Clinical Notes on Methods and Nev Remedies in the Treatment of Diseases of the Upper Air Passages. BY WALTER F. CHAPPELL, M.D., M.R.C.S. ENG., SURGEON TO THE MANHATTAN EYE, EAR AND THROAT HOSPITAL. REPRINTED FROM THE CANADA LANCET, JULY, 1896. NEW YORK: 1896. Clinical Notes on Methods and New Remedies in the Treatment of Diseases of the Upper Air Passages. BY WALTER F. CHAPPELL, M.D., M.R.C.S. ENG., SURGEON TO THE MANHATTAN EVE, EAR AND THROAT HOSPITAL. REPRINTED FROM THE CANADA LANCET, JULY, 1896. NEW YORK 1896. CLINICAL NOTES ON METHODS AND NEW REME- DIES IN THE TREATMENT OF DISEASES OF THE UPPER AIR PASSAGES. BY WALTER F. CHAPPELL, M.D., M.R.C.S. ENG., SURGEON TO THE MANHATTAN EYE, EAR AND THROAT HOSPITAL, New York. These observations are taken from histories of cases seen in private and hospital practice during the past two years. They are intended to place briefly before the general practitioner the most approved methods and remedies which, in the special experience of the writer, have been the most satisfactory in the treatment of the affections under consideration. The results from other remedial measures have been carefully compared and tested, so that, only those drugs which were found to pos- sess superior value are mentioned. New drugs employed :-Camphoric Acid, Ortho, and Para Monochlorophenol, Pyrozone, Lysol, Tannigen, Argentamin, Thiol, Guaiacol, Alumnol, Aluminum Aceto-tartrate, Ichthyol, Creasote carbonate, Tartarlithine, Cocaine saccharinate, Anti- pyrin, Benzoinated Liquid Albolene, Ferropyrin, Iodic acid and Ethyl Bromide. Of these, tannigen, lysol, iodic acid and thiol, did not prove to be of special service. The other drugs are worthy of distinct recognition and will be considered under the diseases which were most relieved by them. For brevity and clearness the subject may be considered under the following divisions, ist, Nose, Accesssory Sinuses. 2d, Pharynx. 3d, Larynx and Trachea. 1. Disease of the Nose and Accessory Sinuses. The methods used were douches, sprays, applications, opera- tive measures and semi-fluid preparations. The latter are formed by precipitating stearate of zinc in benzoinated liquid albolene, to make an opaque, semi-fluid, white, creamlike product. This preparation is neutral to litmus paper, almost tasteless, and entirely non-irritating to any mucous membrane. Any remedy may be added to this product which the nature of the case indicates. This oily base will be spoken of as oleo- stearate of zinc wherever its employment is recommended. («) Acute Rhinitis or Influenza. Without doubt this is one of the most frequent nasal affections to claim our attention and often with indifferent success. To be of any marked service the treatment must be commenced within twenty-four hours of the onset of the symptoms, and internal remedies and local measures adopted. Rest and even temperature are desirable, but of course cannot always be obtained. Considerable relief and decided arrest of symptoms may be expected in every case from one of the following prescriptions:- Tablet triturate rhinitis, of which there are several strengths, one containing camphor gr., belladonna fl. ext. gr., qfiiniae sulph. £ gr. in each tablet is of the most service. One tablet should be administered every fifteen minutes, until eight have been taken, then one every hour or two as required; or pil. phenacetin, camphorae et atropinae sulph., as first recommended by Dr. A. H. Smith. Each pill contains phenacetin grs., camphor -J- gr, atropine sulph. gr., and should be taken once in four hours. The following powder is of considerable value in persons of a plethoric habit or rheumatic tendency:- Pulv. glycyrrhizae co. . . . . 3 i. Sodii bicarbonatis. 3 iii. M. ft. pulv. no. 6. .... . Sig. One every half hour until finished and repeated in six hours if required. 4 5 The semi-fluid preparations are especially suited for applica- tions to the acutely inflamed mucous membranes of a common cold. They may be applied by means of a dropper, or the aseptic injector especially designed for this purpose and shown in the accompanying illustration. ASEPTIC INJECTOR. One of the following combinations is very serviceable:- Liq. Plumbi subacetatis gtt. x. or boric acid grs. x. to one ounce of the oleo-stearate of zinc. When the nasal discharge is profuse and accompanied by excessive sneezing, applications in the form of snuffs give marked relief. One of the best is 1J. Camphor Bismuth, subnitrat. . . aa 3 ss- 3 i. Pulv. acaciae. gr. xx. M. ft. Sig. Snuff to be used every four hours until relief is obtained. Hay fever and intermittent rhinorrhoea from the similarity of their symptoms to those of influenzal colds will be considered under this heading. Intermittent