Chronic Affections Of The Nose | Operating Microscopes

Chronic Affections Of The Nose
By MORRIS J. ASCH, M. D.,
OF NEW YORK CITY.

CHRONIC hypertrophic rhinitis is a condition of the nasal passages characterized by hypertrophy of the mucous membrane covering the turbinal bodies, by enlargement of the bodies themselves, and by outgrowths from the septum or floor of the nose, which may result from local or constitutional causes.

Etiology. Chronic hypertrophic rhinitis may follow repeated attacks of acute rhinitis, whether they result from exposure, unhygienic surroundings, or from unhealthy occupations. Printers and workers in chemicals or in trades where dust abounds are particularly liable to the affection, as the particles thus inhaled aggravate, if they do not cause, it ; while, in addition, there is the class of workmen exposed to both climatic changes and dustsuch as dock laborers and workers in saw mills who are frequent sufferers from the disease.

The condition is not of rapid development, but comes on gradually, attention being called to it by the resulting inconvenience. Some are peculiarly liable by reason of temperament, especially neurotic individuals. Constitutional causes are gout and defective nutrition. Lithemic patients are prone to this affection along with other diseases of the throat and nose met with in gouty subjects. Broken down constitutions, whether resulting from syphilis, or from defective nutrition following acute disease, or any depressing cause such as insufficient nourishment and poor surroundings are easy victims of chronic rhinitis. Leukemia, malaria, and scrofula are all factors in its causation, but although chronic hypertrophic rhinitis occurs mainly in those of poor constitution, yet in persons otherwise healthy an acute catarrh may, under external influences, become chronic and give rise to the pathological changes peculiar to this disease. It has been observed as the result of grip, and is said to occur sometimes after medication with iodin and mercury. Irritation caused by obstruction of the nasal passage, deviation, spurs, or by the 11 narrow nose “of Storck, may produce chronic hypertrophic rhinitis, or by causing a passive hyperemia aggravate it when resulting from any constitutional cause.

Pathology. The prominent condition in chronic hypertrophic rhinitis is hypertrophy of the turbinal bodies and of the mucous membrane covering them. This membrane is richly supplied with blood vessels, and especially veins. It is elastic, and therefore erectile, and forms with the submucous layer true corpora eavernosa, which fill or collapse according as they are supplied with or emptied of blood. When the walls of the venous canals become thickened through hypertrophy and lose their elasticity, the enlargement becomes permanent. Wingrave' says that the condition is not a mere hypertrophy of the structure, but consists of a true degeneration and infiltration of the walls of these vascular spaces; the walls gradually losing their power of active recoil, the vessels become more and more distended and a permanent enlargement, which is in fact a varix, ensues.

In the first stage of the disease the turbinal borders are greatly enlarged and the mucous covering soft and sodden, yielding without elasticity to the pressure of a probe. There is a decided cellular infiltration of the epithelium and subepithelial tissue, especially about the glands and vessels.

The epithelial cells are increased in number, the upper layers becoming flattened or cuboidal, while the ciliated cells are preserved only to a slight extent. The venous channels are distended in the deeper portions. After a time the swelling of the mucous membrane becomes more marked and there is a change from diffuse infiltration to a circumscribed thickening. The appearance of the parts now indicates a fibrous change, and the surface of the turbinals may become irregular from want of uniformity in the swelling.

The inferior turbinal is the part usually enlarged, especially in its posterior extremity. The anterior extremity is also frequently affected, while it is very rare to find enlargement only of the middle portions. These circumscribed infiltrations sometimes appear as true growths of varying color sometimes purple, indicating great vascularity sometimes whitish because of preponderating connective tissue and, thickening of the epithelium.

The surface is frequently smooth, as in ordinary nasal mucous membrane; at other times papillary hyperplasia is so strongly developed as to give rise to a mulberry like appearance. Not infrequently myxomatous changes occur, especially at the anterior extremity of the inferior turbinals, while papillary degeneration is most frequently observed in the posterior hypertrophies. Later on we find cartilaginous and bony outgrowth from the septum and floor of the nose, which by obstruction to respiration and by pressure act injuriously.

Posteriorly the ends of the inferior turbinals, when enlarged, are usually dark red, although sometimes white in color, with a surface varying in appearance, sometimes smooth and rounded, but often rough, irregular, and mulberry like, and occasionally they protrude into the naso pharynx so as to interfere with the functions of the Eustachian tubes. The middle turbinals are also the seat of these hypertrophies, as is also the floor of the nose and the sides of the septum. The pharyngeal tonsil will often be found enlarged.

Later in the disease all these morbid conditions become more marked. The hypertrophied tissue becomes more dense; and in addition to the turbinal enlargements we have eechondroses from the septum and exostoses from the anterior nasal spine of the superior maxillary bone.

The middle turbinals show a hard, resisting surface, filling the whole meatus, tightly pressed against the septum ; although frequently the mucous membrane covering them becomes the seat of a myxomatous degeneration, giving rise to masses which, from their soft and gelatinous appearance, may be mistaken for polypi.

On the posterior portion of the septum there are thick cushion like swellings of the same color as the surrounding mucous membrane, and from the floor of the nose and from the posterior extremity of the inferior turbinals appear firm elastic hypertrophies, usually light in color, either smooth or papillated, although when their surface is rough they are frequently of a darker hue. When the hypertrophies appear on the septum they are often symmetrical in both nostrils. The vault of the pharynx and the larynx are usually involved in the last stage of the affection.

Symptoms. In the first stage of the disease the symptoms are those of ordinary catarrh. The secretion in most cases is thick and scanty, containing large quantities of mucin. It is muco purulent, and on account of its toughness dries most readily and appears as odorless yellow and yellowish green crusts on the walls of the nasal cavity and at its entrance. In rare cases the secretion is free, thin, and serous, as in acute catarrh.

