SEVERE HEMORRHAGES FROM THE NOSE, 
BY 
W. FREUDENTHAL, M. D., 
Instructor of Diseases of the Nose and Throat, New York Post-Gradu- 
ate Medical School and Hospital- Surgeon to St. Mark’s Hospital; 
Attending Laryngologist to Montefiore Home and 
the German Poliklinik. 
Reprinted from 
THE POST-GRADUATE, 
March, 1894. Meriden Gravure Co., Meriden, Conn. Severe Haemorrhages From the Nose.1 
BY 
w. FREUDENTHAL, M. D., 
Instructor in Diseases of the Nose alM Throat, New York Post-Graduate Medical 
School and Hospital; Surgeon to St. Mark’s Hospital; Attending, etc., etc. 
Most haemorrhages from the nose originate from the anterior 
half of the septum, especially from the lower and middle por- 
tion of its cartilaginous part, while bleedings from other parts 
of the nose are much less frequent. The lower turbinated body 
and the posterior part of the septum are but seldom mentioned 
by authorities, The middle turbinated bone is, exceptionally, 
the source of haemorrhage. 
As I have had occasion to observe some extremely severe 
haemorrhages from the middle turbinated, I shall give you the 
details below. From the start, I wish to say, that they are 
sometimes so violent in character, that the life of the patient be- 
comes imperilled in a short time. 
The first case was as severe as I had ever witnessed, and, I 
hope, never again to meet one of similar severity. It was, in 
fact, the most severe case of haemorrhage of the nose of which 
I had ever heard. This is, in short, its history: 
Four years ago, a Mrs. G., native of England, 38 years of age, 
was sent to me by her family physician. She had been treated by 
him for diabetes, and she now experienced some trouble in the 
nose and throat. A few years before, she had been laparoto- 
mised, and at the place of the cicatrization, a hernia had develop- 
ed. I found in the generally healthy looking woman an hyper- 
trophic rhinitis, post nasal catarrh, and a large hyperplasia of 
the tonsil of the tongue. I decided to cauterize the turbinated 
bodies, and so informed the patient, assuring her that there was 
no danger of haemorrhage. I therefore, used the galvano-cau- 
tery on the left middle turbinated body, in a careful manner. 
When, a few minutes later, the lady rose from the chair to go 
home, a mass of blood rushed from the nose, as if suddenly a 
large artery had been cut. The blood flowed from her 
'Read before the Clinical Society, January 6th, 1894 
1 nose and mouth, and all my endeavors to tampon the anterior 
nares were in vain. Post nasal plugging, tried afterwards, if 
anything, only increased the alarming flood. The loss of blood 
was so great, that I seriously feared the woman would expire 
any moment of acute anaemia. At the same time, I dared not 
leave my place and call for assistance, for fear she might fall 
from the chair. Finally, the bleeding ceased to that degree 
that only a small quantity ran from the left nostril. I rose 
quickly and fetched iodoform gauze. Afterwards, while re- 
moving the cotton from the nostril, I succeeded in catching a 
hurried glance of the left middle turbinated body, out of which 
an enormous quantity of blood rushed. However, after a short 
time, I succeeded in stopping the haemorrhage by firmly insert- 
ing a piece of iodoform gauze from the anterior nares. 
This epistaxis was so profuse that not alone the outer gar- 
ments of the lady and my own were saturated with blood, but 
also a pool of blood lay on the floor. As the patient persisted, 
I sent her home in a carriage. Ten hours later, the bleeding 
had stopped, and the tampon was removed, but, as a matter 
of precaution, it was replaced by a new one. Next morning, 
renewed haemorrhage, which, in my absence, was stopped by a 
physician, living in the neighborhood (Ferr. sesquichl. Ergot). 
During the evening of the same day, I removed the tampon, 
which had a disagreeable odor. The patient, complaining of a 
very bad taste and smell, I syringed her nose daily with a slight 
solution of permanganate of potash, without the re-occurrence of 
severe haemorrhage. However, at intervals of four to five days, 
three more haemorrhages occurred, while the patient was rest- 
ing quietly in bed. These were by no means so alarming as 
the first one. No local cause was apparent. 
