BY C. R. ARMSTRONG, M. D., THORNTOWN, IND.

Atrophic rhinitis is that chronic disease in which there is a wasting away of more or less of the mucous membrane, glands, and turbinated bones, and is generally accompanied by some abnormal conditions of pharynx and all the sinuses connected with the nasal cavities.

This is no new disease, but one physicians have had to deal with these many years; one we meet in practice every little while, and one which we cannot study too carefully, because the treatment for the disease in many cases ends in failure to cure.

I do not know that I will be able to say anything new of this morbid condition of nose, but will state a few things as I see them in practice day by day. There is always a favorable point about having a patient with this disease, along with the unfavorable ones. That is—the physician always has plenty of time to study his case and see every minute change in the recovery ere the patient is pronounced cured. This is more commonly known as ozena, or fetid catarrh, from the odor which accompanies the trouble. However, there is a form of the disease in which the atrophy is present, but has no fetor accompanying it. The latter is a much drier form with no secretions at all.

The Ætiology of this disease has been discussed pretty thoroughly. It has been a question as to just what the initial symptoms and changes really are. In a majority of cases it is a secondary disease. That is, it follows other forms of rhinitis. Some authors claim that atrophic rhinitis follows the hypertrophic rhinitis. Others claim that there may be some shrinking in hypertrophic rhinitis, but that it does not end in atrophy, but comes from the purulent rhinitis: I believe they both are right. Either form I feel confident may precede atrophy. Again, I do not think that hypertrophic or purulent rhinitis is always followed by the atrophic form. If they were we would have many more cases of atrophic rhinitis to treat than we do at present. In my opinion this disease is brought on directly at times from various causes. Many a case of ozena has been brought on by the indiscriminate use of caustics on the mucous membrane of nose. Also injudicious cutting away of inferior and middle turbinated bones. Then again there is a predisposition to disease, especially in those people with a syphilitic and scrofulous diathesis. Excessive drinking of alcohol, excessive smoking of tobacco, working in poorly ventilated rooms or where there is a great deal of dust, and where there is an impoverished condition of blood from malaria or malnutrition, all have a tendency to set up this disease.

The name of this ailment tells much of the pathology of the disease. As atrophy implies, there is a wasting away of all tissues attacked. Upon examination the first thing observed is a dry, shriveled state of the mucous membrane of the nose and pharynx. The glands and follicles are all obliterated, which accounts for the dryness of the mucous membrane. The turbinated bones are dwindling away. Frequently the whole anterior portion of the turbinated bones is absorbed. This causes the nasal cavities to be so enlarged that we may see the pharyngeal walls from the anterior opening of nose. The glazed or dry appearance extends to the pharynx and in this manner affects the eustachian tubes. All over the nasal cavities and pharynx numerous granulations can be noticed. Tortuous and enlarged vessels run over the walls. As a rule there is not that bright red congested appearance of membrane as in other forms of catarrh.

Patients with this form of catarrh are frequently mistaken in diagnosing their own cases. I have had them to come in my office asking me to make a prescription for biliousness. They get that idea because they have a dry and coated tongue and a very bitter taste in mouth. After an examination is made you fail to find symptoms to corroborate the patient’s diagnosis, but will soon find the real cause. With the reflected light and nasal speculum it takes but a short time to satisfy your mind from conditions of nose that have all the symptoms of ozena. There is a discharge made up of mucus which is very thick, therefore not very easily expelled, and as a result finds its way into all the fossÆ and crevices in the nose. It is not long until this is dried into crusts which obstruct the passages of air, and being retained, decompose, throwing off a peculiar, penetrating stench. These crusts adhere very firmly to the membranes. The patients will remove them by artificial means, owing to the uncomfortable feeling produced by them. When the scabs are torn away there may be an oozing of blood. A stuffed up and oppressed fullness in the superior and posterior portion of the nasal passages is present. In the first stages of the disease the mucus will fall down from the palate in small slugs or masses, which as the disease goes on become more and more tenacious and more of a muco-purulent nature. In the beginning this discharge can be “hawked up,” but soon it becomes too thick and dry. While the membranes may be so irritated that there will be a free discharge of blood, still there is no real ulcerative process. The septum in some cases is perforated, but this is caused more by tearing away the dried-up discharge than anything else.

