symptom:
Due to deflection of nasal septum (common).
Due to angiose hypertrophy of the mucous membrane (common).
Due to tumors lodged in the nasal chamber.
Due to adenoid hypertrophy in the naso-pharynx.
Due to over-activity of the levator palati muscles (rare).
Cases in which discharge is a conspicuous symptom:
Due to hyperplasia of the mucous membrane over the turbinated bones
(common). The discharge when flowing backward is described as a
dropping; when forward, as a running at the nose. The discharge is
either mucoid or muco-purulent.
Due to tumors lodged in the nasal chambers or appendages. The
discharge is usually excessive. When due to myxomata (polypi) the
discharge is mucoid (common). In inflammatory complications of the
same the discharge is muco-purulent (common). When due to neoplasms
other than myxomata the discharge is purulent, and rarely
muco-hæmic (rare).
Cases in which retention of mucus in the nose or upper part of the
throat is a conspicuous symptom:
Due to retention of inspissated mucus at the roof of the naso-pharynx
(common).
Due to the mucous secretion of the nose and throat being excessively
tenacious (rare).
Cases in which fetor is a conspicuous symptom:
Odor putrid.
Due to retention and decomposition of plasmic exudation from
atrophied bone and mucous membrane (common).
Due to necrosis of the bones within or bordering upon the nose
(rare).
Due to decomposition of muco-pus in the maxillary sinus (rare).
Odor musty.
Due to partial decomposition in small patches of desiccated mucous
crusts (common).
Due to morbid secretion unaccompanied by profound alteration in the
structure of the nose (rare).
Due to ulcerations of the mucous membrane (rare).
Cases in which a sense of dryness is a conspicuous symptom:
Due to ineffective erectile tissue permitting air imperfectly warmed
to enter the nose and the pharynx (often met with in neurosis). It
is caused by temporary constriction of the erectile tissue or by
the atrophy of the tissue.
Due to neurosis. Neurotic patients will often complain of a sense of
dryness in the nose and the naso-pharynx when all the conditions of
excessive mucoid discharge are present.
Cases in which hyperæsthesia exists, so that slight lesions that in any
way interfere with the nasal functions form the basis of persistent
complaint (not infrequent).
Epistaxis.
Epistaxis, or nose-bleed, is a form of local hemorrhage perhaps of more
frequent occurrence than hemorrhage from any other mucous surface of
the body. This is doubtless owing to the extreme vascularity of the
lining membrane of the nose and the special arterio-venous (cavernous)
spaces of the turbinated bones; and the bleeding may be said to be of
grave character in proportion as these spaces are involved. In some
individuals a special disposition to nasal hemorrhage exists. From the
fact that the affection is transmitted from parent to offspring, and is
frequently found in all members of a given family, this form of
hæmophilia is probably dependent upon some structural peculiarities in
the cavernous spaces.
The causes of epistaxis are both local and general. Among the local
causes may be included traumatism, either from blows or other injuries,
attempts on the part of the patient to relieve irritation by picking
the nose, or from the {51} use of cutting or other instruments in the
hands of the surgeon. Septal ulcerations in this way are often
accompanied by moderate bleeding. In a case reported by R. G. Curtin
the nasal branch of the ophthalmic artery was thought to have been
ruptured. Among the general causes the most frequent is undoubtedly the
depressed state of the system preceding or accompanying typhoid and
other anæmic states. Thus, among the prodromes of typhoid fever
epistaxis holds a conspicuous position. It is also seen in chlorotic
females, especially in those suffering from that phase of anæmia known
as Grave's disease. It also occurs in vicarious menstruation and in
local facial or encranial congestions. In those disorders of nutrition
accompanied by a tendency to capillary extravasation, such as purpura
and scurvy, the nasal mucous surface participates in the general
disorder. In a case of the former disorder coming under the notice of
the writer the blood had forced its way out in large quantities by
every capillary avenue.
