Chapter III: Part 3

The symptoms of nasal catarrh which are provoked by the presence of such a growth can be alone successfully treated by the removal of the offending mass. In young individuals--say, from twelve to eighteen or twenty years of age--the finger inserted into the naso-pharynx from behind can often break down the growth. Slight hemorrhage follows this procedure, and the tags of imperfectly-destroyed tissue can be subsequently treated by caustics and powerful astringents. In the event of the patient proving intractable, the growth may be reached from in front through the nasal chamber, and the galvano-cautery can be used by passing the electrode backward through the nostril until it meets with resistance, which is invariably at the pharyngeal vault. Should this method of treatment not be permitted by an undisciplined or nervous person, the prolonged use of a glycerole of iodine may gradually reduce them in size; but no definite result can be promised from such treatment.

_(d)_ Very rarely, through inordinate elevation of the soft palate owing to over-action of the levator palati muscles, the passage of communication between the naso-pharynx and the oro-pharynx is inadequate. Consequently, the nasal chamber is imperfectly ventilated, and its secretions, not flowing backward or being displaced to the normal extent, become semi-inspissated, and create obstruction by lodging in the respiratory tract, either in the premaxillary or palatal portions. To successfully combat this condition it is evident that no local treatment is demanded, either in the nose or the naso-pharynx, other than to increase the tonicity of the pharyngeal and palatal {46} muscles. Very frequently in such cases there is a symmetrical atony in the muscles last named, which demands the internal use of strychnia and iron and the application of galvanism.

PROGNOSIS.--When nasal catarrh has proved to be dependent on defective respiration, the removal of the causes entering into this condition may with reason be expected to effect recovery. The prognosis, therefore, is favorable. In young persons, in whom reparative power is present in the highest degree, and in whom a secondary hypertrophy of the cavernous tissues is least developed, a prompt cure may be obtained by removal of the osseous or other forms of obstruction. In adults, however, the prognosis is less favorable, especially with those who have approached or passed middle life, and who have contracted vicious habits of breathing, which are likely to persist even after the removal of their causes. It is also tenable that in such subjects the mucous lining of the cranio-facial sinuses has become involved. Should anosmia persist after the capacity of the chambers has been augmented--in a word, should this condition not be dependent upon obstruction, but upon changes in the olfactory surfaces--the prognosis is less favorable than in any of the cases of the above-named group.

Treatment will, however, always secure amelioration of the symptoms, and few cases occur which cannot be greatly improved. The general health is invariably benefited. Should a tendency to asthma exist, it is apt to disappear, the complexion clears, and in adolescence the rate of general development is accelerated.

SECOND VARIETY.--The group of nasal diseases included under this head is not a natural one, since it embraces disorders characterized by a negative feature--viz. absence of obstruction to nasal respiration. Nevertheless, it is convenient to consider under a single head a number of relatively infrequent disorders in which there is invariably an underlying constitutional cause. Subjects of disorders herein embraced are not merely sufferers from insufficient oxygenation of the tissues, but have impaired general vitality or possess a decided constitutional taint, whether specific or otherwise. The nasal condition is simply the most prominent of the local manifestations.

Three distinct disorders are herein named: first, chronic inflammation of the nasal mucous membrane; second, atrophy of the turbinals and their associated mucous membrane; third, necrosis of the bones entering into the framework of the nasal chambers.

_(a)_ Inflammatory thickening is a rare affection. It is more frequent in males than in females, and in persons of a sedentary occupation than in those who are actively employed. Those subject to it are apt to have light-blue or gray eyes and auburn or sandy hair. On examination, the chambers may be found free from peculiarities of bony structure, capacious, and without hypertrophy of the cavernous tissues, yet the membranes be of a deep-red color and of cushiony consistence, yield bright reflexes, and the shank of the instrument introduced into the nose is mirrored upon them. The most conspicuous alteration is not seen on the turbinals, but on the septum. The parts are very vascular, and the most moderate manipulation will often end in free capillary oozing. The discharge, though moderate in quantity, is inclined to be purulent, and resembles semi-coagulated albumen. Quite frequently, in the examination of a neglected case, minute flecks of this modified secretion are seen scattered over the septum and the inferior turbinated bone. Rarely, the discharge is maintained by the presence of a morbid growth or inflammatory products, either in the nasal chamber or a chamber accessory to it. The discharge then appears to consist of pure pus mixed with the normal secretion of the nose, and, thus rendered viscid and tenacious, it excites by its presence a condition of the lining mucous surface quite similar to that above described.

