ARTICLE XV.

NASAL CATARRH AND ITS TREATMENT.

BY DR. C. G. STRONG, OF EAU CLAIRE.

Within my own memory Nasal Catarrh was classed among the opprobria of the medical profession and looked upon as a condition which would be little likely to yield to remedies, and altogether, a matter of small importance to the patient's health. In mild cases the physician was prone to say "Oh, it is nothing but catarrh," and turn the patient away with the assurance that it was nothing to cause worry, In severe cases, astringent snuffs, inhalations, herbs smoked through the nose, and change of climate were the remedies usually advised.

But about twenty years ago the trouble began to be recognized as a national evil, and a vast number of patent catarrh medicines and "sure cures" bore ample testimony to the inefficiency of the ordinary professional treatment.

Almost invariably the sufferers were more injured than benefited by the dollars spent in sampling the various cures, and as a result, they grew despondent and looked upon their condition as a matter of great gravity. About this time the tide of catarrhal patents that during a period of several years had drifted away from the general practitioner began to flow, and now they would not be put off. After long introspection and perusal of patent medicine advertisements their troubles had grown great in their minds and they demanded relief.

Then for the first time the profession became strongly interested and began to study and experiment with great vigor, knowing well, that if successful, their labor would be abundantly rewarded. specialty was created and sections on diseases of the throat and nose were assigned a place in our prominent societies. The result is very gratifying. First came Fraenkel, I think, with camel's hair brush

applications directly to the diseased tissues, and recently Hack with the galvano cautery. So great an impetus has the subject received from this latter discovery that during the past eighteen months medical literature has been fairly flooded with articles on catarrh and nasal.reflexes, their pathology, causes and treatment, and the anatomy and physiology of the upper respiratory tract are understood as never before by the general profession. The trouble has been taken from the realm of medicine and made, to our harm I sometimes think, almost entirely a surgical one; and the specialist who has not invented a snare, a cartilage punch, or some peculiar · form of cautery, is indeed lonely.

Concerning the pathology I will say nothing. We can all recognize deflections, polypi,and swollen, inflamed mucous membrane. These with the subjective symptoms,make a diagnosis easy enough. And of the causes of its general prevalence as little need be said. We used to talk very wisely about it; if the patient resided near the sea or the great lakes, the damp air was the reason; if he lived inland it was the dry air and the dust, or it was our exceedingly variable climate, or his habits of life, etc. All these may be true causes and it is also possible that persistent brain work by keeping the vessels of the head engorged may be a cause, or rapid changes of temperature such as railroad baggagemen undergo in winter, or exposure to coal gas fumes, or going from over-heated schoolrooms into the cold outer air, or any other daily irritation of the mucous membrane of the nose may have much to do with the foundation for chronic trouble. But unless the disease is specific or neoplasms are present, I think in many instances it is very difficult to determine the real cause.

The cases with which the practitioner will meet every day may

be grouped under four heads:

First. Cases in which interference with respiration is a prominent symptom-due to hypertrophy of mucous membrane, tumors, deviated septum, or adenoid growths in the naso-pharynx.

Second, those in which discharge, either continually escaping or retained in the naso-pharynx, is the great cause of complaintdue to hypertrophy or polypi, with discharge, mucous or purulent.

the

Third, others in which fœtor is present and noticeable both to
Patient and his friends-due to retention and decomposition of

plasmic exudation from atrophied bone and mucous membrane, or to necrosis of bone.

Fourth, cases in which reflex troubles are prominent.

Some of these are plainly surgical troubles and undoubtedly require surgical treatment, so we will throw them out and be understood as speaking but of such cases as we think may be fairly and advantageously brought within the domain of medicine.

In regard to treatment, I confess that, as a general practitioner, I am at present conservative enough to prefer the milder methods of Fraenkel to the galvano-cautery. From the latter I have occasionally seen very bad results-extensive destruction of mucous membrane with no relief of symptoms. The application requires not only the greatest skill and care, but a ripe judgment. From the former method I have seen no harm occur and in my own practice the results have been uniformly pleasing.

In most cases where polypi or adenoid growths did not first call for removal, the persistent application of strong solutions of nitrate of silver, tannate of glycerine or light touches with chromic acid melted on to the side of a flat probe have proved to be efficient means of treatment. In all cases it is absolutely necessary to thoroughly cleanse the parts either with the spray or preferably with absorbent cotton wrapped around a probe before making the medical application.

