THE 
DIAGNOSIS AND TREATMENT 
OF 
CHRONIC NASAL CATARRH. 
LEFFERTS. • THE 
DIAGNOSIS AND TREATMENT 
OF 
CHRONIC NASAL CATARRH. 
THREE CLINICAL LECTURES 
DELIVERED AT THE COLLEGE OF PHYSICIAN'S AND SURGEON'S, 
NEW YORK, 
BY 
GEORGE MOREWOOD LEFFERTS, A. M., M. D., 
Professor of Laryngoscopy and Diseases of the Throat in the College of Physicians 
and Surgeons; Consulting Laryngoscopic Surgeon to St. Lute's Hospital, 
and the Hew Pork Skin and Cancer Hospital; Sttrgejju. to .j- 
Hew l'ork Eye and Ear Infirmary (Throat Depart;> 
President of the American Laryngological - IsyS iufioer: 
REPRINTED FROM THE MEDICAL NEWS OF PHILADELPHIA, "APRIL lG, 
AND MAY 3, 1S84, AND FROM AMERICAN' CLINICAL 
LECTURES, VOL. II, NO. VI. 
ST. LOUIS: 
LAMBERT & CO. 
1S84. CHRONIC NASAL CATARRH. 
LECTURE /. 
EXAMINATION. 
Gentlemen : Accurate diagnosis being the corner-stone of all 
successful treatment, my first lecture to you of this series must neces- 
sarily deal with the methods of making a direct anterior and posterior 
examination of the nasal passages—in other words, the performance 
of anterior rhinoscopy and of posterior rhinoscopy, or, more properly, 
pharyngo-rhinoscopy. The importance of such an examination, as a 
preliminary step to all attempts at treatment, will be alluded to more 
than once in the following lectures. 
I have been sometimes reminded that there is an idea in the minds 
of very many of our profession that these methods of physical exam- 
ination, procedures which necessarily involve the use of special instru- 
ments, such as the rhinoscope, specula, etc., and require some practice 
to make perfect, demand such a high degree of skill on the part of the 
physician, such an amount of toleration on the part of the patient, and 
the use of such costly apparatus, that they are of necessity confined 
to the hands of a few, who have by special training learned dexterity 
in manipulation, and by opportunity and special study acquired the 
right to denominate themselves S/>ecia/is(s. 
But, gentlemen, this is hardly true, for I know that by the exercise 
of a moderate amount of diligent practice — in other words, learning 
practically where and why he fails in examinations, and not relying 
upon his books alone for his knowledge, by perseverance in the use of 
the necessary instruments, directed by an intelligent appreciation of 4 
CHRONIC NASAL CATARRH. 
the why and wherefore of their application — the general practitioner 
may overcome such difficulties as stand in the way of their successful 
employment, and this with the simplest aids in the way of apparatus. 
If he will do this—and I hope to show you how he can most easily 
accomplish it — I assure him that the results which will be afforded, 
their importance and interest, and his satisfaction at having mastered 
the use of an invaluable diagnostic means and therapeutic aid, which 
to-day are beginning to be considered a very necessary part of medical 
practice, will most richly repay him for the time and labor which he 
has expended. 
Certain instruments are essential for the practice of rhinoscopy, 
but they are few, simple, and not necessarily of great cost. They are: 
i, a good artificial illumination; 2, a concave forehead reflector, and, 
in addition, for anterior rhinoscopy; 3, a nasal speculum, and for pos- 
terior rhinoscopy; 4, tongue spatula; and, 5, a rhinoscopic mirror. 
For ordinary purposes there is no better nor more convenient light than 
that which is furnished by the argand gas burner, mounted upon a drop 
light, which permits of the flame being lowered or elevated at will. 
Such a light is certainly easily procurable, and at a slight cost, if gas is 
obtainable; if not, as in the country, then the ordinary student lamp, 
which burns petroleum or oil, forms a very efficient substitute. Tc 
either of these lamps it is no difficult matter to attach a single piano 
convex lens two and one-half inches in diameter, which fits into the 
metallic chimney or tube known as Mackenzie’s, if you deem it desir- 
able to intensify their illuminating powers. Such an apparatus is 
shown in both of the accompanying illustrations (figs. 1 and 7). 
Our next essential is the forehead mirror or reflector (fig. 2). This 
is a slightly concave mirror, either three and one-half or four inches in 
diameter, with a focal distance of about twelve inches. The glass may 
be perforated at its center, or simply left unsilvered at that point, both 
plans having their advocates; the latter, I think, you will find most sat- 
isfactory, and the only objection that I have ever heard urged against 
it — the liability of a coating of dust gathering upon the uncovered por- 
tion and obscuring the view through it—is one that is certainly very 
easily obviated. How this mirror shall be worn, and how it shall be 
attached to the operator’s head, are also points upon which there is 
some difference of opinion. Bruns, for instance, says that it should EXAMINATION. 
5 
Fig. i. Lamp for illuminating purposes. 6 
CHRONIC NASAL CATARRH. 
be worn in front of the nose and mouth. Johnson prefers to have it 
over the forehead, while Czermack, Mackenzie, and others, among 
whom I rank myself, think that it should be placed directly over one of 
the eyes, the right being usually preferred. There is no question but 
that this last method is the one that is, theoretically, correct, and it is 
fully as easy to acquire as the others. The physician then looks 
through the uncovered portion of the glass, and his eye is within the 
center of the cone of light which is thrown from the mirror into the 
patient’s mouth, while at the same time his eyes are protected from its 
Fig. 2. Concave forehead reflector. 
glare, for the rajs of light from the lamp reach the mirror in an ob- 
lique direction, and do not, therefore, strike against the eye which is 
behind the reflector, while the other is beyond, or, rather, to one side, 
of their line of direction. Both eyes are then to be used in looking at 
the picture which is reflected in the rhinoscopic mirror. 
For attaching the mirror to the head the band shown in the cut mav 
he employed, or, still better, and as I prefer, the head-band known as 
Kramer’s. A suitable dilator for the al<e of the nostril is usually nec- EXAMINATION. 
7 
essary, and is certainly advisable, although a fair examination of the 
parts may be made without it by simply elevating the tip of the nose 
with the thumb and dilating the nasal openings by pressure upon it. 
Of these nasal specula there are many kinds, and some prefer one, 
some another. The two best, perhaps, are those known as Robert and 
Fig. 3. Robert and Collin’s nasal speculum. 
Collin’s speculum (fig. 3), a double-bladed affair, with a broad, trumpet- 
shaped orifice, which is dilated and held open by means of a screw ar- 
Fig. 4. Frankel’s nasal speculum. 
rangement upon its side, and the wire speculum Qfig. 4), somewhat 
similar to a dilator used by oculists for separating the lids. Both these 
are good; the first is a favorite one with me, but I not unfrequently use 
an ordinary ear speculum, especially with small children, and find it an- 
swers a good purpose. Thudicum’s speculum is useful for operations in 
the anterior nares. With these simple means alone, then —viz., those 
thus far alluded to — you will be able to see all of the anterior nares that 
there is to be seen, without the use of further instrumental assistance, 
although many other aids have been devised, which will be found in 
practice more of a hindrance than a help. 8 
CHRONIC NASAL CATARRH. 
For viewing the posterior mires two additional instruments, as has 
been said, are necessary: First — 
The tongue spatula (fig. 5), which 
should always be used. You will 
find that it facilitates the operation 
greatly. That made on the model 
of Turk’s fulfills two indications — 
its handle and shank are at one side of the mouth, 
out of your way, out of your light, while the blade, 
curved downward and corrugated, rests on the 
tongue and draws it forward, and is therefore to be 
preferred. Second — A rhinoscopic mirror (fig. 6). 
This consists of a circular bit of good glass, backed 
with amalgam, and mounted in a frame of German 
silver. To this frame is attached, a right 
angle, a shank four inches in length, that is made 
of some metal which, while it allows of any neces- 
sary bending, is firm; this terminates in, or some- 
times slides into, a light handle, so that it may be 
lengthened or shortened at will, and into which it i> 
fastened by means of a small screw. The diameter 
of the mirrors varies from half an inch to an inch 
on tneir reflecting surface, and the most convenient size is, for ordinary 
purposes, that of one-half inch. 
I now present for your consideration a few hints as to the best man- 
ner of examining the cavities which occupy our attention. I allude to 
the anterior and posterior nares and the upper pharyngeal space, the 
two latter by the aid of the rhinoscopic mirror. The inspection of the 
former — that is, the anterior nares—is easy of accomplishment; but 
that of the latter, the most important as far as diagnostic results go, is 
often difficult. This method of examination, then, is by no means as 
generally applicable as laryngoscopy, and is sometimes, but rarely, 
absolutely impossible of accomplishment. I mention this that you may 
not be disappointed when you fail, and in order that you may com- 
mence your attempts with a fund of patience that will last. Let this 
statement, however, not discourage you; much can be accomplished by 
steady and persevering effort, even in the worst cases. For an inspec- 
F«g-S- 
Turk s 
tongue 
sputulai 
Fijj. 6. 
.Rhino - 
scopic 
mirror. EXAMINATION. 
9 
tion of the nasal passages from the front, vve only need a good light — and 
here the illuminating apparatus and the forehead reflector will be found 
to render the best service — and a suitable dilator for the ala; of the nose. 
