A Contribution to the Pathol- 
ogy and Treatment of the 
Respiratory Yaso-Motor 
Neuroses. 
BY 
JOHN NOLAND MACKENZIE, M. D., 
BALTIMORE. 
REPRINTED PROM 
Cfie ‘Nrto York JtteOfcal .^Journal 
for February 26, 1887. Reprinted from the New Yorlc Medical Journal 
for February 26, 1887. 
A CONTRIBUTION TO 
THE PATHOLOGY AND TREATMENT OF THE 
RESPIRATORY VASO-MOTOR NEUROSES.* 
By JOHN NOLAND MACKENZIE, M. D., 
BALTIMORE. 
We are at present passing through a revolution of senti- 
ment in regard to the pathology of certain affections whose 
external phenomena at least are chiefly or wholly manifested 
in the respiratory apparatus, and notably its upper segments. 
Phenomena inexplicable on commonly accepted beliefs have 
received their fitting explanation in morbid conditions of 
these structures linked to a disordered state—imperfectly 
defined it may he—of the vaso-motor sympathetic. Espe- 
cially is this true of that interesting group of symptoms 
known as “ hay-fever,” hut for which I think the term 
coryza vaso-motoria periodica a more appropriate appella- 
tion. 
In this paper I shall limit myself strictly to the essen- 
tially vaso-motor neuroses, and shall not enter upon the dis- 
cussion of the purely sensitive and motor reflex. As my 
views on the subject of the respiratory reflex neuroses, and 
especially in regard to vaso-motor coryza, differ in many es- 
* Read before the American Laryngological Association, May 29, 
1886. 2 
THE PATHOLOGY AND TREATMENT OF 
sential particulars from those advanced by other observers, 
and as some of my confreres, who have done me the honor 
to quote from my writings, have apparently failed to appre- 
ciate the fundamental ideas underlying my theory of these 
affections, I will ask your indulgence while I recapitulate* 
as briefly as possible, the principal articles of my belief. I 
shall furthermore ask you to refer for a more elaborate state- 
ment of my case to my former communications on the sub- 
ject of reflex and vaso-motor phenomena.* 
That portion of the respiratory apparatus known as the 
naso-bronchial tract is, together with its appendages and 
connections, frequently the seat of certain periodical vascu- 
lar disturbances in which paroxysmal explosions of nervous 
force play a conspicuous part, and which depend, it is rea- 
sonable to assume, upon some form of sympathetic or vaso- 
motor nerve-irritation. The vascular changes with their as- 
sociated nervous phenomena may affect the upper respira- 
tory tract in its entirety, either appearing simultaneously or 
successively in its different segments, or may be chiefly mani- 
fested or localized in some individual portion of the tract 
(nose, pharynx, larynx, bronchial tubes). In the latter case 
the nasal cavities and the bronchial tubes are most frequent- 
ly the areas upon which the nervous shock is expended— 
the two territories being seemingly held in close reciprocal 
relationship by virtue of a physiological law of sympathy 
between the two extremities of a mucous tract. In the one 
* See especially, “Trans, of the American Laryng. Assoc.,” 1884, 
pp. 113 et »eq. Papers on Coryza Vaso-motoria Periodica in “Medical 
Record,” July 19 and Oct. 18, 1884; Rhinitis Sympathetica, “Mary- 
land Med. Journal,” April 11, 1885 ; Origin and Cure of Coryza Vaso- 
motoria, etc., “ Trans, of the Medico-Chirurg. Faculty of Maryland,” 
1885 ; Review of Morell Mackenzie on Hav-Fever, “Am. Journal of the 
Med. Sciences,” Oct., 1885, pp. 611-528; Production of Rose-Cold by 
an Artificial Rose, etc., ibid., Jan., 1886. THE RESPIRATORY VASO-MOTOR NEUROSES. 
3 
case a sympathetic coryza results, in the other a sympathetic 
bronchitis. 
In the evolution of these reflex phenomena two factors 
are conspicuously concerned: a depraved condition of the 
nerve-centers, and an abnormal excitability of certain por- 
tions of the naso-bronchial tract. 
The derangement of the nervous apparatus may be trans- 
mitted from father to son, or it may be acquired in a num- 
ber of different ways. Thus, for example, it may be the re- 
sult of prolonged irritation of the respiratory membrane 
(e. <7., from nasal congestion and inflammation, polypi, etc., 
chronic affections of the larynx, pharynx, and bronchi), lead- 
ing to repeated and continuous vascular disturbances over 
certain areas (as, for example, the frequent engorgement of 
that portion of the nasal cavities covered by erectile tissue), 
with subsequent abnormal irritation of the nerve-centers. I 
do not bring this forward as a mere theoretical assumption, 
but as a fact of personal experience, having been able to 
trace clinically the development of the neurasthenic condi- 
tion from simple pathological irritation in the respiratory 
tract, and notably in the nasal passages. 
