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ATROPHIC RHINITIS.

Source - Therapeutic Gazette, a Monthly Journal of General, Special, and Physiological Therapeutics, by H. A. HARE, M.D. and EDWARD MARTIN, M.D. 1900

DOUGLASS writes in the Post- Graduate for June, 1900, concerning the treatment of this most obstinate condition. He says that the treatment is to be directed first to the alleviation of the symptoms by means of cleanliness, antisepsis, and the use of alkaline, saline, or acid solutions, and, secondly, to

the cure of the disease. He discusses ( 1 ) treatment of the early cases; (2) the unilateral cases; (3) the ulcerations; (4) those with obstructions in superior or middle meatus; and (5) the remedying of general conditions.

The complete removal of the scabs and the cleaning of the nares and pharynx constitute an important part of the symptomatic treatment. He again emphasizes the complete and careful removal of the scabs, and this cannot be trusted to the patient at home. The cases should be made to understand that the physician should see them at least every two days, and, better still, daily; that all the scabs can only be removed by cotton dipped in some solution and carefully applied to loosen them. Every nook, furrow, and fold must be carefully searched. A douche containing any medicament does not cleanse the nose of these scabs, and the patients realize this only too well. When told to use the douche in the interim, they

must also be cautioned against an overuse of it. Realizing that some scabbing still remains, they douche and redouche themselves until they are veritable douche fiends. Patients will often use the douche six or seven times a day, and, in the vain endeavor to remove all secretions, will increase the strength of the solution until real harm will result. The best results are obtained from the use of an antiseptic and deodorizing solution applied twice daily, followed by the medicament we may choose, and on alternate days these cases should be carefully cleansed at the physician's office. Peroxide of hydrogen used as a spray, with water, 1 to 10 or 1 to 20, seems to soften and loosen the scabs well, and is both an antiseptic and deodorizer. After a complete spraying and a wait of a couple of minutes, this should be washed out with a warm normal saline solution, either used in the nasal syringe or douche bag. This spraying and washing can be repeated until about a quart of water is used.

Besides the use of saline solutions, Douglass has found it useful in many cases, particularly when the odor is very offensive, to resort to a weak solution of the metallic chlorides, using mercury bichloride in the strength of about I to 10000. Both of these remedies may be used with salt in the douche, and in these strengths do not act as irritants, but as desirable antiseptic deodorizers and astringents. The method of treatment by acids (citric acid) has recently attracted attention in New York. Solutions of some of the vegetable acids have been used with more or less success. To dislodge the mucus, to act as a deodorizer and a stimulant to the atrophied mucous membrane, the first to be used was trichloracetic acid -in a one- per- cent watery solution. This was given to the patient to use at home, and in the office a two- to five-per-cent solution of the same acid was used in the nasal application. More recently articles have appeared from German sources, claiming excellent results from the use of citric acid in two to six - percent solutions in these cases of atrophic rhinitis. Douglass's own experience with trichloracetic acid has led him to consider it a useful remedy, but less satisfactory on the whole than other methods. With citric acid he has as yet had no experience.

Other deodorizers and antiseptics have been recommended, and the list of applications is almost identical with the list of new pharmaceutical preparations. In other words, everything has been recommended, but one of the two above mentioned methods will suffice for home treatment.

Ichthyol is, after all, a remedy which seems to give the greatest relief when used locally in these cases of atrophic rhinitis.

At a meeting of a section of laryngologists in the Academy of Medicine, New York, last winter, a discussion arose regarding the most useful remedy for the relief of atrophic rhinitis. The consensus of opinion among those who spoke on that occasion was very much in favor of ichthyol in some form or other. Some used it in weak solutions, two to six per cent; some in stronger, twenty-five to fifty per cent; while others preferred the use of ichthyol pure. All agreed that in their experiences it was the most valuable remedy for the relief of the disagreeable symptoms and the best stimulant for the mucous membrane. This coincides with Douglass's personal experience with this remedy. It is his habit to use ichthyol in the treatment of rhinitis in three ways: The first by means of a watery solution of ten- to twenty-per-cent ichthyol applied on a large pledget of cotton, and introduced into the nares upon the atrophied areas. As soon as the nares have been properly cleansed, by any method considered

desirable, the pledgets are placed in the nose, and the patient is allowed to sit in the outer office for a period of fifteen to thirty minutes, after which the pledgets are removed, and the oily sprays are used to finish the treatment.

In cases of atrophic rhinitis presenting ulceration, or localities in the nose where pus is particularly persistent, or in areas that are very much atrophied, it is his habit to use ichthyol in full strength, rubbed directly into the parts, particularly if one of these bad places is upon the nasal septum. Ichthyol is used on cotton which is wound on a probe. This is gently rubbed for a period of four or five minutes into the atrophied mucous membrane.

The third method of using ichthyol is by means of a salve-forty grains of ichthyol and five grains of menthol, added to one ounce of vaseline. This is given to the patient to use at home after cleansing of the nostril, and also each night before retiring. The patient is directed to introduce into the nostril a piece as large as a good-sized bean, and then to snuff it back, when most of the salve will be distributed over the inferior meatus, and will lubricate the nose rather thoroughly during the night, the excess of ichthyol escaping into the postpharynx and acting there as a lubricant.

In selected cases of atrophic rhinitis, where the odor is particularly disagreeable, or the stench intolerable, such as generally arises from some caries or denuded necrotic bone, a rather new remedy seems to work well-ortho - chlor- phenol in solutions with glycerin of the strength of ten to twenty- five per cent. In ten-per-cent solutions it is a very strong stimulant to the nasal mucous membrane. In solutions of twenty- five per cent it is a decided cauterant, the great objection to its use arising from the odor of phenol which it possesses. For this reason it is used only in severe classes of cases which require a strong deodorizer. It is a strong irritant to the mucous membrane, and if used too often or too strong will result in overirritation. It must be used with caution