Tannate of glycerine 2 drachms to 1 ounce, with a few drops of carbolic acid added, I have found of especial benefit when carefully and thoroughly painted all over the diseased tissues, which are usually found on the under surfaces of the inferior and middle turbinated bones. It ordinarily excites a copious discharge of mucus which continues about fifteen minutes. During cold weather patients are directed to remain in the office and avoid exposure to the outer air until the flow ceases. Where the tissues are much swollen the brush will not pass into the nose very far at first but on each succeeding application it will advance farther until finally it can be freely applied in all directions, even into the naso-pharynx. A course of treatment requires from four weeks to as many months.

In the more obstinate cases an occasional delicate touch with chromic acid will hasten the process of cure. It causes intense pain for a moment, but is not followed by the swelling and stuffed-up sensation produced by the cautery. It can almost instantly be pre

pared for use by placing a few crystals on a flat probe and holding it over a spirit lamp when they will fuse and strongly adhere. In this way the probe not only makes an excellent applicator but also becomes a shield to the parts we do not desire to touch. I am told by a physician but lately returned from Europe that, as a remedy for nasal hypertrophy, chromic acid is rapidly growing in favor with the foreign specialists.

The following cases may prove of interest as the types they represent are of frequent occurrence in the experience of us all.

I. V. S., age 27, a book-keeper has had catarrh since childhood and would always catch cold on the slightest exposure. Of late years interference with respiration has been very annoying, and occasionally when in a crowded room a sensation of suffocation would come over him and oblige him to go into the outer air. Upon examination found cartilaginous septum deviated and marked hypertrophy of mucous membrane over inferior and middle turbinated bones in both nostrils. Could introduce very small camel's hair pencil on right side, but on the left it was impossible. Began applications of tannate of glycerine to such parts as could be touched three times a week and in a couple of weeks could introduce brush quite far into the left nostril. The membrane then began to have the characteristic doughy consistency, yielding to pressure but slowly returning to its former size. In four months the patient was apparently cured by the persistent application of the above simple remedy. A slight pharyngitis disappeared upon his ceasing to smoke. In two years there has been no return of the trouble and he has had but one acute catarrhal cold. Except for the deviation of the cartilaginous septum, the appearance of the respiratory tract is normal.

I will say here that it has sometimes occurred to me that a deviated septum might often be a result rather than a cause of catarrh, it being bent by the constant wiping of the nose and the involuntary slight pulling towards the hand holding the handkerchief. When the hypertrophy is gone it seems to have no bad effect.

CASE II. Mrs. T., aged 35, complains of an almost constant neuralgia and frontal headache for months. Awakes with it every morning and pain is sometimes so acute that she is nearly wild. Had tried heavy doses of quinine and other neuralgic remedies in vain, as the relief afforded by them was but temporary. Consulted

me first in February last. As paroxysm was severe prescribed 3 grs. Chloral Butylicum every hour until relieved, and on the next day she reported pain nearly gone. She then said she had been bothered a little for three years with catarrh. With a nasal speculum and reflected light a small patch of mucous membrane as far up as I could see appeared to be slightly engorged. Applied tannate of glycerin to the spot and there was an instantaneous return of the excruciating neuralgic pain which lasted until the next day. Three days after upon a second painting the same suffering was produced but continued only about two hours. After the fourth treatment there was no pain, and after the tenth, as the engorgement had disappeared, the patient was discharged. There has been thus far no return of the trouble.

I will say in conclusion that my object in thus calling attention to the efficiency of mild measures is simply to emphasize the necessity for discrimination in the management of catarrhal cases. The treatment has run too much to the heroic of late. Every time we see a swelling in the nose it is not essential to put a snare about it or to apply the galvano-cautery, as is the too prevailing custom of to-day. Probably eight cases out of ten will be caused by turgescence or inflammatory thickening, and not by hypertrophy. In the latter condition, and in skilful hands, the cautery is undoubtedly the best remedy. In the former it may change an ordinary moist catarrh into the dry and far more troublesome form.

There is no particular skill required in the method of treatment described, and a flat probe slightly roughened on one side, a head and throat mirror, a nasal speculum, and a few small brushes fill the armamentarium.

The two great principles in view are to keep the parts clean from irritating discharge, so as to give them a chance to get well themselves, and the persevering application of some mild, local remedy.