Complete Text (Part 25)

infants, where the use of the nasal douche is impossible and dangerous, the cleansing of the nose by means of a small tampon has been recommended. What is simple chronic rhinitis ? It is a chronic inflammation of the nasal mucous membrane. What is the etiology ? Repeated attacks of acute catarrh and the acute catarrh following acute infectious diseases are the most common causes. Those inhaling various organic and inorganic vapors frequently suffer from chronic catarrh. Heredity is said to have influence in giving rise to it. It sometimes appears as the result of adenoid vegetations and enlarged tonsils. Sexual excitement, pregnancy, menstruation, a gouty or rheu- matic diathesis, predispose to it. INFLAMMATIONS. 205 What are the pathological changes? The pathological changes are slight, The chief condition present is an engorgement of the erectile bodies. The mucous membrane is but slightly swollen. The epithelial layer appears to undergo no change. In the submucous tissues is seen a small amount of cellular infiltration. What are the symptoms? There is an increased irritability of the nasal mucous membrane, as shown by a feeling of stiffness in ope or both nostrils. This is especially seen in a change of atmospheric conditions and when the patient assumes a recumbent posture. The patient has repeated attacks of sneezing, and is constantly catching cold. - There is dilatation, which is recognizable on inspection by a puffy condition of the turbinated bodies. This condition is distinguished from true hypertrophy by making use of the probe, when the swelling is seen to collapse. On the application of cold or cocaine the same change takes place. The secretion varies as to quantity and quality. At first it is thin, but gradually becomes thicker. It may be profuse or scanty as to quantity. The color is dirty white, yellowish, or greenish. It is often seen dried in crusts at the nasal septum and on the anterior ends of the turbinated bodies. If ex- amined by the microscope, the secretion is seen to contain leucocytes, some blood-cells, degenerated epithelium, and micrococci of various kinds. * What are the rhinoscopic appearances? The rhinoscopic appearances show a reddening of the mucous mem- brane, which may be diffused or localized ; swelling, which is present in varying degrees, and a secretion showing^ a variation in character and quantity. Slight erosions are also sometimes seen. What are the complications? Chronic catarrh of the naso-pharyngeal space, with or without hyper- trophy of Luschka's tonsil, is a frequent complication. Hypertrophy of the tonsils, granular pharyngitis, inflammation of the neighboring cavities of the Eustachian tubes and of the middle ear, are often found in connection with chronic rhinitis. Frequent sequels are the develop- ment of myxomatous and fibrous growths. What is the prognosis? The jwognosis of simple chronic rhinitis is, as a rule, good. What is the treatment of simple chronic rhinitis ? If there be any diatheses present, such as the gouty, rheumatic, or tuberculous, these should receive treatment. The general health should receive attention. Hygienic treatment, such as the care of the skin and the use of proper clothing, should not be neglected. The first step in the local treatment consists in a thorough cleansing of the parts by 206 THE NOSE. means of a solution, such as Dobell's, or the use of Setter's tablets. The formula of Dobell's is as follows: R. Acid, carbol., gr. iv; Sod. bicarb.. Sod. bibor. , da. gr. viij ; Glycerin. , |j ; Aquae, q. s. ad ^iv. — M. After the cleansing of the parts the remedy selected should then be applied. This can be done by means of a spray when used in solution, by means of an insufflator when the powder is used, or by means of a cotton probe dipped in a solution and applied to the parts. The rem- edies recommended are insufflations of nitrate of silver, solutions of iodide or sulphate of zinc, and sulphocarbolate of zinc, gr. v to £j. The following prescription has been recommended : R. Iodini cryst., Potass, iodid., Zinci iodid. , Zinci carbolat., Listerine, Aquae, ad %\. — M. Sig. To be used in the form of spray. The following can be applied by means of the cotton-applicator : R . Iodini, gr. viij ; Potass, iodid. , gr. xxxviij ; Grlycerinae, fl^yjss. — M. To prevent irritation after the above application a spray of cosmoline or albalme is effective. "What is chronic hypertrophic rhinitis? It is a chronic hypertrophic inflammation of the nasal mucous membrane. What is the etiology? It is usually the sequel of a long-continued chronic rhinitis, or occurs as the result of repeated attacks of acute rhinitis. What is the pathology? There is an increase in the epithelial cells, with desquamation and sometimes fatty degeneration. The mucosa becomes covered with young- epithelial cells, and there is formation of connective tissue. According to Sajous, the walls of the venous sinuses become thickened, owing to gr. iv ; gr. x; gr. XX gr. XX 3J > U<: 3iv.