The principal symptom, however, and the one most complained of, is that of more or less nasal obstruction, the degree varying with the size of the swelling and the character and quantity of the secretion. Accompanying this is the discomfort produced by the accumulation of secretion in the naso pharynx, where it either dries and is hawked out with difficulty, or is expectorated or swallowed. There is fullness of the head, especially in the frontal region and over the eyes, frequently followed by severe migraine ; in addition there is a sense of dryness of the tongue and throat, which is almost continuous. The secretion of mucus in the throat is abundant in the mornings, and frequently the patient vomits in the effort to be rid of it.

A common fact noticed is the filling of the hypertrophied turbinal with blood by gravitation. It frequently happens that when a patient lies on the side the corresponding hypertrophied part will be distended, while bending the head forward will cause occlusion of both sides ; a reversal of position will favor the return of the blood and the restoration of function of the part.

Mouth breathing, with all its attendant evils, is a prominent feature of the disease, and a nasal twang to the voice is a common accompaniment. The sense of smell is affected, and frequently completes anosmia results, in which case the sense of taste is also impaired. As a result of the attempt to clear the nose of adherent secretion, small hemorrhages occur; and the frequent use of the handkerchief often gives rise to painful eczemas at the nasal orifices.

When the middle turbinals are involved, frequent and severe frontal headaches occur, the result of pressure on the nasal branch of the fifth pair. Pharyngitis, laryngitis, and bronchitis are also present as the result of the nasal lesion. Most common, however, as the result of the obstruction of the nasal passage we find affections of the ear. Chronic catarrh of the middle ear and of the Eustachian tubes is frequent sequelae, while tinnitus and vertigo also occur.

The eyes also suffer as a result of hypertrophic catarrh. Conjunctivitis is not uncommon. In asthenopia with headache, where correction of refraction has not cured, the cause has often been found to be in an enlarged middle turbinal body, the removal of which relieved all the symptoms.

Among other symptoms due to hypertrophic rhinitis are reflex neuroses; not very common, it is true, but still sufficiently so to warrant our examining the nasal cavities for their probable cause flay fever is often relieved by the removal of hypertrophied tissue on the inferior or middle turbinated bodies. Schech speaks of a nervous catarrh of similar origin where a thin, clear, and extremely profuse secretion makes its appearance suddenly and at intervals, associated with diminution or loss of smell, obstruction of the nose, and violent sneezing. These attacks last several hours, and are most frequent at the menstrual periods. Vaso motor disturbances are not uncommon. Reddening and swelling of the face and conjunctiva often appear on the slightest irritation, and disappear as suddenly, leaving no trace.

Asthma is the most common of the reflex disturbances in hypertrophic rhinitis. It usually comes on during sleep, and may be, as suggested by Schech, the direct consequence of irritation of the vagus the result of diseased nasal mucous membrane. Too much stress, be thinks, has been laid on the part the spongy tissue plays in the origin of nocturnal asthma, though it certainly is a factor in its production.

Other reflex symptoms that have been observed are aphonia, laryngeal spasm, and supra orbital and facial neuralgias. Spasmodic cough is not infrequently found to be the result of intranasal pressure, and I have often relieved a cough of long standing by removal of the hypertrophied turbinal body.

It has been my experience that asthma and ha fever, when they can be referred to the nose, depend upon the hypertrophy of the inferior turbinals; while neuralgias and headaches were as invariably the result of pressure of the middle turbinal on the septum. Epileptic attacks and vertigo may be also included among the affections induced by this disease. It will be seen, then, that the results of a diseased condition of the intranasal regions may produce complications far beyond the local trouble in sight; and bearing this in mind, the ophthalmic or aural surgeon of to day can scarcely be said to have made a thorough examination of a patient when the nasal cavities have not been included. It is very certain that the presence of spurs, hypertrophies, and deviations play a very considerable part in the production of catarrhal troubles both of the eve and ear. Affection of the lachrymal ducts, keratitis, purulent dacryocystitis, and impaired vision, together with all the distressing symptoms that belong to mouth breathing, as anxiety at night, disturbed sleep, dryness of the pharynx, larynx, and trachea, with sometimes resulting inflammation, disordered digestion, and mental dullness, all these may follow the condition of the nostrils.

Externally we may have eczema of the nostrils, the result of irritation, sycosis from the constant maceration of the upper lip, pustules, erysipelas, and redness at the tip of the nose from engorgement, the swollen spongy tissue preventing a return of the blood.

When we examine a patient we find appearances varying with the stage of the disease. In its first stage the nostril is more or less occluded anteriorly by an enlarged inferior turbinal body, which is either red or normal in color. The enlargement is spongy and elastic, and, although usually occupying the anterior extremity of the inferior turbinal, it may also be found to involve the middle, causing it to press against the septum. Hypertrophy of the inferior turbinal can be temporarily reduced by pressure with a flat probe, the enlarged sinuses emptying, but immediately filling again. This rapid resumption of shape tends to distinguish the hypertrophic from the chronic form of rhinitis where pressure by a probe simply displaces a certain amount of infiltration.

Cocain in from 2 to 5 per cent., solution has the same effect in rapidly contracting the spongy tissue, but does not entirely dissipate its tumefaction. Those swellings that disappear entirely under cocain belong to simple chronic rhinitis, and not to the hypertrophic variety.

