Modern Methods of Treating Diseases of the Nose and Throat. W nY O. B. DOUGLAS, M. D., Professor ot Diseases of the Nose and Throat in the Post- graduate Medical School and Hospital; Surgeon to the Manhattan Eye and Ear Hospital. REPRINTED FROM THE "Neb) ¥orft jftte&tcal Journal for October 26, 1895. Reprinted from the New Yor/c Medical Journal for October 26, 1895. MODERN METHODS OF TREATING DISEASES OF THE NOSE AND THROAT.* O. B. DOUGLAS, M. D., PROFESSOR OF DISEASES OF THE NOSE AND THROAT IN THE POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL ; SURGEON TO THE MANHATTAN EYE AND EAR HOSPITAL. Our interest in diseases of tlie nose and throat seems to centre upon treatment—that which cures. But first, we must have a knowledge of the diseases, and it may be well to know how we get them—the aetiology—and to con- sider their symptoms, complications, and effects. Diseases of the nose and throat are more numerous—of more frequent occurrence—than at first thought we might suppose; there is a longer list of them, and a larger train of evil effects, than is likely to be recognized by one who has not carefully considered this matter. In the twenty minutes devoted to this subject I can hardly do more than mention a few of the commoner diseases, such as are of most frequent occurrence, and cause, in the aggregate, the most suffering. Things we see oftenest impress us the least. We give more attention to the infrequent diseases than to those we * Read before the New Hampshire Medical Society, June 4, 1895. Copyright, 1895, by D. Appleton and Company. 2 TREATMENT OF DISEASE OF are called oftener to treat. Common, every-day conditions lose their terror, however bad they may have seemed or really were. This law (of callousness) explains our indif- ference to a common cold, which often is but the initiatory stage of grave and fatal maladies. President Lincoln is said to have observed that “ the Almighty must consider common things important, for he made so many of them.” These diseases are important because they are so numerous and so far reaching in their effects. The opprobrium of our profession is in not cur- ing common ailments, those little ills which, in the aggre- gate, cause greatest distress, not the rare, infrequent, ob- scure conditions. Diseases of the nose and throat may be acute or chronic, simple or complicated, local or general, organic or traumatic, acquired or congenital, benign or malignant. An entire catalogue comprising the acute, subacute, and chronic stages would be long and tedious and not to our purpose. But we should be able to distinguish syphilitic, tuberculous, cancerous, exanthematous, diphtheritic, my- cotic, traumatic, and other less important conditions. We must recognize the peculiarities of various tumors; the condition of the numerous sinuses (accessory to the nose and throat), excessive or scanty secretions and their char- acter, empyema, necrosis, etc. We have coryzas, congestions, inflammations, hyper- trophies, hyperplasias, atrophies, and ulcerations; not only these special diseases of the nose and throat, but many so- called constitutional diseases which affect these organs seri- ously. Of the two hundred and fifty more or less distinct diseases that flesh is heir to, a large percentage show effects in the throat, not mere complications, but as a part of the disease; we look there for confirmation of our diagnosis. There are never two noses alike interiorly, any more TIIE NOSE AND TIIROAT. 3 than there are two faces alike; it requires the exercise of good judgment and a moderate degree of skill, often, to distinguish pathological from physiological conditions. Cultivated common sense is never out of place when called in consultation to a case of ordinary nasal catarrh. That which in common parlance is termed catarrh is but a symptom, an expression or effect of a diseased con- dition. We do not think of bleeding as a disease, but as a result of traumatism or other cause. In the popular mind catarrh means indefinitely (as charlatans teach) a blood disease, a had breath, difficult nasal respiration, a dry throat, enlarged tonsils, or bad taste. Patients will tell you their palate is down (meaning an elongated uvula), that they have pain in the nose, over the eyes, in the tem- ples, or back of the ears; that they have a hacking cough, a frequent desire to clear the throat, and point to the su- prasternal notch, saying, “ There is all of the trouble.” These ills may result from one and the same cause; and I desire especially to emphasize the importance of determin- ing first of all the cause of that of which the patient com- plains. Having determined the cause, we seek to remove it. If it is a syphilitic sore throat, give “mixed treatment” if you wish, but you will oftener get positive results from the use of large, increasing doses of potassium iodide. I am in the habit of ordering twenty grains, in solution, to be taken in a glass of milk before eating, three times a day. This quantity is to be increased five grains each day until the desired effect is produced, unless undue iodism re- sults, when the medication may be suspended for a few days. Often three hundred grains in a day are taken by a patient. Locally, spray the diseased parts with peroxide of hydro- gen and insufflate aristol. Tuberculosis of the larynx is one of the most distress- 4 treatment of diseases of ing maladies humanity is called to endure. Our modern methods of treatment have greatly lessened the suffering and resulted in positive cures in numerous cases. The principle, which underlies the various methods of treat- ment is to destroy the germs in their local habitat by cu- retting, and applying either pure lactic acid three times a