IN this paper I will treat of two forms of chronic catarrh- those in which there exist permanent hypertrophies; and those which are characterized by intermittent swellings of the Schneiderian mucous membrane.
These two forms are the most frequent of all varieties of chronic rhinitis.
In the treatment of chronic catarrh, where there exist obstructions of any kind, the first step to be taken is, to remove these obstructions; then; with Homoeopathic remedies, we may expect favorable results. These results we would not obtain without this preliminary treatment.
I know that objections have been made by some Homoeopathic physicians to such a course; they claiming, that unfavorable results follow operative treatment.
These objections, however, come from those who have had very little experience, but who, on the other hand, are always heavily loaded with theories. The large practical experience which I have had, warrants me in saying that these objections are unfounded. I shall prove, on the contrary, that only the most favorable results follow operative procedures when performed in a proper and skilful manner.
It has been said that, where such line of treatment is followed, it does not differ from that used by Old-School specialists; and, moreover, that it makes very little difference, whether a patient is operated upon by an Old-School or a Homoeopathic specialist.
I shall have to take exception to this; because the two have different objects in view; and their respective operative procedures are entirely different.
In the first place, the Old-School specialist uses operative measures as a last resort, and expects such measures will complete the cure. This, it too often, does not do. The Homoeopathic specialist, on the other hand, resorts to operative measures for the purpose of paving the way to future treatment, which must be in part Homoeopathic-to effect a permanent cure.
In the second place, Old-School specialists, as a general thing, remove as much tissue from the nose as possible, leaving the cavities specious,a nd, often, too much so. The Homoeopathic specialist, on the other hand, removes as little tissue as possible and yet quite enough to produce the desired result-which is, to prepare the case for future treatment.
Having differentiate thus between the Old-School and the Homoeopathic specialist, I shall next endeavor to meet the objections made to operative treatment, by adducing facts instead of theories.
It is claimed that the removal of bone, cartilage and mucous membrane, from the nasal cavities, is followed, in time, by their becoming abnormally large, and frequently results in atrophic catarrh.
To the first objection, I will say that it has been proved to be groundless. I have not one, out of the large number of cases upon which I have operated, that presented results claimed above, after the operation. In fact, in two cases to which I wish to call special attention, the operation produced effects just the opposite. Instead of shrinkage of the parts, there was an increase of tissue, and a consequent narrowing of the usual cavity.
Miss. M. came to me, complaining of an obstruction in the left nasal cavity. On examination, I discovered that the septum was slightly deflected to the left, while along the cartilaginous portion there was a horizontal ridge, which completely obstructed the left side. The latter was removed and the septum planed off, leaving the cavity large enough to pass a wooden plug one-quarter inch wide and one-half inch high. This was kept in position for six days-removing it every other day for antiseptic cleansing of the parts. Three months afterwards, I found the nasal cavity in almost as bad condition as before the operation was performed.
A second operation was resorted to. After this, I kept the patient under observation, seeing her two or three times a week. At the end of six weeks, I could see that the cavity was gradually filling up, and that something must be done to arrest the overgrowth of tissue. I then had recourse to the galvanic cautery, using a flat electrode. This was effectual, not only n removing some of the redundant tissue, but also in arresting the further progress of the growth. I will not tax your patience with a description of the second case, as it was similar to the one just cited, and was treated in the same manner, with good results.
In reply to the second objection-that operations on the nasal cavities are frequently followed by atrophic catarrh, I would say, that it is without any foundation whatever. In twenty- five cases, which I have had the opportunity of keeping under observation, and which I examined eighteen and thirty months after the operation, not one presented any evidence of dryness of the parts operated upon, or of atrophic catarrh. In fact, it would have been impossible for any one but the operator, to have discovered what portion of the septum had been operated upon, as the mucous membrane had been reproduced, to all appearance in its original and normal condition. I believe, that all who have had any wide experience in operations upon the nasal cavities, will agree, that only good can result from a properly performed operation.
The failure to obtain good results from operations of this character is due, to most instances, to neglected after- treatment. Hence its supreme importance. It must be frequent and long-continued.
I am decidedly in favor of conservative surgical procedures in cases of chronic catarrh; but there are only three classes of cases in which I would consider it necessary to use operative measures; First, those in which obstructions prevent proper drainage of the nasal cavities; second, those in which the passages are so narrow that the least irritation, whether the result of atmospheric changes, particles of dust or irritating vapors, causing swelling of the parts, and producing contact of the external and internal walls. If left alone, this would result in adhesion of the parts. Third, those in which adhesion of the external and internal walls has already taken place, and to which Browne has given the name of Synostosis.
It is not necessary that every spur and ridge upon the septum should be removed; nor is it necessary that the septum should be perfectly smooth. It is not good surgery, to hold that every departure from the right line in the position of the septum demands treatment. And here is where a great many inexperienced operators make their mistake. It is the neglect of not paying particular attention to what is proper and necessary to be removed that justly brings specialist into disrepute. It is desirable, also, to operate by artificial light reflected from the forehead-mirror; but in that case the operator must be familiar with the use of the head-mirror, and be able instantly and automatically to follow any motion of the patient’s head with the directed illumination during the few minutes consumed by the operations.
