With Compliments of Author THE TREATMENT OF THE NASAL CATARRHS BY WILLIAM T. CATHELL, M. D. OF BALTIMORE [Reprinted from the Maryland Medical Journal of Dec. 27, 1890.] THE TREATMENT OF THE NASAL CATARRHS.* By William T. Cathell, M. D., of Baltimore. Mr. President and Gentlemen:—In these days of scientific research and bright expectation in onr profession, when hosts of bacteriae, micrococci, bacilli and spirillse are being discovered and studied, and the laws of antiseptic surgery and aseptic treat- ment are reaching scientific exactness; while Koch and his co-workers seem to be on the verge of the most welcome and useful discovery ever made by our profession, and while research and progress are making in every other department of medicine, the earnest work of able specialists is also bringing the etiology, the differential diagnosis and the treatment of the various diseases of the upper air-passages, from uncertainty and chaos to a place among the most clearly defined in practical medicine; and I hope by a few brief papers to direct your increased atten- tion to Avhat I have found to be good and successful methods of treating various neglected but important diseases of the nose and throat. This, the first of the series, is on the treatment of the different forms of nasal catarrh. ACUTE NASAL CATARRH, also known by a host of synonyms, is the most frequent of all catarrhs, and is made important by being the starting-point of the majority of cases of the more serious varieties, chiefly because people rarely consider a “ cold in the head ” an affection worthy of more than domestic treatment, and, in fact, the majority of cases do get well spontaneously, while a less fortunate fraction of them proceed by stealthy changes into more serious and stubborn affections. * Read before the Medical and Surgical at its 717th meeting, December 12th, 1890. 2 In treating the initial stage of acute nasal catarrh, the utility of the various preparations of opium, and particularly Dover’s powder, five grains every four hours during the day, and ten, fifteen or twenty grains at bedtime, has surprising efficacy in aborting the disorder, especially when it gives a night of warm, sound sleep. If, however, in addition to the congestion of the nostrils, there are paroxysms of sneezing, I have found nothing to benefit them more than inhalations of the carbonate of ammonia and muriate of ammonia, mixed and scented with oil of lavender, to be held to the nostrils at the moment a desire to sneeze is felt. Later in the affection, when the secretion becomes muco-purulent, the most effectual measure consists in opiates internally, and the application of sedatives and astrin- gents to the congested membranes. Among the latter I have found nothing better than an ointment of cocaine, in combina- tion with an antiseptic and protective, which not only dimin- ishes the hyperaemia and simultaneous hyper-secretion, but also serves, by its contiguity, to mechanically sheathe the irritated parts. The formula I generally employ is as follows: 5.—Cocam. hydrochloratis, Acidi phenici, [• Eugenol, ) aa gr. vi Menthol, gr. xii Lanoline, 3 ii M. Sig.—Apply by means of a camel’s-hair pencil, or a tuft of lint or absorbent cotton. The cocaine and menthol coming in contact with the inflamed turbinated tissue, lessens the sensibility, relieves the congestion, and breaks up the morbid sympathies; the phenic acid benefits by its antiseptic property, eugenol pleases by its acceptable fragrance, and the lanoline aids by its protective and penetrat- ing quality. Among other useful agents may be mentioned palliative snuffs, applied by auto-insufflation. These, although acting on somewhat the same principle, fall short in being rather assuag- ing than positively curative, but, nevertheless, they mitigate 3 the severity and hasten the recovery of many cases. A combina- tion I sometimes prescribe is— 5.—Bismuthi subnitratis, | Acacise, j aa 3 iii Aluminis pulveris, 3 i-ii Morphiae sulphatiS, gr. ii —M. A small amount of sodii bicarbonatis may be added to the above to prevent acid fermentation. This powder and all other powders intended for insufflation should be impalpably fine, for if a snuff has the least perceptible roughness, it will excite sneezing and rhinorrhcea, and insure its own expulsion and its failure as a remedy. It should be used every hour or two, but for not more than twenty hours continuously, otherwise a harmful degree of astringency may be established. Small doses of tinctura aconiti in the form of the London Throat Hospital troches, are a very advantageous accompani- ment of other treatment in cases that exhibit marked pyrexia. Temporary relief may be given to the reflex neurotic head- aches that sometimes accompany the attacks, by repeated inhalations of vapors obtained from a sponge that has been squeezed in hot water, or, better still, by pouring a drachm of the following mixture upon cotton wool in a wide-mouth bottle, and inhaling ad lib.: R.