MEDICAL TIMES. A BI-WEEKLY JOURNAL OF MEDICAL AND SURGICAL SCIENCE. VOL. XII. 1881-1882. PHILADELPHIA: J. B. LIPPINCOTT & CO. 1882. PHILADELPHIA MEDICAL TIMES. MAY 2 1906 PHILADELPHIA, OCTOBER 8, 1881. rence of acute coryza, but without any definite symptoms in the intervals, so that ORIGINAL COMMUNICATIONS RAhe patient is not cognizant of the fact SURGICAL TREATMENT OF NASAL Read before the Philadelphia County Medical Society, BY CARL SEILER, M.D., Lecturer on Laryngology at the University of Pennsylvania, Pathologist of the Presbyterian Hospital, etc. `HE term "nasal catarrh" is at the presTHE ent time a very comprehensive one, and signifies a more or less chronic inflammatory condition of the mucous membrane lining the nasal cavities, which latter term includes, clinically speaking, the nasopharynx, the posterior nasal cavity, and the pharynx, the posterior nasal cavity, and the anterior nares, as well as the frontal sinuses and antra of Highmore. The physiological functions of these cavities-viz., the warming, moistening, and filtering from dust of the air in respiration, and the qualifying of the tones of the voice by resonance, which latter I have endeavored to prove in a paper read before the American Laryngological Association, session of 1881-I will not here enlarge upon, but would say a few words in regard to one peculiarity in the histology of the nasal mucous membrane where it lines the turbinated bones. In this location we find that the submucous tissue which is interposed between the mucous membrane proper and the periosteum of the turbinated bones, and which contains the racemose mucous glands, is composed of strong bands of elastic connective tissue inter lacing with each other, thus forming meshes irregular in size and shape, which contain true venous sinuses lined with endothelium. This arrangement forms just such a tissue as we find in the corpora cavernosa of the penis,-viz., true erectile tissue, which under certain conditions will suddenly enlarge to many times its original bulk, and which was termed by Professor Bigelow "turbinated corpora cavernosa."'* Nasal catarrh may conveniently be divided into three stages, which usually follow each other in regular sequence, but each one of which may also appear independently of the others. These three stages are, first, the congestive stage, which is characterized merely by a frequent recur * Boston Medical and Surgical Journal, April 29, 1875. that he is suffering from catarrh in the first stage, and but rarely applies for treatment; second, the hypertrophic stage, which is marked by true hypertrophy of the mucous membrane and its glands in certain portions of the nasal cavities, especially on the turbinated bones and the septum, and which gives rise to most of the patient; and third, the atrophic stage, the symptoms of catarrh complained of by in which we find a general wasting of the mucous membrane, a want of secretion, and a consequent accumulation of scabs, which become putrefied, thus imparting a peculiar disagreeable odor to the breath, and may lead to ulceration if they remain long in contact with the mucous membrane. The second or hypertrophic stage is the most frequent form of nasal catarrh which and, as surgical treatment is necessary to comes to the notice of the practitioner; effect a cure of this condition, I will describe the lesions and symptoms to which they give rise more in detail, before entering upon the description of the surgical The frequently repeated acute inflammation means most adapted to relieve the trouble. of the mucous membrane in the first stage of catarrh leads not only to a deposit of inflammatory tissue in the mucous membrane, but also to an increase of the glandular elements, and at the same time to an increase in size of the venous sinuses in the erectile tissue covering the turbinated bones, so that gradually localized swellings show themselves, which remaining permanent produce partial or complete stenosis of the anterior nares. The stenosis is more commonly partial while the patient is in the erect position, but frequently bewhen he lies down, or under the influence comes complete in one or the other nostril of mental excitement or anything which tends to increase the blood-pressure in the head, for these swellings, being principally creased in size by a greater afflux of blood composed of erectile tissue, will be ininto their venous sinuses. External irritants, such as dust or acrid gases, produce to swell suddenly. These localized hyperthe same effect and cause the hypertrophies trophies are generally situated at the lower portion of the inferior turbinated bones, but are also found on the middle and supe rior turbinated bones and on the