OBSERVATIONS ONiSOME 
OF THE 
RESULTS OF CUTTING OPERATIONS 
ON THE NASAL SH3PTUM 
BY 
THOMAS R. FRENCH, M. D. 
BROOKLYN 
REPRINTED FROM 
THE NEW TORE MEDICAL JOURNAL 
DECEMBER 1, 1894 
NEWYORK 
D. APPLETON AND COMPANY 
1894 OBSERVATIONS ON SOME 
OF THE 
RESULTS OF CUTTING OPERATIONS 
ON THE NASAL SPEPTUM 
BY 
THOMAS E. FEENCII, M. D. 
BROOKLYN 
REPRINTED FROM 
THE NEW YORK MEDICAL JOURNAL 
DECEMBER 1, 1894 
NEW YOKE 
D. APPLETON AND COMPANY 
1894 Copyright, 1894, 
By D. Appleton and Company THE RESULTS OF CUTTING OPERATIONS 
ON THE NASAL SEPTUM.* 
OBSERVATIONS ON SOME OE 
The few remarks which I have to make, which are pre- 
sented with the hope of eliciting fruitful discussion more 
than for the purpose of contributing any special innova- 
tions, deal with facts which, for the most part at least, are 
recognized by the members of this association, but which, 
so far as 1 am aware, have not been presented for discus- 
sion. These remarks will be directed to a brief considera- 
tion of two conditions which may present as the result of 
cutting operations for the removal of spurs and thickened 
deflected ssepta—viz., perforations and membranous adhe- 
sions. 
Perforations.—To rectify deviations of the cartilaginous 
sseptum without thickening, the advice usually given is to 
destroy the resiliency of the cartilage by cutting through 
it in various ways, fracturing the fragments, forcing them 
up to the median line, and holding them in position until 
healing has occurred. Although by the admirable opera- 
tive methods suggested by Asch, Roberts, and Steele the 
best results are often obtained, it is nevertheless a fact that 
* Read before the American Laryngologieal Association at its six- 
teenth annual congress. 4 
CUTTING OPERATIONS ON THE NASAL S/EPTUM. 
in some cases it is impossible to obtain sufficient relief by 
such means. By those methods the sseptum can not al- 
ways be brought to a perfectly perpendicular plane, and 
unless it is, the greater air pressure on the concave side, to- 
gether with the natural resiliency of the cartilage, not 
infrequently forces the sseptum further toward the narrow 
naris. This is particularly apt to be the case during the 
period of the greatest constructive activity, a period in 
which operations on the sseptum are most commonly de- 
manded. 
If, as is maintained by some writers, ulceration or ero- 
sion of the edges never occurs when a perforation is made 
through the sseptum with a cutting instrument if the 
wound is protected from irritation, or, when ulceration ex- 
ists, it can always be made to heal, and there is no danger 
of ultimate loss of the sseptum or even external deformity 
resulting from a perforation, there can be no objection 
to deliberately cutting away all of the obstructing carti- 
lage, and so opening up both nasal passages and obtaining 
an abundant supply of air through the nose. But is it a 
fact that ulceration never occurs when a perforation is 
made with a cutting instrument if the wound is protected 
from irritation, or that ulceration, when present, can readily 
be made to lieal, or that external deformity never results, 
from perforation of the cartilaginous sseptum ? The dan- 
ger of perforating is spoken of in almost all writings on 
operations on the sseptum, and it is the natural inference 
that it is the belief of the authors that ulceration or erosion 
is apt to follow perforation. Zuckerkandl * says that in 
the cases of healed peiforation of the sseptum dissected by 
him the mucous membrane on the border of the hole was 
found to be very thin, and I presume that is generally if not 
* Anatomic der Nasenhohle, vol. i, second edition, Vienna and Leip- 
sic, 1893. CUTTING OPERATIONS ON TOE NASAL SEPTUM. 
5 
always so ; but this thin covering’ will, I believe, always be 
developed if the wound made in perforating the saeptum 
with a cutting instrument is carefully dressed and protected 
from irritation ; but the patient not infrequently dislodges 
with his finger a few of the crusts formed in the process of 
repair, and ulceration is eventually produced, which in the 
course of time slowly progresses, filling the nasal passages 
with obstructing secretions and causing extensive destruc- 
tion of the saeptum. Because of this danger I have thus 
far never perforated the saeptum unless reasonably certain 
that the edges could be adjusted so that an opening would 
not be left. I may have overestimated the danger of 
leaving a hole in the saeptum, but in the light of the 
evidence presented by a considerable number of cases fall- 
ing under my observation of the destruction resulting from 
perforation, I have been constrained to avoid making one if 
a successful result can be obtained in any other way. I 
have seen a number of cases in which perforation has been 
deliberately made with the most satisfactory results, and 
many others in which the results were far from satisfac- 
tory ; but in none of the latter had careful after-treatment 
been carried out. If it can be demonstrated that with 
proper surgical precautions and after treatment the edges 
of a perforation can always be made to heal, 1 feel sure 
that we would all resort to this method of operating in cer- 
tain cases as being altogether the surest way of obtaining 
permanent relief. 
