F F: T11) C 0 R Y Z A. BY LECTURER ON LARYNGOSCOPY AND DISEASES OF THE THROAT AND CHEST IN JEFFERSON MEDICAL COLLEGE. J. SOLIS COHEN, M.D., (REPRINTED FROM THE PHILADELPHIA MEDICAL TIMES.) PHILADELPHIA: J. B. L I F PI N C O T T & C O. 1874. FETID CORYZA. r~PHE term fetid coryza appears to me better adapted than ozcena to designate the condition under consideration, though merely indicating a combination of characteristic symptoms—discharge and odor—attending disease involving the nasal passages, without defining its nature. Fetid coryza is produced by various affections. It may be due to ulceration of the mucous membrane of the nasal passages or of the sinuses communicating with them, whether erythematous, catarrhal, gland- ulous, scrofulous, syphilitic, lupoid, or cancerous. It may be due to destructive disease of the bones or car- tilages of the nasal organs, or of their periosteum or perichondrium; whether the disease be idiopathic, traumatic, or specific. It may be due to the develop- ment of adventitious growths in the nasal structures themselves, or in others contiguous to them. It may be due to the deposition of calcareous matters from the secretions, and their aggregation into rhinoliths or nasal calculi. It may be due to the retention of some external foreign body, introduced by design or accident, and to the inflammatory processes resulting therefrom. It may be due to some unfortunate individual or family idiosyncrasy without any ulceration whatever, and even with 2 little inflammation or none at all. It may be due simply to retention of nasal excreta and their de- composition in situ. We have, therefore, to interrogate the part and the system in order to make a satisfactory diagnosis as to the cause of the discharge in any given case, and to form a judgment as to the proper method of treatment. In order to examine the parts they must be washed out as thoroughly as possible by the use of the nasal douche, and syringes introduced anteriorly and posteriorly into the nasal passages; the best substance in general being tepid water impregnated with table-salt—a drachm to the pint. If this fails to detach the secretions, the phosphates of am- monia and soda or the carbonates of soda and potassa may prove more efficient in like proportion. Sometimes the forceps or the sponge-mop may be used to detach matters within their reach. In order to make a thorough examination of the parts, it is necessary that they be thoroughly cleansed. After the parts have been cleansed they can be examined before a strong light,—anteriorly by drawing the alae aside so as to dilate the passage, or by intro- ducing a speculum; and posteriorly with fhe rhino- scope. In this way we observe the appearance and condition of the mucous membrane, detect swell- ing, ulceration, retained secretions, foreign bodies, &nd morbid growths, exposed cartilage or bone, etc. The tortuous contour of the turbinated bones and nasal meatuses renders it impossible to examine these structures in their entire extent; but still, under a good light, they can be explored pretty thoroughly, especially with the aid of probes bent so as to admit of application to the surfaces of the various parts, on the same principle employed by the dentist in exploring the tortuous recesses in a 3 carious tooth. Rhinoscopic inspection enables us to examine, in addition, the condition of the glandu- lar tissue at the roof of the pharynx, a structure very frequently implicated in diseases giving rise to the discharge under consideration. In some cases of fetid catarrh, the bones and cartilages of the nose, as far as their condition can be examined, appear healthy; and no ulceration of the mucous membrane can be detected on inspec- tion anteriorly or posteriorly. There seems to be some constitutional idiosyncrasy in these cases, in consequence of which, retained portions of the nasal secretions undergo desiccation, and remain impacted in some portion of the sinuosities of the nasal passages; there undergoing decomposition. This condition of system has been compared to that which is attended by the peculiar, offensive smell of the cutaneous perspiration from the feet and armpits of certain individuals who cannot rid them- selves of their unpleasant odor even by the most scrupulous ablution. In these idiosyncratic cases the discharge is by no means profuse, unless in exceptional instances. Sometimes, indeed, it is quite scanty; but it manifests a disposition to become desiccated into thin scales or crusts, remov- able only with more or less difficulty : sometimes by way of the nostrils anteriorly, and sometimes by a sort of inspiratory nasal screatus, which, after repeated efforts, forces them through the posterior nasal outlets into the pharynx, whence they are ex- pectorated. These crusts usually emit a horrible stench, perceptible at a distance of several feet, and capable of impregnating a large room with their fetor. All that can be effectually accomplished in the way of treatment in these cases, seems to be the pro- motion and maintenance of an active condition of 4 the secretory functions of the skin and kidneys by frequent bathing and copious water-drinking,— keeping up a sort of sewerage, as it were,—and the thorough and efficient cleansing of the parts several times a day, especially at night and morning; mak- ing this act a constituent and essential part of the daily toilet, as much so as the use of the tooth- brush or the wash-basin. For this purpose the nasal douche of Thudichum, or some modification