ATROPHIC RHINITIS.
BY C. R. ARMSTRONG, M. D., THORNTOWN, IND.
Atrophic rhinitis is that chronic disease in which there is a wasting away of more or less of the mucous membrane, glands, and turbinated bones, and is generally accompanied by some abnormal conditions of pharynx and all the sinuses connected with the nasal cavities.
This is no new disease, but one physicians have had to deal with these many years; one we meet in practice every little while, and one which we cannot study too carefully, because the treatment for the disease in many cases ends in failure to cure.
I do not know that I will be able to say anything new of this morbid condition of nose, but will state a few things as I see them in practice day by day. There is always a favorable point about having a patient with this disease, along with the unfavorable ones. That is—the physician always has plenty of time to study his case and see every minute change in the recovery ere the patient is pronounced cured. This is more commonly known as ozena, or fetid catarrh, from the odor which accompanies the trouble. However, there is a form of the disease in which the atrophy is present, but has no fetor accompanying it. The latter is a much drier form with no secretions at all.
The ætiology of this disease has been discussed pretty thoroughly. It has been a question as to just what the initial symptoms and changes really are. In a majority of cases it is a secondary disease. That is, it follows other forms of rhinitis. Some authors claim that atrophic rhinitis follows the hypertrophic rhinitis. Others claim that there may be some shrinking in hypertrophic rhinitis, but that it does not end in atrophy, but comes from the purulent rhinitis: I believe they both are right. Either form I feel confident may precede atrophy. Again, I do not think that hypertrophic or purulent rhinitis is always followed by the atrophic form. If they were we would have many more cases of atrophic rhinitis to treat than we do at present. In my opinion this disease is brought on directly at times from various causes. Many a case of ozena has been brought on by the indiscriminate use of caustics on the mucous membrane of nose. Also injudicious cutting away of inferior and middle turbinated bones. Then again there is a predisposition to disease, especially in those people with a syphilitic and scrofulous diathesis. Excessive drinking of alcohol, excessive smoking of tobacco, working in poorly ventilated rooms or where there is a great deal of dust, and where there is an impoverished condition of blood from malaria or malnutrition, all have a tendency to set up this disease.
The name of this ailment tells much of the pathology of the disease. As atrophy implies, there is a wasting away of all tissues attacked. Upon examination the first thing observed is a dry, shriveled state of the mucous membrane of the nose and pharynx. The glands and follicles are all obliterated, which accounts for the dryness of the mucous membrane. The turbinated bones are dwindling away. Frequently the whole anterior portion of the turbinated bones is absorbed. This causes the nasal cavities to be so enlarged that we may see the pharyngeal walls from the anterior opening of nose. The glazed or dry appearance extends to the pharynx and in this manner affects the eustachian tubes. All over the nasal cavities and pharynx numerous granulations can be noticed. Tortuous and enlarged vessels run over the walls. As a rule there is not that bright red congested appearance of membrane as in other forms of catarrh.
Patients with this form of catarrh are frequently mistaken in diagnosing their own cases. I have had them to come in my office asking me to make a prescription for biliousness. They get that idea because they have a dry and coated tongue and a very bitter taste in mouth. After an examination is made you fail to find symptoms to corroborate the patient’s diagnosis, but will soon find the real cause. With the reflected light and nasal speculum it takes but a short time to satisfy your mind from conditions of nose that have all the symptoms of ozena. There is a discharge made up of mucus which is very thick, therefore not very easily expelled, and as a result finds its way into all the fossæ and crevices in the nose. It is not long until this is dried into crusts which obstruct the passages of air, and being retained, decompose, throwing off a peculiar, penetrating stench. These crusts adhere very firmly to the membranes. The patients will remove them by artificial means, owing to the uncomfortable feeling produced by them. When the scabs are torn away there may be an oozing of blood. A stuffed up and oppressed fullness in the superior and posterior portion of the nasal passages is present. In the first stages of the disease the mucus will fall down from the palate in small slugs or masses, which as the disease goes on become more and more tenacious and more of a muco-purulent nature. In the beginning this discharge can be “hawked up,” but soon it becomes too thick and dry. While the membranes may be so irritated that there will be a free discharge of blood, still there is no real ulcerative process. The septum in some cases is perforated, but this is caused more by tearing away the dried-up discharge than anything else.
