c 
The Pathology and Treatment of 
Intra-Nasal Sclerosis. 
BY 
RALPH W. SEISS, M. D., 
Adjunct Professor of Otology and Instructor in Pathology and Microscopy in the Philadelphia 
Polyclinic. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
February, 1889. Extracted from the 
American Journal of the Medical Sciences for February, 1889. 
THE PATHOLOGY AND TREATMENT OF INTRA-NASAL 
SCLEROSIS. 
By Ralph W, Sf.tss, M.D., 
ADJUNCT PROFESSOR OF OTOLOGY AND INSTRUCTOR IN PATHOLOGY AND MICROSCOPY IN THE 
PHILADELPHIA POLYCLINIC. 
The pathogenesis of advanced nasal catarrh has received but little 
attention from pathologists, and the descriptions of the conditions 
present are of the crudest character in all the general text-books. 
Works on rhinology are but little more satisfactory, and to the recent 
writings of Bosworth, of New York; Mackenzie, of Baltimore; and 
Seiler, of Philadelphia, we owe by far the greater part of our knowledge 
of the subject. Detailed accounts of the treatment of this stage of nasal 
inflammation and of its results are scarcely to be found. 
Leaving, therefore, the simpler phenomena of rhinitis simplex, I will 
pass to the consideration of true rhinitis hypertrophia. This disease is 
readily divided into two stages (J. W. Mackenzie) : a, dilatation with 
hypertrophy; b, complete hypertrophy-or, as I much prefer to call it, 
sclerotic rhinitis. The appearances, on inspection of the latter stage, are 
most characteristic; anteriorly the lumens of the nares are found to be 
of fairly normal diameter, rarely is there much stenosis; the turbinated 
bodies, particularly the lower, are usually of light color, pink, grayish, 
or yellowish ; their surface is very irregular and bossellated; and, on 
pressure with a probe, their hard glassy look is found to be due to a 
dense elastic consistence. Enchondroses of the nasal septum are of 
very frequent occurrence, especially at the extreme anterior lower border 
of the cartilage, or a long, sometimes blade-like, ridge may extend the 
length of the septum narium. Frequently the turbinated body will be 
found to be markedly grooved by a corresponding ridge projecting from 
the cartilage, although a considerable interval of clear space may inter- 
vene at the time of examination; showing, conclusively, that during the 
first stage of the hypertrophic process, and during the preceding stage 
of rhinitis simplex (i. e., vasomotor paresis), the turbinated body pressed 
against the nasal septum. The history of very troublesome stenosis at 
some previous date can nearly always be elicited in the case of intelli- 
gent patients. 
The middle turbinated body is greatly enlarged at its anterior ex- 2 
SEISS, TREATMENT OF INTRA-NASAL SCLEROSIS. 
tremity in many cases; it is commonly compact and fibrous in consist- 
ence, and may be so large and hard as to be firmly jammed in the nasal 
lumen. In advanced cases these nasal fibromas of the middle turbinated 
frequently undergo myxomatous degeneration-forming myxofibroma of 
Ziegler-and are then soft and gelatinous, giving the appearance of a 
sessile polypus. In other cases the middle scroll is extensively atro- 
phied, and has a thin, pinched, bladed ike appearance. 
Posteriorly, as shown by the rhinoscope, the general mucous mem- 
brane has undergone thickening and fibroid change; the membrane is 
very light pink or yellowish in color; hard and dense in appearance 
and on testing with the laryngeal probe. The lips of the Eustachian 
tubes may be entirely yellow, and quite hard from fibroid change. 
These are usually sessile, or more rarely pedunculated posterior hyper- 
trophies ; small, usually much corrugated masses jutting from the floor 
of the nose, from the extremity of the lower turbinated body, or least 
usually from the bony septum. They are white or yellow, and firm 
and elastic in consistence, and are oftenest somewhat symmetrically dis- 
tributed. 
Following the almost universal rule of intra-nasal inflammations the 
upper and lower pharynx present marked and advanced changes. The 
glands forming the much talked-of, but slightly vaguely defined, pharyn- 
geal tonsil, are atrophied, and those which have not undergone sclerosis 
are swollen and intensely irritated, and secrete mucus abnormal in both 
quality and quantity. In advanced cases the size of the pharyngeal 
vault is notably increased by atrophic changes. 
The lower pharynx shows decided atrophy, the changes having been 
already described by me in a previous paper the larynx, as there men- 
tioned, is, in my experience, always involved, and the bronchi are not 
infrequently implicated. 