{47} Under excitement, as after an attack of coryza, the discharge becomes more serous in character, and is occasionally of a chocolate color from its admixture with blood. It is without odor. There is no obstruction to respiration except during sleep, when, in aggravated cases, mouth-breathing may be established. Thus, the patient will often complain of an obstruction which is never present at the time of the examination. He further complains of a sense of dryness in the nose, with some pharyngeal irritation. The palato-pharyngeal and palato-glossal muscles are weak and often asymmetrical; the tonsils are small, but the adenoid tissues are generally unaffected. In a dry atmosphere, especially if it be loaded with irritating particles, the pharyngeal irritation is increased--a complication which is probably due to the inspired air passing too rapidly through the capacious and imperfectly-guarded nasal chambers and throat. Although I have carefully searched for all indications of aural complications, especially for the symptoms of progressive dry catarrh, I have never detected them but in a single instance.

The prognosis is to be guarded, although a careful course of treatment and proper care of the general health will greatly improve, if not entirely cure, the disease.

TREATMENT.--This consists in the application of nitrate of silver, either in strong solution or in the solid stick, to the under surface of the inferior and middle turbinated bones, of washing the parts with a dilute solution of carbolic acid, and of passing through the cheek tissues a constant electrical current of a strength of from five to ten cells. Tonics and alteratives should not be neglected, and an outdoor life, as far as is practicable, should be enjoined. The galvano-cautery may be used to destroy any nodules of tissue which resist other treatment. All applications are well borne, if indeed we may not look upon the condition of the surfaces as partially analgesic, and thus far of unfavorable significance. It is certain that indurated tags of oedematous and chronically inflamed mucous membrane overlying a bone, such as the middle turbinated or the alveolar line about the necks of the teeth, will never yield to anything but the most powerful astringents. Upon such tissues the most concentrated solutions of nitrate of silver are never caustic. The premaxillary portion of the inferior turbinated bone is frequently seen hopelessly infiltrated, and it must then be destroyed by the electro-cautery. When a discharge of a pus-like character exists, careful search should be made for the cause. If a tumor or foreign body be found, it should be removed, but if the cause lie in one of the outlying spaces of the nasal chamber, it is evident that the above treatment is palliative only.

_(b)_ In atrophy of the nasal mucous surfaces and turbinals we have, as in the last-named group, spacious chambers, a purulent discharge, pharyngeal irritation (in many cases), and always associated a thin and relaxed, if not a paretic, condition of the velal muscles. These cases might be looked upon as an advanced stage of the preceding affection, since it may be surmised that the stage of infiltration has been succeeded by one of atrophy. The mucous membranes are everywhere pale, and closely bound to the underlying bony framework. The discharge is purulent and confluent; where in contact with the air it is desiccated, but where protected, as by crust-like surface-layers, it is semi-fluid and tenacious. There is, consequently, no disposition for the discharge to escape from the nose, and it accumulates until the sense of obstruction induces the patient to remove it by artificial means. When first seen, the nasal chambers are frequently so fully occupied with discharge as to conceal the characteristic appearances of the mucous surface. This prolonged retention induces incipient decomposition of the mass, which gives rise to the odor so characteristic of this group of cases.

The subjects of atrophic catarrh (ozæna) are never in robust health. They are, as a rule, of spare habit, anæmic, and with family histories which, while {48} not distinctive, indicate that the affection is, to some degree at least, hereditary. A few cases have come under my notice in which all the general features of atrophic catarrh were present, but with very slight although confluent discharge, unaccompanied by fetor. Such cases are, strictly speaking, examples of atrophic catarrh, while they could not, under the old nomenclature, be included under the head of ozæna.

The prognosis is unfavorable for entire recovery, but treatment systematically pursued will make the patient entirely comfortable to himself and others--will arrest the progress of the disease and vastly improve the general health. As in other forms of nasal disease, should anosmia be present the prognosis is less favorable.