The sufferers from ozena are never the strong and vigorous people. They are generally anæmic and having family histories which would make a physician think that the diseases were hereditary. These discharges being retained so long the poison may be absorbed into the blood, and soon the whole system will show the effects of the poison. In children the nostrils are so filled up that they can scarcely breathe at night, and it will not be far in the future when the child will be weak, nervous, irritable, and unable to sleep well. The stomach raises a disturbance as the disease gets older, which is accompanied by an occipital headache. The food which is eaten goes for naught, because the system does not seem to get the desired nourishment. Taste is destroyed, appetite gone, loss of energy for everything is apparent.
The patients scarcely ever can detect the bad odor unless their attention is called to it. After being told a few times about the odor of the breath they will shun public gatherings. If the patient is a woman, who because of offensive breath is barred from society, she will become morbid and hypochondriacal in time. There is so much of the thick mucus hanging on the walls of the pharynx that the openings into the eustachian tubes are filled up and in a short time a certain degree of deafness appears—roaring in the head and other manifestations of ear trouble. As soon as the hearing is noticed to be abnormal the patient will be ready to consult some physician.
With these symptoms it may not require much time to make a correct diagnosis, but it may be some time ere the patient is entirely free from the trouble even if he does use good homeopathic treatment. Then it is the treatment which interests us most. The patient at the beginning will ask if you can cure him and how long it will require to do it. The physician necessarily must guard his prognosis, especially if it is a case of long standing. If there is much atrophy, which has extended over several years, a permanent cure is very doubtful. But even with these cases much can be done to make patients more comfortable. Correct the odor, the dryness, and the formation of scabs. If the case is not of too long standing, very likely you will be able to produce a healthy condition of the mucous membrane. If you are so fortunate as to produce a cure, the patient will always remember you for it, and you will or should feel proud of it yourself. Much will depend on occupation, age, and persistence with which the patient carries out treatment.
The treatment, to be beneficial, implies the discovery and removal of all predisposing and exciting causes. To do this will require both local and systemic treatment. No cure can result unless good constitutional treatment is persisted in. When taking the case it is wise to inform the patient that he must expect treatment through several months, and even then the case must be examined once in a while or there may be a recurrence of the disease.
Too much time cannot be spent in a careful examination of the patient. Be certain the cause of trouble is ferreted out. The course of treatment will depend upon the cause of the disease. After thorough examination a course of treatment is planned. As I have said before, each case must be studied. There are no specifics for the disease.
In the local treatment the important object is cleanliness. The mucous membrane must be kept in a perfectly clean condition all the time. This is the main object of all local treatment. In some cases I assist nature to heal parts by getting a slight stimulating effect of medicine.
It is not always an easy task to remove all the dry crusts, but where the scabs are very dry I use an application of peroxide of hydrogen on cotton, or with the atomizer, to soften them. When the atomizer or douches are used post-nasal injections must be given as well as through the anterior chambers of nose. Any application can be used which will soften up scabs. Can use “Dobell’s Solution,” solution of sea salt, listerine, or glycerine. After all the crusts have been removed, others must be prevented from forming. This I do by keeping on an application of glycerine. A very good formula to keep the nostrils free is calendula and glycerine, at 2 drams to ounce water, and used in nebulizer or directly applied on cotton. When the odor is present after removal of scabs, I use permanganate of potash, 10 grs. to ounce in spray, or aristol in lavolene used in nebulizer.
After the cleaning process has been gone through with and all the mucous membrane is perfectly clean, naturally it is ready for some healing application. A good one to use is calendula and hamamelis in lavolene. If there should be any ulceration of septum, apply an ointment of yellow oxide of mercury, 10 grs. to the ounce. This will heal ulcer in short time.
Where membranes need some stimulation a glycerite of tar, hydrastis, or eucalyptol in nebulizer will be found to be of service.
Many times patient will complain more of the deafness than anything else. When you have this complication it will be necessary to give attention to some special treatment for the pharynx and eustachian tubes. The latter must be kept open by Valsalva’s method or the Politzer air bag.
In selecting the internal remedy keep in mind the constitutional and local lesions. Often I use the internal remedy locally; say 5 to 20 drops of tincture to ounce water. Make yourself confident that you have the indicated remedy. There are many remedies which are of service. Some of the more common ones, which have syphilitic taint are, aurum, kali iod., mercury, nitric acid, argentum nitricum, and calc. iod. In scrofulous diathesis and ill-nourished patients such remedies as aurum mur., silicea, calc. phos., sulph., phosphorus, ars., hepar sulph., alumin., kali bich., cal. carb., and graphites are useful.