Diagnosis. There should be no difficulty in making a diagnosis of this affection. The only disease with which it might be confused is nasal polypus, but the use of the sound and of cocain should easily differentiate the two conditions. An important point when making the diagnosis is to ascertain whether the hypertrophy is primary or due to a constitutional cause, such as syphilis, as this has an important bearing on the prognosis and treatment.

The prognosis is good if there are no complications.

Treatment. In the first stage of the disease the treatment should be mild attention paid to hygienic surroundings, the nasal passage protected from vitiated atmosphere, and in some cases removal to another climate recommended. Excess of any kind must be prohibited, and any constitutional vice which might be a factor in producing the disease is to be sought for and eradicated, if possible.

It is astonishing how much good can be done in the first stage of the disease simply by attention to the ordinary laws of health. The local treatment must be unirritating. At first only the simplest remedies should be used, by means of the spray or irrigation, by the nasal douche, the nasal douche cup, and insufflation of appropriate solutions through the anterior nasal passage, into the pharynx. The spray, many formulae for which are in constant use, should be applied, if the application be made by the patient himself, by means of the band ball atomizer such as is usually sold in the shops, provided with a blunt nozzle to prevent injury to the nostril. When the spray is used by the physician in his office, compressed air is usually the motive power, contained in a cylinder filled by means of a band pump, although the pumping may be done by means of water power or an electric motor.

While I am accustomed to use the spray in the treatment of chronic rhinitis, I do not look upon it as a curative measure, except in very slight and recent cases, when the clearing away of secretion gives the affected mucous membrane an opportunity to regain its normal condition. I do find the spray very useful, however, when the pressure is raised to forty pounds, to wash away crusts from the posterior nares and especially from the vault of the pharynx so much so that I have never had occasion to use a posterior nasal syringe for the purpose. In atrophic cases of long standing, where the secretion is very adherent, I have sometimes made use of dry cotton, wrapped on an applicator bent at a right angle, to remove' it, but usually the force of the spray is sufficient. If the force of the spray is increased gradually there is no discomfort, nor is any injury inflicted either in the nostrils or the Eustachian tube. A very slight stain of blood may follow the application, but there is no epistaxis or any consequence to alarm the patient.

The solution used in the atomizer varies rather with the fancy of the operator than with the exigency of the case, for any detergent alkaline fluid may be used. Normal salt solution, boric acid gr. x to 3j aq., Dobell's solution with the addition of listerin, or a combination with thymol menthol and eucalyptol as in Seiler's tablets, are all in frequent use. Sajous recommends a solution of bicarbonate of soda and borax, aa gr. viij ; ext. fluid. pini canadensis, M xv; glycerin,3ij ; aquae ad, 3iv. Alum 1 or 2 grains to aq. 3j is used; but in common with the salts of zinc and lead is said to produce anosmia.

Of more importance than sprays in their curative properties are applications made locally to the affected membrane. Nitrate of silver is probably the most efficient of all the simple applications; it can be applied in strengths of two to ten grains to the ounce, but should never exceed this. It must be used with regularity, as an occasional application of it is of no advantage.

In my clinic at the New York Eye and Ear Infirmary, where sprays are largely used as cleansers in all cases of nasal disease, every table at which a surgeon is seated is supplied with a rubber tube which connects with an atomizer by means of a bayonet joint. The compressed air is forced into a large cylinder in the basement of the institution by means of an air compressing engine driven by steam, which is in constant action during the service of the clinic. A safety valve on the cylinder, usually set at forty pounds, prevents the pressure ever rising beyond this point. The cylinder connects by means of an iron tube with the clinic room, where it is distributed to each of the tables at which patients are treated. In consequence of the distance traversed by the tubes some of the pressure is lost before reaching the operator, so that the spray is usually made at a pressure of about thirty pounds, which is the strength I find most convenient, but which can be still further modified by the cut off regulating the spray.

Storck objects to its use in consequence of the stains it sometimes produces on the exterior of the nose, and of the disagreeable sensation resulting. It should never be used as a spray, but applied carefully with a piece of lint wound on the extremity of a fine nasal applicator there should be no external mark, and any disagreeable sensation resulting can easily be relieved by the snuffing up of a little salt water. There is a possibility that a pocket handkerchief used just after the application may be stained. This can be guarded against by giving the patient a Japanese paper handkerchief to use for a little time after the treatment. Iodin and glycerin made according to the following formula: Iodini, gr. vj ; iodidi potassii., gr. xij ; glycerinae, aquae, aa 3j, is an application of great value.

Krieg recommends soziodal of soda and menthol in lanolin and vaselin: Sodii soziodal, menthol, aa or. xv; lanolin, 3ss; vaselin, 3j, to be used as an ointment. Resorcin in 10 per cent. solution has been recommended as an efficient application, and a host of other astringent and alterative substances which too often fail to accomplish the good result promised. Powders are used by some writers, insufflated into the nostril, but they more frequently clog the passages and produce irritation than bring relief. They are to be used, if at all, when the discharge is profuse. Camphor, tannin, bismuth, iodoform, subnitrate of bismuth, and borax, all have been used in this way, either snuffed up into the nose or blown in by an insufflator. I am inclined to believe that more harm than good is produced by this method of nasal medication, except when there happens to be an ulcerated surface, which is not likely to occur in the affection we are discussing.

Occasionally in hypertrophic rhinitis, when it happens that the obstruction is located at the anterior extremity of the inferior turbinal, and is soft, the patient suffers great inconvenience at night from his inability to breathe through the nostrils. In such cases I have found that great relief can be given by the introduction of a vulcanized rubber nasal tube, such as I use after the operation for deviated septum, which should be just, large enough to remain in the nostril when inserted. This gives rise to DO irritation, and enables the patient to sleep in comfort. It is not intended to bring about a cure of the hypertrophy by pressure, but merely to serve as a palliative during the temporary nocturnal swelling that occurs so frequently in this disease.

