_(b)_ Membranous obstruction in the nasal chambers from compensatory
hypertrophy of the erectile tissue, alone or with
hyperplasia.
_(c)_ Obstruction arising from hypertrophy of the adenoid tissue in
the pharyngeal vault.
_(d)_ Contracture of the levator palati muscles.
SECOND VARIETY--that dependent on structural changes in the component
parts of the nasal chamber.
This variety is associated with--
_(a)_ Chronic inflammation of the nasal mucous membrane without
hypertrophy of the erectile tissue.
_(b)_ Atrophy of the turbinals and their associated mucous membrane.
_(c)_ Necrosis of the bones which enter into the framework of the
nasal chambers.
FIRST VARIETY.--Defects in nasal respiration induce hyperæmia,
distension of the erectile tissue, hyperplasia of the mucous membrane,
and {44} inevitable distress in the nose. A sense of fulness across the
bridge of the nose and at its sides is complained of. Frontal headache
may be present.
_(a, b)_ When the septum is deflected and the left nasal chamber is
narrowed, the labor of sustaining nasal respiration is thrown on the
right side. This arrangement invites a flow of blood to the already
large turbinals, and creates obstruction which is frequently referred
to the right side, although both are alike affected. Thus, subjects in
which the initial obstacle is osseous complain of distress caused by
cavernous-tissue hypertrophy of the lining membrane of the opposite
side. This represents a very common class of cases.
When the septum is not deflected, but projections from it impede the
current of air, there may be either unilateral or bilateral
obstruction, dependent upon the shape of the septum itself. Hypertrophy
of the cavernous layer of the mucous membrane usually coexists. These
cases are numerous, but less common than those last described.
Infrequently, cases are seen where the distress is occasioned by
defects of the osseous structures not accompanied by cavernous
hypertrophy.
Treatment of the above disorders consists in restoring nasal
respiration by removing obstructions, whether they be osseous or
membranous. The septal projections may be drilled or filed away, or, if
marked deflection of the anterior portion be present dependent upon a
malposition of the triangular cartilage, an operation simple in
character may be performed for its correction. This consists in
severing the connection of the lower margin of the cartilage with the
maxilla and slipping the partially free cartilage to a new position.
The details attendant upon the operation need not be here given. The
reduction of the hypertrophied membranes can be best accomplished by
cauterization. The most efficient method is by means of the electric
cautery. The electrode used should be flexible and of small size. The
points which most frequently require cauterization are the premaxillary
portion of the inferior turbinated bone, the under surface of the same,
and the septum at the maxillary spur. Rarely the inferior surface of
the inferior turbinated bone at the palatal region requires attention.
The applications are best made over small surfaces at a time, and
should be repeated at intervals of from two to three days until all
suspected points have been at least once cauterized. Not infrequently,
the effect of the cauterization at one spot will cause constriction to
take place in the vessels of the entire mucous surface, so that while
this condition lasts it is impossible to tell what additional points of
the membranous obstruction demand removal. At the following visit,
however, the vessels have become relaxed, the membranes are again
turgescent, and if obstruction now occurs it can easily be detected.
The galvano-cautery can only be used in the nasal chamber in patients
who are earnestly seeking relief and are willing to assist the
physician in all his efforts. With the tractable, intelligent subject
it can with proper care be limited exactly to the spot intended. It is
scarcely necessary to observe that any erratic or unexpected motion of
the head will sear unaffected and sensitive surfaces. The interior of
the vestibule is perhaps the most sensitive of these, and should always
be protected by the use of the nasal speculum. No additional protection
is needed, though in the judgment of others, among whom may be
mentioned E. Shurly of Detroit, Michigan, an ivory shield passed in the
nose parallel to the electrode is a necessary safeguard.