All through the treatment the physician should have perfect control of patient. Should be able to direct his diet and hygiene. Use all means that will recuperate the general health. If patient is laboring day by day in dust and dirt, he may be compelled to change his occupation.
It is only by looking after the general health that the physician may expect to be rewarded with any success.
SPRAYS.[[1]]
BY FRED D. LEWIS, M. D., BUFFALO, N. Y.
In considering the subject of sprays, it is not my intention to present to you a number of formulas that I have found useful in my practice, but to consider the matter on a broader and more general basis. That sprays have been, and are still used, in various conditions with the most gratifying results, we all know. But that they should be prescribed to a much larger extent than they now are is a fact that the physician, as a rule, is not aware of.
We have learned to know that the skin is one of the great vital organs of the human system. That if its action is impeded, the kidneys and intestines are thereby given a greater amount of work to perform. That with the morning sponge, followed by a brisk friction and an occasional Russian or Turkish bath, in chronic cases, such as rheumatism, we can expect quicker and better results from our remedies.
The public generally have been educated to that point where they recognize the importance of proper care of the teeth. They not only regularly cleanse them, but at stated intervals, usually every six months, go to the dentist and have a thorough examination to anticipate rather than wait for trouble.
Many persons have learned that a lavage of the stomach, in the shape of a cup of hot water, before meals, has converted a sluggish digestion into a normal one.
We are all familiar with the structure and object of the nasal cavities. The tortuous turbinateds provide a large surface for the air to secure heat and moisture, before reaching the lungs; and also remove from the air such impurities as are of a solid nature. Now we all know that the atmosphere of cities, especially where there are large manufacturing interests, is loaded with impurities, such as soot, dust, particles of pavement ground to impalpable powder, etc., etc. This fact can easily be demonstrated when the city is on a plain or in the neighborhood of a large body of water. When in the city the air seems pure, the sky unobstructed, and no evidence of floating particles of matter, if an observation is taken from a few miles’ distance, the city appears to be encompassed by a cloud.
That the disposition of foreign matter on the sensitive lining membranes of the nose should produce disturbances, there can be no doubt.
The only point I wish to bring out, and I hope it may stimulate some discussion, is this: Should not the care of the nasal mucous membranes be considered as important as the care of the skin and teeth?
In recent years I have asserted to my patients that the spray, in my opinion, is as essential on the toilet table as the toothbrush. As to the nature of the spray to be used, I think one must be guided by conditions. If there has already been a catarrhal condition established, then some remedial agent had better be employed; but if used simply as a prophylactic, then a neutral cleansing solution would be preferable.
I think this subject is deserving of profound consideration, when we know that there are establishments in most of our leading cities that advertise the cure of catarrh for so much a month. Their methods are simply to insist on the patient coming to their offices daily, and having their noses thoroughly cleansed. And they are curing many cases. Would it not be wise to educate our patients, not only to keep their own noses clean, and thus cure themselves, but, by attending to themselves early enough, avoid the development of that, perhaps, most prevalent of all diseases, catarrh?
GALVANISM IN NASAL HYPERTROPHY.[[2]]
BY JOHN B. GARRISON, M. D., NEW YORK.
Hypertrophic rhinitis is one of the most frequent of the diseased conditions pertaining to the nasal cavities that we are called upon to treat, and the question of the most suitable method of treatment is to be decided with care.
We have all used, for the removal of the excess of tissue, perhaps, with more or less success, the acids, the actual cautery, or some form of cutting instrument, but the patient, at least, will welcome a method that promises a good result with the least amount of pain at the time of treatment, and the least soreness afterward.
I have found that the application of the galvanic current does, in many cases, furnish just the method desired, and I shall beg your attention for a few minutes while I speak of the method as I practice it.
I shall not burden you with my ideas of what cause most enters into the production of these nasal hypertrophies, leaving to you the perusal of the text-books that will give all the knowledge extant upon the subject. We do find an increase of the nutritive forces, and our treatment must be directed to a lessening of the blood supply in some way. Of course where there is a local source of irritation, that must be removed at once. If it is a deflected septum that is causing an irritation by contact with the opposite side, suitable means must be adopted for its repair before attempting to treat the hypertrophies opposing the irregularities of the septum.
