Diseases of the Nose and Pharynx 
-AND- 
Their Treatment. 
By W. CHEATHAM, M. D., 
Louisville, Ky. 
Lecturer on Diseases of the Eye, Ear, Throat and Nose in the University of 
Louisville; Eye, Ear, Nose and Throat Physician to the Masonic 
Widows' and Orphans'Home and Infirmary of Kentucky, etc. 
[Defrint front Virginia Medical Monthly, December, i888.~\ 
It is to the more common forms of the diseases of the 
nose and pharynx requiring surgical interference, to which 
I wish to refer. For permanent relief to most of the more 
common forms of nasal catarrh, surgery is indicated. 
Take, for instance, first, probably the most common of 
nasal troubles, the so-called chronic nasal catarrh. Let me 
cite a case, examples of which I see ten or a dozen daily. 
They come with this history: " Doctor, I catch cold easily ; 
how, I do not know. My head stops up; I get my breath 
with difficulty; my head aches; my ears feel full or stopped 
up. Even between my colds, one or the other side of my 
nose is obstructed; which ever side I lie on closes." Some 
of the patients complain of loss of voice with each cold, 
which is the result of laryngitis, which can never be cured 
until the nasal affection is relieved. Some of them have to 
use their handkerchiefs a great deal. Many of them com- 2 
plain of the mucus dropping back in their throats. This 
must be a familiar picture to most practitioners. 
Now as to the pathology of this condition. The sub- 
mucous tissue of the nose is made up of a mass of blood ves- 
sels, the walls of which either by some dyscrasia or by fre- 
quently-recurring colds, become very much relaxed. These 
vessels are said to empty and fill as those of the penis. 
Some have said that excessive venery will produce this form 
of catarrh. On the least exposure tp draughts of air, the 
blood is driven to the internal organs; the vessels of the 
nasal sub-mucous tissue fill; the nose, as a consequence, is 
obstructed. Of course the condition of the skin, and of the 
general health, have much to do with this, but this is not 
surgery; so I merely mention it. Again, when the patient 
is lying on one side or the other, gravity fills the vessels of 
the lower side. 
Seeing this in the acute stage, local applications, in the 
form of sprays, etc., we can well understand, with general 
treatment, will be of much service; but it is usually many 
months before the patient realizes there is local trouble, and 
many, many more before he will acknowledge to his doctor 
that he has nasal catarrh; and many, many more before the 
rhinologists have an opportunity of seeing him. So it will 
be observed that the chances of seeing the patient in his 
first attacks are but few. 
Admitting what has been said as true, what effect can 
astringents, stimulants, or in fact any local medications, 
have? The true cause is deep-seated in the sub-mucous tis- 
sue, and the disease is what I call nasal engorgement, or en- 
gorgement of the nasal sub-mucous tissue, to distinguish it 
from true nasal-tissue hypertrophy. 
With a weak solution of muriate of cocaine, the two af- 
fections can be differentiated. Cocaine will shrink the en- 
gorged tissue, but will not affect the hypertrophied. In the 
management of this engorged tissue I use to depend upon, 
and extol highly chromic acid, or some of the combinations 
of acetic acid. To get any service from either, a large slough 
must result, which leaves a correspondingly large cicatrix, 
on which the secretions will collect, dry and decompose, for- 3 
ever afterwards causing much discomfort. Chromic acid 
has the effect of shrinking the blood vessels, but it is not 
permanent. We must tie them down or destroy some of 
them; and the indication is to do so with as little superficial 
cicatricial tissue as possible. It can be done by electrolysis. 
This is difficult, though, because it is very painful. You 
may ask, why not prevent the pain by cocaine? Because 
cocaine shrinks the tissue so as to render it very difficult to 
get the needle under it. I have tried the electrolysis, but 
had to give it up. A small electro-cautery has the same ob- 
jection. I had made, as I show you here, a long slender 
knife for the thermo-cautery. This is very painful, the re- 
action following very great, the cicatrix large, and it has to 
be introduced heated. This heat cannot be confined, either; 
all the metal is heated, and the radiated heat doe^ much 
harm. It ties down the vessels, but does more damage than 
necessary. 
The galvano-cautery, which I shall consider now, is, I be- 
lieve, taking everything into consideration, the best. I had 
so much trouble with chemical galvano-cauteries that I had 
to give them up long ago. I have invested hundreds of 
dollars in them, and just when I wanted them for use was 
when they were not in order. After some years of discourage- 
ment, I believe we have at last, in the incandescent current, 
found something that will do the work. I have had led 
from the "Louisville Electric Light Co.," a wire giving me 
such a current. By this rheostat made by the " Gaynor 
Electric Supply Company," of this city, I have complete con- 
trol of the current. You will observe that I can bring this 
platinum knife to any degree of heat I may wish. This can 
be introduced in the nose cold, heated then as wished, the 
application made (by cocainizing the tissue), without pain, 
and the knife withdrawn nearly cold. 