The woman was no bleeder, as she had been successfully 
laparotomised by Dr. Gerster, a few years ago. As the septum 
and its adjacent parts had not been wounded in the least by the 
slight galvano-cauterization performed by me, I was convinced 
that the principal bleeding came only from the spot, which had 
been touched by the galvano-cautery, i. e., from the middle tur- 
binated body. So, this case cannot be clearly explained. 
It is a known fact, that patients with diabetes and the result- 
ing diathesis are predisposed to haemorrhages. One cannot, 
however, hold Mrs. G.’s diabetes responsible for such a tre- 
2 mendous bleeding-, following such a very mild treatment. And 
I should not like to have this case cited as opposing the use of 
the galvano-cautery in diabetic cases, as I have before and 
since repeatedly done so, without any haemorrhage following. 
In the practice of every specialist, such an accident may oc- 
cur, but, as yet, we do not know the reason. 
Incidentally, I might mention, that this case proved very 
disagreeable in another direction, and I simply wish the fol- 
lowing sentence to serve as a warning to my colleagues, who 
might, at some time, be similarly served. 
I treated the woman for several weeks on account of her 
subsequent anaemia, and when she finally reached her 
statusquo ante I sent her my bill. She answered it by a suit 
for damages, on account of malpraetice for $10,000. Some one 
of her friends had told her the physician ought to fore- 
seen and avoided such a haemorrhage. Happily, the difficulty 
ended by the suit being thrown out of court. 
The two other severe cases of haemorrhage which follow 
were cases of vicarious menstruation. This is the form of ep 
istaxis, which takes the place of a menstrual flow in women, or 
for any periodical haemorrhoidal bleeding. Perhaps, some 
or most of you have seen such cases, but, as a rule, they 
are not frequently met with. Their explanation requires our 
careful consideration, as, according to Schroeder, such regular 
vicarious bleedings may occur even in man. Besides, the two 
cases following are exceptionally severe, and this is another 
cause, why we report them. 
The first case, a woman, where the diagnosis of a vicarious 
menstruation was beyond doubt. She was 46 years of age, and 
had not menstruated in a year. For seven months, she had 
nose bleedings regularly at the time of her menstruation. On 
the 21 st of December, 1892, this first occurred, but she attached 
no importance to it, as the bleeding was slight, continued but a 
few days, and then stopped spontaneously. This re-occurred 
on the 20th of January and on the 22nd of February, 1893. She 
could not definitely remember about the month of March, but 
thought she bled slightly from the nose. On the 23rd of April, 
she awoke with a dreadful headache, and towards evening she 
had such a severe haemorrhage from the nose, that she was 
obliged to call her physician. He succeeded in stopping the 
3 bleeding almost entirely, and in the evening of the next day, it 
ceased. On the 22nd of May, the same thing was repeated, 
with the exception that the physician had to apply different 
styptics, before the bleeding stopped. On the 20th of June, she 
had, without any preliminary symptoms, a haemorrhage which 
was more severe than any of the preceding. Three physicians 
attended her, and plugged the post nares by means of Bellocq’s 
canula. Nevertheless, the bleeding did not cease, and the wom- 
an gradually grew weaker. She refused to go to bed, for fear of 
increased bleeding, but sat fully twenty-four hours upright in 
her chair. During that time, different attempts had been made 
to stop the epistaxis, but in vain. 
When I arrived, she was reclining in the chair, supported by 
two women. She was deathly pale, and the pulse could hardly 
be felt. I thought of transfusion of a physiological salt solution, 
but decided at once to make another attempt to stop the bleed- 
ing, which seemed to me the indicatio vitalis. I had the woman 
placed upright in the chair, her head being held by my assist- 
ant. Then, very cautiously I removed the gauze from the 
pharynx and nose. During this time, the patient had to be 
constantly stimulated. I observed that the principal 
bleeding originated from the posterior lateral portion 
of the middle turbinated body. From this source of the bleed- 
ing, it appeared to me that the post nasal plugging as done by 
the physicians before I arrived, was partly justifiable. In the 
generality of cases, I do not approve of plugging from behind, 
and I, therefore, determined, as in my usual custom, to plug 
from in front. 