TREATMENT.--The parts should be carefully cleansed--an act which, while imperfectly accomplished by either the syringe or the douche, is, in my judgment, best performed by the galvano-cautery. This instrument, the one relied upon for the subsequent treatment of the case, is to be selected for its initiation. The largest speculum which the nose will admit being placed in position, a spiral-looped electrode is introduced cold into the nose and held against one of the crusts. When heated it will effect so firm an attachment to it as to enable the mass to be withdrawn with great ease. In patients with {49} whom the palatal portion of the floor of the nose is depressed below the level of the maxillary a considerable quantity of discharge may lie concealed from observation. When, after the removal of all visible crusts, the fetor persists, it is reasonable to suppose that the palatal depression is filled with decomposed pus and mucus. To test such a condition, the electrode should be appropriately curved and introduced. I have been surprised at the quantities of discharge which can in this way be withdrawn from a locality which, as far as I know, cannot be cleansed in any other way.

With the removal of the crust relief is at once experienced, and if the discharge could be removed as fast as it forms the disease would not really be a source of offence. The general health would also improve, from the fact that an atmosphere tainted with a burden of decomposition would no longer be breathed. But in practice this cannot be attained, and it is imperative, after the chambers have been entirely cleansed, to cauterize the lining membrane throughout. I have been in the habit of beginning such cautery treatments with the middle turbinated bone, passing thence to the inferior turbinated bone, then to the roof of the nose in front of the sphenoidal sinus, and lastly to the septum. Small surfaces only should be covered at a single treatment, so that it may take a month or six weeks to finish a single series of applications. This treatment is almost always well borne, nothing ever ensuing beyond a slight headache or a temporary establishment of a serous discharge. Notwithstanding that the condition in question is one of atrophy, the reparative power of the mucous membrane remains apparently unaffected. At all events, no danger from sloughing is to be dreaded after such extensive destruction of tissue. The thin eschars separate within from three days to a week, leaving a healthy mucous membrane beneath. In one instance the cauterization had extended to a sufficient depth to expose the bone, and yet from this denuded surface no exfoliation took place, the parts healing rapidly and satisfactorily. No other local treatment is relied upon for fetid atrophic catarrh than the one mentioned. No disinfectant washes are required if the discharge is removed as described. Should the patient be so situated as to be unable to report regularly for its removal or treatment, a wash composed of one part of Labarraque's solution to sixteen parts of water may be ordered with advantage, or a solution of carbolic acid, gtt. j to fluidounce j, with a little glycerin, may be snuffed up the nose twice a day, or listerine, diluted one-half with water, may be used with advantage. The general health, of course, should be cared for, and any complications met. I have found that during the winter months arsenic and cod-liver oil are well borne, associated with minute doses of Lugol's solution. For adolescents earthy and the calcareous phosphates are indicated, and for all abundant exercise and careful dieting. When the symptoms have been relieved, the patient should be requested to report once a month, for it is not to be expected that all symptoms will disappear, and some point of advice can be advantageously offered at this interval.

_(c)_ Necrosis in the nasal chamber is a cause of catarrh, inasmuch as the fragments of bone lying within the nose excite irritation and induce discharge. I have never seen a case of this form of disease which was not due to syphilis. The remains of syphilitic angina are apt to be present, and the general manifestations of constitutional syphilis are well developed. The septum is more frequently affected than the turbinals.

Discharge due to necrosis can be readily distinguished from that arising from any other cause by the presence of detached fragments of denuded bone, by the characteristic fetor, and by the history of the case.

The prognosis is favorable, for all symptoms will cease upon the extraction of the fragments, or at least those which remain are of an entirely different character, and are due to the resultant imperfections of the septum, and consequent irritation arising from the too free entrance of air into the {50} nose. I have seen in one case an extensive tumefaction and infiltration of the tissues covering the middle turbinated bone at the same time that the septum was breaking down. These masses require treatment with the galvano-cautery and astringents after the dead fragments have been removed.

A TABLE OF NASAL DISEASES GROUPED BY SYMPTOMS.

Cases in which interference with nasal respiration is a conspicuous
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.

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.

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.