The pain of the application is generally slight, and can be in part
annulled by a previous application of a 4 per cent. solution of
cocaine. Some annoyance is acknowledged on the following day from the
pressure of the eschar. Traumatic congestion of the entire mucous
surface of the corresponding chamber is at the same time detected, and
is usually sufficiently decided to produce some of the effects of acute
coryza. This condition will spontaneously terminate in from thirty-six
to forty-eight hours. The most annoying features {45} following an
application of the galvano-cautery which has been too freely made do
not belong to the group just indicated, but rather to reflex
disturbances. Pains are occasionally excited in the teeth, in the
temple, eye, nape of the neck, and the middle ear. On one occasion in
the writer's experience a unilateral reflex excitation of the entire
opposite side of the body occurred, and a prickling sensation, followed
by numbness, ensued, which lasted for twenty-four hours. Very rarely a
congestion of the pharynx, of the larynx, and the larger bronchial
tubes ensues, which can scarcely be directly attributable to the
application, yet it has followed in a sufficient number of cases to
lead me to believe that the two are in some remote way associated.
Perhaps such a condition is analogous to the slight irritation of the
respiratory tract following excision of the tonsil. Careful use of the
galvano-cautery will obviate the conditions above described. They are
important to remember as serving as limitations to the use of this
valuable agent.
_(c)_ It will be seen that osseous obstruction in the nasal chamber and
hypertrophy of the cavernous nasal tissue often coexist. More rarely, a
third element occurs as a complication, or it may be found
independently of all other morbid processes. I allude to the presence
of hypertrophy of the adenoid tissue in the pharyngeal vault. When this
tissue is only moderately developed, it need not, and does not,
interfere with nasal respiration; but when it projects downward to such
a degree as to lie within the axis of the lower portion of the
posterior nares, it produces the same effect upon nasal breathing as
though obstruction existed within the chamber. The growths can be
easily detected, as a rule, from behind by the aid of the rhinal
mirror, but it should not be forgotten that they also can be seen from
in front, provided the chamber is free from obstruction along the
respiratory tract. In some individuals the ribbed or lobate structure
of the mass can be discerned, but more often its presence is revealed
by the minute points of light reflected from the lobules. If it be a
matter of doubt whether these points of reflection are within the nasal
chamber or beyond it in the pharyngeal vault, the patient may be
requested to swallow, or to pronounce the letter _e_; when, if the
point of reflection is within the nasal chamber, it will not change its
position, but if it be within the naso-pharynx, it will be moved
slightly from side to side, or it may for a moment disappear.
The symptoms of nasal catarrh which are provoked by the presence of
such a growth can be alone successfully treated by the removal of the
offending mass. In young individuals--say, from twelve to eighteen or
twenty years of age--the finger inserted into the naso-pharynx from
behind can often break down the growth. Slight hemorrhage follows this
procedure, and the tags of imperfectly-destroyed tissue can be
subsequently treated by caustics and powerful astringents. In the event
of the patient proving intractable, the growth may be reached from in
front through the nasal chamber, and the galvano-cautery can be used by
passing the electrode backward through the nostril until it meets with
resistance, which is invariably at the pharyngeal vault. Should this
method of treatment not be permitted by an undisciplined or nervous
person, the prolonged use of a glycerole of iodine may gradually reduce
them in size; but no definite result can be promised from such
treatment.
_(d)_ Very rarely, through inordinate elevation of the soft palate
owing to over-action of the levator palati muscles, the passage of
communication between the naso-pharynx and the oro-pharynx is
inadequate. Consequently, the nasal chamber is imperfectly ventilated,
and its secretions, not flowing backward or being displaced to the
normal extent, become semi-inspissated, and create obstruction by
lodging in the respiratory tract, either in the premaxillary or palatal
portions. To successfully combat this condition it is evident that no
local treatment is demanded, either in the nose or the naso-pharynx,
other than to increase the tonicity of the pharyngeal and palatal {46}
muscles. Very frequently in such cases there is a symmetrical atony in
the muscles last named, which demands the internal use of strychnia and
iron and the application of galvanism.
