PHILADELPHIA, OCTOBER 8, 1881. ORIGINAL COMMUNICATIONS. rence of acute coryza, but without any definite symptoms in the intervals, so that the patient is not cognizant of the fact that he is suffering from catarrh in the first stage, and but rarely applies for treat SURGICAL TREATMENT OF NASAL ment; second, the hypertrophic stage, CATARRH. Read before the Philadelphia County Medical Society, September 14, 1881, BY CARL SEILER, M.D., Lecturer on Laryngology at the University of Pennsylvania, Pathologist of the Presbyterian Hospital, etc. THE term "nasal catarrh" is at the pres ent time a very comprehensive one, and signifies a more or less chronic inflammatory condition of the mucous membrane lining the nasal cavities, which latter term includes, clinically speaking, the nasopharynx, the posterior nasal cavity, and the anterior nares, as well as the frontal sinuses and antra of Highmore. The physiological functions of these cavities-viz., the warming, moistening, and filtering from dust of the air in respiration, and the qualifying of the tones of the voice by resonance, which latter I have endeavored to prove in a pale read before the American Laryngological Association, session of 1881-I will not here enlarge upon, but would say a few words in regard to one peculiarity in the histology of the nasal mucous membrane where it lines the turbinated bones. In this location we find that the submucous tissue which is interposed between the mucous membrane proper and the periosteum of the turbi nated bones, and which contains the racemose mucous glands, is composed of strong bands of elastic connective tissue interlacing with each other, thus forming meshes irregular in size and shape, which contain true venous sinuses lined with endothelium. This arrangement forms just such a tissue as we find in the corpora cavernosa of the penis,-viz., true erectile tissue, which under certain conditions will suddenly enlarge to many times its original bulk, and which was termed by Professor Bigelow "turbinated corpora cavernosa."'* Nasal catarrh may conveniently be divided into three stages, which usually follow each other in regular sequence, but each one of which may also appear independently of the others. These three stages are, first, the congestive stage, which is characterized merely by a frequent recur Boston Medical and Surgical Journal, April 29, 1875. which is marked by true hypertrophy of the mucous membrane and its glands in certain portions of the nasal cavities, especially on the turbinated bones and the septum, and which gives rise to most of the symptoms of catarrh complained of by the patient; and third, the atrophic stage, in which we find a general wasting of the mucous membrane, a want of secretion, and a consequent accumulation of scabs, which become putrefied, thus imparting a peculiar disagreeable odor to the breath, and may lead to ulceration if they remain long in contact with the mucous membrane. The second or hypertrophic stage is the most frequent form of nasal catarrh which comes to the notice of the practitioner; and, as surgical treatment is necessary to effect a cure of this condition, I will describe the lesions and symptoms to which they give rise more in detail, before entering upon the description of the surgical means most adapted to relieve the trouble. of the mucous membrane in the first stage The frequently repeated acute inflammation inflammatory tissue in the mucous memof catarrh leads not only to a deposit of brane, but also to an increase of the glandular elements, and at the same time to an increase in size of the venous sinuses in the erectile tissue covering the turbinated bones, so that gradually localized swellings show themselves, which remaining permanent produce partial or complete stenosis of the anterior nares. The stenosis is more commonly partial while the patient is in the erect position, but frequently bewhen he lies down, or under the influence comes complete in one or the other nostril of mental excitement or anything which tends to increase the blood-pressure in the head, for these swellings, being principally composed of erectile tissue, will be ininto their venous sinuses. External irricreased in size by a greater afflux of blood tants, such as dust or acrid gases, produce the same effect and cause the hypertrophies to swell suddenly. These localized hypertrophies are generally situated at the lower portion of the inferior turbinated bones, but are also found on the middle and supe rior turbinated bones and on the septum. Those situated in the anterior nares and visible by inspection through the nostrils have been termed anterior hypertrophies, while those hanging from the superior turbinated bone into the post-nasal cavity are called posterior hypertrophies. The former are usually sessile with a broad base, while the latter are more or less pedunculated and can be seen only by means of the rhinoscopic mirror. Other conditions than a hypertrophy of the mucous membrane may give rise to partial or complete stenosis, and consequently to many of the symptoms of nasal catarrh, such as localized or extensive deviation of the septum, congenital malformation of the bones of the skull surrounding the nasal cavities, polypi and other neoplasms, and, finally, foreign bodies introduced into the nostrils. The symptoms to which these conditions give rise are so well known that it is hardly necessary to allude to them here, and I will, therefore, merely for the sake of completeness, say a few words about them. The most prominent and, to the patient, most annoying symptom of catarrh is a copious discharge of thick, ropy mucus, which accumulates in the posterior nares, and from there descends into the nasopharynx, causing a feeling of fulness in that region which the patient endeavors to relieve by hawking. This mucus is the perverted secretion of the hypertrophic glands in the mucous membrane, and