It thus comes to pass, after a time, that the constant ex- 
citation of the nerve-centers by the peripheral irritation so 
alters their reflex excitability that they respond more readily 
to reflex-producing impressions. When, therefore, an in- 
crease of peripheral irritation occurs, either from extraneous 
influences or internal causes, a corresponding excitation of 
the centers is produced which expresses itself in a paroxysm. 
We might draw a parallel here between this chain of events 
and the mechanism of the epileptic attack, or the exaltation 
of the spinal nervous system from abuse or disease of the 
generative apparatus. 
The exalted state of the centers may be conditioned in 
another series of cases, entirely independently of any local 4 
THE PATHOLOGY AND TREATMENT OF 
irritative process in the respiratory tract, by a constant wear 
and tear of the general nervous system from a multitude of 
causes—from the faulty nervous constitution which Beard 
has termed neurasthenia. Such a condition, it is not diffi- 
cult to imagine, might produce in time a disordered state 
of the sympathetic and abnormal functional activity of the 
vaso-motor centers. 
In individuals affected with this form of neurasthenia, 
local organic irritation would be more likely to lead to re- 
flex phenomena referable to the region of the affected part 
than in those whose nerve-centers had not been subjected 
to the same amount of functional strain. In the vaso-motor 
manifestations under review are found simply an application 
and illustration of this natural law. Or, to put it in other 
words, the area in which the vaso-motor reflexes occur will 
depend, other things being equal, on the seat of the local 
pathological process—on the localization of the area of pe- 
ripheral irritability. A polypus in the nose, for example, 
would excite in such a person symptoms referable to the 
respiratory system, while a similar growth in the rectum 
would elicit reflex disturbances referable to the lower bowel. 
Now, as there is no tract more subject to direct irritation 
from the external world than the respiratory, we should 
naturally look to it for manifestations of central vaso-motor 
disturbance, and herein lies the answer to the question which 
may be propounded : Why is it that those vaso-motor dis- 
turbances are so often encountered in the respiratory tract, 
and notably the nasal passages ? 
In still another class of cases the excessive irritability of 
the nerve-centers may find its predisposing cause in patho- 
logical states of the system as a whole, as, for example, cer- 
tain diathetic conditions; or it may be the result of reflected 
irritation from individual parts of the body. 
There are certain diseases that tend to abrogate the func- THE RESPIRATORY VASO-MOTOR NEUROSES. 
5 
tional activity of the nerve-centers, and at the same time show 
a special proclivity to manifest themselves or leave traces of 
their existence in the respiratory tract. I might instance 
gout, rheumatism, certain fevers, syphilis, etc., and it is a 
clinical fact that the origin of the trouble may be traced to 
such a source. You are familiar with the fact that vaso- 
motor coryza was, and is by some at present, supposed to be 
one of the protean manifestations of gout, from the alleged 
frequency with which it is encountered in those of a gouty 
diathesis. If what I have said above is accepted, how- 
ever, it is scarcely necessary to point out the inadequacy of 
this theory, and to lay stress upon the proposition that gout 
enters as a factor into the aetiology of the affection only in so 
far as it is one of a host of diathetic conditions which lead 
to weakness of the nerve-centers and inflammatory condi- 
tions of the respiratory tract. 
In connection with this portion of my subject I should 
like to call attention briefly to the occasional remarkable 
behavior of this group of respiratory neuroses under the in- 
fluence of certain acute diseases. I have observed the whole 
group of symptoms—coryza, asthma, sneezing, cough, etc.— 
completely disappear during an attack of acute rheumatism, 
while in another case a recurrence of the nasal affection and 
asthma took place during an attack of measles after a 
prolonged interregnum of immunity from these condi- 
tions. 
We now come to the discussion of the hypenesthetic 
condition of the respiratory membrane. Is this factor con- 
stant, is it primary, is it the fons et origo of these affections, 
or is it fugitive and secondary ? Is it the result of purely 
local disease, or is it the peripheral expression of more cen- 
tral nerve-irritation ? These questions have an important 
practical bearing on the treatment. 
It seems to me that the existing confusion in regard to 6 
THE PATHOLOGY AND TREATMENT OF 
these questions arises from failure to separate the hyperses- 
thesia naturally associated with the local pathological pro- 
cess and the excessive irritability principally met with dur- 
ing the paroxysms of this class of affection. According to 
my belief, the intense hyperaesthesia characteristic of the 
paroxysm is, like the vaso-motor phenomena (engorgement, 
swelling, etc.) which accompany it, a purely secondary phe- 
nomenon, and occurs only through the intervention of cen- 
tral irritation or paresis. This characteristic irritability 
may pass away with the subsidence of the attack, or may 
be more or less constantly present in the interregnum, ac- 
cording, presumably, to the amount of structural injury 
which the nerve-centers have undergone. This secondary 
hyperaesthesia may be brought about, then, if my view be 
accepted, either by a direct impression made upon the ter- 
minal nerve filaments in the respiratory mucous membrane, 
or by an indirect influence conveyed or reflected through 
the vaso-motor centers from a distant organ ; or, finally, 
from an excitation starting in the centers themselves. 
