i J * SURGEON GENERAL'S OFFICE I ^ »D THE CURE OF CROOKED AID OTHERWISE DEFORMED SOSES. BY JOHN B. ROBERTS, A.M.,M.D., PROFESSOE OF ANATOMY AND SURGERY IN THE PHILADELPHIA POLYCLINIC, LECTURER ON ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO ST. AONES HOSPITAL. JJfe^ ftjlto • / 'RAr. PHILADELPHIA: P. BLAKISTON, SON & CO., 1012 Walnut Street. 1889. 1869 r PHILADELPHIA DOR NAN, PRINTER. TO THE MEMORY OF A PERFECT WOMAN. MY WIFE A N X A H.ROBERTS PREFACE. The following pages represent the result of my ex- perience in public and private practice and are based upon lectures delivered and papers read at the Phila- delphia Polyclinic and elsewhere. This communication —an address before the Philadelphia County Medical Society—was originally published in the Proceedings of that bodv. J. B. R. 11>27 Walnut Street, Philadelphia, June 15, 1889. THE CURE OF CROOKED AND OTHERWISE DEFORMED NOSES. There are many instances of nasal deformity which are a great trial to those who have to bear the disfigurement through life, and whose correction would add much to the popular appreciation of surgery and at the same time be a source of revenue to the operator whose skill succeeded in relieving the unsightly condition. Many of these defects are mere blemishes upon the face of the subject rather than matters of very great importance. There may be little or no obstruction to breathing and very little deformity to the eye of the observer, but the disfigurement causes such a mental effect on the patient as may even lead to a change in his disposition. If, therefore, we can relieve these minor disfigurements, and thereby relieve the worry and anxiety of the patient, we do something which is entirely justifiable. Many forms of defect are found in the physical contour of the nose, and many are the causes giving rise to the varying types of nasal dis- tortion. Faults of development are not uncommon. Accidental injuries, causing fracture or dislocation of the bones or cartilages, may occur in infancy, or at any time of life, and leave .thereafter a very much disfigured organ. Blows of an opponents fist, falls from a horse or carriage, and injuries received while playing ball are not infrequently the disfiguring traumatism. We may also have de- formity due to wounds made by cutting instruments, whereby por- tions of the soft structures have been lost, or to unseemly cicatrization after such wounds. Syphilis, giving rise to necrosis and ulceration of the bones and cartilages, thereby allowing the bridge of the nose to fall in or other changes to take place, is a potent cause of nasal deformity. Ulceration of the alse of the nose due to syphilis, while in the early 8 ROBERTS, stage necessitating active treatment, may later require surgical opera- tion to reconstruct the lost part. Again, in epithelioma it may be necessary to cut away the ala and at once make a new structure. It may, at other times, be necessary to make a new tip to the nose after such an excision for malignant disease. By looking at a skull it is seen that if the septum and nasal bones are destroyed by syphilis, there is a great tendency for the nasal arch, or bridge, to sink in and allow the tip of the nose to turn up; thus leaving only the small prominence formed by the wings and lobe of the nose, and causing great disfigurement of the front part of the face. Again, you may have lateral openings in the nose following specific ulceration. I have under observation at the present time a patient with an opening due to syphilitic ulceration, who has not yet agreed to an operation, but who will possibly do so in time. Fig. 1. b c I have drawn here a number of badly shaped noses, which can be remedied by operation. We may have a nose which sinks in at the top, in which there is not much bridge. This is generally due to want of proper development of the bones and cartilages forming the septum, and is sometimes called the saddle-back nose (Fig. 1, a). A similar nose is often found in inherited syphilis. Then we may meet with a nose bent a good deal to one side (Fig. 2). A slight degree of this de- formity is very common. Again, the organ may be not simply bent, but bent twice or irregularly twisted, as is shown in this drawing (Fig. 3). Bent and twisted noses are very often due to fractures received in early childhood. It is not unusual to see a nose with a large lump CURE OF DEFORMED XOSES. 