Reprinted from the Transactions of the Medical and Chirurgical Faculty of Maryland, 1883. 
SOME REMARKS ON NASO-AURAL CATARRH 
AND ITS RATIONAL TREATMENT. 
/BY 
JOHN N. MACKENZIE, M. D., 
LATE HOUSE PHYSICIAN IN BELLEVUE HOSPITAL, N. Y., AND CHIEF OF CLINIC AT 
THE LONDON HOSPITAL FOR DISEASES OF THE THROAT AND CHEST, SURGEON 
TO THE BALTIMORE EYE, EAR AND THROAT CHARITY HOSPITAL. Reprinted from The Transactions op the Medical and Chirurgical Faculty 
op the State of Maryland, 1883. 
SOME REMARKS ON NASO-AURAL CATARRH AND ITS 
RATIONAL TREATMENT. 
By John N. Mackenzie, M. D., of Baltimore, 
Late House Physician In Bellevue Hospital, N. Y., and Chief of Clinic at the London Hospital 
for Diseases of the Throat and Chest, Surgeon to the Baltimore Eye, Ear and 
Throat Charity Hospital. 
Mr. President and Gentlemen of the Faculty: 
As the media of communication between the external air and the 
organs of respiration, olfaction and audition, and the natural guar- 
dians therefore of their integrity, the nasal passages are constantly 
exposed to the ever-changing conditions of the atmosphere and to the 
injuries incident to occupation. In the discharge of function, their 
mucous membrane must bear the brunt of every barometric fluctua- 
tion—must be affected by every vitiation of the atmosphere. And 
thus, apart from the operation of other agencies which civilization 
and luxury impose, the inner nasal cavities are peculiarly predisposed 
to the influences that determine catarrhal conditions. Nasopharyn- 
geal inflammation is the most common affection of our climate. If 
there be one disease whose name may be aptly derived from that of 
the city where it most prevails, the term Morbus Baltimoriensis may 
be not inappropriately accepted as the local synonym for nasal 
catarrh. As it is the most common, so is it perhaps the least per- 
fectly understood, and I venture to assert that there are many to-day 
to whom the sources of the discharge in that affection are as vague 
and indeterminate as they were in the days when Galen brought the 
secretion from the pituitary gland or from its reservoirs in the ven- 
tricles of brain. 
It would far exceed the limits of this paper to attempt the discus- 
sion of the many abnormal conditions which, separately or collec- 
tively, make up the starting points of naso-aural inflammation, and 
by their constant presence perpetuate it. These remarks will accord- 
ingly be confined to one or two of the more common causes of the 
phenomena whose ensemble makes up the natural history of nasal 
catarrh, and to the radical methods for their removal. 2 
The cases of catarrhal inflammation of the nose commonly encoun- 
tered in practice may be conveniently thrown into two groups or 
classes, corresponding to the stage of the disease at which the patient 
applies for treatment.* 
The anatomical appearances of the first stage consist essentially in 
localized or diffuse injection, with moderate swelling, of the mucous 
membrane. This involves necessarily an increased irritability of 
that structure, which finds its expression in an abnormal excitability 
of the erectile tissue which is found on the inferior and middle turbi- 
nated bones and on the septum. In some persons, the mucous mem- 
brane is thereby rendered so exquisitely sensitive to the slightest per- 
turbation of the atmosphere that the faintest vibration of the air is 
sufficient to produce erection of this tissue and consequent obstruc- 
tion of the nasal passages. A simple catarrhal or granular state of 
the pharynx is usually associated with the hyperaemia and tume- 
faction of the Schneiderian membrane. Mucus collects in the orifices 
of the Eustachian tubes, in the posterior nares and on the pharyngeal 
vault. The mucous membrane covering the turbinated bones and 
septum is at times greatly swollen; at others presents simply an 
injected appearance, according to the degree of abnormal erectility of 
the tissue which separates it from the periosteum and the bone. Such 
patients wonder why it is that they are constantly catching cold, and 
that the slightest change in the weather produces a stoppage of the 
nose and ringing in the ears. They can not understand the tendency 
to sneeze and the hoarseness which is present on arising in the 
morning, or which follows the use of the voice in speaking or singing. 
A more or less constant itching of the nose is facetiously referred to 
the advent of a mythical stranger, and the mere suggestion of chronic 
nasal catarrh is resolutely, and sometimes indignantly, rejected. 
There arrives, sooner or later, however, a time when these symptoms 
become more pronounced. The patient becomes aware of a gradually 
developing difficulty of breathing through the nose. Sleep is ren- 
dered unquiet by the accumulation of mucus in the throat, and the 
patient arises in the morning with a dry throat and a coated tongue. 
The organic matter of the buccal secretions is deposited on the teeth 
and gums and collects and dries at the corners of the mouth; the 
breath is offensive; headache is complained of. Soon the lips become 
fissured and cracked and their mucous membrane peels off—the general 
health begins to suffer—the appetite becomes capricious—more or less 
* In this paper the atrophic stage, or ozaena, will not be considered. 3 
constant ringing in the ears is the rule, followed by gradually deepen- 
ing deafness. These signs indicate an increase in the hypertrophy 
of the nasal membrane—the second stage has been reached ; the ca- 
tarrh has become hypertrophic. Examine the nose now and you will 
find the inferior meatus obstructed by enlargement of the turbinated 
bodies (generally the inferior), and swelling of the mucous covering 
of the septum. When the hypertrophy is anterior the diagnosis can 
be made by inspection of the anterior nares, and in some cases the 
deeper regions of the nose and even the Eustachian tubes can be seen 
with the aid of a strong light and special inspection apparatus. To the 
practised touch the probe is often an important auxiliary in the de- 
tection of posterior hypertrophies, but all such manipulation is ren- 
dered unnecessary by the ease with which the posterior nares may be 
examined by reflected light. The rhinoscope thus becomes the most 
valuable instrument in the diagnosis of hypertrophic catarrh. It is 
only in exceptional cases that the floor of the nostrils and the whole 
of the inferior edge of the lower turbinated bone can be seen in a 
rhinoscopic examination. Generally only the upper portion of its 
posterior end is visible, the lower half being concealed by the veil of 
the palate, and this anatomical fact furnishes an excellent guide in 
measuring the amount of hypertrophy. When, however, the posterior 
part of the lower turbinated body is hypertrophied, it appears in the 
mirror, rising above the velum to a height varying with the amount 
of enlargement. It often projects backward over the palate into the 
naso-pharynx, and occasionally extends across the septum to the nos- 
tril of the opposite side. The inferior meatus may be alone occluded, 
or the whole naris occupied by the hypertrophic mass. The latter 
is occasionally freely movable and may readily be mistaken for poly- 
pus. It may be uniformly smooth or irregularly lobulated, or it may 
be studded with little protuberances, giving it the appearance of a 
raspberry. It varies in color from a dirty grayish or yellowish-gray 
color to a deep red or even purplish hue. In contour, it is either 
rounded or oval; sometimes its upper border is irregular in outline, 
occasionally presenting a depression at its upper inner aspect. 
