ea } E 5 ms ore reheat Wb i rae at ens bees c Sa pie : pes ben eh =m eee PAIR ee RF 40. B74 University Library Ne treatise on disea mn WT i ; ‘Fhe date shows whien this volume was taken. All books not in use MAY 12 1903" : for instruction or re- “1Qiee search are limited to OCT 31 196s four weeks to all bor- ; ae rowers. (Ge Ap t Periodicals of a gen- eral character should be returned as soon as possible ; when needed beyond two- weeks. a special request should be made. All student borrow- ers are limited to two . weeks, with renewal privileges, when the book is not needed by others. Books not needed during recess periods should be returned to the library, or arrange- ments made for their return during borrow- er’s absence, if wanted. ° Books needed by more than one person . belong on the reserve list. olm A TREATISE ON DISEASES OF THE NOSE AND THROAT IN TWO VOLUMES BY FRANCKE HUNTINGTON BOSWORTH, A.M., M.D. PROFESSOR OF DISEASES OF THE THROAT IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE, NEW YORK} CONSULTING PHYSICIAN TO THE O. D, P. DEPT, OF THE BELLEVUE HOSPITAL; FELLOW OF THE AMER- ICAN LARYNGOLOGICAL ASSOCIATION, OF THE AMERICAN CLIMATOLOGICAL ASSOCIATION, OF THE NEW YORK ACADEMY OF MEDICINE; MEMBER OF THE NEW YORK LARYNGOLOGICAL SOCIETY, OF THE MEDICAL SOCIETY OF THE COUNTY OF NEW YORK, ETC., ETC. Volume One DISEASES OF THE NOSE AND NASO-PHARYNX WITH 4 COLORED PLATES AND 182 WOOD-CUTS NEW YORK WILLIAM WOOD & COMPANY 56 & 58 LaFavETTE PLACE 1889 e CoprriaHt, 1889. By WILLIAM WOOD & COMPANY. PRESS OF THE PUBLISHERS! PRINTING COMPANY, 157-159 WILLIAM STREET, NEW YORK, PREFACE, THE following work was originally undertaken with the inten- tion of preparing a Second Edition of the.volume on “ Diseases of the Nose and Throat”: published by myself in 1881, but it soon became evident that the great advances made in the study of dis- eases of the upper air passages during the period which had elapsed since that work was issued, had rendered it necessary to rewrite practically the whole volume. I therefore determined to abandon the attempt to base the present work on my former one, and to write an entirely new treatise. Two chapters, however, of the earlier publication, with some changes and additions, I have re- tained, viz.: that on “ Mucous Membranes” and that on “ Taking Cold,” for while these subjects may possibly seem somewhat ele- mentary to the older practitioner, to the younger physician and to the medical student, I am confident they will prove of value. Aside from these two chapters, the work is entirely new and has been written without reference to the earlier volume. It has been my endeavor to present a full and complete treatise on the sub- jects covered by the title, and in carrying out this endeavor the work has grown on my hands in proportions beyond, perhaps, my original conception, and in place of a single volume which I origi- nally contemplated, I have been compelled to divide the work into two volumes. In the first volume, I have embraced, in the first section, a consideration of diseases of the nasal cavities proper, in the second section that of diseases of the naso-pharynx, while I have added a third section in which there is presented brief de- scriptions of all the various operations which have been resorted to for the removal of growths from the nasal passages or naso- iv PREFACE. pharynx, and which involve incision either of bone or the soft parts. The very large space devoted to a study of diseases of the nose, cannot, I think, subject me to criticism, when we remember the very intricate and highly important functions, which, as we have so clearly learned in the past decade, have their seat in the mucous membrane lining this cavity; and the very wide area of both phys- ical and reflex disturbances which are prone to follow the morbid conditions which are met with there. A chapter on asthma, in a treatise on nasal diseases, may possi- bly be considered somewhat out of place; its propriety, however, I am sure will be more generally recognized when the views which I have so long advocated receive fuller acceptance, as I am con- fident they will, that, in the very large majority of instances, an asthma is dependent primarily upon a diseased condition of the nasal mucous membrane. The separatiori of the nasal cavity from the naso-pharynx, from an anatomical, physiological, and pathological point of view, has been made in the present volume, more distinctly and more definitely, I think, than has been usually done in our text-books on diseases of the nose and throat. This is as it should be, and clears up much that has heretofore been vague and unsatisfactory in our classification of diseases of these regions. In the section on “ External Surgery” the description of the various surgical procedures which have been resorted to for gaining a wider access to the nasal cavity and the naso-pharynx, will, I hope, prove of value. While I have not deemed it necessary to enter into a fully detailed description of each operation, I have given a brief résumé of each procedure, thus enabling the reader to obtain a somewhat rapid, yet complete, survey of the resources at his command in dealing with the graver forms of neoplasms which are met with in these regions. As far as I am familiar with surgical literature, these various operations have not been heretofore grouped together in so full and complete a manner as in the present volume. PREFACE. - At the end of the volume there will be found a number of col- ored plates, illustrative of some of the operations described. These have in each instance been made from colored sketches of opera- tions on the cadaver. It has been my earnest effort to present the study of each dis- ease as fully and as comprehensively as possible; in most instances I have depended entirely on the descriptive text, in others I have introduced illustrative cases, as they seemed to add interest and clearness to the context; while in still further instances it has seemed to me that a better comprehension of the subject would be reached, by presenting a brief résumé of all the cases which have been recorded in medical literature. This latter plan has been followed in the consideration of most of those diseases which are comparatively rare, such as carcinoma and sarcoma of the nose and also of the naso-pharynx, nasal hydrorrheea, etc. The work is fully illustrated, but this I have had done design- edly. In many instances I have illustrated and described instru- ments which I do not consider of value. This has been done on the ground that there is oftentimes something of suggestion and even instruction in not only becoming familiar with the methods by which others attempt to carry out clinical indications, but even more in recognizing their faults. The atomization of medicated fluids for application to the upper air tract will always occupy a prominent place in our armamentarium. In the historical account of the development of the atomizer, therefore, I have introduced illustrations of the various devices out of which grew the perfect instrument of the present day. This may not*be of any practi- cal value, but I am sure it will prove of interest, and to many, instructive. In presenting personal views and opinions, I have desired to do so with all modesty, and yet with the positiveness of conviction. In differing with, or in criticising the views of others, I have en- deavored to do so with becoming diffidence. In making a com- plete treatise of the character of the present, it is impossible not to make use of the literary research and compilation of previous vi PREFACE. writers; this I have done in several instances, but in all cases it has been my desire and effort to give full credit therefor. The work has been done for the older practitioner as well as for the beginner and medical student, and from all I ask a kindly acceptance, to- gether with a full indulgence for such faults and errors as may be found in it, for while prepared by a specialist, and undoubtedly largely written from the specialist’s point of view, it has been my conscious and strenuous effort, throughout, to present such a thor- oughly candid and unbiassed study of the diseased conditions of the upper air tract, as may prove acceptable to the general practi- tioner. In closing, I desire to express my great obligations to my asso- ciate, Dr. E. B. Dench, for his most valuable assistance to me, not only in the literary research which the volume has required, but also in the preparation of the index, reading of proofs, and other labors incident upon carrying the work through press. F. H. B. 26 West 46th St. New York Ciry, October, 1889. TABLE OF CONTENTS. SECTION I. Diseases of the Nasal Passages. CHAPTER I. Methods of Examining the Upper Air Passages, The Laryngoscope, ‘ : a 5, a The Fixed Apparatus, . The Examination, Rhinoscopy, . The Rhinoscopic Tha ge CHAPTER II. Methods of eee the rae Air ce oe Means of Instru- ments, : ot ; Insufflations, Douches, Atomizers, Inhalations, CHAPTER III. Mucous Membranes, . Anatomy, : , ‘ A ‘ j i 4 Ay Physiology, ; Inflammation of Mucous Mienitiies, CHAPTER IV. Taking Cold, CHAPTER V. The Anatomy of the Nose, The External Nose, . The Nasal Fosse, The Accessory Sinuses, The Mucous Membrane, me : A zi é 3 The Turbinated Bodies, ‘ j ‘ ‘ 2 7 PAGE 3-27 5-10 10-13 13-15 15-25 25-27 28-46 28-31 31-34 34-43 43-46 47-56 48-50 50-51 51-56 57-68 69-85 69-70 70-74 74-78 78-81 81-84 Vili TABLE OF CONTENTS. CHAPTER VI. PAGE The Physiology of the Nose, . : . ; > 3 ‘ ; 85-98 The Sense of Smell, . ‘ ; ‘ F 4 j -85-87 The Function of the Nose in Phonwtion; . é ‘ . : 87-89 The Function of the Nose in Respiration, : : : 3: 89-98 CHAPTER VII. General Considerations Concerning Catarrhal Diseases, . : 99-104 CHAPTER VIII. Acute Rhinitis, . ‘ : : : 3 ‘ ; . . : 105-118 CHAPTER IX. Hypertrophic Rhinitis, . Bh et j , ‘ ‘i ‘i ‘i 119-153 CHAPTER X. Purulent Rhinitis of Children, . ; ‘ ‘ j ‘ we. 154-161 CHAPTER XI. Atrophic Rhinitis, i ! z ; ios : ‘ - - 162-179 CHAPTER XII. Croupous Rhinitis, . i ‘ 5 ‘ ; . , é ‘ 180-185 CHAPTER XIII. Nasal Reflexes, . : ; : : . ; : i : : 186-198 CHAPTER XIV. Hay Fever, or Vaso-Motor Rhinitis, : ; ‘ b. he ow 193-231 CHAPTER XV. Asthma, or Vaso-Motor Bronchitis, : é ‘ 5 5 - 232-257 CHAPTER XVI. Nasal Hydrorrheea,. 5 2 é . : : ‘ c 6 258-271 CHAPTER XVII. Anosmia, . 2 : ‘ ‘ ‘ ‘ ‘ ‘+ ‘ : 272-280 CHAPTER XVIII. Deformities of the Nasal Septum, . ‘ : - ‘ ‘ 281-309 Dislocation of the Columnar Cartilage, ; . . : ; 306-307 Perforation of the Septum, . ‘ ‘ : ‘ . . : 307-309 CHAPTER XIX. Epistaxis, . , : : ‘ . ; ; oe . : 310~320 CHAPTER XX. Foreign Bodies in the Nasal Passages, . : A : : : 321-325 TABLE OF CONTENTS. CHAPTER XXI. Rhinoliths, CHAPTER XXII. Parasites in the Nasal Cavities, . CHAPTER XXIII. Syphilis of the Nasal Passages, . The Primary Lesion, The Syphilitic Coryza or Buyihexnss The Mucous Patch, : The Superficial Ulcer, . The Gummy Tumor, The Deep Ulcer of eee srl Bony Necrosis; Treatment, s é CHAPTER XXIV. Congenital Syphilis of the Nasal Passages, CHAPTER XXV. Tuberculosis of the Nasal Passages, . CHAPTER XXVI. Lupus of the Nasal Passages, CHAPTER XXVII. Rhinoscleroma, CHAPTER XXVIII. Nasal Polypus, or Myxoma, CHAPTER XXIX. Fibroma of the Nasal Passages, ‘ ; é , CHAPTER XXX. Osteoma of the Nasal Passages, CHAPTER XXXI. Papilloma of the Nasal Passages, CHAPTER XXXII. Adenoma of the Nasal Passages, CHAPTER XXXIII. Cystoma of the Nasal Passages, CHAPTER XXXIV. Angioma of the Nasal Passages, ix PAGE 326-330 331-335 330-359 336-337 337-338 338-339 339-341 341-344 344-351 352-359 360-368 369-375 376-380 381-386 387-408 409-416 417-421 422-426 427-428 429-430 431-434 x TABLE OF CONTENTS. CHAPTER XXXV. Chondroma of the Nasal Passages, . : : : ‘ . CHAPTER XXXVI. Sarcoma of the Nasal Passages, CHAPTER XXXVII. Carcinoma of the Nasal Passages, CHAPTER XXXVIII. Diseases of the Accessory Sinuses of the Nose, Disease of the Antrum, Disease of the Ethmoidal Sinases, Disease of the Sphenoidal Sinuses, Disease of the Frontal Sinuses, . : ; Differential Diagnosis between Diseases of the Aesessary Cavities, . SECTION II. Diseases of the Naso-Pharynx. CHAPTER XXXIX. The Anatomy and Physiology of the Naso-Pharynx, The Anatomy of the Naso-Pharynx, . : The Physiology of the Naso-Pharynx, CHAPTER XL. Acute Naso-Pharyngitis, CHAPTER XLI. Naso-Pharyngeal Catarrh, . CHAPTER XLII. Hypertrophy of the Pharyngeal Tonsil, or Adenoid Growths of the Vault of the Pharynx, . ‘ ; CHAPTER XLIII. Fibroma of the Naso-Pharynx, . CHAPTER XLIV. Myxo-Fibroma of the Naso-Pharynx, CHAPTER XLV. Chondroma of the Naso-Pharynx, PAGE 435-436 437-452 453-464 465-498 465-479 479-485 486-492 492-496 496-498 501-507 501-506 506-507 508-514 515-539 539-569 570-587 588-594 595 TABLE OF CONTENTS. xi CHAPTER XLVI. PAGE Sarcoma of the Naso-Pharynx, . 3 : : ; . j ; 596-611 CHAPTER XLVII. Carcinoma of the Naso-Pharynx, ; : , . : ; . 612-616 SECTION III. External Surgery of the Nose. CHAPTER XLVIII. External Surgery of the Nose, . : e. 3 : : : 619-651 Manne’s Operation, . : ‘ ‘ : 5 ‘ ‘ : 621 Maisonneuve’s Operation, . ‘ : : : ‘ : 621 Nelaton’s Operation, . j : . : i ‘ : : 622 Botrel’s Operation, F ; : : : ‘ : ‘ 622-623 Richard’s Operation, . s j 4 ; 3 : ‘ i 623 Sédillot’s Operation, . ‘ , 3 : s ‘ , 623-624 Dezeanneau’s Operation, . 3 5 : ; . ; ‘ 624. Dieffenbach’s Operation, : poe 624-625 Lariche’s Operation, . ; ; 5 ; : : d : 625 Rouge’s Operation, . ' : : : : ‘ ; : 626 Palasciano’s Operation, ; : : ‘ ‘ ‘ : : 626-627 Boeckel’s Operation, . on 6m : : ; ; : 627-628 Ollier’s Operation, ‘ : ‘ . J ‘ z : ‘ 629-630 Lawrence’s Operation, . i i 630-631 Langenbeck’s Operation for Resection of the Nasal Bene: : 631-632 Linhart’s Operation, . ‘ ‘ ; ‘ ; ‘ : ; 632-633 Bruns’s Operation, ‘ . : , ; j : 633-634 Fournaux-Jordan’s Operation; 2 ‘ ‘é 3 ‘ ‘ ‘ 634-635 Huguier’s Operation, . : ; : : ; : ‘ ‘ 635-636 Cheever’s Operation, . ; : ; : ‘ ; § j 637-638 Cheever’s Double Operation, ‘ : : : 5 ‘ : 638-639 ° Waterman’s Operation, ; ‘ : : : : : t 639 Roux’s Operation, : . . ‘ 5 : : : . 639-641 Annandale’s Operation, ‘ 641 Langenbeck’s Operation for the “Temporary Resection of she Superior Maxilla, ; : 641-643 Billroth’s Operation for the Temporary Resta ei the oa perior Maxilla, . ‘ 2 : j . ‘ : 5 643-644 Boeckel’s Operation, . ‘ : ‘ F : i : 644 Demarquay's Operation, . , , ; ; i é , 644-645 Maisonneuve’s Operation, . ‘ : 3 ; ‘ j 3 645-647 Péan’s Operation, : : i : ‘ ; ; ‘ : 647-649 Bérard’s Operation, . : ‘ ‘ ; z : 3 : 649-650 Huguier’s Operation, . : : i‘ . ‘ . s : 650 Vallet’s Operation, , ; * 7 , é i ° i 650-651 LIST OF ILLUSTRATIONS. FIGURE PAGE 1. Throat Mirrors, Actual Size, 6 2. The Lennox-Browne Calcium Light, 7 3. Beseler’s Lime Light Laryngoscope, * 7 4. Reflecting Mirror, Mounted on Schreetter’s Head-band, 9 5. Reflecting Mirror, Mounted on Pomeroy’s Head-band, . ‘ 9 6. The Author’s Head-band and Mirror, . . : ; A é 10 7. Head Mirror Mounted on a Spectacle Frame, : ‘ Io 8. Tobold’s Laryngoscope Mounted on the German Buen oo . II g. The “Sass” Laryngeal Stand, with Globe Inhalers, Atomizing Tubes, and Laryngoscope, . : : 12 10. Mackenzie’s Light Condenser, Mouated upon a Ratoliet Move: ment Gas Fixture, ‘ 3 s ‘ 3 F zi “ a 13 11. Frinkel’s Nasal Speculum, : ; : : ; ; ; 3 15 12. Goodwillie’s Nasal Speculum, . ‘ - : ‘ : 5 : 15 13. Elsherg’s Nasal Speculum, ‘ ‘ : ‘ : : 16 14. The Author’s Self-retaining Nasal Speculum, roe, Size, . J 16 15. Jarvis’ Nasal Speculum, . : : ‘ 16 16. Method of Making an mesaindor at the shanna: Wises by Means of Sunlight, the Head of the Patient being in Position for the Inspection of the Inferior Meatus, . ; : ‘ : 17 17. Anterior Rhinoscopy, the Head of the Patient being in Position for the Inspection of the Middle Turbinated Body, j ‘ 18 18, Anterior Rhinoscopy, Position of the Head for Inspecting the Wall of the Pharynx through the Nasal Passages, . ; . 18 19. Turck’s Tongue Depressor, : : . : ; . ‘ 5 ‘IQ 20. Sass’s Tongue Depressor, ‘ ‘ i ‘ ‘ ‘ i ‘ 20 21. Goodwillie’s Folding Spatula, . é : ‘i - : ‘ Z 20 22, The Author’s Tongue Depressor, . ‘ : : ‘ , 2 21 23. Church’s Self-retaining Tongue Depressor, . 21 24. Method of Depressing the Tongue for peeing the Bisa and for Posterior Rhinoscopy, . : . . ‘ ; : 22 25. Method of Making a Posterior Rhinoscopic Examination, . : 23 26. White’s Self-retaining Palate Retractor, . : : 7 5 ‘i 25 say LIST OF ILLUSTRATIONS. FIGURE PAGE 27. The Posterior Nares, : ‘ : ‘ ‘ ‘ ; . ‘ 25 28. Rauchfuss’s Insufflator, . ; : : - "i ‘ 5 A 29 29. Lefferts’ Insufflator, . , ‘ 3 : : - és : : 29 30. Ely’s Powder Blower, : 2 é . : i ‘i , ‘ 29 31. Stoerck’s Insufflator, . ‘ : : : : i - 5 F 30 32. Post Nasal Syringe, . ‘ ‘ r 31 33. Post-Nasal Pipe, fitted to the Ordinasy inevineoa ee i F 31 34. Warner’s Post-Nasal Douche, . é : ; ‘ : 5 32 35. The Ordinary Form of the Nasal Bache, ‘ ‘ F i ‘ 32 36. Method of Using the Nasal Douche, . : ; : , ‘ 33 37. Dessar’s Nasal Cup, . : : : ‘ ‘ ‘ : 5 - 33 38. Sales-Giron’s Portable Atomizer, . ‘ ‘ ‘ i ; ‘ 35 39. Mathieu’s Néphogeéne, ; ‘ ; : ; : , 35 40. Bergson’s Apparatus with Foot Below : ‘ ‘ : : 5 36 41. Sass’s Spray Tube, . ; 36 42. Newmann’s Spray Tubes, Worked . as of the Double Bulbs, 37 43. The Richardson Double-bulb Hand Atomizer; ‘ : : 7 38 44. The Ordinary Hand-pump and Air Receiver, . ; ; ; ; 39 45. Air Pump Worked by Fly-wheel, .. , ‘ ; 3 ‘ : 40 46. The Hydro-pneumatic Pump, . : 41 47. The Ordinary Single-Bulb Hand-Ball Atomizer atte for Nasal Applications, é ‘ : : : : ; ‘ , : 42 48. Delano’s Atomizer, . f : 4 ‘ ss ‘ Z 3 42 49. Mackenzie’s Inhalator, : : i ; ‘ : : 3 3 43 50. Lewin’s Apparatus for Inhaling Nascent Muriate of Ammonia, . 44 51. Large Globe Inhaler, . ‘ ‘ ‘ : : , 5 5 45 52. Diagrammatic Section of Mucous Membrane, . 3 : ‘i . 48 53. Cartilages of the Nose seen in Profile, . . : i ‘ 69 54. Superficial Layer of the Muscles of the Nose, . : 70 55. Outer Wall of the Right Nasal Cavity seen from Within, the Boh Parts being Removed, : : : 72 56. Outer Wall of Left Nasal Cavity, the Inferior and “Middle Turbi- ‘ nated Bones having been Removed, . ‘ i ‘ : ; 56 57. Transverse Section through the Nasal Cavities and Maxillary Sinuses, Showing Irregularities of Development of the Latter, 75 58. Transverse Section through the Nasal Cavities and the Maxillary. Sinuses, Showing Irregularities in the Development of the Antrum, $ . 76 59. Abnormal Opening ve the Prone Staite sad the Orbit, ‘ 77 £0. Abnormal Opening between the Ethmoidal Cells and the Orbit, . 77 61. The Olfactory Cells in Man, 79 LIST OF ILLUSTRATIONS. FIGURE 62. 63. 64. 6s. 66. 67. 68. ‘69. 70. 71. 72. 73: 74. 75: 76. 77: 78. 79: 80. 81. 82. 83. 84. 8s. The Spheno-palatine Ganglion, seen on its Internal Surface, The Formation of the Spheno-palatine Ganglion, . : : Section of the Cavernous or Erectile Tissue of the Middle and Lower Turbinated Bones, Inflated and Dried, Microscopical Characters of Hypertrophic Rhinitis, . , Myxomatous Hyperplasia of the Nasal Mucosa, from the Anterior Termination of the Middle Turbinated Bone, : The Outer Wall of the Nasal Cavity, showing the Macsas 3 Mem- brane in a State of Hypertrophy over the Lower Turbinated Bone, The Outer Wall of the Nasal ent Lined with setae nceue Membrane, ; ‘ C4 ‘ ; , : : Transverse Section through the Nasal Cavities, showing the Mu- cous Membrane over the Lower and Middle Turbinated Bones in a State of Hypertrophy, . : ; ‘ ; Large Masses of Hypertrophied Membrane on the Posterior Ter- mination of Lower Turbinated Bones, More or Less Com- pletely Filling the Posterior Nares, The Author’s Chromic Acid Applicator, Meyrowitz’s Portable Galvano-Cautery Battery, Meyrowitz’s Storage Battery, : 3 : Galvano-Cautery Handle with Flat Eleetiae for Use upon the Turbinated Tissues, Nasal Electrodes, Jarvis’s Wire Snare Ecraseur, Sajous’s Snare, ‘ 7 Lateral View of Posterior eebeaiapti af the haem een of the Lower Turbinated Bone, with Jarvis’s Snare in Position for Section, : : Jarvis’s Transfixion Needles, . . oS Microscopical Appearances in Atrophic Rhinitis, : The Outer Wall of the Nasal Cavity in the Late Stage of Rivets Rhinitis, the Mucous Membrane, and also the Lower and Mid- dle Turbinated Bones, having Undergone the Atrophic Process, Horizontal Deviation of the Septum, probably the Result of a Fracture, F . . ‘ Horizontal Deviation of the Septum, : : : Dislocation between the Lower Border of the Septum and the Superior Maxilla, . Sigmoid Deflection of the Seca, probably the Reads: of a Fracture, XV PAGE 80 80. 83 133 135 136 137 137 138 145 146 147 148 148 150 I51 152 152 165 173 284 284 285 285, xvi LIST OF ILLUSTRATIONS. FIGURE 86. 87. 88. 89. 9°, gl. 92. 93: 94 95- 96. 97. 98. 99. 100. I0l. 102. 103. 104. 10S. 106. 107. 108. 109. 110. III. 112. 113. 114. 115. 116, 117. 118, Bulging of both Cartilaginous and Bony Portions of the Septum into the Right Nasal Cavity, ‘ Transverse Section of Deformity of the Septum, Transverse Section of Deformity of the Septum, Blandin’s Septal Punch, . : 5 ‘ ‘ és ‘ 3 . Steele’s Septal Punch, ‘ : é . ; Adams’s Forceps for Refracturing a Deflected Septum, . Adams’s Nasal Clamp, Adams’s Nasal Plugs, Jarvis’s Cutting Forceps, . . . : ‘ Burrs for the Removal of Septal Deformities, Curtis’s Nasal Trephines,. ° . Seiler’s Nasal Chisel and Gouges, The Author’s Nasal Saw, ; ‘i F 7 Dislocation of the Columnar Cspditeee of the Nose into the Right Nostril, ; 5 Perforation af the Cartilaginous Septum, 3 Microscopical Appearance of a Syphilitic Ulcer at the Muco- Cie neous Junction, ; Microscopical Appearance of Lupus, Microscopical Appearance of Rhinoscleroma, Microscopical Appearance of Nasal Polypus, . : ‘ Microscopical Appearance of a Nasal Polypus which has Under- gone Cystic Degeneration, . Nasal Polypi, ‘ ‘ é ; F Microscopical Appearance of Mises Chances to Myxo-Sar- coma, : ‘ ‘ The. Author’s Snare, . . * . The Galvano-Cautery Snare, Mackenzie’s Snare, . p . . . Wright’s Snare, McKay’s Forceps, : ; : Papilloma of the Nasal Mucous Membrane, Microscopical Appearance of Cavernous Angioma, ; 3 Microscopical Appearance of Adeno-Sarcoma of the Nasal Mucosa, Microscopical Appearance of Round-celled Sarcoma of Nasal Mu- cosa, : 5s ‘ 5 : ; é ; ‘ Microscopical Appearance of Scirrhus of the Nasal Mucosa, Transverse Section of the Maxillary Sinuses, showing the Roots of the Molar Teeth Projecting into the Cavities through the Floor, PAGE 286 290 290 299 299 300 300 300 301 302 302 302 303 307 309 340 378 384 389 390 393 449 459 467 LIST OF ILLUSTRATIONS. xvii FIGURE PAGE 119. Silver Drainage Tube for Antrum, . . a. 3 e 8 . 476 120. Anel’s Lachrymal Syringe for Use in Disease of the Antrum, : 477 121, The Glandular Structures at the Vault of the Pharynx, . j 5; 505 122, Glandular Structures of the Pharyngeal Vault seen in Antero- posterior Section. ‘ 506 123. Lymphatic Hyperplasia of the ee Nines: aati the Morbid Changes in Ordinary Naso-pharyngeal Catarrh, . ‘ 523 124. The Author's Porte Caustique for the Pharyngeal Vault, : ‘ 535 125. Electrode for the Naso-Pharynx, to be Manipulated through the Nasal Passages, . , - ‘ ‘ 3 ae te 537 126. Microscopical Appearance in Kasioid Disease of the Vault of the 127. 128. 129. 130. 131. 132. 133. 134. 135. 136. 137. 138. 139. 140. I4I. 142. 143. 144. 145. 146, 147. 148. Pharynx, ‘ i . ‘ ‘ , ‘ : * - 542 Face, illustrating the Facial Expression Chanitterietic of the Ex- istence of an Hypertrophied Pharyngeal Tonsil, . ‘ ‘ 551 The Author’s Electrode fitted with a Shield for Use in ‘tie 3 Pharyngeal Vault, F i : : 559 Straight Electrodes for the Application of the Givens: iistene to the Pharyngeal Tonsil through the Nasal Cavity, ‘ ; 559 Meyer’s Instruments for the Removal of Hypertrophic paced Tonsils, . ; . F . : : ; : ; 3 560 Léwenberg’s Forceps, é ; ‘ ‘ . F ‘ : ‘ 561 Curtis’s Forceps, é i é : ‘ ; ‘ ; é ; 561 Major’s Adenotome, . . ; 3 . 562 The Author’s Sharp Curette ee the Phagyaved! Vault, : ‘ ‘ 563 Hooper’s Instruments for the Removal of Hypertrophied Pharyn- geal Tonsils, . : ; ; : 565 ‘The Author’s Modification of ‘aus s ers er for the Re- moval of an Hypertrophied Pharyngeal Tonsil, 4 : 3 566 Microscopical Appearance of Fibroma of the Naso-Pharynx, ; 573 Microscopical Appearance of Myxo-Fibroma of the Naso-Pharynx, 590 Microscopical Appearance in Round-Celled Sarcoma of the Naso- Pharynx, : : : : : 5 ‘ ; ; : 607 Microscopical Appearance in Carcinoma of the Wacweisiie : 614 Lines of Bony Section in Nélaton’s Operation, : : : ‘ 622 Sédillot's Operation ; Lines of Bony Section, . : ; : ; 623 Dezeanneau’s Operation; Lines of Section of Hard Palate, . ‘ 624 Dieffenbach’s Operation; Line of Cutaneous Incision, . j : 624 Lariche’s Operation ; Lines of Cutaneous Incision, ; i ‘ 625 Line of External Incision in Palasciano’s Operation, . ‘i J 627 Line of Cutaneous Incision in Boeckel’s Operation, : ; : 627 Line of Bony Section in Boeckel’s Operation, : : 3 : 628 Xvili LIST OF ILLUSTRATIONS. FIGURE 149. 150. ISI. 152. 153. 154. 155. 156. 157. 158. 159. 160. 161. 162, 163. 164. 165. 166. 167. 168. 169. 170. 171. 172. 173: 174. 175. 176. 177. 178. 179. 180. 181. 182. Line of Cutaneous Incision in Ollier’s Operation, Line of Bony Section in Ollier’s Operation, Line of Cutaneous Incision in Lawrence's Operation, Line of Bony Section in Lawrence’s Operation, Line of Cutaneous Incision in Langenbeck’s Operation, Lines of Bony Incision in Langenbeck’s Operation, Lines of Cutaneous Incision in Langenbeck’s Later Operation, Lines of Cutaneous Incision in Bruns’s Operation, . Lines of Bony Section in Bruns’s Operation, . Line of Cutaneous Incision in Fournaux-Jordan’s Operation, Lines of Cutaneous Incision in Huguier’s Operation, Lines of Bony Section in Huguier’s Operation, Line of Cutaneous Incision in Cheever’s Operation, Lines of Bony Section in Cheever’s Operation, Lines of Cutaneous Incision in Cheever’s Double Operation, Lines of Bony Section in Cheever’s Double Operation, . Lines of Cutaneous Incision in Roux’s Operation, . Lines of Bony Section in Roux’s Operation, Line of Bony Section of Palate in Roux’s Operation, Lines of Cutaneous Incision in Langenbeck’s Operation, Lines of Bony Section in Langenbeck’s Operation Lines of Cutaneous Incision in Billroth’s Operation, Lines of Bony Section in Billroth’s Operation, Lines of Cutaneous Incision in Demarquay’s Operation, Lines of Bony Section in Demarquay’s Operation, . Line of Bony Section in Maisonneuve’s Operation, Lines of Bony Section in Maisonneuve’s Operation, Line of Cutaneous Incision in Péan’s Operation, Line of Bony Section in Péan’s Operation, Line of Bony Section in Péan’s Operation, Line of Cutaneous Incision in Bérard’s Operation, Lines of Bony Section in Bérard’s Operation, Lines of Bony Section in Huguier’s Operation, Lines of Bony Section in Vallet’s Operation, . PAGE 629 629 630 630 631 ° 631 632 633 633 634 635 636 637 637 638 638 639 640 640 642 642 643 644 645 645 646 646 648 648 648 649 649 650 651 SEcTION I. Diseases oF THE Nasa Passaces. DISEASES OF THE NASAL PASSAGES. CHAPTER I. METHODS OF EXAMINING THE UPPER AIR PASSAGES. THE essential physiological process by which the human voice is produced in the larynx, its pitch regulated, and its volume and other qualities governed, was a source of speculation even in the earliest days of medicine, and hence the devising of some method by which the mechanism and movements of the larynx might be inspected during life, exercised the ingenuity of many and able in- vestigators, such as Bozzini, Babington, Bennati, Avery and others, who devised special appliances of various forms for the accomplish- ing of this purpose. None of these devices proved successful, how- ever, until, among others, Manuel Garcia, a distinguished teacher of vocal music in London, interested himself in the subject. He fully succeeded in obtaining an ocular view of his own larynx and thereby in studying the special function of the vocal cords in pho- nation, the results of which he presented before the Royal Society of London in a paper entitled “ Physiological Observations on the Human Voice.” * - Garcia’s method was exceedingly simple, and consisted in hold- ing an ordinary dental mirror, inclined at a proper angle, well back in the fauces in such a manner that it should receive the direct rays of sunlight, while, at the same time, the visual image was re- flected back in the same direction and perceived by Garcia in a hand-mirror held before his eyes. Garcia's observations were pub- lished merely as a contribution to vocal physiology. Tiirck, of Vienna, however, soon after, becoming acquainted with Garcia’s experiment, conceived the idea that this method might possess a certain value in the recognition of diseased conditions of the larynx. Failing, however, to improve on Garcia’s simple manipulation, Ttirck * Proc. Royal Soc. London, Vol. VII., No. 13, 1855. 4 DISEASES OF THE NASAL PASSAGES. accomplished no encouraging results. Czermak, of Pesth, however, took up the matter where Tiirck left off, and improving on his methods; suceeded in demonstrating conclusively that this device might be made to render the greatest possible service to medical science, both as a means of diagnosis and as suggesting improved methods of treatment of diseases of the upper air passages. Czermak’s success was due entirely to the fact that, discarding sun- light, he resorted to the use of artificial light, which was managed after the manner already suggested by Helmholtz and perfected by Reute. It is interesting in this connection to notice what a fortunate train of events led up to the perfected laryngoscope, and how sim- ple the development of it became. At this time, the subject of ex- amining the interior of the eye had, for a number of years, been a subject of study by enthusiastic workers, and became really prac- ticable only when Helmholtz first devised his simple apparatus for illuminating the fundus of the eye, consisting of polished plates of glass, by means of which rays of light were projected upon the retina, the arrangement of which need not be entered upon here, but in which the principle was observed that the illuminating and the visual rays must be absolutely in the same line. Soon after this, Reute substituted for Helmholtz’s plates the concave reflecting mirror with the perforation in the centre, which forms the principal feature of the ophthalmoscope. Czermak, substituting artificial light for sunlight, and making use of Reute’s concave mirror, suc- ceeded in rendering practicable this method of examining the upper air passages, and is undoubtedly, therefore, entitled to all credit in having introduced an instrument which has proved of such incal- culable value in the management of diseases of this region, thus giving birth really to a new branch of medicine, whose great service in the diagnosis and successful treatment of hitherto unrecogniza- ble and incurable diseases, no one at the present day will question. Garcia’s and subsequently Czermak’s experiments were largely di- rected to the investigation of the larynx. Hence, the instrument by which the air passages were examined was called the laryngo- scope, and the investigation of those diseases which became a sub- ject of study by means of the laryngoscope, was termed laryngology. This has always seemed to me a somewhat unfortunate designation, in that it rather narrowed the field of study, and gave a somewhat undue importance to the larynx; for, very soon after laryngoscopy became practicable, the facility with which the nose and naso-phar- ynx might be inspected by the same means was recognized, and while these regions were studied with a certain amount of lukewarm interest, the larynx was studied with a degree of enthusiasm which METHODS OF EXAMINATION. 5 resulted in a too great refinement of classification, together with an exaggeration of the clinical significance of what were oftentimes trivial departures from the normal standard. This tendency, I think, has undoubtedly hampered us very much in our study of diseases of the upper air passages, and the proper recognition of the devel- opment of morbid conditions, especially of a catarrhal nature. Much of this limitation, however, has disappeared at the present day, although undoubtedly much still remains. In the following pages the view will be taken that many forms of inflammatory action in the larynx are really secondary to a diseased condition in the nose or naso-pharynx, and therefore a through investigation of these passages is of quite as much, if not greater importance than an examination of the larynx, and hence that a familiarity by prac- tice with the nice manipulations, by means of which the nose and naso-pharynx are examined, is to be sought as of greater impor- tance even than an examination of the larynx, especially in that rhinoscopy requires a much nicer training, both of the eye and hand, than laryngoscopy. In other words, the practice of rhinoscopy is specially urged upon beginners as not only of more importance than laryngoscopy, but as requiring greater manipulative skill, and a better trained eye. : THE LARYNGOSCOPE. This term is generally used to designate the special illuminating apparatus by which the upper air passages are examined, and of course applies equally to rhinoscopy and laryngoscopy.. The es- sential features in the art of examining the upper air passages con- sist in projecting a powerful light through the anterior nares for the practice of so-called anterior rhinoscopy, or into the open mouth for the inspection of the pharynx, or so-called pharyngos- copy. In addition to this, as in laryngoscopy and posterior rhinos- copy, small mirrors are introduced into the fauces, by means of which the illuminating rays are deflected to those parts which are without the line of direct vision, while at the same time visual rays are re-conducted from the illuminated parts back to the retina in the same line as the illuminating rays. The essential parts of the laryngoscopic apparatus then are: 1. The laryngoscopic or rhinoscopic mirror. 2. The source of illu- mination, or the light. 3. The concave reflecting mirror. The Throat Mirror —The laryngeal mirror is asmall round mir- ror encased in a German-silver frame, and attached by its rim toa slender wire stem at varying angles, the whole measuring from six to seven inches in length. They are made in sizes from three- 6 DISEASES OF THE NASAL PASSAGES. eighths of an inch to one inch in diameter, and are numbered from o to 5, as shown in Fig. 1, actual size, each number increasing one- eighth of an inch in diameter from No.0 upwards. They were for- merly made of various shapes, such as oval, square, oblong, etc., but the round mirror has been found best adapted for all purposes. The best mirrors are made of very thin glass and with a narrow rim such as will afford the largest reflecting surface to the smallest bulk, the stem being sufficiently stout to admit of the application of considerable force without bending. The mirror is attached to its stem at varying angles, although usually at about 135° for laryn- goscopy and at about 105° for rhinoscopy. Many attempts have been made to attach the mirror to the stem by an adjustable hinge- joint, without success, however. The Light——The illumination may be derived from the sun, the oxygen-hydrogen light, a gas-jet, or an ordinary coal-oil lamp. If gas is used, the Argand burner gives undoubtedly the better and SEEASETHR EARS co! _WiFIFORD. Fic. 1.—Throat Mirrors, Actual Size, from No. o, % inch in diam., to No. 5, 1 inch in diam. steadier light, although ordinarily a coal-oil lamp is quite satis- factory in giving a whiter and more intense light than the usual city gas supply, and of these undoubtedly the best is one mounted either with the Duplex or Rochester burner. Sajous* states that the whiteness of this light may be increased by dropping a small piece of camphor into the oil, a suggestion which I have verified. The direct rays of the sun afford by far the best source of illumina- tion, and should be used where available in all cases, especially in the first examination of a case, in that it gives a light unequalled in intensity and whiteness by any artificial illuminator that we have. Unfortunately this is not available at all times. Hence, any one devoting his attention largely to this branch of medicine should make use of the oxy-hydrogen light, in that it is only by those powerful illuminators that the parts are brought fully under that nicer inspection which enables us to make the clearest and most thorough diagnosis. Lennox Browne? was, I believe, the first t** Diseases of the Nose and Throat,” Phila., 1886, p. 7. 2‘ The Throat and its Diseases,” Second ed., London, 1887, p. 4o. WETHODS OF EXAMINATION. a to devise an apparatus of this kind suitable for office work. This is shown in Fig. 2. It is, however, I think, somewhat unnecessarily Hil -G.Wood it UP) ennappioe. cE Fic. 2.—The Lennox Browne Calcium Light. Z, The lime candle; S, two concentric tubes through which the gases are directed upon the candle, the inner one connected with the tube at 7 carrying oxygen, the outer one connected with the tube at 7 carrying either hydrogen or common street gas; PC, a perpendicu- lar cylinder of metal inclosing the light; RZ, a horizontal cylinder containing the lenses; 4C, a glass cell containing water, placed in front of the lenses to arrest the heat rays, The whole apparatus is mounted on a split socket, DS, which admits of free vertical motion; and this is carried by the metal arm, GS. complicated. I have, therefore, had constructed for my own use an instrument in which the water-chamber is abandoned as un- necessary ,and other portions of the apparatus much simplified. Fic. 3.—Beseler’s Lime Light Laryngoscope. A, hood for cutting off the rays from the observer's eye; B, oxygen supply tube; C, lime candle. The main features of this device are embodied in the instrument shown in Fig. 3. It is light, movable, easily manipulated, and 8 DISEASES OF THE NASAL PASSAGES. serves a most excellent purpose, and moreover, is much cheaper than Browne's device. It is manufactured by Charles Beseler, of this city. The expense of the oxy-hydrogen light is about thirty- five to forty cents an hour, burning continuously. It will be understood that in this device ordinary street gas is substituted for hydrogen and seems to serve fully as good a purpose. A very ingenious and exceedingly powerful light has recently been intro- duced, known as the Wellsbach light, which consists of a hood, as it were, composed of a patented material which, when suspended over a gas-jet which has been converted into a Bunsen burner, is rendered incandescent. This light where available answers a most excellent purpose in examining the upper air passages, although, of course, it is not as powerful as the lime light or the rays of the sun. Sajous* speaks very highly of the so-called albo-carbon light which consists of a metal globe containing a material called albo-carbon, located in such a way that it is subjected to the heat of the flame, while at the same time the gas passes through it before combus- tion. This, undoubtedly gives a very brilliant white light, but this is due probably entirely to the fact that the gas becomes so far heated before it reaches the burner as to insure the complete com- bustion of its carbon, although the claim is made that it receives certain gases in passing through this material in the metal chamber which add to the intensity of the flame. The incandescent electric light offers no advantages over the ordinary gas jet or coal-oil lamp. Those various devices by which a small incandescent light is attached to a throat mirror, modelled after Trouve’s polyscope, I think are to be regarded as mere playthings and of no practical value, in that a much more powerful light can be thrown into the throat or nose than can be introduced bodily. The same should be said also of the incandescent light attached to the head-band. The Reflecting Mirror—tThe really important feature of every laryngoscopic apparatus is the concave reflecting mirror of Reute, in that by means of this device the rays of light are so far con- verged as to thoroughly illuminate a part, even if the source of the light is not particularly intense, and furthermore this device enables us to manipulate and direct the illuminating rays at our conveni- ence. Whether we examine directly, as through the anterior nares, or whether we deflect the rays by the mirror into the fauces, it is absolutely necessary that this concave mirror be perforated in the centre, in order that the illuminating rays and visual rays shall be exactly in the same line, as it is easy to understand, and does not require any elaborate demonstration to show, that we thus obtain * Loc. cit., p. 5. METHODS OF EXAMINATION. 9 the best inspection of the parts. This mirror may be attached to a simple head-band carried on the forehead, or it may be attached to a fixed apparatus. Fig. 4 represents Schroetter’s head band. A stout band passes around the head and is fastened with a buckle. In front there is attached a thick pad which lies against the fore- Fic. 4.—Reflecting Mirror Mounted on Schroetter's Head-band. head, and two smaller pads below, which rest upon the bridge of the nose. From the metal plate to which the pads are attached, there projects in front a split socket, regulated by a screw, which receives a ball attached to the reflecting mirror. In this manner it is intended that the mirror shall be held in any position, or turned in any direction in front of the eye. A simpler affair than this is ‘what is known as the Pomeroy head-band, shown in Fig. 5, con- structed on much the same principle, but simpler and lighter, doing away with the nose-rest. In both these head-mirrors, the knob which is received into the split socket of the head-band, projects from the back of the mirror-frame; the result is that the lateral Fic. 5.—Reflecting Mirror Mounted on Pomeroy’s Head Band, motion of the mirror is notably restricted. Furthermore, it has been the custom to make use of mirrors of large diameter, even as great as five inches. The weight of a mirror of this size is objectionable, in that a prolonged examination thus becomes wearisome and even painful. There is no great advantage of illumination gained by a 10 DISEASES OF THE NASAL PASSAGES. large-sized reflector. 1, therefore, much prefer a smaller-sized mir- ror, as possessing all the advantages and none of the disadvantages of the larger ones. Fig. 6 shows the writer’s head-mirror which is two and a half inches in diame- ter, with the knob attached to the periphery of the frame, thus giving an absolutely unrestricted movement to the mirror, en- abling the wearer to turn it free- ly in any direction. In addition to this, the split socket is only of sufficient size to receive the knob, while the plate to which the socket is attached is but one and a half inches long. These head-mirrors are usu- ally attached to the head by an elastic band, which is always objectionable. In the writer’s head-mirror, the band is made of half-inch alpaca braid, which is worn with much more com- fort and possesses sufficient elasticity to maintain the in- strument firmly in place. In addition to this, the whole affair is perfectly flat and is (Mil carried easily in the vest pocket. A method of arrang- ff ing the head mirror much in vogue among our English friends is by means of a spec- tacle-frame, shown in Fig. 7. This is a somewhat cumber- some affair, and, moreover, the field of vision is in no small degree restricted in that the mir- ror is held at so great a distance from the eye. = Fic. 6.—The Author's Head Band and Mirror. Fic. 7,—Head Mirror Mounted on a Spectacle Frame. THE FIXED APPARATUS. In the early days of laryngoscopy the idea seems to have pre- vailed that this art could only be practised by means of a somewhat elaborate apparatus. This idea, I think, had its impetus largely in the introduction of Tobold’s' instrument, which seems to be the ** Laryngoskopie und Kehlkopf-Krankheiten,” Dritte Auflage. Berlin, 1874, p. 19. METHODS OF EXAMINATION. II pattern on which most of the laryngoscopes which came later were constructed. This instrument (Fig. 8) consisted of a metal bonnet fitting over a lamp or gas jet, from which projected a cylinder about seven inches in length, containing three double convex lenses, two of which were placed at the proximal end of the cylinder, their faces being in contact, while a larger lens was inserted in the distal end of the cylinder. This apparatus was attached to an upright support from which sprang a jointed arm carrying at its distal ex- tremity the concave reflecting mirror. I have never been able to discover what optical principle was involved in this arrangement of the lenses. Tobold’s idea seemed to be that the emerging rays be- REYNDERS Fic. 8.—Tobold’s Laryngoscope Mounted on the German Student Lamp. came parallel and were subsequently converged by the reflecting mirror. Practically, I do not think this occurs. The only effect of the lenses in the laryngoscope is, that the light thrown into the parts which it is desired to illuminate, assumes the form of a rounded disc, and does not reflect the shape of the flame. The illumination, however, is not increased, and the practical advantage of any laryn- goscope cannot be shown, other than as affording a somewhat con- venient method of office work. In other words, a simple head-band on the forehead, and a good strong source of light, afford us in every respect as good a method of practising laryngoscopy, as the most elaborate apparatus. Dr. Sass, of New York, modified the Tobold’s laryngoscope in presenting an instrument, shown in Fig. 9, of far more elaborate construction, in which the metal hood was \ 12 DISEASES OF THE NASAL PASSAGES. largely increased in size, the light completely shut in, while the cylinder containing the lenses was also much larger. He further- more inserted two plaho-convex, in place of Tobold’s three double convex lenses, one at the distal, and one at the proximal ex- tremity of the cylinder. The illustration further shows the heavy standard which Sass devised for carrying not only the laryngoscope, but also the glass inhalers known under his name. In general, however, his larynscope does not differ in any of its essential fea- Fic, 9.—The ‘' Sass’ Laryngeal Stand, with Globe Inhalers, Atomizing Tubes, and Laryngoscope. tures from Tobold’s. It marked, however, a period in the develop- ment of a tendency toward most luxurious and: expensive fittings for a throat specialist’s office, in that the mere cost of an elaborate Sass laryngoscope, in connection with the pumps and receivers for compressed air, involved an outlay which but few were enabled to meet. A much simpler apparatus is Mackenzie’s light condenser, shown in Fig. 10, which consists of an upright metal cylinder of about three inches in diameter, in the side of which is a fenestra, into which is METHODS OF EXAMINATION. 13 fitted a plano-convex lens, two and a half inches in diameter and comprising about one-third of a sphere. This is so constructed as to be easily fitted over a coal-oil lamp or an ordinary gas jet. It will be. observed that in all these laryn- ; goscopes there is an evident design to shut in, as far as possible, all the rays of light ex- | cept those which emerge from the lenses, the idea being that these examinations should be iB Me : i iy 4 ; i a : ax ae w conducted in a darkened YS room. This is by no means essential, although, where ar- tificial light is used, it is de- sirable that daylight should be excluded to a certain ex- tent, but that a rhinoscopic examination demands that the operating room should as be thoroughly darkened is Fic, race Light Condenser Mounted upon a quite a mistake. As before atchet Movement Gas-Fixture. suggested, I regard the use of an elaborate larynoscopic apparatus as by no means necessary,. in that the examinations can be thoroughly well made simply by means of a head-mirror and a good light. THE EXAMINATION. By far the best source of illumination is sunlight. These rays are utilized by using the small device shown in Fig. 16 which con- sists of a plane mirror, about four inches in diameter, which is mounted on an upright support, to which it is attached by a uni- versal joint. This may be placed in a window, exposed to the sun, and turned in such a direction that the rays of the sun shall be de- flected upon the concave reflecting mirror of a fixed apparatus, or 14 DISEASES OF THE NASAL PASSAGES. in such a direction as that they will fall upon the forehead-mirror of the operator, as shown in the same illustration. In making use of sunlight, the unpleasant effect of the rays striking directly upon the eye, is easily avoided by placing the heliostat a few feet above the right shoulder of the patient being examined, and in such a manner that the rays shall fall at about an angle of 45° upon the mirror. In the absence of sunlight, a very satisfactory examination can be made by the aid of an ordinary coal-oil lamp or gas jet. In making the examination, the lamp is placed at the right hand of the patient, and at about the elevation of his shoulder, while the operator, sitting in front of him, arranges his head-mirror in such a way that the face of the patient is plainly seen through the per- foration, when the mirror is to be turned in such a direction as that the part illuminated is brought under direct vision, without any effort of the eye. In making an examination with Sass’s or Tobold’s laryngoscope, the patient is placed in such a manner that the laryngoscope is on his right, and at about the elevation of the face, when the reflect- ing mirror, supported by its flexible bar, is brought into such a position as to fully intercept the illuminating rays as they emerge from the laryngoscope, and to deflect them upon the face of the patient. In using Mackenzie’s light condenser, the patient is placed in much the same way, while the condenser is so arranged that the rays of light fall upon the head mirror of the operator. A very convenient method of mounting this, is by the ratchet-movement gas-fixture, shown in Fig. 10, whereby the lenses can be easily ad- justed to'the level of the mirror on the forehead of the operator. In using this instrument, one’s movements, are somewhat hampered, in that the head with the mirror attached must be held in one posi- tion, which is necessarily somewhat wearisome, whereas with the unhooded lamp or gas jet, the rays can be easily intercepted in what- ever position, or at whatever level the head of the operator may be. After all, any method of examination is largely a matter of prefer- encé on the part of the operator. There is no great advantage in any, and certainly no great advantage in an elaborate apparatus. If one knows just what one wishes to accomplish, the procedure becomes the simpler as the apparatus is the less complicated. I think, however, while there is a certain amount of convenience in making use of the fixed light, as in the Tobold and Sass laryn- goscopes, one should always become thoroughly accustomed to work with the simple head-mirror and ordinary light, in that thus he is not dependent upon elaborate office-fixtures, but can make METHODS OF EXAMINATION. 15 his examination in the sick-room, or under whatever circumstances he may be called upon to do so. A special operating chair is recommended by many authorities as not only adding to the convenience of a laryngoscopic examina- tion, but more particularly as aiding in the performance of the minor operations upon the throat and nose. I have always accus- tomed myself to the use of an ordinary straight-back chair in my own office work, and believe this method is much to be preferred, in that it better enables the surgeon, in operating outside his office, to adapt himself to improvised conveniences. RHINOSCOPY. The nasal cavity is examined and diseased conditions recognized by illumination and direct inspection through the nostrils, called anterior rhinoscopy, and also by placing mirrors in the fauces in such a manner that the rays of light are reflected through the pos- terior nares, while at the same time the illuminated parts are seen reflected in thé same mirror, and conditions of health or disease recognized. This latter is designated as posterior rhinoscopy. Anterwr Rhinoscopy.—This examination is made by dilating the flexible portions of the nostrils by means of a suitable spec- Fic, 11.—Frankel’s Nasal Speculum. Fic. 12,—Goodwillie’s Nasal Speculum. ulum, and illuminating the cavity by means of light reflected from the concave mirror, so placed that the focus of illumination may fall as nearly as possible upon the part to be examined. A number of instruments have been devised for dilating the nostril for this inspection. In Fig. 11 is shown Frankel’s instrument, composed of two blades regulated by a set screw. It may be in- serted in both nostrils, or in one, at pleasure, and serves to open the parts with considerable force. It is only partially self-retaining, however. Goodwillie’s speculum, shown in Fig. 12, is a much sim- pler device, whose action is evident from the cut. Its third blade, however, it seems to me, accomplishes no good purpose. Elsberg has modified Delaborde’s tracheal dilator, by inserting a set screw 16 DISEASES OF THE NASAL PASSAGES. to hold it open, as shown in Fig. 13, thus adapting it for use as a nasal speculum. This is an instrument of undoubted value in cases where the parts are rigid, and require to be opened with consider- able force. The objection to this speculum is that it occupies one Fic. 13.—Elsberg’s Nasal Speculum. hand in its manipulation. The little device shown in Fig. 14, is an instrument devised by the writer, in which the blades are placed ‘at a right angle to the spring, and is so constructed that the instru- ment is thoroughly self-retaining, and holds the nostril open excel- lently well, while at the same time both hands are left free for other Fic. 14.—The Author's Self-retaining Nasal Speculum, actual size. manipulations. When properly constructed, this instrument has served a better purpose in my own hands than any of those men- tioned. On much the same principle is the convenient little in- strument devised’ by' Jarvis, Shown in Fig. 15, In making an examination of the parts, the patient is placed Fic, 15,—Jarvis’ Nasal Speculum. with his face directly on a level with that of the operator, when, the speculum being inserted, the bridge of the nose is grasped firmly between the index and second finger, while, at the same time, the tip of the patient’s nose is tilted up by the thumb, with a consider- METHODS OF EXAMINATION. 17 able degree of force, as shown in Fig. 16, in order that the light from the head-mirror may be thrown into, and along the inferior meatus. The patient’s head, now, is to be turned very slightly, first to one side and then to the other, enabling the operator to successively inspect the lower portion of the septum, and the face of the lower turbinated body. After these have been thoroughly inspected, the head should be thrown backward, as seen in Fig. 17, until the lower border of the middle turbinated body is brought into view, when, by the same lateral motion of the patient’s head, ‘the face of this body, and that portion of the septum opposite Fic. 16.—Method of Making an Examination of the Anterior Nares by Means of Sunlight, the Head of the Patient being in Position for the Inspection of the Inferior Meatus. is brought successively into view. This backward motion being continued, there is brought under inspection the main portion of the middle turbinated body, and finally its anterior termination, and the vestibule of the nose. This inspection having been made as thoroughly as possible, a ten or twenty per cent solution of cocaine should be thrown in, and sufficient time allowed to elapse for the tissues to undergo thorough contraction, and the blood-vessels to become completely emptied, after which the same process should be gone through a second time. In this manner anterior rhinoscopy becomes of far greater importance even than posterior rhinoscopy, in that by this means the whole of the nasal passages may be brought under examination, from the nostrils to the posterior nares, 2 18 DISEASES OF THE NASAL PASSAGES. and after the membrane has been contracted by cocaine, a part of the glandular structure of the upper pharynx even can be inspected Fic. 17.—Anterior Rhinoscopy, the Head of the Patient being in Position for the Inspection of the Middle Turbinated Body. on one or on both sides. By this means, information is obtained as regards the existence, or degree of inflammatory action in the nasal mucous membrane covering the turbinated bones, the extent of hyperemia, the existence of deformities or deflections of the Fic, 18.—Anterior Rhinoscopy, Position of the Head for Inspecting the Wall of the Pharynx, through the Nasal Passages. septum, the presence of polypi or other tumors, the character of thé secretions of the part, whether mucus or pus, and the existence METHODS OF EXAMINATION. 19 of ulceration, necrosis, etc. In looking directly down the nasal passages, the view of the lower turbinated body is very much fore- shortened, but where the cavity has been dilated with cocaine, as before stated, in many cases it is quite easy to recognize the pos- terior wall of the pharynx, as an elongated, triangular patch, pre- senting a lighter color than that of the turbinated bodies, and moreover the light, falling directly upon it from the mirror, causes it to stand forth, as it were, a bright, glistening patch in the back- ground. It is always easy to ascertain whether the pharynx is seen by this examination, by directing the patient to swallow, or better still, simply to enunciate the letter K, by which the levator palati muscle is brought into vigorous contraction, and thereby swings across the lower and outer portion of the posterior nares, the movement being easily and immediately recognized. The position of the head necessary for this inspection is shown in Fig. 18. Another method of examining the nasal cavities consists in dilating each nostril by means of a speculum, after which the illu- minating rays are projected into one cavity and against the septum, when the other cav- ity is to be inspected. It will be found that the septum is so thoroughly translucent that one of the nasal cavities will be fully illu- minated by rays of light projected through it. The parts seen in this manner present quite a different picture from that shown by the direct illuminating rays, andinformation eee will often be afforded by this method, not easily obtained by the ordinary procedure, in that the light is pro- jected more directly into the recesses beneath the turbinated bones, and hence its prominences and variations from the normal are more easily recognized. In addition to this, transmitted light brings out in a striking manner the irregularities of contour in the septum itself. Posterior Rhinoscopy.—This examination is somewhat more diffi- cult of accomplishment than that through the anterior nares, and re- quires therefore a nicer manipulative skill and dexterity. In order that these parts may be brought into view, it is necessary to so place a mirror in the pharynx as that light may be thrown up into the pos- terior nares, while, at the same time, the palate remains completely relaxed, and the tongue is prevented from protruding itself into the line of vision. Occasionally a patient is met with who will depress y¢ 20 DISEASES.OF THE NASAL PASSAGES. his own tongue in so satisfactory a manner, as to tolerate the exam- ination without the aid of instruments. Ordinarily, however, it is necessary to press the tongue down by means of the spatula. In Fig. 19 is shown Tiirck’s tongue-depressor, a somewhat elaborate and Fic. 20,.—Sass’ Tongue Depressor. expensive instrument, which is of value, undoubtedly, where the pa- tient can manipulate the instrument himself. It is usually, however, better for the operator to manage the spatula, in which case this instrument is, I think, somewhat awkward. The Sass spatula (Fig. 20) is also, I think, open to the same objection. Some form of the folding spatula, such as is shown in Fig. 21, is a very convenient instrument, and can also be carried in the pocket. Depressing the tongue by means of the spatula would seem to be one of the simplest of manipulations, and yet, where awkwardly done, the fauces may be so far irritated as to render the examina- Fic. 2t.—Goodwillie’s Folding Spatula. tion entirely impossible; whereas, if properly done, the examina- tion may be made even in cases of exceedingly irritable throat. It should be borne in mind that if the tongue is pressed directly down into the floor of the mouth, its root is pressed backward into the METHODS OF EXAMINATION. 21 fauces, which in the majority of cases will cause retching or gag- ging on the part of the patient. On the other hand, if the tongue is grasped by a spatula in such a way as to press it forward, it can be entirely controlled without excit- ing any involuntary movements. As best accomplishing this purpose I have had constructed the spatula shown in Fig. 22. The blade is composed of a thin plate of metal three and a half inches long and one inch wide, which tapers toward the handle, which is three inches in length and to which it is attached at arightangle. The blade is fenes- trated at its distal extremity to per- mit of an arching of the tongue into \ it by which the organ iS more firmly Fic. 22.—The Author's Tongue Depressor. grasped, and is slightly curved. A self-retaining tongue depressor is usually not well tolerated by the patient; where feasible, how- ever, the advantage of this device is quite obvious. Church’s instrument, shown in Fig. 23, is perhaps the best of these. In introducing the tongue depressor, its beak should always be carried beyond the arch of the tongue, that is beyond the high- est point to which the tongue is visible; otherwise, in pressing it downward, its an- terior end will be de- pressed, while its cen- tre will arch up and interfere with the in- spection. Further- { more, the beak of the SSspatula should be carried just far enough to cover the arch of the tongue, and no farther; otherwise, its pres- sure on the sensitive parts near the base of the tongue will be liable to excite retching. The spatula should-be held between the thumb and the forefinger, the thumb pressing against its angle, while the second finger passes under the chin of the patient. In this man- Fic. 23.—Church’s Self-retaining Tongue Depressor. 22 DISEASES OF THE NASAL PASSAGES, ner a grasp is maintained of the lower jaw, and control of the movements of the head secured. Then the tongue should be pressed, not downward, but downward and forward, by a rotary movement of the spatula, the beak of the instrument being made to revolve in the arc of a circle which has its centre in the teeth of the lower jaw. If this movement is made with a slow but firm pressure, the whole of the lower pharynx will be brought into open view, while at the same time the palate remains pendulous and re- laxed. If retching occurs during this manipulation, the attempt 9 Fic. 24.—Method of Depressing the Tongue for Examing the Pharynx and for Posterior Rhinoscopy. should always be abandoned for the time, and a few moments of rest given. The position of the hand and the spatula is well shown in Fig. 24. The tongue being depressed, and the palate seen to be relaxed, a rhinoscopic mirror should now be selected, the size of which should be determined upon by the space seen to exist between the base of the tongue and the border of the palate. The largest mir- ror should be selected which can be introduced without touching the parts, in that the parts to be brought under inspection, depend entirely for their illumination on the amount of light reflected from the rhinoscopic mirror, and, of course, the larger the mirror the better the illumination. The rhinoscopic mirror, as before noted, METHODS OF EXAMINATION. 23 is attached to its stem at an angle of about 105°. This should be held lightly in the right hand (see Fig. 25), and passed backward somewhat edgewise, in order that it may pass through the niche be- tween the uvula and right pillar of the fauces, in such a manner that it may not touch the parts, there not being, as a rule, suffi- Fic. 25.—Method of Making a Posterior Rhinoscopic Examination. cient room for it to pass under the uvula. After it has reached the pharyngeal space behind the palate, by slightly rotating the handle from right to left between the fingers, the reflecting surface should be brought around so as to face the operator, and the mirror carried upward until its upper border is slightly hidden by the soft palate. 24. DISEASES OF THE NASAL PASSAGES. The position of the mirror should now be at a right angle with the line of vision, and inclined slightly backward, the handle being held at one side, with its shaft lying against the corner of the mouth, as seen in Fig. 25. The tongue being well under control, the main difficulty of examination now lies in the inability of the patient to control the movements of the palate. If the palate is touched in the slightest degree during the manipulation, it is immediately drawn up against the posterior wall of the pharynx, and of course, the examination entirely prevented. This will only be overcome by the exercise of great care and patience in the manipulation. If a patient is directed to breathe through the nose, while the tongue is being held by a spatula, he will find it an exceedingly difficult thing todo. He can, however, oftentimes succeed in relaxing the palate by uttering a nasal sound. Much aid, therefore, will be ob- tained if the patient be directed to say “Eh,” giving it as fulla nasal twang as possible. If there is still difficulty in controlling the movements of the fauces, they should be anesthetized by means of a ten or twenty per cent solution of cocaine. This is an exceedingly unpleasant application to the fauces, giving rise toa curious sensation of choking or feeling of suffocation, and yet it is never attended with anything more than a temporary inconvenience. As a last resort, other means failing to control the move- ments of the fauces, we may proceed to tie up the palate after the manner first suggested by Desgranges.* This procedure con- sists in passing a cord through each nostril to the pharynx, and drawing it out through the mouth, when it is passed over the ear on each side and tied behind the head. By this means a gentle traction can be exercised on the palate, under which it gradually yields, and is finally folded on itself, as it were, and a broad space afforded for inspection of the parts above. This device of Desgranges is very simple, easily accomplished, and fairly well tolerated by the patient, and should always be resorted to in any case where it would add to the completeness of a diagnosis. An ordinary cord is somewhat irritating and not easily passed. Better still we may use a soft rubber cord, as first suggested by Wales,’ about one-eighth of an inch in diameter and a yard long. The ends are passed successively, first through one nostril and then through the other, until they emerge in the fauces, when they are drawn out through the mouth, and tied behind the neck, or held by an assistant. Their passage is facilitated by smearing the rubber with oil. If any difficulty is experienced in passing the cord, a small velvet-eyed English catheter may be used, the stylet being *Cited by Brevet. Thése de Paris, No. 117, 1855. ? Med. Record, 1875, vol. x., p. 785. METHODS OF EXAMINATION. 25 inserted for passing it through the nares. This procedure is quite easy of accomplishment, and secures all that can be desired in the way of drawing forward the palate for inspection or treat- ment of the upper pharynx. Unfortunately, many patients will Fic. 26.—White’s Self-retaining Palate Retractor. easily tolerate the manipulation but for a brief period, perhaps no longer than is sufficient to make the examination. Palate-hooks, palate-retractors, combination rhinoscopic mirrors with retractors, such as Duplay’s instrument and other devices of this sort, I have never found of any practical value. The best of these probably is the instrument shown in Fig. 26 which has been devised by Dr. Jos. A. White. THE RHINOSCOPIC IMAGE. ‘ The mirror being placed in the position described, there will be brought into view the oval-shaped openings of the posterior riares. Fic. 27.—The Posterior Nares. This posterior rhinoscopic image is shown in Fig. 27, although it should be borne in mind that these parts are only seen in detail and ‘not as a whole. Separating the choane, in the median line will be * Virginia Med. Monthly, March, 1888. 26 DISEASES OF THE NASAL PASSAGES. seen the septum, broad above and tapering to a sharp and narrow edge below. On each side of the septum will be seen, as dark cav- ities, the nasal passages, with the turbinated bodies projecting into them, from the outer wall of each. The superior turbinated body will be just visible, a light reddish band, in the upper part of the image, emerging as it were from the shadow, and seeming to slant upward and forward. Immediately below it, and separated from it in the posterior portion by a dark line, the superior meatus, will be seen the middle turbinated body, appearing as an elongated and somewhat fusiform projection, of a yellowish-red color. Below this again may be seen a considerable portion of the middle meatus, and below this the upper half of the inferior turbinated body, of much the same color as the middle, and giving the impression of a somewhat elongated mass resting on the floor of the nares. The inferior meatus and floor of the nares cannot be brought into view. If, now, the mirror be turned somewhat to one side, there will be seen the eminence surrounding the orifice of the Eustachian tube, separated from the posterior wall of the vault of the pharynx by the sinus of Rosenmiiller. The Eustachian tube being seen in pro- file, the orifice simply shows a dark line on a bright yellow back- ground, which is the anterior wall of the depression leading into it. By changing the inclination of the mirror now to a more obtuse angle, there will be brought into view the dome-like cavity of the vault of the pharynx, presenting a somewhat irregular outline, the surface being marked by furrows and depressions which indicate the site of the pharyngeal tonsil; the parts becoming smoother as the view passes down, until there is seen the deep red, smooth, shining surface of the mucous membrane of the lower pharynx. In adult life, however, as we know, the glandular structures of the pharyngeal vault undergo a certain amount of atrophy, and hence are not prominently visible. In these cases we simply bring into view the smooth surface of the mucous membrane lining this cavity. This change in the inclination of the mirror is best accomplished by simply turning the handle in the fingers, as the attempt to accom- plish it by elevating or depressing the hand, is liable to end in caus- ing retching. To obtain a complete inspection of the vault of the pharynx, it will generally be found best to change the mirror and use one mounted at an angle of 130°, the same used in making a laryngeal examination. This examination reveals the condition of the mucous mem- brane of the nasal cavity, the variety and extent of such hyper- trophic thickening as may exist in nasal catarrh, the condition of the pharyngeal tonsil, the extent of hypertrophy that may exist there, the character and amount of the secretions from the parts, METHODS OF EXAMINATION. 27 the existence of tumors in the nose or vault, ulceration, necrosis, etc. As regards the nasal cavity, not much information is obtained by this inspection, that cannot better be obtained by anterior rhinos- copy. Thus, morbid conditions of the septum I have never seen shown in this way, except the hypertrophy of the mucous mem- brane on either side posteriorly, in connection with hypertrophic rhinitis. Occasionally, however, small polypi well up beneath the middle turbinated body posteriorly, are seen, where the anterior ex- amination fails to reveal them. The pus discharged from the acces- ‘sory sinuses can be recognized also in this manner, although usually this is best detected by the anterior examination. CHAPTER II. METHODS OF TREATING THE UPPER AIR PASSAGES ‘BY MEANS OF INSTRUMENTS. In the local treatment of the mucous membrane of the upper air passages, resort has been had to various mechanical devices, by which the parts were thought to be more thoroughly and efficiently medicated. Thus, various forms of brushes have been devised, to- gether with sponge-holders, douches, atomizers, etc. In the earlier days of laryngoscopy, a considerable amount of importance was: attached to these various methods. I think no one will question, at the present time, that their value was greatly over-estimated, and that in the discussion as to the comparative merits of the dif- ferent methods by which local applications were made, we often- times lest sight of the question as to how far these applications. were efficacious in curing or relieving diseased conditions. ‘With our larger knowledge of the physiology and pathology of the mu- cous membranes of the upper air passages, our dependence upon these various instrumental aids has greatly diminished, and a large majority of them are thrown aside for the simpler methods by which the desired end is accomplished, now that the indications. for treatment have become so clear, positive, and direct. Local ap- plications by means of brushes, largely resorted to in former years, have fallen almost completely into disuse in this country. Those desiring still to-make use of this instrument will require no direc-. tions for carrying out the procedure. The same, I think, can be said of sponge-holders or probes for holding pledgets of cotton. As regards the use of solids, such as nitrate of silver, chromic acid, etc., the methods for their use will be described in the chapters de- voted to the consideration of those diseases in which the use of these remedies is indicated. INSUFFLATIONS. The use of: snuffs, and their application by means of specially devised instruments, possesses a certain amount of value in the treat- ment of the upper air-passages, as was recognized by Galen,’ and > “De Compositione Medicamentorum Localium,” etc., lib. vii., cap. 3. METHODS OF TREATMENT. 29 is resorted to by most physicians up to the present day. These may be used by auto-insufflation or by special applicators. Among the earliest mechanical devices for insufflation was that of Pserhofer," which consisted of a perforated reservoir containing the powder, F1G. 28.—Rauchfuss’ Insufflator. to which was attached a tube extending into the mouth, the powder being drawn up into the air passages. A somewhat similar device was used by Prof. Darwin, while Burow* accomplished the same result by means of a simple tube. The first to suggest an instru- ment by which the powders are thrown into the upper air passages Fic. 29.—Lefferts’ Insufflator, was Rauchfuss, whose instrument, shown in Fig. 28, consisted of a long curved tube, with a fenestra, covered with a slide, through which the powder is inserted. The proximal end of the tube is fitted with a soft-rubber bulb, pressure on which expels the powder from the tube, the distal extremity of which is curved to direct the Re ae Fic. 30.—Ely’s Powder Blower. powder upon the diseased part. Rauchfuss’s instrument is rather awkward of manipulation—an objection which is avoided by attach- ing a rubber tube with a mouth-piece to the proximal end of the tube, as in Lefferts’ insufflator shown in Fig. 29, thus enabling the 1 Schmidt’s Jahrb., 1856, vol. 92, p. 170. ? Deut. Klin., 1853, No. 21. 30 DISEASES OF THE NASAL PASSAGES. manipulator to expel the powder from the tube by blowing, and thus depositing it upon the part which it is desired to medicate. An objection to the tubes is that they deposit the powders in mass. A very ingenious instrument is shown in Fig. 30 which is usually attributed to Ely, of Rochester. It consists simply of a glass bottle, through the cork of which there pass two tubes bent at a right angle immediately above their point of entrance. To one of the tubes is attached an air-bulb, while the other is bent at its distal extremity, upward or downward, or in whatever direction it is desired to carry the powder. The tube to which the air- bulb is attached passes down into the lower por- tion of the bottle, while the other merely passes through the cork. The powder having been placed in the bottle, a quick pressure on the air-bulb drives a current of air down into the bottle, which striking the powder, stirs it into a cloud, and at the same time drives it out through the other tube, and deposits it upon the part it is desired to medicate, in a state of fine and even diffusion. This instrument, made of hard rubber, can be ob- tained of the instrument makers, or any one having a stock of glass tubing may make his own supply. This is unquestionably the best insufflator in use. Its advantages are that it thoroughly diffuses the powder, that it deposits it in a smooth thin film, that it does not pile it on any of the parts, and that it carries it throughout the sinuous cavities. Its only disadvantage is that it does not enable the operator to estimate nicely the amount of powder used, though, as a rule, this is of no consequence. Fig. 31 represents Stoerck’s insufflator which com- bines the advantages of all the above-mentioned instruments. It consists of a small central cham- ber for the reception of the powder, fitted with a movable cover. Projecting from this is the long curved tube for directing the medicament to the : part it is desired to reach. At its proximal end it Fic, 31.—Stoerck’s Insuf-is provided with a tapering socket, communicating sa with the powder chamber by a tube containing a spring cut-off. This instrument is intended for use in connection with the compressed air apparatus. Its working is obvious; the distal point being’ placed in position to throw the powder in the METHODS OF TREATMENT. 31 desired direction, and the instrument connected with the air cham- ber, pressure on the valve lets on a sudden blast which drives the powder to the spot intended to be reached. The advantage to be gained by the use of powders, is a certain amount of permanency of action, as they remain for some time in contact with the part, and becoming slowly dissolved in the mucus, are absorbed by the membrane. The remedies usually employed in this form are tannin, bismuth, alum, borax, ferric alum, zinc, ni- trate of silver, iodoform, opium, morphia, belladonna, benzoin, san- guinaria, galanga, etc. When it is necessary to reduce the strength of an agent, it may be combined with pulv. crete, pulv. acacie, magnesiz carbonas, sacch. alb., etc. If the powder is heavy, it may be rendered lighter by combining with powdered starch or lycopodium. DOUCHES. Fluids may be thrown against the diseased membrane of the larynx, pharynx, or nasal cavity by means of syringes and douches of forms variously devised for special ends. Fig. 32 shows the ordinary post-nasal syringe, a common barrel syringe, fitted with a Fic. 32.—Post-nasal Syringe. curved tube which terminates in a rose douche, delivering jets in every direction. This may be passed up behind the soft palate for injecting through the nasal cavities, or it may be turned downward for injecting the pharyngeal cavity. Fig. 33 represents the pipe of the same instrument fitted for use with the Davidson syringe. It Ais Fic, 33.—Post-nasal Pipe fitted to the Ordinary Davidson Syringe. is equally adapted to the fountain syringe. For injecting through the anterior nares, an ordinary ear syringe answers the purpose very well, but better still is the post-nasal syringe shown above, with the tube straightened. This can be introduced well into the cavity if 32 DISEASES OF THE NASAL PASSAGES. desired. Fig. 34 shows the instrument sold in the drug stores as Warner’s Nasal Douche, a very convenient device for cleansing the naso-pharynx, in cases where the patient can acquire the necessary skill for manipulating it himself. The use of the syringe is to a cer- tain extent limited, in that it is probably not specially indicated in Tic. 34.—Warner’s Post-nasal Douche. 34: other than the atrophic form of chronic rhinitis, in naso-pharyngeal catarrh, and possibly in syphilitic ozena. The nasal douche is an expression which we ordinarily use to ’ define the application of a continuous stream of water through the nasal cavities. The principle on which it acts was first suggested by Weber,' who, in conducting a series of experiments on the sensi- bility of the nasal mucous membrane, ob- served that when a fluid was introduced into the nasal cavities, the soft palate was lifted: so firmly against the posterior wall of the pharynx, as to completely prevent the es- cape of the fluid into the parts below. Acting on this idea, Thudicum * introduced what is now known as the nasal douche, which is shown in Fig. 35. It consists of a reservoir, from the bottom of which leads a rubber tube terminating in a rounded tip so shaped as to fit into the nostril. This tip being placed in the nos- tril, the reservoir containing the fluid is to — be raised above the head, which is bent over Fic. 35.—The Ordinary Form of the a bowl as shown in Fig. 36. As the reser- Pras eneles voir is raised, the fluid enters one nostril, and passing around the posterior border of the septum, escapes through the other in a continuous stream, probably reaching pretty thoroughly the whole of the mucous membrane of the two as —— 4 * ““ Ueber den Einfluss der Erwarmung und Erkdltun der Nerven auf ihr Leitungs- vermégen."’ Miiller’s Archives, 1847, p. 351. 2 London Lancet, Nov. 24th, 1864. METHODS OF TREATMENT. 33 chambers. In Thudicum’s original instrument, the’ reservoir was fitted to a standing rod in such a way as that its height could be regulated according to indications. The little device shown in Fig. 37, which was first suggested. by Dr. Dessar,' is somewhat unique in its simplicity and would seem to afford a convenient method of applying fluids to ‘the nasal cavi- ties, especially of young children, where a more complicated appara- tus cannot well be used. Woakes’’ nasal irrigator is also constructed on much the same plan. The value of the douche, as a means of applying cleansing fluids to the nasal cavity in certain cases, cannot be denied, especially in atrophic rhinitis, and perhaps sy- philitic necrosis. In these affec- tions, of course, it is not a curative measure, while in the ordinary chronic inflammatory action with hypertrophy, it probably not only fails to be of permanent value, but may be mischievous, as first AS SS ae A SAMY CO WS WE: s Fic, 36.—Method of Using the Nasal Douche. suggested by Roosa,? who reported a number of cases of acute otitis media resulting from its use, attributing this accident to the en- trance of fluids into the middle ear. I think it is to be borne in Fic. 37.—Dessar’s Nasal Cup. mind here, that the very large proportion of cases of hyper- trophic rhinitis of long standing, suffer from a mild form of mid- N.Y. Med. Record, 1889, vol. xxxv., p. 280. 2 “ Post-nasal Catarrh,” Phila., 1884, p. 154. 3 Archives of Ophthalmology and Otology, vols. i. and ii. 34 DISEASES OF THE NASAL PASSAGES, dle-ear disease, which acts as a predisposing cause of the acute form, which probably may be precipitated by the use of the douche. Considering, however, this possible danger, and the fact that the use of the douche probably accomplishes no good result in hyper- trophic rhinitis, its use in this affection is therefore to be condemned unreservedly. In atrophic rhinitis, the danger of middle-ear disease from its use is absent, and I consider the douche of great value in this disease, and see no reason for hesitating to recommend it. ATOMIZERS. s Following out the idea that the successful treatment of catar- thal affections depended ‘on our ability to thoroughly reach the parts with our medicating fluids, the plan of reducing our solutions to‘a state of fine atomization would naturally suggest itself as af- fording the best method by which they could be carried into the sin- uous passages of the nasal cavities, or thrown into the air passages below. In view of the very large extent to which the use of atom- izers' has grown in late years in the treatment of diseases of the upper air passages, it becomes a matter not only of historical, but also to a certain extent of practical interest, to trace their develop- ment from the cruder devices of former days, to the perfect instru- ments now provided for our use. This system was first put in practice at certain of the mineral springs of Europe. As these waters were considered as possessing notable virtues, both when taken internally, and as used for bathing, it occurred to the pro- prietors of these springs, that their local action upon the mucous membrane in the air tract might be equally efficacious. For this purpose, a large number of minute jets of water were projected against the walls of the chambers into which patients, well covered with water-proof clothes, were introduced for the purpose of inhal- ing the sprays thus produced’ The first to carry this plan of treat- ment into operation was Auphan’ at Euzet-les-Bains, the same device being subsequently adopted at Lamotte-les-Bains, and by Sales- Girons,? who, in conjunction with Flubé, elaborated the system more fully than had ever been done before, and published his re- sults. Sales-Girons also constructed a portable atomizer shown in Fig. 38 by means of which inhalations could be given of any medi- cinal agent other than the natural waters, the principle being much the same as that already suggested. This instrument was the pre- cursor of a large number of devices for accomplishing the same * Cohen: ‘' Inhalation, its Therapeutics and Practice,” Phila., 1876, p. 184. 2“ Therapeutique Respiratoire,” Paris, 1858. METHODS OF TREATMENT. 35 purpose, such as the Néphogéne of Mathieu,’ shown in Fig. 39, and the atomizers of Lewin, Waldenburg, Schnitzler,, Fournier and others, based on different principles of action, all of them, how- ever, somewhat crude and imperfect. In 1863, Dr. Nathanson sug- gested to his friend Dr. Bergson,’ that if a current of air be driven through one tube, placed at right angles to a similar tube which led to a reservoir of water, a vacuum would be created, by which the water would be drawn up into the vertical tube, until meeting the cur- rent of air, it would be broken into a fine spray. On this principle were con- structed what are usually known as Bergson’s tubes. Bergson, in con- structing hisapparatus, supplied theair current by means of a pair of rubber bulbs connected by tubing, pressure Fic. 38.—Sales-Girons’ Portable Atomizer (Cohen). a,Compression pump; 4, reservoir; Fic. 39.—Mathieu’s Néphogéne (Cohen). a, the c, stream of fluid about to strike the button, compression pump; 4, glass‘globe containing fluid to which is concealed within the drum; a, tube be nebulized; c, the exit tube; a, flexible tube con- with stop-cock; /, drum in which the excess of veying condensed air from the reservoir to the exit spray is condensed; g, the waste tube to carry tube; 4 air reservoir. off the condensed fluid; Z, the manometer. being applied to the distal bulb as shown in Fig. 40, while the cen- tral bulb acted asa sort of reservoir. This device was subjected to various modications until finally Dr. Sass, of New York, con- structed the atomizing tubes generally known as Sass’s tubes. These are made on the Bergson principle, and of heavy barometer glass tubing, but instead of placing the two tubes at right angles, they are joined together, the upper end of the water tube being *Gaz. Hebdomadaire, May 4th, 1860, p. 300. 2 Deut. Klin., 1863, No. vii. 36 DISEASES OF THE NASAL PASSAGES. bent at its upper extremity around to meet the air current ata right angle, as shown in Fig. 41. Subsequently these tubes were Fic. 40.—Bergson’s Apparatus with Foot Bellows (Lewin), «, Reservoir for fluid; 4, a tray; c, verti- cal tube; d, horizontal tube; /, flexible tubing; g, air reservoir; 4, rubber.compressor to be compressed by the foot; z, joint connecting the tubes; 4, the spray; Z, the cap of the reservoir to which the tubes are attached (Cohen). constructed of hard-rubber and metal. An objection to metal is made, that it is liable to the action of the chemical agents used—an Fic. 41.—Sass’ Spray Tube. METHODS OF TREATMENT. 37 objection which is easily obviated by attention to cleanliness, while at the same time a large element of loss by breakage is also avoided by their use. Dr. Newmann, of New York, modified the Bergson tubes by placing one tube within the other, as shown in Fig. 42, the principle on which they act being the same as in Bergson’s. Previous to this, Manz’ had made a somewhat ingenious change, consisting of the introduction of a third tube, passing through the cork of the reservoir bottle in such a way that air from the bulbs was forced both into the tubes and into the reservoir, thus driving the fluid up into the tube to meet the air current. Dr. Richardson, of London, combined the Newmann and Manz a Fig 7. v Fic. 42.—Newman’s Spray Tubes, Worked by Means of the Double Bulbs. devices into what is ordinarily known as the Richardson spray, in which the projecting portion consists of two hard-rubber tubes, one within the other. To the outer tube is fitted, at its distal extrem- ity, a movable cap, perforated in its centre by a small opening. The inner tube passes from immediately behind the opening in the cap, through the centre of the outer tube, through the neck of the reservoir, and down into the fluid. The small projecting nipple on the neck of the bottle or reservoir is for the attachment of the air- bulbs which furnish the air pressure. It opens into the larger tube, and also communicates with the reservoir. As will be seen, when a current of air is pumped in by the bulbs, it is divided into two streams. One stream passes into the reservoir above the fluid, where, being compressed, the fluid is forced up through the central ™ Deut, Klin., 1866, p. 224. 38 DISEASES OF THE NASAL PASSAGES. tube and driven in a small jet against the opening in the movable cap. The other current from the air-bulb passes into the larger tube, and escapes through the opening in its movable cap. The small jet of the fluid striking against the edge of the small opening in the cap, and at the same time meeting with the current of air : Fic. 43.—The Richardson Double-bulb Hand Atomizer (Seiler). escaping therefrom, is broken up into a fine spray, and in this state is carried with the current some distance beyond the tube. A sep- arate movable cap is ordinarily supplied, fitted with a tip, curved in such a manner as to deflect the atomized fluid either upward or downward. This apparatus is shown in Fig. 43. We thus have METHODS OF TREATMENT. 39 illustrated two principles upon which all atomizers are constructed in our day—that of Bergson and of Richardson. The air-current may be supplied by means of the rubber bulbs or by more elaborate devices. The Richardson atomizer is usu- ally provided with a double bulb. This, I think, is an entire mis- take, as the principle upon which the atomizer is constructed gives a continuous atomization by the one bulb, while at the same time it forces the spray much better when the pressure of the hand on the single bulb is the motive power, rather than the contractile force of the central rubber bulb which is usually in- | i | " | ra Fic. 44.—The Ordinary Hand-pump and Air Receiver. troduced in the continuity of the tube. In the use of the Sass’ tubes, a simple hand-ball, ordinarily, is insufficient, hence the com- pressed air apparatus so much in vogue of late years has been introduced. This consists simply of a pump and air receiver, as shown in Fig. 44, the cylinder being charged with air by means of the pump, which is then drawn off as wanted for the production of the sprays; the advantage of the air receiver being that the force of the spray can be regulated with a certain degree of nicety, while the jet is delivered instantly upon turning on the pressure, and: arrested instantly upon its being shut off. The charging of the air receiver by the small pump shown above involves no small amount of laborious exertion. This is to an extent avoided by 40 DISEASES OF THE NASAL PASSAGES. the instrument shown in Fig. 45, in which the pump piston is worked by means of a heavy fly wheel. Of course, all this labor is saved by the substitution of hydraulic pressure, as was first suggested by Dr. Arnold of Roxbury.* He makes use of two jars, connected by a piece of long rubber tubing, one jar being filled with water, while the other is empty. By raising the full jar to a certain height, the water flowing into the empty one pro- duces compression of the air there contained, which is avail- able for use until the air is ex- hausted and the jar is full of water, when the process is re- versed. A continuous supply of air is thus obtained by the alternate use of one jar and then the other, the atomizing tube being connected with the lower jar. No apparatus yet e cevised, perhaps, is more con- " venient for use than the hy- dro-pneumatic pump, shown in Fig. 46, which is worked by the ordinary city water supply. It consists of a metallic box into which water runs from the public main. As soon as the box is filled, by means of a simple mechanism in its up- per portion, the supply is shut off and a waste valve opened, which, in turn, is closed as soon as the box is empty, and the water supply turned on again. We thus have the water-head acting as a piston- head and pumping air through the tube, shown in the figure, © into the air receiver, and storing it for use. This pump continues working until the air-pressure in the receiver equals the water-pres- sure in the supply pipes of the house. It is an excellent device, and will work for weeks and even months without requiring attention. A great deal of ingenuity has been exercised in the construction of these various devices for atomizing fluids, and it has been a Fic. 45.—Air Pump Worked by Fly-wheel. * Boston Med. and Surg. Journal, Dec, 27th, 1866. METHODS OF TREATMENT. 4 broadly prevalent impression that our success in the treatment of diseases of the upper air-passages was largely dependent upon the elaborateness and perfection of our mechanical devices, especially those used for the production of sprays. Furthermore, a good deal of importance has attached, in the minds of many, to the pres- sure of the air by which the fluids are atomized, the ground being taken that at a pressure of fifty or sixty pounds atomized fluids come more thoroughly in contact with the membrane lining the sinuous passages of the nose, and are so driven farther down into the bronchial tubes, the idea still being held that local applications constitute the essential element necessary for the cure of catarrhal diseases. This I believe to be an entire mistake. A catarrhal inflammation, as a rule, is not cured by the local application of Fic, 46.—The Hydro-Pneumatic Pump. astringent, alterative, stimulant or other remedies, as will be more fully elaborated when we come to discuss the particular forms of inflammatory disease met with in the upper air tract. Local ap- ‘plications undoubtedly have done good; they are convenient for cleansing purposes possibly, and astringent applications in the nose or larynx aid us somewhat in the treatment of catarrhal inflammation of these regions, and we cannot well dispense with them, but I am confident that those who place their main reliance on the use of sprays will find themselves disappointed in the results of treatment. Elaborate apparatus is unnecessary. I have always entertained the opinion that all the apparatus necessary for the successful treatment of the ordinary class of cases which come under our observation might easily be carried in a small hand-bag. Regard- ing, then, an atomizing apparatus as a very great convenience, al- though not an absolute essential, it remains to suggest that perhaps 42 DISEASES OF THE NASAL PASSAGES. the most convenient device is the ordinary Sass’s tube, constructed of metal, with the air receiver and pump, preferably the water pump if one’s office is supplied with the public water service; but Fic. 47.—The Ordinary Single Bulb, Hand Ball Atomizer, fitted for Nasal Applications. this apparatus possesses no notable advantages over the simpler devices. In my own office work, after an experience of many years with various methods of atomization, I have finally arrived at the conclusion that one’s work can be quite as well performed, and much inconvenience even avoided, by using an ordinary single bulb hand-ball atomizer. Of these, perhaps the best is that shown in Fig. 47, which is constructed on the principle of Richardson’s atomizer. The device shown is fitted with a rounded bulb to adapt it for nasal application, although the same instrument is supplied with both the la- ryngeal and post-nasal tip. This instrument is used, in the main, to apply cleansing and disinfecting lotions to the upper air passages, and deliv- ers an abundant, yet finely divided spray. For making y applications of astringent, sed- ative, or other medicating solutions, preference should be given to some of the ato- mizers constructed on the Bergson principle. In Fig. 48, there is shown an atomizer, con- structed on this principle, and sold in the drug stores under the Fic. 48.—Delano’s Atomizer. METHODS OF TREATMENT. 43 name of Delano’s Atomizer,.which delivers a very fine spray, the flow of which ceases immediately upon relaxing the pressure upon the bulbs; it is therefore useful in making applications of cocaine, and for this purpose I regard it as of especial value. INHALATIONS. In 1864 Siegle* put in practice the plan of using steam as the power by means of which fluids were atomized in the Bergson tubes. This, however, was not available for a direct application, but could only be used as an inhalation, and it is this principle which is made use of in the ordinary steam atomizers sold by the instrument makers at the present day. The principle on which they act is too well known to need remark. The drugs that can be made use of by means of the Siegle apparatus include nearly the whole list of astringents, alteratives, etc. In addition to these, there are certain drugs which contain principles which are volatil- ized when brought in contact with hot water at a temperature of not less than 150°. This list in- cludes carbolic’ acid, creosote, cam- phor, oil of tar, tincture of benzoin, tincture of myrrh, oil of eucalyptus, terebene, pine-needle oil, ethereal tinct- ure of iodine, etc. A teaspoonful of any of the above, placed in an open- mouthed bottle or cup containing half a pint of water slightly below the boiling point, is placed beneath the mouth, and the fumes inhaled. The same purpose is accomplished in the somewhat elaborate instrument known as Mudge’s inhaler, in which an inhal- ing tube is inserted into the cup, in such a way that the inhaled air is drawn through the fluid. In MacKen- zie’s inhalator, shown in Fig. 49, and instruments of that type, the volatile i oe oils of the medicament used are driven Fic. 49.—MacKeazie's:Inhalator, off more actively by means of a burning lamp placed beneath the reservoir or cup. There are quite a number of drugs which are volatile at the ordinary temperature, the properties of which, as inhalants, possess a certain amount of value. The method by which these are used *“ Die Behandlung und Heilung der Hals- und Lungenleiden durch Einathmungen mittelst eines neuen Inhalations-Apparates,” Stuttgart, 1864, p. 16. 44 DISEASES OF THE NASAL PASSAGES. varies, but ordinarily is quite simple. A glass or vulcanite tube, into which has been inserted either cotton-wool or sponge, is the ordinary. form. The absorbent material is charged with the drug which it is desired to use, and the little tube held either to the nostril or to the mouth, for the purpose of inhaling the fumes. In this way we make use of iodine, creosote, ammonia, oil of tar, oil of peppermint or any of the mint series, and, in fact, most of the aromatic oils. Lewin has suggested a rather ingenious device, by which nascent muriate ammonia is used for inhalation. His apparatus, shown in Fig. 50, consists of three flasks, one containing a solution of caustic ammonia, the second a solution of muriatic acid, the two being connected by means of glass tubes with a third flask, partially filled with water, to Fic, 50.