SHORT NOTES OF UNUSUAL CASES, BY WALTER F. CHAPPELL, M.D., M.R.C.S., Eng. Surgeon to the Throat and Nose Department, Manhattan Eye and Ear Hospital, New York. Reprinted from Annals of Ophthalmology and Otology. 1594. SHORT NOTES OF UNUSUAL CASES, BY WALTER F. CHAPPELL, M.D., M.R.C.S., Eng. Surgeon to the Throat and Nose Department, Manhattan Eye and Ear Hospital, New York. Reprinted from Annals of Ophthalmology an» Otology. 1894. SHORT NOTES OF UNUSUAL CASES BY Walter F. Chappell, M.D., M.R.C.S., Eng. Surgeon to the Throat Department of the Manhattan Eye and Ear Hospital. In private and hospital practice, many cases are met with which differ so much in their etiology, clinical history and response to treatment, that we are sometimes led to think that we have discovered a new or previously unrecognized con- dition ; on further examination, or as the case progresses, it is usually found that these conditions are only types of diseases already named in our recognized tables of diagnosis. A collection of these very interesting cases has recently been under my observation, and while I am unable to give them all a definite place, they doubtless belong to types of familiar diseases. Case I. S. D., 25 years of age. Six months ago had what she thought was a severe cold in the head; the initial symptoms being chills followed by a temp, of 102° F., severe pain in the eye-balls and a tight feeling across the bridge of the nose. At first the nasal discharge was watery in character, but within twenty-four hours small, white, shreddy masses of membrane were blown from both nostrils. At the end of ten days, the fever and acute symptoms subsided and the patient, although weak, resumed her duties. Since this attack the nose has always been troublesome, first one side closing, then the other. Recurrent attacks of nasal hemorrhage following the dis- charge of white membranous masses from both nostrils have been of frequent occurrence and very troublesome. When examined at the hospital the temperature and pulse were normal, but the patient had a very anemic appearance. 4 The left nasal "fossa contained a white membrane attached to a vascular mass on the septum, about half an inch from the floor of the fossa at the junction of the middle and posterior third of the septum. A similar membrane covered the posterior end of the inferior turbinated body. The right nasal fossa was packed with sheets of membrane attached to, and covering, the turbinated bodies and septum. . Small spots of membrane were also visible on the superior wall of the naso-pharynx. Any attempt at removal of this membrane caused profuse hemorrhage. Three pieces varying in size from | to J of an inch in width and a 1|16 of an inch in thickness were excised with scissors and submitted to the pathologist of the hospital for examination. He reported the membrane to be similar in structure to that found in diphtheria, but failed to observe any Klebs-Loefler bacilli. Douches of weak solutions of bichloride of mercury, creoline and peroxide of hydrogen, were employed to detach the mem- brane. Failing to remove any by this means, small portions were clipped off each day with the scissors. After the hemor- rhage was arrested a saturated solution of chromic acid was applied. This treatment was continued for two weeks, until the nares were free of all membranous material, although it showed some inchnation to return at first. An alkaline spray had been used daily during the treatment. About this time a profuse watery discharge became troublesome, and two weeks after the last piece of membrane had been removed, the interior of the nasal cavaties had gradually assumed an edematous appearance, which resulted in what is called "polypoid dege- neration " of the entire mucous membrane of the nasal cavities, and perfectly occluded them. Many of the polypi were removed with the snare, and after a prolonged treatment the nose cleared of all this tissue. Four months later when the patient called at the hospital, foul smelling scabs packed both 5 fossae, which were removed and the mucous membrane found to be in a dry atrophic condition. Case II. C. K., 13 years of age. Two years ago had an attack of acute rhinitis, confined to the left nasal fossa, which was followed in a few days by a yellow, mucous discharge con- taining flakes of white membrane. The acute symptoms lasted about four weeks, when they subsided, leaving the left naris occluded, and it has remained so ever since. The right naris has recently been closed at intervals, and several attacks of difficult respiration have awakened the patient at night. Occasionally a mass would protude from the left nostril, and after a few days, recede. When seen by me both nares were completely occluded, and the patient was obliged to keep his mouth open, and spoke with a decided nasal tone. An examination showed a large, white, leathery mass occupying the position of the left inferior' turbinated body, and protruding backwards through the left posterior naris into the naso-pharynx. The anterior and posterior extremities of this mass, had a cauliflower appearance and varied in size at different times. The growth was removed in three pieces with a cold wire snare. The attachment was confined to the inferior turbinated region and seemed to be a degeneration of, or a growth springing from, the mucous membrane covering the inferior turbinated body. A microscopic examination, made by Dr. E. K. Dunham, proved the growth to be a fibro-myxoma. The base, or attach- ment, was curetted, and the patient left the hospital. Three months later, there was no return of the disease and the cover- ing of the inferior turbinated body appeared healthy. Case III. H. McG. In December 1892, had "la grippe" which took the form of a severe coryza with subacute laryn- gitis. Since