Acute Affections Of The Nose | Operating Microscopes

Acute Affections Of The Nose
By WlLLIAM E. CASSELBERRY, M. D.,
OF CHICAGO, ILL.

Acute Rhinitis. Acute rhinitis, or coryza, colloquially termed "cold in the head," is an acute inflammation of the mucous membrane and submucous tissues of the nasal cavities, the naso pharynx being usually likewise involved, at least to some degree. It not infrequently affects the ears, via the Eustachian tubes, and is prone to extend to the pharynx,, larynx, and bronchioles. This sequence may on occasion be reversed, the rhinitis following an initial inflammation in the lower respiratory tract; or the whole surface may become inflamed at one time. Also, the maxillary, frontal, and sphenoid sinuses and the ethmoid cells, being cavities immediately contiguous to the nasal chambers proper, can rarely wholly escape; and at times one or more of them may present, as a complication, an acute sinusitis far more grave than the original rhinitis.

Etiology. While local inflammation is the salient feature of an acute cold in the head," there is reason to believe that a fundamental disorder of the nerve centers leading to vaso motor paresis is associated therewith. Reasoning from analogy and from pathology and clinical history, one must regard acute suppurative rhinitis as an infection by pathogenic micro organisms, although germs specific to this particular form of suppuration have not as yet been identified. However, certain local and constitutional conditions seem to favor infection, and the latter ensues finally under the influence of vascular disturbance which has been excited by some sort of exposure.

1. Chronic hypertrophic rhinitis, obstructive deformities of the septum, and adenoid vegetations probably, by maintaining local congestion and stenosis, favor recurrent attacks of acute rhinitis.

2. Extreme bodily fatigue or nervous exhaustion, the physical lassitude engendered by excesses, and the tuberculous and syphilitic dyscrasie render the individual more vulnerable upon exposure. The habit of hot bathing, especially previous to going out in cold weather, is a prolific underlying source of rhinitis. These, as well as the custom by many of wearing too heavy apparel and living in overheated apartments, seem to exert a softening influence upon the bodily surface, lessening its resistance to droughts and climatic inequalities.

3. In the presence of such local or constitutional predisposing conditions, acute rhinitis follows certain exposures with such regularity and precision that one must infer a causal relationship to exist between chilling of the body and rhinitis. A draught between the shoulders, permitting the feet or other parts of the body to become cold and damp, exposure to bleak winds, as in driving in an open vehicle, or too rapid checking of the perspiration, causes through the intervention of the vaso motor nervous system a sudden turgescence of the nasal vessels, especially of the turbinal bodies. In the majority of instances this congestion is but transitory, passing off in a few hours and followed merely by increased secretion ; but in other instances it does not subside, but augments in violence, and is followed' in twelve to twenty four hours by a muco purulent and then almost a purulent discharge. This congestion of the nasal vessels occasioned by thus “taking cold “seemingly favors a microbic invasion of the mucous membrane by impairing in some manner its power of resistance.

Extreme heat of weather, especially when accompanied by enervating dust laden winds and acting upon individuals in a starts of fatigue, is capable of exciting a form of' acute rhinitis colloquially termed " heat cold." In like manner a much overheated sitting apartment or assembly hall, or a journey in a superheated railroad car can have a similar result. In fact, a “cold” result quite as frequently from getting too hot as from being too cold.

Again, the subjects of supersensitive nasal mucous membranes may suffer from pronounced nasal irritation when exposed to the inhalations of various atmospheric impurities e. _q. the dust of railroad travel, the smoke and fumes of large cities, particularly when combined with fog, as is often the case in London and Chicago, different kinds of pollen, and even the aroma from horses. Asthmatic symptoms occasionally supervene upon this variety of nasal irritation, and the whole picture differs somewhat from that of an ordinary acute rhinitis, partaking more of the condition which in its typical form is known as “bay fever” or vaso motor rhinitis.

Instances are not wanting of direct infection of one person by the discharges of another an accident which is apt to happen among children by the use of handkerchiefs in common. Suppurative rhinitis in infants is also attributable to direct infection from the vaginal discharge during birth, and this infection may be of a gonorrheal nature. Acute blennorrhea is another term applied to suppurative rhinitis with profuse secretion. The infecting agent may be the gonococcus or other pyogenic micro organisms.

Rhinitis is one of the salient manifestations of genuine influenza; it is an initial symptom of measles; and quasi rhinitis is a prominent characteristic Of iodism, and to a less extent of cinchonism. It is apt to occur during pregnancy and is then aggravated by the passive venous congestion which is incidental to that state.

