CASES FROM 
PRACTICE IN DISEASES OF THE 
THROAT AND NOSE. 
BY W. PEYRE PORCIIER, M. D., 
CHARLESTON, S. C., 
Lecturer on Diseases of the Throat and Nose in the 
Medical College of the State of South Carolina 
and on Materia Mediea and Therapeutics 
and Diseases of the Throat and Nose in 
the Charleston Medical School. 
(.Read before the South Carolina Medical Asso- 
ciation. ) CASES FROM PRACTICE IK DISEASES OF THE 
THROAT AND KOSE. . 
BY W. PEYRE PORCHER, M. D., S. C., 
Lecturer on Diseases of the Throat and Nose in the Medical College of the State 
of South Carolina and on Materia Medica and Thera- 
peutics and Diseases of the Throat and Nose 
in the Charleston Medical School. 
(.Read before the South Carolina Medical Association.) 
Case 1.—Posterior No so-Pharyngeal Fibro-Myxoma of Unusual 
Size—Successful Removal. 
I present here two specimens of posterior pharyngeal polypi, 
marked Kos. 1 and 2. No. 1, which is about the size of a small 
hen’s-egg, wras taken from Miss D. W., set about 21, who had 
been referred to me by Dr. C. H. Schroder, of Charleston, S. 
C. She stated that she had suffered from catarrh for a very 
long time, and that it had been very much aggravated during 
an attack of typhoid fever through which she had just passed. 
Her voice was very distinctly nasal in character, and her con- 
tinuously open mouth and general appearance indicated that 
there was some pathological condition of her throat or poste- 
rior nares. 
Anterior rhinoscopic examination disclosed no hypertrophies 
or other obstructions; color nearly normal and no deviations 
or deflections of her septum. Posterior rhinoscopy disclosed the 
most dependent portion of a tumor which had embedded itself in 
the posterior pharyngeal space, its lowest portion resting just 
above the arch of hersoft palate. The tumor occupied the whole of 
the posterior nasal and pharyngeal space, so that she found it im- 
possible to breathe through her nostrils, and the consequent hab- 
itual mouth-breathing had greatly aggravated the usual dry 
tongue of typhoid fever, and caused her exquisite suffering. 
This obstruction also accounts for her nasal intonation, 
which wTas very marked. 
Being embedded so firmly in the surrounding tissues, it 
would have been very difficult and dangerous, if not impossi- 
ble, to have torn the tumor from its base with forceps; 
another method was equally impracticable, viz.: by means 
of pieces of tape or cord passed through each nostril and encir- 
cling the tumor; or by Olliver’s operation of cutting dowTn 
through the bony portion of the nose and removing the tumor 
through the aperture thus made. I therefore resorted to the 
following expedient, which proved entirely efficient and 
comparatively easy of execution. Before describing this, how7- 
ever, I must show you an instrument which I devised for oper- 
ating on the posterior nasal space. It is a Self-Retaining Uvula 
and Palate Retractor. 2 
Cases from Practice 
This instrument, as will appear from the cut, is an ordi- 
nary palate-hook, upon the stem of which a slide-attachment 
has been added. From the front of this slide project two 
arms, which end in two medium-sized rings, and at its rear 
is an automatic spring-catch which penetrates the per- 
forated stem at short intervals. When in position the two 
rings on the arms rest on either side of the nose, just above the 
alveolar processes, and are easily retained there by the counter- 
pressure of the retracted palate. It is light in construction, 
weighing but four hundred and forty-five grains, easily adjusted, 
and releases both hands for operation and the management of the 
mirror. At my request, Dr. J. Allen Miles, I). D. S., made the 
original model; as 1 found the old method of operating—by 
means of pieces of tape or cord passed through the nostrils and 
clamped ortied over the upperlip—so disagreeable to the patient, 
as well as difficult and awkward to the operator. It lifts up and 
retracts the palate with perfect firmness and security. In 
fact, so entirely efficient has it proved, that with it operations 
can be performed in the posterior nasal space as easily as in 
any other region. It has been highly commended by distin- 
guished laryngologists, as well as general practitioners. 
