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nervous symptoms. In spite of considerable enlargement of cavernous tissue the passages may be clear a variable part of the time. But in the recumbent position, especially during sleep, engorgement occurs in the nostril on the lower side of the head, causing occlusion of the passage. The slight difference in the venous blood pressure produced by turning the head on the other side suffices to transfer the engorgement to the other side, allowing the first affected nostril to clear in the course of a few minutes. Very striking is the alternating unilaterality of the turgescence. Except during acute inflammation or in very irritable subjects with one-sided stenosis, one side of the nose is, as a rule, clear. The same one-sided engorgement can occur in consequence of drafts, dust, or irritating gases and smelis. The occluding vascular turgescence is seen on inspection anteriorly. In some instances a similar but more localized engorgement is found at the posterior end of one or both turbinals on examination. The swelling may subside in a short. time, or under conditions of irritation may alternate between the two sides for a longer period. Cocain or suprarenal solution reduces it at once. (Comp. Fig. 3, Plate I.) 86. In nervous subjects the vascular dilatation may lead to other symptoms. A sneezing fit, sometimes lasting to a distressing extent, with watery secretion, tearing and redness of the eyes, and finally total nasal occlusion, at least one-sided, constitute the attacks of so-called vasomotor coryza or irritable nose. Their frequency depends very much on the nervous condition of the patient and on the opportunities for irritation.

Some patients possess an idiosyncrasy in regard to certain odors or irritants which give them always a severe fit of vasomotor coryza. Such irritants are ipecac, the odor of roses, and perhaps more frequently the smell of horses. The attacks may pass off in a fraction of an hour, or, when severe, may last many hours. These fugitive attacks, resembling a true coryza in their subjective symptoms, have led to much confusion in litera

ture, and account for the many erroneous reports concerning the abortive treatment of "colds." It is singular that the sneezing fits and attacks of vasomotor coryza cease entirely during the course of any severe general disease. The astute observer, Jonathan Hutchinson, has asked pointedly, "Who has ever heard a sick man sneeze?" In markedly neurotic subjects these spells may be followed occasionally by fugitive edema (urticaria) of the eyelids, conjunctiva of the eyeball, or skin of the face next to the nose. Attacks of vasomotor coryza may likewise lead to scotoma scintillans with headache, dizziness, or more generally a feeling of confusion or an attack of asthma, sometimes a prolonged fit of coughing (compare Chapter XXIX.). The results of local treatment show that these nervous phenomena depend on the turgescence in the anterior parts, rather than on the engorgement of the rear end of the turbinals.

87. Treatment must begin with the search for any local irritative lesions. The removal of a small hidden polypus may end all trouble. Proper cauterization of an inflamed or granulating area, successful drainage of a suppurating sinus or a cyst in the maxillary sinus, may effect a cure. Very rarely a fissure in the vestibule keeps the nose irritable. The removal of spurs and ledges on the septum (see Chapter XVI.) is often an indispensable step for success, but may not be followed by a speedy cessation of the irritability-indeed, may prove insufficient, if not accompanied by cauterization of the cavernous tissue. If removal of the presumable irritative lesion fails to cure the irritability, or in case no other lesion can be found, the vascular engorgement and irritability can be permanently stopped by thorough destruction of the cavernous tissue. When there is only vascular enlargement without hypertrophy of the mucous membrane, the swelling cannot be thoroughly taken away with the snare. Cauterization with trichloracetic acid or superficial cauterization with the galvanocautery gives relief, but no permanent results. The only radical way is deep

cauterization by multiple punctures (¶ 27), one side at a time, followed two to three weeks later by the same operation on the other side. The case should then remain under observation for many weeks, and whenever returning symptoms and repeated examination show the vascular areas still capable of engorgement, these should be successively destroyed. It is very rarely necessary to operate on the posterior ends of the turbinals. By these means, persistently pursued, a permanent cure can be obtained. Cases complaining only of mechanical obstruction are much more readily controlled than the nervous phenomena of neurotic patients. The relief from insufficient operations may gradually disappear, and a relapse may occur, since the remnants of cavernous tissue regenerate readily under the stimulus of acute inflammations or persistent irritation.