When we find the hypertrophic process to be so far advanced that .,ordinary treatment is of no avail, we must have recourse to measures calculated to cure by removing a sufficient quantity of the redundant tissue, and by means of the resulting cicatrix insure its permanent reduction. To do this we use caustics, acids, the galvanocautery, the snare, either with the cold wire or galvano caustic loop, or, in case of posterior enlargement, curettes or ring knives. The caustic acids axe used only when the hypertrophy is anterior and is soft. Those in most general use are the chromic and monochloracetic acids. When the use of an acid has been decided on, the nostril is well washed out with a modified Dobell's solution, dried with absorbent cotton, and if the patient is sensitive it is anesthetized with a solution of cocain varying from 2 to 8. per cent. in strength, according to his .susceptibility. It frequently happens that the weaker solution is quite sufficient to deaden sensation, and it is certainly safer to use it in cases where only a brief time will be taken up in any operative proceeding, in view of the toxic effects not infrequently observed after its intranasal use.

The cocain should be applied by means of a pledget of absorbent cotton, allowed to remain in contact with the affected turbinal for about five minutes; it is then removed and the part dried. The chromic' acid is applied by means of a fine probe wrapped with cotton wool, which is moistened and dipped in the acid., so as to permit but a small quantity to adhere. This is pressed firmly against the turbinal for a few seconds, taking care not to affect too large a surface. The acid remaining is neutralized by an alkaline solution. After a little while cicatrization with contraction follows, but the process must be repeated several times before 'any appreciable' improvement is noticed. An interval of a week at least should intervene before an application of the acid is repeated.

The acetic acid is to be used with the same precaution and in the same manner as the chromic acid, except that an aluminum applicator with a pocket to hold the dry acid is used. In the advanced stage of anterior hyper¬trophy, when the fibrous change has become marked, the more powerful agency of the galvano cautery must be invoked. The various forms of bat¬teries and the methods of heating the cautery knife having been mentioned, elsewhere, it only remains to describe the technique of its application. The nostril having been anesthetized with cocain, the margins of the nostril are protected by a speculum Duplay's or a large aural speculum answering the purpose very well otherwise they are likely to be burned. The electrode should not be large, a small knife answering every purpose. It should be heated to a cherry red, and a linear incision of the required length made through the mucous membrane. It is very important that the knife should be heated to the proper temperature; a lower degree of heat than the cherry red will give rise to severe pain, while with a white heat profuse hemorrhage may ensue. Care must also be taken not to burn the septum, otherwise the resulting inflammation may cause synechiae to form. After the cauterization the parts are to be sprayed with Dobell's solution or with liquid vaselin, repeated daily for a week, at which time another cauterization may be per¬formed. Several applications of the galvano cautery are usually required to produce any appreciable result.

The resulting inflammation is slight, and usually there are no uncomfortable sequences if the application has been carefully and judiciously made; yet there are cases on record where serious results have followed either a too extended and deep cauterization or when it had been made too freely to the posterior extremity of the turbinal; for it must be laid down as an axiom that this procedure can only be safely applied to the anterior hypertrophies. Storck protests strongly against the indiscriminate use of the galvano cautery, while believing it to be the best means of application. He complains that it is used too frequently, and especially by inexperienced men who do not know when and bow galvano cautery is to be done, who burn away the mucous membrane in all directions, from which eventual recovery never occurs. On the contrary, there results a still worse condition of the mucous membrane, which becoming adherent to the opposite side, causes synechiae and often complete occlusion. Where a patient has only had chronic nasal catarrh, he now has an occlusion of his nose that makes his life unhappy. No application of the galvano cautery should be made except to parts clearly in the field of vision. He is so strongly impressed with the abuse of this method of treatment that he declares that if it were possible to forbid the use of the remedy by police regulation, be would be the first who would vote for it.

If the galvano cautery is ever applied to the posterior extremity of the inferior turbinal body, it ;hould only be by means of a guarded electrode in the hands of an experienced operator; and even then there is danger of inflammation of the Eustachian tube with resulting purulent otitis. Erysipelas, conjunctivitis, meningitis, and septicemia are Complications that have followed too bold a use of the galvano cautery.

Electrolysis has been recommended by some authors; but the uncertainty of its results and the slowness of the method have prevented its being used extensively.

When the hypertrophied tissues are too extensive to be removed by caustics, or when they are soft and pendulous or circumscribed, we resort to surgical means for their removal forceps, the ring knife, or the snare being used.

In this country the ring knife is rarely employed, although in England Wingrave and in Germany Storck approve its use. Wingrave, in a communication made to the British Medical Association at Bristol in 1894, reports over 200 cases of turbinal varix treated in this way, and as the result recommends the use of the ring knife of Carmalt Jones.

In hypertrophies of the middle turbinal body it not infrequently happens that the part cannot be satisfactorily encircled by the wire loop; in such cases strong forceps, such as are figured elsewhere, are used to remove the superfluous tissue and relieve the obstruction. But by far the most satisfactory method for the removal of intranasal growth is the cold wire snare, used in the instrument devised by the late Dr. Jarvis, or one of its many modifications. This method is preferable for several reasons. It is easily applied and can be used in the narrow passages of the nose, which would be impassable to anything larger than the wire; the inflammatory reaction which follows its use is less intense and less lasting than t at allowing the cautery ; there is less danger of infection, and if proper care be taken there is less danger of hemorrhage; but in order to insure this it is necessary that the section be made slowly, from twenty minutes to half an hour being occupied in the removal of a large hypertrophy. If this precaution is not taken serious hemorrhage may result, especially when Cocain has been used as a local anesthetic, for this not only prevents sensation, but masks the bleeding by the temporary contraction it produces. While it may be said that cocain should be used in all cases, still it has the disadvantage of rendering the operation much more difficult in those cases where the enlargement is principally of the soft tissue, especially in the posterior portion of the inferior turbinals, for it so contracts the tissues that it is almost impossible to encircle them in the loop.

