Treatment will, however, always secure amelioration of the symptoms, and few cases occur which cannot be greatly improved. The general health is invariably benefited. Should a tendency to asthma exist, it is apt to disappear, the complexion clears, and in adolescence the rate of general development is accelerated.
SECOND VARIETY.—The group of nasal diseases included under this head is not a natural one, since it embraces disorders characterized by a negative feature—viz. absence of obstruction to nasal respiration. Nevertheless, it is convenient to consider under a single head a number of relatively infrequent disorders in which there is invariably an underlying constitutional cause. Subjects of disorders herein embraced are not merely sufferers from insufficient oxygenation of the tissues, but have impaired general vitality or possess a decided constitutional taint, whether specific or otherwise. The nasal condition is simply the most prominent of the local manifestations.
Three distinct disorders are herein named: first, chronic inflammation of the nasal mucous membrane; second, atrophy of the turbinals and their associated mucous membrane; third, necrosis of the bones entering into the framework of the nasal chambers.
(a) Inflammatory thickening is a rare affection. It is more frequent in males than in females, and in persons of a sedentary occupation than in those who are actively employed. Those subject to it are apt to have light-blue or gray eyes and auburn or sandy hair. On examination, the chambers may be found free from peculiarities of bony structure, capacious, and without hypertrophy of the cavernous tissues, yet the membranes be of a deep-red color and of cushiony consistence, yield bright reflexes, and the shank of the instrument introduced into the nose is mirrored upon them. The most conspicuous alteration is not seen on the turbinals, but on the septum. The parts are very vascular, and the most moderate manipulation will often end in free capillary oozing. The discharge, though moderate in quantity, is inclined to be purulent, and resembles semi-coagulated albumen. Quite frequently, in the examination of a neglected case, minute flecks of this modified secretion are seen scattered over the septum and the inferior turbinated bone. Rarely, the discharge is maintained by the presence of a morbid growth or inflammatory products, either in the nasal chamber or a chamber accessory to it. The discharge then appears to consist of pure pus mixed with the normal secretion of the nose, and, thus rendered viscid and tenacious, it excites by its presence a condition of the lining mucous surface quite similar to that above described.
Under excitement, as after an attack of coryza, the discharge becomes more serous in character, and is occasionally of a chocolate color from its admixture with blood. It is without odor. There is no obstruction to respiration except during sleep, when, in aggravated cases, mouth-breathing may be established. Thus, the patient will often complain of an obstruction which is never present at the time of the examination. He further complains of a sense of dryness in the nose, with some pharyngeal irritation. The palato-pharyngeal and palato-glossal muscles are weak and often asymmetrical; the tonsils are small, but the adenoid tissues are generally unaffected. In a dry atmosphere, especially if it be loaded with irritating particles, the pharyngeal irritation is increased—a complication which is probably due to the inspired air passing too rapidly through the capacious and imperfectly-guarded nasal chambers and throat. Although I have carefully searched for all indications of aural complications, especially for the symptoms of progressive dry catarrh, I have never detected them but in a single instance.
The prognosis is to be guarded, although a careful course of treatment and proper care of the general health will greatly improve, if not entirely cure, the disease.
TREATMENT.—This consists in the application of nitrate of silver, either in strong solution or in the solid stick, to the under surface of the inferior and middle turbinated bones, of washing the parts with a dilute solution of carbolic acid, and of passing through the cheek tissues a constant electrical current of a strength of from five to ten cells. Tonics and alteratives should not be neglected, and an outdoor life, as far as is practicable, should be enjoined. The galvano-cautery may be used to destroy any nodules of tissue which resist other treatment. All applications are well borne, if indeed we may not look upon the condition of the surfaces as partially analgesic, and thus far of unfavorable significance. It is certain that indurated tags of oedematous and chronically inflamed mucous membrane overlying a bone, such as the middle turbinated or the alveolar line about the necks of the teeth, will never yield to anything but the most powerful astringents. Upon such tissues the most concentrated solutions of nitrate of silver are never caustic. The premaxillary portion of the inferior turbinated bone is frequently seen hopelessly infiltrated, and it must then be destroyed by the electro-cautery. When a discharge of a pus-like character exists, careful search should be made for the cause. If a tumor or foreign body be found, it should be removed, but if the cause lie in one of the outlying spaces of the nasal chamber, it is evident that the above treatment is palliative only.
(b) In atrophy of the nasal mucous surfaces and turbinals we have, as in the last-named group, spacious chambers, a purulent discharge, pharyngeal irritation (in many cases), and always associated a thin and relaxed, if not a paretic, condition of the velal muscles. These cases might be looked upon as an advanced stage of the preceding affection, since it may be surmised that the stage of infiltration has been succeeded by one of atrophy. The mucous membranes are everywhere pale, and closely bound to the underlying bony framework. The discharge is purulent and confluent; where in contact with the air it is desiccated, but where protected, as by crust-like surface-layers, it is semi-fluid and tenacious. There is, consequently, no disposition for the discharge to escape from the nose, and it accumulates until the sense of obstruction induces the patient to remove it by artificial means. When first seen, the nasal chambers are frequently so fully occupied with discharge as to conceal the characteristic appearances of the mucous surface. This prolonged retention induces incipient decomposition of the mass, which gives rise to the odor so characteristic of this group of cases.
The subjects of atrophic catarrh (ozæna) are never in robust health. They are, as a rule, of spare habit, anæmic, and with family histories which, while not distinctive, indicate that the affection is, to some degree at least, hereditary. A few cases have come under my notice in which all the general features of atrophic catarrh were present, but with very slight although confluent discharge, unaccompanied by fetor. Such cases are, strictly speaking, examples of atrophic catarrh, while they could not, under the old nomenclature, be included under the head of ozæna.
The prognosis is unfavorable for entire recovery, but treatment systematically pursued will make the patient entirely comfortable to himself and others—will arrest the progress of the disease and vastly improve the general health. As in other forms of nasal disease, should anosmia be present the prognosis is less favorable.