9 on the end of it, which may be due to hypertrophy of the lobe or to a newT growth developed there. This disfiguring condition is frequently due to acne rosacea, causing unusual development of tissue. This I call the tuberous nose (Fig. 1, b). I often see a man who has exceed- ing hypertrophy of the tip of his nose from acne rosacea, and whose son curiously has a similar nose, but not quite so greatly developed. Both of these men could be greatly improved by operation. The last Fig. 2. Fig. 3. Bent nose. Twisted nose. variety of which I shall here speak is what I call the angular nose (Fig. 1, c), because of the angular appearance of its dorsum, due to an unnatural bony prominence at the lower margin of the nasal bones. A lady came into my office a short time ago with such an elevation on the middle of the nose, due to a bony mass resulting from a frac- ture in infancy. There is also some stopping-up of the nostrils from the fracture, and the occlusion has so interfered with respiration that she has been a mouth-breather since she was three years old. As a result of this the lower jaw has not developed, and she cannot bring the incisor teeth together. She is much more concerned, however, about the appearance of her nose than about the obstruction to breathing. This patient, as well as those suffering from the other varieties of nasal deformity, can be greatly improved in appearance by proper and judicious surgical interference. These illustrations, several of which are taken from a paper by Dr. S. B. Parsons, give an idea of the ordinary deformities which we have in the contour of the dorsum or bridge of the nose. A good many deformities also occur in the septum. In some of the cases just 10 ROBERTS, referred to there is not necessarily much deformity in the septum. In twisted and bent noses, however, there is usually some septal dis- tortion, because the condition, as a rule, is the result of injury. The peculiar broad and flattened appearance of the root of the nose seen in epicanthus may be included in this enumeration of nasal de- formities. Such cases are more apt, however, to be seen by those of us who practise ophthalmic surgery, than by general surgeons who do not attempt eye-surgery. The condition is remediable by dissecting an elliptical portion of skin, with its long diameter vertical, from the root of the nose and bringing the edges together Avith sutures. It is well in cases not very marked to delay operation, however, until the child has grown up, because the development of the bony structures of the nose may cause a spontaneous cure of the deformity. In cases of crooked nose from traumatism, it is very common to have a greatly deformed septum. It is difficult, in fact, for a frac- turing injury to cause much permanent nasal deformity without the cartilaginous or bony septum suffering some lesion at the time of the traumatism. The vomer and the perpendicular plate of the ethmoid are thin and easily broken, while the triangular cartilage is also readily fractured ; hence, in nearly all deformed noses due to blows, deformity of the septum is found. The septal deviation usually inter- feres with respiration, because one nostril is more or less occluded. This causes change in the tone of voice and induces other well- known symptoms. Some persons are more annoyed by the nasal obstruction than by the want of physical comeliness in the external organ. Others care little about the patency of the nostrils, but worry greatly about the unsightly appearance of the. deformed nose. Thus it is that patients come for the relief of one or the other condition, according to the character of their dispositions. Congenital deviation of the septum is by no means infrequent, and may in a similar manner interfere with proper respiratory perform- ance. Such deviation of the septum is more apt to give rise to a curved bulging on one side than to an angular projection. Deviation of the septum due to injury is apt to be angular, and is very often accompanied by cartilaginous or bony outgrowths about the original lines of fracture. If the fracture has comminuted the septal struc- tures to any great extent, both nostrils may become entirely filled with a mass of bone and cartilage. I once saw a case in which nos- trils had to be made by actually quarrying through a mass of this kind by means of a chisel. CURE OF DEFORMED NOSES. 11 In these and other deformities small enchondromas may be found near the attachment of the septum to the floor of the nares, and in any form of septal distortion bridges of cartilage and bone may extend across the nasal chamber from the septum to the turbinated bone. These bridges at times are apparently formed by the coalescence of two opposing masses, just as a column is made in a cavern by the union of a stalactite with an opposing stalagmite. Cartilage tumors Fig. 4. Normal. Curved. Angular. Enchondronia Bridge of Sigmoid. cartilage. Diagrams showing usual variations in shape of septum, as seen when observer looks into anterior nares. in the nose will often be found to have bony nuclei. This fact is worth remembering when the surgeon expects to attempt removal with a single incision made with a knife. Occasionally