I am in the habit in operating by this method of using the Jarvis snare, with a modification in the manner of fastening the wire. In place of the pins around which the wire is wound, in order to bold it, on the original instrument, there is at the end of the movable cannula a steel clamp with its inner surface finely grooved, and which is governed by a screw. The ends of the loop of wire pass between the surfaces of the clamp and are retained in position by a screw working on a male screw passing through the lower clamp. This arrangement has the great advantage that a small loop can be passed into the narrowed nostril and enlarged at the will of the operator. When the loop has been sufficiently enlarged and sometimes it is necessary to make it larger than the turbinal in order to permit of its encircling the projecting extremity it is drawn upon until it is felt that it has the hypertrophy in its grasp. The clamp is then tightened and the loop gradually drawn in by the screw provided for that purpose.

The advantage of fastening the wire by means of the clamp over pins or any method that fixes the ends of the wire is, that if by any chance the cannula should have been screwed down to its fullest extent without cutting through the growth, by simply loosening the clamp the cannula can be run along the wire to its original position, and, the clamp being refastened, the tightening of the loop is begun anew. This maneuver is very useful and has served me more than once in difficult cases. When the anterior extremity of the inferior turbinal is to be removed, cocain may be used if the patient is unwilling to bear the slight amount of suffering entailed by the operation, although it renders the operation more difficult. As before remarked, the loop must be tightened very gradually, or profuse and even serious hemorrhage may occur.

When the posterior extremity of the turbinal is to be removed the operation becomes much more difficult. The location of the swelling makes it more difficult to grasp and the prolonged manipulation is harder to bear. It is not possible to give any detailed instruction as to the method of operating. Each operator, as a rule, has a method of his own, being governed by his own peculiar facility. Some, by a special knack of giving direction to the wire, are able to easily encircle the mass. Others put the loop which has been passed through the nostril in place by means of a finger introduced into the naso pharynx, while others guide it into position by means of the rhinoscopic mirror. Whatever method is used, two objects must be carefully looked out for viz., prevention of hemorrhage and avoidance of infection. To insure this it is necessary, after the operation has been performed in the cautious manner advised above, to use antiseptics. Aristol or dermatol blown into the nostril answers the purpose very well. A pledget of corrosive sublimate gauze is then inserted and removed in twenty four hours, after which it need not be replaced; but the wound must be sprayed with a modified Dobell's solution, consisting of the ordinary Dobell's with the addition of ten grains each of thymol, eucalyptol, and menthol to the pint, and afterward insufflated with the antiseptic powder every day until cicatrization is complete.

When the operation has been performed too quickly and hemorrhage follows, cold or astringents should be applied, or the nose may be sprayed with peroxid of hydrogen or a solution of antipyrin. If these means fail to stay the bleeding, it will be necessary to plug the nostril. This I do in the following manner: I take a wad of antiseptic cotton the size of a two drachm vial or larger, according to the size of the nostril, and tie a silk ligature to its center; this is forced into the nostril so as to close its posterior opening, leaving the end of the ligature projecting beyond the nostril. On top of this, antiseptic cotton is packed until the nostril is filled and the hemorrhage checked. The end of the ligature is then cut to the proper length and fastened to the cheek alongside of the ala of the nose with a bit of adhesive plaster. If this fails to prove effective, the packing must be taken out and replaced in the same manner. This method has always stood me in good stead, and I have never had to use any other means to restrain bleeding, even when very alarming. The packing must be left in place forty eight hours. If removed before that time the bleeding is likely to recur, and occasionally even then, in which case it must be replaced as before. If, however, there should be no return of bleeding, the nostril should be cleansed with a very gentle spray, an antiseptic powder insulated, and the case treated as where there has been no complication.

When instead of the cold wire the galvanic loop is used, the same precaution as to slow section and antiseptics after the operation must be observed. If the wire is heated to a white beat and the section made rapidly, hemorrhage will inevitably ensue. It sometimes happens in a narrow nose that the portion of the turbinal removed by the snare is too large to pass the external orifice; in such cases it falls backward into the pharynx and is expectorated through the mouth, or, as occasionally occurs, is swallowed by the astonished patient.

In addition to hypertrophy of the extremities of the inferior turbinal, other enlargements demand treatment: myxomatous degeneration of the mucous membrane of the middle turbinal, hypertrophies of the floor of the nose, and thickening of the posterior portion of the septum. Each one of these must be treated according to the nature of the hypertrophy and its location. The polypoid thickening of the middle turbinal is best removed by snare, although in careful hands the contact of the galvano cautery will accomplish a good result. For hypertrophy of the floor of the nose Aen cartilaginous or osseous the electro trephine is best suited; when soft the galvano cautery must be used. The swellings on the posterior portion of the septum are more difficult to manage. They should only be subjected to surgical interference when they add to the obstruction of the posterior nasal passage. They are usually soft, and under the guidance of the rhinoscope can be touched with the galvano cautery. There is not, to my mind, the same risk in its use here as when applied to the posterior extremity of the inferior turbinal, for the orifice of the Eustachian tube is less likely to be injured and there are no important structures in the immediate vicinity. When the nasal passage permits, a small electro trephine may be introduced and the projection shaved away: but it is only rarely that this can be done satisfactorily.