then the senses of taste and smell has been much impaired. Ordinary odors produced no impression upon the 6 left nostril, but she was conscious of a very offensive odor being always present in the nose, or using the patient's own words, she always " smelt herself. " Heaviness in the frontal region, with tightness between the eyes and mental hebetude were also complained of. The mucous membrane of the nasal fossae looked pale, dry and leathery. The anterior end of the left middle turbinated body presented an enlarged, strawberry appearance, and completely occluded the left fossae. The enlarged turbinated mass was removed and proved to be expanded bony tissue. Eight days after the operation, the patient was able to taste some articles of food: within six weeks, both smell and taste were completely restored. Case IV. K. B. 26 years of age. About two years ago had a large abscess in the left tonsil. Since then, has had a slight burning pain in that region, running into the ear and extending to the cutaneous surface of the superior and inferior maxillary region and down the anterior border of the sterno-mastoid muscle. After this condition had existed about a year, similar sensation appeared in the left arm and leg, with occasional attacks in the left ovarian region. On rising in the morning, the burning pains were very slight, but as the day progressed, they increased and reached their height between the hours of 1 and 3 P.M. They then gradually subsided. During the attacks, the left cheek becomes red and the patient erratic and restless in her manner. At my first examination, I found the temp. 100° F. and the pulse 120. Every organ was carefully examined by myself and colleagues without finding any organic trouble or anything to account for her condition. The observa- tions extended over a period of eighteen months and the temperature was taken every other day during that time, and daily for three months, without ever finding it below 99° F. or above 101° F. 7 Treatment for malaria, rheumatism, and several other con- ditions which it was suggested might be the cause of this neurotic state, was given thorough trial; nothing influenced the attacks or temperature in the slightest degree, excepting pro- longed rest. This gave temporary relief, but a return to moderate employment renewed the attacks. Case V. Mrs. D. 66 years of age. Although physically strong, comes from a nervous stock, and is of a neurotic temperament. Has always had some throat trouble. When 26 years of age her uvula was amputated. Immediately follow- ing the operation a severe attack of difficult respiration came on, which the patient called "spasm of the throat." A similar attack followed the use of a probang some years later, and after several nervous shocks, she suffered from modified attacks of the old trouble. Mrs. D. came under my care in March, 1893, complaining of a constant desire to clear the throat and a feeling of fullness at the root of the tongue. The mucous membrane of the pharynx and larynx was found congested and the circulation sluggish. For several days I sprayed the throat with Dobell's solution without any difficulty. On the eighth, when about to use the spray, Mrs. D. jumped from my office chair and clutching her throat ran into the adjoining room and dropped on the floor. Violent efforts at respiration began and continued for some moments without any effect. The face became pallid and large drops of perspiration broke out all over the body. Ordinary means failing to provoke inspiration, I touched the forearm with the point of a Pacquelin cautery at white heat. This produced an immediate inspiratory effort; after several applications of this kind, respiration was fully established. Two hours later, a burning sensation was felt behind the soft palate and extended to the larynx and trachea. This was accompanied by a hacking cough and a very restless condition. These symptoms subsided in about 24 hours, with 8 the exception of a stinging sensation in the larynx, which continued at intervals for more than a week. When a Pacquelin cautery is not at hand, Dr. A. H. Smith suggests the use of the closed end of a test tube, heated by a spirit lamp. He has found it a very efficient impromptu counter-irritant. Although the Klebs-Loefler bacillus was not observed in my first case, it seems most probable that it was one of nasal diphtheria extending over a period- of several months. Memb- ranous rhinitis is said not to continue longer than four weeks at the outside. The attachment of the membrane and its efforts at reformation are characteristic of diphtheritic memb- rane only. During the treatment of this case, one of my assistants and myself had several short attacks of pharyngitis. From in- quiries made among the patient's friends, I found that many of them had suffered recently from sore throats of more or less severity. The acute edematous condition of the mucous membrane and its subsequent polypoid degeneration, was a very unusual experience for me; and the present atophic state is also interesting, being probably due, in part, to traumatism. The second case is similar to the first, in early history, but on comparison, it seems most probable that it was one of memb- ranous rhinitis confined to the left naris and followed by a chronic inflammation and subsequent transformation of the mucous membrane of the inferior turbinated body into fibro- myxomatous tissue. When removed, it showed no disposition to return. Anosmia, as in my third case, is not infrequent, as a result of hypertrophies and nasal growth, but the presence of parosmia at the same time and seemingly due to the same cause, appears to be an uncommon experience, as is also the perfect restoration of the impaired senses after such a combination. 22 East Forty-second Street.