the septum has a double or sigmoid curve from above downward, as is shown in the last diagram on the blackboard. At other times the double curve is anteroposterior, so that one nostril is occluded in front and the other nostril occluded in the back of the nasal chamber. When one nostril is obstructed by what appears to be a deviated septum, it may happen that careful examination discloses the fact that there is no corresponding abnormal patency of the other nostril. The condition then is one of abnormal thickness of the septum, with a great degree of overgrowth on one side. This is to be treated by paring away the excess of cartilage or grinding away the redundant bone with the burr of the surgical engine. In septal deviation the distortion is, fortunately, nearly always in the anterior two-thirds of the septum. Hence the deformity is more accessible to operative attack than would be the case if the converse were the rule. There are many methods of relieving these nasal deformities. The method adopted must depend on the character of the condition. If the bridge is sunken, it must be raised and supported by the intra- nasal tissues. If the nasal bones are destroyed by syphilis, they must 12 ROBERTS, be substituted by new tissue, which is usually the tissue of the cheek or forehead, with possibly periosteal or osseous structures taken from the frontal region or from a lower animal. If there is a protuberance at the tip of the nose, it must be cut out and the two sides brought together so as to form a respectable-looking lobe. If the septum is bent over, it is necessary to open the occluded nostril, straighten the septum and keep it in the median line. It is especially important that all recent fractures of the nose should be skilfully treated at once, in order to avoid subsequent deformity. This often is not done. There is a good deal of swelling and pain at the time of injury, which makes it difficult to determine the extent of the lesion; and as the condition is not serious, very little attention is given it, the structures are not accurately replaced, and in a few days, when the swelling subsides, the bones and cartilages are found to have united in bad positions. As a result, one of these deformed noses is the patient's burden through life, subjecting him to the criticism of his friends and the jeers of his enemies. Sometimes the displaced portion of bone is so sharp that it almost projects through the skin. When a fracture occurs, diligent and intelligent efforts should at once be made to restore the bones to their proper position. Anes- thesia should be resorted to if necessary, rather than have the replace- ment not absolutely correct. By looking at this specimen you see that the space under the nasal bones is not very great. In many text-books the surgeon is directed, in fractures of the nasal bones, to insert the end of a female catheter into the nostril, to push the bones into place, and then to put a plug or pad of lint in the nostril. Since the normal space under the nasal arch is narrow, and since in fracture there is great swelling of the mucous membrane, it is prac- tically impossible to follow these directions, because the catheter is too wide. One can, however, get a thin instrument, like a steel director or the back of a small nasal saw, up under the bones. With this they can be elevated into place, and the bridge of the nose then moulded into proper shape with the fingers on- the outside of the in- jured organ. These fractures heal with great rapidity, hence any- thing that is done must be done promptly, as in four or five days the union will be so firm that it will be almost impossible to restore the bones to their proper position if the fragments have been left in a condition of deformity. Syphilis of the nose is exceedingly liable to cause destruction of the bony and cartilaginous nasal structures, and, therefore, should be CURE OF DEFORMED NOSES. 13 treated immediately on its recognition with large doses of mercury and potassium iodide. Many cases are, however, unrecognized or are insufficiently treated, and as a result we have unsightly and un- necessary deformity. Superficial scars can sometimes be relieved by scraping away the irregularly cicatrized surface, since the irregularity in the cicatrization often looks worse than a large smooth scar would. A greater degree of damage will require for its repair the best efforts of a skilled plastic surgeon. Just here let me say that in operating upon the skin of the nose or face an incision made obliquely through the cutaneous tissue leaves a very faint cicatrix, because more correct apposition is obtained when the sutures are inserted. This is illustrated by cutting a card first obliquely and then perpendicularly to its surface. You see that when the pieces