The pathology of sclerotic rhinitis may now be said to be perfectly 
understood, the studies here detailed seeming to bridge over the 
remaining gaps in our knowledge. As an inevitable result of long- 
standing rhinitis, we find the mucous membrane, the submucous, and 
cavernous connective tissue, all densely infiltrated with numerous leu- 
cocytes, which infiltration, following the universal law of chronic in- 
flammations, becomes "organized" into new connective tissue. By the 
contraction and pressure of the new growth, and other processes detailed 
below, the vascular sinuses are gradually obliterated, so that they are 
found only subjacent to the periosteum or perichondrium (Seiler). 
There are four modes of obliteration of the " erectile sinuses " in sclerotic 
catarrh (Mackenzie) : 1. Hypertrophy-new formation-of the con- 
nective tissue, and contraction of the same, above described. 2. " By 
1 The Medical News, October 22, 1887. SEISS, TREATMENT OF INTRA-NASAL SCLEROSIS. 
3 
obliteration of their lumen by masses of round cells," and organiza- 
tion of the same. 3. By the formation of buds on the sinus walls, 
first noticed by Councilman. 4. By the formation of thrombi in 
some cases. The first two processes are those common to any chronic 
inflammation. The formation of these " buds " or septa is of great 
pathological importance; in some sections half the sinuses will contain 
" buds " of fibrous tissue, more or less completely blocking up their 
lumen. Their growth is due to the puckering of the sinus walls from the 
general contraction, plus the persistent irritation and hypertrophy of 
fibroid tissue which are present. The formation of parietal thrombi, 
discovered by Mackenzie, of Baltimore, is what might be expected from 
the active bloodvessel changes which are taking place. They are prob- 
ably common in those exceedingly rapid cases of nasal catarrh in which 
the grade of chronic inflammation is of an acute type. 
It will at once be seen that these phenomena can bring about but one 
result, the conversion of the affected turbinated tissue into a fibrous 
mass. Tissues, other than the vascular sinuses, are synchronously 
affected. The pressure exercised by the new growth induces atrophic 
changes in the glandular structures, which are finally destroyed; the 
ordinary nutrient bloodvessels are also constricted, and the vicious circle 
of changes goes on until, in extreme cases, the lower turbinated body 
may be represented by a mass of mere scar tissue. 
Early in the pathological history of sclerotic rhinitis, changes in the 
epithelial layer take place, shedding and proliferation, and later in the 
process the formation of hypertrophic papillae. This morbid phenomenon 
I have never seen noticed by any previous writer. It will frequently 
be observed, when examining cases of long-standing rhinitis, that the 
mucous membrane covering the scroll-like bodies has a coarsely velvety, 
or very minutely bossellated contour; this appearance is due to the 
growth of papillae from the mucous membrane; multiple " papillomata " 
of very minute size springing from the surface of the turbinated tissue. 
The structure of these projections is precisely that of the so-called typical 
papillomata; they are made up of vascular connective tissue capped 
by layers of epithelium, the bloodvessels being frequently numerous, 
and forming vascular loops. These minute papillomata may undergo 
atrophy, the surface of the turbinated body becoming smooth and glassy, 
or they may persist indefinitely. Clinically, their importance is doubt- 
less considerable, as they must add to the always present septic condi- 
tion by entangling morbid products and increasing the difficulty of 
clearing the nose either by blowing or by medical means. 
The pathological changes in the pharyngeal vault are similar to those 
found in the scroll-like bodies, and may be briefly described as gradual 
glandular and vascular atrophy from the pressure exercised by the new 
formed connective tissue. 4 
SEISS, TREATMENT OF INTRA-NASAL SCLEROSIS. 
The causes of sclerotic rhinitis cannot be given in the present state of 
our knowledge; the long catalogue of etiological factors, given in many 
memoirs and text-books, must appear to any analytical mind illogical 
and untenable. Early stages of nasal catarrh are dependent in part on 
climatic, in part on anatomical and developmental, and largely on factors 
as yet indefinable, which are part of our civilized life. The fads of 
rhinologists, when weighed from the standpoint of the comparative 
pathologist and cautious scientist, will be found to be but sieves. The 
very popular one of unphysiological clothing need only be mentioned; 
surely no unprejudiced man of science will deny that clothing is now as 
well adapted to the needs of the human organism as at any time in four 
hundred years; yet nasal diseases are increasing in frequency yearly on 
our Atlantic seaboard. Also in many European States, where the dress 
does not in any way differ from that worn in the United States, chronic 
catarrh is rather a rare disease. It need only be added that nasal in- 
flammation is much more common in men than in women, and is rather 
rare among actresses and opera singers. 
Why a certain, fortunately small, proportion of cases of chronic 
rhinitis run on to typical sclerotic catarrh, and the larger portion 
remain in statu quo until old age comes to sap the vitality, cannot be 
stated; a low bloodvessel vitality seems to be the immediate cause. 