Perforation of the cartilaginous saeptum, as a result of 
a non specific ulceration or erosion, is described in most 
modern text-books on diseases of the nose, and has been 
made the subject of a number of special articles ; but this 
condition has been so little considered in its relation to 
saeptal operations that I desire to present for discussion a 
question which has frequently arisen in my mind—viz., If 6 
GUTTING OPERATIONS ON THE NASAL SiEPTUM. 
a successful result can not be obtained in any other way, 
are there not conditions under which perforation of the 
cartilaginous sseptum can be made a perfectly justifiable 
procedure ? 
Delavan,* in referring to Blandin’s operation by means 
of the punch, says that “ this procedure is eminently 
clumsy and unsurgical, and in reality is unjustifiable as 
being liable to do more harm than good.” 
Roe f condemns the use of the punch for the removal 
of the angular portions of a deflected saeptum. lie asserts 
that “ by its use we simply cut away a deformity which we 
should correct, and leave a hole through the seep turn in 
which crusts and secretions constantly accumulate, thus 
becoming a lasting source of irritation.” 
Lennox Browne,J in commenting upon Bosworth’s 
statement that he had only once perforated a saeptum, re- 
marks : “ Looking moreover to the comparative frequency 
of saeptal perforations, unassociated with any dyscrasiae, 
caries, or necrosis, and their non liability in such circum- 
stances to cause deformity—a point correctly insisted upon 
by Bosworth himself—one hardly sees why a perforation 
should be so much dreaded.” Elsewhere in the same work 
he writes : “ The entire closing of a perforation by healing 
process is unknown in my experience, and it is doubtful 
if such a happy result ever occurs; but spontaneous or in- 
duced arrest of the ulceration is the rule.” 
Bosworth,* in writing on perforations due to erosion, 
expresses his belief that their clinical significance is trivial, 
that they do not weaken the support of the nose to the 
extent of causing external deformity. 
* Reference Handbook of the Medical Sciences, vol. v, p. 2*72. 
f New York Medical Journal, April V, 1894. 
f Diseases of the Throat and Hose, London, 1893. 
* Diseases of the Nose and Throat, New York, 1889. CUTTING OPERATIONS ON THE NASAL SEPTUM. 
7 
Greville Macdonald,* in writing’ on deflections of the 
sseptum, says: “ Almost always, however, there is a cer- 
tain amount of thickening in the cartilaginous sseptum, the 
paring down of which will generally prove sufficient for 
the removal of symptoms. Should there not he sufficient 
material for this, no objection can be raised to cutting off 
enough of the projecting angle with the saw, although we 
thereby make an opening into the other side. From such 
a procedure there is no risk of subsequent deformity to the 
nose.” 
Mcßride f is of the opinion that falling in of the nose 
does not occur. lie mentions the case of a medical student 
in whom the cartilage was deficient from just within the 
nostrils almost if not quite to the dorsum of the nose. The 
tip of the nose was a little lowered, but no deformity could 
be said to exist. 
Morell Mackenzie, J in writing on traumatic rhinitis, says 
that “the lower and anterior part of the cartilage always 
remains intact; the bridge of the nose never falls in, . . . 
although, when perforation has once taken place, it is diffi- 
cult to prevent the formation of a tolerably large hole in 
the saeptum; the morbid action is strictly confined to a 
small area, beyond which its ravages never extend. The use 
of simple sprays will soon restore the surrounding mucous 
membrane to a fairly healthy condition.” 
Lefferts, # after giving suggestions as to the course to 
be pursued in the treatment of erosion or perforation of 
the sseptum due to mechanical irritation, says : “ Care, pa- 
tience, and persistence are the only elements now necessary 
for the attainment of success.” 
•j- Diseases of the Throat, Nose, and Ear. Edinburgh and London, 
1892. 
* Diseases of the Nose, London, 1892. 
f Diseases of the Throat and Nose. London, 1884. 
# Medical News, vol. xl, 1882. 8 
CUTTING OPERATIONS ON THE NASAL SiEPTUM. 
