Atrophic Rhinitis | Operating Microscopes

Atrophic Rhinitis
By W. PEYRE PORCHER, M D.,
OF CHARLESTON, S. C.

Synonyms. Rhinitis sicca and cirrhotica; Coryza fetida; Ozena, etc.

In atrophic rhinitis, as in atrophy of other organs, atrophic degeneration of the glandular and muscular structures is found in one form or another, whether the disease occurs in the young or the old, in the plethoric or the anemic. Microscopical research amply substantiates this fact, as shown by the investigations of Frankel, Gottstein, Krause, Hartmann, Bosworth, and others. Owing to the various phases which it presents, it has been divided by authors into several varieties namely, mucous or simple dry rhinitis, muco purulent or atrophic rhinitis, and ozena; but the typical form of nonulcerative atrophic rhinitis, attended by the formation and retention of crusts in the nasal fossae, is distinctive, and is characterized by a horrible stench, which once inhaled can never be forgotten.

The odor from syphilitic necrosed bone resembles it in some degree and is quite as objectionable; but the fetor of atrophic rhinitis has more of a musty, graveyard odor, and produces a sensation which is unlike anything else to which it can be compared. It is generally admitted that syphilis is not always a factor in the etiology of typical non ulcerative atrophic rhinitis; but syphilitic ulceration with caries always results in atrophic degeneration of the nasal mucosa, and in the majority of instances the disease will be found combined either with syphilis, struma, or tuberculosis.

The odor varies greatly in intensity in different individuals, as well as the crust formation, even to the complete absence of one or the other symptom; but where the fetor is marked it may safely be depended on that retained secretion will be found in some fossae or in the accessory sinuses; and where the amount of crust formation is very great and long retained, the fetor will usually be proportionately intense. I speak of typical nonulcerative atrophic rhinitis because one of the most common fallacies is that the disease is always accompanied by ulceration. There is never any ulceration except when a crust has been allowed to remain so long that a 'raw surface is left beneath it or where the septum is excoriated by frequent picking with the finger nail, or as a result of syphilitic or tubercular degeneration. It occasionally happens that atrophic degeneration occurs without crusts or odor; but these cases are by no means of frequent occurrence.

Atrophic rhinitis is found so much oftener in the female than in the male that it has been held by some to be purely a woman's disease, as it develops frequently at the age of puberty and is thought to be uncommon after the menopause. This has not been the experience of the writer; however, as many of the worst cases which have come under my care have been in old women who have long passed the menopause; and it has occurred quite as frequently in men as in women. Just when the disease begins or what is the immediate cause, has always been difficult to determine from the history ; as in most, if not all, cases the patients are unaware of its existence until it has become so well established and has made such inroads that it can no longer be overlooked , either by themselves or their friends. It may be found at any age from extreme youth to old age; but in the former case it is very difficult to differentiate it from the syphilitic manifestations with which it is so often combined or on which it is super induced. The poorly nourished or those whose hygienic surroundings are very bad are the most common subjects of the disease, because of the repeated catarrhal attacks to which they are liable and the prolonged purulent discharges I'D which these attacks result.

Symptoms. A typical case of atrophic rhinitis has been described as follows: The patient complains of great, often almost choking, dryness in the throat, of accumulation of mucous crusts, particularly in the vault of the pharynx, and of loss of the sense of smell; an intolerable sickening odor may or may not be present in greater or less degree. On inspection the mucous membrane is found to be dry and shiny, and the turbinals nearly or entirely destroyed by atrophy. The nasal chambers are greatly enlarged, so that the pharyngeal wall can be plainly seen by anterior rhinoscopy. The surface of the turbinals is often rough and irregular from unequal degenerations; and intense congestion from crust irritation is generally present. By posterior rhinoscopy the pharyngeal glandular tissue is found to be almost totally destroyed, and the vault and nasal fossae are blocked by crusts, often intensely offensive, which may be either dry or soft and mucous in character, and often completely occlude the Eustachian tubes and posterior nares. The lower pharynx presents a most peculiar and typical appearance. The posterior wall is dry, often puckered from lack of moisture, and intensely congested. The posterior half arches appear drawn much nearer together than in their normal condition, and on pressure with the probe, the pharyngeal mucous membrane is found to be practically resting on the bodies of the vertebra. Deeply congested and frequently abraded tissues are found on examination with the laryngoscope, and the trachea and bronchi are often also diseased.