The hypertrophy is nearly always bilateral and associated with a 
swollen condition of the tissue covering the middle turbinated bone 
and posterior half of the septum. In two cases I have been able to 
demonstrate its existence even on the superior turbinated bones. 
After the removal of the redundant tissues, small nodular growths 
are occasionally seen in the middle meatus which represent local- 4 
ized hypertrophies or polypoid growths of that region. The hyper- 
trophic turbinated tissues have sometimes a whitish, cedematous, al- 
most hydatid appearance, due to cystic degeneration of the mucous 
membrane. Almost always there is a corresponding hypertrophy of 
the tissue covering the septum, which bulges into the fossae on either 
side and assists in the occlusion of the nostril. In this situation the 
hypertrophied tissue sometimes presents a depression corresponding 
to the convex enlargement of the turbinated bone. Small localized 
hypertrophies of the lateral surfaces of the septum are also observed 
presenting the appearance of papillary growths. Hypertrophy of the 
upper posterior half of the septum is common in long standing cases 
and causes a bulging on either side of the median line, which, with 
the central depression, presents sometimes a heart-shaped appearance. 
The bloodvessels over the septum are often enlarged and tortuous. 
In the majority of cases hypertrophy of the pharyngeal tonsil exists, 
either as a well-defined sessile tumor, or a mass of polypoid vegeta- 
tions. This hypertrophy is at times so excessive as to fill the entire 
naso-pharynx, occluding the nares and Eustachian tubes and pressing 
the velum downward and forward. The lips of the Eustachian tubes 
are generally enlarged, tumefied and reddened, their orifices dilated 
and patulous. This gives the tube the appearance of an enlarged 
cervix uteri in a state of chronic hyperplastic inflammation. Occa- 
sionally a grifnular condition is noticed due to swelling of the mucip- 
erous glands of the tube (tubal tonsil of Gerlach). They are some- 
times occluded from pressure of the enlarged pharyngeal tonsil and 
hypertrophied turbinated bodies. Mucus collects in the orifices of 
the tubes, in the fossae of Kosenmiiller, on the pharyngeal vault and 
in the posterior nares. Usually, a thick, tenacious shred extends 
from the vault of the pharynx to the posterior border of the septum. 
All secretion must be removed before a satisfactory diagnosis can be 
made. 
Adenoid growths appear as sessile or pedunculated vegetations 
of varying size, number and consistence, scattered over the vault, 
posterior and lateral pharyngeal walls, and upper part of the 
septum. They are often massed together so as to form a tumor of 
considerable magnitude. When removed, they present the gross ap- 
pearances of papillomata. Their diagnosis can be made with the mir- 
ror, or, in small children, by means of the finger introduced behind 
the velum. The sensation communicated to the finger is compared 
to that obtained by touching a bunch of worms. They bleed readily 5 
when touched, and, as a rule, discharge profusely. In all cases of 
deafness in children, the naso-pharynx should be examined for these 
growths; if present, their ablation is imperative. If thoroughly re- 
moved, the deafness and nasal discharge rapidly, often immediately, 
disappear; and if the case be not complicated with hypertrophic ca- 
tarrh, no further treatment will be necessary. 
The interruption of function produced by nasal obstruction will 
vary with the extent and character of the occlusion, and the physi- 
ological importance of the occluded portion. Thus obliteration 
of the upper meatuses or malformation of the nasal roof is accom- 
panied by interference with the sense of olfaction and the varied 
train of morbid impressions which follow its perversion. Over a 
century ago, Morgagni* called attention to deflection of the septum 
as a not infrequent cause of unequal distribution of the nervous power 
of smell, andf related a case where, from obliquity of the crista galli 
and consequent diminution in number of the olfactory foramina, this 
sense was supposed to have been less acute in the nostril corres- 
ponding to the narrower side of the cribriform plate. Just here let 
me observe that the ability to respire with freedom through the nose 
by no means negatives the existence of obstruction; the upper nasal 
chambers may be crowded with growths and the pharyngeal vault 
covered with vegetations, and yet respiration go on with perfect ease. 
This is a fact which is systematically and persistently overlooked 
by many practitioners of medicine, and the absence of obstruction is 
too often inferred from the passage of air through the nostrils when 
the mouth is closed. 
Should the obstruction occur in the inferior meatus, the mouth 
becomes the channel through which the air passes to and fro from 
the lungs, and nasal is transformed into buccal respiration. From 
this transference of physiological relations it naturally follows that 
the air reaches the delicate lining membrane of the lower respiratory 
tract in a state unfit for respiration. Hence arise hypersemia and 
chronic inflammation of the pharyngo-bronchial membrane, with 
their associated alterations in the voice. In nasal obstruction of long 
standing chronic inflammatory changes are sometimes induced in the 
bronchial and pulmonary mucous membrane, which are exceedingly 
difficult to deal with even after the original cause is removed, and 
this has doubtless given rise to the popular idea that “ catarrh ” is 
* Adv. anat. 6 in calc, explic. tab. 2 in Decemb. n. 2. 
t De sedibus et causis raorborum. Epist. XIY, cap. 16 in fin. 6 
the forerunner of consumption. Certain it is that nasal obstruction 
predisposes, other things being equal, to inflammatory conditions of 
the respiratory tract, and that the practical physician cannot afford 
to overlook the influence which it exerts in their production. In 
this country, the vast majority of the cases of chronic laryngitis 
originate primarily in disease of the nose, and many a winter cough is 
allowed to go on from bad to worse from failure to recognize this 
relationship. I am furthermore convinced that nasal obstruction 
may and does awaken diseased states of the lungs, and in an indi- 
vidual so predisposed may favor the development of pulmonary con- 
sumption. Fraenkel* states that emphysema frequently coexists with 
nasal stenosis, and Kussmaulf believes that acute hyperaemia of the 
lung may be produced by the forced inspiration of the air. The 
vesicular murmur is weakened, feeble and shortened in inspiration, 
and only approaches the normal when deep inspiratory efforts are 
made. Frequently mucous and subcrepitant rales can be heard in 
different portions of the chest. Attention has been called to certain 
deformities of the chest walls consisting chiefly in malposition of the 
bones and loss of power in the muscular covering. I believe these 
deformities to be rare, except in very young children. 
