CHAPTER IV. DISEASES OF THE VESTIBULE OF THE NOSE. CORYZA. DISEASES OF THE VESTIBULE. 31. The entrance into the nose is not often the primary seat of disease, but suffers frequently in the course of various intranasal affections, especially purulent rhinitis. Eczema occurs sometimes in the acute, more often in the chronic, form. The characteristic vesicles are soon transformed into moist scabs covering an excoriated, bleeding surface. The patch extends usually downward over the upper lip, but is sometimes limited to the floor and sides of the vestibule. Eczema is most commonly seen in scrofulous children. Sometimes it is also a persistent annoyance in adults with morbid nasal secretion. When of long duration, it is likely to cause thickening of the upper lip, typically seen in scrofulous children. The eczematous abrasion may permit the entrance of the tubercle bacillus into the lymphatic system, as indicated by permanent enlargement of the anterior cervical lymphglands. It may likewise prove the starting-point of facial erysipelas. The eczematous crusts should be removed, and the surface protected by a zinc oxid lanolin. salve (50 per cent.). Rebellious cases are cured in the quickest manner by cauterization with silver nitrate, repeated if necessary. Oil of cade salve (1:4) and balsam of Peru act more slowly, but are especially useful in preventing relapses. An annoying and easily overlooked lesion is a shallow fissure at the junction of the septum and the lateral wall of the external nose. It is more or less painful, always tedious in its course, and likely to recur if partially healed. Sometimes it maintains an embarrassing red ness of the tip of the nose. Occasionally it is the starting-point of spells of sneezing. Its presence favors acute "colds." A fissure causes pain when the nasal speculum is inserted. It can be seen on searching for it. It yields most readily to repeated applications of silver nitrate solution (30 per cent.) on thin cotton applicators. Furuncles of the hair-follicles in the vestibule give rise to decided pain and swelling and sometimes to external redness. A furuncle can be recognized as a small papular swelling on the inner surface of the side of the nose. It should be incised if it has not broken spontaneously. Relapses are common. The best prevention in my experience is to brush the inside of the side of the vestibule with a weak (4 per cent.) solution of silver nitrate once in a few days for a number of weeks. CORYZA; ACUTE NASAL CATARRH; ACUTE PURULENT 32. Acute nasal catarrh is the most common of all diseases. Very few persons pass many years without an attack. The well-formed normal nasal passages of vigorous individuals may not be invaded for a number of successive years, while poor health and especially deformed nasal passages and chronic intranasal lesions predispose to repeated attacks within one season. Hereditary syphilis is a noteworthy predisposing condition in infants. No age is exempt, but coryza occurs less frequently after middle age is passed. Least common during equable weather in summer, or during a uniform dry, cold spell in winter, it is most prevalent after changeable weather in fall and spring. Its geographic distribution, too, corresponds with the peculiarities of the climate. The attack begins with sneezing, followed by a feeling. of fulness in the nose and head, which culminates after some hours in nearly total occlusion of at least one side of the nose, sometimes of both. At the same time there occurs a watery, acrid discharge, becoming purulent in the course of about twenty-four to thirty-six hours, E after which time the secretion is a thick, purulent mucus of yellowish-greenish tinge, sometimes slightly bloody. The full feeling increases during the first day, and is sometimes accompanied by considerable headache. On account of the swelling around the Eustachian orifice the ears may feel "stuffy." In children, less commonly in adults, a febrile rise of temperature of from 1° to 3° F. may be noticed. Quite often a general feeling of malaise and lassitude is felt. The tongue becomes coated, the appetite often is impaired, all the more so as the sense of smell may be absent and hence taste interfered with. The smoker refuses his cigar. In the typical attack, not modified by preexisting chronic nasal disease, this condition lasts two or three days, and then begins to decline. The nose becomes clearer,—at least one side at a time,-although the discharge is more likely to increase during the first three days. The secretion is likely to cause excoriation of the skin at the entrance of the nose, which in its turn may prolong the annoyance. The discharge changes gradually into clearer mucus with purulent flakes. In uncomplicated instances, not prolonged by exposure, all symptoms disappear completely in from six to ten days. Inspection shows the