ADVANCE, in the material world, is always gradual and permanent. A rock adds to its size by constant accretions; a tree increases in bulk by new growth each year; everything moves slowly and surely; each advance is perfect in itself, and remains for all time or until changed into other forms of matter.
Per contra, advancement in the mental world is seldom, if ever, slow, gradual, and permanent. Mental early steps in any movement maybe gradual, but a point is soon reached from which a leap is made, and the influence of this has been usually to advance too far, and a partial retreat has been made. This is true in all departments of thought-religious, scientific, medical-even fashions go by fads.
This mental movement may often be most fittingly illustrated by the pendulum. It swings to one extreme, then back to the other, and finally rests at az middle point. The illustration fails only that the resting-point is a step in advance of the starting. The fabled frog, who got out of the well by advancing two feet by day and slipping back one by night, is perhaps a better simile.
For long years the nose, considered as an organ of the olfactory sense alone, was given very little attention. The sense of smell, while giving considerable pleasure and warning of danger form products of decay and disintegration, was not an important sense; it had no standard of excellence, and its loss was unaccompanied by any serious distress; hence, there was little call for its treatment.
At the discovery however, of the respiratory function of the nasal chambers, rhinology sprang into existence, and, almost coincidentally, nasal surgery. From an organ of no importance, the nose vied even with the uterus in the complexity and multiplicity of the ailments laid to its disorders; and with the aid of a local anaesthetic surgical treatment advanced from an occasional operation to remove polypoid growths to almost daily routine practice.
It is not my purpose or intention to dispute the value of nasal surgery; its use is just as much a part of the title to this paper as its limitations. There can be no doubt that it has cured many cases of chronic catarrh; that it has pointed the remedial way in pharyngeal and laryngeal cases which before defied treatment; that it has helped very materially in the development of children by placing them in a condition to use their lungs, and by their use avoid their diseases; that it has conquered troublesome and persistent neuralgias and made the deaf to hear. These are its achievements. I will not dwell upon them; you all recognize them; and to pronounce an eulogy on the achievements of nasal surgery would be valuable only for its rhetorical merit, and that it voiced the opinion of all.
These results have been not only salutary but brilliant and immediate. Few achievements in medicine are more appreciated by the patient or gratifying to the physician than the relief of nasal stenosis. This immediate and gratifying result has been, I fear, an incentive to a too frequent and a times ill-advised use. While recognizing the benefits, we just not generalize too broadly. Every case of middle-ear catarrh is not cured by nasal operation, nor is every asthmatic relieved of his paroxysms.
Further still, every case that goes from our hands breathing more freely through the nostrils than formerly is not permanently benefited. To individualize cases is a work for the future. To precisionize our knowledge and be able to tell just what reflex symptoms we can relieve and just what pathological changes in the nasal chambers are accompanied by peculiar symptoms, must be a work of experience and compilation.
All physicians who do special work in the upper respiratory tract appreciate the benefits of surgical measures. But what of its limitations? They are just as important as its uses. They call for our more special attention because they are not as plainly seen and are more concerned with ultimate than present results.
Historically, nasal surgery is an outgrowth of the discovery of the respiratory function of the nose, and of the dependence of the health of the more delicate structures below upon the power of the nasal turbinated bodies to warm and moisten the air current before it reaches the larynx and lungs.
In subject is to make possible this respiratory function; to bring into service the physiological activity of the turbinated bodies, and it should stop short of any procedure that would interfere with this physiology,. The aim of usual surgery is not to clear an obstructed nostril, but to restore normal physiological breathing.
There are several ways in which the physiological function of the turbinated bodies is lost: first, by atrophy or loss of the turbinated bodies themselves; second, destruction of the natural sensitiveness of the mucous membrane so that it fails to respond to the stimulus of cold or dryness; and third, any obstruction that prevents the air passing through the nasal chambers.
The first class includes atrophic catarrh, specific disease, etc. These are unfortunate cases; the turbinated body itself is wholly or partially lost, and little can be done except in a palliative way; surgical interference, other than the removal of carious bone, is not to be considered.
In the second class, loss of sensitiveness of the mucous membrane, may be placed a few isolated cases of uncertain origin. Atrophic catarrh again, and those cases where, from many and repeated cauterizations, the inside of the nostril becomes a mass of sear-tissue. The cautery has become so general and cocaine has made its use so painless and easy, that it has been much abused; it has been used fearlessly and recklessly and by everybody without regard to the destruction of epithelium.
Scar-tissue is not sensitive-tissue, and a nostril, where the surfaces have been broadly seared over, while it may be more spacious than formerly, is scarcely more useful; the membrane has lost its appreciation of the stimulus of cold, and the turbinated bodies are not aroused into activity. In cauterizing, much more is gained by burning deeply but not broadly; the contraction following is greater, and the mucous membrane is left almost intact, and its sensitiveness preserved.
The third class embraces all cases where the air cannot pass through the nostrils, and hence does not come under the influence of the turbinated bodies. It is in this class of cases that nasal surgery has won its laurels, and its achievements have been so brilliant that we have at times been carried away by them, and aimed to restore the nasal spaces rather than the respiratory function; as the late Sir Morrell McKenzie once said, the nasal spaces have been cleared with an energy that would do credit to a backwoodsman. When a nasal or post-nasal tumor exists it should be removed; a deviated septum, when it obstructs the air-current, should be straightened; hypertrophied mucous membrane should be reduced in the way that will do the least injury to the turbinated bodies.
I believe, that where septal spurs coexist with enlarged turbinated bodies, it is better surgery to operate from preference on the septal tissue and preserve the turbinated bodies intact. In those cases where the obstruction is caused by a projection of the turbinated bone into the lumen of the nostril, we are sorely tempted. The removal of the bone and turbinated body “in toto” would have an immediately gratifying effect upon the patient, but in gaining this we have removed the physiological respiratory organ of the nose; we have also produced a nostril of enlarged calibre and dry, and the ultimate results is retained hardened secretions and atrophy. Instead of restoring usual respiration we have destroyed it, and destroyed it permanently. A patient had better go through life with a partially obstructed nostril than become a sufferer from atrophic catarrh.
Nasal surgery has achieved wonders; it has brought great relief, and to many; but the very of its great use has led to its abuse. Patients are to-day sighing for portions of their anatomy sacrificed to the temporary relief of free nasal spaces.
In deciding upon operative procedures, let us consider not only present effect but ultimate results. Bear in mind, that tissue once removed is tissue lost and cannot be regenerated; that a nasal space too large is a more serious condition than one too narrow, for enlarged calibre means lessened air-blast and imperfect cleansing, and retained secretions soon dry and produce atrophy.
Recognizing these possible and ultimate results as a warning against too great zeal, let our aim always be to restore the physiology of the nose as an organ of respiration; and warned on the one hand and guided on the other, we are safe from temptation and a more lasting good to our patients.