The hyperaesthesia met with in these conditions may 
be general, or localized in individual segments of the respira- 
tory tract. In either case, while all portions of the tract as 
a whole or in part may share in the general hyperaesthesia, 
there are certain areas in which the latler is usually more 
pronounced, in which a greater susceptibility to the impres- 
sions by which reflex acts are produced is discoverable, 
and in which may be most conveniently and satisfactorily 
studied the vaso-motor manifestations of this special class 
of neuroses. These are: In the nasal passages, the area 
covered by erectile tissue, and chiefly that portion found in 
the lower and posterior portions of the nostril (posterior 
end of inferior turbinated body and erectile tissue in the 
septum immediately opposite—reflex sensitive area); in the 
pharynx, the vault and posterior wall; in the larynx, the THE RESPIRATORY VASO-MOTOR NEUROSES. 
7 
inter-arytenoid commissure; and, in the trachea, certain 
areas along its posterior wall. It is worthy of notice that, 
roughly speaking, it is the lower and posterior portions of 
the individual segments of the respiratory apparatus where 
these sensitive areas have been shown to exist. 
According to my belief, then, these affections are inti- 
mately related to some disturbance of the sympathetic 
nerve, and probably a deranged condition of the vaso-motor 
centers themselves.* The neurasthenic phenomena, what- 
ever the condition may be upon which they depend, may, 
as has been pointed out above, be due entirely to a primary 
irritation or well-detined disease in the nostril or in other 
parts of the respiratory tract, but until this condition is 
produced the case is simply one of ordinary nasal inflam- 
mation, and does not become true vaso-motor coryza until 
the nervous apparatus is markedly involved. In other 
words, in considering this affection we are dealing with a 
neurosis, or, at least, with an affection in which the neurotic 
element plays the essential and most conspicuous part. 
In addition to the arguments already advanced in favor 
of this view, I desire to call attention to the existence of 
a hitherto undescribed neurosis of the aural apparatus 
closely allied or analogous in aetiology, mechanism, etc., to 
vaso-motor coryza, of which I have seen one case, which 
will be published in due time. Suffice it to say here that 
in this affection we have to deal with, if we may thus ex- 
press it, a sort of hay-fever of the ear. When to this we 
add the recent observation of Dr. Gradle f concerning a 
periodical affection of the conjunctiva closely analogous to 
hay-fever, we have, it seems to me, additional evidence in 
favor of the sympathetic origin of the affection under re- 
* For an elaboration of this point, see especially “Am. Journal of the 
Med. Sci.,” Oct., 1885, loc. cif. 
f “Am. Jour, of the Med. Sci.,” April, 1886. 8 
THE PATHOLOGY AND TREATMENT OF 
view. In vaso-motor coryza the area over which the reflex 
vaso-inotor disturbances are manifested is chiefly the terri- 
tory which receives its vaso-motor nerve-supply from the 
sphenopalatine ganglion; in the aural neurosis, the phe- 
nomena are localized or more pronounced in the area pre- 
sided over by the otic; in Dr. Gradle’s cases of recurring 
conjunctivitis the parts involved are supplied by the oph- 
thalmic, and so on. 
I would also refer to two additional observations which 
I have made, and which are of especial interest in view of 
the probable vaso-motor or sympathetic nature of the affec- 
tion—viz., the occasional marked swelling of the thyreoid 
gland, and to an enormously swollen and congested condi- 
tion of the auricles analogous to that of the rabbit’s ear in 
the famous experiment of Claude Bernard upon the cervical 
sympathetic. 
I have said above that the two areas most frequently 
and notably concerned in these respiratory vaso-motor dis- 
turbances are the nasal passages and bronchial tubes. This 
leads me to refer briefly to the question of asthma and its 
relation to nasal disease. To Voltolini is universally and 
erroneously attributed the credit of pointing out this inter- 
esting relationship. That the asthmatic paroxysm is not 
infrequently associated with or terminated by a discharge 
of mucus or serum from the nasal passages, is a fact which 
was familiar in ancient times. Thus, among others, Coelius 
Aurelianus,* in speaking of the diagnostic value of an excess 
of mucus in connection with the so-called “convulsive asth- 
ma,” after commenting on its various symptoms, proceeds 
to say: 
“ At si gravior impetus superpositionis fuerit, ora aetjro- 
tantium livescunt, et quidem excluso per nares humore mud- 
* “ De morbis acut. et chron., libri viii ” ; Amstelodami, 1709, lib. iii, 
cap. i, p. 430. THE RESPIRATORY VASO-MOTOR NEUROSES. 
9 
lento, relavantur, atque prcefocationis carent metu, quod non 
aliter cedit, etiamsi per oculos lacrimarum fuerit fluor." 
