tum. This usually causes some pain and headache. It is very slow to open spontaneously. When opened widely with the knife, it heals uneventfully. Even if the cartilage has been perforated by the suppurative inflammation, no unpleasant results are apt to follow after the healing.

MEMBRANOUS RHINITIS. DIPHTHERITIC RHINITIS.

80. Inflammation of the nasal mucous lining, with formation of false membranes, occurs under various conditions and from different causes. It is occasionally observed after extensive cauterization, especially surface cauterizations, and in such cases is a strictly localized process. There is but little annoyance beyond slight soreness and obstruction and perhaps moderate bleeding. The grayish membranes are not detached easily, and when removed, leave a denuded surface on which they form again within some hours. It is due to infection by the streptococcus, rarely the staphylococcus, but always follows a benign course, although it may last two to three weeks.

A more diffuse, and hence more annoying, membranous rhinitis occurs, rarely spontaneously, not uncommonly, however, after scarlet fever. This, too, is due to the streptococcus, yet it is only of local importance and causes no systemic disturbance. Like all nasal inflammations, it threatens the ear.

81. Indistinguishable in its appearance from streptococcus infection is true diphtheritic rhinitis. It causes similar grayish false membranes on a denuded bleeding surface, with rapid regeneration of the membranes after their detachment. The process is sometimes so superficial that it may be termed croupous, while in other cases it involves the depth of the mucous lining, as in typical diphtheria. Yet the disease is of a benign nature as long as it is limited to the nose, and it causes no systemic infection or sequels. The diagnosis of its diphtheritic nature must be based upon finding the bacillus of diphtheria by the microscope or by culture.

Its grave

importance is its contagiousness, all the more so as the patient is scarcely sick. Even after the membranous formation has ceased the diphtheria bacilli persist in the nose for weeks. Some of the accessory cavities are probably always involved in the process, harboring the specific bacteria, even if there be no membranous inflammation in the sinus. It is not known why diphtheria limited to the nasal lining has none of the malignancy characteristic of that disease in other localities.

82. The treatment of membranous rhinitis must depend upon the diagnosis of the parasite causing it. Diphtheria patients must be isolated, even for some time after recovery. Antitoxin should be invariably employed within the first three or four days of the disease. If of longer duration, it is doubtful whether the specific treatment has any influence upon it. In either diphtheritic or streptococcus rhinitis the membrane should be detached gently with forceps as far as it can be done without causing bleeding. No one has recorded a sufficient experience to formulate any rules for medicinal treatment. It is desirable to check secondary bacterial decomposition, but active germicides are not tolerated well by the nasal lining. Sprays of essential oils in watery solution (25) are of some service if used at very short intervals. Löffler's solution (compare ¶ 25), while momentarily very irritant, can be used (after cocain spray), but its efficacy has not been sufficiently tested.

Much more serious is nasal diphtheria when complicating and secondary to diphtheria of the pharynx. Under these circumstances it constitutes one of the most serious manifestations of diphtheria, a great menace to life and always a danger to the ear. Yet it is amenable to the specific antitoxin treatment if resorted to at once. It is, however, mostly in neglected cases of throat diphtheria that the extension into the nose occurs. This complication always involves a very long course-up to many weeks if not treated specifically at the beginning. Further details will be given in Chapter XXIV.

CHAPTER XI.

ENLARGEMENT OF THE CAVERNOUS TISSUE. (IRRITABLE NOSE-CORYZA VASOMOTORIA.)

83. Enlargement of the venous plexus, with increased vascular irritability, is a lesion associated with various nasal affections, but one which may also occur as a sequel without persisting coexistence of other nasal disAs certain characteristic nasal symptoms depend directly upon this condition, it deserves special description.

ease.