The foul breath forms, of course, the most obtrusive symptom. Owing to the atrophy of the nerve filaments in the olfactory region, where the degeneration generally begins, there is complete anosmia, so that the patients are entirely unconscious of the stench which they exhale; but they gradually learn to shun people. Their presence, however, is often only too apparent, even when they are at a distance, unless they are in the open air or the ventilation of the apartment is unusually good.

The trouble is generally attributed by the patients to gastritis, or the complaint is made that they never have occasion to blow the nose from one week to another. When they do, however, a large crust is generally expelled. This gives great relief to the sufferer and lessens the odor for a short time; but it recurs with full intensity as soon as the crusts re form, and becomes more penetrating the longer they are allowed to remain. The color of the crusts varies from brown to green and yellow, and they are sometimes even black on the outside. They are generally bard in the middle, but become softer in consistency as they approach the outside edges.

The eyes and ears are often involved. The mouths of the Eustachian tubes are large and patulous, and not infrequently acute suppurations of the middle ear, accompanied by very severe pain, are caused by small particles of mucus which have been inhaled or driven in by the forcible use of the anterior or posterior nasal douche. When the abscess is complicated with or dependent upon a syphilitic diathesis, there may be a complete absence of pain, and this forms a means of differential diagnosis between an abscess due alone to atrophic disease and that dependent upon the syphilitic diathesis. Bosworth maintains “that in a given number of cases of grave impairment of hearing the number due to hypertrophic disease outnumbers those due to atrophic disease in far greater proportions than the comparative frequency of the two diseases." This is a most rational conclusion for many reasons, but especially because every tendency of hypertrophic rhinitis is to occlude the Eustachian tubes, whereas in the atrophic forms the tubes are open and patulous. Tinnitus and many other intractable forms of ear disease are sometimes distinctly traceable to this disease. Many affections of the eyes may accompany or result from atrophic degeneration of the nose, notably phlyetenular keratitis and conjunctivitis.

Atrophic rhinitis frequently dates from one or other of the exanthemata, scarlet fever, measles, or diphtheria, or more commonly from a series of' bad colds in the head. There is a certain facial expression that is almost typical of sufferers from ozena the low flat nose with the large open nostrils. in old subjects the nose generally appears to be almost sunken in the face. There is a peculiar dry appearance about the vestibule and anterior naris. There is a complete absence of vibrissoe, with widely distended alae, as though the patient was suffering from want of breath. This must unquestionably be, caused by the large plugs of mucus, in which a small hole is often found, on which, unless they resort to mouth breathing, the patients must depend for their supply of air until the plug is removed. So tightly do these crusts become impacted in the nares that their pressure may contribute to cause the abnormal roominess found in the nose, the turbinals are pressed widely apart, there is a complete collapse of the erectile tissue, and in some cases the months of the Eustachian tubes and the posterior pharyngeal wall can be inspected by anterior rhinoscopy. The mucous membrane is conspicuously pale, except around the margins of ulcerations or in localized spots of inflammation. In the incipiency of the disease the mucous membrane will generally be covered with a thick, glairy, white secretion, which constitutes a most aggravating source of annoyance both to the patient and to the practitioner. The patient keeps up an incessant coughing, hawking, and clearing of the throat in the effort to get rid of it, and the physician finds it almost impossible to free the throat and nose, even with the most persistent washing and swabbing out with antiseptic solutions, etc. It is the belief of the writer that many patients have succumbed to this disease before the diagnosis was ever clearly established. The continuous cough and irritation so lowers the vitality of the patient that death supervenes directly or is superinduced upon some intercurrent malady.

Epistaxis not infrequently occurs as a result of erosions caused by dry incrustations on the septum and elsewhere. These erosions may be so small that the point from which the hemorrhage proceeds can only with difficulty be detected. The hemorrhage may also be produced by a perforation through the septum, due to incessant picking of the nose in the' effort to get rid of the crust formation. Hoarseness is often present and the vocal function is always impaired. In the later stages of the disease the crusts break tip, and small particles being inhaled set up violent spasms and incessant and aggravating cough. These small particles are often seen lying upon the vocal cords or other parts of the laryngeal interior, and there can be no question that their presence often results in the most intractable laryngeal and pulmonary inflammation.