At first, the bleeding was so profuse, that the patient fainted 
several times. At last, I inserted a firm tampon so far back that 
it caused a [[strong pressure upon the bleeding vessel, 
and almost immediately, the bleeding stopped. Three weeks 
later, I saw the patient in my office, and after a careful 
examination, found nothing abnormal in her nose except 
slight exostosis on the right side. This proves that the 
bleeding did not depend upon a local cause in the nose. The 
woman had slight haemorrhages in July and August, and has 
since completely recovered. 
The second of such cases was a woman, 49 years of age, in 
the menopause. For the last two months before I attended 
4 her, corresponding to the menstrual period, she had nose bleed- 
ing. The third month it was so severe, that she consulted a 
physician, who treated her for eight days. I was called in 
consultation and I found a very anaemic and extremely nervous 
woman. She could not be induced to sit up, but was lying on a 
bed, resting on her side, in a small, badly lighted bedroom, con- 
tinuously spitting small quantities of blood. Finally, by serious 
threats, I induced her to sit up in her bed. The bleeding was 
thereby increased, but it served my purpose, as I could thus in- 
sert a firm tampon of iodoform gauze towards the one visible 
bleeding spot at the anterior border of the middle turbinated 
body. In a short time, I stopped the haemorrhage. For an hour, 
bleeding ceased entirely, when, suddenly, the patient began to 
spit blood again. As there was no blood running from the ante- 
rior nares, it was evident that another vessel further back had 
begun to bleed. I, therefore, removed the tampon, but no in- 
dividual point of bleeding could be detected, as the blood 
poured from all parts. Then, under great difficulties, accom- 
panied by a great loss of blood, I put in a new one as far back 
as possible. This time, I brought the epistaxis to a complete 
and final stoppage. The woman had, in the next month and in 
each of the two months following, nasal haemorrhages which 
were slight in character. And although she seemed to recover 
from these attacks, she died lately of general debility. 
There is another class of haemorrhages from the nose, which 
I should like to mention this evening. They are not so severe, 
but much more frequent, originating from the anterior part of 
the septum and caused by dryness in the nasal mucosa. Sup- 
pose we have a patient with enlarged turbinated bodies, or 
the like, in whom breathing through the nose is impeded, if 
the occlusion be in the posterior portion of the nasal cavity,, 
the anterior parts will become dry, because the secretion dries, 
on the surface of the mucous membrane. The patient will try 
to get rid of the sensation caused therefrom, by boring with the 
finger, or the like. The consequence will be that the mucosa, 
is eroded, and bleeding sets in. Or, we have a case of rhinitis 
sicca, with or without formation of crusts. FI ere, the irritation 
from dryness will be increased, and the desire to remove the 
crusts will become much more urgent. 
5 In such cases,a bleeding occurs much more frequently,and if 
you do nothing else but cauterize the bleeding vessel, according 
to Kiesselbach and others, you will for the moment stop the 
haemorrhage, but the dryness of the mucous membrane and the 
fragility of the blood vessel will increase still more. Very soon, 
at a neighboring or at the same spot, a vessel will rupture, 
causing a new epistaxis. Such cases I have seen relatively 
often. Only two months ago, a gentleman came to me, who 
had been repeatedly galvano-cauterized in the anterior region 
of the septum described by Kiesselbach. As the bleeding did 
not stop, but returned again and again, he consulted another 
physician, who treated him in quite the same manner. There 
was no improvement, and finally the patient became so weak 
by the permanent loss of blood, that he had to be brought in a 
carriage to my office. I found a generally dry condition of the 
mucous membrane, with abundant formation of crusts and 
scabs. They adhered so tightly to the mucosa, that the most 
careful attempts to remove them caused a fresh haemorrhage. 
On the anterior part of the cartilaginous septum was a bleeding 
vessel. I did nothing else but stop the bleeding by simple 
tamponing with a pledget of cotton, and then soften the 
crusts. The next day, I saw how fragile the mucosa was and 
that any attempt, be it ever so delicate, to cauterize it, would 
make it still more dry and fragile. I went on with my treat- 
ment of softening and removing the crusts, day by day, with 
the satisfaction, that the patient had only few more slight bleed- 
ings, which stopped shortly and then entirely. Afterwards, I 
treated his rhinitis sicca. 
But, gentlemen, what becomes of those cases, when the 
bleeding is but small, and the patients are not treated at all? 
The patients keep on boring with the finger, and gradually out 
of an erosion, an ulcer develops, which finally ends in that 
condition, which was called by Voltolini “Ulcus septum nasi 
perforans.” 
