NOTE ON THE TREATMENT OF COLLAPSE OF THE ALA NASI.

922 condition and to fix the fragments for a time, as otherwise undue mobility may lead to permanent want of union. Such a result is very rare without displacement, and a more common sequel is the formation of an excessive amount of callus from the same cause, leading either to destruction of the epiphyseal line or to interference with its blood-supply. Both these pathological processes may lead to a want of growth on the part of the bone affected, and if such want of growth occurs in one of two parallel bones, or in one half of a broad epiphysis, angular distorsion of the joint may result, as is shown in Case 3. The difficulty in recognising the exact form of injury present in epiphyseal separations depends on the small size of the parts in children and the way in which the bony processes are obscured by the subcutaneous fat. In order to come to a correct conclusion and to effect efficient reduction of any deformity present an anesthetic is always necessary and careful measurement must be made of the bony points, comparing them with those on the sound side. It is often difficult to fix accurately the fragments after reduction for the same reasons, and moulded splints of poroplastic or gutta-percha will be found far more serviceable than those of wood or metal and very easy to apply. The proximity of the injury to a joint always leads to a rapid effusion into the synovial cavity, often consisting of blood. An important point in treatment, therefore is the early passive movement, which should be carried out in order to prevent the formation of adhesions with permanent limitation of movement in consequence. This must be begun before the fracture is sufficiently firmly united for splints to be discarded, and about the seventh or tenth day the limb should be taken down off the splint, and the fractured region being kept fixed by grasping the fragments with the hands an assistant should proceed to move the joint. Very slight range of movement is all that is necessary at first, but all the normal movements of the joint must be commenced ; thus at the elbow or wrist pronation and supination must be practised as well as flexion and extension. A similar passive movement must be carried out each day, and each day the range of movement may be increased, and even at the end of three weeks or a month, when the splint is discarded, it is as well to continue such treatment for another period of three weeks, especially if any pain or stiffness persist. Case 2 shows deformity and pain resulting from improper treatment of a fairly common injury about the elbow in children. One cf two lines of treatment may be adopted in such a condition. If seen sufficiently early the separated fragment may be wired or pegged in its proper position, a proceeding which may lead, not only to union, but to restoration of growth about the epiphyseal line ; but if seen late, as here recorded, no such new growth could be expected and the obstruction to movement and the pain caused by the callus are best overcome by removal of the fragment. The portion of bone removed in this case was much distorted by the addition of callus, and no trace of the epiphyseal line remained, so that no new growth could have subsequently taken place The fourth case is an example of a fairly common complex injury, though the epiphysis of the internal condyle is more

often torn off at the time of dislocation than, as here reduction. This injury has on several occasions been overlooked, and failure to recognise it has led to ulnar paralysis from want of immobilisation and excessive formation of callus, the latter pressing on the Treatment by immediate wiring or fixation of the nerve. fragment in position by strapping has been recommended.

reported, during

The latter was impossible in the present case, as no hold could be gained on the fragment, nor would the subsequent swelling that ensued lead to an unqualified recommendation of this method. Immediate wiring is certainly the ideal treatment if asepsis can be assured, but infection, however slight the risk may be, leads to such serious results in these cases that any line of treatment evading the possibility of such an accident is certainly worthy of consideration. Case 5 shows a simple separation with displacement of the lower epiphysis of the radius and the usual accompanying deformity which differs slightly from that seen in Colles’s fracture. Considerable force is as a rule needed to tear off this epiphysis, and in consequence many of the cases recorded have been compound separations, the lower end of the diaphysis tearing through the skin and often injuring the radial artery. University College Hospital, W.C.

NOTE ON THE TREATMENT OF COLLAPSE OF THE ALA NASI. BY W. J. WALSHAM, F.R.C.S. ENG., SURGEON AND LECTURER ON SURGERY TO ST.

BADTHOLOMEW’S HOSPITAL.