of it, is the best contrivance in most instances; but if the crusts are hard to remove, the use of the pharyn- geal nasal syringe and of the continuous rubber hand-bellows syringe will afford better results ; the latter especially in those cases in which crusts moulded to the contour of the posterior nasal out- let are apt to accumulate, and to dislodge which, readily, a stream of fluid entering with some force from the front is requisite. The ordinary solu- tion of table-salt—a drachm or two to the pint of tepid water—fulfils the requirements of the douche for cleansing-purposes; and detachment of the crusts is facilitated by the substitution or addition, as may prove most appropriate, of equal quantities of alkalines, such as the carbonate or bicarbonate of soda, phosphate of soda, and the like. At least a quart of the cleansing solution should course through the nasal tract at each night and morning ablution ; part of it started through one nostril, and the remainder through the other. After the parts have been cleansed, the douche should again be used, containing a disinfectant in tepid solution. Permanganate of potassa, chlorinated soda, car- bolic acid, and so on, employed in this manner, will, in great measure, control the fetid odor of the secretions. Various local applications are made at times for the purpose of altering the nutrition of the mucous 5 membrane, in the secretion of the glands of which, the diseased action is supposed to reside. For this pur- pose various preparations of mercury and of iodine, the terebinthinates, muriate of ammonia, etc., have been employed in the forms of ointment, powder, solution, and vapor; but, at least in the hands of the writer, they have proved of only questionable benefit. Local cleansing, with disinfectant detergent douches immediately afterwards, and the mainten- ance of the cutaneous and urinary secretions by appropriate remedies, have rendered good service; but, to be efficient, resort to these measures must be constant. Fortunately, in this variety of fetid coryza, the affection, whatever its real nature, moderates in severity as the patient becomes older, so that by middle adult life it has subsided entirely, or in great measure. It is a long while to await perma- nent relief, to be sure, but it is better than no pros- pect of cure. Another form of fetid coryza, attended with cer- tain local manifestations to be described farther on, is engrafted upon the strumous diathesis ; and this variety, from its persistence, and from its ultimate destructive results,—which, when very extensive and insufficiently attended to, resemble so much the effects of analogous conditions in constitutional syphilis,—seems to contribute some force to the doctrine that scrofula is but an inheritance of syphi- lis; modified, it is true, but bearing a relation to that virus similar to that which some authors trace between varicella and variola. These cases usually originate in an acute coryza or catarrh, the result of exposure to cold. This catarrh gradually becomes chronic, the attendant discharge more or less profuse, varying in color 6 and consistence, being at one time muco-puru- lent, at another purulent, sometimes sanguinolent, and so on. The odor of the discharge is exceedingly offensive, and there is a permanently unpleasant odor of the patient’s breath, rendering propinquity to the individual very disagreeable. In these cases crusts of inspissated mucus accu- mulate at the outlets of the posterior nares from detention there of the secretions, and they often become moulded to the form of the opening, pre- senting, when discharged, a peculiar honeycomb- like configuration. These moulds are usually several days concreting, and become discharged perhaps once or twice a week, sometimes oftener, sometimes less frequently. When discharged at long intervals, small, dense clumps of irregular conformation, and of similar constituents, will be occasionally drawn into the throat by forced nasal inspiration, and be then expectorated. These will possess the charac- teristic odor. Sometimes small caseous-like concre- tions will be hawked down, apparently from the glandular tissue at the nasal portion of the roof of the pharynx, similar in appearance to the analo- gous matters sometimes discharged from the tonsils, and, like them, of an intolerable stench when crushed. In some instances, desiccated crusts can be seen upon the glandular masses at the roof of the pharynx, on pharyngo-rhinoscopic inspection. When examined immediately after spontaneous or artificial removal of the crusts, this glandular tissue is seen to be spongy, and, if the removal has been forcible, is most likely to bear decided evidence of hemorrhage. Pain will be complained of in the parts and will be referred especially to the region of the frontal sinuses. This form of disease of the nasal passages is met with in all classes of society : in the robust indi- 7 vidual no less than in the delicate one; in those who have been tenderly reared, and in those who have been brought up in the roughest manner. It may make its appearance at any age, but seems to be most frequently noticed for the first time about the period of the second dentition. Most of the patients I have seen have been girls from six or eight years of age upwards to confirmed puberty or early adult life. If, after thorough cleansing with the douche, syringe, or forceps, the parts are carefully exam- ined,—anteriorly by the aid of hook, probe, dilator, or speculum, and posteriorly by the