LUPOID ULCERATION OF THE NASAL SEPTUM BY E. L. SHURLY, M.D. DETROIT & ^Reprinted from the Archives of Laryngology, Vol. iii, No. 4, Oct., 1882] LUPOID ULCERATION OF THE NASAL SEPTUM* By E. L. SHURLY, M.D., DETROIT. THE cases about to be related have been very instruc- tive to me, and I present them under the caption of lupoid ulceration, although there may be some question, per- haps, as to their real pathological nature. Case i.-A. M., male, set. 40, married 15 years, and father of two children ; speculator ; good family history ; temperate, rarely drinks spiritous or malt liquors, and smokes only occasionally during a week ; in good flesh, but not fat; general health good, excepting headaches, migraine, probably brought on by business worry or malaria, or both. Says he may have had syphilis about 20 years ago, although the doctor whom he consulted said that the sore was only a chancroid, and he very soon recovered, never having had any sore throat or cutaneous eruption. One of his children, a boy 12 years old, although having been delicate, so-called, shows no signs of the syphilitic taint; he rather bears the physical stamp of his mother, who is a woman possessed of what is called the scrofulous diathesis. The other child of the patient, now 20 months old, was "sickly" during the first 8 months of its existence, but thereafter seemed tolerably well nourished, notwithstanding it was bottle-fed, condensed milk being its nutriment. It is, however, rickety to a slight extent, as manifested by the ribs and bones generally. But I have never seen any thing to indicate a syphilitic taint. The patient states upon honor that he has never been affected with any venereal * Read before the American Laryngological Association, session 1882. Reprinted from the Archives of Laryngology, Vol. iii, No. 4, Oct., 1882. 2 E. L. Shurly. disease but the once mentioned, and as he is a plain, outspoken, sensible man-and not a church-member-I believe he would not disguise the truth from me. When he came to me in the autumn of 1879, he complained of some dull frontal headache, stuffiness of the nose, as he expressed it, and the discharge of more or less crusty, non-fetid matter, mostly from the anterior nares. This had been troubling him about three months then, and, he observed, was growing pro- gressively worse. His general health at this time was very good. Upon examination, after washing out the collection of inspissated secretion, I discovered a perforation of the cartilaginous nasal septum, about the size of a silver five-cent piece, which was slight- ly ovoid, and with its upper margin close under the roof of the cartilaginous portion of the nose. The edges of the orifice, which were bevelled, were plastered here and there with masses of red- dish or brownish crusts, which seemed very dry, and a little fetid. The mucous membrane for about a ^th of an inch circumfer- entially around the orifice was thickened, and gave the sensation of hardness to the touch, while the upper margin of the opening was by far the most sensitive. The disease progressed some dur- ing the next six months, so that the opening became irregularly elliptoid, and about as large as a twenty-cent piece, while the nose about this time had perceptibly fallen in. It seemed, how- ever, to get no worse than this, since I found upon examination about a month ago, that the size of the perforation accorded with my last note of April, 1881. The treatment consisted mainly in sprays or douches of sod. bibor. et ac. carbolic., pot. chlor., potass, permang., sp. of aq. picis et sod. bicarb., and other detergents ; and in the persistent use of iodoform, either by insufflation or incorporated with vase- line, glycerine, petrolina oil, etc. Caustics were used but a few times, and mostly on the upper margin ; and internally, the ad- ministration of potassium iodide. Case 2-J. E. H., set. 16 years, German, works in a stable as hostler ; family history good, so far as we could find out; his father died of some acute lung trouble, and his mother, whom I saw several times, seemed to be healthy. I saw, once, at the hospital clinic, a younger sister of his, who appeared pale and cachectic, but said that she was well. Mother stated that this boy had always, pre- vious to his illness, been strong and healthy. Looks well now. Patient presented himself at the out-door department of St. Lupoid Ulceration of the Nasal Septum. 