The position of your patient and the light during your manipulations 
are about the same as those which I have described to you as being the 
correct ones for laryngoscopy, excepting, of course, that the patient’s 
mouth is held closed* —that is, your patient must be seated directly in 
front of you, upon a chair which has been so arranged, in reference to 
the illuminating lamp, as to be convenient (you have arranged this 
light so that it will be upon a level with the mouth or ear of the patient 
whom you are about to examine, and upon his right side), with his 
head thrown slightly backwards, but still on a line with the axis of his 
body, and neither inclined to the right nor to the left—as a rule, a 
position which will place the lower border of the upper incisor teeth 
upon a plane which is horizontal with the base of the soft palate will 
be found a favorable one. A head-rest is unnecessary. The examiner 
now seats himself in front of the patient, takes the knees of the latter 
between his separated legs, and accommodates himself to his patient’s 
height, so that he looks directly at his nose, and is at a distance 
from it which corresponds to the requirements of the focal distance of 
the concave forehead reflector which he has fastened upon his head, 
and by means of which he proposes to throw an image of the gas flame 
used — that is, “the optic expression of the union of all the rays of 
light which it reflects”—into the cavity which he is about to examine. 
If your speculum is now carefully introduced, and the membrano-car- 
tilaginous part of the nose widely dilated (be careful not to pass the 
speculum too high up into the narrow space between the cartilaginous 
septum and outer bony edge of the nostril, to cause pain), while at the 
same time a strong light is thrown into the cavity from your reflector, 
you will see, more or less distinctly, the anterior and parts of the infe- 
rior surfaces of the three turbinated bones, the side of the septum, and 
into the inferior meatus, your view of the two latter, in respect to the 
depth to which your eye reaches, depending entirely upon the natural 
formation of the parts, for it is exceedingly common to find a deflec- 
tion of the septum to one side, usually the left, which narrows more or 
* The details are practically illustrated in the person of a patient during the lecture. 10 
CHRONIC NASAL CATARRH. 
less the respective nares, occasionally occludes it, and prevents all view 
of the parts beyond; on the other hand, cases are met with in whom a 
very wide and roomy meatus permits you to look directly through it 
into the pharynx, and see the pharyngeal orifice of the Eustachian tube. 
A careful inspection by this method, which should always precede or 
Fig. 7. Method of performing anterior rhinoscopy. EXAMINATION. 
11 
follow a posterior rhinoscopic examination, if a correct diagnosis of 
the condition of the nares is to be made, will instruct you as to the 
condition and color, pathological or otherwise, of the lining mucous 
membrane—any changes from the healthy condition being readily 
appreciated, after frequent examinations of the normal parts have been 
made, and familiarized you with the normal appearances — to the 
presence of hypertrophies, common in the hypertrophic form of rhi- 
nitis; to exostoses and cartilaginous tumors of the septum, not unfre- 
quently met with; to the presence of ulcerations or abnormalities of 
secretion; and, finally, to changes from the natural formation of the 
passages — deviations of the septum and the like. 
For the performance of the posterior examination, to illuminate and 
convey to the eye the picture of the upper pharyngeal space, the poste- 
rior nares, and more or less of the posterior portions of the nasal pas- 
sages themselves, we shall need, as I have said: First, a tongue spatula; 
second, a small mirror, bent at more or less of a right angle with its 
shaft; and, third, a good and sufficient source of light, to be used with 
the forehead reflector, and under the same conditions as I alluded to 
above. All these instruments we are supposed to have, and we now 
proceed to use them (fig. 8). The position of the patient, the position 
of his head, your position, and the direction and method of reflecting 
the light, are the same for posterior rhinoscopy as I have described them 
to you to be for anterior rhinoscopy, with two exceptions: First, that 
the focal point of the light is to be thrown into the pharynx; and, 
second, that the patient, with widely opened mouth, allows his tongue 
to lie quietly behind the incisor teeth and depresses it well down upon 
the floor of the mouth with the spatula. The procedure of throwing the 
reflected light from the forehead mirror into the patient’s mouth, and 
then keeping it steadily in one position, you will find, as beginners, 
the most difficult part of the manipulation — at least I have found it so 
with my students. The latter has so many things to remember — the 
position of his patient, of the mirror, the picture of the various parts 
as he sees it, perhaps for the first time — that he is not to be blamed if 
his light does wander, and he suddenly, by some movement of his 
head, leaves the mouth in darkness. Practice will soon teach, how- 
ever, that when the light has once been reflected into the mouth, and 
its brightest point lies, as it should, just below the base of the uvula, it 12 
CHRONIC NASAL CATARRH. 
Fig. 8. Method of performing posterior rhinoscopy. 
can be steadily kept at that point, and the exact focus caused to lie 
accurately, by slight movements, backwards or forwards, as the case 
may be, of his head. To catch the rays of light on his mirror in the 
first instance often gives him some difficulty; but a simple rule will make 
it an easy matter. Let him first place the mirror directly over his EXAMINATION. 
13 
forehead, in the median line, then turn it, keeping its plane parallel 
with that of the face, so that it comes over the right eye, and its axis, 
before vertical, becomes horizontal; he should now be able to look 
directly forwards with both eyes, the right through the perforation in 
his mirror, and then turning its face slowly towards the left—or, in 
other words, towards the lamp, which stands, as you remember, on the 
right side of the patient’s head — he will invariably catch the rays of 
light from it, and find that the illuminated point will be thrown in 
the mirror’s course, directly upon the patient’s mouth. 
If this has been satisfactorily accomplished, the rhinoscopic mirror, 
held in the right hand and well warmed, is now to be carefully intro- 
duced from the corner of the mouth, with its reflecting surface up- 
wards, carried over the tongue and under the velum, which must hang 
motionless, at one side or the other of the uvula, until it stands mid- 
way between the former and the posterior pharyngeal wall, touching 
neither, and at an angle of about 130°. In this position it will be im- 
possible to get the whole picture of the parts at once, and the face of 
the mirror must therefore be turned from side to side to view the lat- 
eral pharyngeal walls, upwards to view the vault of the pharynx, and at 
more or less different angles and inclinations to see completely the 
parts embraced in the posterior opening of the nares; indeed, it may 
have to be introduced upon one side of the uvula, especially if this be 
large, then withdrawn and re-introduced upon the other, if a perfect 
view of all the parts be desired. 
Such, then, is the method of posterior rhinoscopy in an easy case, 
but three difficulties often present themselves which prevent its accom- 
plishment; one is insuperable — a long, hard palate, which approaches 
so nearly to the posterior pharyngeal wall that there is no practicable 
degree of space left through which an examination may be effected, 
but this is very rare. A second is very common, and will require an 
additional instrumental procedure. This condition is one where a 
long, broad, soft palate, a long uvula, and a short distance between 
them and the posterior pharyngeal wall coexist, and an examination 
can only be made when the former are drawn away from the latter. 
This is best accomplished in certain cases by means of the palate hook, 
a hook of metal, broad and well curved where it passes under the 
velum, and covered by bougie material, which is introduced by the left 14 
CHRONIC NASAL CATARRH. 
hand gently under the palate, and the latter drawn towards the oper- 
ator with moderate force — that is, away from the posterior pharyngeal 
wall. I have never known this procedure to succeed perfectly at the 
first trial, but successive and persevering attempts will generally suc- 
ceed in overcoming the spasmodic contraction of the palatine muscles 
which follows any attempt at first drawing the velum forwards. As a 
rule, however, you will find that the same time that is devoted to train- 
ing a patient to tolerate this hook, or any of the other forms of instru- 
ment which the inventive ingenuity of specialists has devised for the 
purpose — and they are many — will be all-sufficient to train him to 
breathe quietly through the nose and cause the palate to hang immov- 
able in the mouth, and in a manner much more comfortable to him and 
less tiresome to you. The third and last difficulty to which I have al- 
luded is met with in nearly all cases, but may fortunately be overcome 
by simple measures. This is the drawing up of the velum and uvula 
tightly against the pharyngeal wall, which occurs as soon as the patient 
opens the mouth widely, or as soon as your instruments are introduced 
within it, and when you remember that the position that we wish it to 
assume — the one that it must assume before your examination can be 
made — is precisely that which it takes when all muscular movement is 
in abeyance, and that the patient can not assist you by carrying out any 
movements or phonating sounds, as he does in laryngoscopy, you will 
see the difficulty that presents itself. Quiet respiration carried on 
through the nose will overcome it, however, and this, which at first 
trial the patient will declare impossible to do, will after a few attempts 
be done, and the velum will be found not only to hang free from the 
pharyngeal wall, but to remain nearly motionless. A free space is thus 
afforded, through which your examination may then be made with 
celerity, accuracy, and completeness. 
The picture that you see (fig. 9) is probably new and strange to 
you. You are looking at parts that are but rarely dissected, seldom 
thoroughly considered in our text-books, rarely correctly represented 
in drawings, and seldom, if ever, examined in the dead-house. To 
recognize all the various details, then, of the nares as seen from behind 
forwards will require special care and study, and all the more so as a 
complete view of all at once is rarely attainable. Your picture is 
made up of sections, as it were, obtained perhaps with difficulty, and EXAMINATION. 
15 
seen in a small mirror. The drawing which I show here will perhaps 
assist you in appreciating their appearance, and render their future 
recognition, after what I shall say about them, I trust, comparatively 
easy. 
Fig. 9. Normal rhinoscopic image. 