There is one symptom of nasal obstruction to which especial im- 
portance must be attached, and for which alone the physician is often 
consulted. Dyspnoea on exertion is one of the most annoying features 
of the case. Such patients complain that in talking they must fre- 
quently pause for breath; that in going up stairs, walking rapidly or 
running—in fine, in all bodily operations which require unusual exer- 
tion, they get very readily out of breath. Difficult breathing is also 
present when the mouth is occupied or closed as in swallowing, smok- 
ing, etc. They are accordingly constantly haunted by the dread of 
heart disease and consumption. Physical examination, however, fails 
to detect any cause for the dyspnoea. At times the breathing is per- 
fectly normal and vesicular; at others a few small mucous rales may 
be heard posteriorly in the inferior lobes or in the infrascapular and 
mammary regions. 
It is a matter of common experience that various forms of excoriated 
mouth depend upon a disordered stomach, the so-called herpetic dia- 
thesis, etc., but occasionally cases occur which cannot be referred to 
these conditions, whose dependence on hypertrophic nasal catarrh must 
be inferred from their disappearance with the cure of the nasal affection. 
* Ziemssen’s Cyclop. Am. ed. 1876, Vol. IV. t Quoted by Fraenkel, L c. 7 
Several factors are probably concerned in their production, among 
which mouth-breathing plays an important part, and, possibly, the 
disordered condition of the stomach occasioned by the nasal discharge. 
The inflammation of the conjunctivae which is so often observed in 
connection with nasal catarrh is generally explained by the extension 
of the inflammatory process through the nasal duct; but I am in- 
clined to regard it in the majority of instances as a reflex vaso-motor 
phenomenon, the vessel dilatation being kept up by the constant irrita- 
tion of the sensitive nasal area. In like manner I would explain the 
recurrent herpes and keratitis which have been observed in connection 
with this disease, the phenomena in these cases being called forth by 
trophic disturbances. Zauful * has found trachoma a frequent com- 
plication of ozaena. 
Besides the part which the nose plays in the processes of olfaction, 
respiration and voice production, it also serves as the channel of con- 
duction of atmospheric air to the middle ear. The aural pressure 
is kept in a state of stable equilibrium by the constant supply of air 
to the cavity of the drum through the Eustachian tube. In the natural 
state this ventilation of the tympanum is continually taking place, 
not only as the result of the partial vacuum created in the naso-pliarynx 
during the act of deglutition, but also during normal nasal respira- 
tion. It follows, therefore, that anything which tends to obstruct the 
passage of air through the nose will interfere to an extent varying 
with the amount of obstruction, with normal aural ventilation, and 
consequently with physiological intra-tympanic pressure. This dimi- 
nution of pressure within the cavity of the drum, which can readily 
be demonstrated experimentally, leads necessarily to inward col- 
lapse of the membrana tympani, with consequent abrogation of func- 
tion in the osseous and muscular apparatus of the middle ear. Catar- 
rhal otitis media with its long train of phenomena is the inevitable 
result; fluid not infrequently accumulates in the tympanum, which 
finds an exit ultimately by perforation of the membrane and leads to 
chronic otorrhcea. This same chain of events follows the obstruction 
of the Eustachian tubes by growths in the pharynx or the pressure of 
the hypertrophied nasal turbinated structures, or by inflammatory en- 
gorgement of the orifices of the tubes themselves. This not only cuts 
off the air-supply from the tympanum by direct occlusion of its natu- 
ral channel, but also, by interfering with the motions of the velum, 
and therefore with the opening of the tube by the tensor palati or 
* Aerztl. Corresp. Blatt. fiir Bohmen. 1875, No. 24, S. 23. 8 
dilator of the tube. The intimate and direct connection of the blood- 
supply of the tube and pharynx with that of the middle ear, and their 
anatomical continuity of tissue, favor, furthermore, the extension of 
the inflammatory process from the one to the other. Indeed, in very 
many cases the aural inflammation is merely a symptom of nasal 
catarrh, and gradually disappears without special treatment upon the 
removal of its primary cause. 
Inflammation of the tube may result in stricture; and in long- 
standing cases of salpingitis, fatty degeneration of the tubal muscles 
occurs with the consequences described above. 
These are by far the most common causes of chronic catarrhal 
inflammation of the middle ear. There is still another way, how- 
ever, in which morbid conditions of the nose may react upon the 
circulation and upon the nutrition of the aural chambers, viz. 
through the reflex agency of the vaso-motor and trophic nerves. I 
am led to the assumption of reflex irritation by the pain and con- 
gestion in the ear which occasionally follow the manipulation of 
instruments within the nasal cavities, or the application of caustics 
or other remedies to their lining membrane, and furthermore, by the 
existence of symptoms referable to the ear (tinnitus, pain, etc.) which 
cannot be explained on any other hypothesis. 
It is impossible to exaggerate the part which diseases of the nose 
play in the production of inflammatory conditions of the middle ear. 
Between 60 and 75 per cent, of all cases of ear disease originate 
primarily in morbid states of the naso-pharynx, and the successful 
treatment of middle ear catarrh will in the vast majority of instances 
depend upon their recognition and removal. So important is their 
relationship that we may lay down the rule, that the examination 
of the ear should he begun, not with the inspection of the external 
meatus and tympanic membrane, but with the exploration of the nasal 
fossce and retro-nasal space.* 
The symptoms of advanced nasal obstruction from adenoid growths 
have been well described by Meyer and others. The pallid counte- 
nance assumes a dull, stupid expression, and the cheeks become 
flabby from elongation of the naso-labial sulci. The mouth is kept 
open, the lower jaw depressed; the gums are fissured and cracked, 
and saliva dribbles from the mouth. This often leads the parents of 
the child to connect the stupid countenance and deafness, which is 
* Comp. Zauful, JJeber die allg. Verwendbarkeit der kalten Drahtschlinge zur 
Operation der Nasenpolypen, Prag, 1878, S. 1. 9 
nearly always present, with imbecility. Some writers call atten- 
tion to the unusual prominence of the front teeth as a symptom 
of obstruction in the naso-pharynx, and Michel* observed in a girl, 
eight years old, the inner canthi of the eye so depressed that her 
countenance wore a strange, Chinese appearance. Deafness and 
tinnitus are nearly always present. Neuralgia is common. Taste is 
impaired; the nasal discharge profuse, excoriating the nostrils, filling 
the pharynx, preventing sleep and provoking suffocating attacks. 