rhinorrhoea appearing at any season of the year, is in the opinion of the writer most frequently of malarial origin. Our best results have followed full doses of quinine administered during the attacks, and the persistent use of arsenic given in increasing doses between the attacks. The treatment of hay fever will depend on whether advice is sought before or during an attack. Many remedies may benefit this affection, but in the writer's experience, the most uniform and decided results are obtained from the use of cinchonidia sulphate. Its influence on the vaso-motor system is in many cases remarkable. It produces a dryness of the naso-pharyngeal membrane almost equal to the effect of belladonna. The writer 6 has seen several patients in whom six grains of cinchonidia given during twelve hours produced an intolerable dryness and thirst. The distress was so great in one case that the hay fever was preferred to the effects of the remedy. When possible, treatment should be commenced ten days before the usual date of the attack, with five grain doses of cinchonidia sulphate three times a day. On the day preceding the usual date of attack, twenty grains should be administered, and the dose in- creased ten grains daily until the symptoms are controlled. If the attack does not appear or is controlled, the dose should be gradually diminished. If the patient is not seen until the attack has begun, full doses of the remedy should be given and in- creased as required. Large doses, or the continuous use of this remedy may cause some nervous disturbance, similar to those produced by quinine. Fifteen or twenty drops of dilute hydro- bromic acid given in water will control the symptoms and should be given when the large doses are reached. Constriction of the chest and other asthmatic feelings which appear as a later symptom in hay fever patients are greatly re- lieved by the administration of sulphur. It may be given in solution with cream of tartar and syrup, or in capsules contain- ing ten or twenty grains, every half hour until the attack sub- sides. Considerable griping and looseness of the bowels follow its administration, in some patients. The writer deprecates the use of cocaine by hay fever patients, as many persons suffering from cocaine habit date their downfall from a cocaine spray prescribed to relief their nasal distress during an attack of hay fever. Very little relief can be expected from local applica- tions alone but to supplement internal medication they are of some value. An application of the following combination, acts as a protective to the mucous surfaces and is very cooling. L Mentholis Camphorae dd grs. v. M-Rub together and add . Oleo-Stearate of Zinc ... § i. M-Sig. Use with a dropper or aseptic injector three or four times a day. (Z>) Hypertrophic Rhinitis. This is one of the most frequent causes of nasal obstruction, and runs either a sub-acute or a chronic course. In the former the hypertrophy is due to en- gorgement of the vessels and dilatation of the sinuses; in the latter, some fibrous change takes place. Local medication in 7 the form of sprays is useful in the more recent cases, such as a half per cent, of camphoric acid in watery solution or one per cent, of menthol in benzoinated liquid albolene, continued for several weeks. If considerable discharge accompanies the hy- pertrophy the spraying should be followed by applications of tannic acid or iodine in a solution of oleo-stearate of zinc. Occasionally the hypertrophy involves not only the mucous membrane covering the turbinated bodies, but also that of the septum. In many of these cases, sprays, applications, or op- erative measures, seem to aggravate the trouble, as it is gouty or rheumatic in origin. The writer has seen patients who dis- charged at intervals small, chalky deposits from the nasal mucous membrane. Remedies to correct this condition are indicated, and tartarlithine is one of the best. When the hypertrophy becomes fibrous in character, minor surgical measures or some caustic must be selected. Powdered nitrate of silver fused to the size of a small bead on the point of a fine applicator is the most ready and efficient caustic. A two per cent, solution of cocaine should first be spread over the mucous surface and the application made in small spots at frequent sittings. Very slight pain or inflammation ensues, and there is a minimum destruction of glandular tissue. (r) Atrophic Rhinitis.