The first object which attracts your attention, as the rhinoscopic 
mirror is passed into position, is the posterior surface of the uvula, and, 
next, the posterior surface of the velum — abroad reddish expanse 
which arches upwards so as to cut off from view more or less of the in- 
ferior portions of the nares proper, and thus hides the greater part, in 
most cases, of the posterior extremities of the inferior turbinated 
bones. The septum nasi now comes into view, and as it is the most 
easily recognizable of all the parts, it serves as a landmark or guide for 
the rhinoscopic picture, as the vocal cords do for that of the larynx. 
It is a thin, sharp ridge, whitish in color, and its sides are readily seen; 
above it widens, becomes of a deeper color, and merges into the parts 
which go to make up the vault of the pharynx; to either side of it are 
seen dark, ovoid openings, the posterior nares, qnd you will observe 
that they are more or less occupied by the three turbinated bones, 
bulbous bodies of a gray or ashy-red color, and that of them we see 
the middle one with part of the middle meatus of the nose most dis- 
tinctly; parts only of the superior and inferior bones are visible, the 
former appearing simply as a narrow projection from the outer wall of 16 
CHRONIC NASAL CATARRH. 
the nares, extending downwards, inwards, and backwards to lose itself 
behind the middle turbinated bone; the inferior, which overlaps the 
middle one, and the upper portions of which alone are usually visible, 
appears as a rounded, hard tumor, with an irregular and grayish-col- 
ored surface. Of the meatuses of the nose the middle is, I have said, 
by far the most distinct; the upper appears only as a dark line, while 
the inferior is only occasionally seen. About the level of the inferior 
turbinated bones — further towards the sides Of the picture, and upon 
a different plane — we see on either side a rounded, smooth projection 
of a bright-red color, and between it and the outer limit of the poste- 
rior nares on the corresponding side a smooth yellowish expanse, over 
which a small vessel can sometimes be seen to course. This projec- 
tion is continuous below, with two sharp elevated ridges, the anterior 
containing the fibres of the levator palati muscle, which pass down- 
wards and inwards to the dorsum of the velum, where they are finally 
lost. They are the pillars of the pharyngeal orifice of the Eustachian 
tube, the triangular yellow colored mouth of which lies between them, 
at the point where they leave the rounded projection above mentioned. 
If we follow this backwards, we shall see that it defines a deep groove 
running upwards and outwards, and which lies between this lateral 
projection and the posterior wall of the pharynx — in short, the fossa 
of Rosenmiiller. 
If the face of the mirror be now turned upwards, the vault of the 
pharynx will be seen, its mucous membrane of a bright-red color, and 
its surface covered with irregular ridges and depressions, due to the 
amount of adenoid tissue here present; below these shade off into the 
smooth posterior pharyngeal wall. 
These points, then, having been seen, our examination is completed 
as far as the normal appearances go. The abnormalities of the parts, 
due to pathological processes, which may be detected by the rhino- 
scope, I have already briefly alluded to when speaking of anterior rhi- 
noscopy, and need not recapitulate them — they will also be described 
in detail, as far as they concern the catarrhal processes, hereafter. 
If the process of examination has been conducted carefully and intel- 
ligently, we are certainly in a position to diagnosticate the conditions 
that are now to be considered, accurately, and to treat them successfully 
— no slight advantages in any case, as I am sure you will acknowledge DIAGNOSIS. 
17 
LECTURE II. 
DIAGNOSIS. 
Gentlemen: Having taught you how to use the instruments for 
diagnosis, I propose commencing to-day the consideration of a subject 
which I know will be of more than passing interest to you. The pa- 
tients that you see before you will illustrate its various phases; they will 
be demonstrated in a few moments. My subject is “ Nasal Catarrh ” — 
one about which much is written to-day by the profession, much more 
said by the laity. It is an extensive one, and I can not hope to treat it 
exhaustively in the time at my disposal in this course; perhaps it is just 
as well that I should not attempt to do so. What you most need, as 
general practitioners, is condensed and reliable information concern- 
ing diagnosis, and practical advice in regard to treatment. 
T have said that the subject will be of interest to you. We all hear a 
great deal about “ chronic catarrh of the nose,” and you will see a good 
deal of it. Patients who suffer from it, and patients who have not got 
it, but imagine that they have, will come to you in numbers. You cer- 
tainly, then, ought to be able to recognize it when present, to exclude 
it when absent, and, above all, be competent to treat it scientifically 
and successfully. Let me ask just here: Do general practitioners 
always recognize it? Do they always examine for it? Are they not too 
apt, in too many cases, to accept the statement of the patient, make no 
examination, prescribe a nasal douche and some wash, and allow the 
patient to disappear, perhaps to excite, in time, a catarrh where none 
existed before? Patients will make their own diagnosis — it is com- 
mon for them to do so — and often come to you for the treatment of 
that which, perhaps, does not exist; often they will treat themselves, 
without any advice. The country is flooded with advertisements, pam- 
phlets, and books on the subject of nasal catarrh. The field is a rich 
one for the quack; “ sure cures ” multiply rapidly; new remedies are 
eagerly sought for by the credulous; “ catarrh snuffs” crowd the coun- 
ters of every drug store, and “nasal douches” are manufactured and 18 
CHRONIC NASAH CATARRH. 
sold by the thousand. The quack does not spare the feelings of the 
patient; he pictures the disease in its most disagreeable aspects; he 
dwells upon the worst symptoms; he confounds other diseases — syph- 
ilis, for instance—with simple catarrh; in short, he frightens. 
Your patients, then, well posted in literature of this class, come to 
you, dreading that the nasal trouble that they have, or, perhaps, have 
not got, will develop into the worst form of catarrh that they have read 
about — above all, that it will develop a disagreeable odor. A symptom 
that they also often dwell upon, regarding it as a sign of the dread dis- 
ease, is “ a constant dropping of mucus in the throat” — an ever-pres- 
ent desire to clear it. Some little mucus they do bring away; often 
not. Let me warn you here that, in a good percentage of these 
cases, all this has nothing to do with “nasal catarrh.” The patient 
is probably suffering from a simple relaxed throat or a chronic phar- 
yngitis in one of its forms—perhaps, and most commonly, a re- 
laxed or elongated uvula—and that these, especially the latter, are 
the matters at fault, not the nose. All this you must prevent, they cry 
to their doctor; they demand treatment at your hands. Now, much of 
this nonsense you, as sensible medical men, can prevent. But, first, 
you must yourself know what “ nasal catarrh ” really is, what forms it 
appears under, and how to recognize the varieties by their intra-nasal 
appearances. The day has gone by when all nasal affections can be 
recklessly and ignorantly classed under the generic name “ catarrh,” 
and so treated. What a multitude of sins that word has covered! 
The one symptom that patients most fear, and justly so, I have al- 
luded to—the foul smell from the nose; but it is in reality a rare one; 
it only occurs in the fetid or atrophic form of nasal catarrh, which is 
by no means so common as the other varieties, and in ozsena, but 
ozaena has nothing to do with nasal catarrh. Do not forget this: It 
only occurs in patients who are the victims of syphilis or struma 
—patients who have syphilitic necrosis of the nasal bones, with a 
stinking, purulent discharge, a discharge due to the presence of dead 
bone. The same thing sometimes happens in scrofulous subjects. 
Under these circumstances, then, you may have the fetid, stinking dis- 
ease, ozaena, but only under these circumstances. Do not call cases 
of nasal catarrh, even the fetid form, ozama; they have pathologically 
nothing in common. Remember, also, that fetid or atrophic catarrh DIAGNOSIS. 
19 
is, as I have said, unusual, and thus you are able at once to reassure 
your patient in regard to the most dreaded symptom. 
I have said this much in order to prove to you the necessity of your 
learning to recognize the varieties of nasal catarrhal disease; for not 
alone diagnosis, but, what is equally important, your correct views re- 
garding the questions of prognosis and treatment, will depend upon 
your acquirement of this knowledge. Some forms of nasal catarrh 
are curable, others are not. Is there, then, more than one form of 
“ nasal catarrh ? ” Most certainly; and you will learn to differentiate 
them. First, acknowledge the fact that they do exist. You will meet 
with three varieties: i. Simple chronic rhinitis (and let me say here 
that I prefer this term rhinitis to the one, “ catarrh, ” which is so 
commonly used); 2, Hypertrophic rhinitis; and, 3, Atrophic or Fetid 
rhinitis. 
Simple chronic rhinitis is, as the name implies, a chronic inflamma- 
tion of the nasal mucous membrane unattended by structural changes 
of any moment. Its only symptom is an increased discharge of mu- 
cus, or, if it has lasted some time, muco-pus. This discharge is thin 
and easily removable, there is no interference with the sense of smell, 
and no obstruction to respiration. The anterior rhinoscopic examina- 
tion will show you simply congestion of the mucous membrane, the 
latter flecked here and there by soft, easily removable, slightly yellow- 
ish mucus. As far as the amount of free space is concerned, it is nor- 
mal; there is no thickening or hypertrophy of the membrane. Pos- 
teriorly the rhinoscopic mirror will exhibit about the same appear- 
ances, except at the vault of the pharynx, where the glandular tissue is 
large in amount. Swelling of these glands gives a turgid aspect to the 
parts, and the secretion which covers them in, in part, is thicker and 
more tenacious — chronic pharyngitis may or may not coexist. Such 
patients do not, as a rule, consult you; the trouble is too slight, and un- 
less they are morbidly sensitive or easily frightened, they allow the 
pathological process, through ignorance of possible results, to con- 
tinue without treatment. Thus week by week, month by month, it 
continues, until the simple form of rhinitis develops into the second 
variety, which we term hypertrophic nasal catarrh, or rhinitis. We 
now have marked structural changes — a proliferation of all the normal 
elements of the mucous membrane, a true hypertrophy. The whole 20 
CHRONIC NASAL CATARRH. 
mucous membrane of the nasal passages, but specially that over the 
lower turbinated bones, is markedly thickened and relaxed; the plexus 
of blood vessels, a true erectile tissue, which underlies the membrane 
in the latter locality, becomes enlarged; the glands at the vault 
of the pharynx participate in the pathological process and likewise hy- 
pertrophy. Secretion is excessive, thick, and tenacious, showing that 
the glandular elements of the mucous membrane have not escaped. 