rhinoscopic mir- ror,—some points of ulceration, superficial or deep- seated, will usually be detected upon the mucous membrane. These ulcerated spots may occupy the free surface of the turbinated bones, or the lower region of the septum ; and even when ulceration can- not be discovered in these situations it is often fair to infer that it is likely to exist upon some portions of the turbinated bones altogether out of the field of direct or indirect vision. The nasal mucous mem- brane will be swollen, often to such a degree as to occlude the passage at one or more points ; in some instances the result of sero-fibrinous or fibrinous infiltration into the submucous connective tissue; in others, the result, in addition, of actual hyper- trophy of this tissue. In some cases little bags of thickened tissue or exuberant folds project from the walls and are sometimes mistaken for neoplasms. The parts are usually very much congested, though they do not bleed as a rule, except upon rough manipulation; and they are very sensitive to con- tact with the probe in some instances, and not at all so in others. The mucous membrane of the posterior portion of the septum is often seen by the rhinoscope, pushed off from its sides by submucous 8 infiltration, bulging into the free space of the nasal outlets so as to present much the appearance of turbid morbid growths. As a matter of course, in this condition, the patient will experience more or less difficulty of nasal respiration; one nostril or the other, in many instances, being impervious to air, nearly all the time. This induces a habit of keeping the teeth slightly apart to facilitate breathing, and favors the formation of chronic pharyngitis ; a condition which is often coincident to all the affections under consideration. If the disease has existed for a number of years —and it is essentially chronic—the ulcerations will have extended beyond the limits of the tissue proper of the mucous membrane, and will have involved the cartilages and the bones, portions of which will sometimes have been destroyed, afid have been discharged spontaneously; so that the cartilaginous septum is in many instances found to have been pierced through, sometimes in one or two small perforations, but ipore frequently in a single large, irregular hole, perhaps admitting the end of the little finger, or the end of, a larger one, and look- ing as if it had been gouged out with some rude tool. In some instances, one or more of the tur- binated bones, usually the middle one, will be necrosed and bare in its entire extent, or the greater portion of it, awaiting its extraction,—an operation readily accomplished with polyp-forceps. Some- times it has been removed spontaneously, or has been pulled out by the patient, leaving a large, free space in the nostril, through which the posterior wall of the pharynx can be seen, or a portion of the upper surface of the velum. In some instances the de- structive inflammation will have progressed to a farther extent, and have involved portions of the 9 superior maxillary bone, from which copious accumulations of fetid pus and necrotic particles will have been discharged at intervals. Cases of this kipd will have produced some alteration in the external configuration of the parts, the nose being sunk in or flattened out, and the nostrils dis- tended. In some instances the orifices of one or more sinuses will be recognized, the tracks of which cannot be readily traced, perhaps because they course around the scroll of the turbinated bone. From these openings, on pressure behind them with a probe, a few drops of creamy pus can often be discharged. Some other evidence of the strumous diathesis is usually apparent. In cases of undoubted syphilitic origin,—and the distinction between scrofulous and syphilitic coryza is not always well marked,—the involvement of bony structures will progress to a much greater ex- tent than has already been described, the earlier manifestations having been similar to those of catarrhal and scrofulous inflammation, but more active. The turbinated bones, the vomer, the nasal bones, the palate bones, the lachrymal bones, the sphenoid, and the ethmoid, will often undergo more or less destruction. In some instances pharyn- geal rhinoscopy and the use of the probe will early reveal necrosis of the vomer, the sphenoid, and the basilar process of the occipital bone. The dis- charge in these cases is not, as a rule, so offensive in odor as in the scrofulous cases; but it is equally persistent, and will continue as long as any dead bone remains undischarged. The tortuous contour of the nasal passages and the sinuses leading to them is such as to render it impossible in many in- stances to remove all of this dead bone by surgical interference through the nostrils anteriorly or pos- 10 teriorly ; so that its discharge must be awaited bit by bit. The amount of destruction that the parts may undergo under such circumstances is enormous. In some instances the cranial vault has been pierced, and the resulting meningitis has put an end to the complaint and to the patient. The amount of the discharge, its consistence, and the intensity of its disagreeable odor, will vary during the course of a fetid coryza, whatever may have been its origin. An inflammation of the parts such as follows a cold, a determination of blood to the head, over-work, the approach of the men- strual flux, all seem to increase the offensiveness of the discharge. This will become moderated after cleansing with the douche, and