are brought together the line of union made at the former incision is not so distinct as that made at the latter place. A good deal of scarring may, however, be made about the nose and yet not show very much finally, if the parts are brought accurately to- gether, and the union takes place rapidly. This is especially true in the rough and coarse skin of many persons, and where lines and creases about the nose are normally present. There are some special plans of treatment which are valuable, and to which I shall now refer. When, after fracture of the nose and adjustment of the fragments, there is a tendency for them to become displaced again, they can usually be kept in position by what is known as Mason's method, though it is reallv a revival of an old method. With an ordinary awl or small drill bore a hole transversely through the bones, and through this thrust a steel pin, to the projecting ends of which attach the ends of a rubber band, so placed as to pass across the bridge of the nose. This band should be so tightly stretched over the nose as to hold the bones up in position. The pin thus acts like the tie-beam which holds an arch together. The tendency of the rubber is to draw the pin up and thus it supports the arch. I thought that I had something new when on this same principle I put a pin through the nose and clamped a shot on the end; but I found that a similar thing had been used many years ago. When the surgeon does not wish t,o use the rubber band, he can clamp shot on the end of the pin, and have the upper part of the nose constantly under ob- servation. Filling the nostrils with plugs of lint or other material to hold the parts in correct position is usually an ineffectual and un- comfortable method. • These methods may be employed in the treatment of recent fractures 14 ROBERTS, or in cases where it is desirable to make a fracture in order to overcome deformity. In correcting osseous deformity of the nose, whether congenital or due to fractures received many years previously, it is very easy with a proper chisel or saw to divide the bones to any extent and in any direction. For most of these operations the ordinary cold-chisel, previously ground to a fine, sharp edge, answers very well. These chisels can be bought for a few cents at the hardware stores. To loosen the nasal arch a small opening should be made at the side of the nose, at the junction of the nasal bone with the lateral cartilage, and the chisel then driven up between the nasal bone and the nasal process of the maxillary bone nearly as high, or quite as high, as the supraorbital ridge. The same thing should be done on the other side. The naso-frontal junction can be separated by introducing a strong steel instrument into the nose and elevating the nasal bones until fracture occurs at or near the suture line, or the bones can be cut loose by intro- ducing a small chisel at the top of the nose. If it is considered necessary, small perforations with a drill may be made along the junction of the frontal and nasal bones before fracture there is attempted. The bones can then be placed in any position desired and held there by a pin, thrust through the nose below them or made to perforate them after drilling with an awl. The circulation of the parts is so good that necrosis is almost impossible. The scars formed by the openings made for the introduction of the chisel cause much less deformity than that for which operation is performed. The nasal bones unite in four or five days without provisional callus, and if they are placed in good position a comely nose results. In some cases it may be better to introduce a small narrow saw into the nostril and saw the bone off on both sides. The chisel is rather a cruder way and perhaps not so accurate. When the bridge of a nose is sunken in a good deal, when it is in fact a little like the saddle-back nose, a gutta-percha splint adjusted to the dorsum of the nose may be used to advantage, after a tenotome, introduced into the nostrils, has been used to cut all structures loose. The gutta-percha is placed in hot water until soft, and then moulded to the nose and allowed to cool, thus forming an external nasal splint. After loosening the bones and soft tissues, the operator carries a wire or silk suture through the nose below the splint and brings the ends up over the splint and ties them. This lifts the middle line or dorsum of the nose into the proper position. After a few days cicatrization takes place and the normal conformation of the nose is maintained. I have not tried this method, but it seems as though it were a good one. CURE OF DEFORMED NOSES. 15 If there is an unseemly bony angle on the bridge of the nose, as in Fig. 1, t^-z_%«.^»^:?