—Acidi acetici glacialis, 1 Acidi phenici, / aa gr. xii Mist, oleoso-balsam (Ger. Pli.), 3 ii Tincturae moschi, gtt. x The period of duration of acute nasal catarrh varies in different individuals according to the rhinorrhcea, the intensity of the attack, and the state of the atmosphere, and all these must be considered in forming an opinion as to duration. CHROMIC NASAL CATARRH is the next frequent in occurrence, and often succeeds a neglected acute attack, especially in those who get exposed to 4 cold and wet. In it the great curative indication is to subdue the chronic inflammation, and to promote the removal of its effects on the structures. In endeavoring to fulfill these indications it is necessary that the diseased parts should be kept as far as possible protected from the irritating influences of cold air, dust and all other irritants. To do this, and also to modify the over-activity of the tissues, no measure has given me such entire satisfaction as the use, by means of the Devilbiss atomizer, of an ointment consisting of b.—Acidi phenici, gr. ii Iodini, gr. iv Atropiae, gr. ss Ungt. petrolei, 3 ii M. Sig.—Use morning and night. If, however, the mucosa is too sensitive to bear the large amount of iodine in the formula, it may be lessened to one or two grains. The irritation arising from its use can be greatly mitigated by following it with a spray of glymol, immediately after which, the morphia powder recommended in the acute variety should be insufflated. If the nares contain inspissated mucus, it is necessary, before using the ointment, to cleanse them thoroughly with an antiseptic alkaline wash. I prefer E. Bald- win Gleason’s excellent combination. The formula is as follows : —Sodii bicarbonatis | Sodii biboratis \ a a 3 i Sodii salicylatis gr. iii Thymol gr. i Menthol gr. ss Glycerinae f§i Aquae ferv. q. s. ad. f 1 iv M.—Add to a quart of water, and use at about the tempera- ture of 100°, by means of Sass’ spray-tubes, or the No. 64 David- son’s nasal spray apparatus. The following powder is also worthy of confidence in this variety, and is of special value where we find commencing hypertrophy: 5 R.—Zinci salicylatis Bismuthi tannatis Sodii biboratis ?aa 3 ss Salol r. xx Pulveris talc 3 ii. M. Sig.—Use as a snuff every four hours. Probe-pointed, soluble, nasal bougies made of bismuthi tannas and sodii biboras in cocoa-butter are also especially efficacious in some cases, one being inserted into each nostril at bedtime. We occasionally meet with cases in which any and every local treatment seems to exert a wrong or an irritating influence; in some of these resolution may be brought about by keeping first one nostril plugged with ordinary raw cotton for 24 hours, and then the other, alternating thus for several days, which acts by excluding currents of air and giving rest to the Schneiderian membrane. HYPERTROPHIC CATARRH is the variety specialists are most often called upon to treat, and fortunately this form, though tedious, is amenable to treatment. The therapeutics that I mentioned in the last variety will also be applicable in the initial stage of this, except that in these cases the post-nasal syringe or Sass’ post-nasal spray-tube must be brought into use. If the bulged membrane is of recent origin, resolution may generally be promoted by the daily use of gum-elastic bougies passed through the nares, and left in position for from five to twenty minutes, according to the amount of pain experienced, beginning with the largest size that can be introduced without decided pain or difficulty. Should this plan not succeed within a reasonable time, and especially if the redundant tissues are encroaching upon each other, some more active measures, such as caustic agents or surgical aid, must be employed. Of the caustics, glacial acetic and nitric acids are preferable; they should be carefully applied on a pled- get of absorbent cotton, twirled upon an aluminium probe, and directed by means of a conical speculum to the point of greatest convexity on the obstructed membrane, followed by an alkaline wash as a neutralizing agent. The acetic acid is preferable when only moderate redundancy of tissue is to be removed. Its application causes but little pain, and only a slight secondary inflammation follows, provided a small plug of absorbent cot- ton saturated with the 4 per cent, solution of cocaine has been used before the caustic application. The nitric acid should be employed where a greater amount of tissue is to be destroyed. It forms a slough, beneath which cicatricial tissue is created. The secondary inflammation following its application is, of course, somewhat more severe than after the acetic. Of all intra-nasal surgery, the galvano-cautery, Jarvis’ ecraseur and the post-nasal forceps present the most radical and potent measures, and their skillful use has not only been a blessing to many a sufferer, but has also done much to give this specialty the position of respect it now deservedly occupies. The action of the cautery is rapid and complete and of special advantage in middle and posterior hypertrophies when they cannot be easily reached by the loop of the Jarvis’ snare. The only draw- back to this method is that if active inflammation is present the cauterization would increase it, therefore when we determine on its use, much time is often lost in waiting for the necessary degree of subsidence. It is used in the following manner: First, thoroughly cleanse the obstructed nostril with an