Such a hypertrophy of tissue, of course, occludes more or less, perhaps 
permanently and completely, but more commonly intermittingly and 
partially, the nasal passages; the patient breathes with difficulty, his 
voice becomes nasal in character, he experiences much discomfort, and 
decides, for the first time, to consult a physician. 
Fig. io. Simple hypertrophic rhinitis. 
Hypertrophic rhinitis, then (fig. io), will be the form of catarrhal dis- 
ease of the nose that you will oftenest be called upon to treat. Fortu- 
nately, you can give your patient great relief—but of this in one moment. 
Make now your anterior rhinoscopic inspection. You will see at once 
that the anterior extremity of the inferior turbinated bone on one, per- 
haps on both sides of the nose projects far out into the free space of 
the nasal passage — indeed, may lie against the nasal septum, and thus 
close the passage — that the mucous membrane covering it is thickened 
and congested, and hidden more or less by thick, muco-purulent dis- 
charge. The thickened membrane over the lower turbinated bone DIAGNOSIS. 
21 
hangs downwards, thus encroaching upon the inferior meatus of the 
nose. If you touch it with a probe, it indents deeply and recovers it- 
self slowly. The membrane covering the middle turbinated bone and 
the side of the septum are affected to a less extent, perhaps not at all. 
Posteriorly observe carefully in the rhinoscopic mirror the posterior 
extremities of both middle and inferior turbinated bones, but specially 
the latter. The mucous membrane is not only markedly hypertrophied, 
but has a peculiar rugged appearance; it is thrown into fissures and 
irregularities, and has a whitish appearance. A veritable tumor is thus 
formed, characteristic in its appearance and marked in its results, for 
it closes, by its bulk, more or less of the posterior nasal opening. This 
closure is also assisted by the thickening that will often be seen in the 
form of an irregular ovoid tumor upon the side of the septum (fig. n). 
Fig. ii. Ovoid thickening on both sides of the nasal septum. Hypertrophy of the 
tissues covering the posterior extremity of left inferior turbinated bone. 
At the vault of the pharynx both mucous membrane and glandular 
tissue are involved, the latter to the greater extent. Thus we see an 
irregular nodular tumor, traversed by seams and fissures, presenting a 
variety of aspects, according to the degree and kind of development, 
but always occupying and obliterating the normal, rounded, concave 
cavity of the vault. Chronic pharyngitis, frequently the follicular form, 
will also be present, and, occasionally, chronic laryngitis. 
As a result of this process of intra-nasal hypertrophy, in certain cases 
following it, when it has lasted some time, or, more rarely, occurring 22 
CHRONIC NASAL CATARRH. 
early in the disease, before hypertrophy is far advanced, the third 
form of nasal catarrh develops. This we call atrophic or fetid rhinitis. 
I have told you that it is by no means as common as the preceding vari- 
eties. It means this: Remember that in the hypertrophic form we had 
in the deeper layers of the tissues a deposition of newly developed con- 
nective and elastic tissue. This may cause two results: First, by its 
mere presence and amount, it may press upon, cause atrophy of, and 
destruction of function in, the glands and follicles which stud the 
mucous membrane. It crowds them to death, so to speak. This may oc- 
cur, as I have said, early in the disease; if later, as it commonly does, 
the process of atrophy of the mucous membrane, and especially of 
the glands, has a different explanation; it is now due to the contraction 
that takes place in the connective and elastic tissue that has been de- 
veloped in the hypertrophic form of the disease. The more and 
more firmly this becomes organized, as time goes on, the more and 
more completely does it compress and destroy the function of the 
secreting glands and follicles, and with them the mucous membrane 
in which they lie and the submucous structures—atrophy. Even 
more, if the process be long continued, the effect of this continued 
pressure, aided by the pressure of inspissated secretions or crusts, is 
exerted upon the turbinated bones themselves. Atrophy, interstitial 
absorption, is set up in them; they become smaller than normal, and 
the result is shown in the abnormally large, wide, roomy nasal pas- 
sages, covered by a tense, dry, shining mucous membrane, often with 
hard crusts of mucus covering it. In these cases you can often look 
directly through the nasal passage back into the pharynx, so wide 
is it. 
The symptoms that these pathological changes occasion are not as 
marked as in the hypertrophic form. There is plenty of room through 
the nose for the respiratory current to pass, hence there is no obstruc- 
tion to breathing experienced by the patient. The discharge, instead 
of being profuse, is scanty, and dries into crusts and scales. There is 
no interference with the timbre of the voice. The only symptoms, 
then, are interference with the sense of smell, as a rule, the atrophic 
process having extended upwards to the olfactory region, and affected 
the terminal fibres of the olfactory nerve, and general uneasy sensa- 
tions, sometimes amounting to pain, with excessive irritability and diagnosis . 
23 
sensitiveness to atmospheric changes. The rhinoscopic appearances, 
both anterior and posterior, are sufficiently indicated in my descrip- 
tion of the disease; I will not, therefore, dwell upon them. The pos- 
terior wall of the pharynx will be dry and shining, and without any 
enlargement of its follicles. 
So much for the atrophic form, but I have coupled with this term the 
one fetid. The latter condition follows the former closely—indeed, is 
part of it if it has lasted any time — and I see no need, clinically, to 
make a distinction between the two. Fetor is the direct result of the 
atrophy, in this way: The secretions are scanty and tenacious, as I 
have told you, and become more and more so as atrophy of successive 
follicles and glands takes place. The explanation of this is simple: 
The atrophic process has affected first and chiefly the serous glands, 
which are numerous in the nasal mucous membrane; their function 
is, by their secretion, to render the nasal mucus thin and watery, but 
this function being abolished by their destruction, the mucus secreted 
by the mucous glands, large numbers of which still remain intact, is 
viscid and tenacious; it adheres to the mucous surfaces, and rapidly 
desiccates in the respiratory current of air. Large crusts and scabs 
thus form readily and cling closely in the nasal passages and at the 
vault of the pharynx. Impacted in the narrowed parts of the canals, 
pent up beneath the turbinated bones, constantly growing in size by 
the addition of the secretions poured out beneath them and prevented 
from escaping, is it any wonder that putrefactive changes set in; that 
the matter thus imprisoned decomposes; that fetor is established; and 
not only this, but the irritation of the mucous membrane, caused by 
the presence of these pent-up purulent discharges — for from muco-pu- 
rulent to purulent they rapidly change — reinfects itself, so to speak, by 
its discharge, excites further discharges, and thus constantly aggra- 
vates the disease. 
So passes the atrophic form of rhinitis into the fetid — not always, 
though, fortunately for the patients, and not very rapidly in any case. 
The symptom of the condition now established may be given in one 
word: fetor — stinking truly in every sense, disgusting to the patient, 
disgusting to his friends, disheartening to the physician, who must 
acknowledge his inability to do more than relieve his patient —cure 
the condition which gives rise to it he cannot. The only difference, 24 
CHRONIC NASAL CATARRH. 
rhinoscopically, which is perceptible between the atrcphic and tetid 
stages of the disease is the increased amount of crusts and yellowish or 
greenish scabs, and, perhaps, the increased degree of space, due to the 
atrophy of all the parts upon which they lodge, which is seen in the 
latter variety. 
Let me now recapitulate. We see, clinically, three forms of chronic 
rhinitis: x, Simple, uncomplicated, chronic rhinitis; 2, Hypertrophic 
rhinitis; 3, Atrophic or Fetid rhinitis. Certainly these names and 
forms must be easy to remember. How important for your success in 
their treatment and views as to prognosis the remembrance of them 
and of their different pathological nature is, I have tried to impress 
upon you. Be sure, then (by means of the direct anterior and poste- 
rior rhinoscopic examination of the parts which I told you, early in the 
course, how to make), that you know just where your patient stands in 
die pathological scale. 
I turn, now, to a part of my subject which will have, perhaps, a more 
active interest for you — namely, the treatment of chronic rhinitis in its 
various forms. Here, again, I must limit my remarks. The medical 
journals teem with advice as to the proper methods of treatment. Ev- 
erybody has something to say about the way to manage chronic 
catarrh of the nose. Much that you read will not commend itself to 
your good judgment, to put it mildly. Some advice is reliable. I shall 
try to remember, in what I am about to say, that I am speaking to those 
who are, or who are about to become, general practitioners, and there- 
fore will not have at their command the elaborate apparatus, the many 
instruments, and the varied means of treatment possessed, perhaps, by 
the specialist, and while I am obliged, in order to make my lecture 
complete, to allude to all recognized methods, surgical as well as medi- 
cal, I intend to give you simple rules, by means of which any one of 
you can treat his cases. You will, of course, understand that I refer to 
uncomplicated instances of chronic rhinitis. If there coexist in given 
cases such complications as deflected septum, multiple hypertrophies, 
nasal polypi, exostoses, and cartilaginous thickenings of the septum, 
large hypertrophies, veritable tumors of the adenoid tissue at the vault 
of the pharynx, it is, perhaps, best that you should entrust them to the 
more skilled hands of those whose special studies and experience fit 
them to undertake the task. DIAGNOSIS. 