Allow me to cite three cases, which correspond to the 
three stages described by Hajek. 
Case i. Woman aet. 32 years, was sent to the German 
Poliklinik, on account of bleeding from the nose, which had 
lasted several weeks. At the rhinoscopic examination, we 
found on the right side of the cartilago-quadrangularis, at its 
6 anterior portion, a grayish white discolorization of the super- 
ficial layer of the mucosa and partial superficial ulceration. 
The surrounding parts of the ulcer were much swollen 
and injected. The ulcer, therefore, was, according to Hajek, 
in the first stage. Neither Syphilis nor Tuberculosis were to 
be found. 
Case 2. Was a woman, 60 years of age, who, during the two 
to three previous years, had suffered from occlusion of the nose. 
She was then treated by a physician and her condition im- 
proved. This year, a return of the same complaint occurred. 
Inability to breathe through the nose to so great a degree that 
she cannot sleep at night, dryness in the mouth, etc. Her con- 
dition objectively is such, as you see perhaps very seldom. I 
cannot remember having found it in literature. On the left 
side of the cartilaginous septum, at its anterior part, you see a 
pretty deep excavation, in which you could place the tip of the 
little finger. This excavation is lined by a very thin mucous 
membrane, on which you can plainly see cicatrices. The sur- 
roundings appear normal. However there is no atrophy of the 
other parts of the mucosa to be seen. There are, besides, 
hypertrophies of the turbinated bodies and other anomalies 
present, which do not pertain to my subject. Being questioned, 
the woman admits, that formerly she used to bore her fingers 
into her nostril, especially when she first had the occlusion in 
the nose. Therefore we conclude, that she had thus produced 
an ulcer, but, after the impediment in breathing was removed, 
most likely, the result of the treatment, the irration ceased and 
the ulceration healed. So, this is an exceptional case of a 
traumatic ulceration of the cartilaginous septum, not coming 
to a perforation, but healing previously by cicatrisation. I am 
convinced, had she not resumod treatment, the renewed irrita- 
tion would have been strong enough to produce a complete 
perforation. The woman looks ruddy and healthy and has 
neither syphilis nor tuberculosis. 
Case 3. A carpenter, 65 years old, who, seven years ago, 
was taken with pains in the left supraorbital region, which soon 
became very violent. They ran along the entire left side of the 
nose and gradually spread over the whole left side of the face. 
The most pronounced pain was in the region of the canine 
fossa and at the ala nasi, as well as in the alveolar process of 
7 the left superior maxilla. It is evidently a case of neuralgia of 
the infraorbital nerve. For these same complaints, patient 
went two years ago to the German Poliklinik. He was very 
nervous and excitable, and continually worked his finger into 
his nose, and this in such a comical, manner, that one could 
not suppress laughter. He said: “It itches and beats and 
scratches constantly within this nose, so that I cannot sleep,” 
and he cannot follow his vocation as carpenter. 
Besides an hypertrophy of the left lower turbinated body and 
a slight dryness, nothing abnormal was found in his nose. The 
hypertrophy was cauterized, but without the slightest success, 
and the patient soon after disappeared. A year ago, he re- 
turned with exactly the same symptoms, to again disappear 
after a short time. This winter he returned for the third 
time with the new complaints of frequent nose bleeding and a 
dry sensation in the nose. When, on examination, I found a 
perfectly developed perforation of the cartilaginous septum, 
imagine my surprise. The perforation was oval and ran from 
the left lower to the right upper portion. The opening was 
larger on the left, than on the right side. The mucous mem- 
brane on the borders extremely thin and smooth, no fresh ul- 
cerations. I asked myself where this perforation originated, 
and of course, thought of syphilis. Although absolutely no 
other symptoms existed, the patient got K. I. in large doses, 
without any result whatsoever. Inunctions led to the same 
negative success, and as there was no tuberculosis, we naturally 
came to the conclusion, that this was a genuine case of perfo- 
rating ulcer of the septum. 
Gentlemen, these last three cases do not strictly belong to 
our theme, but it is my intention to show you by them, that 
they are the initial stages leading to many a severe haemor- 
rhage. 