septum. Those situated in the anterior nares and visible by inspection through the nostrils have been termed anterior hypertrophies, while those hanging from the superior turbinated bone into the post-nasal cavity are called posterior hypertrophies. The former are usually sessile with a broad base, while the latter are more or less pedunculated and can be seen only by means of the rhinoscopic mirror. Other conditions than a hypertrophy of the mucous membrane may give rise to partial or complete stenosis, and consequently to many of the symptoms of nasal catarrh, such as localized or extensive deviation of the septum, congenital malformation of the bones of the skull surrounding the nasal cavities, polypi and other neoplasms, and, finally, foreign bodies introduced into the nostrils. The symptoms to which these conditions give rise are so well known that it is hardly necessary to allude to them here, and I will, therefore, merely for the sake of completeness, say a few words about them. The most prominent and, to the patient, most annoying symptom of catarrh is a copious discharge of thick, ropy mucus, which accumulates in the posterior nares, and from there descends into the nasopharynx, causing a feeling of fulness in that region which the patient endeavors to relieve by hawking. This mucus is the perverted secretion of the hypertrophic glands in the mucous membrane, and is prevented from flowing through the natural channel, the anterior nares, by the presence of the anterior or posterior hypertrophies. The frontal headache which is but rarely absent, and which frequently assumes the character of neuralgia, is caused by the pressure exerted upon the sensory-nerve fibres by the swelling of the mucous membrane lining the frontal sinuses and antra of Highmore. An extension of the inflammation into the Eustachian tube causes a narrowing of its calibre, and consequently gives rise to tinnitus and deafness; and, finally, the partial or complete stenosis of the anterior nares gives rise to a train of symptoms which, being remote from their cause, are frequently either entirely overlooked or are regarded as manifestations of a different disease. As has been said before, the physiological functions of the nose are, besides its being the organ of smell, to filter the air of dust, to raise its temperature, and to make it moist before it reaches the larynx, and to add to the quality of the tone of the voice by its resonance. If, then, there exists an obstruction to the free ingress and egress of air in the nose, the mucous membrane of the larynx will be irritated by a dry cold air filled with fine particles of organic and inorganic dust when respiration is carried on through the mouth, and a chronic laryngitis frequently results. In most cases in which the stenosis is but partial- that is, when the patient can breathe through his nose during the day, but is unable to do so during sleep, and wakens with parched throat and tonguehe does not carry a sufficient amount of air through the narrowed channels to the lungs to thoroughly expand them and sufficiently oxygenize the blood for the wants of the system, and the consequence is a sense of oppression in the chest and a general impairment of nutrition. There is another symptom, which in many cases is very striking, and which is due partly to impaired nutrition and partly to the pressure exerted on the subjacent parts by the hypertrophied mucous membrane of the nasal cavities,-viz., loss of memory, and an inability on the part of the patient to concentrate his mind upon any one thing. If the localized hypertrophy is situated near the opening of the tear-duct, the latter frequently becomes occluded at its lower opening and causes a watering of the eyes, while these same swellings, no matter where situated, reduce the bulk of the nasal cavity, and thus interfere materially with nasal resonance, without which the voice is devoid of its peculiar character. From the foregoing remarks it will appear that the most rational mode of treatment for this stage of the disease consists in the removal of the obstructions in the nose in a manner which accomplishes the object thoroughly and at the same time gives the patient the least discomfort from pain and hemorrhage. The application of caustics, such as chromic acid, nitric acid, acetic acid, etc., with a view to destroy the hypertrophies, gives great pain, which lasts a long time; and, as the action of these agents cannot always be controlled, they are apt to cause serious general inflammation of the mucous membrane lining the nasal cavities. The tearing-out, crushing, or cutting-off of the hypertro phies with sharp or dull forceps gives rise not only to great pain, but also to copious