mucous membrane to be reddened and thickened. The occlusion of the passage is partly due to turgescence of the submucous venous plexus. This may be overcome transiently by the pressure of a probe or by the action of cocain or suprarenal extract. The mucous membrane, however, is, besides, swollen from infiltration with leukocytes and serum. During the receding period the vascularity diminishes and the membrane is sometimes seen to be edematoussoggy. Acute rhinitis is a diffuse process involving the entire lining of the nose uniformly. Examination with the postnasal mirror, when feasible, shows that the pharyngeal tonsil is, as a rule, involved, being reddened and swollen, though to a variable extent in different patients. In some instances the inflammatory redness and swelling extend visibly along the pharyngeal mucous membrane down below the level of the soft palate. Histologically, coryza is a diffuse leukocytic infiltration, with congestion of all vessels, especially the venous plexus, and with partial loss of the ciliated epithelium. Deviations from the clinical course, as described, may occur in either direction. In patients with either chronic suppurative or hypertrophic rhinitis acute exacerbations occur with symptoms of a milder character than in the typical attack. The climax, which is not so severe as in a hitherto normal nose, is reached within the first day, and within from three to five days the symptoms subside to the grade they presented prior to the fresh "cold." Some patients give the history of frequent "colds" lasting only a few hours. These are, however, not inflammatory attacks at all, but merely spells of turgescence of the cavernous tissue, with sneezing, occlusion of the nose, and a copious watery discharge entirely free from pus. On the other hand, nasal stenosis may cause a prolongation of the climax for several days and may lead to an indefinite persistence of the symptoms during the declining stage. Delay in the disappearance of an acute coryza may also be caused by exposure to inclement weather and insufficient protection against cold. In the light of our present knowledge we cannot but attribute acute purulent rhinitis to the action of some widely distributed parasite. In spite of many attempts the virus has not yet been identified. At times coryza attacks a number of persons in a household in succession, so that a suspicion of contagiousness seems warranted. Direct inoculations, however, with the discharge have failed to transfer the disease. The presence of various forms of pyogenic cocci during the declining stage, and especially in protracted nasal suppuration, makes it probable that secondary infection often plays a rôle. Popularly, acute catarrh is always ascribed to "taking cold." As stated in Chapter II., there is no reason to doubt that chilling is an important factor in causing chronic cir cumscribed inflammatory processes to become acute and diffused. The fact, however, that the same chilling of the body does not always or even often lead to the same result signifies that it must coincide with other influences which we do not know. In the acute catarrh of hitherto normal noses the chance of satisfactory inquiry is so rarely afforded to the physician that a definite opinion concerning the importance of "taking cold" cannot be given. An acute purulent rhinitis is often a part of the clinical picture of influenza, although this disease may also occur without it. In measles there is always an inflammatory condition of the nose, with watery discharge as the first manifestation. In some instances the nasal symptoms subside without suppuration as soon as the cutaneous eruption has appeared; in others they develop into an ordinary coryza which is apt to be prolonged in a subacute form. Coryza involves no danger to life in the adult. In infancy, when the nasal passages are relatively narrow, it may be accompanied by great swelling (and subsequent hypertrophy of the pharyngeal tonsil), and the interference with nasal respiration, causing dyspnea and restlessness, gives the appearance of serious danger. But, after all, fatal issues must be very uncommon, if they ever do occur in uncomplicated cases. A serious danger in infants is the possible complication with bronchitis and bronchopneumonia. Although complete spontaneous recovery is by far the most common result, acute catarrh may change into a persistent chronic inflammation if there is nasal stenosis, if it be prolonged by exposure, or if often recurrent. The acute inflammation may also extend into the accessory cavities. This is probably the case more often than is now taught, especially so far as the ethmoid cells and sphenoid sinus are concerned, and the severe headache sometimes present during a "cold" is probably due to this extension. However, most of the acute inflammations of the sinuses heal spontaneously. |