[Reprint from The Laryngoscope, St. Louis, November, 1896.] ANTERIOR SOFT HYPERTROPHIES OF THE NASAL SEPTUM. BY EDWIN PYNCHON, M.D., CHICAGO, ILL. Attending Surgeon for Diseases of the Nose and Throat at Clinic of the Illinois Medical College; Assistant Aural Surgeon to the Illinois Charitable Eye and Ear Infirmary. Deformities of the nasal septum are deservingly recognized as rank- ing first in importance among the causes productive of nasal catarrh in many of its several varieties. The most commonly met with of the septum deformities are: Firstly—Deflections, either simple or serpentine in form, and slight or great in degree. Secondly—Thickenings of or growths upon the septum, either bony or cartilaginous in character. And Thirdly—Perforations. The object of this paper is to emphasize the importance of direct- ing both attention and treatment to another form of septum trouble not infrequently met with, which I have chosen to denominate as an- terior soft hypertrophies. When present, this condition will be found near by or opposite to the anterior end of the middle turbinated body. While sometimes it is observed upon an otherwise normal septum, it is more often associated with one or more of the previously-mentioned septum defects, and in such case tends to magnify the importance thereof, both structurally and pathologically. The diagnosis of this condition is attained by the use of a thin steel nasal spatula, with Steel Nasal Spatula (l/2 size). which pressure can be made, and with this properly directed the soft growth can be materially depressed away from the opposing turbinal, so that space is created where before slight pressure existed. After the parts have been cocainized this soft, bulging mass will be found to have not materially reduced in size, thereby proving that it is not due to turgescence or hypersemia, and that it is a condition of chronic relaxation, or, in other words, a true hypertrophy. In extent it may vary from one-lialf to one-and-one-half inches in length from before backward, often extending well into the superior meatus, and in width one-half inch or less from below upward. While more often uni- lateral, it has in several cases been observed upon both sides of the septum, though differing in degree. In color these growths are red- dish, or the same as that of the adjacent mucous membrane, in con- trast with the soft hypertrophies at the posterior end of the septum, which are invariably white. Thorough ventilation of all parts, and particularly of the attic of the nasal passages, is one of the desiderata of perfect nasal respira- tion; as it is through evaporation alone that the nasal serum can ren- der humid the inspired air, and whenever opposing surfaces touch each other the free circulation of air is impeded, and the nasal secretion instead of being evaporated is retained, and soon converted into a catarrhal discharge, which by its irritating properties, due to partial decomposition, causes the mucous membrane at the points of contact to become still further thickened and more inflamed, until the secre- tion itself as formed is abnormal. The principle of treatment, which we may say en passant is broad enough to apply all along the line in intra-nasal surgery, is to correct the abnormal contact of opposing surfaces, so as to permit of the un- obstructed circulation of air through all parts of the fossae; hence the indication is to destroy such soft hypertrophies as those of which this paper treats, and in practice I have found as a reward the sat- isfactory results which the theoretical indications promise. Conditions such as are here described, while generally of impor- tance only as structural causes of nasal catarrh, may be extensive enough to produce additional complications—as, for example, impair- ment of smell, neuralgic headache from nerve pressure—in this the most sensitive region of the nose, and other neurotic reflexes, as sneezing, cough, etc. The treatment is as simple as any rhinological procedure which the nasal surgeon is called upon to follow, and consists in the making of two, or more often three, parallel incisions with the electro-cautery point, reaching from rear to front of the bulging tissue. It is my ex- perience that the cauterization had better be deep, each line being gone over a second time, and the lines being about one-eightli of an inch apart. No unfavorable reaction or result has been met with, and on about the third day a large slough, an inch or so in length and three- eighths of an inch in width, is removed. Increased freedom in respira- tion is invariably experienced. During the operation care is of course taken to avoid burning the turbinal; and it has been my custom after the operation to thoroughly anoint the parts with a twenty-per-cent, solution of camphor-menthol in lavoline. I will close by reporting one case wherein a marked benefit was de- rived from this operation, it being my first experience therewith. November 8th, 1892, Miss T. H. placed herself under my profes- sional care. Her most pronounced symptoms were susceptibility to coryza and hoarseness, and a chronic bronchial cough of long stand- ing. She stated that she ‘ ‘ easily became tired out, and suffered from a lack of ambition.” She had a badly-coated tongue, and gave a his- tory of constipation. Examination revealed the usual number of nasal hypertrophic obstructions, and their common concomitants, pharyngitis and laryngitis. She had for some time been under the care of specialists of good standing. I began in the orthodox way, by removing all observable nasal de- formities, and next, by electro-cautery dissection, her tonsils, which were of the small, diseased variety, never becoming actually inflamed, but ever discharging that characteristic, chronic, lacunar, cheesy secre- tion. In other words, the line of treatment was to remove all hyper- trophied or diseased tissue, and cause the nares, naso-pharynx and fauces to assume as nearly as possible the form of the ideal model. After each step, during about five months of irregular treatment, the patient experienced increased relief, until most of the symptoms vanished, except the cough, and even this was somewhat modified. During the last month, at my suggestion, she was treated for the cough by a specialist in pulmonary troubles. July 8tli, 1893, she reported: “ General health much better; bowels more regular; and not feeling so tired after exertion; no more soreness of throat or coryza since treatment, but the bronchial cough continues much the same.” By laryngoscopic examination, while the vocal cords appeared normal, there still remained an abnormal redness of the glottic mucous membrane. She expressed a hope and belief that I would find some other abnormality, which, if corrected, would finally cure the cough. Four days later, after a most searching examination, I discov- ered in her left naris, high up in the attic, an extensive soft growth upon the septum, such as has been described. Three days after the cauterization the slough was removed, and from that time on there was a progressive improvement of the cough symptom. August 5th, reported: “Feeling fine; no more bronchial cough; nothing but a slight expectoration in the morning from the little post- nasal discharge still remaining.” For the relief of this, the following. January (1894), I cauterized in the attic of the right naris a soft hyper- trophy similar to, though smaller than, the one in the other naris pre- viously operated upon. December 20th, 1894, reported; “ Compai'ative freedom from colds,, where formerly cold lasted all winter; no recurrence of cough; feel- ing in all ways' very much better. ” Columbus Memorial Building.