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Artificial Bridge of the Nose

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ARTIFICIAL BRIDGE OF THE NOSE. a man into whose nose he had introduced, one year previously, an artificial bridge for the correction of a deformity due to a fracture of the nose, sustained at the age of four and a half years. Practically, he had no bridge, so flat was his nose; but the cartilaginous portion was intact. The result is highly satisfactory. No one could suspect that his nose had ever been in need of surgical care. The arti ficial bridge is entirely comfortable to him ; indeed, it does not seem to him otherwise than as if one of his own bones ; and judg ing by the previous experiences of the reporter, to the number of about a dozen, and dating back, two of them, fully five years, he will wear it without trouble all his life.

Dr. James E. Newcomb, of this city, who recently examined him, says that he can just recognize by reflected light within the nose, through the soft parts, the faint outline of the base of the new bridge.

In all these cases Dr. Dawbarn had used no metal, but a plas tic material, dental pink gutta-percha. This was selected for numerous reasons. First, the assurance of dentists that no ma terial will remain when crowded beneath a gum with less re sultant irritation than this. Second, it is by scalding water easily sterilized, and when so heated can be moulded like the softest putty, but at the bodily temperature becomes nearly as hard as pine. Because it can be so moulded, it is easy to make it exactly the right size and shape by fitting it upon the skin of the nose, where the defect is, before any cutting is done. Finally, the chemistry of the body does not attack it at all, no matter how long it remains in place. It is so shaped as to have a broad base of support, and much narrower where the skin covers it. The technique of the operation is as follows : The nostril on one side is most carefully clipped free from hairs, and both sides are syringed out repeatedly and packed for twelve hours with wet boric gauze. This is not removed until after the operation, thereby preventing blood running back into the pharynx, to the operator's annoyance, but is replaced by fresh boric gauze when the operation is ended.

Under major anaesthesia, and with a slender, small-bladed scalpel, a cut is made well within the nostril, large enough to ad mit the new bridge endwise. The skin is then freed from the subjacent bone along the whole length of the nose, and perhaps nearly as far outward as the infra-orbital vessels upon both sides. This dissection is made to hug the bone as closely as possible. It must be guided by the sense of touch only, and is necessarily as speedy as possible, as blood is pouring out from a multitude of little vessels divided. If bony prominences need removal, this is done by narrow chisel through the same path. As soon as the skin lies perfectly loose where formerly it closely followed the bones, the bleeding is checked by a long half-inch strip of sterile. gauze, dampened and well rubbed with sterile aristoI ; its edges and ends hemmed to avoid loose threads, and compression applied over this. In ten minutes all oozing will be quite checked.

Then the bridge of gutta-percha, prepared and sterilized before the patient was anaesthetized, is slipped into place. It is held there by a single steadying strip of zinc oxide adhesive plaster across the face.

Formerly, he sewed up the wound in the nostril. This was not easy, and now he thinks it worse than needless ; for an oppor tunity for drainage from the lowest point is desirable. This cut takes care of itself without trouble.

Nothing could be simpler than this technique ; and all his cases had been grateful patients except the first. In that case he was too ambitious. The patient, who had always, even before his accident, been characterized by a somewhat distressing pug nose, demanded a Roman organ instead. The general shape of his features seemed to give consent, so the new bridge was moulded accordingly, and all went well for a time. But finally, at the highest part of the Roman arch, the skin showed signs of tension. It slowly sloughed, and when the slough came away the pink gutta-percha was revealed over an area as large as a finger end.

It is of interest, in conclusion, to record the fact that in two of these cases there was suppuration following the operation,— this patient was one of them, and that, nevertheless, the final result was equally good. This satisfactory outcome was doubt less partly because the drainage was so perfect, from the lowest point of the wound, and partly because the bridge, a perfectly solid and smooth mass, presents no crevices nor spaces in which pus can be retained. It is almost impossible to be sure of effective sterilization of the interior of the nose, and he had congratulated himself upon having in this operation no worse proportion of infection than that just mentioned.

DR. Gwyer said he could corroborate the statement made by Dr. Dawbarn that the pink gutta-percha remained ap parently unaffected by the fluids of the body. He had used the material in a case of artificial nasal bridge, operated on several years ago ; the patient had been lost sight of, and he could not state what the ultimate outcome of the operation had been. In a case of facial neuralgia, the patient having been previously operated on by another surgeon and there having been a recur rence, after removing a portion of the superior maxillary nerve, he had inserted a plug of this compositon to occlude the foramen rotundum ; the patient had been seen several years after, and, while the neuralgia had again returned, there had been no trouble experienced from the presence of the foreign body.

DR. L. A. STIMSON said that at a meeting of the Surgical Society about six or seven years ago he showed a patient into whose nose he had introduced a gutta-percha plate for the cor rection of a similar deformity ; and within a year or two a Boston surgeon had reported several cases similarly treated. In his Dr. Stimson said, he introduced the plates through an external incision, which method was perhaps preferable to an incision made within the nostril, as there is less likelihood of subsequent infection of the wound. In no instance did the plates give rise to any trouble. In one case he removed the plate after a year to insert a longer one, and then noted that the condensation of tissue about the plate was sufficient, at least temporarily, to main min the corrected position of the nose after the plate was taken out.

In one case of nasal deformity, Dr. Stimson said, he used an aluminum plate ; in another a packing of silk thread, but the end of the thread protruded at the incision after two or three days, and he removed it.

Dr. joseph D. Bryant said that his first experience in the rectification of a deformity of the nose was about ten or twelve years ago; he employed for the purpose a piece of gold wire, which answered very well, and did not give rise to any trouble for about four years Then the patient returned and showed a line of discoloration on the nose along the border of the wire ; the wire was removed and a strip of celluloid substituted, which rectified the deformity even better than the wire, and up to the present time (now over four years) it has given rise to no trouble.

Dr. Bryant said that platinum has been used in a number of cases to serve the purpose of an artificial nasal bridge, but its period of usefulness is limited, probably, to about three years at the most. For that reason gutta-percha and celluloid appear to be preferable.

Dr. Dawbardrejoined that in the report of this case he did not make, nor intend to make, any claim as to the question of priority. He was pleased to learn that Dr. Stimson had previously employed this material for the same purpose and could indorse its value. The main question at issue seemed to be whether the gutta-percha bridge should be introduced through an external incision, as Dr. Stimson had done, or by the method, followed by himself, from within. Personally, he preferred the latter. In a number of cases where he has employed it, in addition to the case reported to-night, the method proved simple, the deformity was entirely corrected, and there was no resulting scar.

patient, gutta-percha, trouble, operation, deformity, plate and stimson