Symptoms. A sense of stuffiness in the nostrils, with sneezing, burning, and dryness, together with malaise and a slight febrile reaction, is succeeded in a few hours by an acrid watery discharge, which later leads to a free mucopurulent secretion. A simultaneous congestion of the frontal sinuses will occasion headache ; but this does not argue pressure by accumulated mucopurtilent secretion within these cavities, for actual empyema of the frontal sinuses is rare. Much discomfort results from the partial or complete occlusion of the nares, especially at night, the patient necessarily breathing in part through the mouth, which occasions dryness of the throat and a sense of dyspnea; small children will actually struggle for breath and even stiffer attacks of laryngismus stridulus excited in consequence. The sense of smell is obtunded or for the time suspended, and that part of taste which is dependent on the olfactory sense is impaired. A symptom which becomes a serious inconvenience to public speakers and singers is alteration in the quality of the voice, which acquires a guttural and so called "nasal tone" because of limitation of the resonance space by intranasal swelling. The anterior nares become red, sensitive, and excoriated.

On inspection by means of a nasal speculum and reflected light the mucous membrane appears of a darker red color than usual and the turbinal bodies swollen. At times, however, especially at the second stage that of profuse serous discharge the turbinal bodies of now one and then the other side may appear collapsed. At the third stage quantities of muco purulent secretion will be observed. Posteriorly the conditions and aspects are similar.

Diagnosis. From erysipelas, acute rhinitis is distinguished by the gravity of the former affection and the erysipelatous hue which will gradually extend over the lip and nose externally. The nasal irritation from a foreign body is unilateral; that of measles is indistinguishable from simple acute rhinitis until the cutaneous eruption appears ; that of iodism will be associated with cutaneous papules and will promptly cease on withdrawal of the drug. Hay fever occurs in August and September; the patient will perhaps have a history of previous attacks, and in any event the sneezing, burning, post nasal and lachrymal irritation endure without diminution or change for a period much in excess of' simple acute rhinitis.

Prognosis. Simple acute rhinitis, uncomplicated by serious implication of the collateral sinuses or of the ear, will spontaneously terminate in recovery in from five to fourteen days. Nevertheless treatment should not he neglected, for it will certainly lessen the severity and duration of the disease and tend to prevent complications or a transition into chronic nasal catarrh.

Treatment. Sufferers should receive the benefit both of immediate, treatment and of wise prophylaxis. At the time of an attack many remedies are of real service; but a multiplicity of recommendations is confusing and tends to lessen confidence in any one Pine of treatment. I will therefore describe simply my own methods of dealing with these cases.

If it is sought to abort the disorder, a single average sized dose of Dover's powder or of morphin or codein is given at bedtime, also a laxative if needed. The morphin may be combined with atropin to advantage, as in the customary hypodermic e. g., morphin sulphate, gr. 1/6, and atropin sulphate, gr. 1/20. The patient is especially well covered in bed, outside air is excluded, and the temperature of the apartment maintained during the night at 60' to 70' F. This will usually result in a slight excess of secretion from the skin, but no effort is made to produce profuse perspiration. If a decided sudorific effect be desired, a sort of “Turkish bath " may be extemporized previous to retiring by seating the patient, enveloped in a blanket, upon a chair beneath which a small lamp is caused to burn. In the morning on rising three ounces of Rubinat saline water should be taken, provided a laxative has not been administered the night before. If convenient, as in the case of many ladies, confinement to the house for a day or two will insure a prompt recovery.

Quinin has acquired notoriety among laymen as an abortifacient agent; but it is unreliable, and seems even at times to aggravate the condition. Cocain, in the form of a spray, only exceptionally succeeds in actually aborting the disease, although it affords temporary relief; and one is also disappointed in the alleged effects of antipyrin similarly used for the same purpose.

During the course of the affection I have most frequently prescribed prepared 11 rhinitis tablets " (Dr. Lincoln's formula, one half strength), one every two hours, which are composed as follows:

R. Ext. belladonna f1d., Campbora, Quinine sulph.,
gr. 1/8 .008;
gr. 1/4 .016;
gr. 1/4 .016 M.
although other remedies e. g., aconite, potassium bromid, strychnin, or codein may be indicated at particular stages; aconite and potassium bromid early when there is fever, and strychnin later to stimulate the paretic vaso motor system. Codein or morphin conjoined with atropin in small doses is serviceable when there is a harassing cough; and even for the rhinitis itself during the first few days it would be an excellent remedy if it were not for well known objections to its continuous or general use.

Local treatment is of the utmost importance, and the following mixtures render satisfactory service by atomization :
Menthol, Sig. Dilute, adding one teaspoonful of medicine to one ounce of warm water for use as a spray.

Sig. Use with a double bulb (Davidson) atomizer, either alone or following the use of Spray No. 1.

In office practice it is quite customary to spray first with a I/2 per cent., solution of cocain, followed in five minutes by Spray No. 1, and this in turn by the emollient Spray No. 2.

At home either Spray No. I or Spray No. 2 or both may be used every three hours or according to convenience.

