THE idea of this paper has been growing in my mind for several years, a result no doubt, of a growing feeling of inefficiency and futility when following the procedures that have been taught us and are still practised by most of us. It is true that people expect things to be done when they have complaints. Their minds must be treated as their bodies. But let us understand that it is psychic and not practical treatment, less we fool ourselves as well as our patients.
Perhaps, it is due to the fact that I am a very poor actor and feel disgusted with myself when I do things that I feel will be of no value to satisfy my patient and get a fee that has prompted their presentation. I mean this to be anything but a highly technical or scientific paper, just a practical discourse on the misconceptions of diagnosis of everyday procedures in our practice.
It is in the office care of the affections of particularly the nose, however, the larynx and the ear come in for their share, that the usual diagnosis and treatment are so absurd. In my opinion, most of the treatment applied to the office patient is worse than nothing. Why does this condition exist ? Not because all physicians are charlatans or are ignorant. But because affections of the nose and throat are the most common of all ailments.
And because humans have so long had a religious faith; first in priests, then the medicine man, then the true medical man and his concoctions and now in scientific medicine as we know it. These people go to the physician for treatment of symptoms, and treatment they must have, because it is a faith similar if not identical to our religious faith. Consequently, the physician, if he wishes to keep in contact with his people and also live must treat these conditions and he must, in any instances, satisfy their faith.
The fact that many of these conditions do not respond to our therapeutic methods accounts for the great variety of questionable cures. The profession appears sometimes to have followed these methods so long that it believes them itself, and is not doing all it can for its patients. Perhaps if the methods are scrutinized a little more minutely, much of the worthless may be discarded so that a few things a little more pertinent may be used.
With this idea in view, let us consider the common cold. It is the most common of all the diseases. There are many indications that it is infectious and contagious. Still, there are instances when it has not seemed to be infectious, but rather a systemic reaction. A controversy has existed in the past concerning its cause and consequently of its treatment.
It seems now that the etiology is pretty well established and both infectious and systemic reactions exist. It is evident now that there occurs a virus infection of the upper respiratory tract that produces the symptoms known as a cold. It is also very evident that there exists vasomotor reactions, that at the onset, are very similar to infections, that they are instigated or are aggravated by cold and sudden drops in temperature.
So having the acute rhinitis divided into acute virus infections and acute allergic reacts, the treatment of acute infections will be considered. Prophylaxis is the first step in all treatment. It is known that isolation almost eliminates colds but modern society does not permit isolation. Some people have inherently a greater susceptibility to colds than others and the susceptible persons wish to attain the lack of susceptibility of their neighbors. This, as yet, is one of the impossibilities of accomplishment, but a good physician never ceases to try, even if some of his efforts are ridiculous.
Since the cold was thought to be infectious, cultures of the affected part were made. Not a specific, but a variety of bacteria were found. Immediately, vaccines were made and are still made for the prevention of colds. It is now evident that not these bacteria, but a filterable virus is the cause of colds and that the visible bacteria are secondary invaders.
Consequently, if it is possible to increase the immunity to these bacteria, that only prevention of the secondary invasion, and less severe colds can be expected. Practically, they are very popular. The popularity enhanced, perhaps, by the extolling of the manufacture, the desire of the patient to use serums and the desire of the physician to impress the patient by using the most scientific medicine.
This is exemplified in the report of the use of vaccines by the health service upon the students of one of our large universities. The students were divided into three groups. The first group was given a mixed cold vaccine at regular intervals. The second group was given sterile water by the same method at the same intervals. The third group was used as a control.
At the end of the year, the first reported that they had had many less colds, the average showing about two a year per person. The second group reported that they had had many less colds, the average about two each for the year. The control group reported the average of two colds each person. This report shows why vaccine therapy is popular and why its logical use is questionable.
There now exists the vitamin era. There can be no doubt about the necessity of vitamins for general well being of an individual. There are many people suffering from avitaminosis from improper diet. Still, a large percentage of people do not suffer from avitaminosis and still have colds. When this period of wishful prescribing of vitamins for all ailments passes, a sane level of vitamin therapy will be established, which will have its place in medicine.