week, pure iclithyol (Dr. Berens’s method), or a twenty- grain solution of silver nitrate (as practised by Dr. H. B. Douglass). A later method, which promises excellent re- sults, is the injection of a twenty-five per-cent, mixture of creosote by means of a special syringe devised by Dr. Chappell, through whose kindness I am able to show you the original instrument for this purpose. You can find a full account of his method in the New York Medical Jour- nal of March 30th. Local treatment, other than to soothe and cleanse, is of little benefit, unless resort is had to these heroic measures. Sarcoma and carcinoma are best treated by extirpation, if that is possible. Dr. Coley and others report some wonderful results from the injection of the specific germ of erysipelas into the tissues surrounding these tumors in cases where they can not he removed. In treating diphtheria and all acute inflammations of the throat mild medicines given often will serve you far better than harsh and heroic treatment at longer intervals. 1 do not believe that antitoxine has come to stay. Pro- fessor Winters recently gave us (at the New York Acad- emy of Medicine) an expose of its use in the Willard Par- ker Hospital for contagious diseases. It seemed to do more harm than good. I know of no surer way to cure diphtheria than to attack it in situ. My method which has given best results is to begin at the earliest stage possible, and give the fol- lowing medicines with unfailing regularity : THE NOSE AND TIIROAT. 5 No. 1 : IJ Tinct. aconiti gtt. XX Tinct. belladonna} 3 ss ; Glycerini 3 iv; Aquae gaultheiiae ! iv- No. 2 : Potass, cliloratis } 3 ss; Sodii bromidi 1 aa Glycerini 3 ss; Tinct. ferri cldo 3 ss ; Aqua} ad 3 iv- Dose : Half a teaspoonful for an adult. . These are to be given alternately every half hour, thus bringing the doses fifteen minutes apart. This frequency may seem severe upon the patient, who gets little sleep during the first twenty-four hours, but we have a severe antagonist to combat, and must not relax our warfare till we conquer, which I expect to do with almost as much cer- taintj' as 1 should in a case of measles. In addition to Nos. 1 and 2 1 should always use a spray—often and freely —composed of twelve grains of carbolic acid in four ounces of limewater. All these preparations are agreeable to take. I give liquid nourishment freely, milk being ordinarily best, also whisky, sparingly at first, but sufficiently to get the desired effect as a tonic. Bichloride of mercury may be of service sometimes. Intubation or tracheotomy is to be resorted to if necessary. More frequent than any other disease, more widely dis- tributed, and more destructive to usefidness and happiness, if not to life, is that we have spoken of as causing catarrh. And what is the disease ? has been earnestly asked a thou- sand times. What causes such wide destruction ? Has it a specific micro-organism ? I think not. Is it a blood dis- ease ? No. Can it be cured ? Yes. Is it difficult to cure ? 6 TREATMENT OF DISEASES OF Not specially. How should we go about it ? Remove the cause. What is the cause ? Now we have arrived at the starting point; our duty, as surgeons, is to find that cause. Where shall we look ? First in the mouth and throat. Here we shall probably find the index which points toward the cause. Observe the tongue, the fauces, the tonsils, and the posterior and lateral walls of the pharynx. A typical case of “catarrh” would show a relaxed uvula, enlarged tonsils, follicular pharyngitis, and thickened and inflamed tissue back of one or both posterior pillars of the fauces. There would be some hoarseness, with a tickling and tend- ency to cough. Examine, if you please, the larynx ; you will find the vocal bands slightly reddened, the whole larynx mildly congested. Look into the superior pharynx. Here is more trouble. The adenoid growth is enlarged ; the pos- terior ends of the turbinate bodies are hypertrophied ; the sseptum is thickened, and the whole passage is bathed in a thick, tenacious, muco-purulent fluid. Examine the nose anteriorly. The inferior turbinate body is enlarged, the saeptum more or less deflected. In one or both sides you may see above the inferior body a mass filling the fossa and pressing upon the saeptum. It is exceedingly sensitive, and the mucous membrane generally is congested and hyperaesthetic. Cocaine solution (ten per cent.) applied, blanches and contracts the tissues about the lower tur- binate body, and reveals more clearly the middle turbinate, which is still enlarged, though under the full contractile in- fluence of cocaine. If we attempt to pass a probe between the body and the saeptum, we find them in persistent con- tact—often adherent—and it causes severe pain, often re- flected to the supraorbital region, but especially intensifies the habitual pain in the head, wherever it may have been. The history of this case, as given by the patient pre- vious to examination, is about as follows : frequent and THE NOSE AND THROAT. 