He also gives a cold in the head (gravedo) as a symptom 
of asthma. It was not, however, until centuries afterward 
that Zecchius * described an asthma whose cause he as- 
cribed solely to a catarrh of the head, whose premonitory 
symptoms were a pain in the head, a distillation from the 
nose, and a small cough, and whose treatment consisted in 
the use of the ordinary remedies directed against catarrh of 
the head. I have called attention, too, elsewhere,f to the 
“ suffocative catarrh ” of Schneider, and the “ anniversary 
asthma” of Floyer, as bearing upon this relationship. I 
may add that the association of asthma, whooping-cough, 
and sneezing was also observed by Josef Frank.J 
Coming down to more recent times, we find Bree# 
referring to a case of an asthmatic restored from the dis- 
ease— 
“ Whose Schneiderian membrane became unusually dry in the 
progress of his recovery, and was even affected at this time 
with inflammation. The fluctuating qualities of the air, often 
irritating this membrane, occasionally produced a paroxysm 
without expectoration, until the habit of relapse was at last 
conquered by the means employed.” In another place he ob- 
serves: “If there have been frequent repetitions of irritating 
causes and convulsive efforts of the respiratory muscles, the 
asthmatic paroxysm may much more probably supervene upon 
* “ Consultationes medicinales,” Francofurt., 1650, xviii, p. 160 et 
eeq. ; liii, p. 565; lxxiv, p. 708 et eeq.—et in at. loc. 
f “Am. Journal of the Med. Sciences,” January, 1886, p. 52, foot- 
note, and p. 53. 
% “Praxeos medic® universae prmcepta,” Lipsiae, 1818, pars II, vol. 
ii, sec. 1. 
* Robert Bree, “ A Practical Inquiry into Disordered Respiration, 
distinguishing the Species of Convulsive Asthma, etc.,” Phila. ed., 
1811, p. 145. 10 
THE PATHOLOGY AND TREATMENT OF 
the milder effort to reject an acrid particle by sneezing and 
cough.” 
Later on, Rudolf Ferber,* of Hamburg, referring to the 
frequent association of sneezing, migraine, bronchial asth- 
ma, and hay-fever, advanced the theory that these phenom- 
ena were the expression of a neurosis of the trigeminus 
brought about by circulatory disturbances in the lower 
pelvis. These led, he thought, to a slowing of the venous 
current with stagnation of blood in the skin, mucous mem- 
branes, nose, etc. This abnormal condition finally begets a 
disturbance of the sensitive nerves of the parts with a tend- 
ency to reflex phenomena, manifesting themselves chiefly in 
the domain of the trigeminus. Thus the alveoli of the 
lungs and the mucous membrane of the bronchi become 
surcharged with venous blood, and this engorged condition 
probably acts directly on the sensitive filaments of the 
vagus. 
I may mention here a little brochure to which 1 have 
never seen any reference, even among German writers, 
which I stumbled on accidentally in the library of the Sur- 
geon-General’s Office at Washington, and which I take 
pleasure in rescuing from an undeserved oblivion. The 
pamphlet is entitled “ Die Migraine ist eine Angina, der 
acuter Magencatarrh eine Neurose. Ueber die Bedeutung 
der Angina Fauci urn, Hire Verbindung und ihren Zusam- 
menhang mit einer Reihe von Krankheitenand is from 
the pen of Dr. Ferdinand Wydler, of Aarau. The chief 
contention of the author is indicated in the title of his 
work. Among the conditions supposed to depend upon 
slight catarrh of the pharynx are cardialgia, gastralgia, ver- 
tigo, vomiting of blood, epistaxis, sopor, delirium at night. 
* “ Der Niesekrampf u. deren Beziehung zur Migrane, zum Bronchial- 
asthma u. zum Heufieber.” “Arch. d. Heilkunde,” lOter Jahrg., Leip- 
zig, 1869, p. 686. THE RESPIRATORY VASO-MOTOIl NEUROSES. 
11 
heinicrania, neuroses of the trigeminus, cervico-occipital 
neuralgia, angina pectoris, brachial neuralgia, stenocardia, 
etc. He concludes as follows: 
‘‘Nach meiner Auffassung ist die llemicranie, sowie die 
frische Trigeminusneuralgie eine Angina, gleichsam eine frag- 
mentarisclie Angina, mit den begleitenden hervorstehenden 
Krankheitssymptomen der einfachen catarrhalischen Angina 
nervoser erethisclien Personen: eine Angina, bei welcher als 
hauptsachlichste Symptome, Prostration und Kopfschmerz, 
Schwindel, nieistens auch Erbrechen erscheinen, und sich als 
Ilauptleiden hinstellen, die jedoch deutlich von dem Zeicben der 
Zusammenhorigkeit des Zusammenhangs und Ursprungs, von der 
frischen Rdthung der Schlundgebilde begleitet sind.” 
While the enthusiasm of the author carries him a little 
too far, his pamphlet must be regarded as an important con- 
tribution to the literature of the naso-pharyngeal reflex. 