Robinson,* in writing on haemorrhage due to erosion or 
ulceration of the sseptum, asserts that a plan of very simple 
treatment, when persisted in, will bring about a complete 
cure in one or two months. 
E. J. Moure,f in discussing the value of electrolysis for 
the destruction of deviations and spurs of the nasal saeptum 
at the Eleventh International Medical Congress held in 
Rome last month, said that, in cases of marked deviation 
without thickening, he preferred a quickly made perfora- 
tion, permitting the access of air into both nasal fossae ; and 
Ruault, at the same meeting, in referring to the possibility 
of perforation occurring as the result of the use of electrol- 
ysis, expressed the opinion that it was “ absolutely imma- 
terial; indeed, it is often necessary to seek it in place of 
endeavoring to avoid it, as this is the only rational inter- 
vention in cases of total lateral deviation,” 
It will be seen from the foregoing quotations from the 
writings of careful observers that there is no diversity of 
opinion regarding the danger of external deformity occur- 
ring as the result of perforation of the sseptum, that they 
are generally agreed that perforations due to erosion do not 
extend beyond the cartilage, and that, even after the de- 
structive process has continued for a long period of time, 
it can be arrested, and the edges made to heal under appro- 
priate treatment. The question is simply as to whether a 
perforation ever constitutes a morbid lesion unless subjected 
to mechanical irritation. I do not recall having seen a 
case of non specific perforation with unhealed edges in 
which the parts were not being subjected to irritation of 
some kind. 
I am not aware that the presence of a perforation with 
f Journal of Laryngology, Lhinology, and Otology, vol. viii, New 
Series, No. 5, 1894. 
* American Laryngological Transactions, IBS'?. CUTTING OPERATIONS ON THE NASAL SiEPTUM. 
9 
healed edges is in any way harmful, even though it has 
considerable dimensions. A certain amount of catarrhal 
disease of the mucosa is usually present in these cases, bnt 
there is no evidence to prove that the perforations bear any 
causative relation to it unless the edges have for a long time 
been the seat of ulceration. If, therefore, a perforation 
does not in any way interfere with the proper physiological 
function of the nose, its presence can he a matter of hut 
little consequence so long as its edges are healed. 
After the study of perforations in a large number of 
cases, I am inclined to the belief that, with proper care in 
the after treatment, perforations can be deliberately made 
without injury and with great relief in a certain class of 
■cases ; that, if the breath-way through the obstructed side 
can not be obtained without leaving a hole in the cartilagi- 
nous sseptum, such a procedure is justifiable if the patient 
nan be impressed with the necessity of leaving the parts 
alone, and it is reasonably certain that the case can be care- 
fully followed until the healing of the edges has occurred. 
Otherwise, I believe it to be an unjustifiable method of 
operating. I except from this statement the perforations 
made near the entrance of the nostrils, particularly in a 
saeptum bent obliquely across one or both openings by the 
Blandin punch. This method of securing an increased sup- 
ply of air is, it seems to me, a highly objectionable one for 
several reasons: (1) because of the irritation to the edges 
which is certain to be produced by the stream of air drawn 
through the opening ; (2) because of the easy access of the 
finger to dislodge accumulated crusts; (3) even when the 
edges are healed, it is apt to give rise to a whistling sound, 
which is annoying to the patient as well as to others; and 
(4), while perhaps supplying a sufficient amount of air for 
respiration, it does not restore the normal function of the 
obstructed naris. I believe it is safe to say that, if a per-  CUTTING OPERATIONS ON THE NASAL SEPTUM. 
foration is made in the saeptum of a subject free from dys- 
crasia, and the edges are not irritated, hnt rather subjected 
to careful antiseptic treatment, they will heal. Under such 
circumstances T believe that the procedure is safe, is justi- 
fiable, but under any other conditions it is to he condemned. 
The removal of the ban which has been placed on this 
method of operating to the extent which has just been in- 
dicated would, I feel sure, result in relief to a considerable 
number of cases which no other means now employed will 
effectually reach. 
Large perforations increase the liability of fracture of 
the nose; but, if the edges are healed, that certainly is a 
preferable condition to the possession of a stout saeptum, 
if such can only be maintained at the expense of an ob- 
structed naris. My contention, therefore, is this : that, in 
any case without dyscrasia in which it is known that the 
after-treatment- can be thoroughly carried out, and the in- 
telligence of the patient is sufficient to guarantee that the 
wound will not be subjected to mechanical irritation, there 
can be no objection to the removal of a portion of the car- 
tilaginous for the relief of stenosis due to angular 
deflection without thickening, or to the sseptum being much 
too large for the bony framework of the nose. 