Before using surgical measures of any kind, however, it is well to give a trial to local applications of the iodin and iodid of potash solution, which in some comparatively recent cases will cause the hypertrophy to disappear.

Some writers divide the treatment of chronic hypertrophic rhinitis according to the early or late stage of the disease, but in whatever stage the disease comes under treatment, the rule is always to use the mildest method that will accomplish the desired result. Only when local applications fail to reduce the enlarged structure should recourse be had to surgical measures, and then only that surgical method should be employed that will do least harm to the surrounding healthy tissue. Cases have far too frequently occurred where the discomfort of the patient resulting from too radical an operation has brought about annoyance exceeding that of the original disease.

Attention must be paid to proper hygienic measures. The same rules are to be observed as in patients suffering from simple chronic rhinitis. Exercise in the open air, bathing and friction of the skin are particularly to be insisted upon. The whole body should be vigorously rubbed every morning on rising with a horse hair glove or a dry coarse towel and then exposed to the air for some minutes. Cold plunge baths are not to be advised, but the patients, if not too susceptible, may use cold sponging.

Local hygienic measures consist in removing the patient from an irritating or dust laden atmosphere, or in cases where a person's trade or profession makes this impossible, a respirator may be worn or the irritating air be prevented from entering the nostril by a thin wad of Angora wool inserted just within the vestibule, as proposed by Dr. J. Solis Cohen.

The constitutional measures to be employed depend on the condition producing the disease. When the gouty diathesis is prominent, suitable means must be taken to antagonize it. So with syphilis, malaria, anemia, neurasthenia, etc. No specific medication is indicated, only such remedies should be administered as are called for by the condition of each patient.

DEVIATION OF THE NASAL SEPTUM.

Deviation of the nasal septum is one of the most prominent causes of chronic disease of the nose, carrying with it maladies of the accessory sinuses, troubles of audition, and various nervous affections classed as reflex, such as asthma, chorea, and headaches. It is not to be confounded with the simple thickenings of the mucous membrane over the vomer and cartilaginous septum which frequently cause stenosis; but consists in a decided bending of the triangular cartilage of the nose to either side, nearly always accompanied by a corresponding alteration in the shape of the vomer and invariably by a redundant amount of material in the cartilage itself, which may be so great in some cases as entirely to occlude the nostril, and by interfering with proper drainage and respiration cause the varied inconveniences which call attention to the malformation. The character of the deformity varies in different cases. There are five varieties of deviation to be observed. There may be

First. Simple deviation of the cartilaginous septum to either side where there is a simple rounded convexity on one side and concavity on the other, with little or no thickening of the mucous membrane.

Second. Deviation of the cartilaginous septum in the same manner, accompanied by corresponding deviation of the anterior portion of the vomer.

Third. Sigmoid deviation where the cartilage is bent in an " S " shape, with a convexity at its superior and inferior portion in one nostril, and convex at the middle portion in the other, making a sharp longitudinal ridge running posteriorly.

Fourth. The deviation may be angular.

Fifth. It may be vertical, in which case the cartilaginous septum is alone involved. In nearly all cases, though not invariably, the deviation is toward the left. Sex seems to have some influence, as more cases are observed in males than in females.

Etiology. There are several causes of deviation of the septum. Delavan' divides them into predisposing and exciting; lie considers diathesis and racial characteristics as the most important of the predisposing causes, and believes that persons suffering from the strumous, syphilitic, tubercular, or rachitic diatheses are most liable. This view of its diathetic origin is hardly borne out in the cases that have fallen under my observation, where the majority of them seemed to be free from any constitutional taint. As regards the influence of race, deviated septa are much more common among the civilized than the savage races. This is attributed to the greater admixture of types occurring in civilized countries as the result of immigration, while the rarer occurrence of deviation among the less civilized races is due to the purity of the race. Races with aquiline noses are more apt to have deviated septa, except the American Indians, who are singularly free from the deformity.

Exciting causes may be imperfect or unequal development of the plate of the vomer, the result of malnutrition or inflammation.

Obstruction of the anterior part of one naris is considered by Collier 2 to be a factor in the production of the deformity by producing rarefaction posteriorly, the resulting pressure causing deviation on that side.

Deflections of the septum are usually observed in adults or adolescents, but cases have been observed in my clinic at the New York Eye and Ear Infirmary whose age did not exceed four years. Traumatism is an occasional cause of deflection, but the cases due to this cause, unaccompanied by fracture of the nasal bones, are so rare that it can hardly be considered as all important factors in the causation of the deformity. A very important cause is the defective development, of the bony septum. The vomer consists in its early stages of two lamiae enclosing a plate of cartilage which forms the cartilaginom septum; these laminae do not coalesce until after puberty, consequently unequal development of one of these laminae would push the other out of line and cause a corresponding deviation. This unequal development in different directions gives rise to the various forms of deviation observed.

Local malnutrition is, according to Ingals,' an important factor in the production of deflection. Jarvis regards the high arched palate as a cause of deflection, the septum being crowded upward by the hard palate until it yields to the pressure brought to bear on it, the cause of the palatal deformity being explained on the theory of atmospheric pressure, occlusion of the nasal passages creating in them through inspiration a partial vacuum, disturbing the equilibrium of pressure upon the upper and lower aspects of the roof of the mouth. This inequality of atmospheric pressure, exerted during infancy and early growth of the child, gives rise to the permanent deformity of the hard palate, thus interfering with the normal development of the septum, in turn further disturbed by the disturbance of respiration.

The bony ridges found along the line of suture of the septum with the superior maxillary bone are due probably to primary injury, aggravated afterward by hyper nutrition. They can scarcely be classed as deviations, though considered so by many authors who have treated of the subject.