To Spray No. 1 can be added a minute quantity of cocain hydrochlorate equal to I per cent. when diluted; but then care must be observed not to use the spray with greater frequency than every two or three hours, as the too frequent use of even diluted solutions of cocain in the nose results in a reactionary turgeseence of the conchae and, in susceptible individuals, in systemic disorder of the nervous system and irregularity of the heart's action. In fact, one should avoid as far as possible prescribing or placing cocain in the bands of patients; for the sensations engendered by its nasal use, together with the cerebral stimulation by absorption through the nasal mucous membrane, are so enticing as to tempt the patient not only to too frequent and profuse use of the substance for the time being, but also to the formation of a chronic cocain habit.

For young children, who are often terrified by spraying, may be substituted a small syringe or an ordinary medicine dropper used as a syringe, with which to project gently either of these spray solutions through the nostrils. All solutions for nasal use should be somewhat warm.

Of the many vapor inhalations I would mention camphorated steam as a domestic remedy of power. It is conveniently used by placing a pint of steaming hot water in a glass fruit jar and adding two drachms of spirit of camphor: a funnel, preferably of glass, is then inverted to cover the mouth of the jar, and the rising steam is inhaled through the nostrils as it escapes from the small end of the funnel. So used, especially during the evening for a half hour, it conduces to a comfortable night's rest and facilitates recovery. The inhalation of steam through a sponge wrung out of hot water is another domestic expedient. The vapor from a few drops of a mixture of equal parts of spirit of ammonia, carbolic acid, and cologne, inhaled from cotton stuffed into a paper cornucopia, conduces to the comfort of the sufferer, as do pocket inhalers which contain menthol or its combinations.

When intumescence of the turbinal bodies continues to be annoying beyond the usual period of actual acute inflammation, immediate relief will be afforded by two skillfully made electro cauterizations after the manner much in vogue for chronic hypertrophic rhinitis.

Prophylaxis. Those who are exposed to climatic inequalities, and who would at the same time escape recurrent attacks of acute rhinitis, should seek in their mode of life to conserve and increase a natural resistance. To this end, no hygienic detail is of greater importance than the habit of cold bathing immediately on rising in the morning. The bath may be of the plunge, shower, or wet towel variety, with the water at a temperature of 50' to 56' F., taken in a reasonably warm room and followed by friction with a linen crash towel, and this by brief calisthenic exercises. Patients who have a fancied repugnance to cold water are directed to commence by simply rubbing the whole surface of the body quickly with a wet crash towel. The cold bath invigorates the vaso motor nervous system, accustoms the cutaneous surface to changes of temperature, and generally augments the bodily tone. This “hardening process," to get the best effect, should be supplemented by regular and persistent open air exercise in all kinds of weather. When properly clad even delicate patients may safely be discouraged from omitting their outings simply because it rains, snows or blows. To remain indoors because of trifling inclemency in the weather means at certain seasons an uninterrupted confinement to hot and ill ventilated rooms for days at a time, with all the softening effects that such a mode of life invokes.

As to clothing, it is a golden rule to keep comfortable, avoiding an excess, of raiment even more assiduously than a deficiency; and changing even to the underwear as frequently as required by variations of temperature. For instance, on a sultry late November day it is certainly less hazardous to rechange to lighter wear than to endure the general relaxation incidental to being overclad. Even in winter, extra thick underwear is undesirable for those who live chiefly indoors, a light grade of good woollen material, supplemented by varying grades of outer clothing and overcoats, being best. For spring and fall a still lighter article either of good merino or wool, and for midsummer balbriggan or even gauze, is suitable for the ordinarily robust individual. Chest protectors are abominations, and neck mufflers are permissible only on extreme exposure. Ordinarily leather will not keep out moisture; and wet or even damp feet in cold weather, endured for hours without opportunity to change, and is a prolific cause of “colds”. A protective overshoe, as low as will answer the purpose and removed on passing indoors, is therefore a necessity.

Living apartments and offices should not be heated beyond 70' to 72' F., and means should be provided for reasonable ventilation and for imparting to hot air a degree of humidity; however, when the other conditions above mentioned are complied with, the baneful effects of oftentimes uncontrollable superheating become much less manifest.

Finally those individuals who are predisposed to acute rhinitis by reason of adenoid vegetations, chronic hypertrophy of the turbinal bodies, obstruefive deformities of the septum, or nasal polypi, should have such affections remedied by accepted methods, supplementing this treatment by observance of the laws of' hygiene.