The extensive list of therapeutic agents used for colds is indicative in reverse ratio of their effectiveness. Similar therapeutics as such, or as copied by most drug houses selling cold tablets are probably as effective as anything. Still, honestly, I have never seen a real infection of the nose that I felt was terminated by the use of these drugs. Perhaps they may be less severe, who can say, but none are terminated. And the same may be said of the things used for their physiologic action. These not only do no good, but may be harmful.
To me, one of the most absurd treatments is catharsis. It is said that catharsis stimulates elimination of toxins. What toxins? Are there normally toxic materials in the digestive tract? If so how do we live? Or why do we not arrange a continuous purge? Or is it to remove the toxins resulting from the cold in the nose? How have they reached the digestive tract? The real action of the cathartics is to dehydrate the system producing acidosis, one of the conditions that promotes infection.
As further evidence that internal therapeutics have not solved the cold question, physicians have taken to the local and external use of drugs and certain physical forces. For many years, camphor, menthol, and eucalyptus have been popular remedies.
None of these have any antiseptic value nor do they increase the breathing space of the nose. It has been definitely proven that these drugs cause swelling of the nasal tissues and any apparent benefit the patient might imagine comes from the antiseptic effect upon the mucosa. Antiseptics, such as the colloidal silver salts and some of the mercurials have been applied to the nasal cavity and throat in various ways, as tampons sprays and drops.
If these compounds can have any antiseptic effect upon the bacteria of this area in the short space of time that it is in contact with the surface, and if the bacteria do kindly come out of the tissues onto the surface, these tampons and sprays may have some bacteriocidal action. But even with a careful tamponing or thorough spraying, probably only a small part of the surface can be treated.
While, the drop method, unless the patients lie on their backs with their heads hanging, is even less satisfactory because the fluid dropped into the nose simply runs down the floor of the nose into the throat. It is inconceivable that any appreciable bacteriocidal effect can take place and such drugs interfere with the normal protective mechanism of the nose.
It is known that the nasal cavity, including the associated sinuses has certain protective mechanisms to repel all foreign substances, including bacteria from within the nose. The nasal mucosa is lined with ciliated epithelium and upon the surface of this ciliated epithelium is a thin layer of mucus. This mucous layer is being continuously moved along by the action of the cilia, thus removing any foreign material, including bacteria that come in contact with the surface. Any medication that destroys or removes this mucous layer or interferes with the action of cilia of the nose, removes the major protective and reconstructive physiologic action present in these parts.
Now, any irrigation or medication that removes this lining layer of mucus from the nasal cavity, or interferes with the action of the cilia, are definitely harmful. And, it has been shown by definite experimentations that all the drugs commonly used in the nose with one exception, stop the ciliary action for an indefinite time. The one exception is weak solutions of ephedrine in saline.
Still, it is questionable whether this justifies the use of ephedrine or any of the vaso-constrictors in an acute infection of the nose. If the process of repair or inflammation in an infected area be considered, it will be remembered that the first change is an increase in blood supply to the part to bring up anti-toxins and white blood cells to neutralize the poisons produced by the bacteria and to devour the bacteria and destroyed cells. Now, if the vaso-constrictors are used to prevent the increased amount of blood, natures greatest protective mechanisms has been interfered with.
In the case in which there is complete retention of secretions within the nose, or lack of drainage when a single daily shrinking might be permissible. And, it is definitely known that the excessive use of vaso- constrictors will cause a paralysis of the vessel walls, thus increasing the swelling and interfering with the movement of the blood streams. In spite of all the propaganda, there can be no other logical conclusion that vaso-constrictors have a small place in the treatment of acute colds.
The only excuse for using vaso-constrictors in the nose, is that it will increase the breathing space and there are certain people that become panicky when there is the slightest obstruction to the breathing. But when these drugs are used, let it be remembered that a symptom is being treated at the expense of the disease.
Then the question of a sinus disease. There is no place in medicine where more confusion and misconception has arisen than in sinus disease. To the rhinologist, sinus disease implies an infective focus within the sinuses. While allergy of the nose and vaso-motor disturbances, while they involve the sinuses, are not considered sinus disease.
It is to be regretted that the term sinus disease ever was created. While such a condition does exist, many symptoms that are due to entirely different causes have been laid to sinus disease. This is due, in fact, to a lack of thorough understanding of the physiology and pathology of the nose. More real enlightening work has been accomplished along this line in the past decade, than during all previous time.