I am well aware of the dangers associated with this 
teaching; that, if perforation of the saeptum is sanctioned, 
it will be greatly abused ; but this does not alter the fact 
that if the osseous portion of the saeptum is not encroached 
upon and the after treatment is all that it should be, 
greater relief can often be obtained from this procedure 
than can be afforded by any other method of operating. 
Membranous Adhesions.—l do not doubt that you will 
agree with me when I say that one of the most disappoint- 
ing and annoying things in association with nasal surgery 
is the occurrence of adhesions within the nasal passages. CUTTING OPEIIATIONS ON THE NASAL SEPTUM. 
That they are in the majority of cases the result of opera- 
tions performed by unskillful hands is undoubtedly true, hut 
that they occur not infrequently after operations per- 
formed by surgeons of large experience and possessing 
skill and judgment is equally true. 
In addition to the ordinary surgical knowledge one 
needs to possess something of the art of the sculptor as 
well as the skill of the mechanic in order to cope successful- 
ly with the class of cases to which I refer. What may ap- 
pear to be a perfectly satisfactory result immediately after 
an obstructing mass of cartilage has been removed may in 
a few weeks prove to he extremely disappointing and un- 
satisfactory because of the formation of extensive adhe- 
sions binding the walls of the passage together. Such 
cases reflect discredit upon the operator, and certainly in 
most cases the reflection is just and proper, for a want of 
care in operating is no doubt the commonest cause of adhe- 
sions ; but there are cases in which the exercise of the ut- 
most skill and care would seem to he insufficient to prevent 
their occurrence. 
It is, I think, generally agreed that adhesions do not 
occur after operating on the turbinated bodies unless that 
part of the saeptura lying directly opposite has been in- 
jured; and that they do not occur after cutting operations 
on the sseptum unless the turbinated tissue opposite the 
wound has been broken during the operation, or has re- 
cently been subjected to some operative procedure, the 
wound from which has not completely healed ; in other 
words, that adhesions can not occur after operating on 
either wall of the naris if the mucous membrane on the 
opposite side is intact. The sides of a nasal passage may 
be brought into contact after removal of redundant carti- 
age by the collapse of the outer wall, or by turgescence of 
the turbinated structure opposite as the result of irritation 12 
CUTTING OPERATIONS ON THE NASAL SEPTUM. 
from the wound on the sseptum, thus causing contact for a 
varying length of time. It is during this period in such 
cases that adhesions occur if there is a solution of continu- 
ity on both walls at points lying directly opposite each 
other; but if the mucous membrane on one wall is un- 
broken and smooth, adhesions will not take place no matter 
how much swelling there may be or how long the parts re- 
main in contact during the process of repair. 
Occasionally the results of operations on the sseptum 
performed by careful surgeons look like bungling attempts 
to secure relief, for, after the parts are healed, a portion of 
the opposite wall is found to have become adherent to the 
wound, and the condition of the patient is worse than that 
for which the operation was originally performed, and yet 
the operator may feel certain that the opposite wall had 
not been injured by his instruments or been the seat of re- 
cent treatment of any kind. I believe that many such 
cases can be explained by a fact which seems to have 
been overlooked, and has apparently been proved by my 
experience in a number of cases—viz., that cut surfaces on 
the sseptum will become adherent to scar tissue on the 
turbinates made by the galvano-cautery at some previous 
time. My meaning may perhaps be made clearer by refer- 
ring to the cases of three patients quite recently under my 
care for relief of nasal stenosis and in whom adhesions fol- 
lowed operation on the sseptum. 
I was asked to operate in the late spring for the re- 
moval of an overgrowth of cartilage in a very narrow nasal 
passage of a young lady whose inferior turbinates had been 
•considerably reduced in size by the aid of the galvano- 
cautery point several months before. I removed the re- 
dundant cartilage with the saw and immediately afterward 
the patient left town for the summer. When she reported 
again in the autumn I found a long and narrow bridge CUTTING OPERATIONS ON THE NASAL S.EPTUM. 
13 
across the naris corresponding in length and width to the 
wound which I had made in removing the cartilage. As 
O O 
during the sawing operation the greatest care was taken to 
prevent injury to the opposite wall, I could find no other 
explanation for the adhesions than that they had occurred 
between the cut surface of the saeptura and the surface of 
the inferior turbinated body made rough and uneven by 
the previous application of the galvano cautery. 