—Lewin's Apparatus for Inhaling Nascent Muriate of Ammonia. «, Glass vessel, containing strong aqua ammoniz; 4, glass vessel containing muriatic acid; c, glass vessel containing distilled water, slightly acidulated; @, rubber tubing, to which is attached the mouth-piece; ¢, 7, connecting glass tubes; £, A, glass tubes for admittance of atmospheric air, which is attached the inhalation tube. When the air is drawn through the third flask, it draws fumes from the first and second flasks containing muriatic acid and ammonia, which, meeting in the third flask, give rise to the fumes of nascent muriate of ammonia. This apparatus is oftentimes of no little use in the later stages of a winter cold or a bronchial attack, in stimulating the mem- brane to freer transpiration, and thereby promoting a resolution of the inflammatory process, Too much value should not attach to the use of inhalations, in the various forms of acute inflammation which involve the upper air passages. They undoubtedly serve to relieve pain, and per- haps to mitigate the severity of the attack. Certainly, they add much to the comfort in relieving the irritability of the parts, and lessening the severity and frequency of the cough. METHODS OF TREATMENT. 45 On the whole, however, inhalations are to be regarded largely as palliative measures. The elaborate apparatus for inhaling pur- poses may serve to produce a certain moral effect upon the patient, but I doubt if the action of the drug is not quite as efficacious in the simpler devices suggested above, as in the more elaborate in- haler. The steam atomizer, while a somewhat entertaining toy, Fic. 51.—Large Globe Inhaler for Inhaling Fluids Atomized by means of Compressed Air. I have long ago discarded, on the ground that it not’ only accom- plishes little good, but is capable oftentimes of doing mischief. Especially is this true in all forms of chronic disease of the air pas- sages, in that the hot steam, I think, serves to so far relax the parts as to largely counteract all good that may be accomplished by the medicament used. Indeed, none of the above methods of in- halation are to be used in chronic affections, unless, perhaps, the 46 DISEASES OF THE NASAL PASSAGES. muriate of ammonia, which oftentimes serves to loosen the thick inspissated mucus of a chronic bronchitis. Cold inhalations, by means of compressed air in the atomizer, have been, in the past few years, largely resorted to in the treatment of chronic affections of the upper air passages. The method by which they are administered is to direct the spray into one end of a large globe, while the patient, sitting in front of the opposite end, draws the atomized fluids into the air passages. The principle of its action is that the large particles of atomized fluids are arrested in the globe and fall to the sides, while the finer particles of the spray are carried to the air passages by the inspiratory act. The drugs used in this way embrace nearly the whole list of astringents, alteratives, etc., which are supposed to possess a certain amount of controlling influence on catarrhal processes. This is undoubtedly a valuable method of applying astringent remedies directly to the upper air tract, and in those cases where the inflammatory process has invaded the larger bronchial tubes its use is attended with better results than any other device which we possess. Certainly, it is far preferable to hot inhalations, either by means of the steam atomi- zer or the ordinary inhalator. In Fig. 51 is shown one of the more elaborate forms of the globe inhaler. CHAPTER IIL. MUCOUS MEMBRANES. A MUCOUS membrane practially resembles very closely the external integument, but so modified as to adapt it for the special purpose which it is designed to serve in the economy, viz., to afford a proper lining for the various passages and cavities of the body which communicate with the external world; for, as we know, all these cavities, such as the genito-urinary passages, the alimen- tary canal, and the respiratory tract, are lined with a membrane of this kind. In order to adapt it for the special purpose which it is designed to subserve as a lining membrane for these cavities, it be- comes essential that it should be soft, moist and pliable, and more- over that it should be endowed with an apparatus fox maintaining _this soft, moist, and pliable condition; for, as we know, in many of the cavities of the body, especially the air tract, the conditions are such that this soft, moist, and pliable condition would be destroyed, were it not that the membrane contains within itself some appara- tus for supplying the conditions necessary to counteract this ten- dency. Hence, for this purpose, we find the mucous membrane covered with epithelial cells of various characters and arranged in various ways, according to the location and special function which it subserves; the object of the epithelial cells being merely the se- cretion of mucus. In these tissues, we may regard each individual cell as a typical gland, displayed over the surface of the mucous membrane, whose object is to keep the membrane softened and moistened. In fact, nature endows the membrane, in this manner, with its own lubricating apparatus. It is found, however, that epithelial cells simply displayed in layers on an unbroken surface are unequal to the demand. In other words, distributed in this manner, they are not equal to supplying a sufficient quantity of mucus for lubricating the passages. To remedy this deficiency, nature resorts to a very simple device for extending the secreting surface. This consists in folding the membrane upon itself, as it were, or in other words, bending it down into the tissues and back again, to form a small flask-like cavity which is called a follicular gland. In other cases, instead of forming a straight fold, the pouch-like cavity of the simple follicle is folded on itself a number of times, forming 48 DISEASES OF THE NASAL PASSAGES. a group of small flask-like pouches, as it were, which uniting, open upon the surface by a single orifice, thus constituting what is known as a racemose gland. The arrangement of glands and follicles in the mucous membrane, therefore, I take it, are for the purpose of enlarging the surface over which the epithelial cells may be distrib- uted, and, therefore, increasing the secreting power of the mem- brane, in order that its surface shall be constantly supplied with an abundant quantity of mucus, the normal lubricant of the mem- brane. This, then, briefly and simply stated, is the design and function of a mucous membrane, a proper understanding of which is of the greatest importance to the proper appreciation of diseased conditions of the upper air tract. A mucous membrane, wherever Fic. 32.—Section of Mucous Membrane, drawn Diagramatically. 4, Submucous layer of connective tissue; d and e, mucous membrane proper, containing blood-vessels, nerves, closed follicles, connective and elastic tissues fibres, and marked by villi; c, epithelial layer; 4, simple follicle; 2, racemose gland. met with, is much the same thing, its function varying simply with the conditions and environment in which it is placed. Its function in the economy is largely complete when it has provided the cavi- ties of the body with a proper lining. Any other functions which it performs are mainly adventitious. ANATOMY. From an anatomical point of view, we describe a mucous mem- brane as composed of three layers. First, a superficial layer, composed of epithelial cells. Second, the mucosa proper, a layer composed of white fibrous and yellow connective elastic tissue, embracing within their meshes blood-vessels, smooth muscular fibres, different varieties of small glands, and presenting minute processes or villi. Third, an external layer of loose connective tissue; the sub- mucous cellular tissue (see Fig. 52). MUCOUS MEMBRANES. 49 First. The epithelial layer.—An epithelial cell, the typical or elemental gland, is simply a soft rounded cell, containing a nucleus and cell contents, pellucid or granular, and all contained in a cell wall, whose varying shape gives to it its name; such as: 1. Pave- ment or tesselated epithelium, so called from their being pressed down and flattened from above, and crowded together in such a manner as to give an angular outline to each cell. 2. Columnar epithelium: elongated cells with rounded or square ends. 3. Columnar ciliated epithelium: the same shaped cell as the col- umnar, but endowed with fine hair-like processes on the free end, which possess the power of vibratory motion. 4. Squamous epithelium: worn out or dried cells, which are thrown off from the surface. These cells may be arranged ina single layer, or in several layers, one above the other; this latter arrangement is generally found in mucous membranes, in two varieties. a. The laminated pavement. Commencing with the elongated or columnar cells beneath, and becoming rounded above, until they -reach the surface, where they become of the pavement variety. This arrangement is found in the lower portion of the pharynx, and in the cesophagus. 6. The laminated ciliary. Commencing with rounded cells be- low, which, becoming elongated as they approach the surface, show on the upper layer the columnar ciliated cells. This variety is found in the lungs and air passages, except the smaller bronchi. Second. The mucous membrane proper.—Beneath the epithelial cells is found the mucous membrane proper; composed, as stated, of connective tissue, elastic tissue, muscular fibres, glands, blood- vessels, and nerves, and marked by minute processes or villi. The connective tissue which is found in this layer is composed of fine fibrils united into bundles by a small quantity of a clear connecting substance, and forms a close network or an almost homogeneous membrane. In this connective tissue we find certain cells, resembling the white corpuscles of the blood, the so-called leucocytes. This is the connective-tissue corpuscle, or, as it is sometimes called, the migrating corpuscle, and again, the amceboid cell, from its observed power of motion. This cell performs an im- portant part in inflammations, not only of mucous membranes, but of other tissues, as will be noticed further on. The elastic tissue, one of the elementary structures of the body, is displayed more or less freely throughout this layer, and is composed of simple thread- like fibrils, crossing and interlacing in every direction. It is of a yellow color, and possesses a high degree of elasticity. 4 50 DISEASES OF THE NASAL PASSAGES. The muscular fibres are of the unstriated variety, and are very sparsely distributed through the layer. The glands are of two varieties, the simple follicular gland, and the compound follicular or racemose gland. The simple follicle is merely an infolding of the membrane into a straight tube, or flask- like cavity. The racemose gland is composed of a cluster of flask- like follicles, opening into a single duct, whose orifice is upon the surface of the membrane. The vessels are very numerous, and form close meshes in the membrane proper, sending a loop into the smaller villi, and into the larger, a close network. Third. The submucous cellular tissue—This is composed of a more or less loosely connected network of connective tissue, by which the mucous membrane is attached to the parts beneath, and, of course, allows of a very free play between the membrane and these parts. This fact becomes of extreme importance in connec- tion with acute inflammatory affections of the membrane, as it admits of the effusion of serum into this layer, where its attachment is very loose, as in the ary-epiglottic folds of the larynx, the posterior. surface of the epiglottis, and the ventricular bands. PHYSIOLOGY. The function of a mucous membrane is to afford a soft, moist, and pliable lining to those cavities and passages of the body which communicate with the external world. It is lubricated by a clear fluid mucus, which is poured out upon it by the follicular and race- mose glands, whose ducts open upon its surface, and also by the epithelial cells which compose its superficial layer, each epithelial cell being in its small way an independent and secreting gland. Owing to the constant mechanical disturbance to which the membrane is subjected in mastication, speaking, etc., the cells of its superficial layer are being constantly detached and thrown off. In order to compensate for this loss, new cells are being continuously generated from below. The method by which this is accomplished is exceedingly simple, and may be explained by a very brief refer- ence to cell pathology. Virchow first advocated the doctrine, some twenty years ago, which now meets with general acceptance, that every cell grows from a parent cell; and in no department of histo- logical study is the observation more clearly confirmed than in that of mucous membranes. The method of cell-development is prob- ably by one of three processess: 1. Division.—A constriction develops across the centre of a cell which, becoming narrower and of an hour-glass shape, finally sepa- rates, and in place of one cell two cells exist. MUCOUS MEMBRANES. 51 2. Gemmation.—In this process, there appears at some point in the cell-wall a small projection, which protrudes more and more, while its attachment to the parent cell becomes narrower, and finally it drops off, a newly developed cell. 3. Endogenous growth—A new cell is developed inside the parent cell, as the foetus in the mother’s womb; and finally, when it has attained maturity, it bursts its wall and escapes. It is by one of these processes that new cells are being con- stantly generated in the deeper layer of the epithelial coat of the membrane, to make good the waste which is constantly going on at its surface. Another physiological characteristic of mucous membranes is their permeability, by which fluids may penetrate them from with- out, and become absorbed by the blood-vessels, or perceived by the nerves. The activity of this function depends mainly on the thick- ness of the epithelial coat, thus where this is very thin, as over the papillz of the lips and the tip of the tongue, we find the sensitive- ness very acute. An exception to this rule is found in the:fact that the virus of the snake does not permeate mucous membranes, and is in no way absorbed by them, it being necessary that it should meet with an abraded or cut surface, in order to reach the blood- vessels, and be taken up by them. The same is true of the syphilitic virus, which is only inoculable through an abrasion of the mem- brane. INFLAMMATION OF MUCOUS MEMBRANES. Inflammation is that series of changes which takes place in any tissue as the result of an injury, provided the injury is not of such a character as to completely destroy its vitality. This injury may be a direct irritation of the tissue by a mechanical or chemical agent, or by substances carried to it by the blood, or it may be an indirect irritation, as is the case in inflammation of internal organs, as the result of exposure to cold. Through the researches and experiments of Cohnheim, Stricker, Burdon-Sanderson, and others, the nature of these changes is well known. The process comprises: 1. Changes in the blood-vessels and circulation. 2. Exudation of liquor sanguinis, and migration of white blood- corpuscles. | 3. Alteration in the nutrition of the inflamed tissues. - 1. The first effect of an irritation of the tissues is to cause dila- tation of the arteries, followed soon by dilatation of the veins. The dilatation is also attended by an increase in the length of the ves- sels, and they become more or less tortuous. 52 DISEASES OF THE NASAL PASSAGES. The enlargement of the vessels is attended, at the outset of the process with an acceleration in the flow of blood, but this is soon followed by a retardation of the flow, the vessels remaining dilated. As the circulation becomes slower, the white corpuscles, or leuco- cytes, accumulate in the veins, and their natural tendency to adhere to the sides of the vessels is increased to such an extent that they nearly fill the calibre of the tube, and accumulate against its walls, remaining almost stationary, while the blood-current passes by them, though with a greatly diminished velocity. Those immedi- ately in contact with the wall of the vessel are now seen to press against it, and finally to pass through into the tissue beyond, sim- ply transuding the wall, the opening closing up behind them. 2. Associated with the passage of the blood-corpuscles is the exudation of liquor sanguinis. This exudation, which constitutes the well-known inflammatory effusion, differs from the effusion which escapes from the blood-vessels in simple mechanical obstruc- tion, as in dropsy from heart disease or cirrhosis, in containing an amount of fibrin and albumen, varying with the extent and severity of the inflammatory process. 3. The remaining constituent of inflammation is the alteration in the nutrition of the inflamed tissue. The cells which constitute a normal part of the tissue take on an increased activity; the normal processes of physiological growth become greatly exaggerated, and new cells are developed by one of the methods before alluded to. This, in brief, completes the picture of inflammation in general. Confining ourselves now to mucous membranes, we find certain peculiarities manifesting themselves in the processes. Inflammation of mucous membranes occurs in three different varieties: catarrhal, croupous, and diphtheritic. Catarrhal inflammation,—This is by far the form most fre- quently met with. In its milder degrees it is characterized merely by an increased secretion of mucus. An increased flow of blood to the parts, occurring at the outset of the process, seems to stimu- late the cell-elements to an abnormal activity, in which new cells are generated; the glands pour out their normal secretion in excess- ive quantities; an abundant liquor sanguinis transudes the vessels; and the result is an increased secretion of mucus, which is highly charged with young cells, many of them having their source within the epithelial cells, while others are emigrant blood-corpuscles. The membrane at the same time becomes swollen and reddened, as the result of the increased vascularity. If the irritation be more severe, the vascular phenomena are more marked; the cell-generation is more rapid; and as the result of this rapid generation they seem to fail of attaining maturity, and MUCOUS MEMBRANES. 53 are poured out in an unripe state; hence they are smaller, and not so well developed. Many of these imperfectly developed cells can- not be distinguished from pus-corpuscles; while others are larger, and resemble the mucus-corpuscles or leucocytes. Between the mucus-corpuscle and the pus-corpuscle we have no method of dis- tinguishing, except that the former is larger, and of a somewhat more regular outline. The epithelium also loosens, and falls off more rapidly from the surface of the membrane, under the stimulus of the inflammatory process; and as it progresses we have the mucous discharge gradually becoming a purulent one, from being so highly charged with these unripe cell-elements, many of which are vir- tually pus-cells. The process continuing, its activity, which so far has been largely confined to the superficial layer of the membrane, extends to the sub-epithelial layer, or the mucous membrane proper, which now becomes more involved, and the cell-elements here take on renewed activity, and becoming rapidly generated, they distend and infiltrate the parts. The membrane becomes thickened and more swollen; and there now may occur several secondary manifestations of the inflammatory process. As the result of the loss of surface epithe- lium, the membrane may become denuded of its epithelial coat, and there may occur an abrasion, or so-called catarrhal ulcer. As the result of the distention and infiltration of the membrane proper, the glands may become so choked that their contents are impris- oned, and as the result, there is formed a minute abscess, which breaking and discharging, there is left a small ulcer. The acute process may subside, or it may lapse into the chronic state. In this, the increased vascularity subsides to an extent, though the vessels remain permanently somewhat dilated. The cell-production, how- ever, goes on both in the epithelial layer and in the mucous mem- brane proper; and the increased secretion persists; but all in a somewhat diminished degree. Chronic catarrh differs from acute catarrh in that in the former the sub-epithelial layer of the membrane is much more involved. It is thickened and indurated -by its infiltration with the young cells before spoken of, the mucus-corpuscles, and migrating blood-cor- puscles; and also by a renewed activity in another elemental tissue of the membrane, viz., the connective tissue, which plays an import- ant part in chronic inflammation. This tissue is developed now by a slow process of proliferation, and by its peculiar characteristics gives rise to those features of chronic catarrh which render it ex- tremely obstinate to manage. Having been once developed, it is probable that connective tis- sue is never absorbed or excreted as the other cell-elements in 54 DISEASES OF THE NASAL PASSAGES. catarrh; but becoming organized, it remains a permanent element in the membrane to deform, disorganize, and interfere with its proper function. As the result, then, of the new deposit in the membrane, we may have its normal thickness so much increased as not only to interfere with its proper function, but also to impair by mechanical means other functions; as in the hypertrophied mem- brane of the nose, causing nasal stenosis, and thereby interfering with normal nasal breathing. Again, this tissue may be so depos- ited as to press upon the glands and follicles of the membrane in such a manner as to cause their atrophy, thus robbing the mem- brane of its proper supply of lubricating fluid, its mucus, and giving rise to the so-called dry catarrh. It may be deposited about the individual follicles or glands in such a manner as to press upon the outlet alone, thus closing them up, giving rise to small cysts; or their contents becoming imprisoned, undergoing fatty degeneration, and acting as a renewed source of irritation, there may occur a glandular hypertrophy of an individual follicle or gland, giving rise to the so-called follicular inflammation. In addition to this, we notice a tendency in chronic processes to differentiation, by which in the one case the morbid process expends itself upon the epithelial and lymphoid structures, while in the other case it acts upon the connective-tissue elements of the membrane. Thus, in the former we may havea chronic catar- rhal inflammation in which a rapid degeneration of epithelial cells occurs in such a manner as to increase to a very large degree not only their growth, but their loss from the surface, giving rise to a form of secretion from the membrane in which a large amount of mucus is thrown off, heavily surcharged with unripe epithelial cells, causing muco-purulent discharge. Thus, in the purulent rhinitis of children, to be described later,.the essential lesion consists in an intense activity in the epithelial structures. Again, we may have the same activity in the lymphoid cells giving rise to a forma- tive inflammation, as it were, in which the lymphoid cells are rapidly generated and remain a portion of the membrane, instead of being thrown off in the form of a purulent discharge. A lymphoid hyper- trophy is the result of this form of catarrhal inflammation, such as is met with in adenoid disease of the vault of the pharynx, or hypertrophy of the faucial tonsil, or enlargement of the follicles of the lower pharynx. Activity of morbid processes confined largely to epithelial and lymphoid structures, belongs essentially to the younger period of’ life, the diseases above referred to, it will be noticed, being all of them diseases of youth and childhood. The morbid activity in the connective-tissue structures, on the other hand, belongs essentially to later life, hence a chronic inflamma- MUCOUS MEMBRANES. 55 tion of the mucous membrane, resulting in a connective-tissue hy- pertrophy, such as in hypertrophic rhinitis, is essentially a disease of adult life. This is due probably to the fact that the develop- ment and ripening, as it were, of aconnective-tissue cell is a process of years, and that a true connective-tissue hypertrophy can only exist after a catarrhal inflammation has been in operation for a long period of time. Croupous Inflammation—This form of inflammation is of a higher grade, and of a more intense form than the catarrhal; for while it commences in the same manner, with distention of the blood-vessels, escape of liquor sanguinis and blood-corpuscles, and proliferation of cells, it differs from it in the fact that the exuded liquor sanguinis contains a large amount of fibrin and albumen, which coagulates upon the surface of the membrane, and forms a false membrane. This false membrane is of a more or less dense, firm character, and is composed of fibrin, inclosing a large num- ber of epithelial cells in its meshes. At times it may be soft and almost granular in character, so much so that it may be easily re- moved with a soft brush, coming away in small broken particles. At other times it may be of so dense a character that after re- moval it can be torn only with considerable force. Asa rule it can be easily removed, leaving the membrane beneath it in the main intact, merely deprived of some of its superficial epithelial cells. After removal, the same process may be renewed, and a new mem- brane form, or the parts may be restored to their normal condition. The favorite site for this form of inflammation is in the upper air-passages, the pharynx, tonsils, larynx, and trachea, though it may occur in the bronchi, intestinal canal, and other parts. Why this form of inflammation occurs, it is impossible to state; but it is not improbable that it is due to some previously existing blood condition, which dominates the inflammatory process, and so far enriches the exuded liquor sanguinis with the fibrinous material, that it coagulates on its exposure to the air, and so a false mem- brane is formed, in place of the fluid catarrhal discharge. Further evidence that this form of inflammation is due to some previous condition in the blood, is afforded by the fact that its onset and course are usually marked by a febrile movement, far more aggra- vated in character than we would expect to find as merely symp- tomatic of so limited an extent of local inflammation. The tem- perature in simple membranous sore throat, characterized by a croupous deposit on the tonsil, often ranges as high as 103°-104°. Croupous inflammation may manifest itself in a fibrinous exu- dation on the surface of a mucous membrane, as in croupous laryn- gitis, or true croup, membranous sore throat, croupous rhinitis, 56 ' DISEASES OF THE NASAL PASSAGES. etc.; or the exudation may take place in the follicles of the mem- brane, giving rise to an acute follicular inflammation, such as occurs in the affection generally known as acute follicular tonsillitis, which is a croupous inflammation of the tonsil, in which the exudation takes place in the crypts of the organ, rather than upon its surface. Diphtheritic Inflammation.—This variety of inflammation, again, is characterized by the formation of a false membrane, and also commences as a catarrhal inflammation, with its increased blood flow, cell proliferation, and exudation of liquor sanguinis, the exu- dation, as in the croupous form, containing largely of fibrin and albumen; but there is this difference, that while in the croupous form the exudation is poured out upon the surface of the mucous membrane, in the diphtheritic form it permeates and infiltrates its whole thickness, down to the submucous tissues. This exudation permeates the membrane so densely that in coagulating it completely destroys its vitality, and there results a dead membrane, involving the whole thickness of. the mucous membrane. It is removed with considerable difficulty; and in its removal, carrying with it the whole thickness of the membrane, leaves the parts beneath entirely denuded. The false membrane declares itself to the eye as a dead membrane, a genuinely necrosed or sloughing tissue, of a dark grayish color, resembling boiled mac- caroni; in contradistinction from a croupous membrane, which is of a bluish, pearl-gray color, presenting no appearance of necrosis, but rather of an unmistakably living tissue. It should be understood, in regard to these terms, croupous and diphtheritic inflammation, that they only refer to forms of inflam- mation to which mucous. membranes are subject, and not to the specific diseases which are spoken of under the names croup and diphtheria; as, for instance, membranous croup is generally under- staod to be a croupous inflammation of the mucous lining of the larynx, although a better classification would suggest the more expressive and correct name of croupous laryngitis; and also of diphtheria, it is a blood disease, characterized by a local manifesta- tion in the throat, consisting of an acute inflammation of its mucous membrane, which assumes the diphtheritic form; so that when we speak of croupous and diphtheritic inflammation, we simply define the form which the inflammatory process assumes. In regard to catarrhal inflammation, or as it is generally called, catarrh, the same may be said; properly speaking, it means that form of inflammation of a mucous membrane which is characterized by an' excessive discharge of mucus or muco-pus; but a better usage in the direction of an exact classification, would suggest that the local designation should be prefixed, as nasal, laryngeal, bron- chial catarrh, etc. CHAPTER IV. TAKING COLD. ALTHOUGH this is one of the commonest and most familiar of phenomena, both as a matter of clinical observation and of per- sonal experience, if we ask ourselves what especial influences pro- duce the morbid changes which we call taking cold, or what is the true relation between the recognized causes and observed effect, we find it somewhat difficult to give a correct answer to the ques- tion. Among the numerous theories advanced, may be mentioned that of Rosenthal, who asserts that the immediate effect of cold, acting on the surface of the body, is to excite contraction in the peripheral vessels, by which the blood is driven from the surface, in upon the internal organs, and acts there as an irritant, exciting inflammation. This view of the matter is somewhat mechanical, and scarcely ex- plains the action of cold in many instances. Not infrequently, as the result of an exposure, it is not really internal organs that be- come the seat of the consequent inflammation, as an attack of acute eczema, or acute conjunctivitis, may follow; or, as in the case of the commonest of all inflammatory affections resulting from exposure, an attack of acute coryza, a membrane so near the surface is involved that, under the action of Rosenthal’s theory, the blood should, to an extent at least, be driven from the membrane, rather than that it should be flushed upon it from without. Furthermore, as we know, mere mechanical congestion does not lead to true inflammatory action, as shown by the old familiar and often repeated experiment of ligating the efferent veins of the frog’s foot, and observing the result in the web under the microscope. It must be borne in mind that a cold does not result from a low temperature; in other words, absolute cold and taking cold are two entirely distinct expressions. A far more plausible view of the matter is that of Seitz. His theory is that disorders resulting from catching cold are due to the removal of heat to an unusual extent from the external or internal surface of the body; that this causes some functional disturbance, which in its turn gives rise to certain morbid processes in some portion of the body, far removed from the part immediately affected 58 DISEASES OF THE NASAL PASSAGES. by the cold. That the morbid changes are not due to the imme- diate or direct effect of this exposure, is evident from the fact, that as a rule, a certain length of time elapses before these changes set in. The theory of Seitz, it seems to me, is not complete, but leaves the matter still somewhat in the dark. The true action of cold upon the body, in producing morbid conditions, is probably on those nutritive changes which are constantly going on, and by which the animal heat is developed. This heat-production is going on in all the tissues of the body. In order that this function shall not be impaired, it is necessary that the normal temperature shall be maintained. This we know is 988°. Any marked deviation from this normal standard, as the result of extraneous influences, results in morbid changes. If heat-production is arrested in a portion of the body, under the action of intense cold, molecular death of the part ensues, as is the case when gangrene of a limb results from freezing. If the action of the cold is insufficient to arrest the nutritive processes of the part, it may cause only inflammatory action. In these cases, we have only the direct action of a low temperature on the organism. In the ordinary phenomena of “taking cold,” we have still the results of a low temperature acting on the heat-producing processes, but in an indirect manner. The direct action of the cold is, as a rule, upon the surface of the body, but the resultant morbid condition is upon some organ remote from the exposed part. In both cases, however, the cause and the ef- fect are the same, and the connection between the exposure, and the resultant inflammatory condition, is the disturbance of those nutri- tive changes in the tissues which result in the production of animal heat. I think this action may be fairly well illustrated by the famil- iar example of a chandelier of, say, six burners. If these are all lighted, each jet gives forth a steady and equable flame. If now four or five jets are turned off, the remaining jet burns up with a flaring and increased intensity. In the same manner, I think we may explain the phenomenon of an ordinary cold. The nutritive pro- cesses going on in the whole economy are governed by the central nervous system, and furthermore, a certain amount of nervous force is expended in the regulation of these nutritive processes. If,as the result of exposure to cold, these nutritive changes are arrested in a certain portion of the body, the same nervous force being sent out from the central system, it will be understood how this local arrest of the nutritive process in one portion would be attended with a certain amount of increased nutritive activity in another portion; the activity of the nerve centres going on as before. Now, increased nutritive activity constitutes inflammation, and this inflammation locates itself at the point of least resistance, viz., as TAKING COLD. 59 a rule, at some point in the economy where a mild chronic in- flammatory process is going on, which is lighted up into an acute process as the result of a cold. It is not then from an expo- sure of the whole body, that a cold is contracted, but from an ex- posure of a part of the body, as the result of which the phy- siological processes of heat production in that part alone are disturbed, giving rise to increased nutritive activity or inflamma- tion in some organ, far removed perhaps from the site of the pri- mary exposure. Asa matter of clinical observation, we know that colds occur during the spring and fall months, seasons which are characterized by moderately low temperature, but with notable dampness of the atmosphere, together with considerable atmo- spheric motion, or high winds. Hence we recognize that there are three factors generally necessary for the production of ‘‘a cold,” low temperature, air in motion, and moisture. It is also necessary, as a rule, that one or more of these factors should act for a some- what prolonged duration of time. As we know, the momentary action of an intense cold, or draft, or moist atmosphere, does not usually result in any morbid changes, but it is only after a some- what prolonged exposure of the body that the familiar phenomena of a cold ensue. In our ordinary life, there are few of us but that are subject to slight temporary exposures with impunity; as for instance, upon rising in the morning in a cold room, changing one’s clothes, etc. On the other hand, the sitting in a draft for a pro- longed period, with even only a small portion of the body exposed, may lead to serious or grave morbid changes. Among the most familiar causes of taking cold may be enumerated, sitting in a draft, wearing insufficient clothing, wearing thin-soled shoes, insuf- ficiently protected feet, going from a warm room toa cold room, slight exposure while perspiring, etc. Wearing thin-soled shoes, or insufficiently protected feet, is a very prolific source of trouble; as the loss of heat in this manner is far greater than is usually rec- ognized. Especially is this the case if the soles of the shoes are damp, as in this case, of course, the radiation takes place much more rapidly. Again, when the body is perspiring. the loss of heat is going on with considerable activity; hence we find that in this condition, even a slight exposure is liable to result in far more serious dis- turbance than would occur from the same exposure were the body not in an overheated condition. There should, however, be borne in mind this difference, if the perspiration is the result of violent exercise, all the nutritive processes are stimulated to an abnormal activity, animal heat is being generated rapidly, and the perspira- tion necessarily sets in as a conservative measure, to prevent too 60 DISEASES OF THE NASAL PASSAGES. great accumulation of heat in the system, but still as the direct consequence of the violent exercise. If now, in this condition, the body is exposed to the influence of cold, and the perspiration sud- denly checked, very serious consequences may ensue. If, however, on the other hand, a copious perspiration is brought on by artifi- cial means, while the body is in a state ‘of quiescence, as in the hot room of the Turkish bath, the heat source is from without, the heat-producing forces of the system are not disturbed, and the cold plunge, while of course it suddenly checks the perspiration, does not, as a rule, give rise to any untoward consequence. Moreover, the exposure by the cold plunge is only temporary and of short duration, and by the subsequent manipulation, any serious loss of heat which mzy have resulted is speedily and completely restored. A swimmer will remain in water at a temperature twenty or thirty degrees below that of the body, and that, too, for a some- what prolonged period of time; but while in the water, he is ina state of constant and laborious activity, thereby setting in play those processes by which animal heat is generated. But even with this constant activity, if the bath becomes too prolonged, there comes a time when the body is unequal to the task of supplying sufficient animal heat to make up for the loss, and the bather suc- cumbs to the direct influence of this tremendous drain upon the system. But here the result is not an inflammatory attack, as usu- ally accompanies an exposure to cold, but on the contrary it pro- duces great prostration, violent cramps, weakened circulation, intense venous congestion, and in fact, evidence that the whole system is robbed of its normal heat, which tends to retard all healthy functional activity in the body; whereas the results of an exposure to cold are due to a localized arrest of heat production, and a dis- turbance of the balance, as it were, by which nutritive activity goes on in the system. As was said before, the loss of animal heat does not directly produce these morbid changes, but creates or gives rise to certain functional disturbances, with the nature of which we are not entirely acquainted, and these give rise, after a certain in- terval of time, to the morbid changes which we call taking cold. This interval may be short, lasting perhaps but a few hours, as is usually the case in slighter disorders, or it may be prolonged one or two days, or even more. In this case, as a rule, the resultant disorders are of a more serious character. There is generally at- tendant upon taking cold, fever of a more or less marked character. That this fever is not symptomatic, but an essential fever, is shown by the fact that it stands in no constant relation to the morbid changes which result, as in even slight disorders we may have the febrile motion more marked than the fever which accompanies the TAKING COLD. 61 more aggravated forms of inflammatory troubles which may arise from a cold. Moreover, the fever generally sets in immediately after exposure, and when the later morbid changes appear, no in- crease of fever, as a rule, is detected. As regards the local dis- orders, which result from an exposure to cold, we find them mani- festing themselves in any part of the body. We may have acute coryza, pharyngitis, gastric catarrh, muscular rheumatism, cystitis, or, in fact, an attack of inflammation involving any of the organs of the body, as the result of a cold. Owing to their exposed situa- tion, being the first to receive the current of inspired air, with its impurities, or whatever of irritating qualities it may possess, the upper air-passages are perhaps more subject to inflammation than any other portions of the body, and once having become the seat of morbid: changes, there is always a liability to a recurrence of the attack, from a slighter exciting cause than that which gave rise to the first attack. Hence, it is probable that catching cold, in a very large major- ity of cases, develops in an attack of acute inflammation of some portion of the upper air-passages, as being the point of least resist- ance, and further, as these attacks recur with increased frequency and gravity, we find that the morbid process localizes itself farther down, and nearer to the vital centres, and finally this liability, so called, to take cold, which at first manifested itself in attacks of simple coryza, or sore throat, gives rise to a bronchitis, or some still graver affection which, fixing itself upon the lungs, may prove far less amenable to treatment than the simple attacks which preceded it, or even lead to the development of those still graver forms of pulmonary disease, in the management of which our present thera- peutic resources are so feeble. The question is often put to the physician, whether a catarrh will lead to the eventual development of lung disorders; and it seems to me that the answer should be that it may, and that it often does, in the manner above noticed. This may not occur by absolute extension of the inflammatory process, but there can be no question that an individual suffering from a chronic laryngeal catarrh is far more liable to an attack of tracheitis, and that one suffering from a tracheitis is far more sus- ceptible to a bronchitis than one in whom there exists no catarrhal inflammation, and so on, down to the deeper lung tissues. Other causes, of course, may operate in inducing such a sequence of events, such as an impairment of the general health from any cause, but a prominent factor still remains in the existing catarrhal in- flammation above. As regards this so-called liability to take cold, it should be un- 62 DISEASES OF THE NASAL PASSAGES. derstood that this, in a large majority of cases, and probably in every case, is due to an existing chronic catarrhal inflammation, of perhaps so mild a type as to give rise to but very trivial symptoms, or even pass unnoticed; but still, an existing catarrh, the result probably of a neglected cold, and the renewed attacks to which the individual becomes so liable, consists in a lighting up of the old trouble. As each fresh attack subsides, the resolution which the inflammatory process undergoes is less complete, the chronic trou- ble makes itself known by more decided symptoms, fresh colds occur with greater frequency, and there is finally established a chronic catarrh, be it laryngeal, nasal, or of any other part, with its many annoyances, its intractability, and unquestionably the possi- bility of its leading to graver trouble lower down in the air-passages. Our concern, of course, is mainly with affections of mucous mem- branes; but in those cases in which we find that a cold gives rise to an attack of rheumatism, gastric catarrh, cystitis, or any dis- order other than a catarrh of the lining membrane of the respira- tory tract, probably the same rule holds true as before; from some inherited tendency, or acquired weakness, the parts involved in these affections have become the points of least resistance, and hence invite those morbid changes which result from exposure to cold. PREVENTION OF A COLD.—The natural deduction, of course, from what has been said before is, that those conditions which give rise to a cold should be avoided; especially should this be enjoined upon those possessing hereditary tendencies or weaknesses, and those of whom we speak as liable to take cold. These directions, of course, are more important in the months of the year when we have, to the greatest extent, the prevalence of those conditions which, as we have seen, are concerned in the production of a cold: as low temperature, moisture, and air in motion; these we find in the spring and fall. Perhaps the most important direction that can be given in regard to preventing colds, is as to the proper regulation of the clothing. The body should be sufficiently clothed for warmth and comfort, no less and no more. If too little clothing is worn, there will neces- sarily result a loss of animal heat. If too much is worn, the body becomes overheated, and perspiration necessarily ensues to reduce the temperature and restore the proper equilibrium, and conse- quently, as we have before seen, a condition arises in which the _ body is extremely sensitive, and in which it is especially liable to succumb to the influence of cold or moisture. This rule in regard to clothing the body applies to all parts of it. The mistake should always be avoided of coddling any portion, or of leaving any por- tion insufficiently protected. A very frequent and common error TAKING COLD. 63 is fallen into by many, of crowding on too much clothing upon those portions of the body which they suppose to be subject to some special weakness; as for instance, many people, supposing themselves to have weak lungs or throats, fall into the error of piling wrap upon wrap, muffler upon muffler, around their necks and about their chests, thereby encouraging the very condition which they fear, and incurring the risk they desire to avoid; for the excessive muffling of the parts necessarily leads to perspiration, and consequently the danger of its being suddenly checked upon the removal of the wraps. I know of no more prevalent mistake, nor one which is a more prolific source of mischief, than the habit which prevails to so great an extent among us, of muffling up the neck. Especially is this the case when a cold is contracted which develops in a sore throat. Asarule, when a sore throat comes on, the very first remedy which is adopted is to tie a piece of red flannel about the neck. The only advantage of this procedure lies in a certain amount of counter-irritation, due to the harsh fibre of the flannel rubbing against the skin. Aside from this, there is no possible good to be accomplished. It is put on for a protection; it simply renders the neck and throat more sensitive, and entails a greater liability to take another cold. Of course, what is said about the neck may be said about any other portion of the body. There could be no greater error than to suppose that mufflers about the neck protect the throat or that the chest is protected in any way by extra thickness of covering about it. Indeed, the contrary is quite true. Perhaps the very worst place in which to wear the so-called chest protectors, sold in the drug stores, is on the chest. The chest is infinitely better protected, in one liable to bronchial attacks, by an extra sole worn on the boot, than by a felt pad worn across the chest. The whole theory of clothing should be based on the idea that exposure to cold results in an interference with nutrition in some part of the body. Therefore, to prevent taking cold, the heat-producing force of the body should be thoroughly and equably protected in all parts; in other words, the clothing should be uniformly distributed over the body, with simply enough of it for comfort, and absolutely no more. The selection of the proper fabric to be worn next the skin is too often dictated by a consideration of luxury, rather than of health. The most important function that goes on in the skin, is that by which the body is kept at an equable temperature, by means of perspiration. Theoretically, this is accomplished by means of an insensible perspiration, and practically too, except under extraordinary circumstances, when the perspiration becomes profuse. Now this function of perspiration, or heat radiation, takes 64 DISEASES OF THE NASAL PASSAGES. place best when the fabric next the skin is a thoroughly porous one. We have no fabric comparable to pure wool in this respect; the virtues of this fabric being, I take it, due to the fact that wool- fibre is highly elastic, and also curls upon itself in such a way, as that when converted into thread, and woven into a garment, it still affords a highly elastic and porous textile fabric, which best ad- mits of the escape of heat. Silk probably would never be worn as underwear, were it not for the fact that it is the most expen- sive of fabrics. From a sanitary point of view, its use is very objectionable, in that cutaneous transpiration is interfered with. The same is true of cotton and linen, in that their fibre is per- fectly straight, and is also inelastic. A textile fabric, manufactured from material of this character, is denser and less porous than one made from the kinky wool fibre. Hence the latter furnishes us with a material for underwear which in the least degree interferes with the important function of the skin, above alluded to. As re- gards the heat-conducting properties of these different materials, this I regard as a matter of little moment, as compared with the far greater importance of wearing next to the skin a thoroughly porous and elastic fabric. It is the’ habit to change the thickness of the underwear twice and sometimes even three times during the year, through the vary- ing degrees of cold and heat. This plan is not wise in all cases, and is even a source of mischief. We practically live, during a large portion of our time, in much the same temperature, summer and winter, or rather, we endeavor to keep our houses during winter, at a temperature of about 70°. I doubt very much then the wis- dom of wearing very heavy underwear in rooms heated to this degree of heat, as the necessary consequence is a more or less pro- fuse perspiration. A better plan is, therefore, to wear the same thickness of underwear throughout the year, while the protection from the extreme cold of winter is supplied by a change in the outer garments. As before stated, excessive covering should be avoided under all circumstances. This perhaps is a greater error than insufficient protection, although the latter is undoubtedly a frequent source of trouble. This may be said, perhaps, in regard to the feet, quite as much as of any other part of the body, for coming in contact, as they do, with cold floors and pavements, especially when there is water or moisture on the ground, the loss of heat from the general system from that source is necessarily rapid, unless the foot is thoroughly well protected by a thick, dry sole to the boot. There are few but have experienced the direct effect of standing in slip- pers or thin-soled shoes upon a damp or cold pavement, and noted TAKING COLD. 65 the rapidity with which such exposure makes itself felt. In our climate, with its sudden and marked changes of temperature, the proper regulation of the clothing becomes a matter of considerable importance, and perhaps of no little difficulty. The hands and face are rarely covered, as a rule, or protected, and yet we never take cold from their exposure. The deduction is obvious; if cer- tain parts of the body may be exposed with impunity, the converse conclusion is suggested, that by keeping our bodies too warmly clad we have thereby engendered a necessity, which possibly might have been avoided, with benefit to the health and vigor of the sys- tem. The rule may be safely laid down, that, in clothing the body, the trunk and limbs should be made simply comfortable, but never wrapped to the extent of inducing perspiration by the amount of clothing. The foot should be covered with a boot or shoe, with a sole sufficiently thick to prevent the cold or dampness of the pave- ment being felt through it. The neck should never be muffled, or covered with thick wraps or furs, unless rendered necessary by the piercing winds or cold of midwinter, as a mere matter of pro- tection. The head is endowed by nature with its own protection; hats and caps are luxuries, born of modern civilization; had they never been worn, mankind would be better off, and the demand for hair restorers would never probably have existed. Hats and caps, however, being a necessity of modern life, should be light, well ventilated, and designed to retain as little heat as possible; they should not be too heavy, or press with too much weight upon the head, the crown should be perforated, to allow of as free circula- tion of air as possible between the top of the head and crown of the hat, and should be constructed of such material as will allow of the escape of heat. ; The hair, the natural covering of the head, should be so regu- lated as to avoid the exposure resulting from the removal of a considerable amount at one time by cutting; if it possesses a lux- urious growth, it should not be cut when the removal of so much protection of the head is liable to result in catching cold. In short, the body in all its parts should be made comfortable. It should not be so clothed as to cause perspiration, nor that chill- ing can occur. It is said that sealskin sacques have caused more deaths than small-pox in New York, in the last five years. I have no doubt that this is quite true, and the fact is due simply to the vanity or indolence by which a woman will go from the cold air into a warm room, with her sacque on, and remain there for hours, it may be, without removing it. In addition, it might be said that very much harm is done by the habit of wearing heavy clothing, and sitting in overheated rooms. Those who allow themselves to 5 66 DISEASES OF THE NASAL PASSAGES. grow into the habit, by which they are only comfortable in a room at 80°, are simply making hot-house plants of themselves, and are engendering a condition of the system which renders its resisting power very feeble. It is purely a habit, and one easily overcome, not only without risk, but with undoubted benefit to the individual, in the increased vigor of body which will result. In our variable climate, where the daily changes are oftentimes so great, it is a mistake to suppose that we can so regulate our clothing as to protect ourselves from the results of these great changes. We protect ourselves from absolute cold by wearing clothing, but not from taking cold. We protect ourselves from taking cold, by so regulating our habits of life as regards clothing, etc., that we expose ourselves to these changes with impunity. In other words, we inure ourselves to the climate. Perhaps no better aid to this is afforded than in the use of the bath. I think the direct connection between the daily use of the bath, and the avoid- ance of taking cold, will be clearly understood if what has been stated is true, viz., that taking cold is a disturbance of the heat- producing forces, and furthermore, that the nice adjustment of the animal heat in the body, is regulated by the function of cutaneous transpiration, and hence depends on the healthy functional activity of the skin. Perhaps we have no better way of maintaining this function at the highest point of healthy activity, than in the daily use of the cold bath. For those whose physique is equal to it, the daily use of the cold plunge or shower bath is to be recommended, as the best protection possible against taking cold. If this is not well borne, it is indicated clearly by the feeling of lassitude, and chilly sensations, which will follow the use of the bath; the contrary being indicated by the sense of warmth and general invigoration which attends its use. If the plunge or shower is not tolerated, the cold sponge, either of the whole body or to the waist, is to be com- mended. The time at which the bath should be used is preferably in the morning, in that not only the night sleep is a better prepa- ration for it, but also the exhilaration and vigor which follow it, is an excellent preparation for the labor of the day. The Turkish bath, which has become so deservedly popular in our day, while © undoubtedly a luxury, is to be commended with a certain amount of reserve as a preventive, or in the treatment of a cold. Itisa popular saying, that after a violent perspiration the pores of the skin are so thoroughly opened that the cold gets in, as it were. Of course this is an error. Perspiration due to violent exercise ren- ders one liable to a cold if exposed to a draught. The excessive perspiration of the hot-room of a Turkish bath does not expose one to the same extent, but I think there is an exposure even in TAKING COLD. 67 the Turkish bath, especially in the shampooing room, which follows immediately the hot-room, where one is apt to receive a slight chill. As a luxury, then, the use of a Turkish bath is certainly warmly to be recommended. By those suffering from weakness of the upper air-passages, or who are especially liable to take cold, its use is to be resorted to with a certain amount of watchfulness. These suggestions are, of course, such as every physician is familiar with; they are given here, however, more in the way of suggestions than for instruction, for we are far too prone to over- look and forget them, in our dealings with our patients, and allow them often to violate, through ignorance, simple laws of well liv- ing, whose observance might save them much suffering. TREATMENT OF A COLD.—It is very much to be deprecated, that, as a rule, an ordinary cold is allowed to take its own course with- out treatment. Ifa part has once become inflamed, and is permitted to undergo resolution without interference, it is left in a weakened condition, which invites renewed attacks from a very slight cause; for when the acute inflammatory process subsides, complete reso- lution does not take place, but there is left a morbid condition, very mild in character perhaps, but nevertheless one of chronic inflam- mation. This may be so slight as to be scarcely noticeable by the , patient, and yet it is this condition, which takes on a renewed in- flammation from a very slight provoking cause, which oftentimes the patient would escape did it not exist. The ordinary plan of treatment of a cold is so simple, and involves so little trouble, that it is the duty of the physician to urge that all cases, however sim- ple, should be subjected to it. Remembering the causes, as laid down above, which operate in the production of a cold, the first indication for treatment will be to supply as promptly as possible the deficiency caused by this loss of body heat. If this can be done in the early stages, when the secondary inflammatory process has not progressed, or better still, before it has set in, viz., during the preliminary febrile stage, the further progress of the disorder may be promptly arrested; this constitutes what we generally call the abortive plan of treatment. This plan consists, in short, of producing copious perspiration; this perspiration, be it remembered, however, is not primarily the ob- ject it is desired to attain, but ‘it is simply the evidence that that object has been attained. The condition to be corrected is loss of body heat; the measures resorted to for this are measures which have a tendency to increase body heat. The evidence that this has been accomplished, viz., the restoration of this heat, or even more, that an excessive heat has been produced, is manifested by the perspiration. If this so-called sweating can be brought on in the 68 DISEASES OF THE NASAL PASSAGES. early stage, it serves the purpose of arresting the future progress of the trouble, and putting an end to the inflammatory process. If it can be brought about early in the progress of the inflammatory stage, its gravity can be very materially lessened; hence, the earlier this abortive treatment is resorted to, the better the result. The means of accomplishing this is by simple remedies, familiar to all. A decoction of hot tea, taken at bed-time, with the addition of a foot-bath, and a moderate dose of Dover's powder, is all that is necessary; after which the body should be warmly covered in bed, and extreme care exercised to prevent any exposure while the perspiration is going on. If the constitutional symptoms assume a graver form, that is, ifthe fever seems excessive, and the effect on the general system marked, much benefit will be gained by the administration of ten grains of quinine, in connection with the diaphoresis. It is generally asserted that following a copious per- spiration there is danger of contracting additional cold, on leav- ing the bed in the morning. This probably is a mistake, although the simple precaution should always be taken of allowing the body to cool off gradually before rising, by removing a portion, at a time, of the bed covering, and also remaining indoors for a few hours after dressing. If, as the result of this treatment, all symp- toms disappear, little else is needed, except the exercise of ordinary precaution. : If, however, the inflammatory stage has set in, and the result of the sweat has been simply to modify, and not to remove it, other measures, directed to the special locality of the inflammation, should be resorted to. The remedies indicated will be referred to when we come to treat of special diseases. Confinement to the house should be urged in all cases, as of equal if not of greater import- ance than therapeutic measures, especially if the inflammatory con- dition shows any possible grave tendencies. CHAPTER V. THE ANATOMY OF THE NOSE. THE EXTERNAL NOSE. THE external nose, the most prominent feature of the face, is composed of a bony and muscular tissue and in- tegument. The bony portion of the frame- work is composed of the nasal bones, and the na- sal processes of the supe- rior maxillae. The Nasal Cartilages. —The cartilages are five in number, the two upper and two lower lateral car- tilages, often called to- gether the alar carti- lages, and a single carti- lage in the median line supporting these, the tri- angular cartilage of the septum. At the junc- tion of the lateral cartila- ges with the bony frame- work, two or three sesa- thoid or accessory car- tilages are ordinarily found (see Fig. 53). These cartilages are joined to each other and to the bony framework, by articulations which © cartilaginous framework, covered with Fic. 53.—Cartilages of the Nose, seen in Profile. (Sappey.) 1, Right lateral cartilage; 2, its anterior border; 3, an accessory car- tilaginous nucleus attached to the inferior border of the same cartilage; 4, anterior accessory cartilages remarkable for their ovoidal form and the constancy of their existence; 5, external branch of the alar cartilage; 6, union of this branch with the in- ternal branch; 7, 8, 9, secondary cartilaginous branches added to the external branch of the alar cartilage; 10, accessory cartilage not constantly found. allow of acertain amount of motion, which is accomplished through the action of muscles distributed upon their outer surfaces (see Fig. 54). 70 DISEASES OF THE NASAL PASSAGES. The External Muscles of the Nose-—These may be divided, for the sake of brevity of description, into those which dilate the nos- trils, and those which contract them. To the first group belong the levator labii superioris alzequi nasi, which, arising from the nasal process of the superior maxillary bone, passes obliquely downward and outward, and is inserted into the alar cartilage; the dilator naris posterior, arising from the nasal notch of the superior max- illa and from the sesamoid cartilages, is inserted into the skin near the margin of the nos- tril; the dilator naris anterior, whose origin is entirely cartilaginous, and lies immediately in front of the preceding; the compressor nasi, which arises near the incisive fossa, and is in- serted by means of a broad aponeurosis into the fibro-cartilage of the tip of the nose, in conjunction with its fel- low of the opposite side. The only muscle which diminishes the lumen of the nostrils is the depressor alz nasi, : which arises from the i incisive fossa, and, lying ee ee ee Ge between: the mmuraus muscle; 3, labial fibres of this muscle; 4, deep portion of thismus- membrane and the SE ee ene es 6s OE eC anuadles of the Uippap nose; 7, Pyramidalis; 8, 9, transvere muscular fibres which con- pears to be inserted in- verging posteriorly pass beneath the anterior border of the levator. to the septum and pos- terior portion of the ala of the nose. In the lower animals these muscles are highly developed, and perform an important function in the economy, both with reference to respiration and olfaction. In man, however, their importance is not great, although they per- form minor duties in connection with respiration, and possibly in the modification of facial expression. THE NASAL FOSSA. The nasal passages are composed of two wedge-shaped cavities, extending from the nostrils in front, to the posterior nares, two THE ANATOMY OF THE NOSE. 71 oval-shaped openings, by which they communicate with the upper pharynx. The roof of these cavities is narrow, and somewhat arched from before backward, and is composed of the nasal bones in front, the body of the sphenoid behind, and the cribriform plate of the ethmoid between them. The floor is formed by the palatine processes of the superior maxilla and the palate bones. The two cavities are separated from each other in the median line by the septum, which is composed of the perpendicular plate of the eth- moid above, and the vomer below. The articulation of these two bones with each other, leaves anteriorly a triangular space which is filled by a cartilaginous plate, the triangular cartilage of the septum. Up to the seventh year of life the septum lies in the median line, but after this time, as Zuckerkandl* has pointed out, there is usually some slight deviation to one or the other side, not, however, enough to encroach in any degree upon the breathing space. The outer wall of each cavity is formed by the superior maxillary, lachrymal, palate and sphenoid bones, and is traversed antero-posteriorly by three scroll-shaped bones, commonly called the turbinated. The lower turbinated bone is a very thin lamella of osseous tissue, curled upon itself, and forming a scroll, as it were, which is attached to a slight horizontal ridge presenting on the outer wall of the cavity. The extent to which this bone is curled upon itself varies in different cases. The lower border of the bone may be smooth, or incisures of various depths may be seen along its sur- face. The middle turbinated bone belongs really to the ethmoid, and hence it is sometimes called the lower ethmoidal turbinated. It consists of a broad, thin plate of bone, which, springing from the lateral mass of the ethmoid, passes downward, and is curled upon itself in the same scroll-shaped manner as the lower turbinated. The superior turbinated springs also from the lateral mass of the ethmoid. It is smaller and less scroll-shaped,.and really pre- sents but a small ridge on the outer wall of the cavity, which, while in its posterior portion it is entirely distinct from the middle tur- binated bone, anteriorly, is merged with and lost in it. A fourth turbinated bone, designated as the concha santoriniana, has been described by anatomists. Zuckerkandl? has found it in fifty-five cases out of 150. Voltolini? says that this fourth turbi- nated bone is found normally in the negro race. These turbinated bones are nearly parallel with one another, 1“ Anatomie der Nasenholen,” Wien, 1882, p. 45. 2 Op. cit., p. 31. 3 ‘* Rhinoscopie und Pharyngoscopie,” Breslau, 1879, p. 70. 72 DISEASES OF THE NASAL PASSAGES. and divide each cavity into three passages; the lower meatus, be- tween the floor of the nose and the lower turbinated; the middle meatus between the lower and middle turbinated bones, and the superior meatus between the middle and superior bones. In the normal state that portion of the fossa, bounded by the cartilaginous framework, consists of a smooth-walled ovoidal cavity, which is suspended in front of the lower and middle passages, and is usually termed the vestibule. In the anterior third of the lower anpan-e= ty eae FiG. 55.—Lateral Wall of the Right Superior Maxilla, seen from Within, the Soft Parts being Removed. (Zuckerkandl.) a, The unciform process of the ethmoid bone; 4, spaces between the unciform process, the lower turbinated and the palate bones leading into the antrum, normally closed by the soft parts; c,a pro- cessus maxillaris; ¢, point of union between the unciform process and the lower turbinated bone; e, a portion of the furrow between the unciform process and the bulla ethmoidalis; g, bulla ethmoidalis; 7, the lach- rymal bone. meatus, below the lower turbinated bone, is found the opening of the lachrymal duct. Aside from this, the lower meatus presents no points of special interest. Zuckerkandl* attaches a certain amount of importance to the fact that the outer wall of the cavity may be more or less hollowed out, thus encroaching upon the cavity of the antrum. The middle tubinated bone is more or less scroll shaped, like the lower turbinated, and may be described as projecting into the T Op. cit., p. 34. THE ANATOMY OF THE NOSE. 73 nasal cavity from the lateral mass of the ethmoid. As a rule, the outlines of this bone are convex, although in many instances we have it presenting a concavity toward the median line. Zucker- kandl* finds, in a certain number of cases, that the ethmoidal cells may be continued into the body of the middle turbinated bone, thus giving rise to certain abnormalities of contour, as for instance, when its anterior termination presents a rounded expansion, con- sisting of a hollow bony shell covered with mucous membrane. This tumor may attain sufficient dimensions to close the normal orifices of the frontal and maxillary sinuses. Beneath the middle turbinated bone, lies the long unciform pro- cess of the ethmoid (see Fig. 55). This may be described as a narrow bony plate, running downward and backward from the tip " of the middle turbinated, and almost parallel with its lower border. Its purpose is twofold: to articulate with the superior maxillary bone, by means of thin bony plates, projecting from it, to the wall of the antrum, and with the inferior turbinated by delicate pro- cesses from its lower border. These last-named processes close to a greater or less extent, the opening between the nasal cavity and the antrum of Highmore. Just above the anterior termination of the middle turbinated bone, we find a rounded bulging of the ethmoidal cells, where the ethmoid articulates with the nasal process of the superior maxilla, the agger nasi, as first described by H. Meyer.’ Beneath the middle turbinated bone, and extending from near the anterior extremity downward and backward, is seen a deep hiatus, the hiatus semilunaris (see Fig. 56). This is, as its name implies, crescentic in shape, and has a direction downward and backward, the convexity looking forward. This furrow is bounded above by a prominence, which is in reality an expanded ethmoidal cell, and is known as the bulla ethmoidalis, below, by the unciform process already described. The superior extremity of the hiatus semilunaris presents a somewhat circular opening, the orifice of the frontal sinuses. Following this furrow backward, we find it merging into an opening of a more or. less circular shape, and of varying dimensions, the ostium maxillare, leading, as the name implies, into the maxillary sinus. This opening is sometimes absent.3 Behind this, opening, we occasionally find a second leading into the same cavity, known as the ostium maxillare accessorius. In this same furrow we also find the openings of the anterior ethmoidal cells, somewhat irregular in their location, but asarule near the orifice of the frontal sinuses. * Op. cit., p. 29. 2‘ VLehrb. d. phys. Anat.” Leipzig, 1856. 3 Zuckerkandl, op. cit., p. 41. 74 DISEASES OF THE NASAL PASSAGES. Above the middle turbinated bone we find the superior meatus, of chief interest from the fact, that into it open the posterior eth- moidal cells and the sphenoidal sinus, by means of the recessus Fic. 56.—Outer Wall of Left Nasal Cavity, the Inferior and Middle Turbinated Bones having been Removed. (Zuckerkandl.) A, Roof of nose; BZ, floor of nose; 4, Hiatus Semilunaris and ostium maxillare; c, portion of outer wall of nose encroaching upon cavity of antrum; @, opening of lachrymal canal; "2, bulla ethmoidalis; g, small canal between anterior insertion of middle turbinated and the ethmoidal cells; 7, Os- tium frontale; 4, furrow forming boundary between the nasal and nasopharyngeal cavities: ethmoidalis. This small opening lies in the very posterior part of the superior meatus, and when a fourth turbinated bone is present, is situated immediately behind this. r THE ACCESSORY SINUSES. Communicating with each nasal fossa, there are four cavities, usually designated as the accessory sinuses. These are the maxil- lary, frontal, sphenoidal, and ethmoidal sinuses. The Antrum.The maxillary sinus, or antrum of Highmore, the largest of these accessory cavities, is a pyramidal-shaped cavity, hollowed out of the body of the superior maxilla. Its roof is formed by the floor of the orbit; its inner wall is composed of the outer wall of the nasal cavity, while its anterior wall is the malar process of the superior maxilla, the posterior aspect of the cavity THE ANATOMY OF THE NOSE. 75 forming the zygomatic face of the superior maxilla. This cavity varies considerably in individuals, and even among races. Thus, the depth of the canine fossa may encroach notably upon its ante- rior wall. As the result of this peculiarity, in the Mongolian races, this cavity is usually small, as noted by Zuckerkandl.? Or, again, deficient absorption of the alveolar processes in foetal life, may produce marked encroachment upon the lower portion of the cavity. On the other hand, the cavity may be abnormally enlarged from excessive absorption of osseous tissue in foetal life, downward into the alveolar process (see Fig. 57) or forward, as the result of Fic. 57.—Transverse Section through the Nasal Cavities, and Maxillary Sinuses, Showing Irregularities of Development in the Latter. (Zuckerkandl.) «, Antrum enlarged by absorption of the alveolus. which the antrum may extend between the floor of the nose and the hard palate, as seen in Fig. 58, or it may extend up into the malar bone or into the frontal, as the result of a similar process of absorption in this direction. The Frontal Sinuses.—The frontal sinuses are two triangular- shaped cavities, which lie between the two tables of the frontal bone, the floor being formed by the roof of the orbit. They are absent in childhood, but become developed in adult life. They communicate with the nares through the infundibulum, a rounded opening in the anterior extremity of the hiatus semilunaris. Occa- sionally these sinuses are entirely absent. Asa rule, they are sep- arated from one another, but more frequently than in any other of tOp. cit., p. 102. 76 DISEASES OF THE NASAL PASSAGES. the accessory sinuses, a normal opening exists from one side to the other, and in still rarer instances, an opening is found between the frontal sinus and the orbit, as seen in Fig. 59, or between this cavity and ethmoidal sinuses. The Sphenotdal Sinuses.—The sphenoidal sinuses are two compar- atively large rounded cavities hollowed out of the body of the sphe- noid bone, and are separated from each other by a thin lamella of bone or septum. They communicate with the nares by a small ‘opening into the superior meatus. These sinuses are also occa- Fic. 58.-Transverse Section through the Nasal Cavities and the Maxillary Sinuses, Showing Irregular- ities in the Development of the Antrum. (Zuckerkandl.) a, Palatine portion of the antrum projecting be- neath the floor of the nose; 4, small bony ridge; c, groove of the infra-orbital canal; d, infra-orbital portion of the antrum; ¢, prolongation of the antral cavity into the malar bone. sionally absent, their places being filled by solid bone. Zucker- kandl* has also found, in rare instances, instead of two lateral si- nuses, a horizontal plate dividing the cavity, in which case the upper cavity opened directly into the ethmoidal cells, the lower opening into the nasal fossa. A still rarer anomaly is that in which the anterior wall is entirely wanting, the cells opening directly into the ethmoidal sinuses. The Ethmoidal Sinuses—The ethmoidal sinuses differ from all the other accessory cavities, in that, instead of being large hollow cavities, they are composed of a large number of small cells, sepa- ? Op. cit., p. 171. THE ANATOMY OF THE NOSE. 77 WS Fic. 59.—Abnormal Opening between the Frontal Sinus and the Orbit. (Zuckerkandl.) 3, Point 1£ abnormal communication, : Fic. 60.—Abnormal Opening between the Ethmoidal Cells and the Orbit. (Zuckerkandl.) a, Point of abnormal opening. 78 DISEASES OF THE NASAL PASSAGES. rated from each other by thin lamelle of bone. They divide them- selves naturally into two groups, the anterior and the posterior ethmoidal cells; the anterior opening into the nasal cavity in the hiatus semilunaris by means of small openings called the ostia eth- moidalia, while the posterior group opens into the superior meatus, The ethmoidal cells are less definite in their boundaries than any of the others, as they may extend either into the sphenoidal cells pos- teriorly, or into the frontal sinuses. Again, we may have an abnor- mal opening into the orbital cavity, as seen in Fig. 60, in conse- quence of which emphysema of the orbit may occur. The mucous membrane lining these sinuses is continuous with, and differs in no marked degree from that lining the nasal cavities, unless we note.that in the maxillary sinuses the membrane is thrown into folds by a sort of redundancy of tissue, as it were. THE Mucous MEMBRANE. The mucous membrane lining the nasal cavities is continuous with that of the pharynx, and extends into the Eustachian tubes and the accessory cavities. Its superficial layer is composed of columnar epithelium in the upper portion of the cavities, as low as the middle turbinated bones, and the upper third of the septum. The remaining portion of the lining membrane is endowed with columnar ciliated epithelium, although, according to some writers, the epithelium is also ciliated in some portions of the olfactory tract. This fact becomes of some importance, in connection with those diseases of the cavity which act to destroy, or impair the vibratory motion of the ciliz, as this function undoubtedly has an influence in promoting the movement of the mucus, and facilitating its discharge; hence, therefore, its abolition increases the tendency to an accumulation of the discharges in diseased conditions. The muciparous glands are generally of the tubular variety, and possess no peculiar characteristic, except, as observed by Zucker- kandl,* that they are very long, and extend to the deep layers of the mucous membrane, even to the periosteum. In addition to the muciparous glands, we also find in the olfac- tory region, namely, that part above the middle turbinated bones, tubular glands which, from the name of their discoverer, are called Bowman’s glands.? These glands are lined with rounded epithe- lium, which in the blind extremities is large, granular, and contains a certain amount of pigment. In that portion of the nose immediately within the nostril, * Wien. Med. Wochenschr., 1884, vol. 34, No. 38, p. 1124. 2 Todd Bowman’s ‘ Physiology and Anatomy ”’ vol. ii. THE ANATOMY OF THE NOSE. 79 called the vestibule, we find the mucous membrane largely endowed with vascular papilla, and covered with squamous epithelium, in fact, so closely resembling the integument that, as Moldenhauer observes,’ it is really to be regarded as a process of the skin. We find, also, in this locality a number of stiff hairs, termed vibrisse, whose object is merely to purify the inspired air. The Nerves —The innervation of the nasal mucous membrane has its source in the olfactory nerve, together with the nasal branch of the ophthalmic, the superior maxillary branches of the tri- geminus, and filaments from Meckel’s ganglion. The olfactory nerve supplies the nasal cavity with the special sense of smell. This nerve arises by three roots, an external root commencing in the deep substance of the middle lobe of the cere- brum, a middle root from the carunculum annulare, and an internal, from the inner and back part of the anterior lobe. These three roots unite in a flat band which passes forward along the base of the brain until it reaches the upper surface of the ethmoid plate. Here it is expanded into the olfactory bulb, which gives off from fifteen to eighteen branches on either side, which, piercing the cribriform plate, are distrib- uted to the mucous membrane covering the superior and middle turbinated bones, and the upper third of the septum. They terminate in minute thread-like filaments, which pass to the surface of the membrane, between the epithelial cells. In the continuity of this filament, before it reaches the surface, there is found a minute bulb-like expansion, the olfactory cell, as shown in Fig. 61. Tie gac eeae The nasal nerve, arising from the ophthalmic di- factory Cellsin man. vision of the trigeminus, enters the orbit between the ‘7% Schule? two heads of the external rectus, crosses the optic nerve and passes into the cranial cavity through the anterior ethmoidal foramen, only to pass out again into the nose through a slit beside the crista galli, and there immediately divides into two branches: an internal, which supplies the mucous membrane near the anterior part of the septum, and an external, which, descending in a groove ‘on the inner surface of the nasal bone, and sending a few filaments to the mu- cous membrane as far down as the lower turbinated, becomes cuta- neous at the junction of the upper lateral cartilage with the nasal bone, and furnishes cutaneous sensibility to the tip of the nose. The branches of the anterior dental nerve supplying the mucous *** Die Krankheiten der Nasenhéhlen,” Leipzig, 1886, p. 9. 80 DISEASES OF THE NASAL PASSAGES. membrane, are distributed to the inferior meatus and inferior tur- binated bone. The branches from Meckel’s ganglion (see Figs. 62 and 63) enter the nasal cavity through the spheno-palatine forarnen, and Fic. 62,—Spheno-palatine Ganglion. Seen on its Internal Surface. (Sappey.) 1, ‘J‘erminal branches of the olfactory nerve, 2, external division of the ethmoidal branch of the nasal nerve; 3, spheno-palatine gan- glion; 4, termination of the great palatine nerve; 5, posterior palatine nerve; 6, middle palatine nerve; 7, branch of the great palatine nerve supplying the lower turbinated bone; 8, branch from the spheno-pala- tine ganglion to the middle turbinated bone; 9, origin of the branch from this ganglion to the septum; 10, vidian nerve: 11, great superficial petrosal nerve; 12, carotid branch of the vidian nerve communicating with the corresponding branch of the superior cervical ganglicn; 13, carotid branch of the superior cervical ganglion. here divide into two sets: the superior nasal, and the naso-pala- tine branches. The former supply the mucous membrane covering the superior and middle turbinated bones, the lining of the poste- rior ethmoidal cells, and the upper and posterior part of the sep- GANGL. GENICULI Fic. 63. The Formation of the Spheno-Palatine Ganglion. (Heitzmann.) tum. One of these branches forms a communication with the anterior dental nerve within the antrum, giving rise to the so-called ganglion of Bochdelek. The naso-palatine branch passes forward across the roof of the nose, and runs obliquely downward and for- THE ANATOMY OF THE NOSE. Sr ward, along the lower part of the septum, and pierces the hard palate through the anterior palatine foramen, joining the anterior palatine nerve. The Vidian nerve is formed by the union of the greater super- ficial petrosal and the-carotid branches. The former arises from the facial nerve; the latter from the sympathetic plexus which surrounds the carotid artery. These branches unite into one nerve trunk,which passes through the Vidian canal, terminating inMeckel’s ganglion. We thus find the mucous membrane endowed with general sen- sation through the same nerve trunk as that by which vaso-motor control is exercised, namely through the fifth nerve. This peculiar anatomical characteristic in the nasal mucous membrane, has been very largely made use of to substantiate the various theories as regards the causation of hay-fever, asthma and other so-called re- flex neuroses. I question if these theories rest on any well-sub- stantiated grounds as yet. Blood- Vessels. —The vascular supply of the nasal fossz is derived from the anterior and posterior ethmoidal arteries, branches of the ophthalmic, which supply the ethmoidal cells, frontal sinuses, and roof of the nose; the spheno-palatine, from the internal maxillary artery, distributed to the mucous membrane covering the spongy bones, and the septum; and the alveolar branch, from the internal maxillary artery, supplying the lining membrane of the antrum. THE TURBINATED BODIES. In addition, however, to the parts already described, there are found beneath the surface of the mucous membrane, on the faces of the lower and middle turbinated bones, large plexuses of blood- vessels, the turbinated bodies, which have figured so extensively in our literature of the last fifteen years, and have been the sub- ject of so much speculation and discussion. This mass of blood- vessels was recognized by anatomists in the last century, but ina vague and somewhat indefinite way. According to John Mackenzie,’ the spongy character of this tis- sue attracted attention as early as 1656, being mentioned by Rol- fine? | Schneider? recognized it as containing vascular tufts, but did * “ Historical Notes on the Discovery of the Nasal Erectile Tissue.” Boston Med. and Surg. Journal, Jan. rst, 1885. j 2 ‘* Dissertationes Anatomice,” Noribergze, lib. ii., cap. 20. 8 “ De Catarrhis,” Wittburgz, 1661-62, lib. v., passim. 82 DISEASES OF THE NASAL PASSAGES. not recognize its cellular structure. This was first mentioned by ‘Ruppert.’ Duverney? gives a more detailed description, and states that the membrane can be inflated by a blow-pipe inserted into the veins, The first to announce distinctly its true erectile nature was probably Cruveilhier,? who described it as a very vascular and truly erectile tissue, and demonstrated its structure by the injection of mercury through the lymphatics. The first careful anatomical investigation of the tissue was made by Kohlrausch,t who described what he supposed to be large venous sinuses, existing in the deep layer of the membrane. Such a plexus had been previously referred to by Hyrtl, as acknowledged by Kohlrausch. It was subsequently claimed as an independent discovery by Kdllikers In 1873, Bigelow® made some very care- ful observations of these structures, in which he demonstrated the existence of erectile tissue. It should be stated, however, that Kohlrausch? in his investigations had shown the existence of loops or helicine arteries, which at that time were recognized as an ana- tomical condition characteristic of erectile tissue. Kohlrausch’s investigations were made in the moist tissue. Bigelow inflated the moist tissue with a blow-pipe inserted into the veins themselves, as had been already done by Duverney”® and made his sections after the preparations had been allowed to dry. Bigelow’s demon- strations showed a very beautiful spongy tissue, as shown in Fig. 64. These observations were subsequently very nicely confirmed by Ischwald.2 All these investigators asserted that this tissue was erectile tissue, their conclusions being based apparently on anatom- ‘ical study alone. Zuckerkandl,” however, whose classical work on the anatomy of the nose is the standard authority to-day on this subject, has made an exhaustive anatomical study of this membrane, in which he de- scribes the mucous membrane covering the turbinated bones as consisting of connective tissue, the upper surface covered with flat *** Diss, inaug. med. de tunica pituitaria, ejus anatomiam, physiologiam et pathologiam exponens,” Vetero Pragee, 1754, parsi., p. 23. 2 “(Euvres Anatomiques,” Paris, 1761, tome i., p. 222. 3 ‘* Traité d’Anatomique descriptive,” Paris, 1845, tome iv., p. 55. 4 Miller’s Archives, 1853, p. 149. 5 ‘* Handbuch d. Gewebelehre des Menschen,” Leipzig, 1867, p. 741. ® Boston Med. and Surg. Journal, April 29th, 1875. 7 Loc. cit. ® Loc, cit. 9 Progrés Médicale, Sep. 10th, 1887. % Wiener medizinische Wochenschrift, 1884, vol. 34, No. 38, pp. 1121-1125. ‘‘ Schwell- gewebe der Nasenschleimhaut und dessen Beziehungen zum Respirationspalt.” THE ANATOMY OF THE NOSE. 83 epithelium, the deep layer forming the periosteum of the turbinated bones. Between these two layers we have abundant lymph tissue, and possibly lymph glands, although these have not been definitely made out. The tissue covering the turbinated bones is studded here and there with tubular mucous glands, many of which extend completely through to the periosteum. Within this lymphoid structure we have abundant venous plexuses to which he gives the name “ Schwellkérper”’ (swell bodies’. About the venous plexuses, the unstriped muscular fibre is abundantly distributed. The defi- nite localization of the venous plexuses serves to distinguish this tissue from true erectile tissue, such as-is found in the corpora cavernosa of the penis. The arterial supply is derived from the spheno-palatine artery. The capillaries are divided into three sets, Fic. 64.—Section of the Cavernous or Erectile Tissue of the Middle and Lower ‘l'urbinated Bones, Inflated and Dried, x 2 diameters. (Bigelow.) one set being distributed to the periosteum, the second to the glands, the third to the surface. The capillaries distributed to the surface form loops which empty into the veins, together with the super- ficial gland capillaries. The deeper gland capillaries, and those dis- tributed to the periosteum, pass into the veins, forming the so- called Schwellkérper, and the blood is then conveyed by venous channels in the periosteal surface of the membrane, to five distinct plexuses, one going to the veins of the face, the second to the veins of the cranium, the third to the orbit, the fourth to the soft palate, and the fifth to the hard palate. These Schwellkérper are dis- tributed according to Bresgen,’ as follows: one over the lower turbinated body, one along the border of the middle turbinated * “Der Circulationsapparat in der Nasenschleimhaut, vom klinischen Standpunkt be- trachtet,” Deut. med, Wochenschrift, Berlin, 1885, Nos. 34, 35. 84 DISEASES OF THE NASAL PASSAGES. body, and one at the posterior extremity of each of the turbinated bodies. 7 We find, therefore, the nasal cavity containing this most intri- cate and delicate apparatus, which is designed to subserve the function of serous exudation. The special method by which this serous transudation takes place we are scarcely ready to describe, though a very important suggestion comes to us from the notable observation of Chatellier,, who describes certain minute canals, running at right angles to the mucous membrane, penetrating to the lymph channels. Chatellier makes the suggestion that these canals serve the purposé of serous channels. The question arises, whether Chatellier’s canals may not be the tubular mucous glands of Zuckerkandl, ‘ * Annales des Mal. de 1’Or., etc., No. 6, June, 1887. CHAPTER VI. THE PHYSIOLOGY OF THE NOSE. THE nose performs a threefold function in the economy. It is the organ which presides over the sense of smell; it gives a certain character and resonance to the voice; and it has a special duty to perform in connection with respiration. THE SENSE OF SMELL. Minute particles of odorous bodies, floating in the atmosphere, are drawn intothe nasal cavity with the act of inspiration, where, being arrested, and lodging against the moist membrane of the olfactory tract, they are dissolved in its mucus, and in this state of solution, coming in contact with the terminal filaments of the olfac- tory nerve, their peculiar qualities are recognized and appreciated. The proper enjoyment of this function requires that the membrane shall be in a moist condition, that it shall not be clogged by any accumulation of unhealthy mucus or other matters, and that the nasal cavity shall be freely open, and not occluded by tumors or other morbid conditions, but that the inspired air shall have free access to the olfactory tract; and, furthermore, that the olfactory nerve shall be in a healthy condition. That the membrane must be in a moist condition, is shown by the loss of the sense of smell in those suffering from atrophic rhini- tis or dry catarrh. Again, if the membrane is clogged by the secretions of a syphilitic ulcer, or occluded in any way which pre- vents the transmission of the odorous particles to its surface, this sense is abolished. Of course, the occlusion of the nares from the presence of tumors, or from an ordinary acute rhinitis, more or less completely abolishes the enjoyment of this function. It is still a subject of speculation as to just how the olfactory nerve receives impressions from odorous particles. Liegeois' con- tends that the minute particles from odorous substances, impinging upon the surface of the mucous membrane, come in contact with, and mechanically irritate the terminal filaments of the olfactory 1 Arch. de Physiologie, 1868. 86 DISEASES OF THE NASAL PASSAGES. herve. Graham’ has a curious theory that an odor is appreciated by means of its oxidation in the nasal mucous membrane, basing this view on the ground that all odorous particles are easily oxidiz- able, while the converse is true of inodorous matter. Ramsay’ finds a relation between the molecular weight of bodies and their odor- ous qualities, and hence advances the theory that olfaction is the result of molecular vibration. Those bodies possessing high odor- ous qualities, are made up of molecules in a state of high molecular activity, in which the rate of vibration is very rapid. Going down in the scale, we come to bodies made up of molecules in which the rate of molecular movement is too slow to be appreciated by the olfactory nerve. Tyndal? has found matters to be odorous in proportion as they possess the property of heat absorption, which would suggest a theory of olfaction based on the action of heat. Ogle,* in a somewhat elaborate study of this subject of olfaction, has found the sense of smell intimately connected with the distribu- tion of pigment, supporting his view with a number of very ingenious clinical observations, as for instance, he notes that white herbivor- ous animals are far more frequently poisoned than others, owing to the feebleness of their olfactory powers. He also cites the case of a negro boy, who, as the result of a cutaneous affection, became white, with the result of complete loss of the sense of smell; and still further observes the fact, that the dark-skinned races in general, possess far more acute olfactory powers than the Caucasian races. Hence, he evolves the theory that the pigment in the nasal fosse, secreted by Bowman’s glands, serves an important part in the olfac- tory function, but confesses a difficulty in explaining just how it acts. He instances, however, the well-known fact that dark cloth- ing is a far more active vehicle of contagion than light, and, further, that odors are retained for a greater length of time by dark cloth- ing. He goes on to draw an analogy between sight, hearing, and smell, in that the pigmentation of the choroid layer, and the aural ampullz, serves as a vehicle for the reception of light and sound, and he goes on to suggest that, if color is dependent upon heat, why may not an odor, and therefore that the pigment in the nose serves simply as a vehicle for receiving the waves of odor. These theories, at best, are largely speculative, and we content ourselves merely with the assertion already made, that the apprecia- tion by the olfactory nerve, of odorous particles, reqtires simply a healthy condition of the nerve, a healthy membrane, and a patulous cavity. That olfaction is accomplished entirely by the olfactory t Bain’s ‘‘ Science and Intellect,” 3d ed., p. 152. ? Nature, vol. 26, p. 187. 3 ‘* Contribution to Molecular Physics in the Domain of Radiant. Heat,” p. 99. 4 Med. Chirurgical Trans., vol. 53, p. 263. THE PHYSIOLOGY OF THE NOSE. 87 nerve, has been amply demonstrated by physiological experiment, and is further shown in the fact that the nerve, and the olfactory bulb, are very largely developed in those animals in whom the sense of smell is unusually acute. The general sensibility of the membrane is derived from the branches of the trifacial already described. The sense of smell is intimately associated with the sense of taste, in that the loss of olfaction is always attended by more or less complete loss of the sense of taste. This is explained by the fact, that the special sense. of taste is supplied to the tongue from the glosso-pharyngeal nerve. and perhaps the gustatory, and really consists in the appreciation of either the acid, bitter, sweet, or saline character of substances applied to it, and nothing more. The nicer appreciation of flavors is entirely the result of impressions made on the terminal filaments of the olfactory nerve. THE FUNCTION OF THE NOSE IN PHONATION. The function of the nasal cavity in modifying the voice, is one of no little importance, and consists mainly in acting as a resonan cham- ber, as it were, by which the vocal tones are re-enforced. The voice is formed by vibrations of a column of air, set in play by the move- ments of the vocal cords; its pitch being regulated by their tension ; and its volume being dependent upon the force with which the cur- rent of air is driven through the rima glottidis, and hence, by the lateral reach of each cord in a single vibration. The character of the voice, on the other hand, or the tone by which each voice is given its individuality, is dependent largely on the pharynx, mouth, and the formation of the nasal cavity. The larynx simply forms the voice, articulate language being constructed out of the vocal waves, by the movements of the soft palate, tongue, lips, and cheeks. In uttering certain sounds, the soft palate is raised against the wall of the pharynx, and the nasal cavity is more or less shut off. This occurs in the utterance of all the vowels, which are purely oral tones. In the utterance of other sounds, the palate is relaxed, and the air in the nasal cavity, as well as that in the mouth, is thrown into vibration, giving a nasal twang to the voice; this occurs in uttering m, n, ng, etc. A good voice is dependent on the proper use of both the nasal and oral vibrations, and therefore requires that the nasal cavity shall be free from obstruction (by tumors, hypertrophy of its lining membrane, etc.), and that the movements of the soft palate shall not be interfered with. When we make the statement that the vowels are purely oral tones, we overlook a very important fact observed by Meyer,’ that t “ The Organ of Speech,”’ Amer. ed., New York, 1884, p. 236. 