RHINITIS.

ON

W.

J. Penny, F.R.C.S.,

Assistant-Surgeon

Rhinitis is

a

to the Bristol General

common

Hospital.

affection which

causes

much

attention than is

discomfort, so that it deserves more generally accorded to it. Acute rhinitis, catarrh, is unfortunately known to all;

or

the.

common

but the

cases

I propose to refer to, and which come more under the province of the surgeon, are those in which there is some more or less permanent lesion of the structures of

the

nose, and which in many cases

treatment.

These

cases

may be

require

roughly

mechanical

subdivided into

those of: 1.

Irritable vascular

hypertrophy

of the

mucous mem-

brane. 2.

Chronic fibroid

thickening

of the membrane.

3. Chronic catarrhal rhinitis. 4. Ulcerative rhinitis 5. Polypoid rhinitis. 6. Arthritic and osteitic,

combined with

periosteitic

rhinitis. 7. Tubercular rhinitis. 8. Lupoid rhinitis. A

large majority of these are

traumatisms;

an

caused

by neglected colds; atmosphere, of chemically or mechani-

unwholesome state of the

depending either on the

presence

96

MR.

cally irritating agents,

W.

or

J.

PENNY

various constitutional

germs;

syphilis, sometimes gout and rheumatism. They are mainly kept up by changes of atmospheric conditions, injudicious diet, especially conditions, notably

alcoholic

quantity

struma and

in

means excess ;

these

in

excesses?and

cases

some cases,

a

lack of

very small

cleanliness,

it may be meddlesome surgery, deformities of the parts, and other causes too numerous to mention. In these

cases

the

confined to the lower some

pathological change is principally in or respiratory part of the nose;

few instances the whole of the interior of the

affected. there is

a

In the

respiratory

development

greater

area,

infiltration

permits inflammatory upper or olfactory part, is

thinner

and

more

according

of sub-mucous more

in which the

directly

nose

to

Panas,

tissue,

readily

mucous

is

which

than the

membrane

connected

with

the

periosteum. The first group of cases, those of irritable vascular hypertrophy, are not quite so common as the chronic

hypertrophic. The

lesion is

almost

They

occur

chiefly

characterised

in neurotic

subjects. irritable, inflamed,

by abraded-looking, thickening of the turbinated

and septum.

The usual

an

bones

of nasal stenosis

symptoms present, accompanied by sneezing, irritable discharge, one or

reflex

are

and

of the symptoms of reflex disturbance in the by Morell Mackenzie; it may be, irritable cough, weak voice, or even bronchitis.

more area

described

asthma, Hay fever and allied disorders are liable to supervene on slight provocation. These cases should be treated by sedative remedies; soothing injections, such as warm boracic lotion, poppy-head lotion, bathing the nose exter-

nally with the same, gargling the throat; and after this is done, anointing the nose inside and out with some sedative

ON

ointment?vaseline

RHINITIS.

97

lanolin, impregnated with cocaine, lead, belladonna, morphia, or eucalyptus. Powders I have found, as a rule, do more harm than good ; they absorb a certain amount of the watery parts of the secretion, and the rest is left as dried cakes along the or

of

acetate

sides of the

nose, and causes further irritation.

Chronic fibroid

thickening,

or

chronic

hypertrophic

rhinitis,

in many cases is characterised by the absence of other symptoms than nasal stenosis and mouth breathing;

in others there may be symptoms referred to the pharynx, larynx, or bronchial tubes; but, as a rule, in this class the

symptoms

class,

are

anzesthetic,

in which of

in contradistinction to the last The

is found.

hyperesthesia

stuffed up, and

patient

special liability to feeling catch cold. The swelling covering the turbinated bones and septum looks indolent, feels firm, is painless, and does not become congested when touched with a probe. For these cases I have found dilatation with bougies useful: this I believe promotes absorption of the inflammatory material. A solution of chromic acid, applied after the parts are well douched and dried, accelerates the cure. complains

I will quote one case. H. N., set. 33, a groom, for

complained

of mouth

seven

breathing

and

a

or a

years had feeling of being

eight

stuffed up.