The following letter was received from Dr. J. Solis Cohen, to 
whom I submitted a model of the instrument, and he has kind- 
ly consented to its publication : 
1421 Wall Street, Philadelphia, September 28, 1887. 
My Dear Doctor:—To-day is the first opportunity I have 
had to give the instrument you forwarded to me a trial. I 
was very successful in using it, and without cocaine. I like it 
very much indeed, and I think it the simplest mechanism I 
have seen. Yours, very truly, 
J. Solis Cohen. 
The palate being securely retracted with the instrument and 
the patient’s tongue firmly depressed with a Tuerck’s tongue- 
depressor, Dr. Jarvis’s curved snare, which had been previously 
armed with a large wire loop, was passed back of the soft pal- 
ate. With the small rhinoscopic mirror in one hand and the 
snare in the other, the loop was easily made to encircle the 
tumor, slow turns were given to the milled screw or nut, and 
the pedicle was severed close to its origin, which proved to be 
the posterior end of the inferior turbinated bone. 
After pulling the tumor out of its bed, the patient expressed In Diseases of the Throat and Nose—W. P. Porcher, M. D. 
the greatest relief and suffered no inconvenience whatsoever 
from the operation, as the hemorrhage was very small. The 
•stump of the pedicle became enlarged twice afterwards, and 
necessitated a repetition of the operation each time. 
The patient is now in excellent health, and her nostrils are 
perfectly patent and free from obstruction. 
Case 2.— 
This case was very similar to the preceding. The tumor, 
however, was much larger and the patient had in addition nu- 
merous polypi in both nostrils. 
The occlusion which began in the right nostril evidently ori- 
ginated from a shelf of bone which projected from the septum 
and pressed against the right ala—almost entirely occluding 
the right inferior meatus to such an extent that an ordinary 
probe could scarcely be passed into it. It was extremely 
difficult to get at the pedicle after the removal of the tumor, 
and I could only do it by cutting away a portion of this shelf of 
bone so as to permit of the passage of instruments through 
the inferior meatus. The polypi were all removed and the 
patient can now breathe through his nostrils with compara- 
tive ease. 
Case 3.—Hypertrophy of the Pharyngeal Tonsil. 
Case referred by Dr. A. N. Bellinger, of Charleston, S. C. I 
regret very much that the specimen from this growth could 
not have been kept and shown here, as it had to be removed in 
so many small portions, and under so many difficulties, that 
they could not be preserved. 
This patient, like the two former, came to me under the im- 
pression that he suffered from catarrh, and had been on that 
account refused admittance into a naval school ship. He 
was entirely oblivious of the presence of any growth, al- 
though he had very decided nasal intonation of voice. No pos- 
terior rhinoscopic examination had ever been made. He was 
in good health generally, except occasional foetor of breath, 
which annoyed both himself and his family. 
On performing posterior rhinoscopy a tumor presented itself 
growing out from the posterior pharyngeal wall about the size 
of the first phalanx of the thumb, rough and uneven in shape, 
and appearing almost like a malignant growth at first sight. 
It proved, however, to be an unusually large hypertrophy of 
the third or pharyngeal, or, as it is sometimes called, Lusch- 
ka’s tonsil. His turbinated bones were also enlarged from the 
contiguous inflammation. I found the tumor quite sensitive, 
so that the parts had to be thoroughly cocainized before any- 
thing could be done, and the hemorrhage was so great that I 
could only remove it in small portions. 
The self-retaining palate retractor, above referred to, being 
slipped into position, as much of the tumor as possible was first 4 
Gases from Practice 
snared off with the Jarvis curved wire snare, and the base was 
then thoroughly seared with the galvano-cautery knife at a 
red heat. This left the parts comparatively smooth and the 
patient has gone on a sea voyage of several years’ duration. 
Case 4.—Pharyngitis Simulating Incipient Phthisis. 
The next case was of the most unusual interest, every phase 
of its development seeming to shed new light on the 
correctness of the diagnosis, as proved by the entire relief ob- 
tained from what might have terminated with the most dis- 
astrous results. 
The patient, a physician of high standing and great intelli- 
gence, has very kindly given me a written statement of his 
case, which I append : 
Dear Doctor:—In compliance with your request, that I 
should give you a written statement of my indisposition, I 
will say that it commenced about eighteen months ago, when 
I got a fish-bone stuck in my throat, causing much discomfort, 
with hoarseness of voice and violent paroxysms of cough, 
which lasted more or less all night. In the morning I was re- 
lieved. I have had, however, ever since, some irritation about 
the fauces, which at times would increase and bring on the 
cough and hoarseness, which would pass off after a few days. 