TREATMENT.--Epistaxis when a symptom of a dyscrasia is of course to be
treated as a local expression of a general condition. In typhoid fever,
scurvy, and purpura or anæmia the bleeding is a sign of the general
distress, and requires no special local method of treatment. Epistaxis
when of local character should be treated, first, by removing the
cause; second, by diminishing the flow of blood to the part; third, by
cold and astringent washes to the affected surface; and, fourth, by
compression.
First. Should the bleeding be kept up by fragments of bone impinging
upon or lacerating the mucous membrane, they should be restored as far
as possible to their natural position and retained there by appropriate
apparatus. If they are entirely denuded of their periosteum and mucous
membrane, they should be removed. Foreign bodies should be extracted,
and if septal ulceration be present it should be carefully treated, the
crusts removed, the ulcerated surfaces touched with nitrate of silver
in stick, and the nasal chamber plugged from in front to exclude the
outside air.--Second. The position of the body is of great importance
in treating epistaxis. The recumbent position is no doubt to be
preferred. The patient often holds one arm elevated or ties a cord
about the proximal end of a limb. These innocent accessories to
treatment may be permitted, since they are based upon well-known
physiological principles, although it must be said that the bleeding
can in all instances be checked without their aid. Cold applications to
the nape and sides of the neck are often of service. Various internal
remedies, such as ergot, gallic or sulphuric acid, and erigeron, may be
administered with good effect in addition to the local
measures.--Third. Astringent washes, such as a solution of alum--about
drachm j to the pint--will often check a moderate degree of capillary
bleeding without other aid. Tannic or gallic acid may also be used.
Should these measures fail, the Monsel solution may be used on pledgets
of cotton carried up to the bleeding spots. In Curtin's case, already
quoted, a pledget saturated with the solution of the perchloride of
iron placed over the nasal branch of the ophthalmic artery promptly
arrested the bleeding. In lieu of these styptics the platinum wire loop
of the galvano-cautery battery may be used. The writer has often
succeeded in checking bleeding after a removal of a polypus or the use
of the galvano-cautery when the exact position of the hemorrhage is
known by laying upon the affected spot a little square of patent lint.
It acts much as in checking the bleeding from a leech-bite.--Fourth.
Compression of the mucous lining of the nose and exclusion of these
surfaces from the air--a method familiarly known as plugging the
nose--is the dernier ressort in the treatment of epistaxis, and is to
be relied upon in the event of failure of other methods. This failure
is, however, relatively infrequent. Observers agree in describing the
procedure tedious and rather disagreeable, as much to the operator as
to the {52} patient, who has already been exhausted by loss of blood
and the previous measures resorted to for his relief.
[Illustration: FIG. 20. Bellocq's Canula.]
The instrument usually relied upon for this purpose is known as
Bellocq's canula (Fig. 20). This little instrument consists of a hollow
curved tube of metal fashioned somewhat like a Eustachian catheter, and
bearing within it a flexible and adjustable metallic band which carries
at its extremity an eyelet. Any one who has used the Eustachian
catheter will recall the number of instances in which it could not be
passed, or if passed the frequency in which great distress followed. If
this be true of the Eustachian catheter, it is also true of the Bellocq
canula, the difficulty in the case of the catheter, indeed, being the
lesser of the two, inasmuch as the physician has a number of sizes to
select from. Conceding, however, that the instrument (with a long stout
thread passed through the eyelet of the stylet) has been placed in
position in the nasal chamber, one end of the thread is seized within
the mouth and brought out between the lips, while the other, carried by
the instrument, is withdrawn through the nose and is allowed to hang
from the nostril. The two ends of the thread are now tied firmly
together, and a pledget of lint or cotton, fashioned somewhat after the
shape of the posterior naris, is tied to the thread. Traction is now
made upon the nasal portion of the thread until the plug is firmly
lodged against and within the posterior naris. The remaining portion of
the oral thread is now cut off close to the velum, and the free end of
the nasal thread secured by adhesive plaster to the integument. The
nostril should next be stopped from in front by pledgets of lint or
absorbent cotton. The size of the nasal chamber and naso-pharyngeal
varies so markedly that a rhinoscopic examination is of use in fixing
upon the size of the plug. If it be too small, it will be drawn
entirely within the nose, and possibly beyond the bleeding spot. If it
be too large, it will partially or entirely occlude the posterior naris
of the opposite side, and thus by interfering with nasal respiration
greatly increase the distress, or by pressure against the Eustachian
fossa and velum interfere with the hearing and with deglutition. The
plug should be retained in position until a purulent mucus appears
within the nose: this is usually about the third day. The plug now
usually becomes a little loose, and can readily be withdrawn by pushing
it back into the pharynx, where it is seized with forceps. Too long
retention of the plug in position is followed by great fetor and the
free formation of muco-pus--conditions which tend to debilitate the
patient.