Membranous Rhinitis. Membranous rhinitis, also termed croupous rhinitis and rhinitis fibrinosa, is an acute inflammation of the nasal passages accompanied by a whitish membranous exudate which covers the whole or parts of' the inflamed mucosa. A membranous exudate frequently forms in consequence of chemical or electro cauterization of the turbinal bodies; but this condition differs essentially from genuine membranous rhinitis. The exudate is thick, gray white in color, confined to the immediate vicinity of the cauterized site, which it overlaps somewhat, shading off to a thin edge a little distance from the center of the most intense inflammatory action. If this pseudo membrane be forcibly detached on the second day, it redevelops; if allowed to remain it becomes incorporated with the eschar produced by the cautery, and the whole will separate spontaneously like an eschar about the fifth day. There is no evidence that such a membranous exudate results otherwise than from a regenerative type of' inflammation following the application of an intense and destructive irritant. Contaminating microorganisms are found; but to them cannot be attributed the initial pathogenic role. It is of importance chiefly as an object lesson, serving to remind one that all membranous exudates are not to be ascribed to a single cause, and that, however ubiquitous the Klebs Loffler bacillus may be, there are yet other agencies capable of producing an inflammation of the membranous type

As in the throat, so also in the nose, an exudate like that of membranous rhinitis proper can doubtless ensue from infection by any one of several species of pathogenic micro organisms; in many of the cases only staphylococci and streptococci have been found ; while in others of identical clinical course Klebs Loffler diphtheria bacilli have been demonstrated albeit oftentimes sparse in numbers, of questionable virulence, or mixed with other microbes. Of twenty two cases which were subjected by Edmund Meyer' to both microscopic and bacteriologic investigation with animal experiments, in thirteen virulent diphtheria bacilli were present, and in nine there were streptococci of little virulence and the staphylococcus pyogenes albus and aureus. The clinical course in both series of cases was essentially the same.

It is true that the disease ,vbich has acquired the name of membranous rhinitis, even when the diphtheria bacillus is associated therewith, differs radically in symptomatology from typical nasal diphtheria. Its mainifestations are chiefly local, it is not accompanied by constitutional symptoms other than those of a 11 cold in the bead," and it shows but little disposition to extend to the throat. Hence in those cases in which the Klebs Loffler bacillus has been reported, it has sometimes been suggested that this in reality might be the pseudo diphtheria bacillus of Hoffmann, which is little virulent, but which morphologically, studied only by the microscope, is quite similar to, the diphtheria bacillus. As is now well known, the pseudo bacillus is viewed by Escherich as an independent organism, but by Roux and Yersin as an attenuated form of the Klebs Loffler bacillus. Again, since diphtheria bacilli are occasionally present in healthy throats, and as their detection alone, unaccompanied by the usual symptoms, hardly suffices for a diagnosis of diphItheria, so also in the nose the presence of a few. such bacilli does not render it certain that they constitute the responsible cause of the membranous rhinitis. In this connection, Dr. W. H. Gross,' of the Children's Hospital of Boston, presents valuable corroborative evidence. Weekly culture examinations were made from the normal throats and noses of 300 children, the Klebs Loffler bacillus being found in 8 per cent. of the cases. Of this number the nose was the habitat in 65 per cent. and the throat in 35 per cent. In none of these did clinical diphtheria develop.

However, since in Edmund Meyer's thirteen cases all the Klebs Loffler bacilli were found to be virulent, it is impossible to escape the conclusion that these cases at least were of diphtheritic origin, and that there are conditions not yet definitely known, pertaining to the resistance of the individual or to the degree of virulence and number of the micro organisms, which determine a wide variation from the usual clinical picture of nasal diphtheria. Until these conditions are better understood such cases will be found classed under the designation "membranous rhinitis; " although it is expected that in the immediate future the general term " diphtheria " will have appropriated most of them for its own.

Etiology. From an etiologic point of view one may therefore divide socalled membranous rhinitis into two types: diphtheritic and non dipbtheritic. Corroborative evidence of the identity of the diphtheritic type of membranous rhinitis with true diphtheria is occasionally obtainable in a definite history of exposure to infection while in attendance upon diphtheria patients.

Case 1. Miss , a trained nurse, applied for treatment at St. Luke's Hospital, complaining of obstruction of the left nostril, which she had at first attributed to a “cold." The inflammation had commenced while she was nursing a diphtheria patient, and she had been under the treatment of her patient's physician for about eight days. During that time the passage was occluded by a white membranous exudate, pieces of which were detached by forceps and subjected to bacteriological examination, disclosing Klebs Loffler bacilli. On personal examination at the end of the eighth day the vestibule of the nose and the upper lip were found tumefied and incrusted by an excoriating discharge, while the septum and anterior part of the inferior turbinal body were still covered by a thin whitish exudate. On account of the swelling it was impossible to determine the exact extent of the exudate; but none was visible by posterior rhinoscopic examination. A culture taken at this time again disclosed Klebs Loffler bacilli mingled with cocci. The right nostril, while somewhat inflamed, presented no exudate. The patient bad not complained of any constitutional symptoms whatever, but appeared worn out and anemic: she had continued her nursing duties to the end and left the hospital the same day to rest at her own home.