the application of remedies; but will wax just as bad as ever in a few hours, or a few days. When there is an involve- ment of bone, or a fresh involvement of bone, the fetor will be increased until the necrosed portion has become exfoliated and discharged. The patient is usually cognizant of his extremely unpleasant condition to a certain extent, but is un- aware of the full amount of stench emitted from his body, because the sense of smell is obtunded, and in some instances entirely destroyed. With the loss of smell there is, in consequence, more or less loss of the sense of taste ; so much of it as is dependent on the sense of smell. In those cases in which the frontal and maxillary sinuses are affected to a greater extent than the nasal passages, the patient is better able to appreciate his infirmity, for the sense of smell is still conserved to a considerable degree. The offensiveness of the odor in extreme cases is beyond description, and must be felt to be com- prehended. It will impregnate a room for hours, and deter the practitioner from persisting in proper efforts to relieve the local condition. 11 TREATMENT. The treatment of a case of fetid coryza will depend upon its nature. When due to the pre- sence of a foreign body, a rhinolith, or a morbid growth, the removal of the exciting cause will cure the discharge. In cases with constitutional taint, systemic treatment is required. The treat- ment of this condition, in fact, is simpler in prin- ciple than in practice ; but it is always tedious, and often unsatisfactory. Palliation of the severer symptoms and diminution of the fetor can almost always be effected, but a thorough cure often re- quires months of persistent treatment; in some in- stances seeming almost unattainable, and in others, quite so. When the larger bones are diseased, and it is impossible to get access to them, the condition will continue for years ; dead bone being exfoliated splinter by splinter, and fresh involvements becom- ing new sources of evil as older ones are undergoing amelioration. In scrofulous cases we can endeavor to improve the tone of the constitution by resort to systemic remedies, such as cod-liver oil, quinine, and iron, the preparations of iodine, arsenic, and so on ; and we may thus repress increase in the malady, even if we fail in restraining it. The administration of cubebs, preferably, in my own practice, in doses of fifteen to twenty drops, or more, of the oleoresin on sugar, after meals, will sometimes diminish the copiousness of the secretions to a certain extent, and modify their character by the local influence of the drug in its elimination through the mucous membrane of the nasal tract. The decidedly syphilitic cases, when not so far advanced as to be irremediable, are much more manageable under systemic medication than are 12 the idiopathic and scrofulous cases. Here small doses of the bichloride of mercury, with the free use of the iodide of potassium, are just as service- able as in other forms of constitutional syphilis, especially if the general vigor of the patient has not been greatly impaired. If the general health is poor, a generous allowance of nutritious diet, as- sisted by a tonic course of treatment, will be neces- sary before beneficial results can be expected from specific remedies. All forms of fetid coryza require local treatment. The parts should be frequently cleansed, and topical remedies assiduously applied. Without preliminary cleansing, local remedies are of little avail: they become entangled with the secretions to a certain extent, and cannot exert that good effect upon the parts which they exercise when applied upon a clean surface. As mentioned in connection with cleansing the parts preparatory to examination, we use for this purpose the nasal syringe, applied anteriorly and posteriorly, and the continuous nasal douche; em- ploying the medicinal articles already enumerated. These ablutions are b*y no means to be neglected, but should be attended to as punctually and as scru- pulously as the patient attends to other wants of nature. The local applications for remedial purposes con- sist of solutions, powders, vapors, and unguents, brought in contact with the parts by suitable appli- ances. When ulcerated surfaces can be reached by instruments introduced within the nostrils or behind the palate, they should be regularly touched by the sponge, cotton wad, or hair pencil, loaded with a solution of nitrate of silver, sulphate of copper or of zinc, carbolic acid, chromic, nitric, or muri- atic acid, or the acid nitrate of mercury, as the case 13 may seem to demand. Dead bone, where accessible, should be removed by the forceps, assisted, if need be, by the knife or scissors. Too much force should not be exerted in the endeavor to remove dead bone. Jt is better practice often to use frequent traction from side to side with forceps, in a sort of dislodging motion, so as to loosen the pieces of dead bone, and thus gradually render them suffi- ciently movable to be extracted without much physical effort. If the bone is too large for re- moval through the nostril in mass, it maybe crushed between the blades of strong forceps, or divided by cutting-pliers, and be extracted piecemeal. In many instances the dead bone may be removed through the mouth by means of curved forceps passed up behind the palate. The contact of the opposing surfaces of mucous membrane can often be overcome by the daily in- terposition, for an hour or more at a time, of strips of compressed