- Popularly termed "bad smelling catarrh." Cleanliness is the cardinal rule in the treatment of this affection. Hand sprays are not of much service, as they reach only the anterior part of the nasal fossa and frequently leave large masses of thick mucus in the posterior part. For thorough cleansing the nasal douche is necessary. In pre- scribing the latter, the following directions should be given, as improperly used the douche may produce inflammatory action in the middle ear. Directions for using the douche or nasal cup :- ist. Warm the fluid used and apply vaseline to the nasal tip. 2nd. Put the nasal tip in the nostril that has the most obstruction. 3rd. Hold the breath, throw the head slightly backward and allow the fluid to flow gently into the nose. 4th. If you feel that you must breathe, take the tip away and after a few moments begin again. 5th. While using the douche, don't attempt to walk, talk, cough, swallow, sneeze, or become excited in any way. 8 Any alkaline solution may be used in the douche, and after the mucus has been thoroughly removed, some stimulating application should be made. For several years iodine has been used almost exclusively in my service at the hospital, as repeated tests proved it to be more beneficial than any other remedy. Three grains of pure iodine was added to an ounce of oleo- stearate of zinc and applied to the mucous surfaces night and morning with a camel's hair brush. Persistent use of this remedy relieved most cases. In some patients scattered spots of ulceration appear on the septum and turbinated bodies Occasional applications of 50$ solutions, also full strength, of ichthyol, and the daily use of a 5$-io$ solution of ichthyol will prove very serviceable. For a year past, orthochlorophenol has been on trial, and promises to surpass in value other remedies in atrophic rhinitis. A 10-25$ solution in glycerine should be smeared over the mucous mem- brane once or twice a week. Considerable smarting follows, but lasts only a few moments. For home use a one-half to one per cent, solution in oleo-stearate of zinc is applied twice a day. In many cases that had not previously received any treatment, and in several where iodine and ichthyol had failed, the use of orthochlorophenol produced immediate and remark- able results. When the ulcerations on the septum are especially large and do not respond quickly, a 25$ solution of ortho- chlorophenol or the pure drug may be employed. It should be carefully applied in small quantities to small surfaces and pre- ceded by the use of cocaine ; considerable lachrymation and frontal headache may ensue, but are only transient. Any treat- ment to be successful must be continued for several months. (<7) Epistaxis.-Recurrent nose bleed is usually due to minute abrasions of the mucous membrane at the anterior and lower part of the septum. The volume of blood which may flow from them is surprising. Treatment must be directed to the acute hemorrhage and the prevention of its recurrence. Holding the nose between the thumb and index finger, the former making firm pressure over the bleeding point, is usually successful if the patient at the same time assumes the horizontal position. Should this method fail, one of the following haemo- statics may be used: Ten per cent, watery solution of aceto- tartrate of aluminum, pyrozone 3$ solution, 10$ of ferropyrin or antipyrin-salol. The latter is made by filling a test tube, one 9 third with equal parts of antipyrin and salol. It is then heated over a spirit lamp until the mixture is first transformed into a clear liquid, and later takes a well defined brown color ; when the latter color is reached the liquid is ready for use, but must be allowed to cool sufficiently before applying. The solution can be kept warm by placing the test tube in a glass of warm water. All solutions of haemostatics should be applied with a dropper, or spray. In my experience, plugging the nose with absorbent cotton is very undesirable, as a secondary hemorrhage always follows its removal. Sometimes these recommendations prove useless and we are obliged to apply the cautery directly to the bleeding point. Considerable care is necessary to secure the exact heat of the cautery. After the hemorrhage is under control, a short time should elapse, and then the bleeding point should be touched with the finest cautery point or powdered nitrate of silver fused on an extremely fine applicator. The latter method in my practice has been very efficient. As a sup- plementary treatment, some of the oily preparations are very satisfactory, such as tannic acid, rubbed up with oleo-stearate of zinc. The writer has seen severe cases of persistent recur- rent nose bleed yield to the use of semi-fluid preparations, when they were commenced between the attacks. (<?) Frontal Maxillary and Sphenoidal Sinusitis :-Acute in- flammation of these sinuses has been remarkably frequent since the last visitation of the grippe. When recognized early, medi- cinal measures will