Case If. Dr. S , a young physician, was interne at the Children's Free Hospital of Detroit during an epidemic of diphtheria. A few days after the cessation of this continuous exposure lie noticed an inflammation in the left nostril, which progressed to the point of total occlusion by swelling and a white exudate, with an excoriating discharge. He stated that this exudate had been so plentiful that shreds could readily be detached. He was examined about the seventh day, at which time the membrane consisted of a mere film covering an excoriated surface which embraced the vestibule, the cartilaginous septum, and the anterior part of the external nasal wall, extending backward not exceeding three centimeters. A culture was taken and examined by ,Dr. Gehrman, of the Chicago Health Department, in conjunction with his assistant and the patient himself, who reported the presence of Klebs Loffler bacilli. There were no constitutional symptoms, and convalescence was complete in three weeks.

It is thus seen that a liability to the dissemination of diphtheria lurks in the diphtheritic type of membranous rhinitis; it doubtless escapes medical observation and treatment many times, being regarded by the parents of the affected children simply as a "cold," while in reality, from etiologic and pathologic standpoints, it is veritable diphtheria, differing only in degree rather than in kind. Nevertheless, one is not justified in assuming all cases of membranous rhinitis to be diphtheritic, for in many the most careful search has disclosed only cocci. The crucial test lies in the microscopic examination of a culture, which should be deemed imperative in every case.

Pathology. The structure of the pseudo membrane is similar to that which occurs elsewhere in diphtheria. Microscopically, it is composed of proliferated epithelial cells in a fibrinous network.

Symptoms. The symptoms are much the same for both types of the disease, and are ushered in by dryness and fulness of the nostrils with persistent tickling; later there is a free discharge, watery at first, but becoming thick and tenacious. By the third day an exudate will have formed which, if torn away by forceps, leaves bleeding points and soon re forms. The fibrinous deposit may occur in one or both nostrils and may embrace any or all parts of the passages, extending a variable distance backward. It rarely embraces the throat, although it may do so; or rather in these instances it seems to originate in conjunction with acute infectious pseudo membranous inflammation of the faucial and post nasal tonsils. Much discomfort ensues from the total occlusion of one or both nostrils and from the excoriation and tumefaction of the anterior hares, the external nose and upper lip being at times so red and swollen as to suggest erysipelas. In fact, it is likely that the micro organism of erysipelas may be one of those capable of producing membranous rhinitis. These conditions are well exemplified in

Case, 111. Dr. D had been exposed by attendance upon a case of scarlet fever with membranous deposit in the pharynx. He was taken ill with the characteristic symptoms of acute infectious pseudo mem bran ous tonsillitis. Within the right nostril was observed a distinct exudate covering the vestibule, cartilaginous septum, inferior turbinal body, and other parts as far as one could see. It differed from the ideal diphtheritic deposit, being thinner and semi translucent, and had more the aspect of epithe lial d6bri8 ; but was evidently not merely such. The nose externally was swollen and of a decidedly erysipelatous hue, the redness being confined, however, and not extending above the bridge of the nose.

Diagnosis. This will depend upon attention to the salient features already described; if seen late, after the characteristic appearances have subsided it might be mistaken for simple rhinitis which had led to excoriation of the vestibule or for secondary syphilis. Erysipelas should be kept in mind.

Prognosis. The disease has endured usually for about three weeks; nor has this period varied in consequence of treatment, although the comfort of the patient is conserved by remedial measures.

Treatment . For the diphtheritic type of membranous rhinitis antitoxin should be injected, provided the condition assumes a degree of gravity. One would expect this to ameliorate the condition and shorten the duration of the disease.

For the non diphtheritic type the tincture of the chlorid of iron internally best meets the indications. Locally a variety of medicaments have been used; often, however, with disappointing results. Cocain in 2 per cent. to 4 per cent. solution fails to exert its customary degree of retraction ; but wisely employed, especially by means of cotton tampons, it affords relief and is serviceable preceding the application of other remedies. In my own cases, following the cocain I have applied satisfactorily by tampons this lotion:

For its destructive effects upon ;the membrane a Weak solution of one of the iron preparations has been commended, Loffler's solution, appropriately diluted for nasal use, might be substituted. It is composed as follows : Menthol, 10 gm.; toluene, q. s. ad., 36 c.c.; creolin, 2 c.c.; iron chlorid solution, 4 c.c. ; alcohol, q. s. ad., 100 c,c. Medicaments which smart and irritate the nostrils for any length of time had better be avoided or their strength reduced. For his own use an alkaline and antiseptic spray conduces to the comfort of the patient e. g.

Abscess of the Nasal Septum. The condition which for the sake of simplicity in nomenclature is designated 11 abscess of the septum “only occasionally presents the typical characteristics of acute circumscribed suppuration. When caused by traumatism, the first stage may be an effusion of blood beneath the muco perichondrium. of the cartilaginous septum, which is termed “hematoma of the septum." In time the blood degenerates, perhaps becomes infected by pyogenes micro organisms, and changes to a brownish yellow fluid, which when evacuated appears neither like blood nor typical pus. In this state it has been called "cold abscess." Again, when it originates without traumatism and runs an acute course, with pain, fever, and obstructive swelling, terminating in ideal suppurations, it has been spoken of as "acute perichohdritis." Jurasz' has described a form in which the contained fluid is at first serous, termed serous perichondritis. Some sort of abscess is the culminating stage of all these conditions (see page 1117).