Intra-nasal " sclerosis " differs from " atrophy" only in the rapidity and 
extent of tissue implicated. The two diseases have, however, very 
marked differential points, and call for somewhat different treatment.1 
The symptoms of sclerotic rhinitis are many, frequently serious, but 
far from distinctive; rarely is there either hypersecretion or nasal 
stenosis, though the first may be found in cases in which myxomatous 
changes have taken place, and large septal enchondroses may cause the 
latter. Dribbling of thick, tenacious mucus from the posterior nares- 
from the diseased pharyngeal tonsil-is common, and is often most bit 
terly complained of. Frontal headache, from congestion of the frontal 
sinuses, and irregular and frequently severe head pains from implica- 
tions of other bony sinuses, are frequently the cause of patients presenting 
themselves for treatment. The sense of smell is blunted, and taste is, 
consequently, frequently much impaired. 
The chronic pharyngitis and laryngeal implication always present 
give the symptoms already detailed in a previous paper. 
The laryngitis, tracheitis, and even chronic bronchitis, so frequently 
found in advanced cases of this disease, are directly symptomatic of the 
nasal lesions. As Bosworth has so well shown, the turbinated bodies 
are almost the sole source of the moisture needed to saturate the inspired 
air (about 5000 grains of water in twenty-four hours). When from 
1 See The Medical News, April 2, 1887. SEISS, TREATMENT OF INTRA-NASAL SCLEROSIS. 
5 
sclerotic disease the " erectile tissue " is unable to throw out the proper 
amount of moisture, the inspired air reaches the bronchi in a dry and 
unprepared condition, with the result of irritation of the mucous mem- 
brane of the lower respiratory tract, and the lighting up of other grave 
forms of disease. 
Of remote symptoms, languor, nervous irritability, and a variously 
described feeling of abnormality " in the head," are the commonest. 
Asthma, or at least violent panting after slight exertion, is frequently 
complained of. Patients in whom the scroll-like bodies are represented 
by mere scar tissue have invariably, in my experience, been much below 
par, complaining of various neurasthenic indications, general ill health, 
and a great variety of symptoms-whether post hoc or propter hoc no 
claim will be made in the present paper, but the fact is a certainty. 
The conjunctivae are usually injected, and when referred to an oculist 
gross eye changes are generally reported present-the relation of the 
two diseases is a question for the ophthalmologist. 
The Eustachian tubes and middle ears are always involved in pro- 
longed cases of this disease; impairment of hearing, tinnitus aurium, 
aural vertigo, and what may be called ear malaise, are very frequently 
complained of, and aural sclerosis, with extreme deafness, is one of the 
results of this disease in some cases. The glossal papillae are enlarged 
and diseased, and dyspepsia is a most common concomitant. Mental 
symptoms have been noted by many observers: my experience has led 
me to believe them always dependent on the secondary ear lesions; 
where deafness and tinnitus have not appeared the mind will be unin- 
fluenced. Lastly, sleep disturbances and insomnia, whatever relation 
they may bear to the nasal lesions, are of the commonest occurrence in 
this disease. 
The special treatment of this form of intra-nasal inflammation has 
been greatly neglected; many writers claim to have cured this condition. 
I am aware that some gentlemen have also " cured" hepatic sclerosis and 
gastric carcinoma. But to my mind the reproduction of so highly 
organized a tissue as that of the nasal turbinated bodies, when totally 
destroyed by fibroid changes, seems a miracle worthy of Buddhist 
adepts, and totally impossible to accomplish by any means the technique 
of which has been described in less occult lore. 
Although a cure of sclerotic rhinitis is a result impossible for the 
average rhinologist to obtain, yet a great deal can be done by careful 
and prolonged treatment, even in the worst cases. Comparative com- 
fort may be secured, the disease practically arrested, and the remote 
results held off for an indefinite time. 
The treatment may be divided into medical and surgical measures 
The use of " alteratives" in spray is of great value; the sulpho-carbolate 
and the iodide of zinc; solutions of thymol or of " Listerine;" and Boul- 6 
' SEISS, TREATMENT OF INTRA-NASAL SCLEROSIS. 
ton's solution have proved the most valuable in my hands; they must 
be applied with skilful and thorough technique, at first daily, and 
toward the end of the four, ten, or fourteen months of treatment, once a 
fortnight. The careless, awkward douching of the nasal cavities, by 
means of a " perfume atomizer," so often witnessed, is totally without 
value, not infrequently hurtful, and quite unworthy the scientific tech- 
nologist. 