Take a case of engorgement of the tissue covering the in- 
ferior turbinated bone; it is this bone that is most frequently 
involved. I spray the nose with an eight per cent, solution 
of cocaine, and in a few moments insert a piece of cotton, 
saturated with the same solution, which will reach the full 
length of the bone, leaving it in ten or fifteen minutes. I 4 
then insert my cautery-knife back to the posterior end of the 
bone, turn on my current slowly, press firmly on the knife, 
and, bringing it slowly forward, make a deep horizontal in- 
cision the full length of the bone. If the tissue is very much 
engorged, I may make two parallel incisions, then insert 
the same cotton with the cocaine on it, and leave it in several 
hours. No pain results, and but little reaction follows. 
There is usually no hemorrhage. I get as a result one or 
two deep linear cicatrices, which tie the relaxed vessels 
down, and as a result no more nasal stenosis, no more drop- 
ping of mucus into the throat, free respiration, recovery of 
hearing, no more laryngeal catarrh ; or if these little symp- 
toms do not disappear, a short treatment directed especially 
to them, relieve them, with but few chances of a relapse if 
the skin and general condition be properly attended to. 
Hypertrophies of the nasal mucous membrane and nasal 
polyp can be relieved by electrolysis, orthegalvano-cautery; 
but I think the best method is the cold wire snare, of which 
there are numbers. I have tried the Jarvis, the Douglas, 
the Sajous, and almost all that are in use, but I prefer 
Mackenzie's, with a slight modification I have made. Tafel 
Brothers, of this city, made them. I hope soon to make a 
further modification which -will still increase its utility. 
The main beauty of this snare is that it can be manipulated 
with one hand. I have yet to see a polyp, or a hypertrophy 
of the mucous membrane of the nose, or of the turbinated 
bones themselves, that I could not remove with this snare. 
Only a few days ago, I removed quite a large hypertrophy 
from the anterior end of the middle turbinated bone. 
For the removal of bony ridges springing from the septum, 
when I think it is necessary to remove them, (I modify it 
in this manner, as I believe they are often removed when it 
is not necessary), we have chisels, gouges, plows, etc. I have 
a dental engine, with burrs made with extra long shanks, 
with which I propose to tunnel these ridges and crush them 
in, thus again getting a great desideratum, a small cicatrix. 
Deviated septa are, I think, frequently given the credit 
of causing much trouble, without facts to support such. 
There are but few people in the world who have straight 5 
nasal septa-some the result of trauma, but many tlfb re- 
sult of nasal engorgement, polyp and hypertrophies. Re- 
move the cause, and many of them will straighten without 
other treatment. Of course some of such cases, (one of which 
I had some months ago, in which I fractured the septum, 
and splinted by plugs, getting an excellent result), I say, 
some few of them need surgical measures to correct them. 
In the case of the septum that I fractured, I also took from 
one side quite a large slice of cartilage. 
As a cause in some cases, and in some as a result of nasal 
engorgement, we have hypertrophy of the pharyngeal tonsil, 
or the vault of the pharynx filled with adenoid tissue. 
According to Lacauchie, as confirmed by Kolliker and 
Luschka, the adenoid tissue at the vault of the pharynx is a 
conglobate glandular mass, having the same structure as 
the tonsils; and hence it has been termed the pharyngeal 
tonsil. It is soft and spongy, and so closely incorporated 
with the cartilaginous tissue uniting the pharynx to the base 
of the cranium that it is exceedingly difficult to separate 
them. The follicles are identical with the solitary follicles 
of the intestine, and when in great numbers give a glandular 
aspect to the vault of the pharynx. 
Hypertrophy of this gland is more common in childhood 
than in adult life, and is probably oftener present in males 
than in females. Cases I have seen this summer were in 
persons under twenty years of age, the majority being under 
ten years; the youngest is four years old. The symptoms 
are those of a severe cold in the head, with very much less 
secretion from'the nose than commonly marks a simple 
cold. The secretion drops down from behind the soft palate, 
is sometimes very excessive, occasionally very tough and 
difficult to remove, and sometimes the efforts to get rid of it 
produce nausea and vomiting. As stated before, one or the 
other or both nostrils are closed posteriorly, so the breath- 
ing, especially during sleep, is distressing. The child usually 
sleeps with the head thrown back, lying flat on the back, 
and often with the arms over the head. The mouth is wide 
open ; the tongue, becoming very dry, drops back into the 
throat, producing a distressing strangulation ; whereupon 6 
the child cries out and jumps up badly frightened. A short 
period of rest ensues, to be followed by another paroxysm. 