The entire nasopharyngeal mucous membrane is highly vascular, with a decided preponderance of veins in the deeper layer. Around the anterior end of the inferior turbinal, and to a less extent around the posterior ends of both inferior and middle turbinals, the venous plexus in the mucous membrane is massed so as to form a distinct vascular cushion capable of turgescence (see Figs. 8, 9, and 10). Normally, the mucous membrane appears slightly compressible over these areas, showing the normal distention of the vessels by blood. Undoubtedly moderate variations in the vascularity occur during the normal condition, but are not so demonstrable as when the cavernous tissue is increased. Even in a normal nose a visible vascular constriction is produced in these localities by the application of cocain or suprarenal solution. But when the cavernous tissue is morbidly augmented, the changes in its turgescence are very striking. Under the influence of fright or syncope, or upon the application of cocain, the previously swollen mucous membrane shrinks visibly-though without change of color-until it lines the bony contour accurately. As the result of various modes of irritation the vascular swelling may, on the other hand, become so ex

tensive as to occlude the passages entirely. The course of the nerves-presumably both vasoconstrictor and vasodilator fibers-which control these blood-vessels is not known.

The turgescent area at the front part of the inferior turbinal slopes so gradually toward the rear that its limits cannot be defined, especially as the vascular network throughout the entire mucous membrane over the turbinals differs from pronounced cavernous tissue only in degree. The cavernous cushions on the posterior ends of inferior and middle turbinals are more circumscribed. Their normal pale yellowish-pink color changes into a violet-pink hue when their turgescence makes them appear as globular tumors occluding the posterior choana in the postrhinoscopic image. As the result of disease, vascular cushions are sometimes developed in localities where there is normally no cavernous tissue-viz., anteriorly over the tuberculum septi, sometimes on the floor of the inferior meatus, or as part of a hypertrophic protuberance on the septum next to its posterior edge.

Every acute inflammatory attack is accompanied by engorgement of the cavernous plexus. While a single transient coryza leaves no gross change, repeated or prolonged attacks may lead to permanent enlargement of the cavernous tissue. Whether this hypertrophy differs from the original normal structure histologically has not been studied fully. A condition which is of marked determining influence by favoring the augmentation of the vascular structure is the existence of septum irregularities. It is, however, not the extensive deflections or thick prominences causing continuous stenosis which lead to vascular hypertrophy, but rather small spurs and crests which do not perceptibly narrow the passage except while there is vascular engorgement. The larger septum irregularities in connection with any persistent inflammation favor hypertrophy of the entire mucous membrane, which becomes most redundant on the (roomier) side of the septum concavity.

Purely vascular enlargement is readily distinguished from hyperplasia of the entire membrane. In the former case the swelling can be indented with the probe and disappears completely when cocainized. An excised bit of mucous membrane shows normal thickness. In the latter case the probe recognizes the excessive thickness of the lining membrane, which an excision confirms, while after cocain the membrane covering the bone, although somewhat reduced, still shows a distinct augmentation of volume as compared with the normal. Vascular enlargement and actual hyperplasia may be combined to a moderate extent, but any extensive hypertrophy of the mucous membrane as a whole excludes overdevelopment of the venous plexus.

84. In subjects giving the history of frequent, though transient, attacks of coryza and presenting some slight surface irregularity of the septum, permanent enlargement of the cavernous tissue without any coexisting inflammatory lesion is occasionally observed. Women are more liable to it than men. It is not common in children. Closer inquiry always reveals in these patients a neurotic condition, sometimes neurasthenia, often hysteria, sometimes mere nervousness," but always exalted excitability of the nervous system. Quite often, too, the history proves that intestinal disturbances, especially constipation, have been of etiologic influence.

More frequently than as an isolated condition vascular overdevelopment is found in association with other irritative nasal diseases, such as suppuration of the nasal passages or accessory cavities, polypi, or hypertrophic rhinitis in its earlier stages. Under these circumstances, too, the vascular irritability is a mirror of the instability of the nervous system of the individual. Female patients preponderate decidedly. Massive diffuse hypertrophy of the mucous membrane, on the other hand, limits the development of cavernous tissue; advanced atrophic rhinitis excludes it.

85. The complaints are partly mechanical, partly