About three months ago I had a severe attack of asthma, lasting 
about twenty-four hours, followed by constant cough and expec- 
toration. After a careful examination by two of my friends, my 
lungs were pronounced sound and normal. I then went to 
you to have my larynx examined. You pronounced that nor- 
mal, but diagnosed a pharyngitis, which you thought accounted 
for all the trouble, and encouraged me to hope that you would 
soon relieve it, which you have done. After the first applica- 
tion to the throat the irritation was less and the cough and 
expectoration almost ceased. With each subsequent applica- 
tion the improvement has been marked, and now the irritation 
and cough return only occasionally, and the cocaine spray re- 
lieves them with the asthmatic symptoms (which always accom- 
pany them), immediately. Frequently, a week or ten days pass 
without my being inconvenienced or having to use the spray. 
I am entirely satisfied that your diagnosis of my case is correct, 
and your treatment, with the result, has established the fact 
beyond a peradventure. The cough, expectoration and asthma 
are caused by the pharyngitis, and have been relieved by your 
skilled treatment, for which I shall always feel grateful. 
Very truly, yours, 
Dr. W. P. Porcher, March 12, 1888. 
I would state, in addition, that the doctor’s friends and fam- 
ily were so anxious about him, under the impresion that his 
lungs were, necessarily the seat of his disease on account of the In Diseases of the Throat and Nose—W. P. Porcher, M. D. 
5 
extreme violence of the paroxysms of cough, as well as the 
profuse perspiration, expectoration and nervous relaxation fol- 
lowing them, that he was urgently advised to go abroad—or to 
some place where his lungs might heal. Fortunately, however, 
on account of the entire absence of any signs of disease by 
physical examination, the doctor determined this to be a falla- 
cy, and pharyngoscopy amply supported him in this conclusion. 
A distinct localized pharyngitis was diagnosticated, and it was 
determined that the cough was produced solely by 1‘eflex irri- 
tation, first excited by the fish-bone and kept up afterwards by 
the irritating discharge from the inflamed surface. The doc- 
tor was under the impression that this discharge came from 
the larynx, but as there was no laryngeal inflammation present, 
according to Lennox Browne and other authorities, it must 
have trickled down into the larynx, and being an irritant was 
coughed out again. 
The treatment in this case consisted at first simply of a 
strong solution of nitrate of silver applied to the posterior 
pharynx, which had been previously cocainized. This would 
usually serve to relieve his spasms of cough and asthma for 
several days, and on their return a spray of cocaine muriate 
would cut short the paroxysm with perfect certainty. I after- 
wards used a spray of chloride of zinc, grs. xxx—gi of water, 
and removed several enlarged follicles with the galvano-eautery 
knife. 
Here we have exemplified how an inflammation of thepharynx 
can excite and keep up the most severe paroxysms of cough and 
all their sequelae, which, if unrecognized would inevitably have 
been followed by disintegration of lung tissue, and the patient 
would have been regarded as an incurable consumptive. 
DISCUSSION— 
Dr. C. W. Kolloek said that the reports were very interesting 
in as much as they showed how many cases may run on and 
be mistaken for phthisis, whereas a very careful examination 
of the pharynx would show the true state of the case. He 
knew a great many of the profession who were apt to be a 
little incredulous about this, but here was a clear case, where 
the conditions are seen and where improvement has followed 
treatment. 
Dr. Swygert wanted to know what percentage of cocaine 
was used. 
Dr. Porcher stated that he usually used a 10 per cent, solu- 
tion. He sometimes used a 4 per cent, solution and regretted 
it. The former made the parts more thoroughly relaxed, and 6 
DISCUSSION. 
the patient very frequently was perfectly unconscious of any 
pain from an operation. 
I)r. Parker said that he wanted to compliment Dr. Poreher 
and congratulate him before the Association upon the presen- 
tation of this instrument. The merit of the instrument was, 
that it was relf-retaining, like a self-retaining speculum for the 
vagina, in as much as it left the operator with both hands free 
for manipulation, or for the use of other instruments. This 
was an advantage not found in other instruments for elevating 
the palate or drawing it forwards, so as to give a good view of 
the posterior naso-pharyngeal fossa. This instrument was 
beautifully arranged and was perfect in its simplicity. “ It 
left both hands free and was therefore a very great assistance 
in the removal of growths in the naso-pharyngeal fossa, or 
posterior nares where the use of both hands was so advan- 
tageous in perfecting operations of this kind.” 
Dr. Kinloch wanted to know the difference between Dr. 
Porcher’s instrument and that of Dr. Joseph White, of 
Richmond, Ya. 