25 
First of all, let your patient clearly understand whether or no he re- 
ally has “ nasal catarrh;” you may, perhaps, give him much comfort in 
this way. If he has, make up your mind as to the particular form; 
upon this depends what you tell him in the way of prognosis, and what 
you ought to do in the way of treatment. In any event, let him clearly 
appreciate the fact that you cannot cure his disease in as many days as 
he has had it months or years — perhaps that you cannot cure it at all 
(in the atrophic or fetid form) —but that you can give him much relief 
from his most urgent symptoms. Honesty is here the best policy. In- 
form him that he will require some patience, you some regularity in 
his visits (as a rule, the domestic treatment of chronic disease of the 
nose is unsuccessful), that there is here no royal road to success, but 
that, with patience and persistence, much good can be done — that suc- 
cess often, much oftener than is commonly believed, can be attained, 
and by success I mean complete, permanent cure. 
Now, what are you going to do for your patient? First, you are to 
determine carefully whether any indications exist in the given case for 
general constitutional treatment, apart from local measures, and they 
not only often do, but are too often overlooked. If what we term a ca- 
tarrhal diathesis be present, if scrofula or herpetism can be proven to 
exist — in short, if the nasal catarrhal disease depend upon a diathetic 
condition — general treatment has primary importance. Cod-liver oil, 
iron, and the iodides, with other remedies that will suggest themselves 
in particular cases, should be given for long periods. Prophylaxis, 
likewise, should not be forgotten; the careful attention to all habits 
which proceed from due consideration of wise hygienic laws will often 
constitute an important part of the advice that you give to your pa- 
tient. Bathing, clothing, and temperature, friction and shampooing, 
will, in many instances, be a duty upon which you will insist. The 
question here arises whether any of the special agents of the pharmaco- 
poeia that have been from time to time recommended as having a useful 
therapeutic effect upon the mucous membrane of the respiratory pas- 
sages in a diseased condition are in reality of great value. I believe that 
this is questionable. I have made use of many and have never been 
able to convince myself that any one possessed a decided specific effect. 
Cubebs, ammoniacum, muriate of ammonium, and perhaps sulphur, 
have given the best temporary and sometimes permanent results. In 26 
CHRONIC NASAI. CATARRH. 
each case, however, their use has been associated with that of local and 
direct treatment of the mucous membrane. In many cases, on the 
other hand, the affection will appear as a purely local one, and can be 
met and conquered by local treatment alone. This is of unquestion- 
able value; the means we will consider in our next lecture. TREATMENT. 
27 
LECTURE ITT. 
TREATMENT. 
Gentlemen: A very essential principle in the local treatment of 
catarrhal affections of the nasal passages is thorough cleanliness; it 
underlies all others. There certainly can be little remedial value in the 
application of a medicated spray or powder that only reaches parts cov- 
ered and protected by a layer of thick, tenacious mucus, or, still less, 
those encased in an armor of hard, inspissated crusts. On the other 
hand, I am convinced that this matter of cleanliness, if the latter be 
understood to mean frequent, daily, even several times a day, syringing 
of the nose, is overdone, and that it does much harm. The comfort, 
fancied or real, that a patient experiences after the use of his “ nasal 
douche,” even though this relief be only temporary, as it always is, 
leads him to repeat the process with constantly increasing frequency. 
Instances are not unknown where patients will use a quart of a strong 
saline solution, under high pressure, through the nose several times 
daily. Physicians are not entirely guiltless in the matter, for it is not 
infrequently that the patient is misled by their belief that the cure of a 
nasal catarrh lies in the use of a “ douche.” Such practices, I repeat, 
are productive of no good, but much harm. Even apparent temporary 
good effects ultimately fail. The use of strong saline solutions in large 
quantity, passed through the nares under high pressure, is not infre- 
quently an efficient factor in the propagation, if not in the causation, as 
I believe that I have many times seen it, of a chronic inflammation of 
the delicate nasal mucous membrane, with its usual result of perma- 
nent infiltration of the mucous and submucous structures. All this 
rather than a means for its relief. 
While, then, cleanliness is essential, mechanical means for attaining 
it are to be used with great discretion. There is nothing curative in 
their employment — bear that in mind. They are by no means as gen- 
erally necessary as was formerly supposed. I believe that in my prac- 
tice I have discontinued their use in more than fifty per cent of cases, 
and the latter not only do just as well, but better, being relieved of an 28 
CHRONIC NASAL CATARRH. 
element of irritation. All instruments, then, for cleansing purposes, and 
I include here the “ nasal douche ” with its many modifications, an- 
terior and posterior nasal syringes, and the like — I even add cleansing 
sprays — are only necessary and are only to be used in exceptional 
cases of aggravated catarrhal inflammation, with accumulation of pent 
up or hardened secretions, and in cases attended by the formation and 
firm impaction in the passages of hard, dense crusts, as in atrophic or 
fetid catarrh and in ozaena. In simple chronic rhinitis, and in some — 
perhaps one-half— of the cases of hypertrophic rhinitis, their use is not 
required as a rule. The patient can readily remove the soft, semi-fluid 
secretions by simply blowing the nose; if he cannot, or if the secre- 
tions collect at the vault of the pharynx, one jet of spray containing 
some alkali or some “ Listerine,” -thrown by you behind the velum or 
into the anterior nares, just prior to the use of the medicated spray 
or powder, of which I shall speak in a moment, will be amply sufficient 
to loosen and remove them. 
Fig. 12. Nasal spray apparatus. 
Let us suppose, however, that you are called upon to treat a case such 
as I have described, where the use of some instrument is a necessity in 
order that the pent up or hardened secretions may be removed before 
you make your application of the remedial agent. What form of in- 
strument shall you use? Which method prefer? Never use a “ nasal 
douche;” it is an inefficient instrument for the purpose for which it TREATMENT. 
29 
was designed, insomuch as it does not thoroughly wash or cleanse the 
nasal cavities, even when carefully used. I prefer, and I strongly ad- 
vise you to employ, the instrument that I show you here (fig. 12), and 
which I devised some years ago. It is simply an apparatus arranged to 
throw a very coarse spray in the right direction into the anterior nares. 
The conical tip, you see, closes one nostril completely; the fluid then 
enters one nasal passage and passes out by the other. Power is 
obtained by means of a double hand-ball tube. We call it the “ nasal 
spray apparatus.” This apparatus is also manufactured by the David- 
son Rubber Company. Their device of lining the orifice of the nozzle 
with platinum is a useful one, and tends to preserve the working 
qualities of the instrument. The nozzle is fitted to the No. 61 continu- 
ous spray tube. With it the nasal passages and upper pharynx may, 
except in rare instances, be thoroughly cleansed of secretions and crusts 
bv the use of less than one ounce of the medicated fluid contained in 
its bottle or reservoir. Here, at once, is an immense advantage gained 
over the pint or even quart of fluid used commonly in the “ douche.” 
Being a coarse spray, it washes up, loosens, and dislodges the secretions 
(unless they are firmly impacted in extreme cases) by the constant 
commotion of the fluid in the nasal passages, and this very readily and 
quickly. Explicit directions are to be given in every case to the patient 
for its use. I have had them printed, and now distribute them to vou; 
they also accompany each box in which the instrument is sold. They 
are as follows: 
1. Warm the medicated fluid in the bottle before using by holding the filled bottle for 
a few moments in hot water. 
2. Hold the body erect and incline the head very slightly forward over the toilet 
basin. 
3. Introduce the conical nozzle of the apparatus into the nostril (first on the side 
most occluded) far enough to close it perfectly, holding at the same time the horizontal 
tube of the apparatus directly outwards from the face ; do not turn it from side to side 
or downwards, and make a trial of the spray by compressing the hand-ball once, to 
prove that the opening in the nozzle is not occluded in the nostril; then 
4. Open the mouth widely and breathe gently but quickly through it in a snoring 
manner; avoid carefully all attempts at speaking, swallowing, or coughing (at the 
moment that the fluid passes into the upper part of the throat from the nostril being 
operated upon, a desire to swallow will be experienced ; resist it, and the next second 
the fluid passes forwards through the opposite nostril). 
5. Hold the end ball of the apparatus firmly in the right hand (the left holds the 30 
CHRONIC NASAL CATARRH. 
bottle) and operate it briskly, until the spray of medicated fluid, which should be felt 
at once to enter the nasal passage, has passed around it and appears at the opposite 
nostril; at this moment stop. 
6. Remove the nozzle from the nostril, allow the surplus fluid to run out of the lat- 
ter; then blow the nose gently—never vigorously. 