In a sense, it is so new that the rhinologists are not all enlightened, and medical men as a whole, have no idea what it is all about. Then, to add to the confusion, it is the popular disease in society, and all kinds of nasal symptoms have been treated by all sorts of physicians and pseudo-physicians, by all imaginary methods. It is impossible to explain in detail etiology of all the symptoms attributed to sinus, but some clarification is in order.
The symptoms most frequently attributed to sinus disease are nasal discharge, nasal occlusion, headache and neuralgic pain, cough, recurrent and continuous colds, and all the conditions secondary in to focal infection. While all these may be present in infected sinuses, none of them are consistently symptoms of that infection.
Patients are constantly coming and being sent to the office, saying they have; :sinus disease,” because they have an intermittent or continuous discharge, either posterior or anterior from their noses. There are many causes for nasal discharge. First of all, the nasal cavity is a moist cavity. It is lined by a mucous membrane that secretes mucus, having a continuous layer over the entire surface, to temper the inspired air and to filter out foreign materials. Some people just have more mucus in their noses than others.
Some are exposed to extreme degrees of temperatures, humidity, and dust, and it is a normal function to have an increased amount of secretion for protection against these conditions. Consequently, all excesses of secretion are not the result of pathology at all, but are simply an over functioning of a protective mechanism. Persons with a disturbed endocrine balance with resulting vaso-motor changes, tend to have an increase of secretion. Allergic disease in the varied degrees of intensity, is a very frequent cause of increased discharge.
In acute allergic attacks, there is a profuse watery discharge; in the more chronic cases, the discharge is more tenacious and drains posteriorly and is apt to be in chunks of egg white consistency. If it has laid in the nose some time, it may be somewhat opaque. This seems to be the most frequent cause of excessive non-purulent post nasal secretion. An excessive amount of tears drained into the nasal cavity will increase the secretion. There may occur meningeal fluid in the nose. And, of course, purulent secretion from the nose indicates a pyogenic process somewhere in the lining of the nasal cavity or its accessory sinuses.
Nasal occlusion may be the result of deformation of the bony framework or from increase in thickness of the soft tissues. The soft tissues may be swollen due to endocrine vaso-motor disturbances, allergic reactions or inflammatory reaction. In chronic rhinitis, inflammatory swelling is not the rule unless accompanied by allergy. In fact, maxillary and frontal infections are more usually found in the open side of the nose.
HEADACHE AND NEURALGIA PAIN.
There are some three hundred conditions that may cause headaches, but still nearly all headaches are at some time blamed upon sinus disease. It will be much easier to discuss the pains resulting from nasal conditions than all those that are not. Any pressure within the nose, be it caused by framework contacts or soft tissue pressure, may cause headaches. Thus, a septum infringing a turbinate may cause pain. Still, except in acute extensive inflammation of the maxillary sinus, in most inflammation of the frontal which has the characteristic midday pain, and involvement of the sphenoid in which the pain is of the atypical fifth nerve neuralgic or Sluder syndrome type pain, pain is not especially the rule in nasal affections.
Whenever there is an excess of secretion draining post nasally and accumulating in the pharynx or bronchial tree, there will be a cough. The secretion may be purulent or of the allergic type. In fact, if the nasal affection is allergic, the cough may be of the asthmatic type, rather than direct irritation of the secretions.
RECURRENT AND CONTINUOUS COLDS.
Many people present themselves and say that they have a sinus headache or a sinus attack with a history of having no cold or nasal discharge. This is utterly impossible. But, on the other hand, others complain of very frequent or continuous colds with constant occlusion and discharge. Frequent acute nasal infections may not all be the result of chronic sinus disease, but may be suggestive, particularly if the cold never entirely recovers. But care should be taken to determine whether the condition is characterized by a purulent or watery discharge. The condition may be a chronic allergic attack with acute exacerbations.
Considerable controversy exists over the degree of toxic absorption from pyogenic sinuses. If practical observation is of any value, there are cases of focal infection in the sinuses, producing lesion in the other parts of the body. Still, patients with a very marked infection of the maxillaries have been observed for years without the resultant diseases accredited to focal infection. Probably sinus infections are much less dangerous than infected teeth and tonsils.