Although it might be possible for the bony portions to be affected, the usual seat of the disease is the cartilaginous part of the septum, and it may be either unilateral or bilateral.

Etiology. The most frequent cause is believed to be traumatism e. g. blows or falls upon the nose; yet in many cases it is impossible to establish this relationship. Slight contusions, readily forgotten, can determine a hematoma of the septum. This may run an insidious course, endure for days or weeks, and undergo spontaneous absorption, having been little noticed; but in other instances the blood changes to sanguinolent pus and the cartilage itself disintegrates, the abscess contents being retained by the bulging mucoperichondrium. Pyogenic micro organisms could excite suppuration in these and also in so called idiopathic cases by gaining an entrance through the excoriations which are frequent on these surfaces. The disease may occur also during the course of typhoid fever or small pox; and Schech calls attention to the frequency with which facial erysipelas proceeds from abrasions upon the septum, and infers that abscess of the septum can be caused by infection by the streptococcus erysipelatus. In many cases still it is quite impossible to assign any definite cause. This was true in the following case, which is a typical example of the variety termed cold abscess:

case I. Master G , aged sixteen years , while away from home at school, began to suffer from nasal obstruction, which he attributed to an acute exacerbation of his customary " catarrh." No history of traumatism could be elicited, the disease having seemingly commenced as a cold and continued several weeks before it received serious consideration. But nasal obstruction and swelling within and without the nose gratin ally grew so serious that he was sent home, where he was confined to bed, supposed to be suffering from asthma. On examination the diagnosis was at once apparent, for from each side of the septum bulged a fluctuating tumor which completely blocked both nostrils. The enveloping mucosa was unbroken, somewhat inflamed, and the nose generally reddened and edematous. A brownish yellow liquid was withdrawn by a hypodermic syringe, and this was followed by a free incision toward the base of one side and gentle curetting of the cavity. The central portion of cartilage had liquefied; but it redeveloped from the muco perichondrium and perfect recovery ensued.

Symptoms. In case of the transition of a hematoma into an abscess, the disease may manifest itself either quite insidiously or the suppurative change may ensue quickly and be associated with, sneezing, general nasal irritation, and slight fever. In either event the salient symptom ultimately complained of will be obstruction. to nasal respiration, together with the discomforts of mouth breathing.

When the abscess arises in the form and in consequence of acute perichondritis, it is ushered in during a few days by symptoms indicating a high degree of inflammation e. g. chill, pronounced fever, swelling and redness of the whole organ. Spontaneous rupture is more apt to occur quickly in this than in the former type, although it may be much delayed after the subsidence of the inflammatory symptoms, leaving again nasal obstruction as the salient symptom.

Case 11. exemplifies the latter type. Mr. , aged twenty six years, thought he bad contracted a severe " cold in the head,'; the condition commencing with chilly sensations, followed by headache, fever, local sensitiveness, and redness extending to the bridge of the nose. These symptoms gradually subsided, but were replaced by nasal obstruction and what be now supposed was chronic nasal catarrh. The examination was not made till the third week, when a fluctuating tumor was observed to bulge from each side of the septum. Typical PUS was evacuated by an incision and the cavity curetted. The destroyed central part of the cartilage ultimately redeveloped without deformity. He positively denied the least probability of traumatism as a cause.

Diagnosis. By simple inspection with the head tilted backward the semicircular tumor may be seen bulging from one or both sides of the septum (Fig. 569). Palpation by a probe will cause deep pitting or even fluctuation, and aspiration by a hypodermic needle will provide a sample of the contents. It may thus be readily distinguished from polypus, for which it is most commonly mistaken by novices, which occurs but rarely in this situation ; and also from syphilitic gumma, which commonly develops at just this spot. I have seen one case of gumma, in which the central part had liquefied before the occurrence of superficial ulceration, in which the diagnosis would have been impossible had not other syphilitic signs been present.

Prognosis. If recognized reasonably early and the abscess evacuated, the prognosis is very good. Notwithstanding complete liquefaction of the cartilage itself, if the muco perichondritim be preserved another cartilaginous septum will develop, and this usually without deformity. However, if the disease be unrecognized or if the inflammatory action extends to the anterosuperior border of the septum, the line of junction of the septum with the lateral cartilages and nasal bones, softening and depression of these, which constitute the dorsum of the nose, will result. Apart from this "saddleback" deformity or in conjunction with it, perforation of the septum can also ensue.

Treatment. When the initial stage is a hematoma, cold applications would be suitable. In any event, as soon as pus is present a rather free incision should be made low down on one side and the contents expressed. This should be reopened daily with a probe until the cavity has been effaced. It is probably not necessary to curette, wash out, or pack the cavity with gauze, although one or all of these may seem desirable at times.

