A system of practical medicine. By American authors. Vol. 3

by Unknown

FIG. 19.

Antero-posterior section of the bones of the face in position, showing the premaxillary portion of the floor of the nose greatly elevated above the plane of the remaining portions. In ozæna, as mentioned in the text, a disposition of parts may exist similar to that delineated, and cause discharge to collect and undergo offensive decomposition.

TREATMENT.—The parts should be carefully cleansed—an act which, while imperfectly accomplished by either the syringe or the douche, is, in my judgment, best performed by the galvano-cautery. This instrument, the one relied upon for the subsequent treatment of the case, is to be selected for its initiation. The largest speculum which the nose will admit being placed in position, a spiral-looped electrode is introduced cold into the nose and held against one of the crusts. When heated it will effect so firm an attachment to it as to enable the mass to be withdrawn with great ease. In patients with whom the palatal portion of the floor of the nose is depressed below the level of the maxillary a considerable quantity of discharge may lie concealed from observation. When, after the removal of all visible crusts, the fetor persists, it is reasonable to suppose that the palatal depression is filled with decomposed pus and mucus. To test such a condition, the electrode should be appropriately curved and introduced. I have been surprised at the quantities of discharge which can in this way be withdrawn from a locality which, as far as I know, cannot be cleansed in any other way.

With the removal of the crust relief is at once experienced, and if the discharge could be removed as fast as it forms the disease would not really be a source of offence. The general health would also improve, from the fact that an atmosphere tainted with a burden of decomposition would no longer be breathed. But in practice this cannot be attained, and it is imperative, after the chambers have been entirely cleansed, to cauterize the lining membrane throughout. I have been in the habit of beginning such cautery treatments with the middle turbinated bone, passing thence to the inferior turbinated bone, then to the roof of the nose in front of the sphenoidal sinus, and lastly to the septum. Small surfaces only should be covered at a single treatment, so that it may take a month or six weeks to finish a single series of applications. This treatment is almost always well borne, nothing ever ensuing beyond a slight headache or a temporary establishment of a serous discharge. Notwithstanding that the condition in question is one of atrophy, the reparative power of the mucous membrane remains apparently unaffected. At all events, no danger from sloughing is to be dreaded after such extensive destruction of tissue. The thin eschars separate within from three days to a week, leaving a healthy mucous membrane beneath. In one instance the cauterization had extended to a sufficient depth to expose the bone, and yet from this denuded surface no exfoliation took place, the parts healing rapidly and satisfactorily. No other local treatment is relied upon for fetid atrophic catarrh than the one mentioned. No disinfectant washes are required if the discharge is removed as described. Should the patient be so situated as to be unable to report regularly for its removal or treatment, a wash composed of one part of Labarraque's solution to sixteen parts of water may be ordered with advantage, or a solution of carbolic acid, gtt. j to fluidounce j, with a little glycerin, may be snuffed up the nose twice a day, or listerine, diluted one-half with water, may be used with advantage. The general health, of course, should be cared for, and any complications met. I have found that during the winter months arsenic and cod-liver oil are well borne, associated with minute doses of Lugol's solution. For adolescents earthy and the calcareous phosphates are indicated, and for all abundant exercise and careful dieting. When the symptoms have been relieved, the patient should be requested to report once a month, for it is not to be expected that all symptoms will disappear, and some point of advice can be advantageously offered at this interval.

(c) Necrosis in the nasal chamber is a cause of catarrh, inasmuch as the fragments of bone lying within the nose excite irritation and induce discharge. I have never seen a case of this form of disease which was not due to syphilis. The remains of syphilitic angina are apt to be present, and the general manifestations of constitutional syphilis are well developed. The septum is more frequently affected than the turbinals.

Discharge due to necrosis can be readily distinguished from that arising from any other cause by the presence of detached fragments of denuded bone, by the characteristic fetor, and by the history of the case.

The prognosis is favorable, for all symptoms will cease upon the extraction of the fragments, or at least those which remain are of an entirely different character, and are due to the resultant imperfections of the septum, and consequent irritation arising from the too free entrance of air into the nose. I have seen in one case an extensive tumefaction and infiltration of the tissues covering the middle turbinated bone at the same time that the septum was breaking down. These masses require treatment with the galvano-cautery and astringents after the dead fragments have been removed.

A TABLE OF NASAL DISEASES GROUPED BY SYMPTOMS.

Cases in which interference with nasal respiration is a conspicuous symptom:
	Due to deflection of nasal septum (common). Due to angiose hypertrophy of the mucous membrane (common). Due to tumors lodged in the nasal chamber. Due to adenoid hypertrophy in the naso-pharynx. Due to over-activity of the levator palati muscles (rare).
Cases in which discharge is a conspicuous symptom:
	Due to hyperplasia of the mucous membrane over the turbinated bones (common). The discharge when flowing backward is described as a dropping; when forward, as a running at the nose. The discharge is either mucoid or muco-purulent. Due to tumors lodged in the nasal chambers or appendages. The discharge is usually excessive. When due to myxomata (polypi) the discharge is mucoid (common). In inflammatory complications of the same the discharge is muco-purulent (common). When due to neoplasms other than myxomata the discharge is purulent, and rarely muco-hæmic (rare).
Cases in which retention of mucus in the nose or upper part of the throat is a conspicuous symptom:
	Due to retention of inspissated mucus at the roof of the naso-pharynx (common). Due to the mucous secretion of the nose and throat being excessively tenacious (rare).
Cases in which fetor is a conspicuous symptom:
	Odor putrid.	Due to retention and decomposition of plasmic exudation from atrophied bone and mucous membrane (common). Due to necrosis of the bones within or bordering upon the nose (rare). Due to decomposition of muco-pus in the maxillary sinus (rare).
	Odor musty.	Due to partial decomposition in small patches of desiccated mucous crusts (common). Due to morbid secretion unaccompanied by profound alteration in the structure of the nose (rare). Due to ulcerations of the mucous membrane (rare).
Cases in which a sense of dryness is a conspicuous symptom:
	Due to ineffective erectile tissue permitting air imperfectly warmed to enter the nose and the pharynx (often met with in neurosis). It is caused by temporary constriction of the erectile tissue or by the atrophy of the tissue. Due to neurosis. Neurotic patients will often complain of a sense of dryness in the nose and the naso-pharynx when all the conditions of excessive mucoid discharge are present.
Cases in which hyperæsthesia exists, so that slight lesions that in any way interfere with the nasal functions form the basis of persistent complaint (not infrequent).

Epistaxis.