\s\_sv Roberts's barbed needle. Dr. Seiler has suggested that a grooved director be slipped under the cartilaginous ridge or tumor, with its groove presenting toward the mass to be removed, and that a triangular or ploughshare-shaped knife be then pushed along the groove so as to cut off the excrescence. He also employs for removing such growths chisels and gouges of varying shapes set at an angle in a detachable handle. These devices facilitate at times the neatness and rapidity of the operation. The means to be employed in correcting the deformity in cases of bent and twisted nose vary with the characteristics of each case. In- deed, it often happens that the nasal distortion combines the peculiari- ties of more than one type of deformity. I recently saw a gentleman, for example, whose badly bent nose, due to injury sustained in a runaAvay accident, Avas made additionally ugly by a large and un- shapely lobe or tip. It is necessary, as a rule, in remedying bent or tAvisted noses, to cut the cutaneous structures thoroughly loose from the septum and nasal arch by free subcutaneous incisions. This is done with a tenotome introduced usually, but not ahvays, through the nostril, and then carried under the skin. I prefer this method, in order to make as few punctures on the cutaneous aspect of the nose as possible; though, as before stated, small incisions or punctures leave in the end very little scarring. After the external nose has been thus loosened by subcutaneous "undermining" Avith the teno- tome, it is necessary to get rid of bony projections by means of the chisel, to cut aAvay any bone or cartilage occluding the nostril, to divide and readjust the distorted septum Avhich is usually present, and 20 ROBERTS, then to seize the nose with the fingers and twist or bend it into its normal position. When the desired position has been obtained the parts must be fixed there by pins or other means until union has occurred. This requires about a week's time. The errors likely to be committed are insufficient division of the distorted structures and the application of too little force Avhen the attempt is being made to press the organ back into its normal relation Avith the face. If the surgeon will recollect Avhat a great degree of force is required to produce the distortion found in accidehtal nasal deformity, he will better appreciate how much force he may use with impunity in endeavoring to correct these and similar disfigurements. The tuberous nose and the angular nose are easily improved by simply cutting away the excess of tissue and uniting the resulting Avound with fine sutures of catgut or silk. In these, as in all plastic operations, the ingenuity of the surgeon must be exercised to give the least scarring and the most perfect contour. The same shaped nose should not be repaired in exactly the same way in every sort of face. The peculiar facial lines of the individual or the shape of his other features has a good deal to do Avith determining the variety of opera- tive procedure best adapted to the requirements. The question in- volves not only manual dexterity on the part of the operator, but a considerable degree of artistic training. This is equally true when portions of the nose are to be constructed from the cheeks, lip, or finger-tip. Such rhinoplastic operations, however, are rather beyond the scope of the present paper. There is only one thing more of Avhich to speak. It is the correction of those great deformities which occur from sinking of the whole upper portion of the nose as the result of syphilis. A woman came to my office a short time ago who Avas in the habit of Avearing continually a thick black veil to hide a deformity due to such a loss of the car- tilaginous nasal bridge. The point of the nose Avas turned up and there was a deep groove over the area of the sunken nasal bridge. What is required in these cases is the construction of a new bridge. This is difficult Avhen there are no remains of the original bony struc- tures. I accomplished it pretty Avell here, nowever, as the nasal bones remained. I first made a transverse incision across the nose in the deep groove at the line of junction of the deformed organ and the face, cutting thereby directly into the nasal chambers, and then pared every- thing loose inside. The nose Avas then only attached to the face by the columna and the al?e, and could be pulled downward and forward so as to give its tip a natural prominence or eleAration beyond the cheeks. CURE OF DEFORMED NOSES. 21 This procedure left a large opening between the lower portion of the nose and the nasal arch and frontal bone, through which I could look directly into the nasal chambers; and which had to be covered Avith a flap. I laid over it a triangular flap of skin and superficial fascia, dissected from the space betAveen the eyes and from the forehead. Fig.