7 easily acquired cold in the head, pain over the eyes, in the temples, and in the lateral portion of the occiput; eyes watery, sometimes painful, with difficulty in seeing dis- tinctly. The hearing is not so acute as it should be, and there is a buzzing or roaring in the ears. The throat is frequently sore; breathing through the nose is difficult or impossible; and there is mouth breathing, especially at night. The tonsils swell and occasionally suppurate. The stomach is out of order, the bowels are constipated, the liver is torpid, and there is a general tired feeling, with more or less pain of a neuralgic character. Such cases we see very often. It is difficult to believe the little mass we saw pressing the sseptum (in spite of the persuasive cocaine) to be the cause of all this suffering. But I am persuaded that the hypertrophied middle tur binated body is capable of more mischief, can cause more suffering, directly and remotely, than any other mass of its size in the human body. It will not contract—cocaine has proved that—it must be removed. We anaesthetize it as thoroughly as possible ; then, with scissors adapted to the work, shear off such portion as must come away in order to leave the space clear after the parts have healed. I)o not cut away any more tissue than is absolutely necessary, but be sure you get just enough. We can not cut at the farther end and must twist off the mass with forceps. This causes some pain, differing greatly with different peo- ple, but not so severe as that of the extraction of a tooth. A pledget of cotton wound loosely upon an applicator, mois- tened in a solution of acetotartrate of aluminum (a drachm to the ounce), and perhaps fortified in its haemostatic power by a solution of perchloride of iron, is inserted where the tissue has been removed, and a cotton tampon placed in the nostril anterior to the first; this latter cotton to be changed as often as it becomes moist; the former may re- 8 TREATMENT OE DISEASES OF main twenty-four hours or longer, as alum is one of our best antiseptics. This operation is the one most frequently required, but any persistent contact of surfaces in the nose that ought not to touch will certainly cause trouble and must he relieved. Herein lies the key to successful treatment of catarrhal affections—remove the cause. In reviewing older methods the contrast is very marked. Eighteen years ago I was taught by one of the best special- ists in this country to swab out the throat with a solution of silver nitrate, and make similar applications to the lower turbinated bodies if they were thickened. I regret to say that that man—conscientious and honest—met with such poor results, as he told me, that he determined to give up this special work and devote himself to general medicine, and he is to-day in general practice one of the best. The evolution of modern methods has been slow and labored, hut persistent and successful. In no department of surgery have there been greater improvements than in the treatment of nose and throat diseases. I well remem- ber attending a clinic in Charity Hospital, New York, in 1876, at which Professor Lister did an operation demon- strating his then new theory of antisepsis and disinfection. What marvelous changes have grown from that theory ! We might inquire how a mere contact of surfaces (that ought not to touch) in the nose can cause so much trouble. I answer: 1. The immediate local effect upon two surfaces so sensitive must be irritating, evinced by a tendency to sneeze, by local pain, etc. 2. The nose, being an important organ, directly com- municating with the brain and all other organs in the head, must be carefully guarded ; hence there are numerous re- flex irritations resulting from this primary cause. 3. Secretions, which are normally profuse in the nose, THE NOSE AND THROAT. 9 amounting to five or six drachms an hour, are retained by this artificial dam, become acrid, overflow their bounds, irritate adjacent parts, and produce congestions and inflam- mations—e. g., rhinitis, pharyngitis, faucitis, amygdalitis, and laryngitis. 4. By extension of these induced troubles to other organs —the lacrymal ducts, the Eustachian tubes and middle ears, the accessory sinuses, pharynx, fauces, lungs, and stomach. Ninety-two per cent, of cases of otitis media are induced by extension of nasal inflammation. The effort to breathe through an obstructed nostril produces a partial vacuum, acting as a cupping glass, and causing congestion alternat- ing with undue pressure in the tubes and middle ears. Acrid or purulent secretions are forced into the orifices of the tubes by this pressure, and deafness residts in many cases. I have by no means exhausted the list of evils resulting from obstructions in tlie uose, but 1 have mentioned enough to call your attention to the importance of the sub- ject and convince you that the ounce of prevention—re- moving the cause—is worth many times the pound of cure. Adenoids at the vault of the pharynx (a secondary dis- ease of childhood) must be removed with forceps or curette, and should be done while the patient is under the influ- ence of an anaesthetic. It is not so important to excise enlarged faucial tonsils as to cure the cause. I rarely find it necessary to cut them, preferring to take away the irritant. The disease is not often inherent in the tonsil. We should punish the culprit and not the victim. Wrongs are not righted by deploring them, neither are they corrected by counteracting tbeir evil effects. So dis- eases are not cured by treating their symptoms, or sup- pressed by doctoring their results. The terms of success are not subject to revision. Modern methods are founded 10 DISEASES OE TIIE NOSE AND THROAT. upon a knowledge of cause and effect. Like labor in childbirth, effort may be spasmodic, but the more constant it is the better. Cures are always ditlicult and never ac- quired unless we pay the price. We have to deal with organs that are constantly in use, never at rest. Organs of so much importance as the nose are always protected by Nature in a special manner ; but when we consider the excessive exposure to infections—malarial and bacteriological—to dust and noisome gases, to traumatisms and distortions, we wonder only that we are yet alive. No. 123 East Thirty-sixth Street. The New York Medical Journal. A WEEKLY REVIEW OF MEDICINE. EDITED BY FRANK P. 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