These symptoms, together with constant snuffling, are well marked 
among children, and react most powerfully upon the general health. 
Several of my patients complained of a heavy dragging sensation in 
the back of the nose, which they compared to the presence of two 
heavy weights hanging into the throat. (The condition found was 
bilateral turbinated hypertrophy.) Later in life the nostrils become 
abnormally narrow, from arrested development or collapse of the alee 
nasi. The speech becomes nasal, the tone of the voice dull and 
“ dead ” (Meyer). The tone is furthermore weakened and rendered 
indistinct by the interference with the motility of the soft palate 
from the presence of tumors and hypertrophies of the turbinated 
bodies. Obstruction in the nasal fossae (deflected septum, polypi, 
etc.) prevents the free passage of the voice and diminishes corres- 
pondingly the force of the tone. 
A symptom of hypertrophic catarrh which has been overlooked by 
writers is hemorrhage; indeed it is often put down as diagnostic of 
polypi and other growths as contradistinguished from hypertrophic 
conditions of the nasal membrane. My experience furnishes me 
with quite a number of such cases, in several of which the life of the 
patient wras threatened. The bleeding comes from the cavernous 
tissue, and seems to depend sometimes upon stoppage of the nostril; 
for when the nose is freed of mucus and crusts and the normal aerial 
pathway restored, the recurring hemorrhages cease. 
In concluding this account of the symptoms of nasal catarrh let me 
call your attention, briefly, to the subject of reflex phenomena origi- 
nating primarily in morbid conditions of the nose. Some of these, 
such as flushing of the conjunctiva, lachrymation, sneezing, headache, 
and neuralgias in the course of the fifth nerve, are familiar to specialists. 
For some time past I have given considerable attention to the study 
of these reflex phenomena and the mode of their production, and hope 
soon to embody the results of my experiments in the form of a sepa- 
* Die Krankheiten der Nasenhohle, etc., Berlin, 1876, S. 78. 10 
rate paper. I desire to-day simply to insist dpon the great frequency 
of reflex cough as a symptom of nasal disease. In my experience it 
has become so common that I have long since ceased to regard it as a 
curiosity. 
My clinical experience furnishes abundant proof that the cough occurs 
only when, from a local pathological process or ab extra stimulation, ir- 
ritation of the turbinated corpora cavernosa of the nose exists; and I 
have furthermore succeeded experimentally in localizing the area of 
reflex excitability to the mucous membranes covering these erectile 
bodies. Repeated experiments also show that all parts of this sensitive 
area are not equally susceptible to irritation, and that the cough is 
most constantly produced by artificial stimulation of the membrane 
clothing the posterior end of the inferior turbinated body and that of the 
erectile body on the septum immediately opposite. In other words, 
there exists in the nose a reflex sensitive area analogous to that dis- 
covered in the larynx by Stoerk, Yulpian and others.* 
Apart from its physiological interest, the practical importance of 
this fact in a diagnostic and therapeutic point of view is sufficiently 
obvious; in it is found the explanation of many obscure cases of 
cough which heretofore have received no satisfactory solution, and its 
recognition, therefore, is the key to their successful treatment. 
A thorough knowledge of the topographical anatomy of the naso- 
pharyngeal cavities and ability to recognize departures from their 
normal structure, are absolutely essential to him who would under- 
take the rational treatment of what is popularly known as “nasal 
catarrh.” Irregularities of conformation, congenital or acquired, 
play such an important role in the evolution of nasal, and, therefore, 
aural disease, that the surgeon of to-day cannot afford to overlook 
them. With the improved methods of examination now at our com- 
mand, there is no reason why every surgeon should not be able to 
explore the deeper regions of the nose and alleviate the commoner of 
its diseases. 
Systematic treatment is a sine qua non in the successful manage- 
ment of chronic nasal inflammation. There is perhaps no disease 
where lack of method is followed by such signal failure as hyper- 
trophic nasal catarrh, and the unfortunate being who deserts his 
family physician for the prescribing druggist, thence to wander 
* Since writing the above, I have published the results of my experiments in 
the American Journal of Medical Sciences, July 1883. 11 
through every dilution of quackery, is a living daily illustration of 
this truth. 
The indications in the treatment of hypertrophic nasal inflamma- 
tion may be considered under the following heads : 
1. Removal of the obstruction. If the catarrh be dependent upon 
a deflected or dislocated septum, or upon other irregularities in the 
nasal chambers, these must, of course, be rectified before we can pro- 
ceed with the treatment of the case. If adhesions, from syphilis, 
the essential fevers, misuse of caustics, etc., exist, they must be di- 
vided. If the pharyngeal tonsil be hypertrophied, or if growths exist 
in the nose or in the retro-nasal space, they should be removed. If, as 
is often the case, the faucial tonsils be enlarged and indurated, they 
should be excised. It is useless to temporize with sprays, caustic 
applications and other palliative measures. 
2. The nasal and retro-nasal chambers should be thoroughly cleansed 
and kept clean. 
3. The congested or inflammatory condition of the naso-pharyn- 
geal membrane which remains should be treated on the general 
principles which govern the management of simple inflammation of 
this structure, and the patient put under the hygienic conditions 
which favor a return to the normal state. 
In this paper I shall consider principally the first of these indica- 
tions, and shall limit my remarks to the question of the removal of 
the hypertrophied membrane, as this is the operation which is called 
for in the majority of cases. To remove this element of obstruction 
a number of methods have been suggested—caustics, dilatation with 
bougies, sponge tents, etc., galvano-cautery, thermo-cautery, electroly- 
sis, injections, the knife, forceps and cold-wire snare. I shall not 
discuss the comparative merits of these various methods, but will ask 
your attention to the cold-wire snare, a procedure which is the most 
generally effectual, and possesses fewer disadvantages than most of the 
devices which have been enumerated. 
