catarrhal excoriations, the softening of nasal incrustations, the lubrication and palliation of the inflamed mucous membrane, and the cure of hemorrhagic abrasions. ANTERIOR DEFLECTION OF THE NASAL SEPTUM, before and after its removal by means of Detergents and antiseptic washes are employed to carry out the first indication. They relieve the stenosis by softening and washing away the intra-nasal incrustations and thickened mucus. The devices usually employed to render these applications effective are the anterior and posterior nasal syringe, several forms of nasal douches, and various spraying devices. The post-nasal syringe offers a most thorough means for flushing the nasal cavities. When organic stenosis exists, removable, however, by surgical measures, ear-trouble may be caused by fluids being forced into the Eustachian tube. The utility of this means is lessened or lost with infants and very young children. In this class of cases some form of anterior nasal douche or spray may be employed. A simple and useful douche of this kind, extemporized by myself, can be had by fitting the nasal nozzle of a Politzer air-bag to the rubber bulb of a Warner douche. A peculiar pitcher devised by Politzer to pour fluids through the nose may be also utilized. Thudichum's or Weber's gravity douches are also sometimes, but less satisfactorily, employed. A variety of substances have entered into the composition of nasal lotions, among which may be mentioned bicarbonate, biborate, benzoate, phosphate, and chlorate of sodium, in the proportion of from one to five grains to the ounce of fluid. These bland, unirritating salts of sodium are usually employed in solution with glycerin and a mere trace of an antiseptic agent, like peppermint, menthol, salicylic acid, benzoic acid, carbolic acid, or bichloride of mercury. Nasal lotions are, of course, always warmed before using. Astringents are of doubtful efficacy as applied to the pituitary membrane. It is possible that they may occasionally act as mild local tonics. These solutions should be very weak. Ferric alum and sulphate of zinc (gr. ss-i to the ounce) and glycerite of tannin (gtt. x to the ounce) are most commonly employed in the form of a spray. Powders, on account of their irritating qualities, are contra-indicated in hypertrophic rhinitis. Unguents are sometimes useful to soften and soothe the inflamed mucous membrane and to prevent the formation of intra-nasal incrustations. They may be sprayed into the nose or applied by means of a brush. Sprays of heated vaseline prove very grateful. These local measures will naturally have to be combined with appropriate treatment of the effects and complications of the catarrhal processes, commonly observed in the ear, eye, pharynx, larynx, and throughout the system, as manifested by constitutional depression, nervous erethism, mental disturbances, and derangement of the various viscera. CROUPOUS RHINITIS. BY F. H. BOSWORTH, M.D. A MORE correct understanding of inflammatory diseases involving the nasal passages will, I think, be arrived at if we adopt that classification in which the term used to designate a disease also indicates its pathological character. Thus, when we speak of simple rhinitis, we allude to a catarrhal rhinitis, or an inflammation characterized by a fluid discharge; when we speak of croupous rhinitis, we have to do with an inflammation characterized by a deposit, on the external surface of the mucous membrane, of a fibrinous exudation, or false membrane; when we speak of diphtheritic rhinitis, we allude to that form of inflammation characterized by the development of a false membrane which not only lies upon the surface, but also infiltrates the tissues of the mucous membrane down to its deeper layers. The term croupous rhinitis, then, we use to designate that form of acute inflammation of the mucous membrane lining the nose which is characterized by the formation on its surface of a fibrinous exudation. The disease is met with both among children and in adult life. In children it runs a somewhat more protracted course and is attended with symptoms of a graver character, although the disease is rarely in itself a dangerous one. From an examination of the literature of the subject we would gain the impression that it is an exceedingly rare affection, for we find few writers alluding to it; and yet, I think, it is far more common than is usually supposed. Moreover, the literature of the subject is somewhat vague and indefinite, for we find Fränkel' referring to it as a complication of diphtheritic disease of the nose, thus confusing two entirely separate and distinct diseases, an error which Schüler2 also falls into in reporting a case of the disease, still using the term diphtheritic. Cohen, on the other hand, while recognizing it as a disease distinct from diphtheria, describes it as a complication of acute coryza. Later, however, we find Moldenhauer recognizing it as a distinct disease, and giving us an excellent description 2 Jahrbuch für Kinderheilkunde, N. F., Jahrg. iv., 1871, p. 331. 