IN this paper I will treat of two forms of chronic catarrh- those in which there exist permanent hypertrophies; and those which are characterized by intermittent swellings of the Schneiderian mucous membrane.
These two forms are the most frequent of all varieties of chronic rhinitis.
In the treatment of chronic catarrh, where there exist obstructions of any kind, the first step to be taken is, to remove these obstructions; then; with Homoeopathic remedies, we may expect favorable results. These results we would not obtain without this preliminary treatment.
I know that objections have been made by some Homoeopathic physicians to such a course; they claiming, that unfavorable results follow operative treatment.
These objections, however, come from those who have had very little experience, but who, on the other hand, are always heavily loaded with theories. The large practical experience which I have had, warrants me in saying that these objections are unfounded. I shall prove, on the contrary, that only the most favorable results follow operative procedures when performed in a proper and skilful manner.
It has been said that, where such line of treatment is followed, it does not differ from that used by Old-School specialists; and, moreover, that it makes very little difference, whether a patient is operated upon by an Old-School or a Homoeopathic specialist.
I shall have to take exception to this; because the two have different objects in view; and their respective operative procedures are entirely different.
In the first place, the Old-School specialist uses operative measures as a last resort, and expects such measures will complete the cure. This, it too often, does not do. The Homoeopathic specialist, on the other hand, resorts to operative measures for the purpose of paving the way to future treatment, which must be in part Homoeopathic-to effect a permanent cure.
In the second place, Old-School specialists, as a general thing, remove as much tissue from the nose as possible, leaving the cavities specious,a nd, often, too much so. The Homoeopathic specialist, on the other hand, removes as little tissue as possible and yet quite enough to produce the desired result-which is, to prepare the case for future treatment.
Having differentiate thus between the Old-School and the Homoeopathic specialist, I shall next endeavor to meet the objections made to operative treatment, by adducing facts instead of theories.
It is claimed that the removal of bone, cartilage and mucous membrane, from the nasal cavities, is followed, in time, by their becoming abnormally large, and frequently results in atrophic catarrh.
To the first objection, I will say that it has been proved to be groundless. I have not one, out of the large number of cases upon which I have operated, that presented results claimed above, after the operation. In fact, in two cases to which I wish to call special attention, the operation produced effects just the opposite. Instead of shrinkage of the parts, there was an increase of tissue, and a consequent narrowing of the usual cavity.
Miss. M. came to me, complaining of an obstruction in the left nasal cavity. On examination, I discovered that the septum was slightly deflected to the left, while along the cartilaginous portion there was a horizontal ridge, which completely obstructed the left side. The latter was removed and the septum planed off, leaving the cavity large enough to pass a wooden plug one-quarter inch wide and one-half inch high. This was kept in position for six days-removing it every other day for antiseptic cleansing of the parts. Three months afterwards, I found the nasal cavity in almost as bad condition as before the operation was performed.
A second operation was resorted to. After this, I kept the patient under observation, seeing her two or three times a week. At the end of six weeks, I could see that the cavity was gradually filling up, and that something must be done to arrest the overgrowth of tissue. I then had recourse to the galvanic cautery, using a flat electrode. This was effectual, not only n removing some of the redundant tissue, but also in arresting the further progress of the growth. I will not tax your patience with a description of the second case, as it was similar to the one just cited, and was treated in the same manner, with good results.
In reply to the second objection-that operations on the nasal cavities are frequently followed by atrophic catarrh, I would say, that it is without any foundation whatever. In twenty- five cases, which I have had the opportunity of keeping under observation, and which I examined eighteen and thirty months after the operation, not one presented any evidence of dryness of the parts operated upon, or of atrophic catarrh. In fact, it would have been impossible for any one but the operator, to have discovered what portion of the septum had been operated upon, as the mucous membrane had been reproduced, to all appearance in its original and normal condition. I believe, that all who have had any wide experience in operations upon the nasal cavities, will agree, that only good can result from a properly performed operation.
The failure to obtain good results from operations of this character is due, to most instances, to neglected after- treatment. Hence its supreme importance. It must be frequent and long-continued.
I am decidedly in favor of conservative surgical procedures in cases of chronic catarrh; but there are only three classes of cases in which I would consider it necessary to use operative measures; First, those in which obstructions prevent proper drainage of the nasal cavities; second, those in which the passages are so narrow that the least irritation, whether the result of atmospheric changes, particles of dust or irritating vapors, causing swelling of the parts, and producing contact of the external and internal walls. If left alone, this would result in adhesion of the parts. Third, those in which adhesion of the external and internal walls has already taken place, and to which Browne has given the name of Synostosis.
It is not necessary that every spur and ridge upon the septum should be removed; nor is it necessary that the septum should be perfectly smooth. It is not good surgery, to hold that every departure from the right line in the position of the septum demands treatment. And here is where a great many inexperienced operators make their mistake. It is the neglect of not paying particular attention to what is proper and necessary to be removed that justly brings specialist into disrepute. It is desirable, also, to operate by artificial light reflected from the forehead-mirror; but in that case the operator must be familiar with the use of the head-mirror, and be able instantly and automatically to follow any motion of the patient’s head with the directed illumination during the few minutes consumed by the operations.
Antiseptic cleansing of the parts before operating and during healing is desirable. The nasal cavities having been cleansed, the parts should be thoroughly anaesthetized, so that all pain may be avoided. This is best accomplished by saturating a strip of lintine, about half in inch wide, with a 10 to 20 per cent. solution of Cocaine. This is passed into the side to be operated upon by means of a flat applicator, and made to cover the tissue to be removed. Satisfied that all sensibility has been destroyed, we should perform the operation with as little inconvenience to the patient as possible, selecting those instruments which will give the least disturbance to the patient, consistent with the best attainable results. The nasal saw, snare, trephine, drill, chisel and gouge, together with various other accessories, have each their proper place in the domain of nasal surgery.
Having finished the operation, the next important part is the after-treatment. The results will depend largely upon the attention paid to it.
The conditions presents in the nasal cavities will not allow of an antiseptic dressing that may be left there for three or four days, as may be done in other parts of the body; but the healing process must go on in the presence of septic surroundings. In consequence of this, the patient should be seen and treated every other day for two weeks; afterwards, twice a week, until the healing process is completed. During the first week after the operation I would advise insufflation of powdered Europhen.
In the second week, and until the parts are completely healed, liquid Petroleum, to which has been added Calendula and Eucalyptol. By means of an atomizer they are easily brought into contact with the membrane of the nasal cavities, and are not only soothing to the mucous surface, but also protect the membrane from atmospheric influences. During the first week, Arnica may be employed with good result, unless some other remedy is plainly indicated.
There are so many medicines that can be used locally in chronic catarrh that it would consume too much time even to enumerate them.