D. Hayes Agnew informs me that he for a long time practised stopping
nasal hemorrhage by plugging the chamber from in front. Strips of
patent lint four inches long by half an inch wide are employed for this
purpose. They are gradually pushed into the chamber until the entire
space is filled as far as is practicable. An essentially similar method
is described by F. H. Bosworth in his _Manual of Diseases of the Throat
and Nose_.
Morbid Growths.
These may be said to include the myxoma, sarcoma, fibroma, carcinoma,
also the true hypertrophies and submucous inflammatory thickening.
{53} The myxoma, more commonly known by the name of soft or gelatinous
polyp, is the most prominent of the morbid nasal growths. It occurs
ordinarily in small pedunculated seed-like masses, ranging in size from
that of a grain of wheat to a grape. The most common seat is on the
anterior portion of the middle turbinated bone and on the median
surface of the inferior turbinated bone at the palatal portion. Instead
of being pedunculated, they may be sessile; that is, each tumor may
have a base equal to, if not exceeding, any diameter of the tumor.
The symptoms of nasal polypus are of three kinds: (1) those arising
from obstruction of the nasal respiration; (2) those arising from the
irritation excited by their presence; (3) the symptoms, reflex in
character, manifested at points beyond the limit of the nasal chambers.
(1) The polypi necessarily tend to obstruct the respiratory tract of
the nasal chamber. The first symptoms are of this character, and as a
rule furnish the first intimation to the patient that trouble exists.
Difficulty of nasal respiration is acknowledged, accompanied with a
sense of tension and fulness, which is found to be worse during damp
weather than when the air is dry and bracing. If the growths are freely
pendulous, the act of blowing the nose may change the position of the
mass and secure temporary freedom from distress. Incidental to
obstruction, an intonation of the voice is often present. Loss of
smelling and of taste is a frequent result of the mass interfering with
the movement of the odoriferous particles. The loss of the sense of
taste is dependent upon the loss of the sense of smelling.
(2) Polypi when large enough to press against the membranes of the nose
excite an increased flow of mucus. As a rule, this flows forward, and
is removed by the handkerchief. The quantity of fluid thus escaping is
often very great. Patients often report the necessity of carrying about
with them for a single day's use from eight to ten handkerchiefs. In
the turgesence excited by an attack of coryza the mucus becomes thicker
and of a yellowish color. Occasionally a sensation of dropping of mucus
from the nose into the throat is a source of complaint.
(3) The reflex symptoms belonging to the presence of nasal polypi are,
as a rule, referred to the forehead. This is especially the case if the
growths involve the middle turbinated bone. When the tumors are so
located, and have not impinged upon the respiratory tract, the symptoms
of obstruction may be absent, and those of mucus excitement so moderate
as not to excite attention, while the tension in the forehead,
especially over the frontal bos, is pronounced. This sensation is
intensified by prolonged inclination of the head forward, being
especially aggravated in the acts of writing at a desk, working at a
sewing-machine, kneeling at prayer, etc. Occasionally tinnitus aurium
and suffusion of the conjunctivæ are present.
Neglected polypus ends in deformity of the nasal chambers and bones of
the face. The face assumes a peculiar expression called by the older
observers frog face. This is rarely if ever seen in this country, owing
doubtless to the fact that the sufferers from nasal polypus seek
medical advice in the early stages of the affection. Moderate degrees,
however, of deformation of the turbinated bones are often seen.