In this way the little one passes the night, and on waking 
in the morning is as tired as when it went to bed. As a 
consequence, such children are usually anaemic, have little 
appetite, are stunted in growth, have narrow-pointed chests, 
and often the arch to the hard palate is much narrowed. 
The child coughs, catches cold easily, is deaf, and shows a 
deficiency in the articulation of such nasal sounds as mand 
n, or has what Dr. Meyer, of Copenhagen, calls " dead pro- 
nunciation." 
Such patients have no use of their noses; have never 
realized the importance of the organ; can neither breathe 
through them, nor blow them. They never have a good 
night's rest. 
The diagnosis is usually easy. With the rhinoscope no 
mistake can be made; or in small children the finger can be 
used. If the vault is filled with a number of enlarged 
glands it presents to the finger, as Cohen says, the sensation 
of a bunch of earthworms. If seen, it looks much like a bunch 
of cauliflower. Again, it will look as in the patient whose 
history I reported some time ago. 
A young man, aged nineteen years, told me he had never 
known any use for his nose. He had never been able to 
breathe through it, nor blow it. He had Meyer's " dead 
pronunciation " to perfection. He said he had never had 
a good night's rest; was just as tired on getting up in the 
morning as when he retired at night. He ^lept with his 
mouth wide open, and breathed through it both night and 
day-had horrible dreams and nightmares. His mother 
said that at night his breathing could be heard in every 
part of the house, and sometimes, after a severe paroxysm 
or an extra effort to get more air, he stopped breathing so 
long that she had frequently hurried to his bed, fearing 
that he was dead. 
I found his nose quite free, but posteriorly the naso- 
pharynx was filled with a red, glistening mass, convex for- 
ward, and perforated with many openings like the faucial 
tonsils. There was absolutely no space on either side or in 7 
front; it wks adherent to the pharyngeal wall. I endeav- 
ored to snare it, or get hold of it with Mackenzie's laryngeal 
forceps, but failed. I introduced my finger behind the soft 
palate, hugging the wall of the pharynx closely, and found 
that I could tear it loose from the pharynx easily; it yield- 
ing like liver tissue. After getting my finger well up in the 
vault of the pharynx I discovered two horns extending into 
either post-nasal space. These I also tore out with my fin- 
ger. Relief was almost instantaneous. He was now able 
to blow his nose and breathe through it, which to him 
seemed very strange. A weak carbolic wash was given. 
Some slight reaction followed, and for a few days some small 
pieces of tissue were discharged. Several days later he re- 
turned home, having been entirely relieved. Several 
months have now passed since the operation and there is no 
return of disagreeable symptoms. 
It is indeed a triumph for rhinology when a disease that 
had caused nineteen years of distress should be relieved in 
a few minutes by an operation so simple. Of course in 
younger patients relief is not so prompt or easy, many days 
of patient treatment being often required. Children do not 
bear cocaine well, and because of haemorrhage, which al- 
ways attends the operation, general anaesthesia can not be 
resorted to. All wTe can do in these cases is to remove the 
tissue by piecemeal by an operation once every two or three 
days. I sometimes scrape the pieces out with my finger, or 
the curette, or pull them awTay with the forceps. In some 
cases I use chromic acid. I have seen no benefit from 
washes or powders. Not infrequently this trouble exists 
with engorgement of nasal tissue, and sometimes with true 
hypertrophy. Some physicians claim that by removal of 
the hypertrophied and engorged nasal tissue the adenoma 
in the vault of the pharynx will disappear. This has not 
been my experience. If the physician ■will but note the 
number of children presenting the symptoms described at 
the beginning of this year, he will be convinced that the af- 
fection is by no means uncommon; if he could see these 
children after they have been put to bed, and witness the 
distress occasioned by this form of nasal obstruction, he 8 
Would Wonder that it should have received so little atten- 
tion at the hands of medical writers. Since the affection is 
quite common in children (few of whom receive treatment), 
and not common in adult life, it is clear that many of the 
cases are cured by puberty. Great and irreparable damage, 
however, may and often does result before puberty is reached, 
and in view of this fact the importance of early and efficient 
treatment is manifest.