Antiseptic cleansing of the parts before operating and during healing is desirable. The nasal cavities having been cleansed, the parts should be thoroughly anaesthetized, so that all pain may be avoided. This is best accomplished by saturating a strip of lintine, about half in inch wide, with a 10 to 20 per cent. solution of Cocaine. This is passed into the side to be operated upon by means of a flat applicator, and made to cover the tissue to be removed. Satisfied that all sensibility has been destroyed, we should perform the operation with as little inconvenience to the patient as possible, selecting those instruments which will give the least disturbance to the patient, consistent with the best attainable results. The nasal saw, snare, trephine, drill, chisel and gouge, together with various other accessories, have each their proper place in the domain of nasal surgery.
Having finished the operation, the next important part is the after-treatment. The results will depend largely upon the attention paid to it.
The conditions presents in the nasal cavities will not allow of an antiseptic dressing that may be left there for three or four days, as may be done in other parts of the body; but the healing process must go on in the presence of septic surroundings. In consequence of this, the patient should be seen and treated every other day for two weeks; afterwards, twice a week, until the healing process is completed. During the first week after the operation I would advise insufflation of powdered Europhen.
In the second week, and until the parts are completely healed, liquid Petroleum, to which has been added Calendula and Eucalyptol. By means of an atomizer they are easily brought into contact with the membrane of the nasal cavities, and are not only soothing to the mucous surface, but also protect the membrane from atmospheric influences. During the first week, Arnica may be employed with good result, unless some other remedy is plainly indicated.
There are so many medicines that can be used locally in chronic catarrh that it would consume too much time even to enumerate them.
A few only, and the most important, may be mentioned: menthol, Eucalyptol, Calendula, Tar, Thuja, Carbolic acid, Aceto- tartrate of aluminum. By various means, liquid Petroleum will take into solution the drugs mentioned and act as a better medium than water, with the exception of the Aluminum-aceto-tartrate, which should be used in an aqueous solution.
Some specialists have seen quoted as using Menthol with Petroleum in the proportion of sixty grains to the ounce, and oil of Eucalyptus, one drachm to the ounce. This proportion I consider far too strong, as it is not only painful but irritating to the membrane. Menthol should not be used in a proportion to exceed ten grains to the ounce, and sometimes five grains will suffice.
Menthol is indicated in painful inflammatory affections, and where there is frequent erection of the mucous membrane, especially of that covering the turbinated bodies.
Eucalyptol (Sanders) should not be used stronger than half a drachm to the ounce, and, in some cases, ten drops are sufficient. It is indicated in inflammatory swellings of the mucous membrane, accompanied by excessive secretions.
Thuja, combined with Petroleum, has not been mentioned by Old-School specialists, yet it is one of the best local remedies we have. It is useful after operations to assist the healing process, and is also indicated where there is a discharge of offensive purulent mucus and ulceration and scabs in the nostril. It has also given satisfactory results, when not too strong, in dry coryza.
The Aceto-tartrate of aluminum may be used either in solution, in the proportion of one drachm to the ounce, or in combination with Boric acid; equal parts. It has styptic and antiseptic qualities, and is, therefore, used chiefly to arrest haemorrhage after operations and for its antiseptic qualities. It is, however, also useful in hypertrophic rhinitis, a rapid subsidence of the swelling being brought about by insufflations of this drug with Boric acid; equal parts, or one to two.
Hypertrophy of the mucous membrane, the turbinated bodies, may be reduced either by the galvano-cautery or some strong acid. I know of no acid that answers the purpose so well as the Trichloracetic. It has an advantage over all other acids of which I have any knowledge. The pain produced by the cauterization is insignificant; the eschar which is formed is uniformly thick, is almost inodorous, produces no unsatisfactory action, and leaves no unpleasant after-effects. Immediately after the application of the acid a bright ivory-white scab is formed, which remains localized to the point of application. This latter quality is of great advantage, as it does not spread to other parts, as do many delinquescent caustics; for instance, Chromic acid.
Special attention should be paid to keeping spray tubes and instruments clean, for back of the unclean instrument is an unclean and careless operator.
Having journeyed thus far with the Old-School specialist, operating possibly in the same manner and with the same kind of instruments, yet with different objects in view, come we to the place where we must part company.
The Old-School specialist, having finished the operation, and the healing process being completed, if the case is not entirely cured, has nothing else to resort to but local remedies. These, to often, fail to complete the cure.
On the other hand, the Homoeopathic specialist, having prepared his case for future Homoeopathic treatment, looks forward with confidence, knowing that he has a host of remedies which, if carefully selected and applied according to the principle of similia similibus curantur, will effect a permanent cure.
There is no branch of medicine in which greater laurels could be won for Homoeopathy, if we were not too conservative, than in this branch of rhinology.
After the obstructions have been removed, the remedies that will be found to give the best results are as follows:.
Belladonna-Throbbing headache; worse fro motion and leaning forward; tip of the nose red, with burning in the nose; discharge of mucus mixed with blood. Especially useful in the first and second work after operation.