Since the symptoms of soft nasal polypus are produced entirely by
mechanical means, they can be closely imitated if not replaced by other
morbid states of the mucous membrane. A hyperplastic state of the
membrane over the middle turbinated bone will give rise to all the
symptoms of a sessile polypus in the same situation. It is well to
remember that this condition of the membrane often coexists with
polypus, and of course will persist after the polypus has been removed.
It follows that a guarded prognosis should always be made in case of
sessile polypus. A tedious course of treatment of the indurated and
chronically inflamed membranes may be required after the {54} tumors
have been removed before a cure is effected. The prognosis of soft
polypus is more favorable as to the immediate results of treatment than
in sessile polypus. The liability to recurrence can be materially
lessened by carefully conducted after-treatment.
The diagnosis of soft pedunculated polypus is readily accomplished if
the examination is made by aid of an appropriate speculum, the rhinal
mirror, and a powerful light. Even without these aids the tumors can be
seen by direct sunlight within the nostril if they are entirely
occluding the chambers, and even in the event of nothing being visible
by such inspection the movement of the masses by the act of blowing the
nose will be noticed. The fact that the nasal obstruction is aggravated
by damp weather seems to assist the physician in framing a diagnosis.
The diagnosis of sessile polypus requires a careful use of all the aids
of rhinoscopy. They can be distinguished from hyperplasia of the mucous
membrane by their lobulated form, and from the fact that the probe can
move them slightly from their base. They can be distinguished from
adenoid growths at the root of the pharynx by the fact that they remain
unmoved during the act of swallowing.
The disease is not apt to recur if the treatment is thoroughly carried
out.
The treatment of soft polypus consists in their removal. All observers
are now agreed on this point. Injection by astringents and acetic
acid--a process that at one time held out much promise--has been
generally abandoned. In removal of the polypus one of two methods may
be resorted to: that by avulsion, and that by the use of the snare.
Avulsion is effected by forceps adapted for this special use. With such
an instrument the polyps can readily be seized and removed. The rule
that nothing should be seized which is not seen is subject to no
exception. In no other way can the operator be secure against
accidents. Incautious operators have frequently torn away strips of
mucous membrane or portions of the turbinated bones in their crude
attempts to remove these growths. Severe hemorrhage and death through
violent lacerations of the ethmoid bone near the cribriform plate, and
subsequent extension of the inflammation thereby excited to the
membranes of the brain, have been known to follow these crude surgical
procedures.
[Illustration: FIG. 21. The Author's Nasal Forceps.]
W. C. Jarvis of New York has modified the wire snare for application to
the nose for the removal of polypi and hypertrophied tissues, and
reports that it is a safer, more expeditious, and less painful method
of operation than the forceps, which he unqualifiedly condemns. His
instrument, while undoubtedly an ingenious adaptation of the principle
of the snare, and a valuable addition to our means of treating nasal
affections, cannot, in my judgment, take the place of the forceps in
removing nasal polypi. As the aurist finds both the forceps and the
snare useful in removing growths from the external meatus of the ear,
so I am sure the physician will need both in the treatment of nasal
polypi. In many cases the malformations of the nasal septum are such
that {55} I have been unable to use the snare where the forceps could
be used with relative ease. I find when the loop is quickly drawn the
same amount of bleeding follows as when the forceps are used. When it
is slowly drawn, the sitting is tedious, and both the patient and
attendant find the process wearying. The amount of blood lost when the
forceps are properly used is not considerable, and is always under
control. F. H. Bosworth[1] describes the operation as extremely
painful. So far from this being the case in my experience, I find the
patients complain greatly of the constriction of the wire loop on the
pedicle of the polypus, and invariably prefer the forceps. I must add
that this preference was in no way influenced by myself, for I was
disposed at one time to agree with the writers who have of late
criticised the method of removal of the polyps by avulsion.