Finally, Trousseau * discussed at length the relation of 
coryza to asthma, and Follin and Duplay f assert that many 
of those who suffer from nasal polypi “ become subject to 
attacks of asthma.” To Voltolini belongs the credit of cur- 
ing his patient by removal of the nasal neoplasm. 
The older writers, as has already been pointed out,J were 
doubtless familiar with the disease known as “ hay-fever,” 
which they considered as a species of, or identical with, the 
so-called bronchial asthma of the present day. It was not 
until after the observations of Bostock that the asthma aris- 
ing from the emanations of grasses was regarded as distinct 
from the asthma produced by other causes, while it has 
taken nearly a century for us to return to the simpler classi- 
* “ Clinical Medicine,” New Syd. Soc. Trans., London, 1868, vol. i, 
p. 619 et seq. 
f “Traite 616mentaire de pathologie externe,” Paris, 1868—’69, tom. 
3, p. 816. 
J “Trans, of the Med.-Chir, Fac. of Md.,” l.c, “Am, Journal of 
the Med. Sci.,” Jan., 1886. 12 
TIIE PATHOLOGY AND TREATMENT OF 
tication of the older nosologists. Even now our notions of 
the condition known as “asthma” are more or less vague 
and indeterminate. It is looked upon as a disease per se, 
as a distinct pathological entity ; but if we consider exactly 
what is involved in the ordinary conception of this condi- 
tion—that, like many other disturbances of respiration, it 
has no definite anatomical lesion—that it is common to an 
almost indefinite number of pathological states, we shall be 
forced to regard asthma as a symptom which, like cough, 
may be ushered in, follow, or occur simultaneously with 
irritation in various parts of the body, but which is most 
commonly symptomatic of some disorder of the respiratory 
tract. I do not propose, in this communication,'to discuss 
the mechanism of the asthmatic paroxysm ; whether it is 
essentially a spasmodic phenomenon, or whether the bron- 
chial constriction is due to an engorged condition of the 
mucous membrane analogous to that seen in vaso-motor 
coryza—a transference, so to speak, of the nasal swelling to 
the bronchial tubes—are matters which do not come within 
the range of the present inquiry. While there are many 
reasons for belief in the correctness of the latter view, which 
was advanced by Weber,* and which has recently found an 
eloquent defender in Sir Andrew Clarke,f and while such 
* “ Ueber Asthma nervosum.” See “ Tageblatt d. 45 Versamm- 
lung deutsch. Naturforscher u. Aerzte in Leipzig,” 1872, p. 169. 
f “American Journal of the Med. Sciences,” Jan., 1880. In sim- 
ple justice to Trousseau, whom some recent writers seem to overlook, 
it must be stated that he was the first to look upon the peculiar coryza 
(undoubtedly the hay-fever of the present day) occurring in connection 
with asthma (see above) as one of the manifestations of that disease, 
as a part of the asthmatic process, and also the first to suppose that 
the difficulty in respiration, sometimes associated with urticaria, was 
“ occasioned by an eruptive or congestive state of the mucous membrane 
of the bronchial tubes analogous to the eruption and congestion on the 
skin.” (Op. cii., vol. ii, p. 284.) THE RESPIRATORY YASO-MOTOR NUEROSES. 
13 
transference probably does take place in a large number of 
cases, still it were unwise, in the present state of our knowl- 
edge, to eliminate completely the element of spasm as a pos- 
sible factor in other cases, and to lay down the law that 
the constriction of the bronchial tubes alleged to be peculiar 
to this condition can only' be brought about by sudden 
swelling of the mucous membrane. 
An interesting feature of a certain proportion of the 
class of cases we are now discussing is the occasional asso- 
ciation of urticaria, asthma, and coryza. And just here I 
may remark that the relation of asthma to skin affections 
was familiar long before the days of Trousseau. Thus the 
illustrious Hoffmann * mentions, as a fact of common ex- 
perience, that asthma sometimes follows the suppression 
of a cutaneous rash; and before him Baglivi j- had recom- 
mended, in such an event, that the patient should sleep 
with one having the “scabies,” that, catching it, he might 
be relieved of his asthma. It is also related that William 
of Orange was cured of an inveterate asthma during the 
running of a sore on the shoulder produced by the famous 
cannon-ball wound received at the battle of the Boyne. 
In the condition of affairs that we are discussing, the 
coryza may precede the asthma and urticaria in time of 
appearance, disappearing or remaining after their eruption ; 
or the asthma or urticaria may antedate the attack of co- 
ryza; or, finally, instead of alternating the one with the 
* “ Ila experientia docemur, a scabie retropulsa ... a tinea capitis 
male curata . . . nostram passionefn exoriri.” F. Hoffmann, “ Op. 
omnia phjsico-medica,” part ii, § ix, p. 257, Genevae, 1760. In speak- 
ing, too, of the symptoms of asthma, he adds, “ Mucus per nares ex- 
cluditur.” 