Roe,' in a paper on the etiology of deviations of the nasal septum, considers that heredity plays an important part as a predisposing cause, Dot only by the dyserasias which may be transmitted, but also by the blending of different races, bringing about an infinite variation in the conformation of the osseous and cartilaginous structures; and that trauma, nasal obstruction, and unequal growth of the component parts of the vomer are the most frequent exciting causes.

Symptoms. Attention is usually called to the existence of the deformity by the functional troubles which give rise in many cases to serious inconvenience. Obstructed respiration is the most noticeable annoyance, thereby causing mouth breathing with its accompanying inconveniences, nasal voice and post nasal catarrh. Mackenzie reports a case where the most troublesome symptom was epistaxis caused by erosion of the outer wall of the Dose; but the great majority of patients who have come tinder my observation have complained of the impeded respiration caused by the obstructed nostril, and have sought relief oil this account only.

Severe headaches are often caused by a deviated septum, when a deviation in the upper portion of the septum presses on the middle turbinal body, while asthma and affections of the larynx are not infrequent results. A very common symptom is the nasal voice which is nearly always present in well marked cases. Cases have been seen by me where chronic headache and asthma were present and were relieved on restoration of the respiratory function Of the occluded side. When there is considerable deviation the nose is often twisted to one side, but frequently there is only a slight twist of the tip.

Diagnosis. The diagnosis of the affection is very easy and can be made even on a very superficial observation. Examining the nostrils anteriorly there is found a bulging of the cartilaginous septum into one side, either entirely or partially occluding it. On the opposite side there is a corresponding enlargement of the nasal cavity, frequently filled by a hypertrophied inferior turbinal body. This is so frequent a condition as almost to be constant. The septum itself is rarely increased in thickness when there is deviation; but it often happens that the septum is thickened to such a degree as to cause obstruction, and unless attention has been called to the condition an error in diagnosis might easily be made. Inexperienced observers have mistaken a deviated septum for a myxoma, which should easily be recognized by its mobility, softness, and pale color. Whatever the form of the deviation', the symptom , are the same; they do not differ whether it be sigmoid, vertical, or a simple curved bending. It is not always possible to ascertain by anterior rhinoscopy whether the cartilaginous deviation is continuous with the bony septum; but if the case permits it, posterior rhinoscopy will reveal its existence, if present.

Practically, the coexistent deformity of the bony septum is of no importance, as the correction of the deformity in the cartilaginous portion will almost invariably restore the function of the nose and permit respiration.

Treatment. Treatment of deviation of the septum is necessarily surgical; all palliative methods are useless, and simply waste the time of the Surgeon and exhaust the patience of the invalid. Pressure, digital and instrumental, the use of metallic sounds, or of laminaria for gradual dilatation, are methods which have all been tried and relinquished the irritation caused by them more than equaling the discomfort produced by the original trouble, while the results are negative.

Several methods have been devised for the correction of the deformity they vary largely in method and principle, and most of them, because complicated in their technique, have given way to simpler processes.

Dieffenbach, as early as 1845, excised the projecting portion of the deflected cartilage with a knife. Huyler dissected tip the mucous membrane from the prominent portion of the septum and removed the redundant cartilage with scissors. Adams, in 1875, proposed to correct the deformity by means of the forceps which are known by his name. He fractured the septum with them, retaining it in its proper place afterward by means of ivory plugs or steel plates adjusted by screws.

Ingals proposed an oblique incision through the convexity of the Septum, then, having detached the mucous membrane from the cartilage, he excised a V shaped piece, bringing the parts together by suture and holding them in place by tampons.

Glasgow, in 1881, presented to the American Laryngological Association the method of Steele, which consists in making a stellate incision over the deviation, through the mucous membrane and cartilage; the septum is then crowded back and an ivory plug inserted, which is worn until the cure is complete.

Jarvis, in 1882, proposed the removal of the projecting portion of the cartilage by means of the needle and snare. He pierces the base of the projection with a transfixion needle until the point appears, a wire loop of a snare is passed over the projecting point, and the engaged portion is severed.

Roberts of Philadelphia uses pins to hold the septum in place after having corrected the deformity. He makes an incision through the septum along the line of convexity; then pushes a long steel pin through the septal cartilage of the normal nostril a short distance above and in front of the incision. Pressing the end of the nose and septum into proper position, be brings the head of the pin close to the anterior part of the septum, causing the part lying in the obstructed nostril to lie across the incision and adapt itself lengthwise along the surface of the septum beyond. The pin is then pushed in to the head and its point deeply embedded in the soft tissues of the septum and upper and posterior part of the obstructed nostril.

Roe, in 1891, devised a fenestrated forceps for rectifying the deformity by pressure after having partially incised the cartilage by means of a modified Steele's forceps with which he cuts through the cartilage and mucous membrane of one side only, leaving the mucous membrane of the other side intact. As the incision must be made over the convex portion of the deviation, it necessarily follows that in aggravated cases it will not be possible to introduce the instrument in order to make the incision.

Watson of Philadelphia proposed a bevelled incision along the crest of the deviation through the cartilage, but not through the mucous membrane of the opposite side; the upper portion is then pressed over toward the other side until it hooks itself onto the lower and is thus held in place. The projecting base that is left can then, or after healing, be removed by the saw.