COLLAPSE of the ala nasi is a condition well known tothose interested in nasal surgery. It consists in the falling of the external part of the lower lateral cartilage inwards during inspiration, so that it comes in contact with the septum and prevents the patient from drawing air through the nasal chambers on the affected side. Normally the lowerlateral cartilage is doubled on itself, U-like, the inner part, being in contact with the lower end of the septum, whilst the external forms a part of the outer wall of the vestibule. There is an amount of stiffness in the cartilage which keeps. the anterior nares patent and the resiliency of the cartilage where the bend occurs is sufficient, after the two portions of the cartilage have been pressed together, to restore the patency of the anterior nares. In not a few individuals this resiliency is lost, and during inspiration the outer wall ofthe vestibule comes into contact with the septum. In some of these cases there co-exists a dislocation of the anterior end of the septum from tha colume)la, and this, when present, increases the obstruction to free inspiration. Although this collapse of the ala may be called a trifling affection it is astonishing bow much annoyance it gives toIt may easily be overlooked by the the subject of it. surgeon unless he is cognisant that such a condition may occur. For when the speculum is introduced and the blades are separated the collapsed ala at the same time is of course carried away from the septum by the external blade of the speculum and nothing whatever may be discovered on looking into the nasal cavities to account for the patient’s trouble. The surgeon should suspect this condition, bow-ever, if when nothing abnormal is seen in the nasal chambers the patient remarks that he breathes quite com-fortably with the speculum in situ. If now the speculum is removed and the vestibule is examined by tilting up the tip of the nose with the finger it will be seen that the outer wall comes in contact with the inner when the patient inspires. The condition is an exceedingly troublesome one to treat. I t.hink I have seen come good done by face massage-that is, massage of the dilator muscles of the ala-but not much. When there is dislocation of the anterior end of the septum. shaving off the projecting portion will also help matters, though it will not completely rid the patient of his trouble. I have used the various rings, semi-circles, celluloid expanders, short pieces of drainage-tube, &c., that have been from time to time recommended for the condition, and although they may keep the passage expanded whilst in situ and for the timegive relief they soon become irksome and irritable and are abandoned. In one case under my care I bad made a number of similar contrivances of various material carefully moulded and shaped to fit the part accurately. But this patient, like the rest, finally threw them aside and resorted again to his own plan of obtaining relief-namely, rolling up a piece of moist cottonwool into a ball of the size of a small pea which he poked up the vestibule into the little pit just within the limen at the angle of bending of the lower lateral cartilage. This tiny ball of cotton-wool was just sufficient to prevent the ala from collapsing and it gave me the clue to the method of curing the condition. It struck me that if in place of the cotton-wool ball I could transplant there a ball of the patient’s own tissue I should obtain the same end, and this I succeeded in doing in the following way. A strip of mucous membranethick as possible and about three- sixteenths of ari inch in dissected up from the inner wall of the vestibule,. width was leaving the base attached above. The surface of the little the angle of bending of the lower lateral carpit at was next made raw by removing the epithelial tilage The epithelial lining was also removed from thelittle strip of tissue; the tissue itself was rolled up’ bandage-wise and then secured to the rawed surface of’ the pit by a stitch of the finest fishing-gut passed by a needle through the septum into the opposite nostril and back again. When thus fixed the little roll of tissue pressed out the external portion of the lateral cartilage just enough tOo prevent the ala during inspiration from falling into contact with the septum. It cannot be sefn and produces no

as

layer.

923

deformity,

and

so

far

as

my

experience

has gone it is

a

permanent cure for this troublesome condition. The surface left by rolling up the strip of mucous membrane readily

granulates over and causes no inconvenience. Tension in the strip of tissue must of course be avoided and care must be taken that the surfaces of the roll are properly and completely bared and their vascular supply not interfered with by drawing the stitch too tight. The operation is best done under general anæsthesia, as unless the tissues are manipulated delicately the blood-supply of the little strip will be injured and necrosis will take place. Harley-street,

W.

regret that in

dealing with such an exceedingly beneficent method of treatment as this all the internal processes should not yet be fully known. Certain it is, however, that the withdrawal of moisture from the limbs must be accompanied by considerable changes in temperature, and further that it is impossible to speak of a constant dry heat in view of the fluctuations in temperature and moisture. In order to obtain at least some authoritative data for commencing the investigation of these points I had a maximum thermometer constructed which can be placed between the asbestos coverings during the sitting and read afterwards. The following table give the temperatures noted :-

THE

OF SCIATICA, ARTHRITIS DEFORMANS, AND SCLERODERMA BY SUPERHEATED DRY AIR (THE TALLERMAN SYSTEM).

TREATMENT

A REPORT FROM THE LANDESBAD AT BADEN-BADEN.