is prevented from flowing through the natural channel, the anterior nares, by the presence of the anterior or posterior hypertrophies. The frontal headache which is but rarely absent, and which frequently assumes the character of neuralgia, is caused by the pressure exerted upon the sensory-nerve fibres by the swelling of the mucous membrane lining the frontal sinuses and antra of Highmore. An extension of the inflammation into the Eustachian tube causes a narrowing of its calibre, and consequently gives rise to tinnitus and deafness; and, finally, the partial or complete stenosis of the anterior nares gives rise to a train of symptoms which, being remote from their cause, are frequently either entirely overlooked or are regarded as manifestations of a different disease. As has been said before, the physiological functions of the nose are, besides its being the organ of smell, to filter the air of dust, to raise its te make it moist before it reaches the larynx, and to add to the quality of the tone of the voice by its resonance. If, then, there exists an obstruction to the free ingress and egress of air in the nose, the mucous membrane of the larynx will be irritated by a dry cold air filled with fine particles of organic and inorganic dust when respiration is carried on through the mouth, and a chronic laryngitis frequently results. In most cases in which the stenosis is but partial-that is, when the patient can breathe through his nose during the day, but is unable to do so during sleep, and wakens with parched throat and tonguehe does not carry a sufficient amount of air through the narrowed channels to the lungs to thoroughly expand them and sufficiently oxygenize the blood for the wants of the system, and the consequence is a sense of oppression in the chest and a general impairment of nutrition. There is another symptom, which in many cases is very striking, and which is due partly to impaired nutrition and partly to the pressure exerted on the subjacent parts by the hypertrophied mucous membrane of the nasal cavities,-viz., loss of memory, and an inability on the part of the patient to concentrate his mind upon any one thing. If the localized hypertrophy is situated near the opening of the tear-duct, the latter frequently becomes occluded at its lower opening and causes a watering of the eyes, while these same swellings, no matter where situated, reduce the bulk of the nasal cavity, and thus interfere materially with nasal resonance, without which the voice is devoid of its peculiar character. From the foregoing remarks it will appear that the most rational mode of treatment for this stage of the disease consists in the removal of the obstructions in the nose in a manner which accomplishes the object thoroughly and at the same time gives the patient the least discomfort from pain and hemorrhage. The application of caustics, such as chromic acid, nitric acid, acetic acid, etc., with a view to destroy the hypertrophies, gives great pain, which lasts a long time; and, as the action of these agents cannot always be controlled, they are apt to cause serious general inflammation of the mucous membrane lining the nasal cavities. The tearing-out, ing, or cutting-off of the hypertro phies with sharp or dull forceps gives rise not only to great pain, but also to copious hemorrhage often difficult to control. To prevent pain and hemorrhage, I am in the habit of using either galvano-cautery or Jarvis's wire snare in the treatment of these cases, and have found that either method, if properly used, is almost absolutely painless and bloodless, while the purpose of removing the hypertrophies is thoroughly accomplished. My battery and knife for the use of galvano-cautery in nasal diseases I exhibited to the County Medical Society last spring in its crude but serviceable form,* and since then Mr. Flemming has made a more elaborate apparatus, which in its principle is the same, but in which the details have been improved. The knife also has been improved by adopting a slight modification of Shurly's handle and by using a blade which cuts on one side only, as suggested by Dr. Bosworth, of New York. The use of this instrument is very simple and requires but a moderate amount of skill and care; but it should be used in those cases only in which the anterior hypertrophies are not large enough to touch the septum and cause complete stenosis. I do not knife removed while still hot. The ultimate result of the operation is the formation of bands of cicatricial tissue, which by its contraction binds down the swelling and thus prevents the stenosis. The number of incisions necessary to remove, or rather obliterate, the hypertrophies will depend upon their size and degree of firmness. Too much should not be attempted at one sitting, on account of the often severe inflammation following To bring the hypertrophy into view I prefer a rubber speculum to the generally-extensive burns of the mucous membrane. employed nasal dilators, because the latter always stretch the nostrils and disturb the normal relation of parts to each other, thus making it more difficult to decide whether the hypertrophy is touching the septum or not, and because the pressure of the blades against the septum produces more or less pain. The speculum, on the other hand, has the advantage of leaving the parts in their normal condition, pushing the hairs in the nostrils aside and out of view; and in using the galvano-cautery knife it protects the parts not to be burned.