3 Mary's Hospital, Jan. 20, 1881, suffering from a sore throat, and, especially, from obstruction of the nasal passages ; he had been in this condition, he said, about three weeks. Examination of throat and nose showed great swelling of the mucous membrane lining the nasal passages on both sides, so that no good view could be obtained anteriorly. Rhinoscopic examination showed swelling, with great hypersemia of the membrane lining the naso- pharynx, and quite a collection of muco-pus, as well as a few crusts. At the median line on the posterior surface of the soft palate, there was quite a depression, covered by a firm white patch. This proved to be an ulcer. There was no ulceration to be found anywhere else. The pharynx was simply hypersemic. He was treated with a spray of borax and ac. carb., followed by insufflations through the posterior nares of iodoform, and was given, to take internally, -j^th gr- biniod. of mercury with 5 gr. of iod. of potass, in solution. He attended the dispensary quite regu- larly until March, and improved in every way during such attend- ance. Pot. iod. was substituted for the mercurial. In March he came twice, the last time complaining mostly of pain in swallowing. His nose still remained obstructed, and the septum on the right side showed a small ulcerated spot, just opposite the anterior end of the lower turbinated bone. About the same line of treatment was resumed, except, in addition, the use of a little strong tr. of thymol to ulcerated spots. April 4th, it is noted that the soft palate is perforated in the median line, and not far from its junction with the hard palate. It is noted also that the nose is obstructed and shows a small per- foration of the cartilaginous septum in the place noted formerly as ulcerated. He had never had sexual intercourse, according to his statement, under the most rigorous cross-examination, so that I was led to believe he had contracted syphilis from some one of his barn companions-he worked in a private barn, not a livery- stable. Accordingly, I examined the two men associated with him, and could find no trace of syphilis about them, nor any excoriated places or scars which would lead to a suspicion of it. They also told me that they had not had any such disease for several years. There was also no evidence of hereditary syphilis. Notwithstanding all this, I still believed it was syphilis, and con- cluded that he must have become inoculated at the dispensary on some former occasion. He continued under observation until July ; his throat finally 4 E. L. Shurly. becoming well, excepting the perforation of the soft palate-about the size of a three-cent piece,-which still remains. But the mucous membrane of the septum continued growing thicker, while at the same time the perforation of the septum slowly and gradually enlarged ; the process producing an abun- dance of reddish or yellowish crusts. The latter part of March of this year (1882), he again returned to the hospital for treatment, complaining only of his nose. An examination revealed the fact that nearly the whole of the carti- laginous and possibly a little of the anterior border of the bony nasal septum were gone. The anterior naris of the right side was nearly obstructed by the leaning forward of the anterior remnant of the septum adjacent to the nasal column. The treatment has been both local and general: the former consisting of applications of douches and sprays for cleansing purposes, followed by iodoform and strong tr. of thymol to the edges ; while the general treat- ment has been, as in the former case, principally by the adminis- tration of potassium iodide. The boy is really getting better, as there seems to have been no further erosion for some time now. Case 3.-Mrs. E. B., set. 42, married, mother of three quite healthy children, according to report. About thirteen years ago, after attending her brother-in-law, as nurse, through a very se- vere course of typhoid fever-she suckling a babe at the time,- she noticed a papular eruption on the lower lip, which at the time was regarded as a " cold sore." This finally became a small ab- scess, leaving a white scar after suppuration, but was immediately followed by a tubercular sort of swelling of the skin over the left temple-in fact, two or three in different places on the scalp, all of which, however, disappeared without suppuration or any spe- cial treatment. Her husband, about this time suffered also with two abscesses on the back of his neck, which were called carbun- cles. About seven years ago the patient noticed a swelling (hard and painful) on the back of her neck, which soon ulcerated. This could be healed by the application of certain ointments, but would soon recur, always involving new tissue after the ointment was discontinued. This ulceration on the back of the neck contin- ued, and last autumn was about the size of a silver dollar. She came from Elmira, N. Y., to consult me about what she supposed was a chronic nasal catarrh. She stated in the course of the ex- amination that she had consulted two eminent dermatologists in Lupoid Ulceration of the Nasal Septum. 