88 DISEASES OF THE NASAL PASSAGES. t the vibrations of air in the oral cavity, give rise to vibrations in the nasal cavity, the force being transmitted directly through the hard palate. In this connection Czermak,: who has investigated the movements of the soft palate in the utterance of the vowel sounds, by means of a probe passed through the nose, showed the soft palate elevated to the highest degree in the utterance of z (Eng- lish ée), and the lowest in the utterance of @ (American ah), which would indicate a notable change in the nasal chambers, in the utter- ance of these various sounds. Furthermore, a nasal element, I think, is recognizable in the utterance of all sounds, whether oral or nasal. This is even more notable by their absence, as in cases in which the anterior nares are completely occluded, the voice is nota- bly affected, although still possessing the nasal element, by the transmission of vibrations through the hard palate. The same is true, also, where the posterior nares are occluded, as by the result of an adenoid growth in the pharynx. The complete ablation of the nasal chambers, as when they are filled with neoplasms, gives rise to a totally different character of the voice, in which the nasal twang is absolutely destroyed. The prominent function, then, of the nose in phonation, is as a resonant chamber to the voice, used in the production of all articulate sounds. We find an additional and somewhat important function of the nose, in that its upper partial tones, or the overtones described by Helmholz,? serve to re-enforce the harmonics of the voice. In other words, the fundamental note of the voice gives rise to a secondary series of vibrations of the current of air in the nasal chambers, viz.: Helmholz’s overtones, the resultant tone being one which is pleasing to the ear. It would seem also, that the nasal cavities possess a certain amount of importance as an aid to articulate speech, as is evidenced by the fact, that where these cavities are closed, articulation is fatiguing and the voice soon breaks down with any effort requir- ing prolonged use, the whole difficulty disappearing, as a rule, upon the removal of the obstructing conditions in the nose. In the same way, we find that the integrity of the nasal cavity is of special importance in the production of the so-called head- notes, as is shown by Gordon Holmes.3 Hence, while the singing voice demands an absolutely healthy condition of this cavity for: the management of all its registers, it is absolutely essential for 1 ** Ueber das Verhalten des weichen Gaumens beim Hervorbringen der reinen Vocale.” (Sitzungsberichte der Wiener Akademie—mathematisch-naturwissenschaftliche Klasse, Bd. xxiv., S. 4, Marz 1857.) 2 “* Die Lehre von den Tonempfindungen,” Heidelberg, 1863. 3 “Vocal Physiology and Hygiene,” London, 1879, p. 129. THE PHYSIOLOGY OF THE NOSE. 89 vocalization, and especially for articulation in the upper or head- register. THE FUNCTION OF THE NOSE IN RESPIRATION. The nose is usually regarded as merely the organ of olfaction, while its respiratory and phonatory functions are looked upon as somewhat secondary in character. This view I regard as an en- tirely mistaken one, in that the nasal passages contain an exceed- ingly important, perhaps the most important, and certainly the most intricate apparatus, connected with the function of respiration, of the whole respiratory tract, and one on whose normal functional activity depends the integrity of the whole of the mucous mem- brane of the respiratory tract below. The ancients believed that respiration was for the purpose of cooling the blood. Helvetius, in 1729, supporting this view, adduced, as an argument in its favor, the fact that the area of the pulmonary vein was larger than that of the pulmonary artery. In 1823, Fried- erich Hempel’ asserted that the air was heated in the lungs, making no reference to the nose or mouth as bearing part in this function, regarding the nose as an organ to test the quality of the inspired air, before its passage into the lungs. In 1829, Magendie? wrote: “By successively traversing the mouth, nasal cavities, pharynx, larynx, trachea, and bronchi, the inspired air becomes of a similar temperature with the body. . . . The inspired air is charged with vapor which it carries away from the mucous membrane of the air-passages, and in this state, always hot and humid, it arrives at the pulmonary lobules.”” In the same year, Adelon,? making no mention of the functions of the nose in respiration, speaks of the moisture of the expired air having its sole source in the lungs. In 1844, we find Dunglison* making the following statement: “In passing through the mouth, nasal fosse, pharynx, larynx, trachea and bronchi, the inspired air acquires pretty nearly the temperature of the body.” As early as 1845, however, we find appearing in medical literature, evidence of the recognition of other and im- portant functions as belonging to the nasal chambers, independent of the other portions of the upper air-tract. The first evidence of this I find given by Vierordt,; who, I think, was the earliest to emphasize the fact that the air is raised in temperature in passing through the nasal chambers, thus recognizing the fact that the >“ Finleitung in die Phys. und Path. des Mensch.” 2 “Physiology,” Edinburgh, 1829, Milligan's translation, 3d ed., p. 387. 3 ** Physiologie de l'homme,” Paris, 1829. 4‘ Human Physiology,” 5th ed., vol. ii., p. 31. 5 “ Physiologie des Athmens,’’ Carlsruhe, 1845. go DISEASES OF THE NASAL PASSAGES. other portions of the upper air-tract contribute no part in this im- portant function. In 1864, we find Nestor Grehant' investigating this subject | experimentally. His apparatus consisted of a glass tube contain- ing a thermometer, through which the expired air was made to pass by inserting the tube in the mouth. To protect the ther- mometer from the temperature of the surrounding air, which might thus vitiate the experiment, the tube containing it was enclosed within a second tube, and the space between was filled with cotton. Grehant found, with the temperature of the room at 12°C. (53.6° F.), and the patient breathing seventeen times per minute, inspiring through the nose, that the temperature of the air expired through the mouth and apparatus was 35.3° C. (95.5° F.). If, in- stead of inspiring through the nose, the end of the tube within the mouth was closed with the tongue, and inspiration was performed through the mouth and expiration through the tube, then the tem- perature of the expired air was only 33.9° C. (93° F.). Although, as will be shown further on, these results are erroneous, the investi- gations go to show that, even at this time, the importance of the nose as an organ of respiration was beginning to be recognized. In a second series of experiments, Grehant showed that the ex- pired air was saturated with moisture at a temperature of 35°C. (95° F.) and not at 38° C. (100.4° F.) as Valentine had before stated. The error had been made on account of the momentary cooling of the surface of the hygrometer by the expired air; by correcting this error of experimentation, by enclosing the polished face of the hygrometer so that the expired air should not momentarily cool its face, the true result was obtained. Subsequent to this, we find such standard works on physiology as Dalton and Foster making no mention of the fact that the air is warmed and moistened within the nose and mouth, before entering the lungs. Flint,? however, writes as follows: ‘The vapor in the expired air is derived from the entire surface which is traversed in respiration, and not exclusively from the air-cells. The air which passes into the lungs derives a certain amount of moisture from the mouth, nares, and trachea. The great vascularity of the mucous membranes in these situations, as well as of the air-cells, and the great number of mucous glands which they contain, serve to keep the respiratory surfaces constantly moist. This is important, for only moist membranes allow the free passage of gases, which is, of course, essential to the process of respiration.” ? Thése de Paris, 1864, No. 161, ‘‘ Recherches physiques sur la respiration de l'homme.” 2‘ Text-book of Human Physiology,” N. Y., 1876, p. 154. THE PHYSIOLOGY OF THE NOSE. gI Rosenthal’ claims that air is already warmed and saturated when it reaches the alveoli. These functions, however, are attributed to the nose in a some- what adventitious manner, and the general view seems still held that olfaction is the main function of the nasal mucous membrane. Even as late as 1878, we find Remy? alluding to the nose as the organ of olfaction,-and directly stating that its other functions are purely secondary and adventitious. Remy first states that the watery secretion of the nose is for the purpose of moistening odor- ous particles by which they are rendered sensible to the olfactory nerve. His exact language is as follows: ‘‘ Cette membrane forme lextrémité supérieure des canaux respiratoires, mais ce n’est pas la son principal but. Cette muqueuse fait partie constituante d’un organe des sens, et ce n’est qu’accessoirement qu'elle sert a un- autre usage qu’a la function sensorielle.”’ ‘Ina paper on this subject in 18853 I gave somewhat in detail certain views entertained in regard to the respiratory function of the nasal chambers, which were based largely on clinical observa- tion, which I quote somewhat in detail here, as follows: “The normal function of the mucous membrane is to secrete mucus, and only in such quantities as are sufficient to keep the membrane in a soft, moist, and pliable condition. Any excess of this amount becomes a morbid secretion. Normally, nasal mucus is composed of 93 per cent of water and 7 per cent of solid matter. Robbed of a small portion of this water it becomes thick, inspis- sated, and unhealthy. Now, as we know, every breath of air that passes through the nasal chambers, and reaches the passages below, must become surcharged with moisture; otherwise it would rapidly exert a deleterious influence on the mucous membrane of the air passages beyond, by robbing them of their moisture, and so render- ing their mucus thick and inspissated. It is estimated by physiolo- gists that in the course of twenty-four hours about five thousand grains of water are taken up by the inspiratory current of air, in its passage through the respiratory apparatus. If, in other words, the humidity of the inspired air be compared with that of the ex- pired air, it will be found that, in addition to the other changes as regards carbonic acid and oxygen, the inspired air will have gained five thcusand grains of water. Now, I think, I am safe in saying that if five thousand grains of water were extracted from the mu- cous membrane of the bronchial tubes and air-cells in the course 1 “ Handbuch der Physiologie’ von Hermann, 1880, iv., 2S. p. 389. 2 Thése de Paris, 1878, ‘‘ La Membrane muqueuse des fosses nasales.” 3 ‘* Hay Fever, Asthma and Allied Affections,” N. Y, Med. Jour., April 24th and May Xst, 1886. 92 DISEASES OF THE NASAL PASSAGES. of twenty-four hours, the result would, be complete destruction of their function, to such an abnormally dry condition would they be reduced; for, as we know, in each act of respiration, the inspired air reaches only the larger bronchial tubes, and the source of moisture, therefore, of the inspiratory current cannot be from the smaller bronchial tubes or air cells. We are, therefore, forced to the conclusion that this surplus of five thousand grains is taken up by the inspiratory current during its passage through the nasal chambers, and is still retained by it as it makes its way out through the air-passages, for the only source from which this amount of water could be taken up is the nasal mucous membrane. Certainly from no other: mucous membrane of equal area in the body, is it possible that such an mount of water could be secreted in twenty- four hours in health. Now, the mucous membrane of the lower air- passages is endowed with no especial apparatus for the secretion of water; the only secretory apparatus with which it is endowed is in the mucous glands, which secrete mucus alone. “In the nasal mucous membrane, however, we find an apparatus capable of furnishing this water, and this is the so-called erectile tissue of the turbinated bodies. The necessity for some such ap- paratus I need not refer to, further than to say that it is absolutely necessary and essential, for the integrity of the lower air-passages, that the air which reaches them should be so far charged with moisture that they should not be robbed of any of their secretion. Especially is this true in a variable climate like ours, in which so great changes occur, characterized by excessive humidity or abso- lute dryness of the atmosphere. “This, then, is the great and prominent function of the nasal chambers, to so prepare the ingoing current of air that it shall exercise no injurious influence on the mucous membrane of the passages below. It has always seemed to me that this great re- spiratory function of the nasal chambers, has been to an extent overlooked, in regarding the nose as an olfactory organ, for whereas impairment or loss of the sense of smell is but an inconvenience, and not dangerous to the health, the impairment of the respiratory function of the nasal cavities involves very serious danger. Thus the nose as a respiraotry organ, becomes infinitely more important to us than as an olfactory organ. “As before stated, the nasal chambers contain no glands which secrete other than mucus. There are no serous glands. The mechanism, however, by which the water is poured out into the nasal chambers, and the ingoing current thus surcharged with moisture, is in this so-called erectile tissue. The watery constitu- ents of the blood transude the mucous membrane, and appear on THE PHYSIOLOGY OF THE NOSE. 93 the tortuous surfaces and passages of the cavity. Now, unless, the blood-vessels underlying a membrane called upon for this duty were very large and very numerous, they would be inadequate to supply this large demand. Nature, therefore, has furnished the membrane in this region with such an abundant supply of large tortuous vessels, that they assume the appearance of erectile tissue, and thus have given rise to this erroneous idea as to their function, suggested by the name erectile tissue. Were the blood-vessels in this region of the same calibre and capacity as those of other por- tions of the air-tract, it is easy to understand how the extraction of so great a quantity of water would soon render the current sluggish, by its greater consistence, and so completely arrest the function which they were designed to subserve. In addition to this large blood-supply, there must be, of course, some delicate mechanism by which this function is regulated. This control is exercised by the vaso-motor system of nerves. So delicately must this be ar- ranged, that the transudation of serum must accurately adapt itself to every existing atmospheric condition. To-day, for instance, with air saturated with moisture, the turbinated vessels must be so far kept in control by the vaso-motor nerves, that no serum es- capes. To-morrow, again, with an almost absolutely dry atmo- sphere, under the action of the vaso-motor nerves, the blood control is unlocked, as it were; the turbinated vessels are so charged with blood that the current becomes active, and the amount of serum poured out on the mucous surface of the nasal cavity is such as to thoroughly saturate the ingoing current of air with moisture, and still not impair the consistence of the blood flowing through the vessels. This control must be so delicately exercised as to meet not only daily, but even momentary changes in the humidity of the inspired air. It is easy to see, therefore, how great the demand must be upon the vaso-motor nerves which regulate the calibre of these blood-vessels, how constant the watchfulness which controls this exosmotic action, and therefore how easily any impairment of this function might occur.” These views were based on the result of many years of clinical observation of this membrane, both in health and disease. From an anatomical point of view, it is difficult to understand why nature should have placed in these passages the somewhat in- tricate and complex mechanism which we there find, unless it was designed to subserve some important purpose. That this purpose is not connected with the function of phonation or olfaction, I think cannot be questioned. We must then conclude that its design is connected with the function of respiration—a view which I think can alone be entertained after the investigation of the anatomy of 94 DISEASES OF THE NASAL PASSAGES. the membrane already made. We can only conclude, therefore, that this most intricate and delicate apparatus is designed to serve the function already described, of serous exudation. The special method by which this serous transudation takes place we are scarcely ready to describe, though a very important suggestion comes to us from the notable observation of Chatellier.* He describes certain minute canals, running at right angles to the mucous membrane, penetrating to the lymph channels. Chatellier ‘makes the suggestion that these canals serve the purpose of serous channels. The question arises, whether Chatellier’s canals may not be the tubular mucous glands of Zuckerkandl. As before stated, these observations were based entirely on clinical study of the respiratory tract both in health and disease, continuing through a number of years. They have, however, since my views were first published, been confirmed in a very striking manner by Aschenbrandt’s* exhaustive experiments, in which data of a sufficiently definite character are given to establish all of my conclusions. Aschenbrandt’s experiments were conducted in the Phyisologi- cal Institute of Professor Fick, of Wurzburg, and in the following manner: An air aspirator, with a capacity of five litres (five and a quarter quarts), is attached to one of the nostrils by means of a glass tube, in which a thermometer is fixed in such a manner as to register the temperature of the air immediately upon its exit from the nose. One litre (quart) of air is passed every six seconds, each experiment being finished in thirty seconds. Ina large number of experiments Aschenbrandt found, that with the temperature of the air in the room varying from 8° C. (46.4° F.) to 12° C. (53.6° F.), the temperature of the air as it passed from the nose did not vary from 30° C. (86° F.). Now the temperature of the expiratory cur- rent in ordinary respiration is 30° C. (86° F.), which shows conclu- sively that the warming of the air in respiration is done exclusively by the nose. Experiments were also made as to the amount of moisture in the expired air, and were conducted with the same apparatus. He found that each five litres (five and a quarter quarts) of expired air contained 0.18 gramme (2.77 gr.) of water, which constitutes com- plete saturation, and furthermore, that the whole amount with- drawn from the body in twenty-four hours was 500 grammes (7715 grs.), and that the source of this, therefore, was in the nose. A still further conclusion was drawn from these experiments, that all * Annales des Mal. de l’Or., etc., No. 6, June, 1887. 2 ‘* Ueber die Bedeutung der Nase im Respiration,” Wurzburg, 1886. THE PHYSIOLOGY OF THE NOSE. 95 mechanical dust is completely arrested during inspiration, and is deposited on the moist surfaces of the nasal membrane. Subsequent to Aschenbrandt’s observations, Kayser* made a ‘series of investigations in the same line. He made use of the same aspirating bottle as Aschenbrandt, and the thermometer-tube fitted into the nostril was essentially the same. In Aschenbrandt’s investi- gations, however, the upper pharynx was not shut off, and hence warm air could be drawn from the mouth out through the nose, by ‘the aspirator, and thus vitiate the experiment. To obviate this source of error, in Kayser’s experiments the palate is held up by a spatula, after the application of cocaine, and the upper pharynx and nose shut off completely from the lower pharynx and mouth. The temperature of the air after passing through both nostrils, five litres (five and a quarter quarts) in thirty seconds, was found to be the same as in Aschenbrandt’s experiments, 30° C. (86° F.), when the temperature of the inspired air was 12°C. (53.6° F.); with an ex- ternal temperature of 0° C. (32° F.) to—4°C. (24.8° F.), the tempera- ture of the expired air was 27.5° C (81.5 F.). If the temperature of inspired air was 19° (66.2° F.) to 20° (68.7° F.), the expired air * Was 32.3° (90.1°F.) to 33.5° (92.3° F.). For testing the heating power of one nostril, instead of passing a tube through the mouth behind the palate, closing one nostril, and aspirating through the other as Aschenbrandt did, Kayser passed a caoutchouc tube through the inferior meatus of one side, the posterior end of this tube passing beyond the choana; the an- terior end was fitted closely into the nostril by means of a rubber cork. The apparatus for aspiration and determining the tempera- ture was then fitted to the other nostril. It is easy to see that by this means the heating effect of only one nasal cavity was obtained. The palate was held up as in the preceding experiment. In this experiment Kayser differs somewhat from Aschenbrandt, for while Aschenbrandt found that the air was heated just as much in passing through one nasal cavity as through both, Kayser found that it was heated about 0.5° C (0.9° F.) less. Variations in ex- ternal temperature made the same difference in the expired air as in the first experiment. Kayser also performed a series of experiments for the purpose of finding how much the air was warmed in oral breathing. A caoutchouc tube was passed through the inferior meatus of one side to the choana, and the opposite nostril closed with the finger. The tube containing the thermometer was fitted into a cork, and held between the lips. The aspiration was then performed in the 1 Pfleuger’s Archives, vol. xli., 1887, pp. 127-47. 96 DISEASES OF THE NASAL PASSAGES. usual way. Ic was found that the air was heated almost half a degree less than in passing through both nostrils. For determining the amount of moisture in the air after its passage through the nasal chambers or mouth, the thermometer- tube was replaced by a U-tube containing pumice-stone and sul- phuric acid. The increase in weight of the tube at the end of each experiment enabled him to calculate the amount of water contained in the expired air. Asa result of these experiments he found that in its passage through the nose or mouth, the air was completely saturated with moisture. The above experiments, as originally suggested by Aschen- brandt, were intended to approximate, as nearly as possible, the conditions of normal respiration, the tidal air being taken as five hundred cubic centimetres, and the respiration rate as twenty. In thirty seconds, then, five litres (five and a quarter quarts) of air would pass through the respiratory passages. Kayser points out that at least half the time is consumed by expiration and repose, and consequently in the experiment the air has been allowed to remain in the nose and mouth at least twice as long as it does in normal respiration. He, therefore, repeated all of the above ex- periments, regulating the aspirator so that five litres (five and a quarter quarts) would pass in ‘fifteen seconds instead of thirty seconds. He found, however, that this increased rapidity did not notably influence the result, either with reference to temperature or saturation. To simulate as nearly as possible the conditions found in the trachea and bronchi, Kayser made use of a glass tube, of such a length and diameter that its area was about equal to that of the trachea and larger bronchi. This tube was lined with filter paper saturated with water. A thermometer was fixed in this tube so that its temperature could always be determined, and the tempera- ture was kept constant by enclosing it in a hot-air bath. One end of the tube was left open, the other was connected with the tube containing a delicate thermometer, the same apparatus, in fact, used in the preceding experiments for determining the temperature of the expired air. Here he found that lowering the temperature of the air before aspiration, made considerable difference in the tem- perature of the air after aspiration, and that doubling the rate of aspiration also exerted an influence upon the temperature and moisture of the air after aspiration. For the filtering out of mechanical dust, Kayser claims that Aschenbrandt’s investigations are not conclusive, since with the apparatus with which the experiment was made, very little dust could get into the nose at all. He consequently improved the ap- THE PHYSIOLOGY OF THE NOSE. 97 paratus, using a glass globe with three openings. One of these communicated with a bellows used to agitate finely powdered mag- nesia, the second was open to the air, the third was connected with a glass tube fitting tightly into one nostril. A similar tube connected with the aspirator was fitted to the other nostril. If now aspiration is conducted in the usual manner, and at the same time the dust is agitated by the bellows, Kayser finds that dust can still make its way around into the nostril connected with the aspirator, thus proving that the nose is not a perfect filter for mechanical dust. Kayser makes the further observation, that when cold air is in- spired through the nose, there is a notably increased blood supply in the turbinated bodies, thereby increasing their heating capacity. In this connection he suggests that in tracheotomy the inspired air in summer must be of a temperature of 30° (86° F.) to 35° C. (95° F.), and in winter of 25° (77° F.) to 28° C. (82.4° F.), and in each case must be saturated with moisture in order not to produce bronchial irritation; the reason being that the bronchial membrane is not éndowed with a special apparatus for moistening and heating the air. It will be noticed that Kayser makes no definite statement as to the amount of moisture poured out by the venous sinuses of the nose in the twenty-four hours. Aschenbrandt, however, makes the statement that the whole quantity of water, which the air in respiration draws from the human body, amounts to about 500 grammes (7715 grs.) in the twenty-four hours, and this is taken from the mucous membrane of the nose. This observation, however, was scarcely necessary, since the amount given in my original paper, as from twelve to sixteen ounces, is the amount given by all physiologists as the amount taken from the lungs. Both Aschen- brandt and Kayser, however, make the definite statement that all the air which passes to the lungs through the nose is in a state of saturation. Of course, saturated air passing in and out of the lungs, takes absolutely no moisture from the bronchial mucous membrane. The general accuracy of these results has received still further confirmation, in a series of experiments by Bloch,’ who reaches, practically, the same conclusions as Aschenbrandt and Kayser, with the exception, that he finds that the expired air reaches only to two-thirds of the saturation point, and that the heating capacity of the oral cavity is inconsiderable. Clinical observation, I think, should add sufficient weight to the accuracy of the earlier experiments, to practically establish the truth of their teaching. The proposition is proven beyond question, as previously stated 1 Archives of Otology,” vol., xvii. No. iv.; vol. xviii., No i. 7 98 DISEASES OF THE NASAL PASSAGES. by myself, that the sole source of moisture is in the nose. I think we may declare it as an established truth, that the function of the so-called erectile bodies is serous transudation, and that they are designed to subserve no other function in the economy. The observers already quoted have made allusion to the fact already generally accepted by physiologists, that the air in passing through the nose is cleansed, in that floating particles of foreign matter lodge against the moist and tortuous surfaces. Probably, however, this is an adventitious function; certainly it is a very un- important one. I have never regarded the bronchial mucous mem- brane as subject to any serious danger from floating particles of foreign matter making their entrance with the inspired air. In seeking for a proper function to assign to these falsely called erectile bodies of the nose, the assertion has been made, notably by John Mackenzie, that they are designed to swell up and thereby close the nasal passages to prevent the entrance of foreign bodies. This observation, it has always seemed to me, was based on the original mistaken idea that .the turbinated bodies were erectile tissue; and, therefore, their function was to become erect. I think it has been demonstrated that these bodies are not erectile tissue. Further- more, they never become erect in health or disease. Certainly, if mature intended that they should swell out, and thereby occlude the nasal passages to prevent the entrance of foreign bodies, thus -compelling the opening of a far more vulnerable tract through the mouth, nature has been guilty of an awkwardness of design which ‘presents no analogy in the whole human economy. CHAPTER VII. GENERAL CONSIDERATIONS CONCERNING CATAR- RHAL DISEASES. THERE are so many misconceptions in regard to what is ordin- arily called “nasal catarrh,” not only among the laity, but also to no small extent among professional men, that it seems wise here to discuss, in a somewhat general way, certain questions connected with this subject. Perhaps the most prevalent misconception in regard to nasal catarrh is that it is a special disease of the nasal cavity, which leads ultimately to ulceration of the soft parts with necrosis of bone. This view is the one largely encouraged in the advertisements of proprietary remedies for the cure of this affec- tion. It scarcely needs to be stated here, that a simple catarrhal inflammation is always a catarrhal inhammation from its onset, and never results in anything more than a simple hypertrophy of the tissues. Ulceration and necrosis belong to syphilis or some other of the constitutional dyscrasiz alone, and bear no relation whatever to the inflammatory process. Another somewhat prevalent idea, entertained both by the medical men and the laity, is that there is a catarrhal diathesis, a peculiar systemic condition, under the in- fluence of which a patient becomes especially liable to catarrhal inflammation, which may attack indifferently any of the mucous membranes of the body. We not infrequently hear a patient making the statement that all his mucous membranes are weak, and that an inflammation of the mucous membrane, say of the air tract, is liable to be followed by a similar weakness of the intestinal tract, or possibly of the genito-urinary tract. I know of no good ground for this assertion. Certainly, my own clinical experience, which has been somewhat large, fails to justify this view in any manner. The mucous membranes of different portions of the air tract are in exceedingly close sympathy, and a morbid process in one portion is very liable to be followed by a morbid process in another part of the tract, but that there is any sympathy or con- nection between the mucous membrane of the air tract, and the mucous membrane of the food tract, I do not believe to exist. There are many who honestly entertain, and many who dis- 100 DISEASES OF THE NASAL PASSAGES. honestly encourage the idea, for commercial purposes, that a simple catarrhal inflammation of the upper air tract has a tendency to lead to the development of pulmonary diseases. Thus, I find so excellent an authority as Beverley Robinson‘ making the state- ment that “undoubtedly the patient affected with long-standing follicular disease of the naso-pharyngeal space, sooner or later de- velops this same follicular disease of the remaining portions of the respiratory tract; of the pharynx at its middle and lower portions first, then of the larynx and finally of the bronchial tubes. Hence comes, [am now thoroughly convinced, the initial stage in certain instances of what afterward develops into different forms of pulmonary diseases.” A somewhat similar view is advocated by Jarvis.2. Notwithstanding such authority, I fail to find in Robin- son’s argument or Jarvis’s report of cases, any clinical evidence in substantiation of this view. Possibly, a patient with a family his- tory of phthisis, is more liable to fall a victim to this disease with a bad chronic catarrhal affection of the upper air passages, than if his upper air passages were in a state of perfect health, and yet even this assertion it would be ‘difficult to establish on any grounds of clear, clinical observation. I think, therefore, that we must con- tent ourselves for the present certainly, with the view that a chronic catarrhal disease of the nose or naso-pharynx tends to the develop- ment of a process of a similar character in the larynx, trachea and bronchial tubes, but nothing further. In other words, the tendency of a catarrhal inflammation is to extend downward, but it remains a catarrhal inflammation always. The worst outlook, therefore, is in the development of a chronic bronchitis with asthma, excluding cases of purely nervous asthma, which while undoubtedly dependent on a rhinitis or naso-pharyngeal catarrh, are not directly the result of it, but only occur in connection with the peculiar neurotic habit. This question, however, is more fully discussed in the chapter de- voted to the subject of asthma. The word catarrh is derived from two Greek words zard fet, which translated mean ‘“‘to flow downward,” the name being given primarily to a disease of the upper air passages in which the prom- inent symptoms seemed to be a flowing down of the mucus or muco-pus. In this manner, this term “ Catarrh’’ came to be used as designating all diseases of the nasal passages which were character- ized by an abnormal discharge, including tumors, syphilis, scrofula, ozena, as well as the simple chronic forms of rhinitis. If we trans- late the word and use it as meaning simply a discharge, I think we obtain a true estimate of its proper scope. A patient who suffers, * “Nasal Catarrh and Allied Diseases,” second ed., New York, 1885, p. 131. ? Trans. Amer. Climatological Assn., New York, 1886, p. 30. GENERAL CONSIDERATIONS. i0l therefore, with a chronic nasal catarrh suffers from a chronic nasal discharge, the one word being quite as definite as the other This we understand may be the result of a large number of different dis- eases of the nasal cavity. We reach the conclusion, therefore, that a patient suffering from nasal catarrh really has some diseased con- dition of the upper air tract. What this condition is, simply re- mains for us to determine by the improved diagnostic methods of the present day. A somewhat later use of the term was that first described, I think, by Virchow, who restricted it to the designa- tion of a particular form of inflammatory action taking place in mucous membranes, which he termed a catarrhal inflammation, namely an inflammation which was characterized by the pouring out upon-its surface of a secretion which was fluid in character, in contradistinction from a croupous and diphtheritic inflammation, in which the material poured out on the surface contains largely of fibrin and therefore coagulates, thus forming a false membrane. This use of the term catarrh is the one which alone should find place in medical literature. In this manner we obtain a definite. classification of the diseases affecting mucous membranes, in that when we speak of a chronic laryngitis or a chronic rhinitis, we mean a chronic catarrhal inflammation, and when allusion is made to a croupous or diphtheritic inflammation of these parts, we specify this form in including the term croupous or diphtheritic. We re- ject, therefore, entirely, the use of the word catarrh, and in place of it adopt that nomenclature which designates the character of the inflammation and the region involved, and simply regard catarrh as a symptom of any of the many diseases which may affect the upper air tract. A very prevalent idea in regard to catarrhal inflammation is that its prominent symptom is excessive secretion, either of normal mucus or of muco-pus. This is rather a nice question to determine in hypertrophic rhinitis. It is altogether probable that this appar- ent excessive secretion is really a diminished secretion. In health the nose secretes probably a pint of serum, which becoming min- gled with the normal mucous secretion, disappears, without the patient being conscious of it, by evaporation, the water being taken up largely by the inspired current of air. In diseased conditions the amount of serous exudation is not infrequently diminished as the result of hypertrophy, and therefore the mucous secretion not being diluted with this large amount of serum, become thick and inspissated. A pint of healthy sero-mucus, secreted by a healthy membrane, does not make itself felt. Diminish the serous exuda- tion one-half, and we have seven or eight ounces of secretion from which the limited amount of water is taken up rapidly; hence we Tae DISEASES OF THE NASAL PASSAGES. t will find an inspissated mucus which makes itself felt, and gives rise to unpleasant symptoms. In atrophic rhinitis the exosmosis of serum is more or less completely abolished. The whole secretion of the mucous membrane is confined to a mucus, largely surcharged with epithelial cells, giving rise to a muco-purulent discharge, which is dried up by the ingoing current of air, thus resulting in the formation of masses of dried mucus or crusts. We have here avery marked diminution of secretion, and yet apparently an ex- cess, in that every portion of the limited secretion manifests itself in the form of green crusts, which give rise to unpleasant symp- toms. Ina naso-pharyngeal catarrh we have an apparent excess of secretion. The vault of the pharynx contains glands in health, whose function is to pour out mucus for lubricating the bolus of food, and thus facilitate its passage to the stomach. The nor- mal secretion from this region in health is large, but it is a thin fluid, and passes into the pharynx in even large quantities without the individual being conscious of it. In a diseased condition of the naso-pharynx, the secretion becomes impaired, and undoubtedly notably diminished, certainly in its watery constituents. It is this change into a muco-pus, which while apparently secreted in large quantities, remains a thick tenacious mass of mucus adhering to the mucous membrane lining the pharyngeal vault, in such a man- ner that the patient expels it with the greatest difficulty; and hence its presence becomes a source of exceeding great annoyance. The same I think we may say of the larynx and trachea in simple chronic laryngitis and tracheitis, which I regard as almost invariably secondary affections to diseases of the nasal passages. The tract above failing to do its proper duty of warming and moistening the inspired air, the parts below are subjected to the influence of an ab- normally dry current of air in respiration, under the action of which the normal mucus is robbed of a certain proportion of its watery constituents, and becoming thick and inspissated, proves a source of irritation, and is expelled with a certain amount of difficulty. These diseases are not characterized by an excess of secretion but by a diminution of secretion. We are thus led to the view that it is an entire mistake to regard excessive secretion as the prominent feature of a chronic catarrhal inflammation. A proper appreciation of these diseases will be better obtained, I think, when we clearly understand in just what manner a chronic catarrhal inflammation interferes with the very important functions which these parts are designed to subserve. This question is more fully discussed in a later chapter. I have tried to make clear that a nasal catarrh, so- called, means nothing more than that there is some diseased condi- tion of the nasal passages. In treating such a case our first duty is GENERAL CONSIDERATIONS. 103 to make a careful examination of those passages to determine what special morbid condition exists there to give rise to such symptoms as present. A discharge from the nose anteriorly is somewhat un- common. Weshould understand that in what is called an ordinary catarrh, viz., a liability to cold with more or less obstruction to nasal respiration, together with a tendency to accumulation of thick mucus in the fauces, we have to do, usually, with either hypertrophic rhinitis or a naso-pharyngeal catarrh, and these are not infrequently complicated with a deformity of the nasal septum. We have here the three prominent conditions which give rise to an ordinary mu- cous catarrh so-called. These three conditions are somewhat in- timately associated in most cases, and it is by no means easy to determine just where the morbid lesion lies. Certainly the nasal cavity and naso-pharynx react upon each other in a very intimate manner. I am disposed to think that in most cases a naso-pharyn- geal catarrh is dependent primarily on hypertrophic rhinitis, and that an attempt to deal with it is unsuccessful until the hypertrophic rhinitis is brought under control. Furthermore, the hypertrophic rhinitis in the large majority of instances is dependent upon a de- formity of the septum. We have here, therefore, two lesions to re- move before we can successfully attack the naso-pharynx. Further- more, it is by no means easy to recognize by the closest rhinoscopic inspection, what constitutes the morbid lesion in a naso-pharyngeal catarrh. Hence we are compelled to remove the disease of the nasal passages first, in order to determine that the naso-pharyngeal disorder is not entirely dependent upon the nasal. These ques- tions are mainly suggested here as illustrating some difficulties in diagnosis, and of course will be discussed at length in the chapters devoted to their consideration. Furthermore, it may be noted that the idea that a hypertrophic rhinitis gives rise to discharge from the nostril is altogether mistaken. It is altogether probable that the per- verted mucus which accompanies the disease, makes its way largely into the pharynx, and we thus find that a faucial catarrh, often spoken of as a pharyngitis, follicular disease of the pharynx, sore throat, etc., is really a disease of the nasal cavities, and in most in- stances of the mucous membrane covering the turbinated bones. The character of the discharge, whether anteriorly through the nostrils, or through the posterior nares and the fauces, is always something of an indication of the form of disease with which we have to deal. A purely watery discharge usually indicates a vaso- motor disturbance, such as hay-fever or nasal rhinorrhea. A pro- fuse sero-mucous discharge in which the serum is more or less charged with flakes of grayish mucus, is characteristic of nasal polypi. It also occurs in the second stage of acute rhinitis. A 104 DISEASES OF THE NASAL PASSAGES. thick mucous discharge containing flocculi of whitish mucus, and rendered opaque by a moderate mixture of young cells, may occur in connection with hypertrophic rhinitis, but is usually indicative of a disease of the naso-pharynx. This occurs more especially in young children suffering from adenoid vegetations of the pharyn- geal vault. A thick whitish mucus discharged into the fauces, which is drawn down bya nasal screatus, and expelled by hawking, is characteristic of either hypertrophic rhinitis or naso-pharyngeal catarrh. A purulent discharge composed of ‘masses of somewhat thick yellow pus, attended with something of an odor, should always call attention to the probability of the existence of suppurative disease of one of the accessory sinuses, usually the antrum in an adult. A similar form of discharge occurs in the purulent rhinitis of childhood, and in the last stages of acute rhinitis. A purulent discharge through the nostrils, mixed with shreds of necrotic tissue and blood, and also with offensive crusts, indicates the existence of ulceration and probable necrosis, and should always suggest syphilis, although small crusts detached from just within the margin of the nostril may be discharged from slight erosions of the septum. The discharge of greenish crusts, in connection with somewhat healthy looking pus, or muco-pus, in connection with a mild offensive odor, the crusts being bright yellow or greenish in color, and containing neither blood nor necrotic tissue, should suggest the existence of atrophic rhinitis, CHAPTER VIII. ACUTE RHINITIS. ACUTE rhinitis is an acute inflammation of the mucous mem- brane lining the nasal cavities proper, which may confine itself entirely to these passages or, as not infrequently happens, it may extend to neighboring passages, as the pharynx, larynx, and the air passages below, as well as in a mild degree to the accessory cavities, such as the frontal sinus, the antrum of Highmore, and also the Eustachian tube. This tendency to extension, however, it should be stated, is not a characteristic of the earlier attacks of acute rhinitis, but only occurs, as a rule, in those who are ac- customed to take cold easily on slight exposure and are frequently subject to these attacks; each successive attack being to an extent of a more aggravated character and also showing increased dis- position to extend to the passages below, so that, whereas the earlier attacks were confined to the cavity of the nose alone, the subsequent attacks, years later even it may be, show a disposition to extend downward, as it is said, thus giving rise to a laryngitis, or an ordinary winter-cold. As this habit increases, and only as it becomes a habit, do we find these processes reversed, and as a result of exposure the patient now commences to have attacks of Jaryngitis and bronchitis which show a disposition to travel upward, resulting later in an attack of acute rhinitis. The original seat of trouble in all these cases is to be found in the nasal cavities. ETIOLOGY.—It is ordinarily stated that an acute rhinitis is the result of exposure to cold and this is undoubtedly true, but behind this isa very prominent predisposing cause in an already existing chronic inflammation of the nasal mucous membrane, the chronic morbid process preceding the acute process, and rendering the pa- tient especially liable to the occurrence of an exacerbation on slight exposure. It is often stated that cold in the head may arise from the inhalation of acrid vapors, and also that it occurs as the result of a peculiar idiosyncrasy which renders the nasal mucous mem- brane particularly susceptible to certain odors, such as ipecac and iodine. I am disposed to question whether what occurs in these cases is a genuine attack of acute rhinitis, and am rather disposed 106 DISEASES OF THE NASAL PASSAGES. to think it is a temporary disturbance of the great respiratory function of the nose, giving rise to what has been called an in- fluenza, or what in its aggravated form constitutes hay-fever or rose-cold, these affections giving rise to a morbid condition of the nasal mucous membrane which differs essentially from an acute rhinitis, as will be discussed more fully in the consideration of those diseases. Under the same category I should be disposed to place those rare epidemics which are recorded in history as having affected large portions of the population where they prevailed, such as that described by Anglade* as quoted by Mackenzie, in which an entire army was suddenly prostrated with the disease; or the great epidemic of 1762* in which the type of the disease was so severe as to cause a mortality of two percent. It should also be borne in mind that the internal administration of iodides is liable to produce nasal symptoms closely resembling those of acute rhini- tis. It, however, is not attended with any observable constitutional symptoms. Moreover, its action is limited to the production of turgescence of the blood-vessels with watery discharges. In these cases, the morbid process manifests much the same symptoms and runs much the same course as an ordinary attack of acute idiopathic rhinitis. In general then, we may say of this affection that it is caused by exposure to cold, in the manner already so fully discussed in the chapter on taking cold as to render any discussion of the subject here unnecessary. Acute rhinitis also occurs at the onset of cer- tain of the exanthemata, such as measles, typhus, typhoid, erysip- elas, etc. SYMPTOMATOLOGY.—The attack is not usually ushered in by chill, but rather by chilly sensations, a feeling of lassitude and general ma- laise, followed by a mild febrile condition with pains in the muscles, and loss of appetite. These symptoms, as a rule, however, are not well marked, and the patient's attention is first called to a sense of stuffiness about the frontal region, with burning or prickling sensa- tion in the nose, with dryness and heat. This may last a few hours or more, when there sets in a watery discharge of a somewhat acrid character, which gradually changes to a mucous discharge, more or less copious in amount. This, in time, leads to a free discharge of a muco-purulent character. The dryness of the membrane, which characterizes the onset of the attack, is coincident with the stage of congestion and arrest of secretion which mark the commencement of any acute inflammation of a mucous membrane. Following this, there occurs a free transudation of liquor sanguinis from the en- «**Sur le Coryza simple,” Thése de Paris, 1837. 2 **Encyclop. Brit.,” vol. xiii., 9th ed., p. 73. ACUTE RAINITIS. 107 gorged blood-vessels, which goes to make up the more or less pro- fuse serous or watery discharge which constitutes the main portion of the secretion which characterizes the second stage of the attack. The normal glandular structures of the membrane are soon stimu- lated into an excessive and morbid activity and a profuse discharge sets in, consisting of clear, transparent mucus, together with an ad- mixture of epithelial cells and leucocytes and perhaps a few red blood-corpuscles. As the inflammatory process develops, the nor- mal nutritive processes of the membrane are stimulated to an ex- cessive degree, epithelial cells are generated with increased rapidity, and the discharge assumes a muco-purulent character, being thick, yellow and turbid, the color and consistency being entirely due to the very large number of young, unripe cells which become incor- porated with the discharge. The nasal cavity proper is so far the seat of most of the symptoms, these being mainly confined to a sense of discomfort referable to the nose, increased secretion, a sense of fulness or complete closure of the passages due to the swelling of the membrane, together with frequent and often dis- tressing attacks of sneezing. If the frontal sinuses are involved, the attack is attended with frontal headache, oftentimes of a distressing character. This is not due, necessarily, in every case to an exten- sion of the inflammatory process, but rather to the congestion of the mucous membrane lining the cavity, with pressure upon the nerves. In many cases, there is marked irritation of the conjunctiva, together with overflow of tears. This is undoubtedly due to ob- struction of the tear-duct, the swollen mucous membrane of the lower turbinated bone pressing against and occluding the orifice. That this can occur I do not question, although Dr. Allen,‘ in discussing this matter, maintains that the closure of this duct can- not occur except as the result of atrophy, osteitis, or necrosis. The orifice of the antrum of Highmore is often closed, giving rise to a sense of fulness and stuffiness, and oftentimes severe neuralgic pains referable to that region, although fortunately the diseased process rarely extends in its activity to this cavity. When this does occur, however, we have a condition of things of somewhat grave import. This, however, will be discussed in a subsequent chapter. Obstruction of the Eustachian tube, giving rise to deafness, and not infrequently, ringing in the ears, is not an unusual symptom, this being due merely to obstruction, and not to any extension of diseased action, although a direct extension of the inflammatory process to the middle ear, giving rise to acute middle ear disease, is one of the accidents which may occur. *** Relation between Nasal Catarrh and the Closing of the Lachrymal Duct,” Philadel- phia Medical News, February 6th, 1886. 108 : DISEASES OF THE NASAL PASSAGES. As has been already stated, the tendency to extension of the inflammatory process to the accessory cavities is very limited, but this is not true of the pharyngeal vault, for the membrane here, I think, is in all cases in a state of mild acute inflammation, the mu- cous membrane proper being swollen, while the glands, which con- stitute the pharyngeal tonsil, are stimulated to an excessive activity. This is further aggravated by the fact that their normal function is interfered with, which, as has been already stated, is largely de- pendent on a healthy functional activity of the nasal mucous mem- brane; for, during an attack of acute rhinitis, the normal mucous secretion is not swept over and diluted by the moisture-laden vapor of the inspired current of air, it therefore becomes thick, viscid, and inspissated, and so accumulates in the pharyngeal vault, hindering the normal function of the palate, preventing the renewal of air in the middle ear, and increasing the obstruction of the orifice of the Eustachian tube, and giving rise to marked faucial irritation. The sense of smell is generally lost for a time, and as a conse- quence also the sense of taste, this being due mainly to the fact that the odoriferous particles,are entirely excluded from the olfac- tory region. The integument about the orifices of the nostrils is liable to become inflamed, as a result of the irritating qualities of the discharge, which contains largely of saline matter, a condition which is undoubtedly aggravated by the frequent use of the handker- chief to which the sufferer is obliged to resort. D1aGnosis.—The recognition of an acute rhinitis should be based on the same general rules which govern us in the recognition of an inflamed mucous membrane in any portion of the body. An inspec- tion in the first stage reveals to us the mucous membrane covering the turbinated bones in a red and swollen condition, the color being of a distinctly bluish-red or venous tinge, while the surface of the membrane presents a dry and somewhat glazed appearance. The nasal cavity is, of course, largely encroached upon by the swollen membrane, and a deep inspection, therefore, is not easily obtained. During the second stage, we have the color of the membrane notably changing its aspect. It now presents a brighter, more rose- colored tint, somewhat more nearly approaching the arterial color, while its surface is bathed in a profuse discharge of clear, white, watery serum. The deeply-red, highly-turgid appearance which characterizes the first stage has changed notably, the membrane seems less swollen and less highly distended. In the third stage, a still further change is noted. As the secre- tion becomes surcharged with the rapid desquamation of epithelial cells, it assumes a bright yellow color, is notably less in amount, and is of a somewhat thick and viscid character. The membrane ACUTE RHINITIS. 109 beneath it still presents the appearances of active acute inflamma- tion, being swollen in contour and of a bright red color, the normal lumen of the cavity being greatly encroached upon, the tissues over the middle turbinated bone being in contact with the septum almost invariably, and in most cases the same condition existing in the lower meatus. An examination by posterior rhinoscopy shows each posterior naris more or less completely blocked by the swollen membrane of the lower and middle turbinated bones, their gross appearance on inspection corresponding to that of the membrane seen in front, in the different stages of the disease. The vault of the pharynx will be found to contain a large mass of thick, yellow, inspissated mucus, adhering to the crypts of the pharyngeal tonsil, while the membrane surrounding the Eustachian orifice is reddened, but rarely swollen. The lower pharynx oftentimes presents a dry and glazed appearance, due to the habitual mouth-breathing which results from the obstruction of the nasal passages. It may be somewhat reddened as the result of this irritation, but is not, as a rule, in a state of active inflammation, not being a part of the air- passages. It is true of the acute form, as well as of the chronic form of inflammation of these regions, that it confines itself to the physiologically associated tracts,and in extending down, it passes immediately from the nasal passages to the larynx and trachea. When the larynx and trachea are involved, they present the same appearances as are found in ordinary sub-acute catarrhal in- flammation of these regions. PROGNOSIS.—The prognosis in this disease is favorable. It in- volves no danger to life and will run its course, as a rule, in about seven days without interference, leaving behind it probably, how- ever, an aggravation of the chronic condition which undoubtedly underlies and is the most prominent predisposing cause of the acute inflammation. It is understood, of course, that this statement applies to those cases where the accessory sinuses are not involved, and in which there are no aural complications. ; PROPHYLAXIS.—Those who are especially liable to take cold should exercise additional carefulness in the avoidance of those causes which experience teaches them may give rise to an attack of acute rhinitis. Yet, an excessive zeal in this direction is always to be avoided, since that over-carefulness for one’s health which results in muffling the head and neck with too much covering, leads to an over- sensitiveness of the parts, by which the liability to take cold is much increased. It is not well, as a rule, to wear thick wraps about the neck and head, unless it becomes absolutely necessary as a matter of 110 DISEASES OF THE NASAL PASSAGES. comfort. It must be borne in mind that exposure to low tempera- ture alone is not sufficient to produce acold. It is a draft of damp air, usually of a mild temperature, which causes the mischief. The proper regulation of clothing is of the utmost importance, but it is always a mistake to wear more clothing than is absolutely neces- sary, as has already been stated. Furthermore, an equable distri- bution of clothing over the body should be the inflexible rule. We do not protect the throat by wrapping the neck; we weaken it. Exposure from wearing thin shoes never gives rise to cold in the feet. A chest-protector does not protect the chest. In fact, we do not protect ourselves from taking cold in our climate by exceed- ing carefulness in dress. We can only endure with impunity the changes and rigors of our changeable seasons by inuring ourselves to them. There are few measures of greater value as a preventive of colds than the daily use of a cold plunge bath. This not only acts to keep the emunctory functions of the skin in a healthy state of activity, but also serves to harden the parts, as it were, and thus render them less susceptible to the action of cold. This, however, is a measure that we cannot recommend in all cases, for the shock to the heat-producing force is too great in some cases. To those, however, who can take a daily cold bath it is not only a luxury, but a valuable sanitary measure. If, however, the cold plunge is not feasible, sponging the body with cold water to the waist every morning is a measure of undoubted benefit. Of more importance still as a preventive measure is the removal of that condition which, it has been already suggested, is the predominant, predisposing cause of acute rhinitis, namely a chronic rhinitis. Perhaps no fact has been more strikingly noticeable in my practice than the rarity with which patients take cold after commencing treatment for a chronic rhinitis, even the limited improvement secured by one or two applications being sufficient to control this tendency. Too much stress, cannot be laid on the fact, that in all cases the habit of taking cold means a chronic rhinitis, although this may be of so mild a character as to give rise to no marked symptoms, other than this special susceptibility to cold. TREATMENT.—An attack of acute rhinitis may often be aborted if measures are resorted to for the accomplishment of this purpose sufficiently early. This must needs be done very soon after the first local symptoms show themselves, and, as a rule, before the copious discharge of watery serum has set in which marks the second stage of the attack. This plan consists in the administration of from five to ten grains of quinine, followed by some warm drink, such as cham- omile-tea, or a hot lemonade, with the addition perhaps of a hot foot- bath. The object of this, of course, is to produce copious perspira- ACUTE RHINITIS. Ill tion and thus restore the normal heat which has been lost, and to re- establish a proper equilibrium between heat-production and heat- waste. If there is much pain over the forehead and neuralgic pain in the face, due to the involvement of some one of the accessory cavities, ten grains of Dover’s powder may be given with advantage, both to relieve the pain and aid in producing diaphoresis. A popular measure to break up a cold and one much resorted to is the Turkish bath. Now, a Turkish bath is a pleasure and a luxury in health, but I seriously question if its advantages are not very greatly overestimated as a remedial agent. Certainly in inflamma- tory affections of the air-passages, and especially those of an acute character, I believe this resort to be one capable of doing great mischief. The hot room of the bath is unobjectionable while it lasts, but the necessary exposure of the sponging room and the rubbing room so much over-weighs its advantages, that a cold is more liable to be aggravated than benefited by this method. A still further danger is the exposure which one undergoes neces- sarily, on leaving the bathing establishment after the profuse per- spiration. This danger is obviated, and the good effect of a hot bath secured by the excellent suggestion of Cohen,’ who recom- mends that the patient be given a hot air-bath immediately before retiring, by wrapping himself in a warm flannel sheet and sitting in a chair under which an alcohol-lamp is placed. The bath should last from fifteen to twenty minutes. A profuse perspiration is usually the result, and the patient is to wrap himself in the same blanket and retire to his couch. It is also recommended that he take some warm drink, such as hot lemonade, immediately after the bath, and a pitcher of water be placed by his side and that he drink as freely of this as he may desire, although this is contrary to the somewhat curious suggestion of Lower and Williams, that a cold may be aborted by complete abstention from the use of water until the symptoms abate. I have never known this procedure to be put in practice successfully. Cohen also advises as an abortive measure the administration of chloroform, although he fails to sat- isfactorily explain the rationale of its employment. Possessing, as we do, simpler and more efficient remedies, I should hesitate to em- brace this suggestion. The early administration of opium presents a remedy of un- doubted efficacy in mitigating the severity of the attack, and often- times in completely aborting it. This measure, which belonged to the practice of the olden times, receives the indorsement of Mac- kenzie? who gives preference to the use of the tincture of opium, t “Diseases of the Throat and Nose,” First ed. 2 Loc. cit., vol. ii., p. 291. iva DISEASES OF THE NASAL PASSAGES advising that it be administered in doses of from five to seven drops on an empty stomach; this to be repeated, if necessary, at the end of six to eight hours. Lees,’ while indorsing the administration of opium, expresses preference for the use of bromide of potassium combined with belladonna, which he administers to the extent of producing dryness of the fauces. Belladonna, in a somewhat dif- ferent combination, is recommended by Beverley Robinson? who advises the use of the following powder: BR Pulv. fol. belladonne, . ‘ : ‘ . gr. XX Pulv. morphie sulph. . . ‘ ‘ . SB Us Pulv. gum. acaciz, , : ‘i 4s ad 3ss. Asmall quantity of this is to be thrown into the nose at intervals of three or four hours by means of an insufflator. Both Sajous: and Robinson advise the administration of small quantities of the tincture of aconite, in combination with some form of opium, when the fever is unusually high. It is a very common procedure among physicians to confine their patients with a cold in the head absolutely to their rooms and oftentimes to the bed. I am by no means sure that this is wise in all cases. Confinement in the house certainly should be enjoined during inclement weather, but even in the height of an acute rhinitis I have frequently seen benefit result from a brisk walk in the open air in the middle of the day, when the sky is clear and the air not too cold. Confinement in bed I should deem unnecessary, unless the constitutional symptoms were aggravated, or some of the serious complications of acute rhinitis threaten, such as the in- volvement of the accessory sinuses, or an attack of middle ear disease. The foregoing suggestions are made as specially indicatea in the first stage of the disease, and before the discharges have set in, with the idea of arresting the further progress of the attack. Any of these measures may be resorted to in the second or third stages of the disease, but not probably with the result of more than curtailing the duration or the severity of the symptoms. In the later stages of the disease we have to deal with the vexatious ele- ment of excessive secretion, together with the nasal stenosis. The prominent indication then would seem to be the use of astringents, and, as following this indication, we find recommended a long list of drugs, both in the liquid and solid form, which are supposed to possess astringent properties, such as tannin, zinc, "Brit. Med. Journal, Feb. 13th, 1886. 2 Loc. cit., p. 56. 3 ‘* Diseases of the Nose and Throat,” Philadelphia, 1886, p. 68.. ACUTE RAINITIS. 113 copper, alum, bismuth, etc. My own experience teaches me that these drugs possess but an exceedingly limited astringent power, if by an astringent we mean an agent which will limit and control excessive secretion. That these drugs do possess this power ina certain degree it would not be wise to question, when we consider that they have been maintained in practice from the earliest days of medicine. Without, then, especially recommending these reme- dies, they are simply offered as to a certain extent curtailing and diminishing the excessive discharge which characterizes the later stages of the disease. For this purpose there may be used, by means of some simple spray apparatus, a solution of tannin grs. xv. to the ounce; alum ers. v. to the ounce; sulphate of zinc grs. iij. to the ounce; nitrate of silver grs. ij. to the ounce. Or the same astringents may be used in the form of a powder incorporated in similar proportions with powdered starch, magnesia, or lycopodium. If nitrate of silver be used, its better administration would be in the same proportions incorporated with talc. Michel, of Hamburg, advises the use of this drug in the strength of one part in twenty. Another form in which the local use of drugs may be secured is by inhalation. Here we make use of the fact that certain drugs are volatilized by heat. Vapors, it should be stated, however, as a rule, can have but limited action on the mucous membrane of the nose in a state of acute inflammation, on account of the difficulty of thoroughly medicating the whole tract. The drugs which may be used in this manner are benzoin, lupulin, oil of tar, creosote, oil of pine, turpentine, camphor, etc. The method by which these may be used is either by one of the elaborate inhalators sold in the drug stores, or by the following device, which is much simpler and perhaps quite as efficacious. Place from one to four teaspoonfuls of any of the above drugs in an open-mouthed bottle, or even in an ordinary coffee-cup, and pour over it half a pint of water of about the tem- perature of 160°. This being held near the face the vapor of it is drawn in through the nose, or, if that is impossible, drawn through the mouth and expelled through the nose. Cohen recommends the vapor of iodine inhaled in the following manner. A few crystals of the drug being placed in a slender glass tube or quill, this is held in the hand, whose warmth is sufficient to cause a certain amount of volatilization and the vapor is then inhaled through the nostrils. The fumes of chloride of ammonium have, for a long time, enjoyed a well-deserved popularity, not only in the cases under considera- tion, but in all catarrhal affections of the respiratory tract. Their action, as I conceive it, is not to diminish secretion or limit the catarrhal process, but to stimulate the membrane to a certain ex- tent, to dilute, as it were, the mucous discharge, and render its ex- 8 114 DISEASES OF THE NASAL PASSAGES. pulsion more easy of accomplishment by the patient. Perhaps also the stimulating action serves to relieve the distended blood-vessels in producing a freer serous exudation. In early times the volatiza- tion of the salt was accomplished by means of heat. The result of this was a vapor composed of hydrochloric acid and ammonia. Lewin, of Berlin, however, devised an especial apparatus for the accomplishment of this purpose (see Fig. 50) the principle of which, has been imitated in the various devices which are sold in the drug- stores. The additional action of any of the volatile oils or resins mentioned above may be secured by adding them to the water of the third bottle in Lewin’s apparatus. A remedy popular in Ger- many known under the name of Hager’s remedy, is as follows: B Carbolic acid, . : : ; ‘ x . I pt. Strong alcohol, ‘ : : : ; . 3pts Caustic ammonia, . ‘ ‘ : ; . I pt. Distilled water, F : : ; ‘ . 2 pts. This to be used as an inhalation from an open-mouthed bottle. This has been indorsed by Brand‘ and is of undoubted value in giving relief to some of the distressing features of a coryza. An old-fashioned household remedy for a cold consists in put- ting equal parts of vinegar and water on the stove, and thus charging the room in which the patient sits with the vapor of acetic acid. Following this idea, Fritsche * recommends the following: R. Acidi acetici glacialis, Acidi carbolici, : i 5 : » 4 ers. ij. Mist. oleo-balsamic., . : : ‘ ‘ grs. viij Tinc. moschi. ; . . : ‘ gr. i. This is to be used by inhalation from an open-mouthed bottle, or as a vinaigrette. While these remedies possess unquestioned value in the treat- ment of the disease under consideration, we possess in cocaine a remedy, whose action is definite and absolutely certain in controll- ing what is probably the most distressing feature of the attack, namely, the venous turgescence. The peculiar action of cocaine on the blood-vessels has already been referred to and need not be entered upon here. I repeat, however, that in no case since I] first observed this peculiar action have I ever failed to recognize its promptness and certainty in expelling the blood from the mucous membrane, whether in a normal state or in a state of inflammation. This action, however, of cocaine, lasts but three or four hours, when * Berlin. Klin. Wochenschrift, 1872, No. 12. ? Ibid, 1887, No. 27. ACUTE RHINITIS. IIs it is followed by relaxation of the blood-vessels, not by a reaction, as has been claimed by many writers. The question arises, then, as. to how far may we depend upon this drug to permanently control the acute inflammation of the nasal membrane under discussion, if repeated every four hours. My own experience teaches me that when the action of cocaine has exhausted itself, the blood-ves- sels do not return to their original highly distended condition, but that the relaxation is less marked, so that, if in an acute rhini- tis we repeat the application of cocaine as soon as the patient ex- periences any sensation of recurring stenosis, we may eventually depend on very markedly curtailing the duration of the attack, if we do not completely arrest it and keep it under control. In co- caine, then, I believe that we possess a remedy whose value cannot, or should not be questioned, and the efficacy of which is far greater than that of any other single drug, and probably than those above- mentioned combined. A favorite method of administration is as follows: R Cocaine hydrochlor., . j 5 ; . grs. XX. Morphia, . : : : ‘ ; . grs. ij. Aque, . ; ; ‘ 3 ‘ : 2 Sits Ft. solutio et adde, Cosmolini liquid., . : ‘ . ‘ a Sie This is to be used in the Burgess atomizer (see Fig. 47). The above prescription makes an excellent and fairly permanent emul- sion, though, before using, it is well that the atomizer should be thoroughly shaken. An objection lies against the fluid cosmoline ordinarily sold by druggists in that it contains a considerable amount of the volatile oils of petroleum, notably the kerosene, which gives rather an unpleasant odor and taste to the mixture. A preferable oil, but not generally in the market, is the Voschano oil, which I believe is the Russian petroleum product. The immediate effect of this application is an exceedingly agree- able and pleasant one, and if its use is continued, an ordinary cold in the head may be rapidly brought under control. If the above mixture and apparatus are not available, an ordi- nary watery solution of cocaine acts as an excellent substitute. It is well, however, in applying the watery solution of cocaine, to bear in mind that, when the nose is in a highly sensitive state, its reaction ‘ is mildly acid. This may produce an unpleasant effect, hence a sufficient amount of bicarbonate of soda should always be added to render the solution alkaline. Asa matter of convenience, cocaine may be given in the form of a powder, although it is doubtful if any snuff reaches the parts 116 DISEASES OF THE NASAL PASSAGES. with the same degree of thoroughness as a fluid. An excellent formula for this is: R Cocaine hydrochlorat., . . , : . grs. x. Pulv. magnesiz, ; : : : i 2 55), The use of camphor in the past few years has gained a consider- able degree of popularity and is unquestionably a valuable adjuvant in the relief of an acute coryza, if used properly. It should be used well diluted, and in a small quantity. Several serious accidents have been reported from its indiscriminate use. The above formula may be used with the addition of grs. iij. of powdered camphor. The various preparations of mint form both an agreeable and efficacious remedy in catarrhal affections of the nose. The follow- ing excellent formula has been suggested by Rabow:: B Menthol pulv., : : : ‘ ; . grs. iij. Coffe toaste, Sacchari albe, ‘ ; ; ; ; 4a ers. I. M. Use as a snuff. After the vascular plethora has been brought somewhat under control, and the profuse serous exudation has diminished, I find it an excellent practice to make an application of chromic acid directly to the swollen membrane. This is done, not with the idea of de- stroying tissue, but in the method described fully in the chapter on hypertrophic rhinitis, as affording us one of our most effective remedies for directly controlling an inflammatory process. The membrane having been thoroughly contracted with cocaine, and cleansed by repeated wiping with pledgets of cotton, one or two small crystals of chromic acid are applied to the face of the mucous membrane covering the lower turbinated bone, making a small eschar whose office is to pin down the swollen membrane and pre- vent a return of blood to the part. This may seem a somewhat irrational mode of procedure, and yet it is one which, if deftly accomplished, will often secure results of a most gratifying charac- ter. If this measure fails and we find that, after the cauterization, the membrane swells to its original contour, we will have done more harm than good by our efforts, hence exceeding great care should be exercised that the tissues be thoroughly contracted before the acid is applied, and, furthermore, that the caustic should be so laid on as to burn deeply into the membrane over a limited area, rather than spread broadly over its surface. Before closing, mention should be made of the great value of dry heat applied externally over the forehead. A nice way of ac- 1 Deut. Med. Wochenschrift, No. 5, 1886. ACUTE RHINITIS. 117 complishing this is by means of the small hot-water bags sold in the drug-stores, which can be bound upon the forehead and allowed to remain in situ for several hours at a time. The relief to the frontal headache and the sense of distention or fulness across the root of the nose, is often very striking, while at the same time the inflammatory action is probably modified to an appreciable degree. The remedy suggested by Woakes’ for the controlling of neur- algic pain accompanying the disease, may well .be resorted to where the usual narcotics either fail of their action, or are not well tolerated. He recommends that gelsemium be given in the form of the tincture, in doses of 10 minims each, to be repeated every three hours until relief is obtained. A more potent remedy and an exceedingly agreeable one is aconitine, which may be given in doses of 4, of a grain every three hours, care being taken to note the occurrence of the peculiar prickling of the fauces, with numb- ness of the tongue or extremities, which indicates the limit of tol- eration of the drug. If, during the course of the attack, symptoms should appear of threatened involvement of one of the accessory sinuses, resort must be had to measures of a most active character to prevent so serious an accident. These consist mainly in the moderate use of anodynes, and active counter-irritation, with local blood-letting. If the frontal sinus or. the antrum of Highmore is in’danger, dry cupping imme- diately over the part should be resorted to, and if this fails of relief, no hesitation should be felt in immediately applying a blister. At the same time it will be found that the application of water to the nasal chambers, as hot as can conveniently be borne, will aid much in arresting this serious complication. This is usually accomplished by the ordinary fountain syringe, additional hot water being added to the reservoir as the flow is established through the nares. Schech? advises the use of leeches to the root of the nose in these cases. This local blood-letting is accomplished without in- volving the temporary disfigurement which attends the blister or cupping, but I question if it is as efficacious. If inflammation of the middle ear is threatened, vesicating col- lodion may be applied in front of the tragus, but a more effectual remedy probably in this case would be in the use of leeches, in ad- dition to this. Politzeration, as recommended by Woakes,? may be resorted to, although this measure should be used with the greatest caution. Schech* further recommends incision of the membrana tympani, although Buck’ questions the advisability of this, when x ‘* Post-nasal Catarrh,” Amer. ed., Philadelphia, 1884. 2 “ Diseases of the Mouth, Throat and Nose,” English ed., Edinburgh, 1886, p. 224. 3 Loc. cit. 4 Loc. cit. 5 ‘International Cyclop. of Surgery,” vol. iv., p. 710, i DISEASES OF THE NASAL PASSAGES. the morbid process is of a simple catarrhal nature, on the ground that the incision speedily closes and, furthermore, while open it may admit of the entrance of disease-germs. The warm douche, of course, should be freely used in the extenal ear. CHAPTER IX. HYPERTROPHIC RHINITIS. THIs is a chronic inflammation of the mucous membrane lining the nasal cavities, characterized by a permanent dilatation of the blood-vessels, together with increased thickening of the intra-vas- cular tissues, as a result of which the normal lumen of the nasal passages is so far encroached upon as to interfere with free nasal respiration. In addition to this, and what is of still more serious import, the great respiratory function of the pituitary membrane of serous exosmosis becomes obstructed to a notable degree, where- by the mucous membrane lining the air passages below is subjected to such abnormal conditions as lead ultimately to the development of secondary inflammatory processes in this region. Probably in no single disorder of the upper air passages is a thorough understanding of its causes, development, and symptoms more important than in the one under consideration, for, as I firmly believe, a morbid process setting in primarily in the nasal mucous membrane is the cause of a large number of secondary affections involving not only the air passages below, but also organs having no especial physiological or regional connection with the nose. ETIOLOGY.—Perhaps no tissue of the body is more prone to be- come the seat of a chronic inflammatory process, than the nasal mu- cousmembrane. Why this should be so, it is easy to understand if we thoroughly appreciate the physiological function which it is de- signed to subserve, as has already been shown in a previous chapter, for through no other mucous membrane of the body, probably, does there pass during the twenty-four hours proportionately as large a supply of blood. Furthermore, this is not. in a constant, unvarying stream. On the contrary, the amount of blood, and therefore the calibre of the blood-vessels, changes with every variation in the temperature and humidity of the atmosphere. In this fact, then, I think lies the primary reason why morbid changes are so commonly met with in this region. This, however, will only account for those mild cases of rhinitis which scarcely approach the dignity of a true diseased condition, but constitute merely a source of occasional 120 DISEASES OF THE NASAL PASSAGES. temporary annoyance. For the origin of-the graver forms of so- called nasal catarrh we must look further. Taking cold figures in medical literature as a probable cause of most of the acute inflammatory diseases which we meet with in the upper air passages, and chronic inflammation is said to be the result of repeated attacks of acute inflammation. Cohen, Mackenzie, and, in fact, most writers make this assertion. My own belief, how- ever, as already stated, is that the chronic inflammation sets in first, and that repeated attacks of acute inflammation become simply one of the prominent features of the chronic morbid process. Climatic conditions also are said to exercise an unfavorable in- fluence on the development of catarrhal diseases. This assertion cannot be questioned, but that this is an important factor in the production or causation of nasal catarrh I think is open to question. A given case of catarrhal disease which is a source of exceeding great annoyance in the winter, becomes a trivial affection in the warm, dry atmosphere of the summer months, but a change from the damp climate of our seaboard to the pine forests of southern Georgia effects the same thing. It is not fair, however, to say that the winter weather or the seaboard in the one case, has been the cause of the disease, any more than it is to say that the return of the summer or a visit to the pine woods on the other hand has cured it, for a change to a favoring climate or region gives simply a temporary relief. The disease returns as soon as the climatic conditions reappear. The essential cause of the disease exists still, and has existed all the time. I think we are safe in saying, then, that the climatic influences on a catarrhal process are temporary only, whether in affording re- lief to the symptoms or in causing an aggravation of the trouble. I have no disposition-to underestimate the value of a change of climate or the benefit often obtained by the temporary relief which it gives. In the graver forms of disease, we are often compelled to order a change of climate for our patients as affording the only hope of relief. But I think we are never justified in giving hope that a change of climate is going to afford anything but temporary relief in ordinary catarrhal disease of the upper air passages. In those cases, however, in which the disease has given rise to a severe laryngitis or a bronchitis, a change of residence to a more favorable climate often becomes imperative. Catarrh is often designated as an American disease, and without stopping to question the truth of this assertion, search has been made for some peculiar quality of our climate which has given rise to the universal affliction. I think it is very doubtful if the Ameri- can people suffer more generally from catarrhal disorders than HYPERTROPHIC RHINITIS. 121 those living in the same latitudes on the other side of the ocean, Certainly the general assertion is a somewhat loose one, based on no careful observation. I believe the origin of this mistaken view to be largely due to the fact that diseases of the nasal cavities engaged the earlier and more industrious attention of specialists in this country than in Europe, so that a survey of our literature would naturally lead to the conclusion that nasal disease was ex- ceedingly common here. We find Mackenzie* making the asser- tion that, until the year 1880, it had not been his custom to examine the interior of the nose except in patients who referred their symp- toms directly to the nasal passages, whereas we recognize the fact that in the majority of our cases of nasal disease the patient refers the symptoms to the fauces or other parts, and oftentimes denies the existence of nasal trouble. The assertion is also made, in searching for a cause of American catarrh, that it is due to our dry and dust-laden atmosphere. I do not think American people, as a rule, are greatly subjected to the deleterious influence of a dry and dust-laden atmosphere, nor, furthermore, that those who are thus exposed, suffer as a result necessarily from catarrhal disease. Lenox Browne‘ ventures the assertion that ‘ mechanical irritation, as from particles of snuff, the pollen of grass and of flowers, fine dust, etc., is almost as important a factor in the production of nasal erection as changes in the tem- perature of the atmosphere, and if long continued will certainly lead to a permanently enlarged, swollen, and hypertrophied condi- tion of the erectile tissue and mucous membrane generally.” Mac- kenzie* also states that chronic catarrh may be caused by the in- halation of irritating vapors or solid particles suspended in the atmosphere. Turning now to one of the most accomplished of our American writers on this disease, we find Beverley Robinson stat- ing: that “trades in which irritating vapors or dust are breathed more or less constantly are an efficient cause of chronic coryza. Such are, in my experience, those of carpenters, tobacconists, workers in carpet factories, woollen factories, machine shops, chemical works, etc.” One naturally hesitates to take issue with such careful observers as those referred to, and yet my own experience teaches me that, whereas a dust-laden atmosphere may be the source of discomfort and irritation to the nasal passages, yet as an efficient factor in the * “ Hay Fever,” London, 1885, p. 28. 2 ‘* The Throat and its Diseases,’ London, 1888, p. 501. 3 ‘* Diseases of the Throat and Nose,” American Edition, Philadelphia, 1884, vol. 2, p. 313. 4 ‘* Nasal Catarrh and Allied Diseases,” New York, 1885, p. 65. 122 DISEASES OF THE NASAL PASSAGES. production of organic changes in the deep tissues of the membrane, I believe it to be greatly overestimated. I do not think that workers in tobacco or carpet factories, or mines, suffer as a rule from nasal disease. The old discussion in regard to “ miner’s lung,” it seems to me, sustains this point, for it is a well-known fact that workers in coal mines inhale the dust of coal to such an extent that the lung tissue itself even is oftentimes stained with the carbon, yet this occurs without involving these delicate structures in serious danger. When we consider the far greater vulnerability of these tissues than the tissues affected when the dust enters the nasal cavities, the fact referred to would seem to go far toward estab- lishing the view that a dust-laden atmosphere is comparatively harmless to the mucous lining of the upper air tract. As regards the influence of tobacco on catarrhal diseases, I can only repeat here what I stated in a former work, * when, in discuss- ing the use of tobacco as a habit, I wrote as follows: “The progress of the chronic pharyngitis is marked, of course, by repeated acute attacks of ordinary sore throat. As the disease develops under the stimulus of these repeated attacks of acute pharyngitis, or devel- oping from the commencement asa chronic affection, as it occa- sionally does, it comes under the influence of certain secondary predisposing and aggravating influences whose effect is to'greatly increase the morbid condition. The use of tobacco is a habit which it is the fashion to charge with having a large influence in the pro- duction and aggravation of chronic pharyngitis. Smoking and chewing are, undoubtedly, pernicious and uncleanly practices, but that they are responsible to the extent usually laid to their charge in influencing a throat catarrh is probably not true. Tobacco smoke is without question an irritant to the mucous membrane of the air-passages, especially if inhaled in a concentrated form. On the other hand, it is also true that the mucous linings easily become inured to the action of the smoke, so that breathing or inhaling an atmosphere charged moderately with it, is tolerated with immunity. Cubans are, perhaps, among our most inveterate smokers, and that in its worst form in the use of cigarettes, and yet they suffer some- what rarely from throat catarrhs. “T do not wish to say that the use of tobacco may not, or does not exercise an injurious influence on the throat, for it undoubtedly does in many cases, but that this is the result of the direct contact of the smoke with the membrane I regard as very improbable. The effect of smoking in producing gastric disturbance, as shown in the various forms of dyspepsia with which excessive smokers suffer, and this, in turn, leading to the aggravation of an existing pharyngeal + “ Diseases of the Throat and Nose,” N, Y., 1881, p. 82. HYPERTROPHIC RHINITIS. 123 catarrh, would seem to me to present the true explanation of the injurious action of.the habit on the throat. And, again, the absorp- tion of nicotine which necessarily takes place, as evinced by the headache, palpitation of the heart, and muscular tremor which re- sults from the excessive use of tobacco, produces a systemic con- dition, which cannot but react unfavorably on the morbid process in the fauces. From what has been said it will be easily under- stood that, while condemning the use of tobacco as a vicious and uncleanly habit, and asserting that its excessive use may exercise a very injurious influence on the throat, the idea is only intended to be conveyed that the pernicious influence is an indirect one, and not due to the contact of the smoke with the mucous lining of the upper air-passages. Hence, in estimating the influence of the habit on an existing throat-catarrh, the judgment must be based mainly on the evidence of the injurious action of the nicotine absorption, as shown by gastric disturbance or cardiac symptoms. “Tn addition, it may be said that the fumes of tobacco come in contact, to a very moderate extent, with the mucous membrane beyond the palate, and the only smoke which reaches the parts farther down is that which impregnates the atmosphere which the smoker breathes in common with others near him, or in the same room. Hence, of two persons, one smoking, and the other not ac- customed to the habit, it is probable that the smoker escapes with the greater impunity from the direct effect of the vitiated atmo- sphere. I am disposed to regard the habit of chewing as even more vicious than smoking in its effect on the throat, and yet, as a rule, the tobacco chewer does not allow the saliva to reach beyond the mouth, hence it cannot be that its bad effects are the result of direct contact, but are rather due to the indirect effect of the nicotine absorption which must necessarily result from the habit.” The question of diathetic conditions, as influencing catarrhal disorders, figures largely in our older literature, many writers even asserting that there exists a true catarrhal diathesis. This condi- tion, I think, lingers mainly in the minds of the laity, and we fre- quently hear statements made on the part of patients that all their mucous membranes are weak. That there is any special connec- tion between the different mucous membranes of the body not physiologically connected, or anatomically continuous, I think is incorrect. My own observation leads me to the conclusion that catarrhal diseases of any mucous membrane are largely local in character, and that any constitutional disturbance which accom- panies them is secondary in character. Certainly I have never met with any case which seemed to me to presént evidence of a catar- rhal diathesis, 124 DISEASES OF THE NASAL PASSAGES. How far the rheumatic or gouty habit may influence catarrhal processes is an exceedingly nice question to decide. Rheumatic or gouty pharyngitis is undoubtedly met with not infrequently, but the pharynx, as I believe, has no physiological connection with the breathing apparatus. Catarrhal inflammation of the nose due to the gouty or rheumatic diathesis I have not met with. The graver dyscrasiz, such as have been called the tubercular and scrofulous diatheses, undoubtedly exert a certain amount of predisposing influence in the production of catarrhal diseases, if we use this term in the sense of an unhealthy or excessive discharge from the nasal passages. It is doubtful, however, if they ever lead to the production of connective-tissue hyperplasia, the prominent condition which obtains in the disease under consideration. Their influence is, then, to aggravate the symptoms of an existing catar- rhal inflammation, and perhaps hasten the hypertrophic process, rather than to exercise any clearly recognizable causative influence in the development of the inflammatory action. By far the most frequent cause of hypertrophic rhinitis, I believe, lies in a deformity of the nasal septum, giving rise to nasal stenosis, which generally occurs in the anterior portion of the passage. Its method of development is, to a certain extent, mechanical, and may be explained as follows: During infancy or childhood, as we know, the cartilages and bones of the nose are soft, somewhat pliable, and, furthermore, especially subject to injury. The child learning to creep perhaps, or learning to walk, has a fall and strikes naturally the most prominent feature of the face; or again, in childhood or youth, in the rude and boisterous amusements which children in- dulge in, a blow on the nose is one of the most frequent of acci- dents. The effect of this is that, while in many cases it gives rise to noticeable symptoms, as when a true fracture occurs, in a far larger number of cases, the injury gives rise to mere temporary discom- fort, the symptoms pass away, and the accident probably is for- gotten. Now, in the case of fracture with resulting deflection of the septum, the symptoms may set in and develop with a consider- able degree of rapidity, whereas in other cases, where the blow has been less severe, a mild deformity takes place, a low grade of in- flammation, possibly at one of the sutures of the septum, an arthritis perhaps, resulting from a separating of the two plates which form the septum, producing a bony or cartilaginous projection into the one or other nostril which may reach its full extent at the time of the injury, or may gradually develop as the result of a low grade of inflammatory action, and become more extensive in character as time lapses. In every case, however, the effect is a stenosis of the nasal cavity. If now we study the effect of the simple mechanical AYPERTROPHIC RHINITIS. 125 obstruction to the entrance of air to the nasal passages during the act of inspiration, we shall find, I think, that it throws much light upon this question of the causation and development of catarrhal diseases in these cavities. Now with each act of inspiration, that portion of the mucous membrane which lies immediately behind the point of obstruction becomes subjected to diminished atmo- spheric pressure. This diminished pressure acting on the soft, spongy, vascular tissues covering the turbinated bones, results in a tendency to abnormal turgescence. This action is probably very slight in the first few years after the injury has been received. But as time goes on, there is gradually developed a permanent hyper- zmia or distention of the blood-vessels. Furthermore, it may be noticed that if the obstruction be but partial, this turgescence is de- veloped in the narrower passage. If, on the other hand, the injury is such as to completely occlude one passage, all of the inspired air is compelled to pass through the opposite side, and we have the hypereemia and hypertrophy developing in the open side. In fact, it is necessary for the development of this chronic congestion that a current of air should pass through the side affected, as we often see the membrane in that passage which is completely stenosed, as the result of a deflected septum, absolutely bloodless. Not only does it not become the seat of hypertrophic changes, but there is a certain amount of shrinking as it were, in the tissues, not the atrophy which we meet with in atrophic rhinitis, but a bloodless condition of the vessels due to abolition of function. The result of hyperzmia, of course, is to increase nutrition, and we have finally set up certain structural changes in the membrane proper. The superficial blood- vessels and the large venous sinuses of the membrane, more espe- cially the latter, become excessively dilated, the vascular walls lose tonicity, vascular control is impaired, while at the same time, as a result of this hyper-nutrition, the intra-venous tissues become notably thickened, and we have, as a consequence, true hypertrophy taking place, a permanent structural thickening of the membrane. The point which I endeavor to make here of traumatism as the original cause of so large a proportion of these cases of hyper- trophic rhinitis is, I think, an exceedingly important one, and I re- peat again that an essential point of this theory is the fact that the injury itself antedates the morbid symptoms, oftentimes many years, and that the development is essentially an exceedingly slow process. This must necessarily be true, for I think when we ex- amine the mucous membrane histologically we cannot but be con- vinced that the condition is one which has only resulted after long years of development. The natural history of the connective- tissue cell from its first development until it eventually ‘becomes 126 DISEASES OF THE NASAL PASSAGES. an elemental part of the tissue, as a well-developed connective tis- sue cell, is a process of years. Deformities and deflections of the septum are by no means the only cause of nasal stenosis. Any deformity which causes narrow- ing of the nostril, will produce the same train of symptoms. A dis- placement of the triangular cartilage of the septum I have seen act in the same maner. Weakness of the dilator muscles of the nostril also, although rarely, is a very efficient factor in the production of hypertrophic rhinitis. Deformity of the alar cartilages, by which the normal aperture of the nostril is narrowed, we occasionally meet with acting in the same manner. Not infrequently we meet with cases in which hypertrophy has taken place without any mechanical stenosis. These cases may be attributed to taking cold, for this we must recognize as one of the causes of catarrhal disease; for, while undoubtedly the habit of taking cold, as before stated, is due primarily in these cases to the chronic inflammation, and that, as before stated, in the majority of instances is due to deflected septum, we must acknowledge that repeated attacks of acute in- flammation may precede the chronic process. If we search further for the causes of these cases, I think we find them largely in errors of clothing, vicious habits of life, undue exposure, neglect of the skin, and that long train of bad habits which we include under the general designation of improper hygienic surroundings. Any one who dresses improperly, who wears ex- cessively heavy clothing, or, on the other hand, is too thinly clad, who neglects the proper use of the bath, who is badly nourished from improper or insufficient food, who is badly housed, who sleeps in close, illy ventilated rooms, of course is liable to catarrhal troubles unless he possesses some more vulnerable hereditary or acquired habit. In other words, when a man is subject to serious exposure in perfect health, he suffers from a cold in the head far more frequently than anything else unless he has inherited or ac- quired a rheumatic or gouty habit, or possesses some other special weakness, under the influence of which affections of this nature de- velop, as the results of exposure, rather than the catarrhal disorder. SYMPTOMATOLOGY.