It is well known that a loop of wire which is steadily narrowed has great power in severing the attachment of tumors and other outgrowths. When of a large size, it may be sufficiently powerful to pass through bony structures, as well as the softer parts of the body. The principle of the snare has been employed both in the throat, the ear, and the nose; but when my attention was first directed to this subject the forms available were too large and heavy for the delicacy of manipulation demanded in removing small tumors lodged in the narrower recesses of the nose. Moreover, no snare that I could then find would permit the galvanic current to pass through the loop at the time it was being narrowed. I was led, therefore, to inquire into the practicability of an instrument which would at once be light, be of small size, and yet be sufficiently powerful to remove that class of hypertrophied tissues and polypoid growths which are of such frequent occurrence in the nasal chambers. The instrument shown in Fig. 22 combines these qualifications, and satisfactorily performs the service for which it was designed. The only feature of an essential character which may be said to be novel is the fact that the platinum wire (3, Fig. 22) forming the snare is covered with a uniform coat of copper, excepting alone the portion forming the loop, which is bare. As a consequence of this arrangement the current of electricity from the battery is conducted through a double canula (2, Fig. 22) by means of the copper. The length of the instrument being about 9½ inches, and its weight less than ½ ounce, delicacy of manipulation is not interfered with. Besides possessing all the features of the cold wire snare, it has the additional advantage of securing a more rapid and painless operation, without any hemorrhage. Sessile (pyramidal) or resilient growths may be removed by first burning a groove of any depth into them, after which the loop is drawn while the current is passing through it. For this task the cold wire snare is obviously incompetent. Growths of unusual size or hardness may be destroyed by the same procedure, and nodules no larger than a grain of wheat may also be excised with great nicety. {57} It will be seen that failure to remove at least a portion of the growth attacked is an event exceedingly unlikely to occur. I have been particularly struck with the facility with which hypertrophies of the inferior turbinated bone can in this way be treated; and if cocaine be freely applied before the operation, it constitutes, in my judgment, the most speedy and the least painful of any means by which such conditions can be reduced. By using a canula with a curved end it is easy to snare growths situated on the posterior portion of the inferior turbinated bone. The current passing through the battery (Fig. 23, B) to the instrument can be interrupted by any of the numerous devices with which the practical electrician is familiar; or the treadle of the battery can be depressed and locked by the lever-catch, and the interruption of the current be determined by the pressure of the finger {58} on the knob in the handle (Fig. 23, A). This is under all circumstances desirable, since the weight of the cells is sufficient to demand considerable force to be exerted by the foot--always enough to destroy the delicacy of the manipulation of the instrument.

An electrode which is wrapped nearly to its distal end (Fig. 24), and used either in a straight or a curved form, is of great advantage in reaching growths within the naso-pharynx. The straight form can be thrust directly back through the nasal chamber, and the curved form can be passed from the oro-pharynx to the naso-pharynx without danger of burning the posterior border of the soft palate.

{59}

NEUROSES OF THE LARYNX.

BY HOSMER A. JOHNSON, M.D., LL.D.

DEFINITION.--Disorders of sensation or motion, or of both sensation and motion, due to disease, first, of the centres from which the nerves of the organ are derived; second, to disease along the track of the nerves; third, to disease in the terminal distribution of the nerves; fourth, to reflected irritation from neighboring or distant parts; and fifth, to myopathic change. This last condition is not necessarily a neurosis; it is nevertheless a cause of modification of the function of the parts to which the nerves are distributed, often a result of paresis or paralysis, and therefore inseparably associated with the neuroses of the organ. Disorders of innervation, depending upon structural disease of the larynx, such as ulceration or tumor, are not included in this definition.

ANATOMICO-PHYSIOLOGICAL CONSIDERATIONS.--The framework of the larynx consists of cartilages securely but rather loosely articulated with each other. The movements of these cartilages produce changes in the position and tension of the soft parts. The thyro-cricoid articulation allows ginglymoid and sliding motion; the aryteno-cricoid, rotatory and sliding motion; the hyo-thyroid, ginglymoid motion. The physiology of the muscles of the larynx is quite complex, since nearly all have fibres taking a number of different directions, and the changes in the form and positions of the parts depend upon the combined action of different muscles and parts of muscles which may be individually brought into action to produce the required results. The muscles may, however, be roughly divided into groups: 1. Constrictors of the superior strait; 2. Dilators of the superior strait; 3. Adductors of the vocal cords; 4. Tensors of the vocal cords, external, internal; 5. Relaxers of the vocal cords; 6. Abductors of the vocal cords.