Etiology. Many theories have been advanced as to the etiology of this disease. Mackenzie says: “That atrophic rhinitis always appears as a sequel of a pre existing catarrhal inflammation is rendered highly probable from a number of clinical and pathological facts. If the clinical history be accurately taken, it will point to pre existing catarrhal process. As has been indicated above, the rapidity with which the hypertrophic passes into the atrophic form of rhinitis is proportionate in all probability to the possession of some constitutional taint, such as congenital or acquired syphilis."

Dr. Bosworth says that " a purulent rhinitis in childhood is a catarrhal process in the first year and a catarrhal process always; and that it consists essentially in an increased secretion of mucus in the earlier stages, together with rapid desquamation of epithelial cells, which, running its course as a purulent disease in from five to ten years, develops finally into what is known as atrophic rhinitis. The disease, in fact, is the first stage of so called dry catarrh or ozena." The theory that a purulent inflammation of the accessory cavities is the cause of atrophic rhinitis was advanced many years, ago by Michel, and sphenoidal and ethmoidal involvement is common.

A hypertrophied mucous membrane may be found in one nostril with atrophic degeneration in the other; but that does not prove that either condition is dependent upon the other.

One of the interesting theories of the etiology of atrophic rhinitis is that of Lowenberg, who attributed it to micro organisms.

Auche and Brandel I contribute a paper to the bacteriology of atrophic rhinitis, which confirms the observations of many previous students. They examined twenty cases, and their results 'are summed up as follows:

" 1. The diplobacillus of Lowenberg has been demonstrated in all the cases of atrophic rhinitis with or without ozena in course of evolution. It was not found in old atrophic coryzas which bad apparently been cured. It is not the pathogenic agent of ozena.

" 2. The pseudo diphtheria bacillus was found eighteen times out of twenty observations of atrophic coryza in course of evolution. It was met with twice in four patients affected with old atrophic rhinitis which had been much ameliorated. It is not the causative agent of ozena. It is very probably only a saprophyte developed in the Basal chambers of patients affected with atrophic coryza, on account of changes in the secretions of the mucosa.

" 3. The little bacillus of Pes and Gradenigo was only found in cases of ozena (crusts), and only in the proportion of three to twenty.

" 4. Electrolysis produced no effect upon the microbial flora of our patients."

Arslan I after the bacteriological examination of 24 cases, arrived at results which are equall'~ negative so far as concerns the discovery of an organism which could be regarded as the causative agent of the malady, but he is disposed to be rather optimistic in his views as to the efficacy of the serum treatment of ozena. He treated a number of cases with diphtheria antitoxin, but an analysis of all his cases does not seem to me to warrant the hope that in the serum we shall find a satisfactory curative agent for this. distressing malady.

Although Gradenigo has recanted his first favorable opinion of the method and there have been other discouraging reports, there seems to be considerable interest abroad among rhinologists in the outcome of experience with the method. Moline' reports. having cured three cases of advanced ozenic atrophic rhinitis by the repeated injections of 10 cc. of Roux's diphtheria antitoxin. He reserves his decision as to the value of the method for fuller experience, and he suggests that the curative properties may reside in ordinary horse sertim. Compaired sums up his experience with the serum treatment, of ozena as follows:

" 1. At present this procedure is one which furnishes the most positive results in the treatment of ozena.

1 Reme hebdomadaire de laryngologie, etc., No. 41, 1897 ; Wright, N. Y. Med. Journal, June 4, 1898.

Archivio italiano di otologia, vol. vi. fase. 1, 2, 3.

Annales des Maladies de l'Oreille, etc., April, 1897.

The result is shown subjectively by the disappearance of the fetor after the second or third injection of 5 or 6 cc. of serum recently obtained and employed according to all the aseptic and antiseptic rules; and objectively by the absence of dryness in the nasal fossoe with diminution of the crusts and the increase of the nasal secretion.

" 3. Objectively, a change in the color of the mucosa is noted, becoming redder, moist at times, and slightly congested and hyperemic.

" 4. The crusts are less hard, dry, and extensive, and become more fluid, according as the number and dose of the injections increase.

"5. The quantity of 10 cc. proposed by Gradenigo is not free from danger, and this is so even as to weaker doses. For this reason it is necessary to use the injections in gradually increasing doses with great care.

