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CORDES. Archiv für Laryngol., 1900, xi. p. 280.
BAUMGARTEN. Journ. of Laryngol., 1895, ix. p. 60.
YONGE. Journ. of Laryngol., 1904, xix. p. 455.
KRONENBERG. Therap. Monatschr., 1897, xi. p. 259.
REICHERT. Wien, klin. Rundschau, 1897, xi. pp. 285, 307.

LACK. Physician and Surgeon, July 12th and 19th, 1900.

LACK. Proc. Laryng. Soc. of London, June, 1900, and Journ. of Laryngol., 1900, xv. p. 380; Proc. Laryng. Soc. of London, 1900, Dec.; and Journ. of Laryngol., 1901, xvi. p. 64.

CHOLEWA. Monatschr. für Ohrenheilk., 1900, xxxiv. p. 103.

LUC, ZUCKERKANDL and Discussion. Brit. Med. Assoc., Meeting in London, August, 1895; Brit. Med. Journ., 1895, ii. pp. 474-481.

LUC. Tribune Médicale, 1905.

CHAPTER XII.

CHRONIC INFECTIVE DISEASES OF THE NOSE.

Syphilis. Tuberculosis. Lupus. Leprosy. Rhino-Scleroma.

SYPHILIS.

Glanders.

EXTENSIVE destruction of the nose as the result of venereal disease was known and described in ancient times. Syphilis, acquired or inherited, may attack the nose at any stage, but tertiary lesions are by far the most common. They may occur from within a few months up to thirty years or more after the primary infection; but are most common in the first few years, and are often seen in spite of a prolonged course of mercurial

treatment.

1

Primary Syphilis. Chancres in the nose are very rare, although several instances are on record. Thus Chapuis has published an account of twenty-two cases. They are most frequent in the vestibule, but may occur on the mucous membrane, especially on the anterior part of the septum. They are usually caused by picking the nose with an infected finger, or by the use of infected instruments, such as a dirty Eustachian catheter. The symptoms are not characteristic. There is unilateral nasal obstruction with more or less sanious, purulent, often foetid, discharge. There may be neuralgia, headache, and mild constitutional disturbance. On examination a soft or hard ulcer, with a slightly raised edge may be seen; the base is covered with secretion, and bleeds readily if touched. The sub-maxillary glands on the affected side are generally enlarged and hard. Should a chancre occur in the posterior part of the nasal cavity, deafness and earache will probably be marked symptoms. The true nature of the lesion in this region will probably be unsuspected until secondary symptoms appear. The diagnosis is always difficult; but attention to the above points, together with the history, should excite suspicion. When secondary symptoms appear on the skin or in the throat the diagnosis is easy. The treatment and the prognosis are the same as for primary syphilis elsewhere.

1 Gaz. des Hôpitaux, 1894, lxvii. p. 1103.

Secondary Syphilis. The manifestations of secondary syphilis in the nose are mild and often overlooked. They present nothing very characteristic. The earliest symptom is slight catarrh, with general redness and swelling of the mucous membrane. This coryza is more chronic and less severe than in ordinary "cold," and it is said that the redness may be patchy or of a deeper hue, but the diagnosis really depends upon the associated affections of the fauces and skin. In the later stages condylomata and eruptions, similar to those of the skin, have been described: they are extremely rare. More frequent are fissures round the nares and on the upper lip, and acne or sycosis-like nodules in the vestibule. The diagnosis depends upon the presence of the other constitutional manifestations of syphilis. General specific treatment is indicated; no special

local measures are necessary.

TERTIARY SYPHILIS.