It is only within a comparatively recent period that the hypertro- 
phic masses found on the turbinated bones and septum have been as- 
signed to their proper anatomical place among diseases of the nose. 
The ancients probably knew of their existence, but confounded them 
with polypi, an error which has descended to our own time, and into 
which some of the recent writers on the subject have apparently 
fallen. Although these masses were probably again and again re- 
moved by the wire, as any one can convince himself by referring to 12 
the standard surgical works of the last two centuries, their true anat- 
omical significance and relation to nasal inflammation was not prop- 
erly appreciated until Bigelow * demonstrated the erectility of the 
tissues concerned in their development. The credit of urging the 
necessity of the removal of the hypertrophic mass with the cold-wire 
snare belongs to Dr. Jarvis, of New York.f Prior to the introduc- 
tion of the wire, the galvano-cautery had been used both in this* 
country and in Germany. In the latter country it was extensively 
adopted, and it is a noteworthy fact that Zaufal,J who is an enthusi- 
astic advocate of the snare for the removal of polypi, recommends the 
cautery for the hypertrophic masses of the turbinated bodies. 
The use of the snare in the removal of intra-nasal growths dates 
from the time when Robertson § published the account of his instru- 
ment in the Edinburgh Medical Journal for 1805. This was one 
step, and an important one, in the evolution from the ligature 
of the ancients to the apparatus in use at the present day. The 
Greeks and Arabs applied the ligature by means of a peculiar kind of 
forceps which is described and figured by Dionis, but it was not until 
centuries later that the canula was introduced by Fallopius. This 
was variously modified by the surgeons of the eighteenth century, 
prominently by Levret, who, among other contrivances, used a double 
canula with retention rings, and also, in common with Palucci and 
others, a single canula divided at its distal extremity by a small par- 
tition. Various methods have from the time of Riolanus been sug- 
gested for the tightening of the wire, the most interesting of which 
is perhaps the knot-tightener of Graefe, which consisted of an outer 
piece sliding on the canula, and thereby producing compression of 
the tumor. This was subsequently modified by Dupuytren, the 
ligature or wire being attached by several turns to a retention nut, at 
the promixal extremity of the instrument, and compression of the 
mass secured by means of a quick screw, after the method in use at 
the present day. It was probably these instruments that suggested 
the snares of Robertson and Wilde and led to the modifications of Hil- 
ton, Blake, Zaufal, Jarvis and others.^ 
* Bost. Med. and Surg. Joum., April 29, 1875. 
t Archives of Larnygology, April, 1881. 
tUeber die allg. Yerwendbarkeit, etc. 
§ Quoted by Morell Mackenzie, Arch. Laryngology, April, 1882. 
IT On the Literature of the Ligature and Snare, vid. Levret, (Observations sur 
la cure radicale de plusieurs polypes, etc.,Paris, 1749); Velpeau, (Operative Sur- 
gery, Yol. Ill, Am. Ed., N. Y., 1847, pp. 149 and 411); M. Mackenzie (loc. cit.) 13 
The instrument which I show you is the one I have generally 
employed, and is the result of numerous modifications of the original 
canula and knot-tightener. Whatever form of snare be used, the 
most important thing to be looked to is the character of the wire 
employed. Steel piano-wire as recommended by Zaufal,* Jarvis f and 
Bosworth, J is the one commonly employed, as it possesses con- 
siderable resistance and resiliency, and retains its original direction 
to a great extent when projected from the mouth of the canula. 
In performing the operation with the aid of the rhinoscope, the 
nostril is first dilated with the speculum, and the wire loop passed, 
under the guidance of a strong light, through the slit between the 
turbinated bones and septum, into the naso-pharynx. The nasal 
speculum is then removed, and the tongue depressed, either by an 
assistant or the patient himself, with a Tiircks or similar depressor. 
The mirror is then introduced with the left hand, yie loop directed 
over the hypertrophy with the right, and the wire pulled home. The 
mirror and spatula are then removed, and the operation completed by 
slowly tightening the screw. When the pharynx is unusually small 
or narrow, the soft palate may be tied up prior to the operation by 
means of a rubber cord, whose ends are passed through the nostrils, 
brought out through the mouth, carried over the ears and tied under 
the chin, after the method described by Wales,§ or the uvula may be 
elevated by one of the combination tongue depressors in use among 
specialists. These latter accessories are, however, rarely necessary; 
the latter instrument, although theoretically an excellent auxiliary, 
will too often be found an embarrassing impediment, and the eleva- 
tion of the palate will sometimes interfere with rhinoscopic examina- 
tion by the involuntary salivation and gagging which it every 
now and then occasions. Although the rhinoscope facilitates the 
operation and renders it impossible to damage any of the tissues 
adjacent to that to be removed, it is in the majority of cases unneces- 
sary, provided the changed relations of the parts be known and 
mapped out beforehand, and the touch be sufficiently educated to 
recognize the various parts with which the instrument comes in con- 
tact, and, therefore, to avoid needless injury to the sensitive structures 
that it traverses. The mode of operation which I generally adopt is 
*Ueber die allg. Yerwendbarkeit, etc., S. 19. 
f Loc. cit. 
t New York Medical Record, July 9, 1881. 