PROGNOSIS.--When nasal catarrh has proved to be dependent on defective
respiration, the removal of the causes entering into this condition may
with reason be expected to effect recovery. The prognosis, therefore,
is favorable. In young persons, in whom reparative power is present in
the highest degree, and in whom a secondary hypertrophy of the
cavernous tissues is least developed, a prompt cure may be obtained by
removal of the osseous or other forms of obstruction. In adults,
however, the prognosis is less favorable, especially with those who
have approached or passed middle life, and who have contracted vicious
habits of breathing, which are likely to persist even after the removal
of their causes. It is also tenable that in such subjects the mucous
lining of the cranio-facial sinuses has become involved. Should anosmia
persist after the capacity of the chambers has been augmented--in a
word, should this condition not be dependent upon obstruction, but upon
changes in the olfactory surfaces--the prognosis is less favorable than
in any of the cases of the above-named group.
Treatment will, however, always secure amelioration of the symptoms,
and few cases occur which cannot be greatly improved. The general
health is invariably benefited. Should a tendency to asthma exist, it
is apt to disappear, the complexion clears, and in adolescence the rate
of general development is accelerated.
SECOND VARIETY.--The group of nasal diseases included under this head
is not a natural one, since it embraces disorders characterized by a
negative feature--viz. absence of obstruction to nasal respiration.
Nevertheless, it is convenient to consider under a single head a number
of relatively infrequent disorders in which there is invariably an
underlying constitutional cause. Subjects of disorders herein embraced
are not merely sufferers from insufficient oxygenation of the tissues,
but have impaired general vitality or possess a decided constitutional
taint, whether specific or otherwise. The nasal condition is simply the
most prominent of the local manifestations.
Three distinct disorders are herein named: first, chronic inflammation
of the nasal mucous membrane; second, atrophy of the turbinals and
their associated mucous membrane; third, necrosis of the bones entering
into the framework of the nasal chambers.
_(a)_ Inflammatory thickening is a rare affection. It is more frequent
in males than in females, and in persons of a sedentary occupation than
in those who are actively employed. Those subject to it are apt to have
light-blue or gray eyes and auburn or sandy hair. On examination, the
chambers may be found free from peculiarities of bony structure,
capacious, and without hypertrophy of the cavernous tissues, yet the
membranes be of a deep-red color and of cushiony consistence, yield
bright reflexes, and the shank of the instrument introduced into the
nose is mirrored upon them. The most conspicuous alteration is not seen
on the turbinals, but on the septum. The parts are very vascular, and
the most moderate manipulation will often end in free capillary oozing.
The discharge, though moderate in quantity, is inclined to be purulent,
and resembles semi-coagulated albumen. Quite frequently, in the
examination of a neglected case, minute flecks of this modified
secretion are seen scattered over the septum and the inferior
turbinated bone. Rarely, the discharge is maintained by the presence of
a morbid growth or inflammatory products, either in the nasal chamber
or a chamber accessory to it. The discharge then appears to consist of
pure pus mixed with the normal secretion of the nose, and, thus
rendered viscid and tenacious, it excites by its presence a condition
of the lining mucous surface quite similar to that above described.
{47} Under excitement, as after an attack of coryza, the discharge
becomes more serous in character, and is occasionally of a chocolate
color from its admixture with blood. It is without odor. There is no
obstruction to respiration except during sleep, when, in aggravated
cases, mouth-breathing may be established. Thus, the patient will often
complain of an obstruction which is never present at the time of the
examination. He further complains of a sense of dryness in the nose,
with some pharyngeal irritation. The palato-pharyngeal and
palato-glossal muscles are weak and often asymmetrical; the tonsils are
small, but the adenoid tissues are generally unaffected. In a dry
atmosphere, especially if it be loaded with irritating particles, the
pharyngeal irritation is increased--a complication which is probably
due to the inspired air passing too rapidly through the capacious and
imperfectly-guarded nasal chambers and throat. Although I have
carefully searched for all indications of aural complications,
especially for the symptoms of progressive dry catarrh, I have never
detected them but in a single instance.