\ “ Opera omnia med. practica,” ed. octava, Lugduni, 1714, “Prax. 
med., appendix de asthmate,” p. 104. “Ex scabie retropulsa si asthma 
fiat, cum scabioso dormiendum est, ut scabies revocetur, vel urticis 
cedenda cutis” 14 
THE PATHOLOGY ANI) TREATMENT OK 
other, they may appear simultaneously in the individual. 
At the last meeting of this association I stated my belief 
that these phenomena seemingly depend on an imperfectly 
defined neurosis or vaso-motor influence (possibly some 
derangement of the eervico-occipital sympathetic), which is 
probably the connecting link between these affections. 
Now, in attempting to define the reciprocal relationship 
between this triad of conditions, we may regard the skin 
essentially as a part of the respiratory tract—as the external 
or;£an of respiration. It is only necessary for me to recall 
the physiological importance of the skin in respiration 
among some of the lower animals, and the embarrassment 
of respiration in man from pathological or experimental 
suppression of the cutaneous function. We may accord- 
ingly regard this neuro-vascular disturbance of the external 
surface as a natural symptom of the respiratory vaso-motor 
neuroses, and assume that, while the relation of asthma and 
coryza may be explicable by a possible normal sympathy 
existing between the two extremities of the internal respira- 
tory tract, both asthma and coryza may be linked to the 
skin affection by a sympathetic bond which holds in equili- 
brium and close consent the whole mechanism of the res- 
piratory function. 
The principles involved in the foregoing propositions 
have served as the basis and rules of my practice in this 
class of affections during the past three years, and with a 
most gratifying result. In that time between sixty and 
eighty cases of paroxysmal vaso-motor neuroses of the res- 
piratory tract have come directly or indirectly under my 
professional observation. Of this number, the nasal pas- 
sages were most frequently the seat of the vascular disturb- 
ance, and next in frequency the bronchial tubes and 
pharynx. Occasionally the affection was more or less 
clearly localized in the laryngeal cavity, but, according to THE RESPIRATORY VASO-MOTOR NEUROSES. 
15 
my experience, this is an exceptional event. While the sym- 
pathetic nerve disturbances manifest themselves most fre- 
quently in the nasal cavities, in a certain proportion of 
cases the pharynx and larynx appear to be the starting- 
point of the trouble, and I have traced a number of reflex 
phenomena, such as asthma, cough, etc., to diseased condi- 
tions of these structures. The vaso-motor disturbances, 
both of the pharynx and larynx, are, however, commonly 
associated with, or preceded by, similar affections of the 
nasal cavities. In the pharynx and larynx they are char- 
acterized by an excessive degree of hypersesthesia—the 
very act of opening the mouth giving rise in some cases to 
retching and even vomiting. Indeed, a considerable num- 
ber of cases of so-called hypersesthesia and parsesthesia of 
the larynx and pharynx are traceable to some vaso-motor 
disturbance or sympathetic nerve irritation. The changes 
in the vascularity of the mucous membrane often take place 
with great rapidity, the vessel dilatation being quickly re- 
placed by a condition approaching pallor, while the latter 
as quickly gives place to the laryngeal or pharyngeal blush. 
In cases in which the neurotic feature is especially well 
marked, the alternate dilatation and contraction of the ves- 
sels can be most conveniently studied. The suffusion and 
swelling may be diffuse and uniformly distributed over the 
structures, or it may be more pronounced over certain areas, 
presenting a certain anatomical resemblance to a cutaneous 
eruption. 
The secretion of colorless watery fluid is not so constant 
nor so abundant as in analogous conditions of the nasal 
passages, nor is the swelling of the mucous surfaces so con- 
spicuous. The reflex phenomena symptomatic of this class 
of pharyngo-laryngeal neurosis need not detain us at pres- 
ent. Suffice it to say that they are sufficiently numerous, 
and consist chiefly of various sensory and motor disturb- 16 
THE PATHOLOGY AND TREATMENT OF 
ances in the path of the nerves that radiate from the pha- 
ryngeal plexus, and in spasmodic contraction of the pharyngo- 
larvngeal muscles. In one case the spasm of the pharyngeal 
and palatal muscles was so great that it materially hindered 
the passage of air through the nares and laryngeal vestibule, 
causing the patient to start suddenly from his sleep with 
what might be termed a veritable naso-pharyngeal asthma. 
In whatever portion of the respiratory tract these vaso- 
motor neuroses are situated, the general principles of treat- 
ment are in each and every event essentially the same. 
When, some time ago,* I formulated the view according 
to which the so-called nasal or respiratory reflex neuroses, 
the group of phenomena known as “ hay-fever,” “ asthma,” 
and other reflex conditions found in connection with nasal 
disease, may be classed as symptoms which, owing their 
origin to a common cause, form part and parcel of a single 
pathological process, I did so not merely upon theoretical 
grounds, but based my conclusions upon the results of 
clinical experience—upon the observation that the treatment 
of one of these neuroses was essentially the treatment for 
all, and whether we had to deal with paroxysmal cough, 
asthma, or with the ensemble of those phenomena known as 
“ hay-fever,” “ rose cold,” etc., the therapeutic indications 
are identical. 