successfully combat further progress of the inflammation. External and internal heat locally applied is immediately indicated, and should be used on the cutaneous surface in the region of the affected sinus, and by hot alkaline nasal douches. A tense feeling with pricking and pain are usually felt over the inflamed sinus, and great relief from this may be obtained by the persistent application of a counter irritant, such as : IJ Ol. sinapis essent. gtt. x., menthol and camphor ad 3 ss. Sig. Apply as directed. In using this solution over the frontal and maxillary regions, the eyes should be protected. When the sphenoidal sinus is affected there is frequently intense pain just below the occiput, which may be relieved by keeping the back of the head on a bag of very hot water or salt. Sometimes the inflammation progresses to suppuration, and requires the usual surgical measures for relief. 10 (f) Folliculitis Alae Nasi. Although a very simple affection, it causes considerable annoyance and discomfort. Most of the cases are seen in children suffering from a more or less acute ophthalmia, which has spread through the lachrymal canal into the nasacl avity. The dried secretions must first be removed, and then a 10$ solution of nitrate of silver or orthochlorophenol applied. Powdered boric acid is given for home use, to be dusted on three or four times a day, with directions not to wash the parts for a few days. 2. Diseases of Pharynx. (a) Naso-pharynx. The usual affections in this region are post-nasal catarrh and adenoid growths. The hypersecretion of post nasal catarrh is frequently due to nasal obstruction, and relief must be sought from some of the methods already con- sidered. Increase of adenoid tissue is also a prolific source of post-nasal dropping. Occasionally, during an influenzal cold, a pharyngeal tonsil of normal size will share the general in- flammatory condition of the surrounding region, swell consid- erably, and exude a quantity of thick, yellow mucus. Warm, alkaline, post nasal douches are indicated until the acute symp- toms subside; then applications, such as 10$ solutions of alumnol or orthochlorophenol, continued for some time until the secretion is arrested and the gland resumes its normal size and appearance. Follicular hypertrophy and congested vessels also promote hypersecretion in this region. Daily and per- sistent application of a 2% solution of zinc chloride will give very decided relief. A powder composed as follows is ex- tremely serviceable. It does not change chemically, will not become lumpy, is non-irritating and not offensive to the taste. Argent, nit. ..... grs.x-xl. Potass, sulph. . . . . . 3 i. Bismuth subnit. ..... 3 viii. M. Sig. Apply behind the soft palate three times a week. In all cases attention should be directed to the digestion, con- dition of the liver and bowels and mode of life. Adenoid Growths.-The methods and details of treatment of these growths depend on the age, temperament, and general condition of the patient, also on the amount of tissue present. When the growths are small and the enlargement slight, they frequently subside under astringent application, or the relief of some nasal obstruction, which accompanies and is partially re- 11 sponsible for their presence. Removal of adenoids in children may be accomplished with or without an anaesthetic. If the adenoid tissue is moderate in quantity and of the soft, gel- atinous variety, the index finger, properly used, will shell out all that is necessary. In using the finger it is well to protect it in part with a rubber or leather stall, otherwise some injury may be sustained from the child's teeth. Abundant adenoid tissue requires an anaesthetic, preferably nitrous oxide gas or bromide of ethyl. Forceps and curette are both necessary for complete removal of the growths, and the greatest care must be exercised in their use. If the blade of the forceps or curette is pressed too hard into the parts, an unnecessary amount of mucous membrane will be sacrificed. After removal, pyrozone 3$ solution or aceto-tartrate of aluminum, should be applied to the bleeding surface, and the child kept quiet and in an even temperature for twenty-four hours. It is also well to remember that these operations are contra-indicated when any symptoms of acute ear trouble are present, and that chronic aural sup- puration necessitates great care in proceeding with the opera- tion. In adults cocaine anaesthesia is sufficient for the removal of adenoid tissue, and in my experience cocaine saccharinate is preferable for use in all affections of the upper air passages. It is decidedly sweet in taste, always antiseptic, causes less pha- ryngeal discomfort, and equals other preparations of cocaine in anaesthetic properties. Antipyrin and cocaine may be combined when a prolonged anaesthesia is required. The forceps and curette should both be employed, and if the amount of tissue is considerable, several sittings should be given for its removal. Care must also be exercised in the use of instruments, and some antiseptic haemostatic applied after each sitting. (<£) Oro-Pharynx. The treatment of diphtheria has been so thoroughly discussed in all the journals, that the writer will only state that in his opinion antitoxin serum cannot yet be accepted as the final remedy for the treatment of diphtheria. Follicular Tonsillitis.