— INFLAMMATIONS. 207 the formation of connective tissue. New blood-vessels are also formed, whilst the glands and their openings are filled with proliferating cells. There is a secretion, which may be watery or thick. It contains mucin and is muco-purulent. It dries easily, and forms crusts on the walls of the nasal cavities. What are the symptoms? The chief symptom is obstruction to the nasal respiration. This may be temporary or permanent. . If it persist, the face assumes the peculiar expression characteristic of mouth-breathers. As a result, the tongue becomes dry and coated. The sense of smell is diminished, and there may be complete anosmia. The voice assumes a nasal twang. Sleep is often restless. Disturbances in hearing are present, and can vary from simple buzzing to severe inflammation of the middle ear. There is an increase of secretion. Mucus often accumulates in the post-nasal cavity during the night and drops into the throat. This gives rise to a chok- ing sensation, cough, and may even induce vomiting. As a result, the pharynx becomes affected. Epistaxis is often present. Besides these, the patient often experiences a sensation of pressure in the frontal region, and feels indisposed to work, and often has a sensation of itch- ing and burning in the nose. What are the rhinoscopic appearances ? Anteriorly, the membrane appears normal in some cases, in other cases Fig. 82. Dilated Nostril, showing anterior hypertrophy (Seiler) red (Fig. 82). The inferior turbinated is seen swollen, and often lying against the septum. Ulcerations are sometimes seen. Posteriorly, 208 THE NOSE. there is swelling of the posterior ends of the middle and inferior turbin- ated. This is especially noticeable in the lower turbinated. The swell- ing may be very red or whitish, or may present an appearance which by some has been called mulberry-like, and by others raspberry-like. What is the diagnosis? The diagnosis is as a rule easy. It is distinguished from the simple form by the use of the probe and cocaine, as has already been described. What is the prognosis? The prognosis is, as a rule, good. The patient can always be relieved of his chief and most troublesome symptoms — namely, those due to obstruction. What is the treatment of chronic hypertrophic rhinitis ? The treatment consists in the reduction of the hypertrophied tissue. This is effected by means of acids, the gal vano -cautery, or the snare. The acids used are usually the nitric and chromic. In the use of nitric acid great care should be observed, as it is very powerful and destructive in its action. It is best applied by means of a cotton-applicator. Only a small surface should be cauterized at a time, and after its application a saturated solution of bicarbonate of soda should be used to neutralize the action and to relieve the pain. Chromic acid is less dangerous than nitric, and is the acid most com- monly used. In using it a crystal is slightly heated on the end of a probe and applied to the surface to be cauterized. This is followed, as in the case with nitric acid, by an application of a saturated solution of bicarbonate of soda. Before the cauterization the parts should be thor- oughly cleansed. The galvano-cautery is another means for reducing hypertrophied tissue in the nose. Cocaine in a solution of from 4 to 10 per cent, should first be applied. The temperature of the cautery is an important point to be looked after. The condition of cherry heat is least dangerous and least painful. A small amount of surface can be cauterized, or a large amount, according to the judgment of the operator. One can begin at the anterior end, cauterizing but a small space at a time, gradually going backward, or several parallel linear incisions can be made along the surface of the turbinated, beginning at the posterior end. The after-treatment consists in keeping the nose cleansed by antiseptic alkaline solutions. For this purpose Dobell's is perhaps the most useful. In a few days the slough comes away. Serious after-effects have followed the use of the galvano-cautery, so that its application should be limited to anterior hypertrophy only, and a small surface cauterized at a time. Posterior hypertrophies are best removed by means of the snare. Jarvis's snare is the one generally in use (Fig. 83). The wire used should be steel piano-wire. The nostril being dilated by the speculum, the wire is INFLAMMATIONS. 