sponge, or of tubes of laminaria; mechanical appliances which compress the parts as they imbibe moisture from the secretions, thereby favoring absorption of the products of submucous infiltration. Where hypertrophied or exuberant mucous membrane exists, and where internal com- pression is insufficient to enlarge the passage for the free ingress and egress of air and the free discharge of the secretions, it is good practice to twist off portions of the membrane with delicate forceps, so that cicatrization of the irregular edges of the wound may enlarge the passage. The free bleeding accompanying this procedure exerts a salutary in- fluence upon the parts ; and though the operation is very painful, it is so efficient in its relief that the patient will readily submit to it again and again, for the sake of the ease it affords in respiration afterwards. 14 The solutions used by douche or injection may con- tain chlorate of potassa, alum, creasote, or carbolic acid, permanganate of potassa, chloride of lime, or similar substances, which, in addition to their local action on the parts, tend to control fetor. Or we may use special injections or sprays of nitrate of silver, sulphate of zinc and of copper, the sulpho- carbolates of zinc or lime, bichloride or iodide of mercury, chloride of zinc, chloride of lime, and the like. These injections should be employed at least twice a day, night and morning, and, where practi- cable, three and even four times a day; and they should always be preceded by the use of the douche for cleansing-purposes. They should be used in weak dilution at first,—say two or three grains to the ounce,—and be gradually increased in strength as tolerance of them is manifested; care being taken that none of the solution is swallowed by the patient, on the one hand, and that too free use of remedies which act promptly on the system be not made, on the other ; for the nasal mucous mem- brane readily absorbs certain remedies, and the proximity of the olfactory filaments to the nervous centre favors the systemic effect of others. This latter fact is often utilized to subdue the pain in the frontal region, by the local application of an ointment containing three or four grains of morphia, or one or two of the extract of stramonium, to the ounce; not more than the volume of a pea being used at a time. A solution of the chloride of lime was used in this city, with great success, by Prof. Horner, who injected each nostril twice a day with a solution containing a teaspoonful of the chloride of lime in a wineglassful of water. This practice is not much in use to-day, but it deserves to be. A somewhat similar formula, from which I have sometimes ob- 15 tained very satisfactory results, contains from thirty to sixty grains of the chloride of lime to the ounce of the decoction of krameria; of which two or three drachms, or more, diluted with an equal quan- tity of water, are injected into the nostrils night and morning, immediately after the use of the douche. Sometimes the parts will not bear a solu- tion of this strength, and it must be diluted accord- ingly. When the remedy excoriates the external tissues, as it will do sometimes, its use must be sus- pended or its strength reduced, as may seem most judicious. Perhaps a preliminary coating with col- lodion will prevent this excoriation, but I have never tried it. Glycerin is sometimes of great service as an injec- tion, particularly in scrofulous cases. Being bland and unirritating, its affinity for moisture of all kinds facilitates the separation and removal of the secre- tions, inspissated crusts, and detached fragments of dead bone. The addition of iodine, in the propor- tion of a grain or two to the ounce of glycerin, is sometimes advantageous. Prof. Trousseau relied greatly upon certain medi- cated powders to be snuffed up by the patient twice or thrice a day, after having cleansed the nostrils as thoroughly as possible. His principal formulae were calomel, a drachm to the ounce of sugar, and red precipitate, forty grains to the ounce of sugar; their use being regulated in accordance with the irritation produced. Another favorite powder, wTith which he was very successful, was composed of bis- muth rubbed up with equal parts of Venetian talc, and this, on account of its innocuousness, was used as freely as was desired. Camphor, tannin, cubebs, and other substances, separately or in combination, have been used in a similar manner; some practitioners mixing them 16 with two or three times their bulk of Scotch or Welsh snuff. Various mechanical appliances are in use for the purpose of injecting the powders upon the parts. Citrine and other ointments, more or less diluted, are sometimes used locally after thorough cleansing; being applied to the parts by the little finger, a hair pencil, or a cotton wad on the end of a wire. The principal remedies used in the form of vapor are preparations of mercury, evaporated over a spirit-lamp, the fumes from which are drawn by in- spiratory effort through the nostrils. The fumes of muriate of ammonia from the heated salt itself, or in a nascent state from commingling of the vapors of muriatic acid and strong aqua ammonige,are also used a great deal in the scrofulous cases, both for local and constitutional effects. With all these resources at command, we are able to improve the condition of patients affected with fetid coryza, and place them under the most favor- able conditions for the cure of whatever affection has given origin to this loathsome catarrh.