room and avoids physical exertion. The headache of accompanying sinus involvement can be checked by antipyrin in the dose of 1 gram for an adult. The excoriations of the skin under the nose heal under any bland salve (oxid of zinc ointment or cold cream). The treatment of subacute exacerbations and chronic prolongation will be found in Chapter V. CHAPTER V. CHRONIC NASAL INFLAMMATIONS; "CHRONIC CATARRH"; CHRONIC PURULENT RHINITIS. 33. Chronic Catarrh.-The various forms of chronic nasal disease give rise to very similar symptoms-viz., discharge and obstruction. These symptoms were hence referred by the older writers, and are still by the public, to the existence of a "chronic catarrh." The socalled "catarrh," however, can be resolved into a number of separate affections and lesions, varying in character and significance. This clinical analysis is made difficult by the frequent coexistence of several lesions in the nose or throat. By selecting from a larger experience those cases in which only single lesions are present, certain types of nasal and nasopharyngeal disease can be established, which the diagnostician must recognize whether they occur in uncomplicated or in associated forms. The special term "chronic catarrh," if it is to be applied in its conventional sense to a chronic inflammation of a mucous membrane attended with mucous discharge, may be reserved for that form of nasal disease in which there is an excessive production of mucus-viz., retronasal catarrh. The ordinary chronic nasal and pharyngeal affections comprised under the generic term “catarrh” can be classified under the following heads: Deformities of the septum. Sequels of inflammation. Enlargement of cavernous tissue. Diffuse hypertrophy of mucous membrane. Circumscribed hypertrophy of mucous membrane (polypi). It will be most serviceable, however, to describe these affections in an order differing somewhat from the one best adapted for classification. 34. Chronic Purulent Rhinitis.-Symptoms.-Purulent rhinitis is characterized by the discharge of pus from the nose. As this symptom is common to various diseases, it must be determined in every case whether the pus comes from the nasal cavity itself, the roof of the pharynx, or from one or more of the accessory sinuses. According to the area involved in the disease the amount may vary from large masses of pus, viscid by reason of the mucin present, to trifling flakes that are easily overlooked. Some text-books speak of the occurrence of a catarrhal discharge. This term is likely to lead to error. In many forms of nasal disease the mucous membrane is abnormally irritable and secretes freely in response to irritation by dust or chilling of the body. When abundant, this fluid is watery, but when scant, it is very thick and viscid. This transient discharge is either entirely clear, indicating the absence of suppuration, or, when it occurs in connection with any purulent process, it is mixed with streaks of pus. Very scant purulent discharge may escape detection until the flakes are looked for in the water after douching the nose. Although the discharge is mostly blown out, it may pass also into the pharynx when formed in the posterior regions, or be guided thence by a stenosis anterior to the secreting region. The swallowing of copious purulent secretion may give rise to stomach disorders. The other symptoms of purulent rhinitis, variable in different cases, are transient obstruction from the presence. of pus or from vascular turgescence, and irritability, as shown by fits of sneezing and momentary watery flow. Many patients are so little annoyed by the disease that the diagnosis is made only incidentally when ear or throat complications arise. Etiology. Chronic nasal suppuration is not a morbid entity, but may depend upon a variety of conditions. which require detection in the individual case. Acute purulent rhinitis, especially when it is a manifestation of influenza, is likely to become chronic under certain circumstances. These are sometimes constitutional disturbances, chlorosis, malnutrition from other enfeebling diseases, and dyspepsia. Quite often the history is that of recurrent acute attacks, which finally become perinanent, especially when exposure to "cold," insufficient. protection, and longer spells of unfavorable weather have interfered with spontaneous recovery. Most commonly, however, local lesions will be found that account for the persistence of the disease. These are, in general, narrowness of the nasal passages, localized stenosis from deformities of the septum or spurs on its surface, or circumscribed hypertrophies of the mucous membrane in the form of papillomatous tumors upon the inferior turbinal, or polypi from the middle turbinal or external wall. Relatively often nasal suppuration is maintained by the enlarged pharyngeal tonsil in children or young adults. The presence of foreign bodies or of concretions. may protract a nasal discharge indefinitely; in such a case it is most likely to be one-sided. Pathology. Examination shows that the purulent inflammation is rarely an extensive or a diffuse process; more often it is a localized condition, especially in the upper recesses. In the diffuse form the entire mucous membrane is reddened, but not much swollen. Even when a localized focus exists, a diffuse redness may be due to the coexistence of a diffuse non-suppurating, but hypertrophic inflammation, a not infrequent clinical combinaOn the other hand, the entire lower intranasal area may appear normal. Sometimes the source of the discharge may be detected in a limited injected part of tion. the surface high up, the vulnerability of which is shown. by bleeding when touched with the probe, or which is covered with granulations. Exposed bone is never found in simple purulent rhinitis. Its detection signifies syphilis or deep involvement of the ethmoid cells. In every case of nasal suppuration in which the discharge. amounts to more than small flakes of pus, repeated efforts must be made to ascertain or exclude involvement of any of the accessory cavities, according to the methods to be described (40). In a large proportion of cases purulent discharge from the nose comes from one or more of the accessory sinuses. Fetor of the discharge, especially if one-sided, suggests the possibility of a foreign body, particularly in children, or of a concretion (rhinolith). The diagnosis can easily be made with the probe. In ordinary cases of uncomplicated purulent rhinitis the discharge is not fetid. Sometimes, however, the discharge is retained by swelling of the mucous membrane, due to circumscribed edema or granulating surfaces. It becomes inspissated, cheesy in appearance, and horribly offensive. This constitutes the rare form described as rhinitis caseosa. There is usually very much nasal obstruction in this form. By thorough removal of the pent-up secretion by irrigation it is changed into the ordinary purulent rhinitis, which then yields readily to treatment. Uncomplicated chronic purulent rhinitis may disappear without treatment under improved climatic and hygienic environment. As a rule, however, it does not heal entirely during the warm season, but merely improves until unfavorable weather returns. Possible complications to which it may lead are chronic conjunctivitis, purulent inflammation of the tear-sac, ear disease (usually the secretory catarrh in a persistent form), chronic hypertrophic pharyngitis, and laryngitis or bronchitis. Treatment. The treatment is ordinarily successful if |