The method that I prefer and with which I have bad the most satisfactory results is one presented by me at the meeting of the American Laryngological Association in 1890. It has been performed by myself and colleagues very many times and has been uniformly successful. The principle is the same as that of other operations viz, the Destroying of the resiliency of the septum, but the technique of the operation differs, and in that lies the secret of its success. The operation has been slightly modified by me since I proposed it, but in its' important features it remains the same. It consists in making a crucial incision through the cartilaginous septum, breaking down by the finger or forceps the bases of the segment thus formed, and the insertion of a hollow splint. The rapidity and simplicity of the operation commend it, for it can be completed in a very few minutes, even in complicated cases. The instruments 1 employ in the operation are:

First. A pair of strong cartilage scissors, one blade blunt and narrow for introduction into the obstructed nostril, the other, the cutting blade, of a curved wedge shape (Fig. 570), the shanks of both blades being curved outward so as to admit of closing without interfering with the column the handles being of steel and curved like those of a dental forceps. I sometimes use a scissors with blades bent at a right angle with which to make the horizontal cut, but it is not indispensable (Fig. 571).

Second. A curved elevator for breaking up any adhesions that may exist between the septum and turbinal body.

Third. An Adams's forceps or one with stout parallel blades, as in Fig. 572.

Fourth. A hollow vulcanite splint of oval form and of a size according to the nature of the case. I formerly used a triangular tin splint, cut to adapt itself to the cartilage and held in place by a tampon of antiseptic gauze, but the discomfort experienced from the packed nostril and the danger of sepsis led me to devise the hollow splint (Fig. 573), which is thoroughly effective and by permitting the passage of air is more satisfactory to the patient. This splint is a tube of bard rubber of a proper shape to enter the nostril and hold the replaced septum in its new position. The splint as originally devised by me was rounded on its external surface with perforation s which serve to retain it in place (Fig. 573). Dr. Emil Mayer of New York modified it by making it more oval in its caliber and consequently flatter on the sides (Fig. 574) and also larger. The splint slips up under the tip of the nose and is easily retained in its position. There have been other modifications proposed, but I am in the habit of using one or the other of these two, as the shape or size of the nostril may indicate. Both splints are made in various sizes.

The mode of performing the operation is as follows:

Before etherizing, the nostrils are sprayed out with an antiseptic solution. I am accustomed to use] Dobell’s solution with the addition of a few drops of thymol and eucalyptol. The patient then having been etherized and the head drawn over the edge of the operating table so as to permit the blood to flow into the naso pharynx, the steel elevator is introduced into the obstructed nostril and any adhesions which may exist between the septum and the turbinal body are broken tip. When a deviation is the result of traumatism or complicated by it, these adhesions are sometimes bony and require a good deal of force to divide them; in such cases I find a convex gouge to be of service. The blunt end of the scissors is then introduced into the obstructed nostril and the cutting blade into the other end. An incision is made in a horizontal direction across the greatest convexity of the deviation. The scissors are then removed and reintroduced and a vertical incision made at right angles to and across the center of the horizontal one, forming a crucial incision as near as possible over the most prominent portion of the deviation. The finger is then introduced into the obstructed nostril, and with it the segments made by the incision are pushed into the opposite one until they are broken at their base and the resiliency of the septum destroyed.

On this point depends the success of the operation, for unless the fracture of these segments is assured, the resiliency of the cartilage will not be overcome and the operation will fail. The septum is then straightened with forceps, and the hemorrhage, which in many cases is quite brisk, is checked by a spray of ice cold Dobell's solution. A hollow splint of a size and shape suited to the case is then introduced into the affected nostril, a smaller one into the other, and the operation is completed. The splint in the patent nostril is introduced merely to assist in preventing bleeding, and is removed in twenty four hours, as the one in the contracted nostril suffices to bold the septum in position. This splint is removed on the second day after the operation, cleansed thoroughly and replaced, after which it is taken out, cleansed and replaced every day for at least five weeks, by which time the healing of the septum in its modified position should be complete. After the fourth day it will be easy for the patient himself to remove and replace the splint, reporting to the surgeon once or twice a week for observation until there is no further use for its application.

It sometimes happens that the lower segment of the cartilage projects into the nostril. Nearly always this projection is absorbed if left to time, but it can easily be removed by the electro trephine or the galvano cautery. Perforation following the operation is so rare as not to be considered as a probable sequence. The few cases which I have seen where it occurred were due to eachexia and to unskillful performance of the operation. It will not suffice, however, to make the incision, insert the splint, and let the wound take care of itself in order to get a successful result. The patient must be seen every day for the first week, and at least twice a week after that until cured.

The operation is equally effective, whatever may be the character of the deviation ; whether simple convexity, sigmoid, or vertical, the same procedure will apply to all, merely taking care that the incision be made with reference to the shape of the deformity.

Other operations for the deformity consist of the removal of the prominent portion of the convexity by saws, chisels, or burrs operated by the electromotor; but these methods are only available where there is much thickening of the septum and when the permeability of the nostril can be attained without the risk of perforation. It sometimes happens that the thickening of the septum is so great as to permit of this being done, but this condition is rare.

Thoroughly unsurgical is the method of Blandin, in which, by means of a punch, a circular piece is removed from the most prominent part of the deviation a procedure which does not cure the deformity, but simply allows the air to pass out from the unobstructed nostril into the occluded one, while it substitutes one deformity for another, and there ensues a permanent ulceration with its attendant hemorrhage and crusts.

Cauteries and electrolysis have been used to remedy deviations of the septum, but as in the case of the saw these methods can, only avail where the thickened septum is the cause of the obstruction.

Stoker and Hubert advice the use of laminaria bougies and of tampons, but it may be said with certainty that all such measures barely palliate. They cause irritation and produce conditions as unfavorable as the disease they are employed to cure. A long experience has shown me that it is unwise to treat deviations of the septum otherwise than radically. In no other way can the discomfort produced by it be alleviated and the respiratory functions of the nose restored.

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