5 New York City, one of whom pronounced the skin affection lu- pus, and the other one called it syphilis. The nasal affection had developed within the two years preceding, so far as she knew ; examination showed a perforation of the cartilaginous nasal sep- tum about the size of a silver quarter of a dollar, its edges bev- elled, the circumjacent mucous membrane thickened, and the se- cretion crusty, rather scanty, but not fetid. Diagnosing the case as lupus, I consulted Dr. Carrier, of Detroit, a very skilful der- matologist, who concurred not only in the diagnosis, but in the proposed treatment. He kindly took charge of the case, while I saw her from time to time, and she has since returned home ap- parently cured-that is, the ulceration of skin as well as of septum stopped. The treatment consisted in the internal administration of potass, iod., the dose being gradually increased to 20 grains, 3 times daily ; and, so far as the septum was concerned, the per- sistent use locally of iodoform, alone, and in combination with thymol and vaseline. I omitted to state that she had had about four years ago an ulceration of the soft palate, which destroyed a small amount of tissue. Dr. Carrier's notes as well as mine state "that she was questioned very closely for a specific history, and positively avowed that she had never had any sore on or about the genitals, no falling out of the hair, no eruption of the skin-except as given above,-and no osteal pains or disturbance." He also states that mercurial treatment aggravated her disease each time it was adopted. This case was proximately one of lupus without a doubt, but whether or not we have been deceived as to any syphi- litic element in its etiology, the Lord and the patient, per- haps, only know. Case 4.-June 2, 1882. Mrs. F. McR., set. 56 years, widow three years ; family history excellent ; general health good ; never had any cutaneous eruption which " amounted to any thing," she says. About three years ago began having a sensation of stuffi- ness in the nose, attended with watery discharge ; and four years ago, for the first time, noticed a small opening in the cartilaginous nasal septum, about the size of a common pin head ; up to this time she had had frequent light attacks of epistaxis. Three years ago, during the winter season, she had more or less sore throat, and became hoarse. This condition has regularly 6 E. L. Shurly. supervened every winter since, having been more persistent, with more complete aphonia, during the last winter. Examination shows the nasal septum, excepting anterior nasal column, entirely gone, together with most of the lower part of the bony (vomer, etc.), thus throwing the naso-pharynx and nasal pas- sages into one large cavity, for there remains only a vestige of the upper turbinated bones. This cavity is dry, and contains considerable inspissated secre- tion adhering to the several irregularities here and there, but the odor from these is not offensive. Laryngoscopic examination shows the posterior wall of pharynx dry and plastered with dry secretion; upper larynx not hyperaamic, but mucous membrane thickened and granular. Vocal cords thick, round, and dark pinkish color, but their surfaces are smooth. Ordered a douche of potass, chlor, and sod. bicarb, twice daily, followed by insufflation of iodoform and pulv. g. acaciae, equal parts. I have tried in the narration of the foregoing cases as briefly as possible to bring out the clinical diagnostic points, and the apparent benefit derived from the plan of treatment adopted. Only Case 3 might be regarded as really lupus by some, while the other cases might be looked upon as simply ozaena or latent syphilis by other practitioners. It is unnecessary for me, before a body like this, to con- sume time by quotations or abstracts from the current liter- ature of the age, in order to substantiate the statement that the pathogenesis and pathology of scrofulosis, tuberculosis, and syphilis, together with the more local expressions of disease called lupus and ozaena, have not as yet explicitly shown the relationship between these several morbid states. Like many families of cryptogamous plants, whose devel- opment is marked by such periods of specific phenomena as to almost differentiate them into independent species or vari- eties, these morbid conditions give rise, in their sometimes devious and subtle modes of ultimate development, to the most puzzling groups of local expressions. This, I believe, is especially true of scrofula, so despised and slighted by many of us. I am sincere in the belief, that weare far from being done with the so-called scrofula, and that we must yet Lupoid Ulceration of the Nasal Septum. 