This is by far the most common and the most important manifestation of syphilis in the nose. It occurs most frequently from one to three years after the primary infection. The commonest form is a gummatous infiltration which soon softens and leads to a rapidly progressive ulceration of the mucous membrane, with destruction of the cartilages and bones. A gumma is rarely observed; it forms a firm, elastic, sharply circumscribed or diffuse swelling. As the interior of the gumma softens, the surrounding mucous membrane becomes oedematous, the surface gives way, and a small opening forms, through which the broken-down contents may discharge like an abscess. A purplish-red swelling on the septum or floor of the nose, with a fistulous opening near its centre, leading to bare cartilage or bone, is not uncommon. A diffuse infiltration usually leads to extensive superficial ulceration, which rapidly spreads deeper until the cartilage or bone is exposed. The bones or cartilages may also be primarily attacked. The skin, especially that of the alae and tip of the nose, may be affected. It becomes swollen, dark or bluish-red, and soon ulcerates: rapid and extensive destruction, or perforation of the alae, or of the septum, follow. Rarely the ulceration may take another form, spreading slowly, and more. superficially, and healing in one place as it spreads in another. This gives rise to a lupus-like affection-the so-called "syphilitic lupus."

Symptoms. The earliest symptoms may resemble those of an ordinary cold, viz., increasing nasal obstruction, with more or less muco-purulent discharge. As the disease progresses, the discharge becomes more profuse and purulent, it is often blood-stained, and acquires an exceedingly foetid odour: the obstruction becomes complete. Later the discharge may assume the form of large foetid ozaena-like crusts, which are expelled with difficulty, or may pass down the throat this indicates extensive destruction of the nasal mucous membrane. Neuralgic pains in the nose, radiating over the face and head, are common. If the skin or nasal bones

be affected, there is tenderness on pressure. There may be swelling of the nose or adjacent parts of the face, oedema of the eyelids and dermatitis around the anterior nares. A sequestrum may come away, or necrotic fragments of bone may be found in the discharge.

The appearances depend upon the situation and the stage of the disease. When the anterior part of the septum is involved, a small or large ulcer may be seen with characteristic sharp-cut edges and sloughy pus-covered floor. Soon the cartilage becomes bare, necroses, and

FIG. 93.-DEPRESSED BRIDGE OF NOSE RESULTING FROM TERTIARY SYPHILIS.

perforation of the septum takes place. The opening may be small and round, or large and irregular; its edges are thick and covered with granulations and crusts. When healing takes place, the base of the ulcer or edges of the perforation become covered with epithelium, usually squamous; for a long time crusty secretion collects and adheres to the healed surfaces. If extensive destruction of the septum in this region occurs, there is usually some falling in of the tip of the nose.

The bony septum is more frequently affected, and may present similar appearances to those above described, but there is apt to be swelling of the surrounding mucous membrane or exuberant granulations, which Even though a large perforation

prevent a view of the actual ulcer.

occur, or almost the entire bony septum be destroyed, there will be no falling in of the bridge of the nose, unless the nasal bones are also attacked.

The nasal bones may be affected alone or more generally in combination with disease of the septum. The initial lesion is often a subperiosteal gumma. In the early stages it forms a firm elastic swelling over the bridge of the nose, but softening rapidly takes place, and the skin becomes red, swollen and oedematous. The broken-down gumma may burst externally or into the nose and an ulcer form with necrotic bone at its base.

[graphic]

FIG. 94.-"NEZ EN LORGNON" RESULTING FROM TERTIARY SYPHILIS.

The destruction of the nasal bones usually results in the formation of the well-known saddle-backed nose. In a typical case the bridge of the nose may be almost flat with the cheeks and covered with scarred firmly adherent skin the tip of the nose is tilted and the nostrils look forward as well as downward (Fig. 93). More rarely the so-called nez en lorgnon is produced (Fig. 94). This probably results from cicatricial contraction pulling on the bridge of the nose at the junction of the cartilage with the nasal bones following extensive destruction of this part of the septum. When the nasal bones and septum are extensively affected at the same time, the bridge of the nose may lose all its supports and may sink in to such an extent that it seems to consist merely of three loose folds of skin with two small apertures in front representing the nostrils.

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