Such a similar opinion was already expressed by Lefferts and 
Beverley Robinson. Beverley Robinson (N. Y. Medical Jour- 
nal, 1887. Note on a frequent cause of nasal haemor- 
rhage), in speaking of cases of a severe epistaxis, says, in the 
majority;of instances, there was a more or less advanced stage 
of atrophic rhinitis evident. While I cannot quite agree with 
Robinson as to the frequency of these cases, I must emphat- 
ically say that they do occur, and I am utterly surprised to read 
8 Bosworth’s view on this subject, who says: “ It is often stated 
that epistaxis is met with as the result of erosions, which occur 
in connection with the incrustations on the septum in atrophic 
rhinitis. Neither ulceration nor erosion ever occur, I think, in 
atrophic rhinitis, and furthermore, the incrustations, as a rule, 
do not form upon the septum.” 
My cases, together with those previously reported by others, 
will, I hope, disperse every doubt in this matter, to the majority 
of physicians. 
Lefferts1 describes as early as 1882, that condition afterwards 
called by Voltolini: “Ulcus septi nasi perforans,” and recom- 
mends avoidance of the habit of boring with the finger and the 
prevention of the crust formation upon the abraded surface by 
vaseline. While I have noticed that the crust formation is 
mostly on the eroded or ulcerated spot, I have very frequently 
seen crust formations in all other parts of the nose too, a fact 
which Lefferts does not mention, and which makes me 
that he did not mean to speak about atrophic rhinitis. 
The treatment advocated in these cases is in accordance with 
the views as to the origin of the bleeding. 
Robinson, who, like me, has seen such cases of atrophic 
rhinitis with their sequelae, condemns the use of the galvano- 
cautery. He says (loc. cit.) “ Particularly would I refer in this 
connection (i. e. atrophic rhinitis) to the injurious effects of the 
galvano-cautery, which I have known to render a slight affec- 
tion, lasting and very troublesome, by producing raw surfaces 
very difficult to heal in the subjects of this special form of nasal 
disease.” Chiari and others, among them, Cresswell Baber, 
(in Burnett’s System of Diseases of the Ear, Nose and Throat), 
only lately recommended the galvano-cautery, while Bosworth 
and others are in favor of nitrate of silver or chromic acid, 
without however referring to atrophic rhinitis at all. 
We all know that most of these bleedings of traumatic origin 
are slight and stop spontaneously, but, that the above men- 
tioned method of cauterization, whenever the epistaxis is a 
little more severe, is a wrong one, is so decidedly my convic- 
tion, that I have given up using it entirely for such cases, and 
I hope to come to better results without it. I go further and 
IGeo. M. Lefferts: A Practical Point Concerning Epistaxis. Med. News, Vol. 40 
1882, page 100. 
9 say that in dry rhinitis, combined or not with crusts, this meth- 
od of treatment is exactly contradicted. By a slight search, 
you will actually find a bleeding vessel on the septum. A very 
superficial examination will show any one the bleeding point. 
In the numerous cases, however, of this kind, which I have 
seen, there was absolutely no positive necessity to use the gal- 
vano-cautery, in order to stop bleeding, as a very simple tam- 
ponade suffices in most cases. The bleeding having once 
ceased, then treat the primary cause, i. e., the atrophic or hyper- 
trophic condition of the nose, and you will prevent the return 
of it in all cases. 
The other class of haemorrhages has been seen quite seldom, 
although Shurly claims, (Epistaxis. The Medical Age, page 
375, 1884), that as a vicarious menstrual flow, they are frequent- 
ly met with. Furthermore, John Mackenzie, Elsberg, and 
especially Joal (Mont-Dore) have shown the genital origin of 
Epistaxis in some cases. 
The last mentioned author especially tries to demonstrate, 
how, during adolescence, an engorgement of the corpora cav- 
ernosa of the nose takes place by sexual excitement of a physi- 
ological or pathological nature. A rupture of the capillaries 
and with this an epistaxis, can easily be the result of it. To 
prove this, he cites, among others, also very interesting cases 
of onanism. 