7 of necessity acquire more knowledge of its pathological his- tology before denying it a place in the category of diseases. I am firmly convinced that ozaena and lupus, from our present knowledge, ought to be classed together as typical scrofulous disease; and I also believe, with many patholo- gists, that there is a certain natural relationship between tubercle, syphilis, and scrofula, the details of which are really to be worked out yet. Regarding lupus, the literature on the subject is far from extensive, but what exists goes to show, as far as I can learn, that its diagnosis from syphilis, or tubercle, or scrofula, both clinically and microscopically, is not always certain; while empirically considered, it seems to yield, in all of its forms, to those therapeutic meas- ures so long and successfully in use against scrofulous dis- ease,-the antiscrofulitics. I say, empirically, because, so far as I know, the therapy of scrofulous disease, or scrofula, does not rest upon a sci- entific basis. The predilection of lupus for attacking the skin primarily, is, of course, well known, and has constituted quite a point in differential diagnosis. But, of late, so many instances have been published, where the disease has at- tacked mucous membrane primarily, that I think in a given case of disease of a mucous membrane, the absence of any previous or concurrent invasion of cutaneous tissue ought not alone to negative the diagnosis of lupus. ARCHIVES OF LARYNGOLOGY EDITED BY LOUIS ELSBERG, M.D., NEW YORK, J. SOLIS COHEN, M.D., FREDERICK J. KNIGHT, M.D., | PHILADELPHIA, BOSTON, GEORGE M. LEFFERTS, M.D., • NEW YORK, X IN CONJUNCTION WITH Dr. J. Boeckel, Strasburg: Prof. Burow, Konigsberg: Prof. Gerhardt, Wtirzburg; Dr. Heinze, Leipzig; Dr. Koch, Luxembourg; Prof. Krishaber, Paris; Prof. Labus, Milan ; Dr. Massei, Naples; Dr. Morell Mackenzie, London ; Prof. Oertel, Munich ; Dr. Felix Semon, London ; Dr. Smyly, Dublin ; Prof. Voltolini, Breslau ; and Prof. Zawerthal, Rome. It is believed that the time has come for the publication of a journal devoted to the specialty of Laryngology. So much has been achieved in this department of medicine during the last twenty years, that in the regard of both the profes- sion and the lay public it has acquired recognition and a certain amount of inde- pendence. In the further advance in every right direction the Archives is in- tended to give important aid. None of the existing medical journals can occupy its place; it competes with none, and supplements all. It is to be a bond of union between the specialists themselves, and also between them and the general profession. Such a means of communication and interchange of ideas, constitut- ing at the same time a depository of contributions of permanent merit and a mirror of the progress of the specialty as reflected in a comprehensive digest of periodical and other literature in every part of the world, cannot fail to be of value from a scientific as well as a practical point of view. The scope of the Archives embraces Human and Comparative Morphology and Physiology of the Throat, and Pathology and Therapeutics of Throat Diseases, in the widest signification of these terms. All contributions are original. The contents are arranged in'three departments, which are : I. New Contributions to Literature, viz., a. Leading Articles, comprising Monographs and accounts of cases with re- marks. b. Clinical Notes, being a briefer record of interesting cases. c. Society Transactions, i. e., reports of the proceedings of Laryngological Societies, or of matters relating to Laryngology occurring in other societies and not previously published. II. Report of Contemporary Literature, viz., a. Reviews and Notices of Books and Pamphlets. b. Digest of the Literature of every part of the world. III. Miscellany, viz.. News Items, Editorial Announcements, and Answers to Correspondents,-the latter being planned particularly for communication between specialists and gen- eral practitioners. The Archives of Laryngology is handsomely printed in large octavo form, each number containing 96 pages, and the articles are fully illustrated whenever their subjects render this desirable. It is issued quarterly at the price per number of $1.00, and the subscription per year of $3 00 G. P. PUTNAM'S SONS, 27 & 29 W. 23d St., New York. London : N. TRUEBNER & CO., 59 Ludgate Hill. Paris : J. B. BAILLIERE, 19 Hautefeuille. G. P. 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