—The prominent symptoms resulting from this condition are due primarily to changes in the normal secre- tion of mucus. As we have aleady learned in the chapter on the physiology of the nose, the secretion in health consists of a limited amount of mucus together with a very large amount, a pint or more, of serum, whose source is in the venous sinuses, in the deep layer of the membrane, from which it makes its way probably by ex- osmosis. Now, the deposit of connective tissue in the inter-vascu- lar tissues, giving rise to notable thickening, necessarily results in HYPERTROPHIC RHINITIS. 127 an obstruction to this exosmotic process. The amount of serum which transudes is diminished, while at the same time the blood-ves- sels, not being unloaded by normal transudation, become distended. The discharge from the nose itself, instead of being a sero-fluid mucus, becomes thick and inspissated. The membrane becomes swollen and thereby encroaches notably on the normal lumen of the nares,.thereby obstructing nasal respiration. This sero-mucus, which in health makes its way imperceptibly into the fauces and disappears, now shows a tendency to lodge in the nasal chambers, or, flowing back into the posterior part of the lower meatus, is hawked back by a sort of nasal screatus into the pharynx. Further- more, as the result of increased nutrition, there is a certain amount of activity in the epithelial elements on the surface of the mucous membrane by which normal proliferation is notably increased, so that we have the character of the secretion from the nose still further changed by the admixture of young epithelial cells, which renders it somewhat thicker in consistency and opaque in character.- There is no tendency whatever to the formation of crusts or in- spissated masses, nor do fcetid and offensive secretions accompany this form of catarrhal disease. If such symptoms are present, they should always be regarded as evidence that some other form of disease is to be dealt with. It is a popular delusion, fostered by even very intelligent writers and observers, that the secretions in hypertrophic rhinitis are foetid and irritating. Now, the only change that takes place, as I before said, is in the relative amount of normal mucus and serum which affects the consistency of the mucus alone. There are a few epithelial cells added, but these do not affect the character of the discharge to any notable degree. Now, this discharge differs, in its irritating qualities, in no essential degree from the healthy secretion. Probably no secretion of the body is blander and less irritating than that of the nose in health. If there is any element in it which is irritating it is the serum, con- taining as it does a certain amount of saline matter. In hyper- trophic rhinitis this element is diminished, so that we might say, if there is any difference in the secretion in the two conditions, it would be in favor of the secretion from the diseased membrane. The popular fear in regard to nasal catarrh is that sooner or later it will result in offensive discharges. This is based partly on the teaching of irregular practitioners that catarrh, so-called, leads to ulceration and necrosis. It is scarcely necessary to say that ulceration and necrosis belong in no possible manner to hyper- trophic rhinitis,but are only met in connection with syphilis, scrofula, and other grave diseases. This theory of offensive discharges oc- curring in this disease is based also on the teaching that atrophic 128 DISEASES OF THE NASAL PASSAGES. rhinitis is a later stage of hypertrophic. This assertion, I think, was originally made by Frankel in his admirable article on the nose in the fourth volume of Ziemssen’s Encyclopedia, and subse- quently adopted by most other writers. The assertion is, I believe, based on absolutely incorrect clinical observation, as the two dis- eases are totally separate and distinct in character from the com- mencement, as will be shown when we come to the discussion of atrophic rhinitis. The fcetid odor, therefore, is never met with in connection with hypertrophic rhinitis, though we find so careful an observer as Frankel’ stating that hypertrophic rhinitis may give rise to an odor, although not the characteristic odor of ozena. Frankel’s error here is one easily explained, as I have had occasion of observing in a number of instances which have been under my own care, where it was strenuously insisted upon, on the part of patients under treatment for hypertrophic catarrh, that there was an offensive odor. In every case I was enabled to trace the odor to the mouth. The patients sleeping with the mouth open, the tongue became dry and furred, and the thick velvety epithelium on its dorsum was the source of a slightly offensive odor, which persisted for some hours, perhaps, after arising in the morning. In other cases I have traced the odor to the existence of decayed teeth, amalgam fillings in the teeth, etc. In all cases the mouth is to be inspected in the search for the cause of a fetid breath in hy- pertrophic rhinitis, as it cannot be found in the nasal passage. Nasal stenosis with mouth-breathing is always a prominent symptom of the disease, as a necessary result of the mechanical ob- struction to the passage of air through the nose. Mouth-breathing is often considered to be a habit, and we even find various devices resorted to to break up this so-called habit. Now, mouth-breathing probably is never ahabit. It is a necessity due to the fact that the individual cannot get air enough through the nose, and hence is compelled to open the mouth. In consequence of the impairment of the normal function of the nose, under which the exudation of serum is interfered with, we soon have certain changes setting in in the air passages beyond. The first to become affected is the vault of the pharynx. Now, as has already been stated, we have in the vault of the pharynx a large mass of glands which in health pour out a certain amount of mucus which, passing down behind the palate, serves as a lubricant to the bolus of food and facilitates its passage into the cesophagus. This mucus is poured out in large quantities, of which the indi- vidual is unconscious. Now, in order that this function shall go on uninterruptedly, it is necessary that the nasal passages in front of * Transactions of the International Medical Congress, 1881, vol. 3, p. 302. HYPERTROPAIC RHINITIS. 129 it shall perform their functions in a normal manner. In other words, it is necessary that the air which sweeps over the glandular structures at the vault of the pharynx should be saturated with moisture. As soon as this nasal function is hampered, and nasal respiration is interfered with, air is largely taken through the mouth, while that which passes though the nose fails to take up sufficient moisture in its passage to bring it to the point of saturation; when, therefore,it reaches the pharyngeal vault it takes up moisture from the mucous secretion of this region. The result is, that the normal secretion of mucus in the pharyngeal vault becomes thick and in- spissated, and adheres to the parts in a thick tenacious plug, which hangs down behind the velum of the palate, causing excessive an- noyance and oftentimes distress to the patient. During waking hours this is not so noticeable on account of the voluntary efforts of the patient in clearing the nose and fauces. During sleep, how- ever, this pharyngeal mucus accumulates in a large mass, the removal of which in the morning becomes a considerable effort to the sufferer. Furthermore, the pharynx becomes excessively irritable, and the hawking and coughing in the morning is often attended with retch- ing and vomiting. This involvement of the fauces is scarcely notice- able in the earlier stages of hypertrophic rhinitis, but as time goes on, the faucial symptoms become more prominent, and soon the patient is likely to refer most of his symptoms to the pharynx and say he has a bad throat, very frequently entirely overlooking the nasal disorder. His story will often be that in former days he suffered a good deal of annoyance from his nose, but that it has “gone down” to his throat. The explanation of this I take to be that there has been no amelioration of the nasal symptoms, but a marked development of faucial symptoms, and while the nasal dis- ease still persists in as aggravated a form as ever, he gets to a cer- tain extent accustomed to the discomforts of nasal stenosis and overlooks it in the more aggravated discomfort of his throat dis- ease. Throat difficulties are always looked upon with more appre- hension by patients than nasal disorders, and, furthermore, they are the source of more discomfort as involving a far more sensitive region, This faucial accumulation is usually spoken of as naso-pharyn- geal, or post-nasal catarrh. In very many cases, however, we can undoubtedly trace its development to a previously existing disease of the nasal passages proper, in the manner above outlined. That it is met with, however, as an independent disease cannot be ques- tioned, but even in such a case there is still an intimate patholog- ical connection between the two regions, under which they natu- 9 130 DISEASES OF THE NASAL PASSAGES. rally react the one upon the other. These questions, however, will be discussed at length in the chapter devoted to the consideration of catarrhal disease of the naso-pharynx. Catarrhal inflammation of the lower pharynx does not occur in connection with rhinitis, but we not infrequently find the scattered follicles along the surface of the pharynx enlarged and inflamed, together with the chain of glands immediately behind each pillar of the fauces. This follicular enlargement is probably entirely the result of the nasal disorder. It gives rise, however, to no marked symptoms, as a rule, except in nervous, hysterical female patients. As the disease progresses, we find the larynx, trachea, and air pas- sages beyond involved in a mild catarrhal process. This is not due to any extension of disease from the nasal passages, but is due to the same cause which gave rise to the pharyngeal symptoms, and follows very soon upon their appearance. The air reaching the larynx and trachea in an abnormally dry condition, robs the mucous secretion in these organs of its moisture, and renders it thick and inspissated. Its fluidity being destroyed, it adheres closely to the membrane and gives rise to irritation and a subsequently mild in- flammation. As this secondary largyngitis and tracheitis sets in, we find a rather curious development of the disease occurring. Heretofore the patient, as the result of exposure, suffered from cold inthe head. Now his colds result in a laryngitis or bronchitis which, running a somewhat slow and persistent course, seems to travel up- ward. A cold in the head sets in oftentimes days after a bronchitis ora winter cold. This is not the rule, but is of very frequent occur- ence. Why it should be so, I do not pretend to explain. Certainly it is not due to the fact of any improvement in the nasal condition, for that is progressive as long as it is allowed to go on without treatment. Elongated uvula not infrequently occurs in connection with chronic rhinitis, and probably is a direct result of the faucial irrita- tion set up in the later stages of the disease. This elongation, however, is confined entirely to the mucous membrane at the tip of the organ, and does not necessarily involve the muscular tissues; the membrane becomes swollen and infiltrated, and hangs down on the base of the tongue, this condition being aggravated undoubtedly by the hawking and clearing of the throat, which is rendered neces- sary by the faucial accumulation. Cough also is not infrequently present, and oftentimes consti- tutes an exceedingly troublesome symptom. This may be present during acute exacerbations only, or it may complicate the chronic affection. This is often referred to as a reflex cough due to intra- jasal disease. I do not think it necessary to bring in this obscure HYPERTROPHIC RHINITIS. 131 explanation of the symptom, where it is so evidently a direct result of the catarrhal process. In most cases, probably, it is due to the nasal stenosis, causing habitual mouth-breathing with a resultant dryness of the larynx and trachea. In other cases it is due to the catarrhal inflammation which sooner or later involves the whole upper air tract, in the one case giving rise to a dry, hacking, irri- tating cough, unaccompanied by secretion, while in the other case there is a moist cough with more or less profuse expectoration, Symptoms referable to the ears, I believe to be present ina far larger proportion of cases than is usaully recognized by our standard authorities either on throat or on ear diseases. Deaf- ness is perhaps the earliest and most easily recognized symptom with which we meet in this connection, and yet this is a some- what vague expression. A moderate diminution in the hearing distance as tested by the watch will probably be recognized ina very large proportion of cases of intra-nasal disease, and yet where this diminution is but moderate it is not always safe to say that it constitutes a morbid condition directly due to the nasal disease, especially when we remember that, while the watch-test is perhaps the best we possess for testing the hearing, yet it is an exceedingly unreliable and uncertain one. We should avoid, therefore, attach- ing too great importance to it. Disease of the middle ear as recognized by notable impairment of hearing, retraction, atrophy, or calcification of the membrana tympani, together with obstruction of the Eustachian tube as de- termined by politzerization or the use of the catheter, is by far the most frequent morbid condition of the auditory apparatus met with in connection with intra-nasal disease. .This affection is undoubt- edly a direct result of the hypertrophic process in the nasal cham- bers. As regards the method of its development, there would seem to be some difference of opinion. Older writers almost invariably attributed it to the extension of the catarrhal process to the Eusta- chian tube, causing obstruction. In this manner the renewal of air in the middle-ear chamber was said to be mechanically interfered with. An examination with the rhinoscopic mirror of the Eustachian orifices in a very large number of cases shows, I think, that one of the rarest conditions with which we meet is catarrhal inflammation involving the membrane lining the Eustachian orifice, as evinced by redness, swelling, and hypersecretion. Even in cases in which the middle-ear symptoms are well marked, and in which the morbid process has resulted in an extreme degree of impaired hearing, this examination fails to show any evidence of this extension of inflam- mation by continuity of tissue. We must, therefore, seek for some other explanation of this complication. A's we know, the integrity of 132 DISEASES OF THE NASAL PASSAGES, the function of audition is dependent upon equable air pressure on both sides of the membrana tympani. In other words, the air within the middle-ear chamber must be constantly renewed in order that the pressure within the tympanic cavity shall not be diminished. Now, this renewal of air is accomplished during the respiratory process through the nose. If nasal stenosis exists, with each act of inspira- tion there is diminution of the air pressure behind the point of ob- struction. We find, then, a more or less permanent condition of air rarefaction in the vault of the pharynx. This condition necessarily makes itself felt through the Eustachian tube and in the middle- ear chamber. This slight force, acting through a long period of time, results eventually in producing an hyperemic condition of the mucous membrane lining the Eustachian tube and the middle ear chamber, together with retraction of the drum-membrane. This action we see, then, is purely a mechanical one, but it seems to me, it is one which harmonizes more clearly with clinical observation, and lends also intelligence and clearness to our therapeutic efforts. It may be stated here, in support of this view, that this form of middle-ear disease, while frequently met with in hypertrophic rhini- tis, nasal polypus, deflections of the septum, and in fact any disease which gives rise to stenosis, is far less frequently met with in con- nection with atrophic rhinitis and ozena. The above reference is mainly to cases of catarrhal inflammation of the middle ear, but it may be added that, in cases of suppurative otitis, ] have seen results so gratifying in character as to warrant the statement that in all cases of this affection treatment of intra-nasal disease, if present, becomes an imperative duty. In a certain proportion of cases of hypertrophic rhinitis, tinnitus aurium is mét with, usually in connection with middle-ear disease, though in a smaller number of cases there is apparently no organic lesion. That this distressing symptom may be dependent on the nasal disease is shown by the fact that, in a flattering proportion of cases, it disappears under treatment, and even in those instances in which complete cure is not accomplished, marked relief is afforded. Hypertrophic rhinitis is also a prominent factor in the causation of attacks of hay fever and asthma. This, however, will be dis- cussed in the chapters devoted to those affections. Headaches, eye troubles of various kinds, together with a large number of nervous diseases, such as chorea, epilepsy, etc., occur also in connection with intra-nasal disease. The discussion of this relation is more properly relegated to the chapter on nasal re- flexes. PATHOLOGY.—The accompanying cut (Fig. 65) represents a sec- tion of a mass removed from the posterior portion of the lower tur- AYPERTROPHIC RHINITIS. 133 binated bone, The changes may be described as follows: The whole ‘mucous membrane is markedly thickened and deeply corrugated. The epithelial layer is augmented or increased in width. The outer- most layer of epithelium in specimens from the middle turbinated bones exhibit fine ciliae, while in sections from the lower turbinated bones the ciliz are occasionally wanting in places. There are deep valleys running downward into the adenoid layer which are filled with stratified epithelia. The latter consist of elongated epithelia, ten to twelve layers in diameter. The layer nearest the adenoid tissue is occupied by distinctly developed large columnar epithelia, which, especially where they go to fill the valleys, are very large, Fic, 65.—Hypertrophic Rhinitis. 500, a, Epithelial layer; 4, limiting structureless membrane; ¢c, ad- enoid layer; @, blood-vessels filled with blood; ¢, acinous gland; 4, venous sinus composing the so-called erectile tissue. and composed of several strata. The boundary line between the epithelia and the adenoid tissue is everywhere well marked, and in some places there is even present a layer without distinct struc- ture, the so-called structureless membrane. The adenoid layer is very wide, and is composed largely of a myxomatous reticulum, with numerous lymph-corpuscles, while in some portions the lymph-corpuscles are very scanty, and the whole mucosa is composed of very dense decussating bundles of fibrous connective tissue. The mucosa is in all instances richly supplied with relatively wide capillary blood-vessels, mostly filled with blood. The acinous mucous glands are very numerous, and evidently in- creased in size and number. They are composed of cuboidal epithe- lia, which, in. many instances, exhibit the features of inflammatory corpuscles. The ducts of the glands are traceable into the valleys 134 DISEASES OF THE NASAL PASSAGES. blend with that of the outer epithelial coat. The submucous coat, beneath the adenoid tissue, consists of a broad layer of either myxomatous, or fibrous reticular structure, in which there are present enormously enlarged blood-vessels of a venous character. These veins are so abundant that they resemble a true erectile tissue. The connective tissue, however, between these large veins is broader than is usually found in true cavernous tissue, and is supplied with bundles of smooth muscular fibres. The muscle-coat of the veins is also increased in breadth The arteries, though scanty, are all of a wavy course, constitut- ing the so-called helicine arteries. The submucous layer also con- tains a number of racemose mucous glands, increased in size. The presence of these glands in this layer of the membrane is, I believe, anomalous. Around these glands there are found, as a rule, heaps of lymph-corpuscles. The characteristic features of hypertrophy of the nasal mucous membrane, then, may be briefly summarized as follows: fFirst.—Increase of the covering epithelium, without desquama- tion. Second.—Increase of the alenoid layer and its capillaries, with stagnation of blood, together with a new formation of fibrous con- nective tissue replacing the adenoid layer. Third.—Increase of the racemose glands, both in the adenoid and submucous layer. Fourth.—Hypertrophy of the connective tissue between the en- larged veins in the submucous layer Fifth.—In advanced stages of the hypertrophic process, an ab- sence of lymph-corpuscles, they having evidently been transformed into connective tissue. . At the anterior termination of the middle turbinated bone, the hypertrophic process develops in a somewhat different manner, in that, while there is still evidence of inflammatory action, the thickening of the membrane is largely due to a myxomatous trans- formation, which gives to the tissue a somewhat soft, gelatinous consistency, with a gross appearance closely resembling that of an ordinary nasal polypus. The histological structure of this tissue is well shown in Fig. 66. DIAGNOSIS.—The question has been raised as to what constitutes a diseased condition of the nasal mucous membrane, and whether we can recognize it in its milder forms by sufficiently characteristic ap- pearances. I think not only that we can do this, but that we should do so in all cases, with the same delicacy of appreciation as is used in the recognition of diseased conditions of other organs, and this AYVPERTROPHIC RHINITIS. 135 by ocular inspection; for since the introduction of the use of cocaine we are enabled to bring into view the whole of the nasal cavities, in a manner so thorough that no morbid process existing there should escape notice. An examination anteriorly will show the mucous membrane swollen and of a bright reddish-gray color, with perhaps a pink tinge. This is not the bright scarlet color of acute inflammation, nor again the purplish hue of purely venous congestion, but some- thing between the two, the swollen condition being, as we know, due entirely to the plethoric state of the venous sinuses, although the superficial color is given by the hyperemia of the capillaries of the mucosa proper. The surface of the membrane is rounded, Fic, 66.—Myxomatous Hyperplasia of the Nasal Mucosa from the Anterior Termination of the Middle Turbinated Bone. £, Columnar ciliated epithelium; /, infiltration of outermost portion with lymph-cor- puscles; 47, myxomatous tissue; Z, lymph follicle; C, crypt of mucosa cut obliquely; 4, acinous mucous glands. somewhat irregular in shape, and coated with a limited amount of grayish semi-transparent mucus. If the swelling is but moderate, we may inspect a considerable portion of the membrane covering the lower and middle turbinated bones. On the lower turbinated, behind its anterior extremity, we find the surface presenting a slightly rugous appearance, while on the middle turbinated we notice a brighter red color, together with a smooth, shining surface, but slightly coated with mucus, and accord- ing to the extent of the turgescence, approaching more or less closely toward contact with the septum. If there is considerable swelling of the membrane, we find also the lower turbinated bone approx- imating itself to the septum, thus rendering an inspection of the cavities beyond impossible. 136 DISEASES OF THE NASAL PASSAGES. Examination posteriorly simply brings into view the membrane covering the posterior termination of the middle turbinated bone, together with the posterior half or two-thirds of that of the lower turbinated bone. We find here an appearance differing essentially from that seen in front. The membrane here presents a condition which has been called grubworm hypertrophy, from the fact of its striking resemblance to a large white grubworm, lying one on either side of the septum. On the lower turbinates will be seen a rounded, whitish mass, with a raspberry-like outline of surface, presenting minute furrows and fissures crossing it in irregular lines. This Fic, 67.—The Outer Wall of the Nasal Cavity Showing the Mucous Membrane ina State of Hypet- trophy over the Lower ‘Turbinated Bone. same appearance is seen on the middle turbinates, although the masses are much smaller, and present an elongated, spindle-like contour. The superior turbinated tissues may occasionally be seen by this examination, but are rarely the seat of any morbid process. These appearances, as seen through the nostrils, cannot be intelli- gently illustrated, but in Fig. 67 is shown a lateral view of the outer wall of the nasal cavities, in which the mucous membrane is in a state of hypertrophy, and, as-a contrast to this, there is shown, in Fig. 68, the same view in which the membrane is in a fairly nor- mal condition. In Fig. 69, there is shown a transverse section through the nasal cavities still further illustrating a general hypertrophic process as HYPERTROPHIC RHINITIS. =F, NE, ee, - {5 oe ae s . eee TPs PS A acne i “ Vs ce WS Fic. 6..—Transverse Section through the Nasal Cavities Showing the Mucous Membrane Covering the Lower and Middle Turbinated Bones, in a State of Hypertrophy (Zuckerkand]l), 138 DISEASES OF THE NASAL PASSAGES. involving the mucous membrane covering both the lower and mid- dle turbinated bones. A still further development of the hypertrophic process is oc- casionally recognized by the examination, in which the posterior termination of the lower turbinated bones presents the appearance of large rounded masses with the same rugous surfaces, which more or less completely fill the oval openings of the posterior nares (see Fig. 70)—a condition first described, I believe, by Lefferts and to which the name of posterior hypertrophy has usually been given by writers. Bigelow,’ in demonstrating the turbinated bodies, called attention to the fact that, if this tissue is artificially distended Fic. 7o.—Large Masses of Hypertrophied Membrane on the Posterior Termination of the Lower Tur- binated Bones, More or Less Completely Filling the Posterior Nares. by a blowpipe, “a pouch-like process projects from the rear of the bone, increasing its length.” Bigelow’s observation easily explains why these so-called “ pos- terior hypertrophies”’ occur. So far our examination has shown us the existence of hypere- mia of the membrane, the amount of which has been recognized by the eye. The amount of true hypértrophy, which exists in the membrane, has not yet been ascertained. There is now to be thrown into the anterior nares, a four-per-cent solution of ‘cocaine by means of the spray apparatus, the effect of which will be to thoroughly expel the blood from the membrane. The action of the cocaine should be carefully watched, and the thoroughness of the application and the completeness of its action be awaited. When the membrane has become thoroughly exsanguinated, we will find the whole of the nasal passages brought completely under observation, unless some condition other than the one under * Boston Med. and Surg. Jour., April 29th, 1875. AYVPERTROPAIC RHINITIS. 139 consideration exists to interfere with the inspection. We find néw the lower turbinated bone covered with a soft, thick, somewhat velvety membrane, which adheres closely to it, and reveals the bony outline more or less completely, according to the extent of the structural thickness of the membrane. Now, if there were no hypertrophy existing in the mucous membrane, the lower tur- binated bone would appear almost like a cord lying against the ex- ternal wall of the nose, covered by a closely adherent, thin, parch- ment-like membrane, possessing a thickness not sufficient to mask the general contour of the bony structure beneath. If, however, the membrane is the seat of connective-tissue hypertrophy, this will be recognized by the extent to which it does mask the normal bony contour. In front there will be a soft, rounded, cushion- like knob, as it were, grayish-white in color, and which can be moderately indented by the probe, which in all cases should be used freely over its surface, in order to gain accurate knowledge of the extent of the hypertrophic process. Looking along this sur- face beyond the anterior extremity, we will find the membrane pre- senting, as a rule, less evidence of thickening, both on inspection and to the impact of the probe, but still sufficient to give a rounded outline to the bone beneath. If now the head is thrown backward and the middle turbinated tissues are brought into view, they will be seen covering the bone somewhat closely, of the same general tint as the membrane below, but as a rule presenting also a thickened mass anteriorly, which here, instead of hypertrophy, assumes more of a polypoid nature (see Fig. 66). The hypertrophy is of a somewhat myxomatous character, and hence the swelling is not so markedly reduced by the use of cocaine. The probe should be used here also to deter- mine-‘the character and location of the hypertrophic process. If now we examine posteriorly, the same appearances will pre- sent as were seen before the cocaine was applied, with this change, however, that the swollen masses on the posterior terminations of both ‘middle and lower turbinated bones present less prominently, and are smaller in size. Superficially, however, they show the same grubworm-like membrane as before described. TREATMENT.—The first question which arises in the discussion ‘of the treatment of this affection is as to the value of local appli- cations, such as astringents, alteratives, and stimulants. That these have an effect in temporarily relieving the troublesome symptoms of the disease, I think, no one will question, but when we consider what the morbid lesion is, namely, a deposit of connective tissue in the intervascular tissues, whereby the important functions of the membrane are hampered, I think that all must concede that a simple 140 DISEASES OF THE NASAL PASSAGES. local application by means of spray or douche, can have but a very ephemeral effect. Furthermore, their efficiency is quite as great when applied at the hands of the patient himself, as when applied in the office of the physician. There are certain remedies, then, whose action we all recognize, and whose aid we seek by directing that the patients shall make use of them in the intervals of their attendance upon office-treatment. If there is much nasal stenosis with mucus-accumulation in the upper pharynx, a cleansing wash is always grateful to the patient, and he should have it near him for frequent use, simply as a part of his toilet-apparatus. With this we may combine both the cleansing properties of the alkalies with one of the simple astringents, such as: BR Acidi carbolici, : : i . ‘ . grs. iif. Sodii bicarb., . : . . ; : . grs. xij. Sodii biborat., . ; . é ; ; . grs. XXx, Glycerini, : ; : . : ‘ ~ § SS Aque, ‘ : ; : ‘ 5 ‘ ad vi. M. ft. lotio. Or, B Sodii benzoat., Sodii biborat., . < : : 5 aa ors. Xxx. Thymol., : : ‘ , . . grs. ij. Aque, . : : ‘ . . ‘ 6 RUINS Or, B Acidi borici, . : ‘ ‘ 3 ‘ . 3ss. Sodii chloridi, . ‘ j ; : : . grs. xb Sodii tartrat., . : o : : 3 . grs. Xv. Aque camphore, . 3 ‘ . ; . Zi. Aque, . ‘ . ad Svi. To any of the above there fnssyy be added a vegetable or mineral astringent, such as: Acidi tannici, . : : . grs. x. to the ounce. Zinci sulphatis, és ‘ . gs. ij. to the ounce. Aluminis, : : : . grs.v. to the ounce. Zinci sulpho-carbolat., . . grs. iij. to the ounce. Zinci chloridi, . ‘ grs. i. to the ounce. These are best used by the cenventeat little atomizer shown in Fig. 47, thus avoiding the inconvenience and possible dangers of the Thudichum nasal douche, which, moreover, is no more advanta- geous, either as a cleansing device or as a medicating medium, than the atomizer. In the absence of an atomizer, J think the simple device of insufflation of warm salt water from the hand may be safely recommended to the patients, where any comfort results from the cleansing of the passages thereby secured. Snuffs, whether in- AHYVPERTROPAIC RAINITIS. 141 sufflated from the fingers or blown by an insufflating apparatus possess no advantages over aqueous solutions. They simply call upon the mucous membrane for a sufficient amount of water to dissolve their efficient ingredient, before they can exert any influ- ence, unless we except those which are used for stimulating pur- poses, and here we have a method of local relief to those cases which is oftentimes of undoubted temporary benefit. There are certain remedies which, when applied to the nasal membrane, give rise to pain and irritation, for the time, followed by a more or less profuse watery discharge from the nose. Their first effect is rather distressing ; the ultimate effect, exceedingly grateful to the patient. ‘The watery discharge which they excite, seems, as it were, to un- load the plethoric veins by this profuse exosmosis, which in its dis- charge seems to wash out the glands, and carry away a lot of surface débris, by which the membrane is for a time very markedly relieved, and the discomfort of the patient much alleviated. The ultimate effect, however, is of somewhat questionable advantage. Certain of the largely advertized catarrh snuffs sold in the drug-stores act on this principle. The most notable of these remedies are perhaps bicarbonate of soda, bromide of potassium, sanguinaria, galanga, etc. None of these remedies should be applied undiluted to the nasal mucous membrane in a state of hypertrophy; although all of them possess beneficial qualities in the atrophic form of the disease. The only advantage of powders is, that they may be carried in the vest-pocket and used at frequent intervals. The principle of their action is the same as the lotions above given, hence we may prescribe them of the same proportions, substituting a bland, neu- tral powder for the water, as follows: BR Argent. nitrat., ‘ ‘ ‘ ‘ ‘ . grs. ij. Zinci chloridi, ‘ : ‘ : ‘ . grs. iv. Bismuthi subnit., . , ‘ i : » Bij Sacchari lactis, : ; ‘ : ‘ . 3vi. M. B Acidi tannici, . 3 : ‘ : . gYrs. X. Pulv. acacia, . ‘ ‘ ; : i a. Bly M. BR Hydrarg. chloridi mitis, . 4 : : . grs. Xx. Bismuthi subnitratis, : ‘ : , «Bde Magnesiz calc., P . : . , » 388: B Iodol, ‘i i 5 : ‘ . ; . grs. XX. Pulv. camph., . ‘ : . ; : . 3ss. Pulv. acacie, . ; ‘ ‘ Z ‘ . 3iv. M. 142 DISEASES OF THE NASAL PASSAGES. If the stenosis in these cases is troublesome, I see no objection to placing in the hands of the patient a two-per-cent solution of co- caine, with a small atomizer, by the occasional use of which he may give himself the temporary relief that this drug affords. All of these remedies, it should be understood, are merely pallia- tive; the permanent cure of these cases depends upon measures which will diminish hyperemia, remove structural hypertrophy, and restore the normal calibre of the passages, while at the same time the healthy respiratory function of the membrane is re-established. Wagner’ advocates the use of flexible metallic bougies which are introduced daily into one or both passages, and allowed to remain in situ for several minutes at atime. Wagner claims that absorp- tion of redundant tissue is thereby promoted. On general princi- ples, in order to produce absorption, equable pressure must be continuously maintained for a long period of time. Certainly in this case, the pressure is neither equably distributed over the hyper- trophied membrane, nor maintained sufficiently long to produce any permanent results. The injection of ergot into the hypertrophied tissue by means of a hypodermic syringe, as suggested by DeBlois,’ we can easily understand, might have an effect on engorged blood- vessels; but we should scarcely expect it to produce absorption of connective tissue. The removal of redundant membrane can un- doubtedly be produced by the method suggested by Henderson, who advises that a few drops of pure carbolic acid should be in- jected into the tissues in several localities along the.face of the tur- binated bone, thereby securing more or less extensive destruction of tissue by the slough which must naturally ensue. But, the object of treatment, it must be remembered, is not destruction of tissue, but its restoration to a healthy condition. Extensive sloughing, followed by cicatrization, might result in a condition quite as dele- terious, or even more so, than the disease which it was originally designed to remove. The last stage of atrophy is really a stage of cicatrization. If this plan of treatment were carried too far, we might easily produce a condition closely resembling an atrophic rhinitis in its advanced stages. The same objection lies with equal force against the various devices which were greatly in vogue some years since, for wrenching away this hypertrophied membrane by means of forceps, such as those of Robinson,‘ which consist of long, tapering blades with teeth in their whole length, which, seizing the membrane laterally, enable the operator to tear it away. In the * ** Diseases of the Nose,” pp. 70, 71. ? Arch. of Laryngology, vol. iv., p. 20. 3 St. Louis Med. and Surg. Jour., Jan., 1886, p, 28, 4 Op. cit., p. 115, HYPERTROPHIC RHINITIS. 143 same category should be mentioned the canula scissors of A. H. Smith as described by Robinson,’ and Woakes’s’ nasal plough. It should be stated, however, that these devices have deservedly fallen into general disuse. Local astringents having failed to accomplish any notably good results in these cases, these harsh measures, above alluded to, were taken up, and advocated for a while with consider- able earnestness, but the results of treatment proving even disas- trous in many cases, search was made for still other medicaments for controlling the disease and, naturally, the use of caustics was then taken up, and with the idea, I think still, that the destruction of tissue was the end to be accomplished, for we early find recom- mended the most powerful chemical agents, such as Leyden paste, Vienna paste, and nitric acid, together with the galvano-cautery. Some years since, in discussing this question,’ I entered my protest against these measures, claiming that better results would be se- cured by milder treatment, where the object was merely to reduce hypertrophic conditions, and then advocated the use of glacial acetic acid. Since that time, I have abandoned the use of this agent for one possessing more valuable properties as a caustic, namely, chromic acid, on the ground that these powerful agents were apt to do harm rather than good, on account of the difficulties in‘limiting their application. The question suggests itself in this connection, On what theory or conception of the disease has the use of these powerful caustics been based ? In order to understand the application of caustics to the hyper- trophied nasal mucous membrane, we must first form a clear idea of the pathological conditions which we wish to overcome. An hypertrophic rhinitis is the result of certain changes in the mucous lining of the nose. These changes do not affect the epithelial layer at all; the submucosa suffers, if at all, only a slight dilatation of its blood-vessels. It is in the third, or deeper, or cavernous layer, that the important changes take place. Here we havea dilatation of the venous sinuses, increased blood supply, hypernutrition, and a consequent increase of all the elements of the intervenous connec- tive tissue. Again, this hypertrophy does not lead to increased secretion, as is so often supposed. It is the function of the venous sinuses to pour into the nasal cavities about sixteen ounces of clear serum daily, for the purpose of moistening the air before it enters the lungs. This.clear serum, mixed with the normal mucus secreted by the lining membrane of the nose, forms a bland and non-irritating * Op. cit., p. 114. 2 Op. cit., p. 201. 3 “*Some of the Unsettled Questioas concerning Nasal Catarrh.” New York Med. Record, November 6th, 1880. 144 DISEASES OF THE NASAL PASSAGES. fluid, whose presence we are not cognizant of in a state of health. Diminish the diluting serum, by thickening the walls of the vessels, and the secretion becomes thick and gives annoyance. From what has already been said, it is evident that the object of treatment should not be to destroy tissue, but to constrict the blood-vessels, diminish the nutrition, and thus counteract hyper- trophy. We have found that the deep cavernous layer, by furnish- ing an increased blood supply, is the primary seat of the trouble. No destructive agent, applied as we are in the habit of using them in treating the nasal mucous membrane, can cause necrosis of more than the superficial epithelium, and possibly, to a very slight degree, of the submucosa; it does not affect the deep or cavernous layer, which is the one chiefly concerned. To what, then, is the beneficial action of a caustic application due, for they certainly are of great benefit. Until quite recently our caustic applications were effective sim- ply by the contraction of the superficial slough formed. By this contraction the calibre of the venous sinuses was diminished, and the walls of the vessels enabled to regain their proper tone. Since the discovery of the wonderful power which cocaine has of contract- ing blood-vessels, our caustic applications have been much more effi- cient. The ordinary procedure is, by an application of cocaine,’to deplete the vessels by diminishing their calibre; then by applying our caustic to the most prominent points; to pin down this already contracted tissue by the formation of a superficial slough, maintain the vessels in a state of contraction until they can regain their nor- mal tonicity, and thus control nutrition. What agent shall we use to accomplish this purpose? Shall we resort to the various chemical agents, or to the potential cautery ? The effect is the same in either case. For a considerable time I have used chromic acid to the exclusion of all other agents. Its advantages are well expressed by Dr. Squibb,’ as follows: “It is, perhaps, the most important and most valuable of all the erosive caustics, for one simple and characteristic reason, namely, that it is self-limiting in its action, to a degree that no other de- structive caustic is. It is an active oxidizing agent, and destroys the tissues to which it is applied by oxidation. Thus far, its action is similar to other caustics, such as nitric acid, for example. But every molecule of chromic acid which destroys a molecule of or- ganic tissue, is itself destroyed, and rendered inert by being reduced to an insoluble and inert oxide of chromium, and this principle and degree of self-limitation is not obtained from any other caustic. Sulphuric acid is also a destructive caustic, but not in the same way 1 The Ephemeris, July, 1883. HYPERTROPHIC RHINITIS. 145 or by the same reaction as chromic acid, and it is not self-limiting. Both sulphuric acid itself, and the products of decomposition by it, are more continuously and injuriously irritant. It is, therefore, a more painful caustic than chromic acid, produces deeper, more pro- longed, and more irritable sloughing.” We have, then, in chromic acid an agent which fulfils all the indications. The extreme nicety with which it can be applied, without cumbersome or expensive apparatus, its efficiency, and the absence of unpleasant effects following its intelligent use, have been sufficient to commend it to me, to the almost total exclusion of other agents. It:has been claimed that cicatrices result from its use, but I have never observed them. It seems almost paradoxical to control a morbid process by a destructive agent, but at the pres- ent stage of our therapeutic resources we possess no better method. The special manner in which it should be used is as follows: A small, slender probe, such as is shown in Fig. 71, is first dipped in a little mucilage,.and then four or five of the slender acicular Fic. 71.—The Author’s Chromic Acid Applicator. crystals of the acid are taken up upon it, and held over a flame until they are fused into a small tear, as it were, on the end of the probe, which on cooling will present a small, solid red’ bead of amor- phous chromic acid, which can be easily manipulated and carried. to the part, already anesthetized and exsanguinated by the ap- plication of cocaine, which it is desired to medicate, without danger of injuring healthy tissue. The galvano-cautery, since its use was first advocated by Mid- dledorpf,* has come into very extensive use, and is warmly advo- cated by Mackenzie, Moldenhauer, Sajous, Lennox Browne, Seiler, Schech, Robinson, Moure and others. All of these writers give it preference over other methods, and many of them have presented us with ingenious forms of batteries which are claimed to possess certain advantages. A smaller number of authorities, while recommending it, fail to give it the first place as a caustic agent, such as Woakes, Cohen, Wagner and others. I think I do not overstate the case, when | say that the potential cautery possesses no advantages over the chemical cautery if properly and deftly applied, and with a nice appreciation of what is to be accomplished. The galvano-cautery * “Die Galvano-kaustik,” Breslau, 1854. 10 146 DISEASES OF THE NASAL PASSAGES. battery is a large, unwieldly, cumbrous apparatus, exceedingly lia- ble to get out of order, and a constant source of annoyance by its liability to fail us just when it is most needed, from short circuiting, polarization, or more likely still some hidden and undiscoverable fault which hampers its working. In treating hypertrophic rhinitis, this somewhat complicated apparatus is used to develop a certain amount of heat in a small platinum electrode, for the purpose of Fic. 72.—Meyrowitz’s Portable Galvano-Cautery Battery. endowing the electrode with a moderate amount of destructive potency. Now, as we have already shown, the amount of absolute destruction which we wish to accomplish is very limited. It would seem, therefore, that we resort to a somewhat irrational process for accomplishing all this, when a few crystals of chromic acid, fused on the end of a probe, will accomplish the same purpose equally well. In condemning the use of the galvano-cautery methods, I do not attempt to criticise the results thereby obtained. There can HYPERTROPHIC RHINITIS. 147 be no question as to the success of the so-called galvano-caustic treatment. I merely say that we put ourselves to a vast deal of unnecessary trouble and inconvenience when we use this instru- ment. I think, however, another point worthy of consideration is that, in introducing the cautery electrode into the nose, and devel- oping in it a high degree of heat, we do incur a certain amount of risk. The chemical cautery, I think, involves no danger. A plati- num electrode introduced well into the nasal cavity, and heated to a white heat, or even a dull red heat, in contact with the lower and middle turbinated bones, CC yl does certainly add to the | AY | LY /) Sia renee oo \ j Most writersrecognizethis, and make special allusion to the violent reaction that may set in following its use, giving rise to an acute rhi- nitis, a distressing neural- gia, an acute dermatitis, or even an attack of facial erysipelas, as I have seen in three cases—complica- tions which rarely, if ever, attend the proper manipu- lation of a chemical agent. Notwithstanding what has been said, the galvano- cautery is an exceedingly attractive method of treat- ing affections of the nasal cavities, and undoubtedly will always remain a pop- ular instrument, for, when Fic. 73.—Meyrowitz’s Storage Battery. in working order, the manipulation of the instrument isa pleasure to the operator, and undoubtedly produces no slight moral effect on the patient. I have had personal experience with a number of different forms of cautery-batteries, and find it difficult to designate any par- ticular apparatus as offering special advantages. Of the two forms of galvano-cautery batteries, viz., the chemical and the storage, I think the preference usually will be given to the former, in that the charging of the storage battery either requires a somewhat elaborate apparatus in one’s office, or the inconvenience of sending it to the electrician for testorage. Of the dip-plate batteries, perhaps none is better than the inexpensive instrument manufactured by Meyrowitz, Fig. 72, 148 DISEASES OF THE NASAL PASSAGES. for although somewhat bulky in size, it is simple, and not especially liable to get out of order. In Fig. 73 is shown a simple storage bat- tery which has served the writer well in the somewhat limited use of this method to which he resorts. The cautery handle should be light and easy of manipulation. In Fig. 74 is shown perhaps Fic. 74.—Galvano Cautery Handle with Flat Electrode for Use upon the Turbinated Tissues. as efficient an instrument as any other. It is mounted with a flat electrode, suitable for use upon the turbinated tissues. Other forms of electrodes, designed to fulfil special indications, will be selected according to each operator’s preference. Various forms of these are shown in Fig. 75. The electrode should be bént at an angle of forty-five degrees with the handle, thus enabling the opera- tor to follow‘the platinum tip closely with his eye, in order that the cauterization shall always be accomplished directly at the summit of any projecting mass of hypertrophied tissue. The platinum tip used should, asa rule, be quite small, and in making the application a limited surface only should be burned over at each sitting. Furthermore, it is well to keep up a slight motion, if possible, in the instrument after the current is turned on, which should always be done after it is carried to the desired locality, and shut off before it is withdrawn, in order that the electrode may cool, and thus healthy tissue in other parts of: the nostril escape injury by the in- strument on its removal. The object of the slight motion recommended, is to prevent the electrode from adhering to the burned tissues, for when this occurs its withdrawal is usually attended with a tear- ing away, by which the blood-vessels are ruptured, and hemorrhage ensues. The degree of heat in the instrument, where feasible, should be regulated. This is not possible, however, in all cases. A red heat is Fic, 75.— Nasal 3 2 Electrodes. 4,Bulb Preferable, as there is danger of the extreme white pointed; 2. knife; heat burning more extensively than may be desired. ycurette; D, point, It is often recommended to use a cautery-knife, by which the surface of the membrane may be incised as it were, thus burning a furrow well into the turbinated tissues. I think, how- ever, as a rule, a superficial burning, producing a slough such as has been described in connection with chromic acid, will be all that is sufficient, using for this purpose a small flat electrode. A HYPERTROPHIC RAINITIS. 149 twenty-per-cent solution of cocaine, of course, should be used-in the manner already described in connection with chromic acid. After the burning, the cavity should be repeatedly washed out with | a cleansing spray, thus cooling the membrane and allaying such irritation as may be caused by the application. As a rule, caustic applications are not specially painful and yet, in many cases, notwithstanding the use of cocaine, a certain amount of pain referable to the burned surface will be produced, while in others severe neuralgia will be caused as the result of the caustic acting on the terminal filaments of the nerves. Where this occurs, it is well to allay it immediately, otherwise it may persist many hours. For this purpose nothing is better than the application of dry heat, which is usually accomplished by holding a towel against the hood of the rhinoscope or the chimney of a coal-oil-lamp for a few seconds, and applying it to the face, changing the towel fre- quently. This is simple and perhaps more convenient than the hot water bag or the Japanese pocket-stove, either of which may be used. The caustic applications should be repeated at intervals of a week or ten days. These measures will be fully equal to the reduction of chronic hyperemia with hypertrophy of the nasal mucous membrane, where no complications exist. As has already been stated, probably the most frequent cause of hypertrophic rhinitis is a deflected septum, and it is scarcely necessary to state that any measure for the reduc- tion of the hypertrophic process will give but temporary relief, while the exciting cause remains. Hence, from the full apprecia- tion of the mechanism of the development of the disease, we easily understand that our first efforts should be directed toward the re- moval of the obstructing septal deformity. This question, however, is fully discussed in the chapter on that subject. A condition is not infrequently found in these cases which has already been alluded to, and which consists of an hypertrophy of the posterior extremity of the lower turbinated bone. Cauteriza- tion does not reduce these masses, and surgical interference is always necessary. For the removal of this redundant tissue, we possess no device which is so efficient as the cold wire snare écraseur which has come so largely into use of late for the removal of growths, hyper- trophic masses, etc., in the nasal passages. It is interesting to note in this connection that, as Mackenzie has observed, one of the earliest forms of the snare was devised by Robertson’ for the removal of nasal polypi, and that this instrument was subsequently modified by Wilde to adapt it for operating upon aural polypi, t Edinburgh Med. and Surg. Jour., 1805, vol. i., p. 410. 150 DISEASES OF THE NASAL PASSAGES. while a still later modification was made by Hilton, who in turn adapted it again for use in the nose, for the extraction of nasal polypi. These instruments were designed to be mounted with annealed wire,‘ for the purpose of encircling the pedicle of the growth, after which it was torn from its attachments. Hence we see that they were all technically snares rather than écraseurs. To Dr. Jarvis is undoubtedly due the credit of having introduced the principle of écrasement, as applied to nasal growths, or certainly to have demonstrated its great value, when he devised the very ingenious and yet simple device which is known as Jarvis’ Snare* (shown in Fig. 76). It consists of a slender but stout tube, about the size of a No. 3 sound, English scale, on the proximal end of which is turned a thread for about two and a half inches of its length. On this thread there plays a milled nut which carries before it an outer tube, two and a half inches long which slides over the threaded portion. The end of the outer tube is fitted with two small pins for fastening the wire with which the snare is mounted. The wire to be used in this instrument is the highly tempered steel piano-wire, the No. 5 being perhaps best adapted for all purposes. The working of the instrument is obvious. The two ends of the wire are passed up through the inner tube, and firmly fastened to the projecting pins on the outer tube, leaving a loop projecting from the distal extrem- ity, which is drawn within the canula by turning the nut, and thus carrying the outer tube before it. One great advantage of this instrument consists in the substitution of the principle of écrasement for that of snaring, whereby the growth is separated without in- juring healthy tissues, and at the same time the danger of hemorrhage notably diminished. Another, and very important feature of it, consists in the use of the steel — ae piano wire, which furnishes a loop of such strength and Wie Siae. resistance, that it can be readily carried into the nasal Ecraseur. cavity and fitted about a growth without yielding or bending, thus affording a facility in manipulation, which is in no manner equalled by the soft annealed wire loop. A somewhat ingenious modification of the Jarvis’ snare has been constructed by Sajous, as shown in Fig. 77, which consists of a solid * Robertson makes mention of the use of harpsichord wire, though evidently with the design of snaring the growth, rather than of severing its attachments by écrasement. ? Trans. Am. Laryngol. Ass'n, 1880, p. 130. HYPERTROPHIC RHINITIS. 151 stem playing in an outer tube. The proximal end of the stem is fitted with a thread on which plays a nut, while its distal end is slotted on either side for a short distance, and perforated by a small opening. Into this opening are in- serted the two ends of the steel wire, when the stem is drawn with- in the outer tube, thus bending the wire in such a way as to hold the loop firmly in position. The ad- vantage of this device seems to be in the simplicity of its mounting, and the economy of wire. In dealing with the above con- dition of posterior hypertrophy already alluded to, the Jarvis in- strument is to be preferred. This is mounted with a loop, which an examination of the mass has shown to be sufficiently large to embrace it, and is then passed through the nares until the end of the loop passes the end of the tur- binated bone, and is free in the upper pharynx. The loop having been bent slightly to one side be- fore entering the nares, will, by its own elasticity, slip over the mass, when it can easily be drawn into place and the tumefaction cut through. Of course, there is liable to be a considerable hemorrhage as the result of this procedure, but if the operation be done slowly, a half hour or even an hour being con- sumed, it may often be done with- out loss of blood. If, however, hemorrhage does occur, a plug of absorbent cotton can easily be passed back and wedged between the cut surface and the septum, and allowed to remain until the follow- ing day, if necessary. The relief a ( TMM in Fic. 77.—Sajous’ Snare. a, Sectional view; 4, snare showing the method of inserting the wire loop; ¢c, distal end of the inner stem, enlarged. attending this operation is immediate and striking. The accom- 132. «= DISEASES OF THE NASAL PASSAGES. panying illustration, Fig. 78, gives a side view of this posterior hypertrophy. It is a drawing by Dr. Jarvis of a morbid specimen in his possession. There is also shown in the plate the snare in position for severing the mass. A condition not unlike this at the posterior termination of the lower turbinated bone is frequently met with, though in a far less Fic, 78.—Lateral View of Posterior Hypertrophy of the Mucous Membrane of the Lower Turbinated Bone, with Jarvis’ Snare in Position for Section. degree, at the anterior termination of the same body. This consists of a rounded, puffy-looking mass, which encroaches on the lumen of the anterior nares, more or less completely filling it, and serving to obstruct materially the entrance of air. A very simple device for removing this by means of the same snare écraseur has been suggested by Dr. Jarvis.!| This consists of transfixing the mass from below upward and backward by a long, slender transfixion needle, either straight or slightly curved as shown in Fig. 79, and mounted in a suitable handle. The loop of the snare is then passed over the handle of the needle, and subse- Hs CLL MAA MMMM CASWELL NAZARD & COW.F.FORD OZZ MMMM MMI Fic. 79.—Jarvis’ Transfixion Needles, quently over its point, when that portion of the mucous membrane which has been transfixed is cut through and removed. There is thus taken out a small mass about the size of a split pea. The cut surface heals kindly, and the result, in my experience, has been in- variably to relieve the conditon of stenosis. This, of course, ac- complishes what the forceps does, but it does it in an almost painless tN. Y. Med. Record, vol. xxi., p. 563. AVPERTROPHIC RHINITIS. 153 manner, and with absolutely no bruising. The hemorrhage result- ing is not great, and is easily controlled by a plug of cotton inserted for a few minutes. Occasionally there will be found on the an- terior extremity of the lower turbinated bone, a mass which will demand removal by the snare. Hypertrophy of the membrane covering the middle turbinated bone occurs in a large majority of cases on its anterior termination, and occurs here as a condition rarely met with on the lower tur- binated, in that it possesses a looser structure, and assumes more of a myxomatous character (see p. 135), presenting to the eye a bluish-gray appearance, between that of the nasal mucous mem- brane and anasal polyp. This may develop on an otherwise healthy turbinated bone, or the bone itself may become enlarged and un- rolled, as it were, on itself, in such a way as to present a large, shuttle-like prominence, projecting downward and inward, thus encroaching upon the normal lumen of the cavity. No hesitation should be felt in removing this mass, and we possess no method better than the use of the steel wire snare. The steel wire loop possesses sufficient firmness to enable the manipulator to carry it well over the mass which can be then easily severed. In many cases a portion of the bone is removed with the thickened mem- brane, which I think is always permissible, as probably the de- formity of the bone has much to do with the development of the hypertrophy. The snare, I think, should always be used in these cases, as caustics are inadequate to their destruction. The galvano- cautery loop may be used, but the cold wire is more easily manipu- lated and the operation is completed more rapidly. Hemorrhage as the result of operations on the middle turbinated bone is comparatively rare, although three cases of operation in this region at my hands have been followed by this accident; the hemorrhage being exceedingly intractable, plugs not only being rendered necessary, but their removal not being feasible until the third day. In the treatment of all cases of catarrhal disease, special stress should be laid on the enforcement of those general hygienic mea- sures which already have been fully discussed in the chapter on tak- ing cold. A catarrhal process is kept up oftentimes and aggravated by the same conditons which give rise to the phenomenon of tak- ing cold. The same general hygienic laws which we have already discussed under the heading of prevention of cold should be spe- cially enforced, therefore, on our patients under treatment for a chronic catarrhal process. CHAPTER X. PURULENT RHINITIS OF CHILDREN. THIS expression is used to describe an affection, which is met with exclusively in children, and in which the inflammatory process is attended with a purulent discharge from the nasal mucous mem- brane. In literature we find it used in a somewhat vague and in- definite manner by writers, who describe a number of different diseases.under this name. Thus Mackenzie recognizes two forms of purulent rhinitis, acute and chronic. Under the acute form this writer* describes that form of purulent nasal discharge, met with in infancy, which is usually ascribed to a gonorrheea or leucor- rheea in the mother, although he questions the accuracy of this assigned cause. The chronic form of the disease, on the other hand, he* seems to think is only met with in that curious affection, which was first described by Stoerck, as found among the inhabitants of Poland, and which consists in a purulent discharge from the nostrils, with no injection of the mucous membrane, thus distinguishing it from a coryza. The disease runs a very chronic course, and is said to extend to the lower air-passages, giving rise to severe dyspncea. In one case tracheotomy is recorded as having been rendered neces- sary. Stoerck regarded the affection as due to personal uncleanli- ness. Frankel? describes but one form, referring apparently to the same as Mackenzie’s acute variety of the disease. Cohen,* in the chapter on chronic nasal catarrh, describes a purulent form of catarrh, as commencing in infancy, and which, running a chronic course, may develop eventually in ulceration and necrosis. Cohen attributes all these cases to a remote specific in- fection. Beverley Robinson, Sajous, Lennox Browne, and Seiler make no definite allusion to the purulent form of nasal disease. A care- ful examination of the above authorities leads me to think, that they have entirely overlooked that form of the disease, which is the subject of this chapter. * ““ Diseases of the Throat and Nose,” vol. ii., Pp. 294. ? Loc. cit., p. 335. 3 ‘*Ziemssen’s Encyclopedia,” vol. iv., p. 139. 4“ Diseases of the Throat and Nose,” 2d ed., N. Y., 1875. PURULENT RHINITIS OF CHILDREN. 155 While recognizing the existence of the acute purulent rhinitis in new-born children, as dependent, probably in many cases, on in- fection from the vaginal passages of the mother, we meet witha large number of cases, which commence in the earlier years of childhood, in which the disease pursues an essentially chronic course, and in which a purulent discharge is the prominent feature. It is purely local in character, dependent on no constitutional dyscrasia, and consists essentially in an increased secretion of mucus in the earlier stages, together with a rapid desquamation of epithelial cells, which, running its course as a purulent disease, in from five to ten years, develops finally into what is known as atrophic rhinitis. The disease, in fact, is the first stage of so-called dry catarrh or ozena. From a clinical point of view, it is a very noticeable fact, in pathological processes involving mucous membranes certainly, and probably all tissues of the body, that in youth the epithelial structures are especially liable to become the seat of diseased action, whereas in adult life this tendency seems to disappear, and in place of it, there obtains a tendency to the involvement of the connective- tissue structures. Thus, in the earlier years of life we notice this ten- dency in the development of enlarged tonsils, and follicular disease in other portions of the air tract, as well as in the vulnerability of the lymphatic glands, whereas in adult life inflammatory changes in the mucous membrane’ result mainly in a true connective-tissue hypertrophy. This general law has been adduced in my own mind entirely from clinical observation, not from any special pathological study. Furthermore, in searching for some support in works on general pathology, I fail to find any direct statement to this effect. Wagner,’ however, would seem rather to suggest it, for he makes the statement, that ‘during childhood the skin and mucous mem- branes are more excitable, more prone to disorders of the circula- tion. The function of the lymphatics is prominent in childhood, the quantity of lymph is increased, the lymphatic glands at this time have their greatest development; and in the latter we more often observe alterations of nutrition than in adults (the so-called scrofulous diseases).” Now, this peculiar tendency in childhood shows itself in a notable activity in the development of the epithelial cells, under the stimulation of any of those causes, whose agency we recognize in the production of inflammatory processes. Furthermore, this activity in epithelial development may result in two distinct pro- cesses. In the one, we find the new epithelial cells building them- selves upon the parent structures, and remaining a permanent element in the tissue. In other words, a true epithelial hypertrophy * “ Manual of General Pathology,” N. Y., 1876. 156 DISEASES OF THE NASAL PASSAGES. takes place, with the result of, in the case of the tonsillar gland for instance, an hypertrophied tonsil. In another case, the same activity going on in the mucous membrane, and characterized by rapid evolution of epithelial cells, we find that the epithelium is thrown off. In other words a rapid process of desquamation sets in. Now, why these new cells in the one case build themselves upon the membrane, and in the other case are thrown off, I do not suggest a reason. Certainly it is not dependent on any constitu- tional dyscrasia, which destroys the power of the individual cell to maintain its identity as an integral part of the membrane, for if there is any notable dyscrasia in these cases, it would seem to be more marked in those instances in which hypertrophy takes place, rather than the desquamative process. Furthermore, it is a notice- able fact in young children that acute rhinitis, referring to the form of cold in the head, which is met with in adult life, is an exceedingly rare disease. An ordinary acute inflammation of the mucous membrane of the nasal passages in a child, does not result in congestion of the mucous membrane involving the turbinated tissues. If a child has an attack of what is ordinarily called cold in the head, in a majority of instances, it is an acute inflammation, with swelling of the glands, of the vault of the pharyhx, producing more or less complete nasal stenosis, from occlusion of the posterior nares. In the less frequent cases, it is the mucous membrane lin- ing the nasal chambers. When this occurs, we notice this suscep- tibility already spoken of, immediately showing itself, and the superficial layer of the mucous membrane, the epithelial layer, be- comes the seat of marked morbid activity, differing essentially from the process which occurs in adult life. Now, with the first attack of a cold, the symptoms may not differ ina very marked manner from a cold in adult life, but as these attacks recur, there sets in a notable tendency toa rapid proliferation of epithelial cells, which being thrown off in connection with an excessive mucous discharge, gives rise to a muco-purulent secretion. These repeated attacks of the acute disease finally develop into a chronic rhinitis, character- ized by no very noticeable nasal stenosis, but by a more or less profuse purulent discharge, and the disease which is the subject of this chapter is established. Commencing, asa rule, at from three to five years of age, it runs a somewhat slow course of from ten to twelve years, when it develops into an atropic rhinitis, the rapid desquamation of epithelial cells gradually extending to the mucous glands, robbing them of their epithelial lining, and therefore of their secreting power, and so resulting in crust-formation, and other symptoms of atrophic rhinitis, as will be more fully described when we consider the development of that disease. ‘ PURULENT RHINITIS OF CHILDREN. 157 It should’be stated, that the morbid process, from the beginning to the end of the disease, is identical in all its features, except as to the degree of activity. It is a catarrhal process in the first year, and it is a catarrhal process always. The deeper tissue-structures are but slightly involved, and the surface layer becomes the site of but one form of diseased activity, and that consists of an epithelial desquamation together with a muco-purulent discharge. Ulcera- tion of the soft parts, or necrosis of the bone beneath, are never, under any circumstances, a part of the progress of the disease. In some cases, the disease commences in the first year of life, although, in these cases, there is no tendency to a more rapid de- velopment of the later symptoms. Asa rule, the purulent character of the discharge is maintained until about the fourteenth or fifteenth year, although, in one case which has come under my observation, the atrophic stage with crust-formation developed as early as the eighth year of age. ETIOLOGY.—It is a very common assertion, that atrophic rhinitis and ozzna are dependent on the scrofulous diathesis. Of course, this assertion would necessarily include this dyscrasia as the cause of the diseasein question. In my own experience, children affected with this affection present a picture of rugged health, which would scarcely warrant the suspicion of any constitutional dyscrasia, nor can syphilis be said to have any influence, either in producing, or indirectly causing the disease. The clinical history of syphilis presents a series of symptoms, of a totally different character. Many forms of catarrhal disease in children have their origin in an attack of scarlet fever, measles or some other of the exan- themata. My experience is, that a purulent rhinitis rarely com-. mences inthis way. On the contrary, the catarrhal affections which have their origin in a febrile attack, are characterized by hyper- trophic changes. In fact, I find but very few instances of the disease we are considering, recorded among my notes, as having commenced in this way. I know of no assignable cause for the disease, other than taking cold, and this we explain by the neglect of the ordi- nary hygienic rules of proper living, as already discussed in a pre- vious chapter. SymPToMs.— The prominent symptom of the disease, is a muco-purulent secretion, generally of a bright yellow character, and having its source from both nostrils. This is expelled in con- siderable quantities into the handkerchief, and also makes its ap- pearance about the nostrils, constituting what is often called a “dirty nosed” child. There is no especial obstruction to the nasal passages, except as the result of the accumulation and drying of the secretion about the anterior nares. The discharge is generally 158 DISEASES OF THE NASAL PASSAGES. through the nostrils, although more or less of it is drawn down or makes its way into the fauces. During sleep the secretions are apt to accumulate to such an extent as to cause mouth-breathing. The child, of course, is liable to take cold, during which there are ex- acerbations, and the attack is attended with a more profuse dis- charge containing a large amount of serum. During the exacerba- tion sneezing is arather prominent symptom, though at other times it is not present, the sensibility of the nose being diminished rather than increased. Fetor, so prominent a symptom in the atrophic stage of the disease, is never present while the discharge remains fluid and moist. DIAGNOSIS.—A rhinoscopic examination anteriorly, reveals the mucous membrane covering the turbinated bones somewhat swol- len, and of a reddish tint, with perhaps the appearance of a mild subacute inflammation, but rarely presenting the active turgescence, and bright red appearance of an acute inflammatory process. Coating the faces of both the lower and middle turbinated bodies will be seen flakes and strings, and even large masses of bright greenish-yellow muco-pus, in a semi-fluid state. An examination of the fauces will show muco-pus coating the posterior wall of the pharynx, and trailing down its wall in stringy masses. This condition, however, it should be remembered, is also seen in con- nection with disease of the adenoid glands of the vault of the pharynx. An examination of the vault of the pharynx, however, will usually reveal whether any morbid condition exists there to account for this post-nasal discharge. The diagnosis, however, is not based on the rhinoscopic exam- ination alone, but can easily be made both from the objective symptoms, and by elimination. A purulent discharge is met with in children as the result of strumous ulceration and necrosis, the presence of foreign bodies, blennorrhcea, diphtheria, and the late stages of acute rhinitis met with in connection with the exanthemata. If there are any other causes, they are of exceeding rare occur- rence. Syphilitic or scrofulous disease gives rise to an exceedingly offensive discharge of pus, mingled with blood,-from one or both nostrils, but it is accompanied by so many marked symptoms of the blood-poisoning, that a mistake in diagnosis need not be made. A foreign body in the nose gives rise to a purulent discharge, as a rule, from but one nostril. A purulent rhinitis invariably in- volves both sides. Furthermore, inspection and examination with a probe should alway eliminate this source of error. Blennorrhcea occurs as arule in the new-born child, and is characterized by an activity of the morbid process both as regards the amount of dis- charge, and the swollen condition of the membrane, as to render PURULENT RHINITIS OF CHILDREN. 159 its recognition comparatively simple. Furthermore, the conjunc- tival membrane rarely escapes the blennorrhceal poison. Purulent discharge from the nose in connection with diphtheria and the ex- anthemata need, of course, not be confounded with the disease under consideration. PROGNOSIS.—These cases, as before stated, run a course of from eight to ten years’ duration, the symptoms developing slowly, and the discharge increasing in amount, showing a tendency to accumu- late in the passages and becoming thicker and more inspissated in character, as the years go on. During this time the mucosa proper becomes the seat of no marked changes other than a moderate congestion of its blood-vessels. The epithelial layer, on the con- trary, is slowly but surely wasted, from the loss of its superficial layers, and becomes abnormally thin, while at the same time the mucous glands and follicles become, to an extent, involved, so that they also becoming subjected to the desquamative process, lose a certain amount of their lining epithelium. Hence, it will be easily understood, how that, in the later years of the disease, the progno- sis becomes somewhat unfavorable as regards an ultimate cure. In earlier years, however, I believe if proper treatment is adminis- tered, and carried out with sufficient persistence and attention to detail, that we may hope not only to arrest its further progress, but to ultimately entirely cure the affection. TREATMENT.—The first step in treatment will consist in the use of some simple lotion, by which the pus-discharge may be thoroughly removed from the cavity, and the surface of the membrane thor- oughly cleansed. For this purpose any simple alkaline wash will be found efficient, to which may be added a small amount of car- bolic acid or listerine. Dobell’s solution answers an excellent purpose, or perhaps better still we may use one of the following formule: % Listerine, . : : : : : ; wo 3 SSs Sodii biborat., . : ‘ : : ‘ . 3ss. Glycerini, . ; ; : . 3 é . 3vie Aque, é : ; : . : » ad Zvi. Or, R Thymol., . : : : ; ‘ ; 2 RE Sodii chloridi, . : ‘ ‘ : : . 3ss. Sodii benzoat., . « . ; ; ; ‘ . gr. Xx. Aque, ; : 3 ; : : ; ad $vi. Or, B Icthyol., . ‘ : , : : : 2 Rt Potass. chlorid., . ; 3 ‘ ‘ y 2 SS: Liquor calcis, . : ‘ F : ‘ ad = vi. ~ 160 DISEASES OF THE NASAL PASSAGES. These cleansing lotions are best ‘used by means of a small single- bulb atomizer, such as is sold in the drug-stores, the best of which perhaps is that shown in Fig. 47. This should be used at the com- mencement of treatment at least three or four times daily, the wash being thrown into both nostrils, and the child being taught to cleanse the passages as thoroughly as possible by blowing the nose immediately after. In lieu of the atomizer an ordinary ear-syringe may be used, but as a rule I think the atomizer preferable. After the membrane is thoroughly cleansed, an astringent should be used in the same manner, by means of the syringe or atomizer, preference being given to those agents which possess the property of controlling cell-proliferation. For this purpose we may use one of the following: BR Zinci sulpho-carbolat., . : : : . gr. XX. Hydrarg. chloridi corros., ‘ : ; » ert. Aque, . ; . : ‘ - A ad 3 iv M. Or, BR Acidi borici, . ; : ‘ j ‘ s Si Aque, ee : F : “ . . ad 3 iv. Or, R classical monograph, in which he details the results of by far the most thorough and exhaustive series of experiments yet undertaken for determining the causes of the disease. Blackley’s scientific methods of study leave no room to question the fact, that the im- pact of the pollen of flowering plants on the mucous membrane of the upper air passages, is the true source of the symptoms which characterize an exacerbation of hay fever. In 1876 there appeared the admirable monographs of Wyman” and Beard.* The former * London Med. Gazette, 1829, vol. iv., p. 266. ° London Med. Gaz., 1831, vol. viii., p. 411. 3 Gaz. Médicale, 1837, p. 631. 4 Union Médicale, December 17th, 1859. 5 Gaz. Hebdomadaire, 1860, p. 67. ®‘*Der typische Friihsommer-Katarrh oder das sog. Heufieber, Heu-Asthma,” Giessen, 1862. 7 ‘* Pharmakologische Studien iiber Chinin,’” Virchow’s Arch., Feb., 1869, p. 100. ® New York Med. Gaz., Oct. 8th, 1870, p. 226. 9 “Hay Fever,” London, 1873; and 2d ed., 1880. 79 ** Autumnal Catarrh,” New York, 1876. 1 “‘ Hay-fever, or Summer Catarrh,” New York, 1876. 202 DISEASES OF THE NASAL PASSAGES. made an exhaustive study of the geographical features of the dis- ease as it is known in America, establishing the fact that in certain regions patients were exempt from their annual visitation; while Beard, following the method of Phoebus, pursued his investigation by means of circulars sent to physicians and others throughout the country, thus collecting a series of over two hundred cases, an analysis of which led him to the conclusion that the disease was essentially a neurosis. In 1877, Marsh? published his well-known essay, in which special emphasis was laid on the activity of the pol- len of rag-weed, or ambrosia artemisizfolia, as previously noted by Wyman. An exceedingly important observation was made by Daly? in 1882, who questions “ whether we are warranted in believ- ing any case of hay asthma purely a neurosis, without first elimin- ating the possible causation due to local structural or functional disease in the naso-pharynx.” The importance of Daly’s paper. cannot be overestimated, I think, in thus suggesting a diseased con- dition of the nasal cavities as being an important factor in all cases of hay fever, a fact which, while at first received with considerable hesitancy, is, I think, generally accepted now by all observers. In 1883 appeared important papers by Hack,’ Roe.t Hertzogs and Sajous,® in which a morbid condition of the nasal mucous mem- brane was recognized as a predisposing factor of the disease. We now meet with the first recognition of the inappropriateness of the term hay fever in the suggestion of Hertzog, that the disease might more properly be termed rhinitis vasomotorta. In the following year was published a paper by Harrison Allen,’ in which the im- portance of an obstructive lesion in the nose was emphasized, as a predisposing cause of the disease, and in the same year appeared a very suggestive paper by John Mackenzie,’ in which he designates the disease coryza vasomotoria periodica. In 1884 there also ap- peared Morell Mackenzie’s second volume® in which he discusses hay fever in a very lucid manner, adopting the pollen theory of Wyman and Blackley, while he seems rather to attach little im- portance to a diseased condition of the nasal mucous membrane as a predisposing factor. It is noticeable, however, that, in subsequent monographs on the subject,” he recognizes the fact, that in the + Trans. Med. Society, State of New Jersey, 1877. ? Arch, of Laryngology, vol. iii., No. 2, p. 157. 3 Wien. Med. Wochenschr., No. 14, 1853. 4 N.Y. Med. Journal, May 12th, 1883. 5 Allgemein. Med. Central-Zeitung, Oct. 24th, 1883, p. 1,125. © Med. and Surg. Reporter, Dec. 22d, 1883. 7 American Journal of Med. Sciences, Jan., 1884, p. 157. ® New York Med. Record, July roth, 1884. 9 *' Diseases of the Throat and Nose,” London, 1884. 7° ““ Hay Fever,” London, 1884; 3d. ed. 1885 ; 4th ed. 1887. HAY FEVER, OR VASO-MOTOR RHINITIS. 203 majority, if not in all cases of hay fever, the nasal mucous mem- brane presents evidence of disease. In 1886, the author’ published a paper in which it was argued that the prominent predisposing cause of all cases of hay fever was an obstructive lesion in the nose, giving rise to a vascular dilatation, caused by the rarefaction of air in the nasal chambers behind the point of obstruction, and further that three conditions were-essential for the production of the dis- ease: (1) an obstructive lesion in the nose, (2) a neurotic habit, and (3) the impact of pollen upon the nasal mucous membrane. At the same time it was argued that hay fever and asthma were identical, in that one disease was a vasomotor rhinitis while the other was a vasomotor bronchitis. In the same year, Beverley Robinson? took the ground that an obstructive lesion of the nasal mucous mem- brane was not necessarily a part of the disease. In 1887 Sir Andrew Clark? published a paper on the subject, pursuing much the same line of argument as that already advocated by the writer, in assigning three causes for the disease, viz.: a neurotic habit, an intra-nasal pathological condition, and an external exciting cause. The later literature of the subject recognizes and indorses these views, and we find few writers who do not accept what I think is to be regarded as the most important of these conclusions, viz.: that which regards a morbid lesion of the nasal membrane as a prominent factor in causing the attacks. ETIOLOGY.—Bostock‘ in his first paper, which was based en- tirely on his own personal experience, seems to have arrived at no conclusion as to the cause of the disease. At the time of the pub- lication of his second paper,‘ the idea seems to have been preva- lent that the emanations of dry hay had much to do in causing the attack, although Bostock himself regarded this as less active than heat and physical exertion. The elaborate investigations of Phoe- bus‘ also led him to the conclusion that sunlight played an impor- tant part in the production of the disease, although he conceded a certain amount of activity to the emanations from flowers and grasses. Subsequent investigations merely served to specify the peculiar characteristics of dust and vegetable emanations which caused the attacks, in determining that the pollen of certain flower- ing grasses and plants was the morbific agent. I think a great mistake was made by these investigators, in that while searching successfully for the cause of an exacerbation of hay fever, they * “Hay Fever, Asthma and Allied Affections,” N. Y. Med. Journal, April 2qth and May ist, 1886. ? Med. News, July 17th, 1886. 3‘*Speedy and Sometimes Suecessful Method of Treating Hay Fever,’ Brit. Med, Journal, June r1th, 1887, p. 1,255. 4 Loe, cit. 5 Op. cit. 204 DISEASES OF THE NASAL PASSAGES. seemed to regard this as a cause.of the disease itself. When we have discovered the specific agent which produces the attack, we have not explained why any given individual should be subject to this specific cause, while numberless others are exempt. Beard’s admirable brochure, then, was a notable departure from the line of investigation hitherto pursued, in that the analysis of the large number of cases which, he collated, proved beyond question, as it seems to me, that the neurotic habit was present in all individuals subject to hay fever, and still later, Daly’s* original suggestion of a local morbid condition of the nasal mucous membrane added a third factor to the causation of the disease. We thus find that there are three essential conditions necessary for the production of an exacerbation: 1. The presence of pollen in the atmosphere, 2, A neurotic habit, and 3. A local morbid condition of the nasal mucous membrane. I think, these three conditions are, unquestionably, present: in all cases, and that no individual is liable to an attack in whom one or more of these conditions is absent, as a fuller consideration will easily demonstrate. 1. The Presence of Pollen in the Atmosphere-—The pollen theory of hay fever has probably received larger discussion than any other. Its advocates, and those who deny its activity, maintaining their individual positions with considerable skill, and oftentimes with no little acerbity. Certainly, when the pollen theory is advocated as fully explaining an attack of hay fever, the position undoubtedly cannot be maintained; but that the presence of pollen in the atmo- sphere, and its impact upon the mucous membrane of the upper air passages is the immediate cause of the exacerbation, I think cannot be questioned, in view of the exhaustive experiments, and unassail- able conclusions of Blackley,’ which are of so interesting a charac- ter as to warrant their being detailed somewhat fully. Blackley himself was a victim of hay fever, coming on about the roth of June. He made a series of experiments to determine the amount of pollen in the atmosphere, extending through several seasons, from 1866 to 1878, using for this purpose different devices. The apparatus which gave the most accurate results, consisted of a disc of glass, seven-eighths of an inch square, mounted on a central staff, which was surmounted by a weather-vane, the disc itself being protected by a hood. This apparatus was exposed under varying atmospheric conditions, and in different situations, usually in an’ open field. The device for collecting the pollen consisted in plac- ing vertically in a slot, on the surface of this glass plate, a micro- ™ Loc, cit. 2 Op. cit. HAY FEVER, OR VASO-MOTOR RHINITIS. 205 scope slide, one centimetre in diameter, which was coated with a preparation of glycerin, by which the pollen floating in the atmo- sphere settling upon the slide remained adherent to it. This plate was generally exposed day after day for a certain fixed period, usually about twenty-four hours, the object of the vane being to keep the vertical slide directed constantly to windward. From the 28th of May to the 7th of June, pollen was found in the air in small quantities. On the 30th of May the number found on the slide was twenty-five, and with this number he began to suffer with perceptible, but not troublesome symptoms. On the 8th of June the number rose to seventy-six. On the 11th of June, however, the number of pollen grains found on the small discs rose to a little over two hundred and eighty, and it was at this date that the ex- perimenter began to have unmistakable signs of the commence- ment of his summer attack in a troublesome form. From the 11th of June onward, the amount of pollen varied in a notable degree, until on the 28th of June he counted eight hundred and eighty grains on his disc. He noticed that on rainy days the amount decreased in a very marked degree, while at the same time his symptoms very notably abated, although on warm days following rain, the number of grains increased very markedly. Moreover, he noticed that a few hours’ rain made no perceptible difference in his symptoms, whereas a rain of twenty-four hours or longer gave very striking relief, in connection with a notable decrease in the number of grains of pollen found. From the 28th of June onward, there was a gradual diminution, until the 1st of August, when the pollen disappeared, with complete abatement of all his symptoms. These experiments, it seems to me, are not only conclusive as far as the individual case is concerned, but also their accuracy and nicety of detail, and their complete demonstration of the close re- lation between the symptoms and the amount of pollen discovered, go far toward absolute proof of the pollen theory, so-called, in all cases of hay fever. Furthermore, Blackley’s experiments were not conducted in connection with his own individual case alone, but with others. The question arises here, How does pollen act on the mucous membrane? This we cannot answer, other than to state that it produces vascular dilatation, when present in the atmosphere in certain quantities. Thus, Blackley has shown that the condition of the atmosphere, which will deposit twenty-seven grains of pollen on a disc one centimetre in diameter, in twenty-four hours, is un- irritating, but increase the strength of the atmospheric suspension of pollen, until it will deposit two hundred and eighty, and we find it producing marked symptoms of irritation. In the same way, a 206 DISEASES OF THE NASAL PASSAGES. solution of cocaine one grain to the ounce, will have little or no effect locally applied to the mucous membrane, increase the strength of the solution to twenty grains to the ounce of water, and apply it to the mucous membrane, and the result is marked contraction of the blood-vessels. In other words, pollen in the air produces vascular dilatation in certain individuals, in exactly the same manner asa solution of cocaine produces vascular contrac- tion. The most active pollens in the production of hay fever are those of the flowering grasses, such as the different varieties of meadow grass, sweet-scented vernal grass, meadow fox-tail, golden- rod, etc. Thus, Blackley found in his investigations that the pol- lens of these plants constituted ninety-five per cent of the pollens present on his discs. In America, rag-weed enjoys the reputation of being the most active of all plants in producing the autumnal form of the disease. The activity of the pollen of roses is well known, as well as that of the cereals, wheat, rye, Indian corn, oats, etc. In general it may be stated, that probably all pollens which are found floating in the atmosphere, or the so-called anemophilous pollens, possess a certain amount of activity, while the coherent or entomophilous pollens are innocuous. Peaches are also said to excite attacks. This, however, is explained by the fact, that the coat of the peach presents a favorable site for the lodgment of pollen grains, and in that undoubtedly lies the source of irritation. The same may be stated of other fruits, such as pears, plums, the flowers and stalks of potatoes, etc. 2. The Neurotic Habit—The neurotic habit, as demonstrated by Beard, is an essential element of causation in hay fever, and serves:to explain why certain individuals are sensitive to the action of a pollen-laden atmosphere, while others are exempt. What the essential pathological lesion is, in what we call the neurotic ele- ment in hay fever, it is not easy to explain. If we term it an idio- syncrasy, it adds nothing to our information, and yet its existence cannot be questioned. These peculiar idiosyncrasies have been recognized by observers from the earliest times. Under this cate- gory can be placed those cases in which violent sneezing is excited by the presence of ipecac, nausea by the odor of camphor, urticaria by eating shell-fish, and the poisoning of Rhus toxicodendron, etc. These are simple clinical facts which admit of no classification or systematic consideration. In the same manner, clinical investiga- tion shows in a sufficiently large proportion of cases of hay fever, the existence of a family history showing evidence of neurotic ten- dencies, such as fully to justify the conclusion, that behind all cases of hay fever lies a neurotic habit, as a powerful predisposing cause of the disease. HAY FEVER, OR VASO-MOTOR RHINITIS. 207 3. A Local Morbid Condition of the Nasal Mucous Membrane—A local morbid condition of the nasal mucous membrane, as a predis- posing cause, is present in probably all cases of true hay fever. This lesion must necessarily be one of an obstructive character, and one attended with vascular dilatation. The primary lesion, probably in most cases, is the obstruction, as shown by Harrison Allen. The method by which an obstructive lesion in the nose may give rise to local conditions favoring the development of hay fever has already been described in the chapter on hypertrophic rhinitis, the essential condition being that an obstruction in the an- terior part of the nasal chambers gives rise to a diminution of air pressure immediately behind the point of obstruction, in every act of inspiration. This process going on for any lengthened period of time, will necessarily result in a permanent dilatation of the blood- vessels of the soft spongy tissues covering the lower and middle turbinated bones, thus rendering the parts susceptible to the action of the pollen, in that its impact upon a mucous membrane, whose blood-vessels are already weakened, and their contractility impaired, exercises its peculiar action with less resistance. In addition to the three elements of causation already described, I think we must recognize a psychical influence in many of these cases, as acting to produce the attacks, a peculiar mental anticipa- tion, as it were, which can only explain the fact of the annual re- currence of the disease at fixed dates, some patients going so far as to notice that their disease recurs even at a certain hour of the day each year. Now with the varying character of our seasons, it is impossible that the plant which is the active cause of an attack of hay fever in any individual case, should flower at exactly the same time each year, or that the pollen of these grasses should permeate the atmosphere in a sufficient quantity, as that for in- stance, Blackley’s discs would contain two hundred and eighty grains on the 11th of June each year. We can, therefore, only ex- plain the recurrence of attacks in certain cases on fixed dates each year, by the fact that the individual’s mind is so far concentrated on the anticipation of his attack, that when the day comes the hay fever symptoms set in. This psychical influence is well illustrated by the case of John Mackenzie’ in which an attack of rose-cold was precipitated by means of an artificial rose.’ Mackenzie: also re- ports a case in which an attack of hay-fever was brought on by a patient’s gazing upon a picture of a field of hay. The explanation of these cases, I take it, is much the same as that of those cases of intermittent fever in which the paroxysm is postponed by altering * Loc. cit. ? American Journal of Med, Sciences, Jan., 1886. 3 ‘Way Fever,” London, 1887, p. 56. 