7. Repeat the operation upon the opposite nostril. 
In the severer forms of nasal disease — those attended 
by the formation and impaction of hard, dense crusts 
and masses in the nasal passages and upper pharynx-— 
the use of this “nasal spray apparatus” will not be 
sufficient to dislodge them in the first instance, and a 
more powerful means (short of direct instrumental 
removal) must be employed. This result is best ob- 
tained by the “posterior nasal syringe” (fig. 13), of 
hard rubber or metal, with a long, curved nozzle, which 
is used to cleanse the parts posteriorly (by way of the 
upper pharynx and posterior nares). This procedure 
is always disagreeable, sometimes painful, to the pa- 
tient, and care must always be taken not to bruise the 
parts during the introduction of the nozzle of the 
syringe. Toleration will be established after a time. 
For cleansing purposes through the anterior nares-— 
an easier matter — the large, hard rubber syringe of 
the aurist answers the purpose well (fig. 14). 
Fig. 14. Anterior nasal syringe. 
Fig. 13. 
Posterior 
nasal 
syringe. 
Various cleansing and disinfecting solutions may 
be used by means of these instruments. I use with 
the “ nasal spray apparatus” either one of the follow- 
ing: TREATMENT. 
31 
R—Acidi Carbolici* 
Sndii Roratis 3 j 
Sodii Bicarbonatis 3j 
Glycerini J.i 
Aquae Rosa; 3 j 
Aquae ad Oj 
Or, still better: 
R—Sodii Bicarbonatis 3ss 
Sodii Boratis 3ss 
Listerine .- 3 j 
Aqua;, ad 3 iv 
The “ Listerine ” in the latter formula may not be familiar to you. 
It is a preparation that has been introduced by Lambert & Co., of St. 
Louis, containing the essential antiseptic constituent of thyme, euca- 
lyptus, baptisia, gaultheria, and mentha arvensis in combination. Each 
fluid-drachm also contains two grains of refined and purified benzo- 
boracic acid. Thus it may be used in this or in any of the other solu- 
tions of alteratives, astringents, and resolvents of which I shall have to 
speak (usually in combination with some proportion of water — from 
two to ten parts water to one part “ Listerine,” according to the indica- 
tions) as a menstruum, and will be found to serve a useful and pleas- 
ant purpose where an antiseptic is desirable. The thyme and euca- 
lyptus, besides being disinfectants, act also as stimulants to the mucous 
membrane. 
Where a much larger quantity of a cleansing solution is necessarily 
used, as with the anterior or posterior nasal syringe, simple warm 
water, with the addition of borax— ten grains to each ounce — or 
“Listerine” — in the proportion of one part to from two to ten of 
warm water — will answer the purpose. I sometimes — when the dis- 
agreeable odor is strong—use, after a thorough syringing with an alka- 
line solution, a spray of equal parts of “Listerine” and water; it 
destroys fetor very quickly, and substitutes for it the pleasant odor of 
the thyme. 
Let me say here — what you have probably noticed — that I use no 
sodium chloride in any of these cleansing solutions; I believe that it 
does more harm than good; that the saline solution favors endosmosis 
♦This quantity is necessarily often varied to suit the susceptibility of different mu- 
cous membranes. 32 
CHRONIC NASAL CATARRH. 
as it passes over the nasal mucous memorane, and therefore increases, 
rather than diminishes, intra-nasal swelling. 
Having shown you now how the parts may be cleansed, if this be 
necessary, I turn to the question of the direct medication of the disease 
which affects them. If I exclude for the moment the use of caustics 
and of surgical measures in the management of catarrhal conditions 
of the nares, the treatment is based practically either upon the employ- 
ment of various medicatedfluids, used in spray by means of some form 
of atomizer, or upon the use of medicated powders, applied with the 
anterior or posterior nasal powder-insufflator in one of its various 
forms. Both methods have their warm advocates. My own experience 
prejudices me strongly in favor of the spray. I believe that with a 
proper spray-tube, and a pressure of compressed air of about forty 
pounds to the square inch, no more perfect application can be made 
to the parts. This should always, if possible, be through the posterior 
nares. The patient depressing his tongue by means of a spatula, the 
velum palati must be drawn forwards — that is, away from the posterior 
pharyngeal wall — by means of a suitable metal hook covered by bougie 
material, which may be bought at the instrument maker’s under the 
name “Palate-Hook.” This procedure can be readily accomplished in 
all cases after a little practice, and is one that I regard as absolutely 
essential to the thorough success of the application, as it is the only 
way in which a practicable degree of space can be gained through 
which to throw the spray upwards and forwards through the nasal pas- 
sages. To attempt an application with the velum drawn upwards and 
backwards, closely approximated to the pharyngeal wall, is nonsense. 
In this position it will be found the moment that you introduce your 
spray-tube into the patient’s mouth, in nine cases out of ten. The 
palate-hook is held in the operator’s left hand, his right holds and 
controls the spray-tube, and the spray is thus thrown upwards into the 
vault of the pharynx and forwards through both nasal passages, so 
that it appears at both nostrils in a fine cloud. Such an application is 
thorough and complete, not painful, nor even very disagreeable, to the 
patient. That the results obtained by a series of such far exceed those 
obtained by any other method, ample experience has shown me. 
I prefer the high pressure of compressed air to the lower power so 
often recommended. I have never done harm to the mucous mem- TREATMENT. 
33 
brane with it, and the increased power of propulsion in the cloud of 
spray renders it possible to reach all of the many irregularities and 
recesses abounding in the naso-pharyngeal passages. I say nothing 
here except in condemnation of the practice of forcing a probe or 
cotton-holder, charged with a solution of nitrate of silver, up behind 
the velum in spite of the violent muscular contraction of the parts, or 
of the use of small brushes, called “post-nasal,” used in the same way, 
which, from their very size, form, and length, render it a physical im- 
possibility to reach the vault of the pharynx, still less the posterior 
nares, or to enter the latter; medication by such means amounts to 
little. 
Fig. 15. Compressed-air receiver, pump, and spray-tube 
But it is hardly to be expected that the general practitioner will be 
able to command the use of a costly compressed-air apparatus with air- 
pump and spray-tubes, such as I show you here (figs. 15* *6? *7> A, B) ; 
then, in default of this apparatus, the ordinary “hard-rubber atom- 
izers,” which can be bought at a moderate price everywhere, and 
which are constructed upon the principle of either Richardson or 34 
CHRONIC NASAL CATARRH. 
Bergson, must be used, and can be, with good effect (figs. 18, 19). A 
very good atomizer is manufactured by the Davidson Company, and 
Fig. 16. Hard-rubber spray-tubes.* 
Fig. 17. Automatic cut-off 
for spray-tubes.t 
* The “spray tubes” shown in the cut (fig. 16) are made of vulcanized rubber. The 
best and cheapest tubes, however, are probably those made of glass, but they are, 
of course, more fragile than the above or than those made of metal and nickel 
plated, which can, however, only be used with certain non-corrosive solutions. All 
of the above patterns (three constitute a set) can now be procured of the instrument 
maker. 
t This pattern of “cut-off” is preferred by some operators. A cheaper and, I 
think, abetter method is to attach the spray-tube to the connecting rubber tube com- 
ing from the air-receiver by means of a metal bayonet joint, and then control the air 
current through this tube by pressure of it with the thumb against the end of the 
spray-tube, or, if necessary — but it is less convenient — the connecting tube from the 
air-receiver may be simply slipped over the end of the spray-tube at the time the ap- 
plication is made to the throat with the latter, and the air current controlled by the 
thumb, as above described. 
I am frequently asked what form of air-pump — for use in compressing air in the 
cylinder used with the spray apparatus — is best adapted for the service, and will give 
the bert and quickest results. The pumps here figured have — one or the other — been 
in use in my office for the past eight years, and I can speak from experience, there- 
fore, as regards their merits. They are, I believe, the most desirable forms of appa- 
ratus that are now made for the purpose. They were manufactured for me by 
Hermann Weindel, of Philadelphia. TREATMENT. 
35 
Fig. A. Double-acting air-compressor. 36 
CHRONIC NASAL CATARRH. 
Fig\ B. Double-acting air-compressor for high pressures. treatment 
37 
culled nard-rubber atomizer, continuous spray, No. 61. In all the 
propelling power is developed by the use of the hand air-bulbs; these 
should always be double. The hard-rubber tube of the instrument is 
provided with two separate tips, so that the spray may be thrown up- 
Fig. 18. Hard-rubber hand-ball 
atomizer — continuous spray. 
Fig. io. Hard-rubber hand-ball 
atomizer — continuous spray. 
Fig. 20. Atomizer throwing 
a coarse spray. 
Fig. 21. Atomizer (with removable 
tip) throwing a coarse spray. 
wards (naso-pharvnx) or directly forwards (anterior nares). The 
disadvantages of this instrument, which make it inferior to the use of 
the compressed-air apparatus, are the length of time that it takes to 
develop the propelling power by means of hand-ball pressure, an im- 38 
CHRONIC NASAL CATARRH. 
portant point when the instrument is in position in an irritable throat, 
and the fact that both the operator’s hands are required to work it, and 
that, therefore, he can not use the “palate-hook” to draw the velum 
forwards. You will rarely find a patient with a throat tolerant enough 
to allow you to throw the spray, with this instrument, up into the 
vault of his pharynx and posterior nares without the use of the “palate- 
hook,” and you had better, therefore, confine yourself to applications 
made through the anterior nares and forced well back into the phar- 
ynx, if you use it. If no other instrument can be procured, the ordi- 
nary atomizer (figs. 20, 21) will enable you to make a fairly efficient 
application through the anterior nares. 
