recovers from the anaesthetic, 
and before the oral speculum is removed, the na- 
sal cavity is syringed out with cold water, and 
cleared of all necrosed bone and blood. When suffi- 
ciently recovered from the anaesthetic, remove the 
speculum and unstrap the head. If the necrosed 
portions are too large to pass out of the anterior nares, 
let the speculum remain until the patient has regained 
consciousness, and then remove through the naso- 11 
pharyngeal passage or through any breach that may 
be made into the nasal cavity from the mouth. 
The writer never makes use of sponges on cut sur- 
faces in either mouth or nose, but makes use of anti- 
septic paper; or, if there is any hemorrhage from small 
vessels, it may be arrested by applying styptic paper. 
Have never yet had any secondary hemorrhage. 
The writer has made use of the surgical engine for 
the successful removal of adhesions of the soft palate 
against the pharynx, nearly closing up the naso-phar- 
yngeal passage. It has been successfully used in 
trephining the antrum, mastoid cells, exposing the 
superior and inferior dental nerves, opening abscesses, 
resections of the jaws, removal of epulic growths. 
Indeed, in many other surgical operations on any 
part of the body, it can be most efficiently used. 
Case I.—Mrs. C. T., aged thirty-five years; born in 
New York ; married November 25, 1868. Up to this 
time quite healthy. Four months after marriage had 
syphilis, for which she received treatment by her 
family physician. Up to present time has had four 
births. Her first child still-born at six months; 
second child born at full term and lived a week; 
third child still-born at eighth month; fourth child 
born at full term and lived ten months. 
In 1872, had syphilitic laryngitis and was salivated. 
She came under my care in November, 1874. On ex- 
amination I found necrosis of the vomer, lower por- 
tion of the ethmoid, vault of the hard palate, and in- 
ferior turbinated bones of both sides, and alveolus of 
the intermaxillary bone. There was a hole in the 
hard palate a half-inch in length. Front teeth quite 
loose from necrosis of the maxillary bone. These were 
at once removed. Rhinoscopic examination very 
difficult to make, as the uvula and soft palate were 
much swollen. Large ulcers on the pharynx. To 
combat the specific poison the patient was put upon 
iodide of potassium, two grammes, and increased to 
four grammes a day, with tonics and nourishing food. 
April 29, 1875, operated for the extirpation of the 
necrosed bones. There were present, Drs. A. C. Post, 
J. T. Darby, Leonard Weber, L. B. Bangs. All the 
necrosed bones were removed by the revolving mul- 12 
tiple knives through the opening in the palate and 
through the nostrils. The necrosed palatal vault, 
both inferior turbinated bones, and a small portion of 
the vomer, were removed through the opening in the 
palate; through the nostrils, all the necrosed portion 
of the maxillary bone and the anterior portion of the 
vomer and ethmoid. 
The posterior portion of the vomer was now seized 
with the forceps and removed. By this means the soft 
parts covering the vomer were left intact, so that by a 
rliinoscopic examination the posterior part of the sep- 
tum was seen as before the operation. In this case there 
appeared to be a reproduction of bone in this part of 
the vomer, and to some extent of the hard palate. 
A few days after, removed by the knives some small 
necrosed portions of the intermaxillary, after which 
the parts healed rapidly. The voice somewhat nasal 
in tone until the opening in the palate wTas closed. 
In October, 1875, about six months after the ex- 
tirpation of the necrosed bones, uranoplasty was per- 
formed for the closure of the opening in the hard 
palate, which was now three-fourths of an inch in 
length. After removing the mucous membrane from 
edges, an incision is made on each side of the fissure 
through the soft parts and newly formed bone of the 
hard palate. 
The soft parts were cut through by means of a 
galvano-cautery knife, and so had no bleeding. The 
bone is now pierced by the drill, and the bone sepa- 
rated by a chisel after the method of Sir William 
Ferguson; or it may be sawed through, and then they 
are sprung together and the fissure thus closed. In 
this case four horse-hair sutures were used to' hold the 
flaps together. 
These side-incisions must be kept open by packing 
them, or removing the granulations each day, to pre- 
vent healing until the edges of the fissure are united. A 
gutta-percha splint is now fitted and worn over the 
palate. This prevents the food, fluids, and air from 
causing disturbance to the healing process. 
I present wax models of this case taken from casts 
of it before, during, and after completion of the 
operation. 13 
It will be seen that the external appearance of the 
nose has not altered in shape, notwithstanding the nasal 
septum and bony palate, upon which it rests, are gone. 
Have never seen the nose fall in except when the 
cartilage or nasal or maxillary bones were involved— 
in other words, the bridge of the nose. 
Case II.—Mrs. F. C., aged twenty-one years, bom in 
New York State, was sent to me by Dr. J. Marion 
Sims. She was married in 1865; then quite healthy; 
has had three still-born children, and one now living. 
In January, 1872, had inflammation of the brain, 
which was afterward followed by inflammation of the 
bowels. In 1873 had severe neuralgic pains on the 
bridge of the nose, centre of the hard palate, and left 
side of the face. This was followed by a swelling in 
the centre of the hard palate, and all the upper 
teeth were extracted. In December, 1873, when she 
came under my care, her condition was as follows: 
Her physical powers were very much reduced; con- 
stant pains in her head; a hole in the left canine 
fossa; great discharge from the nose and mouth. By 
rhinoscopic examination, and by a probe through the 
hole in the canine fossa, I discovered necrosis of the 
nasal septum and turbinated bones of both sides. 
The specific origin of disease being recognized, she 
was put upon iodide of potassium, tonics, cod-liver oil 
with phosphates. December 26th, as there was a good 
deal of pain and swelling of the nasal septum, it was 
lanced, and bled freely and gave her great relief. 