alka- line wash (I prefer Gleason’s, recommended in an earlier part of this paper), after which completely anaesthetize the growth and neighboring tissue with the 4 per cent, cocaine solution, by either of the well-known methods, taking care to continue this a sufficient length of time. It is also wise to make a few appli- cations of it to the opposite naris, as in some cases great sympa- thy exists. Now, aided by a self-retaining speculum and a good light, bring the surface of the hypertrophy into full view. Then, having adjusted the handle of the galvano-cautery so as not to obstruct vision, carefully introduce the platinum knife, well- heated, up to the septal side of obstruction and make one or two separate incisions into the growth, continuing each not only until sizzling is heard and a white foam observed, but until the underlying bone is felt, then quickly desist. Two sittings should be regularly held each week, and in a short time, seldom 7 later than four weeks, cicatricial contraction will be established and the treatment will have proved successful. The Jarvis’snare is also a wonderfully useful little instru- ment, especially in very large anterior hypertrophies. The wire loop is passed over the growth so as to ensnare it, after which its base should be transfixed by a Jarvis needle, to pre- vent the wire from slipping and thereby secure the growth; then by very slowly turning the thumb-screw the mass is re- moved without haemorrhage. This little operation, when aided by a spray of cocaine, is almost free from pain, and its after-results are very satisfactory. The Jarvis’ snare is also of benefit in posterior hypertrophies where, owing to the location, it is almost useless to attempt their removal by caustic measures. Opera- tion : the locality and size of the growth being observed, the wire, bent to its proper curve, is passed along the floor of the obstructed nasal cavity, taking care that the middle meatus is not entered and damage occasioned. After the obstruction is reached, the snare can, by skillful manipulation, be made to encircle the proscribed tissue, after which it is easy to remove it by slowly lessening the calibre of the loop. In young subjects we not unfrequently find hypertrophy of the mucous membrane on the posterior aspect of the septum; if-there is a necessity for its removal, it can best be done by another very useful instrument, the pharyngotome, which reduces the operation from being troublesome, to one of small matter. ATROPHIC CATARRH is one of the most stubborn to treat of all nasal diseases, and it is advisable at the beginning to frankly explain this to the pa- tient, that the necessity for prolonged treatment may be fully un- derstood. The chief indications in it are to keep the parts clean and bring about local stimulation of the atrophied tissue, that its function may be at least somewhat restored. When we say to keep the parts clean we mean it in the strictest gospel sense, as in this variety of catarrh it is a most requisite procedure, for whenever marked regeneration is brought about, cleanliness is one of the factors. 8 Accumulations of hardened secretions and post-nasal impac- tion will often confront us, and, unless watchful, they will not be dislodged. When they exist, the detergent 1 generally em- ploy is the Gleason solution, which not only cleanses but replaces the fetid odor with the pleasant one of thymol. If the crusts are very adherent, I aid the other measures with the curved forceps. In all cases of atrophic catarrh, the rhinoscopic mirror should be at hand as a guide, or we will never know the true condition of alfairs. If the mirror cannot be adjusted, owing to the irrita- bility of the vault of pharynx, a good view may be had by placing the patient on a table with his head hanging vertically back over the end of it; this makes the procedure a compara- tively easy one. Another little suggestion: In spraying the post-nasal orifices for this or any other purpose, the palate-hook should be em- ployed to draw the velum forward so as to give the necessary space for work. Of the local stimulants, none have given such satisfaction in my hands as argenti nitras in solution. I generally try a solu- tion of one grain to a drachm, and increase or decrease the strength if I find a membranous idiosyncrasy. I have learned by experience that powders are apt either to form crusts or to increase the volume of those already existing, therefore almost contra-indicated in this variety; but bougies of sanguinaria, confined in the nasal cavities by strips of adhesive plaster at the anterior nares, have given me gratifying results in two cases. Finally, the possible agency of the strumous diathesis, and of the syphilitic poison, the general state of health, the influence of abode, occupation, season, food, family predisposi- tion, habits of life, etc., should all be borne in mind, and the indications for hygienic restrictions or constitutional treatment should in every patient be carefully studied and faithfully fol- lowed; for unless we discover and meet all the important indi- cations in cases of nasal catarrh, we can no more cure them than a pigeon can fly with but one wing. 1308 N. Charles St. and 1636 B. Baltimore St.