He had consulted several medical men, one of whom had told him there was no polypus, and nothing

much the matter; and another had ordered I found that his nose was almost

entirely

some

snuff.

obstructed; he

could get a little air through with difficulty, and a small probe could hardly be passed along the floor of the nose.

He was ordered injections, and, as he got better, snufflings of cold water. After the injection the nose was well dried, and then a solution of chromic acid, 10 grains to the

g8

MR.

PENNY

J.

the septum and turbinated bones. After few weeks of this treatment with a tonic, and occasional

ounce, a

W.

painted

over

catheterisations, there

he

practically

was

cured.

In this

case

history of constitutional taint, but the apparently arose from a series of colds. The next class of case, chronic catarrhal rhinitis, is characterised by an increased secretion from the nose. In some instances the discharge is thin, and almost serous in character ; in others, of thick inspissated mucus. In some instances there is a little thickening of the membrane, in others apparently atrophy, and also of the bones beneath. Some of the cases, if neglected, run into the next class, that of ulcerative rhinitis ; but the catarrhal was

no

mischief

proper presents no macroscopical For this class of case powders are useful;

rhinitis

being used,

any thick

should

mucus

be

ulceration. but before

cleared away Ferrier's

snuff, Among powders, and various combinations of boracic acid, or acacia with tannin, are especially useful. Iodoform, if there is any smell, may be added with advantage to the preceding by

alkaline

injections.

?snuffs. Ulcerative rhinitis?sometimes the result of

longrhinitis, or traumatisms, or the lodgment of foreign bodies, sometimes of gonorrhoea or tuberculosis?is intensified by a strumous or syphilitic habit; and in some, indeed, no other cause can be found. continued

a

catarrhal

To this class also

belong

cases

of

ozsena.

All ulcerative

accompanied by ozaena, and ozaena is not necessarily accompanied by ulceration. The worst cases of ozaena depend on a certain amount of caries of the cases are

not

bone; but others may be due and

putrefaction

These

simply

to the accumulation

of the secretions of the

cases are

best treated

nose.

by copious douches,

and

ON

RHINITIS.

99

ointment of some antiseptic material, of which found the following formula especially useful : Iodoform, Ol.

gr.

I have

x.

Eucalyptol,

5

j.

Pulv. Acid.

Boracic, 5 j. Ethereal, ad. 5 j.

Ol. Sassafras Vaseline

x.

A young man came under my care at the General Hospital, who stated that for years he had suffered from a

discharge from his nose?this was not offensive; but he had anosmia, and also some loss of ordinary sensation. Two or three times during the day mucus accumulated, and he blew his mass of hard

nose

to show

From each nostril

me.

expelled,

the size of

a

large The affection comsight. sickening menced with a cold, as he says, after an attack of measles followed by low fever. There was no history of syphilis

filbert?a

or

mucus

was

a

most

other marked constitutional affection.

the cavities of the

nose were

found

Oh examination

large,

the entrance

of air

free; but the mucous membrane in places was abraded and ulcerated, with that peculiar asthenic type of congestion seen sometimes surrounding ulcers of the

leg.

He had consulted several medical

complaint,

all of whom had treated the matter

but ordered him

right. Copious

men

a

powder

lightly,

and told him he would be all

douches of warm water were

paint of chromic acid?10

for this

gr. to 5

j.

water.

prescribed, A

and

fortnight

a

later

he came, saying he had had a hamiorrhage from the nose. Since the last visit he had been using the paint, and his nose had been feeling more the bleeding

stuffy;

relieved

this sensation.