The action for good of these and similar medicines in this stage of 
nasal catarrh is partially due to their antiseptic and mechanical, as well 
as to their stimulant properties. Their first action, if properly used, is 
to cleanse mechanically and render antiseptic the nasal chambers; 
secondarily, the bloodvessels are so affected that the local blood supply is 
increased, the whole tone of the turbinated bodies being thereby im- 
proved. The mucous glands are also stimulated to throw off the pro- 
liferated cells and abnormal mucus which clogs them, and the condition 
of the nasal cavities becomes for a longer or shorter period more nearly 
normal. More energetic stimulation is frequently called for; Seiler's 
iodine solutions, and tincture of myrrh diluted with glycerine to suit 
the individual case, are perhaps the most valuable; both are to be ap- 
plied with the cotton tuft and carrier under full illumination and 
inspection. Mechanical stimulation, by means of cautious curetting of 
the papillomatous turbinated mucous membrane, especially of the post- 
nasal region, is of undoubted value. For some eighteen months I have 
used it as a routine measure with decided benefit. I can find no men- 
tion of its use in rhinological literature. 
The faradic current applied with the positive pole in contact-by 
means of a suitable electrode-with the diseased turbinated body, is a 
very useful " alterative." Its use calls for the most thorough care and 
judgment; the weakest secondary current obtainable from the ordinary 
office battery, as usually used, is frequently too powerful, irritating, and 
injurious; a rheostat may be required, or the current may be regulated 
by only partially immersing the zinc element. 
Operative surgical treatment is very rarely called for in nasal sclerosis. 
If the middle scroll be enlarged and jammed, as previously described, 
pressure must be relieved by cautious destruction of the superabundant 
tissue, by chromic acid (which I usually prefer), with the galvano- 
cautery knife, or with the Jarvis snare. Care should be taken to 
remove no more than is necessary to relieve pressure, the tendency of 
this disease progressively to destroy turbinated tissue being never lost 
sight of. Myxomatous degeneration of the middle turbinated calls for 
special measures; chemical or galvano-cautery is inadmissible, as they 
must be used so vigorously that a dense, contracting scar results, which 
is anything but favorable to the course of the disease. The snare can 
seldom be satisfactorily used, owing to the position and sessile, elastic, SEISS, TREATMENT OF INTRA-NASAL SCLEROSIS. 
7 
and slippery nature of the growth. The writer's, or some similar cut- 
ting forceps, is the best means of reducing the growth, small pieces 
being gnawed off until all myxomatous tissue is removed. It is my 
habit to treat the stump with a strong glycerite of iodine. 
Enchondrosis of the septum narium may incidentally require removal, 
for the technique of which the reader is referred to the classical paper 
of Seiler; they bear no direct relation to nasal sclerosis. Nasal polypi 
may be found, and call for operation by recognized methods. The 
region of the pharyngeal tonsil will call for appropriate treatment, 
which need seldom, if ever, be operative, the post-nasal atomizer and 
applicator being usually sufficient to control the symptoms. Various 
dilutions of fluid extract of eucalyptus, applied by the post-nasal appli- 
cator, have given the writer great satisfaction in controlling the constant 
dribbling from the diseased glands, plus the routine treatment already 
outlined. The pharynx, larynx, and bronchi will require sedative 
therapeutics. 
The constitutional treatment is, of course, of great importance; medi- 
cinal tonics are frequently valuable, but good hygiene with scientifically 
regulated outdoor exercise is of more importance. Where the patient 
is able to reap the benefits of climate change, the less elevated regions 
of the Adirondacks, the Maine woods, and similar " spruce areas," are 
recommended for the summer; and the highlands of the Carolinas, or, 
better, the plateau of Mexico, about Orizaba, are advised for the winter 
season. 
By no method known to me, or described in medical literature, can 
any rhinologist hope to keep his patient permanently free from symp- 
toms by any one course of treatment in the climate of our Atlantic 
States. Cases must be seen at intervals-certainly as soon as warned 
by any return of the old symptoms-if they are to continue comfortable. 
My own practice is to treat cases of nasal sclerosis, for a period varying 
from four or five weeks, to twice as many months, until all important 
symptoms subside, and then instruct them to return at least once a 
month, or to report immediately if they suffer from symptoms of a 
" coldattacks of acute coryza, if allowed to run their course, having 
a most injurious effect on the course of the nasal disease. Of course, 
but a limited number of patients can be induced to follow so laborious 
a course of treatment, but the physician cannot conscientiously offer 
any better alternative. Nor can the victim of advanced intra-nasal 
sclerosis look forward, without treatment, in our climate, to a more 
favorable issue than impaired hearing, injured voice, bronchial disease, 
and much vitiated general health. 
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