The most useful forms of powder-insufflator I show you here (figs. 
22, 23). One, you see, is arranged to deliver, by means of the air 
Fig. 22. Powder-insufflator for 
the anterior nares. 
Fig. 23. Powder-insufflator for the 
posterior nares. 
pressure developed by the hand-balls, a charge of the finely pulver- 
ized powder with which the bottle is charged into the anterior nares; 
the other, with a longer curved tube, performs the same operation in 
the posterior nares. 
Personally, I place very little reliance on the various “ pocket in- TREATMENT. 
39 
halers,” etc. (fig. 24), that are popularly recommended for the cure 
of “catarrh.” Ammoniated and iodized preparations 
sometimes exercise a temporary benefit, but they can 
also readily do harm, if used to excess. Remembering 
this, if you choose to recommend them for the moral 
effect they exercise upon your patient, I have no ob- 
jection. 
I ask your attention now to the specific remedial 
treatment of the various forms of rhinitis. Simple 
chronic rhinitis requires, first, thorough preliminary 
cleansing of the passages. This may be accomplished 
usually by the patient using his handkerchief, unaided 
by any artificial form of apparatus. If the latter, in 
exceptional cases, be requisite, use the “ nasal spray 
apparatus,” with one of the given solutions. The 
post-nasal syringe is never required in this form of the 
disease. Following the cleansing process comes the 
remedial, which must be undertaken by physician or 
patient, with at first daily and then gradually diminish- 
ing frequency, until, at length, a time is reached (after 
several weeks) when the patient is told to present him- 
self for treatment only when he develops, if he should, 
a recurrence of any old symptoms, or an attack of acute rhinitis. 
This consists in the application of the medicament, usually a mild al- 
terative, resolvent, or astringent solution or powder. If the spray ap- 
paratus, with compressed air and some medicated solution, be chosen as 
the means, as I advise, some one of the following formulae may be used, 
with preferably the post-nasal spray tube, but also with the anterior, or 
both. If the “ hard-rubber atomizer ” is the only instrument available, 
then the spray is thrown through the anterior nares. (1) Zinci Iodidi, 
gr. v-gj; (2) Zinci Sulpho-carbolatis, gr. v-gj; (3) Zinci Sulphatis, gr. 
v-gj; (4) Ferri etAmmonii Sulphatis, gr. v-gj; (5) Ferri Chloridi, gr. 
v-gj; (6) Acidi Tannici, gr. v-xx-gj; (7) Potassii Chloratis, Qj-gj, 
are the solutions that I most commonly use, given in the order of 
their preference. In any of these formulae “ Listerine ” may be sub- 
stituted, in part, for the water, in the proportion of one part of the 
former to three of the latter. I ordinarily do so. If the simple rhi- 
Fig. 24. 
Pocket inhaler 40 
CHRONIC NASAL CATARRH. 
nitis has advanced far towards the hypertrophic stage, then I com- 
mence at once with: Iodini Cryst., gr. iv; Potassii Iodidi, gr. x; Zinci 
Iodidi, gj; Zinci Sulpho-carbolatis, Qj; “Listerine,” §j; Aquae, ad 
giv, as a spray. These applications should always be selected with 
due deliberation, in view of the special indications presented by the 
case, care being exercised that the application is of such a strength as 
to cause no irritation of the nasal mucous membrane, one much more 
susceptible than that of the pharynx or larynx. A preliminary trial of 
the strength of the solution should always be made. 
In case these spray-applications are not well borne, or perhaps in ac- 
cordance with the special views of the physician, a medicated powder 
may be substituted. Powders are particularly adapted to the treatment 
of this form of the disease, where the secretions are readily removable, 
the parts soft and absorptive. In hypertrophic rhinitis they are, I be- 
lieve, of little use, and in atrophic or fetid rhinitis, contra-indicated. 
One such powder as, for instance, the following, may be applied by 
means of the anterior, or, if possible, the posterior nasal powder-in- 
sufflator that I have shown you: 
R—Acidi Salicylici grs. x • 
Acidi Tannici 3i 
Bismuthii Subcarbonatis 3i 
or one of these: 
R—Ferri et Ammonii Sulphatis t)i 
Pulv. Amyli J i 
M. 
R—Pulv. Iodoformi 3ij 
Pulv. Gum mi Camphor* 3i 
Pulv. Acidi Tannici grs. v 
Pulv. Gummi Acaciae, ad 3 ss 
M. 
R—Pulv. Morphinoe Sulphatis grs. i 
Pulv. Belladonn® grs. x 
Hydrargyri Chioridi mitis .• grs. xx 
Sodii Bicarbonatis grs. xv 
Pulv. Gummi Acacis, ad 3 ss 
M. 
Other combinations will suggest themselves. 
Whatever be the plan of treatment instituted, not alone in this, but 
in the other forms of rhinitis as well, and its details may readily be TREATMENT. 
41 
determined upon from what has and will be said. It is to be steadily 
persevered in, not necessarily in all cases under the direct manipula- 
tion of the physician himself, but certainly in all cases under his gen- 
eral supervision, and at suitable intervals, which will vary according to 
the grade of the disease, until the morbid conditions for which it 
was undertaken are alleviated. Daily applications at first, then three 
times weekly, then twice, and finally at increasing intervals, dependent 
upon the indications, until a period of at least eight to ten weeks has 
been covered, will be the rule. The necessity even now for the im- 
mediate treatment of any subsequent recurrence of old symptoms, 
which will quickly yield, and for any attacks of acute rhinitis, which 
may or may not occur, I have spoken of. All this is tedious to the 
patient, I know, but, gentlemen, there is no royal road to the successful 
treatment of nasal catarrh. 
In speaking to you now of the treatment of the nextform — hypertro- 
phic rhinitis —all that I have just said is applicable to its earlier stage, 
except that instrumental cleansing will often be requisite; that occa- 
sional use of the post-nasal syringe is a necessity, and that I prefer to 
•commence at once with the formula of iodine, iodide of potash, zinc, 
etc., that I have given you. If the disease is moderate in extent, and the 
hypertrophy of the tissues not excessive, complete resolution may be 
effected by these means. On the other hand, if the process be first 
seen, as it so often is, in its advanced stages, when a firmly organized 
neoplastic tissue exists in a large degree, and seriously encroaches 
upon, even occludes, the nasal cavities, associated with a chronic in- 
flammation involving the greater part of the upper pharyngeal mucous 
membrane, and hypertrophy of the adenoid tissue at the vault of the 
pharynx, the above plan of treatment, as a curative means, is useless; 
some alleviation of the more prominent symptoms may be obtained, 
but more heroic measures will be required to cure, chiefly the use of 
some means by which the hypertrophied membrane and tissues can be 
destroyed. I am bound to admit that it is in the use of these means, 
mainly surgical, and in this form of rhinitis, that you will attain your 
most speedy, complete, and brilliant cures. The destructive agents 
that are at your command are fuming nitric acid, glacial acetic acid, 
chromic acid, the galvano or actual cautery, and nitrate of silver. These 
I have mentioned in the order in which I would select them for use in 42 
CHRONIC NASAL CATARRH. 
any case. I now add the Jarvis ecraseur, and, for the adenoid growths 
of the pharynx, the post-nasal forceps. 
The little operation that I am about to describe to you first is one 
that you will often find necessary; you can readily perform it, and I 
assure you that it will give most gratifying results. 
Let us suppose a case of hypertrophic rhinitis in which you find the 
hypertrophied mucous membrane located mainly over the inferior tur- 
binated bone, in one or both nasal passages; there is partial, intermit- 
tent, or permanent occlusion occasioned by its presence. Take a small 
probe (fig. 25), its end wrapped in absorbent cotton, and saturate this 
Fig. 25. Hard-rubber probes. 
with nitric acid, press out the excess of acid, pass it then through a 
suitable nasal speculum into the naris to be operated upon, under the 
guidance of a good reflected light from your forehead mirror, and with 
a steady hand now draw it along, or press it firmly upon, the turbinated 
bone at its point of greatest convexity, contact being kept up for a few 
seconds. The pain quickly passes away, and on withdrawing the probe 
the parts are seen to have become well whitened or blanched; moder- 
ate inflammatory reaction with a slough of varying depth follows, 
while the consolidation of the submucous tissues by the hyperplastic 
results of the inflammatory process, and the contraction of the cicatri- 
cial tissue occupying the site of the destroyed parts, serve to reduce 
the hypertrophy and its resultant nasal obstruction in a most satisfac- 
tory manner. Frequently one application answers all purposes in 
freeing the nasal passage to the extent of allowing of uninterrupted 
respiration. The process, however, may require repetition. 
The operation with glacial acetic acid is performed in the same man- 
ner; it is less painful, causes little secondary inflammation, and destroys 
less tissue. This agent, then, may be selected for the more moderate 
and more recent cases of hypertrophy. TREATMENT. 
43 
Chromic acid is less painful in its use than nitric; its fumes, though, 
are distressing to the patient. It possesses no advantage, for our pur- 
pose, over the other two. 