§ New York Medical Record, 1875, p. 785. 14 
as follows: The patient is seated in a tall, straight-backed, narrow- 
seated chair, with the head thrown slightly back against the head 
rest (or supported by the arm of the operator). The surgeon, stand- 
ing at the side of the patient to be operated on, and elevating the tip 
of the nose with the thumb of the left hand, passes the wire loop, 
having the requisite diameter and curve, into the nostril. In this 
position the canula of the instrument will form an angle with the 
floor of the nostril varying with the curve of the loop, and its subse- 
quent passage into the nasal fossa will throw the shank of the instru- 
ment toward the median line. It should then be pushed slowly 
and gently backward and slightly downward, until the loop enters 
the naso-pharynx. Bearing in mind the distribution of the fifth nerve 
in the nostril, the snare should be kept as close as possible to the 
floor, hugging the inferior border of the septum, and avoiding as 
much as possible contact with the external wall. This not only 
facilitates its introduction, but lessens the tendency to reflex phe- 
nomena and painful sensation. The wire, being pliable, will adapt 
itself to the sinuosities of the nostril and pass the obstruction with- 
out difficulty. No force should be used; but if the canula be 
arrested, firm and gentle pressure will nearly always cause it to glide 
past the obstruction. The patient should be directed to keep his 
eyes open, and avoid facial contortions, which militate against the 
painless passage of the instrument. In cases where the fossa is more 
or less completely blocked, gradual dilatation with rubber bougies 
will materially aid the subsequent passage of the instrument. As the 
loop passes through the posterior nares over the bulge of the mus- 
cular palate, the contraction of the latter can sometimes be felt as 
it elevates the distal extremity of the wire. The wire should be 
pushed back until it reaches the posterior pharyngeal wall, and then 
gently withdrawn, care being taken to avoid the swollen lips of the 
Eustachian tube. The handle is then pressed slightly inward toward 
the septum as it is withdrawn. This will usually bring the loop 
over the hypertrophied mass. The distal extremity of the canula 
should now be pressed firmly against the turbinated bone, and the 
wire tightened by means of the screw. As the loop passes over the 
base of the palate, involuntary acts of deglutition sometimes occur, 
interfering with the adjustment of the wire. When the latter is 
properly placed, the presence of the growth within its grasp is easily 
recognized by the sense of resistance imparted to the finger in turning 
the screw. By this method the hypertrophied tissue may be 15 
removed without difficulty and with a very slight amount of pain. 
Where, from the extreme narrowness of the passage, the introduction 
of the curved wire gives rise to pain, it may be introduced straight, 
bending it subsequently with the forefinger introduced into the naso- 
pharynx. In several instances I have facilitated its adjustment by 
the following device. A fine rubber cord is tied by one of its extremi- 
ties to the wire loop; the other end is then passed through the 
nostril and carried out through the mouth. The snare is then intro- 
duced into the pharynx. By pulling the cord downward and out- 
ward, the wire is bent and carried over the growth. The subsequent 
steps of the operation consist simply in division of the mass. When 
from anaemia or certain diathetic conditions, loss of blood is to be 
deprecated, the mass may be slowly severed, a half an hour or more 
being consumed in the 4crasement. In ordinary cases I have never 
occupied more than ten minutes in the operation, and although I have 
operated a great many times, have never seen a hemorrhage which gave 
me cause for alarm. Indeed, a moderate flow of blood seems to act 
beneficially, by relieving the engorged condition of the remaining por- 
tions of the mucous membrane. When the hypertrophy is seated 
anteriorly on the bones or septum it can be conveniently snared by 
previously transfixing with a glover’s needle, as suggested by Jarvis.* 
The hypertrophies over the posterior half of the septum are more diffi- 
cult to deal with, and in these cases I believe the galvano-cautery pre- 
ferable to the snare. In a tractable patient the mass may be trans- 
fixed and snared; but I generally resort to one of the other methods 
which have been given above. In one case permanent relief was 
obtained by linear radiating incisions of the mass with a bistoury, 
followed by dilatation with rubber bougies, which act not only as 
dilators but also as tampons to restrain the hemorrhage which follows 
the incisions. In this connection I may add that I have resorted to 
incision of the turbinated bodies in acute coryza, and invariably with 
great and immediate relief. A depletion of the erectile cells is 
thus effected and the nasal stenosis which attends that affection is 
diminished. 
The after-treatment consists in spraying the nostrils with a sooth- 
ing, disinfectant and detergent spray. The one I commonly employ 
is a weak solution of carbolic acid in oil of sweet almonds. A cotton 
respirator should be worn in the nostrils for a day or two after the 
operation to avoid the irritation of the floating particles of dust in 
* Archives of Laryngology, October, 1882. 16 
the atmosphere. The patient may be directed to saturate a ping of 
absorbent cotton with the solution and pass it into the nostril once 
or twice a day until cicatrization is complete. 
I have never seen the disagreeable after-effects here which follow 
the operation with the galvano-cautery. One patient complained of 
pain in the infra-orbital region for one or two days after the removal 
of an anterior hypertrophy; but it was very questionable whether 
this was due to the operation, as he had been for a long time subject 
to neuralgic pains in the course of the trifacial nerve. Rapid ameli- 
oration and disappearance of complications has been the invariable 
rule in all cases where I have performed the operation. 
The amount of hemorrhage will vary with the time occupied in 
the 6craseinent, with the age and vascularity of the mass. The 
slower the traction, the less profuse the hemorrhage. As a rule, the 
cleaner, whiter and older the hypertrophy, the less abundant the 
bleeding. To avoid hemorrhage, it has been advised (Bosworth) to 
tighten the loop slowly, giving one-half turn of the screw every five 
or ten minutes, consuming at least two, or better, three hours, in the 
operation. I have never found such a procedure necessary. When 
the operation is quickly performed, a gush of blood follows the 
removal of the mass and the nose continues to bleed until the 
engorged vascular spaces of the erectile tissue have been depleted. 
The hemorrhage then ceases in many cases spontaneously. Secondary 
hemorrhage sometimes occurs, and generally takes place from six to 
twelve hours after the operation. It is never profuse, and can be 
readily checked by the patient himself. 
In the majority of instances, if the instrument be gently and skil- 
fully introduced, and the facial contraction and straining of the 
patient be controlled, the snaring of the hypertrophy is quite pain- 
less. If the mass be slowly severed, very little pain is felt—some- 
times none at all. I have several times removed the growth without 
the patients being aware of the performance of the operation. When 
the nostril is very tortuous, or when hypertrophy of the turbinated 
bodies coexists with a deflected or irregularly thickened septum, the 
introduction of the snare is sometimes painful, the amount of pain 
depending upon the altered relations of the parts, the degree of 
hyperaesthesia of the mucous membrane, and the curve and diameter 
of the wire loop. The pain may be diminished, however, by hypo- 
dermatic morphia or an anaesthetic spray. In the compression of 
the mass, pain is occasionally referred to various points in the dis- 17 
tribution of the fifth nerve. Various other reflex phenomena some- 
times occur during the operation, such as cough, pain in the ear and 
larynx, movements of deglutition, etc. 
The appearance of the growths when removed is quite character- 
istic, as will be seen by the specimens which I show you. 
The advantages which may be claimed for this operation, apart 
from its comparative painlessness and simplicity, may be briefly 
summed up as follows: 
(1) It fulfils in the simplest and most radical manner the chief and 
absolute indication in the treatment of hypertrophic nasal catarrh, 
viz. the removal of the obstruction. 