The superior strait of the larynx is closed by the action of the oblique portions of the arytenoideus, acting in conjunction with the ary-epiglottici, into which some of its fibres are continued, thus drawing the cartilages of Santorini downward and inward and approximating the ary-epiglottic folds and depressing the epiglottis; while the thyro-epiglottici complete the closure by further depressing the epiglottis. Fibres of the latter muscle, acting alone, may dilate the superior strait by drawing apart the ary-epiglottic folds.

The transverse portion of the arytenoideus and the superior fibres of the crico-arytenoidei postici approximate the arytenoid cartilages. The crico-arytenoidei laterales, and also in a slight degree the external fibres of the thyro-arytenoidei, rotate these cartilages, turning their vocal processes inward: the action of the latter two muscles as adductors is imperfect unless the arytenoids are drawn backward and fixed by the arytenoidei postici.

The tensor group comprises a number both of the extrinsic and intrinsic muscles of the larynx. The crico-arytenoidei postici draw the arytenoids back, external rotation, and consequent abduction, being prevented by other muscles. The anterior fibres of the crico-thyroid and those fibres of the {60} sterno-thyroid inserted anterior to the crico-thyroid articulation approximate the cricoid and thyroid cartilages, and thus tighten the vocal bands. The posterior fibres of the crico-thyroid slide the thyroid upon the cricoid, lengthening the antero-posterior diameter of the larynx. This muscle, acting as a whole, also compresses the alæ of the thyroid with the same effect. The constrictors of the pharynx have a similar function. The hyo-thyroidei, acting in conjunction with the elevators of the hyoid bone, draw the thyroid forward and tilt it downward upon the cricoid. The form and internal tension of the vocal bands are greatly influenced by the thyro-arytenoidei, especially their inner fibres, while the ascending fibres of the muscle draw the inferior portions of the vocal bands upward and prevent the sagging of their edges. This muscle, acting alone, has been thought to cause extreme relaxation of the vocal bands. Modern research renders this statement of relaxation doubtful. The contraction of those fibres of the sterno-thyroidei inserted posteriorly to the crico-thyroid articulation tilts the thyroid upward, and thus relaxes the tension of the bands.

The crico-arytenoidei postici rotate the arytenoid cartilages outward, separating the vocal processes, and, acting in conjunction with the posterior fibres of the crico-arytenoidei laterales, draw the cartilages outward and downward.

In the cadaveric condition, which is one of relaxation of all the laryngeal muscles, the glottis is neither closed nor widely open; the epiglottis is erect against the dorsum of the tongue; the arytenoid cartilages are slightly separated, so that the glottic opening is a triangle with the base posteriorly, as in the act of inspiration, but the separation is much less than in the act of breathing. This condition is met with in paralysis affecting all the muscles of the organ.