-Early treatment is desirable, as many of these cases subsequently become peritonsillar and sup- purate. Cleansing sprays and the application of any good antiseptic will cause the disappearance of the follicular secre- tion and membrane in from five to seven days. This period may be shortened and the constitutional symptoms modified by local applications of creasote carbonate and the administration 12 of two-drop doses of guaiacol every four hours. Whiskey and Ton of a grain of strychnine sulphate should also be given, as they relieve the extreme exhaustion so marked in all cases of acute follicular throat trouble. Mycosis of the tonsil and pharynx resists many forms of treatment. The cautery point introduced at a white heat de- stroys the growths in the follicles, and pyrozone twenty-five per cent, solution is also very satisfactory. Occasionally a short change of climate succeeds when all other methods of treatment have failed. Quinsy or Peritonsillitis.-Unless the patient is seen early it is almost impossible to prevent suppuration. Rest, with ex- ternal and internal heat, applications of cocaine and the administration of arterial sedatives may abort some cases. If the history is rheumatic, full doses of sodium salicylate should be given, as it frequently limits suppuration and modifies the whole course of the disease. Occasionally the acute symptoms subside, leaving a fullness in the pharyngeal wall and tonsil with some bulging of the soft palate. This is really a deep abscess, which may remain quiescent for several weeks unless incised ; but sooner or later inflammatory symptoms reappear, and the abscess discharges of its own accord. After incising a tonsillar abscess the cavity should be washed out with hot water. If the opening is large, solutions of pyrozone or peroxide of hydrogen may be used to thoroughly cleanse the cavity. Peri- tonsillar inflammations are usually dependent on diseased tonsillar tissue with large and deep follicles, also on adhesions of the pillars to the tonsils, leaving deep pockets, which form receptacles for all kinds of decomposing materials. Occasion- ally the tonsils and their secretions are completely encapsuled by the pillars. Preventive measures should therefore be taken in all cases of recurrent peritonsillitis, to correct any unusual condition. Follicular Pharyngitis.-This affection may occur in the acute or chronic form. The former should be treated as an acute follicular tonsillitis. The latter requires prolonged treat- ment to obtain permanent results. The galvano cautery and strong acids, while very efficacious are inadvisable, as they are apt to produce a dry pharyngeal wall. Powdered nitrate of silver fused on a probe and applied to a few follicles at each sitting gives the best results and leaves the 13 mucous membrane in a healthy condition. Caustic iodine simi- larly applied is also very satisfactory. The latter is composed of iodine and carbolic acid crystals, each 120 grains, iodide of potash, 10 grains, rectified spirits, two drachms. Soothing sprays are desirable as adjuncts to the other treatments. Enlarged Tonsils.-In children under fifteen the tonsillo- tome is universally used for the removal of tonsils, and prefer- ably Ermold's guillotine. This instrument is simple in con- struction, without barbs on the fork, and insures the removal of the tonsil without danger of the fork being caught. Two instruments expedite the operation, as the moment one tonsil is excised, the second instrument is taken for the other tonsil. The child then has no oportunity to object, which it will assuredly do if given an opportunity. This supposes that no anaesthetic is employed, which I think can only be necessary in special cases. In adults removal of the tonsils can only occasionally be nec- essary. When determined upon, the personal and family history must carefully be considered, and the blood supply of the tonsils and pharynx examined. If there is no contra indication any of the numerous tonsillotomes may be chosen, and fifteen minutes allowed to elapse between the excision of each