" 6. The treatment in question offers many inconveniences and dangers, but, on the other hand, it furnishes very positive results; therefore it is proper that the study of the method should be carefully pursued."

Notwithstanding the above statement, until a micro organisms is constantly demonstrated in the superficial layers of the atrophied mucous membrane and it is shown that inoculations produce the disease, we must be satisfied with believing that micro organisms are responsible only for the characteristic odor of the altered secretions of atrophic rhinitis, in which they find a suitable medium for their growth. It is probable, from what has thus far been reported, that several microbes are capable of producing the odor when growing in the secretions.

Purulent inflammation originating in any of the accessory sinuses or resulting from a simple acute inflammation may likewise result in atrophic degeneration, with more or less complete destruction of the muciparous glands and follicles. The effect of pus on the epithelial and glandular structures, especially in the nose, need not be dilated on here ; but it has been a well observed fact that atrophic degeneration generally begins upon the middle turbinal bodies, and it has also been noted that scabs which become incrusted .there and elsewhere almost always contain some particles of pus incarcerated on the under surface of them. Of course, it may be said here that atrophy may result from the simple non use of any organ, without the presence of any inflammation, simple or purulent, to produce it. Paradoxical as it may appear, it is nevertheless true that the nares of habitual mouth breathers or those to whom the nose is little more than an ornament of the face, instead of becoming larger from atrophy of the mucosa, become narrower and more occluded, almost as though a hypertrophic instead of an atrophic process bad been established ; so that it cannot be said that atrophic degeneration is in any case due to simple non use of the organ first, because of the fact above cited, and second, because the worst cases of atrophic rhinitis are generally found in those who live in workshops where they breathe the most foul air, sooty emanations, etc.

Atrophic rhinitis occurs quite often at a very early age. Large green crusts forming complete casts of the nose have been found in children of seven years and younger. In these cases the etiological factors of hypertrophy, dust inhalation, etc., may be entirely excluded. This was notably the case in a child of six or seven years of age that was brought to the writer. There was no specific taint in this case, and hence there could be but one cause to which the disease could possibly be attributed namely, a prolonged rhinitis resulting from an acute attack which bad been left to run on until the nasal mucosa was almost entirely destroyed

Polypi, malignant growths, etc., have been cited 'as a cause of ozena. Hereditary abnormal patency of the nostrils has also been advanced as one of the causes of ozena, because of the inability of the patient to free the nostrils of accumulated muco pus. This is too hypothetical to be relied on but there is no doubt that the fetor is due to decomposition and fermentative products, because when the nostrils are cleansed in the proper manner there is an almost complete absence of fetor for many hours afterward. The theory that atrophic degeneration is nothing but a secondary stage of the hypertrophic variety has been refuted time and again by many of the most careful clinical observers, because it affords no explanation of the ozena of early childhood; and the dry rhinitis of later life is not always preceded by hypertrophy, and hypertrophy does not always terminate in atrophy. The theory of Michel that the disease is due solely to purulent discharges flowing from one or other of the accessory sinuses met with much favor for some time; but this also has been refuted, because in some instances the accessory sinuses were not found to be involved or any discharge flowing from them.

Diagnosis. In regard to diagnosis, there should be no difficulty, as the intense fetor at once makes itself known, and in the cases where this symptom is reduced to a minimum the large roomy nostril, together with the characteristic physiognomy, at once proclaims the nature of the malady. I cannot agree with the authors who make separate subdivisions of simple vascular collapse of the turbinals, mucous or simple dry rhinitis, ozena, etc. I am inclined to believe rather that these will be found to be only different stages of the same disease. This also applies to ulcerations which are found in some so called non syphilitic cases and not in others.

The ulcerations will generally be found in those cases in which there has been not only an entire neglect of treatment, but in which the patients have had no relief from the sources of irritation which originally started the disease, and in which the crusts have been retained so long that the mucous membrane has broken down and left the tissues abraded.

The crusts in lupus vulgaris may be mistaken for those of atrophic rhinitis, but lupus generally attacks the outside of the nose as well as the inside; and when the inside is alone involved the crusts adhere so closely that they cannot be removed without hemorrhages and the fetor is never so intense as it is in ozena. In ordinary cases of atrophic rhinitis the crust will be found lining the mucous membrane of both nares. It may completely fill the nasal chamber, being perforated in places for the air to pass through; and when blown out it will show a complete cast of the interior.