hemorrhage often difficult to control. To prevent pain and hemorrhage, I am in the habit of using either galvano-cautery or Jarvis's wire snare in the treatment of these cases, and have found that either method, if properly used, is almost absolutely painless and bloodless, while the purpose of removing the hypertrophies is thoroughly accomplished. My battery and knife for the use of galvano-cautery in nasal diseases I exhibited to the County Medical Society last spring in its crude but serviceable form,* and since then Mr. Flemming has made a more elaborate apparatus, which in its principle is the same, but in which the details have been improved. The knife also has been improved by adopting a slight modification of Shurly's handle and by using a blade which cuts on one side only, as suggested by Dr. Bosworth, of New York. The use of this instrument is very simple and requires but a moderate amount of skill and care; but it should be used in those cases only in which the anterior hypertrophies are not large enough to touch the septum and cause complete stenosis. knife removed while still hot. I do not heat up the platinum loop before introducing it into the speculum, because I do not want the patient to see the glowing knife; but the tissue should not be touched until the proper degree of heat has been attained. The knife should be at a cherry heat when the incision is made; then there will be neither hemorrhage nor much pain; but if the heat is too great, considerable bleeding will follow the incision, and if the loop is not hot enough the pain will be severe. The immediate result of the incision is the formation of an eschar and of acute inflammation surrounding the burned portion of tissue, which stands in a direct relation to the extent of the burn, and which will spread over the whole nasal cavity, producing a more or less severe coryza if not counteracted. The ultimate result of the operation is the formation of bands of cicatricial tissue, which by its contraction binds down the swelling and thus prevents the stenosis. The number of incisions necessary to remove, or rather obliterate, the hypertrophies will depend upon their size and degree of firmness. Too much should not be attempted at one sitting, on account of the often severe inflammation following extensive burns of the mucous membrane. To bring the hypertrophy into view I prefer a rubber speculum to the generallyemployed nasal dilators, because the latter When the hypertrophies are large, and always stretch the nostrils and disturb the especially when they are situated in the normal relation of parts to each other, thus posterior nasal cavity, hanging from the making it more difficult to decide whether posterior portions of the turbinated bones, the hypertrophy is touching the septum or I prefer to use Dr. Jarvis's wire snare to renot, and because the pressure of the blades move them. This admirable little instruagainst the septum produces more or less ment, a description of which will be found pain. The speculum, on the other hand, in the Archives of Laryngology, when has the advantage of leaving the parts in properly used is certainly the most satisfactheir normal condition, pushing the hairs tory means of attaining the end, which is in the nostrils aside and out of view; and the complete removal of hypertrophies of in using the galvano-cautery knife it pro- the nasal mucous membrane. To do this, tects the parts not to be burned. By I proceed as follows in a case of large having the end of the speculum cut slant- anterior sessile hypertrophy. I transfix the ing, the hypertrophic portion of the mucous swelling near its base with a curved needle, membrane can be brought into the rubber devised for the purpose by Dr. Jarvis, and tube and the knife applied without the least then pass the wire loop of the snare around danger of injuring any other portion. the handle of the needle, then over the growth and point of the needle as it emerges from the tissue, and draw the loop tight before making traction with the milledhead screw of the instrument, and then gradually snare off the swelling, occupying from fifteen to twenty minutes in its removal. Having thus brought the hypertrophy into view, the plates of the battery are depressed, the knife introduced into the end of the speculum, and while there it is heated to a dull cherry heat, when a quick incision is made into the projecting tissue, and the Philadelphia Medical Times, August 27, 1881. † See "Galvano-Cautery in Hypertrophic Nasal Catarrh," by Carl Seiler, American Specialist, September 1, 1881. When the wire has passed entirely Pathology and Surgical Treatment of Hypertrophic Nasal Catarrh, Archives of Laryngology, vol. ii. No. 2. |