With these brief prefatory remarks, let us turn to the 
most typical and interesting of these affections, in which 
the nasal passages and adjacent organs are the most con- 
spicuous seats of the vascular disturbances, and which we 
may designate coryza vaso-motoria periodica. 
The chief indications in the treatment of this affection 
are: (1) To remove any existing local respiratory disease 
or irritation ; (2) to so alter the nutrition of the nerve-cen- 
ters that they may not respond so easily to reflex-producing 
* “ Maryland Med. Journal,” April 11, 1885. ‘THE RESPIRATORY YASO-MOTOR NEUROSES. 
17 
impressions; (3) to search carefully for any pathological 
condition, systemic or local, which may be regarded as a 
source of direct or indirect irritation of the nervous or res- 
piratory apparatus, and adopt appropriate measures for its 
relief. Failing in the above measures, (4) the partial or 
complete destruction of the vessels or sinuses over the 
area or areas in which the vascular disturbance is most 
marked. 
I have dilated at length, elsewhere, upon the manner in 
which these indications should be carried out, and shall, 
therefore, on this occasion, only offer a few supplementary 
suggestions. 
The first lesson to be learned in the treatment of this 
affection is that it is a chronic neurosis, and, as such, re- 
quires chronic treatment. It should be remembered lhat 
the peculiar condition of the sympathetic is, like epilepsy, 
with the patient bv day and by night, in winter and sum- 
mer, ready at any moment, under favorable conditions, to 
give expression to its presence by a paroxysm. Any treat- 
ment, therefore, undertaken a short while before the ex- 
pected attack or during its course, is almost wholly pallia- 
tive, and can rarely, if ever, accomplish any permanent 
good. And thus the innumerable remedies (such as chloral, 
belladonna, opium, stramonium, etc.) which have been used 
from time to time can accomplish no lasting good, and in 
many cases either lose their beneficial effects altogether, or, 
in the end, by their constant physiological effects upon the 
nerve-centers, may tend even to aggravate the predisposi- 
tion to the affection. In this category I would place co- 
caine. As I pointed out some time ago,* and also at the 
last meeting of this association,! the long-continued use of 
* Discussion on Cocaine, May 15, 1885. “Trans, of the Med.-chir. 
Fac. of Maryland,” 1885, p. 189. 
f Discussion, June 26, 1885. “ Trans, of the Am. Laryngol. Assoc.,” 18 
THE PATHOLOGY AND TREATMENT OF 
this drug in the nose and throat begets an increased irrita- 
bility of these structures, due, probably, to the repeated 
contraction and consequent fatigue of the contractile ele- 
ments in the smaller vessels and erectile tissues, which ter- 
minates in some cases in a subparalytic condition of these 
structures, and subsequent puffin ess of the membrane. As 
the habitual use of carthartics eventuates, sooner or later, 
in constipation, so the prolonged use of cocaine will result, 
in a certain proportion of cases, in a hypenesthetic condi- 
tion of the mucous membrane. In the case of the erectile 
tissues, it is especially open to the objection that, by bring- 
ing repeatedly into play the contractile power of these 
structures, it may ultimately weaken their walls and lay the 
foundation for a permanent dilatation of the erectile cells. 
In calling attention to these disadvantages of its continuous 
use in these affections, I do not bv any means desire to 
question the many excellent virtues of this remedy. In 
certain acute affections of the mucous membrane, and for 
its effect on the nasal erectile structures, pointed out by 
Bosworth, it is a God-send, but I am convinced that at 
present it is too indiscriminately and injudiciously em- 
ployed. In the disease under review, it has in my hands 
utterly failed to dissipate, except temporarily, its symptoms, 
or to abridge, in the slightest degree, its course. For a 
short while amelioration is secured, but, at the expiration 
of a period varying from half an hour to two hours, the 
symptoms recur, and the drug has to be used again and 
again. 
My custom is to treat this affection as I would any other 
chronic disease of the nervous system. The commence- 
ment of the treatment, accordingly, should date from the 
1885, p. 142. I may add that since then Beverley Robinson (“ Med. 
Record,” Oct. 17, 1885), Ingals (“Journal of the Am. Med. Assoc.,” Feb. 
20, 1886), and others, have recorded similar observations. THE RESPIRATORY VASO-MOTOR NEUROSES. 
19 
first appearance of the patient for consultation, and termi- 
nate, it may be, long after he is apparently free from his 
disease. I can not insist too strongly on the importance of 
prolonged and continuous tonic treatment addressed to the 
nervous apparatus. It may at first fail, and the paroxysms 
return again and again with all their accustomed severity; 
but, if it be persisted in, the time will come, sooner or later 
—provided there is not some incurable lesion—when the in- 
tervals between the paroxysms will be less and less, and the 
attacks themselves less severe, until finally they cease alto- 
gether. 
The great mistake which is universally made, it seems 
to me, is the suspension of treatment upon the termina- 
tion of the attack, and I therefore wish to emphasize 
the importance and necessity of continuous treatment 
throughout the interregnum of fancied immunity from 
the disease. 