209 introduced along the floor of the nose into the naso-pharynx. The patient's tongue is then depressed, and by means of a small rhinoscopic mirror the wire is adjusted to the mass. The use of the rhinoscope, however, is Fig. 83. Jarvis's Snare in Position, showing loop around a posterior hypertrophy (Jarvis). unnecessary, and in a large number of cases posterior rhinoscopy is im- possible. In making use of the snare without the aid of the rhinoscope the operator gently passes the wire along the inferior turbinated space, keeping as close as possible to the septum and the floor of the nose, until the wire impinges against the posterior pharyngeal wall. It is then gently withdrawn a little, and the handle turned inward, when the loop is brought over the hypertrophy. The mass is then divided. By means of the screw on the handle the growth can be removed quickly or slowly at the will of the operator. The after-treatment consists in the applica- tion of a disinfectant spray. The after-effects of the operation are not serious. Hemorrhage rarely occurs if the growth is slowly removed. Secondary hemorrhage may set in, but is easily controlled. Rapid relief is afforded the patient by the operation. What is the etiology of atrophic rhinitis ? As to the real cause of atrophic rhinitis there appears to be some doubt. The majority of observers regard it as a later stage of the hyper- trophic condition. The weight of evidence seems to be against the theory that rhinitis is ever atrophic from the beginning. Predisposition to it is more strong in those with a tuberculous taint. It occurs _ chiefly in young persons from the tenth to the twentieth year, especially at the age of puberty, and attacks females more than males. Abnormal patency of the anterior nares has been ascribed as an exciting cause. 14— Eye. 210 THE NOSE. What is the pathology ? There is formation of fibrous connective tissue, with atrophy of the various layers of the mucous membrane. The surface of the mucous membrane may be deprived of its epithelium or covered with another layer of cells. The glands disappear entirely, owing to the pressure upon them of the newly-formed fibrous connective tissue, or they may be sur- rounded by an infiltration consisting of round cells. The adventitia of the blood-vessels is thickened while as yet no appreciable change has been discovered in the nerve-elements. The atrophy may affect the periosteum and the bones themselves. In this case there is gradual atrophy of the lacunas. Ulceration does not occur in atrophic rhinitis. What are the symptoms? In making a rhinoscopic examination the nasal cavities are found to be unusually widened, so that the posterior pharyngeal wall is plainly visible. The mucous membrane is seen covered in different portions with crusts of mucus, which in color are yellow or brown, or even black. Again, one side of the nose may be found in an atrophic condition, whilst the other is seen to be in a hypertrophic state. There is a very strong odor present in a large number of cases, which is peculiarly characteristic of this condition, and which has given rise to the term "ozaena." The subjective symptoms consist in disturbances of smell. The sense of smell may be considerably diminished or entirely lost. Headache, difficulty of hearing, noises in the ear, are other symptoms which may be present in a more or less marked degree. The voice has a nasal twang, and where the secretion accumulates in the nose obstruction is present. What is the diagnosis ? The diagnosis is, as a rule, easy. The odor must be distinguished from that occurring as the result of caries or necrosis. An exclusion of those diseases giving rise to ozaena must be made. What is the prognosis? The })roff)iosis as regards an absolute cure is bad ; as regards an ame- lioration of the symptoms, it is favorable. What is the treatment of atrophic rhinitis ? The most important point in the treatment consists in the removal of crusts and the prevention of their formation by keeping the nose con- stantly cleansed. For this purpose an alkaline solution should be used. Dobell's serves the purpose as well as any. If there be a very strong odor, listerine can be added. Leffert's spray-producer can be used in applying Dobell's solution, or the following formula may be used : INFLAMMATIONS. 