Abscess and Furuncle of the Nasal Wing. Furunculosis of the wing of the nose is of frequent occurrence and results commonly from infection or irritation in or about the hair follicles, as from pulling out hair The boil is usually quite small, scarcely more than a " pimple," but is accompanied by an amount of tenderness, swelling, and redness of the nasal appendage quite disproportionate to its size, It points inside the wing of the nose in a position difficult of observation even with a nasal speculum, but it can be exposed to view in a small rhinoscopic mirror held just within the vestibule. It should be punctured as soon as suppuration is evident, as this will abbreviate materially the incidental discomfort.

Genuine abscess occurs, but much more rarely, in the same situation, and may be ascribed to similar causes. I have observed but few cases; in one of them, however, the abscess had attained the size of a hickory nut, with large swelling and total occlusion of the nostril. Laudable pus was evacuated by an incision made from within.

L. Wroblewski 1 mentions having seen and operated upon several cases of abscess of the wing of the nose occasioned by the bacillus anthrax benignus.

Erysipelas of the Nose. Too little attention has been drawn to the fact that so called idiopathic facial erysipelas quite commonly originates within the Dose.

Etiology. The cause here, as elsewhere, is an infection by the streptococcus erysipelatus, a micro organism specific to erysipelas, which gains entrance through fissures and excoriations which frequently affect the anterior nares and the cartilaginous septum as well as more rarely the deeper surfaces of the nasal fossa Otherwise trifling intranasal operations may furnish the responsible gap, and it is even possible, although not proven, that infection may occur through an unbroken surface. Certain persons are predisposed to infection on the slightest provocation.

Symptoms. The affection commences like an acute rhinitis of unusual severity. The temperature runs high, there is total occlusion of the nostrils,a profuse excoriating muco purulent secretion, swelling with erysipelatous redness of the nasal appendage, and later an extension of the erysipelatous dermatitis to a variable distance over the face. In like manner it may extend posteriorly to the naso pharynx and pharynx or involve the collateral sinuses of the nose a combination which may present the gravest aspects. On inspection the nasal mucosa appears of a dusky red color, or it may be covered by a thin milky exudate.

Treatment. By way of prophylaxis, especially with those who have a history of previous attacks, excoriations and fissures should receive adequate attention to secure prompt healing ; all operative measures not strictly necessary should be avoided and others made with thorough antiseptic precautions.

During the attack, for internal administration, the classical remedy for erysipelas, tincture of the chlorid of iron in doses of ten minims and upward, has not been successfully superseded. Locally, for intranasal use, sprays Nos. I and 2, formulae for which are given in the section on acute rhinitis, serve a useful purpose ; and as a topical application for the excoriated anterior nares and inflamed skin surfaces, the resorcin mixture detailed in the section on membranous rhinitis can be commended.

Upistaxis Nose bleed. Epistaxis (epi staxo, to flow drop by drop) is a hemorrhage from the nose, and varies in degree' from a trifling inconvenience to an occurrence which involves grave danger to life.

Etiology, Pathology, and Varieties. I. Idiopathic. Even when apparently spontaneous, a slight traumatism as in picking the nose or using a handkerchief roughly may be the exciting cause. The bleeding point can be anywhere in the nasal fossa; but in 90 percent. of the cases by actual count it is found just within the nostril on the cartilaginous septum. This structure is richly supplied with blood by the anterior artery of the septum, a branch of the superior maxillary, and in copious hemorrhages it may be the artery of the septum itself or some of its twigs which have been opened. The vessels are poorly protected by a thin mucosa, and the spot is much subject to erosion, ulceration, and incrustation. With vessels thus ready to break at any moment, a variety of local and constitutional conditions serve to excite bleeding.

It is a well known symptom of typhoid, malarial and pneumonic fevers. It is liable to ensue upon violent exercise or to accompany 11 rush of blood to the bead," from whatever cause, especially in plethoric individuals and in persons affected with passive congestion of the venous system from organic disease of the heart, liver, or kidneys, and during pregnancy. It follows large doses of quinin. It is of course a symptom in ulcerative syphilitic disease, in angioma or "bleeding polypus of the septum," in sarcoma, carcinoma, and other nasal neoplasms. In elderly persons, if recurrent and without other cause, it indicates an ominous degeneration of the vessels. This I have observed in the case of an aged gentleman who had bled profusely in spite of remedies and through the packings for three days, when careful examination by reflected light and with rapid swabbing disclosed a spurting artery of the septum, which was instantly sealed by electro cauterization.

Vicarious epistaxis is a substitution of nasal hemorrhage for the natural menstrual flow, and occurs at times of acute suppression of the menstrual function or of its difficult establishment about the age of puberty and during the menopause. Doubtless in these cases, also, there is a weakness or erosion of the vessels of the septum, which are unable to withstand the hyperemia of the head which results during perversion of menstruation. The menstrual molimen, including the congestive headache, is relieved by the vicarious epistaxis, which within reasonable limits may be regarded as beneficial rather than detrimental. In one case cited by Frankel,' however, the recurrent nasal flow was so profuse that a fatal termination ensued.