January 4, 1876, lanced the nasal septum again. 
February 3d, periostitis of the left nasal bone exter- 
nally*appeared; applied a leech. February 4th, swell- 
ing and pain gone. February 9th, patient having im- 
proved in strength, but still suffering intense pain, 
removed all the necrosed bone by the revolving knives. 
In this operation removed the vomer, lower portion 
of the ethmoid, inferior and middle turbinated, max- 
illary walls of both right and left antrum, and a good 
portion of the hard palate. Present, Drs. George A. 
Peters, E. L. Keyes, F. R. Sturgis, and G. H. Fox. 
February 10th, found the patient going about the 
house attending to some of her household duties; no 
pain since the operation. February 13th, removed 14 
small pieces of the intermaxillary bone. March 6th, 
had some swelling of the left side of the nose, extend- 
ing under the eye. 
Feeling herself so much better after the operation, 
she had neglected to take the potassium as ordered, 
and this is the penalty of such disobedience. Ordered 
a leech and increased the dose of the iodide of po- 
tassium to four grammes per day. March 8th, swell- 
ing very much reduced and pain nearly gone. March 
10th, pain and swelling gone. There was a small 
amount of pus on the left side of the nose, which was 
drawn away with the aspirator. April 10th, patient 
expresses herself as being nearly well. Iodide of po- 
tassium reduced to two grammes every other day. 
Cod-liver oil to be continued. June 23, ’76, patient now 
quite well, and by a rhinoscopic examination no dis- 
charge was discovered. There now only remains the 
opening of the canine fossa to be closed. 
Case III.—Necrosis of turbinated bones from scrofula. 
Miss E. J. A., aged twenty-years, has had discharges 
for some time. Smelling much impaired. On exam- 
ination discovered that both middle turbinated bones 
were necrosed. Considerable bulging of the nasal 
septum to the left side, which, her mother says, came 
from a fall in childhood. Removed the necrosed 
turbinated bones with the revolving knives, while she 
was under anaesthesia produced by nitrous oxide. 
After a month’s treatment the parts healed, respira- 
tion free through the nostrils, and she was discharged. 
Case IV.—The following case was brought to me 
by Dr. Leonard Weber, of this city: William H., 
of New York, aged thirty-two years, with syphilitic 
necrosis of the bones of the nasal fossae. His condi- 
tion was found as follows : Small hole through the 
hard palate one half inch in length ; four fistulous open- 
ings—above the alveolus, at the left central incisor, 
on each side of the left canine, and above the first 
molar of the same side. Some teeth were extracted 
on this side; the sound and firm teeth were allowed 
to remain. 
In the presence of Drs. L. Weber, C. C. Lee, R. P. 
Lincoln, T. R. Pooley, H. G. Fox, L. Spannhake, and 
E. C. Lining, U.S.A., there were removed through 15 
the opening in the palate, and through the nostrils, 
the hard palate, vomer, inferior turbinated bones, can- 
cellated portion of the left maxillary and intermax- 
illary bones. 
The posterior portion of the vomer was dislodged 
and removed by the forceps, without separating its 
covering from the palate. In these extirpations there 
has never been any great amount of bleeding, and 
have never yet had to resort to the tampon. The 
styptic action of the paper controls all bleeding 
from the small vessels. There was much thicken- 
ing of the soft parts, just inside of the vestibule of 
the nostrils ; and as it interferes with free respiration, 
it was removed by means of the galvano-cautery. A 
protecting shield is put into the nostril, the top part 
of which incloses the part to be cauterized. The 
white-hot cautery wire is applied through the shield 
to the part exposed at the top of it. 
Case Y.—H. W. B., from Otsego county, New 
York, had catarrhal difficulty when a child. Has had 
polypi removed from right nostril by family physi- 
cian. In July, 1876, the writer removed a large 
polypus from right nostril, attached by a large pedi- 
cle to upper part of vomer. From pressure the left 
middle turbinated bone had been lost, and from the 
same cause the vomer was pushed to the left. The 
right inferior turbinated was forced down into the in- 
ferior meatus. There were three bends in septum. 
The greatest bend was in the posterior and upper 
part of the septum; the lesser bend in the cartilagi- 
nous septum. The whole septum had also a very 
sharp bend, with hypertrophy of the bone along the 
line of, and bending into, the inferior meatus. This, 
with a pushing downward by the growth of the in- 
ferior right turbinated, produced complete stenosis of 
that nostril. This warping of the septum into the in- 
ferior meatus probably commenced with his trouble 
in childhood. This condition of things prevented 
the free discharge of mucus from the nostrils. In 
September, ’76, removed with the nasal punch a por- 
tion of the bend in the cartilaginous septum. When 
I saw him again in May, ’77, the upper part of the 
vomer had necrosed and passed away, the lower thick 16 
hypertrophied part was removed under an anaesthetic. 
The multiple knife, armed with a shield, passed 
through the inferior meatus, cutting its way through 
to the pharynx. The inferior turbinated bone was 
also removed. This gave a clear passage for the es- 
cape of the mucus and free respiration. 
The most common local application used in these 
cases is a powder consisting of iodoform and cam- 
phor, each four grammes, subnitrate of bismuth, 
thirty-two grammes, blown into the nostrils with sev- 
eral pounds’ pressure, so as to reach every part of the 
nasal cavity. To do this efficiently the powder must 
be impalpable, the calibre of the blower small, and 
applied with considerable force of air, the parts to be 
thorolighly cleansed with salt and tepid water by 
means of a syringe, and then the powder applied 
through the anterior nares.