The galvano or actual cautery, either for the destruction of tissue in 
the nasal passages or at the vault of the pharynx, is, of course, a radi- 
cal and efficient agent. I allude to the former; the latter is hardly 
ever used. Its action is rapid, complete, and not very painful, but as 
its use requires much skill, especially when employed in the naso-pha- 
ryngeal region, you will probably prefer to entrust such cases to the 
hands of the specialists. Instances where it will be required are not 
very many, for I believe that we may accomplish the same results with 
Fig. 26. Galvano-cautery instruments. 
less heroic means. The instruments are shown here (fig. 26), and a 
description of the method of using them will be found in most works 
on diseases of the throat and nose; to these I refer those of you who 
care to pursue the subject. 
Nitrate of silver, as a destructive agent, I mention but to condemn. 
It causes but a superficial slough, and the application is of necessity 44 
CHRONIC NASAL CATARRH. 
frequently repeated in treating hypertrophied tissue of any extent; 
moreover, owing to its powerfully stimulating qualities, it excites cell 
proliferation, and causes structural changes that are not desirable. 
After the use of any form of caustic in the nasal passages, immedi- 
ately upon the withdrawal of the probe, the parts should be flooded 
with an alkaline solution. The subsequent treatment of the case, at 
least until the slough has separated and the resultant ulcer healed, is 
based upon ordinary principles of cleanliness 
Fig. 27. Hypertrophy of the tissues covering the anterior extremity of the right infe 
rior turbinated bone. Slight deviation ot the cartilaginous septum to the left. 
Now, there are two forms of hypertrophy of the tissues over the in- 
ferior turbinated bones that are occasionally met with clinically, and 
which can not be successfully treated by any methods of which I have 
thus far spoken. The operations for their relief need, then, a special 
description. You will be able to perform them readily when you have 
acquired a little skill in intra-nasal surgery. There is no reason why 
you should not attempt them. The first is where the hypertrophy is TREATMENT. 
45 
excessive, and is mainly limited to the anterior extremity of the turbi- 
nated bone (hg. 27) ; to remove it, which you must do surgically, the 
procedure devised by Dr. Jarvis should be undertaken. The growths are 
usually sessile, but can be readily engaged in a loop of tine steel wire 
passed through a dnWcatcecraseur, devised by the same surgeon, if their 
base be first transfixed with a slightly curved needle (fig. 28), until the 
Fig. 2S. “Jarvis’” set of transfixing needles. 
point projects above the growth into the nasal cavity. The wire loop 
is then arranged in such a manner that the portion of the needle pro- 
jecting from the nostril, as well as the needle’s point, is encircled by it, 
very much after the manner of a hare-lip suture. The wire loop is thus 
prevented from slipping off, and a portion of the hypertrophied tissue 
is readily secured, and is removed by screwing down the milled nut of 
the ecraseur and drawing the wire home. This little operation is 
quickly done, and is not very painful or bloody; the relief that it 
affords is great. 
Fig. 29. Kxcessivc hypertrophy of the tissues covering the posterior extremities of 
both inferior turbinated bones. 
More common than the above is excessive localized hypertrophy of 46 
CHRONIC NASAL CATARRH. 
the mucous membrane covering the posterior extremities of the infeiior 
turbinated bones. It may be, as I told you in the second lecture, of such 
an extent that nearly the whole posterior naris is occluded by an ir- 
regular, grayish or whitish, sessile tumor, which projects outwards into 
the free space of the pharynx (fig. 29). Owing to 
its peculiar position it can not be safely reached and 
destroyed by any caustic method; removed it must 
be to cure the patient. The small ccraseur already 
mentioned, and here shown (fig. 30), affords a sat- 
isfactory and efficient means for its entire extirpa- 
tion. The instrument is passed through the nasal 
passage upon the affected side, the size and location 
of the growth having first been carefully studied, and 
the form of the wire-loop arranged accordingly, and 
no great difficulty will be experienced in ensnaring 
it. Slight traction on the instrument and a few 
turns of the milled nut will now receive it firmly in 
the loop, and the mass is then slowly cut through 
by tightening the wire. This little operation alone, 
if judged by its results, constitutes one of the most 
marked advances of recent rhinoscopic surgery. 
Fig. 31. Adenoid vegetations. 
Still another special operation is required in cases 
in which the hypertrophy of the glandular struct- 
ures at the vault of the pharynx is excessive, as is 
so often seen in young subjects, the victims of a 
Fig- 3°- Jarvis’ ecra 
seur — straight and 
curved. TREATMENT. 
47 
nypertrophic rhinitis. The tumor thus formed, which we term adenoid 
tumor or adenoid vegetations, varies, as I have said, greatly in size and 
configuration (fig. 31), but if it be large enough to interfere with nasal 
respiration, if it modify the voice and threaten danger to the middle ear 
by pressure upon the Eustacian orifices, if it give rise to excessive se- 
cretion and cause general discomfort to the patient, there is no question 
but that its removal is indicated. On the other hand, I would warn you 
against the too ready and indiscriminate extirpation of these tumors. 
A certain degree of thickening of the tissues at the vault of the phar- 
ynx is not an uncommon condition in young children who suffer 
from no symptoms of nasal catarrh. Again, this structure atrophies 
normally towards puberty. To interfere with it surgically, therefore, 
simply because it exists, seems to me to be a grave mistake. 
Should you determine, however, after what I have said, that its re- 
moval in a given case is proper, resort at once to surgical measures, 
for medicated sprays are totally ineffectual, and caustics are of little 
use, as well as difficult of thorough application. A pair of long for- 
ceps, such as I show you here, suitably curved to be passed behind the 
velum, and furnished with cutting blades at their extremity (Woakes’ 
forceps, modified by Semon), will be the best means. Another form 
Fig. 32. Post-nasal forceps. 
of forceps is shown in the cut (fig. 32). With either you may under- 
take the operation with confidence, even though you possess but lim- 
ited experience. With care and some anatomical knowledge you can 
do no harm to contiguous parts; the operation, seemingly formidable, 
is, in reality, simple. Hemorrhage is slight, ceases spontaneously, 
and inflammatory reaction is never such as to excite any apprehension 
— at least such is my experience. When the hypertrophy of the tis- 
sues extends broadly, in the shape of small, slightly elevated nodular 48 
CHRONIC NASAL CATARRH. 
masses, over the entire pharyngeal vault, a sharp 
curette, such as is used in uterine operations (fig. 
33), but suitably curved to pass behind the velum 
into the upper pharynx, will answer a better purpose 
in scraping away the vegetations than the forceps, 
which would here be difficult of exact application. 
I need not detain you long in speaking, in con- 
clusion, of the local treatment of atrophic or fetid 
rhinitis. Unfortunately, the disease is beyond our 
powers of cure. The best that we can promise the 
patient is to mitigate his urgent symptoms. I am 
well aware, in making this statement, thrtt some 
profess to cure; I have not been so fortunate as to 
obtain this result. Our indications for treatment 
are twofold: First, to cleanse and dl infect, and 
then to keep clean and disinfected, the nasal pas- 
sages of all decomposing crusts and secretions; 
and, second, to stimulate the atrophied mucous 
membrane, with a view to the regeneration of func- 
tion and character of secretion in the muciparous 
follicles and serous glands, if this latter can be ac- 
complished, a matter which my experience has led 
me strongly to doubt. The first indication is met by 
the daily use of the anterior or posterior nasal syr- 
inge, occasionally by the necessary direct removal 
of hard crusts by means of forceps, and thorough 
washing of the passages with an antiseptic and al- 
kaline solution until all offending secretions are 
removed. I have given you some formulae suit- 
able for this purpose; others are: (1) Glyceriti 
Acidi Carbolici, 3jss> Sodii Boratis, Aquae, Oj; 
(2) Liquoris Potassii Permanganatis, 5jss> Sodii 
Boratis, Aquae, Oj; £3) Acidi Salicylici, gr. x, 
Sodii Bicarbonatis, Aquae, Oj. I, as well as 
my patients, prefer the solution with “ Listerine,” given aibove (Sodii 
Bicarbonatis and Sodii Boratis, aa Jss, “Listerine,” gi, and Aquae, 
ad Siv). 
Fig. 33- Curette. TREATMENT. 
49 
The second indication requires the use of such drugs as Sanguinaria 
(3"-3ss)> (3SS~5SS)> Salicylic Acid gss), Iodine (gr. i-ii- 
Bromide of Potassium ([i)i-gss), etc., which are recommended as 
efficient in the early stages of the disease. They are mentioned in the 
order of preference, and should be used in powder with gum acacia, by 
means of the insufflator. They probably act by giving rise to a local 
irritation of the mucous membrane, which in turn leads to a stimula- 
tion of the glandular structures, and an increased discharge of serum 
and mucus. Some advise, on the contrary, Nitrate of Silver in pow- 
der diluted with starch (gr. and say that it has given good 
results. As next in effectiveness, is recommended the use of a weak 
solution of the Sulphate of Iron and Ammonia (gr. aquze). 
My own experience with any of these means has been limited; such as 
I have used have been ineffectual in their results, and I can therefore 
only reiterate my belief that, in the present state of our knowledge, 
the disease is incurable. 
This finishes, gentlemen, what I have to say to you upon this special 
subject of chronic catarrhal diseases of the nose. My remarks have, 
necessarily, been drawn out to some length, and have occupied some 
time; if, however, I have succeeded in convincing you that all is not 
simply “ nasal catarrh ” that comes to your net, if I have taught you to 
recognize, by my descriptions, the various forms of chronic rhinitis, 
and shown you how to treat each intelligently, according to its indi- 
vidual indications, the time will not have been misspent, and the pur- 
dose of these lectures has been accomplished.