The nerves of the larynx are derived from the pneumogastrics. The superior laryngeal is mainly a nerve of sensation for the parts above the edges of the vocal bands. There are some notable exceptions to this statement: a branch, external, descends to the crico-thyroid muscles and is motor in its function. Filaments from the superior laryngeal endowed with motor functions are also distributed to the folds extending from the arytenoids to the epiglottis; these are the ary-epiglottidean bands, and are concerned in the movements of the epiglottis. It is probable that the arytenoids are also in part supplied by the superior laryngeal; in other words, that both the superior and inferior laryngeal nerves are mixed, branches from the spinal accessory, as well as from the pneumogastric proper, entering to each of these nerves. Beclard[1] states that the one, the spinal accessory, is a nerve of phonation; the other, the pneumogastric, is a nerve of respiration. The sensations of the mucous surfaces below the glottis depend upon filaments from the pneumogastrics returned along with the motor fibres from the spinal accessory. The two orders of fibres go to make up the recurrents. The relations of the recurrents themselves to the large vessels, as well as to the bronchial glands, are of importance. At the point of their origin they are in close relation with the aorta and right subclavian; they are also in close relation with the top of the lungs. Disease of these organs and structures, especially of the large blood-vessels, such as aneurism of the aorta or subclavian, disease of the glands, tumors, abscess, traumatism, etc., may modify or completely destroy the functions of the laryngeal nerves. In short, anything or any condition by which pressure may be made upon the pneumogastrics or recurrents may become a cause of nervous disturbance in the larynx. In addition to this general source of innervation, Elsberg[2] describes a special centre of sensation for the throat in the medulla oblongata. He also describes three kinds of sensibility in the larynx--tactile, dolorous, and reflex. Rossbach[3] details experiments from which he concludes that there are nerve-cells in {61} the mucous membrane of the larynx which preside over the function of secretion. The larynx is endowed with at least two kinds of sensibility: the one tactile--when exalted it becomes painful; the other, reflex sensibility, is double. First, there is as a result of excitement a contraction of the subjacent muscle, and there follows closure of the glottis. This is seen in the application of irritants to the parts, such as solutions of nitrate of silver or other escharotics. There is no cough, but great difficulty of inspiration. Expiration is free and easy. There may follow some degree of pain for several hours. It will be seen that the phenomena are the same as those observed in the irritation of other mucous surfaces. The irritation is immediately translated into motion; this motion is probably reflex, but not necessarily through the centres, such as the brain or cord. The motion is of the subjacent muscles. Second, the mechanical irritation produced by the presence of a drop of water or a morsel of food in the larynx results in violent and explosive cough. The cough persists until the offending drop or body has been removed. This kind of sensibility calls into action distant muscles. There is no spasm of the adductors of the glottis, as in the case of the application of caustics. It is probable that the filaments of the nerves, the irritation of which gives rise to spasm, are distributed more generally than those which preside over reflex action at a distance and produce cough. The one set of functions are designed probably to protect the organ from the intrusion of foreign bodies; the other for their expulsion, as well as for the removal of the secretions of the parts or of matter brought up from below. The hypothesis of a third form of sensibility, as described by Elsberg--namely, the dolorous--seems hardly to be demanded for the larynx more than for all other mucous surfaces subject to pain. The nerve-cells of Rossbach in the mucous membrane may be peculiar to the larynx and trachea, as he claims, but further observations are required for the demonstration of this as a special histological fact distinguishing laryngeal from other mucous surfaces.

[Footnote 1: _Dic. Eng. des Sci. med._]

[Footnote 2: _Int. Med. Cong._, 1881.]

[Footnote 3: _Ibid._]

PERVERSION OF SENSATION OF THE LARYNX.

There is some difficulty in grouping the derangements of the sensibility of the larynx, for the reason that in many cases the perversion of this function is only a symptom of some other disease of the organ. Probably in all cases the trouble is, in fact, an expression either of disturbance in the structures of the larynx, involving more than the sensory nerves, or it is the result of change in structure or function of neighboring or distant parts. Various attempts have been made to classify these disorders according to the kind of perversion and also according to the cause of the trouble. Elsberg, in a paper presented to the International Congress, London, 1881, p. 224. vol. iii., makes an attempt at a scientific classification based upon anatomico-physiological facts. That there is yet much to learn in regard to these facts, especially the physiological facts, will be admitted by every one at all familiar with the literature of the subject. Elsberg, under the term of dysæsthesia, makes two principal divisions--namely, first, disorders having reference to the quantity or intensity of the sensation; this embraces simple hyperæsthesia and simple anæsthesia. The second grand division relates to the quality of the sensation, and includes only paræsthesia or sensory delusions. These grand divisions are still further subdivided.

In fact, we have to do with exaltation of sensibility simply, with sometimes pain; second, with delusion of sensation; and, third, with lost or diminished {62} sensation. For all practical purposes, therefore, we may adopt this arrangement, but should consider it as only provisional, as has been well observed by Schnitzler. These conditions are described under the terms hyperæsthesia, with or without pain; paræsthesia; anæsthesia.

Hyperæsthesia.

DEFINITION.--Exalted sensibility of the larynx, not necessarily associated with pain or other disorders of function. This condition is rare, but it is nevertheless met with. We sometimes find that the larynx is abnormally sensitive to touch or to an irritant, even though there is no marked inflammation. The symptoms and history justify the consideration of the condition apart.