In carrying out this remedial course two difficulties will 
present themselves: the firmly-rooted belief in the patient’s 
mind that there is nothing the matter with him in the in- 
tervals of exemption, and his natural discouragement when, 
in spite of treatment, he may have an occasional return of 
his old disorder. 
The general tonic and hygienic treatment will vary with 
the individual peculiarities of the subject and the conditions 
of his environment, and will usually consist, to speak in 
general terms, of prophylactic measures directed against the 
development of nervous and catarrhal affections. 
Among the many remedies 1 have tried in the constitu- 
tional management of this class of affections, I would men- 
tion and recommend arsenic, phosphorus, zinc, quinine, and 
mix vomica. These drugs may be used alone or in combi- 
nation for an almost indefinite time, if the usual precautions 
in regard to their physiological effects are exercised. The 20 
TI1E PATHOLOGY AND TREATMENT OF 
following method of administration, although it has failed 
me at times, has, nevertheless, been so generally beneficial 
in my practice that I do not hesitate to recommend it for 
your trial: 
(1.) 
$ Zinc, phosphid gr. -fa ; 
Quin, sulph gr. ij; 
Ext. nuc. vom gr. 
M. Ft. pil. no. j. 
S.: To be taken before meals. 
(2-) 
I£ Liq. arsenic, et hydrarg. iodid., gtt. iij ad v. 
S.: In wineglassful water, after meals. 
Formerly I used Fowler’s solution, but for the past year 
have substituted the iodide of arsenic and mercury (Dono- 
van’s). The quantity of the ingredients should he in- 
creased according to the judgment of the physician. Should 
the physiological effects of any of the remedies manifest 
themselves, it should be stopped for a week or so, and then 
resumed in the same or diminished doses. 
I may add, in leaving the subject of constitutional treat- 
ment, that for several years l have employed the above- 
mentioned lines of treatment in simple inflammatory condi- 
tions of the nasal passages and throat, and have found them 
important auxiliaries, especially in the earlier stages of the 
simple inflammatory process, when the vaso-motor element 
of inflammation is chiefly evident from the repeated and 
sudden erection of the turbinated structures.* 
I have also seen good effects from the continuous use of 
the bromides and the iodide of potassium. In two cases I 
have made use of the constant current (from ten to fifteen 
cells), placing one electrode over the nape of the neck, and 
* See article by the writer in the “ Medical News,” Philadelphia, 
April 4, 1885. THE RESPIRATORY YASO-MOTOR NEUROSES. 
21 
passing the other extremity of the current alternately over 
the region of the superior cervical ganglion and through 
the nasal passages. In one, apparent, and in the other de- 
cided, relief to the symptoms was obtained. Although my 
experience with this agent has not been sufficient to war- 
rant me in pronouncing either for or against its use, I con- 
sider it, nevertheless, worthy of further trial. 
In one case a satisfactory result, as far as the ameliora- 
tion of the symptoms was concerned, was secured by par- 
tial obliteration of the pharyngeal vessels with the galvano- 
cautery. The patient, a physician, suffered from the 
pharyngeal variety of vaso-motor neurosis, associated with 
an abnormally large, swollen, and varicose condition of the 
veins on the posterior wall. The vessels were cut across in 
a number of places, and since the operation the paroxysms 
have been notably less severe. 
In regard to the topical treatment of existing nasal dis- 
ease, I can only repeat what I have said over and over again, 
that any treatment addressed to the nasal chambers accom- 
plishes one result, and one only—it closes one door against 
ab extra irritation of the nerve-centers. In many cases, it is 
true, this will be of itself sufficient. The nasal passages 
may be the sole avenues through which the nerve-centers 
are influenced, and, with the removal of the irritant and the 
consequent physiological rest of the centers, the disorder 
may be apparently, and in the course of time actually, dis- 
sipated. But there arc other cases in which, from what I 
have indicated above, such a course will obviously fail. 
Those of my colleagues, therefore, who consider the re- 
moval of the nasal obstruction or irritation as the sole rem- 
edy for this disorder, base their belief, it seems to me, upon 
an incomplete conception of its pathology. The value of 
the galvano-cautery and other therapeutic measures ad- 
dressed to the nasal passages will depend, to a large extent, 22 
THE RESPIRATORY VASO-MOTOR NEUROSES. 
upon whether the existing nasal disease is the primary cause 
of the central irritation, whether it is the sequel of repeated 
attacks of vaso-motor coryza, or whether, it is a purely 
accidental phenomenon. Whether primary, secondary, or 
accidental, it always acts as an excitant of the disease, and 
it is of the utmost importance that it should receive the 
most careful attention. But it must not be forgotten, at 
the same time, that behind the nasal, throat, and head phe- 
nomena stands the neurosis, and that, until the sympathetic 
nerve-irritation is overcome, we can not expect to thor- 
oughly eradicate the disease. REASONS WHY 
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