211 M. R. Thymol, Alcohol. , Glycerin. , Aq., gr. j m ; flSij : ad flgj.- g. Use as a spray. The following formula, recommended by Sajous, can be used in the nasal douche for the purpose of cleansing : R . Sodii borat. , Amnion, chlor., da. gr. xx; Potass, permangan., _ gr. x. — M. Sig. To be dissolved in one pint of water at 100° F. A solution of bichloride of mercury, in the strength of 1 : 4000, may also be used. The use of the post-nasal syringe is a useful adjunct in helping to cleanse the nostril. In using it the nozzle of the syringe is introduced behind the soft palate ; the patient is directed to hold his head forward and the instrument discharged. The application of pow- ders after cleansing the nostrils is advocated by many. Nitrate of silver in the following strength is useful : R . Argent, nit. , gr. ij ; Pulv. amyli, ^ss. This can be gradually increased in strength up to ten grains. The following powders have also been recommended: Sanguinaria, 3ij-|j ; galanga, 3ss-^ss ; salicylic acid, gr. xx-5ss ; iodine, gr. j-ij- Ointments are also of service in the treatment of atrophic rhinitis. They can be applied by means of the cotton applicator. The following are beneficial : R. Iodol., Ung. aq. rosae, R. Iodoformi, Acid, carbol. cryst., Iodi, Petrolati, Medicated bougies and medicated cotton wools, as used by Yoakes, have been found serviceable by some. Tampons of cotton, as recom- mended by Gottstein, are very useful. The tampon can be left in for several hours, and then replaced by a fresh one. Galvano-cautery is used by some, but is required to be used very cautiously. Besides the local treatment, constitutional treatment should also re- gr. xv-xxv £• -M. gr. xij; gr. v; gr. "j ; ij- — M. 212 THE NOSE. ceive attention. Tonics of cod-liver oil, iron, quinine, strychnine, should be given. Hygienic surroundings should receive attention ; proper ex- ercise, ventilation, and the care of the skin. The diet should be regu- lated. What are the synonyms of hypersesthetic rhinitis ? Coryza vaso-motoria periodica. Hay fever, Hay asthma, Autumnal catarrh, Rose cold, June cold, etc. What is the etiology? Three factors are necessary to excite an attack of hay fever. These are, first, the presence of an exciting agent ; secondly, a predisposition on the part of the system to become influenced by such an agent ; and thirdly, a sensitive area in the nose. What are the symptoms? The symptoms are usually those of an acute coryza somewhat intensi- fied, such as itching in the nose, followed by sneezing ; headache and a profuse watery discharge, which is irritative in character. Nasal ob- struction is present. Excessive lachrvmation, often followed by conjunc- tivitis, is a prominent symptom. The patient not infrequently complains of sore throat ; asthma often complicates the attack. What is the treatment of hyperaesthetic rhinitis ? Tonics, especially the nerve-tonics, such as nux vomica, phosphorus, etc., should be administered internally. Quinine is often of great ser- vice. The application of ointments, such as the benzoated oxide-of-zinc ointment and vaseline equal parts, or the belladonna ointment, often cur- tails an attack. Menthol inhalations have proved serviceable. The ap- plication of cocaine in a 4 per cent, solution is recommended. Where there is hypertrophy or polypi in the nose, these should be removed. Sensitive areas should be sought for in the nose by means of the probe, and carefully cauterized by means of the galvano-cautery, chromic acid, or glacial acetic acid. NASAL MANIFESTATIONS OP CERTAIN CON- STITUTIONAL DISEASES. SYPHILIS OF THE NOSE. What is the etiology ? It is here, as elsewhere, the result of syphilitic infection. It may manifest itself in the primary, secondary, or tertiary form. The primary stage is rare, and is usually caused by infected fingers or instruments. The secondary and tertiary forms are more common, and hereditary syphilis is not of infrequent occurrence. SYPHILIS OF THE NOSE. 213 What are the symptoms? The subjective symptoms are those usually present in catarrh, such as a