Dr. Poreher explained that the principal difference first, 
in the fact that Dr. White’s instrument had a little screw, acting 
as a clamp. This was an objection because there was very little 
space in the mouth, and such an obstruction interfered seri- 
ously with the work, and in addition, the screw was more clumsy 
than an automatic or spring catch. The next difference in 
Dr. White’s instrument was, that instead of two rings there 
were two pads on the arms, and the hook consisted of a wire 
loop instead of a flat band. 
Dr. Parker said that he was surprised to hear Dr. Poreher 
speak so lightly of the use of cocaine. He thought it was a 
very dangerous drug, requiring to be administered with great 
care. In two cases in which he used the 10 per cent, solution 
in application to the throat, in two girls, from ten to twelve 
years of age, it produced such nervous symptoms that he had 
to desist entirely from the operations at that time. He could 
speak with some degree of certainty of the depressing and 
alarming influences of the effects of cocaine upon individuals, 
because he had used it himself twice, by the suggestion of a 
medical friend as a suppository ; in one case a suppository of 2 
grains of cocaine hydrochl. was inserted in the rectum. From DISCUSSION. 
7 
8 o’clock A. M. till 12 M. he suffered from palpitation of the 
heart, nervousness and general depression, such as he did not 
care to undergo again or see anybody else go through with. 
The experience of Dr. W. H. Hammond, of Hew York, had 
been very much the same, except that Dr. Hammond had used 
a greater quantity by subcutaneous injection and was not 
disposed to repeat it. He saw it given with the same symp- 
toms by a professional friend in a case of operation on the 
vagina. About 2 minims of a 20 per cent, solution was in- 
jected under the vaginal mucous membrane, and although he 
performed the operation successfully without pain to the 
patient, he never left the patient’s bedside that day till late in 
the afternoon. Owing to its alarming effects upon the patient, 
the use of cocaine had been pretty much given up in 
enucleation of the globe. If Dr. Poreher had not encountered 
such cases, he would do so hereafter. 
Dr. Poreher said that he had read cases in the Journals 
where a great many cases of cocaine poisoning were men- 
tioned, but that he used it very freely by means of Sass’s spray 
tubes and the cotton pledget, and never had a patient to com- 
plain in the least. He usually used a 10 per cent, solution 
sprayed or applied with a cotton pledget in the throat and 
nose, but had never used more than a 4 per cent, solution hypo- 
dermically. He had used it upon himself and was perfectly 
free from pain when the galvano cautery was applied, the 
only sensation that he experienced at . all being a certain 
amount of stimulation and excitement. He used it universally 
with ladies who were delicate and weak and nervous, and 
never heard any complaint of it. The largest quantity that he 
had ever given internally was in a case of stricture of the oeso- 
phagus in a little child who had swallowed some concentrated 
lye. He ordered one-half ounce of a 4 per cent, solution of 
cocaine. The child took first 5 minims every hour or so, and 
that being not sufficient to relieve the spasm the dose was in- 
creased to 10 minims. The child threw up the greater part of 
it—the only constitutional symptoms which appeared was that 
the lower jaw became relaxed, and he noticed one day that the 
child could not shut its mouth. He ordered the medicine dis- 
continued, and was glad to be able to report a successful result 
in that case. 8 
DISCUSSION. 
Dr. Parker, referring to what Dr. Porcher had to say about 
cocaine arresting attacks of asthma and the effect of the 
spray in relieving reflex irritation said, that this was 
perfectly capable of explanation from the anatomical dis- 
tribution of the nerves. He then spoke of the distribution of 
the nerves of the pharynx and their connections, and demon- 
strated how such reflex action was the necessary result; any 
anatomist ought to be able to explain the connection existing 
between the pharyngeal plexus and the pneumo-gastric nerve, 
as a cause of reflex cough. 
Dr. Porcher recited the case of a young lady who had been 
teaching in a public school and was affected with Sub-Acute 
Laryngitis and continuous Cough. He sprayed her throat 
with cocaine, and the effect was almost instantaneous. It pro- 
duced almost phenomenal relief of the hoarseness. He was in- 
clined to think that while it was due to a great extent to its 
effect on the nerves, he thought also that the powerful effect of 
cocaine in contracting the engorged capillaries and relieving 
congestion had a great deal to do with it. 
Dr. C. W. Kollock moved that Dr. Porcher’s paper be re- 
ferred to the Committee on Publication, and that a cut of his 
instrument be made and published with the official proceed- 
ings of the Association. Adopted.