(2) It restores the respiratory current to its normal channel, thereby 
avoiding the irreparable injury with which the organs of respiration, 
vocalization, audition and olfaction are necessarily threatened. 
(3) It removes the most prolific source of the discharge in nasal 
catarrh, and favors the return of the mucous membrane to its normal 
state. 
(4) In the majority of instances it causes the various complica- 
tions, and especially those of reflex character, to disappear. 
(5) By the depletion of the cavernous cells of the turbinated bodies, 
it exercises a beneficial effect upon the whole area occupied by the 
erectile tissue. 
The second indication is best accomplished with a detergent, alka- 
line spray. Carbolic acid, borax, boracic acid, the bicarbonate, phos- 
phate and sulpho-carbolate of soda alone or in combination are the 
medicaments commonly employed. By means of the compressed air 
cylinder, the nasal cavities can be thoroughly cleansed and the crusts 
removed with facility. If a sufficiently powerful spray be not avail- 
able, the latter should be carefully brought away, a probe wrapped 
with absorbent cotton and dipped into vaseline, cosmoline, or some 
such substance being used for the purpose. Sometimes thick shreds 
of mucus are found in the Eustachian tubes and the fossae of Rosen- 
miiller, which cannot be dislodged by the spray and which require to 
be removed with the cotton-carrier or forceps. This cleansing of the 
nose is of the utmost importance. Satisfy yourselves by inspection 
that the parts are clean before applying alterative or other remedies 
to the nose. It is useless to apply them to inspissated mucus. I have 
found the continuous use of alkaline and sulphur waters productive 
of decided benefit in diminishing the secretion. The nasal douche is 
a dangerous remedy. It by no means accomplishes what is claimed 18 
for it, and subjects the patient to inflammation of the middle ear. 
Since Eoosa first called attention to this fact, there has been an almost 
daily accumulation of evidence to warrant the condemnation of its in- 
discriminate use. Acute inflammation and abscess of the middle ear 
have repeatedly followed its use, and in one case death was the result. 
Its employment, therefore, by the physician himself is to be under- 
taken with the greatest caution—to place such an instrument in the 
hands of a patient is, to say the least, an injudicious and dangerous 
experiment. 
Gargles are sometimes of benefit, but the sphere of their usefulness 
is limited. Even by Troelsch’s method very little of the fluid reaches the 
posterior part of the pharynx, and as all communication is shut off 
between upper and lower pharynx in the act, the remedy never 
reaches the spot it is designed to medicate. The medicament may act, 
however, mechanically by producing muscular contraction and there- 
by dislodging mucus from the naso-pharynx. A gargle of water 
will accomplish the same result. 
Mosler’s plan, viz. by regurgitation of the fluid into the naso- 
pharynx, is an unphysiological procedure and a roundabout way of 
accomplishing a great deal of possible harm with considerable diffi- 
culty and personal inconvenience. A better method is to lie flat on 
the back with the head inclined slightly downward, and allow the fluid 
to gravitate into the pharynx. 
The astringent or alterative to be used will depend upon the char- 
acter of the inflammation and upon the susceptibilities of the patient. 
It is better, as a rule, to change the remedy from time to time until 
one is found which accomplishes the maximum of good. One of the 
simplest and best is common alcohol, diluted according to circum- 
stances. Weak solutions of bichloride of mercury, as recommended 
by me elsewhere,* are often of decided benefit. For post-nasal and 
pharyngeal inflammation I have also used the tincture of galanga with 
excellent results. Galanga is an Indian remedy for catarrh, whose 
powdered root has been recommended (Bosworth) in the form of snuff. 
It will be found, however, exceedingly difficult to reduce the root to 
an impalpable powder, and even when mixed with other powders it is 
irritating and often produces attacks of acute coryza. To obviate 
this, I have had an alcoholic tincture of the root, diluted according 
to circumstances, prepared for use in spray behind the soft palate. 
This has an aromatic, not unpleasant odor, and produces a sharp, 
* Maryland Medical Journal, Feb. 15, 1883. 19 
pungent, peppery sensation, which subsides, however, almost instan- 
taneously, and generally affords immediate relief. The application 
leaves an agreeable astringent sensation in the throat which lasts for 
some time, and is not open to the evil results which follow the use of 
nitrate of silver and similar substances in that locality. 
The use of powders in the nose will often do more harm than good, 
unless the substance be reduced to an impalpable state. Their indis- 
criminate use is to be discouraged, especially where the parts cannot 
be thoroughly and repeatedly inspected. Otherwise they will form a 
thick paste with the discharge whose removal they mechanically im- 
pede, or collecting in the crevices of the nasal chamber, lay the 
foundation for crust formation or act as foreign bodies. It is much 
better to apply the remedy to the mucous membrane in some such 
vehicle as glycerine, gelatine, cosmoline, vaseline, etc. This should 
not be thrust blindly into the nose, but the nostril should be dilated 
and the application made directly to the diseased surface. Where 
excoriations or ulcerations of the nostril exist, I have found the 
powder of calendula dusted over the raw surfaces, or applied as a gly- 
ceride, will cause rapid healing and diminution of the discharge. I 
have also found the combination of this drug with boracic acid, as 
recommended by Dr. Sexton,* of New York, in otorrhcea, of consid- 
erable value in purulent cases of catarrh of the nose. 
During inclement weather and when exposed to a vitiated atmos- 
phere, the nasal chambers should be protected by means of a respir- 
ator. Those in common use are ungainly objects, against which personal 
vanity and festheticism alike rebel. Few patients, especially ladies, 
will submit to being muzzled with these unsightly appliances, which, 
besides masking to a great extent their personal charms, are in the 
eyes of their fellow-man the outward and visible suggestion of chronic 
nasal catarrh. When the discharge is not very profuse, absorbent cot- 
ton, medicated or not according to circumstances, may be substituted 
for the ordinary respirator. A small piece of cotton is taken and 
its fibres teazed gently apart with the fingers. It is then folded lightly 
upon itself and introduced into the nostril just beyond the orifice of 
the anterior nares. If care be taken to separate the fibre sufficiently 
loosely, respiration can take place with ease. This simple expedient 
will be found of considerable value to mitigate the severity of the at- 
mosphere and to equalize the temperature within the nasal chamber. 