208 DISEASES OF THE NASAL PASSAGES. the hands of the clock. Many of the earlier writers regarded heat and sunlight as active among the causes of hay fever. This is not to be wondered at, for we not infrequently find patients recognizing this apparent influence. This mistake is accounted for by Blackley, who has shown that the true explanation lies in the fact that a hot dry day is exceedingly favorable for the dissemination of pollen, whereas rainy weather, while interfering with its diffusion, favors its development, hence, pollen becomes unusually active where rainy weather is immediately followed by a heated period. The minute organisms which Helmholtz discovered in the mu- cous discharge from the nose, to whose activity he attributed the symptoms of his disease, have never been verified by other observers. It is altogether probable that what Helmholtz really saw, were frag- ments of mycelium-like threads thrown out by the pollen-cells, under the influence of heat and moisture, and containing the minute fovillee of the pollen-cell. The relief which Helmholtz obtained by the injection of his quinine solution, therefore, must be attributed largely to psychical influence, for while immediately following the publication of Helmholtz’s experience, the use of quinine solutions became exceedingly popular, it has fallen into complete disuse at the present day. Thus, De Budberg* cites a case treated after Helmholtz’s method with complete success. It was found, however, that a douche of chlorate of potash solution was equally efficacious. In this case a large number of spores were found in the mucus, which De Budberg regarded as pollen granules, Age seems to exert a certain predisposing influence in the causa- tion of the disease, in that the larger number of cases develop early in life. Thus, in a series of eighty cases observed by the writer, there occurred: Between the ages of tandio, . . - gcases, “cc “ “cs oc 10 6c 20, 7 3 m 27 “ “a “ “ “cc 20 “ 30, rs 2 : 16 ce oe oc ce 6c 30 “ 4o, . ; wig 4o “ 50, . ‘ SS BID Over 50, ; ‘ : a‘ i ‘ bs cas, “cc 6c 6c be Total, ; ‘ ‘ ‘ ; . 80 cases, We thus find the large proportion of cases occurring between the ages of ten and twenty, while the predisposition seems to dis- appear very largely at the age of forty, although rather curiously, among my own cases, I have had under treatment a patient in whom the disease developed at the age of seventy-three. Wyman,’ in an * Brit. Med. Jour., vol. ii., p. 18, 1881. ? Loc. cit., p. 97. HAY FEVER, OR VASO-MOTOR RHINITIS. 209. analysis of the seventy-two cases which he collated, found the dis- ease occurring as follows: Under I0 years of age, ; . : . II cases. Between 10 and 20,_. : ‘ 3 eo Ape BONER BO. tvs é ss Ecabe “30 “ 40, . : F ; «s & & “40 “ 50, . : : : “EE. * Above 50, . ae. oy ; ; ; a @ 8 These results differ, as will be seen, somewhat from my own, although it should be stated that my own tables give the date of occurrence of the first attack, while Wyman simply reports the age of the patient at the time of observation. All writers coincide in the statement that the disease belongs essentially to the better edu- cated classes, and that it occurs very rarely among the laboring people. This we can easily understand, when we consider that the disease is essentially a neurosis, and that its development is favored by the surroundings and habits of life of the upper classes, while the contrary is true among the laboring people. That the large preponderance of cases occur among males, is also a fact noted by all observers. Of my own cases, fifty-eight were males, while twenty-two occured in females. Of Wyman’s seventy-two cases, twenty-five were females and forty-seven males. Of two hundred cases reported by Beard” one hundred and thirty- three were males and sixty-seven females, while Phoebus, out of one hundred and fifty-four cases, found one hundred and four males and fifty females. We thus find in five hundred and six cases, three hundred and forty-two males and one hundred and sixty-four fe- males. This observation would seem rather to conflict with the idea that hay-fever is essentially a neurosis, in that we ordinarily associate the delicate female physique with a neurotic tempera- ment. I do not think it is a well-established fact, that frail physi- cal development is a necessary feature of the nervous temperament, so that I do not think that these statistics argue against the fact of hay fever being a neurotic disease. The true explanation of the preponderance of male cases of hay fever, is in the fact that males are much more exposed to those conditions which favor the devel- opment of catarrhal disease, such being not only traumatic causes as previously discussed, but also the varying conditions of climate and weather. This fact, then, would seem to lend weight to the view already indorsed, that a catarrhal affection of the upper air passages is a powerful predisposing cause to the development of hay fever. 1 Loc. cit., p. 43. I4 210 DISEASES OF THE NASAL PASSAGES. The powerful influence of heredity is well illustrated by Wy- man’s statistics, who found that in one-fifth of all his cases, more than one member of the same family was affected. The same is true of eighteen of my own eighty cases, while in thirty-nine cases there was either hay-fever or asthma in the family. Wyman’ further quotes in illustration of this feature of the disease, the very curious case of the family of Chief Justice Shaw, who was the only child, in a family of several, who arrived at maturity; his mother had autumnal catarrh; out of four children one son is a sufferer; a son and a daughter have summer cold; a son who has autumnal catarrh, has a daughter who is now twenty-two, who has had au- tumnal catarrh six or eight years. Another striking case is that of the Rev. Henry Ward Beecher, whose sister and nephew suffered from the disease. The impairment of the general health which is occasionally ob- served after. a protracted convalescence from a continued fever, would occasionally seem to act as a predisposing cause of hay fever. Thus, Sajous* has observed cases coming on after an attack of ty- phoid fever, whooping cough, malaria and chicken pox, an observa- tion which fully coincides with my own clinical experience. Diathetic conditions probably exert little if any influence upon the development of the disease, and yet Leflaive? believes that it is a manifestation of the gouty diathesis, an opinion also shared by Lermoyez.‘ PATHOLOGY.—The essential pathological changes which take place in the nasal mucous membrane, are not those which charac- terize an inflammatory process, and yet from the various names which have been proposed for the disease, such as Rhinitis vaso- motoria (Hertzog), Coryza vasomotoria periodica (John Mackenzie), Rhinitis sympathetica, etc., the inference would naturally be drawn that the exacerbation is regarded as an inflammatory process. Now, it should be stated that the first stage of an inflammation is vasomotor paresis, hence every case of rhinitis, whether periodical as the result of pollen, or idiopathic, is a vasomotor process, hence the use of this expression would seem to be redundant. Further- more an inammatory process runs through certain definite stages, and usually terminates by spontaneous resolution. This is not the case in an exacerbation of hay fever, for although its onset in some cases is gradual, in others it comes on quite suddenly, but in its termination it is apt to be quite abrupt, all the symptoms disap- * Loc. cit., p. 103. 2 ** Diseases of the Nose and Throat,” Philadelphia, 1887, p. 178. 3 ** Rhinobronchite Annuelle,”’ Paris, 1887. 4 Annales des mal. de l’oreille, March, 1888. HAY FEVER, OR VASO-MOTOR RHINITIS. 211 pearing immediately on the escape of the individual from the pollen- laden atmosphere. Moreover, the appearances of the membrane in the nose, as will be shown later, do not present the characteristic features of an inflammatory action. In order to understand what the essential lesion is in an exacerbation of hay fever, it is necessary that we should fully appreciate the physiological function of the nasal mucous membrane in respiration. This, as has already been shown before, consists in a process of serous exosmosis, by which there is poured out on the surface of the mucous membrane lining the nasal cavities, from twelve to sixteen ounces of water in twenty- four hours, this process being directly under the control of the sympathetic system of nerves, by which the amount of serum dis- charged is regulated with an extreme degree of nicety, according to the varying conditions of the atmosphere. Now, the pollen of flowering plants, as has already been noted, possesses the peculiar property of producing more or less complete paralysis’of the nerves which control this exosmotic function, in other words the impact of pollen upon this membrane produces a complete relaxation of the large veins which compose the turbinated bodies, under which they become dilated, and their walls admit of free transudation of serum, the veins remaining in this state of dilatation as long as the pollen is present upon the surface of the membrane in sufficient amount, regaining, however, their normal calibre immediately upon the removal of the exciting cause. The capillary blood-vessels of the mucous membrane proper, as a rule, are not involved in the morbid changes which take place in the deep tissues. The pollen, moreover, acts only to dilate those blood-vessels which are involved in this respiratory process, namely the venous sinuses of the turbin- ated bodies, for we find that the blood-vessels of the mucous mem- brane proper are unaffected by its action, retaining their normal calibre. We thus find that the exacerbation is due entirely to peripheral causes. It might be charged that this view militates against the neurotic theory. The part which the general predis- posing neurosis plays in the production of the disease, is that it gives rise to a weakness of the vaso-motor control, which the sym- pathetic and trigeminus nerves exercise over the calibre of the venous sinuses, whereby they are rendered susceptible to the action of pollen. The question arises now, whether this vaso-motor sus- ceptibility can be accounted for in any other way than by conced- ing some pathological change in the ganglionic centres. This is a question which cannot easily be decided, and any discussion of it .can be carried on only upon purely theoretical grounds. I see no reason, however, why the condition may not exist, without neces- sarily involving the nerve centres in pathological changes, although 212 DISEASES OF THE NASAL PASSAGES. the theory of a central lesion is ably advocated by John Mackenzie? who designates it as a “‘ disordered functional activity of the nerve centres,” while Kinnear? is more definite in his conclusions, finding two forms of the disease, which are due in one case to a hyperemia, and in the other to a condition of anemia of the sympathetic gan- glia. Hack,? on the other hand, believes that the morbid lesion consists essentially in a hyperesthetic condition of the olfactory and the fifth pair of nerves. ‘The same view is also entertained by Robinson.* SYMPTOMATOLOGY.—The onset of the attack is marked by a sense of irritation referable to the upper regions of the nasal cham- bers, with a sense of fulness or tightness across the bridge of the nose, accompanied with sneezing of more or less violent character. At the same time patients complain of a curious burning or itching sensation about the roof of the mouth, apparently referable to the upper surfacé of the soft palate. As the attack develops, the nasal membrane becomes swollen, and the passages thereby more or less completely occluded. At the same time the serous exudation sets in, pouring out on the surface of the membrane, and escaping from the nostrils in, oftentimes, large quantities. So profuse is this dis- charge, that patients oftentimes feel apparently the passage of the serum in its escape from the blood-vessels, in a sense of intense irritation or formication about the root of the nose. The escape of serum seems to increase the intense irritation in the passages, as shown by the increased violence of the sneezing, which often occurs in paroxysms of considerable duration. With the occurrence of the nasal symptoms, in many cases there is felt at the same time irritation of the mucous membrane of the eyes, and in rarer cases even of the mouth and ears. These symptoms are undoubtedly '.. due to the pollen acting on these membranes in exactly the same manner that it acts upon the nasal passages. This, I think, was conclusively demonstrated by the experiments of Blackley’ who prepared a decoction of the pollen of gladiolus, the injection of one drop of which into the eye, being followed almost instantly by an intense congestion, and finally cedema of the conjunctiva, with pain and photophobia. This would indicate that susceptibility to the action of pollen is not necessarily confined to the air passages. Blackley * found the mucous membrane of the mouth also sensitive to the irritation of pollen. * “* Coryza Vasomotoria Periodica,” N. Y. Med. Record, July 1gth, 1884. 2 ‘* Hay Fever: A Disease of Central Nervous Origin.” N. Y. Med. Record, July 14th, 1888, p. 32. 3 Wien. Med. Wochenschr., 1883, No. 14. 4 Philadelphia Med. News, July 17th, 1886. 5 Op. cit., p. 103. 6 Op. cit., p. 104. HAY FEVER, OR VASO-MOTOR RHINITIS. 213 These symptoms commencing somewhat mildly on the first day of the attack, gradually increase until the exacerbation has reached its full height at the end of the third or fourth day, by which time the mucous membrane of the whole upper air tract is swollen and intensely irritated, the nasal passages being as a rule completely occluded, while at the same time there is a constant dripping of serum from the nostrils, in quantities sufficient oftentimes to satu- rate six or eight handkerchiefs in the course of the day. The blood in the membrane shows a certain hydrostatic charac- teristic, in that it tends to collect in the most dependent portion. Thus, if the sufferer lies on the back, the fluids collect in the pos- terior extremities of the turbinated bodies in such a way as to com- pletely occlude the nares, while lying on the side will often have the effect of securing patency of the uppermost nasal. passage, while the fluid collects in the lower. The escape of fluid from the nostril often causes an eczema of the skin about the margin of the nostrils and upper lip, which is ‘aggravated by the constant use of the handkerchief. These symptoms show a mild tendency to abatement during the night, which is probably due to the fact, that the air of the sleeping apartment is less laden with pollen than the atmosphere breathed during the day. The waking hours, however, constitute a period of almost unbroken discomfort, and oftentimes suffering. The onset of the attack in most cases is sudden and without warning, although occasionally it is preceded by a feeling of general malaise, with loss of appetite and mental depression, these premonitory symptoms persisting during the course of the exacerbation to a more or less well-marked degree. Aside from these symptoms, evidences of the effect of the disease on the gen- eral system are not present. Thus Blackley’ in a series of careful observations of pulse and temperature, found no deviations from the normal. , : After the disease has persisted for a varying period of time, usually about two to three weeks, in a certain number of cases an attack of asthma sets in, marked by the ordinary symptoms which characterize any attack of so-called nervous or spasmodic asthma. The patient having fallen asleep, is awakened at the end of two or three hours with oppression of breathing, which persisting for some hours, ceases in the early morning, only to return again the follow- ing night. These asthmatic attacks rarely occur with the first attack of hay fever, but the repeated annual visitation seems to develop a tendency, which results eventually in the development of the bronchial disorder. The question arises whether the asthma is due to the hay fever, * Op. cit., p. 205. 214 DISEASES OF THE NASAL PASSAGES. or whether they both may not be due to the same cause. I have already discussed elsewhere the connection between hay fever arid asthma, taking the ground that they are essentially one and the same disease, regarding hay fever as a vaso-motor paresis of the walls of the blood-vessels lining the nasal cavity, while asthma is a vaso-motor paresis of the blood-vessels of the mucous membrane lining the bronchial tubes; an attack of asthma .consisting in a sudden dilatation of the blood-vessels of the bronchial mucous membrane producing a structural stenosis of these tubes, giving rise to the characteristic inspiratory and expiratory dyspneea, while hay fever is due to a paresis of the walls of the blood-vessels forming the turbinated bodies, giving rise to their excessive dilatation, thus causing nasal stenosis with profuse serous exosmosis. This being true, the walls of the blood-vessels of the bronchial mucous mem- brane in a hay-fever patient are in a condition peculiarly favoring their becoming relaxed, when the special exciting causes become active, for the general neurotic condition which renders the nasal membrane of a patient susceptible to the action of pollen, un- doubtedly acts to render the bronchial mucous membrane predis- posed to its action. This condition, then, of the bronchial mucous membrane being present, we can easily understand why the nasal disorder persisting for ten days to two weeks or longer, should result finally in bringing on an attack of bronchial asthma, in much the same manner as an obstructive lesion in the nose predisposes to hay fever, as already described, for here we have two factors acting. Nasal stenosis tends to produce rarefaction of air in the bronchial passages with every act of inspiration, thus producing a tendency to dilatation of the bronchial blood-vessels; and again, there is an intensely active and quick sympathy between the nasal mucous membrane and the bronchial mucous membrane, under which a diseased condition in the nasal cavity tends to develop a similar morbid condition in the bronchial mucous membrane. It is proba-. ble also that the pollen acts with a certain amount of potency on the bronchial membrane, in much the same manner as upon the nasal membrane. The reason why it does not act to produce an attack of asthma with the first onset of the hay-fever, probably lies in the fact that this susceptibility in the bronchial tubes only oc- curs after they have been subjected to the weakening influence of the nasal disorder for a certain period of time. As the patient goes through his attack year after year, it is noticeable that the asthma occurs in many cases earlier each year, until finally the asthma sets in immediately on the advent of the hay-fever season. Still an- other curious fact noticed in these cases, is that not infrequently the bronchial asthma seems to take the place of the hay fever, and HAY FEVER, OR VASO-MOTOR RHINITIS. 215 that a patient may suffer for a number of years with hay fever alone, subsequently having developed asthma in connection with the hay fever, the hay fever gradually subsides, and his attack be- comes what is called hay asthma, or spasmodic asthma, occurring and persisting through the hay-fever season without hay-fever symptoms. A still further change I have seen in these cases, by which the disorder becomes a perennial asthma, or in other words, asthmatic attacks occur at all seasons of the year without reference to pollen in the atmosphere. It is a notable fact in connection with cases such as these, that the purely nervous element, as manifested by the general systemic condition, seems to have increased in a very marked degree. Why, then, in these cases the hay fever should disappear and the asthma take its place, it is not easy to explain, unless possibly that the peripheral irritation has resulted in an intensely irritable condition of the ganglionic centres, or possibly some organic change occurs there, the result of which is that they gradually become overtaxed as it were, or less sensitive to the periodical stimulation, character. istic of the hay-fever season. The essentially neurotic character of the disease is still further shown by the fact that in a certain num- ber of cases the attack is preceded by a cutaneous eruption, usually of a lymphatic character, although Laflaive* has met with cases of urticaria and even eczema. COURSE AND DURATION.—In a very large majority of cases of hay fever, the annual attack commences in the latter part of August, and lasts until frost sets in. The usual date assigned is the 29th of August. Many patients assert that their attack recurs each year on exactly the same date, and even at the same time of day, al- though in most cases the date varies, it may be, several days. As before stated, I believe that in those cases in which the date and hour of the attack are absolutely unvarying, it is due to a peculiar state of mental anticipation which precipitates the attack. I know of no reason why so large a proportion of individuals are attacked in August, other than the fact that the pollen of rag-weed, as demon- strated by Wyman, Marsh and others, is probably the most virulent of all the pollens, and that this weed fructifies most actively at this time. Moreover, rag-weed flourishes throughout a large portion of the country, in a state of luxuriance that is equalled by few other of the anemophilous plants. These cases are usually designated as autumnal catarrh. The next in frequency to this variety, is that which occurs in June, and which is commonly spoken of as rose- cold, from the fact that these patients are susceptible to the action of the pollen of the different varieties of roses which flourish at this « ‘* Rhino-Bronchite Annuelle,” Paris, 1887, p. 47. 216 DISEASES OF THE NASAL PASSAGES. season of the year. Most writers have regarded all cases as com- ing under these two varieties. Beard‘ lays special emphasis on the fact; that he had demonstrated a third variety as occurring in September. As before stated, however, this classification I think only serves to add confusion to the subject, as the disease is essen- tially the same at whatever season it occurs, and, moreover, in not a few instances we find that patients subject to the so-called rose- cold, are subsequently attacked in August with what is called au- tumnal catarrh. Still further, an analysis of cases will show that the attack may come on at any time from the first of May to ‘the last of September. Thus, Beard’ found that the attack set in, as follows: From May Ist to 1oth, ; ‘ e “ toth “ eat 6 i “ 20th “ 31st, “June ist “ roth, II = “ roth “ 2oth, } 8 - “= goth * goth, | “ July ist “ toth, ; 6 s “ —1oth “ 20th, 6 = “ 20th “ 31st, 7 “August Ist to roth, 7. * - 1oth “ 2oth, 81 ie “ 20th “ 31st, 54 “September st to 1oth, 7 s et 1oth “ 2oth, I 4 > 20th “ 30th, 2 Total 198 These figures only apply to the onset of the attack, its duration not being given. An analysis of the duration of the disease in my own eighty cases is as follows: From May Ist to frost, if “ 15th-25th to July Ist, . = “roth to August Ist, . ‘ June ist “ July tst, " “ist “ “ q4th, Ist “ frost, ay “roth “ July 4th, : “roth “ “ 26th, July st ‘“ Sept. Ist, si cc Heo pme NY Aw YS t Op. cit., p. 49. 2 Op. cit., p. 50. HAY FEVER, OR VASO-MOTOR RHINITIS. 217 9 From July roth to Aug. Ist, ‘ : ’ . ot ie “roth “ Sept. rst. : z : 2 2 ne “25th “ frost, : : ; ; : “ Aug. Ioth-27th to frost, . : ‘ . 51 Total . ; ‘ é ; é ; . 80 A mere glance at these figures, I think, shows conclusively the futility of any attempt at a close classification. Furthermore, it is impossible to assign any special pollen as the active irritant in any of the above classes, inasmuch as definite facts of this character could only be ascertained by very close personal experimentation and observation, and of this few patients are capable. It should be added, moreover, in regard to these cases, that it is exceedingly difficult to elicit an accurate clinical history from the patient, with- out close questioning, and even then, the principal points of the histories which an inquirer desires to ascertain, are but vague im- pressions, hence their answers will be of a very general and inde- terminate character, based on an imperfect recollection of their last annual attack. The above figures refer to the disease as manifested in America. In England it usually appears in May and June and rarely lasts into September. The same is true of France, Germany and other European countries. The autumnal variety of the disease would seem then to be exclusively American. An interesting question in this connection arises as to whether the disease is not greatly on the increase. Certainly it fills a much larger space in our literature than ever before, and this is increasing from day to day. Thus, in 1862 Phoebus, as the result of three years’ labor was only able to collate one hundred and fifty-four cases, while Beard in 1876 was able to collate two hundred, whereas, at the present time, collated cases could easily be made to reach into the thousands. This can be explained either by the fact that, with increased knowledge of the disease, cases come under observation more frequently, or that the number of cases which occurs has greatly increased. My own impression is that the latter is true. This belief is based not only on the fact that a larger number of cases come under my own per- sonal observation each year, but on the increased severity of the symptoms observed to develop year by year; as, in many instances, a patient hitherto suffering from a mild rose-cold in the early sum- mer, will now have, in addition, an autumnal attack; and, further- more, patients hitherto suffering merely from the influenza, com- mence now to suffer, in addition, from hay asthma as well. It might be stated here, in regard to my own cases, that they are entirely made up of patients in my own private practice, and, 218 DISEASES OF THE NASAL PASSAGES. furthermore, that whereas I have reported but eighty, quite a large number are not included, owing to the fact that the recorded his- tories are incomplete. GEOGRAPHICAL DISTRIBUTION OF THE DISEASE.—Wyman, in his elaborate treatise on Autumnal Catarrh, has made a special study of the regions of this country where the disease prevails, and of those which are exempt. He found the disease confined mainly'to that region of the country east of the Mississippi, between the thirty-fifth and forty-fifth parallels. In this territory the exempt regions consisted of Canada, the Adirondack Mountains, the ele- ‘vated plateau through the centre of New York, and the Apallachian range. The exempt region consisted of the territory west of the Mississippi, and of those Southern States south of the thirty-fifth parallel, with the exception of a limited area about Milledgeville, Ga., Montgomery, Ala., and Beaufort, N.C. A larger familiarity with the disease, I think demonstrates that Wyman’s conclusions were based on insufficient research, and that we will find hay fever prevalent throughout the whole United States, with the exception of certain elevated districts, such as the White Mountains, the Adirondacks and a.portion of the Southern States. That patients are exempt from the disease in the mountains, I think is to be ex- plained by the fact that the flora of mountainous districts differs materially from that of the valleys, and that the flowering plants whose pollen is the immediate cause of an exacerbation of hay fever, are not found in those elevated regions. That the disease is comparatively rare in the Southern States, is to be explained by the fact that the morbid conditions of the nasal mucous membrane, which constitute so powerful a predisposing cause of the disease, do not prevail in these semi-tropical regions. That it exists in this region, however, cannot be questioned. However, a few cases are found even in the extreme Southern States, their frequency in- creasing as we go northward. That the territory west of the Mis- sissippi is to a certain extent exempt, is explained by Beard on the ground of the lack of vegetation, and the sparsity of population in these immense districts. This immunity, however, is disappearing rapidly each year, as there is nothing in the flora or the climate of the West which affords exemption from the disease, for as popula- tion extends, and urban life increases, the diseases of civilization become more common. It is also a noticeable fact, that some parts of the White Moun- tains, which have hitherto been classed among the exempt regions, have failed in late years to give that complete relief which patients have formerly enjoyed there. This is probably due to the exten- sion of the railroads which have increased the amount of travel, HAY FEVER, OR VASO-MOTOR RHINITIS. 219 and as a consequence probably, extended to a degree the flora of the valleys. ’ DIAGNOSIS.—The disease, it is well known, is not infrequently looked upon as summer cold, and its periodicity overlooked. A mistake in diagnosis, however, need never be made, for there are . certain characteristics which distinguish it in a marked way from an ordinary attack of acute rhinitis. These are the comparative suddenness of its onset, as well as its disappearance, together with the peculiar symptoms which characterize its progress, which are the violent sneezing and profuse watery discharge. Now, in an ordinary acute rhinitis, the stage of the disease which is accom- panied by a serous discharge from the nose is of comparatively short duration, whereas in hay fever this feature of the disease con- tinues during the whole course of the attack. Moreover, in a cold in the head, intense sneezing lasts but a few days, and does not occur in the violent paroxysms characteristic of hay fever. The appearances of the membrane on examination, moreover, are totally distinct in the two affections. In acute rhinitis the membrane is red, highly congested, and pours forth a more or less profuse mu- cous or muco-pus discharge, in connection with the serous exuda- tion, which is seen coating its surface in yellowish semi-opaque flakes or masses. In hay fever, on the other hand, the membrane, although swollen, never presents the bright red appearance of an acute inflammation, but is of a bluish-gray tinge, verging on opales- cence. This is due to the fact that the hyperemia is confined en- tirely to the large venous sinuses which comprise the turbinated bodies, the capillaries of the mucous membrane proper not being congested. In addition to this, the surface of the membrane is covered with slightly viscid watery serum, which gives it a glassy semi-translucent aspect. The swollen condition of the membrane gives rise to more or less complete occlusion of the nasal cavity, the turbinated bodies lying in contact with the septum. At these points of contact, little bridges of viscous serum will be noticed stretching across from one side to the other, giving the appearance of air-bubbles, as it were. Posterior rhinoscopy adds little to our information, other than showing the posterior nares occluded by the swollen grayish membrane covering the turbinated bodies pos- teriorly. Suffusion of the eyes, with photophobia and epiphora, afford a certain amount of diagnostic information, although those may occur in connection with an ordinary cold in the head. PROGNOSIS.—Hay fever rarely involves any marked impairment of the general health, and hence the prognosis is never grave. The main question of interest, however, is whether the disease can be cured. It is a noticeable fact in the voluminous literature on this 220 DISEASES OF THE NASAL PASSAGES. subject, that this feature of the disease has received but slight consideration. Ina certain proportion of cases the disease seems to disappear spontaneously, from no apparent cause. This ten- dency is, however, manifested in but a small proportion of cases. As before noted, eighty cases have come under my personal obser- vation and treatment, while four additional cases have come under treatment for a diseased condition of the upper air-passages, who had in previous years suffered from annual attacks of hay fever. This perhaps will fairly represent the proportion of cases in which we may expect this spontaneous disappearance of the affection. In discussing the question of causation, eighty cases were analyzed in which the disease was periodical, and the histories fully as- certained. I have, however, comparatively full records of one hundred and twenty-one cases. Of this number there were: Cured, . : ‘ : : ‘ : ; . 51 Relieved, é ‘ ‘ : ; ; ‘ - 43 Unrelieved, . i : 5 ‘ : j e 13 Results unknown, . ‘ é j ‘ ; wi Td The above tables embrace all the cases of vaso-motor rhinitis that have come under my observation, including not only the periodical cases, such as autumnal fever and rose-cold, but a large number of patients in whom the symptoms were perennial. Roe’ presents statistics even more favorable than these, in that of forty- four cases under treatment thirty-six were cured, although in sixteen of the thirty-six there was some return of the symptoms. The question arises, How far can we feel assured in any indivi- dual case of accomplishing a successful cure of hay fever? This I think is impossible, as the disease is essentially a treacherous and fickle one, and in those cases which apparently promise the best results, we are often disappointed. The duration of the disease apparently has no influence on the prognosis, for the case of a year’s standing will often prove quite as obstinate to treatment as one of twenty or even thirty years’ stand- ing. We would naturally suppose that where hay fever has led to the development of hay asthma, the neurotic habit was so firmly fixed in the individual as to render the prognosis more grave; and yet this is not true, as is shown by an analysis made by the writer of eighty case of asthma.’ Thirty-four of these cases were hay asthma, and of these eighteen were cured, fourteen relieved, one was lost sight of, and in one, treatment was apparently without effect. The prognosis in hay asthma would therefore seem to be * Trans. Amer. Laryng. Ass’n, 1887, p. 126. ? Amer. Journ. of Med. Sciences, Sept., 1888. HAY FEVER, OR VASO-MOTOR KHINITIS. 221 more favorable even than in hay fever. Age, I think, has an un- doubted influence on prognosis, in that for younger-patients a more favorable prognosis can be given. As before stated, rose-cold seems to affect young people rather than those more advanced in life, hence in a case of rose-cold, the prognosis is more favorable than in a case of autumnal catarrh. We are not warranted, then, in giving an absolutely favorable prog- nosis in any individual case, and yet I think statistics justify us in the expectation that a large proportion of cases can be cured. TREATMENT.—The treatment of hay-fever consists in: : First.—General treatment, for the correction of the neurotic habit. Second. —Local treatment, for the relief of the diseased condi- tion of the upper-air passages. Third.—The treatment of the exacerbation. First. Constitutional Treatment.—The efficacy of internal medi- cation was recognized very early in the history of this disease, and the list of drugs which we find recommended for the correction of the neurotic habit, embraces a large proportion of the so-called nervines as well as many of the anodynes. Among these we include belladonna, zinc, arsenic, phosphorus, strychnine, hydrocyanic acid, valerian, assafcetida, musk, lobelia, amber, the bromides and iodides, chloral, opium, hyoscyamus, quinine, and the various preparations of iron, The usual method of administration of these drugs is to com- mence with small doses from two to four weeks before the annual attack sets in, and gradually increasing the dose, to get the patient thoroughly under the influence of the drug by the time the parox- ysm comes on, and to continue its administration while the attack lasts. Blackley was a homceopathic physician, but his experiments in the therapeutics of this disease seem to have been quite as thor- ough as his investigations of its etiology. He obtained excellent results from the use of arsenite of potash and arsenite of quinine, but his best results were obtained from the use of the iodide of arsenic, administered in the form of a trituration containing about pig Of a grain ina dose. As early as 1828 MacCulloch* urged that the disease be treated by anti-periodic measures, and since his time quinine has been quite a favorite remedy, Beard’ giving this drug the very highest place among therapeutic agents, as having “ helped more cases than-any other single remedy.’ Bromides have been extensively used, both for the constitutional habit, and to mitigate the severity of the paroxysms. Few observers, however, have found them to possess any great efficacy, although combined with chloral, t ‘ Remittent and Intermittent Diseases,’ London, 1828. -?2 Op, cit., p. 158. 222 DISEASES OF THE NASAL PASSAGES. their use is not infrequently indicated during the exacerbation, to allay nervous irritability and to produce sleep. Long before the essential pathological lesion which characterizes an attack of hay asthma was recognized, the use of belladonna was resorted to as an antispasmodic. Thus we find Laforgue‘ claiming specially good results from its administration in connection with opium, while Dechambre? obtained equally good effect from its adminis- tration in connection with quinine. Since the disease has been shown to consist in a vaso-motor paresis, I think we must recognize the fact that the efficacy of this drug is due mainly to its peculiar action on the vaso-motor system of nerves. That belladonna exer- cises a notable influence in controlling the manifestations of this disease has been confirmed by most observers. Dechambre ad- vised that it should be given in gradually increasing doses, until its full physiological effect was obtained, after which the doses should be slowly decreased. This, however, was during the attack. Better results I think are obtained by commencing the administration of the remedy three or four weeks before the attack, and continuing it until its termination. Mackenzie? has found “ valerianate of zinc in combination with assafcetida more valuable than any other drug.” He commences with the administration of one grain of the zinc, in combination with two grains of compound asafcetida pill, before the attack comes on, and at the end of two weeks doubles the dose. I fully believe in the therapeutic value of the salts of zinc in this affection, but regard belladonna as far more efficacious and certain in its action. No combination in my own experience has been at- tended with better results than the administration of both these remedies as in the following: & Zinci phosphidi, . : : : : . grs. viij. Extract. belladonne, . SE M. ft. mass. in pill no. xl. div. s One pill three times a day after eating. Most cases of hay fever show no evidence of impaired nutrition, but on the contrary I think the rule is that they present every evi- dence of vigorous general health. Where, however, there is evidence of impaired nutrition, I think the administration of arsenic is often attended with the best of results, and in these cases the above formula can be amended as follows: BR Zinci phosphidi, . : ; : : . grs. viij. Acidi arseniosi, . . grii M. ft. mass. in pill no. xl. div: 5, One pill after each meal. * Union Médicale, December 17th, 1859. ? Gaz, Hebdomadaire, 1860, page 67. 3“ Hay-fever and Paroxysmal Sneezing,” 4th ed., London, 1887, p. 66. HAY FEVER, OR VASO-MOTOR RHINITIS. 223 Or, again, in certain cases J have combined the three drugs in the same prescription in the above proportions. As noted above, most writers tell us to commence the adminis- tration of constitutional remedies three or four weeks before the hay-fever season. This is not the time, as a rule, when the patient comes under observation; in fact, I think in most instances they come during the attack, or just after it; and this it seems to me is by far the better time to commence treatment, for, as already in- timated, I regard local measures of treatment as of more impor- tance than constitutional. I think, therefore, the time to administer internal remedies for the correction of the general habit, is at the same time in which our local treatment is instituted. The general neurosis which requires correction exists during the whole year, and certainly if the case is one of autumnal fever, the winter or early spring months are quite as favorable to commence treatment as midsummer. If one were to choose the season, however, for treat- ing these patients, I think perhaps the preference might be given to the early summer months, when the warm dry atmospheric con- ditions are least unfavorable to catarrhal disease involving the upper air-passages. As regards the other drugs of the long list above enumerated, I have but limited experience, and little faith in their value. There are certain general hygienic measures, which are of undoubted importance, such as the regulation of the clothing, and the habits of life. These have already been sufficiently elab- orated in previous chapters. There is, however, one measure which I regard as of the greatest importance. This consists in the use of the cold douche on the spine. A sponge bath is not sufficient. The end to be accomplished is the general tonic. effect on the central nervous system, which is produced by the sudden and decided shock of cold water down the spine. The cold shower bath accomplishes the purpose in an admirable manner, and yet this is not always tolerated by the patient. I have rarely, however, seen a patient who could not endure easily the cold douche confined to the spine alone. This plan of treatment is by no means new, for we find Gordon* as early as 1829 laying special emphasis on the value of cold baths in these cases. I believe, however, that the spinal douche is of the greater value. The principle on which this acts has been recognized and rather ingeniously explained by Kinnear,’ who reports six cases of hay fever, in which flattering results were obtained, by the daily application to the spine of Chapman’s ice-bags, the ice being kept in position from an hour to London Med. Gaz., 1829, vol. iv., p. 266. ? New York Med. Record, July 14th, 1888, p. 32. 224 DISEASES OF THE NASAL PASSAGES. an hour and a half. Kinnear’s method secures a longer continued action of the cold, but I am disposed to think equally good results can be obtained by the simple procedure of sitting in a bath-tub, and pressing a sponge full of cold water over the back. Further- more, I take it, a greater shock is secured by an interrupted appli- cation, rather than by a continuous contact. In this connection there might be noted a rather curious and perhaps somewhat homeeopathic experiment of Blackley," who seems to have allowed no possible feature of the disease to escape his ex- perimental investigations. With the view of determining whether invulnerability might not be secured by inoculation, Blackley rubbed some pollen into an abraded surface on the arm. It is needless to state that the results were negative. The above mea- sures of treatment may of course be continued during the exacerba- ation, with promise of either modifying or controlling the symp- toms. Such other treatment as may be required during an attack, is simply that which would be suggested by the general laws which govern the administration of drugs for the control of such symp- toms as may be presented. Of these opium is undoubtedly the most valuable, both to allay the nervous irritability, and for pro- curing sleep. Mackenzie* gives preference to the tincture over any | other preparation, giving small doses, of from five to seven drops twice daily. This, however, as a rule, should be governed by the tolerance and preference of the patient. In many cases, the best action of the drug would be secured by the hypodermatic adminis- tration of morphine, as recommended by Moorhead,3 who first used in this manner, y5 of a grain of morphine, with 1, of a grain of atropia twice daily, but subsequently found his best results from the administration of J, of a grain of the tartrate of morphia twice daily, increasing the dose, as the attack developed, to 5 of a grain three times daily. Opium undoubtedly does more than control the general condi- tion, in that it goes far to modify the severity of the local symp- toms. No physician, however, should take the responsibility of administering to a patient ~, of a grain of morphia three times daily, through the three months of a hay-fever exacerbation, with- out recognizing the exceeding great danger the patient incurs of contracting the opium habit. While, therefore, opium is undoubt- edly among the most efficacious of our constitutional remedies during an exacerbation, I think it well to depend mainly on less dangerous anodynes, such as hyoscyamus, or the bromides alone or in combination with chloral. * Op. cit., p. 254. e Op. cit., p. 66. 3 Brit. Med. Journ., 1886, vol. 2, p. 18, , HAY FEVER, OR VASO-MOTOR RHINITIS. 225 Second.— Treatment of the Diseased Condition of the Upper Air Passages.—If the view maintained in discussing the causation of hay fever be correct, that in all cases a powerful predisposing cause lies in a diseased condition of the upper air passages, it necessarily follows that by far the most important feature of treatment consists in the removal of the morbid local lesion. Local treatment of the nose and upper air passages is recommended by most writers on the subject, and yet I think a glance over the literature of the sub- ject impresses one with the idea, that in a large majority of in- stances the rules laid down for this are exceedingly vague and in- definite. As early as 1837 we find Cazenave * recommending in a general way that the nasal mucous membrane be cauterized with nitrate of silver, a plan of treatment which found many advocates up to the time that the use of the galvano-cautery was introduced by Middledorpf,? which soon became the favorite method of cau- terization, and we commenced to hear much of the treatment of hay fever by the electro-cautery. Now, we certainly do not treat hay fever by this method, but we treat simply the local morbid lesion which predisposes to it. The special affections which act as predisposing causes of hay fever are hypertrophic rhinitis, naso-pharyngeal catarrh, deflections of the septum, nasal polypi, and indeed any obstructive lesion in the nose which tends to produce a chronic turgescence of the blood-vessels. When we include naso-pharyngeal catarrh among the local exciting causes of the disease, and as one constituting an obstructive lesion, it is to be understood that we refer to the very intimate and close sympathy which we find existing between the nose and the naso-pharynx, under the action of which, a morbid process in the latter region seems to act as the immediately exciting cause of an hyperemic condition of the turbinated tissues, this latter being the directly predisposing cause of the hay-fever ex- acerbation. The special indications for treatment are to be sought by careful investigation and diagnosis of each individual case, and such lesion as may be found is to be treated according to the rules laid down in a rrevious chapter. If nasal polypi or other tumors are discovered, they should be extirpated: if a deflection of the septum exists, the obstructing portion should be removed. If hy- pertrophy or chronic hyperemia are discovered, these conditions should be reduced in the manner already described. In brief, the essential requirements of treatment demand that the whole of the upper air-tract be restored to a condition of normal patency. Sajous,? in his interesting monograph, takes the ground that the ™ Gaz. Médicale, 1837, p. 631. 2“ Die Galvanokaustic,” Breslau, 1854. 3 Med. and Surg. Reporter, Dec. 22d, 1883. 15 226 DISEASES OF THE NASAL PASSAGES. cauterization of the nasal mucous membrane results in an alteration of superficial nutrition, which renders the membrane invulnerable to the action of pollen. This theory is an ingenious one, but I fail to understand what is meant by an alteration of nutrition. Nutri- tion is a definite process, and any alteration of it results in a mor- bid condition. I am disposed to think that the excellent results which Sajous obtained from treatment, were really in subduing tur- gescence and reducing the hypertrophied membrane. Sajous,’ writing at a later date, lays special emphasis on the necessity of confining his caustic applications to the sensitive areas, having pre- viously determined these by means of the cold probe, following the method previously described by John Mackenzie.?, The sensitive areas in the nose described by John Mackenzie, I have never been able to definitely locate as such, and still adhere to the belief that the indications for treatment are the reduction of inflammation and the removal of obstructive lesions, and not the control of a hyper- esthetic condition in the nose. I think it is a more rational view that the success in treatment undoubtedly obtained by the advocates of the sensitive area theory by means of cauterization, is directly due to a reduction of inflammation and diminution of blood-supply. Cer- tainly the use of the galvano-cautery would scarcely commend itself to us as a proper application for the overcoming of a purely hyper- zsthetic condition of the tissues. Stoker* reports a rather unique method of treatment, successful in two cases, in which the caustic was applied “at the junction of the nasal bone with the cartilage of the nose, where the external branch of the nasal nerve passes be- tween these structures to become superficial.” I have had no expe- rience with this method, but am disposed to think that the morbid lesion to be controlled is beyond the domain of the nasal nerve. Third.—Treatment of the Exacerbation.—It is a somewhat curi- ous commentary on the correctness of our clinical observations, that although many writers fail to find any benefit whatever from local applications during the attack of hay fever, others advocate, even with a certain degree of warmth, the efficacy of local medica- tion. Thus, Elliottson5 finds a special efficacy in the local applica- tion of the chlorides in solution, directly to the membrane, and also by vaporous inhalations, while Cazenave ® recommended the irriga- tion of the parts with weak solutions of corrosive sublimate, as pre- viously suggested by Trousseau. The weight of Helmholtz’s® great 1 ‘* Diseases of the Nose and Throat,” Phila., 1887. 2,.N. Y. Med. Record, July roth, 1884. 3 Amer. Jour. of Med. Sciences, July, 1883. 4 Annual of the Universal Medical Sciences, vol. iii., p. 269. 5 London Medical Gaz., 1831, vol. 8, p. 411. © Loc. cit. HAY FEVER, OR VASO-MOTOR RAINITIS. 227 name gave considerable popularity to the quinine solutions which he recommended, until De Budberg’* demonstrated the fact that a solution of chlorate of potassium was equally efficacious. And yet ‘at a quite recent date we find Sir Andrew Clarke* claiming most flattering results from the local application of solutions of quinine, carbolic acid, and perchloride of mercury. It is a striking feature of these cases, that the curious psychical condition of mental an- ticipation is such, that every new remedy is attended at first with a certain amount of relief, which in most instances, however, is but temporary. At one time the use of salicylic acid, as recommended by Binz, obtained a certain amount of popularity, and still later that of boracic acid. None of these remedies probably exercise any special controlling influence on the paroxysm. The early recognition of the fact that floating pollen in the at- mosphere was the exciting cause of the attack, led to attempts to protect the mucous membranes from its impact. Thus we find Blackley‘ testifying to the very great relief afforded by the wear- ing of a wire gauze respirator, the efficacy of which was increased by moistening the gauze with a weak solution of carbolic acid. As accomplishing the same purpose Mackenzie: advises that the nos- trils be plugged with cotton wool, although at a later writing’ he simply suggests that much relief may be afforded, and in certain cases the attack even warded off, by wearing a thick veil over the face. I have never had much faith in the efficacy of these measures, and furthermore the discomfort of wearing a respirator or a thick veil during the whole of the hay-fever season would be so great, that many patients would prefer to risk the exposure to the pollen. No local remedy that has ever been used for the relief of an ex- acerbation of hay fever is comparable to cocaine, both as regards the certainty and promptness of its action, and the completeness of the relief afforded. The properties of this drug as an anesthetic were first published in America by Dr. H. D. Noyes, in a letter to the Medical Record’ in which he gave a detailed account of Koller’s great discovery. A few days later, while making use of this agent as an anesthetic in the nose, I first observed its peculiar action in producing contraction of the blood-vessels. As oppor- tunity afforded, I made use of it in cases of hay fever as well as other nasal disorders characterized by vascular turgescence, and * British Med. Journal, 1881, vol. ii., p. 18. ? British Med. Journal, June 11th, 1887, p. 1,255. 3 Deut. Med. Wochenschr., Sept. 22d, 1877. 4 Op. cit., p. 260. 5 ‘* Diseases of the Throat and Nose,” Amer. ed., Phila., 1884, p. 310. 6 ** Hay-fever and Paroxysmal Sneezing,” London, 1887, p. 61. 7 New York Med. Record, Oct. 11th, 1884. 228 DISEASES OF THE NASAL PASSAGES. found it to give complete relief from all the symptoms for the time, publishing soon aftér the results of my experience.’ This action of cocaine in hay fever I attributed purely to its property of contracting the blood-vessels. In subsequent contributions on this subject the view was advocated, notably by Bartholow and Da ‘Costa, that the anesthetic properties of the drug had much to do with the relief afforded. This view, I think, is hardly tenable, when we consider that a local application of a two-per-cent solution gives such complete relief in from two to four minutes. Now, as we know, anesthesia only follows an application of a two-per-cent solution of cocaine in about fourteen minutes, whereas contraction of the blood-vessels ensues in from two to four minutes. In other words, the hay fever symptoms abate as soon as the vascular tur- gescence is allayed. It has been charged, notably by Beverley Robinson,’ that after the vascular distention has been subdued by cocaine, the relief is but temporary, and is followed by a reaction in which the distressing nasal stenosis is even greater than before. I have used the drug very extensively since its introduction, and recall but three instances in which any such reaction was observed. As before stated, the relief is prompt and efficient, although not permanent, lasting but from two to three hours, when relaxation of the blood-vessels occurs, demanding a second application. The formula which I usually give is as follows: & Cocain. hydrochlorat., . i 3 ‘ . grs. Xx. Sodii bicarb., Acidi borici, : ‘ . . . aa grs. x. Aque,’. 3 ‘ : ; ‘ ‘ » $i. M. ft. sol. This is to be used by means of the small hand atomizer shown in Fig. 48 or any small cologne atomizer, such as is sold in the drug- stores. The patient is directed to apply this freely to the nasal cavities as often as may be necessary to control the symptoms. The above solution, as will be seen, is about a four-per-cent solu- tion. It is well to mention this to the patient, directing him to reduce the strength until he finds, what in his own experience, is the weakest solution which may be used and still give relief. In many instances I have found that even a one-half-per-cent solution was quite as efficacious as the preparation given above, and of course it is always desirable that the end should be accomplished with as weak a preparation as possible, as it is well known that the absorption of a drug through the nasal mucous membrane is proba- ***A New Therapeutic Use of Cocaine,” N. Y. Med. Record, Nov. 15th, 1884. ? Med. Record, October 17th, 1885, p. 425. HAY FEVER, OR VASO-MOTOR RHINITIS. 229 bly more prompt than through that of the stomach, hence the con- stitutional effect of the agent is liable to be experienced; and while I regard cocaine as one of the most harmless of drugs as far as any danger of the cocaine habit is concerned, its excessive use is objec- tionable in the same manner as the excessive use of tea and coffee, which are apt to render one somewhat nervous perhaps and wake- ful. A very nice method of administering cocaine is as follows: RB Cocain. hydrochlor., i ; . : . grs. x. Aque, . : : : ‘ . : . gs. M. ft. sol. Adde Fluid cosmoline vel Ol. voschano (see page 115), . : ‘ 2 3h Shake well before using. This is to be used in the atomizer shown in Fig. 47. This is per- haps a less convenient form than the watery solution, but the cos- moline affords an exceedingly grateful and soothing application to the mucous membrane, while the cocaine exercises the same action as in the watery solution. Robinson,’ in reporting cases of hay fever in which cocaine failed to relieve, obtained success from pen- cilling the nasal mucous membrane with a preparation of one part of carbolic acid to three parts of glycerin, one case being com- pletely cured, while two were notably relieved. I should be dis- posed to attribute the results in these cases in part, perhaps, to the peculiar anesthetic properties of the strong preparations of carbolic acid, but mainly to its caustic action. I am confident, however, that the cocaine promises relief in the larger proportion of cases. The main objection to the use of cocaine is not that its use is at- tended with any unpleasant results, but, it must be confessed, that in acertain proportion of cases it fails to give entire relief. This proportion is very small. In many cases, I think its failure must be attributed to inefficient methods of application, such as by droppers, bougies, etc. Certainly we have no means by which the whole membrane can be medicated with the thoroughness of the spray, and hence the atomizer should be preferred in all cases. Macken- zie* recommends the use of gelatin bougies containing 74 of a grain of cocaine combined with 74,5 of a grain of atropine. These are to be inserted into the nasal passages by the patient, and al- lowed to remain there until they melt. This method of application is uncleanly, and furthermore is not thorough, as I think the ap- plication to the middle turbinated bodies is even more important than to the lower, and certainly patients suffering from hay fever * Loc. cit. ? Op. cit., p. 62. 230 DISEASES OF THE NASAL PASSAGES. would not tolerate the insertion of a bougie into the middle meatus. The same objection, I think, lies against all suppositories of cocaine, as well as the gelatin discs and other preparations of the sort. In- sufflations of powders are not open to this objection and are to be recommended as follows: R Cocain. hydrochlorat., . ‘ i : . grs. X. Bismuthi subcarb., ‘ i . ‘ as Magnesia carb. lev., e 4s << Bafe M. Or, R Hydrarg. chloridi mitis, . : . ‘ . grs.v. Cocain. hydrochlorat., . ‘ ‘ ‘ . grs. X. Sacch. lac, ‘ ’ : ‘ ‘ . Sil. M. The addition of morphine to one of these powders is always grate- ful to the patient, but a combination of morphine with cocaine should always be used judiciously. Keeping this in view, the fol- lowing may be used. R Morphine tartratis, . ‘ ‘ ‘ : “She Ie Cocain. hydrochlorat. . ; ‘ . . grs. x. Sulphuri flor., . ; 5: : ‘ ; . 3ss. Sacch. lac., ‘ ‘ 3 : ’ : . iiss. The only objection to the use of a snuff is that we do not, as a rule, get the same thorough penetration of the nasal cavities, as by means of the atomizer. Hinkle* claims excellent results from the local application of antipyrine alone and also in combination with cocaine. A careful reading of his cases, however, would suggest that his results may have been due to the local effect of the cocaine together with the constitutional effect of the antipyrine, for this drug has been shown by Cheatham? as well as by Tyrrell Brooks* to possess the prop- erty, when administered internally, of notably mitigating the sever- ity of the paroxysm in hay-fever. Jedkins‘ reports a case of hay asthma relieved by the syrup of hydriodic acid administered in tea- spoonful doses until relieved. The ocular symptoms, being due quite as much to the direct impact of the pollen upon the cornea and conjunctiva, as to sym- pathetic action, are to be relieved by the same local applications *N. Y. Med. Journal, October 20th, 1888, p. 429. ? Annual of Universal Med. Sciences vol. iii., 1888, p. 267. 3 British Medical Journal, May roth, 1888. 4N. Y. Med. Record, vol. xxvi., p. 260. HAY FEVER, OR VASO-MOTOR RHINITIS. 231 which are applied to the nasal cavity, although with this proviso, in applying cocaine to the eye, the solution should not be stronger than one percent. If, however, the eye is well protected by col- ored glasses, as first suggested by Cazenave,’ in most instances the relief will be such as to render local applications unnecessary. Cheatham’ makes the very excellent suggestion that eserine, in the strength of 7, of a grain to the ounce, should be added to the co- caine solution in order to prevent the dilatation of the pupil. * Loe. cit, ? Medical Record, Nov. 2ist, 1885, p. 567. CHAPTER XV. ASTHMA, OR VASO-MOTOR BRONCHITIS. ASTHMA is a disease characterized by the diurnal and seasonal recurrence of attacks of dyspnoea, due to an obstruction occurring in the bronchial tubes, in such a manner as to interfere with both the entrance of air to the air-cells, and its exit therefrom, in other words, a dyspneea both of an inspiratory and expiratory character. The diurnal character of the disease is shown by the recurrence of the attacks at certain times during each twenty-four hours, usually at night, and lasting for some hours, when relief occurs, which may be more or less complete, until the next daily attack comes on. The seasonal character of the attack manifests itself in the disposi- tion of the symptoms to undergo complete relief at certain periods of the year, usually the warm dry months of summer, and in a less degree, the dry, cold months of winter, during which the patient enjoys complete immunity from his diurnal attacks. ETIOLOGY.—In reviewing the literature of asthma, at the pres- ent day, when our knowledge of this disease has become systema- tized and definite, one is particularly struck with the exceedingly vague and indefinite views which have prevailed in regard to it, up to comparatively recent times, and particularly with the curious theories which have been advanced to account for the symptoms which characterize it; for, while ancient observers could not fail to have their attention prominently attracted to it, by the peculiar character of its manifestations, yet I find that it is rather as a symptom than as a disease, that most writers deal with it. Even as late as 1874, we find Bennett! devoting only a few lines to its consideration as a symptom of emphysema and bronchitis, rather than as a distinct disease, while Watson, in his classical work on the “ Practice of Physic,” although devoting a chapter to the subject, makes the somewhat naive confession that he has never listened to a case by auscultation. As early, however, as 1852, we find careful observers searching for some rational explanation of the peculiar symptoms which characterize this curious affection. As far as we 1 “ Principles and Practice of Medicine.” American edition, Philadelphia, 1874. ASTHMA, OR VASO-MOTOR BRONCHITIS. 233 know, Bergson‘ was the first to make it a distinct disease, although its individuality was denied by Rostan? and by Beau.3 The ancients believed the disease to be due to spasmodic con- traction of the bronchial tubes. This view was, however, contro- verted by Laennec,.who cites, as an argument, those cases of asthma * in which we have puerile breathing over the entire chest, thus show- ing that the capacity of the lungs may be increased during a par- oxysm rather than diminished. Copeland calls the same cases nervous asthma, while Walshe suggests the term hamic asthma. Dr. Bree takes a different view, believing the disease due to some specific irritant in the air tubes and that the asthmatic paroxysm is an effort to expel these so-called irritating humors. Beau,’ whose treatise has already been referred to, believes that all cases develop from a primary bronchitis. Todd®* regards the disease as humoral, comparing it to gout or rheumatism, and believes that the materzes morbi affects the respiratory centre; while Budd ® divides it into two forms; one depending upon cardiac disease, emphysema, etc., the second form due to a spasm of the respiratory muscles. The mere fact that an attack of asthma is always preceded by a feeling of a want of air and increased respiratory effort, is enough to controvert this view. That this view has been held, though, for some time, is shown by the fact that so recent an author as Wintrich’ advances essentially the same idea. The first to write a really exhaustive work on asthma was Henry Hyde Salter.2. His work has become a standard one, and his views have been adopted by most subsequent writers on general medi- cine. He makes the following propositions: first. Asthma is essentially, perhaps with the exception of a single class of cases, a nervous disease, the nerve centres being the seat of the essential pathological condition. Second. The phe- nomena of asthma, distressing sensation and demand for extraor- dinary respiratory efforts, immediately depend upon spasmodic contraction of the cells of unstriped muscular fibre in the bronchial tubes. Zhzrd. The phenomena are excito-motor or reflex actions. Fourth. The extent to which the nervous system is involved differs much in different cases, being, in some, restricted to the nervous apparatus of the air-passages themselves. /zfth. In a large num- * «* Recherches sur l’asthme,” 1852. 2 “De l’asthme ;” Gaz. des hépitaux, No. 31, 1856 3“ Traité clinique et pratique de l’auscultation,” Paris, 1856. 4 Arch. Générale, vol. 78, p. 155. 5 Medical Gazette, 1850. § Med. Chir. Transactions, vol. xxiii., London, 1840. 7 Virchow's ‘‘ Handbuch der Path. und Ther.,” Bd. v., Ab. 1. 8“ On Asthma; Its Pathology and Treatment,” London, 1860. 234 DISEASES OF THE NASAL PASSAGES. ber of cases, the pneumogastric, both gastric and pulmonary por- tions, is the seat of the disease. Sixth. In a large class of cases the nervous circuit involves other nerves beside the pneumogastric. Seventh. There is still another class of cases in which the irritation is central. Zzghth. In acertain proportion of cases the irritation is humoral. We find here that the bronchial spasm theory of the ancients was fully adopted, as the result of large clinical observation and study, and maintained by Salter in the several editions of his popu- lar work. This theory is the one adopted by Biermer'’ also. We see, then, that, according to Salter, asthma is essentially a neurotic disease, and this theory, with some modifications, is the one adopted at the present day. Dr. Burney Yeo? attempts to draw an analogy between the extreme distention of the lungs in asthma and abdominal distention in hysteria. This observation is curious perhaps, but scarcely harmonizes with clinical observation. Morton: draws a similar analogy between asthma and spasmodic croup. The sudden nightly attacks, with daily remissions; a cer- tain periodicity observed in the attacks of both diseases; a dry first stage and moist second stage; all seem to him to point toa certain - similarity between the two diseases. Another curious observation which he makes, is that the tendency to asthma begins at about the time when the tendency to spasmodic croup ceases. He be- lieves that both croup and asthma are due to disorders of innerva- tion of the larynx, on the one hand, and of the bronchial tubes, on the other; the immediate cause of the paroxysm being excess of venous blood in the medulla. This observation is also incorrect, by the decided error in both premises. In the diligent research after the hidden causes of disease, so characteristic of the present day, Leyden * claims to have discovered certain elements in the sputa of asthmatics, known as “ Leyden's crystals,” and misnamed, for some reason, Charcot’s crystals. Ungar, of Bonn, in an investigation of thirty-nine cases of spas- modic asthma, as recently as 1882, found-these crystals in the sputa, but also found that they increased in number the longer the sputa stood, thus, to a certain extent, vitiating Leyden’s theory. Quite recently, Dr. Pfuhl* relates the case of a soldier whose sputa contained large numbers of the crystals of Leyden, without any evidence of asthma. Furthermore, he has examined the sputa in eight hundred and fifty-five cases of pulmonary disease, and has only found the crystals in the one case mentioned above. An * “ Ueber bronchial Asthma,” Sammlung klinischer Vortrage, 1875. ? London Practitioner, 1881. 3 British Medical Journal, January 22d, 1877. 4 Virchow’s Arch., Bd. 54, 1871. 5 Deutsche med. Zeitung, 1887, No. 76. ASTHMA, OR VASO-MOTOR BRONCHITIS. 235 attack of asthma, as we know. consists in the occurrence of more or less well-marked symptoms of oppression of breathing, with a certain amount of periodicity, coming on suddenly, generally at night, and lasting for several hours, the dyspncea obtaining both during inspiration and expiration, while the cessation of the attack is accompanied by a more or less profuse serous and sero-mucous expectoration. This series of phenomena has been explained by the writers quoted above, on the theory that this dyspnoea is due to the contraction of certain muscular fibres, which anatomists have demonstrated as existing in the bronchial tubes, down to their smallest ramifications. It seems rather curious that this theory should not long ago have been questioned. All observers very properly recognize asthma as a neurotic disease, and muscular spasm is undoubtedly a manifestation of the neurotic temperament, and apparently on this trivial ground, the theory has been accepted. If the paroxysm is due to muscular spasm, why should the attack occur, in most instances, only at night? Why should it be affected by changes in temperature? Why should relief be obtained by high altitudes? Why should an attack be aggravated by a damp atmosphere? There is everything in the repose of a quiet sleep, which should protect one from an attack of asthma, and yet a par- oxysm almost invariably comes on during the night. Changes in temperature are not usually recognized as having any marked effect on the nervous system, and yet a change in climate not in- frequently precipitates a seizure of asthma. The sea-shore, rather than mountainous districts, is favorable to the toning up, as it is called, of the nervous system, and therefore asthmatics should suffer least at the sea-shore on this theory; yet the converse is true. Again, a paroxysm of asthma is ushered in suddenly, and during its persistence is characterized, it is true, by symptoms which are easily explained upon the theory of spasmodic muscular contraction of the circular fibres of the bronchial tubes, but the culmination of the attack is invariably marked by a more or less profuse sero- mucous exudation, with cough and expectoration. This in no way can be harmonized with the spasmodic theory. I think, then, this view must be abandoned, as failing to explain the clinical his- tory of asthma, or the clinical history of a paroxysm. In 1872, however, we find the spasm-theory called in question, and what, to my mind, is a far more plausible one advanced by Weber,’ who was the first to teach us that the cause of the parox- ysm lay in a paresis of the vaso-motor nerves, presiding over the vessels of the bronchial mucous membrane. Under the influence of this vaso-motor paralysis, there occurs, from some cause, a sud- * Tageblatt der 45ten Naturforscherversammlung zu Leipzig, page 159, 1872. 236 DISEASES OF THE NASAL PASSAGES. den letting up of the control which is exercised over the calibre of the blood-vessels, whereupon they become distended to such an extent as markedly to interfere with the passage of air through the bronchial tubes. This paralytic condition having lasted several hours, the membrane maintaining a dry condition, as is always the case in the first stage of the inflammatory processes, there follows an escape of serum and sero-mucus, thus relieving the engorged blood-vessels, which soon regain their normal calibre, coincident with the cessation of the paroxysm. We thus have a thoroughly rational and plausible theory, in explanation of the symptoms of spasmodic asthma. As to the causes, however, of the disease, little has been said, further than the causes already stated, as laid down by Salter. Weber’s paper, however, was followed by a series of clinical observations, which largely lent weight to his theory, and also threw much light on the causes of the disease. The first ob- servation of note in this connection was that of Voltolini," who re- ported a case of asthma due to the existence of nasal polypi, as shown by the fact that the asthma promptly disappeared on the re- moval of the nasal growths. This observation was followed by a large number of similar reports by Hanisch, Porter, Daly, Toda, Spencer and others, as noted by Mackenzie,? and gave rise to voluminous discussions by Schaffer, Frankel, Bresgen, Hack and others, not only on asthma as a reflex disease due to nasal polypi, but also as due to other nasal disorders. As before stated, the literature of this subject has assumed large and voluminous proportions, but it still inclines itself to the sub- ject of asthma as a reflex disease. Now, I do not propose to enter into this subject of reflexes, which has always seemed to me asa term oftentimes used as a cloak to conceal our ignorance of the direct relation between cause and effect, but I am convinced that, in very many instances of morbid symptoms occurring as a result of reflex disturbance, we can offer a more rational explanation than “reflex,” in the sense in which the term reflex is so often used at the present day. Following Voltolini’s observations, that nasal polypus was the cause of asthma, and intimately connected with the same line of investigation, came the study of hay fever. The first impetus, as I think, to this line of investigation, was a paper by Daly.2 Up to this date, hay fever had been regarded as simply a _periodical coryza or influenza, in which the paroxysms were charac- terized by the same symptoms as are met with in an ordinary cold * “Die Anwendung d. Galvanokaustik,”’ Wien, 1872, p. 246, 4th ed. ? “Diseases of the Throat and Nose.” American edition, vol. ii., Philadelphia, 1884, P- 357- 3 Archives of Laryngology, vol. iii., p. 157. ASTHMA, OR VASO-MOTOR BRONCHITIS. 237 in the head. As a matter of fact, however, acute rhinitis, and an attack of hay fever, differ in a marked way in many respects. This fact was soon recognized, and a new name was given to hay fever, vaso-motor rhinitis, We have, thus, suggested a connection between the two diseases, and as a clinical fact, the two diseases are inti- mately connected; for, as we know, a large number of hay-fever patients suffer from asthma, following soon after the onset of their nasal symptoms. A natural division of cases of asthma into ay asthma and perennial asthma is thus made, the one term being ap- plied to those cases that are attended with hay fever, the other to those cases in which asthma occurs without reference to seasons, and without the preceding influenza. The question now arises, What, if any, connection exists between the two, or how far are these two diseases one and the same; and, again, what is the con- nection between hay fever and asthma, and are they not, in many respects, the same disease? In a paper read before the American Climatological Association, May 28th,? 1885, I first advanced the view that hay fever and perennial asthma were virtually one and the same disease, the one being a vaso-motor rhinitis, the other being a vaso-motor bronchitis, the paroxysms being excited, in each case, by some peculiar atmospheric condition. The atmospheric condi- tion, as we know, in hay fever is the presence of the pollen of flow- ering plants, or some other vegetable emanation; whereas the at- mospheric condition in perennial asthma, as we may designate those cases of asthma which occur during the whole year, and do not depend upon hay fever, is dependent upon some obscure element which we are, as yet, unable to trace with the same degree of defi- niteness as we are enabled to trace it in hay fever. Hay fever is dependent upon three. conditions: First. A neurotic habit, as was conclusively shown by Beard.’ Second, The presence of pollen in the atmosphere, as shown by _the unrivalled experiments of Blackley.3 Third. A disordered condition of the nasal passages, as shown by Daly.‘ Now, the view that I advocate is that asthma also is dependent on three conditions: first. A general neurotic condition, as demonstrated by Salter.s Second. A diseased condition of the nasal mucous membrane (not the bronchial). Third. Some obscure condition of the atmosphere exciting the paroxysms. * New York Medical Journal, April 24th, May Ist, 1886. 2 ** Tlay-fever or Summer-catarrh,” New York, 1876, 3 “* Hay-fever,’’ London, 1873. 4 Loc. cit. 5 Op. cit. 238 DISEASES OF THE NASAL PASSAGES. The view as regards the neurotic condition is generally ac- cepted; that as regards the atmospheric condition, I think, is one which must be generally accepted by all observers, when we con- sider the diurnal and seasonal periodicity of the paroxysms. As regards the nasal condition, as a predisposing cause of the attacks, the view is a novel one, and, naturally, would be looked upon as the hobby of a specialist. In my original paper, I made this as- sertion, that ‘‘a large majority, if not all, cases of asthma were de- pendent upon some obstructive lesion in the nasal cavity. This is evidenced by the immediate relief from the exacerbation, by the use of cocaine in the nose, in every case in which I have tried it, and, futhermore, by the cure of so many cases by the removal of the obstructive lesion in the upper air-passages.” This paper was read two years ago. The views there stated I would repeat with even more emphasis, for subsequent clinical ob- servation has only served to confirm me in my belief of their cor- rectness. That the lesion in a paroxysm of asthma is a vaso-motor paresis of the blood-vessels supplying the bronchial mucous mem- brane, and not a bronchial spasm, I do not discuss, but accepting this theory as the only one which can explain the symptoms, the question arises, What is the connection between the nasal mucous membrane and that of the bronchial tubes? The subject of the great respiratory functions of the nasal mucous membrane has already been fully treated of in a former chapter, and need not be repeated here. In brief, the most intricate, the most delicate, and most important part of the whole respiratory tract lies in the nose, in that mass of blood-vessels which we call the turbinated tissues, and which serve to supply the inspired air with moisture, by pour- ing out upon the surface of the mucous membrane a large amount of water—sixteen ounces in the course of the day—by which the inspired air becomes saturated with moisture, this function being necessarily regulated with an extreme degree of nicety of adjust- ment. This establishes, in what way or through what nerves or ganglia I do not discuss, but to my mind does unquestionably establish, a most intimate connection between the two portions of the respiratory tract. The blood supply in the nose being reg- ulated by the same vaso-motor ‘tract as that which regulates the blood supply of the bronchial tubes, a disturbance in one region is liable to be followed by a disturbance of the other; a morbid con- dition in one region renders the other especially susceptible to diseased processes. This, briefly, is the history of the connection between the two parts. Hence, we see, therefore, how a diseased condition in the nasal cavity may predispose a neurotic patient, under favorable atmospheric conditions, to an attack of asthma; ASTHMA, OR VASO-MOTOR BRONCHITIS. 239 the same line of reasoning, as will be noted, being followed here as in the case of hay fever. This connection between the two regions I have not found alluded to by any writers, and yet I cannot but think that Hyde Salter’ must have entertained a somewhat similar idea, when he says, in speaking of the causation of asthma, that we may divide the cases into two classes: First, cases in which the essential cause of disease, ‘that which constitutes the individual an asthmatic,” is some organic lesion, possibly not appreciable, either in the bronchial tubes or some part physiologically connected with the bronchial tubes. Second, cases in which the organic lesion does not exist, in which the tendency to asthma is due to some- thing from within, not from without, in which the cause of disease is a congenital and possibly inherited idiosyncrasy. The large clinical observation and study which were the basis of Salter’s classical work, could not fail to have impressed upon him, that a diseased condition of the upper air-passages was prominently active among the predisposing causes of asthma. It would seem a rather broad statement to make, that all cases of asthma find their predis- posing cause in intra-nasal disease, and yet I am very confident that it is very largely, if not entirely, true. Certainly, in my own ob- servation, I have seen no case in which this could not be stated. The question suggested by Mackenzie’ here arises, What consti- tutes a typically healthy nose? Mackenzie seems to think that there is a very large difference in individuals, even in health, and rather suggests that a typically healthy nasal cavity is difficult to find. On the contrary, I think that every nasal cavity, which shows a departure from the normal type, should be regarded as in a diseased condition. The true test, however, in these cases is this: if we find diseased conditions, the removal of which cures an asthma, my proposition, in that individual case, is certainly established. I make the general statement, that all cases of asthma have intra- nasal disease, without giving definite proportions. This may seem rather broad, when we find eminent physicians of the present day, such as Fothergill, Flint, Loomis and others, adhering to the old theory of bronchial spasm, and not mentioning pathological condi- tions in the nasal chamber asa possible cause of the disease. That my view is by no means entertained by laryngologists, is shown by the fact that Bécker* makes the statement that asthma-is seldom associated with polypi, and seldom cured by their removal, and that hay asthma is caused by direct irritation of the bronchi, and, further, that, normally, asthma cannot be produced in the nose. * Op. cit., page 81. 2 ** Hay-Fever,” London, 1885, p. 25. 3 Deutsche medicinische Wochenschrift, 1886, Nos. 26 and 27. 240 DISEASES OF THE NASAL PASSAGES. This first assertion of Bécker seems to me to be a very grave reflection on his skill as an operator. In the Union for Internal Medicine, May and July, 1886, Lublinski, Heyman, Bocker and Krause assert that, in many cases, asthma is independent of a path- ological condition of the nasal passages. Schech,’ however, states that, in sixty-four per cent of cases of asthma, he found intra-nasal disease, and further adds that there must be associated with it excessive nervous irritability—in other words, the neurotic habit. In looking over my notes, I find I have recorded histories of eighty cases of asthmatics treated during the last five years. Not satisfied with the study of these records, and in order to make my investigation as thorough as possible, and, at the same time, bring the reports up to date, I mailed to each one of these patients, some of whom I had not seen for a considerable time, a printed circular, in which I propounded a series of questions. These questions I will not recapitulate, as they are suggested by the headings in the following analysis of my tables. The last question was, “ Please state candidly and without favor, what benefit, if any, you have received from the treatment, and to what you attribute your im- provement or cure.” The following analysis sets forth the result: Total number of cases of asthma, 3 ‘ * ‘ » 80 Males, a . ‘ $ ; ‘ 7 . 47 Females, . : . ‘ F : i » 33 Hay asthma, . ‘ é ‘ ‘ ‘ ‘i : » 34 Males, : ; ‘ : F S . . 26 Females, . ; ‘ ‘i ‘ “ : ‘ 8 Perennial asthma, . ‘ ; 4 ‘ : , . 46 Males, ‘ , ; ‘ : : Z s 2K Females, . ‘ : ‘ 3 : : . 25 PERENNIAL ASTHMA—FAMILY HISTORY. Clear in, . ‘ ‘ ‘i ; j 2 ‘3 ‘ ; : Neurotic, 3 : ‘ Bronchitis and asthma, 2 ‘ : 3 ‘ Asthma, . : Asthma and hay fever, Bronchitis, . : é ‘ ‘ Asthma, bronchitis and neurosis, Phthisis, Hay fever, . : Asthma and neurosis, Unknown, . mde Di cornn rnb NWO Total, ™ Miinchener medicinische Wochenschrift, 1887, Nos. 40 and 41. ASTHMA, OR VASO-MOTOR BRONCHITIS. 241 Hay ASTHMA—FAMILY HISTORY. Asthma in, . 14 Clear in, j 5 Phthisis and neurosis, I Neurotic, 2 Hay fever, . ‘ 2 Asthma and neurosis, 2 “ “hay fever, 2 is “neurosis and hay fever I Neurosis and hay fever, I Unknown, 4 Total, 34 The prominent feature shown here is the large preponderance of cases which show a decided neurotic family history; twenty-five of the thirty cases of hay asthma being of inherited neurotic habit, where the history is known, while in the perennial form sixteen of the twenty-eight cases, in which the history is ascertained, show the neurotic tendency. Age of First Attack. Perennial Asthma. Hay Asthma. Ist ten years of life, 5 5 ad“ 2 9 7 gd.“ -* a 12 II Athy °° ts 6 6 a 5 4 Over fifty years of age, 8 I From birth, I Total, 46 34 Average age of first attack, 3 3 . 29 years. 24 years. Oldest case, 72 years; youngest, delizeuibal: We notice that the tables show that the largest number of cases of asthma, in both forms, develop during the third decade of life, while no period is notably exempt. This differs from Salter, who states that most cases develop during the first decade. CLIMATIC INFLUENCE ON HAY ASTHMA. Greatest relief at high altitude, . ‘ : ‘ : ; A), (ABE ee Tower 3 ‘ ‘ : ; F ‘ I ‘ “sea 7 é ‘ a 3 . . ws “ in New York City; A. ES ‘ 5 ‘ ‘ 3 Suffer equally cnet ; a : a : ‘ . ; 3 Unknown. . : ‘ ‘ : : : : f . 10 Total, . : : ‘ . i ‘ 34 16 242 DISEASES OF THE NASAL PASSAGES. CLIMATIC INFLUENCE ON PERENNIAL ASTHMA. Greatest relief at high altitude, . . 4 ‘ ; . . Il Suffering more “ a Greatest relief at sea, . ‘ ‘ ‘ : : ; ; 2 Suffering more “ i ‘ : ‘ 7 “ equally everywhere, . ‘ : ‘ : : » 12 Greatest relief at low altitude, . ‘ i ‘ , ‘ I a “in New York City, : ‘ ‘ ; ‘ F I Unknown, . : 3 : II Total, . ; 7 : - Z 5 . 46 Combining these two tables in one we find as follows: CLIMATIC INFLUENCES ON THE TWO FORMS OF ASTHMA. Better at high altitudes, 22 “at sea shore, 8 “incity, . ‘ 5 ‘ ‘ : 2 9 Unaffected by locality, ‘ : 3 : 3 ‘ ; 13 Irregular, ; . 9 Effect of locality unknown, ; : 3 j . ‘ « 49 Total, . ‘ a ; ‘ , . 80 We notice here, that whereas, in hay fever, the seashore affords the greatest relief, after asthmatic symptoms set in, the same rule applies to both forms, and that high altitudes are most beneficial; and yet, I think, no rule can be formulated for the cases as a class. They are essentially fickle, and each one must be advised from per- sonal and individual considerations. Hay ASTHMA. Nasal symptoms immediately preceding attack, such as sneezing with watery discharge from the nose, . ‘ ; : . 29 No symptoms preceding attack, . : ; j : : : 5 Total, . : 4 ; : : : . 34 PERENNIAL ASTHMA. Nasal symptoms preceding attack, . ‘ ‘ : » 33 No nasal symptoms preceding attack, 12 Cutaneous eruption preceding attack, I Total, . : 3 ‘ . 46 This showing, it seems to me, is of the greatest importance, as sustaining the original assertion made in the early portion of the chapter. It should be mentioned that many patients entirely ignore the ASTHMA, OR VASO-MOTOR BRONCHITIS. 243 nasal symptoms, in the larger discomfort arising from the dyspneeic attack, and only recall them, when their attention is turned in that direction. We see, then, that, of the eighty cases, the asthmatic attack set in with sneezing, etc., in sixty-two. The one case in which a cutaneous eruption occurred is interest- ing only with réference to the neurotic explosion, Hay ASTHMA. History of previous catarrhal trouble, ; . ; j a 23 No history of previous catarrhal trouble, . i ‘ 3 . II Total, . ‘ ‘ ¢ : 5 i . 34 PERENNIAL ASTHMA. History of previous catarrhal trouble, . : E 5 » 31 No history of previous catarrhal trouble, . ; 4 : a RG Total, . : 4 é ‘ a ‘ . 46 We see here that, of the eighty cases, fifty-four give a history of previous: catarrhal trouble. Yet the testimony of patients in this matter is not to be relied upon, as many patients have undoubtedly notable impairment of the nasal respiratory function, without being conscious of suffering from what they call catarrh. Moreover, ina large proportion of nasal disorders, the symptoms are referred, by the individual, to the throat, while “catarrh” is popularly referred to the nose. INTRA-NASAL CONDITION—HAY ASTHMA. Hypertrophic rhinitis, . 2 3 ; 9 a «and deflected septum, 12 Polypi and deflected a 5 Polypi, : ‘ i ‘ ; ; a a 4 Deflected septum, ‘ . . ‘ . : . ‘ ‘ 3 Elongated uvula, I Total, 34 INTRA-NASAL CONDITION—PERENNIAL ASTHMA. Hypertrophic rhinitis, . 5 ‘ ; ‘ ‘ ‘ é “43 Nasal polypi, . : ; s . II Hypertrophic rhinitis anid deflected septum, ‘ : ‘ hm TT Polypi and deflected septum, . ‘ i ; . . ; 6 Deflected septum, ‘ : ; ; é ; ‘4 3 Adenoid and hypertrophic rhinitis, : ; : i : . 2 Total, . - : ‘ 5 : . 46 Ihave never known a case of hay fever or asthma to occur in other than an obstructive lesion of the nose or upper air-passages, 244 DISEASES OF THE NASAL PASSAGES. as will be seen by this table; this was the case in every one of the eighty cases, including the elongated uvula, which became a source of respiratory obstruction. TREATMENT—HAY ASTHMA, Hypertrophic rhinitis, treatment by caustics: Cured, 7; improved, 6; unimproved, 1. Deflected septum, operated on by author’s nasal saw: Cured, 8; improved, 6. Nasal polypi treated by snare, without caustics : Cured, 2; improved, 1. Treatment by snare and septal saw ii cases of polypi and deflected septum : Cured, 1; improved, 1. Cases treated by uvulotomy : Cured, I. TREATMENT—PERENNIAL ASTHMA. Hypertrophic rhinitis, treated by caustics : Cured, 8; improved, 5. Polypi treated by snare, without caustics : Cured, 15; improved, 3. Deflection of septum operated on by author’s nasal saw: Cured, 3; improved, 4; unimproved, 1. Adenoid growths removed by snare: Cured, 2. The treatment, as will be seen, has been such as our English friends regard as harsh, and in many cases unwarranted. I think it but justice to say that, in some cases, patients have been unwill- ing to continue on account of this, and yet, with the use of local anesthesia, these operations are not painful; itis the nervous strain, on this class of patients, which has taxed them most severely. That the surgical treatment of nasal diseases is fully justified I think the following table amply demonstrates: RESULTS OF TREATMENT—Hay ASTHMA, Cured, . ‘ ‘ ‘ 3 : ‘ } 7 «> 9) Improved, . ‘ A ‘ ‘ - F j Fi , » I4 Unimproved, . ; ; 3 5 A ‘ ‘ : i I Unknown, . ‘ ; : : é % ‘ ¥ r - ° Total, . ‘ ; ; é ‘ ‘4 - 34 RESULTS OF TREATMENT—PERENNIAL ASTHMA. Cured, : i ‘ - A , ‘ ‘s ‘ - 28 Improved, . ; ‘ : s : 3 é ; : s 12. Unimproved, , : : ; : ; i : Unknown, . . ‘ 5 ‘ é : ‘ . - . 5 Total, . : ‘ ‘ . ‘ A » 46 ASTHMA, OR VASO-MOTOR BRONCHITIS. 245 ; I have thus given all the results obtained from the analysis of my cases, as bearing not only on etiology, but also on other branches of our subject. The point upon which I wish to lay special em- phasis here, is the very close and intimate physiological and patho- logical connection between the nasal mucous membrane and that lining the bronchial tubes, and the further fact, that in asthma we must look for the active predisposing cause of the attack, in a dis- eased condition of the nasal mucous membrane. In the above sta- tistics, we have included hay asthma and perennial asthma, consider- ing these two affections as virtually one and the same disease, from a clinical point of view. This is shown by the fact, that, in many instances, they are interchangeable, in that a patient may suffer a number of times from hay fever, without developing asthmatic attacks; finally, however, his hay-fever paroxysm winds up with an attack of true nervous asthma, a still further change consisting in the cessation of the hay-fever attacks, and the patient becoming sub- ject merely to attacks of perennial asthma. This fact I have noticed in quite a number of instances. Why, then, do we regard an intra- nasal disorder as a prominent factor in the causation of a paroxysm in the large majority of cases? It is not intended to convey the idea, that this condition may alone be responsible for an attack of this disease. Thus, it cannot be questioned that, in many instances, cardiac disease is to be regarded as a prominent factor of causa- tion, as well as renal disease, or gastric disturbance; and of the more remote causes, we must recognize the presence of worms in the intestinal canal, uterine disorders, an overloaded stomach, etc. Chronic bronchitis is ordinarily recognized as one of the causes of asthma. This I think is not to be placed in the same category. In this affection, the chronic morbid process of the bronchial mucous membrane develops a relaxation of blood-vessels, which ultimately leads to attacks somewhat resembling an ordinary attack of nervous asthma, and yet I think the two things should not be confounded; the form of disease which we are now discussing being a totally different disease, I take it, from that which occurs in connection with bronchitis, and this should therefore be excluded from con- sideration here. As regards those remote causes, then, I think we must recognize the fact, that even here there must be, in many cases, some local disorder of the nasal cavities, which leads to the development of the reflex disturbance; otherwise, the presence of worms in the in- testinal canal, or other disturbing influences, would scarcely result in the development of an attack of asthma. We have already shown the intimate physiological connection between the nasal mu- cous membrane, and that of the bronchial tubes, and that a weakened 246 DISEASES OF THE NASAL PASSAGES. condition of the passages above, tends to develop a similar condi- tion in the parts below. I think, therefore, we must recognize, in all these unusual reflexes, this tendency to vaso-motor weakness of the bronchial tubes, under the action of which, worms in the intes- tinal canal, undigested food in the stomach, and other causes, may produce an asthmatic attack. We find it often stated, that a par-. oxysm is precipitated by flatulent distention of the bowels; indeed a number of such cases have come under my own observation, but in no single instance has such a case been observed, in which there was not abundant evidence of the reflex disturbance having been directed to the bronchial mucous membrane, by a local lesion in the nasal cavity. In other words, wherever we have had, what appeared to be an attack of asthma brought on by flatulent disten- tion, I have been convinced that the paroxysm was really excited by nasal polypi, hypertrophic rhinitis, or some other lesion of the nasal passages, and the flatulence was either an adventitious symp- tom, or possibly a complicating circumstance, which precipitated the asthmatic attack. Perhaps it would be not wise to say that a patho- logical intra-nasal condition is present in every one of these cases of obscure reflexes, and yet I think it is still less wise to accept evidence of cardiac lesion, or gastric disturbance, as presenting a sufficient cause of the attack, without also examining the nasal cav- ities, to ascertain whether some lesion may not also exist there. The disease being essentially a neurosis, we would naturally ex- pect to find heredity exercising a notable influence, a fact which all statistics fully bear out, in that this disease, as well as hay fever, seems to run in families, as it were. The influence of age and sex has already been clearly shown, in the statistics before given. The possible existence of a rheumatic or gouty diathesis should of course not be overlooked, as factors in the development of these attacks. How they should act, it is impossible to say, and yet here, as be- fore, I think still the possible existence of a predisposing nasal dis- order should not be overlooked. We regard, then, an intra-nasal disorder as not only a powerful predisposing, but exciting cause of an attack of asthma. It should be stated, however, that when we speak of pathological intra-nasal conditions, we include not only a diseased condition of the nasal cavity, but also of the naso-pharynx. Among these, we may enumerate as the most prominent, hyper- trophic rhinitis, deformities of the septum, nasal polypi or other tumors, adenoid tumors of the vault of the pharynx, and naso-pha- ryngeal catarrh. How this latter affection acts, it is not easy to state definitely. As we all know, it is dependent, in no small degree, upon a diseased condition of the nasal cavities proper, and on the other hand, as Tornwaldt has so clearly shown us, it may give rise ASTHMA, OR VASO-MOTOR BRONCHITIS. 247 to a turgescence of the turbinated tissues. We have, therefore, really here two morbid conditions which react the one upon the other, in such a way as to leave us somewhat in the dark as to which is the more active. However this may be, the clinical fact remains, that they both exercise a notable influence in producing that peculiar weakness of vaso-motor control over the blood-vessels of the bronchial mucous membrane, which leads to the development of an attack of asthma. It will be noticed that, in the tables previously given, naso- pharyngeal catarrh was not included among the causes of the dis- ease. This was present in anumber of cases, but is to be regarded as a somewhat secondary cause, in that the vaso-motor paresis which constitutes an asthmatic attack is more intimately associated with disturbances of circulation in the turbinated bodies, and when naso- pharyngeal catarrh was present, it was regarded as either due to the intra-nasal disease, or as a cause of it. SYMPTOMATOLOGY.