The sufferers from ozena are never the strong and vigorous people. They are generally anÆmic and having family histories which would make a physician think that the diseases were hereditary. These discharges being retained so long the poison may be absorbed into the blood, and soon the whole system will show the effects of the poison. In children the nostrils are so filled up that they can scarcely breathe at night, and it will not be far in the future when the child will be weak, nervous, irritable, and unable to sleep well. The stomach raises a disturbance as the disease gets older, which is accompanied by an occipital headache. The food which is eaten goes for naught, because the system does not seem to get the desired nourishment. Taste is destroyed, appetite gone, loss of energy for everything is apparent.

The patients scarcely ever can detect the bad odor unless their attention is called to it. After being told a few times about the odor of the breath they will shun public gatherings. If the patient is a woman, who because of offensive breath is barred from society, she will become morbid and hypochondriacal in time. There is so much of the thick mucus hanging on the walls of the pharynx that the openings into the eustachian tubes are filled up and in a short time a certain degree of deafness appears—roaring in the head and other manifestations of ear trouble. As soon as the hearing is noticed to be abnormal the patient will be ready to consult some physician.

With these symptoms it may not require much time to make a correct diagnosis, but it may be some time ere the patient is entirely free from the trouble even if he does use good homeopathic treatment. Then it is the treatment which interests us most. The patient at the beginning will ask if you can cure him and how long it will require to do it. The physician necessarily must guard his prognosis, especially if it is a case of long standing. If there is much atrophy, which has extended over several years, a permanent cure is very doubtful. But even with these cases much can be done to make patients more comfortable. Correct the odor, the dryness, and the formation of scabs. If the case is not of too long standing, very likely you will be able to produce a healthy condition of the mucous membrane. If you are so fortunate as to produce a cure, the patient will always remember you for it, and you will or should feel proud of it yourself. Much will depend on occupation, age, and persistence with which the patient carries out treatment.

The treatment, to be beneficial, implies the discovery and removal of all predisposing and exciting causes. To do this will require both local and systemic treatment. No cure can result unless good constitutional treatment is persisted in. When taking the case it is wise to inform the patient that he must expect treatment through several months, and even then the case must be examined once in a while or there may be a recurrence of the disease.

Too much time cannot be spent in a careful examination of the patient. Be certain the cause of trouble is ferreted out. The course of treatment will depend upon the cause of the disease. After thorough examination a course of treatment is planned. As I have said before, each case must be studied. There are no specifics for the disease.

In the local treatment the important object is cleanliness. The mucous membrane must be kept in a perfectly clean condition all the time. This is the main object of all local treatment. In some cases I assist nature to heal parts by getting a slight stimulating effect of medicine.

It is not always an easy task to remove all the dry crusts, but where the scabs are very dry I use an application of peroxide of hydrogen on cotton, or with the atomizer, to soften them. When the atomizer or douches are used post-nasal injections must be given as well as through the anterior chambers of nose. Any application can be used which will soften up scabs. Can use “Dobell’s Solution,” solution of sea salt, listerine, or glycerine. After all the crusts have been removed, others must be prevented from forming. This I do by keeping on an application of glycerine. A very good formula to keep the nostrils free is calendula and glycerine, at 2 drams to ounce water, and used in nebulizer or directly applied on cotton. When the odor is present after removal of scabs, I use permanganate of potash, 10 grs. to ounce in spray, or aristol in lavolene used in nebulizer.

After the cleaning process has been gone through with and all the mucous membrane is perfectly clean, naturally it is ready for some healing application. A good one to use is calendula and hamamelis in lavolene. If there should be any ulceration of septum, apply an ointment of yellow oxide of mercury, 10 grs. to the ounce. This will heal ulcer in short time.

Where membranes need some stimulation a glycerite of tar, hydrastis, or eucalyptol in nebulizer will be found to be of service.

Many times patient will complain more of the deafness than anything else. When you have this complication it will be necessary to give attention to some special treatment for the pharynx and eustachian tubes. The latter must be kept open by Valsalva’s method or the Politzer air bag.

In selecting the internal remedy keep in mind the constitutional and local lesions. Often I use the internal remedy locally; say 5 to 20 drops of tincture to ounce water. Make yourself confident that you have the indicated remedy. There are many remedies which are of service. Some of the more common ones, which have syphilitic taint are, aurum, kali iod., mercury, nitric acid, argentum nitricum, and calc. iod. In scrofulous diathesis and ill-nourished patients such remedies as aurum mur., silicea, calc. phos., sulph., phosphorus, ars., hepar sulph., alumin., kali bich., cal. carb., and graphites are useful.

All through the treatment the physician should have perfect control of patient. Should be able to direct his diet and hygiene. Use all means that will recuperate the general health. If patient is laboring day by day in dust and dirt, he may be compelled to change his occupation.

It is only by looking after the general health that the physician may expect to be rewarded with any success.