The cotton respirator should not be confounded with the plugs in 
* N. Y. Med. Record, Dec. 31, 1881. 20 
common use to medicate and give support to the inflamed nasal mem- 
brane. The use of tents of various kinds as a means of conveying 
remedies to the cavities of the nose is of very ancient origin, and it is 
therefore amusing to read the altercations in which some surgeons of 
the present day have indulged as to the priority of their introduc- 
tion in the treatment of nasal inflammation. Where the discharge is 
profuse, or when caries or necrosis of the bones is present, I can strongly 
recommend oakum as a substitute for the cotton tents commonly 
employed. 
In addition to local applications, attention should be given to the 
general health, which is often seriously impaired. The existence of 
diathetic diseases should be carefully sought for and the different or- 
gans and their functions systematically interrogated. It is perhaps 
a trite remark that he is a poor specialist who does not look beyond 
the anatomical limits of his specialty, but successful treatment of his 
patient will often depend more upon the intelligent appreciation 
of associated, though remote, pathological processes, than upon the rou- 
tine treatment with which he assails the organs whose diseases it is 
his peculiar mission to alleviate. 
As a tonic, stimulant, disinfectant and alterative I know of nothing 
better than the sulphate of quinia. Either alone or combined with 
mercury it seems to exert a beneficial effect in quite a number of cases 
of chronic nasal catarrh, and is sometimes an important auxiliary 
in the treatment. 
In the subsequent treatment of the catarrhal otitis media our chief 
reliance must be placed on the systematic inflation of the middle ear 
with atmospheric air, and the use of vapors through the Eustachian 
catheter, or by means of the various appliances in general use. The 
injection of fluids through the Eustachian tube is a practice of 
questionable utility, and it is only in exceptional cases that per- 
manent results may be obtained by the use of electricity. Spraying 
amounts practically to the injection of the remedy in a fluid form, 
the finely divided particles reaching the upper portion of the tube or 
middle ear, if they reach them at all, not as spray, but as a liquid 
injection. Dilatation of the tube with bougies is occasionally of 
decided benefit; but their use requires caution, as it is not unat- 
tended by danger. I believe that the employment of bougies of large 
calibre would diminish materially the danger and be productive of 
more good in the dilatation of the tube, or, at least, its lower portion. 
Among the numerous vapors used may be mentioned the benzoate of 21 
iodine, the iodide, muriate and benzoate of ammonium, and the vapor 
pini sylvestris (London Throat Hospital Pharmacopoeia). If a dia- 
thetic condition be present, or if the general health be impaired, they, 
of course, call for appropriate treatment; hut, as a rule, very little 
can be expected from constitutional medicinal treatment in chronic 
catarrhal inflammation of the middle ear. Cubebs, mercury, the 
salts of ammonium and guaiac will occasionally afford temporary 
relief, and the use of alkaline and sulphur waters, especially when 
combined with local treatment, are sometimes of decided benefit; but 
it is often very difficult to measure the exact amount of influence 
which the former exert in the production of a cure. The treatment 
of the tinnitus—the most annoying symptom—will obviously depend 
upon the condition which produces it. I have rarely seen any 
marked improvement from the use of hydrobromic acid, and the 
same can be said of that much vaunted and grossly overestimated 
drug, ergot. Residence at the seaside will often do more toward dis- 
sipating this troublesome phenomenon than all the medicines of the 
pharmacopoeia. 
One word in regard to the treatment of hypertrophic inflammation 
of the middle ear. Let us take an illustrative case. The drum head 
is gone, a chronic otorrhcea has been established; the ossicles have 
long since been swept away in the discharge. Over the promontory 
the hypertrophic membrane appears as a swollen thickened mass, 
smooth or granular in appearance, or projecting outward as a well- 
defined tumor which every one at the outset of his aural studies has 
mistaken for polypus. This hypertrophic mass encroaches on the 
cavity of the drum and is the most prolific source of the discharge. 
The principles which govern us in the management of hyper- 
trophic nasal catarrh are equally applicable here. If ordinary 
methods fail, or if it be excessive, projecting outward like a polypus, 
it should be snared or excised with the ring knife, or destroyed by 
caustic applications, the galvano-cautery, etc. 
Adenoid growths are best removed with forceps. The instrument 
which I show you is one that I have had made by Willms of this city. 
The blades are fenestrated and slightly flattened posteriorly and su- 
periorly to admit of perfect contact with the walls of the pharynx. 
Their cutting edges are made on the principle of the Liier bone-nip- 
pers except that they are prolonged downward to the shank. When 
closed the edges should be in perfect apposition. Thus constructed 
they will cut with ease through the densest growth. No pulling or 22 
dragging is necessary, as is often the case when the dentated or ordi- 
nary beveled bladed forceps are used; the operation can be performed 
without the slightest discomfort to the patient. The blades bnry 
themselves in the mass and bring it readily away. These forceps 
possess, furthermore, the additional advantage that each blade may 
be used as a curette. The growths being brought away, the instru- 
ment is reintroduced and one blade is fixed, whilst the other is used 
to scrape off the remains of the vegetations. Should the blade slip, 
no harm can be done, for it will close with its fellow of the opposite 
side. We thus have two instruments combined in one. The/-shaped 
curve of the ordinary Loewenberg forceps has been retained as the 
most convenient. 
This instrument may be put to a number of uses. Besides remov- 
ing growths from the throat, it may be used for scraping or nipping 
the granules from the walls of the pharynx, and can be employed to 
remove portions of the tonsils, the stubs left after old follicular dis- 
eases, and other conditions which give rise to irritation and require 
excision. 
In conclusion, gentlemen, let me say that the nose is too often regarded 
simply in its capacity as the organ of smell, and its important physiolo- 
gical relations to the functions of respiration, audition and vocalization 
receive but imperfect attention or are altogether overlooked. Within 
its cavities changes in the air take place which are absolutely essen- 
tial to normal heal thy respiration, and the removal, therefore, of 
nasal obstruction is as necessary to the maintenance of perfect physi- 
ological life as when the obstruction is situated lower down in the air 
passages. The consequences of impeded nasal respiration detailed 
above are not exaggerated; they are facts of every-day experience. 
To insist upon their proper appreciation and upon the radical removal 
of the causes upon which they depend has been the object of these re- 
marks; for it is only by a more careful study of the pathologi- 
cal conditions of the nose, and their relation to diseases of adjacent and 
communicating organs, that we may ever hope to emancipate these 
affections from the dominion of quackery and empiricism and place 
them under the control of rational therapeutics.