—A paroxysm of asthma usually occurs at night, and perhaps, in the majority of instances, during sleeping hours. A patient retires without any premonition of danger, and after sleeping a few hours, is awakened by a most distressing dysp- neea, or feeling of suffocation. He springs up from his bed terri- fied, alarmed, and gasping for breath. His face is turgid, eyes pro- truded, mouth open, with the perspiration starting upon his face. The dyspncea is both inspiratory and expiratory; inspiration being shorter and somewhat quicker, in that it is aided by all the volun- tary and involuntary muscles of respiration, while the expiration is somewhat prolonged, in that the patient apparently seeks a momentary period of rest, in allowing such air as he has drawn into the lungs, to escape voluntarily. Whereas the dyspnoea character- izes both acts of inspiration and expiration, the muscular struggle is largely expended on the inspiratory act. The patient is apt to be somewhat restless in his movements, in search of .some position which will afford relief, a search which is usually disappointed, although the greatest ease is ordinarily obtained in the semi-re- cumbent position. Not infrequently, when the attack is severe, the distress isso great that the pdtient springs from the bed, and rushes to the window in search of air. The pulse is ordinarily somewhat rapid and weak, especially if the paroxysm is prolonged. ‘The temperature usually falls somewhat below the normal, due probably to the fact of insufficient oxygenation. This represents a typical and well-developed attack of asthma, which may last for one to two, three or four hours, and in rare cases may persist from one to three days. In other cases, the attack presents a somewhat milder type, in that the dyspnoea is. by no means so great, and the par- 248 DISEASES OF THE NASAL PASSAGES. oxysm is simply characterized by oppression of breathing, and per- sists for a few hours or a day, in which the patient experiences mere discomfort, rather than actual suffering. When the paroxysm comes on during waking hours, in the large majority of instances, it commences with sneezing and watery discharge from the nose, which may be of such a character as to give considerable annoy- ance to the patient, or be so slight as to scarcely excite attention. In that form of asthma which occurs in connection with hay fever, of course, the attacks are confined only to the hay-fever season, but in the ordinary form of asthma, which we have already designated as perennial, the attacks are usually aggravated by the damp atmosphere of the spring and fall, the patient enjoying a certain degree of immunity during the clear cold weather of winter, and the warm weather of summer. During the damp season, how- ever, the attacks usually occur about the same time each day. During the intervals, the patient enjoys almost complete immunity, although even now, a careful examination of the chest will reveal evidences of contraction of some of the bronchial tubes, as shown by the sibilant and sonorous rales on deep inspiration. The character of the paroxysm is also notably influenced by the changes in weather, in that the attacks are much less severe during the pleasanter days of the spring and fall months. Moreover, in the midst of the bad season, the attacks may be arrested by a change to a dryer climate, especially to high altitudes, where an atmosphere is encountered which seems exceedingly favorable in its influence upon these cases. In most of these patients, also, a peculiar hyperesthetic condition of the whole upper air-tract is present, evidenced by the fact, that the presence of irritating vapors, dust, gases, etc., will produce a temporary sense of dysp- ncea, or even a well-marked paroxysm of asthma, which, however, usually disappears promptly on the removal of the exciting cause. The cessation of the paroxysm is usually attended with a more or less profuse sero-mucous discharge, the clinical significance of which has already been fully discussed, in the statement that this was due to the unloading of the engorged blood-vessels by a serous exosmosis, by means of which their calibre is diminished, and thereby the patency of the bronchial tubes restored. PHYSICAL ‘SIGNS.—On inspection of the chest during a par- oxysm, the first noticeable feature will be, the very marked impair- ment of motion, in that the whole chest-wall seems somewhat rigid, and to move together. This, however, is, to an extent, deceptive, the limited movement of the chest being really due to the limited amount of air which is drawn in, with each act of inspiration. Percussion simply reveals perhaps a slight exaggeration of normal ASTHMA, OR VASO-MOTOR BRONCHITIS. 249 resonance. The diagnosis, of course, is based entirely on ausculta- tion, by means of which there will be recognized the characteristic sibilant and sonorous rales throughout the whole of the chest cav- ity, and heard equally at any point. These are blowing, purring, whistling, cooing sounds, that are caused by the passage of air through the narrowed tubes of various calibres, the walls of which are perfectly dry. In other words, there is total absence of any moisture, but the mingling of dry rales constitutes a confusion of musical sounds, as it were, which can be likened to nothing so much as the cooing of a bevy of pigeons. So loud are these sounds, that they can be heard frequently even across the room. The normal respiratory murmur is of course completely masked by these loud rales, which are heard both in inspiration and expiration, although, as before stated, the expiratory sounds are somewhat prolonged. At the termination of the paroxysm, the dry rales diminish in in- tensity, and to an extent disappear. The moist rales may now be heard, as the serum transudes the blood-vessels, and makes its ap- pearance in the bronchial tubes. DIFFERENTIAL DIAGNOSIS.—It scarcely seems necessary to sug- gest any points of differential diagnosis, and yet there might be a possibility of mistaking an attack of asthma, for spasm of the glottis, hydrothorax, cedema of the lungs, and cardiac disease. In laryngeal spasm, the voice would necessarily be affected, and the dyspnoea would be entirely of an inspiratory character, and its locality recognized by the peculiar sub-clavicular and sub-sternal depression, which would characterize each inspiratory act. More- over the impairment of voice would give further evidence of the laryngeal disorder. In angina pectoris, and hydrothorax, there would be of course no sibilant or sonorous rales. The same is true also of pulmonary cedema, which also is characterized by moist rales, and more or less profuse serous expectoration. In the dysp- noeic attacks of cardiac disease, there is an entire absence of the characteristic sibilant and sonorous rales. PROGNOSIS.—Asthmatic patients are said to be long-lived, which is probably true, in that there is nothing in the disease itself which would tend to shorten life. During attacks, the sufferings of the “patient are extreme, but during the intervals, he enjoys ordinarily the best of health, excluding, of course, those cases which are dependent upon a chronic bronchitis, which, as before stated, is not to be classified with nervous asthma. As regards the disease itself, however, the prognosis, of course, depends largely on our ability to control it. From the analysis of cases given above, it would seem that the plan of treatment there carried out, affords us a method of controlling the severity of attacks, in the large majority of instances, 250 DISEASES OF THE NASAL PASSAGES. and in a very flattering proportion of cases, of radically curing the disease. As regards any tendency to recover unaided by therapeutic efforts, this would seem to exist in but a small degree, although in many cases, especially in youth, the disease seems to disappear without treatment. The longer, however, the attacks have lasted, the less tendency there is for the spontaneous cure. Moreover, it is probably also true, that the longer the attacks have existed, the less amenable they are to treatment. TREATMENT.—The consideration of the treatment of this dis- ease naturally divides itself into three heads, namely: 1. The treatment of the local predisposing cause, which, as we have endeavored to show, consists of a morbid condition of some portion of the upper air-tract. 2. The treatment of the paroxysm. 3. The constitutional treatment, or the treatment of the general neurotic habit. The Treatment of the Local Morbid Condition tn the Upper Atr-pas- sages.—We place this first in importance, in that, as has already been intimated, we regard these measures, not only as the first to be in- stituted, but as those which promise the best and surest results, and even in those cases where local treatment fails to thoroughly relieve the disease, we certainly have prepared the way for the better action of general remedies. In resorting to these local remedies, we search not only the nasal cavities, but the cavity of the naso-pharynx, for the local predisposing cause, but of these two, the measures of treatment are to be first directed to the nasal passages proper, in that, as has already been intimated, we find in the large proportion of cases, that the morbid condition of the naso-pharynx disappears upon the restoration of the nasal passages to a healthy condition of patency, and its lining membrane to a normal condition of functional activity. These measures failing to give relief, treatment must be directed to the naso-pharynx, accord- ing to such indications as present, in the manner to be discussed at length in a subsequent chapter. The conditions which we may encounter in these regions which demand treatment, may be briefly enumerated as follows: hypertrophic rhinitis, deformities of the septum, nasal polypi or other neoplasms, chronic naso-pharyngeal catarrh, adenoid growths or other tumors in the vault of the pharynx, or in fact any condition of the nose or naso-pharynx which constitutes an obstructive lesion. The Treatment of the Paroxysm.—\ have endeavored, in a former chapter, to make clear the intimate sympathy which exists between the nasal and bronchial mucous membrane, and to show how a plethoric condition in one region, is exceedingly prone to be ac- ASTHMA, OR VASO-MOTOR BRONCHITIS.’ 251 companied by a similar condition in the other. Now, if, as I think has been clearly demonstrated, a paroxysm of asthma consists essentially in a turgescent condition of the blood-vessels of the mucous membrane lining the bronchial tubes, which turgescence is prone to be accompanied by turgescence of the nasal mucous membrane, it is easy to understand how the local application of any remedy to the nasal passages, which will control vascular dilatation in this region, should result in either marked arrest or the complete relief, for the time being, of the asthmatic paroxysm. A large clinical experience, has shown this observation to be cor- rect, and hence probably we possess few remedies more active or more certain in their action than cocaine. This, therefore, should be our first resort. It may be applied by means of the small atomizer, shown in Fig. 48, or failing this,an ordinary dropper an- swers an excellent purpose, a small amount being applied to each. nostril, and repeated every five minutes, until relief is afforded. In my own hands, I have seen but few cases in which this remedy was not notably successful. Next in importance to this, we should place datura stramonium, the efficacy of which we find recorded in the early part of the cen- tury. Thus Christie? reports it as having been used with good re- sults, as early as 1805, while similar observations were made by English? and other writers. This drug is used by burning the leaves and inhaling the smoke, this procedure being accomplished by smoking the leaves in a pipe, or in the form of a cigarette, or simply by burning them ona plate. What the action of the drug is, it is difficult to state, other than on purely speculative grounds. Clinical experience, however, teaches us that the fumes of the leaves have a very powerful effect in controlling the distressing features of an asthmatic paroxysm, and, although probably, in the majority of instances, they fail to afford perfect and entire relief,. they rob the attack of much of its distressing character. Another remedy of great efficacy is the fumes of burning salt- petre. This was first reported, I believe, by Harrison, who obtained the remedy from a friend, who found notable relief in saturating paper in a strong solution of nitrate of potash, and then setting it on fire, and inhaling the fumes, having previously allowed the paper to dry, whereby the solids were deposited upon it, the object of the paper being simply to produce ignition of the potash salt. While, perhaps, not as efficacious as the stramonium, the saltpetre * Edinburgh Med. and Surg. Jour., 1811, vol. vii., p. 158. ? Edin, Med. and Surg. Jour., 1811, vol. vii., p. 277. 3 Med. Repository, 1812, vol. iii., p. 311. 4 Lond. Lancet, 1845, vol. i., p. 383. 252 DISEASES OF THE NASAL PASSAGES. is a remedy which rarely fails to afford a certain amount of relief. The combination of these two remedies is one which enters largely into the manufacture of a large proportion of the asthma remedies sold in the drug-stores. Thus Himrod’s powder is composed of the leaves of lobelia inflata, datura stramonium and ordinary tea, mixed with a certain proportion of nitrate of potash, while the “Green Mountain Cure” is composed of the same drugs, in somewhat dif- erent proportions. Probably no combination of these remedies is more effective than the following, from the Brompton Hospital Pharmacopeeia: B Pulv. stramonii, . s : ; : . 3 iv. Pulv. anisi, . Potas. nitrat., . ‘ j F ; . 48 3 ij. Pulv. tabaci, . zi : F . . . grs.v. These powders may be burned on a plate, or smoked in an ordinary clay pipe. Still other remedies, which possess a certain amount of popu- larity for use in this manner, are: datura tatula, datura fatuosa, metél, belladonna, opium, hyoscyamus, arsenic, etc. These, how- ever, are usually used in combination with the stramonium and potash, as in the well-known Espic’s cigarettes, the formula of which is as follows: B Fol. belladonne, . < te é ; . grs. VSS. Fol. hyoscyami, Fol. stramonii, ‘i ‘ y 3 4a grs. ij Fol. phellandrii aquatici, . : : . grei. Extract. opii, ; ‘ ‘ ; é - ord Aque lauro-cerasi, : : . . a Ge iSs This is a very efficacious combination, and is also an exceedingly convenient method of obtaining the fumes of these drugs. Chibrac* reports a case of a man, who obtained notable relief from the in- ‘halation of the fumes of carbonic acid, obtained from a charcoal brasier, while Julius* reports the case of a patient, who obtained relief by smoking cigarettes containing quarter of a grain of white arsenic, although she was compelled to gradually increase the dose up to three grains, on account of a certain tolerance produced. This, I believe, is a plan practised among the Chinese. I have no experience with either carbonic acid or arsenic, but should hesitate to make use of either method; certainly, the latter is open to seri- ous objections. It is a curious feature, in the clinical history of asthmatics, that the efficacy of every remedy seems to exhaust * Union Médicale, 1879, vol. xxviii., p. 617. 2 Lancet, 1861, vol. ii., p. 138. ASTHMA, OR VASO-MOTOR BRONCHITIS. 253 itself, to a certain extent. This is not due, I think, to any tolerance produced by the drug, but rather to the fact, that the longer the disease lasts, and the more fixed the asthmatic habit becomes in an individual, the greater the difficulty in affording relief to a paroxysm- In other words, the morbid lesion which constitutes a paroxysm, being a relaxation of the blood-vessels, their tonicity or power to re- contract seems to be lessened, according as the disease persists for alengthy period of time. Hence, any of the above simple remedies may occasionally fail to afford relief, and it will become necessary to resort to internal medication. Of internal remedies, undoubtedly the most efficacious is opium. This should be administered, where necessity demands, in the form of morphine, and given hypoder matically, as securing the promptest effect of the drug, and in doses of one-eighth to one-sixteenth of a grain, repeated hourly, until relief is afforded. This remedy has undoubtedly been in use for a num- ber of years, and yet curiously enough, we find no allusion to it in literature until Levit reported notably good results from the hypo- dermatic injection of.morphine, while subsequent observations of a similar character were made by Lessdorf,? Anderson, and Oliver.* The latter, however, recommended, that it be combined with one one-hundredth of a grain of atropia. Under the theory that an asthmatic paroxysm is due to muscular spasm, morphine was ad- ministered for the purpose of relaxing muscular contraction. This theory being faulty, we must seek for the beneficial action of the opium in its general sedative action upon the nervous system, and perhaps, also, in a certain amount of sedative influence which it exerts upon the circulation. In much the same way we explain the action of chloral, the efficacy of which was long since recog- nized. According to Williams,’ this is best administered in doses of fifteen to twenty grains, repeated every three hours, until sleep is produced, or in twenty to thirty grain doses, repeated once or twice during the night. The advantage of combining this drug with bromide of potassium, as suggested by Lamadrid,° is recog- _ nized by all, and hence to each dose of the chloral we may add an equal amount of the bromide. If the paroxysms be very severe, we may resort to the administration of chloroform, as was recom- mended as early. as 1849 by Birdsall,’ or of ether, as recommended by Willis,’ although these remedies should be used with a certain amount of hesitation, and with the anticipation of giving but tem- * Gior. Veneto di Sc. Med., Venezia, 1866, 3d series, vol. iv., p. 603. ? Deut. Klin., 1871, vol. xxiii., p. 15. 3 Practitioner, 1875, vol. xv., p. 321. 4 Practitioner, 1876, vol. xvi., p. 137. 5 Brit. Med. Jour., June 13th, 1874, p. 772. 6 Phila. Med. Times, 1874, vol. iv., p. 760. 7 Lancet, 1849, vol.i., p. 336. ® Lond. Med, Gaz., 1847, n. s., vol. iv., p. 271. 254 DISEASES OF THE NASAL PASSAGES. porary relief. The latter is especially objectionable, on account of its peculiar irritating action upon the mucous membrane of the upper air-passages. When Duncan’ first suggested the use of ni- trite of amyl, its use was resorted to with a considerable degree of enthusiasm, as it seemed to give most excellent results, although subsequently it has fallen into disuse, on account of the very dis- tressing symptoms referable to the head to which it gives rise. In the same category we may place the iodide of ethyl, recommended by Sée.? In former times, I found excellent results, in many instances, from counter irritation applied to the spine, either in the form of a mustard plaster, or a blister from two to four inches square, over the fourth and fifth dorsal vertebre. This of course is somewhat objectionable, and in view of the prompt action of the remedies first noted, I have not resorted to this measure in recent years. Probably better and prompter action would be obtained from ap- plying cold to the spine, either in the form of an ice-bag in the same region, or perhaps better still, the long Chapman's ice-bag, over the whole of the spine, its action being probably much the same as that experienced by its use in hay-fever cases, as recommended by Kinnear The use of the galvanic current has been recommended for the relief of the asthmatic paroxysm by Caspari,‘ and it is an excellent suggestion, although scarcely available in most instances. We have thus given, somewhat in the order of preference, the vari- ous measures to which we may resort, in our attempts to relieve the paroxysm, all of which undoubtedly possess notable merit, and yet, as a rule, I think we shall find, in most instances, the best results from the simple measures first enumerated, notably the local ap- plication of cocaine, and the inhalation of the fumes of stramonium and nitrate of potash, in some one of their various combinations. General Treatment.—While I believe the local treatment of a dis- eased condition of the air-passages the most important part of our therapeutic measures, none will question the marked effect of the in- ternal administration of drugs, in this disease. Hence I think we are rarely justified in depending entirely on local measures alone, but when our patients first come under observation, they should be im- mediately put on a course of internal medication also. Of internal remedies, the one which experience has shown us to possess the most notable efficacy in the control of asthma, is undoubtedly iodide of potassium. Its value in this disease was recognized very soon after * Mich. Univ. Med. Jour., 1872-3, vol. iii., p. 588. ? Gaz. Méd. de Paris, 1878, 5th series, vol. vii., p. 79. 4 Loc. cit. 4 Wien. Med. Woch., 1868, vol. xviii., p. 333. ASTHMA, OR VASO-MOTOR BRONCHITIS. 255 its first discovery. Casey* found excellent results from the admin- istration of from two to five grains, three times daily, while Deane’ found it of value, administered in doses of from two-to five grains every two hours, as controlling the severity of the paroxysm. Sub- sequent to this, we find a number of similar observations in litera- ture, with no very specific directions for its systematic administra- tion until Sée* suggested a definite plan for its administration, in following which, I am disposed to think, we will obtain our best results. He commences with the administration of ten grains, well diluted in wine or water, which is to be given three times daily, after meals, for from five to seven days, after which he doubles the dose, and continues it for an equal period. This latter dose usually produces iodism, as evidenced by the metallic taste in the mouth, when he reduces the dose to seven grains, three times a day, for a somewhat long period of time, occasionally interrupting its administration for a day or two, but still continuing to give it for a prolonged period, or. until its efficacy has been thoroughly tested. As regards other remedies, such as lobelia, recommended by Andrew,‘ nitric acid, as recommended by Hopkins,’ belladonna, in large doses, suggested by Wood,’ or the hypodermatic use of atropine, as suggested as early as 1859 by Courty,’ valerianate of atropia, as suggested by Michea,* veratrum viride, found efficacious by Winch,’ platinic chloride, recommended by Dr. Huss,” sulphur baths, as recommended by Courtin,” local application of nitrate of silver to the larynx, as advocated by Bowditch,” quinine, as sug- gested by Dawson,” leonurus cardiaca, as recommended by Spottis- wood,” compressed air, as recommended by Bertin * and Guttman,” and glonoin, as suggested by Fraser,” I have little experience, but am disposed to think that they have been found efficacious in excep- tional cases, and are scarcely to be recommended as available in a * New York Journal of Medicine, 1845, vol. iv. ? Stethoscope and Virginia Med. Gaz., 1851, vol. i., + 572. 3 Gaz. Médicale de Paris, 1878, 5th series, vol. vii., pp. 69 and 79. 4 Glasgow Medical Journal, 1830, vol. iii., p. 190. 5 American Journal of Med. Sciences, 1850, vol. xx., p. 549. ® Philadelphia Med. Times, 1874, vol. iv., p. 804. 7 Gaz. des Hépitaux, 1859, p. 531. ® Gaz. des Hépitaux, 1856, vol. xxix., p. §79- ° Chicago Med. Journal, 1863, new series, vol. vi., p. 511. 7° Jour. des Connais, Med. Chir., October, 1851. ™ Gaz. Méd. de Paris, 1847, vol. ii., p. g6r. ™ Boston Medical and Surgical Journal, vol. Ivii., p. 159. *3 Western Med. Journal, 1848, third series, vol. i., p. 285. ™ Med. and Surg. Reporter, 1879, vol. xl., p. 152. 8 Montpellier Médicale, 1860, vol. iv., pp. 201, 419, 506. *6 Wien. Med. Presse, 1878, vol. xix., p. 764. 7 American Journal of Med. Sciences, October, 1887, and Feb., 1888. 256 DISEASES OF THE NASAL PASSAGES. very large class of patients. In late years, there have come into use two remedies, which possess noted value, these are grindelia robusta and quebracho. The first of these was first recommended by Gibbons,* who found excellent results from its administration, in a flattering number of cases, an observation which has been,con- firmed by a number of other observers. A larger experience, how- ever, seems to show that whereas the grindelia robusta undoubtedly has a powerful effect in controlling the disease when first admin- istered, it seems, at the end of a few months, to lose its efficacy almost entirely. The same I think can be said of the quebracho. We find, therefore, that our constitutional treatment of this dis- ease will depend, as far as internal medication is concerned, largely upon the administration of iodide of potassium, after the manner above detailed. Our systemic treatment, however, is not necessarily confined to the administration of drugs, for very much can be accomplished by certain general hygienic rules. The most important of these is the daily use of the cold bath, either in the form of a’plunge or shower, or where this is not tolerated, the daily sponging of the skin. In addition to this, careful attention must be paid to those general rules of living, which have already been clearly indicated in the chapter on hay-fever, such as the regulation of the clothing, a certain amount of outdoor life and exercise, attention to diet, etc. Asthma is not one of the diseases wherein we can give an abso- lutely favorable prognosis, in all cases. In other words, it is not one of the diseases that we can cure in every instance. Hence, our ther- apeutic resources failing, our final resort will consist in advising our patient to seek relief in change of climate. Unfortunately, asthma is, moreover, a somewhat fickle disease, and hence a climate which is favorable in one case, will prove unfavorable in another, and we may be at times somewhat at a loss, just what advice to give. In general, however, we may say that those cases of asthma which are associated with hay fever will find the greatest relief by residence at the sea-shore, while those which are purely neurotic, such as we have termed cases of bronchial asthma, will seek mountainous re- sorts, or high altitudes. Why high altitude should prove beneficial in these cases, it is difficult to say. Certainly it is not in the di- minished atmospheric pressure, for this would tend to increase vascular plethora. Possibly the beneficial effect of high altitudes lies in the general tonic effect of the pure air, which we find in these regions. Whatever it may be, certainly clinical experience teaches us, that the best climate for the purely nervous asthmatic is the mountain regions. Thus, we find that asthmatics do well in the * Pacific Medical and Surgical Journal, 1867, vol. ix., p. 237. ASTHMA, OR VASO-MOTOR BRONCHITIS. 257 White Mountains, the Adirondacks, Catskills, or in any elevated region, although complete relief is only obtained, probably, at an elevation of between 3,000 and 4,000 feet. This we find in Colorado, which affords a climate better adapted for the larger number of cases than any region found, probably, in this country. It should be said further, in regard to the effect of climate, that whereas re- lief is obtained immediately upon our patients resorting to these regions, and as long as they remain there, yet the disease is not cured, in that they become, as a rule, subject to their asthmatic attacks as soon as they return to the lower level. Hence, we must consider the climatic treatment of asthma as purely palliative, and warn our patients, that permanent relief is only to be obtained by permanent residence in the exempt regions. 17 CHAPTER XVI. NASAL HYDRORRHEA. THIS is a term which we use to designate a curious form of dis- ease which is occasionally met with affecting the nasal passages, in which the prominent symptom consists of a profuse watery dis- charge from the nose, and which, while presenting many of the symptoms of an ordinary attack of hay-fever, occurs at all seasons of the year. There is, however, a certain amont of periodicity about it, in that while occurring every day, it comes on in many instances only at certain definite times each day, while in other instances it seems to persist during the whole twenty-four hours. The disease is an exceedingly rare one, and as we find but few instances recorded in medical literature, perhaps a better apprecia- tion of the peculiar features of the affection will be obtained by a brief resumé of these cases. The first observation on the subject is the report of a case by Rees,’ although long previous to this Ammannus? had recorded an instance, the details of which are not sufficiently clear to warrant its being embraced in this category. Case I.—Rees’s case was that of a woman, aged 52, who suffered from acon- stant dropping of a clear watery fluid from the left nostril. The dropping persisted during the whole of the twenty-four hours, and was especially dis- tressing on lying down, when it caused attacks of suffocation. The general health was notably affected, and the patient suffered from general anasarca, which would indicate that the affection may have been dropsical in its nature although the full details and ultimate result are not stated. Treatment was unavailing. Case II.—Reported by Forster.3 A young woman presented with a history of having suffered for six years with repeated attacks of profuse watery dis- charge from both nostrils, which persisted through the whole twenty-four hours, during considerable periods of time, although there were occasional intervals of three or four weeks’ duration, when the discharge ceased entirely. Her general health was somewhat impaired, although not in a notable degree. The atmosphere of the city aggravated the affection, while the cool air of the country always gave a certain amount of relief. Hot weather also seemed to * London Medical and Surgical Journ., 1834, vol. iv., p. 823. ? Misc. Acad. Anat. Curios., 1671 : Francof. et Lips., 1688, vol. ii., p. 282. «3 New York Medical Times, 1852, vol. ii, pp. 113-115. + NASAL HYDRORRHGEA. 259 exercise an unfavorable influence. She was treated with nitrate of silver both internally and locally without avail. Case III.—Reported by Elliotson.t A female aged 26 was suddenly seized with a profuse watery discharge from the left nostril, which persisted for eighteen months, when it terminated somewhat abruptly, recurring again at the age of 40, coming on somewhat slowly now, and persisting for twenty- three months. The amount of water discharged was usually two quarts daily, although on one occasion it was three quarts. The fluid was of 1.010 specific gravity, and contained sodium chloride and sulphate, asmall amount of mucus, and traces of calcium and phosphoric acid. The first attack seemed to have been brought on by an exposure to cold, which resulted in violent headache and which was only relieved by the sudden onset of the watery secretion. She was treated by means of blisters, leeching, blood-letting and various other measures without avail, the disease disappearing apparently of its own accord. The second attack came on without any apparent cause, and only attained its full activity at the end of two weeks. Again various remedies were tried without avail, until Brodie advised the internal and local use of sulphate of zinc, soon after which the dropping ceased. According to Brodie this was the result of treatment, although it is far more likely that the cessation was spontaneous, as in the first attack. CasE IV.—Reported by Davies.? This was the case of a male, aged 50,who it is stated had syphilis fifteen years previously, although in what form, or with what manifestations is not stated. He was attacked with an abscess at the root of the second molar tooth of the left side, which discharged both into the mouth and through the antrum into the nose. The oral discharge ceased, but the nasal discharge had continued at the time of the report for two years and a half, and consisted of a somewhat profuse, thin, yellow, acrid fluid. It was worse in damp weather, and seemed to be aggravated by mental exertion. No addition to these somewhat meagre details is given, and the question still remains, as to whether this was really a case of nasal hydrorrhcea, or whether it may not have been a case of ordinary purulent catarrh of the antrum. CasE V.—Reported by Tillaux.3 This case was that of a male, who, follow- ing the removal of a nasal polypus, commenced to suffer from a profuse watery discharge from the nose, which persisted during the whole twenty-four hours, excepting that, when in the recumbent position, the discharge ceased, while if the head were bent forward, it seemed to be increased. The amount secreted in twenty-four hours was about nine ounces. An analysis of the fluid showed it to be identical with arachnoid fluid, and Tillaux was led to suppose that in the extraction of the polypus, the cribriform plate of the ethmoid was broken, and that the source of the discharge was the arachnoid cavity. CasE VI.—Reported by Paget.4 In November, 1876, a lady aged 48, while in the enjoyment of perfect health, received a blow over the left frontal sinus. It was a trivial accident and would have been forgotten but that in January, 1877, she had an attack of severe headache, lasting a few days, and in the fol- lowing February she received a severe mental shock. In May of the same * Medical Times and Gaz,, London, 1857, vol. xv., p 290; also, Brown’s Archives, iii., p. 665. ? Lancet, 1870, vol. ii., p. 592. ' 3‘ Traité d’anat. topograph.” Second edition, Paris. 1878, p. 52. 4 Medical Press and Circular, London, 1878, u. s. xxvi., p. 432; also Transactions Clinical Society of London, 1879, p. 43. = vol, 260 DISEASES OF THE NASAL PASSAGES. year, she began to suffer from a profuse watery discharge, confined entirely to the left nostril, which continued over a year and a half, with the exception of an intermission of a fortnight in May, 1878, when she had an attack of bron- chitis, for which she took morphine, and during one night, when it alsoceased spontaneously. With these exceptions, the fluid was constantly dropping during the twenty-four hours, the amount being from about eight to ten ounces a day. It was notably increased by mental distress, and also by exer- tion. At night, during sleep, it would collect in the nostril, pouring out only when the position of the head was changed. In specific gravity it varied from 1.004 to 1.010, and it was composed of 1.015 of solid matter to one hundred parts of the fluid; the solid matter consisting of albumin, chloride of sodium, traces of carbonate of soda and phosphoric acid. Paget prescribed for this patient one grain of sulphate of zinc three times a day, and to increase the dose grad- ually to twice that quantity, and also made a local application of a solution of the same salt, three grains in an ounce of water. This plan was followed for six weeks, when the symptoms subsided in a notable degree, and at the end of three weeks longer had completely disappeared. The patient remained per- fectly well for a month, when, as the result of exposure to cold and great men- tal distress, she was attacked with a severe headache with vomiting, followed by restlessness, delirium, and other evidences of brain disease, and died coma- tose at the end of three days. Post-mortem examination revealed evidences of meningitis, involving a large part of the convexity of the brain. The base of the skull was healthy. In addition to this, there was found in the left an- trum, a number of small rounded polypi, from one-half to two-thirds of an inch in diameter, projecting from its floor and outer wall. The following case is one on which Althaus has built a most interesting. study on the “ Physiology and Pathology of the Fifth Pair of Cerebral Nerves” and is interesting in this connection, in that one of the symptoms consisted in a profuse discharge from the nose, evidently largely composed of serum tinged with mucus. Case VII.—Reported by Althaus.t P.G., aged 27, unmarried, a farmer, lived in Australia, had always enjoyed good health until in June, 1866, he was subjected to serious exposure in riding across the plains in the face of a high wind. While thus exposed, he was attacked with severe pain in the left side of the head, eyes, and face. At first the sensation was as if the face was frost- bitten, but subsequently it became of a dull throbbing character, and continued for five weeks. Some time afterward, as the result of a similar exposure, the right side of the face became involved in the same manner. The pain was not severe, and the attack did not last so long. After the disappearance of the pain, the following conditions set in: the cornez of both eyes became covered with a thick opacity, resulting in complete loss of sight in the right, and im- paired vision in the left. The skin and mucous membrane of the face became quite numb. After a period of some months in the hospital, without much change in his condition, he went to England and placed himself under Althaus’s care, who found complete paralysis of sensation, involving all parts to which the trifacial nerve on each side was distributed. The sense of smell was nor- mal. The vision was obstructed by thick glaucoma of both cornez, although * British Medical Journal, 1878, vol. ii., p. 831; also, Med. Chir’l Trans., vol. lii., p.29. NASAL HYVDRORRHGA. 261 the optic nerve was not affected, the eye symptoms being due entirely to the condition of the cornez. Sensation of the face and scalp was entirely lost, the sense of temperature, touch, and locality being completely ablated. The conjunctiva was entirely anzsthetic, as well as the mucous membrane of the nose and the mouth. From the nose there poured forth such an abundance of acrid “mucus,” that on running down upon the lips, it produced severe excoria- tions, together with complete destruction of the hair follicles of the moustache. Under treatment, which was confined entirely to the systematic application of the galvanic current, the improvement at the end of three months was most striking, and Althaus expressed the conviction that an entire recovery would ensue by the prosecution of this line of treatment. CasE VIII.—Reported by Fischer.t Fischer noticed in one of his hospital cases, a male aged 42, under treatment for a fractured limb, that while in the hospital, he developed a severe attack of headache, followed by a profuse dis- charge from the left nostril, of a thin milky fluid, which was poured out to the amount of about half a pint. The discharge seemed to give relief to the head- ache. The fluid was of 1.003specific gravity, and contained traces of albumin, sodium chloride, and phosphates. Noechinococcus hooks were found. There was no neuralgia of the fifth pair of nerves. The patient had had two at- tacks before, no details of which are given, but he stated that the headache was relieved in each case upon the appearance of the discharge. Case IX.—Observed by the author. Dr. H , aged 58, came under my observation in June, 1882, with the following history. Two months previously he caught what appeared to be an ordinary cold, characterized by nasal steno- sis, sneezing and watery discharge, but these had continued ever since, appar- ently in a periodical manner as follows: He wakens every morning, quite free from every symptom, but usually about nine o’clock, there comes on a feeling of formication about the bridge of the nose, followed by intense sneezing and profuse discharge. It always comes on very suddenly, and persists for from three to six hours, although during the remainder of the day he is not entirely free from his symptoms. Occasionally, although rarely, the attack intermits a single day. The dischargeseems to be of an absolutely pure watery character, and in the course of a daily seizure amounts to several ounces. Examination showed it to contain a small amount of chloride of sodium, with traces of phosphates and lime. This gentleman was seen occasionally, for a period of several years, during which time he was subjected to various plans of internal and local treatment, until the fall of 1884, when the discovery of cocaine placed in his hands a measure which gave more relief than anything which had pre- viously been used, and to this day, he has continued the use of this drug, se- curing such relief as it affords, now a period of five years. It is interesting to note in this connection, that when I first ex- amined this patient, two months after the onset of his disease, I found no notable evidence of any chronic lesion of the nasal cavi- ties, although subsequently he developed ordinary mucous polypi in the nasal chambers, which for the time seemed to aggravate his symptoms, and the removal of which gave a certain amount of re- lief, although limited. The development of the polypi was undoubtedly due to the * Deutsche Ztschr. fiir Chir., Leipzig, 1879, vol. xii., p. 369. 262 DISEASES OF THE NASAL PASSAGES. fact that the mucous membrane became sodden and infiltrated with serum in its escape from the turbinated tissues. In other words, it became so far water-soaked, as it were, as to lead to myxomatous degeneration. It might be stated in this connection also, that a certain amount of relief was given by the application of the galvano- cautery to the turbinated tissues; the action of this remedy being due to the fact, that the superficial cauterization deposited, as it were, upon the surface of the membrane a superficial and inelastic coat, which temporarily gave support to the blood-vessels, and for a time arrested the serous exosmosis. It might be further noted also, that a full trial of a continuous current in this case was made without relief, although a stronger current than that afforded by seven cells was not tolerated by the patient, on account of the severe pain. Case X.—Observed by the author. Dr. D——, aged forty, consulted me on April 7th, 1882, with the following history. For twelve months he had suf- fered from a profuse watery discharge from the nose, which had been a source of such distress to him as to almost incapacitate him for business. The dis- charge was not persistent through the day, but came on usually twice, viz., in the morning at 8, lasting about one hour, and again in the evening, from 5 to 6. The appearance of the discharge was preceded by a sense of intense for- mication about the bridge of the nose, followed soon by the dropping. The amount during the hour usually was about one ounce. On damp days, how- ever, the discharge was persistent throughout the whole day, when its amount was usually a pint. With few exceptions, the discharge ceased during the night. Dry hot weather seemed to give relief. There was a history of inter- mittent fever twenty years before, and again eight years before. Up totwelve months before consulting me, he had been a sufferer from facial neuralgia. This, however, ceased with the setting in of the discharge. An examination showed his nasal cavities to be ina state of perfect health. The discharge was a clear white watery fluid, of a salty taste, and feebly alkaline, and con- tained asmall amount of chloride of sodium, as shown by chemical test. I advised the use of quinine, which he took to the extent of ten grains each night, for three weeks, with the result of absolutely arresting the trouble. A week after, however, he ceased the use of the drug, and the discharge commenced again. He resumed his quinine, now without the slightest effect. During the following summer, he had an additional daily attack of an hour’s duration, from 12 to 1 o'clock. At this time he tried the effect of various remedies. Atropia seemed to aggravate the difficulty. Townsend’s remedy' was absolutely of no avail ; tincture of elfrasia (a homceopathic remedy for hay fever) seemed to give notable relief for a time, in doses of eight minims every four hours. Ergot, in combination with digitalis, also was used without avail. In the fall he com- menced to suffer at night for the first time, and as the cooler weather set in, he resumed the use of quinine with a certain amount of relief, although the continuance of his attack seemed now to have a notable effect on his nervous system, and he commenced to suffer from extreme mental depression. Occa- * A proprietary remedy for hay fever which attained a considerable notoriety at one time, being erroneously reported to have cured Henry Ward Beecher of his hay fever. NASAL HYDRORRHGA., 263 sional doses of quinine now seemed to relieve him during the fall months, and on through the winter. The subsequent history of this case consisted in a cer- tain amount of relief from the occasional use of quinine, and the trial of vari- ous other remedies without effect, until on February ist, 1884, he commenced the use of the galvanic current from a battery of ten cells, with very marked relief, an electrode being applied on either nasal bone. This was continued until July 20th with the result apparently of curing him entirely. At this time he went to the mountains, and while in Saratoga he had an attack of a very severe character, lasting the whole day. He immediately returned home, and resorted to the use of electricity without avail, and in despair, concluded to abandon all treatment, when at the end of a few days, the discharge ceased as suddenly as it had come on, since which time he has enjoyed entire immunity from the affection. It is interesting to note, in connection with this case also, that after the disease had persisted for something over a year, mucous polypi developed in the nasal cavities, which had heretofore been entirely healthy, and, as suggested in the previous case, due en- tirely, I think, to the profuse escape of watery fluid into the mucous membrane. The presence of these growths did not seem to nota- bly increase the discharge, nor did their removal seem to amelior- ate the symptoms. It should be stated in this connection, that this patient, in addition to the use of electricity, subjected himself to a systematic course of Turkish baths, followed by the cold sponge, together with vigorous massage three times each week, during a considerable period of time, in connection with the elec- trical treatment. In addition to the above two cases which came under my own observation, I have in my note-book five others, the details of which, however, are somewhat meagre, and are scarcely worthy of record, other than as illustrating the fact that this disease is by no means so rare as one would suppose, when we consider the small number of cases that have been reported in current medical litera- ture. Of these five additional cases, one was a maiden lady, aged forty, engaged in literary life, and of a decidedly neurotic temper- ament, whom I saw but once. The second, a young lady of twenty-eight, in the enjoyment otherwise of fairly good health, in whom no treatment was of any avail, although under occasional observation during a period of two years. The third was a physi- cian of about forty, whom I saw but once,.and who suffered from hay-fever during four’‘months, while during the rest of the year he suffered from almost daily attacks of watery discharge from the nose, which was aggravated by intense cold, wind, dust, etc. The fourth was a gentleman aged fifty-one, who had suffered for a year with daily attacks, coming on early in the morning, from one to four o’clock, and lasting several hours, during which time there 264 DISEASES OF THE NASAL PASSAGES. was discharged about half a pint of clear watery fluid: This patient I saw but a single time. The fifth was a maiden lady, aged thirty- five, whom I have seen but twice, and who consulted me in regard to a watery discharge from the nose, attended with violent irrita- tion and sneezing, and which came on daily, lasting two or three hours at a time. Case XI.—Reported by Speirs.’ This case was that of a male, aged 58, who for nine months had been troubled with a discharge of watery fluid from the nostrils. The attack came on with sneezing, and was at first thought to be due to an irritating dust, arising from the coarse flannel upon which he had been working. Change of employment, however, had no influence on the discharge. The fluid was clear, watery, and did not stiffen the handkerchief, apparently containing no albumin, and did not excoriate the lip or nostril. The fluid was discharged drop by drop, as a rule, but sometimes it poured in almost a continuous stream from the nostrils. Exercise in the open air seemed to lessen the discharge. The sense of smell was unimpaired. At night he was obliged to sleep in almost an upright position, since when in a recumbent position, the fluid would overflow into the throat, exciting cough. Tannin and glycerin applications were without avail, but the discharge was permanently arrested by keeping the nostril filled with goose grease. Speirs was of the opinion that this application blocked up the passage from the nose into the antrum, which cavity he thought was the source of the discharge, and thus damming back the fluid, caused such changes to take place in the membrane lining this cav- ity, that it no longer secreted so profusely. CasE XII.—Reported by Leber? Leber reports the case of a young woman, 203% years of age, who had suffered from hydrocephalus from birth, and who, in addition to headache and frequent epileptiform seizures, was an- noyed by the dripping of a watery fluid, at first from the left nostril alone, but later the discharge would frequently cease from the left side, and affect the right. The quantity of fluid discharged varied from 4 to 22 cc. in the twenty-four hours. An opthalmoscopic examination revealed atrophy of both optic discs. Although the discharge would occasionally intermit, as did the headache and epilepti- form seizures (though no coincidence was noticed), it never ceased permanently. Case XIII.—Reported by Nettleship.3 This writer reports a rather curious case of this affection, the clinical history of which differs decidedly from those already reported. The patient was a young lady aged 23, subject to hysteria and to palpitation, who was attacked rather suddenly with headache, prostration, and what was apparently a mild amnesic aphasia, forgetting words so that she was obliged to give up her position. During this illness, the eyes were said to have become prominent. There was some muscular weakness, particularly on the left side. There was no vomiting. During her illness the sight became very much impaired but subsequently improved. There was no emaciation. Eighteen months later Nettleship found post-papillitic atrophy of both ontic discs, with contraction of the field of vision, especially at its outer part, the left eye being moreaffected. Two months before Nettleship made this examination, fluid began to drop from the nose. The symptom was less aggravated when she was in bed, but was not affected by abstinence from fluids for an entire day. The secretion of fluid was entirely confined to the left nostril, the mucous membrane of which * Lancet, 1881, vol. i., p. 369. 2 Graefe’s Arch., vol. xxix., I, 273. 3 Ophth. Review, London, 1883, vol. ii., pp. 1 to 3. NASAL HYDRORRAGA. 265 was swollen and excoriated. The fluid was neutral in reaction, and contained chlorides, traces of phosphates and sulphates, with a small quantity of albumin and mucin; hence it was probably nasal and not meningeal. One month later, the fluid became less in quantity from no apparent cause. At this time the patient developed a loud, ringing cough, and examination of the fauces revealed that the palate reflex was entirely lost. The case seems particularly interesting on account of the evidence of hysteria, together with exophthalmos and palpitation. The termination of the case is not given. Cases XIV. and XV. reported by Priestley Smith are some- what similar to the last. CasE XIV.—Was that of a male aged 28, who one month after an attack of small-pox, began to have severe headache and vomiting, soon after which the sight began to fail, and he became blind. The pain in the head remained nu- changed, and four years later fluid began to drop from the left nostril. After continuing four months, the quantity of fluid diminished, and a week later stopped altogether. During this last week the pain in the head became de- cidedly worse, and the patient was very drowsy. On one occasion he slept for 36 continuous hours, and for nearly a week after was constantly falling asleep. At length he brightened up, and the discharge of fluid from the nose returned, this time from the right nostril, The discharge was diminished at intervals, and at these times the pain in the head would be much aggravated, and the patient would be more or less drowsy. These attacks gradually grew more and more severe, and in the later attacks there were some convulsive movements. He died two years after the exhibition of the nasal symptoms. There was no autopsy. Ophthalmoscopic examination during the illness had revealed an atrophy of both optic discs. Examination of the fluid showed its specific grav- ity to be 1.007. It contained alkalies, albumin and mucin, and did not reduce copper. Its source, then, was probably the nose and not the arachnoid space. " CasE XV.—Was a male aged 22, who five years before, after prolonged mental exertion, which had made him very subject to headache, suddenly had a cere- bral attack from which he fell forward, lost consciousness, and developed in- ternal strabismus. For many months consciousness was imperfect, and he was subject to fits of delirium, severe pain in the head and vomiting. He became blind, and ophthalmoscopic examination revealed double optic neuritis, which subsequently passed into atrophy. For fourteen or fifteen months the lower extremities were completely paralyzed. Two and a half years after the begin- ning of the attack, fluid began to drop from the right nostril. Some months later, this became stopped with a polypus, subsequent to which time, fluid came from the left nostril. The polypus was removed from the right side, but soon recurred. The amount of fluid varied from twelve to fifteen ounces in twenty-four hours. When the discharge of fluid became less, he felt pain in the back, between the shoulders, which would gradually creep up-toward the base of the skull, leaving the frontal region free from pain. Exercise increased the flow. His mother noticed that when the nasal secretion became diminished, urinary secretion became more free. The fluid was essentially the same as in the first case. The author was inclined to explain this occurrence by an ob- scure nasal growth, destroying the cribriform plate, or pressing upon it. CasE XVI.—Reported by E. B. Baxter A female, aged 35, had been in * Ophth. Review, London, 1883, vol. ii., p. 4. 2 Brain, vol. iv., p. 525- - 266 DISEASES OF THE NASAL PASSAGES. perfect health up to the time of her marriage, Five months afterward, she had been subjected to considerable worry and anxiety, and began to suffer from certain nervous symptoms, which steadily increased, until she was first seen two monthsafter. She at first suffered from headaches, but shortly after- ward a clear watery fluid, sometimes rather offensive, and occasionally tinged with blood, began to come away from the right nostril. The headache, which was very severe, usually began at the right of the nose, and also involved the temporal region. Ophthalmoscopic examination showed double optic neuritis. The teeth in the upper jaw were decayed. There wasuniform soft hypertrophy of the thyroid body of ten years’ duration. Three years after the symptoms began, the patient died. A rather imperfect autopsy revealed no nasal lesion, and no lesion of the brain. ; Case XVII.—Reported by Mathiesen. The patient was a thirteen-year-old boy, who had a severe fall, following which he was unconscious for some time. The following night he suffered from vomiting and epistaxis. About two months after the accident, he came under observation on account of the dis- charge of a thin watery secretion ofa salty taste from the left nasal cavity. In the course of two hours twenty-five centimetres of this fluid were collected. His general health was good. Five days later the discharge ceased. Micro- scopical examination of the fluid revealed white blood-corpuscles, a few threads of mucus, and pavement epithelium. The fluid was of a specific gravity of 1.006, and of alkaline reaction, and otherwise corresponded to a cerebro-spinal fluid. The writer was in doubt whether the source of the discharge was the cerebral or the nasal cavity. Case XVIII.—Reported by Vieusse.? Vieusse reports the case of a young man, who consulted him eight days after a severe fall upon the head, which had caused unconsciousness, and a discharge of blood from the left ear and nose. When seen by Vieusse, he complained of severe headache, and there was a serous discharge from the nostril. On examination later, it was found that the serous fluid came either from the nostril or left ear according to the position of the head. About two drops were discharged each second. Death occurred, from meningitis, eighteen days after the accident. An autopsy re- vealed a fracture of the base, involving the cribriform plate of the ethmoid. In addition to these we find cases reported by C. J.3 and Lin- gard ‘as examples of this disease, the former of which seems to have been an ordinary case of idiosyncratic coryza, while the latter was a case in which the symptoms were due to the excessive use of the cold-water douche. Lingard’s idea seems to have been, that the watery discharge was due to the fact that the accessory sinuses became filled during the use of the douche, and hence the dripping which followed it, was really the water escaping from these cavi- ties. Whatever may have been the cause, the symptoms disap- peared on abandoning the use of the douche. If Lingard’s view was a correct one, which I very much doubt, the case is certainly quite unique. * Norsk. Magazin for Laegevidenskaben, p. 41, Jan., 1887. ? Gaz, Hebd., 1879, No. 109, p. 298. 3 British Medical Journ., 1879, vol. i., p. 175. 4 British Medical Journ., 1878, vol. ii., p. 921. NASAL HYDRORRHGA. 267 ETIOLOGY.—We have here a collection of exceedingly curious cases, and at first sight it would seem to be by no means a simple matter to give an explanation of the phenomena which they mani- fest, other than pure speculation, and yet I think there is much that is exceedingly instructive. The first feature which strikes us per- haps is the fact, that in a certain class of cases, the escape of watery fluid is purely passive and painless, while in the other, the flow of water gives rise to symptoms of intense irritation, such as we observe in ordinary cases of hayfever. This one symptom will serve to divide these cases, then, into two classes. In the first of these, the essential lesion consists of an ablation of function of the trifacial nerve, which, as we know, exercises an inhibitory action upon the serous exosmosis which takes place normally in the nasal mucous membrane. In connection with the paralysis of this nerve, of course, there occurs paralysis of sensation, and hence the trans. udation of fluid takes place without consciousness on the part of the sufferer. This feature was particularly noticeable in Althaus’s case, in which the pathological lesion seems to have been thor- oughly recognized, and the diagnosis established, of neuritis involv- ing the fifth nerve of both sides. The question arises whether the disease is due to a neuritis, as in this case, or to some other lesion, affecting either the nerve trunk, or the central ganglia, as there is good ground to think existed in Priestley Smith's two cases, as well as in Nettleship’s, although neither of these authors adopted this view. In Paget’s case, an autopsy revealing the existence of polypi in the antrum of the side affected, these were accepted, without question, as the cause of the watery discharge. A more rational. view, it seems to me, is that the polypi were the result of the affec- tion, and that the essential lesion consisted of some obscure condi- tion at the base of the brain, which gave rise subsequently to an attack of acute meningitis, to which the patient succumbed. Cer- tainly it is difficult to understand how the existence of polypi in an antrum should cause the symptoms, while, on the other hand, it is very easy to see how a vaso-motor paresis with profuse watery discharge should give rise to myxomatous degeneration, whether in the antrum or in the nasal cavity, in the same manner as oc- curred in two of my own cases which are reported in full.t In an- other class of the cases, we see that the watery discharge gives rise to an intense irritation of the nasal mucous membrane, as mani- fested by the peculiar formication and sneezing which becomes a source of exceeding great distress This, of course, can only occur in cases where the general and special sensibility of the Schneider- ian membrane is intact, or in other words, in cases in which the ™ Cases IX., X. 268 DISEASES OF THE NASAL PASSAGES. integrity of the trifacial nerve is preserved. We must, therefore, seek for a cause of the hydrorrhcea in these cases, in some cause other than a lesion of the trifacial, We content ourselves with the statement, that the lesion here consists of some disturbance or irri- tation, involving the sympathetic system of nerves. Whether this is peripheral or central, can only be a matter of speculation. It is a noticeable fact, in these cases, that there is no evidence of cere- bral disturbance whatever, other than an occasional headache, which is relieved by the setting in of the watery discharge. The headache is easily explained, in that it is probably an ordinary plethoric headache, which is relieved by the local exosmosis, in much the same manner as we frequently see headaches relieved by the relief of nasal hyperemia. This latter class of cases, therefore, is very closely analogous to ordinary cases of hay fever. More- over, we see in them a certain diurnal periodicity, which would seem to indicate that the causes which act to produce the symp- toms, are operative only under certain atmospheric conditions. In a number of these cases, the membrane seemed to be exceedingly sensitive to the action of cold, wind, dust, or other causes, thus manifesting a condition which is almost always present in hay fever, in that a large majority of patients who suffer from autumnal at- tacks of this disease, are peculiarly sensitive, at all seasons of the year, to the action of smoke, dust, or irritating vapors. Sex would seem to have but little influence on the affection, in that of the twenty-three cases given above, thirteen were males and ten females. It belongs essentially to adult life, as the ages of these patients were from twenty-two to fifty-two, with the exception of Mathiesen’s case, which was a boy of thirteen, who in all probability suffered from fracture of the base of the skull. Traumatism, as a possible remote cause, is mentioned in several of the histories, al- though a careful reading of the cases fails to establish any clinical connection between the injury and the hydrorrhcea. In Tillaux’s case, I think the suggestion of fracture of the ethmoid is quite superfluous, in that the existence of the polypi seems to have been quite sufficient to establish some antedating and efficient cause for the watery discharge. Davies’s case was undoubtedly one of sup- purative disease of the antrum. The neurotic element seems to have been present in many of these cases, in much the same way as we find it in hay fever, which brings us to the question, as to what relation the one disease bears to the other. Certainly, as re- gards the cases dependent on lesion of the trifacial, I doubt if there is any connection, but in those in which the trifacial was not in- volved, and which we refer to some obscure lesion of the sympa- thetic, I think there can be no doubt that the disease is very closely NASAL HYDRORRHGA. 269 allied to hay fever, in that it is dependent, to a large extent, on what we call the neurotic habit. The other two essential causes of hay fever, viz., a diseased condition of the nasal mucous membrane, together with the impact upon it of the pollen of flowering plants, are not present. In my own cases, no lesion was found in the naval cavities. We can only say, then, of these cases, that in con- nection with an intensely neurotic temperament, the nasal mucous membrane is rendered sensitive to some obscure atmospheric con- dition, under the action of which vaso-motor control of the blood- vessels, whose special function is the exosmosis of serum in the normal process of respiration, becomes paralyzed, and that this exosmosis takes place to an abnormally large extent. Under the term neurosis, of course, in our ignorance of essential pathological lesions, we must include some probable organic lesion of the nerve- trunk, or ganglionic centres of the sympathetic system. That there is an atmospheric condition which excites the attacks in some instances, I think we must accept on clinical grounds, in that they occur daily, at about the same time, and in each individual case persist for the same period. This view is, furthermore, strength- ened by the fact that dampness, heat, and other atmospheric con- ditions, have a marked influence in aggravating or alleviating the severity of the symptoms. SYMPTOMATOLOGY.— The symptoms of the affection are clearly indicated in the histories above given, and consist essentially in a dropping of clear, transparent watery fluid from the nose, which may either come on gradually, or abruptly, and while it lasts, con- sists of a constant flow of water from the nostril, which may be attended with a violent sense of irritation or not, according as the disease is dependent upon a morbid condition in the sympa- thetic control of the blood-vessels of the nasal mucous membrane, or of the trifacial. This dripping may continue during the whole twenty-four hours, or it may manifest a certain diurnal periodicity. Where it occurs during the night, it is usually somewhat dimin- ished, although in many cases it continues during the sleeping hours, accumulating in the cavity of the nose, and pouring out, as . it were, on a change of position. If it passes into the pharynx, it may give rise to cough, or even attacks of spasm of the glottis, as occurred in Rees’s case. In Althaus’s case, the discharge poured out upon the upper lip, producing excoriation, and ultimately almost a cicatricial condition of the skin. If the attack is accompanied by sneezing, etc., it may become a source of very great distress and even suffering to the patient. Where, however, sensation is abol- ished in the nasal cavity, the condition is merely one of discomfort and annoyance, as far as the watery discharge itself is concerned. 270 DISEASES OF THE NASAL PASSAGES. PROGNOsIS.—In those cases which are essentially a neurosis of the sympathetic, and which are so closely allied to hay fever, the prognosis is somewhat unfavorable, in that we have difficulties to contend with here, even greater than those with which we have to contend in hay fever. Now, this latter disease, as we know, is an exceedingly fickle one, and in many cases will resist every effort to afford relief, although we have here a definite local lesion in the nose, as a prominent factor in causation, and the removal of which presents a clear indication for treatment. In the disease in ques- tion, however, the only tangible lesion with which we have to deal, is the neurosis, and this in most cases will seriously tax our thera- peutic resources. Of seven cases of this variety which were under my own care, but one was cured, although but three of them were under my care for any prolonged period of observation. More- over, in the one case which was cured, it is somewhat doubtful whether the fortunate termination was the direct result of any therapeutic measures. As regards the cases dependent upon a lesion of the trifacial, no prognosis can be given, unless the special lesion which has caused the disease can be definitely ascertained, in which case the prognosis will be based entirely on this information. TREATMENT.—The indications for treatment are twofold, viz., the use of such local applications in the nose as control vascular turgescence, and second, the resort to such therapeutic resources as we possess, for the remedying of the morbid lesion in the nerve trunk. The first indication is better carried out by the resort to cocaine, whose local action in controlling vascular turgescence is prompt and certain, beyond any other drug which we possess. The patient should be provided with a proper atomizer, and com- mencing with a four-per-cent solution, gradually reduce it, until he finds the weakest solution which will afford him relief, when he is allowed to obtain such comfort as may be afforded by its applica- tion, as frequently as may be demanded. I think it is very ques- tionable, on reading the reports given above, whether internal rem- edies have proven of much avail. Elliotson’s case seems to have been cured by the internal and local use of zinc, yet I think it an open question, whether either the local or internal use of this drug had the slightest influence on the attack. Paget’s case was very similar. In Althaus’s case, the diagnosis was made, and clear indi- cations carried out, with a good result. In the second of my own cases, after the use of numberless drugs, the patient was finally cured by the use of the galvanic current, locally applied, a method of treatment which seems in every way rational, and apparently clearly indicated, and yet in my first case, this resort was not only of no avail in giving relief, but seemed to aggravate the disease. NASAL HYDRORRHGA. 271 The best then that we can say in regard to treatment, is that where we can definitely ascertain the cause of the disease, the indications for treatment are clear. Where the cause of the disease is obscure, as is the case in the large majority of instances, any plan of treat- ment must be to a large extent experimental, and governed by such indications as may be found to exist upon a careful study of each individual case. , CHAPTER XVIL. ANOSMIA. DISTURBANCES of the function of olfaction may manifest them- selves in an increased activity of this sense, giving rise to what is usually designated as hyperesthesia of the olfactory nerve, by the action of which odors are appreciated with a very high degree of sensitiveness. This condition, is almost invariably met with in con- nection with hysteria, and presents no point of special clinical in- terest. Cloquet,’ however, has observed it in connection with dis- ease of the intestines, testicles and uterine organs. Again, we not infrequently meet with a curious perversion of this function, termed parosmia, or paresthesia of the olfactory nerve, under the action of which, imaginary impressions are received, usually of a disagree- able kind, which are purely subjective, and are the result of some pathological lesion in-the olfactory bulb, nerve, or of some central brain lesion. Or, again, it may be purely subjective, as in a case observed by Berard,? in which the patient complained of unpleasant and offensive odors. An autopsy was performed subsequently and the olfactory nerves were found completely destroyed. From a clinical point of view, this condition perhaps occurs most frequently as a subjective hallucination in cases of insanity, although it may occur in connection with any form of organic brain disease. Our main interest, however, in this connection, lies in the consideration of that form of perversion of this function, which is characterized by an impairment or total loss of the sense of smell, usually designated as anosmia. : ETIOLOGY.—This symptom may arise from any condition which either interferes with the entrance to, and impact of odorous par- ticles upon the mucous membrane lining the upper portion of the nasal cavity, called the olfactory tract, or from any morbid condition of the nerve itself, which prevents its full appreciation of the odorous character of those particles. Under this latter head may be embraced lesions of the terminal filaments of the nerve, lesions of the trunk of the nerve, or lesions of the bulb. Under the former class may be embraced acute rhinitis, hypertrophic * Osphreesologie, Paris, 1821, p. 749. ? Froriep’s Notizen, vol. xi., p. 151. ANOSMIA. a7 rhinitis, fractures or deformities of the septum, nasal polypi and other forms of neoplasm. .In much the same way, tumors of the pharynx or palato-pharyngeal adhesions, give rise to anosmia, in that the inspiratory current of air through the nose is interfered with. In these cases, the symptom is due to purely mechanical causes, and yet, while a nicer use of the term anosmia would sug- gest that it would be confined entirely to cases of purely neurotic origin, yet it is customary to group them all under the same con- sideration. Among the causes of the disease, which lie in a mor- bid condition of the nerve itself, are embraced, atrophy of the bulb or of the trunk of the nerve, as in cases observed by Prévost' and Notta,? or the nerve may be absent, as in cases reported by Dubreuil,? Pressat,* Blandin,’ Després,° de SanJuan’ and Bernard.’ In addition to these, several congenital cases have been re- ported by Notta» Traumatism also plays an important part in the production of the symptom, giving rise to fracture of the base of the skull, as observed by Notta® and Molliére,” or in a separation of. the bulb from its branches, as they enter the cribriform plate of the ethmoid, as Ogle ™ suggests, and as probably occurred in Legg’s ” case, where the injury resulted in permanent loss of the sense of smell, although in a very similar case reported by Rotch,* which was attended with hemorrhage from the ears, nose, and mouth, the anosmia disappeared at the end of six weeks. In a case observed by Hamilton,“ permanent anosmia super- vened upon a meningitis following a blow upon the occiput. Tumors of the brain, it would seem, are not liable to give rise to complete anosmia, in that their location as pressing upon both nerves, would be somewhat unusual. Thus, Loder™ met with a case from scirrhus of the pituitary body. Oppert* also found an abscess of this body, pressing on both olfactory nerves, resulting in loss of the sense of smell, Huguenin,” however, in reporting two * Gaz. Médicale, 1866, No. 37, p. 597. * Arch. Générale, 1870, vol. i., p. 385. 3 Gaz. Médicale, 1835, 2s., vol. iii., p. 243. 4 Cited by Longet, Anat. et Phys, du Systeme Nerveux, vol. ii., p. 39. 5 Bul. de la Soc. Anat., Paris, 1827,;Second Edition, 1844, vol. ii., p. 18. © Bul. de la Soc. Anat., Paris, 1841, p. 140. 7 Siglo Med., Madrid, 1857, vol. iii., pp. 211 and 218, 5 Cited by Althaus, Lancet, 1881, p.77I. 9 Loc. cit. to Lyon Médicale, 1871, vol. viii., p. 385. ™ Med-Chir. Trans., 1870, vol. liii., p. 263. ™ Lancet, Nov. 8th, 1873, vol. ii., p. 659. 3 Boston Medical and Surg. Journ., 1878, vol. xcix., p. 130. ™4 Trans. of the Col. of Physicians, Philadelphia, 1870, n. s., vol. iv., 362. 8 Observatio Tumoris Scirrhosi in basi Cranii reperti, Jen., 1790. 6 Dissertatio inaug. de Vitiis Nervorum Organicis, Berol., 1815. My ies ss aa fiir Schweizer Aertze, 1882, vol. xii., pp. 257 and 295. I 1274 DISEASES OF THE NASAL PASSAGES. such cases, has found that this symptom is due rather to a basilar meningitis, excited by the presence of the neoplasm. There can be little doubt that very many cases of cerebral hemorrhage or neoplasm result in a destruction of functional activity in the olfac- tory nerve on one side, and yet this condition is probably so far -masked by the more serious symptoms which result from the cen- tral lesion as to escape notice. The main point of interest in this connection, is that this condition always occurs on the left side, and is associated with aphasia and paralysis of the right side of the body as observed by Hughlings Jackson,’ Ogle- and Fletcher.3 In an interesting case observed by Althaus,‘ this symptom de- veloped in the second stage of an attack of locomotor ataxia, about six years after the onset of the disease, while in one of Molliére’s* cases, it was due to cerebral syphilis, as also in Rom- berg’s 5 case. Those cases, in which the affection'is the resuit of a morbid condition of the terminal filaments of the olfactory .nerve, are probably also to be classed as neurotic. In this category are to be embraced those cases in which permanent.anosmia results from the inhalation of irritating or highly offensive gases, or powerful odors. Thus, Graves® reports a case, in which a man subjected himself to the exceedingly offensive and irritating gases which emanated from a cesspool, for a period of several hours’ dura- tion, with the result of permanent loss of the sense of smell, and again in a case reported by Stricker,’ the same accident happened to an entomologist from working several hours a day in an at- mosphere surcharged with ether, which he used in the prepara- tion of his specimens. It is a noticeable fact, in these cases, that the anosmia only occurred after the terminal filaments of the nerve had been subjected to the irritating action of these agents, fora somewhat prolonged period of time, for while, as we know, if we subject the olfactory tract to the irritating effects of strong am- monia, for instance, the sense of smell is abolished temporarily, although no permanently deleterious effects occur. Its prolonged action, however, must undoubtedly. give rise to some definite mor- bid change. It may be that the physiological irritability of the nerve is destroyed simply by prolonged and excessive irritation, or possibly a localized inflammatory process arises about the terminal filaments, A more plausible suggestion, however, is that of Alt- haus,‘ that a capillary hemorrhage occurs in the nerve itself. * London Hospital Reports, vol. i., p. 410. ? Loc, cit., p. 273. 3 Brit. Med. Journ., April, 1861. 4 Loc. cit. 4“ Klinische Ergebnisse,” p. 18. ® Cited by Notta, loc. cit. 7 Virchow’s Arch., vol. xli., p. 291. ANOSMIA. 275 Atrophic rhinitis, or ozena, in its late stages, is attended with more or less complete loss of the sense of smell. This may be due to the fact, that the crusts and scales of dry mucus which lodge upon the surfaces of the turbinated bodies, prevent the approach of olfactory particles, or it may result from the fact, that the ter- minal-filaments of the nerves are destroyed in the process of atro- phy, which, as we know, results in a condition verging on sclerosis of the mucous membrane, the atrophy of the nerve filaments being due entirely to pressure. It is probable, however, that the anosmia is due to a combination of both these factors. A somewhat curious suggestion is made by Mackenzie,’ that anosmia occurs in connection with paralysis of the seventh nerve, and that the orbicularis muscle being paralyzed, the tears flow over the cheek, instead of through the nose, thereby leading to an abnormal dryness of the nasal mucous membrane. It is scarcely necessary to suggest, that tears flowing through the lachrymal canal, in no way approach the olfactory tract, and furthermore, the nasal mucous membrane receives its moisture from the turbin- ated bodies, rather than from the tear-duct. Allusion has already been made? to the importance which Ogle attributes to the pres- ence of pigment in the olfactory region, in the physiology of olfac- tion, the corollary of which is, that its absence, may be an import- ant factor in the impairment of this function. Ogle substantiates his view by the report of a case in which a colored: boy underwent a process of bleaching, as it were, until all parts of his body, which were not exposed, became white, while at the same time, the sense of smell gradually became impaired, and finally almost completely disappeared. He instances also a number of analogies, both in man and among the lower animals, showing that the sense of smell is more highly developed in the colored races, and furthermore in - animals with a pigmented skin. The argument is ingenious, and admirably sustained, and yet it is certainly impaired by the fact, that albinos, both in man and the lower animals, are not univer- sally anosmic, yet even these, as Ogle shows, afford ground for his argument, in the fact, that among the lower animals, the acute- ness of the sense of smell seems to bear a certain proportion to their general pigmentation. SYMPTOMATOLOGY.—The close relation between the sense of smell and the sense of taste has already been fully discussed in connection with the physiology of olfaction, where it was shown, that the sense of taste consisted only in the ability to appreciate 1 “ Diseases of the Throat and Nose,’ American Edition, Philadelphia, 1884, vol. ii, P. 455- ? Chapter VI., on the Physiology of the Nose. 276 DISEASES OF THE NASAL PASSAGES. the ditter, sweet, salt and acid qualities of substances brought in contact with the mucous membrane of the tongue and palate, and that the more delicate elements of the sense of taste were due entirely to the appreciation of their odor, by the olfactory nerve. A loss of the sense of smell, therefore, is always accompanied by a deterioration of the sense of taste, and it is through this latter de- ficiency, that anosmia really is recognized, in the majority, if not in all instances. There seems to be a connection between the olfac- tory properties of the upper nasal passages, and general sensation, although Magendie* entertained the view, that olfaction was de- pendent upon the branches of the fifth pair, a view which Bernard’ supports, by reporting a case, in which the disagreeable odors of an outhouse were complained of by a patient, in whom the cribri- form plate, together with the olfactory nerves, were found absent on post-mortem examination. This may have been a case of par- osmia, similar to that of Berard’s,? or more probably, as Althaus suggests, the disagreeable odors were largely made up of ammonia- cal effluvia of the fetid hydrogens, which could easily be appreci- ated by the general sensation of the mucous membrane. From a clinical point of view, however, the two properties are distinct, and in no way interdependent, in that the anosmia may be complete while the general sensation is in no degree impaired. In the ma- jority of instances, however, the condition is not one of complete anosmia, but rather a more or less notable impairment of the func- tion. Especially is this true of those cases in which the condition is due to an obstructive lesion in the nose, which prevents the entrance of odorous particles, as in nasal polypi and other tumors, acute rhinitis, hay-fever, etc., the extent of the anosmia bearing a close relation to the patency of the cavity. Where, however, the affection is due to a nerve lesion, the anosmia is usually complete, although it is noticeable in this form of the disease, that, in many cases, the complete loss of function is preceded by certain disturb- ances, such as hyperosmia or parosmia. Thus, in a case reported by Lockeman,} the primary stage of the affection was marked by the appreciation of disgusting odors, while Althaus* has observed a case, in which the odor of phosphorus was a source of great annoyance to a patient, who subsequently developed complete anosmia. PROGNOSIS.—The differential diagnosis between essential, and symptomatic anosmia is a matter of some importance, as regards prognosis, in that while recovery from the former is exceedingly rare, in the latter, we may usually give a favorable opinion, de- t Jour. de Phys. expér., Paris, 1824, vol. iv., p. 169. 2 Loc, cit. 3 Cited by Althaus, loc. cit. ANOSMIA. 277 pendent upon our ability to remove such local obstructive lesion in the nose as rhinoscopic inspection reveals. Perhaps the only cases in which a favorable opinion can be given in essential an- osmia, are those dependent on syphilis. In a case reported by Raynaud’ the anosmia seemed to be due to malarial poisoning, in that it was intermittent, recurring every day at five o’clock; more- over it was entirely cured by the administration of quinine. A nice question arises here, as to how long the olfactory nerve will retain its integrity, while its function is affected by an obstructive lesion of the nasal cavity. It is an almost universal rule in the economy, applying alike to gland structures, muscles, and probably to nerves, that when their function is ablated, they show a tendency at least to degenerative changes of an atrophic character. Hence, if the function of the olfactory nerve is.suspended by some lesion of the nose, which absolutely prevents the approach of odorous particles, this tendency manifests itself, and if the lesion remains for a sufficient period of time, the nerve will have undergone such atrophy as that its integrity cannot be restored by the removal of the obstruction. Perhaps no definite period can be-stated, during which this nerve may retain its functional activity, and probably it varies in different individuals. I have never seen a case, for in- stance, of nasal polypi, in which both cavities were completely filled with polypi without relief for ten years, in which complete and permanent anosmia did not supervene. I have seen, in many in- stances, cases in which the sense of smell was abolished for four to six years, from this cause, and yet ultimate recovery ensued. Notta? has seen a case of anosmia due to polypi, in which recovery took place at the end of fifteen years. We can only state then, that perhaps six or eight years of total ablation of function will result in a permanent loss of the sense of smell, probably as the result-of degenerative changes, either in the olfactory trunk, or at the nerve centres. It is not to be understood that the prognosis is unfavorable in all cases of anosmia due to brain lesions. Thus, in a case reported by Ogle* dependent on apoplexy, there was ulti- mate recovery. A like conclusion also resulted in Rotche’s cases, in which there was probably a local extravasation at the base of the brain; and in three of Notta’s cases, where there was fracture of the base of the skull. These cases, however, are somewhat ex- ceptional. Dubreuil+ reported a case, in which the anosmia oc- curred in connéction with a cleft palate, and where post-mortem examination showed absence of the olfactory nerves, which would suggest an explanation of the symptoms occasionally met with in ™ Union Médicale, July roth, 1879, p. 58. 2 Loc, cit., p. 405. P rc, Clt., Ps 405 3 Loc. cit., p. 273. 4 Loc. cit. 278 DISEASES OF THE NASAL PASSAGES. connection with the deformity, in that a cleft palate is very fre- quently associated with a malformation or deficiency of the brain. PATHOLOGY. —It is impossible to describe any pathological lesion as belonging essentially to andsmia, in that the disease is a symptom of a variety of diseases, rather than a disease itself. Thus, it may be dependent upon a tumor of the brain, pressing upon, or involving the olfactory centre in or near Broca’s convolu- tion; or involving, or perhaps pressing upon, the nerves in their continuity; or upon the bulbs themselvcs. It may be due to con- genital absence of the bulbs and nerves. In Oppert’s* case, there was an abscess of the pituitary gland, and in Bonet’s? cases there was pus formation in the olfactory bulbs themselves. Again, the nerve may become involved in local inflammatory changes in connection with meningitis. The only. special interest which attaches to this branch of the subject, however, is in connection with the changes: which may occur in the olfactory region. I know of no observa- tions bearing on this subject, and yet it seems clear, that, in many cases, we must concede that the diseased condition of the brain itself is responsible for the loss of the sense of smell. Aside from those conditions in which the approach of odorous particles to the terminal filaments of the olfactory nerve is prevented, this condi- tion probably consists of some atrophic change, occurring in the terminal filaments of the nerve, due, either to the pressure of local inflammatory deposits, or to a deficiency of circulation, this latter _condition being the one which exists in the ordinary forms of atro- phic rhinitis; or, again, it may possibly be connected with the de- generative changes which occur in old age. Thus, Prévost* in an examination of a large number of cases, has found certain degener- ative changes in the olfactory nerve trunk, as belonging especially to advanced life, in which the trunk of the nerve is less bulky, and fills a relatively smaller space in the groove of the ethmoid, while the nerve fibres themselves are diminished in number, their place being supplied, as it were, by increased numbers of amyloid cor- puscles. In more frequent instances, however, we must look for local inflammatory changes, as the source of the condition. Thus, in an ordinary acute rhinitis, we may have anosmia persisting for many days after the inflammatory process undergoes resolution; while in hay-fever, in which the local inflammatory action persists for a still longer period of time, there may result an anosmia, of even months’ duration. The same thing also occurs in croupous and diphtheritic rhinitis, especially in the latter, where the symptom is the result of local changes, rather than of blood poisoning. DIAGNOSIS.—The essential importance of the diagnosis consists T Loc. cit. ? Sepulchretum, Geneve, 1700, lib, i., sec. xx., obs. 1., p. 441. ANOSMIA. 279 in the determination, as to whether the symptom be due to a local condition of the nasal chambers, or a diseased condition of the nerve. In other words, whether we have to deal with an essential or symptomatic anosmia. This can only be determined by a care- ful examination of the nasal cavity, and by the elimination of any possible local cause there. This, taken in connection with the his- tory of the case, and the concomitant symptoms, ordinarily will suffice to establish, with a considerable degree of certainty, the existence or non-existence of any central disease. We eliminate, then, from consideration, brain tumors, hemorrhages, abscesses, meningitis, tabes and all diseases of this character, in that, in such cases, an anosmia becomes a symptom of the most trivial character, in the presence of an exceedingly grave organic affection, and only interest, as serving as a possible, though unimportant aid to diag- nosis, in that, as Hugueinin* observes, anosmia may occur in con- nection with brain lesions, even remote from the olfactory centres. The simple test for olfaction consists in the use of odorous substances. In the selection of these, however, one should always make use of a substance which is recognized purely by its odorous qualities, the most delicate test, of course, being the fragrant odors, whereas the disagreeable odors are often deceptive, in that what is. unpleasant, often is not necessarily a genuine odor. If it is desired to accurately and determinately ascertain the condition of the olfactory nerve it will be necessary to resort to the use of the.gal- vanic current, Althaus having shown that this nerve affords a direct response to the electrical stimulus, when healthy. as early as 1740 resorted to this operation in a case in which there was a somewhat extensive necrosis of the alveolar pro- cess, and which had existed for several years. He made the opening sufficiently large to admit the little finger into the cavity, by means of which its walls were subjected to digital exploration. In this case the opening remained patulous, giving rise to a defect in articulation similar to that of cleft palate, which was only rem- edied by wearing artificial plugs. The suppurative disease was cured, however, in a few weeks. In those cases in which, as the result of ‘the long retention of pus, the anterior wall of the antrum has be- come thin, and the pus shows a tendency to point upon the cheek, this disposition should be corrected as soon as possible, by an arti- ficial opening elsewhere, since it is probably never wise to open the antrum through the cheek, as, in that case, a permanent fistu- lous opening is liable to form. DISEASE OF THE ETHMOIDAL SINUSES. In these sinuses, we meet with catarrhal inflammation, and also the suppurative process. In the former instance, it is probably, in most cases, a complication of an attack of acute rhinitis, and hence its symptoms are, to an extent, masked by those of the inflamma- tory process in the nasal cavities. The only feature of the attack, which should direct prominent attention to the ethmoidal sinus, is simply pain, referable to that region, of an intensity and per- * Hyrtl, ‘‘ Topographische Anat.,” Wien, 1871. * Revue de Laryngologie, June, 1887. 3 Op. cit., p. 143. 4 Berliner Klinisehe Wochenschrift, No. 16, 1887, p. 273. 5 Mem. Acad. Fr., 1743. 480 DISEASES OF THE NASAL PASSAGES. sistence not usually characteristic of an ordinary cold in the head. It usually subsides spontaneously, as the inflammatory process in the nose undergoes resolution. Suppurative disease of the eth- moidal sinuses, on the other hand, is an affection of far more seri- ous import, involving as it does, symptoms of a more troublesome and even dangerous character, in that its tendency is toward caries and necrosis of the bony structures underlying the mucous mem- brane. ETIOLOGY.—It may develop from a simple catarrhal process, complicating an acute rhinitis, as in the following case reported by Schaffer : + A soldier, 23 years old, after the ordinary symptoms of a cold in the head, commenced to suffer from a swelling of the eyelids on the right side, together with right exophthalmos; at the same time there set in an ill-smelling, muco- purulent discharge from the right nasal cavity ; an orbital abscess finally devel- oped, from which pus was evacuated by incisions. By injections through these incisions, the fluid flowed freely from the right nasal cavity. Death finally occurred from meningitis, and the post-mortem examination revealed a sup- purative patch of the size of a walnut in the ethmoidal cells, with ulceration of the osseous tissue. The disease may also develop in connection with a chronic rhi- nitis, the hypertrophic process gradually extending toward, and occluding the ostium ethmoidale, in much the same way as has been noticed in connection with disease of the antrum. This ap- parently was the primary origin of the attack in Hartmann’s? case, as follows: A man, aged 26, wasseized with a violent pain over the f-ontal region, which increased in severity, and gradually extended over the whole of the left side of the face, while at the same time protrusion of the left eyeball became notice- able; and slowly increased. At the end of two weeks, marked febrile move- ment set in. Soon after the exophthalmos became apparent, a more or less profuse purulent discharge made its appearance from the nasal cavity, which the patient himself noticed was increased by pressure upon the eyeball. Three weeks after the onset of the attack, he was admitted to the hospital, presenting, in addition to the foregoingsymptoms, immobility of the left eyeball in all direc- tions, with diplopia. The ophthalmoscopic appearances, and pupillary reaction, were normal, the field of vision being free. Under the use of disinfecting lo- tions and palliative measures, the case progressed favorably, and two months after the onset of the attack, a bony sequestrum was removed, and the patient was discharged cured two weeks later. In rare instances, the disease may develop from traumatic causes, as from a blow upon the nose, giving rise to a fracture of the vomer, or a sutural dislocation in the neighborhood of the ethmoid * Prag. Med. Wochenschrift, 1883, No. 20. ? Quoted by Berger and Tyrman, ‘‘ Die Krankheiten der Keilbein-Héhle und des Sieb- bein-Labyrinthes,"’ Wiesbaden, 1886, p. 14. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 481 plate, the inflammatory process attending the accident causing occlusion of the ostium ethmoidale, or possibly the disease may arise from an extension of the morbid lesion. In still rarer in- stances, the os planum itself, or the labyrinthine walls, may be fractured as the result of external injury. The ulcerative processes accompanying syphilis, tuberculosis, and possibly scrofula, may un- doubtedly give rise to a suppurative disease of the ethmoid cells, as stated by Berger and Tyrman,’ yet such cases do not constitute properly an attack of suppurative disease of the ethmoid sinuses, being simply an adventitious complication, the symptoms of which are entirely overshadowed by the graver disease, which has given rise to them. The well-known action of phosphorus on the bones of the face, would naturally suggest this as one of the causes of disease of the ethmoid cells. I am not aware that the ethmoid cells have ever been primarily attacked from this cause, although Scobell Savory? has reported the case of a young man who worked in phosphorus, and who died as the result of disease contracted therefrom, in whom the fost-mortem revealed the ethmoid bone almost com- pletely destroyed by the necrotic process, which also involved the sphenoid, and most of the facial bones. The development of nasal polypi, with its accompanying nasal obstruction, may give rise to ethmoid disease, in much the same manner as that described in connection with disease of the antrum, although the latter cavity is far more liable, I think, to be the site of suppurative disease from this cause. Woakes? endeavors to trace a very close connection between mucous polypi in the nose, and what he terms necrosing ethmoiditis, going so far as to state * that “the two pathological conditions run on side by side, experi- ence confirming, that when polypus exists necrosis is also present, but the converse position cannot be maintained, necrosis being demonstrable earlier, and occurring much more frequently, than does myxoma.” This remarkable statement I cannot indorse, as I regard ethmoid disease as one of the rarest complications of nasal polypi. Berger and Tyrman* mention facial erysipelas as a possible cause of the disease. There seems to be some question, however, whether in these cases the erysipelas be due to an acute rhinitis, or the acute rhinitis the result of erysipelas. Weichselbaum,,° after a 7 Op. cit., pp. 13 and 27. ? Med. Chirurgical Trans., 1874, vol. lvii., p. 187. 3 ‘‘ Nasal Polypus,” Amer. ed., Phila., 1887. 4 Op. cit., p. 23. 5 Op. cit., p. 13. 6 ‘* Phlegmonése Entztindung der Nebenhohlen der Nase.” Wr. Med. Jahrb., 1881, p- 227. 31 482 DISEASES OF THE NASAL PASSAGES. somewhat careful analysis of ten such cases, finds himself still in doubt as tothis point. In either case the ethmoid disease develops as the result of the nasal inflammation. We thus find, in the large majority of instances, the disease de- velops from causes in the nasal cavity. Occasionally, however, we find it occurring as the result of disease in the orbital cavity, as in the case reported by Vossius' in which the extraction of a molar tooth gave rise to a thrombosis of the accessory orbital veins, and the subsequent development of an abscess in the orbital cavity, which penetrated the os planum, and set up suppurative disease of the ethmoid. PaTHOLOGY.—The morbid process here develops in essentially the same manner as that already described in connection with dis- ease of the antrum. The hyperemia results in a sero-mucous ex- udation, which, owing to the fact that the cavity is closed, soon de- generates into a suppurative inflammation. The accumulation of pus soon follows, and distends the cells, while at the same time the inflammatory process in the mucous membrane, extending to its deep layers, which constitute the periosteum of the thin, bony walls, results in the development of a true periostitis. The necessary consequence of this is the early occurrence of necrosis and exfolia- tion of bone. We see, therefore, that the tendency in all cases, and the result in the large majority of instances, of a suppurative in- flammation of the ethmoid cells, is necrosis of bone, hence Woakes’s newly invented term of necrosing ethmoiditis, would seem to be scarcely called for, since all ethmoiditis tends toward, and usually develops sooner or later into, necrosis. SYMPTOMATOLOGY.—The earliest symptom of ethmoid disease is pain referable to the lower frontal region, and generally confined to one side. As the disease progresses, the pain increases in sever- ity, and may extend to the whole side of the face, but being most intense as a deep-seated orbital or frontal pain. The discharge of pus from the nasal cavity of the side affected, sets in early in the attack, and has a bright yellow color and laudable appearance. The pus discharge at first may be attended with the characteristic fetid hydrogen odor. If the flow becomes established, however, this disappears to a great extent, returning in the course of one or two months, with the development of necrosis, when it assumes the characteristic fetor of dead bone. Its character, also, is now changed, in that it may contain shreds of necrotic tissue, or the débris from the process of bony destruction. With the disten- tion of the cells from pus, a giving-way occurs on the side of least t ** Ein Fall von Orbitalphlegmone bei Thrombophlebitis der Orbitalvenen, etc.,” v. Grdafe’s Archiv, vol. xxx. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 483 resistance, which is toward the orbit, hence, a bulging of the eye of that side may occur very early in the disease, accompanied with functional symptoms attendant upon ocular dislocation, such as immobility of the eye, and imbairment of vision with diplopia. Allusion has already been made to the fact, that in a certain num- ber of cases, the direct connection between the exophthalmos and the pus discharge can be démonstrated, from the fact that pres- sure upon the eyeball causes a flow of pus into the nasal cavity. Febrile movement occurs early in the course of the disease, and shows the usual remittent type characteristic of pus formation, showing a daily variation of from one to two degrees, the evening exacerbation of fever rarely developing a temperature above 102°, while the morning temperature will not vary greatly from 100°. Chills or chilly sensations do not occur, except in connection with an unusual access of febrile movement. A pus discharge, although almost an invariable rule, is not always present, as ina case reported by Vernujne,’ a girl sixteen years of age, suffering from naso-pharyn- geal catarrh since she was five years of age, probably the result of scarlet fever, was attacked with the ordinary symptoms of ethmoid disease, with the exception of the purulent discharge. Vernujne made a diagnosis of retention cyst in the ethmoid cells, basing this ‘ conclusion on a somewhat similar case observed by Knapp,* in which a pus sac formed in the ethmoid, and crowding the os planum before it, presented at the inner canthus of the eye, apparently as an osteoma, which, however, upon being opened with a chisel was found to contain pus. DIAGNOSIS.—An examination of the nasal cavity will reveal a discharge of bright-yellow healthy pus, making its way from be- neath the middle turbinated body of the side affected, which always indicates the existence of suppurative disease of one of the acces- sory sinuses. The question to determine now is, which of these cavities is the source of the discharge. Ingals* makes the point, that in antrum disease, the pus flows down over the middle of the lower turbinated body, while in ethmoid disease, it is found on its posterior termination. This condition is not greatly to be depended upon, as whatever be the source of the discharge, if it is large in amount, it diffuses itself pretty generally over the whole of the lower turbinated body, and moreover, the direction of the flow would be determined somewhat by the position of the body. Nor is much information afforded by Frankel’s suggestion, already al- * Amer. Journal of Ophthalmology, 1884, vol. i.. No. 5, p. 129. ? Fifth Ophthalmological Congress, N. Y., 1876, p. 55. 3 ‘* Suppurative Inflammation of the Antrum,” Journal Amer. Med. Association, July 30th, 1887. . 484 DISEASES OF THE NASAL PASSAGES. luded to in the chapter on disease of the antrum, that by lowering the head, the flow is promoted from the antrum, while’ the erect position facilitates the discharge from the other sinuses. Our diag- nosis, then, must be made on the-co-exigtence of a pus discharge from beneath the middle turbinated body, in connection with deep- seated pain and exophthalmos, the latter symptom being the one which points most directly toward disease of the ethmoidal laby- rinth. Berger and Tyrman* mention emphysema of the orbit as occasionally present in these cases, its existence being due to necro- sis of the os planum. This condition can be recognized by the peculiar cracking sound produced by pressure on the eyeball. It would only exist, however, in connection with exophthalmos. PROGNOSIS.—The simple catarrhal disease of the ethmoid si- nuses, which usually occurs in connection with an attack of acute rhinitis, undergoes resolution in the large majority of instances with- out treatment. Suppurative disease, on the other hand, runs a de- cidedly chronic course, and shows little tendency to spontaneous resolution. While the disease confines itself to the ethmoid sinuses, it involves no serious danger to life, but in those rarer cases in which the diseased action extends to the cranial cavity, the prognosis be- comes exceedingly grave, and almost necessarily fatal. Probably in the majority of instances, where the disease extends to a neigh- boring cavity, the orbit is the part invaded. So marked is this, that the existence of an orbital abscess should in all cases suggest the existence of ethmoidal disease as its source, as in a case re- ported by Sonnenberg’ the pus discharge from the nose was not present, until after incision of the abscess in the orbit. Owing to their close and intimate anatomical relation, invasion of the sphe- noidal sinuses is a not infrequent complication of ethmoidal disease, although not one which can be recognized by any diagnostic signs. The suppurative disease confined to the ethmoid cavities, runs a somewhat slow course, and eventually leads to necrosis, which first involves the labyrinthine plates, which may undergo spontaneous expulsion, as in Hartmann’s case already cited, or may éxtend to the os planum, and the cribriform plate, and thus involve the neighbor- ing cavities. In either instance, the labyrinthine walls become subject to the process of caries, under which the destruction goes on very slowly, and the disease runs a course, which may be pro- longed into months or even years. TREATMENT.—The indications for the treatment of ethmoid disease are naturally the same as those in disease of the antrum. T Op. cit., p. 28. ? “Beitrag zur acuten Zellgewebs-Entziindungen der Augenhdhle,”’ Deutsche Zeit- schrift fir Chirurgie, 1877, vol. vii., p. 500. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 485 They consist essentially in thoroughly cleansing and disinfecting the nasal cavity, and subsequently in establishing proper drainage from the diseased sinuses. In most instances, probably, it will be necessary to resort to surgical interference, although occasionally it may be possible by simple measures, such as disinfecting sprays and douches in the nose, and the subsequent use of cocaine to con- tract the tissue, to so far open the nasal passages, and gain access to the normal orifice, as to facilitate the pus discharge, and estab- lish free drainage. Thus, in Hartmann’s case, already alluded to, this was the only measure of treatment applied. Unfortunately, such good fortune cannot always be anticipated, and hence more active measures are demanded in the majority of cases. These consist in establishing an artificial opening into the sinus. This opening must necessarily be made above the middle turbinated body, and hence is an exceedingly delicate and difficult manipula- tion. Ziem, who was the first to open these sinuses, advises that this should be done, after removing a portion of the middle turbi- nated bone, thus gaining a fregr access to the superior meatus, where the posterior ethmoidal cells are to be opened by means of a probe or injection needle carried obliquely along the junction of the bony and cartilaginous septum, upward and backward, and directly into the cells. Schech,’ recognizing the difficulty of gain- ing access to this region through the nostril, suggests that a freer manipulation, and a better view may be obtained, by splitting open the external nose. Ziem seems not to have been especially suc- cessful in his operation, and hence it seems to me, that if it becomes advisable to open the ethmoid cells, it should only be attempted after the external operation as suggested by Schech, although for this purpose, it would be wiser to tilt the nose to one side by means of Boeckel’s operation, or to drop it downward, after Ollier’s method, after which, the cavity being brought thoroughly ‘and widely into view, the cells may be opened by means of a probe or drill, and necrosed bone, if it be present, removed by the curette or gouge. It is only candid to state, however, in regard to this operation, that the literature of ethmoidal disease contains no cases which were treated with notable success in this manner. In most instances, the treatment has consisted in the persistent use of cleansing and disinfecting lotions, and the use of politzerization, after the manner of Hartmann or Ziem. Whenever complicating lesions manifest themselves, their treatment is to be directed by general surgical rules. .If orbital abscess occur, it is to be opened at the earliest moment, and efficient drainage established. * Op. cit., p. 284. 486 DISEASES OF THE NASAL PASSAGES. DISEASE OF THE SPHENOIDAL SINUSES. Simple catarrhal inflammation of the mucous membrane lining the sinuses of the sphenoid bone, occurs probably not infrequently as a complication of an acute rhinitis, as is the case with the other accessory sinuses. This, however, is not evidenced by any very marked symptoms, and may undergo resolution, with the subsidence of the nasal disorder. Suppurative disease in this region, however, constitutes an affection of very serious import, in that, as in the other sinuses, it manifests but little disposition to undergo a spon- taneous cure, but on the contrary gradually extends to the deep layers of the membrane and the periosteum, resulting in a bony necrosis. : ETIOLOGY.—The course and development of the morbid pro- cess here is much the same as we find it in the other accessory si- nuses, and probably arises primarily from obstruction of the ostium sphenoidale, resulting in a retention of secretion, with consequent suppurative inflammation. This obstruction may result from the encoachment of hypertrophic inflammation of the mucous mem- brane lining the nasal cavities, the existence of polypi or other tumors, the presence of foreign bodies, or some deformity of the nasal cavity, which acts to occlude the normal orifice. Zucker- kand1* raises the question, whether in some certain cases the necro- sis may not be primary, and the pus discharge a resultant symp- tom, although favoring the view that in the majority of instances the necrosis is the result of a morbid process in the mucous mem- brane. Schech* states that purulent accumulations in these sinuses have been observed in connection with cerebro-spinal meningitis, this complication resulting probably from contiguity of structure, or this may possibly serve to substantiate the recent view enter- tained in regard to spotted fever, that it is the result of a germ, taken into the system by inhalation through the nasal passages. Berger and Tyrman* enumerate among the causes of the disease, syphilis and scrofula, giving the former as its more frequent cause, although I am disposed to regard intra-nasal disorder, as already stated, as more liable to produce the disease. Zuccarini,‘ in an in- vestigation of the relation of facial erysipelas to typhus fever, has found sphenoidal disease in a post-mortem on one patient, in whom * “ Anatomie der Nasenhohle,” Wien, 1882, p. 174. ? ‘" Diseases of the Mouth, Throat, and Nose,” Eng. ed., Edinburgh, 1886, p. 280. 3 “Die Krankheiten der Keilbein-Hohle und des Siebbein-Labyrinthes,” etc., p. 22. 4 “Gesichtsrothlauf in Verlaufe des Typhus,” Wien. Med. Wochenschr., 1853. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 487 these two affections co-existed. A similar case has come under the observation of Weichselbaum.* PaTHOLOGY.—The pathological changes which take place in the mucous membrane of these sinuses, consist essentially in a catar- rhal inflammation, gradually extending to the deeper tissues, which here constitute the periosteum, as the result of which, the nutrition of bone is so far interfered with, that necrosis occurs in precisely a'‘similar manner to that already described in the discussion of ethmoidal disease, the simple catarrhal inflammation being converted into a suppurative process, as the result of obstruction to the ori- fice, and resultant accumulation of the secretions. Hence, we can easily see how, as noted by Ziem,? the anatomical situation of the orifices of the sphenoidal sinuses and the antrum, favor the devel- opment of suppurative inflammation, being situated on the lateral wall of the sinus, thus differing from the ethmoidal and frontal sinuses, whose orifices admit of freer drainage, while Zuckerkandl? singles out the ostium sphenoidale, as being located in a manner particularly unfavorable to the free escape of accumulated secre- tions. ' SYMPTOMATOLOGY.—More or less profuse purulent discharge from the nasal cavity is a prominent symptom of the disease, this pus being the same bright-yellow healthy pus which is characteris- tic of suppurative disease of all of the accessory sinuses. The dis- charge makes its way backward, asa rule, dropping into the pharynx. Lennox Browne‘ makes the statement that “ sphenoidal discharges may be the forerunner, and possibly the excitant, of obstinate post- nasal catarrh.’”’ This is scarcely a correct observation. Certainly the discharge excites no morbid condition in the mucous membrane over which it passes, and moreover, a pus secretion does not occur in what is ordinarily termed a post-nasal catarrh. Deep-seated pain is always present, referable to the side affected, and in some cases may be of a most distressing character, radiating through the whole side of the face, involving all the branches of the trigeminus, as-in a case observed by Rouge,’ the dental branches of the superior maxillary nerve became the seat of a neuralgia of so intense a na- ture, as to lead Rouge to make a diagnosis of disease of the antrum, for which he performed resection, the death of the patient occur- ring soon afterward. An autopsy revealed an accumulation of cheesy pus in the sphenoidal sinuses, while the maxillary sinus was * Wien. Med. Jahrbuch, 1881. * Monatsschr. fiir Ohrenheilkunde, 1886, No. 3, p. 82. 3 Op. cit., p. 173. 4“*The Throat and its Diseases,” London, 1887, p. 529. 5 Cited by Berger and Tyrman, op. cit., p. 23. 488 DISEASES OF THE NASAL PASSAGES. perfectly healthy. Owing to the proximity of the sphenoidal sinuses to the optic foramina, ocular symptoms might naturally be expected, and hence impairment of vision or complete blindness may occur, as the result of pressure on the optic nerve; as, in the case reported by Horner’ of a girl fifteen years of age, who, after having complained of headache for some time, suddenly became blind in the right eye; at the same time there was exophthalmos and im- mobility of the eyeball; the ophthalmoscopic examination showed slight swelling of the optic nerve; there was no swelling of the eye- lids. Two months after the blindness came on, the patient died of meningitis. The autopsy showed necrosis of the sphenoidal sinuses. The changes were most marked about the right optic foramen. The cellular tissue of the orbit was infiltrated with serum. A similar case reported by Post? presents the additional point of interest, in the ultimate recovery of the patient, who in the course of the disease developed both exophthalmos and amaurosis, de- pendent upon necrosis of the lesser wing of the sphenoid. Extrac- tion of the sequestrum was followed by a return of the eye to its normal position, but the amaurosis was not relieved. ‘The exoph- thalmos in this case may have been due to serous exudation, caused by obstruction to the return circulation, by pressure on the orbital veins in their passage through the sphenoidal fissure as in Horner’s case, or the diseased process of the body of the sphenoid may have extended to the great wings, where they form a portion of the outer and superior wall of the orbit, thus leading to the develop- ment of an orbital abscess, and resultant protrusion of the eye as in the case reported by Panas? where, as the result of an ostitis of the sphenoid, sudden blindness set in, followed by the development of an abscess in the orbit. The notable symptoms then, we find, are a pus discharge with pain, followed, as the disease progresses, by a somewhat sudden occurrence of blindness, and in a certain pro- portion of cases the development of orbital abscess, or serous exu- dation into the cellular tissue of the orbit. Berger‘ calls attention to a peculiar feature of the amaurosis occurring in connection with cases of sphenoidal disease, in that the peripheral field of vision is invaded before the central field is affected. This is explained by the fact, as first observed by Samel- sohn, that the central fibres of the optic nerve are distributed to the macula lutea, while the peripheral fibres are distributed to the outer portion of the retina. 1 Klin. Monatsbl. f. Augenh., Febr., 1863. ° London Lancet, May 6th, 1882, p. 734. 3 Gaz. des Hépitaux, 1873, p. 1148. 4 Revue Mensuelle de Laryngologie, July, 1888, p. 400. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 489 Diacnosis.—A diagnosis of suppurative disease of one of the accessory sinuses having been established by the existence of a discharge of bright-yellow healthy pus from one of the nasal pas- sages, the attention would necessarily be directed toward the sphe- noidal sinus as the seat of the disease, by the fact of the pus pour- ing over the surface of the middle turbinated bone, and that its source can be traced to the superior meatus, provided the nasal passages are sufficiently patulous to admit of a thorough explora- tion. It should be stated, however, that this nice localization of a purulent discharge in this region is very rarely possible by an ex- amination anteriorly, although it may occasionally be accomplished by posterior rhinoscopy. In those cases of ethmoidal disease in which the posterior group of cells is involved, we may also have a pus discharge into the superior meatus. In these cases, the recog- nition of the disease will necessarily be based on a consideration of concomitant symptoms, although it should be stated, that proba- bly, in the majority of cases in which the posterior group of eth- moidal cells is the seat of the disease, the sphenoidal sinuses are involved in the same morbid process, owing to their close anatomi- cal relation, and the fact that the orifices both of the sphenoidal and posterior ethmoidal cells open together into the superior mea- tus, and hence the same causes which would operate to produce suppurative disease in one group, would act equally on the other. The pus discharge makes its way into the pharynx, giving rise to symptoms of ordinary so-called naso-pharyngeal catarrh, although the character of the secretion differs essentially from the ordinary inspissated mucus which is found in the pharyngeal vault in that dis- ease. Suppurative inflammation of the pharyngeal bursa, the so- called Tornwaldt’s disease, gives rise to a pus discharge into the pharyngeal vault. This affection, however, I regard as an exceed- ingly rare one, and furthermore, a rhinoscopic examination should easily establish the source of the purulent secretion. Ziem* has re- ported a rather interesting case, in which a somewhat profuse puru- lent discharge into both the pharyngeal vault and the nasal cavities, had its origin ina cyst of the pharyngeal bursa, the removal of which seemed for a while to arrest the disease, although subsequently it be- came necessary to open the antrum, on account of suppurative in- flammation of that cavity. Further diagnostic signs pointing to sphe- noidal disease, consist of deep-seated pain, exophthalmos, paralysis of the optic nerve, or paresis of any of the motor nerves passing through the sphenoidal fissure. The deep-seated pain is characteristic both of sphenoidal and ethmoidal disease, and presents no points espe- cially indicative of either affection. Exophthalmos is present in a * Monatsschr. f. Ohrenheilkunde, 1886, Nos. 2, 3, and 4. 490 DISEASES OF THE NASAL PASSAGES. large proportion of cases, but is probably not so constant a symp- tom of this affection, as of ethmoidal disease. One of the earliest effects of distention of the sphenoidal sinus by pus, would be pres- sure on the optic nerve, in its passage through the optic foramen, hence the sudden onset of amaurosis occurs in probably a large proportion of cases. An examination by the ophthalmoscope in these cases should reveal the characteristic swollen disc. Still fur- ther diagnostic indications are furnished by the results of pressure on the nerves passing through the sphenoidal fissure, causing ptosis, strabismus, or immobility of the eyeball. COURSE AND PROGNOSIS.—The prognosis of these cases, as a rule, is grave, as owing to the depth and inaccessibility of the parts affected, and the difficulty of reaching them with proper remedial measures, suppurative inflammation sooner or later leads to a ne- crosis of bone, which extending slowly, invades the orbital cavity, producing paralysis of the optic nerve. Death may occur as the result of meningitis as in Horner’s case, or as the result of invasion of the cavernous sinus by an erosion of its wall, as in the case re- ported by Scholz* whose patient, twenty-one years old, suffered from delirium tremens, developing facial phlegmon, subsequently going on to abscess of the cheek. After several days, there was a discharge of pus into the mouth, behind the last upper molar tooth. The patient suffered from frequent rigors. Ten days after the be- ginning of the illness, there were spasmodic contractions of the extremities, with coma; about twenty-four hours after, left-sided ptosis; on the evening of the same day, there was profuse hemor- rhage from the mouth and nose, of which the patient died. The autopsy showed the cause of death to be an erosion of the cavern- ous sinus, and a destruction of the bony substance of the body of the sphenoid on the right side, thus establishing direct communi- cation between the sphenoidal cells and the cavernous sinus. In this case, the primary seat of the disease was in the sphenoidal cells, Blachey? and Lloyd, as cited by Berger and Tyrman,} re- port cases of thrombosis of the circular and cavernous sinus and of the ophthalmic veins. A somewhat unique case is reported by Baratoux,‘ in which nature effected a cure by the spontaneous ex- pulsion of the whole body of the sphenoid through the nose, the singular feature of the case being, that during the course of the disease, there were no symptoms of meningeal irritation or impair- ment of vision. TREATMENT.—The same palliative measures are indicated here, * Berlin. Klin. Wochenschr., 1872, No. 43, p. 516. 2 Gaz. Hebd., 1863, «., p. 44. 3 Op. cit., p. 26. 4 Progrés Médicale, 1883, p. 826. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 491 as noted in the directions for treatment of ethmoidal and antral disease. These consist in the use of cleansing and disinfecting sprays and washes, together with politzerization, either anteriorly, or posteriorly according to Ziem’s method. These should be used frequently and with every thoroughness, in order to secure as effi- cient drainage of the diseased cavity as is possible in this manner. The indications for the radical treatment of the disease consist simply in opening the cavity for the discharge of pus in its early stages, and the removal of necrosed bone where feasible, in its later development. Zuckerkandl* advises the opening of the sphenoi- dal sinus through the nasal cavity, at its anterior and dependent portion, whereby the most efficient drainage may be secured. He directs that the trocar shall be introduced along the septum, pass- ing upward and backward, across the middle turbinated bone, about at the junction of its posterior and middle third, until it reaches the anterior wall of the sphenoid cells, when it is pushed directly into the cavity. Zuckerkandl’s advice is based entirely on anatomical study of the cadaver. The first to perform Zucker- kandl’s operation on the living subject was Schaffer * who succeeded in opening the sphenoidal cells, making use of a spoon-shaped in- strument instead of the trocar, by means of which he also removed small fragments of necrosed bone. It is scarcely necessary to state that this operation demands not only a high degree of manipula- tive dexterity, but also exceeding great care, as it is not unattended with a certain amount of risk of entering the cranial cavity. Indeed so great is this danger that Schech? regards the operation as unad- visable, preferring to approach the cavity through the vault of the pharynx, making his opening through the lower plate of the body ~ of the sphenoid, just behind the border of the posterior nares. In this connection, Schech refers to a case reported by Stoerk, which seems to favor this point of operation, where a spontaneous open- ing at this point occurred in the case of a scrofulous boy, suffering from sphenoidal disease. Bronner,* however, reports a successful case in which the sphenoidal cells were scraped out by means of a sharp spoon, necrosis having been detected by means of the probe. The entire procedure was accomplished by manipulation through the nasal cavity. The case is a notable one, if we accept the cor- rectness of Bronner’s diagnosis, and yet I think this is open to very serious question, in that it would be almost impossible in most cases to absolutely localize the sphenoidal sinuses, by a probe intro- 7 Op. cit., p. 174. ? ““Chirurgische Erfahrungen in der Rhinologie und Laryngologie ;*" Wiesbaden, 1885, p. 4. 3 Op. cit., p. 284. 4 Medical Press and Circular, April th, 1888, p. 343. 492 DISEASES OF THE NASAL PASSAGES. duced through the nostrils, or to intelligently manipulate a curette in this manner. After an opening has been established, the further treatment of the disease consists in daily washing out the cavity, by means of cleansing and disinfecting lotions, while at the same time the patency of the orifice is maintained by proper means. If bony necrosis is found to exist, it should be removed as far as pos- sible, under the general rules of ordinary surgical procedure. If this is limited in extent, a small curette through the artificial open- ing would probably accomplish all that is required. If, however, ‘the necrosis has extended to the body and wing of the sphenoid, its removal can only be accomplished by access through the orbit. DISEASE OF THE FRONTAL SINUSES. While simple catarhal inflammation of the mucous membrane of the frontal sinuses, occurs in connection with a cold in the head, more frequently than that of any of the other accessory cavities, suppurative inflammation, on the other hand, is one of the rarest occurrences. This is probably due to the fact, that the infundib- ulum opens from the most dependent portion of the cavity, thus affording free drainage, while, at the same time, it is probably less liable to become firmly occluded. We find, then, here an acces- sory sinus, in which the anatomical conditions favoring the devel- opment of suppurative disease are absent. Thus Zuckerkandl* states that he has never met with a single instance of uncompli- cated disease of this sinus. ETIOLOGY,—The disease may arise as the result of any condi- tion causing occlusion of the orifice of the sinus, such as hyper- trophic rhinitis, deflection of the septum, the presence of tumors in the nasal cavity, or any other obstructive lesion in the nasal pas- sages. This, however, is a exceedingly rare event. Far more active agents in the production of the disease are traumatism, mag- gots in the nose, gonorrhea, syphilis, scrofula, disease of the eth- moidal sinus, or the development of tumors within the sinus itself. PAaTHOLOGY.—The changes which take place in the membrane, consist briefly in hyperemia, with hyper-secretion, which, as the result of retention, gradually changes into a suppurative process, and in connection with this, the morbid process gradually invades the whole thickness of the mucous membrane, causing marked tumefaction with resultant periostitis, and the development of ex- ostoses or bony plates. In fact, the pathology of disease of the frontal sinus differs in no respect from that of disease of the an- trum already described. * ** Anatomie der Nasenhdhle,” Vienna, 1882, p. 168. DISEASES OF THE ACCESSCRY SINUSES OF THE NOSE. 493 SYMPTOMATOLOGY.—The earliest symptoms which should di- rect attention to a diseased condition of these sinuses, is frontal headache, which may develop into pain of an exceedingly distress- ing character, increasing as the accumulated secretions gather and distend the sinus. A certain amount of relief is gained with the escape of pus, which flowing into the nasal cavity, is discharged through the nose. It is bright yellow, and at first is exceedingly offensive in character. As the flow becomes established, however, the fetor in a measure disappears. The headache is usually per- sistent, although occasionally it may assume an intermittent type. It is increased by mental effort, or the use of alcohol, and at times assumes the character of sick headache, being attended with nau- sea and vomiting. If the pus accumulation in the sinus is large, and its exit obstructed, the roof of the orbit may be so far crowded downward as to produce displacement of the eyeball with diplopia or amaurosis. At the same time, the anterioir wall of the cavity may be so far displaced as to produce notable facial deformity. If the posterior wall of the sinus is displaced, it will be indicated by symptoms referable to the brain, such as dulness or apathy, with increased headache, or sleepiness. The brain symptoms, however, are very apt to be obscure, as is usually the case when pressure occurs on the anterior lobes, although Otto, as quoted by Schech* cites a case where displacement of the posterior wall of the sinus gave rise to unilateral paralysis. If the disease goes on so far as to produce erosion of the posterior wall, with the escape of pus into the brain cavity, the ordinary symptoms of meningitis super- vene; on the other hand, a cerebral abscess may develop without perforation of the bony wall of the sinus. In the same way, ero- sion of the roof of the orbit may occur, resulting in the escape of pus, and the development of an abscess inthis cavity. In this con- nection it should be borne in mind, as stated by Zuckerkandl,’ that a congenital defect occasionally occurs in the development of the bones of the orbit, by which a permanent opening exists in this plate, through which pus from the frontal sinus may make its way into the orbital cavity, without erosion or necrosis. D1aGNosiIs.—The history of the case will often afford diagnos- tic points, leading to the suspicion of the existence of frontal dis- ease, as gonorrhcea, maggots, syphilis, etc. The pus discharge presents the ordinary characteristics of disease of the accessory sinuses, and makes its appearance in the nasal cavity as a bright- yellow healthy pus, flowing over the middle turbinated bone rather nearer the anterior extremity, and is discharged usually through t “ Diseases of the Mouth, Throat, and Nose,” Eng, ed,, Edinburgh, 1886, p. 279. ? Op. cit., p. 168. 494 , DISEASES OF THE NASAL PASSAGES. the nostril. In connection with this the diagnosis usually should be fairly well established, by the existence of frontal pain, tender- ness upon pressure. possible dulness on percussion, as compared with the opposite side, and if distention occurs, the gross eviden- ces of the disease as shown by external deformity, or displacement of the orbital plate. PROGNOSIS.—Simple catarrhal inflammation of the frontal sinus usually undergoes resolution spontaneously. In suppurative dis- ease, this tendency is not remarkable, and, although the prognosis is rarely grave where the disease is uncomplicated, its course is somewhat lengthened and tedious, unless arrested by proper reme- dial measures. Its tendency is not toward the development of necrosis, but to the accumulation of pus in the sinus, with disten- tion and encroachment upon neighboring cavities, as in the follow- ing case reported by Knapp’: A woman, aged 30, had suffered for two years from headaches of a more or less violent character, in which the pain seemed to centre itself about the root of the nose at times. Six days before Dr. Knapp saw her, she was seized with achill, which was followed by a slight swelling of the upper eyelid, with pro- trusion of theeye. On examination the outer half of the supraorbital margin was red, swollen, and painful on pressure, and the swelling was close to the bone. Ophthalmoscopic examination showed slight cedema and congestion of the papilla. A diagnosis of incipient abscess was made. Two days later, the abscess had become very large, and was opened at the junction of the outer and middle thirds of the upper lid. The wound discharged for a few days, and the symptoms apparently disappeared. Six days after the operation, she was quite suddenly seized with headache, and became very weak, followed by vomiting, stupor, and slow pulse (50-60). These symptoms continued for several days, and the patient finally died of cerebral abscess of the left frontal lobe. On the post-mortem examination, the convolutions of the left frontal lobe were flattened; there was some discoloration of the base of this lobe, and the dura mater was adherent for an area of one cubic centimetre. The dura was not perforated. There was discoloration of the cerebral surface of the or- bital roof at the point of adherence of the dura mater, and over an area of one cubic centimetre on the anterior and inner roof of the orbit. The bone was necrotic at this point and a probe could be passed through it into the frontal sinus. The frontal sinus was dilated, and both the frontal and ethmoidal sinuses were filled with pus. The cerebral abscess probably developed from the patch of necrosed bone already described. It will be noticed in this case, that there was no purulentdischarge from the nasal cavity, which would indicate that a complete closure of the infundibilum existed, a condition which prob- ably had much to do in causing the invasion of the cerebral cavity. Still another case was seen by Knapp,? which presents points of interest, as follows: * “Contribution to the Pathology of the Frontal Sinus,” Archives of Ophthalmology, vol. ix., No. 2, 1880. 2 Loc. cit. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 495 A man, aged 30, presented with the history of having suffered from a tumor the size of a walnut which had existed at the inner angle of the eye, for about six years, and which had latterly given rise to a slight exophthalmos. The growth was accompanied with considerable pain, and varied notably in size at different periods of time, each temporary swelling being accompanied by an exacerbation of pain. When seen by Knapp, there had been an exacerbation -of all the symptoms for three months. An incision of the tumor showed it to be an abscess, after the evacuation of which, it was found that both the frontal sinus and ethmoidal cells were involved, and furthermore, that there was poly- poid degeneration of the lining mucous membrane, the removal of which re- sulted in a complete cure at the end of three weeks. In two cases reported by Pettesohn,' nasal discharge had been a symptom for some time. There was a tumor at the supra-nasal angle of the orbit, and cedema of the upper lid. Both cases were cured by incision. TREATMENT.—The primary treatment of the affection consists in the use of cleansing disinfectant lotions, in the nasal cavity, by means of the syringe or atomizer, in order to remove such secre- tions as may lodge in this region, and at the same time establish, as far as possible, free drainage through the normal opening. This, however, in many cases fails to accomplish all that is desired, and hence it becomes necessary to make an artificial opening into the sinus through the bony walls, of a sufficient size and accessibility as to admit of their thorough cleansing, and at the same time se- cure free drainage. ‘The point usually selected for this operation is immediately below the eyebrow, and near the bridge of the nose, where an incision having been made through the integument, the periosteum is elevated, and subsequently the perforation made into the frontal sinus by means of a drill, trocar, or trephine. In this manner, the opening is made as nearly as possible in the dependent portion of the cavity. Where an orbital abscess exists, of course the first indication isto open this by free incision, after which an explora- - tion with a probe would reveal, in most cases, an already existing perforation of the orbital plate, and in those rare instances in which no opening exists here, the bone will be found to be in a condition which will easily admit of perforation. The opening here must be made sufficiently large to give free access to the sinus. It would seem that, even where no orbital abscess exists, we have at the upper and inner angle of the orbit, just within the supraorbital ridge, a site which might well be chosen for an artificial opening, in that the bony plate is quite thin, and the cavity would be surely and thoroughly opened, and furthermore, the resulting cicatrix would be less noticeable. Where the infundibulum is obstructed, it is a matter of considerable importance, even after the artificial opening t “Centralblatt fir prakt. Augenheilkunde,” Feb., 1888. 496 ° DISEASES OF THE NASAL PASSAGES. into the frontal sinus has been established, to reopen also the nor- mal orifice, in order that proper through-and-through drainage may be secured. Schech’ advises the dilatation of the normal orifice by means of a probe passed through the artificial opening, after opening the frontal sinus, and if necessary the forcible passage of a trocar through into the nasal cavity, and the insertion of a drainage tube into the opening thus made. Such a procedure, however, would rarely be necessary. After access has been gained to the sinus, thorough exploration should be made with a probe, which should reveal the presence of necrosis or tumors, and further- more, would make known the involvement of the neighboring sinuses if such exist. Thus, in a case which came under the obser- vation of Welge,? the nose, orbit, antrum of Highmore, and the frontal and ethmoidal sinuses were all thrown into one cavity, so widely had the diseased process extended, as the result, apparently, of a primary disease of the ethmoidal labyrinth. , In some cases it would seem that the disease may be cured by the removal of such obstructing lesion as may be found in the nasal cavity ; thus Schmiegelow? has reported a case of suppurative disease of the frontal sinuses, cured by the removal of nasal polypi. Seiss* goes so far as to state that in the majority of cases the dis- ease can be controlled by “pinning down” the swollen tissues in the nasal cavity which occlude the normal orifice, using applications of chromic acid, after the manner described in Chapter IX. While not indorsing so broad a statement, I am yet disposed to think that much can be accomplished by measures of this character, and yet I think that the statement is fully justified, in cases such as Schmiegelow’s, and those referred to by Seiss, that there may have been a possible error in diagnosis, for in any given case of suppu- rative disease of one of the accessory sinuses, which is dependent upon some intra-nasal lesion, and which is cured by the removal of that lesion, I doubt very much whether it is possible in every case to determine with certainty, which of the accessory sinuses is in- volved. As stated in discussing the subject of disease of the an- trum, I believe that suppurative disease is set up in this cavity, as the result of a morbid process in the nasal cavity, far more fre- quently than in any of the other accessory sinuses. DIFFERENTIAL DIAGNOSIS BETWEEN DISEASE OF THE ACCES- SORY CAVITIES. While the recognition of suppurative disease of one of the acces- sory sinuses of the nose is comparatively an easy matter, the de- t Op. cit., p. 284. 2 ** Diss. de Morbo Sin. Frontal.,” Gottingen, 1786. 3 Hospitalstidende, Feb., 1888. 4 Phil. Med. News, January 5th, 188g. DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 497 termination of which cavity is affected is often involved in consid- erable obscurity, and hence it would seem not out of place, to group together here the different symptoms, with their special diagnostic significance. A pus discharge from the nose is characteristic of disease of all the sinuses, excluding those exceptional cases in which the normal orifice is completely occluded, in which case the abscess is forced, as it were, into neighboring regions, such as the orbital or cranial cavity. Inantral and frontal disease, and in disease of the anterior ethmoidal cells, the pus makes its way anteriorly, and is discharged from the nostril, while in disease of the posterior ethmoidal and the sphenoidal sinuses, it makes its way into the pharynx. In an- tral disease, the discharge is intermittent, and shows a certain de- gree of periodicity. In disease of the other cavities it is usually continuous. Inclining the head well forward, or lying on the un- affected side, favors a discharge from the antrum, while the upright position favors a discharge from the other sinuses. Unilateral pain is present in all the affections. In antral disease, this is most marked in the region of the cheek-bone and teeth. In frontal disease, it becomes a frontal headache, while in the ethmoi- dal and sphenoidal affections, it is more deep-seated, and locates -itself at the roof of the orbit. Exophthalmos is the rule in ethmoidal disease, but also is met with somewhat frequently in connection with disease of the sphe- noidal sinuses. It is exceedingly rare in connection with disease of the antrum, and only occurs where the abscess ruptures into the orbit. In frontal disease, bulging of the orbital plates is not a rare event, but in this case the eye is apt to be crowded downward and outward, so that the eyeball is not protruded to the same extent as is liable to occur in ethmoidal disease. Diplopia, when present, is the result of displacement of the eyeball, and therefore consti- tutes a diagnostic sign of no additional value. Sudden blindness is due to pressure on the optic nerve as it passes through the optic foramen and is, therefore, only met with as a symptom in connection with sphenoidal disease; although, as Ziem has shown, the field of vision may be narrowed in disease of the antrum. Ptosis is the result of pressure on the third nerve as it passes through the sphenoidal fissure. This also, therefore, would point to involvement of the sphenoidal labyrinth. Strabismus would be occasioned by a certain differentiation of the pressure on the nerves passing through the sphenoidal fissure, and would also indicate the existence of sphenoidal disease. Facial neuralgia may occur in connection with disease of any of 32 498 DISEASES OF THE NASAL PASSAGES. the sinuses, although it is most constantly met with in disease of the antrum, less frequently in connection with sphenoidal disease, and with the greatest rarity in connection with ethmoidal and frontal disease. Fetor is present in a very mild degree in disease of all the si- nuses, and may possess a certain amount of intermittency as sug- gested by Luc,’ thus pointing more directly to disease of the antrum, in that the fetor probably attends the escape of pus after a temporary retention. The frequency with which the different sinuses are affected with suppurative disease, affords a certain amount of aid in diag- nosis. Antral disease is by far the most frequently met with, while in the order stated the disease is less frequent in the ethmoid and sphenoid sinuses, while suppurative disease of the frontal sinus is the rarest of all. 7 Jour. de Méd. de Paris, 1887. Section II, Diseases oF THE Naso-Puarynx DISEASES OF THE NASO-PHARYNX CHAPTER XXXIX. THE ANATOMY AND PHYSIOLOGY OF THE NASO- PHARYNX. THAT space which lies behind the posterior nares and the oral cavity, and which extends from the basilar process of the occipital bone to the upper border of the larynx, has usually been described, in works on anatomy, as constituting a single cavity, under the name of the pharynx. Writing on this subject some years since,’ I urged that, from a physiological point of view, this space should be regarded as consisting of two separate and distinct cavities, the upper pharynx and the lower pharynx, or using perhaps a better designation, the naso-pharynx and the oro-pharynx, in that the former belongs to the air tract with certain somewhat adventitious functions perhaps connected with the food tract, while the latter belongs essentially to the food tract, both physiologically and in its anatomical construction, its connection with the air tract being purely adventitious. The upper space has been designated, some- ‘what indifferently, as the upper pharynx, the vault of the pharynx, the post-nasal space, and the naso-pharynx. In our consideration of the subject, I prefer the use of the term naso-pharynx, as more clearly defining the region under discussion. ANATOMY OF THE NASO-PHARYNX. This cavity consists of a somewhat quadrilateral-shaped space, lying immediately behind the posterior nares, and bounded as fol- lows: Its roof is formed by the basilar process of the occipitay bone, together with a small part of the posterior portion of the body of the sphenoid, while it terminates below in an imaginary plane opposite the border of the palate. The posterior wall is formed by the spinal column, the prominence of the arch of the ™N. Y. Med. Record. Nov. 6th, 1880, 502 DISEASES OF THE NASO-PHARYNX. atlas being often recognized at about the point where the vertex of the palatal arch in contraction impinges upon the pharyngeal wall. From this upward, the wall curves forward. The anterior boundary is formed by the two oval openings of the posterior nares, together with the posterior border of the vomer or septum, which presents a somewhat sharp edge below at its articulation with the hard palate, but expands somewhat above, to articulate with the rostrum of the sphenoid. Each lateral wall is marked by the open- ing of the pharyngeal orifice of the Eustachian tube, which presents as a somewhat elongated or ovoid funnel-shaped orifice, or as Roosa: describes it, ‘a trumpet-shaped orifice, nine millimeters high and five millimetres broad.” The opening of the tube is par- tially surrounded by a well-defined cartilaginous ridge, which is mainly formed by a projection of the cartilage which enters into the formation of the tube proper. This eminence is very well marked posteriorly and above, while anteriorly is it less prominent, and immediately below the orifice it is absent. As the mucous membrane is reflected over this cartilaginous ridge or cushion of the Eustachian orifice as it is usually termed, it is thrown into a fold, as it passes from the lower termination of the posterior sec- tion of the ridge to the pharynx below, forming what has been designated by Luschka as the plica salpingo-pharyngea, while by - its reflection from the anterior portion of the ridge a less prominent fold is formed, which extends from the anterior border of the tube to the soft palate. This is called by Luschka the plica salpingo- palatina. Immediately behind the Eustachian orifice, and lying between the cartilaginous cushion and the posterior wall of the pharynx, is noticed an elongated depression, the fossa of Rosen- miiller. This fossa varies somewhat in shape and depth in differ- ent subjects, although it is usually elongated, and much broader above than below, and is mainly of interest in that in introducing a Eustachian catheter, its point is usually first engaged in this de- pression. While at rest, the Eustachian orifice is closed, and is only opened as the result of muscular contraction in the various functional movements of the fauces. The muscle which acts most prominently as a dilator of the tube, is the tensor palati muscle, or as it is gerierally named by otologists, the spheno-salpingo staphylinus, or the dilator tube. It arises from the base of the internal pterygoid plate of the sphe- noid bone and the scaphoid fossa, and from the cartilaginous por- tion of the Eustachian tube throughout its whole length. It then passes downward, forward, and inward, and winds around the ham- ular process of the sphenoid, and is inserted into the soft palate. 1 “Dis, of the Ear,” 3d ed., 1876, p. 209. ANATOMY AND PHYSIOLOGY OF THE NASO-PHARYNX. 503 It enlarges the calibre of the tube by drawing its anterior cartila- ginous margin downward and forward. The levator palati, whose action is less marked than the action of the former in opening the Eustachian tube, and yet undoubtedly possessing a certain function in this direction, is along, rounded, muscle, arising from the petrous portion of the temporal bone, and from the cartilaginous portion of the tube, from which, passing downward and inward, it spreads out into a broad tendon, and is inserted with its fellow into the median line of the soft palate, the fibres blending with the mucous membrane of this structure. By its contraction, it lifts, as it were, the lower édge of the collapsed tube into such a position, that its lateral walls separate, and the lumen becomes patulous. The palato-pharnygeus, which arises from the soft palate, the posterior portion of the hard palate, and from the cartilaginous portion of the Eustachian tube, passes downward to the thyroid cartilage, some of the fibres blending with the corresponding mus- cle of the opposite side. Its action is to fix the cartilaginous por- tion of the tube to which it is attached, and thus aid the action of the levator palati. The orifice of the Eustachian tube is usually described as open- ing into the anterior and lower portion of the lateral wall of the naso-pharynx, opposite the posterior termination of the lower tur- binated bone, from which it is distant about three-eighths of an inch, while its average distance from the nostril is, according to Luschka,? two and three-quarters inches, although, according to Mackenzie,’ the distance is three and one-fifth inches. Kostonecki,? however, has shown, that there are very great variations in the locality of this orifice, as regards its vertical position, in that in many cases it is found much higher in the lateral wall of the pharynx than in others. This fact, however, is constantly brought to the notice of otologists in passing the Eustachian catheter, in that in many cases the tip must be carried well upward, in order to engage in the tubal orifice. The cavity of the upper pharynx differs greatly in different individuals, without reference to their physical development. Luschka’s measurements, however, are as follows: its vertical and antero-posterior measurements are about the same, viz., three- quarters of an inch, while its width is about one and three-eighths inches. The fibrous basement structure of the naso-pharynx con- sists of a thick aponeurosis, which has its attachment to the basi- * “Der Schlundkopf des Menschen,” Tubingen, 1868. . ? “Diseases of the Throat and Nose,” Phila,, 1884, vol. i., p. 18. 3 Arch, fiir Mik. Anat., 1887, vol. xxix., p. 539. 504 DISEASES OF THE NASO-PHARYNX. lar process of the occipital bone, and the petrous portion of the temporal. Beneath this tissue are found certain muscular struc- tures, involved in the movements and support of the head. Its internal surface is lined with mucous membrane, which differs in no essential features from the mucous membrane of the respiratory tract. It is richly endowed with mucous glands, both the tubular and racemose varieties, while its epithelial surface is covered with columnar ciliated epithelium. That however, which gives the pharyngeal vault an especial interest, and also endows it with certain important functions, is the crowding together of a large number of glands into a distinct mass, in the upper and central portion of the cavity, constituting what is known as the pharyngeal tonsil, or the third tonsil, and sometimes called Luschka’s tonsil, in that this writer first gave us a complete anatomical description of it, although according to Cohen’ the mass was recognized and dissected by William Hunter in the last century. I find, however, no record of this in any of Hunter’s writings. According to Luschka,’ there is always present in this region, although in varying degrees of development, a soft mass of tissue, of about one-quarter of an inch. in thickness, spread over the roof and posterior wall of the naso-pharynx, covering the whole extent of the basilar process of the occipital bone. It extends the whole width of the pharynx, to the fosse of Rosenmiiller, and even encroaches upon the cartilaginous eminences surrounding the Eustachian tube. The gross appearance of this mass of glands varies somewhat, presenting occasionally a soft cushion-like outline covered with small rounded elevations, while in others it is trav- ersed by fissures in various directions. -The most constant appear- ance, however, and that seen in the largest majority of cases, is that in which the mass is traversed longitudinally by a series of fissures or indentations, of perhaps a quarter of an inch in depth, with a slight disposition to branch, asit were, giving rise to a sort of crow’s-foot appearance on the surface. (See Figs. 121,122.) At the lower portion of the pharyngeal tonsil, in the median line, Luschka describes an opening, about the size of the head of a pin, some- times larger, sometimes smaller. This opening leads into a small sac, about three-quarters of an inch long, and a quarter of an inch wide, to which Luschka gave the name bursa pharyngea, a term already used by J. O. Meyer,? to describe a similar anatomical con- dition found in the pharynges of certain of the mammalia, in that this sac formed a bursa between the adenoid tissue already de- * “Diseases of the Throat and Nasal Passages,” Phila., 1879, p. 253. 2 Op. cit. 3 “* Neue Untersuchungen auf dem Gebiete der Anat. und Physiologie,” Bonn, 1842. ANATOMY AND PHYSIOLOGY OF THE NASO-PHARYNX. 505 scribed, and the basilar process of the occipital bone. The anterior wall of this cavity is lined with glandular tissue. The tissue form- ing the posterior wall, is, according to Luschka, joined by a distinct ligament to the basilar process of the occipital bone. Ganghofner* and Schwabach? deny its existence as a distinct anatomical struc- ture, taking the ground that this bursa, so-called, is really the re- cessus pharyngeus medius, or simply the median fissure of a normal pharyngeal tonsil, or possibly an hypertrophied one, which undergoing the changes incident upon maturity, has by a process of unfolding, as it were, or shrinking up upon the median line, re- sulted in an adhesion of the super- ficial layers of the adenoid tissue over the median fissure, in such a way as to form this bursa-like cavity. It: is difficult to understand why nature should have found it neces- | sary to establish a bursa here, for any purpose of function, especially one of the size Luschka describes. Certainly there is no function of the pharynx which requires the pres- ence of such an appendix. Hence, the objections made by Ganghofner and Schwabach seem to be exceed- ingly well grounded, for certainly 5 Luschka's original descri pt ion Fic, 121.—The Glandular Structures at the scarcely strikes one as that ofa per- Vault of the Pharynx (Luschka). 1, 1, Ptery- goid processes; 2, vomer; 3, posterior portion of manent and constant anatomical the vault of the nasal fossz; 4,4, Eustachian eked tubes; 5, orifice of the bursa pharyngea; 6, 6, condition. Moreover, Luschka de- Rosenmiiler’s fosse; 7, median folds formed scribes it as a condition present in >Y he slandular tissues. only a certain proportion of cases. I think, then, that we must abandon Luschka’s idea of a normal pharyngeal bursa in this region, and regard the condition he describes as the adventitious result of certain. morbid conditions of the glandular structure in this region, as described by Ganghofner. This region derives its arterial supply from the ascending pharyn- geal branch of the external carotid, and the ascending palatine branch of the facial, together with the palatine and the spheno-pal- atine branches of the internal maxillary. The veins open into the internal jugular. The nerve supply is derived mainly from the * “* Ueber die Tonsilla und Bursa Pharyngea.” Sitzungsbericht der k. Academie der Wissenschaften, Bd. Ixxviii., Abth. iii., Oct. roth, 1878. ? Arch. fir Mik. Anat., 1887, vol. xxix., p. 61 et.seq. 506 DISEASES OF THE NASO-PHARYNX. second division of the fifth pair, together with branches from the glosso-pharyngeal and vagus. PHYSIOLOGY OF THE NASO-PHARYNX. While the naso-pharynx is situated apparently in the continuity of the respiratory tract, and furthermore its mucous membrane shows the anatomical characteristics of the mucous membrane lining the respiratory tract, namely in the fact that it is covered with columnar ciliated epithelium, yet I am disposed to think that the function of the naso-pharynx has mainly to do with the food tract. In the ordinary process of deglutition, it is absolutely necessary that the lower pharynx should be thoroughly lubricated by mucus, in order that the bolus of food shall pass over it without hindrance. Now, as we know, the lower pharynx is very sparsely endowed with glandular structures. It is lined by a hard dense membrane, fitted eminently to permit without in- jury the passage of harsh, and oftentimes irritating particles of food, but it is endowed with a very scanty secreting apparatus. The glands neces- sary to furnish this region with a proper lubri- cant, were they imbedded in the tissue of the lower pharynx, would be exceedingly liable to injury, from the constant irritation of food in the act of deglutition. Hence, we find them removed, as it were, to the three sides of the pharynx most convenient for their location, namely, to the well-protected recess found between the.two pil- lars of the fauces, where they form the faucial Fic. 122,— Glandular tonsils, and to the still better protected recess, Structures of the Pharyn- i geal Vault, seen in An- the vault of the pharynx. In these three regions ‘ero-posterior Section. - we find masses of glands, which pour out large quantities of mucus, whose sole and only function is to thoroughly lubricate the bolus of food, and facilitate its passage down into the cesophagus. The vault of the pharynx affording the best protec- tion, necessarily becomes the site of the largest aggregation of these glands, and as Luschka has shown us, nature has chosen this locality for the main distribution of the glandular structures de- signed for this function. The normal secretion from the pharyngeal tonsil consists of an absolutely clear, transparent, somewhat viscous mucus, of the ap- ANATOMY AND PHYSIOLOGY OF THE NASO-PHARYNX. 507 pearance and consistency of the white of anegg. Not infrequently, as we examine the lower pharynx, we will notice a large mass of this mucus escaping from beneath the palate, and passing into the pharynx below, from one to three drachms in amount, this without consciousness on the part of the patient. This is the healthy se- cretion of the glands, and the secretion of this mucus is their main function. The pharyngeal vault being, adventitiously as it were, a part of the air tract, it is of course endowed with certain anatomi- cal features, characteristic of the air passages. Its main function, however, I regard as a sort of diverticulum of the food tract, for the safe lodgment of these glands. The function of this region in connection with the auditory ap- paratus will more properly be discussed in a later chapter. Its function as a resonant chamber for the voice is also somewhat secondary, and possesses no point of special importance. CHAPTER LX. ACUTE NASO-PHARYNGITIS. TuIs term is used to designate a disease, frequently. met with in the spring and fall months, and which in many of its features closely resembles an ordinary acute rhinitis, or cold in the head, and yet differs in a notable degree from this affection, both as to the region involved in the inflammatory process, and in the char- acter of the symptoms. The disease consists essentially in an acute inflammation of the mucous membrane lining the vault of the pharynx, and hence we use the term acute naso-pharyngitis, which is a somewhat awkward and perhaps unfortunate designation, and yet I know of no better one, 'under which to definitely describe the affection. ETIOLOGY.—Exposure to cold we regard as the prominent ex- citing cause of all acute inflammatory processes involving the mu- cous membrane of the upper air passages. Aside from this, I know of no cause for the disease. As a predisposing cause, however, we recognize a previously existing naso-pharyngeal catarrh probably in all cases, adopting the same view here, as that already expressed in regard to chronic catarrhal affections of the nasal passages, that the chronic process is the first to arise, and that recurrent attacks of acute inflammation become one of its most prominent symptoms. It is met with much more frequently in adult life than in youth, in that at this period of life the naso-pharynx is perhaps the most frequent site of a chronic catarrhal process, and thereby the weak- est portion of the upper air-tract. An ordinary cold, as we call it, in very young children occurs usually in connection with adenoid disease of the pharyngeal vault, or with the purulent rhinitis of childhood. This tendency disappears at puberty or perhaps be- fore, after which an exposure results more commonly in an ordinary acute rhinitis, or a typical cold in the head. After this tendency has persisted for a somewhat lengthy period of time, encouraged perhaps by irregularities in habit of life, indiscretions, improper clothing and other errors of hygiene, the pharyngeal vault becomes involved, as a secondary result of the morbid process in the nasal passages, and becomes the seat of an inflammatory process in con- ACUTE NASO-PHARYNGITIS. 509 nection with the attacks of acute rhinitis, and still later, the ten- dency to acute rhinitis disappears, and we have the colds resulting in an acute inflammation at the pharyngeal vault. In other words, chronic inflammatory processes tend to pass downward in the air passages, carrying with them the tendency to recurrent attacks of acute inflammation. Aside from these considerations, the predis- posing causes of the disease will be more particularly discussed in the consideration of the general subject of naso-pharyngeal catarrh, in another chapter. SYMPTOMATOLOGY.—The attack comes on somewhat suddenly, as the result of exposure, and usually is marked by notable consti- tutional disturbance, as shown by a certain amount of febrile move- ment, as marked by flushed skin, headache, loss of appetite, etc. The thermometer may indicate a temperature not over perhaps 100° to 101°, and yet the general disturbance is more marked than would be expected from so lowa degree of fever, in that the general malaise and feeling of illness and prostration, oftentimes will com- pel a patient to abandon his usual occupation, and perhaps confine himself to his room or even bed. One of the earlier sensations is a feeling of burning or dryness, referable to the back of the throat, or as the patient usually ex- presses it, in the roof of his mouth, swallowing becoming painful, and even to an extent difficult. This is due to the abnormal dry- ness of the membrane, which, as we know, characterizes the first stage of all acute inflammatory processes in the upper air passages. Now in the nose, as we know, this first stage persists usually but a few hours, or at the utmost, a day. In the naso-pharynx, however, this first stage will oftentimes last two, three, or even four days, constituting a period of considerable discomfort and even distress to the patient. In connection with this, as indicating a close con- nection between the naso-pharynx and the digestive apparatus, there is liable to be a torpid condition of the bowels, or even obstinate constipation, in connection with complete anorexia, and a tendency to nausea. The second stage of the attack is characterized by the setting in of a more or less profuse muco-purulent discharge from the affected region, which passes down behind the palate and into the fauces, from whence it is either expectorated, or passes into the cesophagus, and is swallowed, or, again, it may make its way into the nasal cavities, and is voided through the anterior nares. This secretion consists of a somewhat thick, grayish, opaque mucus, which is voided in considerable quantities. The setting in of the secretion seems, to an extent, to aggravate the gastric dis- turbance, especially giving rise to a tendency to nausea or vomit- 510 DISEASES OF THE NASO-PHARYNX. ing, the appetite being, at the same time, considerably impaired. The mucus passing into the nasal cavities, seems to excite a certain amount of irritation in this region, giving rise to sneezing and per- haps a watery discharge from the nose, although the secretion that is voided anteriorly I think usually has its source in the pharyngeal vault. The sneezing and irritation often lead to the idea that the attack is one of ordinary cold in the head, and yet it is never char- acterized by that distressing nasal stenosis, and intense form of irritation, which occurs in connection with acute inflammation of this locality. This stage of the attack may persist from ten days to two weeks, with no very marked change in the symptoms, either of the local discharge, or of the general feeling of malaise and pros- tration. The third and last stage of the disease, consists of a gradual letting up of the subjective symptoms, and a diminution of the dis- charge. The voice is affected very early in the attack, and in a somewhat peculiar manner, which is almost characteristic of this form of cold, in that it has a curious, hoarse, metallic ring to it, which weakens the tone, although it is never entirely lost. This is due to a certain amount of sympathetic irritation or hyperemia of the mucous membrane lining the larynx, which merely impairs the tone, the resonant chambers not being encroached upon. Pain is always a prominent feature of this form of cold during all stages of the attack. This is usually referable to the roof of the mouth, or upper portion of the throat, from which point it seems to radiate toward the angles of the jaw, and even may extend up to one or both angles of the face, giving rise to a facial neuralgia. This pain is of a purely neuralgic character, and is due probably to the in- volvement of the terminal filaments of the nerves in the pharyngeal vault. Why a facial neuralgia should so frequently complicate the disease, is by no means easy of explanation, unless on the ground that there is in the disease itself, a prominent neurotic element? Certainly it occurs frequently in women of a nervous and perhaps -hysterical temperament more frequently than in others, and where met with in such patients, it assumes an aggravated form, and moreover, the nervous symptoms are more distressing. I think something of the same sort also is noticeable in men, especially those who have passed middle life, and have arrived at that age, when any attack of illness is watched with a certain amount of ex- aggerated apprehension. Pain in the back of the neck is also prominent in these cases, which consists of a stiffness or soreness in the large muscles, rather than ina neuralgic pain. Cough is rarely met with, although a more or less disagreeable sense of itching or scratching about the fauces is liable to be a prominent source of ACUTE NASO-PHARYNGITIS, 511 complaint. Furthermore, the disease does not show any marked tendency to extend down into the trachea and bronchial tubes, although it almost invariably involves the lower pharynx. This lack of tendency to extension is probably due to the fact that nasal respiration is not ordinarily interfered with, and that breathing takes place through the normal passages, and furthermore that the great respiratory function of the nose is unimpaired, which as we know serves very largely to protect from irritation the mucous membrane of the bronchial tubes and the passages below. When we consider that the mucous membrane of the upper and lower pharynx is involved in the acute inflammation, we can easily understand how symptoms referable to the ear should, in most cases, be a prominent symptom, owing to the fact that the inflammatory pro- cess extends to the orifice of the Eustachian tubes, resulting in a temporary stenosis, with impairment of hearing, and a sense of dulness in that region. This symptom, however, it should be stated, is more characteristic of the second stage, during which there is a more or less profuse secretion in the pharyngeal vault. During the first stage, the mucous membrane is dry, and the parts which it covers are, as we have seen, stiff and somewhat immovable. This condition extends somewhat to the muscular structures which act upon the palate, as the result of which, the movements of the pal- ato-pharyngeus muscle is impaired, giving rise to the difficulty in deglutition, already referred to. Hence, in this first or dry stage, we find not infrequently that the Eustachian tubes are maintained in a closed condition, as evidenced by the fact that the patient hears his own voice with a distinctness which may be almost a source of distress. This symptom, however, of autophonia usually disap- pears with the setting in of the secretion, characteristic of the sec- ond stage. PaTHOLOGY.—Any discussion of the pathology of this affection would be purely speculative, in that I know of no special examina- tions of this tissue, in a state of acute inflammation, as ever having been made. We can only base our conclusions on the general laws, which govern a manifestation of an acute inflammation as affecting mucous membranes in general. This point has already been sufficiently discussed in a previous chapter (p. 51). DIaGNosIs.—These patients usually complain of a severe cold in the head and throat. Hence, our first impression is, that we have to deal with an acute rhinitis. This, however, will be completely eliminated by an examination through the anterior nares, which will reveal the turbinated tissues slightly swollen perhaps, and yet showing no evidence of acute inflammation. Moreover, both sub- jectively and on inspection, these passages will be found fairly open 512 DISEASES OF THE NASO-PHARYNX. to the current of inspired air. An examination or the fauces will reveal, in the first stage of the attack, an intensely hyperemic and slightly swollen condition of the mucous membrane lining the lower pharynx, while its surface will usually present a dry and somewhat glazed aspect, the color being of a deep red, verging on a purplish hue. With the rhinoscopic mirror, the vault of the pharynx will present the same turgid condition, and a similar red- dened color, with an entire absence of any evidence of secretion. In the second stage, however, an examination of the fauces will show the membrane swollen, reddened, and coated with long stringy flakes of grayish opaque mucus, whose source evidently is in the pharyngeal vault. If wenowinspect the upper portion of, the naso- pharynx, the same hyperemic condition will be recognized, while its glandular tissues will be seen covered with patches or masses of the same grayish mucus, as was observed in the lower portion of the cavity. An acute rhinitis having been eliminated, the main point of diagnosis, here, would be to determine the absence of an acute follicular inflammation. This, of course, should be determined in the fact, that in the exudative form of the disease, there is a lack of the mucous secretion, while at the same time, the characteristic white spots, marking the existence of a croupous exudation in the crypts of the follicles, is absent. Of course, this last point is only fully determined, after a thorough cleansing of the pharyngeal vault by means of a spray through the nose, or a post-nasal syringe. Moreover, the latter disease, it should be borne in mind, is accom- panied, especially in its earliest stages, by a temperature of from 101° to 103°, while in the catarrhal form of inflammation, the tem- perature rarely exceeds 100°. PROGNOSIS.—These attacks involve no special danger to life, although they run a somewhat prolonged course, as already stated, and may last from ten days to two weeks, during which time the patient suffers, not only from the exceeding discomfort, and even distress of the local affection, but also notable general malaise, with prostration. In fact, during the attack, the patient is apt to think himself, and he really is, quite ill, and even incapacitated for his ordinary duties. The disease, however, shows no marked tendency to extend to the passages below, and generally terminates in com- plete resolution, or if the patient has previously suffered from naso- pharyngeal catarrh, it simply leaves behind a somewhat aggravated form of the chronic disease. Mackenzie‘ who alludes very casually to this affection, and Sajous* who devotes a chapter to its consider- ation, seem to suggest that the acute form of the disease may de- *“* Dis. of the Throat and Nose,” Amer. ed., Phil.; 1884, vol. ii., p. 472. 2 **Tis. of the Nose and Throat,” Phila., 1886, p. 216. ACUTE NASO-PHARYNGITIS. 513 generate into the chronic. As already stated, I think it is an al- most invariable rule that the chronic inflammatory process precedes the acute, and that recurrent attacks of acute inflammation are to -be regarded as a prominent symptom of the chronic lesion. It might be stated, in this connection, that the above writers, as far as I know, are the only ones who refer to this form of a cold, TREATMENT.—At the onset of the attack, the effort should be made to break up the cold, in much the same way as we try to abort an attack of acute rhinitis. For this purpose, we may give ten grains of quinine, while, at the same time, certain measures are instituted for producing diaphoresis, such as the administration of hot drinks in connection with the hot foot bath, preference being given to this simple device, rather than a warm bath or the Turkish bath, either of which are to be regarded as involving a certain amount of risk of additional cold. The simple foot: bath, produc- ing moderate diaphoresis, should answer every purpose. In this connection, also, we should bear in mind the intimate relation between the pharyngeal structures, and the digestive ap- paratus, a relation which has already been referred to, in connec- tion with the symptoms which a cold of this kind gives rise to. Hence, we administer a full dose of calomel or blue mass, in con- nection with the quinine, usually ten grains of either being suffi- cient. This is given at bedtime, to be followed in the morning (and each morning during the existence of the cold) by a glass of Kissingen, Geyser, or Congress water, or indeed any of the milder bitter waters, the indication being to keep the bowels fairly well relaxed during the whole continuance of the attack, although the quinine and mercurial dose is usually not to be repeated after its first administration. If headache is a prominent symptom, perhaps we have no better remedy than the administration of antipyrine in doses of ten grains, to be repeated every hour, until relief is ob- tained, although it will rarely be found necessary, and perhaps not wise, to'administer more than a third dose. Pain, as before stated, is always a prominent symptom, and for the relief of this, we ad- minister some preparation of aconite, and, of these, none is so prompt and efficient in its action as the alkaloid aconitia, which is conveniently administered in the form of the tablet triturates or in granules, preference always being given to Duquesnel’s prepara- tion, as being, perhaps, the most reliable. This should be adminis- tered in doses of z+, of a grain every hour, in the case of a male, and every two hours, in that of a female, until the pain is relieved, or the constitutional effect of the drug is manifested, as shown by numbness and tingling about the fauces or lips, vertigo, or faint- ness. In administering so powerful a remedy as this, one of course 33 : 514 DISEASES OF THE NASO-PHARYNX. needs to exercise considerable care, and where it is impossible to see a patient soon, I have usually directed the drug in the above doses, to be taken every hour for three hours during the early morning until three doses have been taken, and to repeat the same process in the early afternoon, and again in the evening, if necessary. I have rarely seen a case of acute naso-pharyngitis, with prom- inent neuralgic symptoms, in which the aconitia did not afford striking relief, and not only does it seem to control pain, but it seems to exercise a beneficial effect on the inflammatory process, and not infrequently it acts to completely arrest the attack. The above measures go far toward supplying us with all the therapeutic methods necessary, in the management of an attack of acute naso-pharyngitis, although where the symptoms are persist- ent, and the attack prolonged, much aid will be afforded by the resort to local measures, and, of these, I should place as of the first importance, especially in the first stage of the attack, the reduction and control of the plethoric condition usually present in the tur- binated tissues of the nasal cavity. This is accomplished by the local application of a strong solution of cocaine, for depleting the blood-vessels, after which, an application of chromic acid should be made after the manner already described in the treatment of hyper- trophic rhinitis. This application will not only exercise a beneficial effect on the inflammatory process in the naso-pharynx, during the first stage, but it also serves to modify the nasal hyperemia which complicates the attack. As soon as the stage of secretion sets in, and the excessive discharge from the pharyngeal vault makes its way into the nasal cavity, giving rise to irritation of these parts, local applications to the primary seat of the attack in the pharyn- geal vault are always grateful, and afford a certain amount of relief. For this purpose, the ordinary nasal douche, with water as hot as can be borne (which is made saline by the addition of common salt), is of no little value, or the post-nasal pipe, in connection with the nasal douche is, perhaps, still better, as directing the stream immediately against the primary seat of the disease. This may be repeated as often as three or four times a day. Where the douche is not available, the spray, with any simple cleansing wash (mak- ing use of any of the formule already given in the chapter on hyper- trophic rhinitis) will always be grateful to the patient. Snuffs and powders are of but little service in this form of disease, and may even be a source of annoyance. A two or four per cent solution of cocaine is always grateful, and affords relief to the painful symp- toms for two or three hours, and possibly also modifies the inflam- matory process. There is no possible objection to its use, anda preparation should always be placed in the hands of the patient, to use as freely as may be desired. CHAPTER XLI. NASO-PHARYNGEAL CATARRH. THIs is a term used to designate a disease, characterized by an ‘excessive secretion of mucus or muco-pus from the glandular struc- tures of the vault of the pharynx, and which, passing down behind the palate, diffuses itself over the lower pharynx, where it gives rise to more or less irritation, and excites a constant hawking and ex- pectoration in connection with an annoying nasal screatus. This term of naso-pharyngeal catarrh is a somewhat unfortunate one, and yet it is difficult to suggest a better term. According to Mackenzie it was first described by Frank in 1794, although in our own day, attention has been notably directed to it by Horace ‘Dobell* who based his observations largely on clinical study, with- out making any definite suggestions as to the pathological character of the disease. Subsequently we have observations on the same ‘subject by Wendt,’ who first described two varieties, a hypertrophic and an atrophic, a classification subsequently adopted by Lennox Browne.2 These writers, however, fail, it seems to me, to make any distinction between catarrh of the naso-pharynx, and catarrh of the nasal passages proper. Hence, their description of the disease 13 somewhat vague and unsatisfactory. Beverley Robinson,‘ how- ever, following the same classification, was the first, I think, to describe the disease as confined to the naso-pharynx proper, which he designates as a follicular disease of the naso-pharyngeal space, still, however, describing two forms, a dry and moist. Macxenzie,’ dropping this classification, discusses the subject somewhat at length, but still I think in a vague and indefinite way, under the general head of catarrhal disease, although he devotes a separate chapter to rhinitis, which he designates as chronic nasal catarrh. All these writers fail to give a clear clinical description of catarrhal inflammation of the naso-pharynx, in contradistinction to catarrhal inflammation of the mucous membrane lining the nasal cavity, and * “Lectures on Winter Cough,” London, 1866, Ist ed. 2 Ziemssen’s ‘‘ Handb. der Therapie,” Leipz., 1874, Bd. vii. 3 ‘* The Throat and its Diseases,” London, 1878, p. 153. 4 ‘* Nasal Catarrh,” New York, 1880. 8 ‘‘ Diseases of the Throat and Nose,” vol. ii., p. 472. 516 DISEASES OF THE NASO-PHARYNX. furthermore, fail to indicate what special pathological changes in the pharyngeal vault give rise to the disease. The same, I think, can be said of Cohen," Seiler,? Woakes,3 Schech,! and Sajous.* In 1885 Tornwaldt*® comes forward in a somewhat elaborate mono- graph, in which he essays to prove that the very large proportion of cases are due toa morbid condition of the pharyngeal bursa, which manifests itself in two ways, (1) a chronic catarrhal inflam- mation of the pharyngeal bursa and (2) in a cystic degeneration of the bursa, with closure of its orifice. Tornwaldt bases these con- clusions on a very careful examination of twenty-five cases, which he claims demonstrated not only his primary conclusion, but also that many cases of pharyngitis, laryngitis, bronchitis, as well as gas- tric catarrh, cough, asthma, headache, pains in the chest, affections of the ears, hyperemia and hyperplasia of the nasal mucous mem- brane, and even nasal polypi, are directly due to a diseased condi- tion of the pharyngeal bursa, and furthermore, that the treatment of the bursa is sufficient to give relief to all the foregoing train -of concomitant affections. Following very soon after the publication of this monograph, Tornwaldt’s disease, as it is called, became a subject of a somewhat animated discussion in the journals, Bresgen’ Keimer*® and Lennox Browne? taking issue with Tornwaldt’s view purely on clinical grounds; while, on the other hand, with equal positiveness, we find Broich” and Luc” claiming to have observed all that Tornwaldt observed, in their examination. of the naso- pharynx, and to have had equal success in the treatment of the pharyngeal bursa, as far as the catarrhal inflammation of this region is concerned, although failing to notice any cases of cystic degen- eration. Both these writers, also, claim to have cured nasal disease by treatment of the pharnygeal bursa alone. Schwabach,” discuss- ing the question from a purely anatomical point of view, and basing his conclusions on a series of investigations upon the dead body, comes to the conclusion that the bursa pharyngea is not a special anatomical formation, but is merely a portion of the pharyngeal tonsil, and, therefore, that it has no independent pathological char- * ** Dis. of the Throat and Nasal Passages,” N. Y., 1879. ? ** Diseases of the Throat,” Phila., 1883. 3 ‘““ Post-Nasal Catarrh,’’ Phila. , 1884. + “Dis. of the Mouth, Throat, and Nose,” Engl. ed., 1886, 5 “* Dis. of the Nose and Throat,” Philadelphia, 1886. © “* Ueber die Bedeutung der Bursa Pharyngea,” etc., Wiesbaden, 1885. 7 Deut. Med. Woch., 1887, No. 5, p. 86. ® Monatsschrift fiir Ohrenheilk., 1886, No. 4. 9** The Throat and its Diseases,” London, 1887, 2d ed., p. 509. 7° Monatsschrift fiir Ohrenheilk., 1886, Nos. 5, 6, 7. ™ La France Médicale, 1886, Nos. 120 and 121. 7 Arch. fiir Mik. Anat., 1887, vol. xix., p. 61. NASO-PHARYNGEAL CATARRH. 517 acter. Notwithstanding the criticism of Bresgen and others, Torn- waldt’s propositions are laid down with so much clearness, and his clinical cases reported with so great accuracy, that I think we must accept them as demonstrating the fact that a certain proportion of cases of catarrhal disease have their source in this so-called pharyn-, geal bursa. The question as to whether this cavity, which Luschka has demonstrated to exist in the pharyngeal vault, is a true bursa, has already been discussed in the section on the anatomy. of the naso-pharynx, where the view was taken, that the weight of evi- dence goes to show that it is not a constant anatomical condition, but rather the result of a diseased action of the normal lymphoid structures found in that region. The position, then, which we are compelled to take in the matter, is that naso.pharyngeal catarrh is undoubtedly, in many cases, due to a diseased condition of this so- called bursa pharyngea, but my own clinical studies go to show that we have, in addition to this, a catarrhal disease, which gives rise to a secretion, whose source is in the whole pharyngeal tonsil, viz., that mass of glands which is found normally distributed over the larger portion of the posterior and upper wall of the naso-pharynx. It seems to me entirely too narrow a, view of the case, to say that all cases of naso-pharyngeal catarrh are dependent on the existence of a bursal cavity. Wherever we have muciparous glands gathered together in large masses, we have an anatomical condition which predisposes the part to a chronic inflammatory disease, in which the prominent lesion consists in cell desquamation, in connection with an apparent increased mucous secretion. This we find in the early stages of atrophic rhinitis, namely in the purulent rhinitis of chil- dren. We also find it, to a certain extent, in chronic inflammation of the faucial tonsils, and I think we are bound to accept the view, that we may also have the same morbid condition existing in the glandular structures of the pharyngeal vault. A chronic inflamma- tory process involving these glands, and attended with a moderate amount of diffuse hyperplasia, may result, then, in a muco-purulent discharge from the broad evenly distributed cushion of glandular structure, spread over the pharyngeal vault, or the hyperplasia may take such a form, as that the lateral lobes of the pharyngeal tonsil may be crowded toward the central line, and the superficial layer of epithelium of the one side of the central fissure, or recessus pharyngeus medius, may become united with the superficial layer of the opposite side, in such a way as to give rise to the bursa-like cavity of Luschka or Tornwaldt, after the manner first suggested by Schwabach,’ the formation of the bursa being a somewhat ad- ventitious incident of the morbid changes which take place in the * Loc. cit. 518 DISEASES OF THE NASO-PHARYNX. tissue, as the result of the inflammatory process, thus adding an en- tirely. new condition, which serves to prolong, and possibly aggra- vate the catarrhal affection. ETIOLOGY.—AIll chronic inflammation, involving glandular struc- tures, develops in two distinct directions. It may result in a rapid cell development, in which the newly proliferated cells become part of the membrane, thus giving rise to true hypertrophy, or the cell proliferation may take on such extreme activity, as that the newly developed cells are thrown off, in connection with an ex- cessive discharge of mucus, thus giving rise to a muco-purulent discharge. Now, as we know, inflammatory changes in the mucous membranes of young people show a marked tendency to invade the lymphatic structures, while in adults, it is the connective-tissue structures which are more especially involved. Following this rule, I think we must look for the primary source of the naso-pharyn- geal disease to the earlier period of life. Now, in the majority of instances, an inflammatory process in children, involving the phar- yngeal vault, gives rise to an hypertrophy of the pharyngeal tonsil, or so-called adenoid disease. Hence, it is altogether possible, that, in many cases, an enlarged pharyngeal tonsil in childhood, leads to the development, in adult life, of one of the forms of naso-pharyn- geal catarrh heretofore described, which, as it undergoes the atro- phic changes which occur at puberty, takes on a desquamative process, and so develops into a muco-purulent discharge from the naso-pharynx, or the muco-purulent catarrh may set in, without the existence of a pre-existing hypertrophy. In these cases, we undoubtedly find an active exciting cause, in some one of the ex- anthems, especially scarlet fever or measles. After its onset, I think the disease should be regarded in all cases as a purely local condition, and not dependent on any general dyscrasia, although Beverley Robinson’ lays special emphasis on the fact, that the dis- ease is due, not only to a catarrhal diathesis, but may be, and fre- quently is attached to the “gouty, hepatic, syphilitic, scrofulous and tubercular diatheses, and a malarial influence may likewise be evident,” a statement which he repeats in the second edition of his work ;* while Moure? also gives the first place to the strumous dia- thesis, as the cause of the disease. Lennox Browne,‘ on the other hand, while making the statement in his first edition, that patients suffering from naso-pharyngeal catarrh are generally scrofulous, * “* Nasal Catarrh,” New York, 1880, p. 145. 2 *“ Nasal Catarrh,” New York, 1885, p. 140. 3 ** Manuel Pratique des Mal. des Fosses Nasales,” etc., Paris, 1886, p. 256. 4“ The Throat and its Diseases,” London, 1878, p. 163. NASO-PHARYNGEAL CATARRH. 519 seems to have abandoned this view entirely in his second edition.* I doubt the influence of atmospheric conditions in directly causing the disease, although they undoubtedly have a marked influence on the character of the symptoms. As regards taking cold, I am disposed to think, that, in most in- stances, the chronic inflammatory process exists first, and that this renders the patient susceptible to atmospheric changes, with the result of his taking cold, and that repeated colds become a symp- tom of the chronic inflammation, rather than that chronic inflam- mation results from the repeated colds. The use of tobacco, it is claimed, may be the source of a phar- yngeal catarrh, a statement which is based, I think, on no very careful clinical observation. The offending element in the use of tobacco is the nicotine, whose action is on the nervous system, while the direct action of the fumes of the tobacco smoke is merely to cause a temporary irritation of the mucous membrane. Hence, I think, we may safely state, that the effect of tobacco-smoke is to temporarily, and perhaps permanently, aggravate an existing catarrhal lesion, while its causative influence in the primary pro- duction of the inflammatory process in the naso-pharynx is very limited. The use of alcohol, on the other hand, is undoubtedly a prolific source of naso-pharyngeal catarrh, owing partially, perhaps, to the direct local action of alcohol upon the pharynx, but mainly, I take it, to the fact that there is a very close and intimate relation be- tween the pharynx and the stomach, and that the chronic gastritis which so frequently results from the use of alcohol, gives rise to a sympathetic inflammation of the pharyngeal mucous membrane. The possibility of contagion causing a catarrhal inflammation of the nasal cavities proper, has been the subject of no little dis- cussion. I believe Beverly Robinson? is quite alone in the sugges- tion, that a person possessing the favorable constitutional diathesis, may contract the disease by contagion—a view which, I think, de- mands for its acceptance larger clinical evidence of its correctness than we at present possess. By far the most frequent and most potent of all causes which lead to the development of a naso-pharyngeal catarrh, is a diseased condition of the mucous membrane lining the nasal passages proper. In the chapter on the physiology of the nose, the intricate and ex- ceedingly important respiratory function of the turbinated bodies was discussed at considerable length, and an important feature of that discussion consisted in the assertion that the integrity of the mucous membrane of the whole upper air-tract was directly de- « ‘The Throat and its Diseases,” London, 1887. ? Op. cit., 2d ed., p, 135. 520 ‘DISEASES OF THE NASO-PHARYNX. pendent upon a healthy condition of the respiratory function of the nasal mucous membrane. If then, we have a chronic inflamma- tion, with hypertrophy of the nasal membrane, interfering with the normal nasal respiration, and hampering the normal process of serous exosmosis, the very first portion of the respiratory tract beyond the nasal cavities, would be necessarily immediately sub- jected to the deleterious influence of this impaired function. And this, I think, is shown by clinical observation, in that, as a direct result of hypertrophic rhinitis, we have the normal function of the pharyngeal tonsil notably interfered with, and furthermore, its glandular structures subjected to the constant irritation arising thereby. As the result of this, the normal secretion of mucus is interfered with, cell desquamation stimulated, and the normal mucus, which as we have shown, is clear, white and easily fluid, be- comes changed into a thick inspissated mucus, largely surcharged with unripe epithelial cells, and, in fact, becomes transformed into a muco-purulent discharge, which adhering to, and clinging upon its surface, hangs down between the palate and pharyngeal wall in thick masses of stringy mucus, which are expelled with great diffi- culty. I think it probable that in many cases the amount of the secretion from the pharnygeal vault in this disease, instead of being increased, is to an extent decreased. In other words, while in health, we have a very large amount of white transparent mucus poured out, of which the patient is unconscious, and which passes down into the pharynx for lubricating the bolus of food in degluti- tion, in disease, this secretion is much diminished in amount, and lodging in the cavity, is expelled with difficulty. Especially is this the case, where the affection is due to disease of the nasal cavity proper, for if the air, passing through the nasal cavities, does not become saturated with moisture in that passage, it reaches the pharyngeal vault in an abnormally dry condition, and therefore robs the mucus found in this cavity of a portion of its watery con- stituents, thereby rendering it thick and inspissated. And herein, it seems to me, lies one very important feature of the influence of a diseased condition of the nasal cavity, in giving rise to a naso- pharyngeal catarrh. In atrophic rhinitis we have a condition of the nasal mucous membrane, in which the venous sinuses, in which the serous exosmosis has its source, are more or less completely obliterated, resulting in an abnormally dry condition of the nasal mucous membrane, and in which its surface is usually covered with dry greenish crusts. The inspired air, in passing through a nasal cavity in this condition, does not become surcharged with moisture, and hence, reaching the pharyngeal vault in this abnormally dry state, it exerfs exactly the same influence as that already de- NASO-PHARYNGEAL CATARRH. 521 scribed above, in connection with hypertrophic rhinitis, only its influence is more marked and more direct. The condition of the naso-pharynx, in this disease, is one in which this cavity is filled and blocked with large masses of thick and inspissated mucus, and even may be abnormally dry, giving rise even to dry crusts. This condition is usually described under the designation of atrophic, or dry pharyngitis. I am certainly of the opinion, that in the very large majority of instances, this dry phar- yngitis is nothing more than a abnormally dry condition of the normal pharynx, rendered so, as the result of the air passing through a nasal cavity, in which the respiratory function has been abolished by the atrophic process. In other words, pharyngitis sicca is purely a symptomatic disease, and a variety of naso-pharyngeal catarrh. The truth of this is shown in a striking manner, in those cases of atrophic rhinitis in which, as the result of constant douching, the atrophic condition is relieved, and the serous exudation so far stimulated and encouraged as to keep the. membrane in a fairly moist condition. PATHOLOGY.—The essential pathological lesion which consti- tutes a naso-pharyngeal catarrh, whether it is due to a diffuse hy- perplasia and cell desquamation, involving the whole of the pharyn- geal tonsil, or whether it may be due to the adventitious formation of Tornwaldt’s bursa, has already been sufficiently indicated, by the discussion in the early part of the chapter. It need only be added that, in those cases where the bursa has been formed, the superficial epithelial layer of the gland structures becomes now, in the latter form of the disease, the lining epithelium of a partially closed cavity, the result of which is necessarily to stimulate them to still more active desquamation and secretion. As we know, where mucus is secreted in a closed cavity, or a cavity whose walls are in contact, the secretion becomes a pus secretion, and the mere presence of the pus, constantly bathing the cyst walls, stimu- lates them to still greater activity, and freer secretion. As we have already suggested, the primary morbid lesion is identical in both forms of the disease, the formation of the bursa being simply an adventitious incident of the inflammatory process. We now see, how this formation of the bursa results in a very notable in- crease of the pus secretion. On the other hand, however, it must be remembered, that in those cases where a bursa is formed, it results in a folding in, as it were, of the outlying glandular struc- tures to the median line, the outlying furrows of the pharyngeal tonsil disappearing. Hence, the amount of secretion in Tornwaldt’s disease is not necessarily greater, and probably is, as a rule, much less than in the diffuse form of the disease, for in Tornwaldt’s dis- 522 DISEASES OF THE NASO-PHARYNX. ease, the source of the discharge is from this small adventitious cavity, while in the diffuse form, the secreting surface involves the whole posterior wall of the naso-pharynx, extending from one Eustachian tube to the other. Moure* is responsible for the asser- tion, that where the pus discharge is very profuse, its source may be in a suppurative inflammation of the mucous membrane lining the sphenoidal sinus. The existence of such a complication would manifest itself by symptoms rather more pronounced than a mere naso-pharyngeal catarrh. As the result of the more or less com- plete closure of the orifice of the bursa, we have, in a certain pro- portion of cases, the formation of a retention cyst, a condition which Tornwaldt? found in forty-five out of two hundred and two cases? of bursal disease. Similar cases have been reported by Zahn,* Troeltschs and Czermak.’ I regard it as a somewhat suggestive com- mentary on the ordinary correctness of our clinical observations, that Tornwaldt should ‘assert with a considerable degree of posi- tiveness, that Stérk’s case of sphenoidal disease’ already referred to in the chapter on that subject, was really a case of disease of the pharyngeal bursa—a view which would seem to be confirmed by the suggestion of Beverley Robinson,’ that the mucous membrane of the accessory sinuses is so very scantily supplied with glands, that it could scarcely be the source of a very profuse purulent se- cretion. I have removed, by mean of the curette and snare, small masses of the diseased tissue in the diffuse form of the disease in a number of instances, the microscopic character of which is fairly well shown in the accompanying cut (Fig. 123). In all cases, it need scarcely be stated, the patients from whom this tissue was removed were adults. The pathological conditions observed were as follows: The hyperplasia was characterized by the bulging of the mucosa, which assumed the form of small raspberry like projections, which gave the vault of the pharynx a somewhat mammillated contour. Under the microscope this feature is evidenced by the presence of globular protrusions between. which there are furrows of varying depths (see Fig. 123 K). The lymph tissue is richly supplied with blood-vessels, and a rather dense fibrous connective tissue, the latter holding clusters of lymph corpuscles. The lymph follicles T Op. cit., p. 259. 2 Op. cit., p. 70. 3 Op. cit., p. 70. 4 Deut. Zeitschr. ftir Chir., xxii., pp. 392-399. 