Kali Bichromicum.-Frontal headache; formation of hard plugs in the nostrils; dryness of the nose; with a feeling of pressure at the root of the nose; tenacious, ropy discharge from the posterior nares, adhering to the pharynx and removed with difficulty.
Kali Iodatum.-Acts similarly to Kali bichromicum, except that the Kali iodatum patient has more hypertrophy of the mucous membrane of the nose; the threat is dry; the glands enlarged, or presenting some evidence of scrofulous or syphilitic taint.
Lobelia Cerulea.-Great depression of spirits; pain in the left side of the head and over the root of the nose; first, itching and tingling feeling in the left nostril, followed by frequent sneezing, with copious discharge of thick mucus from both nostrils; nostrils very sensitive, so that inhalation of air creates a slightly painful feeling. This remedy is especially adapted to such cases as are subject to catarrhal inflammation of the posterior nares and fauces, and in which there appear upon the posterior and lateral walls of the pharynx red elevated spots.
Passiflora Incarnata.-Distressing pain at the root of the nose; complete stoppage of one or both nostrils; discharge slight and thick; restless asleep.
Paris Quadrifolia.-Pain in the right temporal region, extending to the frontal sinus and root of the nose; discharge of red or greenish mucus on blowing the nose; stiffed condition and fulness at the root of the nose; constant hawking of tenacious mucus; fauces dry in the morning.
Hyoscyamus.-Buzzing and singing in the ears; sense of smell weak; jerking pain at the root of the nose; mucous membrane of the nose dry; this remedy is given by the Old-School when the secretions are excessive, and there is much restlessness- a few drops of the tincture being given; when the secretions are suppressed, especially after operations, it will give good results when given in the 3d or 6th potency.
Spigelia.-Pain in the temple or forehead, extending towards the eyes; discharge thin, copious, flows mostly through the posterior nares, causing choking at night, and when lying down; I have verified the latter symptoms in my practice repeatedly.
Senecio Aurens.-Inability to fix the mind on any one subject; dull, stupefying headache; secretions slight or suppressed; sneezing, burning and fulness in the nostrils-the burning being especially confined to the naso-pharynx; dryness of the mouth and pharynx; some pain in swallowing.
Thuja.-Pain at the root of the nose; ulceration and scabs in the nose; discharge of thick, sometimes offensive, green mucus, mixed with blood; red, itching eruption on the alae of the nose, which is frequently moist.
Wyethia.-Pain over the right eye; picking, dry sensation in posterior nares; sensation as if some foreign substance were in the nasal passages-an effort to clear them through the throat affords no relief; dryness of the fauces, with constant desire to clear the throat by hemming.
Besides these remedies, the following deserve due consideration: Arsenicum, Ars. iod., Calc. phos. Calc. carb. Calc. iod., Hepar., Hydrast. can.,, Hydrast. mur., Puls., Sepia, Bals. Peru.
As a general rule, the above remedies will be found sufficient. However, in particular cases, other remedies may have to be chosen.
In addition to the treatment given above, the nasal cavities should be cleansed once a day with some non-irritating solution, either with a douche, atomizer, or very small syringe.
I always advise the use of a small glass syringe, directing the patient, as the piston or rod is pushed in to gently snuff up the solution, propelling it along the nose to the naso-pharynx, cleansing this cavity, and allowing it to pass out through the mouth.
GEORGE H. QUAY, M.D.: I like the ring of Dr. Teets’ paper. Would that every Homoeopathist in the land could read it and profit thereby.
There are two classes of men in our school: one, who thinks that every case he has demands an operation, and when he is unable to perform it must turn it over to and Old-School surgeon who will not even recognize him as a physician; the other class, who imagine that everything under the sun is amenable to internal medication-this is then class who, in the main, bring our school into disrepute. We accuse the Old-School of not investigating, when our won ranks are full of the same tribe.
The men in our school, possessing the largest experience in the treatment of catarrhal troubles of the upper respiratory track, are the ones who most readily acknowledge the need of surgical interference in these complaints. In fact, there is no rhinologist of extended experience but can adduce case after case of hypertrophic rhinitis that failed to obtain relief from internal prescribing alone, or combined with spray, until redundant tissue was removed. In the form of rhinitis just alluded to, the results following proper operative treatment are often little less than miraculous.
There is one condition that I think is often overlooked or neglected in hypertrophic rhinitis. I refer to the enlargement of the posterior end of the lower turbinals. In m,y experience this raspberry-appearing enlargement is one of the most frequent accompaniments of hypertrophic catarrh. The quickest and surest way to reduce it is to slowly amputate with the cold snare.
In cases combined with sneezing do not fail to treat this portion of the lower turbinal, and septum directly opposite.
In regard to the means of cauterizing, I find nothing that gives the pleasure and satisfaction of the galvano-cautery. Acids I seldom resort to, except acetic on the septum. The fumes of chromic, in fact of all acids, are too penetrating. There is another condition frequently existing in chronic rhinitis that causes much discomfort. I refer to hard pieces of mucus attached to the vault of the pharynx. The remedy is the post-nasal douche; sprays usually have no effect. Finally, do no forget local cleanliness.