One very interesting case had been previously reported by 
Obermeyer1 . It was that of a servant girl, 24 years old, 
who had just recovered from typhoid fever, and was preg- 
nant in the sixth month. She had her first menstruation when 
she was 15 years old, and never since, but instead, nose 
bleeding every four weeks, always lasting three days. She lost 
each time one ounce of blood, the bleeding occurring one to 
three times daily. She had severe pains in the limbs, became 
dizzy, and things appeared to swim around her, so that she was 
compelled to turn following the direction of the surrounding 
objects. She never became unconscious. Six weeks after her 
confinement, she again had nose bleeding, which, however, was 
slight and lasted from one to eight days. 
xOtto Obermeyer: Ein Fall von menstruellem Nasenbluten. Virchow’s Archiv. 
Bd. 54, page 435. 
10 A few more interesting cases of vicarious menstruation have 
been reported by B. Frankel (v. Ziemssens Handbuch), which 
would take too long to enumerate to-night. 
I am convinced, that such haemorrhages of genital origin are 
more frequent, than we imagine. But, how very dangerous 
they might become, under certain circumstances, my cases give 
evident proof. 
The treatment of these cases requires sometimes a physi- 
cian’s whole attention and self-control. It is evident, that by 
innumerable different ways, you can reach the desired result. 
Smaller haemorrhages generally stop by themselves. In some- 
what larger haemorrhages, one should, if at all possible, try to 
find the bleeding vessel or vessels, and plug them directly, and 
according to my conviction, it does not matter as much, what 
kind of material you use for it, as, that really a firm pressure is 
exercised upon the bleeding vessel. I am sorry to say, that we 
are not always able to see the bleeding vessel, as a capillary 
bleeding coming from all parts prevents us from seeing any- 
thing but a rush or mass of blood. .But, even in such cases, we 
very often succeed in discovering one or more bleeding spots. 
Of late, again, bacon is suggested and to me it is plausible 
that it will answer our use nicely in some cases, as it is smooth 
and pliable. I have not as yet used it. 
Henocque of Paris and Hinkel of Buffalo, have found that anti- 
pyrin has a decided haemostatic effect by producing constriction 
of the vessels, as well as coagulation of the blood. You may give 
it in powder, in solution or incorporated with gauze. Injections 
of hot water are reported to give good results in such cases, 
and we have to mention the enthusiastic report of Geneuil1, who 
“succeeded in checking epistaxis by means of injections of 
lemon-juice, after every kind of haemostatic had failed.” He 
proceeds as follows: “After washing the nostril with fresh 
water, with a glass urethral syringe, he injects as much fresh- 
ly-squeezed lemon-juice as the syringe will hold. In one or two 
minutes, the blood ceases to flow. One injection is usually suf- 
ficient. Dujardin-Beaumetz reports a striking case in which 
the method of Geneuil was sufficiently effective to take the 
place of tamponing. ” In this connection, Dr. S. Marx of this 
According to Annual ot the Universal Medical Sciences, 1890. Vol. IV D. 18. 
11 city, reminded me of the fact, that one of the readiest, simplest 
and surest methods of checking a post-partum haemorrhage, is 
to carry a pared lemon in the hand into the uterus and squeeze 
the juice into the uterine cavity. 
Blisters over the liver, hot water as hot as one can stand it, 
injections of ice water, or with turpentine, turpentine internal- 
ly, ice-compresses over the nose and a score of more remedies 
have been recommended, and each one may be good in 
certain cases, if it is at hand. But, in such an alarming 
epistaxis, which comes so entirely unexpectedly, that you can- 
not leave the patient alone for a moment, take the first piece of 
cloth or cotton and push it into the nose. 
In haemorrhages of the posterior parts of the turbinated bod- 
ies, the antero posterior plugging recommended a very short 
while ago by de Roaldes (Med. Rec., Oct. 14, 1893, p. 485) seems 
advantageous. The article appeared, however, after the above 
cases had disappeared. However this may be, the principal 
thing is, that one should always try to see the bleed- 
ing vessels and then push up one or more pledgets of cotton, 
till a firm pressure upon the bleeding vessel is exercised, and 
not, as Creswell Baber says, “ until the front part of the cav- 
ity is filled up.” This, I consider the most important of all the 
rules in recent and very severe bleedings, because danger- 
ous haemorrhages occur when least expected, and when we 
have nothing at our disposal except perhaps some cotton out 
of which a tampon is easily and quickly made. 
Luckily, such terrible haemorrhages as I described above, in 
the woman with Diabetes, are very rare. 
Lexington Avenue. 
12