BY DR. FR. NEUMANN. IT is seldom that a specific method of treatment withstands the test of years and continues to fulfil its original promise so well as the Tallerman system for the application of superheated dry air. The apparatus itself has been so frequently described that I may confine myself to a brief indication of its essential features, though there are, on the other hand, thousands of physicians who have not yet seen it. Two different forms are used : (1) for the pelvis ; and (2) for the extremities. The apparatus can be heated by electricity or by gas or even by oil, and the temperature in the interior is brought up to 300° F. That such temperatures are actually reached in the upper part of the cylinder is proved by the reading of the thermometer affixed to the top; but whether temperatures so high as the thermometer indicates are maintained inside in an equal degre-whether a limb lying in the apparatus is surrounded by a uniformly heated atmosphere so that we can speak of the contin2cous action of superheated air when once the maximum is reached-that question has hitherto been a matter of assumption. I have endeavoured to solve it in a simple manner. When any portion of the body is insprted in the the floor on which it rests is protected by a cushion of asbestos resembling a thick layer of felt. Above this and around the limb a covering of woven asbestos, which is like lint in appearance, is disposed. The patient must be completely undressed and comfortably wrapped up in loose cotton wraps and blankets on account of the profuse perspiration which usually occurs during and after the sitting and also to ease the respiration and the action of the heart. Obviously the limb is not exposed to the direct action of the hot air, and for this reason-that if it were left uncovered the radiant heat from the metal falling on to the skin must have either a scorching or at least a very irritating and painful effect. The loosely clothed portion of the body inside the apparatus experiences in general no disagreeable sensations from the heat. Where the covering comes into direct contact with the skin the feeling is only one of moderate warmth, but where between the folds hot air has free access to Lhe cuticular nerves one has the sensation of a very intense but comforting heat. The dry air enveloping the limb must obviously draw from it a large amount of moisture through the difference of temperature and saturation ; and it follows from elementary physical laws that as large quantities of moisture are withdrawn more and more blood is forced to flow from the deep-seated tissues, where it is cooler, to the heated surface and into the dilated vessels of the skin. For a closer examination of these processes, however, further investigation is needed. It is a fact that the coverings in which a limb rests when under treatment become moist and that occasionally in a fold of asbestos shut off from evaporation a small quantity of water-unquestionably the product of condensation-may

cylinder

and yet such moisture never becomes superheated, for otherwise scalding would occur, and this we have never observed at the Landesbad in upwards of 2000 Nor is a single case of scalding noted in the whole of the English literature which I have perused. It is a matter for

collect;

applications.

This table shows that inside the cylinder in the course of hour’s use considerable variations in temperature occur, which certainly cannot be without influence on the contents of the superficial blood-vessels and on the amount of evaporation. Immediately after leaving the apparatus the limb is injected and of a uniform red, but has not the slightest appearance of cyanosis or stasis. Doring treatment the whole body falls into a pleasant perspiration ; the pulse is accelerated by some 10 to 20 beats in the minute, but is not noticeably full or dicrotic, still less small and inegular. Cardiac or cerebral sensations of a disagreeable character only occur in highly nervous patients, in whom the mere apparatus-or the oven" s people often call it-of itself excites alarm. With increasing experience and observation I have been able, as others have done, to apply the treatment without anxiety to patients suffering from arteric-sclerosis, myocarditis, and moderate valvular disease. Here, as elsewhere, observations of the temperature taken in the mouth or axilla have shown that there is never an important increase in the body-heat, the rise scarcely reaching to Celsius as a rule. This conclusion is confirmed by the fact that treatment never induces albuminuria, but rather that it diminishes existing albuminuria from organic kidney disease. English writers represent the curative action of the treatment in a light which we cannot altogether endorse. My own belief is that super-heated dry air will come much more into general use as a therapeutic agent and will obtain permanent recognition if attention is directed strictly to the results derived trom a wide field of observation. Among the English contributions to the subject we find the statement repeatedly made that the local action in a limb or joint on one side of the body benefits the corresponding part on the other side in a striking manner. I willingly admit that the general stimulation of the circulation and of perspiratory excretion may produce general relaxation of the tissues and relief from pain, but our observations afford no evidence that a curative effect is actually transferred frcm one side to the other by a sort of sympathetic action-whatever that may mean. Equally doubtful, in my opinion, is the assertion that in arthritis deformans, for instance, or in neuralgia such as sciatica, a striking and immediate remission of pain sets in. Nor is the reduction of swollen joints effected so rapidly as is stated in many reports. Oil the other hand, it is unquestionable that in many cases the curative action continues after treatment. The improved circulation and marked stimulation of the lymphatic system lead in many cases to vigorous nutrition of the parts affected ; and so it happens that patients are discharged, going somewhat dejectedly away on crutches and sticks apparently unimproved and uncured, of whom we subsequently hear that improvement, cure, and ability to return to work have been gradually established. It is also much truer to nature that the healing process should follow this course than that of suggestive and miraculous change. Further, the gradual improvement in the condition of atrophied muscular tissues, the increase an

.