tonsil. Com- plete removal of the gland should not be attempted, as it is apt to result in an uncomfortable dryness of the throat. The writer has never used the cautery loop in removing ton- sils, believing that the cicatrix from a burn, causes a permanent dryness more distressing that the presence of large tonsils. When it seems undesirable to use the tonsillotome, the frequent application of caustic iodin will sometimes diminish hypertro- ph'ed tonsillar tissue. Haemostatics and antiseptics are advisable after all ton- sillotomies. (r) Laryngo-Pharynx. Hypertrophic lingual adenitis. In- creased adenoid tissue at the root of the tongue is frequently overlooked, although it is the most usual cause of fulness and desire to clear the throat. Only a few nodular masses may be present, or several groups of large, pale, flabby masses, which completely fill the glosso-epiglottic fossae, and overhang the epiglottis in pressing backward over the glottis. Any strong astringent will relieve the cases with moderate growths but something more radical is necessary when the tissue is abundant. 14 In the latter cases, the galvano-cautery gives the best results and should be used when practicable. The epiglottis should be avoided, oedema may result if it is burned. Solid nitrate of silver or chromic acid may be used, but are not so effective. Occasionally the growths are in two large masses resembling enlarged tonsils. The lingual guillotine, suggested by the writer and later improved upon by Dr. R. C. Myles, is the best means of removing large isolated growths. Occasionally the lingual hypertrophies becomes acutely in- flamed and small yellow secretions fill the follicles ; soothing sprays are the only treatment needed, as the trouble causes slight pain on swallowing and disappears in a few days. A col- lection of varicose veins at the root of the tongue produces considerable tenesmus in this region, and should be treated by the galvano-cautery. Attention should also be given to the digestion. j. Disease of Larynx. The most frequent inflammatory affections of the larynx are either subacute or chronic. The subacute casos are usually caused by cold and are quickly relieved by sprays of one per cent, solutions of alumnol or two per cent, argentamin. Argen- tamin solutions are very satisfactory for laryngeal sprays, as they do not produce the dryness and spasms which usually follow the use of nitrate silver in the larynx. In chronic laryngitis, rest of the voice is of primary import- ance ; 5$ solution of argentamin or of zinc chloride are about the best applications for the physician's use. For home use, one grain of iodine in an ounce of benzoinated liquid albolene as a spray, is of service. The neoplasms of the larynx are innocent or malignant. The former are usually papillomatous in charac- ter, and in adults are easily removed by Grant's guarded forceps. In children, this is not so easy and they are apt to recur. Dr. Delavan has recently suggested sprays of absolute alcohol for laryngeal papillomata, and in the writer's experience it is very successful. Tracheotomy is also to be recommended for the treat- ment of recurring papillomata in children, as physiological rest produces atrophy of the growths. In maligant diseases an early diagnosis is of the greatest importance. If this is made, a com- plete removal of the larynx is indicated, and may prolong life many years. 15 When the disease has made considerable progress nothing can be gained from this procedure and tracheotomy gives the most relief. Tubercular Laryngitis.-The treatment of this terrible disease is curative or palliative. The former is not frequently successful, but in selected cases, curetting and submucous in- jections of creasote will arrest the disease. Of palliative measures, many remedies will give relief if persistently em- ployed. Thorough cleansing of the larynx is of the first importance and alone gives great comfort. Applications of creasote in castor oil, and iodoform in ether are the best reme- dies for the relief of pain and general laryngeal distress. The automatic syringe and Mizpah dropper are the best means of applying solutions to the larynx. In the later stages of tuber- cular laryngitis, accompanied by extreme ulceration, io per cent, solutions of parachlorophenol give some relief, but cocaine is the only remedy which affords comfort while eating. If the epiglottis is much affected food is apt to drop into the trachea. To prevent this the patient should be directed to flex the chin on the sternum during the act of swallowing. In chronic tracheitis creasote and malto-yerbine relieve the cough, and intra-tracheal injections of selected remedies are of undoubted value. 7 East 55th Street.