The prognosis is to be guarded, although a careful course of treatment
and proper care of the general health will greatly improve, if not
entirely cure, the disease.
TREATMENT.--This consists in the application of nitrate of silver,
either in strong solution or in the solid stick, to the under surface
of the inferior and middle turbinated bones, of washing the parts with
a dilute solution of carbolic acid, and of passing through the cheek
tissues a constant electrical current of a strength of from five to ten
cells. Tonics and alteratives should not be neglected, and an outdoor
life, as far as is practicable, should be enjoined. The galvano-cautery
may be used to destroy any nodules of tissue which resist other
treatment. All applications are well borne, if indeed we may not look
upon the condition of the surfaces as partially analgesic, and thus far
of unfavorable significance. It is certain that indurated tags of
oedematous and chronically inflamed mucous membrane overlying a bone,
such as the middle turbinated or the alveolar line about the necks of
the teeth, will never yield to anything but the most powerful
astringents. Upon such tissues the most concentrated solutions of
nitrate of silver are never caustic. The premaxillary portion of the
inferior turbinated bone is frequently seen hopelessly infiltrated, and
it must then be destroyed by the electro-cautery. When a discharge of a
pus-like character exists, careful search should be made for the cause.
If a tumor or foreign body be found, it should be removed, but if the
cause lie in one of the outlying spaces of the nasal chamber, it is
evident that the above treatment is palliative only.
_(b)_ In atrophy of the nasal mucous surfaces and turbinals we have, as
in the last-named group, spacious chambers, a purulent discharge,
pharyngeal irritation (in many cases), and always associated a thin and
relaxed, if not a paretic, condition of the velal muscles. These cases
might be looked upon as an advanced stage of the preceding affection,
since it may be surmised that the stage of infiltration has been
succeeded by one of atrophy. The mucous membranes are everywhere pale,
and closely bound to the underlying bony framework. The discharge is
purulent and confluent; where in contact with the air it is desiccated,
but where protected, as by crust-like surface-layers, it is semi-fluid
and tenacious. There is, consequently, no disposition for the discharge
to escape from the nose, and it accumulates until the sense of
obstruction induces the patient to remove it by artificial means. When
first seen, the nasal chambers are frequently so fully occupied with
discharge as to conceal the characteristic appearances of the mucous
surface. This prolonged retention induces incipient decomposition of
the mass, which gives rise to the odor so characteristic of this group
of cases.
The subjects of atrophic catarrh (ozæna) are never in robust health.
They are, as a rule, of spare habit, anæmic, and with family histories
which, while {48} not distinctive, indicate that the affection is, to
some degree at least, hereditary. A few cases have come under my notice
in which all the general features of atrophic catarrh were present, but
with very slight although confluent discharge, unaccompanied by fetor.
Such cases are, strictly speaking, examples of atrophic catarrh, while
they could not, under the old nomenclature, be included under the head
of ozæna.
The prognosis is unfavorable for entire recovery, but treatment
systematically pursued will make the patient entirely comfortable to
himself and others--will arrest the progress of the disease and vastly
improve the general health. As in other forms of nasal disease, should
anosmia be present the prognosis is less favorable.
[Illustration: FIG. 19. Antero-posterior section of the bones of the
face in position, showing the premaxillary portion of the floor of the
nose greatly elevated above the plane of the remaining portions. In
ozæna, as mentioned in the text, a disposition of parts may exist
similar to that delineated, and cause discharge to collect and undergo
offensive decomposition.]