2. Traumatic. Hemorrbage following fractures and other intranasal accidents, while profuse for a short time, commonly ceases spontaneously. If persistent in spite of packing, it indicates an injury to neighboring parts. Serious bleeding has occasionally resulted from otherwise trifling intranasal operationse. g. removal of spurs from the septum, cauterization of the concha, etc., so that means to cope with this contingency should be provided and operations possibly declined on persons from whom a bleeding history is elicited.

Symptoms. Only the premonitory symptoms of those subject to habitual epistaxis require special mention. Patients complain of vertigo, tinnitus, temporal throbbing, a sense of cerebral pressure and headache, while the cheeks are flushed and the conjunctivae injected. They are gratified at the bleeding for the relief which it brings.

Diagnosis. in the absence of actual hemorrhage only a careful search and palpation with a probe, at the risk of exciting bleeding, will disclose the responsible vessels.

Treatment. Most attacks cease spontaneously inside of half an hour. Simple expedients are : the superficial plugging of the nostril with cotton, pressure of the nasal wing against the septum, the insertion of a finger into the bleeding nostril, ice applied to the side of the nose and held in the mouth, the application of ice in small pieces within the nostrils, ice to the back of the neck and along the spine for its reflex action, the injection of hot water, 120' F., or spraying of hot vaselin into the nose 2 damming of the blood into the general venous system by constriction of the extremities near the trunk by straps or handkerchiefs, and the administration internally of a mixture of gallic acid, antipyrin, and fluid extract of ergot.

Spraying the nostril by strong astringent solutions of tannic acid, iron, or alum is seldom effective and is objectionable on account of the irritation produced, although the insufflation of powdered matico is generally commended. A better and really effective spray is composed of 4 per cent. solution of' cocain in 2 per cent. solution of antipyrin, materials which act as powerful vessel constrictors. After spraying, a pledget of cotton soaked in peroxid of hydrogen may be introduced well into the nostril, the pressure from the liberated gas in all directions assisting in the formation of a clot.

Really serious cases are prone to resist all of these measures, and then one must either locate the bleeding vessel by rapid swabbing and cauterize it by electricity, chromic acid, or nitrate of silver, named in the order of desirability, or, in case the hemorrhage is too profuse to permit of this procedure, or if for other reasons it cannot be accomplished, one should pack the nasal fossa from front to back with 10 per cent. moist iodoform gauze. This is best done by a slight modification of the plan first proposed by Dr. E. Fletcher Ingals.' Two strips of double tbickness gauze, each two feet in length and a full inch in width, are prepared, and near the distal end of each (the end first to be inserted) a strong thread is tied. The first strip is passed through the inferior meatus to the naso pharynx, fold after fold being pushed in until the lower channel is full. The second strip is passed.iD like manner well into the middle meatus, and traction is then made on the threads in order firmly to pack the gauze at the rear end, the surplus of gauze in front is cut off and the threads anchored to a padded stick across the nostril. In narrow nostrils there may be room to manipulate but one strip of gauze, and this will then suffice. The point is that the gauze shall be placed as far backward as the naso pharynx and not merely stuck in front.

Plugging the posterior Dares is a common resort for obstinate epistaxis; but it is liable to provoke inflammation of the middle ear, mastoiditis, and brain complications. I have seen a patient's life placed in jeopardy thereby, and am firmly of the opinion that posterior plugging should be avoided whenever possible. A substitute is found in the above described method of packing the nose from in front, which will suffice for all cases of strictly nasal hemorrhage.

When, however, the bleeding is from the naso pharynx itself, as from the removal of “adenoids " or tumors or from operations on the posterior ends of the turbinated bodies, it may be necessary to plug posteriorly.

A wad of iodoform gauze, adapted in size either to fit well into the choana or to fill in part the naso pharynx, according to the location of the bleeding point, is tied across the middle by strong double silk thread. A soft catheter is passed through the nose, and to its end, picked from the pharynx by forceps, one double thread is tied, and the plug, assisted by a finger around the velum, is thus drawn into the naso pharynx. These threads are best anchored to a small padded stick across the anterior Dares. The other string ends, or one of them, is maintained through the mouth as "a leader" by which to detach the plug. The posterior packing should not remain longer than twenty four to thirty six hours without removal. A still less septic plug and one perfectly soft and globular can be prepared, as suggested to me by Dr. Ethan A. Gray, by making it double, as it were, one layer inside the other, the strings being secured around the inner kernel and both layers being covered by thin rubber cloth. Thus I have saved the life of one patient who required packing for a period of five weeks.

NOTE. Other acute diseases of the nose, primary and secondary syphilis, nasal diphtheria, acute sinusitis of the maxillary, frontal, ethmoid, or sphenoid cavities, and traumatism will be considered in the respective chapters devoted to these conditions as a whole.

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