† By having the end of the speculum cut slanting, the hypertrophic portion of the mucous membrane can be brought into the rubber tube and the knife applied without the least danger of injuring any other portion. Having thus brought the hypertrophy into view, the plates of the battery are depressed, the knife introduced into the end of the speculum, and while there it is heated to a dull cherry heat, when a quick incision is made into the projecting tissue, and the * Philadelphia Medical Times, August 27, 1881. † See "Galvano-Cautery in Hypertrophic Nasal Catarrh," by Carl Seiler, American Specialist, September 1, 1881. When the hypertrophies are large, and especially when they are situated in the posterior nasal cavity, hanging from the posterior portions of the turbinated bones, I prefer to use Dr. Jarvis's wire snare to remove them. This admirable little instrument, a description of which will be found. in the Archives of Laryngology, when properly used is certainly the most satisfactory means of attaining the end, which is the complete removal of hypertrophies of the nasal mucous membrane. To do this, I proceed as follows in a case of largeanterior sessile hypertrophy. I transfix the swelling near its base with a curved needle, devised for the purpose by Dr. Jarvis, and then pass the wire loop of the snare around the handle of the needle, then over the growth and point of the needle as it emerges from the tissue, and draw the loop tight before making traction with the milledhead screw of the instrument, and then gradually snare off the swelling, occupying from fifteen to twenty minutes in its removal. When the wire has passed entirely Pathology and Surgical Treatment of Hypertrophic Nasal Catarrh, Archives of Laryngology, vol. ii. No. 2. through the tissue, which it does generally with a jerk, the hypertrophy comes away sticking to the transfixing needle. In the same manner can localized deviations of the cartilaginous septum be ablated if they interfere with the functions of the nose. If, however, the hypertrophies are situated so far back that they project into the posterior nasal cavity and can be seen only with the rhinoscopic mirror, the manner of removing them is very different. The mode of attachment and apparent size of the swelling having been determined by means of the rhinoscopic mirror, the wire loop is made of a size large enough to slip over the hypertrophy, and its size is measured, before introducing it, by means of the little measuring device attached to the instrument. This is done to determine when the tissue has been cut through by the wire, for it often happens that shreds of mucous membrane are drawn by the wire into the tube of the instrument, making traction as difficult as though the tissue had not yet been cut. If the patient's palate is at all unruly, it must be secured by passing an elastic band through the nose and out of the mouth, where it is secured by means of Jarvis's tape-holders in such a manner as to draw the palate forward without making undue traction. The tape is best drawn through the nose by means of a large Eustachian catheter, through which is pushed first a piece of catgut string until its end appears in the pharyngeal cavity, where it can be secured by a pair of forceps and drawn out through the mouth, the other end still projecting from the nose. The catheter is then withdrawn, and the tape secured to the end of the catgut string projecting from the nose, when it may be drawn through the nose and mouth and be held by the tape-holder. The palate being thus secured, the rhinoscopic mirror, also devised by Dr. Jarvis, and which is a combination of tongue-depressor and rhinoscopic mirror, is introduced with one hand, bringing the hypertrophy into view, while with the other hand the snare is passed through the anterior nares, and its wire loop is passed over the swelling guided by the rhinoscopic mirror. I will state here that if the left side of the nose is to be viewed by means while the snare, of course, is directed in each case by the other hand. As soon as the wire loop has passed over the hypertrophy and has slipped over the pedicle, which always exists to a greater or less extent, it is tightened rapidly until the tension is considerable and the patient begins to feel the pressure. After this the tension must be gradual; and I find a good rule is to turn the milled head of the screw until the patient blinks with his eyes, then to let him rest for two or three minutes, and then repeat the turning of the mill-head. In this way the largest hypertrophy may be removed without pain or hemorrhage of any account, and the whole operation will not occupy more than one to one and a half hours. In the posterior hypertrophies, the wire does not cut through the tissue with a jerk, as is the case in the anterior hypertrophies, but does so gradually, and the measuring device on the instrument must be watched to see when the loop has passed into the tube of the instrument. In most cases the hypertrophy comes away with the snare, but in some cases it remains in its place after it has been severed from its connection with the turbinated bone. Under such circumstances it should be at once removed with a pair of forceps; but the patient should not be allowed to blow his nose to remove it, for fear of starting hemorrhage. After having carefully inspected the posterior nares with a view to ascertain whether other swellings are to be removed at a subsequent sitting, the tape is taken out and the patient allowed to depart, usually extremely happy from the circumstance that he can now breathe freely through his nose, which before the operation he could not do. This paper has become already longer than I anticipated; and I will therefore leave for a future occasion the consideration of the removal of obstructions in the nasal cavities other than those spoken of. 1346 Spruce Street. HAS EACH OF THE ZYMOTIC DISEASES A SPECIFIC POISON? BY G. HAYWARD COBURN, M.D. was see Echel of the rhinoscope I find it better to hold JANUARY 30, I was called to see Ethel the mirror in the left hand, and if the right of diphtheria; pain in head and back, side is the one to be examined the mirror high pulse and temperature, false memis best introduced with the right hand, | brane covering both tonsils and uvula. |