TREATMENT.--The parts should be carefully cleansed--an act which, while
imperfectly accomplished by either the syringe or the douche, is, in my
judgment, best performed by the galvano-cautery. This instrument, the
one relied upon for the subsequent treatment of the case, is to be
selected for its initiation. The largest speculum which the nose will
admit being placed in position, a spiral-looped electrode is introduced
cold into the nose and held against one of the crusts. When heated it
will effect so firm an attachment to it as to enable the mass to be
withdrawn with great ease. In patients with {49} whom the palatal
portion of the floor of the nose is depressed below the level of the
maxillary a considerable quantity of discharge may lie concealed from
observation. When, after the removal of all visible crusts, the fetor
persists, it is reasonable to suppose that the palatal depression is
filled with decomposed pus and mucus. To test such a condition, the
electrode should be appropriately curved and introduced. I have been
surprised at the quantities of discharge which can in this way be
withdrawn from a locality which, as far as I know, cannot be cleansed
in any other way.
With the removal of the crust relief is at once experienced, and if the
discharge could be removed as fast as it forms the disease would not
really be a source of offence. The general health would also improve,
from the fact that an atmosphere tainted with a burden of decomposition
would no longer be breathed. But in practice this cannot be attained,
and it is imperative, after the chambers have been entirely cleansed,
to cauterize the lining membrane throughout. I have been in the habit
of beginning such cautery treatments with the middle turbinated bone,
passing thence to the inferior turbinated bone, then to the roof of the
nose in front of the sphenoidal sinus, and lastly to the septum. Small
surfaces only should be covered at a single treatment, so that it may
take a month or six weeks to finish a single series of applications.
This treatment is almost always well borne, nothing ever ensuing beyond
a slight headache or a temporary establishment of a serous discharge.
Notwithstanding that the condition in question is one of atrophy, the
reparative power of the mucous membrane remains apparently unaffected.
At all events, no danger from sloughing is to be dreaded after such
extensive destruction of tissue. The thin eschars separate within from
three days to a week, leaving a healthy mucous membrane beneath. In one
instance the cauterization had extended to a sufficient depth to expose
the bone, and yet from this denuded surface no exfoliation took place,
the parts healing rapidly and satisfactorily. No other local treatment
is relied upon for fetid atrophic catarrh than the one mentioned. No
disinfectant washes are required if the discharge is removed as
described. Should the patient be so situated as to be unable to report
regularly for its removal or treatment, a wash composed of one part of
Labarraque's solution to sixteen parts of water may be ordered with
advantage, or a solution of carbolic acid, gtt. j to fluidounce j, with
a little glycerin, may be snuffed up the nose twice a day, or
listerine, diluted one-half with water, may be used with advantage. The
general health, of course, should be cared for, and any complications
met. I have found that during the winter months arsenic and cod-liver
oil are well borne, associated with minute doses of Lugol's solution.
For adolescents earthy and the calcareous phosphates are indicated, and
for all abundant exercise and careful dieting. When the symptoms have
been relieved, the patient should be requested to report once a month,
for it is not to be expected that all symptoms will disappear, and some
point of advice can be advantageously offered at this interval.
_(c)_ Necrosis in the nasal chamber is a cause of catarrh, inasmuch as
the fragments of bone lying within the nose excite irritation and
induce discharge. I have never seen a case of this form of disease
which was not due to syphilis. The remains of syphilitic angina are apt
to be present, and the general manifestations of constitutional
syphilis are well developed. The septum is more frequently affected
than the turbinals.
Discharge due to necrosis can be readily distinguished from that
arising from any other cause by the presence of detached fragments of
denuded bone, by the characteristic fetor, and by the history of the
case.
The prognosis is favorable, for all symptoms will cease upon the
extraction of the fragments, or at least those which remain are of an
entirely different character, and are due to the resultant
imperfections of the septum, and consequent irritation arising from the
too free entrance of air into the {50} nose. I have seen in one case an
extensive tumefaction and infiltration of the tissues covering the
middle turbinated bone at the same time that the septum was breaking
down. These masses require treatment with the galvano-cautery and
astringents after the dead fragments have been removed.
A TABLE OF NASAL DISEASES GROUPED BY SYMPTOMS.