The hypertrophies that I shall speak of as being most amenable to treatment by means of the aid suggested in my title are mainly those of the turbinated bodies: and, of these, the inferior is the one most often enlarged. It may be confined to either extremity, or the whole body may be the subject of hypertrophy. When, as is sometimes the case, the bony portion of the turbinate has become enlarged, the saw, and not electricity, will be the best means of cure.
But when the occlusion of the nares is caused by true increase of tissue we have, in galvanic electricity, a potent agent to safely and rapidly remove the obstruction.
To prepare a case for treatment, I always first thoroughly irrigate the nasal cavities with some antiseptic fluid, using the post-nasal syringe. The solution that I most frequently use is Electrozone one part, and tepid water four parts. Then an application of a four per cent. solution of cocaine is made to the location about to be treated, simply to prevent the little pain which accompanies the introduction of the electrode.
The electrode I use is a slender needle about the size of an ordinary darning needle, of suitable length for easy use on the part selected, and I insulate it by dipping it in shellac and laying it away until it is perfectly dry, then scraping away the insulation as far from the point as it is calculated it will be impaled into the tissues. It is fastened into an ordinary needle-holder and connected with the negative pole of the battery, when it is introduced into the tissue at the point selected. The patient is then given the sponge electrode connected with the positive pole of the battery and is told to grasp it firmly, and the current is slowly turned on until the meter registers from three to five ma., which current is allowed to remain stationary for about five minutes, unless the patient is very nervous, when three minutes should be the limit.
The current is now turned off as gradually as it was turned on and the needle carefully removed. I do not attempt a second treatment at the same point until a week has expired, and in some cases two weeks can be permitted to go by before the shrinkage due to the electrolysis has subsided. The stronger currents have been tried, but the strength I have used and given here acts much more pleasantly and gives equally good results.
During the summer just past I had the opportunity of noticing the reduction of an enormously hypertrophied inferior turbinate in a most unexpected manner, which I am glad to relate at this time.
A lady of about fifty years of age, who was stopping at the hotel at which my family and myself were located, came to me one day to ask my opinion as to her eye and nose. She had had a stricture of the nasal duct for a number of years, which had been duly dilated several times, and for a considerable time had had a dacryocystitis which annoyed her greatly, and from which she was able to press a large amount of mucus and pus from the canaliculus.
The inferior turbinate on the affected side was hypertrophied for nearly its whole length and was in contact with the septum for some distance at the anterior extremity, being of a deep red color and very sensitive to touch. I told her that I believed it would be necessary to remove the turbinate with the saw and advised its removal as soon as possible, giving it as my opinion that it would be necessary to do the operation before the condition of the eye could be relieved. The patient admitted the force of my argument, but was inclined to wait a while until she could get her courage up a little higher. Meanwhile she wanted the canal dilated and begged me to do it. Visiting New York, I supplied myself with a canaliculus syringe and a set of Bowman’s probes, and on my return announced myself ready to commence treatment. I proceeded to insulate the probes in the manner alluded to for needles in nasal work, scraping the points bright for about a quarter of an inch.
Before introducing the probe I washed the sac out thoroughly with a fifty per cent. solution of enzymol, and then, connecting the probe electrode with the negative cord of a galvanic battery by means of an artery forceps, introduced it (No. 2,—a No. 1 would not pass in the ordinary manner with considerable pressure) into the canal, and turned on the current until the meter registered two milliamperes. Using just enough pressure to guide the electrode, it gradually found its way along the canal, and in less than five minutes it had entered the nasal cavity without causing the loss of a drop of blood. In three days I passed a No. 4 in the same manner, and four days later a No. 6 passed easily. Three days after this a No. 7 was passed, and that size was passed three or four times afterwards at intervals three or four days. After the first passage of the No. 7, all of the solution used for the purpose of cleansing the sac passed through into the nasal cavity directly from the syringe, and there was no further collection of pus in the sac during a week in which the syringe was not used.
The point I wanted to bring out, however, is that after the second treatment by electricity, the color of the mucous membrane covering the turbinate began to grow paler, and at the end of the treatments the entire body had contracted sufficiently to permit free and easy drainage and natural respiration.
I am led, by this, to the thought that it may be good treatment in many cases of hypertrophy of the inferior turbinate, and possibly the others as well, to use the insulated probe electrodes in the lachrymal canal with the weak current, not exceeding one or two milliamperes. The careful use of this method may prove it to be a valuable addition to the present means of treating a class of cases that are troublesome to the patient and the doctor.