5 ** Lehrb. Ohrenheilkunde,” 1877, p. 32I. 6 ‘*Der Kehlkopfspiegel und seine Verwerthung,” etc., Leipz., 1863. ; 7 ‘‘ Klinik der Krankheiten des Kehlkopfes, der Nase und des Rachens,” Stuttgart, 1880. 8 Op. cit., p. 123. NASO-PHARYNGEAL CATARRH. 523 are scarce and small. The accompanying figure (Fig. 123) shows two of these follicles, one on either side of the furrow. In none of the specimens examined was the presence of acinous glands demonstrable. In this feature, therefore, the tissue differs essen- tially from ordinary glandular hyperplasia, in which both the lymph tissue and the acinous glands are augmented in number and size. We are led to the conclusion, therefore, that the increased se- cretion in naso-pharyngeal catarrh has its source largely in the furrows or fissures above described, for as we know, epithelium situated in this manner is transformed into mucus much more readily, and with greater activity, than when it is located upon the Fic. 123.—Lymphatic hyperplasia of the Pharyngeal Mucosa, illustrating the Morbid Changes in ordi- nary Naso-pharyngeal Catarrh. £,Columnar Ciliated Epithelium; 7, Small poorly defined lymph fulli- cles: L, Lymph Tissue intermixed with Fibrous Connective Tissue ; A, Crypt on surface, surface. Our greatest difficulty in understanding this somewhat curious disease naso-pharyngeal catarrh, lies in the attempt to har- monize clinical observation with the pathological changes revealed by the microscope, for while increased secretion is undoubtedly a prominent feature of the disease, the microscope fails to reveal the presence of those conditions usually associated with hyper- secretion, namely an increase, or even the presence of acinous glands. We must conclude, therefore, that the increased secre- tion has its source in the fissures, or furrows, before alluded to, which present anatomical conditions not unlike ordinary mucous glands, and therefore take on a like functional activity. In addi- tion to this I think we must recognize the fact, that this activity 524 DISEASES OF THE NASO-PHARYNX. is in no small degree stimulated by the presence of the lymphatic follicles, and the diffuse lymphatic hyperplasia, which act probably in much the same manner as the presence of a foreign body. SYMPTOMATOLOGY.—The prominent symptom of the disease consists in the discharge from the vault of the pharynx, of a more or less profuse thick, yellow, muco-purulent discharge, which pour- ing out from the glands of the vault, makes its way down the pharyngeal wall and into the lower pharynx, or adhering closely to the membrane lining the vault, gives rise to more or Iess irrita- tion, with a nasal screatus, and ineffectual attempts to dislodge it. Now, as before stated, the character of this secretion is, in most instances, due to the fact that the nasal cavity itself is diseased, and hence the secretion from the pharyngeal glands becomes thick and inspissated, as the result of abnormally dry air passing over it, and robbing it of its moisture. It is idle to suppose that the glands secrete a thick, tenacious, inspissated mucus in this state. No glands secrete other than a perfectly fluid mucus. This abnormal condition of thickness and inspissation is due to changes in the secretion after it is poured out from the glandular structures, and not to changes in the secreting organs. In many cases, the prom- inent subjective symptom of which the patients complain, is that of a constant “dropping ” in the throat, the secretion being thinner and more nearly normal makes its way down and drops into the fauces. The density of the discharge varies greatly at different times and in different subjects. In some cases, it is almost a fluid pus. Especially is this true, if the source of the discharge is in a bursal cavity. When its source, however, is from the broadly diffused ‘hyperplastic glands of the pharyngeal tonsil, it is a thick, yellow, grayish, tenacious mucus in all cases. The secretion is usually constant, day and night, yet while through the day its dis- lodgment is effected by voluntary motion, and perhaps flows more freely as the result of the normal movements of the fauces, during the night it accumulates in considerable quantities, with the result of imposing upon the patient a prolonged effort of hawking and nasal screatus, by which he attempts to dislodge the accumulated mass in the morning upon rising. Furthermore, this nocturnal accumulation not infrequently produces nausea and even vomit- ing, by its mere presence in the fauces. As evidence of the intimate connection between the pharynx and the stomach, and as lending weight to the view that the naso-pharynx belongs properly to the food tract, I have very frequently observed that patients suffering from a catarrhal affection of this region rise in the morning in comparative comfort, but immediately upon taking breakfast, and afterward, there seems to bé excited thereby a profuse muco- NASO-PHARVNGEAL CATARRH. 525 purulent secretion from the naso-pharyngeal glands, which persists oftentimes for several hours, apparently while digestion is going on. As is usual, in all cases of a chronic inflammatory process in the upper air-passages, its progress is marked by more or less fre- quently repeated attacks of subacute inflammation, as the result of slight exposure to cold, during which the symptoms are markedly aggravated for the time. Moreover, we find the disease noticeably subject tq changes in the weather, all the symptoms being worse in the fall and spring months, while the summer months give more or less complete relief. Place of residence, also, has a marked in- fluence on the symptoms, in that residence in a dry and equable climate affords relief; while in a damp climate, especially near the salt water, the symptoms are notably aggravated. It is usually stated, that the larynx and the air-passages beyond, are the seat of a mild chronic inflammation, owing to the fact that the secretions make their way down the pharynx, and pass into the larynx, causing local irritation and inflammatory changes there. I do not suppose that the secretion from the nasal passages or the pharynx ever makes its way into the laryngeal cavity under any circumstances. All extraneous matter passing through the phar- ynx is taken into the stomach, by an involuntary action, which is usually beyond the control of the patient. Certainly the presence of mucus in the pharynx, if it does not excite involuntarily the act of deglutition, becomes such an annoyance to the patient, that he is constantly tempted to swallow the mass, in order to relieve the throat of its irritating influence. Hence, I do not believe that naso-pharyngeal catarrh gives rise to a laryngitis in this manner. Those cases of laryngitis and bronchitis, with the attendant cough, which occur in connection with a naso-pharyngeal catarrh, I be- lieve to be the direct result of a morbid condition of the nasal pas- sages, unless, perhaps, the disease of the naso-pharynx gives rise to so great obstruction to normal nasal respiration as to compel habitual mouth breathing, in which case, sooner or later, laryngeal and bronchial trouble will develop. Inflammation of the lower pharynx, or an ordinary pharyngitis, is not a concomitant of naso-pharyngeal catarrh, although I think this is a view usually taken by most observers. I believe a simple pharyngitis to be a somewhat rare affection. It is too much our habit to examine the fauces of a patient, and observing the tonsil slightly red, congested, relaxed, or flabby perhaps, to at once make a diagnosis of pharyngitis without stopping to question ourselves as to the fact of there being absolute evidence of inflammatory action there. As before stated, the lower pharynx belongs essen- tially to the food tract, and not to’ the air tract. It is involved 526 DISEASES OF THE NASO-PHARYNX. sympathetically with gastric catarrh, but not, as a rule, with catar- rhal disease of the air-passages. Tornwaldt* reports having ob- served five cases of asthma, all of which were cured by the incision, and subsequent treatment of cysts, which he found had developed in the pharyngeal vault. He makes the general statement, that the disease was a reflex symptom, dependent upon irritation of the glosso-pharyngeal, vagus, and trigeminus nerves. We have already discussed the causation of asthma, taking the ground that it may be due to any obstructive lesion in the upper air-passages. These cases of Tornwaldt’s are certainly unique. My own experience, however, has taught me to regard asthma as more closely depend- ent upon some disturbance of the great respiratory function of the nasal passages. Tornwaldt goes still further, in making the state- ment that hyperemia and hypertrophy of the nasal mucous mem- brane are dependent upon bursal disease, or rather, as he puts it, that they are coincident with bursal disease, and disappear on the removal of the disease in the naso-pharynx. In this view he is supported by the observations by Luc’ and Broich.? I confess.my entire inability to reconcile this statement, either with my own clinical observations, or with my knowledge of the physiological and pathological processes of the upper air-tract. I can only ex- plain it to myself, by taking the view, that the nasal disorder was of an unusually mild type, and that the removal of a far more prominent source of distress to the patient, rendered the remaining nasal disorder a comparatively trivial symptom. Ten cases are reported by Tornwaldt, in which headache was a prominent symptom, and relief obtained by treatment of the naso- pharyngeal trouble. This also we must accept as an interesting contribution to clinical medicine, as confirming the teaching first made prominent by Hack, that in every case of cephalalgia, a thor- ough inspection of the respiratory tract must be made in order to detect any possible source of irritation or diseased action in that region. Whereas the relief of this distressing symptom is one of the most creditable of our successes in throat practice, there is no special symptom, in any given case of headache, which warrants us in the positive assertion that it is dependent on disease of the air- passages, and yet this distressing disease is relieved, in a large pro- portion of cases, by treatment directed to this region. It is still a very prevalent impression among otologists and others, that catarrhal disease of the middle ear is very frequently due to a morbid condition involving the naso-pharynx. Tornwaldt, in his monograph, indorses this view. Now, while it isan undoubted fact that hypertrophy of the pharyngeal tonsil is the cause of ear T Op. cit., p. 49. 2 Loc. cit, NASO-PHARYNGEAL CATARRH. 527 troubles in young childern, in the very large majority of cases I think that this is due mainly to the fact, that the pharyngeal space is very largely encroached upon, and its normal functions interfered with, by the mere mechanical pressure of the hypertrophied lym- phatic tissue. In adult life, however, whether a naso-pharyngeal catarrh is due to Tornwaldt’s bursa, or to a diffuse hypertrophy covering the space, this thickening encroaches so slightly upon the pharyngeal cavity, that its normal function is but little interfered with. I do not believe that a middle-ear catarrh is ever dependent on an extension of the catarrhal process from the pharyngeal vault, but is due, either to a diminution of normal atmospheric pressure in the naso-pharynx, and to interference with the renewal of air in the middle ear, or to interference with the circulation of blood by the mechanical presence of enlarged glands. Hence, I think it is exceedingly doubtful, whether we are justified in looking for the source of ear disease in adults, in the pharyngeal vault, when we consider how far more active, and absolutely direct in its action upon the auditory apparatus, is a diseased condition of the nasal cavities proper. A morbid condition of the nasal mucous mem- brane then, in adult life, is the more prolific source of ear disease, and not the glandular structures in the vault of the pharynx. That we not infrequently meet with impaired hearing in connection with naso-pharyngeal catarrh cannot be questioned. In these cases I think that we must look for the source of both the ear trouble and the catarrhal disease in a previously existing adenoid growth. In other words, I think that if we carefully investigate the clinical history of these cases, we shall find that the catarrhal trouble of adult life had its origin in an adenoid during youth, and that this was the original cause of the deafness, which being moderate in extent, had only become a notable infirmity later in life. Torn- waldt asserts that hyperemia and hypertrophy of the nasal mucous membrane, and even a persistence of nasal polypi, may be the direct result of a naso-pharyngeal catarrh, a view in which he is sustained, to a certain degree, by Broich* and Luc.’ This assertion I find it exceedingly difficult to harmonize in any way with my own clinical observations. That a nasal hyperemia or hypertrophy may give rise to a naso-pharyngeal catarrh, has already been stated. That the converse is true as a general rule, I find difficult of rational explanation. The same must be said, also, in regard to Tornwaldt’s assertion that gastric catarrh may be dependent upon naso-phar- yngeal disease. As already suggested, there is a close and in- timate relation between the lower pharynx and the stomach, under which a catarrhal condition of the lower pharynx may be depend- ® Loc. cit. 528 DISEASES OF THE NASO-PHARYNX. ent upon a gastric catarrh. We undoubtedly meet with many cases, in which the presence of the thick tenacious mucus in the fauces gives rise to hawking and spitting, which may result in vomiting, but this does not constitute gastric catarrh, but is very simply explained by the fact, that the presence of the tenacious mucus, impinging upon the lower pharynx, acts as any foreign body, and vomiting is produced, much as we produce it artificially, by titillating the fauces with the finger. I am disposed, therefore, to say that Tornwaldt’s proposition must be reversed, and that if there is any connection observed between the naso-pharynx and the stomach, the latter is the offending organ, and that the naso- pharyngeal catarrh is dependent upon a morbid condition of the stomach rather than the reverse. DIAGNOSIS.—The recognition of this disease is based partially on an examination of the pharyngeal vault by means of the rhino- scopic mirror, and in part by the exclusion of disease of the intra- nasal cavity, although in many instances we shall be compelled to depend largely on the subjective symptoms. I think, that in no case can we decide that the catarrhal symptoms are directly due to the morbid condition of the vault of the pharynx, until the ele- ment of intra-nasal disease has been entirely eliminated. An ex- amination of the pharyngeal vault by means of the rhinoscopic mirror, ordinarily will reveal to us an unbroken continuity of smooth membrane, as we slowly change the angle of the mirror in order to bring successively into view the posterior wall of the pharynx and trace it up to the broad expansion of the septum an- ‘teriorly. If, however, in making this examination, we find this continuity interrupted, or, in other words, if instead of the smooth rounded dome-like cavity of the naso-pharynx, we find projecting into it from the posterior wall a glandular mass, of sufficient thick- ness to protrude itself into the line of vision, in such a way as to partially shut off the direct view of the vault of the pharynx, we recognize this as a morbid condition, characteristic of this disease. Tornwaldt insists, that for a thorough inspection of the pharyngeal vault, the palate should be drawn forward by means of the palate hook. This undoubtedly enables us to use a larger mirror, and thus obtain a better view, in that the cavity is more thoroughly flooded with light. I think, however, that unless the space between the posterior pharyngeal wall and the edge of the palate is very narrow, a little experience should enable us to recognize a diseased condition without this procedure, especially when we consider, that the palate retractor is only tolerated by a comparatively small proportion of patients. Tying up the palate, after the manner already described, is, I think, usually better tolerated even than is NASO-PHAR YNGEAL CATARRA. 529 the palate retractor, and unquestionably, for a thorough diagnosis in these cases, an inspection should be made by the aid of this pro- cedure, or after the manner suggested by Tornwaldt. There are two conditions, as already suggested, which we may recognize in the pharyngeal vault : one, an enlargement of the pharyngeal bursa, and in the other, the broad diffuse hypertrophy. The latter has been already described. The bursa is easily recognized, as a rounded, almond-shaped projection in the median line, and about midway between the prominence of the atlas and the dome of the pharynx. The noticeable condition that is characteristic of both forms of naso-pharyngeal disease, is the large amount of thick in- spissated muco-pus, which is found in this cavity. This may be seen, thoroughly well diffused over the whole of the posterior wall of the pharynx, in a thick, gray blanket, as it were, or we may find it hanging down from the upper portion of the glandular struc- tures, in yellowish-gray strings, stretching from the roof to the soft palate below. Tornwaldt suggests, that in bursal disease dried crusts are found lying immediately upon the surface of the rounded projection of the bursa, and that upon detaching this, its removal will be followed by a small string of yellow muco-pus, which is drawn directly from the bursal orifice. This may be true, but it requires very nice manipulation and delicate observation to verify it. We find thus, that the diagnosis of this disease ordinarily should be easy, as based on the direct inspection. The symptoms, how- ever, always should aid us very greatly, in that the dropping of mucus from the pharyngeal vault or its lodgment in thick, in- spissated masses, between the palate and pharynx, is so character- istic of the disease as to render the diagnosis comparatively simple, even when based on subjective symptoms alone. The statement has already been made, with a considerable degree of positiveness, that hypertrophic rhinitis does not ordinarily give rise to an ex- cessive discharge. In other words, that disease of the nasal cavities does not result in the formation and accumulation of mucus, either in the passages proper, or in the discharge which makes its way from the nose into the vault of the pharynx. Any excessive secre- tion of mucus or muco-pus in the vault of the pharynx has its source in the vault of the pharynx, and not in the nose. The same, I think, is true of atrophic rhinitis or ozena, and nasal polypi. Syphilitic disease, resulting in ulceration and necrosis,*may occa- sionally give rise to-so profuse a discharge of pus, as that it may make its way into the pharyngeal vault, but in these cases the syphilitic diagnosis should be so simple that a mistake need scarcely ever be made. Disease of the accessory sinuses gives rise to a purulent discharge from the nose, which not infrequently makes its 34 530 DISEASES OF THE NASO-PHARYNX. way into the pharyngeal: vault, especially where the patient is in the recumbent position, as during sleep, in which case the symp- toms closely simulate those of the naso-pharyngeal disease. During waking hours, however, this pus discharge is largely voided through the anterior nares into the handkerchief, presenting the character of a bright-yellow fluid pus, not specially resembling the thick in- spissated muco-pus of naso-pharyngeal disease, and moreover, a discharge from the accessory sinuses is attended with the charac- teristic fetid hydrogen odor, and odor is never present in any form of catarrhal disease of the naso-pharynx; and, moreover, a careful inspection of the nasal cavities should always reveal the immediate source of the pus discharge. PROGNOSIS.—This disease involves no dangerous tendencies, and shows no very marked disposition to increase, although it is essentially a chronic affection, and moreover, shows no tendency whatever to a spontaneous cure. As already stated, it is not to be regarded as an efficient cause of laryngeal or bronchial disease, asthma, or deafness. Hence, I think the statement that we occa sionally see made, that pulmonary disorders may have their starting point in a naso-pharyngeal catarrh, may be dismissed, as based on no well-grounded clinical observation. The prognosis, as regards a cure of these cases, must be based mainly on our special skill in removing the definite morbid lesion, which our examination shows us to be present. In the present state of our knowledge of disease of the upper air-passages, I think we are in perhaps the larger pro- portion of cases justified in assuring our patients of a complete relief from all the troublesome symptoms of the disease, and it is a serious reflection on our special skill, if we fail to justify the prom- ise. At best, however, the disease is a somewhat -obstinate one, and we must not expect the same brilliant results, which we so fre- quently obtain in the treatment of diseases of the nasal passages proper, for while in the latter region our therapeutic measures are followed so frequently with the most prompt and flattering results, in catarrh of the naso-pharynx the amelioration of symptoms is in most instances slow, and the cases oftentimes exceedingly dis- couraging. I am of the opinion that, in the very large major- ity of cases, the disease can be cured, provided the patients are willing to submit to the long-continued course of treatment often required, * TREATMENT.—The question of a systemic habit, acting as a predisposing or exciting cause of naso-pharyngeal catarrh, has already been’ discussed, and the view taken, that the disease was mainly of a local character. Hence, I am disposed to question the efficacy of internal medication, such as has been suggested by Bev- NASO-PHARYNGEAL CATARRH. 531 erley Robinson, Moure,’ and others, although if the gouty or rheu- matic habit is present in these cases, there can be no question that the cure of the disease will be markedly facilitated by the adminis- tration of gouty and rheumatic remedies, and yet my own clinical experience does not justify the claim that a cure can be accom- plished by those measures alone. In this form of catarrhal disease, as in that involving the nasal passages proper, it scarcely need be stated, that general hygienic measures may be of the utmost im- portance, such as the regulation of the clothing, the habits of life, attention to the skin, bathing, and other general measures, such as have already been discussed in the chapter on taking cold. Rob- inson,3 in a number of communications on this subject, has advo- cated, with a considerable degree of enthusiasm, the internal ad- ministration of cubebs, as possessing specific properties in the treatment of this disease. As I understand it, he does not posi- tively state that it cures, but rather that it ameliorates the severity of the symptoms. Its action, I take it, is simply as a stimulant, by which a freer and, therefore, a more fluid secretion of mucus is ex- cited from the glandular structures in the pharyngeal vault, which flowing with greater readiness, is expelled more easily from the fauces, and thus becomes a much less annoying source of distress to the patient. The use of alcohol undoubtedly aggravates an existing naso-pharyngeal catarrh, both by its directly irritating qualities on the pharynx, but more especially by its indirect action, in setting up a gastric disturbance which reacts somewhat unplea- santly upon the pharyngeal membrane. Hence, its use should be always interdicted. It has been the custom for many years, and largely as a matter of routine practice, I think, to forbid the use of tobacco in any form to patients suffering from catarrhal disease of the air-passages. I have always considered nicotine absorption to be the vicious factor in the use of tobacco, and that the nervous sys- tem mainly suffers from the use of the weed, in that the action of nicotine is probably altogether on this system alone. In addition to this, tobacco smoke contains a certain amount of ammoniacal vapor, and where there is wood-fbre present, as in poor grades of tobacco, and especially in cigarettes, a small quantity of pyro- ligneous acid. These substances are both, to an extent, irri- tating to mucous membranes. Hence, we frequently notice, that a patient suffering from naso-pharyngeal catarrh, is greatly in- convenienced, and his trouble even aggravated by smoking. In these cases, it is necessary that the habit should be abandoned. But the cases of catarrhal disease which are aggravated by smoking are the exception, rather than the rule, and I believe it is perfectly ¥ Op. cit., p. 139. 2 Op. cit., p. 261. 3 Op. cit., p. 142: * 532 DISEASES OF THE NASO-PHARYNX. safe, when asked the question as to whether the use of tobacco is injurious, to say to those individuals, that their own experience must be the guide, and if they find that the use of tobacco is in- jurious, to stop it, otherwise, I even think that it is unwise to com- pel them to abandon a habit, which is a source of comfort and pleasure, and which, even in many cases, may be of decided benefit for its soothing influence upon the general system. The practice has come largely into vogue of late years, of treating catarrh at our prominent Spas, both in this country and abroad, by the internal administration of mineral waters, combined with their local appli- cation, by means of atomizers and douches. I have never seen any notable good results accomplished by these methods. Where a laxative is indicated, undoubtedly the use of a glass of mineral water is of advantage, taken internally, but I know of no particular waters which possess any special virtue in this direction. Robin- son‘ and Moure? both claim, that those mineral waters which con- tain largely of sulphur, are of special advantage in the treatment of this disease. This idea is not a new one, as the practice has been in vogue for many years, apparently based on the idea that there is some analogy between the skin and mucous membranes, and that because sulphur waters are beneficial in cutaneous diseases, they should possess a certain virtue in catarrhal affections. I see no objection to their use, as most of our patients are benefited by the use of a mild alterative and laxative mineral water. Too great re- liance, however, should not be placed on this method of treatment. In this, as in all forms of catarrhal disease, climatic influences are very marked, in that the symptoms largely disappear by a change of residence to a warm and dry climate, and moreover, they are markedly aggravated by the damp weather of spring and fall. This change of residence, however, affords only temporary relief, in that the symptoms all return, as soon as the patient is subjected again to the influence of cold and damp atmospheric conditions. The radical cure of the disease depends, I think, altogether on certain local measures, applied directly to the seat of the disease. Astringent washes and douches, in this form of the disease, exert not only a palliative influence, but also exercise certain curative powers. The vault of the pharynx is coated with a thick, tenacious blanket, as it were, of muco-pus, which is very largely the source of the unpleasant symptoms which characterize the disease. If’ this be thoroughly removed, twice each day, it not only mitigates the symptoms, but serves in a marked way to improve the charac- ter of the discharge, and to medicate, to a certain extent, its appar- ent causes, and furthermore, it removes a source of irritation, and 1 Op. cit., p. 141. ? Op. cit., p, 262. NASO-PHARYNGEAL CATARRH. 533 seems to encourage a healthier action in the gland tissues. For this purpose, there may be used any lotion which possesses the action of dissolving mucus, and at the same time of controlling cell proliferation. For this purpose we may use one of the following. BR Acidi carbolici, . S wt 2 4 . grs. iij. Pot. chlorat., . ‘ i ‘ é F . 31, Glycerini, . . , . : . . 3 Aque, . : . 3 5 . . ad vi, M. B Acidi borici, . : ‘ ‘ ‘ a . 3iss. Aquz, . ; Fi _ 5 . z « Svi. M. B Zinci sulpho-carb., . - . F ‘ . grs. iij. Acidi salicylici, . : ; ‘ . at eae Aquz, . 3 ‘i : ‘ i : . 3vi M. % Potass. permanganat., . s - . - 38S Aqua, . ‘i : . . : ‘ . Svic M. B Aluminis aceto-tartar.,’ . ‘ . ‘ » Bi Aque, . ‘ ‘ ‘ 3 3 . ad Zvi. M. The above drug may also be used pure in the form of a powder, and insufflated behind the palate. The pharyngeal vault is not sufficiently well reached through the nasal passages by means of atomizers, to thoroughly remove the mucus which lodges there. The ordinary nasal douche answers a fairly good purpose, although by far the best device for a thorough cleansing of the pharyngeal vault is the post-nasal syringe shown in Fig. 32. This, however, is not easily manipulated by the patient, and the formule above given, are designed to be used night and morning, by the patients themselves. Hence, they should be instructed to use the little device, shown in Fig. 34, which, after a little practice, is easily manipulated. This may be used with the simple bulb attached as shown in the figure, or the post-nasal tip may be attached to an ordinary Davidson or fountain syringe, as shown in Fig. 33. As will be noticed, these devices direct the lotions in quite a free stream, directly against the diseased part, thus thoroughly washing t This is I believe a German proprietary medicine and is put up in this form, and also as Aluminium Aceto-glycerinatum. It seems to have obtained considerable notice in the treatment of naso-pharyngeal catarrh, and although I‘have used it in a number of cases with benefit, it is by no means a specific, 534 DISEASES OF THE NASO-PHARVNX. away the accumulated mucus, not only from the gland surface, but also from the interstices or fissures which divide the ridges or emi- nences which make up the pharyngeal tonsil. In addition to the above plan of treatment, which adds greatly to the comfort of the patient, as before stated, still further and more radical measures are demanded at the hands of the surgeon, and these consist in the thorough destruction or eradication of the offending tissues. Many patients may object to radical measures by means of the cautery, or to surgical interference, and in these cases, a certain amount of reliance can be placed on the local ap- plication of strong drugs, stronger than those above enumerated. Hence, after thoroughly cleansing the part, in the manner before stated, there may be applied by means of a pledget of cotton at- tached to a bent probe, the officinal glycerole of tannin, or better still, the officinal or the compound tincture of iodine, the applica- tions being repeated at intervals of from three days toa week. Or we may use a solution of nitrate of silver, twenty to thirty grains to the ounce. The acetic acid preparations seem to possess a special action on this form of hypertrophy, hence their use is often specially indicated, preference being given to the monochlor-acetic acid, in its undiluted form. Lactic acid, also, is worthy of trial, and may be used in a solution of thirty to sixty grains to the ounce. In making these applications, it is necessary to avoid touching healthy parts, hence the palate should be controlled by means of the palate hook, or better still, it should be tied back, by means of a rubber cord, after the manner described on page 24. A very simple device by which this measure, which is often unpleasant to the patients, may be avoided, is to make use of a cotton pledget, twisted firmly on the end of a bent probe, the pledget being made sufficiently large to enable the operator to coat its posterior aspect only with the agent to be used. This can, by a quick manipula- tion, be carried to the pharyngeal vault and swept rapidly over the part, and then withdrawn, without the necessity of there being any injury done to the healthy tissues of the soft palate. A simple little instrument for making stronger applications still is shown in Fig. 124, which, as will be noticed, consists of a minute shallow cup, with its concave surface presenting posteriorly, mounted ona long steel wire, which plays in a curved tube, the distal end of which is enlarged sufficiently to enable the cup to be withdrawn entirely within its lumen. In this cup may be fused chromic acid preferably, or perhaps nitrate of silver, and this is carried to the vault of the pharynx, when the cup holding the caustic is protruded from the tube, by pressing upon a button at the proximal end of the tube, and after sweeping it over the part which it is desired to NASO-PHARYNGEAL CATARRH. 535 medicate, the cup is withdrawn into the enlarged distal end of the tube, when the instrument is easily removed without injuring healthy parts. The above simpler measures of local application involve a some- what prolonged course of treatment, and one in which the ultimate success is not of a most satisfactory character. As before stated, the radical cure of the disease consists in the thorough destruction of the offending tissues. Where Tornwaldt’s bursa is shown by examination to exist, probably the best device for its destruction, is in the measure advocated by Tornwaldt himself, which consists in the use of the galvano-cautery electrode. For this purpose, he uses a pointed platinum tip, which is to be inserted directly into Fic. 124.—Author’s Porte-Caustique for Pharyngeal Vault. the opening of the bursa, the manipulation being accomplished with the aid of the rhinoscopic mirror in position. After the elec- trode is well inserted the current is closed, and the sinus is cut through and thus thoroughly opened, or else its cavity is destroyed by thorough cauterization. Tornwaldt claims, that if thoroughly done, one application is usually sufficient, although I think, in most cases, there will be required repeated applications, not only to destroy the sinus itself, but also to destroy the hypertrophied glandular structures, which go to make up the whole mass of its walls. I have always regarded the galvano-cautery as an exceed- ingly awkward device for accomplishing a comparatively simple result, in that it is cumbersome, fickle, and always treacherous. There can be no question, however, that in the treatment of naso- 536 DISEASES OF THE NASO-PHARYNX. pharyngeal catarrh it possesses advantages over any other device that we possess. The object here is the destruction of tissue, and this destruction must be accomplished with a certain degree of nicety. The galvano-cautery enables us to carry a very harmless and unirritating instrument to the diseased part with ease and facility, which, after it has reached the part which it is desired to cauterize, is converted into a powerful destructive agent, by simply closing the electric current. After it has done its work, the circuit is opened, and the instrument, being allowed to cool off, is changed again to a state of harmlessness, and thus withdrawn without in- volving healthy parts. In the destruction of Tornwaldt’s bursa, as will be noticed, an exceedingly nice manipulation is necessary, ac- cording to Tornwaldt’s method. This, however, should ordinarily be accomplished with ease and certainty, provided the palate is held well under control by means of rubber cords, or Frankel’s de- vice of a combined tongue depressor and plate hook. In a certain number of cases, Tornwaldt* injected the bursa with a ten-per-cent solution of nitrate of silver, making use of a small syringe with a long curved platinum tube, the end of which was inserted directly into the bursal orifice. In other cases, pure nitrate of silver was fused upon the end of a probe, and passed into the bursa, although his results were not as good as with the galvano- cautery electrode. Broich,? on the other hand, depended almost exclusively on the injection of nitrate of silver, abandoning the, use of the galvano-cautery on account of the intense reaction which seemed to follow its use, in producing violent occipital and cervical pains. Where the orifice of the bursa cannot be seen, the elec- trode is simply to be forced directly through the wall, without reference to a normal opening, and the cavity opened up in its long diameter. This closed condition may be the result of morbid action, or there may be a congenital cyst, as in the case reported by Lehmann,? in which the cyst was extirpated by means of a pair of curved scissors. In those cases, in which the catarrh is dependent upon a broad, flat, diffuse thickening of the glandular structures in the pharyngeal vault, the indications for treatment are the destruc- tion of the glandular tissue, and for this purpose, we resort to one of the measures already noticed, giving preference to the chromic acid, by means of the little instrument shown in Fig. 124. ' If these measures fail, however, we resort to the more powerful action of the galvano-cautery. In this, as in all measures, the part should be thoroughly cleansed first, by the use of the syringe, in order to remove all the adherent muco-pus, after which, the palate being 7 Op. cit., p. 80 et seq. ? Loc. cit. 3 Langenbeck’'s Arch., Bd. xxxvi., Heft 1. NASO-PHARYNGEAL CATARRH. 537 held well under control by means of the retractors or cords, the electrode is passed well up to the upper border of the gland struc-, tures, somewhat to one side of the median line, when the circuit being closed, it is drawn down in a vertical line, to a point perhaps a quarter of an inch above the promontory of the atlas, after which, if the patient tolerates the manipulation, a second and parallel furrow may be made on the other side. The electrode to be used in this manipulation may be the ordinary knife-shaped electrode bent to the proper angle, or as better protecting the soft parts, there may be used the instrument shown in Fig. 128, in which, as will be seen, the tip is formed by a spiral wire, covered with a hood. Where the manipulation behind the palate is not feasible, the pharynx may be reached directly through the nose by the instru- ment shown in Fig. 125, in which the transverse wire across the end of the electrode constitutes the cauterizing part. This is easily tolerated, and serves an excellent purpose. It can be used on both sides at the same sitting, the cauterization being repeated at the end of a week. After the use of the galvano-cautery, the douche or spray should be again used, in order to cool the part, and con- Fic. 125.—Electrode for the Naso-pharynx, to be manipulated through the Nasal Passages. trol any tendency to inflammatory reaction. In addition to this, the patient himself should be directed to use the douche twice daily, after the manner already indicated, and report for treatment at the end of a week, when the same procedure may be repeated. As Broich discovered, the galvano-cautery, even in the pharyngeal vault, isnot unattended with a deleterious effect, in the form of an in- tense inflammatory reaction with neuralgia, etc., hence its use must be resorted to with the greatest possible care. Furthermore, it is not easy to absolutely destroy living tissue rapidly by means of the electro-cautery, the treatment of these cases of broadly diffused thickening, therefore, is oftentimes obstinate. If this be the case, I think resort should immediately be had to the use of the curette, shown in Fig. 134. The palate being well retracted, the whole area of the pharyngeal vault may be thoroughly scraped, and the offending tissue removed’ at one sitting, although, as a rule, more than one will be required. The manipulation must be accomplished with a certain amount of rapidity, in that hemorrhage at the outset is rather profuse, although never persisting to the extent of being troublesome. The pharyngeal vault is not as easily anesthetized by the use of cocaine as the membrane lining the nasal cavity, and yet no operation should be attempted in this region, without first 538 DISEASES OF THE NASO-PHARYNX. making a thorough application of a twenty-per-cent solution of this drug, allowing from five to eight minutes to elapse before operative procedure. ‘This region is not particularly sensitive, and yet an operation here is attended: with more or less pain. This. however, is largely mitigated, although as before stated, not en- tirely controlied by the use of cocaine. CHAPTER XLII. HYPERTROPHY OF THE PHARYNGEAL TONSIL, OR ADENOID GROWTHS IN THE VAULT OF THE PHARYNX. THIS term is used as more accurately describing that condition of glandular hypertrophy in the upper pharynx, which has usually been described under the term adenoid vegetations. It may be defined as a true hypertrophy of the normal lymphoid structures found in the pharyngeal vault, and whose existence has been recog- nized since the days of William Hunter. The diseased condition in this.region was first described by Wilhelm Meyer,’ of Copen- hagen, whose classical paper on the subject was based on the study of one hundred and two cases which had been under his personal care, and which was so thoroughly exhaustive in all its features, clinical and other, that it leaves little to be said on the subject that has not already been well considered by Meyer. It should be stated, however, that Czermak* had recognized and de- scribed, with a considerable degree of accuracy, the same condition as early as 1860, although he failed to recognize its clinical impor- tance. Following Meyer, there appeared important contributions onthe same subject by Loewenberg,? J. O. Roe,‘ Bosworth, B. Frankel,® Chatellier,7 Hooper,’ and others, by which, while our clini- cal knowledge of the disease increased, the correctness of Meyer's original deductions were fully confirmed. ETIOLOGY. —The disease is essentially one of child-life, devel- oping in infancy, and probably not infrequently being congenital. *** Adenoid Vegetations in the Naso-pharyngeal Cavity,” Med. Chirurgical Trans., liii., p. 191. ? “* Du Laryngoscope,” etc., French ed., 1860. 3 ‘*Tumeurs Adenoides du Pharynx Nasal,” Paris, 1879. 4 ‘* Adenoid Growths in the Vault of the Pharynx,” Med. Record, September 13th,, 1879. 5 ‘* Adenoma of the Naso-pharnyx,” Journal of Otology, Jan., 1882; and, ‘‘ Growths in the Nasal Passages,” Med. Record, Jan. 13th, 1883. 6 ‘* Ueber adenoide Vegetationen,” Deutsche Med. Wochenschrift, No. 41, 1884. (Pages in references refer to Separat-Abdruck.) 7‘*Des Tumeurs Adenoides du Pharynx Nasal,” Paris, 1886, ® Boston Med. and Surg. Journal, March 15th, 1888. = vol, 540 DISEASES OF THE NASO-PHARYNX. Like other glandular hypertrophies, these growths show a tendency to apparently disappear at puberty. This may be explained by a diminution in the morbid activity of the tissues and a certain amount of shrinking which occurs in this peculiar form of growth at this age, and also by the fact that they occupy a relatively smaller space in the now more widely-developed pharyngeal vault. Meyer," in an analysis of his cases, showed that they occurred at the following ages: Under 5 years, . ‘ : : ; . 3 cases. Between 5 andio, . : 5 : : Ba . 10 “ 15, . ; ‘ ; 22g a 15 “ 20, . : ; ‘ . er eS 20 “ 25, . é : é 2 Ip # 25 “ 30, . : : ‘ 2 ie 4 “cc 30 oe 35, 4 “ “ce 35 “cc 40, I “ “40 "45, 2“ Total, “ : ‘ : : : .Io2 “ An analysis of my own cases shows a somewhat different result as follows: Of 75 cases there were, Under the age of Io years, j : . § cases. Between loand 15, _ . : 2 ; » 1 “ . 15 “ 20, . : ; , geass v 20 “ 30, . ‘ ‘ ; Bue 30 “ 40, . ‘ ; b st, [ag 40 “ 50, . < ‘ ‘ SL Sa 2 Above the age of 50, . : : : ¢ GE Total, é : : ; é : 75 It will be noticed, that the average age of Meyer’s cases is much less than my own. This difference is to be explained, in that I be- lieve that in many instances the small glandular hypertrophies found in adult life, are identical with those of child-life, and are to be treated on the same principles. I have, therefore, included in my tables a larger number of those broad flat growths, which con- stitute the essential morbid condition of many cases of so-called naso-pharyngeal catarrh. The predisposing cause of the disease lies in that general predisposition, by which in young children a morbid process develops and has its highest activity in the epithe- lial and lymphatic structures, which disappears at puberty, and changes to a tendency to activity in connective-tissue structures, * Loc. cit. HYPERTROPHY OF THE PHARYNGEAL TONSIL. 541 as is more fully described in the chapter on purulent rhinitis. The question arises here, how far any general dyscrasia, such as scrofula, syphilis, or tuberculosis may predispose to this disease. Léwenberg* states that the lymphatic temperament is the “cause of the disease in the very large majority of the cases which he has seen;”’ while Potain? states that this tendency to the in- volvement of the lymphatics in morbid processes, characteristic of child-life, or lymphatisme as he calls it, is but a normal condition, which, carried one step further, gives us the true pathological con- dition of scrofula. Lowenberg, therefore, apparently leans to the view of a scrofulous taint in these cases, while Meyer and all subse- quent writers reject thistheory. The cause of these growths, then, is simply a tendency to hypertrophy, as the result of inflammatory changes, which characterize the lining membrane of the upper air- passages and their appendages under the stimulus of repeated “ colds, as formerly stated by myself? It occurs in children more frequently than in adults, for the same reason that all glandular structures in children are more prone to take on morbid changes. The local inflammatory changes in the region of the fauces which accompany eruptive fevers in children, not infrequently prove a starting point of changes which result in hypertrophy of the phar- yngeal tonsil, or stimulate into a renewed activity an already ex- isting growth in this region. Heredity has an undoubted influence, as we not infrequently see a number of children in the same family affected similarly, as noted by most observers. The publication of Meyer's paper gave rise to the suggestion, that the disease was peculiar to northern climates. Further study, however, shows us that it prevails to quite as great an extent in temperate regions. Meyer* reported, that out of his 102 cases, 52 were males and 50 females, but further observed, that after 15, the larger propor- tion were females. Of my own cases, 49 were females, and 26 males, but my tables show the average age of my cases much older than those of Meyer, 21 being under 15, and 54 above that age. Of the large proportion of cases in which I have seen it occur, less than half showed any morbid condition in any portion of the nasal passages. A frequent condition with which it is asso- ciated, is hypertrophic rhinitis. In ten of my seventy-five cases, it was associated with marked enlargement of the faucial tonsils, while in a much larger proportion, there was moderate enlargement of these glands. In four cases, it was met with in connection with atrophic rhinitis, three of these having reached the stage of ozena, * Op. cit., p. 12. ?** Dict. Encyclop.,” Art. Lymphatique. 3 “ Growths in the Nasal Passages,” Med. Record, Jan. 13th, 1883, 4 Loc. cit. 542 DISEASES OF THE. NASO-PHARYNX. PATHOLOGY.—A microscopical examination of the pharyngeal tonsil shows its construction to be as follows (see Fig. 126): First, it is covered by a layer of columnar ciliated epithelium which exhibits the features of stratified columnar epithelium. The single columnar cells greatly vary in height, and exhibit sometimes long, sometimes short, bent cilia. Between the elongated feet of the epithelial cells irregular corpuscles of varying shape are visible, such as occur throughout the mucous layer of the aérial passages, the larynx, the trachea, and the bronchi. Only in one specimen was one side of the tumor covered by a narrow layer of stratified epithelium, probably corresponding to the medial aspect of the Fic. 126. —Hyperplasia of Pharyngeal Tonsil or Adenoid Disease of the Vault of the Pharynx. Z, Columnar ciliated epithelium; 7, myxomatous mucosa crowded with lymph corpuscles; /, lymph follicle; L, lymph vessel; 5S, inter-follicular tracts. tumor, without cilia, with a gradual transition into columnar epi- thelium. Second, all the tumors exhibit a lobate appearance, the fissure between the lobes being sometimes shallow and at other times very deep, dividing the whole mass into a number of longitudinal ridges. Each ridge may again exhibit a varying number of shallow papillary protrusions. Under the microscope correspondingly we observe large protrusions, which are caused by the follicular formation of the tissue, and small ridges of a papillary aspect caused by narrow protrusions of the subjacent tissue. Third, the main mass of the tumors is composed of lymph tissue, formerly termed adenoid tissue, from the mistaken idea than this HYPERTROPHY OF THE PHARYNGEAL TONSIL. 543 tissue is glandular in nature. No epithelial formations enter, how- ever, the structure of the tumor, save the depressions and furrows between the lobes, sometimes penetrating very deeply into the mass of the tissue, and there producing manifold secondary con- ‘ volutions. Beneath the epithelial cover there is no fibrous connec- tive tissue around the lobes, while the papillary elevations are pro- duced by a delicate fibrous connective tissue freely supplied with lymph corpuscles. According to the general structure of lymph follicles and lymph ganglia, we find in the tumors under consideration a varying num- ber of lymph follicles, consisting of an accumulation of lymph cor- puscles, and supplied with a comparatively small number of blood- vessels. The follicles are separated from each other and inclosed by what is known as inter-follicular strings. In these both a myxo- matous reticulum and the fibrous variety of the connective tissue is more developed than in the follicles, and the blood-vessels are somewhat more numerous. Only in one of the specimens was there a marked fibrous inter-follicular tissue with comparatively few lymph corpuscles. In all others the fibrous connective tissue was but little developed, which feature would account for the com- parative softness of these new formations. With high power of the microscope in all specimens, the features common to lymph tissue are discernible. There is a myxomatous reticulum ill-defined and crowded with lymph corpuscles, in the meshes within the follicles. There isa more developed myxoma- tous or fibrous reticulum, with comparatively less lymph corpuscles in its meshes, within the inter-follicular strings. In one case, a cyst was observed in the tissue near the surface, just perceptible to the naked eye, the size of a small pin’s head. This cyst was lined on one side by flattened epithelium, on which even cilize were still recognizable, while the opposite side lacked an epithe- lial cover, but was composed of lymph corpuscles, in connection with a delicate myxomatous tissue, filling in part the cyst. This latter feature indicated that the cyst had not arisen simply from an ob- struction of an interlobular fissure, but was due to a transformation of the epithelial cover, at least on one side, into a medullary, and from this into a myxomatous tissue. The examination proves the formations under consideration are no tumors, in the proper sense of the word, but a hyperplasia of the lymph tissue, which constitutes the so-called pharyngeal tonsil. A difference between hyperplastic faucial tonsils and pharyngeal tonsils, is that, in the former, the fibrous connective tissue is, as a rule, far more developed than in the latter, which is usually ac- counted for by the fact, that while the latter lies ina region entirely 544 DISEASES OF THE NASO-PHARYNX. protected from the impact of food, or other matters, the former is constantly subjected to pressure and irritation from this cause, a process which necessarily gives a density and firmness to the faucial growth. In the main, however, the pathological lesion is identical in the two, being a true hypertrophy, and so warrants the use of © the name tonsil, as applied to both. Now all writers regard the morbid process which results in this form of growth, as one of true hypertrophy, except Woakes. The mammillated appearance which the surface of these tumors often presents, however, has given rise to the statement on the part of Woakes* that the tissue may be of a papillomatous character. He divides these growths into two varieties, one being simply hypertrophy of the normal tissue found in this region, and the other he calls lymphoid papilloma. This view is further supported by the peculiar course which the blood- vessels take in their distribution through the growth, which Frankel describes as fan-shaped. Frankel further states, however, that the adenoid tissues preponderate to such an extent, that they should never be mistaken for papillomatous growths. Woakes, therefore, is quite alone in his view, all other observers regarding the growth as simple hypertrophy of the normal glandular structure. In connection with the disease in the pharyngeal vault, we often find a chain of enlarged follicles, extending down on either side of the lower pharynx, immediately below the posterior pillars of the fauces, and also a large number of scattered follicles over the phar- yngeal surface, in a state of enlargement, constituting a chronic follicular pharyngitis, or what is often called pharyngitis granulosa. Léwenberg ’ regards this as a primary stage of glandular enlarge- ment in the pharynx, which extends to the tissues above, while Roe? makes the point, that while the disease of the lower pharynx is an hypertrophy of the normal glands, that in the pharyngeal vault is characterized by an involvement of all the normal elements of the mucous membrane, claiming a difference in the pathological processes of the two regions. We have already shown, that the diseased process in the upper pharynx involves mainly the lym- phatic structures, while the connective-tissue element plays but a very small part in the process, Hence, I think, we may safely say, that the disease of the two regions is identical. Furthermore, my own observation goes to show that they develop together. _ Follic- ular pharyngitis is an exceedingly common affection in childhood, and I think we rarely meet with a case in which the glands of the vault of the pharynx are not notably involved. SYMPTOMATOLOGY.—The prominent and most troublesome symptom to which the presence of these growths gives rise, is an *** Post-Nasal Catarrh,” Phila., 1884, p 163. ? Op. cit., p. 18 3 Loc. cit. HYPERTROPHY OF THE PHARYNGEAL TONSIL. 545 excessive discharge of mucus or muco-pus. The source of the dis- charge is, undoubtedly, in the diseased glands themselves, their normal secretory function not being destroyed by the morbid process, which has given rise to the hypertrophy, but is, on the contrary, greatly increased, in the manner already discussed in connection with the pathology of naso-pharyngeal catarrh, the view being taken there that the crypts and fissures in the surface of the tissues constituted a secreting membrane closely resembling muci- parous glands, and that the secretion was still further augmented and stimulated by the pressure, the hypertrophied lymphatic tissue acting somewhat in the manner of a foreign body. We find them, therefore, pouring out large quantities of mucus or muco-pus, which in the greater proportion of cases makes its way into the lower pharynx. In those cases in which the growth has attained a large size, the discharge makes its way through the nasal cavities proper, and is voided through the nostrils. It possesses the character of a thick, ropy, and tenacious mucus, which tends to accumulate in the nares, especially in young children, who find difficulty in expelling it, both from inexperience, and from the occlusion of the posterior nares by the overhanging pendulous growths. Another symptom which may be traced directly to the existence of these growths, and perhaps the first to be noticed will be the altered character of the voice. This is changed into what Meyer calls the dead voice. It is the voice of one with a cold in the head, that is, the nasal twang is more or less completely abolished. In this way “‘m” and ‘‘n” become “eb” and “ed.” In order to give rise to this, the growth need not be large. It may occlude but a small portion of the posterior nares. In order that the voice shall have its full nasal resonance, the vault of the pharynx should be quite clear. If but a small growth projects from its wall, it seriously interferes with the sound-waves, which in nasal sounds, should have a clear field from the vocal cords to the roof of the nares. If they impinge upon the slight projecting shoulder of a growth, located in the pharyngeal vault, they are to an extent smothered, and the whole tone of the voice deadened. The manner in which the singing voice is affected by these growths in the pharyngeal vault, offers many points of great inter- est. Nature is very lavish in her endowment of the various organs of the body, by which their different functions are performed, and so supplies an organ capable of doing vastly more work than it is usually called upon to perform. The larynx when called upon for an ordinary voice, responds readily, and will supply apparently a clear, healthy, conversational voice for years, even when there may exist very marked morbid changes. Let the voice be taxed by a 35 546 DISEASES OF THE NASO-PHARYNX. prolonged and labored effort, as in a sermon or address, and the weakness soon makes itself felt. The singing voice taxes the very highest powers and capabilities of the larynx, and demands not only a healthy larynx, but a healthy condition of the whole upper air-tract. The recognition of this latter truth I believe to be of the utmost importance. The vocal waves are set in motion by the vibration of the vocal cords, the pitch of the tone is regulated by the tension of the cords, and here in the main, the function of the larynx ceases, unless we add, perhaps, quantity or loudness of voice. Those qualities of the voice which we call timbre, its character and resonance, are given it by the pharyngeal and nasal cavities. These should be entirely clear of any obstructing morbid condition, or changes in their lining. In the lower or chest register, so-called, the nasal and pharyn- geal cavities are of comparatively little importance. The voice depends largely on the larynx. Inthe middle register, a healthy pharynx is of importance, but in the head register, a healthy nasal and pharyngeal cavity are absolutely essential. The manner in which the singing voice soon breaks down under the action of a pharyngeal growth, is quite simple. As soon asa note in the upper register is attempted, the singer is conscious of something wanting, the tone is muffled, from the fact that the vocal waves striking upon the mass are suppressed, as it were, the sounding-board func- tion of the pharynx being destroyed. The singer, therefore, in order to overcome this obstacle, attempts, though generally without suc- cess, to increase the power or volume of the voice. The larynx is taxed beyond its strength, and ruptured capillaries or ruptured muscular fibres result, and a chronic laryngitis is the consequence. It is a very noticeable fact with singers, that it is the head regis- ter which becomes first impaired in a failing voice, and in many cases it is the head register alone which is weak, the middle and chest notes being taken with ease and in clear voice. This illus- trates the truth of what I have for a long time urged in my teach- ing. The nasal passages are the first to become the seat of catar- thal disease, and the tendency is very marked for this to extend downward, and furthermore, that in the very large majority of in- stances, so-called chronic laryngitis is but a secondary condition, resulting from disease in the nasal cavities, the laryngitis being a symptom, as it were, of the disease in the parts above. In Meyer's original paper, prominence was given to the occur- rence of ear-symptoms in connection with adenoid disease. Proba- bly no symptom of the disease possesses greater importance, or requires more thorough appreciation and study, than that of ear- complications, occurring, as they do, early in life, and at a time HYPERTROPHY OF THE PHARYNGEAL TONSIL. 547 when their prompt recognition only, may save the patient from permanent loss of this important faculty. The proportion of cases which escape ear-trouble is probably small. Woakes' goes so far as to state, that not more than five per cent of his cases es- caped ear-complications, while Urbantschitsch,? out of one hundred and seventy-five cases of adenoid vegetations, found the hearing affected in one hundred and thirty. In Meyer’s one hundred and two cases of glandular hypertrophy, seventy-two suffered from aural disease, while Swinburne found ear-complications in twenty- seven cases out of forty-two cases observed of adenoid disease. In my own seventy-five cases, eight cases showed extreme deafness, and twenty moderately impaired hearing. Looking at the question from the reverse point of view, we find Swinburne‘ making the statement, that out of one hundred and seventy-nine cases of middle-ear disease, he found that twenty-seven had adenoid vegeta- tions. These statistics embrace cases of all ages, and although I have no data to go on, other than the general result of observation, I think it safe to say, that if the adults were eliminated, we would find a still more striking connection between adenoid growths and * aural disease. Looking at the question from both points of view, probably a very large majority of cases of ear-troubles in children under the age of twelve, are dependent upon vegetations in the pharyngeal vault, and furthermore, that while not adopting the rather startling statistics of Woakes, I think it safe to say, that a careful examination in children would reveal an even larger pro- portion of ear-complications than those already cited. The two aural conditions met with in adenoid disease are chronic catarrhal otitis, and chronic purulent otitis. The method of development of these two diseases I believe to be essentially the same. It is usu- ally stated that ear-disease from the presence of adenoid growths in the pharyngeal vault is due to pressure on the Eustachian ori- fice. These growths are of a soft, pulpy consistency, while the eminences which surround the Eustachian orifice are hard and dense; hence, any pressure exerted upon them by an adenoid growth, would have but slight, if any effect. I think a far more plausible explanation of the symptoms, is in the interference with the renewal of air in the middle chamber, caused by their pres- ence in the pharynx. Any cause which interferes with free nasal respiration, if continued sufficiently long, is liable to cause impaired hearing, by its interference with this function. The method in which this occurs, I take it, is that nasal stenosis, arresting the to- * « Post-nasal Catarrh,” Phila., 1884, p. 168. 2 Cited by Chatellier, op. cit., p. 51. 3 New York-Med. Record, Oct. 6th, 1883, p. 373. _ 4 Loc. cit. 548 DISEASES OF THE NASO-PHARYNX. and-fro current of air though the nasal passages, causes a stagna- tion in the pharyngeal vault, and necessarily a certain amount of rarefaction of air in that region. Moreover, the free action of the levator palati muscles is interfered with by the presence of these growths, and this movement is of the utmost importance in ac- complishing this mechanism of air renewal. In studying these parts by the rhinoscope, the impression is gained that the tendency of muscular movement here is to force air into the middle ear. The constant and almost ceaseless impulse of sound-waves upon the tympanum, must necessarily cause a rarefaction of air in the middle ear, and this loss is compensated for by the mechanism above alluded to. . As a result, then, of this interference with the normal respira- tion, rarefaction of air gives rise to a condition of hyperemia of the mucous membrane extending through the Eustachian tube and middle ear. Now, this hyperemia does not constitute inflamma- tion. Inflammation, as I take it, is attended with hypersecretion. Hypersecretion is not always a feature of chronic catarrhal otitis media, so-called. The Eustachian orifice is closed, the air in the. middle chamber rarefied, the drum-head retracted, and further changes in connection with the more intricate apparatus of the ear results inimpairment of function. Ina very large number of cases this process continues, leading to ankylosis of the ossicles, and atrophy of the tympanic membrane. In the smaller proportion of cases, arising in the same manner from nasal stenosis and rarefac- tion of air in the middle chamber, we have set up a true catarrhal inflammation with hypersecretion. Now, as an invariable law, where we have catarrhal inflammation setting up in a closed cavity, this process is converted into one of suppuration. This is true in the vagina, in the urethra, in the accessory sinuses of the nose, and in fact in all the mucous-lined cavities of the body. As the result we have a chronic suppurative otitis media. Why this occurs in one case and not in the other I have no suggestion to make. Woakes* suggests that the suppurative form is more frequently met with when the adenoid vegetations affect mainly the vault; on the other hand where the growths are fewer in number, and are situated on the posterior wall, the disease is more apt to assume the non-suppurative form. It should be stated, however, that the suppurative form of the disease may be developed from the non- suppurative in the following manner. After the chronic catarrhal inflammation has existed for a long time, the drum-membrane be- comes excessively thin and atrophic. By some unknown cause, frequently without doubt mechanical, this membrane is perforated, T Op. cit., p. 169. HYPERTROPHY OF THE PHARYNGEAL TONSIL. 549 and air admitted to the middle ear through the external canal, thus giving rise to a suppuration. That the ear-symptoms are due to an extension of catarrhal inflammation to the Eustachian tube, as advocated by Frankel, ‘Woakes, Léwenberg, Beverley Robinson and others, I think is very questionable. Certainly it is very rare to find the lining membrane of the Eustachian orifice in a condition showing any evidence of catarrhal inflammation by rhinoscopic examination. Loéwenberg' directly asserts, that the presence in the pharynx of an inflamma- tion, which easily spreads to the middle ear, is the cause of the ear- symptoms, but inflammation is not necessarily an accompaniment of adenoid disease in the vault of the pharynx. Most writers at- tribute the ear-symptoms to mechanical obstruction, which is un- doubtedly a very active contributing agent in their development, but not, I think, the most prominent one. Blake,? of Boston, ad- vocates a very ingenious theory, that hyperemia is set up in the middle ear, by interference with the return circulation, on account of the superficial pressure exercised on the pharyngeal veins by the morbid growth, and also on the veins coursing through the deep-seated tissues. Nasal stenosis is quite a prominent symptom of the affection, and is present even in cases where the growth has not attained an unusual size. This may not be so noticeable during waking hours, but during sleep, when the voluntary muscles of respiration are not brought into play, it is more prominent, and the patient sleeps with the mouth open. It is a very noticeable fact, that these growths show a marked change in size when examined at different periods, which would indicate simply, that under the influence of damp weather, or other causes, they are liable to become the seat of an active turgescence or distention of their blood-vessels, by which their size is temporarily increased. This occurrence, especially in children, is attended with an increase of secretion, with obstruction to nasal breathing; in fact, the child has apparently an ordinary cold in the head, attended with its usual symptoms. As already noted, we must bear in mind that an acute rhinitis is comparatively rarely met with in a child, and that in-most instances, when a child has an apparent cold in the head, it is really suffering from a subacute inflammation of the pharyngeal tonsil. In other words, the clinical history of chronic inflammation or hypertrophy of the pharyngeal tonsil is marked, like inflammatory processes in other portions of the upper air-tract, by a liability to repeated attacks of acute inflammation. 7 Op. cit., p. 35. 2 “ Relation of Adenoid Growths in the Naso-Pharynx, to the Production of Middle- ear Disease in Children,” Boston Med. and Surg. Journal, March 15th, 1888. 550 DISEASES OF THE NASO-PHARYNX. Cough is present in certain cases, especially if there is much secretion, which has made its way down the pharynx into the larynx, exciting a laryngitis. The cough, again, may be the result of the habitual mouth-breathing. Headache is an occasional symptom, not perhaps occurring ° with the same frequency as it is met with in hypertrophic rhinitis. Frankel’ discusses this symptom somewhat at length, without, however, suggesting an explanation of it. It probably arises in much the same manner as do those cases which depend on disease of the nasal chambers. Asthma, also, may be dependent on the existence of adenoid growths, as noted by Frankel and Chatellier. One such case has come under my own observation, in which complete cure was ob- tained by the removal of the growth. Epistaxis, of somewhat trivial character, occasionally occurs, or the child may on awakening in the morning, discover blood clots in the mouth, which have resulted froma slight hemorrhage during sleep. Chatellier? mentions nightmare, as a symptom of the disease. This symptom is rather an accompaniment of enlarged tonsils, a disease in which it occurs quite frequently. I should be disposed to attribute it to the enlargement of the faucial tonsils, which so frequently accompanies the affection under discussion. Snoring, on the other hand, is almost always present in disease of the pharyngeal vault, due probably to a certain amount of relaxation or weakness of the palatal supports, which accompanies the dis- ease. Frankel* states that this symptom is not due to a vibra- tion of the palate, but is produced by laryngeal obstruction, and gives an exceedingly curious explanation. He says, that during normal respiration, the lower jaw is held in position by atmospheric pressure; that the nasal passages being obstructed in these patients, the mouth falls open, and as a result of this, the base of the tongue falls backward upon the epiglottis, thereby obstructing the larynx, and giving rise to the symptom. This is ingenious, but affords a better explanation of the occurrence of nightmare, than of snoring. In very young children, the inability to nurse, as the result of nasal stenosis from this or any other cause, is well known. Spasm of the glottis, also, from nasal stenosis, in children of neurotic habit, may be a very troublesome symptom of the disease. Both Hooper‘ and Chatellier’ mention night-sweats as one of the symptoms of the disease. This symptom is present in a certain proportion of cases, but probably only in those in whom the health * Loc. cit., p. 18. ? Op. cit., p. 28. 3 Loc. cit., pp. 10, 11. * 4 Loc. cit. 5 Op. cit., p. 28. HYPERTROPHY OF THE PHARYNGEAL TONSIL. 551 has become deteriorated, as the result of disturbed sleep and im- paired nutrition. Most writers allude to the chest deformity, which is said to ac- company adenoid disease, and quote the very distressing case de- picted by Dupuytren in his “‘ Mémoire sur la depression laterale des parois de la poitrine,”* of a child with enlarged tonsils, and that deformity of the chest which we call pigeon-breast, who fell, after violent and useless efforts to breathe, into a most alarming state of convulsions, etc. It is customary to quote the case with the com- ment that Dupuytren had here to deal with a case of adenoid dis- ease. As already stated, children with adenoid disease enjoy fairly good general health. Certainly no such deformity as that described by Dupuytren could well be pro- duced by enlarged faucial or phar- yngeal tonsils, unless there already existed some previous systemic con- dition, such as rachitis or any general condition which might lead to that curious disease of the bones which we call mollities ossium. Probably no symptom of ade- noid disease is more striking or char- acteristic, than the peculiar facial appearance which these patients present. This symptom, however, as a rule, is most noticeable in chil- dren under the age of fifteen OF Fic, 127.—The Face of a Girl illustrating the sixteen years, but so notable is it Peculiar Facial Expression which is Character- in these young people, that prob. S,0f te Exstenes of an Hypetophid ably in the majority of cases, a sin- gle glance at the patient will be sufficient for a correct diagnosis. This peculiar facial expression consists essentially in a broadening and flattening of the bridge and root of the nose. Now, add to this the open mouth, usually rendered necessary by the nasal stenosis, and you will give to the child a curiously vacant, semi- idiotic look, which is very striking (see Fig. 127). Now, Meyer attributes this to a sinking in of the nasal bridge, owing to disuse of the nasal passages. David? enters into a full discussion of this question, and states that, as a result of the disuse of the nose, the accessory sinuses, which in health perform certain functions, fall also into disuse, and therefore the bones of the face fail of full development. In this manner, the cheeks assume a flattened ap- t Répertoire Générale d’Anatomie et de Physiologie, 1828, p. 110. 2 Cited by Chatellier, op. cit., p. 48. 552 DISEASES OF THE NASO-PHARYNX. pearance, the eyebrows are depressed, and indeed the whole facial contour is to an extent flattened, as it were, and presents a vapid and featureless expression. Frankel’ suggests an additional ele- ment of facial distortion, in that, as a result of the habitual mouth- breathing, the naso-labial fold is drawn downward and backward, and in extreme cases, the external angles of the eyes also sink -downward. These conditions may possibly be present in cases of long standing, but I think, ordinarily, the essential feature of the facial expression lies at the root of the nose, in its broadened and flattened contour, by which there is apparently a widening of the distance between the two eyes. The idiotic expression is perhaps fanciful, for the mere opening of the mouth and depression of the jaw gives that, although the dull expression is undoubtedly en- hanced by the impairment of hearing, which so frequently exists in these cases, for although writers allude to a certain dulness of intellect, which occurs in these patients, I do not think the observa- tion is a correct one, this dulness being due to an apparent lack of attention, which partially deaf children show. Frankel? discusses this question quite fully, and while denying that these patients are naturally dull of intellect, suggests that the habitual mouth-breath- ing, disturbed sleep, headaches, and impaired hearing, from which they suffer, produce a condition of apathy, which might be called dulness. Certainly, in my own experience, I have never been able to discover that these patients were not the possessors of the ordi- nary brightness and alertness of intellect, of children in ordinary health. That there is any morbid development of the facial bones, as suggested by David, becomes questionable, when we remember how rapidly all these conditions disappear, after the removal of the growths, as do also the other symptoms alluded to, such as mental apathy, inattention, etc. Where the growths are large, and nasal stenosis marked, the sense of smell is necessarily impaired, from the imperfect manner in which odorous particles reach the terminal filaments of the olfactory nerve. The sense of taste also is im- paired, as is usually the case where the sense of smell is defective. A somewhat unique symptom has been noted by Scanes Spicer, who observes that in a certain proportion of cases of adenoid dis- ease, the transverse nasal vein, which courses beneath the skin across the bridge of the nose, is dilated, and shows as a well-marked blue line. This, Spicer states, is due to pressure of the enlarged glands in the pharyngeal vault, on the tributary veins, as they pass through the palatine foramina, and disappears upon the extirpation of the growth. t Loc. cit., p. 11. ? Loc. cit., p. 15. 3 British Med. Journal, August 27th, 1887. HYPERTROPHY OF THE PHARYNGEAL TONSIL. 553 DIAGNOSIS.—The prominent symptoms of facial expression, dead voice, nasal stenosis, and catarrhal discharge, will ordinarily prove sufficient for a correct diagnosis. Examination, however, by the rhinoscopic mirror, gives always the additional information of the size of the growth. By anterior examination, nothing will be learned ordinarily, other than the absence of a diseased condi- tion of the nasal cavity, to account for the trouble. If the pas- sages, however, are clear, the growth in the pharynx may be fre- quently recognized by this examination, as stated by Frankel? and Michel * although this is disputed by Roe.3 By posterior rhinoscopy, with the tongue depressed, and the palate relaxed, a thorough in- spection of the tumor may be secured, even in the smallest chil- dren, if care and patience are sufficiently exercised. Instead of the rounded dome-like cavity of the pharynx, there will be pre- sented a rounded mass, of a reddish-gray tinge, with a mammillated surface, hanging down, as it were, and obstructing the view into the nasal cavities. I think the best test for the existence of an adenoid growth, is the ability to trace the continuity of the pharyn- geal wall, by inclining the mirror slowly forward, in such a way as to bring into the field of vision progressively, the posterior wall of the pharynx, gradually passing over to the broad expanded upper portion of the nasal septum, and tracing its converging lines, until it reaches the palate. Now, if in this inspection we find the view of the upper portion of the nasal septum obstructed in a greater or less degree, we recognize the presence of a growth whose uni- form contour and symmetrical appearance will indicate hypertrophy of the normal tissues, or an adenoid growth. In tracing the con- tinuity of smooth surface, from the pharynx to the septum, we will find that even a comparatively small growth will interrupt the view, and shadow the broad upper portion of the nasal septum. The size of the growth will be estimated by the extent to which the nasal septum is veiled on inspection by the pendent growth. In most cases, the growth presents itself in vertical ridges, separated by fissures, presenting something of the appearance of the brain- surface. In other cases, we find a somewhat mammillated appear- ance, which has given rise to the mistaken idea advocated by Woakes, of the papillary character of the growths. In adult life, the growth presents a smoother contour, the fis- sures having to an extent disappeared. The location of the growth does not, I think, vary greatly in different cases. It constitutes, in mild cases, a broad ridge extending across from one Eustachian tube to the other. If the tumor is of larger size, the centre of this ridge becomes enlarged and rounded, and projects further down- Loc. cit., p. 20. ‘‘Krankheiten der Nasenhohle.” 3 Loe. cit. o 554 DISEASES OF THE NASO-PHARYNX. ward and forward toward the soft palate. Meyer’ describes these growths as being found both in the fornix, or upper portion of the pharynx, and the posterior or lateral walls of the upper pharynx, and very rarely on the floor of the nares, where they form, as it were, a duplicature of the soft palate. He also describes hard round spots on the velum, which he considers of an identical nature. This glandular hypertrophy of the floor of the nares, or velum palati, however, I should regard as belonging to another category. As to the varying locality of growths in the pharynx, I should regard this distinction as based simply on observations of the same growths, which present merely variation as to their development or shape, just as we have variations in the extent and shape of the development of hypertrophy of the faucial tonsil. The lower pharynx presents no distinctive appearances in these cases, although it is an almost invariable rule that we find here a condition of chronic follicular pharyngitis. There is also usually present more or less purulent secretion, whose source is in the dis- eased condition of the pharyngeal vault. Lennox Browne? alludes to a symptom which is usually pres- ent where the faucial tonsil is not enlarged, which consists of a “peculiar narrowing, associated with thickening of the fauces, and a want of definition about the pillars.” This symptom is not, how- ever, present, except where the growth has attained considerable dimensions. All observers recommend a digital exploration of the pharyn- geal vault, as an additional aid to diagnosis. This is not a difficult manipulation, and is generally fairly tolerated by children, and yet I think is rarely necessary. Very little information is gained thereby which is not already obtained by the subjective symptoms and rhinoscopic examination; although, where rhinoscopy is imprac- ticable, this should be always resorted to as giving us information not only of the presence of the growth, but also of its size and character. Lennox Browne? makes an excellent suggestion on the carrying out of this manipulation, which is, that when the finger has reached the pharynx, the lower portion of the septum should be first sought, and this traced up with the tip of the forefinger, until the growth is impinged upon, when the exploration of the right and left lateral walls may be completed. Hooper* makes the statement that in children the contraction of the muscles of the palate against the forefinger, may give the mistaken impression of a protruding growth. It is simply to be remembered that the growth is posterior, and does not present in front. The same may 1 Loc. cit. 2 ‘* The Throat and its Diseases,” London, 1887, p. 518. 3 Op. cit., p. 519. 4 Loc. cit. HYPERTROPHY OF THE PHARYNGEAL TONSIL. 555 be said of hypertrophy of the posterior extremity of the lower tur- binated bone, which occasionally protrudes from the posterior nares. Meyer mentions also two almost pathognomonic signs of ade- noid disease: first, in practising inflation of the middle ear by the Eustachian catheter, the stream of air, after having passed freely into the tympanic cavity, will suddenly stop, and in a short time will flow on again as freely as before; second, a gurgling or bub- bling sound of thick mucus, behind the nasal cavity, is heard during inflation, and sometimes bubbles of the same viscid mucus will appear at the nostril through which the catheter has been intro- duced. Both symptoms disappear after removal of the vegetations. I should scarcely attribute great diagnostic value to these symp- toms, although undoubtedly present in many cases. Schech* quoting Semon, advocates as an equivalent for digital examination of children, which is occasionally difficult and even painful, that the permeability of the naso-pharynx be tested by injecting a small quantity of warm water, by means of a ball syr- inge. If the water does not at once flow in a stream from the other nostril, but, on the contrary, escapes through the mouth, then it is certain that there is an obstruction in the naso-pharynx. This method is also recommended to prove whether or not an opera- tion has restored the passage. This device is a most excellent one, and may well be resorted to before digital exploration is practised. A much better device, however, is in the use of fluid cosmoline or sweet oil, atomized by the instrument shown in Fig. 47. As we know, when this is atomized it forms a cloud, as it were, of the density of smoke. If this is sprayed into one nostril, where the nasal passages and naso-pharynx are clear, it will emerge from the opposite side in a stream whose force and direction are almost equal to that with which it escapes from the tip of the atomizer. If, on the other hand, the naso-pharynx is obstructed, the spray emerges from the opposite side in a very feeble stream, or even fails to emerge entirely. This is, I think, without doubt our best, and certainly our easiest test for the existence of an adenoid growth in the naso-pharynx, and one which I regard as almost absolutely diagnostic. Graucher* states that the presence of an adenoid gives rise to changes in the auscultatory sounds of the chest, which he claims to possess a certain amount of value, stating that when the nasal passages are occluded in this way, the vesicular murmur does not ‘* Diseases of the Mouth, Throat, and Nose,” Eng. ed., Edinburgh, 1886, p. 107, 2 Annal. des Maladies de l’Oreille, etc., May, 1886. 556 DISEASES OF THE NASO-PHARYNX. remain smooth. I should not, however, attach any great value to this diagnostic sign. PROGNOSIS.—The prognosis in these cases is always favorable, as regards the entire disappearance of symptoms as the result of treatment. It has already been stated, that there is a tendency at puberty for these growths to atrophy to a certain extent. The question arises, then, how far we may be justified in leaving mild cases to the natural course, when the development attending upon puberty may be expected in the near future. There is undoubtedly ‘an atrophic process, which sets in at puberty, but this does not always cause an entire disappearance of the tumor. The fact that its symptoms are markedly ameliorated, is probably due in part to the great development which takes place at that age, causing the glandular mass to occupy a relatively smaller space in the breath- ing passages. I think, when we consider that the treatment in- volves no possible risk to the patient, and furthermore that the growth is subject to attacks of acute inflammation, by which dan- ger, oftentimes of a serious character, is threatened to neighboring organs, that we are rarely justified in adopting the expectant course. It should be stated, furthermore, that these tumors do not, as a rule, entirely disappear at puberty, but in many cases remain as a permanent source of a chronic naso-pharyngeal catarrh. If serious ear-complications have already set in, before a case is subjected to treatment, I think we may lay it down as a rule, that in children a favorable prognosis may be given, not always perhaps as to the ultimate restoration of hearing, but as to im- provement in the majority of cases, and an arrest of further exten- sion of the disease in nearly all cases, provided, of course, that this complication is dependent upon adenoid disease, with no other complicating morbid lesion. This statement can be safely made with regard to chronic catarrhal otitis media. It is also true in suppurative disease, I think, with few exceptions. In those cases which have gone on to necrosis, we all recognize the peculiar ob- stinacy of the affection with which we have to deal, and yet my own experience teaches me that we are often warranted in giving a favorable prognosis, as regards improvement, even here. TREATMENT.—The simpler methods of general medication are probably indicated in many of these cases, on account of the im- pairment of the general health, which is often present, as the result of disturbed sleep, and imperfect oxygenation of the blood, from interference with normal respiratory action. These measures em- brace simply the administration of cod-liver oil, with general tonics, Most writers suggest the use of the iodide of iron, or some other of the iodine preparations, probably with the idea of securing the HYPERTROPHY OF THE PHARYNGEAL TONSIL. 557 general tonic effect of the drug, together with its alterative action, but it is very doubtful if we ever promote absorption in these growths by any internal medication. This remedy, again, is ad- vocated on account of a supposed strumous diathesis, which under- lies these growths. As already stated, scrofula is not present, as a rule. We therefore may content ourselves with the administration of some simple form of iron, combined with barks, for its general tonic effect. My own preference, however, is decidedly in favor of cod-liver oil, where tolerated, as exercising its general tonic effect in these cases, with better results than any other remedy we pos- sess. In the majority of cases, however, probably no internal medi- cation is indicated. The question as to the value of local treatment by’means of douches and sprays, is rather an interesting one. In the majority of ordinary catarrhal affections of the upper air-passages, the use of astringent sprays is attended with very little, if any permanent benefit. In glandular enlargements, however, of the kind under discussion, especially when we consider their very soft consistency, and low grade of organization, the use of astringents is attended, oftentimes, with the best of results, both in limiting the amount of secretion, and in securing an absolute reduction in the size of the growth. This, however, is all that is accomplished. A cure cannot be looked for, unless in the very early stages of the disease, when the growth has attained but a limited size. Furthermore, I think much can be accomplished by the use of astringents in preventing the frequent recurrence of attacks of acute inflammation, to which those suffering from the disease are so liable. The only form of medication probably, that is adapted to the disease, is that of a watery solution. A well-grounded prejudice exists against the use of the Thudichum nasal douche in adenoid disease, although Léwen- berg,’ Woakes,* Schech, and Moure* recommend its use. There is no doubt that mischief may be done by the use of this device, in that the growths hanging down behind the posterior nares, so far occlude these openings, as in many cases to prevent the flow around the septum into the opposite passage. This interference with the flow we have already noticed as a diagnostic point made by Semon. Now, the nasal douche never should be used, unless the exit of the fluid from the nose is quite as free, if not freer, than its entrance, owing to the danger of its being forced into the Eustachian tubes. I think now that the ingenuity of our instru- ment-makers has placed in our hands so many and such efficient hand-ball atomizers at a moderate price, that preference should always be given to the spray, as a means of local application, over 1 Op. cit. 5538 DISEASES OF THE NASO-PHARYNX. every other device, as affording a method of thoroughly reaching the part, in such a manner as to involve no possible injury to neighboring organs. We give preference then to the instrument shown in Fig. 47. Probably no better astringent can be used in these cases than tannin. My own custom is to prescribe this, in the following combination: B Acidi carbolici, . : ; a ; + @Ye ks Acidi tannici, : ‘ : . : . grs. xl. - Sodii biborat., : , : : . grs. XX. Glycerini, : : : : ; . 38s. Aque, . : : : ; y . ad Ziv. This is to be applied twice daily at home. One of the most trouble- some features of the disease, is the large accumulation of mucus in the nasal cavities, and the difficulty the child experiences in expel- ling it. The above lotion is cleansing, disinfectant, and astringent, and being thoroughly applied at the hands of the mother or at- tendant, fulfils well these three indications. In the absence of an atomizer, a small ear-syringe is well adapted for medicating the parts. For simple cleansing purposes, any of the following solutions may be used: Sodii chloridum, . ; . grs. x. to the ounce. Potassii chloras, ‘ : . grs. x. to the ounce. Ammonii murias, . ; . grs.ij. to the ounce. Sodii benzoas, . ‘ : . grs. x. to the ounce. To which any of the following astringents or alteratives may be added: Zinci sulphocarbolas, 3 . grs. ij. to the ounce. Alumen, . 2 ‘ : . grs. iij. to the ounce. Boro-glyceride, : ; . 3i, to the ounce. Resorcin, . : , : . grs.ij. to the ounce. As before stated, all that can be expected by local medication, is a modification of the symptoms. A radical cure is dependent upon a thorough extirpation of the offending glands. This must be ac- complished, either by destructive agents, such as the chemical or potential cautery, or by the snare or cutting instruments. Owing to the prejudice against surgical operations in the minds of many people, we will occasionally be compelled to resort to destructive agents for the removal of these growths, although in all cases, I may state here, the complete extirpation of the growths by an op- eration is the preferable mode of procedure. The use of caustics is attended undoubtedly with successful results, although it involves a long course of treatment, with many repetitions of the caustic HYPERTROPHY OF THE PHARYNGEAL TONSIL. 559 application. Here I think the galvano-cautery possesses a destruc- tive power which is far more active than are chemical agents, and is always to be preferred. The manipulation by which this is ac- complished, is quite simple. The only risk to be avoided is of burning the soft parts. The electrode should be carried to the parts before the current is turned on, and then allowed to cool before it is withdrawn, otherwise the palate or other healthy tissues Fic. 128,—Author's Electrode fitted with a Shield for use in the Pharyngeal Vault. would be cauterized. The electrode shown in Fig. 128, it will be noticed, is fitted with a hood in such a manner as to thoroughly protect the palate from injury in withdrawing the instrument, Lowenberg’ suggests, that the cauterizing instrument should be adjusted by the aid of the rhinoscopic mirror, or by the finger in- troduced behind the palate. This is scarcely feasible in most cases, and is rarely necessary. In small children, it is not always feasible to introduce the curved electrode behind the palate, hence we are compelled to introduce the instrument through the nasal passages. If introduced in this manner, the platinum tip will usually strike the central portion of the mass, and a considerable destruction of tissue may thus be accomplished. Moreover, there is abundant Fic. 129.—Straight Electrodes for the Application of the Galvano-cautery to the Pharyngeal Tonsil, through the Nasal Cavity. room for a vertical movement to be permitted in this manipula- tion, by which successive portions of the growth may be subjected to cauterization. The electrodes by which this is accomplished are shown in Fig. 129. In the absence of the cautery-battery, chemical agents must be used. Of these, I should give preference to chromic acid fused on the end of a properly-shaped applicator, which may be arranged in the same manner, with a protecting * Op. cit., p. 57. 560 DISEASES OF THE NASO-PHARYNX. hood, as the electrode already mentioned, or the applicator may be concealed in a tube, as shown in Fig. 124, and protruded after the instrument has been passed into the pharyngeal vault. Manipula- tion through the lower pharynx is not always tolerated by young children, and in a number of cases, where the nasal passages have admitted of it, I have made the application directly through the nares, the applicator being protected by a small slender tube, and protruded after this has been passed through the nasal cavities. This manipulation has become an exceedingly simple and feasible one, since the use of cocaine has enabled us to thoroughly open up the nasal cavity by contraction of its blood-vessels. The concealed applicator is an old device, and one which has long been used for making applications to the turbinated tissues in the nasal passages. — —_—_—<—— Fic. 130.—Meyer’s Instruments for the Removal of Hypertrophic Pharyngeal Tonsils. a, Nitrate of silver applicator; 4, mouth gag; c, ring knife; d, lithotrite-like instrument for the removal of growths on the lateral walls. Léwenberg prefers nitrate of silver. Chromic acid, however, is a more powerfully destructive agent. Either of them are easily fused on the end of an applicator, and constitute convenient destructive agents. As already stated, the complete extirpation of these growths by a surgical operation should always be resorted to, in preference to any other measures. Most observers who have written on the sub- ject of adenoid growths, have presented instruments and: methods of their own devising for the accomplishing of this end. Meyer* uses a ring-knife, consisting of a small transverse oval ring with one sharp though not absolutely cutting edge, as shown in Fig. 130, c. The patient being seated with the mouth-gag (see Fig. 130, 4) firmly fixed in position, the ring-knife is passed through the nose, and its t Loc. cit. HYPERTROPHY OF THE PHARYNGEAL TONSIL 561 manipulation directed by the left forefinger, passed into the vault of the pharynx. In this manner, the growths are removed as far as-possible on that side, when, if necessary, the knife is transferred to the other nostril, and the remainder of the tumor extirpated. Where there are portions left on the lateral walls of the upper pharynx, he completes the operation by means of the instrument, not unlike a lithotrite, shown in Fig. 130,d@. To prevent recur- Fic. 131.—Léwenberg’s Forceps. rence, which in a subsequent paper* he said had taken place in thirteen of his cases, he advises a weekly application of the miti- gated stick of nitrate of silver, by means of the instrument shown in Fig. 130, a. The use of forceps for the removal of these growths was proba- bly first suggested by Lowenberg, whose instrument is shown in Fig. 131. It has a cutting.edge on the distal extremity of the blades. Its movements are guided by the left forefinger in the pharynx or by the rhinoscopic mirror, Cohen? recommends the evulsion of the growths by a gouge-cutting forceps, modelled after Mackenzie’s laryngeal forceps. Woakes? modifies Léwenberg’s forceps by prolonging the cutting edge down on the posterior aspect of the blade, thus adapting the instrument to cutting on the STEMANNACC. Fic. 132.—Curtis’ Forceps. posterior wall of the pharynx; while Schech®* still further modifies Léwenberg’s instrument, by prolonging the cutting edge completely around the three aspects of the distal extremity of the blades. Curtiss has made a still further change, in which the blades are fenestrated (seé Fig. 132). * Trans. International Med. Congress, 1881, vol. iii., p. 282. 2 “‘ Diseases of the Throat and Nasal Passages,” 2d ed., N. Y., 1879, p. 262. 3 Op. cit., p. 174. 4 Op. cit., p, I10. 5N. Y. — Record, vol. xxviii., p. 446. 3 562 DISEASES OF THE NASO-PHARYNX. In the above instruments the blades all operate transversely in the pharynx. Schutz,’ however, recommends the use of a forceps with a fenestrated blade operating antero-posteriorly, the only advantage of which lies in the fact that in this manner, perhaps, the pendulous masses which are occasionally found in the upper portion of the vault, are more easily seized, while those portions of the growth which lie more on the posterior wall would scarcely be grasped, Major's ade- notome* (see Fig. 133) is also constructed on this principle. Its mechanism is easily understood by a reference to the illustration. The use of a curette naturally suggests itself for the extirpation of these growths, as first mentioned, I think, by Léwenberg.? His in- strument has a sharp cutting edge, and is attached to its handle by Fic, 133.—Major’s Adenotome. an S-shaped stem. Victor Lange*indorses this method of opera- tion, while Chatellier’ considers it a rather dangerous operation. Frankel® advises it only in cases where the growths are not to be reached with the forceps. This instrument is undoubtedly avail- able for use when the growth is small, but is not to be recom- mended in the case of a large growth. It is also useful for the removal of the remaining fragments if the main mass has been removed by one of the other methods.