3 Diseases of the Throat and Nose, 2d ed., p. 332. Monatschrift für Ohrenheilkunde, No. 9, 1887. of its course and symptoms; in the same manner examples of the disease were reported by Hartmann,' Seifert, and Ryerson.3 Causation. When we come to consider the causes of the disease, we enter upon the discussion of pathological problems by no means yet fully determined. I think, however, that the weight of clinical evidence is largely in favor of the view that a croupous exudation is a local manifestation of a general disease. Thus, a diphtheritic exudation we regard as local evidence of the general disease which we term diphtheria; and so a croupous exudation is to be regarded as the local evidence of a general disease to which we have as yet given no definite name. That this is true, I think, is fully evidenced by the fact that the disease is invariably attended with very great systemic disturbance and general febrile movement, far more so than would be commonly expected as symptomatic of a purely local inflammatory action. The prominent general condition, probably, is an excess of fibrin in the blood, which we may call hyperinosis, and which so far dominates the local inflammatory action as to change a simple catarrhal inflammation into one attended with an escape of fibrin from the blood, which changes the simple mucous discharge into a fibrinous exudation, and, as the result, the formation of a false membrane. Now, furthermore, I believe that a croupous exudation is primarily due to the deposit of a germ upon the surface of the mucous membrane, which, making its way into the blood, gives rise to this condition of hyperinosis, and which at the same time, also, has a certain influence, perhaps, in exciting the croupous inflammation at its point of entrance. Of this we have abundant clinical evidence in the fact that the surface of the tonsil is the most frequent site for the formation of any false membrane, whether croupous or diphtheritic, and in the ragged surface of the faucial tonsil we have the physical conditions which afford the most favorable site for the lodgement of a germ, in that it becomes entangled, as it were, in the crypts or innumerable open-mouthed follicles which are found in this region. Furthermore, that the disease should be exceedingly rare, as involving the nasal cavity, is accounted for by the fact that here we have to do with an absolutely smooth surface, which is constantly bathed in the profuse flow of serum which constitutes the respiratory exosmosis, and, still further, any lodgement of a germ on this surface is prevented by the constant to-and-fro current of air, and also by the ceaseless activity of the vibratory movements of the cilia. At a rather interesting discussion on this disease which occurred at the sixtieth meeting of the German Naturalists and Physicians, Bresgen made the observation that not infrequently it resulted from the use of the galvano-cautery in the nose. I suspect that he regarded the superficial slough which resulted from the cauterization as a croupous exudation, a morbid condition essentially different. Hering and Schmithinson, in the same VOL. II.-26 1 Deutsch. Med. Wochenschr, 1887, No. 9, p. 641. 2 Münchener Med. Wochenschr, 1887, No. 38. 3 New York Med. Record, July 30, 1887. discussion, alluded to the insufflation of impure water as a cause of the disease, an observation which it would be rather difficult to verify. A croupous exudation undoubtedly occurs after operations in the nose which involve a section of the membrane, a condition having thus been established which favors its development,―viz., a cut surface. The disease, however, in this case differs essentially from the idiopathic attack of croupous rhinitis, in that the membrane shows no disposition to extend, although the attack is attended with quite as well marked evidences of systemic disturbance as in sporadic cases. I think, then, that we may consider that the disease is a germ-disease, caused in exceedingly rare instances by the germ lodging upon and making its way into the interstices of an apparently sound mucous membrane, and in other cases invited by the open-mouthed follicles of the cut surfaces in connection with operations in this region. Pathology. The essential pathological lesions observed in the mucous membrane proper are those of an ordinary acute rhinitis, and consist, briefly, of a hyperemia of the blood-vessels both of the turbinated tissues and of the mucosa proper, together with a general increase of the nutritive processes met with in that disease,—namely, increased exudation of serum, and cellproliferation. On the surface of the membrane, and somewhat loosely adherent to it, is found a false membrane, presenting the following characteristics: there is a basement-substance of fibrillæ of fibrin, and considerable granular fibrin. Entangled in this basement-substance we find numerous white blood-cells and epithelial cells, undergoing granular degeneration and coagulation necrosis; some red blood-cells are also to be observed. The membrane thus presents the ordinary characteristic appearances of a croupous membrane. The exudation occurs on the faces of the lower and middle turbinated bones, and, in aggravated cases, on the septum. I have never noticed any tendency to extension to the accessory sinuses, although their orifices are closed by the swollen nasal membrane, and distressing symptoms referable to those cavities may occur thereby. Symptomatology.-A croupous rhinitis follows the rule observable in all cases of diseases of the upper air-passages characterized by the superficial deposit of fibrinous exudation, in that its onset is attended with wellmarked evidences of general disturbance. In most cases the invasion is attended with a chill, although in many cases there is merely a chilly sensation. This is followed by general febrile motion, the thermometer, as a rule, on the first day marking a temperature of 102° to 103° F. The higher temperatures are not usually observed in the nasal disorder. In connection with the fever there is usually pain in the back, headache, depression of spirits, and the chain of symptoms which are embraced under the expression of general malaise. The high temperature lasts from one to two days, when it subsides, and the further progress of the disease is attended with a temperature of 100° to 101° F., or, in certain cases, even as low as 99° F. The subjective symptoms, attended with sneezing and watery discharge, indicate apparently a cold in the head. This, however, is soon followed by |