[Footnote 1: _A Manual of Diseases of the Throat and Nose_, 1881, p.
241.]
No matter which of the methods be accepted, the treatment of polypus
resolves itself into two simple propositions. When one or two large
polypi are present in a capacious nasal chamber, the removal of the
growths either by avulsion or snaring is a simple matter, and can often
be accomplished in a single sitting. When numbers of small polypi are
scattered over a large surface, particularly if they grow from the
sides of the middle turbinated bone, the treatment is tedious, and even
after the growths are removed a series of applications are required to
cure the thickened and infiltrated mucous membrane.
Sarcoma, fibroma, and carcinoma are infrequent causes of nasal disease.
When located in the nasal chambers they do not present any characters
with which I am familiar which distinguish them from the expressions
they assume in other parts of the body. When involving the respiratory
tract they alike create symptoms by obstruction, by excitement of the
secretions, and by the reflexes due to the involvement of the branches
of the fifth pair of nerves. When situated in the olfactory track the
obstruction to nasal respiration is absent, but the reflex symptoms are
pronounced: the patient is liable to depression of spirits and to
frontal headache. Encroachment upon the orbital, pharyngeal, and
encranial spaces is common in the last stages.
Perhaps the most common way in which these morbid growths induce
symptoms referable to the nose is by obstruction of the respiratory
tract by the incursions of a mass originating at a point beyond the
limits of the nasal chambers. In this way a growth in the pharynx may
close one or both choanæ, or protrude into the nose from the
spheni-palatine space by breaking down the ascending plate of the
palatal bone as it forms the median wall of this space; or the growth
may project inward from the superior maxilla.
In one case under my care, of obscure growth high up within the nose,
which ended fatally by involvement of the membranes of the brain, a
tenacious mucus of a dark chocolate color was withdrawn from the nose
into the throat. The peculiar color of the mucus was found to be caused
by a mixture of blood. In my judgment, this peculiar mixture of blood
and pus was significant. The blood and mucus had not been mixed in the
nasal chamber to cause the chocolate or rusty hue, for then we would
have had the appearance customary in epistaxis of bright blood and
frothy mucus mechanically held together. The even dissemination of the
blood through the mucus would point to the conclusion that the blood
had escaped in small quantity at the time of the formation of the
mucus. Why such mucus does not constantly form in inflammatory states
of the mucous membrane of the nose, as it does from the pulmonary
mucous membrane in pneumonia, I am not prepared to say. But existing as
it did in a case where a deep-seated disease was present may be
accepted as a fact in some way connected with the invasion of a morbid
growth in and upon the nasal mucous surface.
The pharynx is always in a state of hyperæmia when morbid growths of
{56} the above groups are present in the nose. The front of the velum
is apt to be covered with a great number of minute papillæ, which,
however, are often seen in anæmic individuals, and are not therefore
pathognomonic.
The treatment of the growths enumerated and the general conduct of the
cases are subjects for the general surgeon, and a consideration of them
here would be out of place.
It may, however, be well to describe a few instruments which have been
found useful in the large group of cases where cauterization is the
principal treatment indicated. Foremost among these is the instrument
shown in Fig. 22, which combines advantageously the essential features
of the galvano-cautery and the wire snare.
[Illustration: FIG. 22. The Galvano-cautery Snare described in the
text: 1, the cable of the battery; 2, the canula (which is not shown in
full length); 3, the platinum wire; 4, the vulcanite carriage, with
screws holding the ends of the platinum wire in metallic contact with
the hinge-connections, by which the current is transmitted from the
battery; 5, a slotted barrel of aluminium; 6, a movable nut on the
screw; 7, a small portion of the screw disengaged from the slotted
barrel; 8, milled stationary screw-head.]
[Illustration: FIG. 23. The Double Battery employed by the Author: The
two sets of plates are seen united by a flat band of metal. The case
which encloses the two separate batteries opens in front, displaying
the cells, the plates (which are seen pendent over the cells), and the
treadle. Above the figure of the battery lies a figure of the Flemming
electrode handle and the electrode in position.]