In syphilitic ulceration the ravages of the disease are far more general than in lupus and the sequestrum rapidly forms, which, together with the history of the case and the peculiar fetor may make the diagnosis very clear. The presence of rhinoliths can only be determined with the aid of the rhinoscope and the probe. Tubercular ulceration may be mistaken for ozena, especially in the incipiency of the disease; but here again we must rely on the history, the general appearance of the patient, and the microscopical examination.

Pathology. Opinions vary so much in regard to the pathology of atrophic rhinitis in accordance with the various theories of the etiology of the disease that it is difficult to arrive at any definite conclusion in regard to it. It is generally admitted that it is similar to that of atrophic degeneration in any other organ i. e., a gradual wasting away of the different layers of mucous membrane and the conversion of their individual elements into fibrous connective tissue. The walls of the erectile spaces are converted into dense fibrous bands, which in contracting obliterate the erectile cavities. This fibrous degeneration may be confined to the deeper layer and the epithelial layer be intact; or the epithelial layer may be destroyed, while the deeper layers are less involved. The limits of this article make it impossible to go into the minute microscopical appearances of this condition; but this can be found in any of the text books on the subject.

Prognosis. It is beyond question that this disease is one of the most intractable to deal with in the whole field of medicine, and from the very nature of the case it is held by a very large number of most eminent authorities to be incurable. There are still a large number, however, as will be seen later, who believe that the raucous membrane can be so changed by judicious use of stimulants, antiseptics, constitutional treatment, etc., that a virtual cure is brought about; and in the light of the most recent investigations it is the opinion of the writer that this latter conclusion will be found to be correct.

Treatment. It is apparent, then, as has been stated by some writers, that atrophic rhinitis is not a disease per se, but is the result of any inflammation, acute or chronic, specific or non specific, whether excited by exposure to cold or continuous inhalation of irritating dust, vapors. etc., which ends in a purulent discharge, and which may or may not involve the accessory sinuses, but is sufficiently prolonged to wash away the epithelium and destroy the nasal mucosa. If this is true, what measures should best be instituted for the relief of the patient, and what hope have we that the formation of scabs may be stopped?

In response to an article by the writer, this subject was very fully discussed at the meeting of the American Laryngological Association in 1896, and again it was made the special subject of discussion at the annual meeting in 1897, and a great many varieties of treatment were suggested. The following resume of remarks will give some idea of most advanced views of the treatment of this disease (see also page 885):

Dr. C. C. Rice expressed his belief that the disease was intimately dependent upon some constitutional taint or unhealthy occupation or manner of living. He therefore urged the necessity of giving patients out of door work with good hygienic and sanitary surroundings. He recommended a combination of 75 per cent. compound stearate of zinc with boric acid and 25 per cent., compound stearate of zinc with alum. This powder should not be used after the discharge has been stopped and congestion controlled, as it is too drying. In the markedly congestive forms of atrophic rhinitis seen in immoderate cigarette smokers and alcoholic drinkers this powder is a valuable one. It goes without saving that we should not promise any benefit from any form of treatment unless excessive smoking and drinking are given up.

Dr. Wright recommended mild stimulation with a weak solution of thymol.

Dr. Delavan concurred with Dr. Wright, and recommended electricity for the same reason.

Dr. Vanderpoel had used dipbtheria antitoxin based on the similarity between the Klebs Loffler bacilli of diphtheria and those found in atrophic rhinitis, and in one case there was no return of the crusts which the patient had had before the attack of diphtheria.

Dr. Logan laid stress on the necessity of establishing free drainage from the accessory sinuses, so as to stop the continual discharge of pus over the middle and upper turbinals.

Dr. Casselberry advised that patients should select the warmer, moist, and salubrious climate of the Southern seashore rather than the dry regions of the West.

Dr. Mackenzie recommended weak solutions of bichlorid of mercury rather than strong antiseptics. A form of stimulation in the shape of massage has been strongly recommended by Laker of Vienna. Massage may be applied to the nose either by the aid of an electrical vibrator or simply by titillating the parts with a probe armed with a pledget of cotton.

