(a) Irritability of erectile tissue;

(b) Permanent dilatation of erectile tissue; And the hypertrophic into

(a) Dilatation with hypertrophy;

(b) Complete hypertrophy.

He also describes atrophic or cirrhotic rhinitis as the late, or contracting stage of chronic rhinitis.

Simple Chronic Rhinitis. From the repeated determination of blood to the part and consequent increased nutrition, before the changes of permanent hypertrophy become prominent, we have an increased glandular activity, affecting the mixed glands in the fibrous layer of the mucous membrane, and the columnar cells of its epithelium (goblet cells). This results in increased secretion of varying thickness, from almost pure mucous to almost pure serous. It is usually of the color and consistency of cream. If very thick it may easily become inspissated and form crusts. These crusts differ very much from the crusts which form in atrophic rhinitis. They are smaller, do not cover ulcers, have no collection of foul, green1sh pus under them, and have little or no odor.

The secretion is composed of mucous, dead leucocytes and epithelial cells, and a varying quantity of fluid. The presence of this secretion is the principal symptom of simple chronic rhinitis. It is usually attended by a slight but not disagreeable odor. The secretion may obstruct nasal respiration by its bulk, but can usually be removed by blowing the nose. It is easily cleared with spray, forceps and cotton carrier.

In investigating a case of this sort, the invasion of the accessory sinuses must not be lost sight of. Antral, ethmoidal and sphenoidal disease present similar symptoms, and a glance at sawn sections of the head will show how easy it is for inflammation to spread to them from the nose, and how the abnormal secretion from them must find its vent through the nose.

Hypertrophic Rhinitis. As we have seen, this is simply a further stage in the pathological progress. According as the vascular or hypertrophic element predominates, we have the first or second stage, according to Mackenzie's classification.

I said nothing of anatomical changes in simple chronic rhinitis, because to the naked eye there are none. Inspection reveals turbinals of varying size, but within the limits of comfortable nasal breathing, and the presence of an excessive amount of secretion. In hypertrophic rhinitis the picture and history are very different. The patient complains of obstructed nasal breathing, usually affecting one side at a time, both seldom being free at once. The change from being occluded to being patulous is apt to take place quickly, and often with a mucous "click," audible to the patient. There is a "stuffy" feeling in the head, which often amounts to frontal headache. The amount of secretion varies very much, and is not characteristic. The symptoms are more constant as to character and location in proportion as the element of hypertrophy predominates. Nasal respiration usually becomes impeded during the night, and as a result of mouth-breathing the patient awakens with obstructed nose, dry mouth and throat, and a feeling of lassitude and aversion to exertion that may last the greater part of the day.

The secretion, being deprived of its normal outlet anteriorly, finds its way back into the pharynx, causing a sensation of fullness, or occasional dropping, and giving rise to constant hawking and spitting, so disagreeable to hear, and which keep up a constant irritation of the pharynx. The descriptions furnished us by "catarrh specialists" of how this secretion drops into the stomach and subsequently invades the entire mucous membrane system, causing all the ills that flesh is heir to, have no foundation in fact. Cases are not rare in which a gastric catarrh accompanies a nasal catarrh, but it is simply a coincidence, post hoc but not propter hoc.

On inspecting such a case we find the breathing space of the inferior meatus seriously encroached upon. The increased amount of tissue comes chiefly from the inferior turbinated body, the septum often contributing a cartilaginous of bony spur or ridge, arising along the line of some of its sutures. As far as the inferior turbinal is concerned, it may be generally enlarged, or the process may be more or less limited to the anterior or posterior end. Of the middle turbinal, the anterior extremity is most and most often affected. There is VOL. XV-23

nothing in the appearance of the case to indicate how much of the increase of tissue is due to vascular distension, and how much of it is true hypertrophy. By the application of a solution of cocaine (four per cent.), with an atomizer or cotton carrier, a vascular constriction is produced, which does away with the dilatation element. What remains is hypertrophy. Treatment. Common to the treatment of both forms of chronic nasal catarrh is the use of some cleansing solution to keep the passages free from secretion, and to enable medicaments to be applied to the diseased membrane, and not to a layer of inspissated mucus. For the physician's office an atomizer, connected with a compressed air tank (Fig. 5), is

the most convenient and efficacious means at our disposal for applying this solution. For the patient's own use the "Bermingham Nasal Douche" is excellent. It is cheap, clean, cannot get out of order, and if the directions which accompany each instrument are followed the risk of exciting middle ear inflammation is very small.

The solution is used for cleansing only. It is a well-known fact in physics that if fluids of different density are in contact with the two sides of an organic membrane an inter

change takes place, known as osmosis. This is prevented if the solutions are of the same density and similar reaction. It is therefore important, to prevent further effect than simple cleansing, that the solution used, which will be on one side of the nasal mucous membrane, have the same specific gravity and reaction as blood serum, which is on the other side. A cursory examination of some of the more commonly used sprays and their relation to blood serum was made, with the following result:

Theoretically, therefore, Dobell's solution is the best. Practically, the carbolic acid it contains makes it objectionable to the patient. Seiler's solution and glyco-thymoline differ mainly in coloring matter, and are next to Dobell's in choice. It will be seen that the ideal spray solution has not yet been put forward. An additional objection to boro-lyptol is that it has formed an excellent culture bed for aspergillus in my spray tubes.

In simple chronic rhinitis, after cleansing, various local applications add to the patient's comfort. Astringents are curative. In proportion as vascular dilatation is present, antipyrine in four per cent. solution, or menthol and camphor in powder with boracic acid, or in solution with albolene, will contract the tissues and make the patient comfortable for a few hours. Iodide of zinc, chloride of zinc, sulpho-carbolate of zinc, alum, tannic acid and hydrastis form a list of astringents from which to choose. Iodide of zinc, gr. v to 3 i, is very efficacious. It may be sprayed or applied on cotton.

I am partial to powders in the treatment of this condition, especially when combined with stearate of zinc. This is an insoluble and exceedingly tenacious substance, and remains

in contact with the mucous membrane and exerts its influence much longer than any other form of application, it being often found on the membrane twenty-four hours after the application is made. The scoop powder blower (Fig. 6) is the most convenient means of applying powders.

Fig. 6 Powder Blower.

The treatment should be frequent. The cleansing solution ought to be used three or four times a day, or even oftener if necessary, and the other application made daily at first, and less frequently as the symptoms subside. Reappearance of symptoms and acute attacks, if promptly met, can usually be promptly subdued.

To be of avail, treatment of the nose should be supplemented by strict attention to hygiene, and of course any gross morbid condition or constitutional affection should receive appropriate care. Ca va sans dire. Hygiene of dress is a weighty problem. Subjected as we all are to sudden and severe changes of temperature, an acute cold is a common affliction, and its avoidance a source of much solicitude and care to those who are susceptible. These will find it to their advantage to wear the same weight of underclothing (light woollen) the year round, and regulate their comfort by the outer garments. A daily cold plunge or sponge bath, at least of head and neck, and careful attention to foot wear, will bear good fruit. "Keep the feet warm and the head cool" is as good as it is old. It is hardly necessary to warn men against slippers. It is almost useless to decry them to women. The woman who ventures out in inclement weather, with head and body well protected and feet well exposed in thinsoled shoes or slippers, wonders why, in spite of her care, she takes cold so often and so regularly. No amount of preaching can convince them that a shawl or wrap will do better service on the feet than on the shoulders. Before Dame Fashion's whim the medical man must bow in respectful