In another case in which an operation of a similar char- 
acter was performed in the late spring, and in which equal 
care was taken to avoid injury to the opposite wall, adhe- 
sions occurred during the summer, and I am convinced that 
they were not due to injury of the turbinated tissue during* 
the operation. I had advised the removal of a large spur 
on the saeptum of this patient a year before, but as she ob- 
jected to a cutting operation at that time I contented my- 
self by destroying with the galvano-cautery a considerable 
amount of hypertrophied turbinated tissue lying opposite 
the portion of the cartilage which was removed a year later. 
I am unable to find any other explanation for the adhesions 
in this case than that the scar tissue resulting from the 
galvano-cautery incisions formed a good surface for the 
granulations of the saeptal wound to become attached to. 
In still another case, operated upon for the removal of 
an ecchondroma, just before the summer vacation, quite 
extensive adhesions were found to be present in the au- 
tumn. In this case applications of the galvano cautery had 
been made to the turbinated tissue in the same naris by 
another physician some months before she came under my 
care. 
What the characteristics of cicatrices produced by the 
galvano-cautery on turbinated tissue are, that render them 
liable to become engaged in the process of repair of a 
wound in contact with them, I am unable to say. The CUTTING OPERATIONS ON TOE NASAL SEPTUM. 
microscope will, no doubt, assist in making this plain, and 
I regret that I have not had an opportunity to make such 
an investigation. It is more than likely that their liability 
to become attached to cut surfaces depends largely upon 
the character and extent of the burned surface of the tur- 
binates—that is, whether the scar is the result of a wound 
made by incisions with the edge or point of a loop, or by a 
Hat burner. 
If my deductions, in regard to the liability of adhe- 
sions occurring between cut surfaces on the saeptum and 
cicatrices on the turbinate tissue resulting from the use of 
the galvano cautery knife, are correct, then in patients who 
present themselves for treatment, whose nares have never 
been subjected to operative procedures, and in whom there 
is need of the destruction of turbinated tissue and removal 
of obstructing cartilage or bone, the saeptum should be 
operated upon first, when, after a mouth or more has 
elapsed and it is certain that the mucous membrane is 
completely reformed, the turbinates can be safely de- 
stroyed by any method. If, however, as is not infrequent- 
ly the case, patients object to a cutting operation on the 
saeptum, but are willing to submit to the destruction or re- 
moval of the turbinated hypertrophy, preference should be 
given to the use of the snare or acids, in order to avoid the 
possibility of leaving a surface which might become ad- 
herent to a wound opposite in the event of a cutting opera- 
tion on the saeptum being performed later. In all cases 
requiring cutting operations on the saeptum, inquiry should 
be made to determine whether the galvano-cautery has 
been used on the turbinated body opposite. If it has been, 
it is advisable to keep the wound under observation for at 
least two or three weeks in order to prevent adhesions, 
should a tendency to their formation be shown. 
Without doubt adhesions are frequently occasioned by CUTTING OPERATIONS ON THE NASAL SEPTUM. 
saws with unprotected ends, and the unskillful use of tre- 
phines and cutting forceps in narrow passages. A dis- 
tinct advance will be made when all instruments used for 
saeptal operations are constructed with a view to preventing 
the possibility of wounding the outer wall of the naris. 1 
believe that severe haemorrhages following cutting opera- 
tions on the saeptum are not uncommonly due to injury of 
turbinated tissue, and a pointed saw seems to be peculiarly 
adapted to insure injury in a narrow passage. 
An error which experience has taught me is that of 
cutting outward with the saw at the floor of a narrow 
naris in finishing a section from above downward. Injury 
of the inferior turbinated body is apt to be produced in 
this way and result in adhesion of the sides at, or just 
above, the floor, which not only cuts off a part of the 
breath-way but interferes with proper nasal drainage. 
In my opinion the upward cut ought always to be made 
first in dealing with large spurs or deflections, for, if the 
section is begun above, the lower portion of the part to be 
removed is almost instantly obscured from view by the 
blood clots which form on the floor of the naris. This re- 
mark is especially applicable to sawing operations per- 
formed while the patient is under the influence of ether. 
If a saeptal projection is removed by cutting entirely in 
one direction, a ridge is not uncommonly left at the edge 
of the wound which necessitates further operative interfer- 
ence to eradicate. It is a good rule, in operating with the 
saw, to begin the section by cutting upward, and finish it 
by cutting downward; but whether it is begun from above 
or below, the section should be finished by a cut from the 
opposite direction, for in this way the maximum amount 
of tissue can be removed from the sseptum with the least 
danger of injury being done to the outer wall.