The Germans and Italians recommend bichlorid of mercury strongly on the assumption that the disease is due to the presence of bacteria. Koch and Lowenberg claim great benefit from a solution of 1 : 2000 or 1: 4000, applied with a spray or brush. Cardonne of Naples and Marano also advocate the same treatment. Belfanti has used the diphtheria antitoxin with great benefit in ozena; and other observers have used the same treatment, but not with uniformly good results.

Dr. George Stoker of London warmly recommends the use of oxygen gas in this affection and chronic aural suppuration. The nose or ear is first thoroughly cleansed with warm water and the gas is then applied from four to six hours daily, with intervals of one half hour. The efficacy of this plan of treatment is beyond question where free outlet is given to all pus cavities and free ingress of oxygen is allowed.

Where a specific element is present mercury should be pushed to the extent of moderate salivation. A patient recently under the care of the writer became severely salivated, with the result that the formation of crusts as well as the severe headaches which had occurred daily before the treatment has ceased entirely and the patient considers himself cured He has experienced no ill effects whatsoever from the salivation, and denies absolutely any venereal infection ; nevertheless, the atrophic condition has undoubtedly been materially benefited. He used locally also a spray, as follows: R. Glycerin pur., 3ij ; sodii bibor., 3v; aquae destillatae, 3j. The nose was thoroughly sprayed with this solution three times a day. The use of the galvanic current applied locally, first recommended by Shurly of Detroit and afterward by Delavan and Hartmann, has produced excellent results.

A great many drugs have been used for their irritating and stimulating effects. Among these may be mentioned iodoform, iodol, aristol, salicylic acid, camphor, iodin, perchlorid of iron, tannin, alum, opium, 25 per cent. trichloracetic acid, etc. The writer has used with much success a solution of iodin, glycerin, and potassium iodid applied on a cotton pledget high up in the vault of the nose. This produces a very profuse discharge of mucus, which washes away the crusts and after a time appears to prevent their formation.

The use of caustics, the electric cautery, chromic acid, etc., should never be indulged in because of their injurious effect on an already attenuated membrane. Almost every drug in the Materia Medica has been tried in one way or another to cure this disease, and they have been given up because the'y proved either entirely valueless or only palliative. Dioxid of hydrogen was at one time highly extolled, but has been abandoned because it leaves the mucous membrane as dry as ever. Oily solutions in combination with various drugs act as excellent stimulants and protectives, but do not accomplish much in the way of cure.

In conclusion, the writer would suggest the following plan of procedure: A rigid examination should first be made to determine if there is any discharge of pus from the accessory sinuses, any sign or possibility of specific taint, any history of tubercular or diphtheritic disease, and the general hygienic and sanitary surroundings of the patient should be carefully investigated. Should a pus discharge be found from any of the accessory sinuses,. free outlet should be given to it and the sinus should be carefully washed out with hydrogen dioxid and dusted with some antiseptic powder. If in any case there is the least likelihood of a specific complication, mercury and opium with mercurial inunction should be pushed until mild salivation is produced. It has been the experience of the writer that the combination of mercury and opium has a much more rapid and satisfactory effect than iodid of potash, even when given in very large doses. The patient should be ordered to keep the nose thoroughly cleansed always with Seiler's solution or a spray of glycerin and biborate of soda or some other mild stimulant used three times a day. If the patient has had diphtheria or the crusts still persist, diphtheria antiioxin may be administered and a solution of bichlorid of mercury (1:2000) be sprayed daily. The patient should be directed to live out of doors a , much as possible, and his general health should be built tip with tonics, cod liver oil, etc.

The limits of this article entirely forbid further elaboration of this subject. Suffice it to say that the best results will be obtained when the patient is instructed how to maintain thorough cleansing so as to promote adequate nasal respiration, as well as the healing of all ulcerations, proper drainage, and the restoration of the normal mucous lining membrane as far as possible. He should have plenty of fresh air and sunshine, as well as absolutely hygienic surroundings. In some instances a visit to the seashore or some mineral springs will exert a marked influence for the better. J. N. Mackenzie advises that "as little liquid nourishment should be taken as is compatible with the comfort of the individual."

The ingestion of large quantities of liquids is to be deprecated, as well as alcoholic beverages of any kind, unless taken in great moderation. Healthy out door exercise, combined with the observance of the ordinary rules of health, will generally so moderate the worst features of the disease as to render the patient comparatively comfortable, if not entirely relieved.

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