Cauterization can be dispensed with or deferred in those patients whose complaints depend on some nervous condition of transient or controllable nature. The nervous nasal symptoms are, for instance, apt to be exaggerated during a pregnancy, to subside again later on. As there are some instances of miscarriage on record, attributable to cauterization, discretion should be exercised. A patient run down by overwork, anxiety, or loss of sleep may become comfortable by proper hygienic management without local treatment. The injurious influence of digestive disturbances upon the nose must not be overlooked. Relief may be obtained by avoiding hitherto disregarded exposure to dust. A trip to the mountains or to any dustless locality with mild climate is apt to give at least temporary benefit.

CHAPTER XII.

RETRONASAL CATARRH.

88. Retronasal catarrh is characterized by a mucous secretion in the posterior part of the nose, with absence of all gross lesions. The disease-the most frequent of all nasal affections in the United States-is not correctly described in most text-books, and is generally confused more or less with hypertrophic rhinitis. While, indeed, it is often associated with other forms of nasal disease, it occurs in the uncomplicated form sufficiently often to justify its recognition as a disease entity.

The only symptom is the secretion of mucus dropping into the pharynx. The mucus is thick, usually somewhat inspissated, foamy from air-bubbles, and in cities is stained grayish dark by soot and dust. While containing a few round cells microscopically, it is not at all purulent. From the posterior parts of the nose it flows into the pharynx, to be swallowed or spat out. When very viscid, it adheres to the posterior surface of the soft palate and is removed by the familiar guttural gurgling sound of hawking, which throws the palate into vibration. When very abundant, the patient occasionally draws it into the pharynx by a strong nasal inspiration, as he cannot expel it forward. The discharge is not identical with pus formed at the roof of the pharynx in inflammation localized at that spot. In a normal nose there is no secretion whatsoever, sufficient to flow or to collect, except momentarily in consequence of external irritation.

89. In uncomplicated retronasal catarrh no gross lesions whatsoever can be detected in the nose or nasopharynx. Such uncomplicated cases are more common among females than males. More frequently, however, retronasal

catarrh is associated with hypertrophic rhinitis, sometimes with other nasal lesions. We may thus find septum deformities and thickening, diffuse localized hypertrophy of mucous membrane on the turbinals, enlargement of cavernous tissue, and hyperplasia of the various areas of pharyngeal adenoid tissue. But none of the lesions are constant or essential. The amount and viscidity of secretion are, however, very much influenced by any interference with the patency of the nasal passages. The disease is relatively rare in subjects with wide passages, while the annoyance from the "sticky" discharge increases with the degree of nasal stenosis. Any obstructing lesion, even transient enlargement of the cavernous tissue, is thus an aggravating factor in the disease.

90. The disease, almost unknown under the age of puberty, is common only after adolescence, being more frequent-at least in its associated form-in the male. Every-day observation shows its extreme distribution, as judged by the characteristic hawking noise wherever people meet. On account of the slight annoyance and the absence of sequels, patients with the pure type of the disease do not commonly seek treatment. The disease usually lasts indefinitely, improving in mild weather, but rarely disappearing entirely, except under improved climatic environment.

It is of inflammatory origin, as can be learned in those rare cases which seek advice at the beginning. It is temporarily aggravated by every fresh coryza. In the absence of lesions visible during life and in default of autopsies we can only infer that it consists in a low grade. of superficial inflammation localized in the posterior region of the nose.

91. There is no treatment known which can directly cure a retronasal catarrh and stop the dropping of mucus. In the rare instances of retronasal catarrh with normal caliber of passage,-which we do not see often, since such patients are so little annoyed,-local applications of any kind have proved useless. I base this opinion fully as

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