Chronic purulent noses with polyps and perhaps asthma, just plain chronic purulent noses, and polyposis of the nose without purulent discharge, perhaps with asthma, presents a real nasal problem in both diagnosis and treatment. A colleague, who is a chest specialist, frequently sends me this type of a patient. The patient has a frank asthma with a nose filled with polyps with or without purulent discharge.
His x-ray of the sinus shows them to have thickened lining. He asks that I clear up the sinuses to relieve the asthma. What is the pathology chronologically? Did this patient first have a purulent infection of the nose, then develop a bacterial allergy that produces the asthma or was the patient allergic to some extrinsic proteins which produce the asthma and the polyps. The sinus x-ray will show a thickened lining of the sinuses regardless of whether there is an infection of the nose, or an allergic reaction. Either condition may exist.
If the infection is primary and the allergy secondary, probably the infection should be attacked radically and supporting desensitization used. But if the allergy is primary, surgery, except to remove the polyps for the sake of breathing, is absolutely useless. And in the former condition, it is no easy task to clear up an infection in the presence of an allergic reaction. Too, another situation sometimes arises as exemplified by a patient under my observations. The patient had a severe maxillary infection which was very slow in recovering fully. It finally became chronic and frequent lavages over a period of three years, did not improve the condition.
The patient eventually stopped smoking cigarettes and immediately the sinus became normal. The explanation is this. The patient acquired a mild bacterial allergy from the infection, which delayed the recovery, but as happens frequently, the bacterial allergy subsided and a sensitiveness to the cigarette smoke developed. It was this sensitiveness that was keeping the sensitized tissue irritated. When the cigarette smoke was removed, the whole process was quiet. Cigarette smoke is only one allergen. Any other inspirator or ingested protein may do the same thing.
Granting that nasal affections are principally pyogenic infections processes and allergic reactions and that many of their symptoms are similar, how are they to be differentiated? History is important. Sinus infection usually dates to a certain severe cold or general infection disease, such as influenza, measles, scarlet fever, or pertussis in children. The severity of the symptoms may show relapses or exacerbations with recurrent colds. While the allergic condition usually gives a family history of allergy, other allergic manifestations in the patient and the onset is usually not associated with general illness.
Too, much can be determined by the appearance of the nasal membranes. In acute infection, the membrane is swollen, bright red with perhaps small haemorrhages and covered with purulent secretion. In chronic sinus infection, the nose may be very little swollen and may appear quite normal but careful inspection will reveal purulent secretion in the middle meatus or in the naso-pharynx. An allergic membrane on the other hand will be swollen and moist, frequently bluish in color, or a bluish background and a pale surface. If both an infection and allergic reaction exist, there may be purulent secretion, or if there is no infection, only a watery secretion will be seen. Polyps or hyperplastic swelling are always evidence of allergy.
Smears from the nose that show a preponderance of eosinophils indicates allergy. Also, an increase of eosinophils in the blood is an allergic sign. X-ray diagnosis can be very useful but too often is misleading. Most people who take x-rays of the sinus do not get pictures that can be diagnosed and are unable to read the pictures after they are made. Too often a picture that shows a shaded lumen is considered a positive sinus, but it may be either an allergic swelling or a pyogenic thickening.
A proper x-ray should reveal the thickness of the mucosa and if it is an inflammatory thickening, there will be a dense line next to the bone while a thick membrane without this line indicates allergic membrane. The treatment of allergic affections is usually not surgical unless the condition may be mixed, but consists of avoiding the provoking allergy or in reducing the susceptibility by injection of small doses of the allergen. While in uncomplicated infections, drainage, lavage and surgical eradication are the methods.
Probably surgery has received much of its bad reputation in sinus disease because it is applied too often to allergic conditions. Surgical eradication can and does eliminate sinus infection but it will not eradicate allergic reaction. However, as before stated, the mixed condition, the bacterial allergic reaction present a compound problem that tries the ingenuity of the physician to cure, and too frequently, can not be eliminated by methods now available.
The treatment of chronic forms of deafness has also been an unsatisfactory procedure. And unsatisfactory for two reasons. First, because of “lack of definite location of the pathologic lesion” and on account of the peculiar psychic reactions of deaf people. The ear is a difficult organ to study. One can not look into the ear and study its pathology. It is only possible to study symptoms. Nor is it convenient to study lesions of the ear in the pathologic laboratory. Consequently, only fragmentary information has been obtained.