He

was now

ordered to continue

100

the

MR. W.

and to

injections,

iodoform and

proved,

and he is

now on

with inherited

The condition

the

high

belong

cases

local

syphilis;

acid,

ointment of boracic

an

use

eucalyptus.

To this class also

PENNY

J.

as

im-

rapidly

road to recovery. of snuffles in children

well

as

treatment

general

should be carried out. Cases not

I

which

infrequently chronic

some

Mackenzie

of

and

of the

diffused

come as

polypoid

rhinitis

They apparently depend

irritation,

general thickening appearance these cases

called

have

seen.

characterised

are

membrane, which polypus.

polypi,

and

Schech

upon

by

has Some

mucous

under the class described

sessile

are

by

a

the of

Morell

polypoid

as

the latter also states that it is very difficult hard and fast line between hypertrophies of the

vegetations: to draw

a

mucous

membrane and real

neoplasms.

call attention to

fact that

from the

in the lack of

is, the hypertrophic

the irritable vascular rhinitis and

a

by

What I wish to

rhinitis exists

differing and from

firmness, vascularity

the lack of

It has somewhat the appearance the synovial membrane in pulpy swellings of

hyperesthesia.

presented by joints. This condition is rarely found over the whole surface, but is frequently combined with a congestive thickening of the rest of the membrane, and is best treated by scarification and removal of any particularly thickened parts. Careful after-treatment must be carried out; and here again chromic acid is useful, and in some cases astringent ointments or powders. There is another class of bone and

cases

due to

thickening

of the

when not

periosteum perichondrium, which, on injury, are due to some constitutional dependent These cases are and struma. taint, chiefly syphilis recognised with difficulty, until some serious mischief is or

ON

RHINITIS.

IOI

when

diagnosis is easy. Treatment should be general principles. In old-standing cases of hypertrophic rhinitis, with a certain amount of thickening of the bone and periosteum, caused,

carried out

on

which does

described,

not

previously

little oleate of mercury (10 p.c.), to the interior and exterior of the nose,

both

applied

subside after the treatment

I have found

a

useful.

Tubercular a

or

well-marked

a

girl

lupoid

case

rhinitis is

of the

former;

I have not

rare.

seen

but at the present time

lupoid rhinitis is under my care at the In this case both alse are destroyed, and the

with

Hospital. lining membrane

is

so

thickened that the lumen is almost

obliterated.

The membrane presents the red tubercular appearance characteristic of lupus in other parts, and the

treatment should be carried out on the same lines. Professor Bosworth, in an interesting paper abstracted for another part of this journal, alludes to a condition which has

not been

previously

bony thickenings along bones.

but which in time states that

"

of the

where the

the

vomer

another."

*ng these

area

Small exostoses

angle

ethmoid, one

the sutural lines of the intra-nasal

due, in the majority of cases, early life, unrecognised and untreated, cause all the phenomena of reflex dis-

turbance in the reflex the

He refers to

This he considers is

to traumatisms in

at

described.

can

Morell Mackenzie

nose.

also often be

perpendicular plate

and the

cartilage

he has cured

of

the

of the septum meet

Professor Bosworth claims that

bony growths

perceived

by

remov-

number of

large breathing, asthma, hay fever, bronchitis, diseases, &c., &c. He is to be congratua

cases of mouth

laryngitis, lated I

on

ear

these very favourable results.

had occasion

recently

to

remove

a

cartilaginous

MR.

102

W.

J.

PENNY ON

RHINITIS.

*

growth

from the

right

nostril of

a

behind the

growth

the

was

growth

on

the

followed

these symptoms.

right

side.

marked

by Cartilaginous

In this

boy.

the top of the nose and septum were left, and a good deal of hypertrophic

displaced

case

to the

rhinitis existed The removal of

improvement

of all

tumours of the nose are

rare.

In

among other methods of examination, that attention has been called to the fact that

conclusion,

I do not

see

valuable indications of the condition of the be obtained from the mouth.

an

examination of the

nose can

often

palate through